The Evolution of Medi-Cal

Nobody knew the blockbuster news of Friday that Toby Douglas deciding to step down as head of te California Department of Health Care Services and for Medi-Cal–but one day before the Medi-Cal Stakeholder Advisory Committee was still noteworthy for the news and information it did provide.

The main topics were a deeper discussion on network adequacy and timely access in the Medi-Cal program; and a broader discussion on the negotiations for a new 1115 waiver. These are both parts of a evolution of Medi-Cal–not just expanding coverage, but to a different way of providing care.

TIMELY ACCESS: With regard to timely access, it seemed after that presentation even more urgent that the Governor sign SB964 (Hernandez), to improve network adequacy, which is now on his desk.

Many of the Committee’s participants had requested this briefing. DHCS (Department of Health Care Services, which administers Medi-Cal) and DMHC (over commercial markets and  most Medi-Cal managed care) are taking additional steps to determine ongoing compliance with network adequacy and timely access requirements, including a new timely access verification study announced by DHCS, public posting (for the first time ever) of DHCS medical audits, and annual reporting of network adequacy by DMHC as well as geoaccess mapping at the plan/provider level which is being used by both departments. SB964 would provide structure and support for this increased oversight.

The promise of Medi-Cal managed care is that Californians in managed care will have the same consumer protections whether they are enrolled in Medi-Cal managed care or through coverage on the job or coverage they buy as an individual. The Brown Administration has pointed to these California consumer protections like timely access to care as they worked to expand Medi-Cal managed care, moving almost a million kids from Healthy Families to Medi-Cal, imposing mandatory enrollment of managed care on hundreds of thousands of seniors and persons with disabilities, expanding managed care into rural areas, and now embarking on a “pilot project” that will affect 800,000 Californians covered by both Medi-Cal and Medicare. But if health plans use different networks for Medi-Cal than for commercial coverage, those networks should be surveyed separately. The Administration is taking some steps to provide more effective oversight but given the decades of complaints about lack of access in Medi-Cal managed care, more needs to be done.

WAIVER: The provider access discussion set the tone and helped to frame the main topic and purpose for yesterday’s gathering: the Medi-Cal waiver renewal process, which is about to move at a very fast clip.  The state is entering into negotiations with CMS on its Medi-Cal waiver renewal: lots of new ideas about expanding access to the remaining uninsured, as well as ideas about care delivery and payment methodologies will be tested over the next five years, with everything at stake for beneficiaries.

The state can certainly take pride in the many successes of the current “Bridge to Reform” waiver: the Low Income Health Programs that were an early Medicaid expansion, Delivery System Reform Incentive Pool (DSRIP), among others.  The waiver renewal will build on these successes and on lessons from any missteps.

Lots of unknowns and pitfalls here, particularly when DHCS starts looking at shared savings models where the savings achieved through any delivery system reforms or efficiencies would be shared with the Feds. Is California poised to become the next “accountable care state?” Some advocates express concern–since in the wrong hands or under certain state fiscal conditions, large scale accountable care arrangements can easily devolve into Medicaid block grants or per capita caps that take an already starved base of funding and constrain it into the future.

Like New York’s recent waiver and consistent with California’s grant application for system transformation (CalSIM), California expects to focus its waiver to emphasize payment and delivery system reform and re-aligned incentives for providers to coordinate care more efficiently. There was some discussion about new delivery models in order to improve access though this was long on aspirational vision and short on specifics.

Other advocates continued to raise issues around increasing access to care and coverage, and ensuring that the safety net survives and thrives–most notably the public hospitals, which they note put up the money to draw down the federal matching funds.

The state hopes to submit its waiver renewal request by mid-February (!) and technical advisory groups are forming now (track the process here).

OTHER UPDATES: The state is about to transition more seniors and people with disabilities into managed care as part of the Coordinated Care Initiative—but will beneficiaries have the access to coordinated care they need to manage chronic conditions? Gary Passmore of the Congress of California Seniors notes there’s a cost to not sorting this out early on—for care delivered too late, in the wrong settings for this population the costs can add up quickly.

In related news, DHCS also announced that it may delay the implementation of the pregnancy wrap and the wrap for recent lawful immigrants who are low-income, childless adults. This is not good news for pregnant women: once the pregnancy wrap is implemented, pregnant women up to 138%FPL will be eligible for no-cost, full-scope Medi-Cal (instead of pregnancy-only coverage) and pregnant women 139%FPL-208%FPL will remain in Covered California but with zero premiums and zero cost sharing. For recent lawful immigrants who are low-income childless adults, it is better news: they stay on state-only, zero-cost Medi-Cal but once the wrap is implemented they will be covered through Covered California but with zero premiums, zero copays and continued coverage for adult dental. Implementation of these coverage “wraps” was set for January 1 but may be delayed. More to follow on this.

Big news today, as Toby Douglas, the director of the Department of Health Care Services, announced he would be leaving that post by the end of the year. For the last four years in that position, he ran Medi-Cal, which provides health care and coverage for a staggering 11 million Californians–more than a quarter of the state.

It was a surprise for many of us–we were with Toby all yesterday at an all-day Medi-Cal Stakeholders Advisory Committee, and he hid this news like a good poker player. The meeting provided updates on what will be his legacy at the Department: the shift of seniors and people with disabilities into coordinated and managed care, the budget cuts during the recession and the partial restoration of key benefits, the absorption of programs like Healthy Families, and most notably, the expansion of coverage and the other eligibility and enrollment changes under the Affordable Care Act. He talked about the need for the Department and Medi-Cal to grow and evolve, to meet a new mission and mandate.

The meeting, which we will post the notes from shortly, also delved deeply into two areas that he will start the work but leave unfinished for his successor: the work to ensure access to patients in Medi-Cal, with more rigorous reviews of network adequacy and timely access, and the discussion around a new 1115 waiver and negotiations with the federal government–the plan for Medi-Cal for the next five years, and the implementation of additional delivery system reform.

It’s hard to overstate the importance of Medi-Cal in general, of Toby’s job, and as part of the Affordable Care Act. Covered California may have been the bright shiny object, but Medi-Cal covered more people and could be seen as having greater successes (nearly 2 million enrollees, the Low-Income Health Programs and express lane enrollment) and failures (the still-pending 350,000 backlog of applications).

We are glad Toby is staying through the end of the year, to provide a good transition, and appreciate his work, and wish him well in whatever his new career offers.

BethAbbottSwearingIn

Also this week, our former colleague Beth Abbott started as the new head of the Office of the Patient Advocate. We are excited about her tenure, and were happy to see these pictures of her getting sworn in by Health and Human Services Secretary Diana Dooley. We look forward to seeing who Secretary Dooley gets to swear in for the DHCS job in the beginning of 2015.

ALERT: Your Health or Your Home?

HEALTH ACCESS ALERT: Friday, September 12, 2014

ALERT: CALL GOVERNOR BROWN TO SIGN SB1124, SO CALIFORNIA FAMILIES AREN’T FORCED TO CHOOSE BETWEEN THEIR HEALTH AND THEIR HOME

*        Key bills on the Governor’s desk–Governor Brown has month of September to sign or veto bills including SB1124(Hernandez), to limit Medi-Cal “estate recovery” to long term care–so signing up for Medi-Cal managed care doesn’t put the family home at risk.

*       CALL (916-445-2841), E-MAIL or TWEET GOVERNOR BROWN to urge signing of SB1124 and reward responsibility, so low-income families aren’t penalized for doing the right thing: meeting the mandate and signing up for coverage, saving up and buying a home.

*        COMING NEXT WEEK: Call-in Days for SB 964 (Hernandez) to ensure network adequacy and timely access to care for all managed care patients, including those in Medi-Cal and Covered California.

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Governor Brown has until September 30 to sign or veto several critical health and consumer protection bills, including SB1124 (Hernandez), a crucial bill that protects California families from having to choose between their health and their home.

SB1124 (Hernandez) would limit Medi-Cal “estate recovery” to long-term care, so the state collects only what is required under federal law, aligned with 40 other states. Current California policy places a lien on the assets of Medi-Cal managed care patients 55 and over–discouraging them for signing up for coverage, even as there is no such repayment expected of those higher-income families getting assistance in Covered California.

SB1124 rewards personal responsibility for those Californians who do the right thing by meeting the mandate to sign up for health coverage, and who save and buy a home despite limited incomes. A wide range of consumer, health, low-income, senior, and community organizations–and editorials from the Los Angeles Times and other newspapers–are urging Governor Brown to sign the bill.

CONTACT GOVERNOR BROWN

1.      Calls are best: (916) 445-2841. Give the name of the bill you are calling about first and a simple statement of support (1-2 sentences max). For example:

My name is ______ and I’m calling to ask you to please sign SB1124 (“Limit on Medi-Cal Estate Recovery”) into law. No one should have put the family home at risk just to get help with their medical costs.

2.    Email the Governor at: https://govnews.ca.gov/gov39mail/mail.php .
- Choose the right bill (ex: SB1124) under “Please choose your subject.”

- Fill out the form carefully (note that the ‘con’ button comes before the pro button!)

You can include a few sentences in this email form, but keep your statement brief, as in this example:

“Please sign SB1124 into law. My in-laws, both in their late 50s, have worked hard all of their lives, but now they have jobs that do not provide health insurance. They refuse to sign up for Medi-Cal because they don’t want to put the family home at risk. If they do end up in the E.R, doesn’t Medi-Cal have to pay that bill anyway?”

3.    Tweet today! and though the end of September. Here are a few suggestions, but make your own!

·       CA should not keep low-income Californians in poverty for having Medi-Cal. Ask @JerryBrownGov to sign SB1124 #SaveMyFamilyHome

·       Medi-Cal should be a safety net program – not a long-term loan program. @JerryBrownGov sign SB1124 #SaveMyFamilyHome

·       Reward responsibility: Don’t force CA families to choose between their health and their home. @JerryBrownGov sign SB1124 #SaveMyFamilyHome

4. Share Your Stories!

If you have been directly impacted by any of the circumstances above, please share your story with us at www.health-access.org by clicking on the “Share Your Story” icon or call (916) 497-0923.

Example

Paul and his wife, both age 62, are between jobs and uninsured. When they went to sign up for coverage on Covered California, they learned they qualify for Medi-Cal but that the  state would go after their home or other assets after their death. “We didn’t work for 30 years to pay off our mortgage, to hand it over to the state. Our home needs to go to our children. This is blatant age discrimination. The policy should have failed on this alone. Because of this I did not sign up for Medi-Cal.”

Many low-income Californians age 55 and older are reluctant to enroll in Medi-Cal because they are afraid the state will ‘recover’ their house when they die. The federal government requires states to recover against the estates of Medi-Cal beneficiaries age 55 and older, but only for long term care services such as nursing home care. Yet California is one of only ten states that collects for all medical care, including premiums paid to a health plan.

 

Thank you for your efforts in support of this important piece of legislation. Questions about the bill can be directed to Health Access, or to Linda Nguy (lnguy@wclp.org), Legislative Advocate at Western Center on Law and Poverty, a co-sponsor of SB1124(Hernandez) with California Advocates for Nursing Home Reform.

Key Health Bills On the Governor’s Desk After Legislature Adjourns

HEALTH ACCESS ALERT: Tuesday, September 2, 2014 

KEY PATIENT PROTECTIONS ON GOVERNOR’S DESK AS LEGISLATURE ADJOURNS

*        Legislature ends 2013-14 session with a flurry of activity; Governor has month of September to sign or veto bills passed, including SB 964 (Hernandez) on network adequacy and timely access to care.

*       Also pending on Governor’s desk are key Medi-Cal bills: limiting Medi-Cal estate recovery (SB1124), and allowing State to accept foundation money for Medi-Cal renewal assistance (SB18).

       Closely-fought bill to require paid sick leave passes, as does SB1094(Lara), to expand the Attorney General’s authority to enforce conditions of non-profit hospital mergers and acquisitions. Other measures on out-of-pocket costs stall, with advocates commiting to action next year.

*        POST-LEGISLATIVE SESSION RECEPTION TODAY to wish Health Access’ Beth Abbott well as she transitions to her new post as director of the revamped Office of the Patient Advocate. Please RSVP here for the reception Today, Tuesday, September 2nd, 4-7pm, Ambrosia Cafe in Sacramento.

   Be a Member of Health Access To Help CA Seize The Opportunities In Health Reform
   Read Our Health Access Blog for More Updates; Also Follow Us on Facebook!
   Read Real-Time Updates on ACA Implementation on Twitter @HealthAccess!
 
 

The Legislature ended its 2013-14 session early Saturday morning, passing a flurry of bills to the Governor’s desk for his consideration.  Some key health care consumer protections and proposals made it through the legislative process, and are now headed to the Governor for his final review. Several other measures stalled, some earlier in the year and some in the last days or even hours of the session.  Governor Brown now has the month of September to either sign or veto bills before him.

BILLS HEADED TO THE GOVERNOR:

In this year where California was successful in enrolling people into coverage under the Affordable Care Act, new scrutiny focused on whether patients had timely access to care once enrolled in Medi-Cal managed care, which has long been criticized for lack of adequate access,  or Covered California with some plans offering “narrow networks.” Passing this week was the Health Access California-sponsored bill, SB 964 (Ed Hernandez), which would require DMHC to do annual reviews for timely access and network adequacy, separately for Medi-Cal managed care and the individual market so that consumers in Medi-Cal and Covered California have the guarantee that they can get needed care, when and where they need it.

Two important Medi-Cal bills are also headed to the Governor. SB 18 (Leno/Hernandez) would have the State accept $6 million from the California Endowment to fund Medi-Cal renewal assistance by community based organizations, and drawing down federal matching funds as well.

Getting near unanimous votes in the legislature was SB 1124 (Hernandez) which would limit Medi-Cal estate recovery to long-term care, so those getting Medi-Cal managed care services would not find that their family home had a claim on it after death. Over 40 states already do this, allowing Medi-Cal to be a true safety-net for medical care without putting the family’s assets at risk. “Estate recovery,” which amounts to about $500 per month in liens for those over age 55, arbitrarily seeks assets from a small slice of lower-income families who are trying to do the right thing and get covered. While this would have a small state budget impact, enactment would be a big deal for families’ economic security: health and low-income advocates are making it a major priority to get the Governor’s signature.

Another Health Access California-sponsored bill that is headed to the Governor is AB 2088 (Roger Hernandez), which makes, in the large group market, limited benefit plans supplemental to comprehensive coverage. This consumer protection already exists in the individual and small employer market; the bill closes a loophole for employers to possibly avoid compliance with the full intent of the ACA. Employees who accept employer coverage are barred from subsidies in Covered California even if that coverage is unaffordable or does not meet 70% minimum value: AB2088 would protect those employees by assuring that they get comprehensive coverage.

Also passing, but not without major effort, was SB 1094 (Lara), which would expand the Attorney General’s authority to enforce conditions of non-profit hospital mergers and acquisitions, to assure that a nonprofit hospital will continue to serve its community after a transaction in which ownership changes. SB 1094 initially failed passage on the Assembly Floor and was granted reconsideration, passed out of the Assembly Floor Thursday evening with a vote of 43-27 thanks to the tireless work of advocates ranging from Planned Parenthood to the California Labor Federation, from SEIU to Consumers Union to Health Access California. This bill is now headed to the Governor.

A last minute bill of interest to health advocates in Fresno County was AB 2731 (Perea) which would give Fresno County the budget flexibility it says it needs to preserve safety-net services to the undocumented and indigent—the bills allows the County to defer the county’s maintenance of effort requirement for its transportation fund, with the freed-up resources required to go to indigent care. The County felt that the language in the budget passed in June was too restrictive, and had voted to nearly eliminate its medically indigent program a few weeks ago—but put a 90-day stay in anticipation of a legislative fix such as AB2731, which now heads to the Governor.

While not about health insurance or treatment, the health-related bill that got the most attention was AB 1522 (Gonzalez), the requirement on employers to offer at least 3 days of paid sick leave to their workers. While major cities across the country have adopted similar policies, California would be only the second state to require paid sick leave—but with a major and problematic exemption of home care workers, a carve-out requested by Governor Brown, but actively opposed by the unions representing in-home supportive services caregivers.

There were also a few bills that were held in the Legislature, some with commitments from the Administration to address the issue at hand in the next legislative session and others with commitments from the State to address the issue at hand via changes in regulations.

BILLS HELD:

Three bills on trying to make out-of-pocket costs manageable were held—but health advocates hope to revisit these issues in the year ahead.

AB 1917 (Gordon) which would have capped prescription drug co-pays at 1/12 of the annual out-of-pocket limit so that patients with HIV/AIDS, cancer, MS, and other diseases will not be forced to pay high upfront costs for their medication was held due to insurer and Administration opposition. Assemblyman Gordon, sponsoring organization Health Access California, and others are committed to continuing the effort and conversation with the Administration to address this issue in the next legislative session.

Another bill that has been held is SB 1176 (Steinberg), which would have made a health plan or insurer responsible for tracking out-of-pocket costs for in-network providers, and reimbursing the consumer when they exceed their out-of-pocket limit. The Department of Managed Health Care has committed to developing regulations that will require health plans and insurers responsible for tracking out-of-pocket costs for in-network providers and responsible for reimbursing consumers when they exceed their out-of-pocket limit.

Also not proceeding was AB 2533 (Ammiano) which would have ensured that if a patient can’t get timely access to care, the health insurer must arrange for needed care out-of-network, but with in-network cost sharing. This is now the practice with plans regulated at the Department of Managed Health Care, but not the Department of Insurance.

Finally, a late push to extend the July 2015 sunset for the California Health Benefits Review Program, which provides University of California analysis of benefit mandate proposals, AB 1578 (Pan), stalled in literally the last moments of the legislative session.

Below is a full bill list of all the key health legislation on the Governor’s desk.

 

RECEPTION TODAY: This afternoon/evening, Health Access California is hosting a reception to recognize our director of administrative advocacy, Beth Abbott, as she is about to start working as the Governor’s appointment to direct a revamped Office of the Patient Advocate. The reception will take place Tuesday, September 2nd, from 4-7pm, at Ambrosia Cafe in Sacramento. Please RSVP at this link to join our advocates and colleagues to wish her well.

 

*** 2014 HEALTH CONSUMER BILLS ON THE GOVERNOR’S DESK  

Ø  Insurance Consumer Protections

NETWORK ADEQUACY OVERSIGHT OF HEALTH PLANS: SB964 (Ed Hernandez) requires the Department of Managed Health Care (DMHC) to do annual reviews for timely access and network adequacy to be done separately for Medi-Cal managed care and the individual market so that consumers in Medi-Cal managed care and Covered California get timely access to necessary care. Sponsored by Health Access California.

JUNK INSURANCE FOR LARGE EMPLOYERS: AB2088 (Roger Hernandez) while not banning limited benefit plans, makes them supplemental to comprehensive coverage. California’s Insurance Code allows the sale of “insurance” that provides very limited benefits with a minimum actuarial value of less than 60%. This bill extends this consumer protection to large employer coverage, closing a loophole for employers to possibly avoid compliance with the full intent of the ACA. Sponsored by Health Access California.

SB959 (Ed Hernandez) is the clean-up bill for the individual and small group market reform legislation to implement the ACA enacted in 2012 and 2013. SUPPORT.

Ø  Medi-Cal

FOUNDATION & FEDERAL FUNDS FOR MEDI-CAL RENEWAL: SB18 (Leno/Herrnandez) provides $6 million to the State from the California Endowment to fund Medi-Cal renewal assistance Sponsored by Health Access California.

LIMIT ON MEDI-CAL ESTATE RECOVERY: SB1124 (Hernandez) limits Medi-Cal estate recovery. California is one of only ten states that impose estate recovery on more than long term care services, where the state, for those over 55, recovers the cost of all medical care from the estate of an individual after death. This has discouraged some from signing up for Medi-Cal coverage. Co-sponsored by Western Center on Law and Poverty (WCLP) and California Advocates for Nursing Home Reform. SUPPORT.

AB2325 (Speaker Perez) would create a Medi-Cal medical interpreter program. The bill was vetoed last year: this is a re-introduction of that measure. SUPPORT.

Ø  Cost/Quality Transparency

SB1182 (Leno) would provide claims data or other detailed information to large purchasers.  SUPPORT.

AB1962 (Skinner) would make transparent what dental-only plans spend, as a percentage of premium, on patient care. It requires specialized dental-only plans to disclose a “medical loss ratios” as for medical coverage. The bill is sponsored by the California Dental Association. SUPPORT.

Ø  Hospital Oversight and Consumer Protections.

SB1094 (Lara) amends existing law on Attorney General oversight of nonprofit hospital mergers and acquisitions. It extends the review period from 60 days to 90 days. It also gives the Attorney General authority to enforce conditions of hospital transactions. This bill is sponsored by the Attorney General. SUPPORT.

SB1276 (Ed Hernandez) updates the Hospital Fair Pricing law (which Health Access California sponsored in 2006) by: defining a reasonable payment plan as monthly payments that are no more than 10% of income after essential living expenses; allowing underinsured individuals with high health costs (over 10% of income) to receive the hospital fair pricing discount even if they receive a discounted rate on their cost sharing from their health plan or insurer. It is being sponsored by Western Center on Law and Poverty based on their experience assisting consumers. SUPPORT.

Ø  Prevention and Other

SB912 (Mitchell) would eliminate the sunset on the current requirement that vending machines in state buildings include 35% healthy food and drinks. Sponsored by California Pan-Ethnic Health Network. SUPPORT

AB 2731 (Perea) would allow Fresno County budget flexibility in their county budget to spend $5.5 million for indigent healthcare by deferring the county’s maintenance of effort requirement into a Proposition 42 transportation fund. SUPPORT.

Legislative Update

HEALTH ACCESS ALERT: Tuesday, August 25, 2014 

KEY PATIENT PROTECTIONS UP IN LAST WEEK OF LEGISLATIVE SESSION

*        Key health bills, including SB 964 (Hernandez) on network adequacy and timely access to care, are among hundreds of bills Legislature must pass by Sunday; If approved, Governor Brown would have September to sign or veto.

*       Also pending: key Medi-Cal bills: limiting Medi-Cal estate recovery (SB1124), and allowing State to accept foundation money for Medi-Cal renewal assistance (SB18).

*        Most closely-fought health bill SB1094(Lara), to expand the Attorney General’s authority to enforce conditions of non-profit hospital mergers and acquisitions, to assure that a nonprofit hospital will continue to serve its community after a transaction in which ownership changes. Advocates urged to call in support.

*        POST-LEGISLATIVE SESSION RECEPTION to wish Health Access’ Beth Abbott well as she transitions to her new post as director of the revamped Office of the Patient Advocate. Please RSVP here for the reception Tuesday, September 2nd, 4-7pm, Ambrosia Cafe in Sacramento.

   Be a Member of Health Access To Help CA Seize The Opportunities In Health Reform

   Read Our Health Access Blog for More Updates; Also Follow Us on Facebook!

   Read Real-Time Updates on ACA Implementation on Twitter @HealthAccess!

In this last week of the 2013-14 legislative session, the Assembly and Senate will voted on hundreds of bills by Sunday, including those of strong interest to California patients and health consumers. Bills must pass out of the Legislature by the end of the week and if passed, the Governor has the month of September to decide their ultimate fate.

Below is a list of specific bill pending in this crucial week. On the Assembly floor for a vote as early as today is a key bill to ensure network adequacy and timely access to care, SB 964 (Ed Hernandez), a Health Access California-sponsored bill which would require DMHC to do annual reviews for timely access and network adequacy, separately for Medi-Cal managed care and the individual market so that consumers in Medi-Cal and Covered California get timely access to necessary care. Consumer groups are actively working to get this bill passed.

Two important Medi-Cal bills are also up for a vote on the Senate floor: SB 18 (Leno/Hernandez) would have the State accept $6 million from the California Endowment to fund Medi-Cal renewal assistance, and drawing down federal matching funds as well; SB 1124 (Hernandez) would limit Medi-Cal estate recovery to long-term care, so those getting Medi-Cal managed care services would not find that their family home had a claim on it after death. Advocates are gearing up to generate calls and letters to the Governor’s office on these important bills.

A new bill that is advancing in the Legislature, AB 1578 (Pan), would extend until June 30, 2016, the operative date of the California Health Benefit Review Program (CHBRP) and further expand its role to include an assessment of legislation that impacts health insurance benefit design, cost sharing, premiums, and other health insurance topics. This short-term extension will give the Legislature and other stakeholders the opportunity to consider how the role of CHBRP should be revised post-ACA. This bill requires bipartisan support because it requires a two-thirds vote to extend funding.

The most contested health bill this week seems to be SB 1094 (Lara), which would expand the Attorney General’s authority to enforce conditions of non-profit hospital mergers and acquisitions, to assure that a nonprofit hospital will continue to serve its community after a transaction in which ownership changes. SB 1094 failed passage on the Assembly Floor in a vote last week, but has been granted reconsideration, and advocates ranging from Consumers Union to Planned Parenthood to the California Labor Federation to Health Access California are making a strong push for passage. The debate on the Floor was contentious, with Republicans and some Democrats siding with hospitals in opposition. Democrats in support, like Assemblymember Holden expressed “this is about protecting the interests of consumers.” Consumer and community groups are urged to support this key measure in this crucial week.

Other key bills are listed below.

RECEPTION: We hope to celebrate next week, after the legislative session ends, as Health Access California will host a reception to recognize our director of administrative advocacy, Beth Abbott, as she is about to start working as the Governor’s appointment to direct a revamped Office of the Patient Advocate. The reception will take place Tuesday, September 2nd, from 4-7pm, at Ambrosia Cafe in Sacramento. Please RSVP at this link to join our advocates and colleagues to wish her well.

BILL LIST

Here’s a broader list of the bills of interest to health care advocates, pending floor votes in the state legislature this week. It’s the last week for consumer and community groups to weigh in to the Legislature:

NETWORK ADEQUACY OVERSIGHT OF HEALTH PLANS: SB964 (Ed Hernandez) requires the Department of Managed Health Care (DMHC) to do annual reviews for timely access and network adequacy to be done separately for Medi-Cal managed care and the individual market so that consumers in Medi-Cal managed care and Covered California get timely access to necessary care. Sponsored by Health Access California.

PRESCRIPTION DRUG COST SHARING: AB1917 (Gordon): would cap prescription drug co-pays at 1/12 of the annual out-of-pocket limit so that patients with HIV/AIDS, cancer, MS, and other diseases will not be forced to pay high upfront costs for their medication. Sponsored by Health Access California.

JUNK INSURANCE FOR LARGE EMPLOYERS: AB2088 (Roger Hernandez) while not banning limited benefit plans, makes them supplemental to comprehensive coverage. California law allows the sale of “insurance” that provides very limited benefits with a minimum actuarial value of less than 60%. This bill extends this consumer protection to large employer coverage, closing a loophole for some large employers to avoid offering comprehensive coverage to their employees. Sponsored by Health Access California.

SB1176 (Steinberg) makes the health plan or insurer responsible for tracking out-of-pocket costs for in-network providers, and reimbursing the consumer when they exceed their out-of-pocket limit. SUPPORT.

SB959 (Ed Hernandez) is the clean-up bill for the individual and small group market reform legislation to implement the ACA enacted in 2012 and 2013. SUPPORT.

AB 2533 (Ammiano) would seek to ensure timely access to necessary care at in-network cost sharing. SUPPORT.

Ø  Cost/Quality Transparency

SB1182 (Leno) would provide claims data or other detailed data to large purchasers.  SUPPORT.

AB1962 (Skinner) would make transparent what dental-only plans spend, as a percentage of premium, on patient care. It requires specialized dental-only plans to disclose a “medical loss ratios” as for medical coverage. The bill is sponsored by the California Dental Association. SUPPORT.

AB 1578 (Pan) would extend until June 30, 2016, the operative date of the California Health Benefit Review Program and further expand its role to include an assessment of legislation that impacts health insurance benefit design, cost sharing, premiums, and other health insurance topics. SUPPORT.

Ø  Hospital Oversight and Consumer Protections.

SB1094 (Lara) amends existing law on Attorney General oversight of nonprofit hospital mergers and acquisitions. It extends the review period from 60 days to 90 days. It also gives the Attorney General authority to enforce conditions of hospital transactions. This bill is sponsored by the Attorney General. SUPPORT.

SB1276 (Ed Hernandez) updates the Hospital Fair Pricing law (which Health Access California sponsored in 2006) by: defining a reasonable payment plan as monthly payments that are no more than 10% of income after essential living expenses; allowing underinsured individuals with high health costs (over 10% of income) to receive the hospital fair pricing discount even if they receive a discounted rate on their cost sharing from their health plan or insurer. It is being sponsored by Western Center on Law and Poverty based on their experience assisting consumers. SUPPORT.

Ø  Medi-Cal

SB18 (Leno) provides $6 million to the State from the California Endowment to fund Medi-Cal renewal assistance Sponsored by Health Access California.

SB1124 (Hernandez) limits Medi-Cal estate recovery. California is one of only ten states that impose estate recovery on more than long term care services, where the state, for those over 55, recovers the cost of all medical care from the estate of an individual after death. This has discouraged some from signing up for Medi-Cal coverage. Co-sponsored by Western Center on Law and Poverty (WCLP) and California Advocates for Nursing Home Reform. SUPPORT.

AB2325 (Speaker Perez) would create a Medi-Cal medical interpreter program. The bill was vetoed last year: this is a re-introduction of that measure. SUPPORT.

Ø  Prevention

SB912 (Mitchell) would eliminate the sunset on the current requirement that vending machines in state buildings include 35% healthy food and drinks. Sponsored by California Pan-Ethnic Health Network. SUPPORT

 

Update from the Financial Solvency Standards Board

The Financial Solvency Standards Board (FSSB) Meeting of August 20, 2014 covered several topics of interest to advocates, including initial findings on the Alameda Alliance and its corrective action plan (CAP). A common theme running through several agenda topics is the need to catch solvency problems before they get to the CAP stage. DMHC was questioned closely as to whether their gradations of “closely watched plans” and “those under a Corrective Action Plan” (CAP) were not meaningful since apparently those plans that were being “watched closely” did not generally prevent them from going into a financial tailspin.

Initial findings from the assigned conservator, Berkeley Research Group, suggest the Alameda Alliance, which serves Medi-Cal patients, is on the mend, though the devil may be in the details. The number of outstanding claims decreased to 175,000 from 300,000, and the time to process claims shrank from 100 to 50 days. So far so good, but what’s not clear is whether Alameda Alliance can—or should—handle the massive surge in enrollees, up to 230,000 members and counting. Financing and solvency are the tip of vast iceberg where utilization and care management come into play. Thankfully, most FSSB members prefer to look at the solvency issues in the deeper context of overall plan performance. FSSB members asked whether it is prudent to permit new enrollees to Alameda Alliance when its financial condition remains precarious.  DMHC’s position is that it will strengthen their financial underpinnings to have a bigger membership base, but some question whether it is wise to let more consumers join—particularly since its solvency is not yet assured.

Several members of the FSSB asked questions beyond the specific case of the Alameda Alliance.  What has DMHC learned now that they have undertaken the extraordinary step of installing a conservator at the plan?  This step, in essence, is very expensive and puts them in the unenviable position of actually running the health plan.  This should enable them to refine their oversight protocols to tailor them to predict more accurately these kind of failures.  Should they be asking for additional or different data?  Should they have intervened sooner?

This discussion also led to whether the standard of Tangible Net Equity (TNE) is the right one.  If a plan has one dollar in assets more than it has in debts, is that enough?  Many CFOs and actuaries on the board requested a re-examination of what that standard should be with an eye toward emulating market scrutiny tools which examine Risk Based Capital which are becoming much more commonplace than TNE.

Risk-Bearing Organization (RBO) Solvency in the Face of Increased Medi-CAL Enrollment

With more Medi-Cal enrollees than ever assigned to risk-bearing organizations (RBOs) as a result of the broader shift toward mandatory managed care and the state about to enter into a Medi-Cal waiver renewal process, it will be important to monitor RBOs closely, again before they trigger a CAP.  Board members are asking to consider the RBOs performance and solvency in context of overall plan solvency, something the DMHC examiner says is happening already. It’s not enough to look at contractual requirements, says Health Access’ Beth Abbott, or financial solvency indicators in isolation, especially given the reality that the shakiest plans are those that serve the most vulnerable Medi-Cal consumers.

Enrollment in Individual Market Plans Monitored by DMHC

Overall the ACA brought 1 million more covered lives into the individual marketplace, and the number of grandfathered and non-ACA compliant plans is steadily decreasing (see details here). That’s good news for California consumers, but now the focus shifts to practical issues that could easily make or break the long-term success of health reform: are consumers getting the care they need, at the right time and place? And are the agencies with oversight of plan performance, like the DMHC and DHCS, equipped to monitor the plans as California insurance marketplace and Medi-Cal shifts more of the risk to the plans and RBOs? The challenge for regulators (and advocates) is to minimize disruption for consumers as the landscape for insurance solvency and performance continues to shift.  This is clearly a work in progress.

Covered California Ramps Up for Open Enrollment

Here’s our report, from Judi Hilman, our new Director of Policy Research and Communications, on the five-hour Covered California Board meeting on Thursday, August 21

 Though not without controversy and heated repartee, the first full Board meeting at their new digs across from the Cal Expo summarized both how far California’s exchange has come in meeting its initial goals and how much farther it has to go to reach consumers with enrollment barriers.

Speaking directly to the latter, Black Caucus Assembly Members Cheryl Brown and Steven Bradford challenged Covered CA for failing to engage credible marketing strategies, indicating their disappointment with enrollment results for African Americans. They specifically asked Covered CA to contract with firms with a proven track record in targeting African Americans and to dedicate sufficient resources to these contracts. Board members and public comments alike affirmed the need to address these concerns.

Resolving Eligibility Inconsistencies (Executive Director’s Report)

Covered California Executive Director Peter Lee tackled an issue of grave concern to advocates: resolving eligibility inconsistencies (when the exchange cannot verify income or immigration status usually because the enrollees do not allow their personal data to be ‘pinged’ through the federal data hub). In particular, over 100,000 Californians–most if not all are likely citizens–need to show documentation of their citizenship or will be discontinued from coverage. To minimize disruption to the renewal process, Covered CA is taking a high-touch, multi-channel approach and reaching out to impacted consumers soon after Labor Day.

Public comments highlighted the need for a broad marketing strategy with nuanced messaging for immigrant communities, particularly those with fears of deportation. Several others asked for translation of notices into the 13 threshold languages (languages spoken at a high proportional rate by region) per state law. 

Board Advisory Committees: Restructuring and Network Oversight

Board members and stakeholders were generally supportive of a plan to consolidate various outreach committees, including the Marketing, Outreach, and Enrollment Advisory Committee, now chaired by recently-nominated Health Access Executive Director Anthony Wright, while still leveraging input from the community-focused subcommittees of specific sub-populations, including African-American and Latino groups.

Speaking for Health Access, Beth Capell asked that two recurring topics figure prominently into the Plan Management Advisory Committee’s benefit design discussion: network adequacy (assigned to the September meeting) and alternative benefit designs (grandfathered plans that do not meet ACA or California’s more ambitious ‘active purchasing’ requirements), given that the latter make up a diminishing sliver of market share.  

The Return of Proposition 45

Executive Director Lee provided the staff’s long-promised analysis of the potentially disruptive impacts of Prop 45 on Covered California’s active purchasing goals, open enrollment timeframes, marketplace choices, and subsidies for consumers. The materials feature correspondence, including from the Insurance Commissioner, who is supportive of Prop 45, making declarations about his intentions in implementation to resolve some of the issues addressed. Two board members–Schwarzenegger appointees Susan Kennedy and Kim Belshe–argued that the Board should take a position on the ballot measure, while Paul Fearer, Secretary Dooley, and Executive Director wondered, regardless of their personal opinion on the subject, if that wasn’t the best for Covered California’s trust and brand–and noting how much time on this issue was distracting from preparation for the next open enrollment. The discussion indicated that the September meeting will have a placeholder item for potential action.

New Regulations: Proposal to let Insurance Agents off the Hook?

Covered California adopted new rules on agents and brokers, and a range of other subjects. Not enough notice was given to properly debate the details, like the proposal to relax training and contractual requirements for insurance agents and brokers, said Beth Capell on behalf of Health Access. The Exchange offered to work with advocates and potentially make adjustments. One question raised by advocates including us and Consumers Union: Does it make sense to change the agent’s license agreement period to five years from one year in such a dynamic marketplace?

Other Discussions Worth Noting

Looking ahead to open enrollment for year 2, advocates highlighted the need to minimize churning and ease the transition between Medi-CAL and Covered CA, especially for mixed coverage families and to help enrollees choose the right plan, i.e. one that maximizes the subsidies and benefits available. The Board got presentations from Kaiser Family Foundation—these are worth a look, providing reasons for Covered California’s success in year one and valuable lessons for outreach and enrollment in year two. In general they suggest a focus on market segmentation and personal, ‘high-touch’ outreach strategies.

See all meeting materials here: http://board.coveredca.com/meetings/ 

Update from Covered California’s Plan Management Advisory Meeting

If we go by recent reports that both the number of uninsured Californians and the premium rate increase have been cut in half, Covered California is off to a promising start. Critical challenges remain (network adequacy, enrollment simplification, engagement of under-enrolled groups, and more), however, and last Friday’s Covered California Plan Management Advisory Committee is grappling with many of these issues.

  • Recertification of Plans: What happens to current enrollees when a health plan does not recertify its products on the exchange? The onus is on the plan to notify enrollees in plenty of time for them to find another plan for 2015, but what if the consumer does not choose a new plan? Based on the fact that 89% of CC enrollees that are getting subsidies, consumer advocates serving on the committee would prefer for these individuals to be auto-enrolled in a subsidized plan. CC officials are looking for some way (a hook in state law, final exchange rules to be issued by the Feds, etc.) to do this.
  • The ‘Renewal Journey’ for Covered California Enrollees: Heading into the open enrollment season, Covered California’s own guiding principles for the renewal journey were as follows:
      • Focus on the consumer experience by offering service options and making the process easy.
      • Engage and leverage our certified delegates, partners, and plans.
      • Maximize retention by providing an automatic renewal option where possible.
      • Encourage consumer self service through the website, Interactive Voice Response (IVR), and others tools.
          Advocates should ask how Covered California meets these goals. With renewal notices scheduled for release this October, advocates and enrollment counselors need to understand that the window for open enrollment (Nov 15-Feb 15) is much narrower than last year, though the deadline for Jan. 1 effective coverage is still December 15.  Current enrollees who miss this December 15 deadline will have to re-apply for 2015 during open enrollment and will have no more than a one month interruption in coverage. As always these issues highlight the tensions or trade-offs between wanting consumers to actively shop with thoughtful choices and wanting to maximize enrollment for the sake of risk management.   As organizational partners, including navigators and application assisters, set about to recalibrate strategy for the next enrollment cycle, it will be important to consider this tension. See the

    full powerpoint presentation

        for a handy list of key dates in the renewal process. There you can also find content summaries for each of the renewal notices.
  • APTC (Advanced Premium Tax Credit) reconciliation. Paying Uncle Sam at tax time is complicated enough for many consumers; for some, the addition of APTC reconciliation is simply another factor to calculate at tax-time, along with the employer withholding, and/or various deductions; for others, this will be a new complication to deal with. An example of particular note: anyone who has a Covered California subsidy to help afford their premium will no longer be able to use the 1040EZ form. It’s not too soon for advocates and assisters and members of the media to prepare to help consumers through this process and to encourage Covered California to simplify the process even further (check out what they have planned so far in the powerpoint).

Appropriations Committees Pass Key Health Bills

HEALTH ACCESS UPDATE: Thursday, August 14, 2014 

KEY HEALTH CONSUMER PROTECTION BILLS HEAD TO FINAL FLOOR VOTES, AFTER PASSING APPROPRIATIONS COMMITTEES TODAY

*        Important health bills advance, including ones sponsored by Health Access California, and head toward floor votes in final two weeks of legislative session.

*       Bills passed by Appropriations Committees today include those to help consumers once they get coverage, with ensuring network adequacy (SB964) and timely access to care (AB2253), avoiding junk coverage (AB2088), putting in place rate review (SB1182) for large employers, getting insurers to track out-of-pocket expenses (SB1176), limiting Medi-Cal estate recovery (SB1124), and accepting foundation money for Medi-Cal renewals (SB18) and more.

        Bills held and stalled for the year include two to create on all-payer claims databases, a bill on hospital community benefits, and a measure codifying Covered California privacy protections.

*        In other news, Health Access’ Beth Abbott appointed by Governor Brown to be director of the revamped Office of the Patient Advocate.

 

Today, the Appropriations Committee of both the California Senate and Assembly met, and decided the fate of hundreds of bills, including several to provide new consumer protections and oversight to benefit health care consumers.

Over 300 bills in the Senate and over 150 bills in the Assembly were “on suspense,” being evaluated in terms of their cost and fiscal impact, until today, where a portion of them were released, set to go to floor votes in the next two weeks. Bills must pass through final floor votes and the full Legislature by the end of August. If passed, the Governor would have the month of September to sign or veto.

Bills that passed Appropriations Committee today included key bills to ensure network adequacy and timely access to care: SB 964 (Ed Hernandez) would require DMHC to do annual reviews for timely access and network adequacy, separately for Medi-Cal managed care and the individual market so that consumers in Medi-Cal and Covered California get timely access to necessary care. AB 2533 (Ammiano) would ensure timely access to necessary care at in-network cost-sharing.

SB 1176 (Steinberg) gives health plans and insurers the responsibility to track out of pocket costs–and reimbursing when patients hit the out-of-pocket maximum.

Another bill, AB 2088 (Hernandez) would extend consumer protections against “junk” insurance to large group market, banning large employers from offering limited benefit plans to their employees, unless the limited benefit plan was supplemental to comprehensive coverage.

Two important Medi-Cal bills also passed.SB 18 (Leno) would have the State accept $6 million from the California Endowment to fund Medi-Cal renewal assistance, and drawing down federal matching funds as well. SB 1124 (Hernandez) would limit Medi-Cal estate recovery to long-term care, so those getting Medi-Cal managed care services would not find that their family home had a claim on it after death.

SOME BILLS HELD: afterNot all bill survived the Appropriations Committee process. Two bills, SB1322(Ed Hernandez) and AB1558(Roger Hernandez) to create versions of an all-payer claims database–to provide more cost transparency in our health system–were held. AB503(Wieckowski) on hospital community benefits was also held, as was SB974(Anderson) to codify Covered California’s privacy protections. These held bills, and others, are stalled for the year.

BILL LIST

Many bills did make it through the Appropriations process, and consumers groups are mobilizing in support. These are some of the bills of interest to health care consumers pending for floor votes in the state legislature in the next two weeks:

Ø  Insurance Consumer Protections

NETWORK ADEQUACY OVERSIGHT OF HEALTH PLANS: SB964 (Ed Hernandez) requires the Department of Managed Health Care (DMHC) to do annual reviews for timely access and network adequacy to be done separately for Medi-Cal managed care and the individual market so that consumers in Medi-Cal managed care and Covered California get timely access to necessary care. Sponsored by Health Access California.

·         STATUS – ASSEMBLY FLOOR

PRESCRIPTION DRUG COST SHARING: AB1917 (Gordon): would cap prescription drug co-pays at 1/12 of the annual out-of-pocket limit so that patients with HIV/AIDS, cancer, MS, and other diseases will not be forced to pay high upfront costs for their medication. Consumers would still have the annual out of pocket limit of no more than $6,350 for an individual or $12,700 for a family under the ACA, but the cost of any one drug can’t be more than 1/12 of the annual limit or $530 for a single month’s prescription rather than $6,350 as current law provides. Sponsored by Health Access California.

·         STATUS – SENATE FLOOR

JUNK INSURANCE FOR LARGE EMPLOYERS: AB2088 (Roger Hernandez) while not banning limited benefit plans, makes them supplemental to comprehensive coverage. California law  allows the sale of “insurance” that provides limited benefits with a minimum actuarial value of less than 60%. This bill extends this consumer protection to large employer coverage, closing a loophole for employers to avoid compliance with the intent of the ACA. Sponsored by Health Access California.

·         STATUS – SENATE FLOOR

SB1176 (Steinberg) makes the health plan or insurer responsible for tracking out-of-pocket costs for in-network providers, and reimbursing the consumer when they exceed their out-of-pocket limit. SUPPORT.

·         STATUS – ASSEMBLY FLOOR

AB 2533 (Ammiano) would seek to ensure timely access to necessary care at in-network cost sharing. SUPPORT.

·         STATUS – SENATE FLOOR

SB959 (Ed Hernandez) is the clean-up bill for the individual and small group market reform legislation to implement the ACA enacted in 2012 and 2013. SUPPORT.

·         STATUS – ASSEMBLY FLOOR – CONSENT

SB20 (Ed Hernandez) modifies the individual market open enrollment period for the 2015 policy year to be November 15, 2014-February 15, 2015, so that it is consistent with the dates announced by the federal government exchange. SUPPORT.

·         STATUS – SIGNED BY THE GOVERNOR  

SB1034 (Monning) would delete 60 day waiting period for California insurance. California law would not permit any waiting period as a result of a pre-existing condition. Federal law would permit employers to impose a waiting period of as much as 90 days for workers and dependents. SUPPORT.

·         STATUS – GOVERNOR’S DESK 

Ø  Cost/Quality Transparency

SB1182 (Leno) would implement large group rate review for rate increases. It also provides claims data or other detailed data to large purchasers.  SUPPORT.

·         STATUS – ASSEMBLY FLOOR  

AB1962 (Skinner) would make transparent what dental-only plans spend, as a percentage of premium, on patient care. It requires specialized dental-only plans to disclose a “medical loss ratios” as for medical coverage. The bill is sponsored by the California Dental Association. SUPPORT.

·         STATUS – SENATE FLOOR

Ø  Hospital Oversight and Consumer Protections.

SB1094 (Lara) amends existing law on Attorney General oversight of nonprofit hospital mergers and acquisitions. It extends the review period from 60 days to 90 days. It also gives the Attorney General authority to enforce conditions of hospital transactions. This bill is sponsored by the Attorney General. SUPPORT.

·         STATUS – ASSEMBLY FLOOR

SB1276 (Ed Hernandez) updates the Hospital Fair Pricing law (which Health Access California sponsored in 2006) by: defining a reasonable payment plan as monthly payments that are no more than 10% of income after essential living expenses; allowing underinsured individuals with high health costs (over 10% of income) to receive the hospital fair pricing discount even if they receive a discounted rate on their cost sharing from their health plan or insurer. It is being sponsored by Western Center on Law and Poverty based on their experience assisting consumers. SUPPORT.

·         STATUS – GOVERNOR

Ø  Medi-Cal

SB18 (Leno/Hernandez)would have the state Department of Health Care Services accept foundations funds (currently offered by the California Endowment) and get federal matching funds to help provide assistance for Medi-Cal renewals. Sponsored by Health Access California and Western Center on Law and Poverty.

·         STATUS – SENATE FLOOR

SB1124 (Hernandez) limits Medi-Cal estate recovery. California is one of only ten states that impose estate recovery on more than long term care services, where the state, for those over 55, recovers the cost of all medical care from the estate of an individual after death. This has discouraged some from signing up for Medi-Cal coverage. Co-sponsored by Western Center on Law and Poverty (WCLP) and California Advocates for Nursing Home Reform. SUPPORT.

·         STATUS – –ASSEMBLY FLOOR  

AB2325 (Speaker Perez) would create a Medi-Cal medical interpreter program. The bill was vetoed last year: this is a re-introduction of that measure. SUPPORT.

·         STATUS – SENATE FLOOR

Ø  Prevention

SB912 (Mitchell) would eliminate the sunset on the current requirement that vending machines in state buildings include 35% healthy food and drinks. Sponsored by California Pan-Ethnic Health Network. SUPPORT

·         STATUS – ASSEMBLY FLOOR