New Energy At Covered California’s Marketing/Outreach Advisory Group

With only two weeks to go until Covered California open enrollment, it’s no wonder it was standing room only at today’s Marketing, Outreach, and Enrollment Assistance Advisory Group (MOEA) meeting at Covered California headquarters. Chaired by Health Access’ own Anthony Wright, it has been restructured:instead of separate committees representing communities of color groupings (African American, Asian/Pacific Islander, and Latino), the communities of color groups are integrated with the larger advisory group, but they can also meet apart to generate community-specific input as needed. The discussion already feels more lively and productive under the new structure.

Much of the meeting was spent digesting the lessons from year 1 of open enrollment. As noted in the meeting, Covered California staff have done a good job distilling the lessons, but the real test will be in the execution of processes designed to act on those lessons—community partners play a key role here.

As Peter Lee pointed out, starting next year Covered California will be doing more with less—and with even less in the ensuing years. All the more reason to take the lessons to heart. Here are a few to ponder as you (yes, you, or really anyone else reading this…year 2 open enrollment, being shorter than year 1, will need all-hands on deck)  prepare for open enrollment:

Highlighted Lessons from Year 1 Strategies for Year 2
Overall Covered California exceeded enrollment projections, but it fell short in certain communities, like Latino and African American. Marketing and outreach is more heavily focused on engaging specific communities.
More service center reps speaking foreign languages
Consumers were more likely to choose the best plan (maximizing subsidies and cost sharing assistance to get the best benefit package possible) if they used some form of in-person assistance Connect consumers as much as possible with assisters (enrollment counselors, navigators, and agents), while maintaining the ability to fill out applications by phone and online.
Covered California’s 81% effectuation rate (how many actually pay their first premium or “binder” payment) could be improved. Arrange for all QHPs to take binder payments on Covered California, as the final step in enrollment.  Note to plans: it’s up to you to step up to this opportunity.
Maximize retention. Work with stakeholders and advocates to make the notice clearer for all (much of this process happens in the AB1296 Workgroup)

Here are a few highlights from the subcommittees’ brainstorm on the bus tour, community outreach, messaging, and social media:

  • Partner with high-profile leaders or heroes in targeted communities.
  • Designate ambassadors to get their friends and families enrolled (give recognition and  support and maybe business cards to individuals who go above and beyond in their tweeting or retweeting activities to boost enrollment
  • Hook into local community events like fairs, planning ahead for permits and the like.
  • Train the CEEs (Certified Enrollment Entities) on the right messaging regarding eligibility by immigration status.
  • Engage cell phones in social media campaigns.
  • Use infographics to tell stories with the new messaging on the benefits of insurance.
  • Give community partners ample opportunity to review or collaborate on collateral.

 What can you do now to act on these lessons

  • Click around the Covered CA website. Notice the Find Help Near You button, but note that a new website design will be launched November 8. Prepare to promote the new site.
  • Promote the use of Covered California’s Shop and Compare Tool now, so folks are ready to renew or enroll on November 15: http://www.coveredca.com/shopandcompare/#calculator
  • Get your organization ready to piggy back on the Covered CA bus tour and the overall marketing focus on friends helping friends.

This post was written by Rose Auguste, Health Access Organizer (Northern California).

The work to cover all Californians continues at the local level.

On Wednesday, October 8th community members, health and  immigration advocates, students and Alameda County legislators held a press event at the Oakland State Building in support of SB1005 (Lara), the Health For All Act.  The “H4All” Act expands access to health care coverage for all Californians, regardless of immigration status.  Event participants held signs bearing an image of a ticking clock, stating “The Time Is Now,” highlighting the urgent need for H4All Community members shared personal stories of how the lack of access to healthcare has had a negative impact on them, their families, and their community.

“No one should suffer or die from an easily treatable condition, regardless of where they were born,” said Beatrice Sanchez, a student at the College of Alameda and member of ASPIRE (Asian Students Promoting Immigrant Rights through Education), in reference to her mother’s death due to limited access to care and fear of financial burdens. Ms. Sanchez’s story illustrates the human toll of inaction or complacency on this issue.

The California Endowment recently released a new poll, which shows that a majority of Californians support healthcare for all Californians, including undocumented residents.  Alameda County Assembly Member Rob Bonta also spoke at the event, where he pledged his continued support and commitment to making the Health for All act a budget priority in the 2015 legislative session.  A Health for All event was also held on October 14 in Los Angeles. 

Earlier this year, a coalition of immigrant, health and community advocate came together to advocate for the passage of SB1005.  Although the legislation made some progress through the 2014 Legislature, it was eventually held in Senate Appropriations.   SB1005 author Senator Ricardo Lara has stated that “a majority of Californians agree that a truly healthy state depends on expanding access to health care for everyone, regardless of their immigration status.”  Senator Lara has pledged his commitment to bring the initiative (Note: The new bill number will be released in December 2014).  In preparation for the 2015 legislative session, supporters have stepped up their Health for All advocacy campaign.

If you or your organization is interested in getting involved with the Health For All campaign or sharing a consumer or provider story about the need for affordable health care coverage for the remaining uninsured, please email:

Rose Auguste, Health Access Organizer (Northern California), rauguste@health-access.org o call 510-842-6770.

Muneera Gardezi, Health Access Organizer, mgardezi@health-access.org or call 310-597-2083.

Pictured above, from right to left: Beatrice Sanchez, Akiko Aspillga, California Assembly Member Rob Bonta, and Sandy Valenciano. 

Health reform heroes to be honored this Saturday…

This Saturday evening, we at Health Access will be pleased to celebrate the successes of the Affordable Care Act in California with our colleagues at the California Black Health Project, which is hosting their Heroes in Health Care gala at the Sacramento Convention Center.

A broad range of people will be honored, including Senator Bill Monning; Assemblyman Dr. Richard Pan; Sacramento Mayor Kevin Johnson; Peter Lee, Director of Covered California; Herb Shultz, former regional director for the U.S. HHS Department; Bernard Tyson, chairman and CEO of Kaiser Permanente; Ellen Wu, former director of California Pan-Ethnic Health Network; and our own Anthony Wright, executive director of Health Access California.

The full flyer and invitation is at the CBHN website here, along with ways to get tickets. We look forward to see seeing you and other allies and friends there.

For an inclusive Ebola response…

The headlines this weekend are again about Ebola, despite the fact that the handful of Americans who have gotten it are those who were caregivers in direct contact with Ebola patients. The concerns are understandable, but it’s also clear the issue has been hyped–there are literally dozens of public health issues that will impact more Americans.

I have been surprised that the attention on Ebola has caused a debate about quarantines and closed borders. If one were to build a policy response about Ebola, it seems it should be more inclusive rather than nativist or reactionary. After all, Ebola is a powerful reminder that the world is interconnected, and another reason we should care about a problem in Africa. A policy response should include: boosting public health infrastructure, including epidemiology resources, approving a surgeon general (given the need for a trusted messenger), more steps to universal health care (health system works better if everyone is included), foreign aid to Africa and the real crisis there, immigration reform (bring folks out of shadows so they feel comfortable to report what’s going on in their community), drug development reform (to better incentivize cures at NIH and drug companies, even for “rare”–and thus less profitable–diseases), investments and better training for frontline health care workforce, a national paid sick days policy (so those sick don’t feel compelled to come to work–to expose their co-workers to the flu or worse), and recognition and prioritization of funding for other health issues that kill far more people–or even a bigger push for folks to get their flu shots, etc.

If we are going to focus on Ebola in our policies, let’s at least do it in a way that strengthens our health system for everyone.

Office of the Patient Advocate Releases 2014-2015 Health Care Quality Report Cards

The much anticipated 2014-2015 edition of the OPA’s Health Care Quality Report Cards comes months ahead of the usual release date so that the information can be of use to consumers in the coming open enrollment season. The OPA release actually includes three different report cards: one for the health plans (HMOs); one for Preferred Provider Organizations (PPOs); and one for the Medical Groups. All told, the findings will of interest to more than 16 million Californians, most enrolled in job-based coverage but also those enrolled in the individual marketplace through Covered California.

There’s good news and bad on these tools. Historically, the tools have not been all that well utilized by consumers or employers. While many Californians not in position to make their own plan selection—their employer typically picks it for them—the report card is useful for those who have choices in “open enrollment” period coming this fall, including potentially for those in Covered California. Purchasers and employers have been clamoring for better tools, and indeed the tools seem to be getting better (learn more here).

Health Access is honored to feature OPA Director Beth Abbott (former Director of Administrative Advocacy at Health Access) in a Q & A about the new report cards…

Health Access: What’s new or different about the 2014-15 Report Card Release?

Beth Abbott of the OPA: This year’s release provides one point of entry to the most recent quality information on all commercial plans in the state: www.opa.ca.gov . The release features a few new measures, including the percentage of readmissions to hospitals that are preventable.  This is important because if the readmission to the hospital shouldn’t have been necessary, it both increases the cost of the care and can have an adverse impact on health outcomes. 

HA: Why release the report card now?

BA: We are releasing the Report Cards to coincide with open enrollment periods for both employer-sponsored health coverage [for people who get their insurance through their job) and for people who are making selections of plans through our state-based marketplace at www.CoveredCA.com.  This means that this easy to use tool is available at the precise time when many Californians will be making selections and they will be able to evaluate health plans, PPOs (Preferred Provider Organizations), and medical groups, not only based on costs, but also with the most up-to-date quality information at their disposal. 

HA: What is your long range vision for the report card and related transparency tools?

BA: We want to have consumers select health plans based on value, which is the intersection between cost and quality.  Getting the cheapest plan based on the monthly premium is not always the best choice, since there are also out-of-pocket expenses that should be considered when you use the plan (deductibles, co-payments and the like.)  Also, if a plan is low cost, but does not deliver good quality, it is not a good choice.  Using the OPA Report Cards to evaluate the plans enables the consumer to consider quality metrics in easy-to-understand terms.  In addition to having consumers use the Report Cards to evaluate health plans as a matter of routine, we would like to see employers and unions who contract with health plans factor those quality measures into their contracting decisions.  In other words, when they are deciding which plans to offer to their employees, they offer them a selection based not only on costs, but what kind of results they get for their patients based on accepted clinical standards and patient experience. 

HA: What can the report card do to help advance the goals of health reform?

BA: One of the chief goals of the Affordable Care Act is to promote the integration of health care for the patient and to help lower the costs of providing health care.  These cost and quality measures go hand in hand.  If health care achieves a high degree of integration, patients don’t have to undergo duplicate tests and procedures, and their clinical data can be easily shared among the team that is treating them so that all information is available.  A well-integrated approach to care means, for example, that simple things can be handled by email between the patient and the doctor or pharmacist. This gets answers to the patient more quickly without having to wait for a formal appointment to be scheduled.  All of these kinds of things mean that the cost of health care is going down and the quality of health care is much more coordinated and responsive to patients’ needs. 

HA: What can groups like Health Access go do to help promote use of the report card?

BA: Health Access and its allies, friends, and relations can help by publicizing the Reports Cards.  It continues to amaze me how few people actually are familiar with these important quality tools.  I have come to refer to the Office of the Patient Advocate that I now work for as the “best undiscovered gem in CA state government.”  People should share our website with their employer, their union, their PTA group, their church or synagogue organization, their neighborhood association, and all of their friends.  I want this to be second nature for everyone who is making a health plan choice to get the right plan for them. 

The OPA has provided the following tools for community partners to use in getting the word out about the Report Cards.

  • A web badge designed for other organizations to place on their websites that will link people directly to the Health Care Quality Report Cards. The html code needed for the web badge placement can be found on this webpage: www.opa.ca.gov/Pages/PartnersBadges.aspx.  There also are general OPA web badges available in additional languages and sizes that link to OPA’s home page instead of the Report Cards.
  •  OPA’s social media accounts and links:
    Facebook -  Office of the Patient Advocate
    Twitter – @CAPatientAdv
    YouTube – CAPatientAdvocate
  • Last but not least, OPA has a “California Health Care Report Card” Mobile App available for free download through iTunes and Google Play. An overview about the Mobile App and the links to the two online stores can be found here: www.opa.ca.gov/Pages/MobileApplications.aspx.

HA: Anything else we should know about the report card and the OPA?

BA: If you think you want to stay with the plan you have now, you might want to look at our Report Cards, and click on your plan name.  It will give you your “plan profile” with all the details.  You can also click on any other plan you have under active consideration for a comparison.  And if you have particular health concerns in your family, e.g. diabetes or a heart condition, you can compare plans clinical measures of that treatment to make sure you’ve selected a plan that excels in that kind of care. 

Legislative Wrap-Up: 2014 Bills Signed/Vetoed by the Governor

HEALTH ACCESS UPDATE: Friday, October 10, 2014

2014 LEGISLATIVE WRAP-UP: GOVERNOR BROWN SIGNS KEY PATIENT PROTECTIONS INCLUDING SB964(HERNANDEZ) ON TIMELY ACCESS TO CARE
* Other bills of note signed include SB18(Leno/Hernandez) to accept foundation and federal funding for community groups to help Medi-Cal enrollees with renewals; SB1052(Torres) on disclosing formularies; SB1053(Mitchell) on contraceptive coverage; SB1182(Leno) on disclosing large group claims data; and more.

* Key bills vetoed include SB1124(Hernandez) on limiting Medi-Cal estate recovery; AB2088(Hernandez) on avoiding junk coverage; and SB1094(Lara) on hospital merger oversight. Consumer groups vow to continue efforts next year.

* Full bill list below of fate of 2014 legislation that made it to the Governor’s desk.

The 2014 legislative session came to an end last week. The Governor’s deadline to sign or veto bills has come and gone; Governor Jerry Brown had until September 30th to sign or veto bills presented to him by the legislature.

After several years of significant legislative work to pass dozens of bills to put in place the key component of the Affordable Care Act in California law, it was the administrative work to implement and improve health reform that took center stage. That said, several key health consumer bills of note were passed and signed into law by Governor, even as some priority bills were vetoed as well.

The new law SB964(Hernandez) has perhaps most direct impact on the biggest number of consumers on one of the highest-profile issues of the year–the question of whether Californians, once covered, can get care. SB964 will increase oversight of timely access and network adequacy of all health plans, thus benefitting over 21 million Californians. In this year where California was successful in enrolling millions 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 or other commercial plans offering “narrow networks.” SB964, sponsored by Health Access California requires the Department of Managed Health Care to do annual reviews for timely access and network adequacy for all plans, with reviews done 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 they need it.

The Governor also signed two other bills to help access to care for those insured. SB 1052(Torres) requires the development of a standard drug formulary template which health plans and insurers must use to display their drug formularies and to post their formularies on their Internet Web sites. This bill also requires the California Health Benefit Exchange (Covered California) to provide links to the formularies. SB1053(Mitchell) was also signed and willeliminate cost sharing for FDA approved female contraceptives that are generic or preferred brands and allows substitution of non-preferred contraceptives, unless a therapeutic equivalent contraceptive is provided by the plan with no cost sharing.

To help consumers keep their coverage, SB 18 (Leno/Hernandez) provides the State $6 million from the California Endowment to fund Medi-Cal renewal assistance by community based organizations, drawing down $6 million in matching federal funds as well. This is the first ever renewal period since the process and rules changed under the ACA. Consumer advocates worked hard to pass this bill to ensure people eligible for Medi-Cal – many who have never had Medi-Cal before – got the necessary help to renew and maintain their health coverage. Thanks to the California Endowment and the Governor for his signature of SB 18, the State now has the necessary resources to ensure people who are eligible for Medi-Cal are able to successfully renew and maintain health care coverage.

On cost, quality and transparency, the Governor signed SB1182 (Leno), which requireshealth plans and insurers to share claims data or other detailed data to very large purchasers that have 1,000 or more enrollees or that are multiemployer trusts with at least 500 members. AB1962(Skinner) was also signed and would make transparent what dental-only plans spend, as a percentage of premium, on patient care by requiring specialized dental-only plans to disclose a “medical loss ratios” as for medical coverage.

For the remaining uninsured, SB 1276(Hernandez) by Western Center on Law and Poverty updates the Hospital Fair Pricing law enacted in 2006 after a five battle and sponsored by Health Access California. SB1276 defines a reasonable payment plan as monthly payments that are no more than 10% of income after essential living expenses and allows 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.

To help the remaining uninsured in Fresno, the Governor signed AB 2731(Perea) which will allow Fresno County to spend $5.5 million for indigent healthcare by deferring their county maintenance of effort requirement for local streets and roads. The Fresno County Board of Supervisors must now take action to reverse a decision to undo their safety-net program.

Consumer, community, senior, and low-income advocates were very disappointed in some key vetoes, but vowed to continue the work next year, and saw hope for progress in the Governor’s veto messages.

SB 1124 (Hernandez) would have limited 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 follow this practice, allowing Medi-Cal to be a true safety-net for medical care without putting the family’s assets at risk. “Estate recovery” amounts to about $500 per month in liens for those over age 55. It arbitrarily seeks assets from a small slice of lower-income families who are trying to do the right thing by getting covered and owning a home. Advocates vowed to continue to work to fix this policy that penalizes low-income families taking personal responsibility by building savings while signing up for coverage. The Governor’s veto message suggested addressing this issue in the budget process next year, which advocates will do so Californians can get the coverage they need without any fear of any financial repercussions for their family. Advocates have appreciated the testimonies from impacted Californians, and continue to seek those stories for the continued effort.

Health Access California-sponsored bill AB 2088 (Roger Hernandez), which would have made limited benefit policies supplemental to comprehensive coverage sold to large employers was also vetoed. This consumer protection already exists in the individual and small employer market; the bill closes a loophole for larger 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 provides less than 60% minimum value. Advocates are disappointed by the AB2088 but will continue next year to work to limit this “junk” coverage and ensure employees get comprehensive coverage.

The veto of SB 1094(Lara) on Attorney General oversight over hospital sales and mergers was also a disappointment to consumer groups, labor, and Planned Parenthood alike. SB 1094 would have enhanced the Attorney General’s oversight of nonprofit hospital mergers and acquisitions. It sought to extend the review period from 60 days to 90 days. It also would have given the Attorney General authority to enforce conditions of hospital transactions. This bill was sponsored by the Attorney General.

Below (and on our website) is a longer bill list of the key health legislation (all supported by consumer groups including Health Access California) acted upon by Governor Brown in the past month:

BILLS SIGNED BY THE GOVERNOR

Ø Insurance Consumer Protections

OVERSIGHT OF HEALTH PLAN NETWORK ADEQUACY: SB964 (Ed Hernandez) requires the Department of Managed Health Care (DMHC) to do annual reviews of all health plans for timely access and network adequacy and that reviews 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.

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.

SB1052 (Torres) would standardize plan formularies so that consumers know which plans cover which drugs at what costs. This measure applies to the individual and employer coverage markets.

SB1053 (Mitchell) eliminates cost sharing for FDA approved female contraceptives that are generic or preferred brands and allows substitution of non-preferred contraceptives, unless a therapeutic equivalent contraceptive is provided by the plan with no cost sharing.

Ø Medi-Cal

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

SB1089 (Mitchell) is a clean-up measure to AB 396 (Chapter 394, Statutes of 2011) which established a voluntary program to allow the State, on behalf of counties and the California Department of Corrections and Rehabilitation, to draw down Federal Medicaid funding for hospital inpatient and inpatient psychiatric services for Medicaid eligible detained juveniles at no cost to the State.

SB1341 (Mitchell) would require that the Statewide Automated Welfare System (SAWS) has the ability to make use of the Medi-Cal rules housed in the IT system, CalHEERS, jointly operated by the California Health Benefits Exchange and the Medi-Cal program.

Ø Cost/Quality Transparency

SB1182 (Leno) requires health plans and insurers to share claims data or other detailed data with very large purchasers that have 1,000 or more enrollees or that are multiemployer trusts.

SB1340 (Hernandez) would eliminate gag clauses in contracts between types of health care providers and health plans or insurers.

AB1792 (Gomez) would require the Department of Finance to report on the cost of public assistance received by employees of California employers.

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.

Ø Hospital Oversight and Consumer Protections.

SB1276 (Ed Hernandez) updates the Hospital Fair Pricing law which Health Access California sponsored in 2006 and which says that low-income uninsured and underinsured cannot be charged more than the higher of Medicare or Medi-Cal. SB1276 defines a reasonable payment plan as monthly payments that are no more than 10% of income after essential living expenses and allows 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. Sponsored by Western Center on Law and Poverty.

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.

Ø Other Bills

SB20 (Hernandez) would revise the open enrollment dates for the individual market to conform to current federal guidance, which is November 15-February 15. SUPPORT.

SB1004 (Hernandez) would change the definition of hospices to eliminate the requirement that patients forego curative treatment. SUPPORT.

SB1034 (Monning) would eliminate waiting periods due to pre-existing conditions, conforming California law to federal law with respect to waiting periods for health insurance. SUPPORT.

AB2731 (Perea) would allow Fresno County to spend $5.5 million for indigent healthcare by deferring the county’s maintenance of effort requirement necessary to receive state funding for local streets and roads.

BILLS VETOED BY THE GOVERNOR

Ø Insurance Consumer Protections

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.

Ø Medi-Cal

LIMIT ON MEDI-CAL ESTATE RECOVERY: SB1124 (Hernandez) would have limited Medi-Cal estate recovery to long-term care. 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.

SB1002 (De Leon) would have better aligned Medi-Cal and CalFresh reporting periods in order to streamline benefit delivery and improve low-income Californians’ access to federally funded health and nutrition benefits.

AB2325 (Speaker Perez) would have created a Medi-Cal medical interpreter program.

Ø Hospital Oversight and Consumer Protections.

SB1094 (Lara) would have enhanced 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.

SB204 (Corbett) would have required the Board of Pharmacy to survey pharmacists and electronic health record vendors to determine utilization of standardized prescription directions for use adopted pursuant to Board regulations.

Better Know a New Law: SB964 on Timely Access to Care

One of the most far-reaching and consumer-friendly health care bills enacted this year by Governor Jerry Brown was SB 964 by Senate Health Committee chairman Dr. Ed Hernandez, and sponsored by Health Access California.

Addressing two pressing issues for consumers, network adequacy and timely access to health care, SB 964 was a natural progression of decades of policy work going back to 1975 when then Governor Jerry Brown signed the Knox-Keene Act to assure that consumers in managed care receive the care they need when they need it, at in-network cost sharing. Over the decades since additional consumer protections have been put in place to make meaningful the bedrock principle for managed care: patients accept limited networks and the health plans in return guarantee that the network is adequate enough to provide timely access to care, including primary care in their geographic region, and access to medically necessary care at in-network cost sharing.

Over seven million Californians are or will be enrolled in Medi-Cal managed care: almost 3 million of them will be new to Medi-Cal managed care, either as a result of transitions from fee-for-service and Healthy Families or due to the ACA changes. This is more than a quarter of the population of California.  At a time when we are shifting an unprecedented number of people into Medi-Cal managed care plans and with the consumer concerns about the “narrow networks” in Covered California plans, it becomes   even more important that we fulfill the promise of the law and ensure that consumers can get the care they need, when they need it.

SB 964 builds on decades of policy work around consumer protections, and the work of the Department of Managed Health Care (DMHC), by enforcing the timely access and network adequacy standards in law and assuring that consumers have timely access to necessary care.

History

When the Knox-Keene Act was first implemented, DMHC’s predecessor) reviewed network adequacy whenever a health plan was initially licensed or moved into a new area (for instance, when Kaiser Permanente opened a new facility in Bakersfield) or whenever there were sufficient complaints to raise an alarm.  In 1975, this probably seemed sufficient.  However, this meant that there were health plans that had been operating for decades without a careful look at whether the networks were adequate and care was provided in a timely manner. .

The timely access statute adopted in 2003 required annual review of timely access compliance.  Unfortunately, the prior Administration bungled the compliance procedures for timely access, allowing different health plans to use different metrics and approaches for determining compliance and thus making enforcement quite difficult.  Under the current Brown administration the DMHC has taken a number of steps to encourage more standardized reporting on timely access and to improve the information collected on network adequacy.

SB 964 standardizes the data to be annually reported by health plans regarding network adequacy and allows the further development of standardized annual reporting on timely access.

Medi-Cal Managed Care

A fundamental promise of Medi-Cal managed care is that Medi-Cal managed care enrollees will receive the same consumer protections as other Californians enrolled in managed care.

SB964 takes a number of steps to assure that consumers in Medi-Cal managed care have the same protections as other Californians in managed care:

  • It requires that if a health plan uses a different network for Medi-Cal managed care than for other lines of business, the annual review for timely access and network adequacy be done separately for the separate Medi-Cal network.
  • It repeals the existing exemption of Medi-Cal managed care plans from medical surveys done every three years, building on  the Brown Administration’s current practice.
  • It requires health plans to submit to DMHC the same information on networks and network changes that is already submitted to DHCS so that the departments may check for inconsistencies.
  • In the only provisions affecting DHCS, it requires DHCS to post on its website completed medical audits. DMHC already posts completed medical surveys: DHCS does not. This furthers transparency for Medi-Cal managed care plans.

Covered California and the Individual Market

California has led the way in implementing the Affordable Care Act. Not only have the number of uninsured been cut in half, the rate of increase in premiums in the individual market has also been cut in half. In driving down the increase in premiums in the individual market, health plans have made numerous changes, including shifting to narrow networks. The Department of Managed Health Care  will soon release two targeted investigations arising out of these changes in the market for coverage sold directly to individuals, inside and outside Covered California.

SB964 takes a critical step to assure that in future years, networks in the individual market are adequate by requiring that if a health plan uses a different network for the individual market than for the small employer market, then the annual reporting on timely access and network adequacy shall be done separately for the different networks.

SB 964 will help people like Charlie who recently was unable to get routine medical care for more than six months:

CharlieSpiegelPhoto_SB964NetworkAccess

Though Charlie has an Obamacare Platinum Plan, he was unable to get routine medical care for more than six months. “I chose the Platinum level “Premier Direct Access” plan offered by Anthem Blue Cross Plan,” says Charlie, “because my Sutter primary care doctor was in that network.”  “But before I could get in for an initial appointment, Anthem cancelled their contract without notice, leaving me with $640 of not covered expenses!”

“At the same time I had to postpone a scheduled colonoscopy, I also continue to be unable to schedule a required sleep study for potential apnea, which my brother has and which led to a coronary event for him.  And Anthem will not even say if my requested provider is In Network or not.”

SB964: Adequate Networks and Timely Access to Managed Care

Almost twenty million Californians rely on coverage regulated by the Department of Managed Health Care. Stories from consumers like Charlie and recent enforcement actions and investigations by the DMHC indicate a need to further strengthen enforcement and oversight of timely access and network adequacy.

For these reasons, we are pleased that Governor Brown has signed SB 964 into law. and Health Access and other consumer advocates are already working with DMHC to begin implementing the new law. The bill takes effect on January 1.

Wal-Mart Drops Part-Time Coverage, As Anticipated for a Decade

Wal-Mart’s decision to drop health coverage for part-time workers is not a shock–it’s a move anticipated for years, especially here in California, which has been debating policy proposals on this issues for over a decade.

The important news is that thanks to the Affordable Care Act, workers will still have health care coverage options available, through Medi-Cal or Covered California. After decades of employers dropping health benefits, it’s so critical that the ACA is now offering affordable options for working families.

But while workers health care options are protected under the ACA, it’s unfair and unsustainable to allow Wal-Mart and other companies to shift health costs onto taxpayers. We need the employer responsibility provision in the ACA implemented and enhanced to ensure our health system is sustainable in the long-term, to protect taxpayers, and to provide a level playing field for employers who do offer coverage to their workers.

For years, California has had one of the worst rates in the nation of employers offering health coverage to their workers and families. As a result, California voters and policymakers have actively considered proposals to employer-based coverage, including Proposition 166 in 1992 and Proposition 72 in 2004; SB2(Burton) in 2003; and AB880(Gomez) in 2013. The ACA’s employer responsibility philosophy was reflected in the AB1x1(Nunez/Schwarzenegger) proposal in 2007 and in the currently operating Healthy San Francisco. California has had a decade-long debate anticipating this moment when Wal-Mart drops coverage–the question now is if our policymakers can finally act to protect taxpayers and our health system.

Progress on the County Safety-Net, In LA and Fresno

Consumer, community and health advocates have been cheered by events this week that should improve access to health care in two major California counties for the remaining uninsured.

* Tomorrow, October 1, Los Angeles will launch “My Health LA,” a new program to provide primary and preventive care for the remaining uninsured, including those excluded from Medi-Cal.

* On another front, Fresno County got help this weekend when Governor Brown signed a bill to provide it budget flexibility so it can continue its indigent care program–something it voted to end just last month.

Given the new context of the Affordable Care Act (ACA), other counties are looking to adjust or extend their safety-net services in the coming year. With our success in enrollment Californians in ACA coverage, counties are appropriately looking to see how to revamp and extend their safety-net services for the remaining uninsured, including for those without options under the ACA due to immigration status. We are pleased to see progress by counties, the traditional health provider of last resort, to be innovative in meeting the ongoing needs of the remaining uninsured in their communities. In particular, immigrants are a crucial part of California’s economy and community–they should be fully included in our health system as well.

A study conducted by Health Access California last year found that California’s safety net for the remaining uninsured is uneven, with different eligibility rules on income and immigration and different services offered county-by-county.

LOS ANGELES: LA County is taking a major step forward today in launching My Health LA. Hundreds of thousands of low income people who have been denied access to health care will be able to sign up for care for the first time. We applaud Los Angeles County for My Health LA, and stepping up to provide a medical home that includes care that is primary and preventive, not just emergency and episodic. It’s inspiring to see Los Angeles, for so long ground zero of the crisis of the uninsured, work to fulfill the promise of health care reform, that everyone—regardless of income or background—could have access to basic care. When we start open enrollment in November, all Angelenos below poverty will be eligible for something–and if not Covered California or Medi-Cal, then My Health LA. We want to spotlight those counties that are stepping up to ensure access and afford basic care.

The program was approved by the Board of Supervisors last week and is slated to cover approximately 150,000 low-income uninsured Angelenos and build on the success of its precursor, Health Way LA.

Applicants must be L.A. County residents, age 6 and older, below 138% of the Federal Poverty Level, uninsured, and not eligible for Medi-Cal. My Health LA is a primary care program financed through 65 million dollars approved by the Board of Supervisors.  It covers primary and preventive care including pharmacy and in limited cases, dental services.  MHLA also covers specialty care and urgent and emergency care at DHS facilities.

Link to DHS/My Health LA Website:  http://dhs.lacounty.gov/MHLA

Link to Federal Poverty Levels:  http://file.lacounty.gov/dhs/cms1_215467.pdf

MHLA Customer Service Line:  1-844-744-6452 (MHLA)

FRESNO: While several counties look to augment or extend their services, Fresno County was the only county to take action to roll back eligibility in their indigent care, in a vote last month. But that decision had a 90-day stay, pending legislation that was signed into law by Governor Brown this weekend. AB2731(Perea) gives Fresno County the budget flexibility it says it needs to continue to provide safety-net services. We hope that with these new developments, Fresno County revisits its recent vote and commits to continue to provide safety-net health care services for the remaining uninsured. California is stronger when everyone has access to care and coverage. It’s more cost-effective to have access to primary, preventive, and specialty care than to just address the issues in the emergency room. By ensuring that Californians have that access, counties can make sure that their residents are healthy and contributing economically to their communities.”

The Health Access report from last year on the county safety-net can be accessed by visiting www.health-access.org or directly by visiting:

http://health-access.org/files/expanding/California%27s%20Uneven%20Safety%20Net%20-%20A%20Survey%20of%20County%20Health%20Care.pdf

Assembly Health Committee Delves into Medi-Cal

Last week, the Assembly Committee on Health, chaired by Assemblymember Richard Pan held an oversight hearing to delve further into selected Medi-Cal issues , some of which the committee had examined in previous informational and oversight hearings.  Here’s a report from our legislative advocate Sawait Hezchias-Seyoum:

The committee invited stakeholders and the the Department of Health Care Services (DHCS) to obtain status reports and updates on Medi-Cal related issues including, the enrollment backlog in Medi-Cal, provider directories and adequacy of networks, access to dental care and the Dashboard.

Cathy Senderling of California Welfare Directors Association and Elizabeth Landsberg of Western Center on Law & Poverty both testified on the enrollment backlog in Medi-Cal and the impact it has had on consumers throughout the state.  During their panel presentation, Assemblymember Roger Hernandez expressed his concern over the backlog, explaining that his district, which is in large part comprised of low income people and immigrants, has been disproportionately impacted.

While significant progress has been made to reduce the backlog, DHCS reported today that there are still approximately 250,000 Medi-Cal applications that have not been processed.  CalHEERS was designed to interface with various federal, state, and local information technology systems in order to facilitate the purchase of health insurance, however today’s hearing highlighted the system issues that have contributed to the backlog of applications.

Following the discussion with the California Welfare Directors Association and Western Center on Law & Poverty, Republican Assemblymember Jim Patterson asked Director of DHCS, Toby Douglas when the state expects to clear the current backlog.  Toby explained that while he is not able to provide a definitive date as to when the backlog would be cleared, he and the Department is committed to ensuring consumers have access to Medi-Cal within the 45 day period it currently takes to process Medi-Cal applications.

On the subject of provider directories and adequacy of networks, the California Association of Health Plans said that the health plans need accurate information from providers to in order to keep their directories current. Louizos also stated that an internal survey they did of their networks showed that 90% of their contracting providers accept Medi-Cal patients.  Dr. Pan indicated that there is a difference between a provider who sometime accepts Medi-Cal and a provider willing to accept additional Medi-Cal managed care patients today. The Assembly and Senate Joint Legislative Audit Committee is also working on their own audit which should be released soon.

Brett Johnson, representing the California Medical Association explained that there are many things that could be done to ensure accurate and up-to-date provided directories, including matching provider directories against the universal provider source that is widely used in the industry, requiring lists to be updated more often, requiring valid e-mail addresses for providers and utilizing other innovative technological tools that exist.  On network adequacy, Johnson explained that their Medi-Cal managed care physicians continue to experience difficulty referring out to specialists.

During the hearing, Assemblymember Patterson shared a story of a consumer who showed up at the pharmacy to pick up a prescription only to find out that he had been dropped from coverage.  Patterson explained that he continues to hear of consumers who are dropped from coverage and usually without their knowledge.  Toby explained “the buck stops here” in terms of ensuring adequate access to care in Medi-Cal, however if a consumer has been dropped from coverage without their knowledge than that person likely has coverage through Covered California and should contact Covered California for assistance.

The discussion around Dental Care centered on inadequate access to care throughout the state and especially Sacramento County.  Sutter Medical Center,  a key service provider in Sacramento  for Medi-Cal beneficiaries who need inpatient dental anesthesia because they are developmentally disabled  recently announced that it would discontinue dental anesthesia services  but has agreed to provide services through January 1, 2015.   DHCS shared that work groups have been established to help create more efficient and uniform anesthesia protocol, to identify administrative barriers and improvements for payments and also to identify other care providers who can accommodate and provide services to Medi-Cal beneficiaries.

Another highlight from the hearing was the discussion around the Medi-Cal Managed Care Performance Dashboard. Today’s hearing provided an opportunity to explore how the dashboard can be improved and leveraged to better monitor quality and access to care in Medi-Cal Managed Care.  Abbi Coursolle from National Health Law Program provided several recommendations to the committee on how the dashboard could be improved, such as breaking down the data by race and ethnicity.