Covered California Board Addresses 1332 Waiver, Quality Requirements, Special Enrollment Verification and other Hot Topics

This blog was written by Kate Burch

On April 7, 2016, the Covered California Board addressed several hot topics at their April meeting. You can find a recording of the board meeting, links to the presentations, and links to all of the proposed regulations, attachments, etc. here.

1332 Waiver Report

Stakeholders and experts have been very involved in working with Covered California over the last three months to develop the ideas and possibilities for a 1332 waiver, which allows states to make certain changes to their implementation of the ACA as long as they meet key goals on coverage, affordability and more. The Covered California staff considered the many proposals that were put forward and presented an analysis of some of the possibilities to include in a 1332 waiver.

The Covered California staff report cleared the way for a waiver to allow undocumented immigrants to purchase insurance through the marketplace, with their own money. The analysis by staff shows that the proposal to expand access to undocumented immigrants meets all of the federal guidelines for a 1332 waiver and would not be overly burdensome for Covered California to implement. Developing a targeted waiver proposal and fleshing out the details will require significant time and Covered California is “ready and willing,” as Peter Lee said, to embark on that process if the legislature decides to move forward with a 1332 waiver.

It’s now up to the legislature to move a 1332 waiver forward and up to advocates to keep pushing the issue at the state and federal level to make equal access to Covered California a reality.

In addition to the proposal to include undocumented immigrants, Covered California staff looked at other proposals for 1332 waiver topics. The staff report strongly supports a phased approach to the 1332 waiver, with only a narrow, focused waiver feasible this year, and with broader changes possible in future years when there’s more time for analysis and development of proposals. Details of their analysis are available here. You can also read a previous blog post here.

Model Contract and Benefit Design for 2017 – 2019

The Covered California Board adopted the proposed model contract and benefit design for plan years 2017-2019.

There were no changes to the medical benefit design that was presented in February. There were minor changes clarifying aspects of pediatric dental benefits that are included in QHPs. For the optional stand-alone family dental plans, changes removed outdated codes, standardized some cost sharing, and standardized the exclusion of adult tooth whitening, implants, and adult orthodontia.

The model Qualified Health Plan Issuer Contract includes changes that makes it more clear what Covered California expects from the plans in the way of improving both the delivery and quality of care provided to consumers. Changes include language that will help ensure that subsidy-eligible individuals are guided to purchase insurance through Covered California so they are able to get help paying for insurance; policies that should help ensure that insurance agents have no incentive to guide consumers toward particular plans or metal tiers; clarification of the appeals process and timelines for sending important notifications to consumers; and groundbreaking quality requirements and performance standards, along with a pilot period to implement them.

Quality and Delivery System Reform

When Covered California presented their proposed model contract at the February board meeting, it included innovations to move toward achieving higher quality health care and lower costs. The presentation at April’s board meeting included changes to the now infamous “Attachment 7” based on stakeholder feedback. Covered California’s board has said that putting consumers first means putting high expectations on the plans they contract with. They’re raising the bar on the plans they contract with to drive the effort to serve consumers well, to ensure that care is delivered more effectively and people are getting the right care at the right time.

Covered California’s model contract seeks to adopt payment strategies that reward value. They want patient-centered benefit design that will encouraging patients to get primary care and encourage plans to move towards integrated, coordinated care. While the requirements around quality improvement are in line with the federal requirement that any health plan that has participated in a Marketplace for two consecutive years implement and report on a Quality Improvement Strategy, Covered California’s approach to “track, trend, and improve” over time goes well beyond what is required in the federal marketplace and will greatly benefit California consumers. Some of details include:

  • All plans will have to assign a primary care clinician to enrollees within 30 days of enrollment if the enrollee hasn’t selected one on their own.
  • There won’t be any deductibles for primary care or specialty visits in silver, gold, and platinum metal tiers for the individual market.
  • Plans have to incentivize patient-centered medical homes and integrated health care models.
  • Payment reform will reward hospital outcomes and results; plans must exclude outlier hospitals (or justify keeping them in-network) starting in 2019.
  • In an effort to start reducing health disparities, plans must improve collection of self-identified racial/ethnic information; and must track, trend, and improve over time care related to diabetes, asthma, hypertension, and depression.
  • To better engage people in making the best choices for their health care, plans with more than 100,000 member must create tools enabling consumers to compare costs and quality when choosing a provider. Smaller plans have to have other options for members to understand costs.
  • Health plans also need to promote consumer access to and use of their personal health record.
  • While most of the performance standards will be measured based on Covered California enrollees only, plans must report disparities reduction across all their lines of business.

This part of the model contract to improve quality and equity was hailed as transformative and groundbreaking, supported by advocates, and even by industry, which appreciated the extra time to craft what they called more workable guidelines.

Special Enrollment Verification

All consumers can sign up to purchase health insurance during open enrollment, but if they want to sign up outside of open enrollment they need to have a qualifying special event in their life. This can include a change in family size, a change in income, moving, divorce, losing employer-sponsored coverage and a number of other events. Covered California’s current policy is to rely on self-attestation; consumers say what their special life circumstance is when signing up during the special enrollment period, electronically sign that it is true under threat of penalty, and they are able to enroll. Health plans have expressed concern that people who sign up during special enrollment cost them more money than people who sign up during open enrollment, and imply that consumers are trying to game the system by only signing up once they get sick, rather than doing the right thing and signing up during open enrollment.

Covered California staff presented a Special Enrollment Policy for discussion, with the intention of voting on it at the next board meeting. Covered California’s guiding principles for special enrollment are that only people who have a qualifying life event should sign up during special enrollment; people should not be delayed in getting coverage because of the verification process; documentation should be verified prior to coverage taking effect so consumers will not end up cancelled retroactively; and electronic verification should be utilized as much as possible.

Covered California staff would like to continue with self-attestation for 2016 and engage in a random sampling verification process. Covered California would require that a random sample of people enrolling during the Special Enrollment Period provide documentation to prove the qualifying life event that they attested to. If Covered California can’t verify the qualifying life event, the individual will be ineligible to enroll during the Special Enrollment Period.

Language on the application will more strongly explain consumers’ financial liability for incorrectly attesting to a qualifying life event and will require that consumers acknowledge that they might be asked to verify their qualifying life event.

In 2017, Covered California seeks to phase in electronic verification of documents whenever possible, and implement collection or verification methods for events that can’t be verified electronically. Covered California has not explained how they will address situations where documentation does not exist, or is not available within 60 days of a qualifying life event. Examples include someone fired from a low-wage job where there isn’t any formal letter of termination, or someone who has a baby and doesn’t receive a birth certificate for several months. Another example is a young adult who moved from renting a room in a group home and didn’t have a previous utility bill in their name.

Consumer advocates raised these grave concerns about the lack of such documentation, and sought more evidence (than the only anecdotal stories that the insurers have provided publicly) that some consumers were actually gaming the system, rather than not having documentation. Stakeholders and the Covered California staff agreed to continue working on the issue.

Individual Eligibility and Enrollment Regulations Readoption

In addition to the changes to Special Enrollment policy, the proposed Individual Eligibility and Enrollment Regulations include removing inapplicable definitions, amending regulations to comply with the recent federal regulations, and updating language to include Qualified Dental Plans. The Covered California Board will vote on the Individual Eligibility and Enrollment Regulations at the next board meeting.

SHOP Appeals Regulations

The Board voted to authorize Covered California staff to file a permanent rule-making package with the Office of Administrative Law. There are minor changes to ensure compliance with federal regulations and some additional appeals requirements.

Certified Application Counselor Program

The Board voted to amend the Certified Application Counselor regulations so that Covered California will continue paying for the fingerprinting and background checks for Certified Application Counselors. Prior to this vote, Covered California was scheduled to stop covering those costs at the end of June 2016. With the change, Covered California and the Board acknowledge the value of the unpaid Certified Application Counselors, including the almost 12,000 enrollments they were responsible for during the third open enrollment period. Continuing to cover the costs of fingerprinting and background checks will enable many community organizations and health care clinics to keep helping their clients with Covered California enrollment and utilization.

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