On Thursday, California new health benefits marketplace, Covered California, had their first board meeting since November, and the first since the new coverage started on January 1. Elizabeth Abbott, our director of administrative advocacy, has written up notes:
Moving from Planning to Implementation at the Exchange
Bouquets. . .and Brickbats at the Exchange Meeting Regarding Enrollment
As the meeting began, the Exchange Board accepted congratulations on behalf of their staff, their contractors, and their partners on the enrollment numbers in the Covered California Exchange reflected through January 14, 2014. They have enrolled 625,564 people through the middle of this month which is a huge leap forward from enrollment numbers beginning in October 2013. Eighty-five percent of those individuals are eligible for subsidized coverage; 15% have signed up for non-subsidized coverage. California’s Exchange is tackling a large and diverse population with many challenges including the sheer numbers of inquiries and some systems and telephone access problems. In what has not been generally recognized as an equally important success, California has transferred another 630,000 people into the Medi-Cal program from the counties’ low income health program. In addition, the Exchange has referred another 584,000 people to the counties to be screened by the counties for Medi-Cal eligibility. The costs of the Medi-Cal program are paid for by the federal government for the first three years, and 90% of costs thereafter. California clearly leads the other states with these enrollment numbers and the relative smoothness of their debut.
However, Covered California staff expressed their disappointment in three broad categories where they were not able to meet their targets to sign up certain populations during the first three months of the open enrollment period. They reported more work to do based on key demographics:
- Race/Ethnicity. The Latino population is underrepresented in the enrollment numbers so far. 74,090 Latinos enrolled or only 18% of the total. It should be closer to half of the new enrollees, based on Latinos’ share of the uninsured. Only 10,867 African-Americans enrolled, or about 2.6% of the new enrollees which is less than half of their percentage of California’s eligible population.
- Age. Covered California signed up a smaller number of young people than hoped for who are eligible (ages 19 through 29), the so-called “Young Invincibles,” who came in at about 55% of projections. Also only about 70% of those in the 30-44 age group signed up. While there is an expectation that more younger folks will sign up as we approach the deadline, there’s clearly more work to do.
- Geography. Covered California has below-average sign ups in key counties in California including Los Angeles, the Inland Empire (San Bernardino and Riverside counties), and the Central Valley.
In addition, reports from the Exchange staff themselves, and public comments from doctors, insurance agents, health plans, consumer advocates, the public, and inquiries from board members themselves reveal there are many fixes and improvements needed to help Covered California realize their enrollment targets. For example, the problems reported included:
- Insufficient customer service representatives at the service centers which resulted in callers having to wait sometimes more than an hour to talk to someone or having to call in many times over several days,
- No “professional hotline” to assist trained insurance agents and certified enrollment counselors for expedited inquiries,
- Poorly translated, stilted messages in Spanish, Chinese, and other languages at the call centers,
- A slow and cumbersome process to train and certify assisters and agents, resulting in fewer trained people to help consumers,
- An over-reliance on ineffective major media outreach, and
- Not enough “on-the-ground” familiar, trusted local sources to reach out to various underserved communities to assist with enrollment.
The Covered California staff and board expressed appreciation for the candid feedback and they pledged actions, already underway and planned for, to remedy this shortfall between their expectations and their performance. They are gearing up rapidly for the second half of the 2014 open enrollment period (through March 31, 2014). These actions include:
- Hiring 350 more Covered California staff, mostly for the Fresno service center,
- Installation of more telephone line capacity at the service centers,
- Use of more effective targeted media outreach,
- Implementation of a more streamlined process and other improvements to speed up the certification process for agents and assisters, and a dedicated phone line for assistance to answer their questions,
- Development of better consumer notices and web functionality, email alerts re the status of applications, program updates and notices, use of Frequently Asked Questions to improve communication with consumers and their agents and assisters.
Board members cautioned that the Covered California staff should assure that the solutions they were undertaking matched the problems identified. Remedies should not be just “more of the same.” For example, does it make sense to emphasize insurance specifically to cover a “pre-existing condition” where the consumer had been previously denied, if most of the targeted population had never had insurance before? They also urged the staff to undertake a more in depth review of media buys to determine which ones worked, and which ones did not, particularly with populations that they had not been successful in reaching.
Everything You Wanted to Know about Pediatric Dental Benefits
There have been a lot of difficult policy decisions that had to be made by the Exchange, not the least of which was in the area of Pediatric Dental Benefits, one of the 10 Essential Health Benefits called for in the Affordable Care Act. In working on the implementation of that provision, Covered California convened a stakeholder advisory committee (composed of health plans, providers, and consumer advocates) over the last several months to determine the details of this complex policy area and the best way to deliver those benefits, display them on the website for consumers to choose, and how to pay for them. The principal disagreement revolved around whether to include the pediatric dental benefit as part of comprehensive health plan choice included with all the other services from an insurer for a set price or to list it for separate purchase as a “stand alone” dental benefit separately available as a supplement only from dental health plans.
There were arguments on each side of the issue. However, Covered California was disturbed by the fact that such a small percentage of families with children (less than 30%) elected to separately purchase the pediatric dental benefit during the first three months of the open enrollment period. The advantages of incorporating the pediatric dental benefit with all of the other benefits in one comprehensive plan that consumers could select would result in letting consumers take advantage of the premium tax credit (financial assistance) for that benefit and ensure the enrollment of all eligible children. This option would also result in sharing the very small cost across populations with and without children, help to reduce other consumer out-of-pocket expenses, and ensure a meaningful dental benefit.
The Exchange Board voted to include the pediatric dental benefit as part of the package of benefits offered by all the health plans included on the Exchange. There will be accommodations over the first transitional year. While dental plans spoke in favor of the separate purchase option, both the health plans and consumer groups argued in favor of combining all of the medical and dental services under one comprehensive plan which the board ultimately adopted. As Health Access’s legislative advocate, Beth Capell, said at the public meeting in favor of the board’s action: “Ten Essential Health Benefits means exactly that: 10 Essential Health Benefits for all California’s children enrolled with the Exchange.”
So What’s New for 2015?
The Covered California staff gave a preview of what they are considering for health plan renewals for 2015 and the requirements for new plan entrants who have not previously participated. This decision will be put before the board at the February 2014 meeting for their discussion and a vote. The staff proposal recommended that no changes be made to plan design for 2015 because they will have very little information regarding what worked—and what didn’t–until later in 2014. The staff believed it would be too early to assess their plans’ performance and the impact on consumers until later in the year when it would be too late to redesign plan offerings in time to alter plan specifics with new rates for the 2015 plan year.
Although the board will not make a decision regarding plan design until the next meeting, health plan representatives asked for as much time as possible—until early June—to submit their plan designs and proposed rates for 2015. Consumer advocacy groups urged the board that even without major changes, there were still opportunities to increase standardization among health plan offerings to make it easier for consumers to comparatively shop between plans. There will also be time to further assess plan performance and to improve standards regarding the customer service provided by health plans. Consumer advocates described great differences among health plans regarding the willingness of some plans to grant extra time for payment of premiums, establish retroactive eligibility to the first of January based on mid-month sign-ups, and provide early access to doctors, hospitals, and pharmacy benefits even before the paperwork was completely processed by Covered California or the health plans themselves.
Covered California had a little less than three months left in the 2014 open enrollment period to sign up the remaining eligible Californians, improve Covered California’s customer service, and begin on an accelerated timeline for the newly-announced open enrollment period, scheduled for November 15, 2014 through January 15, 2015 for the coming year’s 2015 enrollment.
Prepared by Elizabeth Abbott, January 24, 2014