Exchange Makes Big Decisions on Creating the Service Center, Negotiating with Health Plans, Etc.

The California Health Benefit Exchange Board met yesterday in Sacramento to make some big decisions regarding the operations of the Exchange.  Stakeholders packed the auditorium, forming long lines to give public testimony on a number of issues.

Among the eagerly awaited agenda items was the discussion of Naming the Exchange.The new name will of course, be part of a larger branding effort.  The short list of names for consideration will be finalized this week, and the naming is to be final Septemer 28th, 2012.  The branding project has an end date of November 1, 2012.  A version of the short list discussed yesterday can be found in the materials from the Executive Director’s report here.

The next big issue tackled by the Board was Premium Aggregation.  Health Access and a number of our allies that represent consumers disagreed with the Exchange staff’s recommendation that individuals getting coverage through the Exchange pay premiums directly to health plans.  We believe that there are many important benefits to having the Exchange collect premiums:
1. Having consumers pay premiums to the Exchange is essential to the branding and marketing of this new, and little known entity.  Consumers will benefit from knowing who is providing them with this service, helping them get premium subsidies, and who stands prepared to provide them with consumer assistance.
2. Having one place to go to pay premiums, ask questions, and get help is really important for consumers, particularly those who have not had much experience with insurance, or those who experience cultural and linguistic barriers to access.
3. Many families will have family members that either qualify for different programs, or will experience fluctuations in income that may change which programs they qualify for.  Having a single place for consumers to go will greatly reduce confusion and prevent any tax consequences that may arise from changes in income and eligibility.

While the Exchange Board members and staff seemed interested in these arguments, they expressed trepidation over the amount of work entailed in collecting, or aggregating premiums, a task which would be new to the Exchange. The federal law does require that consumers have the option of paying the insurers directly–but advocates wanted the Exchange to provide a choice. In the end the Board voted unanimously to have the health plans continue to collect premiums, citing their vast experience taking money from consumers.  The Board and staff did discuss practices that could be put into place in attempt to address the concerns raised by advocates.

There was a significant discussion on the standards for Qualified Health Plans–the rules by which the Exchange would solicit, and ultimately negotiate, with health plans who want to offer plans in the Exchange. Some key decisions got broad acceptance, including the standardization of rating rules, and of benefit designs–both to allow consumers to have “apples-to-apples” comparisons, and to help prevent adverse selection where insurers use benefits to attract only healthier people.

Other decisions were more contested–for example, the definition of “essential community providers,” which are safety net hospitals, clinics, and doctors that currently provide health care to the uninsured, and that will be required to be in the Exchange’s insurance plans, so that those patients can continue with the providers that that may have been going to previously. Some providers wanted the definition to be broadened to include them. Others, including public hospitals, community clinics, and several consumer advocates, believed that the definition was too broad–and thus did not ensure that the key safety-net providers would be included in the insurer’s networks.

Another issue was on the standards, particularly on network adequacy, where the Department of Insurance and Department of Managed Health Care have different laws and enforcement. The Exchange proposed to simply defer to the existing regulators. Advocates and many providers argued that the Exchange should provide a comparable floor to ensure consumers get timely access to a doctor or specialist, similar to the current standard at the Department of Managed Health Care. This is the first non-unanimous vote that the Board has taken, as Dr. Ross voted no on this specific recommendation. The rest of the QHP recommendations were adopted unanimously.

Another issue that garnered a great deal of attention was the discussion of  Service Center Options.  The service center is the public face of the Exchange, it is where and how individual consumers (and small businesses) will interact with, or use the Exchange.  The Affordable Care Act requires that Exchanges provide access through the internet, phone, and in person; and the design of the new service center must provide a world class customer service experience that is simple and streamlined.  On the front end, the Exchange must ensure that customer service representatives/eligibility workers are prepared to assist consumers with applying for both public and private programs through a streamlined and customer oriented screening and referral process; and on the back end, that the systems are in place for efficient communication between all of the branches of the service center in order to do “real-time” eligibility determination.  The Board had considered several different models of Service Center design, and the staff recommended that the Board adopt a Centralized Multi-Site Model.  A number of county eligibility workers (who currently deal with county level public program eligibility) attended the hearing to testify about their commitment to helping with this work.  When it came time to vote, Board Member Kim Belshe abstained, saying she was not able to get adequate answers to her questions about how this Service Center model would interact with CalHEERS, the California Health Eligibility Enrollment and Retention System that the Exchange is spending a great deal of time and resources along with DHCS, MRMIB, and other agencies to build.  CalHEERS is the IT system that is intended to make streamlined, one-stop, real-time eligibility, enrollment, and retention possible.  Belshe felt that without being able to understand the interaction between CalHEERS and the Service Center model, she needed to withhold judgement at this time.

The Exchange Board also discussed issues related to Agent Payment, and to the Small Group Health Options Program.  The next meeting of the Exchange will be on September 18, 2012.

Health Access California promotes quality, affordable health care for all Californians.
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