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In this issue:
- Provider search function operational on Covered California website
- Covered California launches pre-enrollment, technical difficulties persist
- Federal, state regulators weigh in on grace period proposal
- CMA updates exchange toolkit
- Health and Human Services to hold small business webinars
- CMA House of Delegates approaching, health reform remains a focus
In what has been one of the most fluid deadlines put forth by the state’s health benefit exchange, Covered California launched the online provider search function on Monday, October 7. The search will allow patients to determine if a particular physician is contracted with any of the participating health plans.
Though aimed at patients, physicians can also use the search to determine which plans list them on their exchange provider directories. The California Medical Association (CMA) recommends physicians review their status with plans offered in their area to determine whether they are showing as participating or non-participating.
The provider search is available through Covered California’s “Preview Plans” tool. Find out if you’re contracted by using the following steps:
- Visit www.CoveredCA.com and click on the “Start Here” button near the center of the screen.
- Next, select the “Preview Plans” tab at the top of the next screen.
- The user will then be directed to provide some general demographic information and click “See My Results” at the bottom right.
- Click “Preview Plans” again on the next page, then select the “Find Your Doctor or Hospital” bar in the middle of the screen, which opens a dropdown box with both “Find Your Doctor” and “Find Your Hospital” options.
- Select the “Find Your Doctor” option, and input the physician's name and location. If the desired physician is contracted with a participating Covered California health plan, his or her name should appear in the subsequent provider list.
- Select the desired name from the list and choose the “Add to My Providers List” option. If you would like to search for another physician, click "Find Your Doctor" again and repeat the process. Once your list is complete, select the “Choose a Plan.” Those plans in which the chosen physician(s) participate will show a green checkmark box in the “My Doctors” row within the summary at the lower half of the page. A red minus-sign box indicates that the physician does participate in the plan.
Covered California had also promised the ability to download copies of provider directories furnished by qualified health plans via Covered California’s website. This option does not appear to be available yet on the www.CoveredCA.com website as of Monday, Oct. 7.
The topic of provider directories has been one of the most closely watched topics being handled by Covered California, by both patients and the physicians who will ultimately provide care through the state’s new online marketplace. Since early 2013, Covered California has been touting the provider directory as a way to help transform the millions of Californians currently without health insurance into “informed shoppers” when it comes time to enroll.
Both provider and patient advocates have been eager to know which providers are being included in the exchange network. Providers’ interest has been stoked by the general ambiguity with which some health plans have conducted their provider contracting, such as failing to identify products as exchange products and using “all products” or “all affiliates” clauses to include physicians in an exchange network.
If you find that you are being identified as contracted with an exchange product but did not intend to do so, contact CMA at (800) 786-4262.
CMA will continue to monitor the implementation of the Covered California provider directories and keep readers informed of any significant developments.
Covered California is now open for business, but the launch was anything but a smooth start.
The online marketplace officially opened at 8 a.m. on Tuesday, October 1, but immediately was plagued by long loading times, delays and other technical glitches that could be expected from such a large-scale launch. On Tuesday evening, exchange officials released a statement noting that the site would be taken offline overnight while some of the issues were corrected, and would be re-opened on Wednesday morning.
A little before 11 a.m. on Wednesday, the site was back online and fully operational.
During the first five days of activity, Covered California reported more than 1 million visits to the online market place, with 16,311 households completing applications and being determined eligible for subsidies, Medi-Cal or to enroll in an individual private plan.
Due to technical issues with the California Healthcare Eligibility Enrollment, and Retention System (CalHEERS), which is used to actually enroll participants, the number of people who have successfully enrolled in Covered California plans won’t be known until November. After weekend maintenance, however, some CalHEERS functionality had been added to the site, such as the “find your doctor or hospital” function, as discussed in "Provider search function operational on Covered California website," above.
Major strides have been made on the topic of the federal grace period provision, an issue which initially looked as though it would bring significant financial risks to the state’s physicians.
In a major win for CMA, after more than a year of advocacy, the Centers for Medicare & Medicaid Services approved the state Department of Managed Health Care (DMHC) proposed interpretation of federal grace period law that would require plans to suspend an enrollee’s coverage for months 2 and 3 for non-payment of premiums. Covered California had previously interpreted the federal law to allow for the potential pending and denying of claims during months 2 and 3. This would have put physicians at significant financial risk.
Initially, it was feared that the federal grace period provision, which allowed for health plans to pend claims after the first month of the three-month grace period allowed for non-payment of premiums, would result in physicians providing services only to have payment for those claims suspended and then denied if the patient was terminated for non-payment of premiums. The grace period provision, which was included in the Affordable Care Act, also conflicted with payment and rescission standards set forth in California’s Knox-Keene Act.
The proposal to suspend coverage was put forward by DMHC in an attempt to remedy the state-federal conflict and preserve California’s hard-fought patient and provider protections. Under DMHC’s proposal, physicians would provide services during the first month of the grace period, and those claims would be paid normally. However, during months two and three of the grace period, providers would not be under an obligation to render non-emergent services pursuant to their contracts with health plans, and health plans would not be under an obligation to pay claims for those services if rendered - similar to an HMO enrollee seeking out-of-network care. Enrollees would still be able to pay out-of-pocket for services on a fee-for-service basis, as well as pay off their premium balance to have coverage reinstated prior to the end of the third month.
DMHC has since communicated the basics of its suspension of coverage policy to plans participating in Covered California’s new online marketplace. Additionally, Covered California staff outlined how it sees the grace period provision functioning during its September meeting, noting that plans will be responsible for informing physicians that an enrollee’s coverage has been suspended, paying claims submitted during the first month regardless of whether or not premiums had been paid, and enrollees would assume financial responsibility for any care received during the second and third months of the grace period under a coverage suspension. Stakeholders are still awaiting details as to the requirements on plans for reinstating a patient’s coverage, such as applicable notices and timeframes.
The California Medical Association is now focused on ensuring that impending DMHC and Covered California guidance and regulations implement the suspension of coverage policy in a manner that poses the least possible risk to physicians and patients.
The California Medical Association recently-updated its exchange toolkit, "CMA’s Got You Covered: A physician’s guide to Covered California, the state’s health benefit exchange." The toolkit was developed to educate physicians on the exchange and ensure that they are aware of important issues related to exchange plan contracting.
The toolkit is available free to members only at www.cmanet.org/exchange.
Beginning this month, the U.S. Department of Health and Human Services will be hosting a series of webinars intended to provider small businesses with an overview of the Affordable Care Act (ACA) and how to enroll in small business health insurance marketplaces.
The webinars will be offered in a five-part series beginning in October and will cover topics including insurance reforms, the small business health care tax credit and employer shared responsibility provisions (i.e., the penalties for not offering coverage or offering inadequate coverage that were recently delayed until 2015). The series will continue into November, with those dates to be announced in the coming weeks.
The webinar series could be of particular use to physician practices that will be enrolling in Covered California’s Small Business Health Options Program (SHOP).
Registration links for the upcoming webinars are available below:
- Thursday, October 10 at 2:00 PM ET
- Thursday, October 17 at 2:00 PM ET
- Thursday, October 24 at 2:00 PM ET
- Thursday, October 31 at 2:00 PM ET
The California Medical Association (CMA) annual House of Delegates will convene in Anaheim at the Disneyland Hotel on October 11-13. At this year’s meeting, resolutions related to the Affordable Care Act and health reform in general will, once again, be taken up by the house.
Here’s a brief summary of notable resolutions relating to the topic of health reform:
201-13: Single-Payer Health Care for California
The topic of single payer health care has become an annual issue at CMA’s House of Delegates and will be taken up once again during the 2013 meeting of the house.
401-13: Modifications to the Affordable Care Act
This resolution asks that CMA work to modify the Affordable Care Act, specifically requesting that CMA support legislation modifying the ACA health insurance requirement to a high deductible catastrophic health insurance instead of the current ACA mandated health insurance, which requires coverage for essential health benefits and sets caps on patients’ out-of-pocket costs. The resolution would also support full federal and state income tax deductibility of all out of pocket health care expenses.
402-13: 90-day grace period
This resolution deals with the issue of the 90-day grace period, which CMA has focused on extensively during the past few months. Specifically, the resolution asks that CMA demand that the Department of Managed Health Care require that insurance companies involved in health insurance exchanges make it clear on the insurance cards which patients are federally subsidized, provide a user-friendly hotline or fax-back for authorization at the time of service, as well as guarantee payment for those claims with an authorization. That authorization would guarantee payment of the claim regardless of final coverage status. The resolution also requests that physicians be given the right to collect payment at time of service or refuse treatment to those patients whose guarantee of coverage cannot be verified at time of service.
403-13: Require All Health Insurers to Accept Covered California Patients
This resolution asks that CMA work to ensure that all risk-bearing health care providing entities in the State of California be required to accept a pro rata share of the Covered California patients pool.
405-13: Reducing Administration Burdens in Health Reform
This resolution seeks to decrease administrative burden in the implementation of the ACA by asking that CMA support legislation mandating the use of a uniform credentialing process and form, as well as require the use of a uniform prior authorization process and form for medical services. The resolution further asks that CMA urge California’s health benefit exchange to require administrative simplification by participating health plans and monitor the health plans' progress in reducing unnecessary administrative burdens on the delivery system.
410-13: Merging Premiums for Covered California and Workers’ Compensation Programs
This resolution asks that CMA work to require that employers who offer a platinum level or equal coverage to all employees be allowed to be exempt from the health care portion of the workers’ compensation premium.
This year, CMA will be live tweeting from the meeting (@cmaphysicians). Follow along and join in the conversation using #HOD2013.
For more information...
For more information on any of the issues discussed in this issue, or to suggest topics to be discussed in later editions, please contact Brett Johnson at (916) 551-2552 or email@example.com.