California Health Care

by John Hansen

June 2016, Blue Shield of California is mandating that all health insurance brokers selling their plans sign up to receive their commissions by Electronic Funds Transfer (EFT). This will help lower operating costs for this California health plan that is fighting hard to compete with Anthem Blue Cross and Kaiser Permanente.

Due to the implementation of Obamacare in California, Medical Loss Ratios (MLR) have to be at 80%. This means that the expenses for health plan administration, marketing and health insurance broker commissions cannot exceed 20%.

Blue Shield has many agents that get monthly commission checks, often of $20 or less per month. Now, the health plan will no longer be sending paper checks. Requiring EFT deposits for all their health insurance brokers will improve their efficiency and save them quite a bit of money in the administration department.

Quality of care, efficiency and affordability have been some of the key goals of the Obama Care program. California...

by John Hansen

Many Covered California consumers have complained during the first couple years of the Affordable Care Act that they are having trouble getting their doctors to accept their health insurance coverage. Physicians and clinics have made the following statements.

This could be for various reasons. In some cases, medical insurance carriers payout less for the California Health Exchange plans, so physicians don’t want to accept them. In other cases, it’s just that doctors have heard they might get paid less.

Some doctors don’t want to take the more affordable Bronze and Silver Covered California plans. These plans require the customer to pay out more money at the point of service. Some physicians are concerned about having to hunt down payments from customers on these lower end plans.

In most cases, this is not true. However, sometimes there are differing payout schedules for individual health insurance plans than for group health insurance plans. Covered California mostly...

by John Hansen

The Newly Eligible Qualified Alien Program (NQI) is going into effect. In order to meet the requirements, you must be a qualified alien and the following must be true:

43,000 people are expected to meet these criteria. They can enroll through the Covered California website.

by John Hansen

The Covered California Open Enrollment 2016 turned out 200,000 new enrollees and 300,000 people switching from one California health care plan to another. In 2017, we expect these numbers to be about the same. 

The subsidy market is plateauing. There are still a lot of uninsured, but many may remain uninsured. Los Angeles still has a lot of people without medical insurance, and there are other pockets of uninsured around the state that Covered California is trying to target for California health care plans.

However, these individuals have stayed uninsured thus far, and unless the penalties increase, they’re likely to stay uninsured. The penalty has now topped out at 2.5%.

If Democrats are in power, conversations about increasing penalties may begin. Higher penalties will force more people to get medical insurance including healthy young people, which could give the California Health Care Marketplace more stability.

Covered California Open Enrollment 2017 is expected to mi...

by John Hansen

We were promised the Affordable Health Care Act, but for many it seems like it should just be called the “Care Act”. If you’re not poor and on subsidies, prices have actually risen. Health care in our state is actually less affordable than it was before Obama Care California came to be.

California health insurance companies have been trying to respond to the problem of affordability. They have made efforts to get their risk pools stabilized, but this has been difficult since Health Care Reform. The goal is to provide affordable health care by only having rate increases that are lower than Consumer Price Index (CPI), but we are likely not going to see that at least until 2019.

The two biggest drivers of cost in California health care are Minimum Essential Benefits (MEB) and Guaranteed Issue coverage.

Since the passage of Obama Care, no longer can medical insurance carriers in California deny coverage to people with serious health conditions. “Auto-issue health insuran...

by John Hansen

Already, the Covered California Health Exchange is requiring all carriers (even Blue Cross/Blue Shield PPO’s) to assign all members a Primary Care Physician (PCP). They want everyone to have a doctor, and they want everyone to be getting their checkups and preventative tests.

Evaluations will be done on doctors and hospitals to see how well they’re doing related to various health care outcomes. These results will be published, and will likely influence consumer choice regarding selection of health insurance coverage.

Peter Lee of Covered California even mentioned the possibility of kicking health plans out of the California Health Exchange based on this data. As an example, he mentioned the possibility of Obama Care California not contracting with providers who have higher rates of C-sections.

Covered California is on the warpath for quality of care. They are expected to be testing hospital quality, admission rates, infectious disease rates and more. Quality ratings are...

by John Hansen

You’ve heard of soda taxes and bagel taxes in New York. Even a fat tax was proposed. “Weigh in, buddy. Uh oh, you’re weight’s up, so that means that your taxes are going up as well.” This sounds like a preposterous idea from a George Orwell science fiction book, but it may just be the reality that we will be facing with regard to health care in California in the future.

The government, and therefore tax payers, has been paying for health care in California since Medi-Cal and even more so since the passage of the Affordable Care Act (ACA). When you make poor health choices that lead to medical problems, you end up at the doctor or the hospital. Health care costs go up. Health insurance premiums rise. The government has to fork out more money because you just haven’t been able to lay off the Oreo cookies.

In the past, your obsession with cake has been your own deal. But now your fellow Californians are all paying the price for you to have those little treats. Ever...

by Wendy Barnett

I got enrolled on an Obamacare plan during the Covered California Open Enrollment, and now I find out that I have been terminated for lack of documentation. Can I get reinstated? What do I do?

In the last couple months, Covered California and their licensed insurance agents have been following up with clients who need to submit supporting documentation. The type of documents requested, are usually proof of income and proof of legal presence. A full list of allowable documents can be found here.  However, some insured on these Obamacare California health plans have not submitted their documents in time, and their medical coverage has been terminated.

Yes, in many cases California consumers who have been cancelled due to lack of documentation have been able to get their health insurance plan reinstated. Covered California’s mission is to get all consumers in this state covered with a health plan. Toward that end they have created a process by which Californian’s who ha...

by Wendy Barnett

You may have an issue with your enrollment application, with the health plan, or with the Covered California website, etc. When you contact Covered California as a consumer (800-300-1506) or as an agent (855-777-6782), you will get one of two responses.

When you call back to check on your issue, you should reference your ticket number. You may be told, “There is no new news. Please call back in one week.”

One agent called the individual consumer line and found that the issue had been “escalated.” The agent received a reference number for the escalation to the help desk / customer resolution team. This means that the ticket gets some priority over other issues that are not as urgent.

At that point, the Covered California representative said, “We need to wait for the customer resolution team to resolve the issue. If it hasn’t been resolved within 30 days we could ask for it to be ‘escalated’ again.”  In cases of escalation, the expected time frame is 30-...

by Wendy Barnett

At times a consumer has issues with their Obamacare California health plan or their application, and they need to file an appeal. Perhaps you were denied coverage for some reason that you thought was not legitimate. In cases like these, you can go file an appeal either by email or by phone.

In one case, one of our agents, Wendy Barnett, filed an appeal on behalf of a client. The agent said, “It was a long, drawn out process that involved a judge. The judge responded back with an order that was missing some information critical to the appeal.”

Ms. Barnett followed up by calling the California Department of Social Services (CDSS), a Health and Human Services Agency, who is in charge of appeals. She explained that the answer was vague, and she asked the judge to review the decision. The judge quickly responded with a revised order stating that Ms. Barnett’s client would get a two month refund, which was the desired outcome.

However, Covered California did not give the...