California Health Care
by John Hansen
Illegal immigrant adults who do not have lawful presence in California can now get restricted Medi-Cal health insurance coverage by enrolling through the California Health Exchange, Covered California. They must have a household income that is less than or equal to 138% of the Federal Poverty Level (FPL) to qualify.
In 2010, when the Affordable Care Act (ACA) was front and center in the media, this was a hot button issue. Conservatives in California were concerned that they would end up footing the bill for health insurance for immigrants who were not lawfully present. However, the reality is that we only have two options:
Most Californians can’t stomach the idea of leaving people outside the hospital to die, so option #2 isn’t really an option. Health care for immigrants must be provided, and someone has to pay for it.
Before Health Care Reform and up until recently, usually private hospitals got stuck with the bill. Uninsured immigrants would show up at their doorstep...
by John Hansen
Minors without lawful presence can now qualify for child health insurance coverage through Medi-Cal if the household income is no more than 266% of the Federal Poverty Level (FPL).
The question of California health care coverage for illegal immigrants has been a hot political issue in the state and in the country. Many are concerned that giving those without lawful presence medical insurance will attract more illegal immigration. However, if these individuals do not have insurance, then what do we do when they have a health care need?
Do we leave illegal immigrants outside the hospital to die like they do with the uninsured in China? Or, do we offer them care? If we offer health care services to illegals, then who pays for this care? Should the private hospital have to foot the bill? Or, should the government pick up the tab?
Then, the question becomes what about child only health insurance in California for illegal immigrants? What about children who do not have lawful pre...
by John Hansen
At the CAHU Capital Summit on May 18, a California insurance agent asked Mary Watanabe, Deputy Director of the Department of Managed Health Care, about the difficulties he is having finding providers for the mental health care that is supposed to be included on the Obamacare California plans.
The insurance broker questioned, “Regarding the mental health component of new ACA plans, I’m finding it challenging for clients to access mental health benefits [in California]. Have you seen a trend related to this?”
Watanabe acknowledged right away that this has been a problem, especially in the more rural areas of California. She said, “My biggest advice would be to come to us early through the two-step process.” The process she was referring to was that of filing an Independent Medical Review (IMR).
Watanabe said that the Department of Managed Health Care has a separate group working on mental health care in California and the group is struggling to find solutions. In so...
by John Hansen
Since the implementation of the Affordable Care Act (ACA) commissions for health insurance agents have drastically decreased. This has caused many brokers to rethink whether or not they want to stay in the industry.
Michael Lujan, the current President of CAHU, says that by 2018 they are expecting that the amount of agents in the California market will drop by 25%. This is an alarming trend in an industry where consumers are desperately needing the assistance of knowledgeable professionals.
May 17, California Insurance Commissioner Dave Jones commented that insurance agents did the “lion share” of enrollments for Covered California. Mary Watanabe, Deputy Director of the Department of Managed Health Care, argued that agents are critical for consumers and promised the support of her organization in helping agents solve customer disputes with California health insurance plans and providers.
Lujan says he feels personally that agent commissions for individual as well as f...
by John Hansen
Mary Watanabe, Deputy Director of the Department of Managed Health Care, spoke to a room full of California health insurance brokers on May 18. At the beginning of her talk, she said, “Remind me to talk about broker commissions if I forget.” Someone from the crowd called out, “Don’t worry. We will.” To which people responded with laughter.
Watanabe pointed out that the issue of commissions for agents of health insurance in California has been on the radar of the DMHC for a couple months. There are a few issues that are of concern.
Some carriers have been varying commission rates based on metallic tier. They’ve paid lower commission rates for the Bronze tier and the high deductible health plans. Likely, carriers figured that since they were making less on these lower cost plans they would lower commissions. See Covered California Plans for a breakdown of benefits by metallic tier.
Also, some carriers have said they won’t pay commissions outside of Open Enrollmen...
by John Hansen
At the CAHU Capital Summit 2016 on Wednesday, May 18, Mary Watanabe, Deputy Director of the Department of Managed Health Care (DMHC), asked the rhetorical question, “Does the DMHC have teeth?” The answer is a resounding yes.
The DMHC is a government agency in California that works to protect 25 million insured on California health insurance plans in the state. A year ago the department took over the conservatorship of a poorly managed health plan. That is the kind of power this department wields.
The DMHC does not have the power to set rates for health plans. However, they assess the rates of plans and make recommendations if they feel the prices are unreasonable. Resistant carriers may find that the DMHC publishes their recommendations in order to create additional pressure.
They do surveys on a cycle of 3 years to assess health care organizations. And at times they do non-routine surveys when needed.
As far as teeth, the Department of Managed Health Care has been given...
by John Hansen
The Department of Managed Health Care, which protects 25 million California insured, has a newsletter with helpful information. Sign up for the DMHC’s “Listserv” at www.HealthHelp.ca.gov to receive updates and notifications about public meetings.
On the right side bar of the page toward the bottom, there is box that says, “Keep In Touch”. Simply enter your email and click the “Next” button. Then, you’ll receive helpful information and the latest news from the Department of Managed Health Care.
This information is helpful for those covered on health insurance in California, whether that be through commercial coverage or through a government health plan. Also, these updates are helpful for California insurance brokers who assist clients who are under the protection of the Department of Managed Health Care.
by John Hansen
The Department of Managed Health Care often plays the role of the enforcement arm of legislation related to health care in California.
According to SB 137, the DMHC regulates provider directories put out by California health insurance carriers like Anthem Blue Cross, Blue Shield of California and Health Net. After reviewing these directories, they found that 25% of the listings were incorrect.
In these directories, they found many doctors that were deceased or retired as well as hospitals and facilities that no longer provided health care in California. Thus the DMHC has put pressure on carriers to clean up their provider directories and only include physicians who are actually available in the network. Also, they will be mandating how the directories should be set up including search functions, etc. Mary Watanabe said, “This is a lot of work but it will make things better.”
According to SB 1052, the Department of Managed Health Care has been given the task of standar...
by John Hansen
The Consumer Help Center at the Department of Managed Health Care (DMHC) has assisted more than 1.7 million Californians resolve complaints and issues with their CA health care plans. Their services are fast, free and confidential. Deputy Director, Mary Watanabe, says that the DMHC is the “best kept secret in California.”
If your California health plan denies, delays or modifies your request for care you can apply for an independent Medical Review (IMR). If an IMR is decided in your favor, the plan must provide the requested service. “Approximately 60% of IMR requests result in the consumer receiving the requested service,” says Mary Watanabe.
There are two steps in the health plan grievance process.
First, file a grievance or complaint with your California health insurance plan. Plans are required by law to resolve enrollee complaints within 30 days. If there is an immediate threat to your health or your request was denied as experimental/investigational, you may...
by John Hansen
The Department of Managed Health Care (DMHC) was established in 2000 through consumer sponsored legislation. It regulates the health care and medical insurance for 25 million Californians including the majority of those on Obamacare California plans insured through Covered California.
The mission of the DMHC is to “protect consumers’ health care rights and ensure a stable health care delivery system in California.” The department is funded by assessments on health plans, so they are not dependent on the state legislature for income.
The DMHC regulates 121 California health insurance plans, including 72 full service plans and 49 specialized plans. They regulate all HMO plans in California and some PPO and EPO products as well as dental and vision plans. They oversee some large group, most small group, most Medi-Cal Managed Care plans and many individual and family products. The department gets its authority from the Knox Keene Health Care Service Plan Act of 1975.
It...