Covered California: Ten things every ob-gyn should know

C. Brett JohnsonC. Brett Johnson, JD, MPH, MS, associate director for medical and regulatory policy, California Medical Association

With the new year, California’s health benefit exchange, Covered California, is in full swing. As of December 31, the exchange had enrolled roughly 500,000 individuals, accounting for nearly a quarter of all exchange enrollments nationwide.

For those unfamiliar, Covered California is a marketplace for health insurance products, not an insurer. It offers insurance products that qualify individuals for federal premium subsidies. Because Covered California is a marketplace, products offered through it generally should be thought of as commercial health insurance products as opposed to public coverage with a set fee schedule.

Covered California, however, has also taken on the role of active purchaser, meaning that it will behave much like a large employer negotiating coverage terms (eg, premiums and patient cost-sharing) on behalf of its employees. This detail, coupled with requirements in federal and state law, creates a number of important considerations for physicians participating in exchange plans.

That being said, whether your practice is participating or not, here are 10 things to know and do as we move forward with Covered California:

1. Verify your participation status and information in Covered California’s central provider directory
Though the directory has improved significantly, the California Medical Association (CMA) continues to find errors in the information listed. Members have reported errors in their participation status, board certification, languages spoken, address, and specialty. Indeed, in the first weeks of the directory’s existence, the specialties of ophthalmology and ob-gyn were inversed for a number of physicians. To verify your status, follow the directions found in CMA’s “
Surviving the First Month of Covered California.”

2. Review any contracts or contractual amendments for exchange participation
If you are participating in Covered California, it may be helpful to undertake a review of any exchange-specific contract provisions, such as exchange-specific rates and policy manuals that may be incorporated by reference. If questions arise, ask the plan-specific contact listed in CMA’s “
Surviving the First Month of Covered California.”

3. Be aware of off-exchange products that use exchange plan networks
Every plan offered in the exchange must also be offered outside of the exchange, using the same network. This requirement has resulted in a number of practices unknowingly seeing patients out of network for commercial products that use an exchange network, as these identification cards do not have the Covered California logo on them. For example, a Blue Shield identification card may read “individual PPO” in the upper right and list “enhanced PPO” as the product, but only upon further investigation will it show the network as “IFP off exchange,” which is an exchange network.

4. Know who can help patients get further information on and enroll in exchange plans
For practices getting exchange enrollment questions that its staff is unprepared to answer, printing out a list of nearby certified enrollment assisters may be helpful. These can be found on the
Covered California enrollment assistance website.

5. Assess your practice’s policies on extending credit to and collections from patients
Some exchange plans will impose high cost-sharing burdens on patients. Furthermore, the currently evolving situation of the first month’s premium due date and delays in enrollee welcome packets may make eligibility verification difficult for some patients. Practices should consider strategies to protect themselves from such financial risks. Please refer to the
CMA physician guide to Covered California for further information.

6. Be prepared for exchange patients in grace period coverage limbo
Exchange enrollees receiving subsidies, currently 85% of those in Covered California, will have three months of premium delinquency before being terminated for non-payment. If a practice renders services to these patients in the latter two months of the three-month grace period, the plan has the option to suspend payment on those claims and deny them if the patient is terminated for non-payment. California will require exchange plans to represent coverage as inactive for those patients in months two and three of the grace period and give notice to certain physicians of record as to the patient’s status. Practices should have a policy in place for when they encounter patients in this period of uncertain coverage. Please refer to the
CMA physician guide to Covered California for further information.

7. Know the participation status of physicians, facilities, and other providers to which you may refer or use on a regular basis
Covered California plans require that physicians provide advance notice to patients of any out-of-network providers in the treatment plan and allow such patients to opt out of their inclusion in the treatment plan. If, however, the provider is listed as participating in the plan’s directory, the practice cannot be held liable for the inclusion. Please refer to the
CMA physician guide to Covered California for further information.

8. Be aware of patient cost-sharing across exchange plans
Covered California plans will expect practices to consider the cost of a treatment plan to the patient. Furthermore, treatment compliance challenges may arise among exchange patients due to high costs related to brand drugs, imaging, and specialty visits, among other things. More information can be found in the
Covered California benefit summaries.

9. Let no envelope from a health insurer go unopened for too long
Exchange plans are continually developing critical details as to how these plans will operate, especially in the areas of claims and billing. Many of these details are likely to come via policy manual amendments, which could be in a small envelope easy to overlook. Stay up to date on such significant changes by subscribing to
CMA Practice Resources, a free e-bulletin that focuses on critical payer and health care industry changes and how they directly affect the business of a physician practice.

10. Stay current on significant Covered California developments that may affect your practice
Stay up to date with
CMA Reform Essentials, a free e-bulletin designed to provide readers with the latest developments of California’s implementation of federal health care reform.

American Congress of Obstetricians and Gynecologists
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