Wednesday, January 16, 2019

Health Reform Heats Up

More than three years have passed since the Affordable Care Act (ACA) was into law, setting into motion some of the most dynamic and volatile years the nation’s health care industry has ever seen.

Since its inception, the law has been a subject of controversy, inspiring hotly contested debates in Washington, D.C., Sacramento and across the entire nation.  For some, this dramatic overhaul of the nation’s health care system represents our national leaders finally making good on the long-overdue promise of “health care for all.” Others claim that the law is a clear overreach of federal authority that threatens to overburden an already fragile economy.

Although the law remains controversial, the United States Supreme Court has ruled that the law is constitutional and active steps are being taken to move forward at the federal and state level. With many of the provisions set to take effect on January 1, 2014, state officials across the nation are scrambling to make sure they’re ready to implement the law’s sweeping changes.

The road has already been a somewhat rocky one.

Throughout the implementation process, the U.S. Department of Health and Human Services has been narrowly meeting its own deadlines, often times leaving states waiting for federal guidance that could dramatically alter their own implementation plans. With several major deadlines coming in the next few months, many observers expect this problem to only get worse.

Adding to the headache for the federal government is the fact that the ACA has received mixed support from the states, which has complicated implementation efforts nationwide. As of early February, only 19 states had elected to develop their own state-run “exchange,” an online marketplace where consumers can purchase subsidized coverage. An additional five states will form state-federal partnerships to operate their marketplaces, while the remaining states have declined to participate, meaning the federal government will be responsible for operating exchanges in those areas.

Despite these problems, the march toward reform continues on.

The Next Major Milestone
The next major milestone toward full implementation is set to take place on October 1, 2013, when state exchanges are set to begin their pre-enrollment. In the first years following these marketplaces going live, more than 32 million currently uninsured Americans are expected to gain coverage, either through an exchange plan or the ACA’s massive expansion of the Medicaid program. Some analysts expect as many as 5 million of these newly insured to come from California.

Three months after the pre-enrollment begins, January 1, 2014, exchanges are set to go live, meaning that millions of Americans will, for the first time, be able to purchase coverage using the federal subsidies promised in the ACA.

In order to navigate this massive undertaking, states will need to decide which plans will be offered through their exchanges, construct the actual online marketplaces through which consumers will purchase coverage and implement major public outreach campaigns to ensure that these citizens – many of whom have never had the benefit of “open enrollment” or a similar purchasing period – understand how and where they can sign up for coverage under the reform law.

California Leads the Way
Despite the uncertainty swirling around the ACA’s implementation, California looks to be on track to meet the coming deadlines.

In the days following the ACA’s passage, California was the first state to establish a health benefit exchange and has been working toward implementation ever since. That exchange, recently named Covered California, has already launched its online consumer marketplace, www.coveredca.com, and is one of 25 states that have gained conditional approval from the federal government to operate its own insurance marketplace.

There is, however, still much work to be done at the state level.

Unlike most other states, California opted to adopt an “active purchaser” model when building its new exchange, meaning Covered California’s Board of Directors will be responsible for selecting which insurance providers will be allowed to offer products on the exchanges. The selected products, known as qualified health plans (QHPs), will be required to meet a set of benefit standards finalized by the Covered California board late last year. The QHPs will be selected through a competitive bidding process set to begin in the coming months, and it’s anticipated that somewhere between three to five QHPs will be selected for each one of California’s 18 geographical rating regions.

Protecting Physician Interests
Unfortunately several recent decisions by the exchange board have placed California’s physician community on its heels. The California Medical Association (CMA) has been an active participant in stakeholder hearings and is working to ensure that the interests of physicians and their patients are taken into consideration as the exchange prepares to open for business.

Several of issues of concern arose when the board was working to finalize the benefit standards that interested payors will be required to meet in order to have their products considered for the QHP designation.  One major concern for physicians is how the exchange plans to deal with monitoring and ensuring network adequacy among of QHPs.

Throughout the benefit design conversation, exchange staff continued to favor the existing method of network monitoring, which calls for the Department of Managed Health Care (DMHC) and Department of Insurance (DOI) to be responsible for ensuring that plans offered to consumers have enough participating providers. In other words, the status quo. Several stakeholders, including CMA, have noted that those two entities are currently unable to ensure adequate networks among existing plans and would likely be overwhelmed by the added task of monitoring additional exchange products. While CMA asked that the exchange take an active role in monitoring networks beginning in 2014, the DMHC/DOI method remained in the final benefit standards adopted by Covered California’s Board of Directors in August, meaning it could become the norm once the state’s marketplace goes live.

CMA also voiced concern over the exchange’s handling of the “grace period” provision included in the ACA. Under current California law, patients who are delinquent on their premiums are allowed a full 90 days to settle up before their policy is terminated for nonpayment. However, under the ACA’s grace period provisions, exchange plans will be allowed to suspend payment for services rendered if an enrollee is more than one month delinquent. If the patient fails to settle up within the three-month grace period, the plan can then terminate coverage for nonpayment and deny all pending claims for services. In this scenario, physicians could potentially be on the hook for 60 days worth of services with no avenue for recourse.

CMA has repeatedly asked Covered California’s board to reconcile the state and federal policy, but to date an adequate fix has not been presented.

Given the exchange’s accelerated timeline, as well as the exchange board’s tendency to revisit issues that were previously thought to be decided, it remains possible that both of these matters, along with others that have caused concern to physicians, could see some sort of resolution before 2014.

To be sure, the next few months will be some of the most important and tumultuous times the medical community has faced in recent memory, but as a CMA member you have the comfort of knowing that your interests are being advocated for in front of all the key players driving the nation’s reform efforts.

For more information on the implementation of health reform in California, subscribe to CMA Reform Essentials. This newsletter, available to both members and nonmembers, covers the activities of the state’s health benefit exchange board and legislation significant to California’s ongoing reform efforts. Subscribe today at www.cmanet.org/newsletters.


I Need News & Information

Tags

2013 2014 Ebola Outbreak 2014 Election 2016 2018-2021 ACA AIDS Annual Report Appointments Assembly Business and Professions Committee Awards Ballot Initiatives Boxer Budget Burnout CA Ballot Initiatives CAFP California CMA CMA Annual Report Comments Congress Construction Controlled Substance CURES Discontent Dolores EHR Election Election 2014 Exchange Governance Grace Period H.R.2. Health Exchange Health Laws Healthcare Laws HIE HIT HIV Hizon HOD House House of Delegates ICD-10 IEHP Languages Lee Legislation Mahdi Meaningful Use Medical Medi-Cal Medicare MICRA Mode of Practice No on 46 NoOn46 opiods Opioids Outstanding Contribution Patients Paul Green Practice Management Prop 46 Prop 56 Proposition 46 Public Health Alert Rajaratnam Rancho Springs Rating RCMA Repeal Risk Management Riverside Community Hospital Riverside County Schedualing Senate SGR Southwest Healthcare Stage 2 Strategic Priorities Survey Termination Trial Lawyers Uppal Vaccines Volunteer White Wilson Creek Winery 2014 2014 Election 2014 laws 2015-2017 2016 2016 Election 2018 46 AB 3087 AB 880 ABX2-15 ACA Advocacy Affordable Care Act AHCA AMA Anthem Blue Cross Assembly Assembly Bill Attestation Awards Big Tobacco Blue Shield of California Burnout CA CA Senate Cal INDEX California California Laws California Legislation California Society of Plastic Surgeons Californian Physicians Cameron Kaiser CCI CDC CEO Clearinghouses CMA CMS Coalition for Patient Access and Quality Care Committee Congress controlled substances Coroner Council on Graduate Medical Education Covered CA Covered Califonria Covered California CPT modifer CSPS CURES Cuts Deadlines deductible Delegates Delivery Models DHCS donate Drugs Dual Elligibles Ebola EHR eligibility Employment Law End-Of-Life Energy and Commerce Committee Republicans enrollment Exchange FAQ Federal Federal Legislation Feinstein Funding Future Gary Honts Grace Period Health Care Reform Health Reform Healthcare Rates Healthcare Reform Hernandez HIPAA ICD-10 IEHIE IEHP Imagine Plastic Surgery Increase Installation insurance JFK Memorial Hospital Kaiser Permanente Laws Legislation Legislative Alert Loma Linda long term disability LTSS MA Mahdi Managed Care marketing Meaningful Use Measles Medicaid Medi-Cal Medical Board medical practices Medicare member benefit MICRA Molina National Prescription Drug Take-Back Day Nomination Nominations Nondiscrimination Posting norcal Noridian Obamacare Insurance October 22 On-Call opiod opiod advocacy opiod crisis opiod enforcement opiod epidemic opioid opioid abuse Outstanding Palmetto GBA Patient Patient Care patients Payment Models PHA Physician Aid-in-Dying Physician Burnout Physician Recruitment Plastic Surgery POLST Practice Management practice managment Practice Mangement prescribing opiods prescription drugs President Priorities privacy Professional Liability Prop 46 Prop 56 Proposition 46 Proposition 56 Public Health Public Health Alert RCH RCMA RCMA Member Red Tape Reputation Retreat Risk Management Riverside County RIVPAC SB 491 SB 492 SB 493 SB 62 Scope of Practice Sequestration SGR social media State Capitol Stress Survey Telemedicine Tenet Thakur Law Firm Transforming Your Practice UC Riverside Vantage Virtual We Care for California Workers' Comp
Home   |   Physicians   |   Resources   |   Benefits   |   Events   |   About   |   Patients   |   Join
Copyright (c) 2019 Riverside County Medical Association