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Covered California Update

Covered California Update

Covered California Sees Strong Enrollment Numbers in 2016: Covered California released a detailed breakout of its 2016 enrollees at its Board meeting on February 18. Nearly 440,000 new enrollees had selected a Qualified Health Plan (QHP) as of February 6, 2016. Low-income (88%) and communities of color (66%) continue to represent the majority of Exchange enrollees with Asians at 20%, Pacific Islanders at >1%, Black or African-American at 4%, Latino at 36%, American Indian or Alaskan Native at > 1%, and multiple races/other at 7%.

While Covered California’s preliminary enrollment numbers are strong, they provide an incomplete picture of the enrollee population as close to one-third of enrollees (119,510) did not respond to demographic questions. Covered California plans to provide additional data on its 2016 enrollee population including information on the written and spoken languages of its enrollees at a later point this year.

Covered California Revamps its 2017 Standard Benefits Designs: Covered California’s Board approved changes to the 2017 standard benefit designs that will help to encourage the use of preventive care by Covered California enrollees. The changes include lowering co-pays for primary care, mental health, rehabilitation and urgent care by $5-10 dollars in every metal tier except Bronze. Additionally the new designs will alleviate consumer confusion by removing the extra deductible and physician copay from Emergency Department services. Additionally a drug cap will be applied after the deductible for High Deductible Health Plans (HDHP) as required by law (AB 339). In order to make these changes, Covered California raised co-pays in other areas where care is accessed less frequently, including x-rays/diagnostics, imaging, and ED facility copays. Additionally there will be increases in the Maximum Out-of-Pocket (MOOP) by $550 (Silver and Gold), $300 (Bronze) and $100-250 (Enhanced Silver).

Covered California Poised to Approve Quality Initiatives that Prioritize Health Disparities Reduction in the Exchange: California has the opportunity to lead the nation by ensuring that health equity is not only important but central to all of its quality improvement strategies and to the exchange’s ability to achieve its mission of reducing health disparities in our state. As part of its 2017 contract requirements, Covered California is proposing to require health plans to meet concrete, enforceable year-over-year health disparities reduction goals in specific target areas where known health disparities exist. These areas include: diabetes, hypertension, asthma and behavioral health. Chronic conditions are the leading cause of death in the United States and the biggest contributor to health care costs. Sociodemographic factors such as income, race, ethnicity and geographic location can impact the prevalence of these types of conditions. According to the California Health Care Foundation (CHCF), about 40% of adults in California — over 11 million people — reported having one or more chronic condition, and about 3 million adults reported having two or more.[1]  Adults on public insurance plans were more likely to have one or more chronic conditions compared to those on private plans or the uninsured. To help meet these ambitious health disparities reduction goals, the Exchange is also requiring health plans by 2019 to improve their collection of demographic data, achieving 80 percent self-reported racial/ethnic identity of their enrollees. Self-reported data is data reported directly by an individual and is the gold standard for demographic data collection according to the National Quality Forum.

While these provisions are a great first step, CPEHN has urged Covered California to ensure health equity is an integral component of all of Covered California’s key quality improvement initiatives. For too long quality improvement and disparities reduction have been treated as separate objectives. This approach is not feasible in a state like California where a majority of Covered California enrollees (60%), and the majority of the state’s residents, are racially and ethnically diverse. Disparities in access to care are pervasive which is why the Centers for Medicare and Medicaid Services (CMS) is now recommending that agencies evaluate disparities impacts and integrate equity solutions across all CMS programs.[2] There is a clear rationale for prioritizing and integrating health equity in quality improvement initiatives. Most quality improvement strategies will not automatically benefit all segments of the population equally. For example, an intervention that improves quality at the same rate for all racial and ethnic groups leaves existing disparities constant. Additionally, without an explicit focus on disparities reduction, other quality interventions such as pay-for-performance programs may have the unintended consequence of worsening health care disparities by creating pressure for providers to avoid caring for people who are perceived to be high-risk patients.[3]

Making equity a central component of Covered California quality improvement initiatives will help to ensure those initiatives are actually meeting overall quality improvement goals. Covered California has delayed a vote until April 2016 on its 2017 required quality improvement initiatives. CPEHN will continue to monitor developments in this area and notify advocates of opportunities to advance concrete goals towards achieving health equity in Covered California.

Advocates Alarmed by Covered California’s Proposal to Require Paper Documentation as Proof of Eligibility During Special Enrollment Periods (SEP): Advocates raised concerns at February’s Covered California meeting over a new proposal to require paper documentation for all Special Enrollment triggers except the loss of Medi-Cal coverage. A special enrollment period is a period outside of an open enrollment in which an individual can get health insurance coverage due to qualifying life events such as a change in family status, job loss, or birth of a child. Currently individuals can self-attest to these qualifying life events thereby making it easier to enroll in health coverage. Health plans however are asserting that because of this policy, some enrollees with high health care needs are unfairly accessing coverage. According to its own estimates, Covered California’s proposed new paper documentation requirement could bar as many as 10-15% of enrollees from accessing coverage through special enrollment in Covered California. This policy will be especially onerous for low-income communities of color and Limited English Proficient (LEP) who may be unaware of the rules and/or have difficulty locating and mailing in the necessary documentation to keep their coverage. Advocates submitted a sign-on letter and testified to the Board in opposition to this onerous proposal. In response, Covered California has proposed to include consumer advocates in discussions on the SEP proposal and proposals to address consumer barriers such as allowing electronic verification in place of paper documentation of special enrollment events. Covered California staff will bring the final process back to the Board in April for action, with the anticipated start date of June 1, 2016.


[1] “Californians with the Top Chronic Conditions: 11 Million and Counting,” California Health Care Almanac 2015. California Health Care Foundation, April 2015.


[2] “The CMS Equity Plan for Improving Quality in Medicare,” September 2015.

[3] “Quality improvement efforts under health reform: How to ensure that they help reduce disparities – not increase them,” RM Weinick, R Hasnain-Wynia – Health Affairs, 2011.

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