CMA SERVICES: Three Things You Should Know About Covered California

CMA Center for Economic Services

At the close of this year’s open enrollment period, nearly 1.4 million consumers had completed the Covered California enrollment process, which significantly surpassed initial expectations. This makes it critical that physicians and their staff understand these new insurance products to minimize the inevitable frustration and confusion from such a large-scale change to the health insurance industry.

Know Your Participation Status
In late April 2014, the California Medical Association (CMA) surveyed physicians about their contracting experience with Covered California plans, also known as exchange plans. Eighty percent of respondents reported that they had been confused about their participation status in an exchange plan and that they believed such confusion had negatively impacted patient care.

Unfortunately, checking your practice’s participation status is not as straightforward as it might seem. Earlier this year, Covered California took down its cross-plan provider directory, which was plagued with inaccuracies. Add to that the fact that some exchange plans have used vague contract terms and amendments that rope physicians into participating in their exchange networks, often without their express consent or knowledge, and you’ll see that “Do you take my insurance?” is not always an easy question to answer.

Physicians are encouraged to verify their participation status on the individual exchange plan’s online provider directory. When searching, it’s important to select the correct exchange product type, as Anthem Blue Cross and Blue Shield of California are using significantly narrowed networks for their exchange products.

It is also important that front-office staff have a clear understanding of their physicians’ participation status. With all the new exchange plans added to the mix, it is no longer satisfactory to simply accept “I have Blue Shield” as an indication of whether the patient can be seen in-network. It is important, when scheduling, to determine in advance if the physician is indeed in the patient’s network.

When scheduling an appointment, practices should request that the patient provide the office with a copy of the front and back of their insurance ID card. Having a copy of the ID card in advance will allow the practice to clearly identify whether they are in the patient’s network and also to verify patient eligibility before the visit. Taking these steps could help patients avoid out-of-network costs, which can lead to frustration when they are faced with larger-than-expected bills.

For a detailed list of the exchange plans and products, see “Qualified Health Plan Networks for Covered California,” available in the CMA exchange resource center at www.cmanet.org/exchange.

Be Aware of Mirror Products
Every plan offered in the exchange must also be offered outside of the exchange, using the same provider network. This has resulted in a number of practices unknowingly seeing patients out of network for products that use an exchange network, as these ID cards will not have the Covered California logo on them. The issue is specific to just Anthem Blue Cross and Blue Shield of California, because they are the only two plans offering narrowed networks. Practices must review patient ID cards and eligibility information closely to identify whether the practice is in or out of network for that particular plan.

Understand the Grace Period
Federal law allows Covered California enrollees who receive financial subsidies to keep their health insurance for three months after they have stopped paying their premiums. This is known as the “federal grace period.” In the first 30 days of the grace period, federal law requires plans to pay for services incurred, but in months two and three of the grace period, plans can pend and deny claims. So it will be extremely important that practices verify eligibility on all exchange patients, ideally on the date of service, or as near the time of service as possible. If the patient is in months two or three of the grace period, the health plan should indicate that coverage is inactive or otherwise suspended.

Insurance cards for exchange enrollees do not indicate whether the enrollee is subsidized. Current enrollment trends predict that nearly 90 percent of those with exchange coverage will be subsidized and receive the three-month grace period. In other words, if you see a Covered California logo on the ID card, you should assume they will have the three-month grace period.

Unsubsidized exchange patients and those with a mirror product are not entitled to the 90-day federal grace period; rather, they only receive the 30-day grace period called for under state law.

Practices should have policies in place regarding how they will handle patients who are in months two or three of the grace period. Patients should ideally be made aware of this policy in advance. If a patient’s eligibility verification comes back indicating their coverage is not active, the practice should treat the situation as they would any other patient who has had a lapse in coverage. For non-emergent services, patients may be given the option to either pay cash at the time of service or reschedule to a later date, when their coverage is effective. The office policy should include how patients will be triaged to determine whether their condition is emergent or urgent, and the policy should be approved by the physician.

Having Trouble Finding an In-Network Provider?
Patients who are having trouble finding an in-network physician or facility are encouraged to contact the Department of Managed Health Care’s Help Center at 888-466-2219.

Available Resources
The following resources (and many more) are available free to members in CMA’s exchange resource center at www.cmanet.org/exchange.
Covered California: Know Your Participation Status. This document provides detailed instruction on how to check your participation status with the various exchange plans.
“Surviving Covered California” Tip Sheets. These documents contain tips on what to expect from and how to survive the first year of Covered California.
Qualified Health Plan Networks for Covered California. This document will help both physicians and patients decipher the new exchange product networks.
Covered California: Understanding the Grace Period for Subsidized Exchange Enrollees. This document contains answers to frequently asked questions about the Covered California grace period.
CMA’s Got You Covered. CMA’s comprehensive exchange toolkit for physicians.
Frequently Asked Patient Questions about Covered California. Available in both English and Spanish, this document provides answers to the most common patient questions.

Still Have Questions?
Members and their staff have FREE access to CMA’s reimbursement helpline at 888-401-5911 or economicservices@cmanet.org.

---

CMA’s Center for Economic Services offers help to CMA members with contracting, billing and payment problems.