Health Care Reform: The ACA, Your Practice, and You - Part 1 March 17, 2014 Covered California, Health Care Reform ACA, Affordable Care Act, Andrew Calman, Covered California, Obamacare 0 Reprinted from the January/February 2014 issue of San Francisco Medicine. By Andrew Calman, MD, PhD, and Steve Heilig, MPH The initial rollout was a disaster. Of the people who were supposed to benefit from health care expansion, few said they understood the new law. Its approval rating was a dismal 28 percent, and opposition was fierce. The year was 1966, and under the guidance of Bay Area native Philip R. Lee, MD (assistant secretary of health, later chancellor of UCSF, and longtime SFMS member), the new program called “Medicare” overcame its initial stumbles to become successful and overwhelmingly popular. Fast-forward to 2014, when another Lee—Peter Lee, Phil’s nephew and formerly chair of the Pacific Business Group on Health—is overseeing the rollout of Covered California, California’s health exchange under the Affordable Care Act—aka “Obamacare.” Unlike the federal website (healthcare.gov) used by some thirty-four states, Covered California’s website (coveredca.com) has been feature-rich and relatively glitch-free, leading to robust early enrollment numbers. The first San Francisco enrollees have already received their Covered California insurance cards. Some Covered California enrollees could begin seeing physicians as early as January 1, although uninsured Californians have until March 31 to sign up for coverage and avoid a 1% tax penalty. Instead of focusing on the politics, let’s look at the practical issues of what these patients—and their doctors—can expect from this new program. Although there is a small-business option in the early stages of implementation, Covered California primarily impacts the individual health insurance market. Preexisting conditions are no longer a barrier to coverage. All individuals (except undocumented immigrants) who are not covered by an employer-sponsored or government insurance program are eligible to enroll. All programs must offer a defined, comprehensive benefits package; guaranteed issue; community rating (adjusted only for age and smoking history); preventive care without co-payments or deductibles; and an annual out-of-pocket cap between $2,250 and $6,350. Patients who were previously enrolled in plans that do not meet these requirements, and who desire a plan with less coverage than the standard plan, have been offered reissue for one year or may enroll in a Covered California plan. Depending on family income, individuals and their families will be eligible for Medi-Cal, subsidized private insurance, or unsubsidized private insurance. Families earning below 133% of the Federal Poverty Level (FPL, about $15,000 for an individual or $31,000 for a family of four) will qualify for Medi-Cal. For the first time, this includes Medi-Cal eligibility for adults without dependents, and it also includes expanded mental health and dental care. This expansion is expected to increase the Medi-Cal rolls by about 20%. Most new enrollees will be nondisabled adults between the ages of 18 to 64 and will receive care through the San Francisco Health Plan, which administers Medi-Cal HMO’s through the Community Health Network (SFGH and its satellite clinics), Kaiser, Brown & Toland, Hill Physicians, and Chinese Community Health Plan. Eligibility and claims should be no different from those for current managed Medi-Cal enrollees. Physicians contracted with these plans should expect to see a substantial increase in Medi-Cal patient load. Next Up: Federal subsidies & eligibility, metal-tier plans in Covered California, premium estimates. Comments are closed.
