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Will exchange users have to have medical homes?

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Provider network rules, balance billing and treatment of transgender family members are some of the topics that have come up in public comments on a model contract the California health insurance exchange system is developing.

The groups submitted the comments to the board of Covered California, the entity in charge of setting up a state-based individual exchange and a state-based Small Business Health Options Program (SHOP) small-group exchange for California.

The Patient Protection and Affordable Care Act of 2010 (PPACA) requires the U.S. Department of Health and Human Services (HHS) and state agencies to have exchanges, or health insurance marketplaces,” open in all 50 states and the District of Columbia by Oct. 1.

The Covered California board approved part of a model contract for the “qualified health plans” (QHPs) that are on track to sell coverage through the exchange at a recent board meeting. The board hopes to complete work on the QHP contract May 23.

The California Association of Health Plans (CAHP) provided extensive comments on matters such as how active Covered California should be in reviewing QHP marketing materials; plans’ interest in the ability to make quarterly rate changes; and information collection requirements.

One version of the model contract called for plans to health assessments from enrollees.

CAHP President Patrick Johnston asked the board to soften that requirement.

“We agree that it is important for plans to encourage the completion” of a health wellness assessment, Johnston said in a letter. “But, given the low rates of participation, we continue to believe that requirement requirements provide very little value, and we suggest that such provisions be deleted from the contract.”

Johnston also asked that exchange revise a section of the model contract that deals with primary care physician assignment, to be more welcoming to the many popular preferred provider organization (PPO) plans that do not require enrollees to designate primary care providers (PCPs).

The Covered California board wants plans to move in the direction of giving patients medical homes, or assignment to PCPs that help actively oversee their care.

Johnston suggested that many PPO enrollees prefer to have a different kind of relationship with PCPs.

“There may be other ways besides PCP assignment to get at the underlying goal of ensuring that enrollees know the value of their plan and are able to navigate the system and access care,” Johnston said. 

In a comment included as a note on one version of the draft, CAHP said, “One of the reasons an enrollee has likely selected the PPO product is that they want the ability to go to any physician of their choice. Assigning a PCP in this circumstance will just create confusion and likely resentment from the enrollee.”

Staffers at two advocacy groups, the National Health Law Program and the Western Center on Law & Poverty, came at the draft from a different perspective.

The staffers objected, for example, to Covered California’s acknowledgement that insurers don’t want the exchange to be a “third regulator,” on top of California insurance regulators and HHS.

The National Health Law Program and Western Center “appreciate the importance of making sure that Covered California operates efficiently, and that QHPs are not over-burdened by duplicative regulatory review,” the advocacy group staffers said. “That said, given Covered California’s role as an active purchaser, we urge the board to ensure that it retains a role in reviewing and evaluating QHPs’ performance in areas that are particularly important to Covered California’s mission.”

The advocacy groups want to see Covered California to approve all QHP marketing materials, the advocacy group staffers said.

“Without prior approval, QHP issuers will be free to design materials that target healthier populations, creating a high risk of cherry picking,” the staffers said.

The staffers also are pushing for the exchange to include specific protections against balance billing, or the practice of letting providers bill patients for the difference between the amounts insurers will pay providers and the billed amounts.

“We urge Covered California to make clear that QHPs must ensure that consumers are held harmless when a needed service is not available in their plan’s network so that they are forced to seek out-of-network care,” the staffers said.

Masen Davis, executive director of the Transgender Law Center, asked Covered California to support use of state definitions of terms that affect transgender consumers, and to continue to require plans to collect voluntarily reported data on matters such as sexual orientation and gender identity.

Collecting the data will be key to addressing health disparities affecting lesbian, gay, bisexual and transgender Californians, Davis said.

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