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.