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Covered California

This document summarizes key points from the CAHAM Annual Conference held in September 2014, focusing on Covered California health plans. It highlights the various metal tier benefit levels, including Bronze, Silver, Gold, and Platinum. The importance of verifying patient eligibility, changes in premium payment methodologies, and the challenges faced by health plan employees in confirming coverage are discussed. Additionally, it provides real-life eligibility examples and solutions for ensuring proper identification and documentation in hospital settings.

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Covered California

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  1. Covered California Keep calm and keep asking questions

  2. Covered California Health Plans CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  3. Metal Tier Benefit Levels • Bronze • Silver • Gold • Platinum CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  4. HOSPITAL A - Plan ID’s #1 (1 hospital) CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  5. Plan ID’s #2 & 3 (Bronze Level Plan ID’s) CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  6. HOSPITAL B - Plan ID’s NO PENDING CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  7. HOSPITAL C - Plan ID’s CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  8. Identification Easy ID? CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  9. EASY – Anthem BRONZE Card CHANGED STANDARD DEFINITIONS! Basic PPO = Bronze; Enhanced PPO = Silver Preferred PPO = Gold; Ultimate PPO = Platinum CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  10. Blue Shield Eligibility Enhanced PPO = Silver CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  11. Health Net – no level listed CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  12. Covered CA Identification • Eligibility – IFP does not show icon • Eligibility systems do not always show Covered CA benefits • Health Plan employees do not always know CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  13. Premium Payments • Old Methodology – Employer Pays premiums and deducts employee amount from pay check • Covered California Methodology – Patient pays premiums, has 90 days to pay CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  14. Premium payment methods • Health Plan – best • Broker – can cause delay in eligibility • Covered CA – delay in eligibility CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  15. Other Complications • Health plan receives matching federal funds • Patients do not have checking accounts –working on a cash payment process at stores CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  16. Eligibility Examples

  17. COVERAGE ELIGIBILITY– month to month Pt. Discharged – what health plan? • Jane Kawabunga is admitted on March 31st as Health Net gold and is verified as covered. • Jane is discharged on April 2nd and leaves the hospital before Patient Access can speak to her because the nurses did not call to say that she was leaving. • Patient Access checks the eligibility vendor and calls Health Net but cannot validate April coverage. • PA cannot talk to Jane because she is staying at her boyfriend’s and the wrong phone # was entered from the demog sheet which was difficult to readand not verified. CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  18. What Health Plan should we use? • Health Net Gold • Health Net Pending • Health Net bronze • Private Pay CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  19. What Health Plan should we use? - Answer • Health Net Gold Leave the original plan ID because the patient was verified as covered at time of admission. CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  20. Changes Made • Reminder to Reverify benefits on month end • Reminder to verify demographics and unclear writing • Educate the clinical staff CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  21. COVERAGE ELIGIBILITY– month to month – Pt. In-house • John Kawabunga is admitted on April 30th as Health Net gold and is verified as covered. • On May 1st Patient Access checks eligibility vendor and calls Health Net but cannot validate May coverage. What do we do? CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  22. COVERAGE ELIGIBILITY– month to month – Pt. In-house • Follow hospital procedure and talk to the patient/family – avoid letters at bedside • Verify premium payment or expected payment date • DOCUMENT discussion with patient/family (name, relationship, request, outcome) CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  23. Changes Made • Follow up with the patient prior to month end to pay the premium • Ask for proof of payment CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  24. What Health Plan(s) should we use? • Mortimer Applebush is admitted to Behavioral Health • Morty (his aka) has Blue Shield/Arta • We are contracted with Blue Shield/Arta, however, upon calling to verify coverage, it is found that Behavioral Health is carved out to MHSA and not contracted at this facility after providing the facility tax ID. • Morty has Medi-Cal secondary.  CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  25. What Health Plan(s) should we use? • Blue Shield • Blue Shield/Medi-Cal • Other Non-Contracted • Other Non-Contracted/Medi-Cal • Medi-Cal CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  26. What Health Plan(s) should we use? 4. Other Non-Contracted/Medi-Cal We will bill Blue Shield because Medi-Cal will deny if there is other coverage. CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  27. Other Issues • Cancer patients are changed to HMO during treatment, treatment is stopped until the assigned HMO can see the patient • Non-Contracted Covered California is paying $500/day, excluding co-pay • What else? CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  28. Business Office Operations effects – So far….

  29. Eligibility • No change seen yet in the eligibility process • Increased expanded Medi-Cal • Increased Presumptive Eligibility = increased follow up to ensure Medi-Cal application completion CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  30. Actual Account Follow up #1 • 1/1/14 – Pt Admitted, Pt had not received insurance card • 1/2/14 – Received Ins Info from the patient, called Blue Shield, no record of pt Pt states premium was paid • 1/7/14 – Called Blue Shield, obtained benefits: PPO, no ded; 80%; no mention of Covered CA • 1/17/14- Received Insurance Card with Covered CA icon • Jan/Feb – Follow up calls • 3/3/14 – Cld Ins: Total charges, $39,000, Pmt $2,000; Pt Liability $15,000 CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  31. Actual Account Follow up #2 • 1/6/14 – Pt Admittedto ED Trauma, pt intubated, rec’d demog info from sister, no ins info • 1/8/14 – Spouse states Blue Shield Silver, premium paid 1/6, presented BS invoice • 1/8/14 – Called Blue Shield, no record of patient (daily calls to Blue Shield) • 1/11/14- Patient expired • 1/13/14 – Blue Shield gave benefits, cannot pre-cert due to expiration, bill with med rec • 1/22/14 – billed with med recs and trauma info • Feb 2014 – called for status and potential missing information and checked website for follow up • 3/5/14 – Blue Shield denied for documentation CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  32. Health Plan Weirdness • Medi-Cal AND Covered California Managed Care • LA Care Mismatched systems • ? • ? CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  33. Low benefits/No explanation • Patient Admitted with bronze plan in March: $5,000 deductible, then $500 per day - Patients AND some counselors do not understand coverage CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  34. Other Issues • Increased Patient Anger • Health Plan confusion as to what is covered • Incorrect website information regarding contracted hospitals • Covered California impacts non-Covered California plans • Plans won't deny policy based on pre-existing but won’t pay CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  35. Surprising Goal • Increased patient education • Assist with plan level selection PRIOR to open enrollment • Education on benefits • Increased dialog while in house • Increased physician education CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  36. Solution • On-site Financial Patient Advocate • Helps patients navigate through the proces • Insurance eligibilty • Sponsored Care • Sort through bills • Redetermination for Medi-Cal • Workers Comp CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

  37. Surprising Goal • Otani Consulting Group, Inc. • Lynn.Otani@otaniconsulting.com • (310) 346-1958 CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

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