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Covered California Challenges

The challenges facing the Covered California health insurance marketplace are unique. At any given time, almost 7 million Californians have no health insurance - a number exceeding the entire population of Massachusetts. The diversity of Californians will tax outreach efforts. It’s individual health insurance market is huge - over 2 million people. These are some of the main issues the California Health Benefit Exchanges faces today.

Adverse Selection

Adverse selection describes a situation where individuals with higher health risks buy more insurance. When claims increase as a result of sick people buying health insurance, premiums go up too. Young, healthy people will not buy health insurance because they feel it costs too much. Worse, they buy it only when they become sick or have an accident. So the pool of insurance owners does not have enough healthy people to cover the medical claims of the high risk individuals. More…

Affordability of Coverage

The affordability of health care coverage in California is perhaps the single biggest challenge to the success, not only of Covered California but of health care reform in general. At the core of the affordability challenge is the fact that the Affordable Care Act (ACA) does little to reduce rapidly escalating health care costs. In fact, various ACA guidelines could to push up health insurance premiums. More…

Agent Issues

California health insurance agents are expected to be an important outreach and enrollment channel for Covered California. The Exchange must design policies to address several agent issues including Medi-Cal enrollment, training and certification, commission parity inside and out of the Exchange, and unbiased access to consumer information. More…

Essential Benefits

Essential health benefits are a key piece of healthcare reform. Essential benefits are a package of basic health benefits meant to set a benefit floor for all health insurance plans from 2014 going forward. While the ACA sets forth categories of benefits to be included, it was expected that HHS regulations would further specify essential benefits at the federal level, but in mid-December 2011 HHS announced that it was passing the responsibility for defining essential benefits to the states. More…

Health Plan issuers

The Exchange must partner with California’s Health Plan Issuers to meet its enrollment goals. The cooperation of the carriers will be essential to the Exchange’s success. As the Exchange begins enrollment activities starting in 2013 and into its first years of operations in 2014 and beyond, the investment that health plans devote to marketing and retention will play a critical role in creating consumer awareness of the Exchange. More…

IT Systems

The Exchange IT task is massive. An estimated 3.5 million Californians will be eligible for federal “tax credits” or subsidies to cut the cost of their health coverage when they begin buying policies through Covered California in 2014. An additional 1.9 million will qualify for expanded Medi-Cal coverage. More...

Medi-Cal Integration

There are significant gaps between where Medi-Cal is now and where it must be to be integrated with the Covered California in 2014. While the Affordable Care Act (ACA) provides a vision and new tools for a vastly simplified eligibility and enrollment system, it also creates new technical complexities that will challenge California’s ability to achieve its intent and promise. In addition, the ACA creates a huge expansion of Medi-Cal enrollment. More…

Navigator Issues

The Affordable Care Act (ACA) does state that the “Secretary (HHS) shall establish standards for navigators.. including provisions to ensure that a navigator is licensed if appropriate.” How prescriptive the proposed regulations will be shall significantly impact this question. However, flexibility is essential so that California can enforce her existing licensing laws. More…

Standardization of Benefits in QHPs

The Exchange must consider its options related to the degree to which the benefits offered in QHPs are standardized versus allowing more variation among QHPs. While ACA requirements ensure minimum coverage and a level of standardization, they allow for a wide range of potential variation in plan designs. More…

Uninsured Californians

Nearly 14 percent of Californians — over 7 million people — are uninsured at least part of the year. Of the uninsured, 40% or 2.8 million California citizens, have incomes of below the federal poverty level (FPL) and qualify for Medi-Cal but are not enrolled. This fact highlights the outreach and enrollment challenge the Exchange faces. More…

User Experience

Covered California has to be more than a health insurance marketplace. There are already some excellent broker operated, web-based portals, like eHealthinsurance.com and HealthcareShopper.com, that present plans and rates to individuals and small businesses. The private sector is more than able to adapt to the new Affordable Care Act (ACA) rules and develop dynamic choice portals. If the private market can deliver choices, the Exchange has to deliver more than choices. More…

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