covered california

Covered CaliforniaKeep calm and keep asking questions

CAHAM Annual Conference - Otani Consulting Group, Inc. September 2014

Covered California Health Plans


Metal Tier Benefit Levels

• Bronze

• Silver

• Gold

• Platinum


HOSPITAL A - Plan ID’s #1 (1 hospital)

Plan Name/INSURANCE NAME ELIG PYR

Blue Shield PPO DMD05664

Health Net PPO DMD12345

Health Net Community Care HMO DMD23456

Anthem BX EPO DMD34567

Anthem BX HMO DMD45678

KAISER HMO DMD56789


Plan ID’s #2 & 3 (Bronze Level Plan ID’s)

PEND PYRPlan Name/INSURANCE NAME (Pending elig/premium) ELIG PYR Plan Name/INSURANCE NAME (eligible )

IHI070BA BLUE CROSS EPO-PEND CVD CA IHI070B1 BLUE CROSS EPO BRZ-CVD CA

IHI070BB BLUE CROSS HSA -PEND CVD CA IHI070B2 BLUE CROSS HSA BRZ-CVD CA

IHI186BA HEALTH NET PPO -PEND CVD CA IHI186BB HEALTH NET PPO BRZ-CVD CA

IHI056BA BLUE SHIELD EPO HSA-PEND CVD CA IHI056B1 BLUE SHIELD HSA BRZ-CVD CA INDEM

IHI056BB BLUE SHIELD PPO-PEND CVD CA IHI056B2 BLUE SHIELD PPO BRZ-CVD CA INDEM

IHI217BA KAISER HMO HSA-PEND CVD CA IHI217B1 KAISER HMO HSA BRZ-CVD CA INDEM

IHI217BB KAISER HMO-PEND CVD CA IHI217B2 KAISER HMO BRZ-CVD CA INDEM


HOSPITAL B - Plan ID’s NO PENDING

COVERED CALIFORNIA ELIG PYR Plan Name

12345 BLUE CROSS CVD CA 45678 BLUE CROSS ANTHEM

74184 HEALTH NET CVD CA 74185 HEALTH NET PPO

60331 BLUE SHIELD HSA INDEM

60332 BLUE SHIELD PPO


HOSPITAL C - Plan ID’s

COVERED CALIFORNIA ELIG PYR Plan Name

Trying to add BLUE CROSS CVD CA 45678 BLUE CROSS ANTHEM

74185 HEALTH NET PPO

60331 BLUE SHIELD HSA INDEM

Trying to add Blue shield PPO 60332 BLUE SHIELD PPO


Identification

Easy ID?


EASY –

Anthem BRONZE Card

CHANGED STANDARD DEFINITIONS!

Basic PPO = Bronze; Enhanced PPO = Silver

Preferred PPO = Gold; Ultimate PPO = Platinum


Blue Shield Eligibility

Enhanced PPO = Silver


Health Net – no level listed


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


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


Premium payment methods

• Health Plan – best

• Broker – can cause delay in eligibility

• Covered CA – delay in eligibility


Other Complications

• Health plan receives matching federal funds

• Patients do not have checking accounts –working on a cash payment process at stores

Eligibility Examples


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 read and not verified.


What Health Plan should we use?

1. Health Net Gold

2. Health Net Pending

3. Health Net bronze

4. Private Pay


What Health Plan should we use? - Answer

1. Health Net Gold

Leave the original plan ID because the patient was verified as covered at time of admission.


Changes Made

1. Reminder to Reverify benefits on month end

2. Reminder to verify demographics and unclear writing

3. Educate the clinical staff


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?


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)


Changes Made

1. Follow up with the patient prior to month end to pay the premium

2. Ask for proof of payment


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.



1. Blue Shield

2. Blue Shield/Medi-Cal

3. Other Non-Contracted

4. Other Non-Contracted/Medi-Cal

5. Medi-Cal



4. Other Non-Contracted/Medi-Cal

We will bill Blue Shield because Medi-Cal will deny if there is other coverage.


Other Issues

1. Cancer patients are changed to HMO during treatment, treatment is stopped until the assigned HMO can see the patient

2. Non-Contracted Covered California is paying $500/day, excluding co-pay

3. What else?

Business Office Operations effects – So far….


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


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


Actual Account Follow up #2• 1/6/14 – Pt Admitted to 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


Health Plan Weirdness• Medi-Cal AND Covered California Managed Care

• LA Care Mismatched systems

• ?

• ?


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


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


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


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


Surprising Goal

• Otani Consulting Group, Inc.• [email protected]

• (310) 346-1958

mailto:[email protected]

covered california

Documents

health net cvd ca

basic ppo

silverpreferred ppo

bronze enhanced ppo

blue shield hsa indemtrying

blue shield eligibility

gold ultimate ppo

complicationshealth