COVERED CALIFORNIA POLICY AND ACTION ITEMS November 19, 2015

Transcription

1 COVERED CALIFORNIA POLICY AND ACTION ITEMS Nvember 19, 2015

2 2017 QHP: RECERTIFICATION, NEW ENTRANT Anne Price, Directr f Plan Management Divisin

3 2017 CERTIFICATION PROCESS Cvered Califrnia is in the prcess f determining ur 2017 certificatin plicies that take int cnsideratin a multi-year strategy. Subcmmittees, cmprised f stakehlders, regulatrs, and carriers have been meeting t review benefit design changes and new carrier quality requirements that culd be included in the 2017 certificatin applicatin and final cntract fr Individual, Small Business and Family dental lines f business. The majrity f wrk is expected t be cmpleted in early January with a staff recmmendatin t the bard in the January bard meeting and final apprval by the bard expected during the February bard meeting. The 2017 applicatin prcess is expected t run thrugh May 1st, with negtiatins ccurring late May thrugh mid June. 2

4 INDIVIDUAL CERTIFICATION GUIDING PRINCIPLES Prvide stability fr cnsumers by having a stable prtfli with three-year cntracts, f carriers, prducts, and netwrks that ffer distinct chice and quality healthcare at a cst with annual changes that are at, r belw, trend. May allw fr the cnsideratin f new carriers in 2018 and 2019 based n differentiatin f prduct, netwrk, peratinal capabilities, and quality innvatins that will benefit Cvered Califrnia cnsumers. Prmte cntinued grwth and implementatin f integrated mdels f care such as Accuntable Care Organizatins (ACO), Medical Hmes, and mdels that reimburse and supprt primary care. Implementatin f new prvider payment mdels that benefit cnsumers receiving the right care, at the right time and right place. Allws fr annual changes t benefit designs that prmte preventative care, increase management f chrnic cnditins and increase access t needed care. Revise cntract t require cntinued imprvement and hld carriers accuntable fr the delivery f quality care t cnsumers that fcuses n the unique ecnmic, demgraphic and reginal variatin that exists within ur membership. Require effrts that increase new enrllment, effectuatin, and imprve retentin. Identify pprtunities t reduce administrative csts t favrably impact affrdability. 3

5 PROPOSED APPROACH FOR 2017 INDIVIDUAL CARRIER CERTIFICATION Fr 2017, recmmend ne QHP Certificatin applicatin that is pen t all licensed health insurers with selectin criteria that reflects cnsumer chice, value, quality and stability. The 2017 applicatin is fr a multi-year cntract term ( ) with annual plan re-certificatin that includes review and Cvered Califrnia apprval f the fllwing: Cntract cmpliance and perfrmance review Rates Benefits Netwrks New prducts Updates t Perfrmance Requirements May allw new entrants in 2018 and 2019 if the carrier is newly licensed r a Medi- Cal managed care plan and the additin brings value t what is already being ffered in the regin(s). Cnsider changing exchange participatin fee amunt r methdlgy that may include changing the structure f the fee t a percent f grss premium. 4

6 DENTAL CERTIFICATION GUIDING PRINCIPLES (INDIVIDUAL AND COVERED CALIFORNIA FOR SMALL BUSINESS) With family dental being a new ptin fr 2016 fr the Individual market, the guiding principles fr 2017 certificatin will be fcused n stability in prducts ffered and stability in future premium changes as we lk t cntinue increasing enrllment in this line f business. Fcus n strategies t retain members and increase new enrllment. Prvide stability fr cnsumers by having a prtfli f carriers, prducts, and netwrks that ffer unique chice and quality dental care at a cst with annual changes that are at r belw trend. Allws fr annual changes t benefit designs that prmte preventive care and value. Require cntinued imprvement in the quality f care prvided t cnsumers. 5

7 PROPOSED APPROACH FOR 2017 DENTAL PLAN CERTIFICATION (INDIVIDUAL AND CCSB) Fr 2017, recmmend ne QDP Certificatin applicatin that is pen t all licensed dental plans. The 2017 applicatin is fr a multi-year cntract term ( ) with annual plan re-certificatin that includes review and Cvered Califrnia apprval f the fllwing: Cntract cmpliance and perfrmance review Rates Benefits Netwrks New prducts Updates t Perfrmance Requirements N new dental insurer entrants thrugh 2019 except newly licensed. Allwance fr changing exchange participatin fee that includes changing the structure f the fee t a percent f grss premium fr HMO and PPO dental plans. 6

8 SMALL GROUP CERTIFICATION GUIDING PRINCIPLES Guiding principles fr 2017 certificatin are fcused n increasing Cvered Califrnia enrllment in the expanded small grup market with a strategy that ffers lng term cst sustainability fr cnsumers Cnsider hw the individual carrier prtfli aligns and cmplements the small business prtfli. Prvide a cmpetitive prtfli f prducts that will ffer emplyees f small grups the chice t enrll with a carrier that is fcused n prviding quality care at premiums that are at r belw ther ptins available in the small grup market. Flexibility t adjust prducts, netwrks and premiums cnsistent with regulatry requirements. Certificatin and cntract requirements that include expectatins fr quality imprvement. Benefit designs that prmte preventive care, increase management f chrnic cnditins and increase access t needed care. Opprtunities t reduce administrative csts t favrably impact affrdability. 7

9 PROPOSED APPROACH FOR 2017 SMALL GROUP CERTIFICATION Cvered Califrnia fr Small Business QHP certificatin applicatin, pen t all licensed health insurers and nt limited t carriers wh are QHPs fr Individual Multi-year cntract term ( ) with annual carrier certificatin that includes review f premium cmpetitiveness and stability, perfrmance, and cmpliance with QHP cntract requirements Allwance f new carrier entrant ff annual certificatin cycle if the carrier is a Qualified Health Plan fr the Individual prduct* Allwance fr quarterly change in rates, prducts, plans and netwrks (subject t Cvered Califrnia apprval)* *staff is recmmending that the last tw items be changed in the 2016 regulatins t allw fr these changes in the 2016 calendar year 8

10 2017 BENEFITS AND CONTRACT UPDATE Anne Price, Directr f Plan Management Divisin

11 OBJECTIVES OF COVERED CALIFORNIA S 2017 BENEFIT DESIGN AGENDA Organizatinal Gal Cvered Califrnia shuld have benefit designs that are standardized, prmte access t care, and are easy fr cnsumers t understand. Benefit Design Gal Prvide input t Cvered Califrnia staff as we develp recmmendatins fr the 2017 benefit plan designs that cnsider a prgressive strategy f ptential benefit changes thrugh 2019 Subcmmittee Objectives 1. Address benefit design pririty areas that will reduce barriers and imprve cnsumers access t needed care 2. Cnsider benefit changes that align value with imprved health utcme 3. Identify and recmmend benefits changes that may be necessary t meet Actuarial Value (AV) requirements 4. Identify benefit design areas that shuld be imprved fr cnsumer understanding f cverage and ease f plan cmparisn 10

12 OBJECTIVES OF COVERED CALIFORNIA S 2017 QUALITY AND VALUE AGENDA Organizatinal Gal Cvered Califrnia will be a catalyst fr change in Califrnia s health care system, using its market rle t stimulate new strategies fr prviding high-quality, affrdable health care, prmting preventin and wellness, and reducing health disparities Quality Subcmmittee Gal Prvide input t Cvered Califrnia staff as we develp recmmendatins fr 2017 cntract requirements that will target further imprvements fr the quality and delivery f care t cnsumers and align effrts fr participatin with ther State and Federal initiatives Prvide feedback n gal-setting with an eye fr targeted imprvements by

13 2017 CERTIFICATION PRELIMINARY TIMELINE ACTIVITY DATE Medical, Dental Benefits and Quality Subcmmittee Meetings with Carriers, Stakehlders and Regulatrs Plan Management Advisry Updates f Subcmmittee Meetings September Nv 2015 Octber 15 th and Nvember 12th Cntinued Subcmmittee Meetings December 2015 January 2016 Plan Advisry Meetings January and February 2016 Bard Recmmendatin fr 2017 Certificatin, Benefits Designs and Cntract Quality Requirements Bard Apprval f 2017 Certificatin, Benefits Designs and Cntract Requirements January 2016 (Date TBD) February 2016 (Date TBD) 2017 Applicatin Open t Health and Dental Plans March 1, Applicatin Due t Cvered Califrnia May 2, 2016 Cvered Califrnia Applicatin Evaluatin and Carrier Negtiatins June 6 June 17 Public Annuncement f Preliminary Rates Week f July 4 Regulatry Review f Rates Begins Week f July 4 12

14 INDIVIDUAL ELIGIBILITY & ENROLLMENT REGULATIONS READOPTION (Actin) Katie Ravel, Directr f Plicy, Evaluatin, and Research 13

15 KEY CHANGES TO ELIGIBILITY & ENROLLMENT REGULATIONS Cvered Califrnia staff is seeking actin this mnth t readpt with changes Staff cntinues t wrk with stakehlders t refine the appeals regulatins t reflect prcess imprvements Clarifies the language regarding expedited appeals and appeal decisins Clarifies the language regarding the implementatin f the appeal decisins Adpted timeframes fr implementing appeals decisins Nn-Tax Filer attestatins Reslutin

16 CERTIFIED INSURANCE AGENTS (Repeal) Kirk Whelan, Directr f Outreach and Sales 15

17 AGENT REGULATIONS Agent regulatins were develped t incrprate the terms f the Agent Agreement Recent legislatin clarifies that Cvered Califrnia agreements d nt need t be prmulgated in regulatins. Due t ur amending the Agent Agreement, the current regulatins will be ut-f-date. Since there is n lnger a need t put the Agent Agreement in regulatins, staff is recmmending the repeal f the agent regulatins and is seeking Bard apprval t d d. Reslutin