Covered California First Year Success

By Joan Trezek;

The signs of Fall Open Enrollment season are everywhere—on TV sets, in the newspaper and in mailboxes. It’s the time of year when consumers can sign up for health insurance coverage or change carriers or plans within a carrier’s offerings. The enrollment season officially began November 15 and ends on February 15, 2015. However, Medicare’s season is earlier—Oct. 15 through December 7 this year.

For people who have coverage through a large employer or with Medicare plus a supplemental plan which helps with expenses that Medicare doesn’t cover, the process is fairly straightforward—learn what is new, determine if the dollars you pay still suit your budget and personal/family needs, and finalize your decision to stay with what you have or make a change.

Covered California: Plans for Individuals & Small Business

However, last year a new entity appeared on the scene in California, the first state in the country to pass legislation to implement the Affordable Care Act (ACA) and one of the most successful states to implement it. The marketplace, known here as Covered California, is a partnership with the California Dept. of Health Care Services. Utilizing top-rated carriers, it is a marketplace for affordable health insurance plans that include federally mandated benefits for individuals and small businesses (up to 50 employees).

No individual (plus dependents) who qualifies is turned away. Health history or a pre-existing condition is no longer a basis for insurers to deny coverage or make it difficult to afford. To save time and eliminate qualification uncertainty, a single application is designed to serve both Covered California and Medi-Cal applicants (whose income doesn’t qualify for CC plans).

There are four basic plans: bronze, silver, gold, and platinum with varying deductibles and monthly premiums so that consumers can choose the plan that suits their medical needs, budget, and, ability to access a particular primary care physician or specialist if a PPO plan is chosen. According to California Certified Insurance agent, Rod Ford-Smith, president of Navigate Health Insurance in Walnut Creek, the process of figuring out what plan is the best fit begins with earning consumers’ confidence while gathering basic facts. Needed are: adjusted gross income based on the last tax return or most recent pay stub; number of people in the household to be covered, their ages; zip code (which determines pricing). “A good part of my job is educating consumers and asking the “what is important…” questions as they look at the various plans. Consumers need to understand terms like “deductible, co-pay, monthly premium as well as the difference between plans, i.e., PPO, HMO, EPO,” he says.* He points out that subsidies are available for what are typically considered moderate to relatively high incomes and influenced by the number of dependents and household zip codes.

Just as individuals have options to choose from, so too do small businesses that can access group rates that are advantageous for owners and employees. This underscores the value of providing insurance as a benefit to help retain and recruit new employees. Tax credits are available for qualifying small businesses. CPAs and insurance agents can make the calculations to help business owners learn whether they qualify.

During the first year, even with a steep learning curve, 1.2 million Californians who previously lacked health coverage were enrolled. The Commonwealth Fund estimates that the uninsured population of California was cut in half—from 22% uninsured to 11%. Officials expect enrollment to reach 1.7 million by the end of this Open Enrollment season, with 1.5 million receiving subsidies and 200,000+ unsubsidized.

Second Year Ramps up Service, Communications

This fall communications efforts have been significantly increased. The “I’m In” marketing campaign was launched utilizing television spots and featuring real people sharing their experiences and peace of mind at having health coverage they can afford. Based on the “lessons learned” from last year, a team of health leaders will participate in a nine-day bus tour visiting 21 California cities to promote the program. Moreover, some 200 storefront locations, primarily in malls, will be available soon for face-to-face interaction. This addition comes as a result of recognizing that healthcare is personal and local—decisions need a human face and neighborhood availability.

The number of trained, knowledgeable people who can facilitate enrollments has been substantially increased to some 28,000 people, including 12,000 Certified Insurance Agents plus thousands of enrollment counselors and county eligibility workers. Expanded Service Center hours and staff should make call centers operate more efficiently than in the past. The toll-free number is 1-800-300-1506.

Consumers looking for help in their neighborhood can visit and click “Find Local Help” to search by ZIP code for free help to sign up for coverage. The web site offers a wealth of information, including videos, Frequently Asked Questions, Forms/Applications, and a “shop and compare tool” so consumers can see how plans compare. Information is provided in many languages—Spanish, Arabic, Farsi and several Asian languages.

Joan Trezek, principal, Trezek Public Relations, Danville, CA

*A little help with terms

A Preferred Provider Organization (PPO) is typically a hospital/health system with affiliated doctors and services. PPO plans offer flexibility. A primary care physician is not required though many people do have one. Patients can go to any health care professional without a referral—inside or outside of your network.  Staying in network means smaller copays and full coverage. Going out of network increases out -of-pocket costs, and not all services may be covered.

A health maintenance organization (HMO) is a prepaid health plan of hospitals and physicians (Kaiser is an example) wherein subscribers-patients choose a primary care physician to coordinate care. All your health care services go through that doctor. That means patients need a referral before seeing any other health care professional (except in an emergency). An Exclusive Provider Organziation or EPO is essentially a PPO with a narrower offering of doctors, facilities, and services. Each has its advantages.