March Covered California Board Meeting

March 27, 2015

Now that California’s second open enrollment has closed, it’s time to continue thinking about the future. During Covered California’s latest board meeting, there was a lot of discussion about the 2016 plan year and beyond. Below are the details from the March 5th board meeting.

New Appointees

It was announced that Governor Brown named two new board members to replace the vacancies that will be left by Kim Belshe and Susan Kennedy. The new appointees are Genoveva Islas and Marty Morgenstern.

The board approved Karen Ruiz, the previous project director of CalHEERS, as the new Chief Technology Officer for Covered California.

2015 Open Enrollment Update

Although, we were able to cover many Californians’ during the first open enrollment, it is exciting to note that even more people are getting enrolled.


Retention rates were more positive than forecasted. It was predicted that 2.5% of consumers would leave their Covered CA plan each month. In actuality, 1.5% of consumers left, largely due to transitions into employer-sponsored insurance, Medicaid, and Medicare. Other enrollment updates included effectuation rates and special enrollment numbers. Covered CA forecast that 85% of consumers would effectuate (pay their monthly premiums), only 80% of consumers effectuated. This matched the national average. Additionally, fewer individuals utilized special enrollment periods than anticipated. There were a smaller number of individuals that had job-based conversions and transitioned out of Medi-Cal. One reason given for low Medi-Cal transitions was the lack of redeterminations at the county level. This caused the base of those up for renewals to be smaller. Yet, for those up for renewals, they renewed at a strong rate.


In January, Covered California sent out 1095A forms, which detailed the tax credit subsidies received, to individuals that received premium assistance in 2014. Approximately 90% of forms reached the intended person and held accurate information. For individuals who did not receive forms or received forms with inaccurate information, about 100,000 persons, Covered California followed up and sent corrective forms.

Clarification was also given regarding a new special enrollment opportunity. For consumers unaware that they may face a penalty for being uninsured in 2014 or those that learned that they might face a penalty in 2015, a limited time Special Enrollment period was introduced. Consumers have until April 30th to self-attest that they were not informed that they were at risk for a tax penalty. It was made clear that this is not an extension to open enrollment.

Recertification and New Entrants

Policies for 2016 certification and recertification of SHOP and dental plans were approved in January, but clean up items were discussed. Announced items included:

  • For the 2016 plan year, plans that were grandfathered will need to become ACA compliant
  • New plans will have the opportunity to become Qualified Health Plans (QHPs) effective October 15, 2015
  • Current QHPs will also be given the opportunity to offer new products, effective October 15, 2015
  • There will be no new benefit design for dental plans

Standardized Benefit Design

Although a standardized benefit design for 2016 was adopted during the January board meeting, several proposals were brought before the board.


In previous plan years, Emergency Room (ER) cost sharing was mixed with both coinsurance and co-pay plans. It was stated that the facility fee was set at a flat rate (co-pay) and the physician fee at a coinsurance fee. The mismatch of cost sharing fees makes it difficult for plans to offer alternate cost sharing structures. As a result, Covered California staff proposed a flat co-pay for ER physicians in silver plans.

Specialty Drugs

Due to the expensive drugs coming down the pipeline, that range from $30,000 to $100,00, Covered California is interested in identifying how hefty price tags on future drugs will impact medication adherence, medical costs long term, and long term affordability. To help alleviate the financial burden of specialty drugs on individuals with ongoing chronic needs, there were 4 proposed actions.

  • Require more transparency about formulary information and increase the accessibility of information for both consumers and advocates
  • Develop standardized definitions for formulary tiers
  • Establish requirements that prescriptions for chronic conditions like HIV are available outside of tier 4, which has the highest cost sharing
  • Consider placing a per script per month cap on specialty drugs. There was a request placed for health plans to analyze whether they have the ability to administer this type of product and how a cap would impact actuarial value. Based on received information from plans, Covered California staff will bring a recommendation forward on how to implement a cap during the May board meeting.

The hope is to guide consumers to the most appropriate and cost effective drugs, support premium affordability, and preserve the health plans’ ability to maximize savings and control drug costs.

Enrollment Assistance

To help successfully transition enrollment workers from the In Person Assistance program to the non-compensated Certified Application Counselor (CAC) program, Covered California will continue paying assisters the $58 per application fee. This will allow assisters to continue their work, and help individuals that qualify for the new special enrollment category. Payments will end June 30, 2015.

Other Things We Learned

  • The service center handled 1.3 million calls. There was a better and faster response rate, 50% of calls were answered in less than 30 seconds. Also, there was only 10% abandonment (consumers that did not stay on the line) compared to last year’s 50%.
  • More individuals signed up for coverage with assistance, especially in Asian communities
  • More consumers chose Kaiser plans during this open enrollment
  • There was a slight increase in consumers that chose bronze plans
  • In May, there will be a draft report on surveyed consumers about their experience and understanding of Covered California. Information will not only identify the types of programs chosen, but will also describe consumer knowledge of their choices.
  • Covered California will transition from federal funding to sustainable funds in 2017. A sustainability plan has been developed, which would create a 3-month reserve. Action on the sustainability plan will be taken at the next meeting.

The next meeting is planned for Thursday, April 16, 2015. As always, the meeting materials are available on the HBEX website.