(Blog post care of ITUP intern Christina Vane)

Last week on the Blog, we began the conversations about health reform “navigators,” organizations and individuals who will be helping participants embark on what will undoubtedly be the confusing task of applying for and selecting a health insurance plan through the Exchange.

In what seems to be an effort by the Legislature to ease the process even further, AB 2787 (Monning & Alquist) is moving through the legislative process; if passed, the bill would create the California Health Ombudsman Office to further consumers' abilities to digest and navigate the new reform legislation.

What’s an ombudsman, you ask? In simplest terms, it is a trusted person or agency that smooths the process, investigates complaints and mediates settlements between parties (in this case, the insured members and health plans).

As envisioned by AB 2787, the new Ombudsman office would be established using part of the $30 million in newly-appropriated Consumer Assistance Grants with the intention of boosting consumer protections. The creation of the office will hopefully help consolidate the nine (or so) agencies that currently provide consumer assistance with health plans.

If implemented, the Office will help Californians:
• Lean more about their health care choices;
• Enroll in health plans;
• Obtain tax credits created by the health care reform law; and
• Receive answers to their questions through a 24-hour hotline.

The bill would also require state agencies to make referrals as well as coordinate and record consumer complaints in concert with the Ombudsman Office. For this reason, the bill is currently receiving opposition from many health plan and health insurance lobbying groups stating unnecessary spending of funds for duplicative services.

Current status... The bill passed the Senate Health Committee last month and is scheduled to go before the Senate Appropriations Committee sometime in August. Let’s see what happens!

The federal government is now accepting applications for health reform’s Consumer Assistance Grants. The grants will provide nearly $30 million to help states educate consumers about their health coverage options and ensure access to accurate information about health reform.

All States and territories may apply for these grants to expand consumer assistance efforts such as:
· Helping consumers enroll in health coverage;
· Helping consumers file complaints and appeals against health plans;
· Educating consumers about their rights and empowering them to take action;
· Tracking consumer complaints to help identify problems and strengthen enforcement; and
· Establishing a health insurance consumer assistance (or ombudsman) program through the state’s insurance department, attorney general, or independent consumer assistance agency.

Eligible applicants include state insurance departments, attorneys general offices, independent consumer assistance agencies, and other state agencies. States and territories may also partner with non-profit organizations that have a track record of working with consumers.

Grant applications are available now! Go to the federal government's grant website and search for CFDA # 93.519.

In the application, states must explain how the program will assist people with all types of coverage, collect data about any problems and questions, and provide assistance in a culturally appropriate manner.

Applications are due September 10, 2010.

Yesterday, the state convened the fifth in a series of §1115 Hospital Waiver Stakeholder Adviser Committee Meetings, conducted in accordance with the Bagley-Keene Open Meeting Act.

The meeting included updates on:
(1) negotiations with CMS;
(2) state legislation;
(3) budget neutrality;
(4) federal financing; and
(5) early implementation activities.

Speakers included:
• David Maxwell-Jolly, DHCS Director
• David Panush, Senate President Pro-Tempore’s Office
• Sumi Sousa, Assembly Speaker’s Office
• Toby Douglas, DHCS Chief Deputy Director, Health Care Programs
• Gregory Franklin, DHCS Deputy Director, Health Care Operations

I. Update on Discussions with CMS (David Maxwell-Jolly)
• In June, the state sent a 70 page concrete waiver proposal to CMS
• Since then, there has been a very intensive and steady back-and-forth
• CA has been extremely well received by CMS, with “attention and vigor”
• CMS very much in a problem solving mode, looking for solutions
• CMS likes CA’s approaches to better care coordination, medical home, ACOs.
• CMS especially interested in effective investments in our safety net systems and global budgeting proposals
• CMS wants to ensure mandatory enrollment of the SPD population happens as a graceful transition. CA must identify folks with high healthcare needs and be sure the state is doing everything to ensure plan readiness.
• Lots of interest from CMS re: coordinating behavioral and physical health.

II. Legislation / Trailer Bill Language Update
David Maxwell-Jolly
o Lots of talk in Sacramento since language went live last month, lots of dialog around the issues being raised, solutions emerging. There are continuing and frank discussions with health plans, advocates and other stakeholders.
o Common concern: implementing the waiver provisions effectively and meeting the needs of the beneficiaries
o Moving toward more specifics on care coordination and medical homes.
o Will be one, if not more, rounds of additional amendments.
o Trying to strike a balance between what is practical and reasonable ways to meet critical needs so that the systems do work

Sumi Sousa
o Lots of attention/conversation on the SPD, CCS, and duals. Refinement will happen, but the attention will shift a little now.
o Time to start focusing on important hospital financing provision – nothing else will matter without a $ figure at the end

David Panush
o Amendments to the Waiver bills are being done through an iterative process.
o New amendments probably out in the middle of next week.
o These won’t be the final set of amendments. We are still waiting on CMS for financing piece (more below). Once we know the total federal financing piece, the discussion will turn to “how the pie gets sliced up.”
o “The next 5 weeks will be the most strenuous and there is no inevitably.” We’re pushing the agenda, but it’s a huge ask. The only way this is going happen is by achieving consensus (state, CMS, plans, stakeholders). Must be some unification. If not, we can just stall and try again next year.

III. Budget Neutrality (Toby Douglas)
- Goal: construct budget neutrality (BN) that brings in most federal funds
- BN based on a few components:
1. Coverage Expansion: with health reform, states can begin on coverage of childless adults through a state plan amendment (SPA). Instead, CA is requesting to do so under the waiver. If we’re permitted to do so, we want to count this expansion outside of BN requirements.
2. Public Hospital Spending: making the assumption/assertion that had CA not entered the last Public Hospital waiver, we would have seen massive growth in cost (8.5%) for Public Hospital expenditures through 2015. Therefore, with a large trend line absent a waiver, there’s a lot of room for BN.
3. Implementation of Organized Delivery Systems of Care for Special needs Populations: absent this waiver, expenditures for this program will grow much faster. With better coordination, we will reduce the trend rate
4. Longstanding recipient of funding under the LA County waiver. Continuing to carry that forward should be counted with a BM gain.
5. Also $360m per year we just received, added in 5th yr of waiver; we should continue to receive that in the new waiver.
- If all 5 pieces receive CMS approval, CA will be able to draw down $10 billion over 5 years.

IV. Waiver Financing (Toby Douglas)
- Overall Point: no state general funds. Plus, MOE under ARRA and PPACA. So, need to look for other opportunities:
o Expanding state-only programs being claimed under waiver (currently 6 programs) to more programs: workforce money, MRMIP high risk pool (prop 99 funds should be claimed under waiver), parolees assistance, IMDs, and over-night hospital stays in corrections.
o Global Payment Process for Public Hospitals – set limit of funding that they have to live within, then they have to try to allocate care and promote prevention. Payments would be above cost.
o Improvement pool – through IGTs, allow public Hospitals to invest in deliver systems through improved flow of patients through out patient system.
o IGTs for non-contract Hospitals – allowing for IGT above cost, supplemental payments for that group, to help private safety net systems.

V. Preparing for Implementation (Greg Franklin)
- Some preparation for the waiver being done now, especially with the SPD Transition.
o Provider cross-walk takes Fee-For-Service (FFS) providers and cross walked it with plan providers, continued to build providers for SPD populations.
o Aggregate data: number of Medi-Cal only population by aid code provided to plans in June. Will be posted to website by Aug/Sep.
o 2009 Paid Claims Raw Data for FFS service, county specific – this has been shared with plans.
o County Alternative Model – those Counties that are interested due back Aug 15.
o Outreach and Education Work
• SPD sensitivity training.
• Western University of Health Sciences developing it, will be developed with stakeholder input, conducted in Jan 2011 for everyone (one in Nor Cal, one in So Cal)… trainers for plans, train-the-trainers, DHS managed are staff, community organizations, etc.
• Informing Materials and Presentations
• UC Berkeley will be developing pre-enrollment notifications and other materials, in all threshold languages and alternative formats
• Starts no later than Nov. 1,
• Revising facility site review tool.

As you know, California’s existing §1115 Medicaid waiver expires on August 31st, and the state is currently in the process of applying for its renewal. In June, DHCS submitted an initial waiver proposal to CMS, and the two entities are currently engaged in negotiations regarding the eventual scope of the waiver and the ultimate financial contribution from the federal government. If all goes well, DHCS will submit a final waiver application no later than September 1st.

To help you better understand the state's initial 70-page waiver proposal, ITUP has just produced a document entitled Summary, Thoughts, and Analysis that highlights potential opportunities for various stakeholders within the coverage expansion component of the waiver and includes a plethora of ITUP recommendations. Be sure to check it out.

In addition, earlier this month DHCS published a Vision Document that describes how the components of the waiver proposal will help the state make significant strides in implementing health reform, including coverage expansion to the newly eligible Medicaid populations, expansion of Medicaid benefits for new and existing populations, delivery system reform, administration simplification, and payment reform. Also a great read.

Both documents are useful tools to help one make heads-and-tails of the waiver.

The Patient Protection and Affordable Care Act has provisions for state exchanges to extend grants to “navigators” in order to assist and guide participants in purchasing reliable health care through the complexities of the insurance market.

Below is a quick summary of what we know now (which is very little). And/or, you can read the law for yourself.

Navigator duties can/may include:
• Public education;
• Distributing fair and impartial information;
• Assisting in Exchange enrollment;
• Providing culturally and linguistically appropriate information;
• Referring grievances;and
• Providing general health insurance consumer assistance.

In order to be eligible to serve as a navigator, candidates CAN be:
• a member of trade/industry/professional associations;
• a member of fishing/ranching/farming organizations;
• a community group;
• a chamber of commerce or unions;
• resource partners of small businesses; and/or
• licensed insurance agents and brokers capable of demonstrating having existing relationships or the feasibility of establishing relationships with employers, employees, consumer or self-employed individuals likely to be qualified for the Exchange.

A Navigator CANNOT be a health insurer or entity receiving direct consideration from a qualified health provider offering insurance.

Though concern exists regarding the addition of navigators to a field that is saturated with specially trained insurance-savvy brokers and agents, the role of the navigators seems to be concentrated on a more local and community level, thus giving special assistance to those who are first-time insurance buyers.

Only time will tell if their role is redundant, but with the establishment of California’s Health Benefits Exchange on the horizon, many may find it comforting to have local patterns to help with the novel and potentially complex insurance health plan options in the Exchange.

Much more to discuss as details emerge...

On Tuesday, ITUP staff joined a discussion with HHS Secretary Kathleen Sebelius as she offered insight about the nation’s new investment in preventive care, "marking a fundamental shift from treatment to prevention." As you can read in the blog post immediately below, starting September 23rd new health plans will be required to cover preventive services at no additional cost to individuals.

Here’s some of the pertinent Q-and-A with Secretary Sebelius:

Disease and Prevention
Q: Will patients with chronic diseases be considered to be seeking preventive care or treatment for their illness?
A: That would not be preventive care; that would be considered medical management, and thus, left up to the health plans.

Q: In the area of colorectal screenings, in which there are at least three different screening options, is there anything that ensures that insurers won’t simply steer patients in one direction, but rather leave the decision to physicians and their patients? Is there any protection involved?
A: No, I don’t believe there is any protection involved. I know this might be an issue, but I’m not aware of any problems in this area.

Benefits of Prevention
Q: Which preventive benefits are included in the new provisions, and will there be a cap?
A: The regulation has tables that list vaccinations and benefits that are included. (See this list). There is no technical cap on the benefits.

Budget for Preventative Services
Q: What percentage of the overall legislation is being devoted to preventive care? I think this needs more priority.
A: The new law aims at ensuring a comprehensive approach in which prevention is an important part. We have allotted $15 billion over the next 10 years in a fund for prevention and public health.

Q: Will there be any financial incentives for plans to participate? Is this something that we should be encouraging, or is there a disconnect in this area?
A: I don’t think there is a disconnect. We are trying to give more Americans access to the preventive services that have usually been typical of large employer health plans.

Wellness
Q: Many people have made reference to wellness; can you speak about grants that will be awarded to small businesses in terms of that?
A: That is an ongoing discussion with Congress, so we don’t currently have a timeline for when this will happen. However, for follow-up information, feel free to reference the newly-launched health reform website.

Q: We are looking to develop a community wellness program. We have seen many benefits in the modified behaviors treatment. Is there any care that specifically addresses this? Do you see anything coming that speaks specifically to modified behaviors?
A: Services have been recommended for body mass index consultations, nutritional counseling, etc. The preventive services page on the health reform website can provide a more comprehensive list for you.

Q: Pesticides have been documented as unhealthy; what will be the reimbursement for services in this area?
A: Part of the recommended services come from the “bright future” guidelines. So we will leave this discussion to doctors and their patients, but we are certain that environmental health will come up in their discussions.

As you know, the federal reform law requires states to have fully functioning exchanges by January 1, 2014. It specifies that the exchanges offer coverage for individuals and small businesses, and that the exchanges be operated by a government agency or non-profit entity. Health plans must adhere to the exchange guidelines in order to offer subsidized coverage through the Exchange. Purchase of insurance through the exchanges will be available for U.S. citizens and legal permanent residents. The exchanges will also contain new consumer protections that health plans must adhere to in order to take advantage of the new market.

While states will be obliged to adhere to those federal requirements, the law leaves a majority of the construction of the exchanges to the states.

Some of these large questions include:
• Should the state establish its own pool or be part of the federal pool?
• Should the exchange be statewide or a regional consortium of neighboring states?
• Should the entity be a public agency, public-private partnership, or a private non-profit organization?
• Should the exchange be a web-portal, like E-Insurance or an active price and coverage negotiator?
• Should a board govern the exchange? If so, how? Make-up? Selection?
• What will be the relationship between the exchange, private insurance and public programs?
• Should Medi-Cal and Healthy Families be a part of the Exchange? If so, should the Exchange be authorized to do Medi-Cal and Healthy Families eligibility determinations and redeterminations?
• Should there be a separate small employer pool or should individuals and small employers buy as part of the same pool?
• Can there be a public option in the exchange?
• How do we maximize participation and outreach?
• How will the Navigator grants operate and who will be eligible for them?
• What will be the roll of brokers? CAA’s?

One of the two exchange bills moving rapidly in the legislature this summer, AB 1602 (Perez) and SB 900 (Alquist & Steinberg), will likely pass this year and become law. It will begin to set the framework for California's Health Benefits Exchange and include initial answers to many of these key questions.

If you have thoughts on any of these topics, or suggestions for how they might be actualized and implemented, NOW is the time to speak up. Reach out to your legislature, comment on this blog, contact me (cliff @ itup.org), and make your voice heard!

To assist you, be sure to check out our new side-by-side comparison of the Exchange bills.

Legislative Update: The two pieces of exchange legislation, AB 1602 (Perez) and SB 900 (Alquist & Steinberg), recently passed out of the opposite houses' Health Committees and are now awaiting hearing in the opposite houses' Appropriations Committees.

While the bills are very similar (they would both, if passed, establish the Exchange and set forth its foundation and scope), they do contain notable differences. ITUP has recently posted a side-by-side comparison of the Exchange bills. Check it out!

Below are links to a series of new HHS brochures and materials related to the implementation of the Affordable Care Act.
 
· Patient Protections & Insurance Reforms
· Poster: Are You Eligible for the Pre-Existing Condition Insurance Plan?
· The Affordable Care Act — What it Means for Those with Pre-Existing Conditions
· Medicare and the New Health Care Law — What it Means for You
· Closing the Prescription Drug Coverage Gap

For questions or comments on any of these, you can email HHSIGA @ hhs.gov.

Yesterday, MRMIB's Deputy Director of Legislative and External Affairs Jeanie Esajian made a few announcements regarding the state's new high risk pool.

MRMIB submitted two documents to CMS Thursday. The first details how MRMIB will run the new pool. The second is to solicit responses from plans who may want to participate in the pool.

MRMIB will hold a conference for potential vendors on July 12th, and it hopes to get proposals in by July 21st.

Ultimately, the Agency hopes to begin taking patient applications by the end of the summer and sees the new pool up-and-running by September.

For more, see today's California Healthline article.

Along with the tumult and flux that will invariably come with the implementation of health reform, the next few years offers California an opportunity to reexamine existing health care systems and structures. Reform implementation, therefore, brings with it the possibility of better designing the way health coverage and health care are administered and delivered in our state.

At ITUP, we'll be exploring those possibilities, particularly focusing on four areas, among others:
(1) The California Health Benefits Exchange;
(2) Medi-Cal Eligibility and Enrollment Simplification;
(3) Stability in Payment and Reimbursement Reform; and
(4) Creating an Integrated Safety Net and System of Care.

For instance, on number (2), we have already begun thinking and writing about opportunities for Medi-Cal Modernization.

To further the conversation on number (4), the Robert Wood Johnson Foundation (RWJ) has provided a two-year grant to examine well-functioning safety nets that provide low-income patients affordable access to comprehensive care.

The recipient of that grant, Mark Hall, Professor of Law and Public Health at Wake Forest University Medical School, has recently released five in-depth case studies examining the costs and adequacy of better functioning safety net systems in Asheville NC, Boston MA, Denver CO, Flint MI, and San Antonio TX.

For those interested in how we in California may one day provide more effective, coordinated care, be sure to read Professor Hall's case studies.

On Thursday, ITUP staff joined representatives from the U.S. Department of Health and Human Services for the first of their weekly conference calls with states on implementation of the health reform. Speakers included: Governors’ staffs, state Insurance Commissioners, state contacts on high risk pools, state Medicaid Directors, and intergovernmental organization partners.

Here are some of the major take-aways and pertinent Q-and-A:

Health Insurance Web Portal
• HHS: After just under three months, the federal health reform website is now LIVE. The goal of the site is to empower consumers, providing them with information to get better coverage options. By answering a few simple questions, individuals can receive a list of state-specific private and public health insurance options available to them and their family.
• If there are issues with the website or information you’d like to see that isn't yet there, you can email questions or comments to lisa.wilson @ hhs.gov.

Exodus of Individual Insurers
Bill from Illinois: We face the potential under health reform of insurers deciding to exit the marketplace rather than meeting the requirements to participate. There may be individuals who were currently insured, but will lose their coverage due to insurer withdrawal, thus being put back into the marketplace to buy insurance. Is there any way for those individuals to access the high risk pool before the 6-month stipulation?
• HHS: Under the reform statute, if the insurance company can demonstrate that the market will be destabilized, then the Secretary can reduce the 80% medical loss ratio threshold. We encourage companies to submit data that would show such destabilization would occur. There are a few things on which the Secretary doesn’t have discretion; one of these is the 6-month qualification period. As you know, there are existing high risk pools for which that restriction may not apply, but for the federally authorized ones, it is clear that individuals must be uninsured for at least 6 months.

State High Risk Pools
Anne from California: Can states make their own lists of potentially eligible beneficiaries? Can they alter those lists?
• HHS: We have received proposals from states that have their own lists and those that do not. We do not believe that there is anything in the federal law preventing states from administering their own lists. So states can do so, as long as they get it federally approved.

Allison from Nevada: If a person currently has insurance, but the insurance doesn’t cover their condition (i.e. limited or bare-bones coverage), can they be eligible for the pool?
• HHS: No. They have to be completely uninsured for 6 months. Even if they have a plan that doesn’t cover their needs, any coverage prevents them from being eligible for the new pools.

Yvette from California: Is there a cap on the insurance through the pool?
• HHS: That varies by state. In the 21 states where the government is administering the high risk pool, there will be no annual or lifetime limits. It is however a mixed bag among the states. You can email at highriskpools @ gms.hhs.gov for more info.

Mary from Arizona: Is the credible coverage from the new laws and not from HIPAA?
• HHS: There is a gray area between acceptable benefits and credible coverage. It depends on the state. If there are acceptable benefits, then it is okay. If you have specific questions, please just email highriskpools @ gms.hhs.gov to submit a question.

Joel from California: What about individuals in states not participating in the program?
• HHS: Regardless of any state you live in, you will have access to the risk pool plans. If your state chooses not to run its own pool, you will have access to the federal pool/plan.

Mary from Nevada: In Nevada, premium rates won't be available until July 15. Can you tell us now what the copay will be so people can plan for that event?
• HHS: The premium is a range of premiums for someone in his/her 50s. It isn’t precise, but we want to give a range of what the cost for the plan would be. The premiums allow one to have initial deductible of $2500, not subject to preventive services. It also includes generic prescriptions copays of $4 and $30 for brand names. Details will be on the website soon.

Lenny from Mississippi: Will premiums be subsidized by income?
• HHS: No, we do not have the authority to subsidize by income, only by age. There will be one standard deductible and one standard premiums package. They are both being developed to reflect standard risk rates as closely as possible.

Mary Beth from Florida: Will there be enough money to pay for coverage in the pools? How can states stretch the limited federal dollars until full implementation of reform in 2014?
• HHS: We have received projections from states. The challenge is that this is a new product, with exception of Maryland, there is no other state that has done this. We have projected loss, but we don’t have actuarial data yet. Based on experiences that we have had, we believe that we can at least double the amount of people who have high-risk coverage. Probably around 200,000 total people at one time will be covered. In terms of the concern about funding made available from Congress, we have a number of steps we can take: modify benefits package, co-pays, premiums, initial deductibles. If some states have lackluster growth, we could redistribute some of the funds to other states, we do have that authority. Also, the Secretary does have authority to place limitation restrictions to stay within the funding allowed.

Data Submission
Nicole from CA: Regarding early retiree programs, when will HHS provide more info about the data submission program?
• HHS: We just started receiving applications on this. We will start to release more Q&A’s imminently. We are aware of your question and will answer it shortly.

On Monday, the U.S. Supreme Court denied an appeal against Healthy San Francisco, essentially securing the legality of the city's universal health care program. Created in 2006, Healthy SF provides health care for 53,000 San Francisco residents who lack private insurance and are not eligible for Medicaid and Medicare. To pay for the coverage, businesses with at least 20 workers that do not provide insurance to their workers must give part of their wages to the city to pay for the $200 million program.

The Golden Gate Restaurant Association, the entity that originally brought the law suit, argued (a) that the city is not authorized to compel companies to pay for the health benefits of its workers, and (b) that it is not lawful to require owners to pay into the city health care pool due to the fact that federal law generally prohibits state and local interference in the area of benefits that offered to employees. By choosing to not hear the case, the Court in essence nullified the Restaurant Association's arguments.

The Obama administration recommended the court turn down the case in part because the recently enacted national health care reform would make it less likely that other places would create programs similar to that of San Francisco. Yet the general consensus is that Healthy San Francisco will remain a necessary component of the city’s health care system due to the fact that the national plan excludes some populations of Americans, including undocumented workers, eligible for coverage under the San Francisco plan.

For more on the case and the Court's decision, see recent articles in the San Francisco Chronicle and Associated Press.

Also on Tuesday, the CA Assembly Health Committee passed SB 810 (Leno), the California Universal Health Care Act. SB 810 would set up a single payer system in California, essentially replacing private insurance companies with a single health care pool into which all California residents pay. The system would be administered by the state and rates for health services, prescription drugs and medical supplies would be negotiated to and set by a designated commissioner.

State Senator Mark Leno (D-San Francisco) argued that a single payer system would reduce administrative costs, increase shared responsibility, promote choice, allow for actuarially sound reimbursements, streamline benefits, and increase efficiency. Funding for the bill would come from shifting the $200 billion that Californians currently spend on private coverage to the single payer system. SB 810 also calls for bulk purchasing of prescription drugs and medical equipment, estimated to save California $5.2 billion in the first year.

Read the SB 810 fact sheet.

SB 810 is nearly identical to SB 840 (Keuhl), legislation was introduced by Senator Sheila Kuehl in 2006 and again in 2008, and legislation vetoed twice by Governor Schwarzenegger. If it reaches the governor’s desk, SB 810 is expected to be vetoed as well.

The bill now goes to the Assembly Appropriations Committee...

Good news from Sacramento... The Senate just voted on - and narrowly passed! - Assembly Bill 1887 (Villines) and Senate Bill 227 (Alquist).

Now onto Schwarzenegger's desk... A signature from the Governor is expected since he has publicly expressed support for the new high risk pool. With more than $761 million in new federal money being given to the state to cover tens of thousands of uninsured (and medically uninsurable) Californians, Schwarzenegger recently referred to the new pool as a "win-win opportunity for California."

With this vote and expected signature, the state will be moving quickly to establish the new pool. Jeanie Esajian, spokesperson for MRMIB (the agency that runs MRMIP and will administer the new pool), was quoted yesterday as saying that "[o]ur plan, if everything goes smoothly, is to begin taking enrollment in August and be open for business in September."

The California Senate convenes at 1:30 pm today, and on the docket are Assembly Bill 1887 (Villines) and Senate Bill 227 (Alquist), bills that together would establish the state's new high risk pool for those who have been denied health coverage because of diabetes, heart disease, high blood pressure, a history of cancer or some other pre-existing condition.

The bills both include "urgency clauses" -- language that allows the state to begin implementing the policies immediately. These clauses also trigger the legislature's 2/3 vote requirement, which means the high risk pool bills will need to garner bi-partisan support in the Senate (which they did in the Assembly) in order to pass.

The Governor has expressed publicly his enthusiasm for California's establishment of this pool and is expected to sign the bills into law if they can move off the Senate floor and onto his desk. Stay tuned...

Connecticut has become the first state to utilize federal health reform’s option to expand Medicaid eligibility to low-income parents and childless adults. Connecticut estimates that approximately 45,000 new poor adults will be eligible who have household income up to 56% FPL or $6,650 per year for an individual. These individuals will receive full Medicaid benefits, instead of very limited benefits through a state-funded program.

For more on Connecticut, see the HHS press release.

California is also looking to maximize the new federal funds available now to expand coverage. Instead of directly expanding Medi-Cal eligibility, the state is planning to initiate Coverage Initiates (CIs) in every county under our new 1115 Hospital Waiver (under the existing Waiver, there are 10 county CIs). Then, in 2014, the state will transition those covered by the CIs into Medi-Cal.

State legislation to implement California's new waiver is now in print! SB 208 (Steinberg & Alquist) will be heard in Assembly Health Committee next Tuesday, June 29th. Stay tuned!

Next week is going to be an exciting one for health policy in Sacramento. In addition to voting on the High Risk Pool, the 1115 Hospital Waiver, and the Health Insurance Exchange, the Legislature will also be taking up important insurance market reforms.

On June 29th, the Assembly Health Committee will be hearing Senate Bill 890 (Alquist & Steinberg), legislation that addresses many of the shortcomings in the state’s individual health insurance market and provides a bridge to the full implementation of federal reform.

In particular, the bill:

• Requires there be only five standardized insurance products (5 HMO products and 5 PPO products) so people buying coverage can make an “apples-to-apples” comparison of identical products;
• Requires all health insurance products to cover medically necessary care, and would prohibit annual or lifetime benefit limits;
• Allows people to switch to a different plan offered by a competing plan or insurer if, after one year, the person goes to a competitor’s plan with equal or lower benefits;
• Requires plans to use a standard application for individual coverage with standard scoring for purposes of offering coverage;
• Require plans to change premium rates for adults based on one year changes in a person’s age; and
• Requires plans to meet a medical loss ratio (MLR) in the large group market of 85%, with an MLR of 80% or better in the individual and small group market. The MLR is the percentage of premiums a health plan spends on medical care, versus administration, marketing and profit. If a plan doesn’t meet this standard, the plan would have to provide a refund to consumers at the end of the rate year.

Stay tuned to the blog for updates as SB 890 and other the other health reform implementation legislation moves through the Capitol this summer.

On Tuesday, the Departments of Health and Human Services (HHS) issued regulations to implement health reform's new Patient’s Bill of Rights.

The Right's include:
• Children accessing insurance regardless of pre-existing conditions.
• Choosing a doctor or pediatrician from your plan’s provider network.
• Seeing an OB-GYN without needing a referral.
• Reviewing insurers’ premium increases.
• Getting the most from your premium dollars.
• No lifetime limits on coverage.
• Keeping young adults covered.
• No arbitrary rescissions of coverage.

For more, see the HHS Patient's Bill of Rights Factsheet.

In addition to tackling the High Risk Pool and 1115 Hospital Waiver, policy makers in Sacramento are also hard at work on legislation that will establish the framework for the California Health Insurance Exchange.

AB1602 (Perez) is set for hearing in the Senate Health Committee on June 30th, and SB 900 (Alquist/Steinberg) will be heard in Assembly Health on June 29th.

At or before both hearings, amended language for each bill will be presented. Among others topics, the bills will likely address:
• The general structure and governance of the Exchange;
• Whether the Exchange will be a public agency, a semi-government entity, or a separate, non-profit organization;
• How the individual and small business markets will operate within the Exchange; and
• To what extent health plans -- including local initiatives and county-organized health systems -- will participate in the Exchange.

Here are additional sources of information on the Exchange:
• ITUP's initial analysis and recommendations, April 19, 2010
• Legislative Analysts Office report, May 13, 2010
• Congressional Research Service report, April 15, 2010
• Kaiser Family Foundation brief, April, 28, 2010