Covered California January Board Meeting

January 16, 2015

New year, new Covered California board meeting. Here are the details from the first meeting of 2015.

Plan Certification and New Entrants

A new policy was adopted for recertifying plans for the 2016 plan year and welcoming bids from insurance companies that have not previously participated in the Exchange.

New entrants will be considered in the following scenarios:

  • A plan is newly licensed in California
  • A Medi-Cal Managed Care plan chooses to expand into Covered California
  • Plans that have not previously offered in Covered California can join the Exchange only in counties with less than three current plan options (Regions 1, 9, 11,12, and 13)
  • SHOP welcomes bids from all plans
  • No new dental plans will be considered

New plans will have to apply to Covered California by May 1. New entrants in SHOP will have the ability to begin offering coverage as early as October, due to the expiration of non-ACA compliant plans in the small group market.

Standardized Benefit Design

A standardized benefit design for 2016 was adopted, with a few minor changes from what staff proposed in December.


  • The Silver tier will offer just one standard plan (no separate copay/coinsurance plans, although this remains in other tiers and in SHOP)
  • Deductible exemptions will remain the same
  • Outpatient surgery and all inpatient services in Silver is all 20% coinsurance, while all other services are simple copays.
  • The Silver structure in SHOP has changed to feature $1,500 medical and $500 brand pharmaceutical deductibles.

Bronze & Catastrophic

The Bronze structure proposed last month (in which lab work and outpatient rehab are exempt from the deductible, but the deductible increases to the out-of pocket maximum amount of $6,500) was adopted, however a HSA option with a $4,500 deductible and 40% coinsurance on most services will also be available.

A catastrophic plan with a $6,850 deductible and out-of-pocket maximum will also be available. Three non-preventive primary/urgent care/mental health visits will remain exempt from the deductible in Bronze and Catastrophic.

Gold and Platinum plans will stay essentially the same. There may be changes to the benefit design later, contingent upon the outcomes of Covered California’s work with stakeholders on high-priced specialty drugs. The full benefit design structure can be viewed here.


Close to 230,000 new consumers have enrolled in Covered California plans through January 12. Some great demographic data was revealed, and it’s pretty interesting to compare the statistics to those from year one.

While the percentage of enrollees receiving premium assistance (88%) and the distribution of metal tiers is exactly the same as the outcomes from last year (62% Silver, 26% Bronze), more Californians are enrolling through agents and the service center and more millennials are signing up. The table below points out some intriguing trends in enrollment by ethnicity – the racial demographics currently resemble those of open enrollment last year, while those who have completed the application process but have not picked a plan are totally different, with much higher percentages of Latino and Black consumers. Covered California is asking agents, CECs, and call center staff to reach out to those who haven’t selected a plan to help them understand their options and cross the finish line.

enrollment by ethnicity

Covered California marketing is in full swing, targeting certain communities through tailored messaging and mediums.


The newest challenge for the Exchange is providing subsidy reconciliation document to enrollees. Individuals who received premium assistance in 2014 will receive a 1095A form, which will detail the quantity of subsidies received, from Covered California, then consumers will use this form in filing their taxes. A press event focusing on 1095As is planned for Tuesday, so look out for more info then.

Enrollment Assistance

A change in compensation structure of Navigator Program was adopted. While Navigators are supposed to be paid in installments when they meet enrollment goals, the enrollment progress has been difficult to assess in a timely manner because the milestones are based on effectuation (plan selection AND premium payment). Navigators claim that they are providing extensive assistance to consumers in ways that don’t count towards the milestones, such as help understanding notices, renewals, and Medi-Cal enrollment. Covered California has decided to base the second payment on plan selections rather than effectuation so that the Navigators can fund their continued important work. Staff also indicated that additional changes to the Navigator and in-person assistance programs may come in the next few months.

Other Things We Learned

  • CalHEERS is working four times faster than it did last year
  • The service center has drastically improved response times – the percentage of calls answered within 30 seconds increased from less than 8% in November to 48% in January
  • Current carriers intend to expand coverage in regions 3 and 6

No meeting is planned for February so the Exchange can focus on the last days of open enrollment. As always, the meeting materials are available on the HBEX website.