CMA responds to Covered California's unveiling of plans for new online marketplace

May 23, 2013
Area(s) of Interest: Advocacy Health Care Reform 

SACRAMENTO-Today, Covered California, the state agency implementing the Affordable Care Act (ACA), announced participating health insurers and proposed premiums for the state’s exchange, which is expected to provide health insurance coverage to roughly 5 million Californians following its launch in January 2014.

In all, 13 commercial health plans were selected to offer products on the exchange, including California’s three largest insurance providers, Kaiser Permanente, Anthem Blue Cross and Blue Shield of California.

The California Medical Association (CMA), representing more than 37,000 physicians across the state, has been an active partner in the implementation process, providing feedback to the exchange board every step of the way as it works to establish the framework for the massive coverage expansion under the ACA. However, physicians are still concerned about some pieces of the exchange.

“We certainly want to see Covered California be a success in expanding coverage to Californians,” said Paul R. Phinney, M.D., CMA president. “We look forward to working together to resolve remaining questions and concerns that might deter physicians from participating in the exchange.”

One major concern for contracting physicians is a loophole in the ACA that could leave physicians to foot the bill for services provided to patients who have failed to pay their insurance premium. The law allows for a three month “grace period” for non-payment of premiums, but only requires insurers to pay the claims through the first month of non-payment. The final version of the exchange model contract includes a provision that requires 15 days advance notice to physicians when a patient has entered the second month of the grace period, but still leaves the burden of 60 days worth of unpaid claims on the physician and the patient.

“The notification requirement is certainly a step in the right direction,” Dr. Phinney said. “That said, the remaining risk is still large enough that some physicians could be put out of business if left on the hook for tens or thousands of dollars. It is imperative for access to be more than an empty promise of an insurance card, that physicians are not deterred from participating in Covered California.” 

While Covered California staff has stated that exchange enrollees will have access to an adequate network of health care providers, CMA has repeatedly asked that the exchange take extra steps to ensure that provider directories submitted contain up-to-date and accurate networks.

A history of poorly monitoring network adequacy, along with the fact that many physicians are likely to be hesitant to contract with exchange plans, casts doubt over Covered California’s claim that it will provide enrollees access to “80 percent of practicing physicians” in the state.

 “We need to ensure adequate networks, because without them, the expansion of health care coverage will be for naught,” Dr. Phinney said. “Access to coverage doesn’t equal access to care.”


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