Fly On The Wall View as CA Shapes Its Exchange

[Zantastic]

California has a website, healthexchange.ca.gov that tracks its progress toward establishing its Health Exchange. There's some interesting reading there, particularly on this page where I found this document that, when finalized, will be the contract between the exchange and the insurers.

A lot of the document is your standard legal mumbo jumbo, but section 3 has some good information, especially 3.06.

3.06
Essential Community Providers

Except if Contractor has qualified under the alternate standard for essential community providers provided by the Affordable Care Act as has been determined by the Exchange, Contractor shall maintain a network that includes a sufficient geographic distribution of essential community providers (“ECP”) that are available through Contractor to provide reasonable and timely access to Health Care Services to low-income populations in each geographic region where Contractor’s QHPs provide services to Enrollees.

Low income is described as below 200% of FPL. My 2012 MAGI was just under that limit, so this has an impact on me.

It looks to me like there may be a two tiered system. If you fall below 200%, the premium will be very low as will all of your out pocket costs, based on this chart showing sliding scale subsidies for Deductibles, Co-Pays, and Max Out of Pocket. However, the provider networks probably won't be as robust as the over 200% tier. Section 3.06 (a) clarifies "sufficient geographic distribution of essential community providers", but I'm not fluent in legalize, so I may be reading too much into this.

Keep in mind that this is just California, and the documents have not been finalized. There's an ongoing back and forth between the exchange and the insurance companies that you can get a flavor of by reading this short Power Point presentation.

I just realized that I linked to the wrong document that discusses what I quoted above. I corrected it above and it's also here.

 

[donheff]

It will be interesting to watch how implementation proceeds. We should get a pretty good sample of reports by state from our members.

 

[Zantastic]

I just realized that I linked to the wrong document that discusses what I quoted in my first post. I corrected it above and it's also here.

 

[dgoldenz]

There has been a lot of talk on the agent/insurance company side of things about more limited networks for policies purchased through the exchanges than outside of the exchanges. This seems to confirm the system heading in that direction.