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What San Diegans Need To Know About California's Health Care Exchange

What San Diegans Need To Know About California's Health Care Exchange
GuestsGary Rotto, Director of Health Policy and Strategic Communications at the Council of Community ClinicsJeannette Shay, Director of Government and Community Relations at Family Health Centers of San Diego

ST. JOHN: Today on Midday Edition, President Obama today countered criticism of his health perform saying insurance companies are sending half a billion dollars in rebates to some 8.5 million consumers. Despite efforts to delay the start date of the reforms today, in California the new health insurance exchange is in place. The date when people can sign up is barrelling toward us, in October, but few people know exactly what it will mean for them. I spoke renal with Gary Rotto, and Jeannette Shay at family health centers of San Diego. Both providers for low-income families who don't even have health insurance. ST. JOHN: So what happens on October 1st? ROTTO: That is where the health insurance exchange will open their website for website for basically preenrollment, who want to find out if they're eligible for subsidy exchange or Medi-Cal. They'll be able to go on their site, put in some basic information, and register. ST. JOHN: Have we heard very little about this considering it starts so soon? ROTTO: Well, we've heard little in the public because there's a lot of infrastructure work being done. There's the contract being written with various organizations such as ours, and 211 to do outreach information. You've had some testing going on at the three call centers where they have had people who would potentially be a part of the exchange. And they have been able to test their program there to make sure that the information they're putting in is accurate. So you've got a lot of behind the scenes work going on. ST. JOHN: For somebody who is wondering will I be eligible for this new exchange, give us a list of who is eligible. ROTTO: You're eligible for the exchange -- actually anybody who's not eligible for Medi-Cal is eligible if you don't have insurance, you're not provided by the employer, or you're self-employed. The question would be whether you're eligible for a subsidy, for premiums or co-pay. You can go on now to the covered California website and be able to put in the baseball information. And they'll give you a ball park if you're eligible, and how much your premium would be on an annual or monthly basis. ST. JOHN: So you would encourage people to go to the website right now and start researching this? SHAY: Yes, absolutely. ST. JOHN: Do you have an estimate of how many San Diegans might be eligible? ROTTO: Amongst San Diegans -- we think in the first year, there's going to be between 10,015,000 that will be registering and receiving a subsidy. The question is how many other people are -- cannot receive a subsidy but still want to buy insurance through the exchange? ST. JOHN: Janette, are you going to be involved with outreach as well? SHAY: Absolutely. We have a team of outreach workers in the community, helping educate parents about what plans are available. We have staff out this to help people to do their applications. When people do their applications, they have a lot of questions. It can be difficult to figure out how to document your income the right way, and where you need your birth certificate looked at. So we have all of those staffed in our clinics, people can come to the healthcare provider, sort of a 1-stop shop to help people enroll. This summer we're going to be doing a tremendous amount of outreach to educate people, then October 1st, we'll be working one-on-one with patients and their their families to help them complete the applications and enroll. ST. JOHN: So have plans been chosen? ROTTO: Correct. And the exchange has come out with their qualified health plans as they're called. There are a number who have applied, and said we want coverage, here's what we plan to do, and state is this selected sum, and told others they're not eligible. And for San Diego, there are six different companies that will be qualified health plans or QHPs. ST. JOHN: Interesting. ROTTO: Anthem blue cross, blue shield, health net, Kaiser, Molina, and Sharp. ST. JOHN: That's good to know. Can you give us a sense of what the premiums might be? This is the big question for people who don't have health insurance now. It's good to know, okay, there are six plans we'll be able to choose from. But where are the premiums going to fall? ROTTO: You're going to hear about metal plans, silver, bronze, gold, platinum, and that all has to do with how much of your healthcare will be paid by the coverage that you have, if you have hospitalizations or doctor visits or specialists, etc. I usually use the silver plan as my basis for when I look at what somebody is going to get coverage for and how much the cost would be. I'm looking at a document here from Cover California single income person -- I'm looking at the different payments they would make. Primary care about $15, $20 for a specialist. ST. JOHN: This is presumably by the month? And then you would pay -- ROTTO: Then you would have co-pays. But let me give you an example of somebody who is 30 years old, makes $45,000 a year, single person, their cost would be $261 a month, based upon what their income is, and that's not even by age because you can't characterize it by age anymore. Of ST. JOHN: So there's no difference if you're 20 or in your '40s? ROTTO: Well, the levels have been flatteneded. So a senior would normally be paying so much more. Now if you're in your 60s, you won't be. There are only three different levels so to speak. ST. JOHN: Now, I have to say that I've heard on the grapevine, people are saying they're in their 20s and they're paying $300 a month. Maybe that's for the gold-plated plan? ROTTO: Right now, you don't have different plans that people can measure what they're paying by. So if they're an individual paying on their own, it's just the general market rate. You don't get the advantage of a pool. Just like at Costco, when you walk in to a place where you have a pool of individuals coming together as members, you're able to drive prices down and get a bargain. And that's what covered California is all about, creating this market saying we're going to have this many people. In San Diego, I gave you a number of what I thought our clinics would be receiving as far as new patients. And the actual number that we're looking at for San Diego County itself. It's somewhere between $30,000 to $60,000 just in the first year. And covered California says to any of these plans, we're going to bring you this many people, what's the rate you're going to get us? You'll get a much better rate than an individual trying to buy it on their own. ST. JOHN: Does it depend on some degree if everybody jumps in and signs up right in October? ROTTO: You probably won't have the individual rates. You'll have pretty close, but probably not till October 1st will you have a better more than a ball park figure. Balboa Park Balboa Park, and they've said this is what we're going to offer. ST. JOHN: And Janette, have you seen a lot of people who are enthusiastic about this or confused or how are people in the community? SHAY: I think people are optimistic, but a little bit confused. One other key point is that it's not only just covered California, the new healthcare exchange, but there's also an extension of Medi-Cal. If you're a family that makes 133% of poverty or less, so that would be about $31,000 a year for a family of four, you're eligible for Medi-Cal expansion. And that has no co-pays, and it has no monthly premium. And Medi-Cal in the past, you had to have children or a certain series of conditions in order to qualify. So this is one of the first times that just based on income a single adult might also be able to qualify for Medi-Cal. So these are the kinds of questions we're having our patients ask us. Is it Medi-Cal I'm applying for, or covered California? And what's the premium for me? So those are the reasons why there have been grants organizations like family health centers of San Diego and other clinics so we can really help people look at their income, their actual family situation and help direct them to the plan that makes the best sense for their family. ST. JOHN: What about who have looked? Gotten an estimate of their premium and think I couldn't afford this? SHAY: What recourse is there for that? Every individual mandate stands with a few exceptions. There's a hardship exception. But everybody has to have some type of insurance. And it's been capped so it would be no more than 9.5% of a person's income should be what they're paying for their health insurance. And for many of these plans, it will actually be less than that. ST. JOHN: So what kind of a reaction have you been having at the clinics? I know your main goal is to disabuse people of myths. What kind of myths have you heard that people need to understand? ROTTO: Well, some people think that all of this has been delayed or it was never passed by Congress or the legislature hadn't taken action. For a while they had not taken action on the expansion Janette was talking about. They did take that and the governor has signed it. ST. JOHN: So that's probably for the lowest income people? Which is really good news for them. ROTTO: And then you have covered California, which not only being this market, but also there's a 5-person independent board helping to write the regulations for how the market is going to work, how the health insurance exchange is going to work in California. So they needed to come up with what are the criteria for evaluated health plans? How are we going to go about outreach and education? Let's put a grant together. Let's have organizations bid for that. And what are they going to do? So for example, we're going to be out in what I call 1,800 touch-points throughout the county over the next 18 months to engage with people. Jeannette and family health centers are going to be out there, Say San Diego, 211 will be doing work as well. So the board at the top says here's what we want to have happen, how do we make it happen? And it's infrastructure building. ST. JOHN: So the board hasn't yet completed that. You haven't even got the contract yet to do the outreach, I understand. ROTTO: They approved the preliminary contract, and we're waiting for the final language on both sides. But we are doing the work already. ST. JOHN: So people are thinking I know this is coming down the line toward me, and people are aware they will get penalized if they don't purchase health insurance. So where do they go to find out about this? They can go to the website. Is there a place they can go to talk to a real person? ROTTO: Certainly they can call any of our health centers. 211 is being trained, and they're such a wonderful resource in the community. They're a part of this outreach and education also. I know that there are also other community groups that are being engaged, whether by us or other organizations. Whether they're a part of that outreach or not, are they want to engage with people in it the community to try to get information out this and encourage people to get covered. ST. JOHN: And for someone who wonders, does this include dental and vision, does it depend on what kind of plan you have? ROTTO: Well, you have ten essential benefits. If I can roll through those real quick -- you've got ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse, prescription drugs, rehabilitation services, your laboratory services, blood work, etc, preventative and wellness and chronic disease management. And pediatric services. And it includes for pediatrics, oral and vision. But there's some discussion going on with the California board right now whether that's part of one plan or whether people would have to subscribe to that separately. ST. JOHN: I do want to ask about the penalty. We talked about the premiums. What would the penalty be? ROTTO: Either the greater of $95, and I forget what the percent was. SHAY: It's 1% of family income. ROTTO: Thanks for bailing me out on that one, Jeannette. I appreciate it. ST. JOHN: That's good. This is so interesting because even the outreach people are still sort of trying to remember all the details of this. So those of us who are new to it don't need to feel so bad that we feel perhaps less informed than we should be. So thank you so much for filling us in to some of the details and giving us some hope that there will be more outreach and more information forthcoming before the October deadline. I'd like to thank Gary Rotto, the director of health policy at the council of community clinics. Good luck to you. ROTTO: Thank you so much, Alison. ST. JOHN: And Jeannette Shay, director of government and community relations at family health centers of San Diego. Thank you. SHAY: Thank, Alison.

President Obama today countered criticism of his health reform law from Republicans, saying insurance companies are sending half a billion dollars in rebates to some 8.5 million people.

In spite of efforts in Washington DC to delay the start date of the reforms, in California, the new health insurance exchange, Covered California, is in place. The date when those who are uninsured can start signing up, is barreling towards us but few people know exactly what it will mean for them.

From KQED News and The California Report

Covered California will begin enrolling individuals for health coverage on October 1. This week the health exchange started training 2,000 workers who will help people with enrollment.


To help you get the answers to key questions we spoke to two San Diego health care professionals: Gary Rotto, Director of Health Policy and Strategic Communications at the Council of Community Clinics and Jeannette Shay, Director of Government and Community Relations at Family Health Centers of San Diego.

What happens on October 1?

Covered California will open their website for pre-enrollment. Individuals and families who are uninsured can find out if they are eligible to enroll in the health insurance exchange or in Medical. Enrollment will continue through March 31, 2014.

Who's eligible to buy health insurance under the exchange?

Legal residents who don't have health insurance through an employer, or who are not eligible for Medical. Officials estimate about 5.3 million people are eligible for insurance in Covered California.

Who's eligible for a tax credit, subsidy?

Officials estimate that up to 15,000 San Diegans will be eligible for a subsidy in the first year of the health exchange. Tax credits are available for individuals and families who meet certain income requirements. Those who make between 138 percent and 400 percent of the federal poverty level may be eligible for a tax credit. Covered California estimates about 2.3 million California residents will be eligible for a tax credit or subsidy.

There's also Medi-Cal assistance. California is expanding Medi-Cal under the Affordable Care Act starting in 2014. Health coverage will be free for those under the age of 65 who earn less than $15,000 for a single individual and $31,180 annually for a family of four. Previously single adults were not eligible for coverage under Medi-Cal.


How many health plans do I have to chose from?

Covered California has approved 13 health plans. San Diegans will have 6 insurance companies to choose from. Blue Cross, Blue Shield, Health Net, Kaiser, Molina and Sharp Health Plan.

What medical services do the health plans cover?

The plans cover 10 essential benefits, ambulatory patient services, emergency services, hospitalization, maternity new born care mental health substance abuse prescription drugs, rehabilitation services, laboratory services, preventative and wellness, chronic disease management and pediatric services. Coverage for dental and vision is still being worked out.

How much will it cost?

What you pay will depend on which plan you buy and whether you are eligible for tax credits or subsidies. There are also four levels of coverage: Platinum, Gold, Silver and Bronze. The higher the metal category the higher percentage of medical expenses that a health plan will cover.

Covered California has an online calculator to help you find out your potential insurance cost.

How much is the penalty if I don't buy health insurance?

In 2014, the penalty will be 1 percent of annual income or $95, whichever is greater. You will have to pay the penalty when you file your taxes at the end of the year. But the penalty will become increasingly more expensive after the first year.

If you have a specific question about the Affordable Care Act you can submit it here.

Follow our weekly Q-and-A series, Second Opinion, where our Speak City Heights reporter Megan Burks answers questions from San Diegans on the Affordable Care Act.