As the California Legislature came back this week from vacation, several key health consumer protection bills are pending, backed by consumer, community, and health organizations, but actively opposed by health insurers. The bills, set to be considered in these last few weeks of the legislative session, would address the most notable concerns raised by consumers in the first year of implementation of the Affordable Care Act: insurers’ “narrow networks” of providers, and managing out-of-pocket costs.
California has led in expanding coverage under the Affordable Care Act, but we have more to do to make sure that coverage is meaningful for all consumers, once enrolled. Pending state legislation would increase insurance oversight to ensure consumers, once covered, have timely access to care, and without the barrier of undue out-of-pocket costs. We need California legislators to stand with consumers in the face of insurance company opposition to these common sense patient protections.
** Ensuring Network Adequacy and Timely Access to Care:
SB964 (Hernandez): Regulatory Review and Surveys of Network Adequacy/Timely Access
· SB 964 requires DMHC to conduct *annual* reviews of health plans for timely access and network adequacy separately for Medi-Cal managed care and the individual insurance market, including Covered California plans.
When patients agree to a limited network of providers, the insurers are committing to have a network adequate to provide timely access to care. SB964 will increase oversight and enforcement of insurers so people can get they care they need where and when they need it. Whether “narrow networks” in some Covered California plans, or access issues in Medi-Cal managed care plans, the insurers must meet a minimum standard, and SB964 ensures pro-active monitoring by the regulators.
AB2533 (Ammiano): Ability to Go Out-of-Network at In-Network Costs If No Timely Access
· AB2533 would allow a patient who cannot see a provider within 10 business days (the established timely access standard) to go outside the network for care arranged by the health plan and pay the same in network cost for care.
This bill provides a real-world remedy for people who can’t get timely access. Insurers promise the networks are big enough to provide access to care in a timely fashion; otherwise, the insurers are making a false claim. AB2533 is crucial for lower-income families inside and outside Covered California who can’t afford out-of-pocket costs for out of network care.
** Helping Consumers Deal With Out of Pocket Costs:
AB1917 (Gordon): Making Prescription Drug Cost Sharing Manageable
· This bill caps prescription drug co-pays at 1/12 of the individual annual out of pocket maximum, which is $6,350 for the 2014 plan year, a limit that increases annually as health care costs rise.
This bill ensures people with chronic illnesses who depend on high cost life-saving drugs pay no more than $530 up front instead of over $6000, which is current cap. Someone who has MS, HIV, or another chronic illness should not have to pay thousands of dollars up front for life saving prescription drugs. This bill works within the out of pocket maximum limit that is set by the ACA, to ensure consumers aren’t forced to choose between their money and their health when paying for prescription drugs.
SB 1176 (Steinberg): Tracking and Reimbursing Out-Of-Pocket Costs
· The ACA established out of pocket maximum limits and in California that limit is $6,350 for an individual or $12,700 for a family for the 2014 plan year, a limit that increases annually as health care costs rise. This bill requires insurers to track out of pocket costs paid by consumers and reimburse consumers who go over their out of pocket limit.
This is a practical bill that ensures the out of pocket limit is a meaningful protection, by having the insurer track cost-sharing, and automatically reimburse the patient if they go over the cap. Patients with big medical expenses have enough to deal with, they shouldn’t have to keep all their medical receipts in a shoebox to get the benefit of the out-of-pocket maximum in the Affordable Care Act.