COVERED CALIFORNIA In 2010, Congress passed historic sweeping health care legislation, the Patient Protection
FREQUENTLY ASKED QUESTIONS about California’s Health Benefit Exchange for Physicians and their Staff
and Affordable Care Act (ACA), which reformed the individual and small group health insurance markets and, beginning in 2014, will provide health insurance to much of the nation’s uninsured. Under the ACA, two-thirds of California’s uninsured may be covered by private insurance through a health insurance exchange purchasing pool. California’s exchange, Covered California, began enrollment on October 1, 2013 – with coverage beginning on January 1, 2014. The following FAQ for physicians and their office staff provides answers to the most commonly asked questions about exchange eligibility and enrollment.
What is Covered California? Covered California is the new marketplace where Californians can compare and purchase health coverage. Through Covered California, many patients will be eligible for financial assistance to help pay their premiums and even co-pays. Through Covered California, individuals and small businesses can compare different health insurance companies and learn whether they qualify for premium assistance and tax credits. Californians will also be able to find out if they are eligible for low-cost or no-cost health coverage through Medi-Cal.
How will Covered California impact my practice? The impact on physician practices will vary greatly depending on the mix of patients in your practice and the extent to which you contract with Covered California plans. Millions of previously uninsured Californians will now be eligible for health insurance through Covered California and Medi-Cal. Your patients with employer-sponsored coverage are not likely to see significant changes in their coverage. Small and medium sized physician practices with 50 employees or less are also eligible to participate in the Small Business Health Options Program (SHOP). For more information, visit www.coveredCA.com.
Which patients can buy coverage through Covered California? Legal California residents, except for currently incarcerated individuals and legal minors, are eligible to buy insurance through Covered California.
Which patients are eligible for subsidies through Covered California to purchase coverage? Premium assistance is available to individuals and families who meet certain income requirements and do not have access to affordable, adequate health insurance through their employers. Eligibility for premium assistance is based on family income and the number of people in the family. The size of the premium assistance is calculated on a sliding scale, with those who make less money getting more financial assistance. Individuals with incomes up to $45,960 and a family of four with an income up to $94,200 may be eligible for premium assistance.
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EXCHANGE RESOURCES FOR PHYSICIANS The California Medical Association (CMA) has developed several resources to help educate physicians on the exchange and ensure that they are aware of important issues related to exchange plan contracting. Among those resources is "CMA's Got You Covered," a physician's guide to Covered California. This resource is FREE to members and provides a comprehensive overview of the Affordable Care Act and the exchange, key issues to watch and things to consider when deciding whether to contract with an exchange plan. This guide and other exchange-related resources are available at www.cmanet.org/ exchange.
Legislative Wrap Up A Year of
Challenges, Victories CMA’s 2013 Legislative Wrap Up By Juan Carlos Torres, CMA VP of Government Relations
This year turned out to be a challenging year for the California Medical Association (CMA). We knew going into the legislative session
that 2013 would be a historic year, with the implementation of the Affordable Care Act (ACA) and the wave of legislative freshman. It lived up to our expectations.
With the beginning of each session, there are new legislators that come to Sacramento from all walks of life. CMA’s government relations
team is challenged with getting to know them, educating them on issues of importance to the physician community and identifying the physicians with whom they have—or should have—relationships. While the Legislature has had up to one third of its members turn over in any given year, this year a majority of legislators were new to Sacramento. The challenging task of educating the new class was magnified. In addition, 2013 included 12 special elections that resulted from various vacancies created by departures and resignations. CMA faced an unprecedented number of scope of practice expansion bills introduced in the Legislature. These scope bills were painted by supporters as necessary reforms to help implement the ACA. Those who wanted to expand scope had a key message: we need allied health professionals, including nurse practitioners, optometrists and pharmacists, to do more in order to prepare for the many Californians added to California’s health care system through the ACA implementation. Our message was simple: we will not jeopardize patient safety and we need to promote integration of allied health professionals, not fragment them as these proposals suggested.
Additionally, CMA members and their staff have free one-on-one access to CMA's practice management experts through the CMA reimbursement helpline at (888) 401-5911 or economicservices@cmanet.org.
We faced a concerted effort by the nurse practitioners, optometrists and pharmacists who joined together to push their agenda collectively. They put in significant resources to mount a public relations campaign and were actively pursuing newspaper editorial boards across the state to promote their agenda. With the help of our specialty partners and our local medical societies, CMA won the argument in the Capitol. >>
WINTER 2013
CMA > Governance HOD 2013 Reform
HEALTH REFORM HEATS UP AS THE CLOCK RACES More than three years have passed since the Affordable Care Act (ACA) was signed into law, setting in motion some of the most dynamic and volatile years the nation’s health care industry has ever seen. BY JAMES NOONAN l CMA Staff Writer
IN A NUTSHELL By Steven E. Larson, M.D., MPH, Chair of the CMA Governance Technical Advisory Committee
GOVERNANCE
REFORM
S
&ABUSE WHAT PHYSICIANS NEED TO KNOW TO COMPLY WITH STATE AND FEDERAL LAWS
M
ost physicians strive to work ethically, providing highquality medical care to their patients and submitting proper claims for payment. Unfortunately, the presence of some dishonest individuals has created the need for laws that combat fraud and abuse in the health care system. This trend has intensified with the passage of federal health reform legislation in 2010. The laws covering “fraud and abuse” have proliferated and broadly prohibit activities, some of which physicians may have in the past undertaken in good faith. Depending on the law, violations may be punishable by criminal and civil penalties, civil monetary penalties, payment suspensions, mandatory or discretionary exclusion from state and federally funded health programs, including Medicare, and other sanctions such as licensure actions or asset forfeitures. This article examines the most important fraud and abuse laws that apply to physicians.
kickback statute prohibits knowingly and willfully offering, soliciting, paying or receiving remuneration (essentially anything of value), directly or indirectly, in exchange for or to induce patient referrals for which payment can be made under a federal health program, or to induce recommending or arranging for the purchase of items or services covered by a federal health program.
Change is never easy. But oftentimes is it necessary, and
In a nutshell, the reforms will make CMA more relevant
even invigorating. The California Medical Association
and effective by focusing the association on, and
(CMA) is about to embark on a journey of change that
bolstering its resources to address, the critical issues of
will position our association as a nimble, proactive
universal importance to physicians. By doing so, CMA
organization ready to lead the practice of medicine
will be better able to protect the interests of its physician
into a brave new world. In 2013, the CMA House of
members and, even more importantly, guide the future
Delegates (HOD) approved a plan to reform the way our
of our profession, not only in California but nationwide.
150 YEARS OF TRADITION For 150 plus years, CMA has been guided by the HOD, which meets once a year to set policies and direct resource allocation. This has led to a sometimes unwieldy 581-member HOD, a Board of Trustees numbering more than 50, a seven-member Executive Committee and hundreds of other members serving as alternate delegates and in various capacities on dozens of councils, committees, sections and mode of practice forums. Over the years, there have been several task forces assigned to this subject. It wasn’t until this year, however, that the abstract discussions about “governance reform” began to produce concrete results. These discussions resulted in big questions. Does the HOD foster a reactive culture rather than a proactive one? Does it inhibit CMA’s ability to take quick action in a rapidly evolving health care environment? While these questions were being asked, the HOD was spending most of its time on a growing number of resolutions that struggled to
worth it? There is not a doubt in my mind.
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be assigned or implemented because of resource limitations. The CMA Board of Trustees, realizing that a floundering governing style prevented the organization from quickly acting on issues of universal import to the membership and their patients, created a committee—the Governance Technical Advisory Committee (GTAC)—to look at this issue. The GTAC confirmed what the executive committee had feared —the association was unable to quickly address universal issues that arose faster than the once-a-year HOD meetings could handle. And, there were other inefficiencies in CMA’s governing bodies and processes. And there was the cost. An independent study commissioned by CMA (an activity-based costing, or “ABC” study) found that CMA governance is far more resource-intensive than previously thought, accounting for almost one-third of CMA’s operating budget—an allocation that commensurately reduces resources available for advocacy and other member services.
The California Legislature had an active year, passing many new laws affecting health care. Below are highlights of the new laws likely to impact physicians next year and beyond. For more details, see “Significant New California Laws of Interest to Physicians for 2015,” in the California Medical Association’s online resource library at www.cmanet.org/resource-library.
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HOUSE OF
ONE MUST IMAGINE SISYPHUS HAPPY
DELEGATES 2014
THE CALIFORNIA MEDICAL ASSOCIATION’S 2012 LEGISLATIVE WRAP-UP CMA FIGHT
cma fights for physicians
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Throughout this article, you will find references to “CMA On-Call” documents. On-Call is the California Medical Association’s online health law library. On-Call documents are available free to members at www.cmanet.org/cma-on-call. Nonmembers can purchase documents for $2 per page. _________________________________________________________________________
Anti-kickback laws
2012 LEGISLATION with over 400 bills
MICRA OPPONENTS
evil micra devils try to hurt us
The statute has been interpreted broadly to include any kind of compensation, and to apply so long as one purpose of the compensation is to induce referrals. Violation of the statute is punishable by a $25,000 fine and up to five years imprisonment and is grounds for exclusion from the Medicaid and Medicare programs. Violation of the statute also exposes the violator to civil monetary penalties. The statute and accompanying regulations, however, provide safe harbor provisions that, if met, guarantee compliance with the law.
HOUSE
OF DELEGATES
In years past, the California Medical Association (CMA) has defended physicians in battles waged by hospitals, health plans and mid-level practitioners, but this year we initiated a few fights of our own. CMA did what physicians do best: We fought to protect patients.
California Medical Association delegates set policy and elect officers at annual meeting
CMA fought to keep patients out of the middle of billing disputes, to educate parents about immunizations, to require mandatory flu vaccinations for health care workers, to remove sugared beverages from schools, to create a physician health program, to expand residency programs and a last minute effort to save the
More than 500 California physicians convened in San Diego, December 5-7
for the 2014 House of Delegates (HOD), the annual meeting of the California
Medical Association (CMA). Each year, physicians from all 58 California
Healthy Families Program.
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Both California and federal law prohibit kickbacks and fee splitting by physicians and other health care providers. The federal anti-
counties, representing all modes of pr actice, meet to discuss issues related to
By Jodi Hicks, CMA VP of Government Relations
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SPRING 2014
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CMA On-Call
New Health Laws
CMA CMAENVISIONS ENVISIONSAANEW NEWFUTURE FUTUREFOR FORORGANIZED ORGANIZEDMEDICINE MEDICINE
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2015
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association is governed. Will it be easy? No. Will it be ince its inception, the Affordable Care Act (ACA) has been a subject of controversy, inspiring hotly contested debates in Washington, D.C., Sacramento and across the entire nation. For some, this dramatic overhaul of the nation’s health care system represents our national leaders finally making good on the long-overdue promise of “health care for all.” Others claim that the law is a clear overreach of federal authority that threatens to overburden an already fragile economy. >>
The reforms will make CMA more relevant and effective by focusing the association on, and bolstering its resources to address, the critical issues of universal importance to physicians.
health care policy, medicine and patient care and to elect CMA officers.
Illustration by Brett Johnson
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