Filed Under:Health Insurance, Individual Health

Insurers to exchange: You're not my regulator

The board will consider the third draft of the model Tuesday.
The board will consider the third draft of the model Tuesday.

Carriers thinking about selling plans through the Covered California health insurance exchange program "don't want Covered California to be a 'third regulator.'"

Staffers on the board of Covered California -- the California Patient Protection and Affordable Care Act (PPACA) health insurance exchange -- have included a discussion of that issue in the third draft of a model plan contract the exchange is developing.

The board is set to discuss a presentation on the model contract Tuesday at a meeting.

Carriers have concerns about how Covered California would go about handling matters such as network adequacy, provider credentialing and utilization review, staffers said in comments included in the draft.

Similarly, the staffers found that insurers believe the current draft of the model contract is too one-sided.

The staffers are recommending that the exchange address the insurer concerns by deferring to regulators on areas such as financial solvency and credentialing.

"Keep areas where [the] exchange must also be concerned with direct consumer impacts," the staffers said.

The staffers suggested, for example, that a carrier that sells through the exchange should have to consult with the exchange on changes in its service area, covered drug list or network capacity, because those are matters that could have an immediate, dramatic effect on an enrollee's experience.

Some carriers have asked about model passages that refer to an "administrative manual" that has not yet been developed.

The exchange could defer creation of the manual at this time and work with the "qualified health plans" (QHPs) that sell coverage through the exchange to develop the business rules on operational interfaces and other requirements, the staffers said.

In a section on language requirements, staffers suggested limiting requirements for support for languages other than English to Spanish.

But the exchange should keep the Spanish-language support requirements, because as many 50 percent of the exchange users could be speakers of Spanish, the staffers said.

QHPs will not have to start asking enrollees to volunteer sensitive information, such as information about "race, ethnicity, sexual orientation, gender identity and disability status" until 2015.

QHPs will have to start asking enrollees for that information in 2015, because "reducing health disparities is a key goal," staffers said.

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