About Holding Insurers Accountable
Health insurance companies have enormous power in California. In fact, 94% of the commercial health insurance market is controlled by just six companies. They are increasingly denying enrollees access to care, and even refusing to pay for care that’s already been delivered, all while enjoying record profits. According to the federal government, some insurance companies are denying more than a quarter of Medicaid managed care requests. CHA is working to hold insurers accountable for meeting their basic responsibilities to patients and advocating for increased oversight and accountability for insurance companies.
CMS Provides “Two-Midnight Rule” Guidance for Medicare Advantage Plans
What’s happening: The Centers for Medicare & Medicaid Services (CMS) issued a frequently asked questions (FAQ) document on finalized contract year 2024 Medicare Advantage (MA) policies.
What else to know: The document provides guidance on how the “two-midnight” hospital admissions policies apply to MA patients when MA organizations are permitted to deny payment through post-claim audits.
Survey: Insurance Company Red Tape Leaves Thousands of Patients Stranded in CA Hospitals Every Day
SACRAMENTO (February 6, 2024) — Every day, an estimated 4,500 Californians are left stranded in hospital beds long after they have been medically cleared for discharge, many of them victims of insurance companies’ bureaucratic red tape or failure to have enough care providers available to help patients recover after their hospital stay. This startling statistic is among the key findings of a recent survey of hospitals conducted by the California Hospital Association (CHA).
DMHC Responds to CHA, Hospital Council Advocacy on Central Valley Capacity Crisis
What’s happening: The Department of Managed Health Care (DMHC) has issued All Plan Letter 23-027, urging health plans to reduce administrative barriers for hospitals in the Fresno County area during a surge in the demand that strained hospital capacity.
What else to know: The communication from DMHC was the result of extensive advocacy from CHA and Hospital Council — Northern & Central California leadership and staff to DMHC, seeking its support in working with plans to facilitate patient discharge and transfers.
CHA Advocacy Materials on Key Issues Available
What’s happening: CHA has released advocacy materials — infographics, key messages, and issue briefs — for a suite of priority issues for 2024.
What else to know: Infographics offer a quick view for people in a hurry (e.g., lawmakers) while issue briefs provide a deeper dive for those who want more information (e.g., staffers). Both are ideal leave-behinds. Key messages are for use in developing talking points or presentations, or for general information.
Summary: Finalized Interoperability and Prior Authorization Policies
What’s happening: A members-only summary of finalized interoperability and prior authorization processes is available.
What else to know: The final rule is scheduled for publication in the Feb. 8 issue of the Federal Register.
CHA Analysis Reveals How Insurer Practices Impede Patient Care
What’s happening: CHA developed a detailed analysis of how insurance company practices negatively affect patients, which is a key proof point supporting a comprehensive strategy to hold insurers accountable for patient care in California.
What else to know: One of CHA’s priorities this year is to create greater accountability (network adequacy, prior authorization, medical necessity, payment practices, and parity) for insurers operating in California.
DHCS Must Take Steps to Ensure Network Adequacy
What’s happening: In a letter to the California Health & Human Services Agency (HHS), CHA President & CEO Carmela Coyle expressed concern that arbitrary decisions by Medi-Cal managed care plans to terminate contracts with safety net hospitals undermines network adequacy and worsens existing critical capacity issues.
What else to know: The letter also requests that HHS investigate and address recent concerns that have emerged in Orange County. HHS oversees the Department of Health Care Servies.
New Federal Electronic Prior Authorization Requirements Finalized
What’s happening: The Centers for Medicare & Medicaid Services (CMS) has finalized policies to advance interoperability and streamline prior authorization processes by using application programming interfaces (API) technology.
What else to know: The final rule also requires payers to provide a specific reason for denied prior authorization decisions and publicly report certain prior authorization metrics.
CHA Comments on Proposed Changes to Medicare Advantage Plans
What’s happening: CHA submitted comments on the proposed technical changes to Medicare Advantage plans for contract year 2025.
What else to know: Comments were due to the Centers for Medicare & Medicaid Services on Jan. 5.
Managed Care Plans to Face Sanctions from DHCS for Poor Performance
What’s happening: Medi-Cal managed care plans (MCPs) will face sanctions from the Department of Health Care Services (DHCS) for failing to meet quality performance standards.
What else to know: DHCS has issued All Plan Letter (APL) 23-012, which updates and clarifies the policy on the imposition of administrative and monetary sanctions to plans that fail to meet minimum performance for required quality performance measures.