Square peg, round hole. More than a third of silver plans offered on the federal health insurance marketplace may be listing inaccurate or incomplete prescription drug cost-sharing information because their formularies don’t fit neatly into the federal government’s online template, a recent analysis found.

Healthcare.gov is the online gateway for consumers in 37 states to compare the health plans available to them on the individual market.

The website’s prescription drug formulary information is divided into four tiers: generics, preferred brands, non-preferred brands and specialty drugs. The analysis by Avalere Health, a research and consulting organization, found that 35 percent of silver-level plans offered this year on the federally facilitated exchange don’t follow this model.

Many plans have five or six drug tiers, says Dan Mendelson, CEO at Avalere. Seventeen percent, for example, use multiple specialty drug tiers, and many plans split generic drugs into two categories rather than one, he says.

“The plans are doing the best they can with the fields they have to convey the information,” he says.

Why does it matter? In their efforts to force fit their plans into the federal government’s information grid, consumers aren’t necessarily getting the complete information they need to accurately predict their out-of-pocket costs. This can be especially problematic for plans with multiple specialty tiers, where cost sharing may increase significantly for drugs in the highest tiers.

Administration officials had no response Thursday.

If consumers click through from the healthcare.gov website to the benefits and coverage summary that every insurer has to provide for each plan, drug coverage details will generally be more clearly spelled out.

It’s an evolution, says Mendelson. “The system this year is worlds better than the system last year, and next year it needs to be better than this year.”

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Medi-Cal applicants who have been waiting for more than 45 days can receive temporary health benefits while officials determine eligibility for the public insurance program, a state Superior Court judge ruled this week.

The decision came in a lawsuit filed in September alleging that a large backlog of applications to California’s Medicaid program left hundreds of thousands of people unable to access health care.

“The ruling is absolutely vital in ensuring benefits for everyone who is entitled to them,” said Cori Racela, an attorney with Neighborhood Legal Services of Los Angeles County. “They may have medical needs while they are waiting for their application to be processed.”

The suit, which was filed in Alameda County Superior Court by a coalition of health advocates and legal services groups, cited delays in enrolling pregnant women, children and adults with life-threatening conditions.

Advocates said many either had to postpone treatment or pay cash to see doctors.

In one case cited in the suit, a man died of a pulmonary embolism while awaiting the outcome of his Medi-Cal application. His approval notice didn’t arrive until two months after his death.

His mother, Frances Rivera, said she was thrilled that the people who need Medi-Cal can get it in a timely way. “Hopefully somebody’s life will be saved because of this decision,” she said in a written statement.

In the Jan. 20 ruling, Alameda County Superior Court Judge Evelio M. Grillo ordered the state Department of Health Care Services to make timely determinations on the Medi-Cal applications. Grillo ruled that applicants who are likely to be eligible for benefits but whose cases have not been decided within 45 days can receive provisional benefits. The judge also ordered the state to notify applicants that they have a right to an administrative hearing on their eligibility.

“It is clear that the Department has failed to comply with the timeliness standard for making eligibility determinations to the irreparable harm of Petitioners and many others,” Grillo wrote.

Medi-Cal is California’s version of Medicaid, the publicly funded insurance program for poor and disabled residents. Prompted by the Affordable Care Act, California expanded Medi-Cal last year to include those without children and those with higher incomes.

The state faced a deluge of applications and last spring, and the backlog hit about 900,000 before the state was able to bring it down. In addition to receiving new applications this year, the state now also is processing renewals for existing Medi-Cal recipients.

Twelve million people are enrolled in Medi-Cal, including more than 2.7 million who have signed up since January 2014.

Jose Morales, who lives in Altadena, said his family was caught in the backlog. His four children waited for about nine months to get Medi-Cal and whenever they needed care, he paid out of pocket.

He made numerous calls — to the state, the county and the insurance broker who helped him apply. Finally, Morales said, Neighborhood Legal Services was able to help him get coverage for his children.

“It was a headache,” he said. “With four kids, insurance is crucial. If one gets sick, they all get sick.”

State health care services officials said Thursday that the backlog has been reduced by more than 95 percent and that the department planned to finish processing the rest of the remaining applications this week.

In addition, the officials said they are now immediately enrolling 80 percent of new applicants found eligible for Medi-Cal.

“We are committed to complying with any court orders and to further improving this process so that all individuals who qualify for coverage can be enrolled in Medi-Cal as quickly as possible,” a department statement read.

State officials had argued to the court that patients all along could get their medical bills covered for care received while their applications were pending.

But Racela said the ruling was critical in ensuring that the practice of giving applicants temporary coverage was cemented in policy. “For people who are now signing up, the likelihood that they will have to go through months long waits to get care is much smaller,” she said.

AnnaG@Kff.org

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Medicare is giving bonuses to a majority of hospitals that it graded on quality, but many of those rewards will be wiped out by penalties the government has issued for other shortcomings, federal data show.

As required by the 2010 health law, the government is taking performance into account when paying hospitals, one of the biggest changes in Medicare’s 50-year-history. This year 1,700 hospitals – 55 percent of those graded – earned higher payments for providing comparatively good care in the federal government’s most comprehensive review of quality. The government measured criteria such as patient satisfaction, lower death rates and how much patients cost Medicare. This incentive program, known as value-based purchasing, led to penalties for 1,360 hospitals.

However, fewer than 800 of the 1,700 hospitals that earned bonuses from this one program will actually receive extra money, according to a Kaiser Health News analysis. That’s because the others are being penalized through two other Medicare quality programs: one punishes hospitals for having too many patients readmitted for follow-up care and the other lowers payments to hospitals where too many patients developed infections during their stays or got hurt in other ways.

When all these incentive programs are combined, the average bonus for large hospitals — those with more than 400 beds — will be nearly $213,000, while the average penalty will be about $1.2 million, according to estimates by Eric Fontana, an analyst at The Advisory Board Company, a consulting company based in Washington. For hospitals with 200 or fewer beds, the average bonus will be about $32,000 and the average penalty will be about $131,000, Fontana estimated. Twenty-eight percent of hospitals will break even or get extra money.

On top of that, Medicare this year also began docking about 200 hospitals for not making enough progress in switching over to electronic medical records. Together, more than 6 percent of Medicare payments are contingent on performance.

“You’re starting to talk about real money,” said Josh Seidman, a hospital adviser at Avalere Health, another consulting firm in Washington. “That becomes a really big driver; it really gets the attention of the chief financial officer as well as everybody else in the executive suite of the hospital.”

Among these programs, the Hospital Value-Based Purchasing initiative, now in its third year, is the only one that offers bonuses as well as penalties. It is also the only one that recognizes hospital improvement even if a hospital’s quality metrics are still subpar. The value-based purchasing bonuses and penalties were based on 26 different measures, including how consistently hospitals followed a dozen recommended medical guidelines, such as giving patients antibiotics within an hour of surgery, and how patients rated their experiences while in the hospital. Medicare also examined death rates for congestive heart failure, heart attack and pneumonia patients, as well as bloodstream infections from catheters and serious complications from surgery such as blood clots.

Adding An Efficiency Measure

Medicare this year added a measure intended to encourage hospitals to deliver care in the most efficient manner possible. Federal officials calculated what it cost to care for each hospital’s average patient, not only during the patient’s stay but also in the three days before and a month after. Often the biggest differences in medical costs between hospitals are due to what happens to patients after they leave. For instance, Medicare pays more to inpatient rehabilitation facilities than it does to skilled nursing homes, even though both treat similar kinds of patients.

“It’s your one opportunity either to make money on pay-for-performance or at least recoup some of the potential losses you have from the other programs,” said Paul Matsui, who directs data research at The Advisory Board Company.

This year, Medicare judged hospitals based on how they performed in comparison to others in the second half of 2012 and all of 2013, and how much they had improved from two years before. Medicare adds a hospital’s bonus or penalty to every Medicare reimbursement for a patient stay from last October through the end of September.

Nearly 500 more hospitals earned bonuses in the value-based purchasing program compared to last year. The biggest is going to Black River Community Medical Center in Poplar Bluff, Mo., which is getting a 2.09 percent increase, the analysis found. The largest penalty this year is assigned to the Massachusetts Eye and Ear Infirmary, a teaching hospital of Harvard Medical School, in Boston. It is losing 1.24 percent of its Medicare payments.

The Massachusetts infirmary said in a statement that it was losing only about $60,000 because most of its patients do not remain overnight in the hospital, and the penalties only apply to inpatient stays. The infirmary had so few of those cases that Medicare could not assess its performance on more than half the measures the government uses. Medicare’s program “is a poor match for what” the infirmary does, it said.

Nationally, the average bonus for hospitals under value-based purchasing was a 0.44 percent increase, while the average penalty — not including the other penalty programs — was a 0.30 percent reduction, the KHN analysis found. The actual dollar amount will depend on the mix of Medicare patients that hospitals treat through September and how much they bill Medicare. Medicare set aside 1.5 percent of its payments for the incentives, totaling about $1.4 billion.

States Most Impacted

Medicare awarded bonuses to at least three-fourths of the hospitals it evaluated in Alaska, Hawaii, Maine, Minnesota, Montana, Oregon, South Dakota and Wisconsin, the KHN analysis found. Medicare penalized more than half the hospitals it evaluated in Arizona, Arkansas, California, Connecticut, Delaware, the District of Columbia, Florida, Nevada, New Jersey, New York, North Dakota, Pennsylvania, Washington and Wyoming.

More than 1,600 hospitals were exempted from the incentives, either because they specialize in narrow types of patients, such as children or veterans, or because they are paid differently by Medicare, such as all hospitals in Maryland and “critical access hospitals” that are mostly in rural areas.

Hospitals awarded bonuses in one year of the value-based purchasing program do not necessarily do as well the next year. Out of 2,672 hospitals that have been evaluated in all three years of the program, roughly a quarter got bonuses all three years and a quarter lost money in all three years. The rest had a mix of bonuses and penalties, the KHN analysis found.

Matsui said swings were not surprising given that hospitals are getting acclimated to the programs and Medicare has added new measurements each year. “In the grand scheme of things,” he said, “we’re still in the embryonic stage of the pay for performance programs.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

PASADENA, Calif. — Angel Torres hasn’t been to the doctor since coming to the United States illegally more than two decades ago. But now, his vision is getting blurry and he frequently feels tired. Torres, 51, worries he might have diabetes like his brothers.

“Time is passing,” he said in Spanish. “I need to get checked out.”

Torres is in luck. He lives in California, which has a dramatically different approach than most other states to health care for immigrants without authorization to live here.

Several counties — including Los Angeles, where Torres lives — offer these immigrants free coverage allowing them to receive care at local clinics. In addition, as many as 500,000 low-income immigrant parents eligible for President Barack Obama’s new deportation relief likely will qualify for Medi-Cal, California’s version of Medicaid. Already, young adults who were brought here as children and have been granted similar immigration relief can receive the state-funded insurance.

And in December, legislation was proposed to extend state-subsidized health insurance to everyone, including those barred from getting covered through the Affordable Care Act. Federal dollars could not be used.

The push to offer health insurance to all Californians regardless of immigration status is the latest in a series of immigrant-friendly state policies over the past few years. Already, immigrants here illegally can obtain licenses to practice medicine, law or other professions, and as of this month, they can apply for driver’s licenses.

There is no guarantee that other states will follow California’s lead, but the size and demographic makeup of the state ensure it a prominent role in the national debate over coverage of people living in the country illegally.

“If California goes out on a limb on this, it could have an impact on other states,” said Randy Capps, director of research for the Migration Policy Institute, a nonpartisan think tank based in Washington, D.C. “It is a really big thing.”

California has been a leader on immigration issues in the past. For instance, it was one of the first states to offer in-state tuition to students living in the state illegally.  Now, about 20 states do so.

Still, some states are unlikely to consider offering them health coverage in the near future. In the South, for example, advocates for expanded coverage say they are still trying to convince officials to expand Medicaid programs to include more U.S. citizens and legal residents. The federal law allowed states to extend Medicaid to include people at slightly higher incomes and without children.

“We are having a very different conversation,” said Cindy Zeldin, executive director of Georgians for a Healthy Future. “I think we are really far away as a state from where California is.”

California, however, is very far from where it used to be.

In 1994, voters passed an initiative, Proposition 187, that sought to deny education, health care and other benefits to immigrants living here illegally.

“It is really an important development that California – 21 years after Prop. 187 – is where it is,” said Thomas A. Saenz, president of the Mexican American Legal Defense and Educational Fund, or MALDEF. “That change, in less than a full generation, is what we are going to see increasingly across the country.”

Saenz attributes California’s transformation in part to the growth of the immigrant population and Latino electorate. He also believes people have come to understand that issues like health affect everyone — one person’s inability to get treatment can sicken others in the community.

In addition, Saenz and others say immigrant youths brought illegally into to the country by their parents, when they were too young to make choices, have put a human face on the issue.

“We have to credit … the young undocumented activists who have come out and said, ‘I am unafraid and I am here,’” said Gabrielle Lessard, health policy attorney with the National Immigration Law Center.

U.C. Berkeley graduate Jose Flores, 23, is one of them. His face is on billboards around the state as part of a campaign for universal health coverage. Flores received temporary legal status through the Obama administration’s  plan for undocumented youth and can now apply for Medi-Cal, though his parents are still in the country illegally and uninsured.

“I have always thought the best way to receive support is through being open about our status,” he said.

Not everyone is so thrilled with the push for expanded coverage. Tim Donnelly, a former state assemblyman said covering any immigrants here without authorization is fiscally irresponsible and threatens to “erase the line between legal and illegal.”

“We’ve finally gotten the seesaw of the California budget under control,” said Donnelly, who was a leader in the Minuteman citizen border patrol group. “It’s the wrong time to open up a can of entitlement worms.”

In the meantime, local initiatives in California are paving the way for broader change, said Anthony Wright, executive director of the consumer group Health Access.

“We think that these county efforts, whether they be in San Francisco, Alameda or Los Angeles, provide momentum,” he said. They could be “bridges to a statewide solution.”

Los Angeles County rolled out its $61 million program last fall called My Health LA, which provides free coverage to immigrants living in the country illegally and pays community clinics to care for them.

Angel Torres signed up at Community Health Alliance of Pasadena this month. Patricia Monroy, a clinic employee who helped him apply, told him that he could seek care at certain clinics and publicly-funded hospitals in the county but that he should avoid private facilities. “It’s a county program,” she reminded him. “It’s not insurance.”

At another clinic participating in My Health LA, El Proyecto del Barrio in the San Fernando Valley, Maria Lara signed up, along with her 11-year old daughter. Her son, born several months ago in the U.S., receives Medi-Cal, she said.

Lara said that just a few weeks before his birth, her husband was deported. Now she lives off the support of her church. A friend told her she could get free health coverage at a local clinic. She was nervous but anxious to get treatment for a thyroid condition identified during her pregnancy, when she had coverage under the emergency Medi-Cal program.

“Now I can make an appointment and not wait for hours in the emergency room,” she said.

Another patient, Aldo Corado, said he has relied on public hospitals and clinics with sliding scales since a car accident five years ago left him paralyzed and in a wheelchair. When he heard about My Health LA, Corado eagerly enrolled.

On a recent January morning he came to El Proyecto because of a lingering cough. Corado said he can’t work so appreciates the free coverage. But the father of two U.S.-born children said he is hopeful that he will get on Medi-Cal.

“It would be practically a dream for immigrants to have Medi-Cal,” he said, adding that it could enable him to have more access to specialists and physical therapy.

The bill, proposed by Sen. Ricardo Lara, would allow low-income immigrants to receive Medi-Cal and those with higher incomes to purchase plans with state subsidies. He proposed a similar bill last year but it stalled in committee.

A U.C. Berkeley study issued in May said that covering all immigrants in California illegally would increase Medi-Cal spending by 2 percent in 2015 while increasing enrollment by 7 percent. The cost of about $360 million would be significantly offset by a drop in health-care costs for the uninsured as well as an increase in sales tax revenue from managed care health plans, the study by the U.C. Berkeley Labor Center wrote.

When Gov. Jerry Brown issued his spending plan this month, he didn’t include an estimate for how much it would cost to extend Medi-Cal to the immigrant population granted deportation relief under the Obama order. The deportation relief applies to certain parents of U.S. citizen or legal resident children. Health officials said it was too early to tell how many people would apply.

About 1.85 million immigrants living in California illegally are uninsured, Capps of the Migration Policy Institute said. He estimated that Obama’s new policy could bring forward between 450,000 and 500,000 people who could qualify for Medi-Cal.

Meanwhile, the campaign to cover everyone in California is continuing. The California Endowment is promoting the coverage through billboards, social media and radio ads. Daniel Zingale, senior vice president at the organization, said Obamacare should have included this immigrant population.

“In California, that is a real problem,” he said. “We have to find a way to finish the job.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Money talks.

A temporary Medicaid pay raise that was part of President Barack Obama’s health law made it easier for poor adults to get appointments with primary care doctors, according to a study published Wednesday.

Paying more to doctors who participate in the federal-state insurance program for the poor usually improves access for patients, but the law’s two-year limit on the raise, its slow rollout and other regulatory problems made many skeptical about how physicians would react to the extra money — which in many states equated to a 50 percent pay hike or more.

The federally funded pay raise started in 2013 and ended Dec. 31, though a few states have continued the higher rates using their own money. The money was included in the health law to ensure there would be enough doctors to handle the surge of people who gained Medicaid coverage starting in 2014. Under the law, Medicaid would pay the same rates to family physicians, pediatricians and internists as Medicare, the federal health program for the elderly and disabled. The higher reimbursement was available whether or not states expanded Medicaid.

The 10-state study, published in the New England Journal of Medicine, found the availability of primary care appointments for Medicaid patients rose by nearly 8 percentage points after the raise was enacted, compared to only about a 1 percentage point increase among privately insured patients who were used as a basis for comparison.

States where doctors had the biggest pay raises — New Jersey, Pennsylvania, Illinois and Texas — all increased appointment availability by at least 10 percentage points. In each of those states, doctors received at least a 66 percent pay hike, the study said. The other states in the study were Georgia, Arkansas, Massachusetts, Oregon, Iowa and Montana.

“The two-year fee increase in Medicaid appears to have led primary care providers to make more appointments available for new Medicaid patients, at least in these 10 states,” said Genevieve Kenney, a senior fellow at the Urban Institute who worked on the report with University of Pennsylvania researchers.

The study did not examine whether the pay raise led more doctors to participate in the federal-state insurance program who were previously not seeing Medicaid patients. Most state Medicaid officials have said they did not see such a surge of new doctors.

The study was done by having staff posing as patients call primary care physicians’ offices and ask for new patient appointments. The calls were initially made in November 2012 through March 2013, before the pay raise was implemented in most states. A second round of calls was made from May 2014 through July 2014.

Medicaid enrollment has soared by nearly 10 million people in the past year as 27 states expanded eligibility for the program under the law. Even in states that did not expand, Medicaid enrollment has jumped due to publicity about the Affordable Care Act and its new online marketplace.

The big question is whether doctors who saw more Medicaid patients when they were paid more will limit their number since the program expired.

Tom Banning, CEO of the Texas Academy of Family Physicians, said he believes that is happening. “Unfortunately, we are hearing from doctors that have had stop seeing Medicaid patients because they can’t take the financial hit.”

Douglas Curran, a family doctor in  Athens, Texas, is one of those cutting back.  He said the Medicaid pay raise had helped his 14-physician group more than double the number of new Medicaid patients it saw in the past two years. “It allowed us to see these patients in the office rather than the emergency room,” Curran said.

Before the pay raise, the rural practice had strict limits on Medicaid appointments because of the low fees.

But despite gaining several thousand new Medicaid patients, Curran said the pay cut means the group will restrict Medicaid appointments once again. “We are going to see as many as we can afford,” he said.

Existing Medicaid patients will face longer waits for appointments and new Medicaid patients are likely to get turned away.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.