CalOptima Health in Orange County could join Covered California. Here’s what it could mean for members

CalOptima Health, the public health insurance plan for low income people and families in Orange County, is looking to join the Covered California marketplace. Let’s break down what that means, who stands to benefit, and why it’s taken Orange County so long to get here.

What is Covered California?

When former President Barack Obama signed the Affordable Care Act in 2010, it allowed states to set up an insurance marketplace or exchange — exactly what it sounds like, members could shop around for health insurance plans and get federal discounts if they qualified.

California was the first state to introduce such a marketplace when then-Gov. Arnold Schwarzenegger signed Assembly Bill 1602, creating the California Health Benefit Exchange, more commonly called Covered California.

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What is CalOptima Health?

CalOptima Health is Orange County’s public health insurance plan for low income people and families. All of CalOptima’s members get their health insurance through Medi-Cal.

What would happen if CalOptima Health joins Covered California?

Yunkyung Kim, the chief operating officer at CalOptima, told LAist that MediCal has specific income requirements, meaning members have to earn below a certain income level to be eligible. If your income goes above that threshold, you lose coverage.

“ What we are hoping to do is be there for our members and our families when their income goes up and down, because a lot of time that income difference is very small,” she said. “It could be something like a parent working overtime during that year that just pushes the income just over that limit. It could be because someone got a very small raise.”

By joining the insurance marketplace, CalOptima can provide a continuity of care, Kim added.

There are currently five insurance plans offered on Covered California, she said. If CalOptima joins, it will create a sixth option so members can stick to the same doctors they’re used to.

About 10,000 members will benefit if CalOptima joins Covered California as they experience income fluctuations, she said.

Why now? Have other counties joined Covered California?

L.A. Care Health Plan, which administers Medi-Cal in Los Angeles County, and Inland Empire Health Plan are members of the Covered California marketplace.

In 2011, the Orange County Board of Supervisors amended an ordinance that restricted entry of CalOptima to Covered California because the ordinance stated “it is not intended that the Health Authority compete with private sector health plans.” At the time, only current Supervisor Janet Nguyen was on the board.

On Dec. 3, the Board of Supervisors voted to amend the ordinance to allow CalOptima to join Covered California. Nguyen was not present at that meeting as she was only sworn in the following day replacing the seat left empty by disgraced former Supervisor Andrew Do.

On Dec. 17, the ordinance came back in front of O.C.’s leaders for a second reading, however Nguyen requested additional time to review it.

“ I was here in 2011 at this board when we  voted to not allow CalOptima to be part of Covered California because CalOptima is not a private insurance agency,” she said. “It is a public agency that is supposed to purely provide medical assistance and health benefits.”

Nguyen served on the board of CalOptima during her first term on the board of supervisors. During her tenure, CalOptima underwent controversial changes. In January 2013, the Orange County Grand Jury released a withering report that found that hospital lobbyists wrote a county ordinance. Investigators also alleged that Nguyen and two CalOptima lawyers were “disruptive” and created an “unsafe” environment as they remade the board of directors leading to an exodus of 16 executives.

At the time of the Grand Jury report, Nguyen vigorously disputed the findings in an op-ed published in the Orange County Register, calling the allegation that a lobbyist had written the ordinance "outright wrong."

A year later, a federal audit found “widespread and systemic” failures at CalOptima. Federal auditors found that members were denied medications, even when they were covered by the plan. CalOptima also could not demonstrate that fraud, waste and abuse training was provided to employees and allegedly failed to pay for emergency services for members.

When is the second reading?

The Board of Supervisors is set to consider the second reading of the ordinance on Jan. 14 at their first meeting of the new year.

• You can check out the O.C. Board of Supervisors full calendar here.
• Learn how to submit a public comment to the O.C. Board of Supervisors.