San Diegans for Healthcare Coverage


Our Mission
To bring diverse constituencies together to identify and pursue strategies for expanding health care coverage and access to health care in the region.

A Coalition for Health

SDHCC Principles and Elements for Health Reform

Consensus General Positions
  • The system of providing healthcare coverage and care in the United States is broken and getting worse
  • Reforms should consider whether and where a complete overhaul is required and where building on existing elements of the healthcare system will best meet reform objectives.
  • Achieving comprehensive health reform over the next four years is imperative to individuals and families, business, government and the economy.
  • Developing solutions, oversight and funding for health coverage is everyone’s responsibility – government, business, and individuals.
Principles and Required Elements for Health Reform
  • Access:  All citizens and legal residents should have access to affordable healthcare coverage and care.
  • Meaningful, Accessible Coverage:  Establish meaningful basic/minimum benefit package (Exhibit 1) that provides access to medically necessary care and services and encourage early intervention, preventive care, disease management, and healthy behavior incentives.
  • Affordability:  Both coverage and premium share should take family income into consideration:
    • Co-payment levels by family income category and are not a barrier to needed care
    • Deductible levels by income category, with no deductibles for low to modest income individuals (under 300% FPL)
    • Specific services should be exempt from deductibles (e.g., well-child care, screening exams, recommended periodic exams)
    • Any deductibles should apply after a specified level of eligible expenses are incurred
  • Employer Participation:  Incorporate incentives for employers to voluntarily provide coverage, especially those not currently providing coverage (premium assistance program through the workplace, state tax credits, etc.).  Incentive program (premium assistance) should have defined benefit packages and options to purchase more extensive coverage.   This is especially important for those employers with under 10 employees (50% of uninsured).
  • Reimbursement:  There must be adequate reimbursement to healthcare providers, including elimination and avoidance of cost-shifting from public payors.
  • Reinsurance:  Offer government funded reinsurance program for both premium assistance program and for individual guaranteed issue programs; do not carve-out individuals by disease from risk pools.  Any program should ensure continuity of coverage and care, especially when an individual is diagnosed with a chronic disease.
  • Cost Containment:  Ensure transparency, care guidelines and reporting that allow for consumer options, encourage cost containment and reflect evidence based protocols.
  • Administrative Simplicity:  Simplify and minimize administration, consolidate and eliminate fragmented programs.  Incorporate requirements for easy enrollment in coverage through electronic, web-based systems and other means; minimize administrative burden on employers and employees; maximize opportunities for eligibility simplification rather than complicated and costly documentation requirements.
  • Local Outreach and Enrollment:  Incorporate requirements and structure for local outreach, education and enrollment; healthcare delivery and networking relationships are local.  .
  • Program Evaluation and Adjustment:  Establish clear objectives for both process and outcomes, including measures and methods of measuring.  Integrate the ability to make program adjustments as necessary to meet objectives.

Exhibit 1

Minimum Basic Benefits Package

Service Category

Benefit Description

Primary Care:  Services provided by primary care provider (PCP), including office visits, supplies and administered drugs; preventive, wellness exams and education.

Must select a PCP from a specific group/clinic in plan network.  No coverage outside of designated group.  May switch PCP through plan (HMO).

Specialty Care:  Services provided by a specialist, including office visits, supplies and administered drugs and outpatient and inpatient consultations, maternity, surgery and other procedures.

On referral by PCP for initial consultation to group panel; prior approval for ongoing care; No coverage outside designated panel. (HMO)

Diagnostic: Laboratory, Radiology, Cardiac and other diagnostic tests and procedures ordered by a physician. Includes routine screening exams (mammograms, pap smears, colon exams)

Routine tests and screening ordered by PCP.  Some expensive tests prior approved by plan. (HMO)

Hospital:  In-patient hospital medical, surgical and maternity services or maternity delivery services and newborn care.  All hospitalizations are approved and reviewed by plan.

Medically necessary hospitalization in hospital designated by primary physician and plan. 
(HMO)

Pharmacy:  Prescription drugs ordered by your physician necessary to treat a medical condition.

Covers drugs through tiered system of generic, preferred and non-preferred only.

Rehabilitation Services:  Outpatient Therapy, Home Health Care or Skilled Nursing Facility (SNF) services and equipment necessary to improve functioning following an illness or injury.

Medically necessary outpatient therapy and home health care; short term rental/  purchase of most required medical equipment at 80%; up to 30 days in a Skilled Nursing Facility for rehabilitation. All with plan approval. 

Transplantation – Investigational:  Organ transplant services and treatments still under investigation (e.g., drugs, devices, treatments)

Organ transplants covered at designated facilities for cases approved by health plan according to transplant criteria.  Investigational services, drugs and devices not covered.

Mental Health:  Outpatient and inpatient mental health and chemical dependency services.

Up to 20 visits per year for therapy; up to 20 days per year in hospital for mental health or chemical dependency treatment with prior plan approval.

Quality of Life:  Services are not to treat a current medical condition but which may improve quality of life (e.g., Fertility treatments, Weight reduction, etc.)

Covers such things as weight-reduction program/procedures at 50%, infertility treatments at 50%

Dental:  Services provided by a dental health professional to care for teeth. 

 X-rays, Cleanings each six months at no cost. $50 deductible ($150 per family), then 80% for basic dental services (filling cavities, removal of teeth, oral surgery). 50% for major dental services (crowns/bridges , repairs) Annual max $2,000.

Vision:  Eye examinations (including acuity, pressures, etc.), glasses and contact lenses.

Routine eye examination every two years; $100 for glasses or lenses every two years.

Not Covered:  Complementary Services (Acupuncture, Chiropractic), Experimental Services, non-emergency out of network or unauthorized services. 

Notes:
Minimum, basic benefit package developed through focus groups and Business and Labor Roundtable forums
HMO Model of Coverage for basic benefit plan
Co-payment levels to be established based on family income group to eliminate barriers to necessary care.
No deductibles for those under 300% FPL and only modest deductibles based on family income group above 300%; Preventive and screening services excluded from deductible application

 
San Diegans for Healthcare Coverage