San Diegans for Healthcare Coverage

San Diego Healthcare Connection (SDHC) Pilot Demonstration Project

Overview

General SDHC Design:

A group coverage program for employers with uninsured employees,including the SDHC benefit plan and premium assistance program for uninsured employees under 300% of the federal poverty level (FPL) and other benefit options for employees above that limit.
State program with San Diegans for Healthcare Coverage (SDHCC) as the local administrative arm under State oversight; a federal waiver would be required as done with other states for similar programs.
Basic essential benefits covering outpatient, inpatient, diagnostic and treatment services, basic dental and vision services with co-payment levels for employees participating in premium assistance program based upon family size and income.

Demonstrate/test Employer and Employee interest in SDHC Program (enrollment, retention, satisfaction, contribution thresholds)

Estimate savings to public programs (Medi-Cal, AIM, County Medical Services)

Estimate reductions in uncompensated care and longer term health and social costs of foregone care

Assess and compare access and health outcomes

Estimate overall cost savings to business, government and individuals of full SDHC program expansion

Target Population(s)

Working uninsured who work more than 20 hours per week.
Dependent coverage if foundation funding can be secured to cover employer share; Dependent children enrollment in existing public programs (Medi-Cal and Healthy Families).

Employer Participation

Employers not offering coverage for a period of 6 months or more would be eligible to participate with contribution of approximately 30% of SDHC benefit plan premium increasing to 40% in third, 50% in fourth and 60% in fifth year of program; program flexibility on employer share if annual retention drops below 80% at any one increase.
Employers currently offering coverage or having offered coverage in past 6 months eligible to participate at current/prior contribution levels.

Employee Participation

Employees with family incomes under 300% FPL eligible to participate in SDHC benefit plan through SDHC participating health plan with premium assistance program.
Employees with family incomes over 300% FPL eligible to participate in benefit plan options offered by employer through SDHC participating health plans.
Employees currently enrolled in coverage or eligible for Medi-Cal cannot participate in premium assistance program; employees who become eligible for Medi-Cal due to chronic medical condition (e.g., end stage renal disease, AIDS) required to apply for Medi-Cal and, if eligible, would be disenrolled from SDHC program.

Health Plan Participation (Coverage Vehicles)

Commercial plans approved to offer coverage in San DiegoCounty and offer SDHC benefit plans and portfolio of benefit plans for those over 300%; for over 300% employers may chose up to two benefit plans.
Participate in and support program administration, rules, payment terms, reinsurance and SDHC evaluation through provision of summary and individual (HIPAA compliant) demographic, encounter and claims data and comparative summary data for similar populations.

Administration

SDHCC as designated local outreach, education, enrollment and eligibility entity under State oversight.
Third Party Administrator for premium collection and distribution and reinsurance administration.
State policy oversight and administration of key elements.
Independent Evaluator for program and estimated financial impacts (shared foundation funding).

January 11, 2007