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California Health Exchange Profile


Establishing the Exchange

On September 30, 2010, former Governor Arnold Schwarzenegger (R) signed into law two complementary bills, AB 1602 and SB 900, to establish the California Health Benefit Exchange. California was the first state in the nation to pass legislation creating a health insurance exchange after the enactment of federal health reform. Current Governor Jerry Brown (D) called a special legislative session in late 2012 to allow the state to draft additional supplementary legislation to implement the Affordable Care Act (ACA) in California. In October 2012, the Exchange announced that its new name would be ‘Covered California.’

Structure: The legislation defines California’s Exchange as a quasi-governmental organization, specifically an “independent public entity not affiliated with an agency or department.”

Governance: Covered California is governed by a five-member board, including the Secretary of California Health and Human Services (or designee) as a voting, ex officio member, two members appointed by the Governor, one member appointed by the Senate Committee on Rules, and one member appointed by the Speaker of the Assembly. The legislation specifies that each appointed member of the Board should possess expertise in key subject areas such as, individual or small employer health care coverage, health benefits plan administration, or health care finance. While serving on the Board, members must not be affiliated in any way with a carrier or other insurer, an agent or broker, a health care provider, a health care facility or clinic, or a trade association for these entities. Also, members must not be health care providers, unless receiving no compensation for services provided.

Current Board members are:

  • Diana S. Dooley (Chair), Secretary of California Health and Human Services
  • Kimberly Belshé, Public Policy Institute of California
  • Paul Fearer, Union Bank and Pacific Business Group on Health
  • Susan Kennedy, former Chief of Staff for Governor Schwarzenegger
  • Dr. Robert Ross, The California Endowment

The Board of Covered California has been meeting monthly since April 2011 and hired an Executive Director who began on October 17, 2011. Covered California has a staff of 138 employees.

In September 2012, the Board approved the creation of three key stakeholder advisory groups meant to inform the Board’s policy decisions and shape the implementation of the Exchange. Stakeholder advisory groups will include, Plan Management and Delivery System Reform; Marketing, Outreach and Enrollment Assistance; and the Small Employer Health Options Program. In November 2012, Covered California adopted a Tribal Consultation Policy and added a Tribal Consultation advisory group to help structure the relationship between the Tribes and the Exchange, build a partnership, and maximize the participation of eligible American Indians in the Exchange. In January 2013, the membership of the four stakeholder advisory groups was announced.

Contracting with Plans: The Board will selectively contract for health coverage offered through the Exchange, “seek[ing] to contract with carriers so as to provide health care coverage choices that offer the optimal combination of choice, value, quality, and service.” California has experience acting as an active purchaser from other programs, such as the Children’s Health Insurance Program (CHIP), small-business purchasing pool, and the state employee purchasing pool. The legislation directs the Board to define minimum requirements that carriers must meet to be considered for participation in the Exchange.

To mitigate the risk of adverse selection, the legislation requires carriers, whether or not they participate in the Exchange, to offer at least one choice at each of the four coverage levels. Catastrophic plans will only be offered by carriers participating in Covered California. Also, products offered within the Exchange, either for individuals or small employers, must be offered to that population outside the Exchange.

In November 2012, the Board released a final Qualified Health Plan (QHP) Solicitation to carriers for bids to offer, market, and sell QHP coverage through the Exchange beginning in 2013. Bids were due from carriers by January 20, 2013 and Covered California expects to negotiate and finalize contracts by June 1, 2013. Bids will be evaluated based on the mix of health plans in each region of the state that meet the Exchange’s goals to promote affordability, competition, alignment of delivery systems, and long-term partnerships. The Board is also developing a model QHP contract, incorporating comments from stakeholders.

Earlier in the year, the Exchange led multiple stakeholder group sessions with consumer advocates, brokers, and business representatives to gather feedback on plan selection and design issues including, the optimal number of plans with which to contract, network criteria, out-of-pocket cost design, dental and vision coverage, and health system reform. The Exchange released a draft report in July 2012 on QHP options and recommendations based largely on stakeholder feedback. Initial recommendations on plan and network design included requiring all QHPs to offer all metal tiers, limiting each issuer to propose 2-3 products per geographic region, and standardizing family tiers and tier ratios.

In September 2012, the Board approved using the eValue8 tool, which measures and evaluates health plan performance, as part of the QHP solicitation to support a quality rating system.

On February 13, 2013, Covered California announced that it will require standardized benefits and cost-sharing across all the health plans that participate in the Exchange. The final benefit plan designs specify the benefits that will be offered by all plans and the deductible, copayment, and co-insurance amounts that will be required of plans at different metal tiers. Bidders responding to the QHP Solicitation will be required to bid at least one of the Covered California’s adopted standardized benefit plan designs in each region for which they submit a bid; however, they may also propose an alternative benefit design and may offer the Exchange’s standardized Health Savings Account-eligible (HSA) design.

Dental and Vision Benefits: In October 2012, the Board adopted a policy supporting stand-alone pediatric vision plans on the same terms as pediatric dental benefits in both the Individual and SHOP Exchanges. Also, the Board approved offering stand-alone vision plans providing services to adults and children for benefits not offered through the EHB benchmark plan. On January 8, 2013, the Board released a solicitation inviting vision and dental issuers to submit bids to offer supplemental dental and vision plans on the Exchange. Bids were due April 8, 2013.

Risk adjustment, Reinsurance, and Risk corridors: The Exchange decided it will initially rely on the federal government to administer risk adjustment and reinsurance programs for the state.

Consumer Assistance and Outreach: The Affordable Care Act (ACA) requires that state exchanges employ Navigators to assist with education and enrollment activities but leaves considerable flexibility for states to define their program. Given California’s complex linguistic and cultural diversity and its size, the state began soliciting broad stakeholder input for an Assister program. In June 2012, Covered California subcontractors released recommendations and a final work plan for Phase 1 and 2 of the statewide Assisters Program. The Assisters Program will consist of Navigators and In-Person Assisters (IPAs) that will include non-profit organizations, community clinics, County Social Services offices employing Eligibility Workers, and labor unions. Other entities that may participate as enrollment assisters but will not be paid by Covered California include health insurance agents, hospitals, and providers. Navigators will be compensated through competitive grants, as required by federal statute, and IPAs will be paid $58 per successful Exchange application and $25 per renewal. Training and certification guidelines for both types of Assisters have been developed.  It is expected that the IPA application will be released in the spring with training of IPAs to begin in August, while the Navigator application will be released over the summer with training of Navigators to begin in November.

The state procured subcontractors to develop an outreach, marketing, and education strategy and has detailed enrollment goals which have been broken out by potential enrollees’ insurance status and demographic characteristics. Between September and December 2012, the state planned to refine their media plan and begin to develop the training curriculum for the Assisters program. Then for Phase II, between January and July 2013, the state plans to begin educating consumers and to begin paid media promoting the benefits of coverage.

Covered California is also using federal funding for an Outreach and Education Grant Program that will engage organizations and entities with relationships with California’s uninsured population to increase awareness and understanding of health coverage options. This program will complement the state’s broader marketing strategy and help build capacity for the Assister Program. On January 21, 2013, Covered California released the Request for Applications for the Outreach and Education grant program. The program will award $43 million in grants to community organizations, $40 million to entities targeting individuals and $3 million to entities targeting small businesses eligible to purchase coverage through the SHOP Exchange. Applications were due March 5th and award notices are expected by the end of April.

In February 2013, Covered California announced the launch of its new consumer and business website ( to provide information on the coverage opportunities that will be available. The website is available in English and Spanish and numerous fact sheets have been translated into 11 other languages.

Small Business Health Options Program (SHOP) Exchange: In October 2012, the state released a solicitation for the Administration of SHOP Operations that is expected to be awarded by early 2013. On April 4, 2013, Covered California announced that it had awarded a contract to Pinnacle Claims Management Inc. to administer the SHOP Exchange. The contract includes maintenance and enhancements of the SHOP Exchange through December 2015. Over the summer, the Exchange Board approved a position for someone to oversee the SHOP Exchange. California indents to pursue the option for the employer to choose the plan tier, while the employee chooses the issuer and plan.

Information Technology (IT): Additional legislation to help guide the state toward streamlined eligibility and enrollment systems for Medi-Cal, Healthy Families, and the Exchange was signed into law in October 2011 (AB 1296). The legislation requires the creation of a single statewide application that will be available on paper and electronically for all systems and entities accepting and processing applications and eligibility. It also requires a simplified citizenship and identity verification at application and renewal and increased coordination with other public programs.

In June 2012, the Exchange Board, in collaboration with the Department of Health Care Services and the Managed Risk Medical Insurance Board, procured a subcontractor for the development and operations of a new Eligibility, Enrollment and Retention System (CalHEERS) which will serve as the technology infrastructure for all three agencies. Stakeholders were given the opportunity to provide comments on specific design elements and the Board solicited two different approaches to Medi-Cal case data management- either building to allow the data to reside at the county level or pushing the data to a central hub.

In May 2012, the Board began solicitation for a subcontractor to develop and assess alternative approaches for a state-wide Exchange Service Center and then released a report outlining the options being considered. The County Service Centers will support eligibility and enrollment for the Exchange and the state plans to fill approximately 850 positions for customer support. In October 2012, the state released a Request for Offers to counties that previously expressed interest in providing Service Center functions for the Exchange. In April 2013, Covered California announced the three sites for the statewide Service Center. Staff at the Service Center will respond to questions related to coverage through the Exchange and will refer calls related to Medi-Cal coverage to Consortia-Based Service Center Networks that will include some county customer service centers. By 2015, the Exchange aims to enroll 1.4 million Californians in coverage.

Covered California is also participating in the “Enroll UX 2014” project, which is a public-private partnership creating design standards for exchanges that all states can use.

Basic Health Program (BHP): California has considered an optional coverage program available through the ACA which allows states to use federal funding to offer subsidized health insurance to adults with incomes between 139 and 200% of the federal poverty level (FPL) who would otherwise be eligible to purchase subsidized coverage through an Exchange. Following delay in the release of federal guidance on the BHP, California developed an alternative Bridge Plan proposal that would certify certain Medi-Cal managed care plans as bridge plans, allowing individuals transitioning from Medi-Cal to the Exchange to remain in the same plans. These would also offer lower premiums, thereby increasing the affordability of coverage for low-income Exchange enrollees. On March 11, 2013, the Exchange sent a letter to HHS requesting approval of the proposed Bridge Plan.

Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. Legislation selecting the Kaiser small group HMO plan as the state’s EHB benchmark plan and the state’s Healthy Families (CHIP) program as the pediatric dental supplemental benefit was signed into law in October 2012 (AB 1453/SB 951).

Exchange Funding

The legislation creates the California Health Trust Fund within the State Treasury, which will be continuously appropriated and used to manage the finances of the Exchange. The legislation also authorizes a loan of up to $5 million from the California Health Facilities Financing Authority to assist in establishment and operation of the Exchange. The California HealthCare Foundation and the Blue Shield California Foundation also funded activities in preparation for applying for the federal Establishment grant.

In September 2010, the California Health and Human Services Agency received a federal Exchange Planning grant of $1 million. The state also received a federal Level One Establishment grant of $39.4 million on August 12, 2011 which will be used for overall business and operational planning, research and analysis, and implementation of an information technology system. The state was awarded a second Level One Establishment grant in June 2012 for $196.4 million for continued Exchange development. In January 2013, the state received a $674 million federal Level Two Establishment grant that will enable the state to continue implementing its Exchange and will finance the Exchange’s operations through December 2014.

Next Steps

On January 3, 2013, California received conditional approval from the U.S. Department of Health and Human Services (HHS) for its state-based exchange. Final approval is contingent upon the state demonstrating its ability to perform all required Exchange activities on time and complying with future guidance and regulations.

Additional information about the California Health Benefit Exchange can be found on the Exchange’s website:

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