California Medical Association

Friday, February 5, 2016

San Francisco Medical Society Blog


Providing news to the San Francisco Medical Community.

Covered California Update: Patient Eligibility and the 90-Day Grace Period

Under the Affordable Care Act, Covered California enrollees who receive federal premium subsidies (approximately 90% of enrollees) to help pay their premiums are entitled to keep their insurance for three months after they have stopped paying their premiums. In the first month of the grace period, federal law and California regulations require plans to pay for services incurred even if the patient fails to pay the premiums due by day 90 (CCR §1300.65.2(b)(1)(A)). But in months two and three of the grace period, plans can “suspend” coverage and pend or deny claims if the patient doesn’t true up on his or her premiums by day 90.

In 2014, CMA was successful in advocating that plans be required to clearly communicate to practices through their real-time eligibility and verification systems if an enrollee’s coverage is suspended during the second and third months of the grace period. Further, the regulation requires plans to reflect “suspended” coverage on day one of the second month of the grace period, and requires plans to use one of three eligibility status indicators to reflect suspended coverage – “coverage pending,” “coverage suspended” or “inactive pending investigation” (CCR §1300.65.2(b)(C)).

If a plan fails to reflect suspended coverage using one of the above indicators on day one of the second month of the grace period, and a physician provides services to a subsidized enrollee, the plan is financially responsible for the claims incurred (CCR §1300.65.2(d)(5)). However, practices must be able to prove that the plan did not comply with the regulation.

It is extremely important that practices verify eligibility on all exchange patients, ideally on the date of service, or as near the time of service as possible, and that the practices retain a printout of the eligibility verification and includes it as part of the patient’s chart. If a patient’s eligibility verification comes back indicating his or her coverage is suspended, the practice can treat the situation as it would any other patient who has had a lapse in coverage. For non-emergency services, patients may be given the option to either pay cash at the time of service or reschedule to a later date. 

Further, California regulations require the plan to notify any provider with an outstanding prior authorization if the patient is in months two or three of the grace period (28 CCR §1300.65.2 (d)(2)). If the plan fails to comply with the notice requirement and the services are provided in good faith, pursuant to the authorization, the plan is responsible for paying the authorized claim(s) (28 CCR §1300.65.2 (d)(5)).

Click here for more information on Covered California and FAQs for physicians.

SFDPH Health Advisory: Zika Virus

Mosquitoes associated with the Zika virus have been detected in the Bay Area, but none has been found to carry the disease linked to birth defects in newborns in South America.

Zika is a mosquito-borne virus that causes mild illness with fever, rash, joint pain, and conjunctivitis in approximately 20% of those who become infected. Outbreaks have occurred in locations in Africa, Southeast Asia, the Pacific Islands, and the Americas. Cases in the United States (including California) have been diagnosed in returning travelers. Recently in Brazil, increased numbers of fetal deaths and newborns with microcephaly have been noted among mothers who were infected with Zika virus while pregnant. However, additional studies are needed to understand potential embryonic and fetal effects of Zika virus.

The U.S. Centers for Disease Control and Prevention (CDC) has issued a travel alert (Level 2-Practice Enhanced Precautions) for people traveling to areas where Zika virus transmission is ongoing. Currently: Mexico, Central America (El Salvador, Guatemala, Honduras, Panama), South America (Brazil, Colombia, French Guiana, Paraguay, Suriname, Venezuela), and the Caribbean (Puerto Rico, Haiti, Martinique).

Pregnant women are advised to consider postponing travel to these locations, and all travelers are advised to take strict precautions to avoid mosquito bites. 

Actions Requested of All Clinicians

  1. Counsel pregnant women to consider postponing travel to areas where Zika virus transmission is ongoing and counsel all travelers to these areas to use strict precautions to avoid mosquito bites.
  2. Consider Zika testing per CDC guidance. At this time, asymptomatic individuals will not be tested. Zika testing is indicated for pregnant women who have traveled to an area of Zika transmission and had symptoms of Zika virus, or if there are findings of fetal/newborn microcephaly with a history of maternal travel.
  3. Contact SFDPH for assistance if Zika testing is indicated per CDC guidance. Specimens cannot be sent directly to CDC, and testing must be coordinated by the local health department. Contact SFDPH Communicable Disease Control Unit (CDCU) 24/7 by calling (415) 554-2830.

Click here for the SFDPH Health Advisory issued on January 22, 2016.

SFDPH Health Update: Healthy Super Bowl 50

The San Francisco Department of Public Health (SFDPH) is working to support Super Bowl activities to ensure that visitors and local residents have a safe, positive, and healthy experience. Game day is Sunday February 7 in Santa Clara, but many additional activities, celebrations, and visitors from around the globe will be in San Francisco from January 30 through February 8.

A few potential public health issues include:

  • Influenza virus is active both locally and nationally, and visitors will be arriving from regions with extensive influenza activity (see
  • Norovirus is active locally and nationally. Norovirus is highly contagious and spreads through close person-to-person contact, contaminated food or water, contaminated surfaces, objects and utensils, and via aerosol particles from vomitus (see
  • Inebriation could be an issue during Super Bowl events. The SF Sobering Center provides safe sobering for acutely intoxicated individuals. The Sobering Center is expanding capacity to augment its existing 24/7 sobering services, and will have an overflow area during the peak drinking times and days. To refer clients, please contact the center at (415) 734-4227.

San Francisco physicians are asked to:

  1. Encourage and provide influenza vaccination for all persons 6 months of age and older who have not already received 2015-16 vaccine.
  2. Emphasize standard precautions and common sense measures that reduce disease transmission, for example, staff and patients should avoid touching their eyes, nose, and mouth, use proper hand hygiene, practice cough etiquette, and stay home and limit contact with others when ill. Surfaces contaminated with vomit, diarrhea, or respiratory secretions should be immediately cleaned and disinfected.
  3. Report communicable diseases and outbreaks in a timely manner to the SF Communicable Disease Control Unit (CDCU) so that CDCU can follow-up to prevent further spread. A list of legally-reportable conditions, along with forms and time windows for reporting, is available at CDCU may be reached 24/7 by calling (415) 554-2830.
  4. Be on the lookout for temporal or geographic clusters of illness that could be clues to an intentional release of a biologic agent, and immediately report cases to CDCU 24/7 by phoning (415) 554-2830.

Click here for the SFDPH health update issued on January 26, 2016.

CURES 2.0 Update; Technical Assistance Available to Users

The California Department of Justice (DOJ) implemented an upgrade in early January to the Controlled Substance Utilization Review and Evaluation System (CURES), California’s prescription drug monitoring system. Known as “CURES 2.0,” the system promises a significantly improved user experience and features a number of added functionalities.

All users who log into CURES after January 8 will be prompted to update their security information in order to confirm their account. Those users who meet specific web browser compatibility requirements will be directed to CURES 2.0, while others will be routed to the old CURES 1.0 interface. After following this security step, physicians may experience a 15-20 minute wait before being able to log into the system with their updated credentials.

Physicians who encounter technical difficulties – such as logging into their accounts, retrieving their log-in information or verifying their accounts – should contact the DOJ CURES Help Desk at (916) 227-3843 or Providers are also encouraged to report these technical issues to the California Medical Association’s member help line by calling (800) 786-4262 or emailing

All individuals practicing in California who possess both a state regulatory board license authorized to prescribe, dispense, furnish or order controlled substances and a Drug Enforcement Administration Controlled Substance Registration Certificate must be registered to use CURES no later than July 1, 2016. To register using the new automated system, visit

Click here for FAQs developed by the Department of Justice.

Click here for additional information about CURES 2.0 from an earlier SFMS blog post.


CMA Issues New Physician Resource on California’s End of Life Option Act

The California Medical Association (CMA) has released a new On-Call document to help physicians understand ABX2-15, California’s End of Life Option Act. The guide was developed by CMA’s Center for Legal Affairs to help physicians and patients understand the End of Life Option Act, which will go into effect 90 days after the special session of the California state legislature ends.

California became the fifth state in the nation to allow physicians to prescribe terminally ill patients medication to end their lives. ABX2-15, the “End of Life Option Act,” was passed in October 2015 and permits terminally ill adult patients with capacity to make medical decisions to be prescribed an aid-in-dying medication if certain conditions are met. (ABX2-15, Stats. 2015, Ch.1; Health & Safety Code §§443et seq.)

The 15-page guide offers FAQs and outlines documentation and forms required to adhere to this legislation.

Click here to access the End of Life Option Act Guide for Physicians.

CMA removed its longstanding opposition to physician aid-in-dying last May. The San Francisco Medical Society, citing both surveys of physician opinion and the reassuring evidence from other states, successfully advocated that CMA become neutral on the bill and topic, thus allowing the legislation to reach Governor Brown. SFMS will continue to work for improved end-of-life care and patient choice, and feel that this bill will advance those goals for all Californians.

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