>> yeah. observation first. i think that as my questions were, and related to commissioner's questions and i think that one of the challenges that we are going to face going forward is can ditly picking the poison of just saying, if you are above 20 employees you have to comply with the aca. like, anywhere else. above 50 employees. >> and the other groups that want to catch that are not in it, and that poison, verses the poison, of the acao which predates the aca and but create as a system where you can't take advantage of the efficiencies, and it will be confusing for employers, that grow, and it will be confusing and at some point, we might come to the conclusion, like, wow this is complexity and why did we ever go there and because the aca gets better in

terms of our interpretation of better, and so we have the courage to watch as this thing involved to say wait a second, let's examine it and make sense and, my specific questions with recommendations three, and this may be a naive question, but can we do that? given federal and state, tax laws, and etc., etc.? >> can we implement this without being in violation of federal laws? >> we have, we have been doing it so far and it has not, been, any trouble, and many of our employers take advantage of it and have the hr departments that have in the brokers that we have worked with, saw, no problem. >> okay. >> so... >> and in i think that commissioner taylor-mcghee? >> i have some concerns about the out of pocket minimum.

the $4,000 to a maximum, and the $4,000 to the $6360 and so i am trying to wrap my brain around you know, is someone just said a minute ago, something about a mobility and what is relative, right? >> and so, how does this and what was the sort of take away if you will when you were trying to figure that out, and is it the deductible with that, balance, or the... >> yes. it was. >> so on to speak, one are on the other. >> it is not one are the other, it is both. >> we lowered the deductible and a lot of plans were come misser ate with that and we increased the out of pocket maximum because of the reality of so many plans going right to where the acr said that they could. right up to that dollar amount. and so, it, or if you change

that you throw, the balance of the 50 percent basically of the plans, and being available to the employers or plans you are going to throw that quite a bit out of whack and so given how many plans that we saw, and at the 6350 level, and the advisory group was extremely uncomfortable and felt that many and several members, i can't speak for all of them on that, obviously. because, that is we heard, and somewhere not comfortable with that and i understand that. but, what you see, is going right to the max that they can go to. so, that, and that was kind of why i said before why they chose the $4,000 amount, because they thought that that was going to be the max. but it ended up going much higher under the coverage california. and the aca. and so, you know, one of the members of the group kept

saying, representing the employers, kept saying that, i can't see the fairness, in you putting it at an amount, that is not at the level that the aca is requiring and that so many of the insurers are migrating to. and i believe that it is in the brons, 6500 is in the bronze and silver and gold category and that is in the, max that you can do, under all of those and it is just the platinum level that goes lower. than that. >> and it was the biggest one,... >> and i would say, both that and the out of pocket, or the deductible were both%backer, and what we ended up doing is that we have five different plans and they did look at out of different out of pocket maximum and so at different level and different levels of deductible and so we looked at,

and we looked at other ideas before and that was toward the end and those were five ideas of the group that asked us to look at. and looked at how, you know, what the percentages would be of the plans, and how many two meet it and not meet it, but, it is you know, kind of where they are gravitating to right now. >> and you know, one thing to add to it, i forgot to mention this, and this speakers, and mentioned it, that we did say, that we will see where it goes in two years, it is on page 13 of your report, and so will conduct the promise to conduct a review of the plans, and on this small business market place as compared to the

minimum standards is that if the percentage of plans, is lower than 40 percent, than dhp will make a full recommendation, and make recommendations for your consideration. >> and so we did agree to that to help an agreement along because it was the struggle, for obvious reasons. >> and so, i would like to follow up on that question. because i think that, and i think that the end of the speakers spoke to the trade off being, and within the lower, deductible. >> yes. >>september

second meeting. as well as go over the impact that was requested by the commission and so to review, and at the september second meeting, we recommended the following changes, on the healthy san francisco side and we recommended that the current transition period, which allows the people who are eligible for coverage california to enroll

in and or stay, in healthy san francisco, and be extended to another year, through december 31, 2015, and we also recommended that healthy san francisco are expanded to allow uninsured seniors to participate, and we recommended lowering the upper almost level from 400 to 500 percent of poverty to align them with the subsidies under the affordable care act and all of these policies were designed to or in tended to maintain the continuity of coverage and to reduce the gaps as well as to make sure that hel ygt san francisco is available able for the people who don't have other options and the city option, on the side, and we sought, to encourage the use of the mri funds that are contributed by the employers, and from the hcso.

totals include the cost of providing care for senior and providing care for under, healthy san francisco and then savings would be, and it would be realized from the people leaving the program as well as the cost ainvoice ans for caring for people through a cost effective manner through hel ygt san francisco and i

will go through the details on each policy. >> and so, for the extending the healthy san francisco, transition, period it is actually the most costly of all of the changes that we have proposed. and currently for the 2014, calendar year, and we estimate that it costs 8.2 million dollars and this amount is corrected for an ongoing, decline that we are seeing, and in the healthy san francisco enrollment. and so, we have corrected that for the people who are taking advantage, of the extension period, currently, and so... >> just a point of clarification on that. >> sure. >> if we did nothing, today, and we did not accept your recommendation. like, that cost in 2014, would, and we would still incur that, correct? >> and if we. >> we have the people that are currently enrolled in hel ygt san francisco and through the end of this calendar year and that is already happening. >> right. >> and so that 8.82 million will be incurred for 2014. >> if we did nothing today. >> if we did nothing today.

>> how is that an additional cost to your recommendation. >> the 2.67 million for next year is an additional cost. >> 8.28 for this year. >> right >> is not like, and that is happening. >> that is already in effect. yes. >> or, are we talking about the calendars years or fiscal years. i should clarify that these are calendar years and anything that is a 2014 cost is the current year cost under the existing policies. >> so, for 2015, again, if we, assume that that enrollment continues, we could expect to see, to encure the cost of 2.67 million, and then in 2016, and once that transition period ends, and we would realize that the savings, and because the people who are taking advantage of the transition, would no longer be eligible. and but, for it to the commissioner singer's point, and we do have another open enrollment coming up, and we

may realize what we may not incur all of these costs because we may have an exit from the program. >> my point was different. and my point was that, as, as we look at the incremental cost of what you are asking us to approve, and it is really, what is in 15 and 16. >> and to everything else. and we have, we are doing. >> yeah. >> and yeah, that is right. >> and so, do you mean, incremental costs? because, this says that our current program, with the lesser enrollees but adding the seniors is 2.67, million? >> and this is to determine in the incremental cost? >> and where to find the 2.67, because we have some people, already, on the program, where we are adding the seniors. and one of the questions was how much is it costing us, to add the seniors? >> but, that i will go over that in the next. and this particular, slide is just for extending the transition period. and so, just, the healthy san francisco.

and allowing the coverage california and this will cost us to extend the transition period. >> yes. >> for one year. >> and to ex-expand the eligibility for seniors, currently our 2014 cost, for caring for our seniors who are uninsured is 2.56 million dollars, and we are getting that, by using charity care, report and so, in 2015, if all of the seniors were to transfer to healthy san francisco, because the healthy san francisco, per person cost is actually lower than our charity cost, properson cost and we will actually be paying, less for them, at 2.39 million dollars. >> and then, in 2016, so, it is something is in the 2015 cost is that also, will include, and if we were to allow the seniors in, and we will have to allow them to take advantage of the transition period and so we have built in, a higher estimate in 2015, saying that more people will be enrolled, and then in 2016, fewer people

will actually be eligible for healthy san francisco, and this costs should go down. >> is this, and is that 14 costs. and generally, fund, costs or is it your estimation of what we pay, as a system, giving charity care at other hospitals? >> that is the general fund cost, to dph. >> and from charity care,and we

expecting them go into healthy san francisco that we are going to have lower costs for them, and because, they will get into other parts of the system, which will then cover the cost. and so, is that what you are saying? >> i aapproximately pologize for that confusion, the charity care costs that i am referring to are the charity care costs for the department of public health and so that will be general and for, you know, you are right, we don't see all of the uninsured. >> okay. >> in our department. >> and so then this will have more of the uninsured, seniors being seen under healthy san francisco. and get into the other part of the system. >> yes, sir. >> coleen do you worry about leakage from everyone that does the charity care in the city? to us? and healthy san francisco?

>> so. the hospitals are provided the charity care in the city through their, and i mean that through the healthy san francisco programs and all hospitals participation in the healthy san francisco is as the charity care and thes not paid for by the city. >> and it is, a program that harasses the charity care object gli gaysings that the hospitals already have and so we would not expect an increase in the cost of hospital charity care, if they moved into the healthy san francisco. >> right. but my question is a different one and it is, do you, and so, i am, and for example, i am documenting 17-year-old, and i am low income, and san francisco, the principals, and you get the healthcare. and today, that person could be in an institution outside of the dph, and being treated under charity care and they could move in, under this, in to healthy san francisco and it might be the right quality thing and i am asking a

question. >> that is correct. >> and we could move into, healthy san francisco, and keep their same hospital providers. >> and so, i understand that. yeah. >> but, you, and i think that we just have to, keep the nose out, and this is not that many people that remember, any way but just keep the nose out that the concerns that the staff has raised previously about you can among them, that about this issue, so, i just think that we, everyone has got to participate in that. >> right. and the request that we had the last time was to give it to the financial review of what the proposal was and so this is an attempt to do that. >> and so, that the net and, like, what you are asking us to, and what you asked us to vote on last time, and now. is a net, extra spend, of, 6.85, plus, 0.69. roughly. >> and so,; is that correct?? >> okay. >> i move that we accept and go back and vote on the... on the resolution.

>> yeah. >> the resolution. >> and yeah, now that i understand this. >> and i would hope that you would change the word endorses us to approve. and because we are supposed to approve the changes, right? >> could i make one more, and if we are going to use the resolution, and we should actually be approving these changes, right? >> and thank you. >> yes. >> and that is all, and thank you for the two of you and with regard, and when you don't understand the facts and you are trying to go with it... and the policy for me is uninsured means, you know, it means no healthcare and so i think that we will proven otherwise, i think that we will need to make sure that these individuals that don't have insurance have access and i think that san francisco comes in and counting 370 bodies and so for 6 million dollars, we are going to insure, 370, which is 80, senior and 175, below the federal poverty level that were not able to get in and the 117, that did not have proof of non-insurancebility, and so about 370, and so is that the way that and is that the

correct way to think about it and, is 370 and cost us $6 million and next year because of the savings anthe transfers to medical those will all net out and we will get down to zero which is 700 million, which is do the right thing for one year, and, that, if that so me is what i am understanding, because i am not sure that i am understanding. >> actually i would say that the largest, number of patients, that were, participants that we are talking about are in the transition period and there are nearly 5,000 of those. there are 5,000 people who are in healthy san francisco now who are eligible for coverage california. and so, we will do, what we can in our enrollment process and then we, the renewal of the healthy san francisco to make sure that we council them on the obligation to maximize the enrollment out of healthy san francisco and health insurance. >> and that is better, for the 6 million that do the right thing for 5,000. >> sxh commissioner