Monthly Archives: April 2012

Moving into the future

The next set of sections are the 1300’s. The main title is “Affordable Coverage for All Americans”. Subtitle – Qualified Health Plans. Another scintillating section, I’m sure.

Sec 1301 – Qualified health plans are ones that are 1) certified 2) provide essential services (remember those guys!) 3) are offered by insurance companies that offer plans in silver and gold. No really, that’s what it says “silver level” and “gold level”. Don’t know what those are – I suppose we will learn that down the road.

Co-op programs offered by the state are included, as well as Medical Home type plans.

Unless specifically identified, self-insured plans are not counted as “health plans”.

I’m sure these details will be debated by health plans (or NOT health plans as the case may be) to get out of these requirements

Sec 1302 – Essential Health Benefits

We talked about these briefly in post “Sorry for the hiatus” but here they are in their own section.

Essential health benefits actually have more to them that offerings. They also have to limit cost-sharing according to the Act, and offer more metalized health plans – bronze, silver, gold and platinum. I’m really looking forward to figuring out what these are.

SO it is up to the Secretary (of Health and Human Services) to define these benefits, but they will be in these categories:

Ambulatory patient services

Emergency Services


Maternity and Newborn Care

Mental Health and Substance use services

Prescription Drugs

Rehabilitative services

Laboratory Services

Preventative, wellness and chronic disease services

Pediatric services – including oral and vision!

This last one is especially interesting, since it wouldn’t require separate insurances for dentistry – and presumably would alter the amounts that are reimbursed. Also, not all insurance plans currently provide maternity care.

It is sometimes argued that people shouldn’t have to pay for other people’s babies, but then health people shouldn’t have to pay for lifestyle induced diseases either then, under that logic. I think we all need to just accept that if we have a health care system at all, we are paying for other people’s choices. If we don’t like it – there are plenty of countries where the medical care is completely non-existent. Move there.

There are then lots of details about how you get certification. The required elements include: not weighting one section more than another; not discriminating against people due to age, disability or expected length of life; take into account diverse health needs; not denying this coverage to individuals (not sure how that is different than discriminating, but then I’m not a lawyer); no pre-authorization of emergency services (whoever once thought up the idea that what you should do when you are getting rushed to the emergency room is call your insurance company is probably 1) rich 2) a real jerk); not charge extra for out-of-network charges; and review this issues.

Cost –sharing gets some treatment as well. Cost-sharing, starting in 2014, shall not exceed $2600 for individuals, and $5150 for families. This is based on 223(c)(2)(A)(ii) of the Internal Revenue Code of 1986, so if that section is updated, so are these numbers. Also, the Act itself allows for increases based on premium increases.

Cost-sharing includes deductibles, co-insurance and copays, but not premiums, charges for out-of-network, or uncovered services.

Aha – we have now come to what the metals mean:

Bronze – plan provides benefits that are actuarially equivalent to 60% of the full actuarial benefits

Silver – plan provides benefits that are actuarially equivalent to 70% of the full actuarial benefits

Gold – plan provides benefits that are actuarially equivalent to 80% of the full actuarial benefits

Platinum – plan provides benefits that are actuarially equivalent to 90% of the full actuarial benefits

I don’t know about you – I like platinum.

Some people (under 30, poor, or those who cannot get affordable coverage otherwise), who may not want expensive metal health insurances, can get catastrophic plans instead. These plans have 0 benefits, until you spend the above numbers, although they do provide 3 primary care visits per year.

So that looks like there is an option for people who don’t really want much health insurance. Kind of like the liability insurance in the car world.



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Sorry for the hiatus – teething baby!

Subtitle C – Quality Health Insurance Coverage for All Americans

Section 1201

Here is the part that prohibits both denying coverage for pre-existing conditions, and prohibiting discriminatory health insurance rates. Insurance companies are still allowed to charge different rates for individuals or families, by geographic area, by age, and tobacco use. But not by gender. Or health status. Or medical condition. Or past medical claims. Or evidence of insurability. Or disability. Or genetic information! Or receiving health care at all.

It also requires that health insurance plans accept all employers and individuals, if they offer insurance to any employer or individual, although imposing enrollment time periods for changes are still ok. This coverage must also be renewable.

You can also still offer discounts for participating in wellness programs, subject to certain requirements, even if those wellness programs encourage things that could be described under the terms medical condition (like weight loss, or decreasing BMI). Reimbursements for fitness centers, diagnostic tests, encouraging preventative care, smoking cessation programs, and attendance at health seminars, as long as they are offered to everyone, are not subject to the requirements of other wellness programs.

Health insurance plans can also not discriminate against health care providers.

Individual and small-group plans must provide certain minimum “essential coverage“. Cost-sharing is subject to limitations. They have to provide child-only plans, if they offer any plans at all. And you can’t make people wait more than 90days for coverage.

There are also protections for people engaging in clinical trials, allowing them to participate in those trials, prohibiting conditions or limits on routine costs of participation, and prohibiting discrimination if they participate in the trial. It does not require them to cover the cost of whatever the clinical trial is studying, or the costs of creating data. NIH – you are still in the business of paying for that.

Section 1251

You don’t have to terminate any health care you had when the Act went into effect. Whatever insurance you had, you keep. Some of the provisions of the Act will apply to these plans, however (reducing excessive waiting periods, rescission elimination, extension of dependent coverage, and annual limits). Adult children provisions only apply if the adult child is not eligible for other group health insurance.

Section 1252 – Rating Reforms Must Apply Uniformly to all Health Insurance Issuers and Group Health Plans. The title says it all.

Section 1253 – Reports shall be generated for self-insurance plans. Reports I say!

Section 1254 – Studies shall be done! Of Large Group Markets! And to see if these reforms will cause more employers to self-insure. And whether self-insured health plans lead to lower costs. And whether insurance plans offer fewer benefits in economic downturns. And conflicts of interest of self-insured companies. Reports! That no one will probably ever read.

Section 1255 – effective dates!

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And we move faster, faster through time and space, well, just the PPACA, really

Moving into Subtitle B – Immediate Action to Preserve and Expand Coverage (I can see why Scalia didn’t want to read this thing – it’s boring!)

Section 1101 – Immediate Access to Insurance for Uninsured Individuals with a Pre-existing condition  isn’t the section that requires that health insurance companies cover people with pre-existing conditions. That’s a later provision which could bankrupt the entire insurance industry, without the companion provision to ensure that healthy people buy insurance.

What is does, though, is create a high-risk insurance pool, with higher administrative costs than are allowed for normal insurance (read, larger profits are allowed) and where premiums can be higher, although still subject to some standards and rules. You have to be a U.S. citizen or national, have a pre-existing condition, and not be covered under other coverage for at least 6 months. So, if you lose your group insurance, you still have to wait a few months to apply for this coverage.

The section attempts to prevent insurance companies from ‘dumping’ insurees by imposing sanctions. Although that doesn’t necessarily eliminate dumping, if the sanctions are low enough.

It also appropriates $5,000,000,000 to pay any claims in these pools that the insurance companies can’t pay out of premiums. This high risk pool ends when the Exchange systems starts on January 1, 2014.  Then people with pre-existing coverage are allowed to buy into the high-risk pools created by the Exchange system. Or when the Secretary decides they are spending too much money, and stops accepting people. In short then, if you have no access to group coverage, you aren’t completely hosed by your pre-existing conditions like you are now, just mostly.

Section 1102 – Reinsurance for Early Retirees

This section creates a pot of money to pay back money to employer based helath plans that cover early reitrees (at least 55, but younger than the Medicare eligibility level – you Internet billionaires who retired at 35 – pay for your own health care!) They are paid back for claims that are over $15,000 (at a rate of 80%) but less than $90,000. They are supposed to use these costs to lower the cost of the insurance, specifically in regards to chronic conditions. There is another $5,000,000,000 for this.

Section 1103 – Internet Portals to SPAAAACE! Or Information about Affordable Coverage Options. The first one sounds more fun.

Creates an Internet website (as opposed to some other kind of website?) that gives information on health care eligibility, premium rates, cost sharing, ratios of health care expenditures to administrative expenses.

Section 1104 – Administrative Simplification!!!

Specifically of HIPPA (Health Insurance Portability and Protection Act), about electronic funds transfers between health care providers and insurers. It is 5 pages long. That’s the simplification. Feel free to read it – nothing very exciting there.

Section 1105 – Effective Date – my favorite section. Effective Date of the day the Act was passed (March 23, 2010). Administrative Simplification is ours!!!

 Now that’s progress!

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A Three-fer for you!

Section 1002 – Finally!

This section is entitled” Health Insurance Consumer Information.”  Here the Federal Government wants to help the states create programs to help the consumers of health care insurance (us!) navigate the sometimes difficult process. It offers grants to create both assistance programs, and ombudsman (I love that word. Om-buds-man. There are so many things you could do with that.) for dealing insurance.

To get the grant, you have to create these offices, which will help people file appeals, track what problems people are having with insurance, educate consumers, assist them in enrolling in group health insurance, and resolve tax credit problems. They also have to track this data, and submit it to the Secretary of Labor. There was $30,000,000 available in the first year, and then it has to be reauthorized every year after that.

And that, my friends, is IT for section 1002.

Section 1003 – Ensuring that Consumers Get Value for their Dollar

This section also amends the Public Health Service Act (remember that from the first day!). This section allows the Department of Health and Human Services to review premiums to ensure that they are not rising too quickly. Health plans that are found to have unreasonable increases must justify their increases. This premium review process will continue, with Federal government support, to identify patterns of increases. It also addresses how this premium review process will affect the Health Insurance Exchanges that are part of the overall larger mandates for health insurance. That comes in around section 1300 – so we’ll get to it. There are funds appropriated for this process, and states can apply for grants to get them of between $1,000,000 and $5,000,000 a year. Given that they allocated $250,000,000 for the whole process, they have enough money for every state to get the maximum.

This section also creates something called a Medical Reimbursement Data Center. These will help to develop geographically accurate fee schedules, update these using the best statistical tools, and make the information public, about both the fees and the methodologies. This attempts to address the issue of transparency in the fees – which directly impacts the doctors that are receiving reimbursements. However, the insurance companies are not required to give data to these centers. So how accurate they might be is debatable.

Section 1003 – done!

Section 1004 just lists the effective dates of the sections preceding, with 1002 and 1003 immediately, and the rest six months later. So they have been in effect for a while. Has everyone been enjoying their ombudsman?

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