Monthly Archives: May 2012

Consumer Choice

Since the word on the street is that the Supremes will decide on this law by the end of June for sure – I am making a concerted effort to finish going through it before then.

Section 1312 is entitles Consumer Choice. Since one of the criticisms of this law is that it removes Consumer Choice – by forcing people to buy health insurance – let’s see what this section actually says.

The first part says that qualified individuals (defined below) may by qualified health care plans and that qualified employers (defined below) can provide qualified health plans. Those individuals can then pay the premiums. Oh boy.

All people who purchase individual insurance are considered part of a single risk pool. All people in the Small Group Market are part of a single risk pool. States can require that these plans be merged.

These Exchanges don’t prohibit individual insurance from being offered outside the Exchange and they don’t change what States already require to be offered.

It states then that the Exchanges are voluntary. No person has to participate in the Exchange. No person is compelled to purchase a qualified health plan. Unless you are a member of Congress. Members of Congress (and their staff) must purchase plans that are created by the PPACA, or are in an Exchange. Which of course leads me to the question – does this imply that members of Congress are not people?

There are no fees imposed if people choose minimum essential coverage outside of the Exchange. It creates brokers and agents to facilitate enrollment in the Exchanges.

Qualified individuals are people seeking insurance who are residents of the State they are seeking insurance in. Those people in prison or jail don’t count. Qualified employers are small employers who to choose to allow their employees to have access to the insurance plans in the Exchange. In 2017 the Exchanges are opened to large employers. You must be a citizen or lawful resident to participate in the Exchanges.

We still haven’t gotten to the fee portion of the PPACA – that will be exciting when we do.

Section 1313 relates to Financial Integrity of the Exchanges. They will keep receipts! They will be subject to investigations! Audits! If they are bad, the Feds will take away their allowance. (No really – they will reduce the payments they are eligible for under this Act). There will be GAO oversight about operations, administration, utilization, improvements, cost and affordability, and access.

We are 10% done! With 13 posts. You may end up seeing more than one a day as we get to the end. But onward!


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In need of health care myself

I’ve fallen back off the posting wagon, due to illness in the youngest son, and myself. We had to enjoy some fine health care – which, thankfully, we have. The next sections of the PPACA are actually quite interesting. They discuss the Exchanges, or the private market compromise so as not to have government provided health care (except for the Armed Forces, the VA, Medicaid, and Medicare of course) once everyone is required to buy health care insurance.

Sec 1311 gives money to the states to set up these Exchanges, which most likely due to insurance laws are run through the States. They have to be set up starting in 2014, and money won’t be available after January 1, 2015.

The Exchanges themselves are to “facilitate the purchase of qualified health plans” and assist small businesses in doing the same, which under the PPACA are now required to offer health insurance in finding appropriate plans. These are separate goals, although states can choose to offer a single Exchange to achieve them both. There are some restrictions placed on advertising, so as not to scare off people with high medical needs, ensure provider choice, assistance for low income people in finding health insurance, meet certain quality standards and plans for improving quality, and share information with those people who would choose to enroll in these plans.

The plans would be rated, by a system developed by the states, to make decision making easier on the prospective enrollees. These ratings, and all of the other information, would be available by the aforementioned Internet Portals (Portals!!). The Exchanges would have open enrollment periods similar to the ones that current health insurances have. There are special provisions that say that stand-alone dental plans can be offered, even though they don’t offer any of the previously described qualifying health benefits.

The states retain the right to add benefits to the plans in their Exchanges, above and beyond the Federal minimum, but these costs must be borne by the state.

So, to sum up, the Exchanges will certify health plans, operate a toll-free number where you can ask for assistance, operate the Internet Portal, rate the health plans, present the details of the health plans in a standardized format, tell people when they are eligible for Medicaid, CHIP, or any state assistance program for health care, provide a calculator that tells people how much their insurance actually costs after the tax credits (that we haven’t gotten to) are applied, grant certifications that people are exempt from the penalty for not purchasing insurance (we’ll get to that soon), tell the employers who ceases to have insurance each year, and establish something called the Navigator program (explained at the end of this post).

The Exchanges have to be self-sustaining, they must consult with the relevant stakeholders, and they must publish their costs. The Exchanges also ask the health plans to justify any rate increases they wish to implement, and then use this information in deciding whether the plan can be offered in the Exchange. It also requires the insurance plans to increase their transparency of costs. They must also implement methods to improve health care quality such as patient-centered education, reduction of medical errors, wellness and health activities, and reduction of disparities.

The final part of this section provides grants for Navigators, or entities that have previously established relationships with employers and employees, consumers, or the self-employed, that could be used to facilitate those groups’ purchases of the health plans available from the Exchanges.

So – there you have it – one of the more controversial sections of the PPACA. The only one more controversial is the section that provides for the penalties if you don’t buy a health plan. We shall press on and try to get to that one quickly.

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Special Rules – oh boy

Section 1303 starts out very tame. And by tame, I mean that it says that States can pass laws that prohibit abortion in their Exchange plans, if the States want to. Nothing controversial there, nope. It goes on for several paragraphs about this. If you do provide abortions in your Exchanges, you of course cannot use any of the money the Federal government gave you, unless they are for rape, incest, endangerment of the life of the mother (because of the Hyde Amendment).

It also explains how the coverage for abortions (which by the way, the plan refers to as coverage of services described in paragraph (1)(B)(i) – presumably because they didn’t want to keep drawing attention to the actual service in question) will be paid for, how the premiums will be collected, and then kept in segregated accounts, to be used for just those services described in paragraph (1)(B)(i). They minimum premium will be $1. So essentially, once this goes into place, if you ever want an abortion, or think that they should be paid for by your health insurance, you have pay $12 a year. It’s unclear from this writing how that would work, exactly. Would only women pay? If so, that would violate the previous sections on prevention of discrimination by sex. Would men pay if they supported insurance paid abortion? Would the insurance plan just charge everyone, and then you could opt out if you didn’t want to (the economically more efficient way to do it)?

Then there is a bunch of CYA stuff. This section doesn’t preempt state law, or federal law. You can’t discriminate against providers that don’t provide abortions, or institutions that don’t allow them. It doesn’t affect Civil Rights Laws. It doesn’t change current law about Emergency Services.

And, of course, it shouldn’t surprise you that this is the only Special Rule. Because our country is Special.

Section 1304 is definitions. Large Market. Small Market. Group Market. Individual Market. Large Employer. Secretary. No sense in repeating that here – just look them up if you want to know. Although, I will point out that one of the things they define is “Educated Health Care Consumers” which they define as an individual who is knowledgeable about the health care system, and has background or experience in making informed decisions regarding health, medical, and scientific matters, but could also be defined as “human unicorn”.

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