So the vast majority of the PPACA was affirmed as constitutional. Now I suppose that means I have to finishing going through it. I’ll pick it back up tomorrow, with renewed enthusiasim. Goal: to complete the whole thing by the November election.
What will happen?
So I’ve been remiss in posting to this as much as I would have wanted to. Some of it has been my personal life getting in the way (remember my two kids!) but most of it has been a classic economic tradeoff. If the Supremes strike the whole PPACA down this month, I’d have felt really silly stressing about getting it done super fast. So – I’ve slowed down. Once we know what happens (and I don’t think they will strike the whole thing down, but I doubt they will just say it can all stand either. We’ll see.) I’ll get back on the blogging horse.
Until then – think about ponies and kitties frolicking in the grass. That should cheer you up.
Remember the Tooth!
So I had to have a root canal a couple of weeks ago. Could explain why my energy level has been Less than Zero ™. But we press on with the next section of the PPACA.
The next big section of the PPACA again relates to the Exchanges. This larger section is called “State Flexibility Relating to Exchanges”.
Sec 1321 involves a lengthy, and perhaps somewhat repetitive, statement of what the requirements are for the new health insurance Exchanges. It states that the Secretary for HHS shall set up requirements for the Exchanges, how to offer qualified health plans (remember those!) through the Exchanges, the establishment of risk and reinsurance programs (which we haven’t discussed yet), and other appropriate requirements, such as whether you should wear a morning coat to a wedding after 10 a.m. (Maybe not that last one.)
The states are required to set up Exchanges by Jan 1, 2014, and if they are determined by Jan 1, 2013 to be unlikely to have these on time, then the Secretary can set them up for the states. This is enforceable (according to this law) by the Public Health Service Act.
Has it occurred to you by now, as it has to me, that this is a really dull Act?
Sec 1322 – Federal Program to Assist Establishment and Operation of Nonprofit, Member-Run Health Insurance Issuers. These are the CO-OP Health plans. Since presumably these plans won’t have giant piles of cash sitting around to help them be a part of the new mechanisms, the federal government will give them loans and grants to come into existence. They have to be actual non-profits, and not use these funds for propaganda or influencing legislation. Can we get more rules like this?
Lots of stuff about the boardmembers of the loan granting program– 15 members, unpaid except for travel expenses, terms expire in 2015.
The CO-Ops get to not pay taxes on the loans and they are subject to oversight by the GAO. Fun, thy name is the GAO.
Filed under PPACA
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!
Filed under PPACA
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.
Filed under PPACA
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”.
Filed under PPACA
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
Hospitalization
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.
Filed under PPACA
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!
Filed under PPACA
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!
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?
Filed under PPACA
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