Tag Archives: essential coverage

Back in the Saddle

So, the holidays are over, the Supremes have spoken and the backlash is started. So, I guess I should finish this thing.

Section 1323 of the PPACA gives money to the territories to help them enact the provisions of the PPACA. Puerto Rico (remember them) gets $925,000,000; and all the other territories get to split $75,000,000.

Section 1324 is entitled “Level Playing Field“. I don’t think they are talking about baseball, or cricket though. What is does say is that if a state offered plan is exempted from a law, then the privately offered plans in that state must also be exempted from the law. These exemptions are mostly in the areas of renewals, ratings, preexisting conditions, non-discrimination, etc. Presumably, this will maintain competition for privately offered plans.

Section 1331 gives states the right to establish different health care programs for lower income, but not eligible for Medicaid, individuals. These plans cannot cost more than an individual would pay for private insurance. The plans must also be competitively bid out to those who would provide the health care. One interesting point about these alternative plans is that people who participate in them cannot also purchase insurance through an Exchange. Presumable, this is to prevent double paying, or other cost increasing tactics.

Section 1332 gives states the right to do better. They can be waived from all requirements of the PPACA if they provide as much coverage as, without being more expensive than, and cover as many people as the PPACA, without increasing the Federal deficit (i.e., just giving everyone Medicaid). So, get out there and innovate, states!

Section 1333 deals with the sticky wicket that is the fact that insurance is typically sold on a state basis, and not a national one. Insurance plans can offer themselves in more than one state, but they have to be subject to any individual state laws that deal with insurance. These “compacts” as they are called here cannot be offered before 2016.

Section 1334 discusses multi-state health plans. These appear to be mostly the plans that will be offered in the exchanges, and requires that there be at least two such plans available through the Exchanges. States can increase the health coverage offered through these plans, at their own cost.

The next sections deal with reinsurance, and risk adjustment, so will probably take some more explaining.

Welcome back to the PPACA!


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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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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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