Tag Archives: pre-existing conditions

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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