Tag Archives: women

Sec 1001 – the final push

Since I’ve already determined that I will need to get through more than one section a night to get to the end of this law in a reasonable time, I’ll attempt to get through at least the end of Section 1001 tonight.

There are three remaining sub-sections. The first, while long, can be summed up rather succinctly. Entitled “Bringing Down the Cost of Health Care” it requires that health insurance plans submit details of their plan premiums (or revenues) versus losses (or claims).

We should pause for just a moment to recognize that this terminology implies something specific. When you go to the doctor, your insurance company doesn’t think this is a good idea that could potentially save your life – they see it as a loss to their company – the same kind of loss that the grocery store entails when they have to throw away expired milk. Insurance companies would like nothing better than for you to pay premiums every day of your life and never, ever go to the doctor. Unlike car insurance, or fire insurance, where there is a strong chance that you can go your entire life without needing the payout, people are going to go to the doctor. But, we shan’t dwell too much on the fact that insurance is a stupid way to provide a product that everyone is going to need as some point. The best insurance companies can do is try to have more healthy people than sick (at least that they pay for).

Ok, so back to the Act. The insurance plans submit a report with the claims, the costs for improving health care quality, and non-health related costs (often referred to as administrative costs). Then, if the plan spends less than 85% (for large market plans, 80% for small market) of the premiums on health care claims, or quality improvement, they have to give money back to the people who paid the premiums. This started in 2011. In 2014, this payment is based on a three-year average of the ratio.

The second part for tonight requires that plans have an effective appeals process for denied claims, that complies with these regulations , which give some basic timeframes for appeals.

The last part (oh the progress!) says it is called “Patient Protections.” These protections state that you can pick any participating primary care provider that you want. Additionally, that emergency services, if offered, are covered without pre-authorization (because not everyone remembers to call the insurance company on the way to the hospital when they are dying), and covered at the same rate, regardless of whether the doctor or the emergency room is ‘in-network’ or not. The Act defines emergency medical conditions in terms of what is reasonable to a layperson, rather than an insurance administrator, and an emergency service to be an exam and stabilization. It allows you to choose to pick a pediatrician for the primary care provider of children. Finally, the protections ensure that you do not need a referral to see a gynecologist or obstetrician. If you see an OB/GYN, then the care he or she authorizes is as if the primary care physician had done so. It apparently doesn’t require that the plans offer these cover ages, just discusses what happens if they do.

So, we have come to the end of Section 1001. Hopefully the Supreme Court Justices can hold off on their decision until I’ve finished the whole thing, and then they can just read this blog instead of the Act itself. 😉

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Filed under Economics, PPACA

Price above rubies?

I promise that I will get back to the PPACA. Probably tonight, because I wanted to be done by June, and at this rate, that will be June of 2015. First, though, I wanted to address briefly the issue of the worth of women.

Now, this is a relevant issue right now in a lot of arenas. Without getting too political, there are those right now saying that women’s health care shouldn’t be paid for in the same way as a man’s would be. Additionally, there are only 11 states that ban the practice of charging women higher insurance rates than men (known as gender rating – which the PPACA would ban nationally – we’ll get to that in a later section). This pricing discrimination makes sense from a purely financial standpoint – in part because women physically have babies while men don’t. Women also tend to go to the doctor more when they are younger. And because our model of health care is based on insurance, this means that women are more expensive in their younger years, when they are getting insurance through private companies and not through government funded Medicare.

So what does this have to do with me? Well, I just graduated with my Master’s in Public Health. My graduation ceremony is in June. My older son lives out of state with his dad during the school year, so I would need to fly him up special to go. And I was having difficulties booking the flight. Because I didn’t feel as though this accomplishment was worth the money for the airfare. Even though the cost was a fraction of the total cost of the degree, and even though I would like nothing more than to have both of my sons there when I walk.

How can I expect other people to value me and other women equally when I don’t myself?

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Filed under Personal