I've been extremely busy in recent weeks and anything not business related has pretty much taken a back seat. But I have made the rounds through the bloggerhood enough to see there is a frothing frenzy of misinformation and demonization developing over the dastardly health care reform. There was enough alarming screed and liars claiming to have read this document to prompt me to start reading the WHOLE document - even though I must do it in small bits of time that I can scrape together these days. Here is what I have gleaned so far:
Section 102 – Protecting the choice to keep current coverage.
This section allows those with current employer coverage to keep it but does require that the coverage meet the minimum requirements set by this bill in 5 years. So there will be a set of standards by which health plans will be judged.
Section 111 - Prohibits pre-existing condtions clauses.
Section 112 – Prohibits the cancelling of health insurance or refusal to renew coverage based on anything but nonpayment of premiums or fraud.
Section 113 - Will limit increases in rates based on factors such as age or location. This section also mandates that a study be done to ensure that the coverage risk is evenly spread out so as not to penalize one group over another.
Section 114 – Prohibits discrimination in benefits for mental health or substance abuse issues.
Section 115 – Ensures that any PPO health plan have an adequate network so the consumer can get in network treatment.
Section 116 – Calls for a medical loss ratio to be met. Simply put, if an insurance company collects X number of dollars from enrollees but pays out for medical expenses less than a preset percentage, they will have to rebate back to the consumer. (It could be argued that this would cut the insurance company’s profits and I suppose that is true – but the other side is it would no longer be profitable for the insurance companies to give that bonus money to providers for NOT performing life saving tests).
Sections 121 & 122 – This outlines what will be expected of all qualified health plans: There will be non-exchange participating plans (mostly current employer plans) and exchange participating plans (the so-called “public” plans).
Limits cost sharing (aka co-pays), requires coverage of medically acceptable items and services.
The plan cannot impose an annual or lifetime limit on any treatment.
A qualified plan must cover: hospitalization, outpatient services, professional services of doctors and other health care professionals, equipment and supplies, prescription drugs, rehab services, mental health and substance abuse treatment, preventative services, maternity and well baby.
No cost sharing (ie co-pay) for preventative and well baby services.
Annual deductible in year 1 will be $5,000 individual and $10,000 for family.
Co-pays until deductible met would be 70%/30%.
Section 123 – Establishes a health benefits advisory committee. They will establish benefits standards.
This section also provides for establishing an Enhanced Plan and a Premium Plan for those who desire to have more coverage.
Section 131 thru 137 – Provides additional consumer protections such as fair marketing practices in regard to health care plans, fair grievance and appeals mechanisms, accurate and timely disclosure of plan details in plain language and includes a provision for advance notice of any plan changes. All plans will have to comply to the same set of standards.
Sections 141 thru 144 – These sections cover the duties of the Health Choices Commissioner in ensuring that all plans are compliant. There is also a provision for a Health Insurance Ombudsman who will provide assistance and handle grievances for individuals.
The 150’s sections cover things like Whistleblower protection and prohibiting discrimination of health care plans.
Then comes the STANDARDIZE ELECTRONIC ADMINISTRATIVE
TRANSACTIONS section that seems to cause great alarm. I’m not sure why exactly. I mean, I’m not too keen on all my personal information out there in cyberspace but we have had electronic records for years now and so our information has been floating around out there for a long time.
Particularly rankling to many is:
‘‘(D) enable the real-time (or near real
time) determination of an individual’s financial
responsibility at the point of service and, to the
extent possible, prior to service, including
whether the individual is eligible for a specific
service with a specific physician at a specific fa
cility, which may include utilization of a ma
chine-readable health plan beneficiary identi
‘‘(E) enable, where feasible, near real-time
adjudication of claims;
‘‘(F) provide for timely acknowledgment,
response, and status reporting applicable to any
electronic transaction deemed appropriate by
Looking at this one section at a time: D is pretty much what happens now in larger medical facilities. If I needed to go to a specialist (when I had insurance) at the large metropolitan complex, they would take down my information, check my insurance and tell me what was covered, if the doctor was in my network and what my co-pay would be. Nothing too exciting or radical there.
For some reason there are people who want to read E and F together and come to the conclusion that the Secretary or some other government entity (read; devil) is going to dun their bank account.
But they are actually labeled separately. E has to do with adjudication, which generally means to settle a dispute. So, if taken by itself like it was written, I go to the doctor’s and they tell me my co-pay for a procedure will be $X but this is a preventative visit and there should be no co-pay so I protest. E says the provider or their employees should do what they can to resolve the issue as quickly as possible, preferable before I leave the office.
That leaves F. No where does F talk of obtaining funds. It addresses timely acknowledgement, response and staus reporting – regarding any electronic transaction deemed appropriate by the Secretary (of Health). This makes perfect sense if you have started reading from the beginning of this document, especially the entries describing how the Health Secretary will be responsible for establishing universal electronic standards.
Now if you add G and H which follow D,E and F in the document, it becomes a little clearer.
'(G) describe all data elements (such as
reason and remark codes) in unambiguous
terms, not permit optional fields, require that
data elements be either required or conditioned
upon set values in other fields, and prohibit ad
ditional conditions; and
‘‘(H) harmonize all common data elements
across administrative and clinical transaction
This brings me to page 60 of HR 3200, just 957 pages left!
AARP has an informative article with resource references HERE. Worth reading ~