Universal Health Care Blogging - Part 3

Sec. 102, (c)(2) SEPARATE, EXCEPT COVERAGE PERMITTED: Excepted benefits will be allowed (as per section 2791(c), which I regret I still have not found), but they are not included within health insurance coverage as is defined by this bill. Such benefits have to be offered and priced separately from health insurance coverage (I'm not sure, but I think this is saying that we would have to possess supplemental insurance).



Sec. 111. PROHIBITING PRE-EXISTING CONDITION EXCLUSIONS: This section makes it sound as if no pre-existing conditions shall be excluded. I could be wrong, but that's my understanding.



Sec. 112. GUARANTEE ISSUE AND RENEWAL FOR INSURED PLANS: It gives the only reason for possible withdrawal of coverage from a recipient would be for the cause of insurance fraud and it cites sections 2712(b)(2) of the Public Health Service Act.



Sec. 113. INSURANCE RATING RULES: The following exceptions are given as a reason to change the premium rate:

(1) Age: The Commissioner will set the parameters, but variation by age will be permitted. However, as long as the highest premium does not exceed the lowest premium of 2 to 1.

(2) Area: A premium rating area will apply, which will be specified as by the Commissioner in conjunction with State regulators.

(3) Family Enrollment: The ratio for the premium for family coverage shall remain in uniformity with the individual premium, consistent with rules of the Commissioner (So does that mean when one premium goes up, the other must also be raised?).

(b)(1) Study and Reports, STUDY: "The Commissioner...with the Secretary of Health and Human Services and Secretary of Labor, shall conduct a study of the large group insured and self-insured employer health care markets. Such study shall examine the following:

(A) (paraphrased) Different types of employers and what insurance products they purchase vs. those that self-insure;

(B) Similarities and differences between typical insured and self-
insured health plans;

(C) The financial solvency and capital reserve levels of employers that
self-insure by employer size (Okay, why is this ANY of their business? It would
sound as if they were doing this to set parameters that have to be met and if not, the public option would be forced upon certain employers);

(D) The risk of self-insured employers not being able to pay obligations
or otherwise becoming financial insolvent (Again, see my parenthetical comment above. I call this "micromanagement");

(E) The extent to which rating rules are likely to cause adverse selection in the large group market or to encourage small and mid-size employers to self-insure.

(b)(2) REPORTS: "...the Commissioner shall submit to Congress...a report on the study conducted after (1). Such report shall...ensure that the law does not provide incentives for small and mid-size employers to self-insure or create adverse selection in the risk pools of large group insurers and self-insured employers..."

Sec. 114. NONDISCRIMINATION IN BENEFITS; PARITY IN MENTAL HEALTH AND SUBSTANCE ABUSE DISORDER BENEFITS.

According to subsection (a)(b), there cannot be a withholding of benefits or
benefit structures for qualifying health benefits plans in regard to such persons (my abbreviated understanding of these two subsections).

Sec. 122. ESSENTIAL BENEFITS PACKAGE DEFINED:

(b) Minimum Services to be Covered: hospitalization; outpatient hospital and outpatient clinic services, including ER services; professional services of doctors and other health care professionals; services, equipment and supplies in connection with the doctor's or health care professional's services rendered whether in the hospital, clinic, patients' homes or other settings, as appropriate; prescription drugs; rehab and habitative services; mental health and substance abuse services; preventive services; maternity care; well baby and well child care, oral, vision, and hearing services, equipment and supplies for children under 21 years of age.

(c) Requirements Relating to Cost-Sharing and Minimum Actuarial Value:
(1) NO COST-SHARING FOR PREVENTIVE SERVICES - means exactly
that (I don't fully understand. I still think this means that it's not allowing
your secondary or tertiary coverage to pick up where your primary coverage
leaves off. If you have a greater knowledge of this, please clue me in).

(2) ANNUAL LIMITATION - As you all know, there are usual yearly
limitations with certain health care plans.

(3) APPLICABLE LEVEL - $5,000 for an individual and $10,000 for a
family. "Such levels shall be increased (rounded to the nearest $100) for
each subsequent year by the annual percentage increase in the Consumer
Price Index..."

(4) USE OF COPAYMENTS - "In establishing cost-sharing levels for
basic, enhanced, and premium plans under this subsection, the Secretary
shall, to the maximum extent possible, use only copayments and not
coinsurance.

Sec. 123. HEALTH BENEFITS ADVISORY COMMITTEE: In a nutshell, this committee shall be a "panel of medical and other experts...to recommend covered benefits and essential, enhanced, and premium plans." It shall be chaired by the Surgeon General. The members shall be made up of 9 members who are not Federal employees or officers and will be appointed by the President. Nine members who are not Federal employees...appointed by the Comptroller General appoints members to the Medicare Payment Advisory Committee..." An even number of members (not to exceed 8) who ARE Federal employees and officers, will be appointed by the President.

These members will serve on the Committee in 3-year terms. The members ranks will be comprised of "providers, consumer representatives, employers, labor, health insurance issuers, experts in health care financing and delivery, experts in racial and ethnic disparities, experts in care for those with disabilities, representatives of relevant governmental agencies, and at least on practicing physician or other health professional and an expert on children's health." They claim that this broad spectrum of representatives is to ensure that no single sector unduly influences the recommendations of such Committee."

Okay, y'all, NO MAS! I can't handle anymore of this for now. I'll be back after sleep and much caffeine.

Love Ya,
God Bless!