You've been proven completely wrong on multiple subjects where you claim your opinions as facts. When disproved you ignore, deflect, etc.. Maybe you should stop posting so confidently about things you appear to know absolutely nothing about?????
You've proven nothing except your own partisan ignorance and the continued need for you to wear a helmet everywhere you go.Originally posted by: Pens1566
You've been proven completely wrong on multiple subjects where you claim your opinions as facts. When disproved you ignore, deflect, etc.. Maybe you should stop posting so confidently about things you appear to know absolutely nothing about?????
SEC. 102. PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE.
(a) GRANDFATHERED HEALTH INSURANCE COVERAGE DEFINED.?Subject to the succeeding provisions of this section, for purposes of establishing acceptable coverage under this division, <the term ??grandfathered health insurance coverage?? means individual health insurance coverage that is offered and in force and effect before the first day of Y1 if the following conditions are met:
(1) LIMITATION ON NEW ENROLLMENT.?
(A) IN GENERAL.?Except as provided in this paragraph, the individual health insurance issuer offering such coverage does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day of Y1.
(B) DEPENDENT COVERAGE PERMITTED.?Subparagraph (A) shall not affect the subsequent enrollment of a dependent of an individual who is covered as of such first day.
(2) LIMITATION ON CHANGES IN TERMS OR CONDITIONS.?Subject to paragraph (3) and except as required by law, the issuer does not change any of its terms or conditions, including benefits and cost-sharing, from those in effect as of the day before the first day of Y1.
(3) RESTRICTIONS ON PREMIUM INCREASES.?The issuer cannot vary the percentage increase in the premium for a risk group of enrollees in specific
grandfathered health insurance coverage without changing the premium for all enrollees in the same risk group at the same rate, as specified by the Commissioner.
(b) GRACE PERIOD FOR CURRENT EMPLOYMENT BASED HEALTH PLANS.?
(1) GRACE PERIOD.?
(A) IN GENERAL.?The Commissioner shall establish a grace period whereby, for plan years beginning after the end of the 5-year period beginning with Y1, an employment-based health plan in operation as of the day before the first day of Y1 must meet the same requirements as apply to a qualified health benefits plan under section 101, including the essential benefit package requirement under section 121.
(B) EXCEPTION FOR LIMITED BENEFITS PLANS.?Subparagraph (A) shall not apply to an employment-based health plan in which the coverage consists only of one or more of the following:
(i) Any coverage described in section 3001(a)(1)(B)(ii)(IV) of division B of the American Recovery and Reinvestment Act of 2009 (PL 111?5).
(ii) Excepted benefits (as defined in section 733(c) of the Employee Retirement Income Security Act of 1974), including coverage under a specified disease or illness policy described in paragraph (3)(A) of such section.
(iii) Such other limited benefits as the Commissioner may specify. In no case shall an employment-based health plan in which the coverage consists only of one or more of the coverage or benefits described in clauses (i) through (iii) be treated as acceptable coverage under this division.
(2) TRANSITIONAL TREATMENT AS ACCEPTABLE COVERAGE.?During the grace period specified in paragraph (1)(A), an employment-based health plan that is described in such paragraph shall be treated as acceptable coverage under this division.
(c) LIMITATION ON INDIVIDUAL HEALTH INSURANCE COVERAGE.?
(1) IN GENERAL.?<Individual health insurance coverage that is not grandfathered health insurance coverage under subsection (a) may only be offered on or after the first day of Y1 as an Exchange-participating health benefits plan.
(2) SEPARATE, EXCEPTED COVERAGE PERMITTED.?Excepted benefits (as defined in section 2791(c) of the Public Health Service Act) are not included within the definition of health insurance coverage. Nothing in paragraph (1) shall prevent the offering, other than through the Health Insurance Exchange, of excepted benefits so long as it is offered and priced separately from health insurance coverage.
Pages 16 to 18 of the House version of the bill.
On those pages, you'll find:
Your current plan WILL instantly become "Grandfathered Health insurance Coverage" for a period of "up to five years." During that time, if your plan changes any aspect of their coverage, which happens almost annually for some plans, then you will immediately lose said coverage and the plan would lose its "grandfathered" status.
At the five-year mark, even if you're still lucky enough to have it, you will lose said coverage instantly.
Once you lose the "Grandfathered" coverage, for any one of the reasons above, or the other reasons listed in the bill, you (or your employer) will only be authorized to choose coverage from the Government-approved plans that are listed on the mysterious "Health Insurance Exchange."
The "Commissioner" and his staff will come up with the criteria for HIE qualification some time in the future AFTER the bill is passed. If your company's current plan does not meet those criteria, you'll be off to select one on your own from the list -- which, given the much higher costs of paying for your own coverage, will likely end up being the "public option."
Whatever the case, qualification for the HIE will be completely at the whim of the Government. If, at any point in the future, they decide to disqualify EVERY listing on the Exchange, except for the "public option" of course, they will be completely free to do so without citizen interference.
Later in the bill, it states that if you choose not to elect a HIE plan, you (not your employer) will be subject to a 2.5% Federal Income Tax penalty every year -- a rate that is once again at the whim of the "Commissioner."
Fun stuff, eh?
It would help tremendously if you'd read the actual bill... but, as i stated above, if this version of the bill passes, the Government will control whether or not you get to keep your current plan, period.
Originally posted by: TheSkinsFan
SNIP
I read that section 102 in HR 3200 and I'm no lawyer but it seems to me health insurance companies right now can tweak their plans and get some sort of government stamp of approval. Then they can offer those new plans after this bill passes? Or no?
I understand that my plan as it is now will get fvcked after 5 years, but can't they just make new plans?
They can make new plans; but yes, they will need to be vetted by the Government to get listed on the new Health insurance Exchange.Originally posted by: DLeRium
Originally posted by: TheSkinsFan
SNIP
Can you answer my question:
I read that section 102 in HR 3200 and I'm no lawyer but it seems to me health insurance companies right now can tweak their plans and get some sort of government stamp of approval. Then they can offer those new plans after this bill passes? Or no?
I understand that my plan as it is now will get fvcked after 5 years, but can't they just make new plans?
Originally posted by: TheSkinsFan
They can make new plans; but yes, they will need to be vetted by the Government to get listed on the new Health insurance Exchange.Originally posted by: DLeRium
Originally posted by: TheSkinsFan
SNIP
Can you answer my question:
I read that section 102 in HR 3200 and I'm no lawyer but it seems to me health insurance companies right now can tweak their plans and get some sort of government stamp of approval. Then they can offer those new plans after this bill passes? Or no?
I understand that my plan as it is now will get fvcked after 5 years, but can't they just make new plans?
Some people, such as myself, believe that will lead to fewer and fewer approved options -- one day resulting in a list with just one option -- that being the "public option."
Originally posted by: spidey07
Originally posted by: Carmen813
No, there are not other options out there.
I'm on Family Health Plus, which is a type of Medicaid. However, the income requirements are more stringent than I think you realize. It is in part the reason why our income is kept low, there is a "cliff" where we aren't making enough to afford insurance (even through an employer) and are simultaneously making to much money for public options. There is no private insurance available to us, it does not exist in any sort of reasonable payment platform.
Here's the problem. I'm moving in a week to a new county. In NYS, the County pays for medicaid, even though its managed by an HMO (in my case bluecross/blue shield). Since I'm moving to a new county, I need to re-apply, you can't transfer it (apparently, I'm working on that). So that means for about 2 months (60 days for application to go through) my wife and I wouldn't have coverage. HealthyNY, the next step above FPH, costs about $450 a month for 2 people. It's out of our budget range.
My wife requires prescription medications to manage chronic pain. Without them, she is basically bed-ridden and disabled. With them, she can maintain a somewhat normal life, including holding down a full time job. They cost about $200 a month without insurance.
If you are curious as to why we are moving, it was because I worked hard and received a full scholarship (worth about $28,000 a year) to get a Master's degree. I am not lazy, and neither is my wife. I could buy graduate student insurance, but the plan my university offers is not adequate for someone with my medical history. I have a CT scan scheduled for September, a requirement to make sure my cancer hasn't come back. The idea is to catch it early if it does, so I have a chance to survive. Of course, these scans cost $4,000 or so, well out of my ability to pay without some type of assistance.
So, put on my shoes for five minutes and tell me what to do. Find me the free market solution you've advocated throughout this thread. The problem I have is not with the health coverage I've received with FHP, it's in fact been fantastic, but rather the difficulties in the way NYS has setup its payments (something my friend in Ohio tells me he doesn't have to worry about).
I think perhaps this will help you understand why I cannot tolerate the status quo.
So let me get this straight? You're having difficulty with a government plan on a county/state level and you think federal would be better? Your case is troublesome and extremely small changes could address it, it is not IMHO justification for fucking everything up for the entire country for what is absolutely a very small minority of patients.
Originally posted by: TheSkinsFan
Originally posted by: Carmen813
I'm calling BS here. We know exactly what the public options will require, it's the exact same as any other exchange program.
Please list those specific requirements for me now.
SEC. 122. ESSENTIAL BENEFITS PACKAGE DEFINED.
(a) In General- In this division, the term `essential benefits package' means health benefits coverage, consistent with standards adopted under section 124 to ensure the provision of quality health care and financial security, that--
(1) provides payment for the items and services described in subsection (b) in accordance with generally accepted standards of medical or other appropriate clinical or professional practice;
(2) limits cost-sharing for such covered health care items and services in accordance with such benefit standards, consistent with subsection (c);
(3) does not impose any annual or lifetime limit on the coverage of covered health care items and services;
(4) complies with section 115(a) (relating to network adequacy); and
(5) is equivalent, as certified by Office of the Actuary of the Centers for Medicare & Medicaid Services, to the average prevailing employer-sponsored coverage.
(b) Minimum Services To Be Covered- The items and services described in this subsection are the following:
(1) Hospitalization.
(2) Outpatient hospital and outpatient clinic services, including emergency department services.
(3) Professional services of physicians and other health professionals.
(4) Such services, equipment, and supplies incident to the services of a physician's or a health professional's delivery of care in institutional settings, physician offices, patients' homes or place of residence, or other settings, as appropriate.
(5) Prescription drugs.
(6) Rehabilitative and habilitative services.
(7) Mental health and substance use disorder services.
(8) Preventive services, including those services recommended with a grade of A or B by the Task Force on Clinical Preventive Services and those vaccines recommended for use by the Director of the Centers for Disease Control and Prevention.
(9) Maternity care.
(10) Well baby and well child care and oral health, vision, and hearing services, equipment, and supplies at least for children under 21 years of age.
(c) Requirements Relating to Cost-sharing and Minimum Actuarial Value-
(1) NO COST-SHARING FOR PREVENTIVE SERVICES- There shall be no cost-sharing under the essential benefits package for preventive items and services (as specified under the benefit standards), including well baby and well child care.
(2) ANNUAL LIMITATION-
(A) ANNUAL LIMITATION- The cost-sharing incurred under the essential benefits package with respect to an individual (or family) for a year does not exceed the applicable level specified in subparagraph (B).
(B) APPLICABLE LEVEL- The applicable level specified in this subparagraph for Y1 is $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 (United States city average) applicable to such year.
(C) 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.
(3) MINIMUM ACTUARIAL VALUE-
(A) IN GENERAL- The cost-sharing under the essential benefits package shall be designed to provide a level of coverage that is designed to provide benefits that are actuarially equivalent to approximately 70 percent of the full actuarial value of the benefits provided under the reference benefits package described in subparagraph (B).
(B) REFERENCE BENEFITS PACKAGE DESCRIBED- The reference benefits package described in this subparagraph is the essential benefits package if there were no cost-sharing imposed.
(a) Establishment- For years beginning with Y1, the Secretary of Health and Human Services (in this subtitle referred to as the `Secretary') shall provide for the offering of an Exchange-participating health benefits plan (in this division referred to as the `public health insurance option') that ensures choice, competition, and stability of affordable, high quality coverage throughout the United States in accordance with this subtitle. In designing the option, the Secretary's primary responsibility is to create a low-cost plan without comprimising quality or access to care.
(b) Offering as an Exchange-participating Health Benefits Plan-
(1) EXCLUSIVE TO THE EXCHANGE- The public health insurance option shall only be made available through the Health Insurance Exchange.
(2) ENSURING A LEVEL PLAYING FIELD- Consistent with this subtitle, the public health insurance option shall comply with requirements that are applicable under this title to an Exchange-participating health benefits plan, including requirements related to benefits, benefit levels, provider networks, notices, consumer protections, and cost sharing.
(3) PROVISION OF BENEFIT LEVELS- The public health insurance option--
(A) shall offer basic, enhanced, and premium plans; and
(B) may offer premium-plus plans.
(c) Administrative Contracting- The Secretary may enter into contracts for the purpose of performing administrative functions (including functions described in subsection (a)(4) of section 1874A of the Social Security Act) with respect to the public health insurance option in the same manner as the Secretary may enter into contracts under subsection (a)(1) of such section. The Secretary has the same authority with respect to the public health insurance option as the Secretary has under subsections (a)(1) and (b) of section 1874A of the Social Security Act with respect to title XVIII of such Act. Contracts under this subsection shall not involve the transfer of insurance risk to such entity.
(d) Ombudsman- The Secretary shall establish an office of the ombudsman for the public health insurance option which shall have duties with respect to the public health insurance option similar to the duties of the Medicare Beneficiary Ombudsman under section 1808(c)(2) of the Social Security Act.
(e) Data Collection- The Secretary shall collect such data as may be required to establish premiums and payment rates for the public health insurance option and for other purposes under this subtitle, including to improve quality and to reduce racial, ethnic, and other disparities in health and health care.
(f) Treatment of Public Health Insurance Option- With respect to the public health insurance option, the Secretary shall be treated as a QHBP offering entity offering an Exchange-participating health benefits plan.
(g) Access to Federal Courts- The provisions of Medicare (and related provisions of title II of the Social Security Act) relating to access of Medicare beneficiaries to Federal courts for the enforcement of rights under Medicare, including with respect to amounts in controversy, shall apply to the public health insurance option and individuals enrolled under such option under this title in the same manner as such provisions apply to Medicare and Medicare beneficiaries.
Originally posted by: TheSkinsFan
They can make new plans; but yes, they will need to be vetted by the Government to get listed on the new Health insurance Exchange.
Some people, such as myself, believe that will lead to fewer and fewer approved options -- one day resulting in a list with just one option -- that being the "public option."
Originally posted by: Athena
Originally posted by: TheSkinsFan
They can make new plans; but yes, they will need to be vetted by the Government to get listed on the new Health insurance Exchange.
Some people, such as myself, believe that will lead to fewer and fewer approved options -- one day resulting in a list with just one option -- that being the "public option."
You don't seem to understand what the Exchange is; it is a consortium of private insurers. Companies aren't "listed", they contract with the Comissioner to provide one or more levels of coverage. The Insurance Exchange(s) is completely irrelevant to what employers offer. If you read the bill, it talks about Exchange Plans and non-Exchange plans.
Originally posted by: Carmen813
My case was resolved today, less than 24 hours later. There will be no problem, I was panicked yesterday because the people I spoke to were not informed of how the system works (they were secretaries, it's not their job to know, so I can't really blame them). Don't use me as an excuse to forward your agenda, you dodged my question completely.
They've been unregulated all this time and the experience has not been successful. Study after study has shown that individuals have been exploited.Originally posted by: charrison
The problem with the exchanges is that to qualify you must be govt regulations. These regulations typically just drive up the cost of plans. I am willing to be we wont see many high deductable low cost plans show up on those exchanges.
And accelerate the race to the bottom.Drop the govt exchanges and just let health care be sold across state lines.
Originally posted by: Athena
Originally posted by: TheSkinsFan
They can make new plans; but yes, they will need to be vetted by the Government to get listed on the new Health insurance Exchange.
Some people, such as myself, believe that will lead to fewer and fewer approved options -- one day resulting in a list with just one option -- that being the "public option."
You don't seem to understand what the Exchange is; it is a consortium of private insurers. Companies aren't "listed", they contract with the Comissioner to provide one or more levels of coverage. The Insurance Exchange(s) is completely irrelevant to what employers offer. If you read the bill, it talks about Exchange Plans and non-Exchange plans.
Originally posted by: Athena
They've been unregulated all this time and the experience has not been successful. Study after study has shown that individuals have been exploited.Originally posted by: charrison
The problem with the exchanges is that to qualify you must be govt regulations. These regulations typically just drive up the cost of plans. I am willing to be we wont see many high deductable low cost plans show up on those exchanges.
And accelerate the race to the bottom.Drop the govt exchanges and just let health care be sold across state lines.
Health-Insurance Exchanges: What They Would (and Wouldn't) Do
All of which is irrelevant to Health Insurance Exchanges -- which only apply to individuals' i.e. people who purchase plans on their own (and small business who choose to use them)Originally posted by: DLeRium
[It's pretty likely that most people's plans today is getting them better care than UHC will. So yes, we aren't regulated as much as we will be later, but it seems the market has defined pretty good coverage for employer based insurance. I mean seriously, who here has a failboat employer plan that doesn't give them anything at all?
I've already read all of sections 121, 122, 124, etc, that deal with the so-called "standards" and details. Sadly, the only dollar amount they list is the one pertaining to cost-sharing. Other than that, we don't know jackshit about the standards.Originally posted by: Carmen813
Originally posted by: TheSkinsFan
Originally posted by: Carmen813
I'm calling BS here. We know exactly what the public options will require, it's the exact same as any other exchange program.
Please list those specific requirements for me now.
Your wish is my command. This section is referenced directly in the section about the establishment of the exchange system. The establishment of the public option also references this section (under Title I of the bill)
SEC. 122. ESSENTIAL BENEFITS PACKAGE DEFINED.
(a) In General- In this division, the term `essential benefits package' means health benefits coverage, consistent with standards adopted under section 124 to ensure the provision of quality health care and financial security, that--
(1) provides payment for the items and services described in subsection (b) in accordance with generally accepted standards of medical or other appropriate clinical or professional practice;
(2) limits cost-sharing for such covered health care items and services in accordance with such benefit standards, consistent with subsection (c);
(3) does not impose any annual or lifetime limit on the coverage of covered health care items and services;
(4) complies with section 115(a) (relating to network adequacy); and
(5) is equivalent, as certified by Office of the Actuary of the Centers for Medicare & Medicaid Services, to the average prevailing employer-sponsored coverage.
(b) Minimum Services To Be Covered- The items and services described in this subsection are the following:
(1) Hospitalization.
(2) Outpatient hospital and outpatient clinic services, including emergency department services.
(3) Professional services of physicians and other health professionals.
(4) Such services, equipment, and supplies incident to the services of a physician's or a health professional's delivery of care in institutional settings, physician offices, patients' homes or place of residence, or other settings, as appropriate.
(5) Prescription drugs.
(6) Rehabilitative and habilitative services.
(7) Mental health and substance use disorder services.
(8) Preventive services, including those services recommended with a grade of A or B by the Task Force on Clinical Preventive Services and those vaccines recommended for use by the Director of the Centers for Disease Control and Prevention.
(9) Maternity care.
(10) Well baby and well child care and oral health, vision, and hearing services, equipment, and supplies at least for children under 21 years of age.
(c) Requirements Relating to Cost-sharing and Minimum Actuarial Value-
(1) NO COST-SHARING FOR PREVENTIVE SERVICES- There shall be no cost-sharing under the essential benefits package for preventive items and services (as specified under the benefit standards), including well baby and well child care.
(2) ANNUAL LIMITATION-
(A) ANNUAL LIMITATION- The cost-sharing incurred under the essential benefits package with respect to an individual (or family) for a year does not exceed the applicable level specified in subparagraph (B).
(B) APPLICABLE LEVEL- The applicable level specified in this subparagraph for Y1 is $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 (United States city average) applicable to such year.
(C) 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.
(3) MINIMUM ACTUARIAL VALUE-
(A) IN GENERAL- The cost-sharing under the essential benefits package shall be designed to provide a level of coverage that is designed to provide benefits that are actuarially equivalent to approximately 70 percent of the full actuarial value of the benefits provided under the reference benefits package described in subparagraph (B).
(B) REFERENCE BENEFITS PACKAGE DESCRIBED- The reference benefits package described in this subparagraph is the essential benefits package if there were no cost-sharing imposed.
(b) ADOPTION OF STANDARDS.?
(1) INITIAL STANDARDS.?Not later than 18 months after the date of the enactment of this Act, the Secretary shall, through the rulemaking process consistent with subsection (a), adopt an initial set of benefit standards.
fixed.Originally posted by: Athena
Originally posted by: TheSkinsFan
They can make new plans; but yes, they will need to be vetted by the Government to get listed on the new Health insurance Exchange.
Some people, such as myself, believe that will lead to fewer and fewer approved options -- one day resulting in a list with just one option -- that being the "public option."
I don't seem to understand what the Exchange is; it is a Federal Government listing of approved private insurers. Companies are "listed" using To-be-determined standards. The Insurance Exchange (singular) is completely relevant to what employers offer.
Where are you getting the idea that there would be more than one HIE? Please refer to the specific language in the bill that is giving you that impression.Originally posted by: Athena
All of which is irrelevant to Health Insurance Exchanges -- which only apply to individuals' i.e. people who purchase plans on their own (and small business who choose to use them)
Originally posted by: Athena
They've been unregulated all this time and the experience has not been successful. Study after study has shown that individuals have been exploited.Originally posted by: charrison
The problem with the exchanges is that to qualify you must be govt regulations. These regulations typically just drive up the cost of plans. I am willing to be we wont see many high deductable low cost plans show up on those exchanges.
And accelerate the race to the bottom.Drop the govt exchanges and just let health care be sold across state lines.
Originally posted by: Athena
All of which is irrelevant to Health Insurance Exchanges -- which only apply to individuals' i.e. people who purchase plans on their own (and small business who choose to use them)Originally posted by: DLeRium
[It's pretty likely that most people's plans today is getting them better care than UHC will. So yes, we aren't regulated as much as we will be later, but it seems the market has defined pretty good coverage for employer based insurance. I mean seriously, who here has a failboat employer plan that doesn't give them anything at all?
Section 208: OPTIONAL OPERATION OF STATE-BASED HEALTH INSURANCE EXCHANGESOriginally posted by: TheSkinsFan
Where are you getting the idea that there would be more than one HIE? Please refer to the specific language in the bill that is giving you that impression.
That's not really true. Most people who have employer-paid insurance are satisified...those in the individual market are significantly less satisfied. And since 89% of individuals who go looking for individual coverage never get coverage due to underwriting or affordability issues, they aren't even included in your satisfaction statistic.Originally posted by: charrison
And most people, some 80% are happy with their non govt approved insurance plan.
Drop the govt exchanges and just let health care be sold across state lines.
Originally posted by: spidey07
Originally posted by: Carmen813
My case was resolved today, less than 24 hours later. There will be no problem, I was panicked yesterday because the people I spoke to were not informed of how the system works (they were secretaries, it's not their job to know, so I can't really blame them). Don't use me as an excuse to forward your agenda, you dodged my question completely.
What question did I dodge? Congrats on handling your business by the way but what question did I dodge?
And again, your situtation is the extreme minority and no reason to fuck up the rest of the population's happiness with their great healthcare.
Originally posted by: spidey07
Originally posted by: Athena
Originally posted by: TheSkinsFan
They can make new plans; but yes, they will need to be vetted by the Government to get listed on the new Health insurance Exchange.
Some people, such as myself, believe that will lead to fewer and fewer approved options -- one day resulting in a list with just one option -- that being the "public option."
You don't seem to understand what the Exchange is; it is a consortium of private insurers. Companies aren't "listed", they contract with the Comissioner to provide one or more levels of coverage. The Insurance Exchange(s) is completely irrelevant to what employers offer. If you read the bill, it talks about Exchange Plans and non-Exchange plans.
Again, I am in control of my own destiny. I WILL NOT ALLOW a government agency dictate my health and health insurance.
Originally posted by: TheSkinsFan
I've already read all of sections 121, 122, 124, etc, that deal with the so-called "standards" and details. Sadly, the only dollar amount they list is the one pertaining to cost-sharing. Other than that, we don't know jackshit about the standards.Originally posted by: Carmen813
Originally posted by: TheSkinsFan
Originally posted by: Carmen813
I'm calling BS here. We know exactly what the public options will require, it's the exact same as any other exchange program.
Please list those specific requirements for me now.
Your wish is my command. This section is referenced directly in the section about the establishment of the exchange system. The establishment of the public option also references this section (under Title I of the bill)
SEC. 122. ESSENTIAL BENEFITS PACKAGE DEFINED.
(a) In General- In this division, the term `essential benefits package' means health benefits coverage, consistent with standards adopted under section 124 to ensure the provision of quality health care and financial security, that--
(1) provides payment for the items and services described in subsection (b) in accordance with generally accepted standards of medical or other appropriate clinical or professional practice;
(2) limits cost-sharing for such covered health care items and services in accordance with such benefit standards, consistent with subsection (c);
(3) does not impose any annual or lifetime limit on the coverage of covered health care items and services;
(4) complies with section 115(a) (relating to network adequacy); and
(5) is equivalent, as certified by Office of the Actuary of the Centers for Medicare & Medicaid Services, to the average prevailing employer-sponsored coverage.
(b) Minimum Services To Be Covered- The items and services described in this subsection are the following:
(1) Hospitalization.
(2) Outpatient hospital and outpatient clinic services, including emergency department services.
(3) Professional services of physicians and other health professionals.
(4) Such services, equipment, and supplies incident to the services of a physician's or a health professional's delivery of care in institutional settings, physician offices, patients' homes or place of residence, or other settings, as appropriate.
(5) Prescription drugs.
(6) Rehabilitative and habilitative services.
(7) Mental health and substance use disorder services.
(8) Preventive services, including those services recommended with a grade of A or B by the Task Force on Clinical Preventive Services and those vaccines recommended for use by the Director of the Centers for Disease Control and Prevention.
(9) Maternity care.
(10) Well baby and well child care and oral health, vision, and hearing services, equipment, and supplies at least for children under 21 years of age.
(c) Requirements Relating to Cost-sharing and Minimum Actuarial Value-
(1) NO COST-SHARING FOR PREVENTIVE SERVICES- There shall be no cost-sharing under the essential benefits package for preventive items and services (as specified under the benefit standards), including well baby and well child care.
(2) ANNUAL LIMITATION-
(A) ANNUAL LIMITATION- The cost-sharing incurred under the essential benefits package with respect to an individual (or family) for a year does not exceed the applicable level specified in subparagraph (B).
(B) APPLICABLE LEVEL- The applicable level specified in this subparagraph for Y1 is $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 (United States city average) applicable to such year.
(C) 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.
(3) MINIMUM ACTUARIAL VALUE-
(A) IN GENERAL- The cost-sharing under the essential benefits package shall be designed to provide a level of coverage that is designed to provide benefits that are actuarially equivalent to approximately 70 percent of the full actuarial value of the benefits provided under the reference benefits package described in subparagraph (B).
(B) REFERENCE BENEFITS PACKAGE DESCRIBED- The reference benefits package described in this subparagraph is the essential benefits package if there were no cost-sharing imposed.
In fact, if you look at Sec 124, page 36, you'll find this gem:
(b) ADOPTION OF STANDARDS.?
(1) INITIAL STANDARDS.?Not later than 18 months after the date of the enactment of this Act, the Secretary shall, through the rulemaking process consistent with subsection (a), adopt an initial set of benefit standards.
So, they are giving "The Secretary" a year and a half to come up with the "initial" standards AFTER the bill is passed. Swell.
Standards = details. A simple list of titles for the type of services that might be covered in any plan (Section 122) doesn't quite cut it for me.