Some interesting provisions of the House health care insurance reform bill

[JDPriestly]

In response to a question about the cost of the healthcare insurance under the House reform bill, here are some random quotes from the bill. The line numbers to the left are a bit confusing because they don't always appear on the left in this copy. Sorry.

HR 3962, Title I, Immediate Reforms
Sec. 101(g)(2) COVERED BENEFITS.—Covered benefits under the program shall be determined by the Secretary and shall be consistent with the basic categories in the essential benefits package described in section 222. Under such benefits package—
(A) the annual deductible for such benefits may not be higher than $1,500 for an individual or such higher amount for a family as determined by the Secretary;
(B) there may not be annual or lifetime limits; and
(C) the maximum cost-sharing with respect to an individual (or family) for a year shall not exceed $5,000 for an individual (or $10,000 for a family).

Later
‘‘SEC. 2714. ENSURING VALUE AND LOWER PREMIUMS.
2 ‘‘(a) IN GENERAL.—Each health insurance issuer
3 that offers health insurance coverage in the small or large
4 group market shall provide that for any plan year in which
5 the coverage has a medical loss ratio below a level specified
6 by the Secretary (but not less than 85 percent), the issuer
7 shall provide in a manner specified by the Secretary for
8 rebates to enrollees of the amount by which the issuer’s
9 medical loss ratio is less than the level so specified.

. . . .

SEC. 104. SUNSHINE ON PRICE GOUGING BY HEALTH IN18
SURANCE ISSUERS.
19 The Secretary of Health and Human Services, in con
20 junction with States, shall establish a process for the an
21 nual review of increases in premiums for health insurance
22 coverage. Such process shall require health insurance
23 issuers to submit a justification for any premium increases
24 prior to implementation of the increase.
. . . .

SEC. 213. INSURANCE RATING RULES.
17 (a) IN GENERAL.—The premium rate charged for a
18 qualified health benefits plan that is health insurance cov19
erage may not vary except as follows:
20 (1) LIMITED AGE VARIATION PERMITTED.—By
21 age (within such age categories as the Commissioner
22 shall specify) so long as the ratio of the highest such
23 premium to the lowest such premium does not ex24
ceed the ratio of 2 to 1.
(2) BY AREA.—By premium rating area (as
2 permitted by State insurance regulators or, in the
3 case of Exchange-participating health benefits plans,
4 as specified by the Commissioner in consultation
5 with such regulators).
6 (3) BY FAMILY ENROLLMENT.—By family en
7 rollment (such as variations within categories and
8 compositions of families) so long as the ratio of the
9 premium for family enrollment (or enrollments) to
10 the premium for individual enrollment is uniform, as
11 specified under State law and consistent with rules
12 of the Commissioner.
. . . .
1 (c) REQUIREMENTS RELATING TO COST-SHARING
2 AND MINIMUM ACTUARIAL VALUE.—
3 (1) NO COST-SHARING FOR PREVENTIVE SERV4
ICES.—There shall be no cost-sharing under the es5
sential benefits package for—
6 (A) preventive items and services rec7
ommended with a grade of A or B by the Task
8 Force on Clinical Preventive Services and those
9 vaccines recommended for use by the Director
10 of the Centers for Disease Control and Preven11
tion; or
12 (B) well-baby and well-child care.
13 (2) ANNUAL LIMITATION.—
14 (A) ANNUAL LIMITATION.—The cost-shar
15 ing incurred under the essential benefits pack
16 age with respect to an individual (or family) for
17 a year does not exceed the applicable level spec18
ified in subparagraph (B).
19 (B) APPLICABLE LEVEL.—The applicable
20 level specified in this subparagraph for Y1 is
21 not to exceed $5,000 for an individual and not
22 to exceed $10,000 for a family. Such levels
23 shall be increased (rounded to the nearest
24 $100) for each subsequent year by the annual
25 percentage increase in the enrollment-weighted
VerDate Nov 24 2008 12:56 Oct 30, 2009 Jkt 089200 PO 00000 Frm 00107 Fmt 6652 Sfmt 6201 E:\BILLS\H3962.IH H3962 rmajette on DSK29S0YB1PROD with BILLS
108
HR 3962 IH
1 average of premium increases for basic plans
2 applicable to such year, except that Secretary
3 shall adjust such increase to ensure that the ap4
plicable level specified in this subparagraph
5 meets the minimum actuarial value required
6 under paragraph (3).
7 (C) USE OF COPAYMENTS.—In establishing
8 cost-sharing levels for basic, enhanced, and pre9
mium plans under this subsection, the Sec10
retary shall, to the maximum extent possible,
11 use only copayments and not coinsurance.
. . . . 115
HR 3962 IH
1 (6) LEVELS OF COST-SHARING FOR ENHANCED
2 AND PREMIUM PLANS.—
3 (A) ENHANCED PLAN.—The level of cost
4 sharing for enhanced plans shall be designed so
5 that such plans have benefits that are actuari
6 ally equivalent to approximately 85 percent of
7 the actuarial value of the benefits provided
8 under the reference benefits package described
9 in section 222(c)(3)(B).
10 (B) PREMIUM PLAN.—The level of cost
11 sharing for premium plans shall be designed so
12 that such plans have benefits that are actuari
13 ally equivalent to approximately 95 percent of
14 the actuarial value of the benefits provided
15 under the reference benefits package described
16 in section 222(c)(3)(B).

http://docs.house.gov/rules/health/111_ahcaa.pdf
. . . .

[truedelphi]

1. Here's something I have been pondering - what exactly is exact difference between a cost co-pay a

A deductible? And is a cost co-pay the same as cost sharing?

Will one pay both a $ 1,500 deductible and then pay also cost sharing?

What exactly is cost sharing?

After calling three Representatives and not being able to induce staff at any of the offices to send me the 1,900 page bill, I feel really frustrated. At local Congress Person's office, I was told the quota had already been reached in terms of sending out the bill.

(AND yes, I know. A PDF of the 1,900 pages is online. But myprinter needs to load the whole thing in memory and then select out the pages I want, and it finds that so confusing it CRASHES!)

If they cannot even make their 1,900 page bill accessible, then how can I trust them to implement those 1,900 pages?

[ChicagoSuz219]

2. This may help you...

If you're curious as to what's in the Congressional healthcare bill & don't want to wade thru 1000+ pages, here's a link to a "Readers Digest"-version of it at only 61 pages...


http://energycommerce.house.gov/Press_111/health_care/hr3962_Section_by_Section.pdf

[truedelphi]

3. Someone else had pointed me there but the document is riddled with

Errors.

Starting with the first paragraph, which mentions
$ 5 million when it should be 5 Billion.

On edit: or else it is highly ambiguous. Maybe the $ 5 million is the cap for an individual? The program has a cap, but I am not sure whether it is 5 billion or even more??

Anyway while the over structure is fully laid out, the nuts and bolts are left out, and like they often say, it is all in the details.

[ChicagoSuz219]

4. It should, at least, make it easier for you to look it up in the BIG one... nt

[truedelphi]

5. You are right. I will use it in that manner.

Thanks for the tip.

[ChicagoSuz219]

7. You're welcome. nt

[Hannah Bell]

6. problem with such "summaries" is they omit interesting minor items, e.g.

for this section, the summary omits the piece about how waivers will be granted if employers can show "hardship".

so in effect, they *can* reduce benefits.

Sec 110.  
Prohibition against postretirement reductions of retiree health benefits by group health plans.  

Prohibits employers from reducing retiree health benefits below what was offered to retirees at the time of their retirement nless reductions are also made to active workers’ health benefits.  Effective as of date of enactment. 

[Hannah Bell]

8. here's another useless "summary" point:

Sec. 201.  

Requirements reforming health insurance marketplace.  Broadly outlines the standards for reforming the health insurance marketplace. 



uh, no, that section is about how instead of increasing reimbursement rates to reflect inflation, they're going to take expected "productivity improvements" into account = reimbursement rates BELOW the rate of inflation = defunding medicare.