Insurers, you may not include pre-existing condition exclusions in your health plans or any other limitation based on an individual or health-related factors.
This I very, very much like. If that were the end of the bill, I could walk away happy. But, we're just at p. 19 and have about 1,000 more to go.
The only reason an insurer can refuse to issue or fail to renew your insurance is if you haven't paid, they've told you you haven't paid and you had a window of time to pay but still didn't. Sounds good to me. That's how my power works, too.
Insurers also cannot discriminate against people with mental health disabilities or substance abuse issues. Odd to me this gets thrown in specifically and is not included with general pre-existing conditions.
Check your pockets:
Premiums can't change except:
a. by age categories set by the Health Care Commissioner (a national health care administrator position created by the bill)
b. by location
c. if the size of your enrolled family changes
Premiums can also change after the Commissioner's office does a study on the insured and not insured, and what their outcomes are in relation to money spent. The Commissioner has 18 months to do the study after Congress enacts the bill. That should definitely be worth watching.
Here after, the Commissioner will be identified as the "Commish" for levity's sake.
Making Premiums Lower (p. 24)
Plans would be required to meet a medical loss ratio set by the Commish every year. If you don't meet it, you have to give the surplus dollars back to your enrollees.
The Commish has to promise to set that ratio with market competition and consumer value in mind.
Can you even imagine? My jaw is nearing the floor with that one. Is this bill trying to force private plans out of the market by making it harder to make money? I agree with a single-payer system and am still perplexed by this.
Subtitle C: You're In!
Now, what's covered?
Some talk of the difference between Health Care Exchange-participating and Health Care Exchange non-participating plans. However, those have not been defined yet. Brilliant structuring. Big Thank You to the House on that one.
The Essential Benefits Package does not impose an annual or lifetime limit.
This, to me is also very big. My insurance caps me out at $1 million over a lifetime, and I'm pretty sure yours might, too. No cap would be great, but I'm questioning the feasibility of this.
Other minimal benefits are: in-patient and out-patient care, physician costs and equipment, PRESCRIPTION DRUGS (high-five, Congress!), rehab, mental health and substance abuse services, preventative services that get an A or B from the Clinical Preventative Services Task Force and CDC recommended vaccines, maternity, well baby and vision and hearing equipment and supplies for kids under 21.
Are some services missing? I can't think of any, but please comment below if you can.
The bill also specifies no cost-sharing (a.k.a. CO-PAYS) for preventative services. This, to me, is suspect, my insurance plan also says that, but when I went to the dietitian, I certainly had to pay. It seems my plan's definition of "preventative" is quite small. Hell, I think they should have bought my bicycle helmet, but whatever. Also, verdict still seems to be out on whether preventative measures work. I'd maybe like us to put that funding towards something we can prove is working... like drugs.
Out of pocket CO-PAYs cap out at $5,000 for an individual and $10,000 for a family. These levels will go up every years based on the Consumer Price Index.
CO-PAYS should touch out at somewhere around 30 percent of a plan's actuarial value. I'm not exactly sure what this means. Check out p. 30 and see if you can explain it to me better. If you buy into an enhanced plan, that number drops to 15 percent. And for all you premium shoppers out there, your plan will cover 90 percent of the value of the benefits (you pay 10 percent). This is all on p. 33.
The Commish is not enough. We need a Committee!
We're going to need a private-public committee, the Health Benefits Advisory Committee, that will recommend what benefits to cover and define plan benefit levels. (So far, we've just touched on essential in this blog.) We've got 60 days to set it up.
The Surgeon General will be the chair along with 9 presidential appointees (Federal employees) and 9 Comptroller General appointees (or non-Fed folk), oh and 8 more Fed guys. Oh, at least one person has to be a practicing physician. You think? We're going to pay per diem for these expert committee members.
No word on if the Commish gets a seat or not.
Lord-A-Mighty! In my limited experience with government (the seven-strong Golden City Council), I've found that you really need less people to get more done. I am very wary of this committee. Staff employees are the people who do the actual work and provide data for analysis. I suspect we're just going to end up with a new government agency.
Next up, policy prophylactics. More protection for consumers.
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