Again I’ll start with the table of contents. Note the new legislative fun – this title has SUBtitles. No, not what we see in foreign movies, but rather groupings of the included sections.
Subtitle A—General Standards
Sec. 201. Requirements reforming health insurance marketplace.
Sec. 202. Protecting the choice to keep current coverage.
Subtitle B—Standards Guaranteeing Access to Affordable Coverage
Sec. 211. Prohibiting preexisting condition exclusions.
Sec. 212. Guaranteed issue and renewal for insured plans and prohibiting rescissions.
Sec. 213. Insurance rating rules.
Sec. 214. Nondiscrimination in benefits; parity in mental health and substance
abuse disorder benefits.
Sec. 215. Ensuring adequacy of provider networks.
Sec. 216. Requiring the option of extension of dependent coverage for uninsured
Sec. 217. Consistency of costs and coverage under qualified health benefits
plans during plan year.
Subtitle C—Standards Guaranteeing Access to Essential Benefits
Sec. 221. Coverage of essential benefits package.
Sec. 222. Essential benefits package defined.
Sec. 223. Health Benefits Advisory Committee.
Sec. 224. Process for adoption of recommendations; adoption of benefit standards.
Subtitle D—Additional Consumer Protections
Sec. 231. Requiring fair marketing practices by health insurers.
14 sections in four groups. Wheeeee.
The first grouping is general standards. Let’s get started.
Section 201 is really “the minimums.” That is, what are going to be the minimum benefits, access, and other elements health insurance is going to be required to include?
The very first thing it notes is that if a plan doesn’t meet the standards at the start of Y1 and doesn’t meet any of the ‘you can do this later’ authorizations it’s not a qualified plan. Ummm, qualified plan. While not literally correct, think of these as legal plans (ie the feds won’t arrest the companies for running the plans). So meet the standards, qualify for the exceptions, or get out of the business.
The rest of 201 is definitions. Only one of these caught my eye. For this title an enrollee can mean participant and/or beneficiary. That’s a bit subtle and might be very relevant in ‘fine print law’ situations.
202 is a big deal politically. The concept is simple – this is the section that says you get to keep the insurance you already have; nobody is going to make you change. It’s also got a lot of things to consider.
First item: You only get to keep it if you already have it OR if you’re the dependent of someone who already has it. To understand, assume your company has a plan that has two ‘old-timers’ on it, and it’s 2013. You cannot join the old-timers’ plan even though the company is paying a ‘company plan’ for it. HOWEVER, if you’re a dependent of one of the old-timers you CAN be put on the plan. OK? OH – and the benefits, terms, conditions, and cost-sharing can’t change or it removes the grandfather protection.
Second item: if the plan isn’t ‘qualified’ the grandfathering is only good for five years. With exception for certain ‘limited benefit’ plans such as plans for specific diseases. Ummm, let’s say you purchase a plan that only covers for cancer expenses – hospices, etc. It doesn’t have to pick up all the other qualifying elements. Keeping it simple, the intent is that a plan touted as a general plan meet minimum standards, but narrow focus plans are not general plans.
Ending with a quick burst: transitional plans (from old to qualified) during the grace period are ok even if not ‘qualified’; individual insurance is pretty much the same as employer provided insurance; ‘excepted benefits’ plans can be wiggled in but mainly as supplements, not replacements for qualified plans.
Did you notice the big frustration? Despite the subtitle’s name, we saw no standards. Don’t fret, they’re coming.
Subtitle Standards of affordability
If you read the previous post that had a bunch of ‘do it now’ provisions, most expired when The Plan went into effect – notionally 2013. Guess what’s happening here? Yep, we’re going to eliminate redundancies. The ‘do it now’ expires because the “do it forever” is here.
Section 211: prohibiting preexisting conditions exclusions. Pretty logical, actually. Since coverage is (more or less) universal there are no pre-existing conditions that were not covered by someone. Still, this is preventing a loophole.
212: guaranteed issue, renewal and prevention of rescissions. Ya can’t deny, ya can’t take it away. Ya can charge more for higher risk, but there are restrictions on how MUCH more you can charge (that’s coming later).
213: Insurance rating rules (where differences in rates can be made). Age can apply so long as the most expensive is no more than double the least expensive. Rates can vary by area but it’s got to be justified to the commissioner. There’s some slight variation allowed for family vs individual – the family rate does not have to be a multiple of the individual rate based on number of family members. On the other hand it can’t get wildly different, and it’s up to the commissioner (from HHS) to set the line. Commissioner is prohibited from using some services for basing the line: prenatal, delivery and postnatal care being an example.
This section also requires a study and report to ensure the prices and limits are right – basically it’s a feedback report to congress of “is it working, and if not where do we need to adjust?”
Section 214 says, basically, that there’ll be no discrimination (you basically know the list) in benefits available or pricing, and further that a qualified plan will offer mental health benefits. No, that last isn’t quite accurate as it’s possible for a plan to have zero mental health benefits and qualify. Saying it better, if a plan offers mental health benefits there is a list of what must be available: in- and out-patient, counseling, substance abuse treatment.
Section 215 says that if the plan uses a provider network (approved list of providers) the list must be of adequate size (numbers and coverage area for the insured) and must be current and easily accessible (internet mandatory, other methods allowed).
216 repeats another of the ‘immediates’ – a dependent without other insurance available can remain on (not return to) the plan till they’re 27.
The subtitle ends with 217 which is to the insurance company’s benefit. Basically it says the company can change the premiums if necessary (ie, not covering payouts) but must give at least 90 days warning. Then it gives the loophole, shorter warning “in cases where the change is necessary to ensure the health and safety of enrollees.” Watch for abuses here if this goes into effect.
Third subtitle is for standards of benefits.
The first thing 221 tells us is that while basic benefits are in 222, 224 will describe the process for adding, removing and approving changes in basic benefits. In other words this isn’t fixed but can be changed by executive process. That… could be ugly. We’ll see better when we get to 224. In the meantime, 221 tells us we have two types of coverage from which to choose, and that narrow focus supplements (aka excepted benefits plans) are allowed. The two types are non-exchange participating and exchange-participating health benefit plans. At this point the difference is not described, but we’ll get there eventually. Finally, the section tells us that plan providers can use managed services so long as they’re based on valid medical evidence and are relevant to the patient; and that a plan provider is allowed to subcontract to other providers so as to provide all necessary services for qualification. That last is a very interesting clause. I expect to see two types of business spring up: a ‘umbrella only’ provider which is essentially a gateway to a smorgasbord of specialized providers; and the specialized providers. Potential loopholes abound.
222 is a big one – finally, what are essential benefits.
It begins by cheating. The insurance pays for the cost and pays in a timely fashion, and will have benefits equivalent to what the average business-paid plans have at the start of this plan. In other words, if most company plans have a benefit, it becomes an essential benefit.
That said, it goes on to list some things that will be in regardless. These include:
- Outpatient hospital, outpatient clinic, and emergency department services;
- Access to and payment for professional physicians and other health professionals;
- the equipment, supplies and services the preceding professionals need to do the job;
- prescription drugs;
- Rehabilitative and habilitative services;
- Mental health, substance abuse treatment, and behavioral health treatment;
- Preventive Services recommended with grade A or B by the Task Force for Clinical Preventive Services. At this time there’s no A and B only printout. The so-called “pocket guide” is 289 pages long. Suffice it to say it includes vaccines and a lot of screenings and such based on probable need. As a quick example: genetic testing for the BRCA (breast cancer susceptibility gene) is a D for most women. If there is a family history of breast cancer, however, it’s a B grade.
- Maternity care;
- Well-child care, oral, vision, and hearing services, supplies and equipment to age 21. (21? That seems a bit much to me.);
- Durable medical equipment, prosthetics, orthotics, and supplies for the same.
But wait, there’s more (sigh).
This section also requires no cost-sharing for preventive services or well-baby/well-child care (see again my remark of: “To age 21?”)
Cost sharing (deductibles, copays, etc) are capped at $5000 per individual and $10,000 per family. Caps will be increased based on, well, basically based on actuarially identified increases in costs. Where possible copays will be preferred. The actual costs and benefits paid is in general to be such that the insurance pays 70% of the benefit and the cost sharing covers the other 30%.
Assessment and brief counseling for domestic violence will be an essential.
A REALLY BIG ONE: Abortion services cannot be mandated as part of the essential benefits for standards of ‘qualified’ plan. Those abortion services for which federal funding is prohibited by law (as of 6 months prior to the respective plan year) cannot be included in a public health insurance plan Those abortion services for which federal funding is allowed by law MAY be included in a public health insurance plan. And finally, there is no restriction on abortion services (other than general legal restrictions) for private plans. Let me simplify:
Private plan may have abortion, cannot be made to have abortion. Public plan will not have abortions not allowed by federal funding, may but are not required to have abortions for which federal funding is allowed.
Finally, HHS is required at the end of the first year of The Plan to provide an report on the identified need for including oral health care in the essential benefits package.
Know what? I need a break, and so probably do you. Next post on the subject I’ll try to finish Div one Title two, which includes how the rules are set and changed in this subtitle. Go do something to ease the numbness.