Div A, Tit 3, part 2: Exchange Details

Section 303 appears at first blush to be a repeat of an earlier section on what minimum benefits need to be in the QHBP to be part of the exchange. There are, however, some extra and separate issues that come up here worth noting.

First, a provider (not just companies) may offer more than one type of plan but one MUST be basic services. The additional plans can be enhanced, premium, and premium plus. No, these do NOT apply to “extra services provided” – well, the plus does, but I’ll get there in a minute. Instead they apply to cost-sharing. Basic provides all services, and the users will have about a 30% cost-share up to the cap ($5000 per individual, $10,000 per family). Enhanced – which can have (and probably will have) higher premiums – will have a reduced cost-share of about 15%, and Premium plan cost-share will be about 5%. Premium plus will add benefits such as dental and vision to a premium level plan. (Recall, please, that the commission is supposed to see if dental – sorry, oral – needs to be added to the basic.)

A plan provider will have no more than 10% difference in cost-sharing between levels, but can tier within the levels. OK, let’s clarify that a touch. The cost-share for “no-frills” premium can be no more than 20% less than the cost-share for “no-frills” basic. HOWEVER, each of those can have variations in their plans that can push some of the pricing differently. The specific example given in the bill is breaks for preferred or participating (aka in-network) providers or classes of (or sources of, etc) prescription drugs.

Oh – a state can mandate more to ‘essential services’. Not less, but more.

Then we hit a section that, well, there’s a reason it’s in such dense legislative language. Actually, we hit a typo. It references 222(d)(4)(A) and (B), and 222(d) has no subsections. 222(e), however, does; and even has (4)(A) and (4)(B). They’re abortion provision. Recall that (A) is those for which federal funding IS NOT allowed and (B) is those for which federal funding IS allowed. Now let’s look at the section.

The commissioner will ensure there is one plan which allows both (4)(A) and (4)(B) services. The commissioner will also ensure there is one plan which does NOT allow (4)(A) services, and it MAY ALSO not allow (4)(B) services. IOW, the commissioner will ensure that those who want and those who do NOT want abortions to be an option for them will have an insurance provider available.

Expect screaming to occur here.

Oh – to ensure legality the commissioner is to ensure that credits (government subsidy for low income) are not spent on the actual (4)(A) services. (If you’ve been involved in government finance you probably know that money set aside for account A can’t be spent on account B even if A is flush and B is short without authorization. More than a few people who didn’t understand that have taken hits on the subject. This is not a fake-out accounting separation, it’s pretty real.)

I think, given how hotbutton that may be, I’ll stop here on this post and continue on the next.

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