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KEY PROVISIONS THAT TAKE EFFECT IMMEDIATELY UNDER SENATE BILL AS AMENDED BY RECONCILIATION BILL

Below are some of the key provisions that will take effect immediately, under the legislative package the House passed this weekend (the Senate health bill as amended by the reconciliation bill). The reconciliation bill is based largely on the improvements put forward by the President’s proposal – moving towards the House bill in certain critical areas.

1.
SMALL BUSINESS TAX CREDITS—Offers tax credits to small businesses to make employee coverage more affordable. Tax credits of up to 35 percent of premiums will be immediately available to firms that choose to offer coverage. Effective beginning for calendar year 2010. (Beginning in 2014, the small business tax credits will cover 50 percent of premiums.)

2.
BEGINS TO CLOSE THE MEDICARE PART D DONUT HOLE—Provides a $250 rebate to Medicare beneficiaries who hit the donut hole in 2010. Effective for calendar year 2010. (Beginning in 2011, institutes a 50% discount on brand?name drugs in the donut hole; also completely closes the donut hole by 2020.)

3.
FREE PREVENTIVE CARE UNDER MEDICARE—Eliminates co?payments for preventive services and exempts preventive services from deductibles under the Medicare program. Effective beginning January 1, 2011.

4.
HELP FOR EARLY RETIREES—Creates a temporary re?insurance program (until the Exchanges are available) to help offset the costs of expensive health claims for employers that provide health benefits for retirees age 55?64. Effective 90 days after enactment

5.
ENDS RESCISSIONS—Bans health plans from dropping people from coverage when they get sick. Effective 6 months after enactment.

6.
NO DISCRIMINATON AGAINST CHILDREN WITH PRE?EXISTING CONDITIONS—Prohibits health plans from denying coverage to children with pre?existing conditions. Effective 6 months after enactment. (Beginning in 2014, this prohibition would apply to all persons.)

7.
BANS LIFETIME LIMITS ON COVERAGE—Prohibits health plans from placing lifetime caps on coverage. Effective 6 months after enactment.

8.
BANS RESTRICTIVE ANNUAL LIMITS ON COVERAGE—Tightly restricts new plans’ use of annual limits to ensure access to needed care. These tight restrictions will be defined by HHS. Effective 6 months after enactment. (Beginning in 2014, the use of any annual limits would be prohibited for all plans.)

9.
FREE PREVENTIVE CARE UNDER NEW PRIVATE PLANS—Requires new private plans to cover preventive services with no co?payments and with preventive services being exempt from deductibles. Effective 6 months after enactment.

10.
NEW, INDEPENDENT APPEALS PROCESS—Ensures consumers in new plans have access to an effective internal and external appeals process to appeal decisions by their health insurance plan. Effective 6 months after enactment.

11.
ENSURING VALUE FOR PREMIUM PAYMENTS—Requires plans in the individual and small group market to spend 80 percent of premium dollars on medical services, and plans in the large group market to spend 85 percent. Insurers that do not meet these thresholds must provide rebates to policyholders. Effective on January 1, 2011.

12.
IMMEDIATE HELP FOR THE UNINSURED UNTIL EXCHANGE IS AVAILABLE (INTERIM HIGH?RISK POOL)—Provides immediate access to insurance for Americans who are uninsured because of a pre?existing condition ? through a temporary high?risk pool. Effective 90 days after enactment.

13.
EXTENDS COVERAGE FOR YOUNG PEOPLE UP TO 26TH BIRTHDAY THROUGH PARENTS’ INSURANCE – Requires health plans to allow young people up to their 26th birthday to remain on their parents’ insurance policy, at the parents’ choice. Effective 6 months after enactment.

14.
COMMUNITY HEALTH CENTERS—Increases funding for Community Health Centers to allow for nearly a doubling of the number of patients seen by the centers over the next 5 years. Effective beginning in fiscal year 2010.

15.
INCREASING NUMBER OF PRIMARY CARE DOCTORS—Provides new investment in training programs to increase the number of primary care doctors, nurses, and public health professionals. Effective beginning in fiscal year 2010.

16.
PROHIBITING DISCRIMINATION BASED ON SALARY—Prohibits new group health plans from establishing any eligibility rules for health care coverage that have the effect of discriminating in favor of higher wage employees. Effective 6 months after enactment.

17.
HEALTH INSURANCE CONSUMER INFORMATION—Provides aid to states in establishing offices of health insurance consumer assistance in order to help individuals with the filing of complaints and appeals. Effective beginning in FY 2010.

18.
CREATES NEW, VOLUNTARY, PUBLIC LONG?TERM CARE INSURANCE PROGRAM—Creates a long?term care insurance program to be financed by voluntary payroll deductions to provide benefits to adults who become functionally disabled. Effective on January 1, 2011.

OFFICE OF SPEAKER NANCY PELOSI
MARCH 22, 2010

HOW DEMOCRATIC HEALTH CARE BILLS COMPARE

By RICARDO ALONSO-ZALDIVA

and ERICA WERNER

Associated Press Writers

A comparison of the health care bills before Congress:

The Senate Democratic bill

(Patient Protection and Affordable Care Act):

WHO’S COVERED: About 94 percent of legal residents under age 65 — compared with 83 percent now. Government subsidies to help buy coverage start in 2014.

COST: Coverage provisions cost $848 billion over 10 years.

HOW IT’S PAID FOR: Fees on insurance companies, drugmakers, medical device manufacturers. Medicare payroll tax increased to 1.95 percent on income over $200,000 a year for individuals; $250,000 for couples. New 5 percent tax on elective cosmetic surgery. Cuts to Medicare and Medicaid. Forty percent excise tax on insurance companies, keyed to premiums paid on health care plans costing more than $8,500 annually for individuals and $23,000 for families. Fees for employers whose workers receive government subsidies to help them pay premiums. Fines on people who fail to purchase coverage.

REQUIREMENTS FOR INDIVIDUALS:Almost everyone must get coverage through an employer, on their own or through a government plan. Exemptions for economic hardship. Those who are obligated to buy coverage and refuse to do so would pay a fine starting at $95 in 2014 and rising to $750.

REQUIREMENTS FOR EMPLOYERS: Not required to offer coverage, but companies with more than 50 employees would pay a fee of $750 per employee if the government ends up subsidizing employees’ coverage.

SUBSIDIES: Tax credits for individuals and families likely making up to 400 percent of the federal poverty level, which computes to $88,200 for a family of four. Tax credits for small employers.

BENEFITS PACKAGE: All plans sold to individuals and small businesses would have to cover basic benefits. The government would set four levels of coverage. The least generous would pay an estimated 60 percent of health care costs per year; the most generous would cover an estimated 90 percent.

INSURANCE INDUSTRY RESTRICTIONS: Starting in 2014: no denial of coverage based on pre-existing conditions. No higher premiums allowed for pre-existing conditions or gender. Limits on higher premiums based on age and family size. Starting upon enactment of legislation: children up to age 26 can stay on parents insurance; no lifetime limits on coverage.

GOVERNMENT-RUN PLAN: A new federal insurance plan would be offered to compete against private carriers. The government would negotiate — not dictate — payment rates for medical providers. Unlike the House bill, states could opt out of the plan. It’s not clear the proposal commands enough votes to survive. One compromise under consideration would replace it with national nonprofit health plans administered by the Office of Personnel Management, which oversees the popular Federal Employees Health Benefits Plan.

HOW YOU CHOOSE YOUR HEALTH INSURANCE: Self-employed people, uninsured individuals and small businesses could pick a plan offered through new state-based purchasing pools. Would generally encourage employees to keep work-provided coverage.

DRUGS: Grants 12 years of market protection to high-tech drugs used to combat cancer, Parkinson’s and other deadly diseases. Drug companies contribute $80 billion over 10 years with the majority of the money used to limit the prescription coverage gap in Medicare.

CHANGES TO MEDICAID: Income eligibility levels likely to be standardized to 133 percent of poverty — $29,327 a year for a family of four — for parents, children and pregnant women. Federal government would pick up the full cost of the expansion during the first three years. States could negotiate with insurers to arrange coverage for people with incomes slightly higher than the cutoff for Medicaid.

LONG-TERM CARE: New voluntary long-term care insurance program would provide a basic benefit designed to help seniors and disabled people avoid going into nursing homes.

ANTITRUST: Amendment expected to be offered on the Senate floor to strip the health insurance industry of its antitrust exemption.

ILLEGAL IMMIGRANTS: Would be barred from receiving government subsidies or using their own money to buy coverage offered by private companies in the exchanges.

ABORTION: Private companies in the exchange could offer abortion coverage, but people would have to use their own money — not federal subsidy money — to buy that coverage. Strict segregation of private from taxpayer funds would be required, and taxpayer dollars could only be used in cases of rape, incest or danger to the mother’s life. The new federal insurance plan also could offer abortion coverage. An amendment by Sen. Ben Nelson, D-Neb., would tighten those restrictions along the lines in the House bill, but the amendment is not expected to pass.

The House bill

(Affordable Health Care for America Act):

WHO’S COVERED: About 96 percent of legal residents under age 65 — compared with 83 percent now. Government subsidies to help buy coverage start in 2013. About one-third of the remaining 18 million people under age 65 left uninsured would be illegal immigrants.

COST:The Congressional Budget Office says the bill’s cost of expanding insurance coverage over 10 years is $1.055 trillion. The net cost is $894 billion, factoring in penalties on individuals and employers who don’t comply with new requirements. That’s under President Barack Obama’s $900 billion goal. However, those figures leave out a variety of new costs in the bill, including increased prescription drug coverage for seniors under Medicare, so the measure may be around $1.2 trillion.

HOW IT’S PAID FOR:$460 billion over the next decade from new income taxes on single people making more than $500,000 a year and couples making more than $1 million. The original House bill taxed individuals making $280,000 a year and couples making more than $350,000, but the threshold was increased in response to lawmakers’ concerns that the taxes would hit too many people and small businesses.

There are also more than $400 billion in cuts to Medicare and Medicaid; a new $20 billion fee on medical device makers; $13 billion from limiting contributions to flexible spending accounts; sizable penalties paid by individuals and employers who don’t obtain coverage; and a mix of other corporate taxes and fees.

REQUIREMENTS FOR INDIVIDUALS: Individuals must have insurance, enforced through a tax penalty of 2.5 percent of income. People can apply for hardship waivers if coverage is unaffordable.

REQUIREMENTS FOR EMPLOYERS: Employers must provide insurance to their employees or pay a penalty of 8 percent of payroll. Companies with payrolls under $500,000 annually are exempt — a change from the original $250,000 level to accommodate concerns of moderate Democrats — and the penalty is phased in for companies with payrolls between $500,000 and $750,000.

Small businesses — those with 10 or fewer workers — get tax credits to help them provide coverage.

SUBSIDIES: Individuals and families with annual income up to 400 percent of poverty level, or $88,000 for a family of four, would get sliding-scale subsidies to help them buy coverage. The subsidies would begin in 2013.

HOW YOU CHOOSE YOUR HEALTH INSURANCE: Beginning in 2013, through a new Health Insurance Exchange open to individuals and, initially, small employers. It could be expanded to large employers over time. States could opt to operate their own exchanges in place of the national exchange if they follow federal rules.

BENEFITS PACKAGE: A committee would recommend a so-called essential benefits package including preventive services. Out-of-pocket costs would be capped. The new benefit package would be the basic benefit package offered in the exchange.

INSURANCE INDUSTRY RESTRICTIONS: Starting in 2013, no denial of coverage based on pre-existing conditions. No higher premiums allowed for pre-existing conditions or gender. Limits on higher premiums based on age.

GOVERNMENT-RUN PLAN: A new public plan available through the insurance exchanges would be set up and run by the health and human services secretary. Democrats originally designed the plan to pay Medicare rates plus 5 percent to doctors. But the final version — preferred by moderate lawmakers — would let the HHS secretary negotiate rates with providers.

CHANGES TO MEDICAID: The federal-state insurance program for the poor would be expanded to cover all individuals under age 65 with incomes up to 150 percent of the federal poverty level, which is $33,075 per year for a family of four. The federal government would pick up the full cost of the expansion in 2013 and 2014; thereafter the federal government would pay 91 percent and states would pay 9 percent.

DRUGS: Grants 12 years of market protection to high-tech drugs used to combat cancer, Parkinson’s and other deadly diseases. Phases out the gap in Medicare prescription drug coverage by 2019. Requires the HHS secretary to negotiate drug prices on behalf of Medicare beneficiaries.

LONG-TERM CARE: New voluntary long-term care insurance program would provide a basic benefit designed to help seniors and disabled people avoid going into nursing homes.

ANTITRUST:Would strip the health insurance industry of a long-standing exemption from antitrust laws covering market allocation, price-fixing and bid rigging. The bill also would give the Federal Trade Commission authority to look into the health insurance industry at its own initiative.

ILLEGAL IMMIGRANTS: Would be barred from receiving government subsidies but permitted to use their own money to buy coverage offered by private companies in the exchange.

ABORTION: Private companies in the exchange could not offer plans covering abortion if those plans received federal subsidy money. Most plans in the exchange would be affected, because most consumers in the exchange would be using federal subsidy money to buy coverage. The new government plan could not offer abortion coverage. Insurance companies would be permitted to offer supplemental abortion coverage in separate plans that people could buy with their own money. Use of federal money for abortion coverage would be limited to cases of rape, incest or danger to the woman’s life.

Los Angeles (myFOXla.com) – Accidents happen… and if you have medical insurance, money should be the last thing on your mind when you’re in the emergency room.

Unfortunately, many insured patients find out there’s a gap in the system and that they’re still on the hook for thousands of dollars.

You can watch Phil Shuman’s report in the video below.

 

The Hospital Association of Southern California advises that you shouldn’t wait for an emergency.

• Check your health plan’s web site or handout book for the names of every doctor in the network… and what percentage of costs will be covered. 
•  Before an emergency happens, designate someone close to you as your advocate in an ER situation. 
• Also, Cosumer Watchdog’s Judy Dugan advises that you should keep meticulous records.
• Lastly, don’t be afraid to argue the doctor’s bill. If you put up a fight, many doctors will reduce charge.
   

If you have concerns regarding “Balance Billing” and/or charges for an “out of network” doctor, check out consumerwatchdog.org .

Source:  http://www.myfoxla.com/dpp/health/Medical_Billing_Controversy

Anthem plans across the country are working to develop innovative products and programs that help address rising health care costs. Through pay for performance initiatives, consumer directed health plans and transparency initiatives; Anthem is providing access to the information needed to drive down health care costs.

While many people may believe that insurer profits are the driving force behind increasing health insurance premiums, research reveals very different reasons for the high cost of health insurance.

A May 2009 report titled “What’s Really Driving the Increase in Health Care Premiums?” addresses the issue. The report, issued by the WellPoint Institute of Health Care Knowledge, compiles research from sources such as PricewaterhouseCoopers, the Robert Wood Johnson Foundation, the Kaiser Family Foundation, the Bureau of Labor Statistics and the Congressional Budget Office.

According to the report, the “key drivers” of spiraling U.S. health care costs are:

• Advances in medical technology and subsequent increases in utilization;
• Price inflation for medical services that exceeds inflation in other sectors of the economy;
• Cost-shifting from people who are uninsured and those receiving Medicare and Medicaid to the private sector;
• High cost of regulatory compliance; and
• Patient lifestyles, such as smoking, physical inactivity and obesity.

Citing PricewaterhouseCoopers research from 2008, the report found that only three cents of every health care premium dollar is spent on health insurer profit.

According to the Institute’s report, newer medical technologies tend to increase costs because they are generally more expensive than the older technologies they replace. While the availability of more advanced, superior technologies can yield better results for some patients, these technologies and diagnostic tests may be used inappropriately in some situations where existing, older technologies are more effective and accurate.

View a copy of the full report, “What’s Really Driving the Increase in Health Care Premiums?”

National Spotlight

Senate Finance Committee Releases Second Document on Policy Options for Health Reform

During April and May, the Senate Finance Committee has held various meetings and roundtable discussions with stakeholders on policy options for health reform legislation that the committee plans to unveil in June.  The committee has held three roundtable discussions with stakeholders and health care experts on the topics of delivery system reform, expanding coverage, and financing of health reform.  Following each of these roundtable discussions, the committee has released a detailed document outlining the options under consideration by the committee.  The most recent document was released on May 14, 2009 related to the policy options being considered by the committee to expand affordable coverage to all Americans.  The first document released at the end of April describes options to reform the health care delivery system and the third document to be released later in May will contain options for financing comprehensive health care reform. The options being considered by the committee to expand coverage to all Americans fall into the following eight categories:

· Insurance Market Reforms: The committee is considering various changes to the insurance market including guarantee issue, renewability and elimination of pre-existing condition exclusions for the individual market and a new micro group market consisting of employers with ten or fewer employees. Limitations on rating rules are under consideration for the individual and small group markets with a phase in of these federal rating rules in the states. Also under consideration are options for the functions, eligibility, and structure of a single health insurance exchange or multiple exchanges to help people find, compare, and enroll in health coverage.

· Making Coverage Affordable: The committee is considering options to establish a minimum set of benefits to be offered by insurers, designation of four benefit categories to be offered by insurers, and tax credits for low-income individuals and small employers.

· Public Health Insurance Option: Under consideration by the committee are five options for offering a public health insurance plan to compete with private insurers.  The five options include not offering a public option, offering an option like Medicare where the government sets provider payment rates based on Medicare rates and providers must participate, a level-playing field option where payment rates are set above Medicare rates and provider participation is voluntary, a third-party administrator (TPA) option administered by regional TPAs that would establish provider networks and negotiate payments with providers, and a state-run option.

· Role of Public Programs: Various options are under consideration for public health insurance programs. One option would expand Medicaid to parents and children under 150 percent of the federal poverty level.   Another option provides three alternatives for accessing coverage through Medicaid which include keeping Medicaid in its current structure, offering Medicaid through an exchange, and a third option where parents and children would access Medicaid under the current structure and other Medicaid eligible adults would get a subsidy to purchase coverage through an exchange. Other options under consideration by the committee include public program options for those age 55 to 64 and providing the Children’s Health Insurance Program through an exchange for children not eligible for Medicaid.

· Shared Responsibility: The committee is considering requirements for individuals to purchase coverage, whether employers should be required to offer coverage, and options for exemptions from the requirements and fines for noncompliance.

· Prevention and Wellness: Under consideration by the committee are options to increase coverage of preventive services in Medicare and Medicaid, state grants to provide preventive services for the uninsured, and tax incentives for workplace wellness programs.

· Long Term Care Services and Supports: The committee is considering options to increase access to home and community-based services in Medicaid including increasing federal matching funds and waiver flexibility, facilitate community living, and promote innovation.

· Options to Address Health Disparities: Options under consideration by the committee to address health disparities include the uniform collection of data on race, ethnicity, gender, and disability to assist in the measurement and research of health disparities, providing states the option to cover legal immigrant adults, and options to promote maternal and child health.

President Obama and Stakeholders Discuss How to Reduce Health Care Cost Growth

President Obama and Administration officials met with health care industry stakeholders on May 11, 2009 to discuss how to reduce the growth rate of health care costs.  Attendees at the meeting included representatives from America’s Health Insurance Plans, the American Hospital Association, the American Medical Association, the Advanced Medical Technology Association, the Pharmaceutical Research and Manufacturers of America, and the Service Employees International Union.  The stakeholder groups represented at the meeting presented the President with a letter indicating their commitment to decrease the annual health care spending growth rate by 1.5%, a savings of $2 trillion or more over ten years, by:

· Implementing proposals in all sectors of the health care system focusing on administrative simplification, standardization, and transparency that supports effective markets.

· Reducing over-use and under-use of health care by aligning quality and efficiency incentives among providers across the continuum of care so that physicians, hospitals, and other health care providers are encouraged and enabled to work together towards the highest standards of quality and efficiency.

· Encouraging coordinated care, both in the public and private sectors, and adherence to evidence-based best practices and therapies that reduce hospitalization, manage chronic disease more efficiently and effectively and implement proven clinical prevention strategies.

· Reducing the cost of doing business by addressing cost drivers in each sector and through common sense improvements in the care delivery models, health information technology, workforce development, and regulatory reforms.

President Obama indicated that these efforts would be compatible with his and Congress’ efforts to pass health care reform legislation this year and that legislation must decrease rising health care costs, allow Americans to retain the coverage and doctor choices they currently have if they so desire, and provide Americans access to quality and affordable health care.

House Democrat Coalitions Announce Principles for Health Reform

The “New Democrat Coalition” of approximately 60 moderate democrats and the “Blue Dog Coalition” of approximately 50 conservative democrats in the House of Representatives recently released principles for health reform.  On May 7, 2009, the New Democrat Coalition released health reform principles that focus on improving access, quality, and affordability in the health care system by: 1) fostering and harnessing innovation, 2) building on the strengths of the private market, and 3) realigning the health care system to better coordinate care, focus on prevention, and purchase value.  On May 12, 2009, the Blue Dog Coalition released their principles for controlling costs, increasing value, and improving access through: 1) realignment of payment incentives, cost and quality transparency, and public program integrity to control costs, 2) strengthened care coordination, financial wellness incentives, and investment in health research to increase value, and 3) coverage tax credits, rural payment modernization, increased loan assistance for providers in underserved areas, expanded telemedicine, the elimination of pre-existing condition exclusions, and improvements in long term care services to improve access.

State Spotlight

Iowa Enacts Health Reform Legislation

On May 19, 2009, Governor Culver signed health reform legislation that establishes a ”Health Care Coverage Commission” to study and develop methods to affordably insure all citizens through public programs, private insurance, and other mechanisms. The Commission is charged with:

· Recommending options for coordinating a “Children’s Health Care Network”  to cover children under the age of nineteen with a family income less than 300 percent of the federal poverty level through the modification of existing public programs that maximizes federal funding and to provide access to affordable private coverage for children not eligible for public programs.

· Evaluating ways to ensure a seamless transition between public programs and private health insurance coverage for children and adults.

· Developing options that would provide individuals and families with access to three separate affordable benefit plans (basic, intermediate, and comprehensive) that could be subsidized for those with lower incomes, with the goal of providing plans and subsidies that limit spending to 6.5% of family income.

· Studying options to pool employees of counties, cities, schools, community colleges, nonprofit employers, and small employers with the state employee health plan.

· Evaluating the ramifications of requiring employers with more than ten employees to offer a Section 125 cafeteria plan to their employees for the pretax purchase of health insurance coverage.

· Studying options for the development of an “Exchange” or “Connector” type structure to provide access to affordable health care coverage through an existing government agency or a newly created entity.

© 2009 UnitedHealth Group