The following are three sections of the Reconciliation worth reviewing.
The first is the standards for the plans mandated. There is no intention to manage demand in this plan. It mandates massive amounts of coverage and there is not a single element of responsibility on the part of the patient to improve their own health. For example one may become as obese as one whats and one is insured for all resulting harm to society at large by those who remain healthy. The elements are:
Subtitle B—Standards Guaranteeing Access to Affordable Coverage
SEC. 111. PROHIBITING PRE-EXISTING CONDITION EXCLUSIONS.
SEC. 112. GUARANTEED ISSUE AND RENEWAL FOR INSURED PLANS.
SEC. 113. INSURANCE RATING RULES.
(a) IN GENERAL.—The premium rate charged for an insured qualified health benefits plan may not vary except as follows: (1) LIMITED AGE VARIATION PERMITTED.—By age (within such age categories as the Commissioner shall specify) so long as the ratio of the highest such premium to the lowest such premium does not exceed the ratio of 2 to 1. (2) BY AREA.—By premium rating area (as permitted by State insurance regulators or, in the case of Exchange-participating health benefits plans, as specified by the Commissioner in consultation
SEC. 114. NONDISCRIMINATION IN BENEFITS; PARITY IN MENTAL HEALTH AND SUBSTANCE ABUSE DISORDER BENEFITS.
SEC. 116. ENSURING VALUE AND LOWER PREMIUMS. (a) IN GENERAL.—
A qualified health benefits plan shall meet a medical loss ratio as defined by the Commissioner. For any plan year in which the qualified health benefits plan does not meet such medical loss ratio, QHBP offering entity shall provide in a manner specified by the Commissioner for rebates to enrollees of payment sufficient to meet such loss ratio.
Subtitle C—Standards Guaranteeing Access to Essential Benefits
SEC. 121. COVERAGE OF ESSENTIAL BENEFITS PACKAGE. (a) IN GENERAL.—
A qualified health benefits plan shall provide coverage that at least meets the benefit standards adopted under section 124 for the essential benefits package described in section 122 for the plan year involved.
(1) NON-EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS.—In the case of a qualified health benefits plan that is not an Exchange-participating health benefits plan, such plan may offer such coverage in addition to the essential benefits package as the QHBP offering entity may specify.
(2) EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS.—In the case of an Exchange-participating health benefits plan, such plan is required under section 203 to provide specified levels of benefits and, in the case of a plan offering a premium plus level of benefits, provide additional benefits.
SEC. 122. ESSENTIAL BENEFITS PACKAGE DEFINED.
(a) IN GENERAL.—In this subdivision, the term ‘‘essential benefits package’’ means health benefits coverage, consistent with standards adopted under section 124 to ensure the provision of quality health care and financial security, that— (1) provides payment for the items and services described in subsection (b) in accordance with generally accepted standards of medical or other appropriate clinical or professional practice; (2) limits cost-sharing for such covered health care items and services in accordance with such benefit standards, consistent with subsection (c); (3) does not impose any annual or lifetime limit on the coverage of covered health care items and services; (4) complies with section 115(a) (relating to network adequacy); and (5) is equivalent, as certified by Office of the Actuary of the Centers for Medicare & Medicaid Services, to the average prevailing employer-sponsored coverage.
(b) MINIMUM SERVICES TO BE COVERED.—The items and services described in this subsection are the following:
(1) Hospitalization.
(2) Outpatient hospital and outpatient clinic services, including emergency department services.
(3) Professional services of physicians and other health professionals.
(4) Such services, equipment, and supplies incident to the services of a physician’s or a health professional’s delivery of care in institutional settings, physician offices, patients’ homes or place of residence, or other settings, as appropriate.
(5) Prescription drugs.
(6) Rehabilitative and habilitative services.
(7) Mental health and substance use disorder services.
(8) Preventive services, including those services recommended with a grade of A or B by the Task Force on Clinical Preventive Services and those vaccines recommended for use by the Director of the Centers for Disease Control and Prevention.
(9) Maternity care.
(10) Well baby and well child care and oral health, vision, and hearing services, equipment, and supplies at least for children under 21 years of age.
(c) REQUIREMENTS RELATING TO COST-SHARING AND MINIMUM ACTUARIAL VALUE.—
(1) NO COST-SHARING FOR PREVENTIVE SERVICES.—There shall be no cost-sharing under the essential benefits package for preventive items and services (as specified under the benefit standards), including well baby and well child care.
(2) ANNUAL LIMITATION.—
(A) ANNUAL LIMITATION.—The cost-sharing incurred under the essential benefits package with respect to an individual (or family) for a year does not exceed the applicable level specified in subparagraph (B).
(B) APPLICABLE LEVEL.—The applicable level specified in this subparagraph for Y1 is $5,000 for an individual and $10,000 for a family. Such levels shall be increased (rounded to the nearest $100) for each subsequent year1 by the annual percentage increase in the Consumer Price Index (United States city average) applicable to such year.
(C) USE OF COPAYMENTS.—In establishing cost-sharing levels for basic, enhanced, and premium plans under this subsection, the Secretary shall, to the maximum extent possible, use only copayments and not coinsurance.
The above set of benefits will be quite costly. The idea of a catastrophic coverage was totally rejected. There is gross neglect of cost sharing of any reasonable form. For those under $100,000 annual income there is Government, namely taxpayer, support.
The next area is the bundling issue, namely giving control over to the hospitals along with Government. The Plan states:
SEC. 1152. POST ACUTE CARE SERVICES PAYMENT REFORM PLAN AND BUNDLING PILOT PROGRAM.
(a) PLAN.—
(1) IN GENERAL.—The Secretary of Health and Human Services (in this section referred to as the ‘‘Secretary’’) shall develop a detailed plan to reform payment for post acute care (PAC) services under the Medicare program under title XVIII of the Social Security Act (in this section referred to as the ‘‘Medicare program)’’. The goals of such payment reform are to— (A) improve the coordination, quality, and efficiency of such services; and (B) improve outcomes for individuals such as reducing the need for readmission to hospitals from providers of such services.
(2) BUNDLING POST ACUTE SERVICES.—The plan described in paragraph (1) shall include detailed specifications for a bundled payment for post acute services (in this section referred to as the ‘‘post acute care bundle’’), and may include other approaches determined appropriate by the Secretary.
(3) POST ACUTE SERVICES.—For purposes of this section, the term ‘‘post acute services’’ means services for which payment may be made under the Medicare program that are furnished by skilled nursing facilities, inpatient rehabilitation facilities, long term care hospitals, hospital based outpatient rehabilitation facilities and home health agencies to an individual after discharge of such individual from a hospital, and such other services determined appropriate by the Secretary.
(b) DETAILS.—The plan described in subsection (a)(1) shall include consideration of the following issues: (1) The nature of payments under a post acute care bundle, including the type of provider or entity to whom payment should be made, the scope of activities and services included in the bundle, whether payment for physicians’ services should be included in the bundle, and the period covered by the bundle.
(3) Whether the bundle should be applied across all categories of providers of inpatient services (including critical access hospitals) and post acute care services or whether it should be limited to certain categories of providers, services, or discharges, such as high volume or high cost MS– DRGs.
(4) The extent to which payment rates could be established to achieve offsets for efficiencies that could be expected to be achieved with a bundle payment, whether such rates should be established on a national basis or for different geographic areas, should vary according to discharge, case mix, outliers, and geographic differences in wages or other appropriate adjustments, and how to update such rates.
(5) The nature of protections needed for individuals under a system of bundled payments to ensure that individuals receive quality care, are furnished the level and amount of services needed as determined by an appropriate assessment instrument, are offered choice of provider, and the extent to which transitional care services would improve quality of care for individuals and the functioning of a bundled post-acute system.
(6) The nature of relationships that may be required between hospitals and providers of post acute care services to facilitate bundled payments, including the application of gain-sharing, anti-referral, anti-kickback, and anti-trust laws.
(7) Quality measures that would be appropriate for reporting by hospitals and post acute providers (such as measures that assess changes in functional status and quality measures appropriate for each type of post acute services provider including how the reporting of such quality measures could be coordinated with other reporting of such quality measures by such providers otherwise required).
(8) How cost-sharing for a post acute care bundle should be treated relative to current rules for cost-sharing for inpatient hospital, home health, skilled nursing facility, and other services.
Finally there is the proposal for Health Centers, or a modicum of the old Public Health Care System. It is funded as follows:
TITLE I—COMMUNITY HEALTH CENTERS SEC. 2101. INCREASED FUNDING.
Section 330 of the Public Health Service Act (23 U.S.C. 254b) is amended— (1) in subsection (r)(1)— (A) in subparagraph (D), by striking ‘‘and’’ at the end; (B) in subparagraph (E), by striking the period at the end and inserting ‘‘; and’’; and (C) by inserting at the end the following: ‘‘(F) Such sums as may be necessary for each of fiscal years 2013 and 2019.’’; and (2) by inserting after subsection (r) the following: ‘‘(s)
ADDITIONAL FUNDING.—For the purpose of carrying out this section, in addition to any other amounts authorized to be appropriated for such purpose, there are authorized to be appropriated, out of any monies in the Public Health Investment Fund, the following:
‘‘(1) For fiscal year 2010, $1,000,000,016 ‘‘(2) For fiscal year 2011, $1,500,000,000. ‘‘(3) For fiscal year 2012, $2,500,000,000. ‘‘(4) For fiscal year 2013, $3,000,000,000. ‘‘(5) For fiscal year 2014, $4,000,000,000. ‘‘(6) For fiscal year 2015, $4,400,000,000. ‘‘(7) For fiscal year 2016, $4,800,000,000. ‘‘(8) For fiscal year 2017, $5,300,000,000. ‘‘(9) For fiscal year 2018, $5,900,000,000. ‘‘(10) For fiscal year 2019, $6,400,000,000.’’.
There is no part of the Reconciliation which speaks to abortion thus eliminating the Stupaks, if they so chose.
The first is the standards for the plans mandated. There is no intention to manage demand in this plan. It mandates massive amounts of coverage and there is not a single element of responsibility on the part of the patient to improve their own health. For example one may become as obese as one whats and one is insured for all resulting harm to society at large by those who remain healthy. The elements are:
Subtitle B—Standards Guaranteeing Access to Affordable Coverage
SEC. 111. PROHIBITING PRE-EXISTING CONDITION EXCLUSIONS.
SEC. 112. GUARANTEED ISSUE AND RENEWAL FOR INSURED PLANS.
SEC. 113. INSURANCE RATING RULES.
(a) IN GENERAL.—The premium rate charged for an insured qualified health benefits plan may not vary except as follows: (1) LIMITED AGE VARIATION PERMITTED.—By age (within such age categories as the Commissioner shall specify) so long as the ratio of the highest such premium to the lowest such premium does not exceed the ratio of 2 to 1. (2) BY AREA.—By premium rating area (as permitted by State insurance regulators or, in the case of Exchange-participating health benefits plans, as specified by the Commissioner in consultation
SEC. 114. NONDISCRIMINATION IN BENEFITS; PARITY IN MENTAL HEALTH AND SUBSTANCE ABUSE DISORDER BENEFITS.
SEC. 116. ENSURING VALUE AND LOWER PREMIUMS. (a) IN GENERAL.—
A qualified health benefits plan shall meet a medical loss ratio as defined by the Commissioner. For any plan year in which the qualified health benefits plan does not meet such medical loss ratio, QHBP offering entity shall provide in a manner specified by the Commissioner for rebates to enrollees of payment sufficient to meet such loss ratio.
Subtitle C—Standards Guaranteeing Access to Essential Benefits
SEC. 121. COVERAGE OF ESSENTIAL BENEFITS PACKAGE. (a) IN GENERAL.—
A qualified health benefits plan shall provide coverage that at least meets the benefit standards adopted under section 124 for the essential benefits package described in section 122 for the plan year involved.
(1) NON-EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS.—In the case of a qualified health benefits plan that is not an Exchange-participating health benefits plan, such plan may offer such coverage in addition to the essential benefits package as the QHBP offering entity may specify.
(2) EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS.—In the case of an Exchange-participating health benefits plan, such plan is required under section 203 to provide specified levels of benefits and, in the case of a plan offering a premium plus level of benefits, provide additional benefits.
SEC. 122. ESSENTIAL BENEFITS PACKAGE DEFINED.
(a) IN GENERAL.—In this subdivision, the term ‘‘essential benefits package’’ means health benefits coverage, consistent with standards adopted under section 124 to ensure the provision of quality health care and financial security, that— (1) provides payment for the items and services described in subsection (b) in accordance with generally accepted standards of medical or other appropriate clinical or professional practice; (2) limits cost-sharing for such covered health care items and services in accordance with such benefit standards, consistent with subsection (c); (3) does not impose any annual or lifetime limit on the coverage of covered health care items and services; (4) complies with section 115(a) (relating to network adequacy); and (5) is equivalent, as certified by Office of the Actuary of the Centers for Medicare & Medicaid Services, to the average prevailing employer-sponsored coverage.
(b) MINIMUM SERVICES TO BE COVERED.—The items and services described in this subsection are the following:
(1) Hospitalization.
(2) Outpatient hospital and outpatient clinic services, including emergency department services.
(3) Professional services of physicians and other health professionals.
(4) Such services, equipment, and supplies incident to the services of a physician’s or a health professional’s delivery of care in institutional settings, physician offices, patients’ homes or place of residence, or other settings, as appropriate.
(5) Prescription drugs.
(6) Rehabilitative and habilitative services.
(7) Mental health and substance use disorder services.
(8) Preventive services, including those services recommended with a grade of A or B by the Task Force on Clinical Preventive Services and those vaccines recommended for use by the Director of the Centers for Disease Control and Prevention.
(9) Maternity care.
(10) Well baby and well child care and oral health, vision, and hearing services, equipment, and supplies at least for children under 21 years of age.
(c) REQUIREMENTS RELATING TO COST-SHARING AND MINIMUM ACTUARIAL VALUE.—
(1) NO COST-SHARING FOR PREVENTIVE SERVICES.—There shall be no cost-sharing under the essential benefits package for preventive items and services (as specified under the benefit standards), including well baby and well child care.
(2) ANNUAL LIMITATION.—
(A) ANNUAL LIMITATION.—The cost-sharing incurred under the essential benefits package with respect to an individual (or family) for a year does not exceed the applicable level specified in subparagraph (B).
(B) APPLICABLE LEVEL.—The applicable level specified in this subparagraph for Y1 is $5,000 for an individual and $10,000 for a family. Such levels shall be increased (rounded to the nearest $100) for each subsequent year1 by the annual percentage increase in the Consumer Price Index (United States city average) applicable to such year.
(C) USE OF COPAYMENTS.—In establishing cost-sharing levels for basic, enhanced, and premium plans under this subsection, the Secretary shall, to the maximum extent possible, use only copayments and not coinsurance.
The above set of benefits will be quite costly. The idea of a catastrophic coverage was totally rejected. There is gross neglect of cost sharing of any reasonable form. For those under $100,000 annual income there is Government, namely taxpayer, support.
The next area is the bundling issue, namely giving control over to the hospitals along with Government. The Plan states:
SEC. 1152. POST ACUTE CARE SERVICES PAYMENT REFORM PLAN AND BUNDLING PILOT PROGRAM.
(a) PLAN.—
(1) IN GENERAL.—The Secretary of Health and Human Services (in this section referred to as the ‘‘Secretary’’) shall develop a detailed plan to reform payment for post acute care (PAC) services under the Medicare program under title XVIII of the Social Security Act (in this section referred to as the ‘‘Medicare program)’’. The goals of such payment reform are to— (A) improve the coordination, quality, and efficiency of such services; and (B) improve outcomes for individuals such as reducing the need for readmission to hospitals from providers of such services.
(2) BUNDLING POST ACUTE SERVICES.—The plan described in paragraph (1) shall include detailed specifications for a bundled payment for post acute services (in this section referred to as the ‘‘post acute care bundle’’), and may include other approaches determined appropriate by the Secretary.
(3) POST ACUTE SERVICES.—For purposes of this section, the term ‘‘post acute services’’ means services for which payment may be made under the Medicare program that are furnished by skilled nursing facilities, inpatient rehabilitation facilities, long term care hospitals, hospital based outpatient rehabilitation facilities and home health agencies to an individual after discharge of such individual from a hospital, and such other services determined appropriate by the Secretary.
(b) DETAILS.—The plan described in subsection (a)(1) shall include consideration of the following issues: (1) The nature of payments under a post acute care bundle, including the type of provider or entity to whom payment should be made, the scope of activities and services included in the bundle, whether payment for physicians’ services should be included in the bundle, and the period covered by the bundle.
(3) Whether the bundle should be applied across all categories of providers of inpatient services (including critical access hospitals) and post acute care services or whether it should be limited to certain categories of providers, services, or discharges, such as high volume or high cost MS– DRGs.
(4) The extent to which payment rates could be established to achieve offsets for efficiencies that could be expected to be achieved with a bundle payment, whether such rates should be established on a national basis or for different geographic areas, should vary according to discharge, case mix, outliers, and geographic differences in wages or other appropriate adjustments, and how to update such rates.
(5) The nature of protections needed for individuals under a system of bundled payments to ensure that individuals receive quality care, are furnished the level and amount of services needed as determined by an appropriate assessment instrument, are offered choice of provider, and the extent to which transitional care services would improve quality of care for individuals and the functioning of a bundled post-acute system.
(6) The nature of relationships that may be required between hospitals and providers of post acute care services to facilitate bundled payments, including the application of gain-sharing, anti-referral, anti-kickback, and anti-trust laws.
(7) Quality measures that would be appropriate for reporting by hospitals and post acute providers (such as measures that assess changes in functional status and quality measures appropriate for each type of post acute services provider including how the reporting of such quality measures could be coordinated with other reporting of such quality measures by such providers otherwise required).
(8) How cost-sharing for a post acute care bundle should be treated relative to current rules for cost-sharing for inpatient hospital, home health, skilled nursing facility, and other services.
Finally there is the proposal for Health Centers, or a modicum of the old Public Health Care System. It is funded as follows:
TITLE I—COMMUNITY HEALTH CENTERS SEC. 2101. INCREASED FUNDING.
Section 330 of the Public Health Service Act (23 U.S.C. 254b) is amended— (1) in subsection (r)(1)— (A) in subparagraph (D), by striking ‘‘and’’ at the end; (B) in subparagraph (E), by striking the period at the end and inserting ‘‘; and’’; and (C) by inserting at the end the following: ‘‘(F) Such sums as may be necessary for each of fiscal years 2013 and 2019.’’; and (2) by inserting after subsection (r) the following: ‘‘(s)
ADDITIONAL FUNDING.—For the purpose of carrying out this section, in addition to any other amounts authorized to be appropriated for such purpose, there are authorized to be appropriated, out of any monies in the Public Health Investment Fund, the following:
‘‘(1) For fiscal year 2010, $1,000,000,016 ‘‘(2) For fiscal year 2011, $1,500,000,000. ‘‘(3) For fiscal year 2012, $2,500,000,000. ‘‘(4) For fiscal year 2013, $3,000,000,000. ‘‘(5) For fiscal year 2014, $4,000,000,000. ‘‘(6) For fiscal year 2015, $4,400,000,000. ‘‘(7) For fiscal year 2016, $4,800,000,000. ‘‘(8) For fiscal year 2017, $5,300,000,000. ‘‘(9) For fiscal year 2018, $5,900,000,000. ‘‘(10) For fiscal year 2019, $6,400,000,000.’’.
There is no part of the Reconciliation which speaks to abortion thus eliminating the Stupaks, if they so chose.
Posts
