EPT
EDIT: The bill makes a lot of modifications to Medicare, which I won't be reading about. There's some other inane stuff... I won't be posting a summary of every single section.
TITLE I
Sec 101
This section discusses the immediate formation of a temporary "high risk pool program," basically a health insurance program for people who aren't on Medicare, Medicaid, or health insurance from their employer AND have tried to get health insurance but were denied it or offered it as a higher price since they had a pre-existing condition.
Important: "The premium shall be set at a level that does not exceed 125 percent of the prevailing standard rate for comparable coverage in the individual market"
So, basically, since this program is taking in all the high risks but can only charge 125% more than normal, it's probably going to lose a lot of money. 5 billion dollars has been set aside for this plan per year it's running. But... it's only a temporary fix.
Sec 102
This section basically says that if health insurance companies make more than 15% off of their customers, they have to refund their customers. In other words, if insurance company A charges $125 billion in premiums and pays out $100 billion to hospitals, they have to refund their customers $10 billion.
Sec 103
This section makes it harder for a health insurance provider to stop providing coverage by claiming fraud by the consumer. In other words, if you made a mistake like putting the wrong height/weight on your health insurance app, the health insurance provider cannot immediately take away coverage if you get sick; it must convince a third party arbitrator that you meant to commit fraud before it can take away coverage.
Sec 104
"The Secretary... shall establish a process for the annual review of increases in premiums for health insurance coverage. Such process shall require health insurance issuers to submit a justification for any premium increases prior to implementation of the increase."
Sec 105
Health insurance companies must provide health insurance plans that include coverage of dependent children under the age of 27 instead of 18. So if you are living in your parents' basement up to the age of 27 they can more easily cover you under their health plan
.Sec 106
Title: "LIMITATIONS ON PREEXISTING CONDITION EXCLUSIONS IN GROUP HEALTH PLANS IN ADVANCE OF APPLICABILITY OF NEW PROHIBITION OF PREEXISTING CONDITION EXCLUSIONS."
Your homework is to figure out what this means!
As far as I can tell, this section involves enacting a temporary measure making it more difficult for health insurance companies to deny coverage based on pre-existing conditions before the permanent measure discussed later in the bill, which will totally ban denying coverage based on pre-existing conditions, goes into effect.
Sec 107
Title: "PROHIBITING ACTS OF DOMESTIC VIOLENCE FROM BEING TREATED AS PREEXISTING CONDITIONS."
Self-explanatory. It's pretty amazing this had to be added, lol.
Sec 108
Title: "ENDING HEALTH INSURANCE DENIALS AND DELAYS OF NECESSARY TREATMENT FOR CHILDREN WITH DEFORMITIES."
Again, self-explanitory.
Sec 109
There will no longer be lifetime limits on aggregate dollar benefits in any health insurance plan.
Sec 110
Title: "PROHIBITION AGAINST POSTRETIREMENT REDUCTIONS OF RETIREE HEALTH BENEFITS BY GROUP HEALTH PLANS."
2 ez
Sec 111
If you are an employer, and you provide health insurance to your retirees before they are eligible for Medicare, the government will help you pay your retirees their obligated benefits.
I think this section is trying to encourage employers to extend coverage to youngish retirees who don't qualify for Medicare.
Sec 112
This section creates subsidies for "Wellness Programs" in small businesses, which are basically programs which would teach employees how to live healthier lives and why certain lifestyle changes would benefit them. Actually this is a little hard to explain so let me just copy/paste what a Wellness program is:
+ Show Spoiler +
(c) Wellness Program Components- For purposes of this section, the wellness program components described in this subsection are the following:
(1) HEALTH AWARENESS COMPONENT- A health awareness component which provides for the following:
(A) HEALTH EDUCATION- The dissemination of health information which addresses the specific needs and health risks of employees.
(B) HEALTH SCREENINGS- The opportunity for periodic screenings for health problems and referrals for appropriate follow-up measures.
(2) EMPLOYEE ENGAGEMENT COMPONENT- An employee engagement component which provides for the active engagement of employees in worksite wellness programs through worksite assessments and program planning, onsite delivery, evaluation, and improvement efforts.
(3) BEHAVIORAL CHANGE COMPONENT- A behavioral change component which encourages healthy living through counseling, seminars, on-line programs, self-help materials, or other programs which provide technical assistance and problem solving skills. Such component may include programs relating to--
(A) tobacco use;
(B) obesity;
(C) stress management;
(D) physical fitness;
(E) nutrition;
(F) substance abuse;
(G) depression; and
(H) mental health promotion.
(4) SUPPORTIVE ENVIRONMENT COMPONENT- A supportive environment component which includes the following:
(A) ON-SITE POLICIES- Policies and services at the worksite which promote a healthy lifestyle, including policies relating to--
(i) tobacco use at the worksite;
(ii) the nutrition of food available at the worksite through cafeterias and vending options;
(iii) minimizing stress and promoting positive mental health in the workplace; and
(iv) the encouragement of physical activity before, during, and after work hours.
(1) HEALTH AWARENESS COMPONENT- A health awareness component which provides for the following:
(A) HEALTH EDUCATION- The dissemination of health information which addresses the specific needs and health risks of employees.
(B) HEALTH SCREENINGS- The opportunity for periodic screenings for health problems and referrals for appropriate follow-up measures.
(2) EMPLOYEE ENGAGEMENT COMPONENT- An employee engagement component which provides for the active engagement of employees in worksite wellness programs through worksite assessments and program planning, onsite delivery, evaluation, and improvement efforts.
(3) BEHAVIORAL CHANGE COMPONENT- A behavioral change component which encourages healthy living through counseling, seminars, on-line programs, self-help materials, or other programs which provide technical assistance and problem solving skills. Such component may include programs relating to--
(A) tobacco use;
(B) obesity;
(C) stress management;
(D) physical fitness;
(E) nutrition;
(F) substance abuse;
(G) depression; and
(H) mental health promotion.
(4) SUPPORTIVE ENVIRONMENT COMPONENT- A supportive environment component which includes the following:
(A) ON-SITE POLICIES- Policies and services at the worksite which promote a healthy lifestyle, including policies relating to--
(i) tobacco use at the worksite;
(ii) the nutrition of food available at the worksite through cafeterias and vending options;
(iii) minimizing stress and promoting positive mental health in the workplace; and
(iv) the encouragement of physical activity before, during, and after work hours.
Sec 113
Title: "EXTENSION OF COBRA CONTINUATION COVERAGE"
Self-explanatory, if you read up on what COBRA is:
http://www.dol.gov/ebsa/faqs/faq_consumer_cobra.HTML
Sec 114
This section provides for grants to be given to the individual states for the general goal of insuring the uninsured population. In other words, the feds are basically saying to the states, "hey, maybe you guys can make better use of this money than we can."
+ Show Spoiler +
(b) Types of Programs- The types of programs for which grants are available under subsection (a) include the following:
(1) STATE INSURANCE EXCHANGES- State insurance exchanges that develop new, less expensive, portable benefit packages for small employers and part-time and seasonal workers.
(2) COMMUNITY COVERAGE PROGRAM- Community coverage with shared responsibility between employers, governmental or nonprofit entity, and the individual.
(3) REINSURANCE PLAN PROGRAM- Reinsurance plans that subsidize a certain share of carrier losses within a certain risk corridor health insurance premium assistance.
(4) TRANSPARENT MARKETPLACE PROGRAM- Transparent marketplace that provides an organized structure for the sale of insurance products such as a Web exchange or portal.
(5) AUTOMATED ENROLLMENT PROGRAM- Statewide or automated enrollment systems for public assistance programs.
(6) INNOVATIVE STRATEGIES- Innovative strategies to insure low-income childless adults.
(7) PURCHASING COLLABORATIVES- Business/consumer collaborative that provides direct contract health care service purchasing options for group plan sponsors.
(1) STATE INSURANCE EXCHANGES- State insurance exchanges that develop new, less expensive, portable benefit packages for small employers and part-time and seasonal workers.
(2) COMMUNITY COVERAGE PROGRAM- Community coverage with shared responsibility between employers, governmental or nonprofit entity, and the individual.
(3) REINSURANCE PLAN PROGRAM- Reinsurance plans that subsidize a certain share of carrier losses within a certain risk corridor health insurance premium assistance.
(4) TRANSPARENT MARKETPLACE PROGRAM- Transparent marketplace that provides an organized structure for the sale of insurance products such as a Web exchange or portal.
(5) AUTOMATED ENROLLMENT PROGRAM- Statewide or automated enrollment systems for public assistance programs.
(6) INNOVATIVE STRATEGIES- Innovative strategies to insure low-income childless adults.
(7) PURCHASING COLLABORATIVES- Business/consumer collaborative that provides direct contract health care service purchasing options for group plan sponsors.
Sec 115
Oops, I was wrong in my post below. This section gives the HHS Secretary the power to create national standards for electronic communications between health care providers and health insurance companies! I'll let Sen. Al Franken explain why this is useful:
"Because of the complexity of health care in this country, there are billions of administrative transactions between health care providers, payers, intermediaries, and vendors. Right now, these systems are not standardized, resulting in an unnecessary and costly burden on providers and patients. Physicians reported spending at least three hours weekly interacting with plans; nursing and clerical staff spend much larger amounts of time. When time is converted to dollars, clinical practices nationwide spend at least $23 billion to $31 billion each year on unwieldy interactions with health insurance companies."
Title II
Sec 201
Definitions and stuff like that are found in this section
Sec 202
This section assures you that the government won't force your insurance company to stop offering you the coverage you have now.
Sec 211
Probably the most important part of the bill. Read it in full and Google any terms you don't know
A qualified health benefits plan may not impose any preexisting condition exclusion... or otherwise impose any limit or condition on the coverage under the plan with respect to an individual or dependent based on any of the following: health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability, disability, or source of injury (including conditions arising out of acts of domestic violence) or any similar factors.
Sec 212
This section makes it so that health insurance companies are obligated to offer their health insurance plan to you if you want it. They are also obligated to allow you to renew you coverage. There are exceptions in cases of fraud and non-payment.
Sec 213
Insurance companies are only allowed to charge different premiums for the same plan based on
- age
- geographic location
- family enrollment
and for no other reason.
Sec 214
This section builds on the concept of not allowing insurance companies to discriminate on the price of premiums between buyers.
Also, certain protections extended to mental health patients in previous legislation are now extended to mental health patients in more situations. Yeah, random, I know.
Sec 215
This is a really neat section and hard to summarize, so I'll just copy and paste here. "Provider network" just means hospitals the plan is accepted at.
+ Show Spoiler +
(a) In General- A qualified health benefits plan that uses a provider network for items and services shall meet such standards respecting provider networks as the Commissioner may establish to assure the adequacy of such networks in ensuring enrollee access to such items and services and transparency in the cost-sharing differentials among providers participating in the network and policies for accessing out-of-network providers.
(b) Internet Access to Information- A qualified health benefits plan that uses a provider network shall provide a current listing of all providers in its network on its Website and such data shall be available on the Health Insurance Exchange Website as a part of the basic information on that plan. The Commissioner shall also establish an on-line system whereby an individual may select by name any medical provider (as defined by the Commissioner) and be informed of the plan or plans with which that provider is contracting.
(c) Provider Network Defined- In this division, the term `provider network' means the providers with respect to which covered benefits, treatments, and services are available under a health benefits plan.
(b) Internet Access to Information- A qualified health benefits plan that uses a provider network shall provide a current listing of all providers in its network on its Website and such data shall be available on the Health Insurance Exchange Website as a part of the basic information on that plan. The Commissioner shall also establish an on-line system whereby an individual may select by name any medical provider (as defined by the Commissioner) and be informed of the plan or plans with which that provider is contracting.
(c) Provider Network Defined- In this division, the term `provider network' means the providers with respect to which covered benefits, treatments, and services are available under a health benefits plan.
Sec 216
This is a section that makes it easier to cover your dependent child as a parent.
Sec 217
"In the case of health insurance coverage offered under a qualified health benefits plan, if the coverage decreases or the cost-sharing increases, the issuer of the coverage shall notify enrollees of the change at least 90 days before the change takes effect (or such shorter period of time in cases where the change is necessary to ensure the health and safety of enrollees)."
