Health Care Not So Simple #5 Sec 1501 to 1561

In an effort to understand the Affordable Care Act, five furlough mornings have been spent reading the contentious legislation currently causing U.S. government offices to be shuttered.

My assessment so far, is the law makes the consumer its primary focus as well as trying to create financial stability for families. The legislation does impose more regulation and responsibility on the healthcare industry and for employers.

The prickly question that remains unanswered so far is; What are the healthcare plans spending 26-30% of my healthcare premium on to administer a payment on my healthcare bill. Read below for understanding.


Sec 1501

An interesting tidbit thrown in here that has not been mentioned through the media at large - Half of all bankruptcies nationwide are caused by medical medical expenses. The underlying idea is that strengthening coverages for families strengthens their financial security.

Health Plan administrative costs in 2006 were 26-30% of the premiums in small group markets. (Anecdotally, this reminds me of being a private owner of a small restaurant. I paid 22% over the invoice cost for food purchases where the large restaurant purchasers paid 6%. As consumers we are doing the same, paying higher premium for  participating in smaller buying groups).

Individuals not purchasing health insurance will pay a tax in their yearly tax filing. In 2014 it will be $95 and the penalty will increase in future years.

It exempts prior health care sharing ministries (religious exemptions) in existence since 1999.

Sec 1513-1515

This section discusses employer sizes, who has to be covered, notifications and reporting requirements that have to be made. There are potential penalties and tax credits based on the size of the employers business, the number of employees and how long employees have to wait for their insurance coverage to start.

Sec 1553 -1561

Discrimination is prohibited against any healthcare entity or provider who will not provide assisted suicides, euthanasia, or mercy killings.

No regulation shall impede healthcare accessibility.

Any employer providing health insurance for it's employees does not have to participate in the Healthcare Exchange.

No employee may be discharged based on their use of the healthcare exchange or for reporting a violation.


In summary, Sections 1501 through 1561, support the individual, regulate the healthcare plans and the employers. It's definitely a contentious bit of legislation as it probably when the Americans with Disability Act and the Family Medical Leave Act and Social Security were implemented. I'd like to look down the road 20-30 years from now and see it's contribution to our society and if the melodrama of this is as bad as the news makes it out to be. I'll be reading on. Peace to you.

Diane

Health Care Simplified? Oh Yeah! Sec 1322-1421

                A Personal Review of the Patient Protection and Affordable Care Act (P.P.A.C.A.)

My personal quest is to become better informed about the Affordable Care Act as it is the primary reason I am on furlough from my job. 
Information is being presented in multiple posts. 

Sec 1322 Competition is not impaired. "Nothing in this section shall be construed as authorizing the Secretary to interfere with the competitive nature of providing health benefits through qualified nonprofit health insurance issuers." 

Funding of the Bill - appropriates $6B for the states health care exchanges. (It does not discuss what it currently costs the taxpayers for the uninsured). Comptroller General will monitor markets and number of qualified plans in the markets and will make recommendations for increased competitions within the healthcare markets. 

Provider Participation - no healthcare provider will be required to participate in a community healthcare option. 

"State may elect to prohibit Exchanges in such State from offering a community health insurance option if such State enacts a law to provide for such prohibition. " States may provide additional insurance options but will defray costs for the individuals. 

Nothing prohibits a healthcare provider from taking an out of pocket payment for services. 

Protection for access to end of life care - community healthcare options cannot prohibit access to end of life care. 

Consumer protections laws of the state apply. 

The states have flexibility to offer health care coverage alternatives to low income individuals not eligible for medicaid. Healthcare exchange options to be provided to individuals 133% -200% over the federal poverty line and persons 65 and older. 

Sec 1333 Two or more states can provide one healthcare exchange. Healthcare plan providers may offer plans in more than one state. 

Sec 1341 Discusses use of third party administrators. 

Sec 1342 Discusses risk adjustments which you would need to be a risk adjuster to understand. I defer to the subject matter experts. 

Sec 1401 Discusses premium assistance and tax credits for the individual.

Sec 1411 Discusses eligibility to participate in healthcare exchanges. If Employers do not provide affordable coverage they may be liable for a portion of the premiums made for individuals in the healthcare exchange.

Sec 1413 Streamlines procedures for enrollment. 

Sec 1414 Disclosures. Social Security numbers and names will be used to administer the provisions of the act and will only be used to establish eligibility for the health care exchange. 

Sec 1415 Any refund at the end of the plan year is not considered taxable income. 

Sec 1421 Small Business Tax Credit - Employers are eligible for tax credits based on the formula identified in this section. See your tax accountant for more information. 

I took some time off from reading the A.C.A. yesterday to play with my three year old grandson. I tried to remain present (not reading my iPhone, logging into email or reading the news) and participated in the play yard with him. We rolled in the leaves, played rake monster, took pictures, and we giggled a lot. We had a great time during some very precious moments.  For a time it lifted up my worries of getting back to my job and paying bills. I challenge you to find a moment to be present and count your blessings! 

Health Care Simplified? Oh Yeah! Sec 1301 - 1322

                A Personal Review of the Patient Protection and Affordable Care Act (P.P.A.C.A.)

My personal quest is to become better informed about the Affordable Care Act since it is the primary reason I am sitting at home on furlough from my job. Also listening to the news and reading commentaries, that are more inflammatory than explanatory, is drudgery. I make no claim to being a subject matter expert. If you have any questions or reservations about the material presented below there are more educated individuals and I invite you to contact them.

That said, let's begin.

Sec 1301-1304 Qualified plan definition. Plans offered will meet minimum requirements for coverage for emergency, hospitalization, preventative care, etc. Emergency services will cost the same whether in  network or out of network. Periodic reviews of plans will be made by Sec of Labor to identify gaps in care or healthcare accessibility. These sections regulate the insurance provided and ensure minimum coverages are intact. There is no requirement to provide abortion service coverage. It also provides a non-discrimination clause.

"(3) PROVIDER CONSCIENCE PROTECTIONS.—No individual health care provider or health care facility may be discriminated against because of a willingness or an unwillingness, if doing so is contrary to the religious or moral beliefs of the provider or facility, to provide, pay for, provide coverage of, or refer for abortions."


Health care providers are required to continue providing emergency services.

Sec 1311The federal government will provide money to the states to establish the insurance purchasing exchanges and will ensure the health plan providers meet the minimum requirements of the ACA. States may require an additional benefits be added to the plans. The state exchanges will not be funded by the government after 2015 and the states may charge the health plans a fee to manage the exchanges. A consumer notification of health plan costs will be provided on the health care exchange site. Prior to an increase in fees, health plan providers must publicly provide justification for the new fee. States may work together and share exchanges. The state can contract these services with a minimum requirement in type and qualifications of the providers of services.

Individuals may purchase insurance outside of the exchange. An insurer cannot charge a cancellation fee if someone goes elsewhere for their insurance. Non citizens cannot participate in the exchange.

Sec 1313 Protections against fraud and abuse are defined in this section. Government Accountabilities Office has oversight authority and will audit the exchanges within the first five years.

Sec 1321 Provides states flexibility in operation, establishment and enforcement of the health care exchanges.

Sec 1322 FEDERAL PROGRAM TO ASSIST ESTABLISHMENT AND OPER- ATION OF NONPROFIT, MEMBER-RUN HEALTH INSURANCE ISSUERS. Provides the ability for consumer owned cooperative exchanges to be established. It is defined as a Consumer Operated and Oriented Plan. CO-OP. The federal government will provide loans and grants for start ups. Loans became available in July 2013.

A personal interjection here:
I am very surprised at Sec 1322 CO-OP and the fact that it is not a well known fact. This ability to form cooperatives may in fact create competition in the market thus health plan prices in theory could go down. Additionally, if I read this correctly groups of individuals that want to create health plans specific to their religious beliefs can do so as long as the plans meet the minimum requirements of the law.  I hope this has been as educational for you as it has been for me.

Happy Monday. Diane

Health Care Simplified? Oh Yeah! Sec 1101 - 1252

           A Personal Review of the Patient Protection and Affordable Care Act (P.P.A.C.A.)

My quest for information appears to be a very long one as I attempt to read the Affordable Care Act in its entirety. I do this on an especially cold dreary Sunday morning. Leaves are dropping off the trees here faster than honeybees gather in a field of lavender flowers. Thankfully we didn't get the three feet of snow South Dakota did yesterday. 

Onto the task...

A friend of ours posted this article today and I think it's worthy of reposting in this blog. PolitiFact has demystified some continuing rumors swirling around the Obamacare. Check it out. 

http://www.tampabay.com/news/politics/national/politifact-the-top-15-myths-about-obamacare/2144026


Now back to the Affordable Care Act discussion.  Here is the link to the first post if you want to catch up. 

http://managingforward.blogspot.com/2013/10/healthcare-act-simplified-oh-yeah.html

Sec 1101 This section is very long. It discusses creating a temporary high risk pool for the uninsured and how it is funded. If an employer is found to have persuaded a high risk employee to not participate in the employer provided insurance, the employer may have to reimburse the state 65% of the premiums for the state coverage of that individual. In other words, all you employees need to have coverage, not just a select few. 

Sec 1102 Temporary reimbursements to employers will be made for keeping early retirees (not eligible for medicare) on their insurance plans. This ends January 2014. 

Sec 1104 Health plans will need to be able to prove compliance by 2015 and ensure their proprietary operating systems meet the intent of this law. This section sets operating and reporting standards for the industry. 

Sec 2704 A health plan may not impose pre-existing condition exclusion. 

Sec 2701 May not impose unfair health insurance premiums. 

Sec 2702 Insurance companies must accept every employer and individual that applies for coverage. 

Sec 2703 Guaranteed renewability. Insurance plans "may not establish rules for eligibility (including continued eligibility) of any individual to enroll under the terms of the plan or coverage based on any of the following health status-related factors in relation to the individual or a dependent of the individual:

‘‘(1) Health status.
‘‘(2) Medical condition (including both physical and mental illnesses).
‘‘(3) Claims experience.
‘‘(4) Receipt of health care.
‘‘(5) Medical history.
‘‘(6) Genetic information.
‘‘(7) Evidence of insurability (including conditions arising
out of acts of domestic violence). ‘‘(8) Disability.
‘‘(9) Any other health status-related factor determined appropriate by the Secretary."

Sec 2705 Any conditions set for a rebate on a premium or lower premium needs to be offered to all. 

Participation in wellness programs can result in a discounted premium however an individuals health status cannot be a requirement for that discount. The wellness program will be designed to promote health or reduce disease. The wellness program cannot set unreasonable standards to be attained. 

Sec 2706 The insurance companies can contract with health care providers and may set quality and performance measures.  

Sec 2707 Comprehensive health insurance will minimally include what is defined in the Affordable Care Act. Insurance companies may provide more but must at minimum include what is required by the law. 

Sec 2708 An insurer cannot impose more than a 90 day waiting period before an individual can use the health insurance coverage. 

Sec 1251 Everyone maintains the right to continue their current health insurance coverage. 

Sec 1252 In a given state, all new standards and reforms will apply evenly to all health plans.

Stay tuned to my next blog and have a great Sunday! 

"By perseverance the snail reached the ark" or in this case the turtle! Charles Spurgeon 

Healthcare Act Simplified? Oh yeah! Sec 2711 - 2794, Sec 1101 - 1103

A Personal Review of the Patient Protection and Affordable Care Act (P.P.A.C.A.)

Would you really like to know what is in the Obamacare bill that has this country in so much turmoil? Is it really as out of touch with reality as the news makes it? Is the country really going to financially meltdown because of this legislation? We've heard the ongoing sensational news, influencing our opinion, along with those numerous Facebook and Twitter posts fraught with high emotions. This has culminated with Congress shutting down the government on October 1, 2013 because the politicians can't find agreement over this piece of legislation.

I've decided  to figure this out myself. Mainly because the circus of emotion causing many lives to swirl in so many directions, is in itself unsettling, and I am very curious of what it is really all about.

Much of my job is spent reviewing and summarizing communications and policy into bite size pieces of information for the reader, depicting information in a non biased yet informative way, thereby allowing them to make informed decisions. I'll attempt to do this in my blog over a period of days or weeks since the ACA is a really LONG bill.

By no means, am I an expert or subject matter expert on this legislation, AND if you have any questions or are a bit (or a lot) cantankerous about it, I encourage you to reach out to your insurance company, attorney, hairdresser, Facebook page or butcher for clarification.  My goal is to demystify this legislation for me and share it with you.

On the upside, I will provide you a summary of what I found in my research of the Patient Protection and Affordable Care Act.

Do you have a good cup of coffee to sip while reading this? I suggest you get one.

Sec 2711-2714
No lifetime limits to insurance. The insured can't be kicked off health insurance because it cost the insurance company too much. Someone may be removed for fraudulent practices.

A health plan will cover preventative services.

Coverage will be made available for your unmarried child up to age 26.

Sec 2715
A template will be created by the government, no longer than four pages in length, for insurance companies to use in order to provide information regarding their healthcare plans. The information will be readable. If the healthcare provider changes coverage, notifications will be made in a similar format. This way information is consistently provided to the insured in a readable and consistent manner.

Sec 2716
It prohibits employers from providing healthcare to employees on a sliding scale based on salary. All employees will be treated similarly. If Joe pays $200 - Jerry will pay $200.

Sec 2717
Healthcare providers will be able to demonstrate they are ensuring quality of care to include patient education and wellness efforts. In other words, they will need to be able to prove they are taking care of you and at the same time are being efficient about it. They will need to offer ongoing wellness efforts for patients.

Sec 2718
The insurance provider will need to provide an accounting for patient care related costs and non-claim costs AND provide a pro-rated rebate to the plan enrollees if the cost of coverage exceeded premiums paid by the plan participants by 20-25%.

Sec 2719
During an appeals process the health insurance company has to provide the claimant with the records they have regarding care provided.

Sec 2793
The states may be provided monetary grants to establish an ombudsman who will in turn assist the insured in an appeal process with the insurance companies.

Sec 2794
The states will ensure the consumer gets what they paid for and are informed of premium increases.

Sec 1101
Immediate access for the uninsured with pre-existing conditions will be implemented within 90 days of the bill be signed into law.

Sec 1102
Employers providing insurance will be able to get some reimbursement for keeping early retirees on their plans (Retirees not eligible for medicare).

Sec 1103
States will provide information in an internet format to consumers regarding affordable insurance plans. This format will provide comparable cost information on the plans. It will also provide information on how much insurers are spending on non clinical costs.

This is enough for one blog post. I'll continue to provide updates as I plow through this legislation.
Happy Saturday. Diane

If you want to read it for yourself here is the link


http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf

The program M.A.S.H. during the 70's was fraught with conflict between Major Burns and Captains Pierce and Hunnicut. Constant conflict played out in their behaviors and shenanigans. Burns never got what he wanted and Pierce and Hunnicut made sure he never got what he wanted. Behaviors were bad and they often hurt each other. Sometimes there was collateral damage and other people got hurt. Yes, it was a comedy; however, the underlying theme of conflict played out in the Korean war and between the people who served there. 

I've spent many hours as a facilitator working with people in conflict. I've experienced firsthand that when people remain focused on their position, it delays, aggravates and extends good decision making. Often during positional stances, as we have seen in our country's current crisis, resolution to problems is painfully slow and can bring work to a grinding halt (the soon-to-make-history partial federal shutdown of 2013).  

Resolution cannot come during positional statements. One can't reach compromise for either side by demanding  without compromise. When neither party considers finding, or minimally entertaining, a middle ground, they all end up losers. Unfortunately, the human condition leans towards entrenching and hunkering down into personal positions.

All parties lose as we have seen during struggles throughout history. Frustrations mount to the point that people say some pretty awful things to each other and behave even worse. We've observed people behave in ways and sometimes feel ashamed for them. Ashamed that they haven't found the ability to see how badly they are behaving towards fellow humans like themselves. You would think that in the 21st century, we would be educated enough to work towards kinder and smarter resolutions for disagreements. 

As a little Italian grandma often said to me, "Treat others the way you want to be treated." How often do we lose sight of that and forget the other person is not our enemy? Rival Tony may have a differing opinion, and, yes, that is allowed in our country. Being able to voice an opinion or need was what our founding fathers built this country around. But, really,  can we find better words to voice our opinion, other than calling someone a booger butt, or words that portray much uglier human emotions? Seriously, you want to burn that other person's home down? What does that accomplish besides creating a lot more anger, along with that sickly smokey stinky smell that you get from a burnt down building? Plus, it really destroys the scenery that one prizes so much. 

Alfie Kohn eloquently argues that our struggle to defeat each other -- at work, at school, at play, and at home -- turns all of us into losers. We've seen it on the playground as kids. Someone always loses. Can we start playing nicer in the worlds playground?  Can't we find a middle ground so no one loses? Is it possible?

Today, because of being furloughed from my job, because people can't find a way to cooperate, I made three phone calls: One to a kind housekeeper that I don't pay a lot, but who makes my work and home life easier; another to my hairdresser who is getting married soon and depends on my business; and another to stop a retirement savings deduction I make to help in my elder years. I have a few more phone calls to make, and oh, yeah, my visit to see my parents in Texas...no store-bought mementos this time. So, Texas, you lose, too. It's very sad. 

 No one wins. 

W. Edwards Deming, an organizational development guru in the early 1900's, stated, "Stop fighting for a bigger piece of the pie. Instead cooperate to make the pie bigger. Then everybody wins." 

How do we do that? 

1. Stop calling names and get off the position train. You have said what you want 500 different ways. Realize you aren't saying anything new. Stop. You are repeating yourself. Enough said! 
2. Settle down, have a cup of coffee with the person you need to strike a deal with. Realize they are people just like you with families, friends, dogs, rabbits and maybe even a few chickens. Someone likes them, maybe you should. 
3. Realize you have differing opinions. 
4. Put them on the table. 
5. Brainstorm the pros and cons. 
6. Call in an impartial someone to help if you need to. Lots of us like to help. And here is the big one:
7. Find a way you can both live with, what will get you to yes. 

Please, it's the 21st century and it can be done.