The bill: http://help.senate.gov/BAI09A84_xml.pdf

**My thoughts will be offset by asterisks.  Italics and quotations are words directly from the bill.  3103 was the first thing that caught my eye in the Table of Contents which is why I read it first.  If the spacing is off, I apologize.  When I previewed the post, the spacing was all single spaced despite having the correct spacing when I wrote the post.  Didn’t know how to fix it.**

Sec. 3103 Seeking the best medical advice

The Secretary with NIH, CDC, Institute of Medicine of the National Academies of Science and others shall create a “Medical Advisory Council” to council the Secretary of Health on subsections “h” and”i”.

The Secretary shall appoint members to the council. Members in the council will serve for 3 years. Structured by quorum and needs a majority to vote. Members receive no payment, can employ any number of staff they need. A federal employee may be detailed to the Council. The council can hold hearings and receive testimony. The council gives reports to the Secretary on the best medical advice. The Secretary will review (along with the CDC and NIH) the report and then pass the Report onto House and Senate Committees.

House Committees: Education and Labor, Energy and Commerce, Ways and Means

Senate Committees: Health Education Labor and Pensions.

Any reports shall be considered binding unless Congress enacts a joint resolution against them within 90 days.

Subsection H

The reports shall contain recommendations on essential health care benefits eligible for credits (See SEC 3111). The essential benefits actuarial value should be equal to the actuary value of a “typical employer plan”. What constitutes a “typical employer plan”, and its subsequent actuary value, shall be determined by the Secretary.

**Definition: actuary values in the health care are used to measure the percentage of payments for medical expenses. The typical value goes from 0.0-1.0. See: http://www.chcf.org/topics/healthinsurance/index.cfm?itemID=133789 **

What are the Essential Benefits:

-Ambulatory patient services.

-Emergency services.

-Hospitalization.

-Maternity and newborn care.

-Mental health and substance abuse services.

-Prescription drugs.

-Rehabilitative, habilitative, and laboratory services.

-Preventive and wellness services.

-Pediatric services, including oral and vision care as determined appropriate by the Council.

The council will also describe what the criteria is for minimum qualifying coverage (health insurance plans).

The council will also determine what is affordable coverage for different income levels.

Subsection I

The Council will make sure that benefits are not “weighted” toward any category in the essential benefits.  When determining minimum qualifying coverage, the Council will take into consideration how much they are willing to pay based on actuary values. The Council shall exclude from minimum qualifying coverage any coverage that provides reimbursements for the treatment of ” a single disease or condition or an un reasonably limited set of diseases or conditions” and exclude coverage that has an out a pocket limit exceeding $5,000 for individual and $10,00 for family. [Title 16 >Subtitle A >Chapter1 >Subchapter B >Part VII > sec 223]

**This passage confused me.  I’m guessing they are talking about disaster medical coverage when speaking of excluding coverage for a single disease.  Also they point to the IRS code, section 223 to find the out of pocket expenses they will exclude.  When I checked, Sec 223 dealt with health savings accounts and the only reference to money to do with defining high deductible health plans.  If anyone got a different reading of that subsection please give your correction.**

The Council may use different criteria on young adults.

Sec. 3101. Affordable Choices of Health Benefit Plans

Once the bill is enacted, the Secretary will make awards to states from money made available during 2009 to 2014. The amount will be based on a formula decided by the Secretary. The formula shall include a minimum amount given per state and additional money based on population. This will all be determined by the Secretary. The funds shall be used for planning and establishing a Health Benefit Gateway. The grant can be re-awarded if the Secretary feels that progress is being made on the Gateway.

The Gateway is a mechanism that allows qualified individuals and employer groups to purchase healthcare. A Gateway must be voluntary and NO ONE can be compelled to enroll. A Gateway can be established by a state or by the Secretary. The Gateway can only include qualified insurance plans and a public option. Any qualified health plan must include the essential benefits. All insurance plans are subject to the certification practices of individual Gateways.

All Gateways must provide information on:

-premiums

-out of pocket expenses

-availability of in/out of net work doctors

-the 0-3% surcharge to insurance plans (these surcharges cover administrative/operational costs incurred by the Gateway)

-data of how often enrollees utilize “A” or “B” rated preventive services as recommended by the US Preventative Services Task Force.

Gateways can enter into agreements (SEE Section 3105) and purchase long term coverage. The Gateway must also collect/analyze/respond to complaints by those enrolled. The Gateway shall utilize the National Health Plan Identifier System (define in SEC. 222 of the Bill)

Gateway insurance plans whose enrollees receive less of the recommended preventative services (compared to the average) shall be charged a penalty fee by the State. Plans whose enrollees receive more of the recommended preventative services (compared to the average) will receive additional payment. The Secretary will decided what the average should be.

ENROLLMENT

The Gateway shall identify those without coverage. The Gateway will assist them in enrolling in a qualified health plan, Medicaid, CHIP, etc. The Secretary will oversee enrollment to make sure those people are directed into the most appropriate program for them. The Gateway will have to consult with consumers, those who are experienced with healthcare enrollment, State Medicaid offices and population advocates.

The Secretary along with the National Coordinator for Health Information Technology will develop protocols to help enroll people. They will match people against Federal/State data, allow people to apply online and use “other functionalities necessary” to facilitate enrollment.

Grants may be awarded to states to develop electronic enrollment software, use public education campaigns and create telephone “help lines”. Grant will also be awarded to community groups for “infrastructure and training to establish electronic assistance programs”. States who do not adhere to these standards/protocols, may lose funding.

Gateways can operate in multiple states and it can create subsidiaries. Subsidiaries must be in geographically distinct areas. Individuals can enroll in qualified health plans, employers may select qualified health plans (See Sec. 3111).  Self employed individuals will automatically be deemed an employer and must notify the Gateway if they want to be considered an individual.  If you elect to be considered an individual and are self employed, they will consider your income business income but will not treat your premium payments as employer provided benefits.  Each individual in the Gateway is considered to be part of a single risk pool.

‘‘(j) SINGLE RISK POOL.—A health insurance issuer shall consider each enrollee in a qualified health plan to be a member of a single risk pool.”

**The closest explanation of “single risk pool” I could find is single payer.**

**This next thing must be their definition of a joke.  But maybe they’ll keep their word this time.**

‘‘(k) EMPOWERING CONSUMER CHOICE.—
13 ‘‘(1) CONTINUED OPERATION OF MARKET OUT14
SIDE GATEWAYS.—Nothing in this title shall be construed to prohibit a health insurance issuer from offering a health insurance policy or providing coverage under such policy to a qualified individual where such policy is not a qualified health plan.

‘‘(2) CONSUMER CHOICE OF PLAN.—Nothing in this title shall be construed to prohibit a qualified individual from enrolling in a health insurance plan where such plan is not a qualified health plan.

23 ‘‘(3) CONTINUED OPERATED OF STATE BENEFIT REQUIREMENTS.—Nothing in this title shall be construed to terminate, abridge, or limit the operation of any requirement under State law with respect to any policy or plan that is not a qualified health plan to offer benefits required under State law.”

The Secretary will establish criteria for a qualified health plan and that criteria will include:

-company can not discourage enrollment of those with health needs

-insurance products has to be simple and comparable

-give wide choice of providers

-give details of plan which includes– benefits, maximums, limitations, exclusions, service area, premiums, cost sharing requirements, how to access providers and the appeals process

-provide coverage for essential benefits

-receipt of accreditation in a timely fashion by the National Committee for Quality Assurance

-implement improvements to the payment structure (Subsection “m”)

-have an adequate appeals process

-can not use a benefit design likely to discourage enrollment

Subsection M

Provide a payment structure that allows for increased reimbursements for health outcomes improved by: “quality reporting, effective case management, care coordination, chronic disease management, medication and care compliance initiatives, including through the use of the medical home model defined in section 212 Affordable Health Choices Act”, promotion of wellness activities and prevention of readmission through patient education and counseling, discharge planning and “post discharge reinforcement by an appropriate health care professional”

The Secretary, along with experts, will develop the guidelines to implement the above. Health insurers will also have to notify the Gateway of their compliance to the above.

They can NOT interfere with State authority.

‘‘(n) NO INTERFERENCE WITH STATE REGULATORY

5 AUTHORITY.—Nothing in this title shall be construed to preempt any State law regarding market conduct or related consumer protections.”

Beginning Jan 1, 2012 a qualified health plan may contract with hospitals with 50+ beds who make use of the patient safety evaluation and implements the provisions in Subsection M. Or they may contract with a health care provider if they use the mechanisms described by the Secretary to improve health care quality. The Secretary can adjust the bed requirement and establish exceptions to when contracting.