Still in the context of the disclosure by the insurance company.
‘(H) a statement that the outline is a summary of the policy or certificate and that the coverage document itself should be consulted to determine the governing contractual provisions; and
‘(I) a contact number for the consumer to call with additional questions and an Internet web address where a copy of the actual individual coverage policy or group certificate of coverage can be reviewed and obtained.
‘(c) Periodic Review and Updating- The Secretary shall periodically review and update, as appropriate, the standards developed under this section.
Nothing unusual about any of this.
‘(d) Requirement To Provide-
‘(1) IN GENERAL- Not later than 24 months after the date of enactment of the Patient Protection and Affordable Care Act, each entity described in paragraph (3) shall provide, prior to any enrollment restriction, a summary of benefits and coverage explanation pursuant to the standards developed by the Secretary under subsection (a) to--
There is a window of vulnerability of three years. As consumers of health care insurance I would ask my health care insurance company if their standards are within the provisions of the Reform Act? If the reply is no, then find out if there are other insurance companies already meeting that goal.
Below is simply the people to whom the information has to be disclosed.
‘(A) an applicant at the time of application;
(B) an enrollee prior to the time of enrollment or reenrollment, as applicable; and
‘(C) a policyholder or certificate holder at the time of issuance of the policy or delivery of the certificate.
All that language is simply common sense, but, do to the dysfunction of the judiciary in being particular in regard to language the reform bill is forced to spell everything out. It is contract law. Common sense is not a judges forte.
Below is the vehicle, being particular, of which the policy needs to be accessible. Other laws apply here as well, including any handicap laws which would require either brail or recording/audio access of the insurance policy.
‘(2) COMPLIANCE- An entity described in paragraph (3) is deemed to be in compliance with this section if the summary of benefits and coverage described in subsection (a) is provided in paper or electronic form.
Below describes whom exactly is going to be issuing policies to citizens.
(3) ENTITIES IN GENERAL- An entity described in this paragraph is--
‘(A) a health insurance issuer (including a group health plan that is not a self-insured plan) offering health insurance coverage within the United States; or
‘(B) in the case of a self-insured group health plan, the plan sponsor or designated administrator of the plan (as such terms are defined in section 3(16) (see immediately below) of the Employee Retirement Income Security Act of 1974).
Established language. Constitutional. Smart, very smart.
(16) (click here)
(A) The term “administrator” means—
(B) The term “plan sponsor” means (i) the employer in the case of an employee benefit plan established or maintained by a single employer,
(ii) the employee organization in the case of a plan established or maintained by an employee organization, or
(iii) in the case of a plan established or maintained by two or more employers or jointly by one or more employers and one or more employee organizations, the association, committee, joint board of trustees, or other similar group of representatives of the parties who establish or maintain the plan.
Back to the main Reform Bill:
This is just notification to the insured of a modification to a policy. The notice has to be at least 60 days from effectiveness. It would provide time to find another policy if the modification causes hardship to the insured. The companies unable to turn applicants that means there would be options to changing from one plan to another provided there were such options within an employees benefits. Otherwise, they would have to look outside the employer's offerings.
Back to the main Reform Bill:
This is just notification to the insured of a modification to a policy. The notice has to be at least 60 days from effectiveness. It would provide time to find another policy if the modification causes hardship to the insured. The companies unable to turn applicants that means there would be options to changing from one plan to another provided there were such options within an employees benefits. Otherwise, they would have to look outside the employer's offerings.
‘(4) NOTICE OF MODIFICATIONS- If a group health plan or health insurance issuer makes any material modification in any of the terms of the plan or coverage involved (as defined for purposes of section 102 of the Employee Retirement Income Security Act of 1974 - click here) that is not reflected in the most recently provided summary of benefits and coverage, the plan or issuer shall provide notice of such modification to enrollees not later than 60 days prior to the date on which such modification will become effective.
If an insurer does not notify an insuree it is a fine of $1000.oo per occurrence. So, if a company has insurance for 1000 people that means the fine is one million US. The fine is prohibitive in large enrollments. It is probably prohibitive in small or individual enrollments because the policy premiums would not cover most of the fine. I don't believe that is a slap on the wrist. I think this provision also gives brevity to the insured to sue if there was no notice and there are services sought and used that are no longer covered. If the insurer does not notify a certain provision is no longer covered that opens up liability to the insurer for negligence in the case of subsequent expenses by the enrollee. Civil suits.
‘(f) Failure To Provide- An entity described in subsection (d)(3) that willfully fails to provide the information required under this section shall be subject to a fine of not more than $1,000 for each such failure. Such failure with respect to each enrollee shall constitute a separate offense for purposes of this subsection.
‘(g) Development of Standard Definitions-
These are the definitions not already covered elsewhere. This is important because it states the 'minimum' language the Secretary of Health and Human Services is to define that will be carried in insurance policies. It also does not limit the language to become dysfunctional if the terms of such contracts expand. The danger here is that language will change and if not standardized 'well' could contradict the meaning of 'common sense' language and turn the entire contract into alphabet soup. I believe there should be language included here that limits how 'strange' the legaleze can get. I do not believe 'contract law language' can have exotic derivatives that the financial industry enjoys or should I say exploits. That is a better word, the Secretary of Health and Human Services needs to write into this provision that no contract law language in regard to health insurance will be exotic or exploitive. She might want to consider naming a source of such language as well such as The Oxford Dictionary. It is unfortunate it has to go that far.
‘(1) IN GENERAL- The Secretary shall, by regulation, provide for the development of standards for the definitions of terms used in health insurance coverage, including the insurance-related terms described in paragraph (2) and the medical terms described in paragraph (3).
‘(2) INSURANCE-RELATED TERMS- The insurance-related terms described in this paragraph are premium, deductible, co-insurance, co-payment, out-of-pocket limit, preferred provider, non-preferred provider, out-of-network co-payments, UCR (usual, customary and reasonable) fees, excluded services, grievance and appeals, and such other terms as the Secretary determines are important to define so that consumers may compare health insurance coverage and understand the terms of their coverage.
‘(3) MEDICAL TERMS- The medical terms described in this paragraph are hospitalization, hospital outpatient care, emergency room care, physician services, prescription drug coverage, durable medical equipment, home health care, skilled nursing care, rehabilitation services, hospice services, emergency medical transportation, and such other terms as the Secretary determines are important to define so that consumers may compare the medical benefits offered by health insurance and understand the extent of those medical benefits (or exceptions to those benefits).
‘SEC. 2716. PROHIBITION OF DISCRIMINATION BASED ON SALARY.
The President of the company pays the same price as the janitor. The cost to the janitor cannot be higher for health care insurance to compensate the CEO's contribution to the cost of the plan. Maybe I should have used the word peasant. The peasants of a company can't be 'tapped' for higher premiums so the CEO doesn't have to pay a dime.
‘(a) In General- The plan sponsor of a group health plan (other than a self-insured plan) may not establish rules relating to the health insurance coverage eligibility (including continued eligibility) of any full-time employee under the terms of the plan that are based on the total hourly or annual salary of the employee or otherwise establish eligibility rules that have the effect of discriminating in favor of higher wage employees.
However, the peasants can be paying less than the CEO. However, that is to only occur if there are other peasants paying lower in the same 'status' work. In other words if a newly higher peasant is required to pay higher premiums that an peasant of ten years seniority it would be wrong and that cannot be done. The newly hired peasant cannot contribute to the CEOs premiums when the others don't.
‘(b) Limitation- Subsection (a) shall not be construed to prohibit a plan sponsor from establishing contribution requirements for enrollment in the plan or coverage that provide for the payment by employees with lower hourly or annual compensation of a lower dollar or percentage contribution than the payment required of similarly situated employees with a higher hourly or annual compensation.
‘SEC. 2717. ENSURING THE QUALITY OF CARE.
Ah, oh. There are reporting requirements to be 'in place' within two years of the President's signature. I can understand why all this doesn't start for a few years. There is compliance developed and written by the Secretary of Health and Human services that has to be in place to 'require' all the provisions of this law be honored. So, it takes time. The laws took time to write and the expression of the law takes time to develop and implement.
‘(a) Quality Reporting-
‘(1) IN GENERAL- Not later than 2 years after the date of enactment of the Patient Protection and Affordable Care Act, the Secretary, in consultation with experts in health care quality and stakeholders, shall develop reporting requirements for use by a group health plan, and a health insurance issuer offering group or individual health insurance coverage, with respect to plan or coverage benefits and health care provider reimbursement structures that--
And there is a lot to put in place. Standards of which health is to be reported and then the actual data, where it will be recorded and how it will be used to establish standards for insurance. It is a huge job. A lot has to be done in two years and I am pleased it will be completed under the first term of this President.
‘(A) improve health outcomes through the implementation of activities such as quality reporting, effective case management, care coordination, chronic disease management, and medication and care compliance initiatives, including through the use of the medical homes model as defined for purposes of section 3602 of the Patient Protection and Affordable Care Act, for treatment or services under the plan or coverage;
Hospital readmissions are one of the biggest problems in skyrocketing health care costs. The Secretary of Health and Human services has to get this right to help with the cost curve. Part of it is the 'value cost' system mentioned earlier and filling in the gaps to health care so that costs are not prohibitive to 'best value outcomes.' We already know the methodology the Secretary will implement, it is a matter of getting it done. The methodology was previously noted with 'value of care.'
‘(B) implement activities to prevent hospital readmissions through a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional;
These all relate to the cost curve and its inherent effect to improve it as well as improve the wellness of Americans and HENCE the goal of better quality of life. Good health is directly related to quality of life.
QUALITY OF LIFE IS A HUMAN RIGHTS ISSUE.
(C) implement activities to improve patient safety and reduce medical errors through the appropriate use of best clinical practices, evidence based medicine, and health information technology under the plan or coverage; and
‘(D) implement wellness and health promotion activities.
‘(2) REPORTING REQUIREMENTS-
A lot of the language here is self explanatory, clear and concise.
‘(A) IN GENERAL- A group health plan and a health insurance issuer offering group or individual health insurance coverage shall annually submit to the Secretary, and to enrollees under the plan or coverage, a report on whether the benefits under the plan or coverage satisfy the elements described in subparagraphs (A) through (D) of paragraph (1).
‘(B) TIMING OF REPORTS- A report under subparagraph (A) shall be made available to an enrollee under the plan or coverage during each open enrollment period.
(C) AVAILABILITY OF REPORTS- The Secretary shall make reports submitted under subparagraph (A) available to the public through an Internet website.
‘(D) PENALTIES- In developing the reporting requirements under paragraph (1), the Secretary may develop and impose appropriate penalties for non-compliance with such requirements.
It is my belief other administrations will exploit the Exceptions in (E). So, compliance is everything and there are breaks for those that exceed expectations. I believe that is a mistake. There should be limits to the exceptions that do not extend beyond two enrollee periods.
‘(E) EXCEPTIONS- In developing the reporting requirements under paragraph (1), the Secretary may provide for exceptions to such requirements for group health plans and health insurance issuers that substantially meet the goals of this section.
The next section is in regard to Wellness and Prevention Programs. It is nearly 8PM and I'm taking a break for awhile. I'll try to cover more after about 1 AM.
