...continued from before, including the cartoons of the health care reform politics...

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 tTo 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—

(i) the person specifically so designated by the terms of the instrument under which the plan is operated;

(ii) if an administrator is not so designated, the plan sponsor; or

(iii) in the case of a plan for which an administrator is not designated and a plan sponsor cannot be identified, such other person as the Secretary may by regulation prescribe.

(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.

‘(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 tTo 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) .

‘(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.

continued from previous...

‘SEC. 2714. EXTENSION OF DEPENDENT COVERAGE.

‘(a) In General- A group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children shall continue to make such coverage available for an adult child (who is not married) until the child turns 26 years of age. Nothing in this section shall require a health plan or a health insurance issuer described in the preceding sentence to make coverage available for a child of a child receiving dependent coverage.

This states that parents can extend their coverage for dependent children. It also states the children that were covered and become 'independent' of their parents' coverage is not automatically eligible for the health care insurance they enjoyed for 18 to 26 years of their life, not including pre-natal care.

I thought C.O.B.R.A. allowed that, but, I could be mistaken. I am fairly certain this is one of the provisions that was changed in the Reconciliation Act of 2010.

Qualifying Events for Covered (click here)
Dependent Children
�� The parent-employee dies;
�� The parent-employee’s hours of employment are reduced;
�� The parent-employee’s employment ends for any reason other than his or her gross misconduct;
�� The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);
�� The parents become divorced or legally separated; or
�� The child stops being eligible for coverage under the plan as a “dependent child.”

‘(b) Regulations- The Secretary shall promulgate regulations to define the dependents to which coverage shall be made available under subsection (a).

The Secretary of Health and Human Services has the right to define 'dependents.' That can change with every administration though. I don't like that.

(c) Rule of Construction- Nothing in this section shall be construed to modify the definition of ‘dependent’ as used in the Internal Revenue Code of 1986 with respect to the tax treatment of the cost of coverage.

The definition that the Secretary of Health and Human Services is law. There is no other definition such as the one in the Tax Code that applies. The Senate bill was completely 'designed' to alienate the electorate from the achievements of this administration. It is very hostile. Very. There should never be a bill that removes the rights of citizens, so much as increases them. This provision was specifically written to victimize the citizens of the USA. There was one purpose in mind and that was to 'kill the bill.'

‘SEC. 2715. DEVELOPMENT AND UTILIZATION OF UNIFORM EXPLANATION OF COVERAGE DOCUMENTS AND STANDARDIZED DEFINITIONS.

‘(a) In General- Not later than 12 months after the date of enactment of the Patient Protection and Affordable Care Act, the Secretary shall develop standards for use by a group health plan and a health insurance issuer offering group or individual health insurance coverage, in compiling and providing to enrollees a summary of benefits and coverage explanation that accurately describes the benefits and coverage under the applicable plan or coverage. In developing such standards, the Secretary shall consult with the National Association of Insurance Commissioners (click here) (referred to in this section as the ‘NAIC’), a working group composed of representatives of health insurance-related consumer advocacy organizations, health insurance issuers, health care professionals, patient advocates including those representing individuals with limited English proficiency, and other qualified individuals.

The only way States can complain about States' Rights is if their regulations are tighter than the ones passed by the federal government. The States have to live up to the higher of the two standards and improve the quality of life of their citizens. The States do not have the 'right' to impoverish their people in regard to their quality of life if federal regulations demand it.

Health Care Reform Bill Draws Measured State Regulators' Response (click here)

By PHIL GUSMAN
Published 3/22/2010

NU Online News Service, March 22, 3:32 p.m. EDT

State insurance commissioners said they will work to implement aspects of federal health care reform where they are required to do so, but acknowledged that state legislatures could still challenge the reforms.

Oklahoma Commissioner Kim Holland, who is secretary treasurer of the National Association of Insurance Commissioners (NAIC) said during a teleconference she expects her state’s legislature may push back against the upcoming federal law.

Oklahoma is a conservative state, and the health care reform bill represents “extraordinary preemption.” she said.

In that case, she said, it is the role of insurance commissioners to provide impartial information as it is requested so that the legislators can make decisions.

Kansas Insurance Commissioner Sandy Praeger, who is chair of the NAIC Health Insurance and Managed Care Committee agreed, stating that regulators are responsible for making sure that when legislatures do make decisions, those decisions are based on accurate information and experiences from insurance departments.

Speaking to the threats of lawsuits that have cropped up from some states since the passage of the bill in the House of Representatives, Commissioner Praeger said such actions will not delay insurance commissioners from beginning work on implementing reforms where they are required to do so....

The Constitutional challenge to the Health Care Reform Bill will also be defeated here:

...“State regulators (click here) are best positioned to perform rate review and many of us do so with great success,” said Jane L. Cline, NAIC President and West Virginia Insurance Commissioner. “Some, however, have not been given the authority by their state legislatures to review and deny unjustified increases. We believe that a federal backstop could help encourage these legislatures to provide that authority.”

“It is absolutely critical that the state role in assuring the solvency of health plans and promoting competitive markets be preserved,” said Sandy Praeger, Chair of the NAIC Health Insurance and Managed Care Committee and Kansas Insurance Commissioner. “Protecting consumers from high premiums remains a priority, but it is even more important to protect them from insolvency.”

Vice-Chair of the NAIC Health Insurance and Managed Care Committee and Pennsylvania Insurance Commissioner Joel Ario pressed insurers to support reforms that would reduce the fragmentation of health insurance pools. “One problem with premium increases is that rates go up a lot more for some people than for others,” he said, noting that premiums in a reformed marketplace would be more stable for all Americans....

The Obama Administration was thorough in calling in all the authorities to the dynamics of the bill. They didn't leave a stone unturned and that defeat any challenge to the bill.

...Members of the NAIC met with President Barack Obama (click here) and Health and Human Services Secretary Kathleen Sebelius to discuss rate increases in the health insurance industry. The meeting, which also included top health insurance executives, was called to address recent significant rate increases as part of a larger discussion on how to improve health insurance markets for all consumers....

NAIC’ is an age old non-profit organization that has a lot of clout. It was established in 1871 and has advised State Regulators for that entire time. They are the quinessential authority on the health care insurance industry and how States interface with those companies. If this organization says the States need guidance and interference by the federal government than the States are out of bounds when it comes to screaming about Constitutionality. The people of the USA rely on their 'infrastructure' to discern what is best in policy and legislation, that is exactly the course President Obama took. There is no challenge to the bill here.

Everybody has been CONSULTED.

‘(b) Requirements- The standards for the summary of benefits and coverage developed under subsection (a) shall provide for the following:

(1) APPEARANCE- The standards shall ensure that the summary of benefits and coverage is presented in a uniform format that does not exceed 4 pages in length and does not include print smaller than 12-point font.

No fine print.

‘(2) LANGUAGE- The standards shall ensure that the summary is presented in a culturally and linguistically appropriate manner and utilizes terminology understandable by the average plan enrollee.

Grammar and spelling count. If health insurance companies are selling their products to the citizens of the USA then they have to speak their language in ways they understand.

‘(3) CONTENTS- The standards shall ensure that the summary of benefits and coverage includes--

‘(A) uniform definitions of standard insurance terms and medical terms (consistent with subsection (g)) so that consumers may compare health insurance coverage and understand the terms of coverage (or exception to such coverage);

Nothing unclear here.

‘(B) a description of the coverage, including cost sharing for--

All the costs have to be relieved along with the coverage the policy provides.

‘(i) each of the categories of the essential health benefits described in subparagraphs (A) through (J) of section 1302(b)(1) of the Patient Protection and Affordable Care Act; and

‘(ii) other benefits, as identified by the Secretary;

The Secretary has considerable power here to fine tune the benefits as they are to be addressed by the insurance companies, however, there is nothing in the verbiage that indicates the Secretary can 'diminish' any benefits. It clears states, "other benefits." That is a clear understanding there are MORE and not LESS benefits for the insured.

‘(C) the exceptions, reductions, and limitations on coverage;

The policies have to include in readable format the above. This is consumer protection and seeks to limit the ability to commit fraud. ie: ERISA and the fraud in Medicare Advantage. It will all be controlled by demands for explicit language. It is really unfortunate the American people have been 'worked over the coals' so to speak by this industry. It is plainly clear the legislative bodies of the USA don't trust them at all. Very unfortunate.

‘(D) the cost-sharing provisions, including deductible, coinsurance, and co-payment obligations;

‘(E) the renewability and continuation of coverage provisions;

The critics of this legislation simply do not recognize the damage the health care insurance industry has done to the people of this nation. They don't take this issue seriously.

‘(F) a coverage facts label that includes examples to illustrate common benefits scenarios, including pregnancy and serious or chronic medical conditions and related cost sharing, such scenarios to be based on recognized clinical practice guidelines;

And the legislators in the House and Senate that opposed this bill for political fodder are divisive as well as unethical. To actually allow it to continue for over 20 years and do NOTHING. Wow. And to realize the opportunity came in the way of a minority President dedicated to the 'people' and maintain a posture of 'obstructionism?' Double wow.

‘(G) a statement of whether the plan or coverage--

‘(i) provides minimum essential coverage (as defined under section 5000A(f) of the Internal Revenue Code 1986); and

‘(ii) ensures that the plan or coverage share of the total allowed costs of benefits provided under the plan or coverage is not less than 60 percent of such costs;

The bill provides for ''minimal essential'coverage as stated in a military bill which contains health and dental coverage for the military. It states the 'benefits' of any policy will be no less than 60% of the cost to the consumer. That is a low percentage, but, the consumer will at least know it. This is exactly why there needs to be a Public Option. That low percentage qualifies for 'mandatory coverage' but allows a lot of cost to fall on the shoulders of the consumer.

Using 'standard issue' government language also prevents any unconstitutionality as well.

A BILL (click here)

To amend the Internal Revenue Code of 1986 to ensure that health coverage provided by the Department of Defense is treated as minimal essential coverage.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. TREATMENT OF DEPARTMENT OF DEFENSE HEALTH COVERAGE AS MINIMAL ESSENTIAL COVERAGE.

(a) In General- Section 5000A(f)(1) of the Internal Revenue Code of 1986, as added by section 1501(b) of the Patient Protection and Affordable Care Act, is amended--

(1) by striking clause (iv) and inserting the following new clause:

`(iv) medical coverage under chapter 55 of title 10, United States Code, including coverage under the TRICARE program;';

-CITE-
10 USC CHAPTER 55 - MEDICAL AND DENTAL CARE                 01/05/2009  (click here

(2) by striking `or' at the end of clause (v);

(3) by striking the period at the end of clause (vi) and inserting `; or'; and

(4) by inserting after clause (vi) the following new clause:

`(vii) the Nonappropriated Fund Health Benefits Program of the Department of Defense, established under section 349 of the National Defense Authorization Act for Fiscal Year 1995 (Public Law 103-337; 10 U.S.C. 1587 note).'.

(b) Effective Date- The amendments made by this section shall take effect as if included in section 1501(b) of the Patient Protection and Affordable Care Act and shall be executed immediately after the amendments made by such section 1501(b).

I need to pause here for awhile.

continued...

...moving on...

‘SEC. 2713. COVERAGE OF PREVENTIVE HEALTH SERVICES.

‘(a) In General- A group health plan and a health insurance issuer offering group or individual health insurance coverage shall, at a minimum provide coverage for and shall not impose any cost sharing requirements for--

Those words are fairly clear and appropriate . I want to expand on 'fluidity' as a concept to legislative language. Words such as 'unreasonable' or 'reasonable' brings in the judiciary as a partner and will add to the cost of the government. It is my opinion, those words need to be removed and 'actual' figures stipulated. In other words, in defining deductibles a percentage of the cost to a specified percentage limit should be stipulated. And by percentage I mean do the homework and find out exactly what the 'mean' household income is for the USA and stipulate what deductibles are going to be MINIMALLY.

The deductible issue should be clearly stated in a formula to any insurer. That formula would assign a percentage of the Mean American Family Income to health care including cost of the insurance. That formula, written into legislation, should not allow for manipulation and may even benefit some Americans better than others, however, it will be clearly a benefit to the majority of Americans and can be compensated in other ways through increased 'Earned Income Tax Credits' to those families that earn less than the 'mean.'

I mean if the people that care the most about our citizens, namely the Democrats, can't limit the draconian mechanisms of the Republicans, isn't that unethical to the electorate? I believe it is and allows for criticism that should not exist.

Now, to the legislation.

‘(1) evidence-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force;

It means that the items falling under this 'task force' work will be covered. Evidence based means that there is 'sound' reason for a health provider to REQUIRE items for a patient through acceptable ordering procedures now in practice. It limits exploitation of insurance companies to bill for unnecessary items and uphold the dignity of the provider to be sure the citizen has all they need to carry out the 'therapeutics.'

There is absolutely nothing wrong with having a Task Force to set standards and priorities based on current practices that are prudent to a citizen of the country. The real challenge is for the PROFESSIONS to continue to update what indeed is required for their patients to achieve the goal of the therapeutics.' It is up to concerned providers to be sure the Task Force or any other committee making decisions to this effect have complete and current knowledge so 'standards' to insurance providers are appropriate and timely.

Task Forces and Committees is the way the people will speak to the professions and insurance providers. It is the way it is. Citizens need to be involved at this level and I believe there is also Consumer Protections built into all this. Believe me, we have the right President and the right legislature to do this job.

(2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved; and

‘(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration.

The government cannot be negligent of its citizens. Standards that apply to immunizations will be honored. There are tried and true methodologies that state what those standards are and there are updates by Health and Human Services to new standards as they are discovered by the professions. This does not place demands on the citizens to comply. It demands the health insurance policies to be sure the coverage is there for those that want it. There will be significant 'evidence' supported provisions in this bill. Evidence means there is research that backs up the need. For any government at any level to demand a private sector comply with established standards there has to be evidence to back up that demand.

‘(4) with respect to women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration.‘(b) for purposes of this paragraph.

There is nothing ambiguous about that. Preventive care for women to be paid by health care insurers will be established by guidelines by Health Resources and Services Administration (click here) that is a part of the Executive Branch under Health and Human Services.

RNs on the rise: Report shows number of nurses continues to climb (click here)

March 22, 2010

...The HRSA report, “The Registered Nurse Population: Initial Findings from the 2008 National Sample Survey of Registered Nurses,” also contains comparisons to the organization's eight previous surveys. A final report will be published this summer. More information is available at the HRSA Web site.

That is a good thing as long as they are in practice and not working in other fields that Bachelor prepared nurses can do. It means the cost of health care will come down and that will be reflected by the HRSA reports that can demand changes in the cost to consumers.

‘(5) for the purposes of this Act, and for the purposes of any other provision of law, the current recommendations of the United States Preventive Service Task Force (click here) regarding breast cancer screening, mammography, and prevention shall be considered the most current other than those issued in or around November 2009.

Opportunity for Public Comment (click here)

The public comment being taken currently is in regard to renal disease. But, it serves as an example to the access the public has in achieving goals in preventive services. Appropriate health organizations such as National Kidney Foundation (click here) will comment to this agencies to protect citizens and uphold professional standards. I am confident that if the National Kidney Foundation was worried about the standards being set they would seek public opinion is writing to their legislators and otherwise to effect necessary compliance. Citizens have to have faith in organizations that have developed within the democracy to uphold the integrity of the professions and its standards. Everyone cannot be their own advocate, it would take more time than anyone has in a lifetime to do that. Citizens have to be reasonable and trust.

Screening for Breast Cancer (click here)

Release Date: November 2009 Updated: December 2009

READ YOUR NEWSPAPERS. That is why there are newspapers !!!!!!!

Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement (click here)

1. U.S. Preventive Services Task Force*

American Cancer Society Guidelines for the Early Detection of Cancer

The American Cancer Society recommends these screening guidelines for most adults.

Breast cancer(click here)

The people at these Executive Branch agencies are important, but, just as important are the independent agencies such as The American Cancer Society. There are checks and balances within our society and that is a good thing. Being sure the health insurance companies pay for preventive services will bend the cost curve down. Short term financial gains for stockholders aren't the same as long term deficit and debt reduction for the nation.

The cost of health care to consumers, not to mention longevity, relies on the 'best practices' to reduce health care costs. That is different than dividends to stockholders and bonuses to CEOs. What is good for the citizen is good for the country.

Nothing in this subsection shall be construed to prohibit a plan or issuer from providing coverage for services in addition to those recommended by United States Preventive Services Task Force or to deny coverage for services that are not recommended by such Task Force.

‘(b) Interval-

‘(1) IN GENERAL- The Secretary shall establish a minimum interval between the date on which a recommendation described in subsection (a)(1) or (a)(2) or a guideline under subsection (a)(3) is issued and the plan year with respect to which the requirement described in subsection (a) is effective with respect to the service described in such recommendation or guideline.

‘(2) MINIMUM- The interval described in paragraph (1) shall not be less than 1 year.

‘(c) Value-based Insurance Design- The Secretary may develop guidelines to permit a group health plan and a health insurance issuer offering group or individual health insurance coverage to utilize value-based insurance designs.

March 3, 2010

Patient-Centered Primary Care Collaborative Unveils New White Paper Aligning Benefits of Value-Based Insurance Design With Medical Home. (click here)

Health Affairs, 26, no. 2 (2007): w195-w203
(Published online 30 January 2007)
doi: 10.1377/hlthaff.26.2.w195
© 2007 by Project HOPE

Value-Based Insurance Design (click here)

Michael E. Chernew, Allison B. Rosen and A. Mark Fendrick

When everyone is required to pay the same out-of-pocket amount for health care services whose benefits depend on patient characteristics, there is enormous potential for both under- and overuse. Unlike most current health plan designs, Value-Based Insurance Design (VBID) explicitly acknowledges and responds to patient heterogeneity. It encourages the use of services when the clinical benefits exceed the cost and likewise discourages the use of services when the benefits do not justify the cost. This paper makes the case for VBID and outlines current VBID initiatives in the private sector as well as barriers to further adoption.

Quality, cost (click here)

...Asked for his definition of health care value, Denis Cortese, MD, president and CEO of the Mayo Clinic, sounds exasperated. “It should be clear at this point to nearly everyone, but I suppose it’s not,” says Cortese. “Value is quality relative to cost. Right now plans do not pay for value. They pay for process. That’s a reason value is hard to agree on, hard for some people to define. But the purpose of process should be to improve value, requiring a joint effort between insurers, providers, payers, and patients. It requires new models of care. Primarily it requires knowing outcomes, and acting on that knowledge.”

A form of benefit design that is value oriented, endorsed by Cortese and others, is growing in popularity, especially among employers. Named value-based insurance design (VBID), it promotes the use of services when the clinical benefits exceed the cost and discourages the use of services when the benefits do not justify the cost. There are many proponents, including several payers and some health plan executives. The classic VBID example is lowering — even eliminating — the cost of treatment-related medications for diabetes patients. In fact, a recent study at the University of Michigan did find that lowering copayments does increase compliance.

The basic idea is to organize care delivery around medical conditions instead of uncoordinated, sequential visits to multiple providers, physicians, departments, and specialties — the existing and prevalent system that VBID advocates say works against value and increases costs. In the current system, everyone is required to pay the same out-of-pocket amount for health care services. But value depends on patient characteristics, so there is enormous potential for underuse and overuse of resources.

Acceptance of that idea relies on a practical definition of value. Cortese has such a definition: value = (outcomes + safety + service)/(cost + time).

That is a practical equation because:

• Cost and time are easily measurable. “The denominator is cost over a period,” explains Cortese. “You determine the value of a service over time.”...

Example:

Congestive Heart Failure. It is a 'symptom' that is treated as a disease. It is a symptom of a weakened heart for whatever reason that occurs, through genetics, heart attack, virus, obesity, diabetes and the list continues.

If a patient is NON-compliant with their medications they will require repeated hospitalizations and it diminishes their quality of life. Congestive Heart Failure is a chronic condition, the benefit of 'compliance' is realized over time after the diagnosis is made. If the medications are 'pivotal' to the best outcomes of treatment regimes/therapeutics then the 'value' is on the medications and how well compliance is achieved. If 'the best value' is for patients to receive uninterrupted medication compliance than it is best to 'fill in the donut hole' in a manner that will be workable for the consumer and those that manufacturer the medication. The 'value' for reimbursement for a physician lies in encouraging 'compliance' through a patient/citizen understanding the importance of taking the medication AS ORDERED. The reimbursement system to the folks involved is based in 'the best value' for the citizen and ultimately for the USA's society.

This requires a great deal of 'judgement' by physicians to 'call the shots' on what exactly is the 'best value' for their patients. It is physician 'top heavy' and requires professional organizations of physicians to be forthcoming in participation to those that will set the standards.

The other aspect is that there has to be 'exceptions' to the rule through dense verifiable medical records that shows any patient that might fall outside the 'compliance' guidelines through no fault of their own, thus, requiring services other than those 'value based.'

I have to run an errand. I'll be back.

H.R. 3590 (click here) as recorded on "OpenCongress"

In the Senate of the United States,

December 24, 2009.

Resolved,That the bill from the House of Representatives (H.R. 3590T) entitled ‘An Act to amend the Internal Revenue Code of 1986 to modify the first-time homebuyers credit in the case of members of the Armed Forces and certain other Federal employees, and for other purposes.

AMENDMENTS:

Strike all after the enacting clause and insert the following:

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

(a) Short Title- This Act may be cited as the ‘Patient Protection and Affordable Care Act’.

(b) Table of Contents- The table of contents of this Act is as follows:

Sec. 1. Short title; table of contents.

TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS

It continues from here.

The bill was adapted and renamed from a previous focus. The House decided to abandon the original contents of this 'bill number' to the Senate version S. 1728 - Service Members Home Ownership Tax Act of 2009 (click here). That is all this is about.

Subtitle A--Immediate Improvements in Health Care Coverage for All Americans

Sec. 1001. Amendments to the Public Health Service Act.

‘PART A--Individual and Group Market Reforms

‘subpart ii--improving coverage

‘Sec. 2711. No lifetime or annual limits.

a) IN GENERAL.—A group health plan and a health insurance issuer offering group or individual health insurance coverage may not establish—
(1) lifetime limits on the dollar value of benefits for any participant or beneficiary; or
(2) unreasonable annual limits (within the meaning of section 223 of the Internal Revenue
Code of 1986) on the dollar value of benefits for any participant or beneficiary.

(b) PER BENEFICIARY LIMITS.—Subsection (a) shall not be construed to prevent a group health plan or health insurance coverage that is not required to provide essential health benefits under section 1302(b) of the Patient Protection and Affordable Care Act from placing annual or lifetime per beneficiary limits on specific covered benefits to the extent that such limits are otherwise permitted under Federal or State law.

Nothing complicated about this. There is no lifetime annual limits in any health care insurance.

I believe there might be a concern regarding annual limits in this verbiage, however, the President has made it clear that needed to be cleaned up. The Reconciliation Act may address this. The wording is a little muddy. And below the insurance companies cannot take back their coverage, except, if there is fraud by the subscriber. So don't lie. No one should ever lie about their health anyway.

Sec. 2712. Prohibition on rescissions.

''A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not take back such plan or coverage with respect to an enrollee once the enrollee is covered under such plan or coverage involved, except that this section shall not apply to a covered individual who has performed an act or practice that constitutes fraud or makes an intentional mis-representation of material fact as prohibited by the terms of the plan or coverage. Such plan or coverage may not be cancelled except with prior notice to the enrollee, and only as permitted under section 2702© or 2742(b).

Rather than inserting the provisions with the table of contents it is better to accept the content the way it is laid out. The table of contents is extensive and complete, so the substance of the bill starts here:

TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS

Subtitle A--Immediate Improvements in Health Care Coverage for All Americans

Part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.) is amended--

(2) by redesignating sections 2704 through 2707 as sections 2725 through 2728, respectively;

(3) by redesignating sections 2711 through 2713 as sections 2731 through 2733, respectively;

(4) by redesignating sections 2721 through 2723 as sections 2735 through 2737, respectively; and

(5) by inserting after section 2702, the following:

‘Subpart II--Improving Coverage

‘SEC. 2711. NO LIFETIME OR ANNUAL LIMITS.

‘(a) In General- A group health plan and a health insurance issuer offering group or individual health insurance coverage may not establish--

That seems fairly clear.

‘(1) lifetime limits on the dollar value of benefits for any participant or beneficiary; or

‘(2) unreasonable annual limits (within the meaning of section 223 of the Internal Revenue Code of 1986) on the dollar value of benefits for any participant or beneficiary.

Unreasonable is a fluid term. Who defines unreasonable? The term was placed into the Senate bill because of concerns of the impact on the industry and whether or not there would be undo constraints on the citizens because of it. One has to remember the Senate bill when it came out of the Finance Committee was supposed to be approved of by the Republicans of that committee. In fact what occurred in the Senate Finance Committee was a lot of betrayal of bipartisanship. Senator Baucus was convinced there would be bipartisan support for the bill because of the work done in the Finance Committee. In fact the Republicans on the Finance Committee turned their backs on bipartisanship and only used their opportunity in committee to try to destroy what the House had begun. Basically, the Republicans in the Senate Finance Committee is what 'set up' all the anger and contention in the nation. They were unfaithful to the public trust afforded them.

I consider 'unfaithfulness to the public trust' a huge ethics issue, however, during the majorities of the Republicans the Ethics Committees were nearly carved to the bone and primarily reduced to unlawful acts being the focus of ethics. That isn't an Ethics Committee, that is a simply a record keeping variety of a judicial ruling. Ethics has to be returned to the Ethics Committees of the House and Senate. It allows too much co-mingling of interest of the private sector with the best interest of the citizen.

‘(b) Per Beneficiary Limits- Subsection (a) shall not be construed to prevent a group health plan or health insurance coverage that is not required to provide essential health benefits under section 1302(b) of the Patient Protection and Affordable Care Act from placing annual or lifetime per beneficiary limits on specific covered benefits to the extent that such limits are otherwise permitted under Federal or State law.

The language really isn't great here. I don't like the bill singling out the 'individual.' 'per beneficiary' is a focus on the individual. That isn't good. Because it is the individual that is suppose to be protected, not 'the group.' That is to begin with. It allows too much 'play' in an opportunity to attack 'the individual' with the understanding that 'an individual' has different 'qualities' than the group. A group health insurance plan is suppose to protect the individuals in it. This section allows the group to be divided into individuals. I don't like it. The reform is suppose to protect all Americans equally.

The operative words are 'that is not required to provide essential health benefits under section 1302(b) of the Patient Protection and Affordable Care Act.'

That provision states, that if there is health care insurance in the market place, allowed by laws under Federal and State laws that does not provide 'essential' services they are excluded from the laws of this section. No. That is not the way to treat comprehensive health care reform if one is to protect the nation's citizens. It needs to be understood that every citizen is covered by health insurance to cover all essential needs. Annual physicals and regular 'basic screenings' have to be a part of every American's coverage. If a person decides not to exercise their rights to coverage of those benefits and ignores the value of those benefits to their health there is little anyone can do about it. However, to allow health care insurance companies to actually write policies that exclude essential coverage when the nation is attempting to bend the cost curve down is a violation of the public trust as far as I am concerned. The President made it clear that the legislation was to protect all citizens in the same way and to allow exploitation to continue and allow inflationary costs is simply "W"rong. I hope this is cleared up in reconciliation. It is appropriate that the federal government 'LIMIT' the instruments available to the citizens of the USA while providing the private sector the opportunity to protect them. Excluding such instruments from availability to citizens is the right thing to do. There is no reason for them. Why would there be? All people are the same physiologically. To allow such policies to exist is contrary to COMPREHENSIVE reform. Once a person is insured with 'proper' health care there is no need for any other coverage. That would be duplication of services and allow for exploitation that should not exist. Nothing saying people can't be covered by two insurances as in married folks and their children, but, there really is no need for it. If deductibles are realistic and affordable there is little need for two insurance companies to cover one person. Two insurance companies covering one person increases the cost of health care. Riders such as the 'supplement' to Medicare can be a part of a 'second' policy to cover all deductibles, however, and I can't say this enough, if the deductibles per person are reasonable there is no need for even a rider on their policies to cover all the deductibles. The reason why such instruments exist today is because deductibles are out of control. They are increased while costs to purchase also increases.

I think that is enough about that.

continued...