Talking health choices for Americans

Published 8:54 am Saturday, September 5, 2009

Following are some of my thoughts on TITLE I-Protections and Standards for Qualified Health Benefits Plans under America’s Affordable Health Choices Act of 2009.

1. Can we afford this? The first title of the act spells out what a QHBP will look like. The act states “The purpose of this title is to establish standards to ensure that new insurance coverage and employment based health plans that are offered meet standards guaranteeing access to affordable coverage, essential benefits and other consumer protections.” Even though the act says the new plan must be affordable, the Congressional Budget Office has stated that the plan will cost taxpayers $1.6 trillion over the 10 years following enactment. Just think what this plan will cost individuals and businesses of this country.

The requirements for a Qualified Health Benefits Plan are very explicit and unless a plan meets certain requirements it will not be deemed a QHBP. While this sounds OK, the act does not directly state, at least at this point, that within five years of enactment every insurance policy in the United States or its territories must have benefits identical to those of a QHBP. Simply put, every health insurance policy in the United States will be the same.

2. Keeping your current plan. Yes, you may keep your current policy, as long as the “individual health insurer offering the coverage does not enroll any individual in such coverage if the effective date of coverage is on or after the date of year 1 (Y1)” of the new law. In other words, you may keep your plan as long as there are no more insurance policies written like the current one you have. Hence, you cannot keep that policy if you change the policy in any way, especially when you change jobs. This little glitch in the law becomes moot in 60 months when all policies must match the government mandated requirements in all respects.

3. Standards guaranteeing access to affordable care: The act is very detailed in what a QHBP should guarantee to the insured as it relates to affordable care.

A. No pre-existing conditions may be imposed on any individual or dependent;

B. All plans must be guaranteed to be issued and renewed as long as premiums are paid;

C. Insurance premiums between the highest rate and lowest rate for all ages and all categories of risk may not vary by a ratio greater than 2 to 1;

D. The Commissioner shall make reports and recommendations as he deems appropriate to ensure “that the law does not provide incentives for small and mid-size employers to self-insure;”

E. Mental health benefits and substance abuse disorders must be on equal footing with all other health insurance coverage;

F. HMOs will be required to provide transparency in pricing between in-network coverage and out-of-network coverage — this may not be all bad on this point:

G. The Commission shall ensure that “a QHBP shall meet a loss ratio established” by the government. In other words, Uncle Sam will say what the prices for the insurance policies will be.

4. Standards guaranteeing access to essential benefits: In this standard, the act is very explicit what all future insurance policies must look like:

A. In general, it limits co-pays, has no annual limits and is equivalent at least to Medicare and Medicaid (which currently is pretty good);

B. Covers the normal things but adds prescription drugs, rehab, any other appropriate item needed to carry out good medical care, mental health and substance abuse disorders, preventative services and vaccines, maternity and well baby care.

C. No co-payments allowed for preventative services and a cap is placed on co-pays for all items at $5,000 for an individual, $10,000 for a family;

5. Additional consumer protections.

A. All marketing will be governed by a set of government designed standards;

B. All plans must have fair grievance and appeals mechanisms;

C. Plans must have transparency in its operation. A very important aspect of this is that plans, in a timely manner, will have to disclose their denial rates as well as every other operational aspects of the plan — in plain language;

D. Claims must be paid timely;

6. Governance: The act establishes an independent agency within the executive branch known as the “Health Choices Administration” essentially a new Health Czar. This section of the Act spells out an exhaustive set of powers the Health Czar will exercise to carry out the act:

A. A Health Insurance Ombudsman is established;

B. Focus to promote accountability-whatever that means;

C. Discrimination, especially based on health issues, is prohibited;

D. Whistleblowers are protected — they should be;

E. Collective bargaining is allowed;

F. Section 2714 of the Act requires that rebates to the insured will be required of the insurer to maintain the highest loss rates possible “designed to ensure adequate participation by issuers, competition in the health insurance market, and value for the consumers so that their (the insured’s) premiums are used for services.” This could be construed that all insurance issuers should be not-for-profit — just like the post office;

G. Insurance policies cannot be rescinded except for clear and convincing fraud;

H. Within two years of adoption of the act, all insurance claims must be processed electronically and in a timely manner;

I. In Section 164 the Act requires that employment plans which cover retirees will be subsidized.