Tuesday, March 30, 2010

What's In the Health Care Bill: Title I, Subtitle C. Quality Health Insurance Coverage for All Americans

This is part of a series in which I'm reading the health care bill, because I really don't know what to think of it without doing so. The introduction to the series is here. Title I, subtitles B and C are here and here, respectively. The bill itself, as passed, is here.

Part I -- Health Insurance Market Reforms

Section 1201. Amendment to the Public Health Service Act.


Section 2704 [again, of the Public Health Service Act as amended]. Prohibition of preexisting condition exclusions or other discrimination based on health status.

Insurance companies can't exclude people based on preexisting conditions.

Section 2701. Fair health insurance premiums.

The only acceptable variation in rates for a particular health plan are based on whether it's individual or family coverage, rating area (each state sets up one or more rating areas within the state), age (up to 3 to 1), and tobacco use (up to 1.5 to 1).

Section 2702. Guaranteed availability of coverage.

Health insurers have to accept everyone who wants coverage, except that:
  • They can set enrollment periods, subject to restrictions set by HHS.
  • They can stop adding new customers because it will interfere with their ability to serve their existing customers, provided that they apply this uniformly; and
  • They can stop adding new customers because they can't afford to cover any more people, provided that they apply this uniformly.
Essentially, this extends the rules for restricting coverage in the group market to insurers operating in the individual market.

Section 2703. Guaranteed renewability of coverage.

They have to give you the option to renew coverage, except if you're fraudulent, don't pay your bills, they're stopping offering coverage or the particular type of coverage you have (provided they don't immediately re-enter that market, and that they tell you in advance and such), you move outside the service area, or your employer leaves an association through which the coverage was provided. Again, this essentially extends the rules on renewability of group health insurance to individual health insurance.

Section 2705. Prohibiting discrimination against individual participants and beneficiaries based on health status.

It's what it sounds like. Again, extending prohibitions on such discrimination that already exist in the group health insurance market.

It also creates requirements for wellness programs that don't discriminate based on health status -- they have to either provide incentives regardless of success (e.g., subsidize gym membership whether or not you actually lose weight), or provide alternative ways of getting incentives for people for whom the normal standards are unreasonably difficult or medically inadvisable (for example, if your wellness program involves incentivizing weight loss, you can't just give people money for being thin -- you have to give fat people money for losing reasonable amounts of weight).

There's an unfunded mandate for a 10-state project instituting such wellness projects.

Section 2706. Non-discrimination in health care.

Providers can't discriminate against health care providers, but they can pay them different amounts based on quality or performance measures. Also, they can't discriminate against employees who rat them out under the Fair Labor Standards Act.

Section 2707. Comprehensive health insurance coverage.

Health insurance issuers have to cover an "essential benefits packange," which will be defined by the Secretary of HHS, but includes at least the following categories of service: walk-ins, emergency services, hospitalization, maternity/newborn care, mental health and substance abuse services, prescription drugs, rehabilitative services, lab services, preventive and wellness services, and pediatric services, as well as anything else HHS adds to that list.

Adjusted for the overall cost of health care, your out-of-pocket expenses are limited to $5,000 for individuals and $10,000 for families.

If an insurance company provides a particular level of coverage (bronze, silver, gold, or platinum -- more on that in subtitle D), they have to provide a child-only plan that provides that level of coverage.

None of this applies to dental-only plans.

Section 2708. Prohibition on excessive waiting periods.

Health insurance plans can't have waiting periods of more than 90 days before they cover you.

Part II: Other Provisions

Section 1251. Preservation of the right to maintain existing coverage.

None of the changes made in subtitles A or C apply to your current health insurance; even if you renew that coverage after this act is passed. Also, your family members can join your current health plan, and employers can add new employees to their plan, even if those plans would otherwise be illegal under this act. If you're guaranteed coverage under a collective bargaining agreement, that coverage can persist as is until that collective bargaining agreement terminates, but changes to the plan to make it conform to this law don't terminate your collective bargaining agreement.

I suppose it's reasonable (sort of) as a way of allaying people's fears that this will affect their health insurance, to say if you're happy with your annual limits, or your lack of preventive care or dependent coverage, you can keep them. But this also allows your insurer to rescind or cancel your health insurance based on health status, not have an appeals process, hike your premiums unreasonably and without justification, not report on how they spend your premiums and reimburse you if their administrative costs are excessive, and not provide you with a nice statement of your benefits so you can comparison shop.

Section 1252. Reforms must apply uniformly to all health insurance issuers and group health plans.

When a state adopts standards of the kinds we've seen so far, they have to be uniformly applied to all health plans in the market where they apply.

Section 1253. Effective dates.

This subtitle takes effect on January 1, 2014, and applies to plan years beginning after that point.

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