Scared Monkeys Discussion Forum

the Secretary shall reimburse such plan for 80 percent of that portion of the costs attributable to such claim that exceeds $15,000, but is less than $90,000. Such amounts shall be adjusted each year based on the percentage increase in the medical care component of the Consumer Price Index (rounded to the nearest multiple of $1,000) for the year involved.

...Amounts paid...shall be used to lower the costs borne directly by the participants and beneficiaries for health benefits provided under such plan in the form of premiums, co-payments, deductibles, co-insurance, or other out-of-pocket costs. Such payments shall not be used to reduce the costs of an employer maintaining the participating employment-based plan...

The Secretary shall conduct annual audits of claims data submitted by participating employment-based plans...

LIMITATION TO AVAILABLE FUNDS- The Secretary has the authority to stop taking applications for participation in the program or take such other steps in reducing expenditures under the reinsurance program in order to ensure that expenditures under the reinsurance program do not exceed the funds available under this subsection.

This almost slipped my mind - "BUDGETARY IMPLICATIONS- Amounts appropriated under clause (i), and outlays flowing from such appropriations, shall not be taken into account for purposes of any budget enforcement procedures including allocations under section 302(a) and (b) of the Balanced Budget and Emergency Deficit Control Act and budget resolutions for fiscal years during which appropriations are made from the Trust Fund."

(3) ENFORCEMENT OF NETWORK ADEQUACY- In the case of a health benefits plan of a QHBP offering entity that uses a provider network, the contract under this section with the entity shall provide that if--

(A) the Commissioner determines that such provider network does not meet such standards as the Commissioner shall establish under section 115; and

(B) an individual enrolled in such plan receives an item or service from a provider that is not within such network;

then any cost-sharing for such item or service shall be equal to the amount of such cost-sharing that would be imposed if such item or service was furnished by a provider within such network.

SEC. 115. ENSURING ADEQUACY OF PROVIDER NETWORKS.
(a) In General- A qualified health benefits plan that uses a provider network for items and services shall meet such standards respecting provider networks as the Commissioner may establish to assure the adequacy of such networks in ensuring enrollee access to such items and services and transparency in the cost-sharing differentials between in-network coverage and out-of-network coverage.

(b) Provider Network Defined- In this division, the term ‘provider network’ means the providers with respect to which covered benefits, treatments, and services are available under a health benefits plan.

(1) IN GENERAL- For purposes of this division, the term ‘affordable credit eligible individual’ means, subject to subsection (b), an individual who is lawfully present in a State in the United States (other than as a nonimmigrant described in a subparagraph (excluding subparagraphs (K), (T), (U), and (V)) of section 101(a)(15) of the Immigration and Nationality Act)--

101(a)(15)(K) subject to subsections (d) and (p) of section 214, an alien who--

101(a)(15)(K)(i) is the fiancÉe or fiancÉ of a citizen of the United States and who seeks to enter the United States solely to conclude a valid marriage with the petitioner within ninety days after admission;

101(a)(15)(K)(ii) has concluded a valid marriage with a citizen of the United States who is the petitioner, is the beneficiary of a petition to accord a status under section 201(b)(2)(A)(i) that was filed under section 204 by the petitioner, and seeks to enter the United States to await the approval of such petition and the availability to the alien of an immigrant visa; or

101(a)(15)(K)(iii) is the minor child of an alien described in clause (i) or (ii) and is accompanying, or following to join, the alien; Leg Hist

101(a)(15)(T)

101(a)(15)(T)(i) subject to section 214(o), an alien who the Attorney General determines—

101(a)(15)(T)(i)(I) is or has been a victim of a severe form of trafficking in persons, as defined in section 103 of the Trafficking Victims Protection Act of 2000,

101(a)(15)(T)(i)(II) is physically present in the United States, American Samoa, or the Commonwealth of the Northern Mariana Islands, or at a port of entry thereto, on account of such trafficking,

101(a)(15)(T)(i)(III)

101(a)(15)(T)(i)(III)(aa) has complied with any reasonable request for assistance in the investigation or prosecution of acts of trafficking, or

101(a)(15)(T)(i)(III)(bb) has not attained 18 years of age, and

101(a)(15)(T)(i)(IV) the alien would suffer extreme hardship involving unusual and severe harm upon removal; and

101(a)(15)(T)(ii) if the Attorney General considers it necessary to avoid extreme hardship—

101(a)(15)(T)(ii)(I) in the case of an alien described in clause (i) who is under 21 years of age, the spouse, children, unmarried siblings under 18 years of age on the date on which such alien applied for status under such clause, and parents of such alien; and

101(a)(15)(T)(ii)(II) in the case of an alien described in clause (i) who is 21 years of age or older, the spouse and children of such alien,

if accompanying, or following to join, the alien described in clause (i);

101(a)(15)(U)

101(a)(15)(U)(i) subject to section 214(p), an alien who files a petition for status under this subparagraph, if the Attorney General determines that

101(a)(15)(U)(i)(I) the alien has suffered substantial physical or mental abuse as a result of having been a victim of criminal activity described in clause (iii);

101(a)(15)(U)(i)(II) the alien (or in the case of an alien child under the age of 16, the parent, guardian, or next friend of the alien) possesses information concerning criminal activity described in clause (iii);

101(a)(15)(U)(i)(III) the alien (or in the case of an alien child under the age of 16, the parent, guardian, or next friend of the alien) has been helpful, is being helpful, or is likely to be helpful to a Federal, State, or local law enforcement official, to a Federal, State, or local prosecutor, to a Federal or State judge, to the Service, or to other Federal, State, or local authorities investigating or prosecuting criminal activity described in clause (iii); and

101(a)(15)(U)(i)(IV) the criminal activity described in clause (iii) violated the laws of the United States or occurred in the United States (including in Indian country and military installations) or the territories and possessions of the United States;

101(a)(15)(U)(ii) if the Attorney General considers it necessary to avoid extreme hardship to the spouse, the child, or, in the case of an alien child, the parent of the alien described in clause (i), the Attorney General may also grant status under this paragraph based upon certification of a government official listed in clause (i)(III) that an investigation or prosecution would be harmed without the assistance of the spouse, the child, or, in the case of an alien child, the parent of the alien; and

101(a)(15)(U)(iii) the criminal activity referred to in this clause is that involving one or more of the following or any similar activity in violation of Federal, State, or local criminal law: rape; torture; trafficking; incest; domestic violence; sexual assault; abusive sexual contact; prostitution; sexual exploitation; female genital mutilation; being held hostage; peonage; involuntary servitude; slave trade; kidnapping; abduction; unlawful criminal restraint; false imprisonment; blackmail; extortion; manslaughter; murder; felonious assault; witness tampering; obstruction of justice; perjury; or attempt, conspiracy, or solicitation to commit any of the above mentioned crimes; or

101(a)(15)(V) subject to section 214(q), an alien who is the beneficiary (including a child of the principal alien, if eligible to receive a visa under section 203(d)) of a petition to accord a status under section 203(a)(2)(A) that was filed with the Attorney General under section 204 on or before the date of the enactment of the Legal Immigration Family Equity Act, if—

101(a)(15)(V)(i) such petition has been pending for 3 years or more; or

101(a)(15)(V)(ii) such petition has been approved, 3 years or more have elapsed since such filing date, and--

101(a)(15)(V)(ii)(I) an immigrant visa is not immediately available to the alien because of a waiting list of applicants for visas under section 203(a)(2)(A); or

101(a)(15)(V)(ii)(II) the alien's application for an immigrant visa, or the alien's application for adjustment of status under section 245, pursuant to the approval of such petition, remains pending.

(B) SUBSIDIZED INDIVIDUALS DESCRIBED- An individual described in this subparagraph is an Exchange-eligible individual who is either of the following:

(i) AFFORDABILITY CREDIT ELIGIBLE INDIVIDUALS- The individual--

(I) has applied for, and been determined eligible for, affordability credits under subtitle C;

(II) has not opted out from receiving such affordability credit; and

(III) does not otherwise enroll in another Exchange-participating health benefits plan.

Nothing in this subtitle shall allow Federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States.

I'm on a rant here!

I just saw on TV that they estimate 23 billion a year is paid fraudulantly on behalf of Medicare and Medicaid recipients. Even the OIG admits it's primarily to providers who haven't navigated the rules and regulations properly around providing those services to Governmentally insured individuals. GEE! YA THINK? It might have something to do with the THOUSANDS of pages of regulations that change monthly! So, included in the Health Care proposal is 100 million to catch those providers who are just providing Health Care and have either miscoded something, allowed a patient in the waiting room while a provider takes lunch (yeah, that's a rule), has a sign in sheet with anyone elses name on it, is a day late on the required monthly treatment plan, or has a transcription service who gets the transcripts back in 48 hours rather than 24!

I'm serious here: I could provide services for 1/3 the cost if I could simply employ a Board Certified Physician to provide health care to patients, submit the claim, complete with notes if they'd like, and expect payment. I have no problem at all being reviewed for quality of services provided. But, I have compliancy consultants to help me navigate the requirements, accountants to help me structure fee and compensation schedules to meet the rules, employees hired to oversee Physician notes, and staff to keep up with the paperwork. Providers are scared to prescribe pain medications when they are genuinely needed because it's a short path to red flags and it automatically requires random drug screenings and pill counts and that just adds another logistical layer to keep up with. Licensed Psychiatric Professionals must be brought in for counselling if chronic pain is the problem and any kind of long term pain medication is required.

I don't know what else I can do to try to do this right, yet I live in fear for everything I've worked for all my life. Recently, a cardiac group in Nashville was "descended" upon by an outsourced Medicare company to "spot inspect" and they were cited for over a million dollars in payback. All Medicare payments stopped while the group filed an appeal. The issue? Labs were done without a specific written order. All payments for each patient were marked for repayment. The cardiologists were sending the patients to the lab for work and the charts included the presenting problem, complete with references to proposed course of actions based on lab results, the lab results themselves and follow up care based on the lab results, but there wasn't a seperate written order for the labs. The group SPENT over a million dollars on the appeal and won a year later. They had the deep pockets to weather it. I wouldn't. I don't have the money to withstand that kind of assault, and all my personal assets would be subject to seizure for payback. The outsourced companies doing the inspections work on commission, and they have every incentive to find something, anything, that will pay their salaries.

It's wrong. It's just wrong.

OK, thanks for your patience. Rant over.

‘subpart b. surcharge on high income individuals.’.

(c) Section 15 Not To Apply- The amendment made by subsection (a) shall not be treated as a change in a rate of tax for purposes of section 15 of the Internal Revenue Code of 1986.

(d) Effective Date- The amendments made by this section shall apply to taxable years beginning after December 31, 2010.

SEC. 442. DELAY IN APPLICATION OF WORLDWIDE ALLOCATION OF INTEREST.

(a) In General- Paragraphs (5)(D) and (6) of section 864(f) of the Internal Revenue Code of 1986 are each amended by striking ‘December 31, 2010’ and inserting ‘December 31, 2019’.

(b) Transition- Subsection (f) of section 864 of such Code is amended by striking paragraph (7).

WhiskeyGirl, you have likely read more of the bill than many of the Democrats. We'll see how many of them who are up for re-election within the next two years are willing to nose dive their chance to remain in office by voting for HR 3200? I expect with Obama's approval rating finally dropping like a stone, that not many will.

I understand the flow chart to administrate this fine smoke and mirrors lets play socialist plan is a pure exercise in layer after layer of bureaucracy.

reality is that 10 M of our currently 'uninsured' are the illegal aliens.

The University of Chicago Medical Center is forging ahead with a major financing plan to pay for a large part of its new hospital pavilion in the face of a turbulent economy that has triggered layoffs and spending reductions at the facility this year.

The South Side teaching hospital early next month plans to issue bonds to raise $225 million through the Illinois Finance Authority to support the university's capital projects, "highlighted by the construction of a new patient tower pavilion on the main campus," according to a report released last week by Moody's Investors Service.

...The total cost of the pavilion will be about $700 million, with additional funds to finance the facility coming from fundraising and the medical center's cash.

Like other hospitals across the country, U. of C. has been hit hard by an increasing number of uninsured patients who cannot pay bills. The medical center cut about $100 million from its budget, including more than 450 jobs. It also stepped up relationships with community hospitals and clinics as part of its Urban Health Initiative, designed to free up space for specialized patients who can generate more revenue.

The U. of C.'s plan comes as rivals put off building or expanding facilities amid the recession. Among them are Loyola University Medical Center in Maywood and Advocate Health Care, the largest Chicago-area provider of medical care.

But medical center Chief Executive Dr. James Madara is committed to what he has called a "high technology platform" and is forging ahead with plans to open the new pavilion in 2013. Construction began in May.

NorthShore-U of C program seeks slice of transplant market
By: Mike Colias July 22, 2009

(Crain’s) — NorthShore University HealthSystem and University of Chicago Medical Center are teaming up on a new organ-transplant program, the hospitals said Wednesday. Under the pact, U of C specialists will treat NorthShore patients at a new transplant evaluation center in Evanston. Patients who are candidates for heart, liver, lung or other organ transplants would get diagnostic work and other services there and then likely would be referred to U of C in Hyde Park for surgery.

...

“This essentially could be a way to enhance (U of C’s) marketshare by establishing a beachhead in Northwestern’s service area,” says Roger Evans, a Minnesota-based consultant who advises hospitals on their transplant programs.

...

But the transplant venture underscores the business opportunities for both hospital systems. It gives U of C better access to the affluent northern suburbs. And NorthShore gets to leverage the U of C brand: The program is named the University of Chicago Transplant Evaluation center.

WG as always, you do an outstanding job of ferreting out the fine print. I wish I had more time to review but in a quick scan you're onto the meat of this.

There are no government programs that do not require layer after layer of bureaucracy and 'partners' in private industry are rife within this document. Another shell game like ACORN and one designed to give our government perhaps the ultimate control over the largest industry in our country - healthcare.

Yes, I think this is going to be Obama's "Waterloo". Let the games begin, this is a president who is so full of own supposed capability to pull a fast sale that I hope he's lost all perspective.

What’s happening here is that the baton is being passed. Many of those homeowners we’ve been reading about for years with those crazy subprime loans have been swept to the street.

Taking their place in the foreclosure line are homeowners who have lost their jobs and are now falling behind on their payments.

I photograph and do video tours for real estate in the Boston area. I have shot millions and millions of dollars worth of homes in the past 4 months. High end homes have virtually sat untouched on the market since last November all over the country, yet so many more of these homes have been put on the market this spring and summer. Many of these homes were purchased within the past 5 years or less. Most are owned by young couples with small children.

My take: As bonuses dried up, jobs were lost, salaries were cut, coupled with many of these loans resetting, plus the difficulty in obtaining the jumbo loans in order to attract high end buyers - not to mention the fact that I'm sure many of these folks overextended themselves just a wee bit (!)....

Hopefully I'm wrong, but I have a funny feeling the foreclosures will be spreading to the high end this fall and winter. Big time.

Bloggers, writers of R.E. articles and readers, EVERYONE, please remember to keep in mind that for several years, the National Association of Realtors and your State Association of Realtors continue to revise and revise and revise down the seasonal and yearly forecast for the number of homes they say will sell.

When these continually revised and lower numbers are then reached, writers and reporters who are not in the Real Estate industry, together with those who are and the many people whose income depends on spinning any and all news and numbers in a positive way, shout from the roof tops that "the numbers have increased", blah blah blah. The dead cat bounce.

There may be higher sales one month over the prior month, but these numbers were revised downwards and more importantly, the prices for homes continue to slip. That is important.

What is also important - and I haven't seen any news to the contrary - there is a huge "shadow" inventory of foreclosed and short sale homes going to hit the market here and throughout the U.S. No one can deny that. Economics 101. Without rising employment and rising salaries, there is no and will be no home stabilization.

People jumped into the bubble and are now losing money if they need to sell. Just as many of us bought stock in Sun Micro at $80.00 and after 10 years it is still around $9.00. I need to sell this stock. Anyone want to buy it from me at $81.00 so that I can break even after paying my stockbroker! Sorry. I sound like more home sellers still in denial and living in fantasy land.

TUCSON, Ariz. -- The National Council of La Raza will buy foreclosed homes in Phoenix to rehabilitate and then sell to low-and moderate-income Latino families under a pilot program partly funded by the charitable arm of Citigroup, officials announced Thursday.

New York-based Citi Foundation is providing $1.75 million to the NCLR, of which $235,000 will go to the group's Raza Development Fund. That money will allow the fund to acquire properties, maintain and rehab them and then sell or lease them, Citi Foundation community relations vice president Eric Eve said.

"This is the next stage of the foreclosure crisis, working with nonprofit organizations like NCLR to help strengthen and rebuild communities that are struggling through the current foreclosure crisis," he said.

The money will be paired with about $4 million from the fund he manages and federal stimulus program money expected in December or January, said Tom Espinoza, president and CEO of the Raza Development Fund in Phoenix.

Starter homes in the target neighborhoods are ranging between $60,000 and $100,000, and the plunge in values -- as much as 50 percent in just three years -- will enable some families to obtain mortgages now, he said.

After reading the 'reinsurance' section of this bill, it looks to be that those folks with a VEBA or similar will never have to pay a penny for their healthcare.  Their programs in theory are already funded, and the HR 3200 will overpay for their copays, dedutibles, and coinsurance - paying tens of thousands to cover an entire claim, while the money is to be used to ensure the participants have no out of pocket expenses. 

The rest of America has the public plan, subject rationing, and a political based sliding scale of copays and premiums. 

It seems like those with the VEBA and similar will not be contributing to the public plan or subject to any additional taxes or fees.

I wonder is this is where the money from the recovery and reinvestment act is going?  Is money being funded through some of the fuzze language to community groups and similar that are paying the mortgage payments and other bills of interest to the community group?  Is the money ensuring that some do not lose their homes, or go hungry while they are jobless?

I wonder how much of recovery and reinvestment amounts to a pass-through? 

What are the characteristics of those losing their homes today compared to those losing their homes prior to the passage of the recovery and reinvestment act? 

What are the racial and ethnic characteristics of those foreclosed upon that are now renting back their homes from the government?  Are any groups more affected than another?  Creating a generation of housing sharecroppers? 

Perhaps the stimulus was intended to be a bill of pass throughs for Obama's special interests?  No jobs, but to ensure that some survive financially and others do not?

jmho

not just your opinion WG, it's being proven out and I think Obama ramming HR 3200 down his own party member's throats is making even democrats finally realize that Pelosi and Obama were sister/brother under the skin all along. The power grab is enormous rolling off that alliance and we will be paying for it for decades to come.

It is all about special interests, now it's coming to light that ACORN has been involved with HR 3200 all the while behind the scenes.

The destruction of our country's political system, all due to an effort to redistribute the wealth likely driven by a belief that black americans deserve reparations.

(2) SOLICITING AND NEGOTIATING BIDS; CONTRACTS- The Commissioner shall--

(A) solicit bids from QHBP offering entities for the offering of Exchange-participating health benefits plans;

(B) based upon a review of such bids, negotiate with such entities for the offering of such plans; and

(C) enter into contracts with such entities for the offering of such plans through the Health Insurance Exchange under terms (consistent with this title) negotiated between the Commissioner and such entities.

(3) FAR NOT APPLICABLE- The provisions of the Federal Acquisition Regulation shall not apply to contracts between the Commissioner and QHBP offering entities for the offering of Exchange-participating health benefits plans under this title.

"What are the key changes that Medicare Contracting Reform brings?"

As CMS moves forward with Medicare Contracting Reform, we will ensure that changes are managed effectively and coordinated with other Program initiatives. CMS will ensure that Medicare claims continue to be processed effectively, accurately and in a timely manner. Under Medicare Contracting Reform, contracts will be subject to the Federal Acquisition Regulation. Differences between the Title XVIII contracts (current contracts) and the Federal Acquisition Regulation contracts (future contracts) are:

CURRENT CONTRACTS
• Restrictions on who can receive contract award
• Generally limited to cost reimbursement contracts
• Performance standards and criteria are published in the Federal Register
• Either party may terminate
• Must submit monthly expenditure reports, which do not have to be approved in advance in order to access funds
• Contracts/Agreements renewed year to year

FUTURE CONTRACTS
• Full and open competition is required
• Several types of contracts are available
• Performance standards are contained in the contract
• Only Government may terminate for convenience or default
• Must submit a voucher in order to get paid, and payment is made after voucher is approved
• Contract period of performance is a maximum of 5-years

EMERGENCY SERVICES
Emergency Services is a program for people who have an emergency medical condition and cannot get Medicaid or BadgerCare Plus because of immigration or citizenship status.

You may be able to get Emergency Services, if you are:
• Age 65 or older, or
• Blind or disabled, or
• Under the age of 19, or
• Pregnant, or
• Have children under age 19 in the home, and
• Meet all other program rules.

Social Security Numbers are not required. Information about your family will not be shared with the United States Citizenship and Immigration Services (USCIS) (formerly INS).

"This has been an example of just pure misinformation out there,” President Obama recently asserted on a radio program.  “None of the bills that have been voted on in Congress, and none of the proposals coming out of the White House propose giving coverage to illegal immigrants -- none of them."

House Speaker Nancy Pelosi told CNN, “No, illegal immigrants are not covered by this plan [H.R. 3200].”

Senate Minority Whip Jon Kyl, who also serves on Finance, expressed similar concerns.  "It’s a logical question for people to ask," he said. "In the last couple of bills … there were efforts to ensure that only eligible people would get the benefits … those efforts were defeated by Democrats. ... That illegal immigrants get care ... [is] a big burden on hospitals."

The ranking Republican on the House Judiciary Committee, Rep. Lamar Smith, said, “[T]he bill contains no provisions preventing illegal immigrants from participating in the Health Insurance Exchange that is to be created, including the government-run ‘public plan’ that will be available through the federally-run and federally-subsidized exchange. This is in direct conflict with the president’s claim that illegal immigrants will not be insured under his plan.”

Rector said H.R. 3200 “turns that [eligibility check requirement] on its back and tramples it into the dust.  It basically says we will not verify; we will not check.”

In several places, the legislation defers the writing of details to the health bureaucracy.  That approach lets lawmakers say “such-and-such isn’t in this bill.”

H.R. 3200 establishes an “enroll first, don’t ask questions later” regime.  The ostensible goal:  universal coverage with easy and fast enrollment.

The lackadaisical process for getting people -- including illegal aliens and immigrants supposed to rely on their visa sponsor’s financial support -- into government health care at taxpayer expense amounts to a scam and a scandal.