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Author Topic: Senate's ‘‘America’s Healthy Future Act of 2009’’ Discussion  (Read 2167 times)
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WhiskeyGirl
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« on: October 19, 2009, 07:56:09 PM »

I found a like here -

http://finance.senate.gov/press/Bpress/2009press/prb101909.pdf

Quote
‘‘SEC. 2203. GUARANTEED ISSUE AND RENEWAL FOR IN7
SURED PLANS.

8 ‘‘(a) IN GENERAL.—Except as provided in this sec9
tion, a health benefits plan shall be treated as a qualified
10 health benefits plan only if the offeror of the plan—
11 ‘‘(1) in the case of a plan offered—
12 ‘‘(A) in the individual market in a State,
13 must accept every individual that applies for en
14 rollment in the plan;

How long will indiviudal plan be offered?  Will community groups be sending the sickest possible people to apply?  People who use say $10,000 a month in benefits, and paying only say $300 in premiums?

My guess is that this will be the death of individual insurance.
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It doesn't do any good to hate anyone,
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WhiskeyGirl
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« Reply #1 on: October 19, 2009, 07:58:19 PM »

If you need to fill beds, just round up some patients, apply for insurance and you have a paying customer!  If a hospital could get $100,000 monthly by paying just $300 a month for that person, what a racket.  How can I sign up?

Quote
‘‘(c) HEALTH STATUS-RELATED FACTORS.—For
25 purposes of this section, the term ‘health status-related
19
O:\FRA\FRA09275.xml [file 1 of 7] S.L.C.
1 factors’ means health status, medical condition (including
2 both physical and mental illnesses), claims experience, re3
ceipt of health care, medical history, genetic information,
4 evidence of insurability (including conditions arising out
5 of acts of domestic violence), and disability.

No need to worry if they're insured.  Just sign them up after they check in!
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All my posts are just my humble opinions.  Please take with a grain of salt.  Smile

It doesn't do any good to hate anyone,
they'll end up in your family anyway...
WhiskeyGirl
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« Reply #2 on: October 19, 2009, 07:59:50 PM »

Quote
‘‘(2) BY FAMILY ENROLLMENT.—The premium
4 rate may vary by family enrollment (such as vari5
ations within categories and compositions of fami6
lies) so long as the ratio of the premium for the fol7
lowing types of enrollment to the premium for indi8
vidual enrollment does not exceed the following ra9
tios:
10 ‘‘(A) Individual, 1 to 1.
11 ‘‘(B) Adult with child, 1.8 to 1.
12 ‘‘(C) Two adults, 2 to 1.
13 ‘‘(D) Family, 3 to 1.

Will it be cheaper for the biggest families to take the private insurance option?

Why would a family with say 18 members pay just pennies compared to what other combinations pay? 
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All my posts are just my humble opinions.  Please take with a grain of salt.  Smile

It doesn't do any good to hate anyone,
they'll end up in your family anyway...
WhiskeyGirl
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« Reply #3 on: October 19, 2009, 08:13:28 PM »

Quote
16 ‘‘(b) SINGLE RISK POOL.—
17 ‘‘(1) IN GENERAL.—For purposes of applying
18 the insurance reform requirements under subpart
19 1—
20 ‘‘(A) INDIVIDUAL MARKET.—The offeror of
21 an insured qualified health benefits plan offered
22 in the individual market in an area covered by
23 an exchange shall consider all enrollees in the
24 plan, including individuals who do not purchase
25 such a plan through an exchange, to be mem26
bers of a single risk pool.
25
O:\FRA\FRA09275.xml [file 1 of 7] S.L.C.
1 ‘‘(B) SMALL GROUP MARKET.—The offeror
2 of a qualified health benefits plan offered in the
3 small group market in an area covered by an
4 exchange shall consider all enrollees in the plan,
5 including individuals who do not purchase such
6 a plan through an exchange, to be members of
7 a single risk pool.
8 ‘‘(2) STATE ELECTION.—A State may elect to
9 combine the individual and small group markets
10 within the State for purposes of applying this sub11
section.

In my mind, I have to wonder.  Why is it that some companies only offer individual insurance?

Why isn't the risk pool based on reality?  I think real life risks do not conform to political legislation.

Quote
4 ‘‘(1) IN GENERAL.—The Secretary shall estab5
lish 1 or more risk adjustment models for proper ad6
justments of premium amounts payable among
7 offerors of qualified health benefits plans that take
8 into account (in a manner specified by the Sec9
retary) the differences in the risk characteristics of
10 individuals and employers enrolled under the dif11
ferent plans so as to minimize the impact of adverse
12 selection of enrollees among the plans.

I think it likely that any insurance program or provider, individual or group, will die long before any adjustments are made by state or federal govenment politicians.

Maybe it will take years and many hearings?  Appeals? 

Company will die due to adverse selection and high claims.  jmho
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All my posts are just my humble opinions.  Please take with a grain of salt.  Smile

It doesn't do any good to hate anyone,
they'll end up in your family anyway...
WhiskeyGirl
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« Reply #4 on: October 19, 2009, 08:28:03 PM »

10 ‘‘SEC. 2213. ESTABLISHMENT OF TRANSITIONAL REINSUR
11  ANCE PROGRAM FOR INDIVIDUAL MARKETS
12 IN EACH STATE.

Quote
p. 28

‘‘(A) the offerors of health benefits plans
5 that are offered in the individual market are re
6 quired to make payments to an applicable rein7
surance entity for any plan year beginning in
8 the 36-month period beginning July 1, 2013;
9 and
10 ‘‘(B) the applicable reinsurance entity col11
lects payments under subparagraph (A) and
12 uses amounts so collected to make reinsurance
13 payments to offerors of health benefits plans
14 described in subparagraph (A) that cover high
15 risk individuals for any plan year beginning in
16 such 36-month period.

A 'reinsurance' plan or subsidy?  So, insurance companies cannot determine their premiums, rates, or the amount they must send to another government entity.

Quote
p. 29

Such method shall
4 provide for identification of individuals as high5
risk individuals on the basis of—
6 ‘‘(i) a list of at least 50 but not more
7 than 100 medical conditions that are iden8
tified as high-risk conditions and that may
9 be based on the identification of diagnostic
10 and procedure codes that are indicative of
11 individuals with pre-existing, high-risk con12
ditions; or
13 ‘‘(ii) any other comparable objective
14 method of identification recommended by
15 the American Academy of Actuaries.

ok.  So there is a list of at least 50, but not more than 100 conditions...  Who determines the conditions?

How does this compare with real world underwriting guidelines?  There are conditions that may require lots of monthly treatment, not such a burden, or some conditions that are catastrophic in nature.  What will it be?  $200 a month conditions?  Or end of life conditions costing millions of dollars?

Why isn't this based in real life?

A short list of conditions, does it really offer protection against adverse selection or community organizations?  I don't think so...jmho.


Quote
continue with P. 29

16 ‘‘(B) PAYMENT AMOUNT.—
17 ‘‘(i) IN GENERAL.—The formula for
18 determining the amount of payments that
19 will be paid to the offerors of health bene20
fits plans that insure high-risk individuals.
21 Such formula shall provide for the equi22
table allocation of available funds through
23 reconciliation and may be designed—
24 ‘‘(I) to provide a schedule of pay25
ments that specifies the amount that
30
O:\FRA\FRA09275.xml [file 1 of 7] S.L.C.
1 will be paid for each of the conditions
2 identified under subparagraph (A); or
3 ‘‘(II) to use any other com4
parable method for determining pay5
ment amounts that is recommended
6 by the American Academy of Actu7
aries and that encourages the use of
8 care coordination and care manage9
ment programs for high risk condi10
tions.

Equitable distribtion...why isn't it based on actual expenses?

This looks like a casino based payment system. 

Quote
p. 31

8 ‘‘(B) SPECIFIC REQUIREMENTS.—The
9 method under this paragraph shall be designed
10 so that—
11 ‘‘(i) the contribution amount for each
12 offeror proportionally reflects each
13 offeror’s fully insured commercial book of
14 business for all major medical products
15 and third party administration fees;
16 ‘‘(ii) the contribution amount can in17
clude an additional amount to fund the ad18
ministrative expenses of the applicable re19
insurance entity;

"offeror's...commercial book of business for all major medical products and third party administration fees"

Will the profits/administration expenses of large group plans, the 'third party administration fees' now subsidize the individual and small group reinsurance plan?

How much will be needed to fund the ongoing operations of the "applicable reinsurance entity"?

How will business be able to keep the government or it's arms honest?
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All my posts are just my humble opinions.  Please take with a grain of salt.  Smile

It doesn't do any good to hate anyone,
they'll end up in your family anyway...
WhiskeyGirl
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« Reply #5 on: October 19, 2009, 08:37:27 PM »

Rationing?

p. 39

Quote
23 ‘‘(2) INSUFFICIENT FUNDS.—If the Secretary
24 estimates for any fiscal year that the aggregate
25 amounts available for payment of expenses of the
40
O:\FRA\FRA09275.xml [file 1 of 7] S.L.C.
1 high risk pool will be less than the amount of the
2 expenses, the Secretary shall make such adjustments
3 as are necessary to eliminate such deficit, including
4 reducing benefits, increasing premiums, or estab5
lishing waiting lists.

We won't charge more for sick folks, we'll just reduce payments to providers for these toxic patients, increase someone's premiums, or put folks on a waiting list.
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All my posts are just my humble opinions.  Please take with a grain of salt.  Smile

It doesn't do any good to hate anyone,
they'll end up in your family anyway...
WhiskeyGirl
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« Reply #6 on: October 19, 2009, 08:44:54 PM »

P. 32, GM/Chrysler/UAW/VEBA subsidy/bailout?

Quote
8 ‘‘(iv) in addition to the aggregate con
9 tribution amounts under clause (iii), each
10 offeror’s contribution amount reflects its
11 proportionate share of the $5,000,000,000
12 amount used to fund the retiree reinsur13
ance program under section 2216.

So, does this mean that individuals, small business, and those self insuranced on Main Street  will be bailing out GM/Chrysler/UAW healthplan?


page 41, the GM & Chrysler VEBA / UAW and perhaps other subsidy paid for by taxing the individual, group premium payors.

Quote
15 ‘‘SEC. 2216. REINSURANCE FOR RETIREES COVERED BY EM16
PLOYER-BASED PLANS.
17 ‘‘(a) ADMINISTRATION.—
18 ‘‘(1) IN GENERAL.—Not later than 90 days
19 after the date of enactment of this section, the Sec20
retary shall establish a temporary reinsurance pro21
gram to provide reimbursement to participating em22
ployment-based plans for a portion of the cost of
23 providing health benefits to retirees during the pe24
riod beginning on the date on which such program
25 is established and ending on the date on which the
42
O:\FRA\FRA09275.xml [file 1 of 7] S.L.C.
1 Secretary estimates that applications for payments
2 under this section will have been made that equal
3 the funds made available under this section (reduced
4 by any administrative costs of the program).
5 ‘‘(2) REFERENCE.—In this section:
6 ‘‘(A) HEALTH BENEFITS.—The term
7 ‘health benefits’ means medical, surgical, hos8
pital, prescription drug, and such other benefits
9 as shall be determined by the Secretary, wheth10
er self-funded, or delivered through the pur11
chase of insurance or otherwise.
12 ‘‘(B) EMPLOYMENT-BASED PLAN.—The
13 term ‘employment-based plan’ means a group
14 health benefits plan that—
15 ‘‘(i) is—
16 ‘‘(I) maintained by one or more
17 current or former employers (includ
18 ing without limitation any State or
19 local government or political subdivi
20 sion thereof), an employee organiza
21 tion, a voluntary employees’ bene
22 ficiary association, or a committee or
23 board of individuals appointed to ad
24 minister such plan; or
43

O:\FRA\FRA09275.xml [file 1 of 7] S.L.C.
1 ‘‘(II) a multiemployer plan (as
2 defined in section 3(37) of the Em3
ployee Retirement Income Security
4 Act of 1974); and
5 ‘‘(ii) provides health benefits to retir6
ees.
7 ‘‘(C) RETIREES.—The term ‘retirees’
8 means individuals who are age 55 and older but
9 are not eligible for coverage under title XVIII
10 of the Social Security Act, and who are not ac11
tive employees of an employer maintaining, or
12 currently contributing to, the employment-based
13 plan or of any employer that has made substan14
tial contributions to fund such plan.
15 ‘‘(b) PARTICIPATION.—
16 ‘‘(1) EMPLOYMENT-BASED PLAN ELIGI17
BILITY.—A participating employment-based plan is
18 an employment-based plan that—
19 ‘‘(A) meets the requirements of paragraph
20 (2) with respect to benefits provided under the
21 plan; and
22 ‘‘(B) submits to the Secretary an applica23
tion for participation in the program, at such
24 time, in such manner, and containing such in25
formation as the Secretary shall require.

As an example, Why would you give the UAW retirees $5 billion and then tax them at the 40% rate for having a Cadillac plan?

This doesn't make sense.  Am I connecting the right dots?  Maybe the 40% tax is a clever distraction from the $5 billion?
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All my posts are just my humble opinions.  Please take with a grain of salt.  Smile

It doesn't do any good to hate anyone,
they'll end up in your family anyway...
WhiskeyGirl
Monkey All Star Jr.
****
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Posts: 7754



« Reply #7 on: October 19, 2009, 08:54:05 PM »

P. 46, GM/Chrysler/UAW/VEBA subsidy/bailout?

Quote
46
O:\FRA\FRA09275.xml [file 1 of 7] S.L.C.
1 ‘‘(3) LIMIT.—To be eligible for reimbursement
2 under the program, a claim submitted by a partici3
pating employment-based plan under paragraph (1)
4 with respect to any individual shall not be less than
5 $15,000 nor greater than $90,000. Such amounts
6 shall be adjusted each fiscal year based on the per7
centage increase in the Medical Care Component of
8 the Consumer Price Index for all urban consumers
9 (rounded to the nearest multiple of $1,000) for the
10 year involved.
11 ‘‘(4) USE OF PAYMENTS.—Amounts paid to a
12 participating employment-based plan under this sub13
section shall be used to lower costs for the plan.
14 Such payments may be used to reduce premium
15 costs for an entity described in subsection
16 (a)(2)(B)(i) or to reduce premium contributions, co17
payments, deductibles, co-insurance, or other out-of18
pocket costs for plan participants. Such payments
19 shall not be used as general revenues for an entity
20 described in subsection (a)(2)(B)(i). The Secretary
21 shall develop a mechanism to monitor the appro22
priate use of such payments by such entities.

This looks a lot like what was in HR3200. 

Reinsurance money to be used to reduce premium costs, contribution, copayments, deductibles, co-insurance or out of pocket costs.

What do these retirees have to pay for?

Is this really reinsurance?  Or a UAW bailout?


Paid for by individual, small group, and employer risk pools?
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All my posts are just my humble opinions.  Please take with a grain of salt.  Smile

It doesn't do any good to hate anyone,
they'll end up in your family anyway...
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