Monday, November 2, 2009


This summary covers the provisions of Subtitles A, B, and C of Title II.

Subtitle AGeneral Standards
Sec. 201. Requirements reforming health insurance marketplace.  A health benefits plan can not be a qualified health benefits plan (sold in the insurance exchange0 unlsess it meets three requirements as spelled out in Subtitle B (relating to affordable coverage), Subtitle C (relating to essential benefits) and Subtitle D (relating to consumer protection.)

Sec. 202. Protecting the choice to keep current coverage.  Individual health insurance plans that are in force on the first day of the exchanges are grandfathered in.  In other words if you have an individual policy you like you can keep it.  New dependents can be added but the insurance company can not enroll new people.  The insurer can not change the benefit or terms or conditions.  The insurer can vary the permium but the change has to be by risk group.  Current employer-based plans are grandfathered in for five years.  After that they must meet the requirements of a qualified benefits plan Subtitles B, C, and D.  In general after the health insurance exchange is created individual insurance that is NOT grandfathered in can only be offered through the insurance exchange.

Subtitle BStandards Guaranteeing Access to Affordable Coverage. 
Sec. 211. Prohibiting preexisting condition exclusions.  An individual can not be denied coveage based upoin any of the following: health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability, disability or source of injury (including acts of domestic violence) or similar factors.

Sec. 212. Guaranteed issue and renewal for insured plans and prohibiting rescissions.  Regardless of how the insurance is offered whether employer-based, through the health insurance exchange or otherwise, enrollees are guranteed the right of renewal of their insurance and their insurance coveage can not be rescended except in cases of fraud.

Sec. 213. Insurance rating rules.  Premiums may vary only by age (2 to 1 ratio highest to lowest premium premium for oldest enrollee can not be more than twice that of the youngest), area, and family enrollment.

Sec. 214. Nondiscrimination in benefits; parity in mental health and substance
abuse disorder benefits.   health insurance issuer offering group health insurance coverage in connection with a group health plan, may not establish rules for eligibility (including continued eligibility) of any individual to enroll under the terms of the plan based on any of the following health status-related factors in relation to the individual or a dependent of the individual:
(A) Health status.
(B) Medical condition (including both physical and mental illnesses).
(C) Claims experience.
(D) Receipt of health care.
(E) Medical history.
(F) Genetic information.
(G) Evidence of insurability (including conditions arising out of acts of domestic violence).
(H) Disability.

Sec. 215. Ensuring adequacy of provider networks.  Insurance providers that use a provider network must make information about the participants in their provider network available to enrollees over the internet.

Sec. 216. Requiring the option of extension of dependent coverage for uninsured
young adults.  The insurance provider must make coverage available to dependent children on enrolless under the age of 27 who are not enrolled in another insurance plan.

Sec. 217. Consistency of costs and coverage under qualified health benefits
plans during plan year.  Insurance must provide at least 90 days notice to enrollees of a decrease in coverage or if cost-sharing increases.

Subtitle CStandards Guaranteeing Access to Essential Benefits
Sec. 221. Coverage of essential benefits package.  Insurers must provide a benefits package that at a minimum meets the requirements of Sec. 222.

Sec. 222. Essential benefits package defined.  The following are the minimum essential benefits that insurers must  offer enrollees:

(1) Hospitalization.
(2) Outpatient hospital and outpatient clinic services, including emergency department services.
(3) Professional services of physicians and other health professionals.
(4) Such services, equipment, and supplies incident to the services of a physician or a health professional’s delivery of care in institutional settings, physician offices, patients’ homes or place of residence, or other settings, as appropriate.
(5) Prescription drugs.
(6) Rehabilitative and habilitative services.
(7) Mental health and substance use disorder services, including behavioral health treatments.
(8) Preventive services, including those services recommended with a grade of A or B by the Task Force on Clinical Preventive Services and those
(9) Maternity care.
(10) Well-baby and well-child care and oral health, vision, and hearing services, equipment, and supplies for children under 21 years of age.
(11) Durable medical equipment, prosthetics, orthotics and related supplies.

There can be no cost-sharing for preventive services recommended under grade A or B by the Task Force or well-baby and well child care.
Cost sharing for other parts of the minimum benefits package are not to exceed $5,000 per individual or $10,000 for a family. This will increase $100 per year.  The cost sharing must be designed to provide benefits that actuarially equivalent to approximately 70% of the full actuarial value of the benefits under the minimum benefits package.

Assessment and brief counseling for domestic violence is included.

Abortion coverage is PROHIBITED as part of the minimum benefits package.
Abortion coverage may not be required (or prohibited) ofprivate insurers participating in the health exchange.
The public option shall provide abortion coverage for which public funding is allowed based on the law as in effect 6 months before the beginning of the plan year involved. 
Nothing in the Act prevents the public option from providing for or prohibiting abortion services for which federal funds are not permitted 6 months before the beginning of the plan year.  If federal funds for abortion coverage are allowed by law, then the public option would included them.  If they are not allowed then “nothing in this Act shall be construed as preventing the public health option from providing for or prohibiting coverage of [such] services.  A later section says that federal funds used for the affordability credit MAY NOT be used for payment for Abortion coverage NOT allowed by by federal law (p. 246).  Additonally funds used for grants such as for establishing school-based clinics MAY NOT be used to fund abortions. (p. 1359)

Sec. 223. Health Benefits Advisory Committee.  A nine member Health Beneftis Advisory Committee representing a cross-section of health care system interests will be established to recommend changes in benefits with public and state input.

Sec. 224. Process for adoption of recommendations; adoption of benefit standards.  Secretary has 45 days from receiving the recommendations of the Health Benefits Advisory Committee to adopt the recommendations or explain why the recommendations will not be adopted.  Specifies Secretary will follow the rule making process with public disclosure

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