Thursday, November 5, 2009

Summary of Title III-Subtitle B of House Health Bill

Here is a summary of the provisions for the PUBLIC OPTION in the House plan. As you read the actual wording you will find yourself wondering what all the fuss has been about.


Subtitle BPublic Health Insurance Option

Sec. 321. Establishment and administration of a public health insurance option as an Exchange-qualified health benefits plan. Establishes a public health insurance option that can only be sold through the Exchange. The public option “shall comply with requirements that are applicable under this title to an Exchange-participating health benefits plan, including requirements related to benefits, benefit levels, provider networks, notices, consumer protections, and cost-sharing. The public option must offer basic, enhanced and premium plans and MAY offer premium-plus plans.

Sec. 322. Premiums and financing. The Secretary shall establish geographically adjusted premium rates consistent with the requirements of Exchange-participating plans and the rates MUST be at a level to fully finance the costs of health benefits provided and administrative costs. The public option gets $2 billion of start-up funding from the Treasury which must be paid back to the Treasury over 10-years. The public option is to receive no additional funding and cannot receive a bailout such as under a program like the Troubled Assets Relief Program.

Sec. 323. Payment rates for items and services. The Secretary will negotiate payment rates with providers that cannot be lower than Medicare rates nor higher than the aggregate of average rates paid by private insurers in the Exchange. The provider network will consist of Medicare providers unless they choose to opt out. Providers have at least 1-year to opt out and cannot be penalized for doing so. Providers who opt out will be allowed to opt back in.

Sec. 324. Modernized payment initiatives and delivery system reform. The payment mechanisms and policies under this section may include patient-centered medical home and other care management payments, accountable care organizations, value based purchasing, and bundling of services, differential payment rates, performance or utilization based payments, partial capitation, and direct contracting with providers. These options may vary by geographic area.

Sec. 325. Provider participation. Providers must be licensed, certified, or otherwise permitted to practice under state law to be public option providers. There will be Preferred Physicians (PPO), non-preferred providers who agree to not impose charges that exceed the sum of in-network cost sharing plus 15 percent, and Other providers who agree to accept the payment under Section 323 as payment in full. Providers excluded from participating in Medicare are excluded from participating in the public option.

Sec. 326. Application of fraud and abuse provisions. Waste, fraud, and abuse provisions of Medicare apply to the public option.

Sec. 327. Application of HIPAA insurance requirements. Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) required the Department of Health and Human Services (HHS) to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. The public option must abide by these rules.

Sec. 328. Application of health information privacy, security, and electronic transaction requirements. Privacy and wrongful disclosure rules of Medicare apply to the public option as they do to private insurance plans participating in the Exchange.

Sec. 329. Enrollment in public health insurance option is voluntary. No one can be required to enroll in the public option.

Sec. 330. Enrollment in public health insurance option by Members of Congress. Members of Congress can enroll in the public option

Sec. 331. Reimbursement of Secretary of Veterans Affairs. Veterans Affairs will be reimbursed for the cost of non-service-connected care or services provided by Veterans Affairs to an individual covered under the public option.

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