Truth about the Senate and House health plans

There is a lot of misinformation about the proposed health reform plans. To get the truth, click on this link:

http://www.nytimes.com/interactive/2009/11/19/us/politics/1119-plan-comparison.html#tab=0

Three out of five Conference Board economic indicators are postive

The Conference Board reports that three out of five indicators of the state of the economy it tracks were positive last month. The Employment Trends index is particularly important because it suggests that hiring should begin again early in 2010.

Click on the indicators to go to the Conference Board site for more information

U.S. Indicators

Consumer Confidence
Index®
5.7 pts

U.S. Leading Index
1.0%

Help-Wanted Online
83,200

Employment Trends Index
0.7%

CEO Confidence
8.0 pts

Budget reconciliation—The Democrats’ final option on health reform

Senator Joe Lieberman (I, CT) announcement that he was prepared to join with Republicans to filibuster health reform that contained a public option makes Senate Majority Harry Reid’s task of rounding up 60 votes to pass health reform in the Senate much more difficult. So, without Lieberman is health reform dead? No. The Democrats are prepared with an option that will allow them to pass health reform with as little as 51 votes in the Senate by using something called “budget reconciliation.” This past summer the Democrats wrote into the budget rules that anytime after October 15th they could use the reconciliation procedure to pass health reform if they chose.

The Senate rules allow reconciliation on matters that pertain to the budget which are considered as too important to be weighed down by partisanship, which of course health reform is. Since reconciliation bills must pertain to the budget, the Senate is not allowed to use them for matters that would set policy. That would appear to require Democrats to strip out of the health bill important provisions such as consumer protections that are not related to the budget in order to use the reconciliation process.

For this reason, some lawmakers have warned that a reconciliation health bill would have to leave out important provisions (such as consumer protections), resulting in the need to have two health bills, one containing the budgetary items and passed under reconciliation and the other dealing with non-budgetary and non-controversial items. Congressional staff are already working on splitting the bill. Of course the non-budgetary health bill would require 60 votes which might be difficult to obtain. Additionally, if getting one health bill through the Senate is hard, getting two bills through the Senate this year is probably impossible.

So, if health reform dead? Nope. The Democrats have third option if they can’t get 60 votes on the health bill. Here is how it would work.

The requirement that reconciliation bills deal strictly with budgetary matters is called the Byrd Rule. The Democrats could attempt to get 60 votes to waive the Byrd Rule thus allowing them to pass the health reform bill including the non-budgetary items with just 51 votes.

You may ask why Senators Lieberman, Mary Landrieu, Ben Nelson and Olympia Snowe would vote to waive the Byrd Rule when they would not vote for the health bill. The answer is that the non-budgetary items that would have to taken out of the health bill under the Byrd Rule are very, very popular among Democrats, independents and even many Republicans. These include insurance reforms such as not allowing insurance companies to use preexisting conditions to deny coverage or drop coverage when people get sick. It would be much easier to get 60 votes to support including these popular reforms in the bill rather than the public option. Conservative senators could vote to support the popular reforms but still vote against the final bill.

As they say, there are multiple ways of skinning the health reform cat. Democrats may just have found another one.

Health reform and the Ordinal Fallacy--Why delaying health reform is a bad idea

The Conduct of Inquiry by Abraham Kaplan is one of the books that had the greatest influence on my thinking about life, politics, leadership and human behavior. Among the others are Human Competence by Thomas F. Gilbert, Management: Task, Responsibilities, Practices by Peter F. Drucker, and Leadership by James MacGregor Burns. Kaplan’s place on this list is due to his discussion of something he calls the “ordinal fallacy” which is highly relevant to our current discussion of health reform.

In his book, Kaplan discusses a debate between scientists over the proper role of behavioral science in shaping public policy. Some argued at the time (this was 1964) that science should be divorced from policy because behavioral scientists “never know enough, or with enough certitude, to proved a scientifically valid basis for adopting one policy rather than another.” Kaplan admits that this is true. He writes, “what we actually know with confidence about human behavior is pitifully little compared with the magnitude and complexity of the problems confronting us…more research will always be needed, at least research into the particularities of specific concrete situations.” On the other hand, says Kaplan, those who would argue that science has no role in shaping public policy because of this lack of certainty are mistaken.

“It is not required that we know everything, but only that we know something relevant. A scientific approach does not suddenly come into being at the magical moment when we know ‘enough’; such moments never arrive. To await them constitutes what I have called the ‘ordinal fallacy’: first this, then that—first I will achieve power, then use if for the public good; first I will master my medium, then use it to say something significant; first I will pursue wealth, then use it in the pursuit of happiness. And as in politics, art, and morality, so here—first I will acquire the knowledge, then use it as a basis for sound policy. But whether it be due to human failing or to the human condition, we must do as we aspire from the beginning, or else resign ourselves to not doing at all…We are playing lightning chess—with this difference, that if we stop to analyze all the variations the move will be made for us, and with supreme indifference to its outcome.”

In the current debate over health reform, there are those who say “wait.” They argue that the Democrats and the Obama administration are moving too fast, that we should take more time and “get it right.” We should do nothing or very little now in the hope that next month, next year or next decade we will find the perfect answer and be able to draft the perfect health policy. However, to wait is to commit the ordinal fallacy since we will never know the perfect way to reform health care in this country. We can never be certain that any particular policy we adopt will fix the health care problem. What we can know with certainty is that health care will be reformed. Doing nothing doesn’t mean that nothing about our health delivery system or access to care will change. It will. We can use the incomplete knowledge we have and intervene now to reform America's health care system and hopefully direct it along a better path or we can commit the ordinal fallacy and thereby allow forces with a supreme indifference to our welfare control our destiny. It’s our choice.

A Public Option NO/Nothings and even Lieberman should love

Is it possible to design a public option that would guarantee state-subsidized insurance to everyone in the country between the ages of 19 and 64 that would be acceptable to NO/Nothings, Joe Lieberman, Blue Dog Democrats and progressives including the Attack Democrat? Maybe.

How about a plan that offers a health insurance benefits package to uninsured adults of all incomes -- from young people just out of school to early retirees; has affordable monthly premiums, based on income, and a full range of coverage, including preventive care, emergency room and hospital visits, primary care and specialist physicians, pharmacy, behavioral health services and prescription medications; and is a government-sponsored, government-subsidized and government-administered health coverage program but one that contracts with private insurers as managed care organizations to coordinate the benefits, enroll and set rates with providers, and pay for the services?

Such a plan exists in Joe Lieberman’s home state of CT and was signed into law by a Republican governor. Under the plan a family of four with annual income under $33,075 gets coverage for $75 per month per person with a $150 individual and $300 family deductible. A family of four with annual income over $66,150 gets coverage for $259 per month per person with a $900 individual and $1,750 family deductible.

Read more about the plan at:

http://www.charteroakhealthplan.com/coh/site/default.asp

Of course this type of plan would need some tweaking. Under the CT plan, you have to be without health insurance for six months. We would need to eliminate the wait and let anyone who was uninsured or who couldn’t get affordable coverage apply right away. And, we would want to lift the lifetime maximum that is just $1 million in the CT plan. Still, it would be a starting point and would be something Lieberman and the NO/Nothings couldn’t oppose…..well, let’s say “shouldn’t oppose” because as we know they find a way to oppose everything. How could the keep the name “NO/Nothing,” if they ever even said “Maybe/Something?”

So, forget this post. Sorry I brought it up. Let’s scrap everything and just enroll everyone in Medicare.

One step closer to health reform

Congratulations to Speaker Pelosi, President Obama, the House leadership and House Democrats for an historic achievement in passing bipartisan legislation to reform health care and doing it with votes to spare.

The bill isn’t perfect. The abortion funding restrictions inserted at the last minute are much to severe and an insult to American women. The public option is much weaker than it needs to be. Hopefully both of these weaknesses and others can be corrected at a later date. For now, Americans should celebrate. It has taken more than 100 years but we are finally moving in the direction of providing affordable health insurance to all Americans, not just seniors. The House bill will also lower the deficit and begin to bend the health insurance cost curve if only a little.

Now on to the Senate. Senator Reid has said he hopes to bring the Senate Health reform bill to the floor before Thanksgiving. If he can, there is hope that President Obama might be able to sign health reform into law by the end of the year.

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.

TITLE III—SUBTITLE B: PUBLIC HEALTH OPTION

Subtitle B—Public 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.

THE lesson from yesterday's elections--It's Jobs Stupid

What is the message for Democrats from the New Jersey and Virginia elections yesterday? Simple.

IT’S JOBS STUPID

Here is a prediction. Either the Democrats and Obama get their acts together and stimulate the economy enough to bring unemployment down FAST and get it down to under 8 percent by next fall or they LOSE big time in next year’s elections. It’s that simple.

Health reform doesn’t matter. Get something passsed on health care, anything and get on to job creation. Afghanistan doesn’t matter. Make a decision, any decision that will get the most American troops as possible out of harms way and get the topic off the blogs.

Focus on what matters. And, NOTHING MATTERS but JOBS, JOBS, JOBS, JOBS, JOBS, JOBS, JOBS, JOBS, JOBS, JOBS, JOBS, JOBS.

I know, the American people don’t have an appetite for another stimulus package and the Republicans are already yelling and screaming about the deficit so a second stimulus is a hard sell. Well, don’t call it a stimulus and don’t try to pass another big package. Scrape up whatever money you can find in the budget and throw it at job creation. Find Republican and Blue Dog Democrat projects they want for their home states and districts that will quickly create jobs and pass laws giving them their projects provided they get rolling and creatng jobs FAST. Offer them some tax incentives for all those small business owners provided the incentives get spent creating new jobs in the first half of next year. Do something and do it FAST.

Think--Works Progress Administration--find the money and do it FAST.

I repeat:

IT’S JOBS STUPID

Summary of Title III-Subtile A of House Health Bill

TITLE III—HEALTH INSURANCE EXCHANGE AND RELATED
PROVISIONS
Subtitle A—Health Insurance Exchange

Sec. 301. Establishment of Health Insurance Exchange; outline of duties; definitions. Creates a Health Insurance Exchange with the Heath Choices Administration.

Sec. 302. Exchange-eligible individuals and employers. Specifies who is eligible to obtain insurance through the exchange. There is a three year transition period. The first year of the program will be 2013. In that year, individuals without health insurance through an employer will have access to the exchange along with the smallest employers (employers with 25 or less employees.) In 2014, the exchange is expanded to add in employers with 50 or less employees. In 2015 and beyond, the exchange is further expanded to in the larger employers – employers with more than 50 employees.

The section goes on to outline the health benefits programs that will be available on the exchange:
•Qualified health benefits plans, as discussed in earlier.
•Grandfathered programs (programs already in existence prior to the start of the health exchange as discussed in the post covering Title II.
•Part A of Medicare
•Medicaid
•Health coverage given to members of the armed forces
•Veterans Administration coverage
•Other coverage such as state high risk pools, so long as they are approved by the Commissioner

Sec. 303. Benefits package levels. Specifies four levels of plans that can be offered in the Exchange: Basic, Enhanced, Premium and Premium Plus. The first three differ in that each additional level lowers cost sharing. The Premium Plus plan offers additional benefits such as dental and vision. The Commissioner oversees the plans offered and must approval future premium increases.

Sec. 304. Contracts for the offering of Exchange-participating health benefits
plans. The Commissioner is given authority to enter into contracts with insurance companies to offer plans in the Exchange. He can also enter into a contract under this subsection with a QHBP offering entity for the offering of health benefits plan with the same benefits in every State so long as such entity is licensed to offer such plan in each State and the benefits meet the applicable requirements in each such State. This would allow insurance companies to sell plans across state lines, i.e., nationally.

Sec. 305. Outreach and enrollment of Exchange-eligible individuals and employers
in Exchange-participating health benefits plan and Sec. 306. Other functions. Allows the Commissioner to advertise the Exchange, define the enrollment process, create enrollment periods and so on. Largely technical.

Sec. 307. Health Insurance Exchange Trust Fund. Establishes a Trust Fund to pay for operation of the Exchange. The Trust Fund is funded from fines/taxes levied on people and companies who fail to meet the requirements of the health insurance mandates for coverage This includes the penalties paid by people who fail to get coverage (mandated coverage), employment taxes levied against companies who elect not to provide health coverage when they are obligated under this law to do so, and certain excise taxes levied against those who fail to meet certain health coverage requirements. These taxes and penalties will be collected by the IRS, and used to reduce the amount the federal treasury has to give the health exchange to operate.

Sec. 308. Optional operation of State-based health insurance exchanges. A state or group of states can set up their own Exchanges with approval of the Commissioner. It a state or group of states set up their own Exchanges, they will not have to participate in the national exchange.

Sec. 309. Interstate health insurance compacts. Effective January 1, 2015, 2 or more States may form Health Care Choice Compacts to facilitate the purchase of individual health insurance coverage across State lines.

Sec. 310. Health insurance cooperatives. Not later than 6 months after 15 the date of the enactment of this Act, the Commissioner, 16 in consultation with the Secretary of the Treasury, shall establish a Consumer Operated and Oriented Plan program under which the Commissioner may make grants and loans for the establishment and initial operation of not-for-profit, member–run health insurance cooperatives that provide insurance through the Health Insurance Exchange or a State-based Health Insurance Exchange

Sec. 311. Retention of DOD and VA authority. This section does not affect DOD or VA authority over armed forces and veterans health plans.

The Republican health reform plan—It's strictly a political gesture, just like always.

After all these months the Republican No/Nothings are said to be preparing their own health care reform bill to counter the Democratic proposals. We shouldn’t expect much. The late minute discovery by the Republicans that they need to offer some kind of alternative plan reminds me of the Medicare debate in 1960. After opposing all Democratic proposals for health insurance for the aged, indeed all forms of universal health insurance, the Republicans found themselves in a bind. It was a presidential election year and Medicare was becoming the number one domestic issue. Vice President Nixon who was running for the presidency and his supporters were terrified that the lack of a Republican plan for addressing an important public concern might threaten their chances of election. Finally, President Eisenhower, who had resisted all proposals for health insurance for the aged including those put forward by his own Secretary of HEW, finally agreed to have a Republican plan for Medicare introduced in the Senate by Senator Levertt Saltonstall (R, MASS). Essentially the plan offered only a modest expansion of existing public assistance programs for the aged. Columnist Edward Chase wrote: “It is hard to escape the conclusion that the [Republican] plan is strictly a political gesture, reluctantly taken to ease the politically untenable situation into which sheer negativism had placed the party.” We’re seeing the same thing from the No/Nothings this time around.

The Final House Bill--Title II--Subtitles D, E & F

Here is a summary of the remainder of Title II of the House health reform bill that I did not cover in my previous post.

TITLE II—PROTECTIONS AND STANDARDS FOR QUALIFIED
HEALTH BENEFITS PLANS


Subtitle D—Additional Consumer Protections

Sec. 231. Requiring fair marketing practices by health insurers. The Commissioner shall establish uniform marketing standards all Qualified Health Benefits Providers (QHBP0 (in Exchange) must meet.

Sec. 232. Requiring fair grievance and appeals mechanisms. QHBP’s must provide timely grievance and appeals procedures including internal and external reviews.

Sec. 233. Requiring information transparency and plan disclosure. Requires QHBP’s and employer-based health plans to provide accurate and timely disclosure of plan documents, terms, conditions, claims payment polices, periodic financial disclosure, data on enrollment, claim denials, etc. Disclosures must be in plain language. Private information must be protected.

Sec. 234. Application to qualified health benefits plans not offered through the
Health Insurance Exchange. Application of this sub-titled to health insurance providers not participating in the exchange is up to Commissioner.

Sec. 235. Timely payment of claims. QHBP’s must comply with Medicare standards for timeliness of payment of claims.

Sec. 236. Standardized rules for coordination and subrogation of benefits. Commissioner to set rules for coordination of benefits involving individuals with multiple insurance plans.

Sec. 237. Application of administrative simplification. QHBP’s must comply with administrative simplification procedures of Medicare.

Sec. 238. State prohibitions on discrimination against health care providers. This act does not supersede state laws dealing with discriminatory practices when it comes to health insurance.

Sec. 239. Protection of physician prescriber information. Orders Sec of Health and Human Services to conduct a study and make recommendations to Congress on the use of physician prescriber information in sales and marketing practices of pharmaceutical manufacturers.

Sec. 240. Dissemination of advance care planning information. QHBP’s shall for the dissemination of information related to end-of-life planning to enrollees as an option. The information presented to the enrollee shall not presume the withdrawal of treatment and shall include options to maintain all or most medical interventions. No one can be required to complete an advanced directive or any other end-of-life planning document. No one may be required to consent to a restriction in the amount or scope of treatment. Nothing in this section shall be construed to promote suicide, assisted suicide, euthanasia, or mercy killing. This section does not preempt state law.

Subtitle E—Governance [In general this subtitle sets up office of Health Choices Commissioner to administer the health insurance exchanges and establishing qualified plan standards.

Sec. 241. Health Choices Administration; Health Choices Commissioner. Establishes Health Choices Administration in Executive Branch headed by Health Choices Commissioner

Sec. 242. Duties and authority of Commissioner. Spells out the duties of the Commissioner to operate the Health Insurance Exchange, conduct compliance examinations and audits, etc.

Sec. 243. Consultation and coordination. Commissioner is to coordinate his activities with State Attorneys General, National Association of Insurance Commissioners, appropriate State agencies, FTC, other Federal agencies and Indian tribes.

Sec. 244. Health Insurance Ombudsman. Creates ombudsman to receive complaints and assist individuals seeking information about the Health Insurance Exchange.

Subtitle F—Relation to Other Requirements; Miscellaneous
Sec. 251. Relation to other requirements. Does not supersede other state or Federal requirements for insurance providers not operating through the Exchange or offering employer-based plans.

Sec. 252. Prohibiting discrimination in health care. All health care and related services covered by the Act shall be provided without regard to personal characteristics extraneous to the provision of high quality health care or related services.

Sec. 253. Whistleblower protection. Whistleblowers cannot be discriminated against.

Sec. 254. Construction regarding collective bargaining. Doesn’t supersede collective bargaining agreements.

Sec. 255. Severability. If any provision of the Act is found unconstitutional, the remainder of the Act is not affected.

Sec. 256. Treatment of Hawaii Prepaid Health Care Act. Doesn’t supersede Hawaii Prepaid Health Care Act.

Sec. 257. Actions by State attorneys general. State attorneys general may bring civil actions in the name of the state on behave of natural persons residing in the state.
Sec. 258. Application of State and Federal laws regarding abortion. This Act does not supersede or change any existing state or Federal law regarding abortion nor rights and obligations of employees and employers under title VII of the Civil Rights Act of 1964.

Sec. 259. Nondiscrimination on abortion and respect for rights of conscience. Outlaws discrimination by any Federal, State or local agency that receives Federal financial assistance under the Act against any individual or agency for NOT providing, paying for or covering abortion including individual physicians, health care professionals, hospitals, health insurance plan and so on.

Sec. 260. Authority of Federal Trade Commission. FTC will prepare reports and studies to share information about the business of health insurance.

Sec. 261. Construction regarding standard of care. The development, recognition or implementation of any guideline or other standard under a provision of this subsection shall not be construed as establishing a standard of care or duty of care by health care providers to their patients in any medical malpractice action or claim.

Sec. 262. Restoring application of antitrust laws to health sector insurers. Ends health insurance industry’s exemption from antitrust laws.

Sec. 263. Study and report on methods to increase EHR use by small health care providers. The Secretary is to study potential methods for encouraging the increased use of electronic medical records through such means as providing higher rates of reimbursement to providers who use electronic records, promoting development of low-cost electronic record software, training and education on use of electronic health records, and providing assistance to providers in implementation of electronic health records. By December 31, 2013, the Secretary is to make recommendations to Congress on legislation and administrative actions needed to increase the use of medical records.

Truly fair and balanced news shows

Check on this page for links to truly fair and balanced news shows as a welcome relief to the biased coverage of Fox News.

Orin Hatch: The diabolical Democrats will destroy the two-party system

No/Nothings continue to try to trump each other in who can make the dumbest comment about health care reform.  Today it’s Orin Hatch’s turn.  Hatch (R-UT) in an interview with CNSNews says we should oppose health care reform because it threatens the two-party system.  Reform, Hatch said, is a diabolical effort on the part of the Democratic Party to destroy the two-party system by giving Americans what they want.  “And if they get there [pass reform] then of course you're going to have a rough time, you're going to have a very rough time, having a two-party system in this country. Because almost everybody's going to say all we ever were, all we ever are, all we ever hope to be depends on the Democratic Party.”

See the video here: http://www.youtube.com/watch?v=xLx6R0OZ28s&feature=youtube_gdata

So, health care reform will not only destroy private insurance but it will destroy the two-party system.  Democrats please stop trying to make voters like you.  You know there is no way NO/Nothings can compete with a party that actually does something to make the lives of Americans better.  How diabolical.

House Final Bill TITLE II—PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS

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

Subtitle A—General 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 B—Standards 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 C—Standards 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