Reading the ACA, part 2

Another ACA post, brought to you while we borrow internet so my host sister can work on TOEFL prep. If this doesn't interest you, please ignore!

July 14, 2014

Day Two. I actually kind of enjoyed my efforts of Day One, so I’m feeling positive going into an amendment to the Public Health Service Act. Let’s get to it!

This is part of that section that prohibits insurers from refusing to provide coverage for pre-existing conditions. From my recollection, this was a huge deal. This part also talks about how insurance eligibility can’t be affected by:

-       health status

-       medical condition (physical and mental)

-       claims experience

-       receipt of health care

-       medical history

-       genetic information

-       evidence of insurability (including conditions arising out of acts of domestic violence)

-        disability

-       anything else the secretary says

These factors also apply to continued eligibility. So if I’m eligible one year and am diagnosed with a chronic condition, my insurer can’t boot me the next year.

I think the domestic violence notation is particularly interesting. I suppose this means that if someone experiences intimate partner violence and can’t access her or his home to get insurance information, she or he can’t be determined ineligible. Does that seem right?

Page 91 includes talk about wellness programs. They’re not allowed to be “a subterfuge for discriminating based on a health status factor” or “highly suspect” in their methods. I’m digging the sinister language. SUBTERFUGE.

Some kind of 10-state demonstration of wellness programs should have started by July 1 of this year. Or a demonstration of states applying the provisions to existing health-promotion programs? I’m not entirely clear on what’s being demonstrated on p. 93.

Bronze, silver, gold and platinum plans: These designations refer to how much the health care benefits are worth (compared with the actual cost of services). For bronze it’s 60 percent, for silver it’s 70, gold is 80 and platinum is 90. From what I can tell, catastrophic plans are allowed if you meet certain criteria (younger than 30 and poor, it appears).

Abortions: not paid for by federal funds, ever. It looks like insurance companies aren’t required to pay for them, but I need to verify with section 1303 and the “special rules.” I know the U.S. pays for them for military members in case of rape. I’m not sure what the rest of the rules are. But as always, in general, no abortion funding.

It looks like states can make their own abortion rules for community health insurance plans, as long as no federal funding goes to them.

Something funny is happening on page 124. This is an amendment about optional services, and it says the secretary, when estimating basic costs, can’t take into account “any cost reduction estimated to result from such services, including prenatal care, delivery or postnatal care.” What I’m getting is that the secretary isn’t allowed to look at the future benefits of having insurance coverage for these “extra” services. Right? My brain flagged this because it seems to suggest that even when there’s good scientific evidence about future benefits of investing in care now, the government can’t calculate them in looking at costs of service.

BUT this is referring to actuarial costs (remember how “actuary” is always the No. 1 job on those “best jobs” lists?), so maybe this is more about accounting rules than public health.

As everyone probably knows, these exchanges are called American Health Benefit Exchanges. Another program exists to help small businesses, the Small Business Health Options Program (SHOP, naturally).

Note: insurers aren’t allowed to market their plans in such a way that would discourage people with significant health needs from enrolling. Insurers are also supposed to include providers in their network who serve low-income, medically underserved people. Sounds like a good thing.

Also, the much-talked-about government portal for insurers is supposed to allow us to compare plans based on ratings by those enrolled.

Plans should have annual enrollment periods (with exceptions), as employer-provided insurance typically does. If you’re an American Indian, there are special monthly enrollment periods for you.

Exchanges have to be government agencies or nonprofits established by states. I’m trying to determine whether there are other examples of the latter bit. Is it common? What other nonprofits are established by states?

Dental insurers are allowed to offer their plans through the exchanges, as long as they provide pediatric dental benefits.

Several sections have discussed “child-only plans” for those younger than 21. I think insurers are required to provide these plans, but I’m not sure why. So parents have to get full insurance for their kids even if they themselves qualify for catastrophic? Must investigate.

State power: States can require their insurers to provide additional benefits, but they have to work to defray the cost to the consumer.

The health exchanges are supposed to be self-sustaining as of Jan. 1, 2015.

On p. 144, the measure states that health exchanges “shall not utilize any funds intended for the administrative and operational expenses of the Exchange for staff retreats, promotional giveaways, excessive executive compensation, or promotion of Federal or State legislative and regulatory modifications.”

That’s kind of specific, right? I totally feel like government agencies would justify using their proceeds on “staff retreats.” And I wonder what determines “excessive executive compensation”? I suppose you’d have to be called out on this to get caught. Also, the exchanges are supposed to report “monies lost to waste, fraud and abuse” on their Internet websites.

Health plans must justify premium increases before they’re implemented, and they have to “prominently post” the increases on their websites.

If you’re in jail or in the U.S. illegally, you’re excluded from all of this.

OK, that’s all for today! I wanted to hit 80 pages since I could feel my momentum waning. There was some interesting stuff today, though I wouldn’t call any of it surprising.

We’re ending on p. 161, at “Sec. 1313. Financial Integrity.” Are you as excited as I am? (Here’s a preview: exchanges are supposed to do accurate accounting. THE FUN NEVER STOPS.)