Jackson Jambalaya

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Here is today's reading the health care bill. Feel free to clarify or make serious comments about the bill. If corrections are needed or the wrong interpretation is used, feel free to point it out as I'm no authority on this subject by any stretch of the imagination. Fire away.

Page 104. Section 1302: Essential Health Benefits Requirements. Section (b)(1) on page 105 states the following benefits will be included in every plan: Emergency services, hospitalization, maternity and newborn care, mental health and substance abuse treatment, ambulatory patient services, prescription drugs, rehab services and devices, lab services, preventative and wellness services, chronic disease management, and pediatric services. Pediatric services MUST include oral and eye care.

Section (A) on page 106 states the "scope" of the benefits mandated by this section must be equal to the "scope" of the benefits provided under the "typical" employer plan. Who shall determine what is "typical? Why the government of course. It will take a survey of all plans and ensure your plan conforms to the norm.

Section (4)(B) on page 107 states the government will not base use age, disability, or expected length of life in determining coverage, premiums, or benefits.

Once again, the out-of-network issue rears its head. (ii) on page 108 states "is such services are provided out-of-network, the cost-sharing requirement (expressed as a copayment or coninsurance rate) is the same requirement that would apply if such services were provided in- network". So does that mean health insurers can no longer limit coverage or how much they will pay if you use out-of-network services?

Limits are placed on deductibles. A deductible can not exceed $2,000 for an individual plan or $4,000 for all other plans. This can be adjusted if it affects the "actuarial value" of the plan. Huh? Cost-sharing is defined as well. The law defines its as any deductible, copay, coninsurance, or payment made by anyone for a "qualified medical expense" but does not include premiums.

There will be levels of plans (page 114) and to show the government is actually creative, they are called bronze, silver, gold, or platinum. Each level is determined by the percentage of benefits that are covered under the plan as compared to their full value.

Bronze: Plan covers 60% of the full value of the benefits.
Silver: Plan covers 70% of the full value of the benefits.
Gold: Plan covers 80% of the full value of the benefits.
Platinum: Plan covers 90% of the full value of the benefits.

Section (e) on page 116 covers catastrophic plans. It says such plans are qualified if the only people allowed to enroll in them are under the age of 30. It must also offer coverage for three primary care visits. Suppose you are a lawyer, 6 years out of law school, have your own practice, and want to just carry catastrophic coverage but are 33 years old. You will be out of luck and unable to purchase a catastrsophic plan.

Section (f) on page 118 also requires the insurer to offer a "child-only plan" for those under the age of 21 if it offers a regular plan as well.

Copy of Bill