Category Archives: Healthcare

A Common Gal Looks at ObamaCare, Part 7: Limits on Losing Coverage

A Common Gal Looks at ObamaCareI’m reading up on The Patient Protection and Affordable Care Act (PPACA, aka “ObamaCare”). That includes the act itself, amendments passed shortly afterward, and the recent Supreme Court ruling. It’s a lot of pages (906, 55, and 193 respectively), but I want to understand it. I’m documenting my read-through here. I am not a lawyer or a healthcare professional, just a common college-educated person. These are my thoughts, not advice to you. Read the act yourself like the free person you are. ;o).

No-No’s on Rescinding Coverage

The Patient Protection and Affordable Care Act (PPACA) has protections against the insurer yanking away coverage for no good reason. This is called “prohibition on rescissions.”[1] But there are limits. Your coverage CAN be rescinded if you:

  • Use fraud, and/or
  • Intentionally misrepresent material facts as prohibited by the plan or coverage. (Why do they use blah-blah language like this? What’s the difference in “plan” and “coverage”? Meh.)

They also have to give you prior notice. (I didn’t see any details yet about how MUCH prior notice, however.)

Notice that is ONLY talking about coverage being “rescinded[2]” (terminating the contract for insurance coverage from the beginning, as if the policy had never been issued) – it doesn’t mention cancelling your policy going forward from a certain date, or just failing to renew coverage. (Slippery dudes, aren’t these legislators.)

The way I’m reading “rescission” (the act of rescinding), it refers to the insurance company playing “take-back”: You get your premiums refunded, but you have to give back what benefits you got under the policy, as in anything the policy paid during that coverage period to your doctor, hospital, etc. Yikes.

No-No’s on Cancelling Coverage

Rescinding your coverage isn’t the only way your insurance company can give you the kiss-off: It can also cancel or fail to renew your coverage for certain reasons. For details on this, the PPACA points to two specific sections of ye olde Public Health Service Act: Section 2702(c) and Section 2742(b).  I wavered over a momentary impulse to tear at my hair at the thought of undergoing the tortuous (to me) process of looking something up in that gigantic act again, but I found a different and delightfully authoritative source without having to go bald in fits and snatches. The Internet is my SAVIOR sometimes.

Instead of locating those original texts, I cheated and read summaries in the Federal Register, which said, “These provisions generally provide that a health insurance issuer in the group and individual markets cannot cancel, or fail to renew, coverage for an individual or a group for any reason other than those enumerated in the statute.”

The Register then was nice enough to summarize those reasons, so here you go.

Why your insurer CAN cancel your butt (or fail to renew your policy covering said butt):

  • Nonpayment of premiums
  • Fraud or intentional misrepresentation of material fact
  • Withdrawal of a product or withdrawal of an issuer from the market (I assume this means their company no longer offers that kind of insurance … or the company itself withdraws from the market. You agree?)
  • Movement of an individual or an employer outside the service area
  • Cessation of association membership (applies to bona fide association coverage only)

For overachievers: You don’t have to hit all of these; one is enough.

Bona Fide Associations

That last one threw me for a loop. (The word “bona fide” always makes me giggle and think of Jethro Bodine trying to sound fancy about ciphering and such.) So I looked it up, with the help of our recurring guest, that good ol’ attention whore, the Public Health Service Act.[3] Basically, it just means groups that are formed for legit reasons, not solely to glom onto some insurance coverage. See details below if you want the fancy lawyer talk.

When you’re talking about a state’s health insurance coverage, a bona fide association has to meet all six of these criteria:

  • Has been actively in existence for at least five years;
  • Has been formed and maintained in good faith for purposes other than obtaining insurance (emphasis mine)
  • Does not condition membership in the association on any health status-related factor relating to an individual (including an employee of an employer or a dependent of an employee);
  • Makes health insurance coverage offered through the association available to all members regardless of any health status-related factor relating to such members (or individuals eligible for coverage through a member);
  • Does not make health insurance coverage offered through the association available other than in connection with a member of the association; and
  • Meets such additional requirements as may be imposed under State law.

I’m going to go soothe my brain with a well-earned diet Coke now.

Other Posts on ObamaCare:

  • Part 1: Intro
  • Part 2: Types of coverage, no discrimination
  • Part 3: Exchanges and what they do
  • Part 4: Your cost limits and adjustments
  • Part 5: Deductibles and preventive care
  • Part 6: Four levels of coverage

Footnotes! We Have Footnotes!


[1] Section 2712.

[2] I don’t usually cite Wikipedia because, well – ew – but it can contain some good general information. This discussion of “rescission” (the act of rescinding) aligns with other definitions I read online and is much easier to read than most: http://en.wikipedia.org/wiki/Rescission.

[3] See Title XXVII of the Public Health Service Act, SEC. 2791. [42 U.S.C. 300gg–91] Definitions, (d)(3). You can find it here: http://www.nadp.org/Libraries/HCR_Documents/phsa027.sflb.ashx.

8 Comments

Filed under Healthcare, Politics

A Common Gal Looks at ObamaCare, Part 6: Four Levels of Coverage

A Common Gal Looks at ObamaCareI’m reading up on The Patient Protection and Affordable Care Act (“ObamaCare” … although I supposed I really should start using the real acronym, PPACA, instead of the nickname conservatives gave it). That includes the act itself, amendments passed shortly afterward, and the recent Supreme Court ruling. It’s a lot of pages (906, 55, and 193 respectively), but I want to understand it. I’m documenting my read-through here. I am not a lawyer or a healthcare professional, just a common college-educated person. These are my thoughts, not advice to you. Read the act yourself like the free person you are. ;o).

Different levels of healthcare coverage are defined in the Affordable Care Act: bronze, silver, gold and platinum.[1]

Fretful writer side note: I wish that authors of legislation (and authors in general) would get more original than using metals or jewels (*yawn*) to create memorable scales of intensity. Why not go with increasingly hard woods? Balsa, Magnolia, Pecan, Ebony. Besides, I’d love to hear a Republican defend a “balsa plan” as being good enough for the poor — or see a white conservative gladly signing on for an “ebony plan.”

Ahem. Anyway …

I attempt to translate legalese into people-speak, below. Note that “actuarial value” means “the percentage of total average costs for covered benefits that a plan will cover.” So if your plan has an actuarial value of 70%, then you have a 70/30 plan (you pay the 30% for all covered benefits). (Thank you, healthcare.gov, for coming to my rescue again with your understandable definitions.)

Levels of Coverage

Level of Coverage What They Say What I Think It Means(WHY don’t they just write it this way?)
Bronze A plan in the bronze level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 60 percent of the full actuarial value of the benefits provided under the plan. Your bronze plan gives you 60/40 coverage.
Silver A plan in the silver level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 70 percent of the full actuarial value of the benefits provided under the plan. Your silver plan gives you 70/30 coverage.
Gold A plan in the gold level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 80 percent of the full actuarial value of the benefits provided under the plan. Your gold plan gives you 80/20 coverage.
Platinum A plan in the platinum level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 90 percent of the full actuarial value of the benefits provided under the plan. Your platinum plan gives you 90/10 coverage.

 

So, basically, every state that manfully sucks up its frothing “states rights” outrage and signs on for the Affordable Care Act has to run the gamut from bronze to platinum coverage.

Why Have Levels?

I did a cursory search through the act to get a sense of why these definitions are needed. I think it is because states need to provide healthcare plans with different levels of coverage. If you choose to get less (bronze, 60/40 coverage), you pay less. This makes healthcare more affordable for poor people, gives them options to choose, and probably reduces the cost of coverage in general for the state because some people will choose the cheaper levels.

Health Savings Accounts Can Be Considered

The Secretary of Health and Human Services has the option of considering the money your employer pays into health savings accounts[2] when “determining the level of coverage for a plan of the employer.” Here’s what I *think* that means: If you choose to use a health savings account, whatever the company pays into that account for you will count toward the employer’s contribution for your health insurance. Now that’s cool. I didn’t even know employers COULD pay into your health savings account.

Healthcare.gov explains that a health savings account lets taxpayers squirrel away some pre-tax money to use for qualified medical expenses. Funds roll over each year if you don’t spend them (unlike a flexible spending account).

Meh, Just Come Close

There can be “allowable variance” in the bronze, silver, gold, and platinum plans’ coverage as long as the variations aren’t big[3]. For example, instead of the bronze plan offering 60/40 coverage in your state, it could be 58/42 or 62/38. Look for standards to develop on how big the variation can be. A quick search online tells me it may be about +/- 2%.

Catastrophic Plan

Section 1302 (e) seems to offer an alternative to the bronze, silver, gold, or platinum levels of coverage. It’s entitled “Catastrophic Plan.”  Here’s what I *think* it means:

A health plan that does NOT provide the bronze, silver, gold or platinum levels of coverage is still cool as one of the acceptable plans under the Affordable Care Act if it meets ALL of these conditions:

  • The only people who can enroll in it are under 30 or have an exemption based on poverty or other hardship[4], AND
  • People get the essential healthcare benefits[5] after they’ve paid their share of costs,[6] AND
  • There is coverage for at least three primary care visits, AND
  • It’s offered only in the “individual market.” (I guess this means catastrophic healthcare plans for individuals, not for families.)

Child-Only Plans

Section 1302 (f) just says that the whole bronze-silver-gold-platinum plan levels must also be offered as child-only plans (under age 21 at the beginning of a plan year).

Time to Flip Back to Earlier Pages

This concludes my look at Section 1302 of the Affordable Care Act. (One section down!) Next, I’ll go BACK to Section 2711 where I started. (Remember that? I was looking at it when the act started referring me hither and yon.)

Other Posts on ObamaCare:

  • Part 1: Intro
  • Part 2: Types of coverage, no discrimination
  • Part 3: Exchanges and what they do
  • Part 4: Your cost limits and adjustments
  • Part 5: Deductibles and preventive care
  • Part 7: Limits on losing coverage

Footnotes! We Have Footnotes!

See below for references to places in the Affordable Care Act that correlate to my summaries in this article.

[1] Source: Section 1302 (d)(1).

[2] That is, a health savings account per Section 223 of the Internal Revenue Code of 1986. Source: Section 1302 (d)(2)(B).

[3] Source: Section 1302 (d)(2)(C)(3).

[4] The person has to have a certification that he/she is exempt per section 5000A of the Internal Revenue Code of 1986 – specifically Section 5000A(e)(1) (relating to individuals without affordable coverage) or Section 5000A(e)(5) (relating to individuals with hardships). No way am I going to look up the details of an IRS requirement – you are on your own for that one, dudes!

[5] Because it’s really easy to get lost in jargon, I’m going to keep repeating the definition of “essential healthcare benefits” per this act, anytime I reference them in my posts:

  • Ambulatory (“walk in”) patient services
  • Emergency services
  • Hospitalization
  • Maternity/newborn care
  • Mental health and substance use disorder services (including behavioral health treatment)
  • Prescription drugs
  • Rehab and habilitative services/devices
  • Lab services
  • Preventive/wellness services and chronic disease management
  • Pediatric services (including oral and vision care)

[6] See Section 1302(c)(1)(A) and (B).

2 Comments

Filed under Healthcare, Politics

A Common Gal Looks at ObamaCare, Part 5: Deductibles & Preventive Care

A Common Gal Looks at ObamaCareI’m reading up on The Patient Protection and Affordable Care Act (“ObamaCare”). That includes the act itself, amendments passed shortly afterward, and the recent Supreme Court ruling. It’s a lot of pages (906, 55, and 193 respectively), but I want to understand it. I’m documenting my read-through here. I am not a lawyer or a healthcare professional, just a common college-educated person. These are my thoughts, not advice to you. Read the act yourself like the free person you are. ;o). Also note: This act refers a lot to “health care plans”; for simplicity’s sake, I sometimes just say “insurance” or “health insurance.

Yesterday’s dive into the Affordable Care Act was unsatisfying because I couldn’t find the text of another act that’s referenced within. But I got a little help from a friend in looking it up. ;o)

Section 1302(c)(2)(D) of the Affordable Care Act says, “Coordination With Preventive Limits. Nothing in this paragraph shall be construed to allow a plan to have a deductible under the plan apply to benefits described in section 2713 of the Public Health Service Act.”

OK … so if you have health insurance under the Affordable Care Act, your deductible doesn’t apply to benefits listed in Section 2713 of this other act. Sounds like I need to look up the Public Health Service Act. Hello, Google.

Well, the Public Health Service Act dates back to nineteen-freaking-forty-four and has been expanded and amended multiple times since then. It’s captured in the overwhelmingly large Title 42 of the U.S. Code, so I looked through that … and looked … and looked … and gave up and sent up a smoke signal for help. The reason I couldn’t find it? It’s because it’s new. Section 2713 is being added on by virtue of Section 1001 of the … you guessed it … Patient Protection and Affordable Care Act! Now why couldn’t the legislators just have referred to that section within THE SAME ACT instead of sending me chasing all over the Internet? Oh, legislators – quit hazing me. ;o)

Deductibles & Preventive Care

Good ol’ new Section 2713 is all about preventive health services. If I’m reading Section 1302(c)(2)(D) of the Affordable Care Act correctly, deductibles don’t apply to the latest recommended types of preventive health services, including:

  • “Evidence-based items or services” (Um … isn’t all medicine evidence based?)
  • Immunizations
  • “Evidence-informed preventive care and screenings” for babies, kids and teens
  • “Additional preventive care and screenings” for women if the care/screening is included in comprehensive guidelines but NOT described in the act’s list of essential healthcare benefits.[1]

Section 2713 also specifies what agencies make the recommendations. The Secretary of Health and Human Services oversees the timing of when those recommendations are made vs. when the recommendations are effective.

If your eyes haven’t glazed over yet, here’s one more confusing bit: All of this does NOT prevent coverage of services that go beyond those recommended, nor does it deny coverage for services that are not specifically recommended. It’s just that your deductibles don’t apply (if I am reading this correctly).

Value-Based Insurance

Another option is troubling to me: The Secretary of Health and Human Services also can “develop guidelines to permit a group health plan and a health insurance issuer offering group or individual health insurance coverage to utilize value-based insurance designs.” The Washington Post describes what this means:

Value-based insurance design is “the idea that consumers’ out-of-pocket medical costs should be based on the value of a service to their health rather than its price.”

Theoretical example: It might be valuable to the insurance plan for people with chronic illnesses like diabetes or high cholesterol to take preventive steps to prevent more costly problems later on, so their preventive care and medication could be free or very low cost. But expensive procedures that are deemed “overused” (perhaps knee surgeries or MRI scans) could be discouraged with higher out-of-pocket costs.

Managed Care magazine said, “It promotes the use of services when the clinical benefits exceed the cost and discourages the use of services when the benefits do not justify the cost.”

I can tell you right now that this does not sound awesome to me. What it sounds like is an accountant (rather than a doctor) deciding whether a medical procedure is “worth it” to offer to me at a reasonable price under the insurance plan.

You can read about concerns over value-based insurance in this Kaiser Health News article.

Coming Up

My next article will describe definitions of “levels of coverage” (bronze, silver, gold, and platinum) under the Affordable Care Act and why this matters.

Other Posts on ObamaCare:

  • Part 1: Intro
  • Part 2: Types of coverage, no discrimination
  • Part 3: Exchanges and what they do
  • Part 4: Your cost limits and adjustments
  • Part 6: Four levels of coverage
  • Part 7: Limits on losing coverage

Footnote! We’ve Got a Footnote!


[1] Essential healthcare benefits are listed early on in the act, and they are:

  • Ambulatory (“walk in”) patient services
  • Emergency services
  • Hospitalization
  • Maternity/newborn care
  • Mental health and substance use disorder services (including behavioral health treatment)
  • Prescription drugs
  • Rehab and habilitative services/devices
  • Lab services
  • Preventive/wellness services and chronic disease management
  • Pediatric services (including oral and vision care).

2 Comments

Filed under Healthcare, Politics