Doughnut Hole - The legislation would provide immediate relief and gradually close the Medicare Part D doughnut hole. Beginning next year, Medicare would contribute an additional $500 and then the initial coverage limit will increase and the catastrophic cap level will decrease until the hole is closed completely by 2019. This provision is financed by applying Medicaid rebates to dual eligibles (who would remain in Part D) The bill also includes the PhRMA deal to reduce by 50% all costs for brand name drugs for individuals in the doughnut hole until it is closed.
Age-rating - The legislation provides for strict 2:1 age rating limits (allowing insurers to charge an older individual a premium no more than two times a younger individual). Currently, insurers can charge up to 7 times or more based on age.
Health status - The bill would prohibit insurance companies from denying coverage based on pre-existing conditions, prevent discrimination based on gender and prevent life-time caps on insurance benefits.
Affordability - The legislation provides subsidies for premiums and cost-sharing for individuals and families up to 400% of poverty. Those below 150% of poverty would be eligible for Medicaid with no asset test (see below for more details). Those between 150% and 400% of poverty could receive sliding-scale subsidies in the Exchange that limit their premium contribution to between 3% and 12% of income. Plans in the Exchange would cover at least 70% of costs, and out-of-pocket spending for deductibles, copays and coinsurance is limited to $5,000 for individuals and $10,000 for families for individuals between 350% to 400 % federal poverty level, with lower caps for those with lower incomes.
Medicaid Expansion - The bill would expand Medicaid up to 150% of poverty and eliminate asset tests for all enrollees not receiving long-term care. States would receive a 100% FMAP until 2015 after which they would receive a 91% FMAP. It would eliminate the asset test for eligibility groups other than long-term care.
Medicare Physician Payment - H.R. 3962 would pay bonuses to physicians providing primary care services and those practicing in the most efficient geographic areas. It also introduces a physician resource use feedback program, and creates new accountable care organizations and a medical home pilot program to provide for coordinated and comprehensive care. The House has introduced a separate piece of legislation (H.R. 3961) that would eliminate the current Sustainable Growth Rate (SGR) formula that determines how Medicare's physicians are currently paid. This bill would prevent physicians who treat Medicare patients from receiving a scheduled 21.5% cut in payments for next year, as well as future cuts.
Medicare Advantage - The bill would gradually cut Medicare Advantage (MA) rates so that by 2013 these plans would be paid the same rate as Medicare pays for traditional Medicare benefits. MA plans in high-penetration areas where reductions could be most disruptive would be eligible for "quality bonus payments" based on their performance for specific quality measures.
Biologics - The bill creates an FDA licensure pathway for "biosimilar" generic biologic products, with an industry-friendly 12 years of market exclusivity. Also encourages use of generic biologics by placing them in the same Medicare billing code with interchangeable products.
Secretarial Negotiation - The bill eliminates the provision in the Medicare Modernization Act that prohibits Medicare from negotiating drug prices with pharmaceutical companies, allowing Medicare to negotiate for lower prices (similar to the provisions in H.R. 4, which passed the House in the 110th Congress).
Medicare Part D low-income provisions - The bill increases the Medicare Part D and Medicare Savings Program asset tests to $17,000 for individuals ($34,000 for couples), eliminates the cost sharing for duals who receive home- and community-based services, allows CMS to assign enrollees to plans that best meet their needs, and further streamlines outreach and enrollment.
CLASS Act - The bill establishes the Community Living Assistance Services and Supports (CLASS) program, a national voluntary insurance program for long-term services and supports to help individuals pay for the services and supports they need to live independently in their homes and communities.
Transitional and Nursing Care - The bill provides payments to certain hospitals to address issues that result in high readmission rates. Payments can be used for a variety of activities, including transitional care services. Transitional care is also part of the Medicare Medical Home Pilot Program. The bill also includes funds to increase nursing education capacity.
Territories - The bill allows Puerto Rico and the territories to participate in the Health Insurance Exchange. It also provides up to $4 billion to fund affordability credits if the territory adopts the insurance reforms, consumer protections, and other requirements for individual and employer responsibility in the Act. Also, the Medicaid expansion for the territories remain intact. Additionally, a report on achieving parity by 2020 is due in October 2013.
Individual Mandate/Employer Mandate - The bill requires individuals to have qualifying coverage or face a penalty (which would be assessed at the lower of the national average premium or 2.5% of the individual's modified adjusted gross income). Some exemptions apply. The bill would also impose an employer mandate that employers must offer health insurance coverage to their employees or face a penalty up to 8% of their payroll. Small employers would pay a smaller penalty and would be eligible for tax credits.
Public Option - The bill provides for a public option that is offered in addition to private plans offered in the Exchange. The public plan must meet the same requirements as other qualified plans. The bill allows Medicare providers to opt out of the private plan if they do not want to participate and the Secretary will negotiate plan networks and payment rates with providers.
I see the word 'subsidy" in there a lot....I wonder how all of that will be paid for?
8% penalty on employers...I wonder how many employers will tell their employees "screw you" and jump on that 8%?
So there goes that "you can keep your current plan" jazz.
At any rate, there is no reason for a 2000 page bill. Should have been progressively addressed with the first priority being to cut Medicare fraud and waste costs, second to induce competition across state lines to bring current premium costs down, third..address malpractice costs to reduce defensive diagnosis and further reduce medical costs. But common sense has no place in Congress.
This type of action that is currently being moved through will be a total cluster that we will begin paying for on day one but not seeing any benefit until later this decade.
That's O.K. though, once it finally gets morphed and re-morphed it will be 3000 pages, cost 4 times what they "guess" it will and be shot down and they all will have to start over again and do it right.
This is just a trial run at how not o get reform passed.
posted by pancho3
about 1 month ago
Thanks for posting this; There are a lot of good changes here. Can insurers charge more for people with preexisting conditions even though they cannot deny coverage?
They are now. John McCain’s campaign manager never got re-employed and just lost his "Cobra". He can't get re-insured because he now has a pre-existing condition. But he can buy a super-expensive policy that most of us can't afford.
His comment was, "Don't feel sorry for me; I am fortunate that I am very wealthy and can afford it."
Says a lot for the Republican HealthCare for the people, doesn't it?
i realize they are charging people with pre existing conditions right out of the market now. I just want to be sure that practice will be eliminated if people are to be penalized for not purchasing insurance.
Oh yeah, one of my many applications for health insurance came back approved for a monthly premium for 2000.00 a month. I can't afford that!
Of course I have a 5000.00 deductible, Dr. visits related to Lupus would not be covered for 2 years. Cancer would not be covered for the same period. Heart would not be covered because I have a slight murmer that I've had since birth...Not hardly worth it.
If anyone's concerned about how the various subsidies could be paid for, all the government needs to do accelerate the withdrawal from Iraq, a country should have left right after the Hussein government fell. Us staying inflamed those who wanted just that and helped cause the insurgency fuels the insurgency today. Setting up an inept puppet government did us no good either. The last I looked we were spending nearly $1 billion per year for GW's Vietnam.
