http://thomas.loc.gov/cgi-bin/query/z?c111:H.R.3200:

What is this section for if not government controls?

http://thomas.loc.gov/cgi-bin/query/z?c111:H.R.3200

Subtitle E–Governance

SEC. 141. HEALTH CHOICES ADMINISTRATION; HEALTH CHOICES COMMISSIONER.

(a) In General- There is hereby established, as an independent agency in the executive branch of the Government, a Health Choices Administration (in this division referred to as the `Administration’).

(b) Commissioner-

(1) IN GENERAL- The Administration shall be headed by a Health Choices Commissioner (in this division referred to as the `Commissioner’) who shall be appointed by the President, by and with the advice and consent of the Senate.

(2) COMPENSATION; ETC- The provisions of paragraphs (2), (5), and (7) of subsection (a) (relating to compensation, terms, general powers, rulemaking, and delegation) of section 702 of the Social Security Act (42 U.S.C. 902) shall apply to the Commissioner and the Administration in the same manner as such provisions apply to the Commissioner of Social Security and the Social Security Administration.

SEC. 142. DUTIES AND AUTHORITY OF COMMISSIONER.

(a) Duties- The Commissioner is responsible for carrying out the following functions under this division:

(1) QUALIFIED PLAN STANDARDS- The establishment of qualified health benefits plan standards under this title, including the enforcement of such standards in coordination with State insurance regulators and the Secretaries of Labor and the Treasury.

(2) HEALTH INSURANCE EXCHANGE- The establishment and operation of a Health Insurance Exchange under subtitle A of title II.

(3) INDIVIDUAL AFFORDABILITY CREDITS- The administration of individual affordability credits under subtitle C of title II, including determination of eligibility for such credits.

(4) ADDITIONAL FUNCTIONS- Such additional functions as may be specified in this division.

(b) Promoting Accountability-

(1) IN GENERAL- The Commissioner shall undertake activities in accordance with this subtitle to promote accountability of QHBP offering entities in meeting Federal health insurance requirements, regardless of whether such accountability is with respect to qualified health benefits plans offered through the Health Insurance Exchange or outside of such Exchange.

(2) COMPLIANCE EXAMINATION AND AUDITS-

(A) IN GENERAL- The commissioner shall, in coordination with States, conduct audits of qualified health benefits plan compliance with Federal requirements. Such audits may include random compliance audits and targeted audits in response to complaints or other suspected non-compliance.

(B) RECOUPMENT OF COSTS IN CONNECTION WITH EXAMINATION AND AUDITS- The Commissioner is authorized to recoup from qualified health benefits plans reimbursement for the costs of such examinations and audit of such QHBP offering entities.

(c) Data Collection- The Commissioner shall collect data for purposes of carrying out the Commissioner’s duties, including for purposes of promoting quality and value, protecting consumers, and addressing disparities in health and health care and may share such data with the Secretary of Health and Human Services.

(d) Sanctions Authority-

(1) IN GENERAL- In the case that the Commissioner determines that a QHBP offering entity violates a requirement of this title, the Commissioner may, in coordination with State insurance regulators and the Secretary of Labor, provide, in addition to any other remedies authorized by law, for any of the remedies described in paragraph (2).

(2) REMEDIES- The remedies described in this paragraph, with respect to a qualified health benefits plan offered by a QHBP offering entity, are–

(A) civil money penalties of not more than the amount that would be applicable under similar circumstances for similar violations under section 1857(g) of the Social Security Act;

(B) suspension of enrollment of individuals under such plan after the date the Commissioner notifies the entity of a determination under paragraph (1) and until the Commissioner is satisfied that the basis for such determination has been corrected and is not likely to recur;

(C) in the case of an Exchange-participating health benefits plan, suspension of payment to the entity under the Health Insurance Exchange for individuals enrolled in such plan after the date the Commissioner notifies the entity of a determination under paragraph (1) and until the Secretary is satisfied that the basis for such determination has been corrected and is not likely to recur; or

(D) working with State insurance regulators to terminate plans for repeated failure by the offering entity to meet the requirements of this title.

(e) Standard Definitions of Insurance and Medical Terms- The Commissioner shall provide for the development of standards for the definitions of terms used in health insurance coverage, including insurance-related terms.

(f) Efficiency in Administration- The Commissioner shall issue regulations for the effective and efficient administration of the Health Insurance Exchange and affordability credits under subtitle C, including, with respect to the determination of eligibility for affordability credits, the use of personnel who are employed in accordance with the requirements of title 5, United States Code, to carry out the duties of the Commissioner or, in the case of sections 208 and 241(b)(2), the use of State personnel who are employed in accordance with standards prescribed by the Office of Personnel Management pursuant to section 208 of the Intergovernmental Personnel Act of 1970 (42 U.S.C. 4728).

SEC. 143. CONSULTATION AND COORDINATION.

(a) Consultation- In carrying out the Commissioner’s duties under this division, the Commissioner, as appropriate, shall consult with at least with the following:

(1) The National Association of Insurance Commissioners, State attorneys general, and State insurance regulators, including concerning the standards for insured qualified health benefits plans under this title and enforcement of such standards.

(2) Appropriate State agencies, specifically concerning the administration of individual affordability credits under subtitle C of title II and the offering of Exchange-participating health benefits plans, to Medicaid eligible individuals under subtitle A of such title.

(3) Other appropriate Federal agencies.

(4) Indian tribes and tribal organizations.

(5) The National Association of Insurance Commissioners for purposes of using model guidelines established by such association for purposes of subtitles B and D.

(b) Coordination-

(1) IN GENERAL- In carrying out the functions of the Commissioner, including with respect to the enforcement of the provisions of this division, the Commissioner shall work in coordination with existing Federal and State entities to the maximum extent feasible consistent with this division and in a manner that prevents conflicts of interest in duties and ensures effective enforcement.

(2) UNIFORM STANDARDS- The Commissioner, in coordination with such entities, shall seek to achieve uniform standards that adequately protect consumers in a manner that does not unreasonably affect employers and insurers.

SEC. 144. HEALTH INSURANCE OMBUDSMAN.

(a) In General- The Commissioner shall appoint within the Health Choices Administration a Qualified Health Benefits Plan Ombudsman who shall have expertise and experience in the fields of health care and education of (and assistance to) individuals.

(b) Duties- The Qualified Health Benefits Plan Ombudsman shall, in a linguistically appropriate manner–

(1) receive complaints, grievances, and requests for information submitted by individuals;

(2) provide assistance with respect to complaints, grievances, and requests referred to in paragraph (1), including–

(A) helping individuals determine the relevant information needed to seek an appeal of a decision or determination;

(B) assistance to such individuals with any problems arising from disenrollment from such a plan;

(C) assistance to such individuals in choosing a qualified health benefits plan in which to enroll; and

(D) assistance to such individuals in presenting information under subtitle C (relating to affordability credits); and

(3) submit annual reports to Congress and the Commissioner that describe the activities of the Ombudsman and that include such recommendations for improvement in the administration of this division as the Ombudsman determines appropriate. The Ombudsman shall not serve as an advocate for any increases in payments or new coverage of services, but may identify issues and problems in payment or coverage policies.

That accusation is a scare tactic pushed by the insurance industry and their paid lobbyists. It is completely untruthful. The plans under consideration will improve things considerably for small business. I can’t wait!

We need tort reform. We need portablity of insurance. We need doctors to advertise what there prices are. We need to shop around for the best value in a doctor just like any other purchase.

Government controlled health care is not the solution

I’ve worked hard (gaining experience, training, continued education, etc.) all my adult life to improve my marketability as an employee. This hard work and personal effort enables me to seek employment with companies who provide the quality “benefits” I want for myself and my family. I have also made the choice to pay for those benefits, typically “buying-up”. I spent my earnings on health and dental insurances instead of the daily latte’s, the big screen TV’s, or the new cars every 3-5 years. For me it boils down to a matter of personal choice – a matter of hard work – a matter of accepting personal responsibility for both my financial and my physical well-being – a matter of making sound decisions.

During this time, my family has experienced it’s share of medical issues. A major back surgery, a total knee replacement, and most recently a heart attack, not to mention all miscellaneous medical and dental expenses that come with birthing and raising three children. We are talking hundreds of thousands of dollars in expenses. If it were not for my employee benefits and the private insurance carriers (forget the HMO’s and HSA’s) we would have been financially devastated and probably living off public assistance. Instead, we are all still working, contributing, members of society.

I understand that sometimes, “I can’t afford it” is a real issue – but I feel that all too often it is overused and overstated. Personal choice is the core of the issue in all things. The choice to simply work, the choice to improve ones place/marketability in the employment arena, the choice to participate in employer sponsored plans, the choice to “buy-up” instead of buying the latest cell phone/package, or the granite counter tops and the stainless steel appliances. Unfortunately in today’s society there is an entitlement attitude. Too many of us want it all, while wanting others to pay for it.

And I agree with the question: If, as history shows, government is unable to effectively and efficiently run a program (i.e. Social Security, Veterans Health Care, Medicare, etc.) why should we believe that this new program will be different (better)?

Fool me once shame on you, fool me twice, shame on me.

You keep yours, let me keep mine.

Keep up the polite, logical arguments!

Two things:

1) Please explain my error in reading the bill text. What have I misread?

2) If your distrust of insurance companies arises from the experiences of your friends and family, what about your personal experience? You are a small business owner; do you offer coverage to your employees? How has that gone? Have your friends and family appealed insurance decisions or consulted the state insurance commissioner regarding the issues they feel are unjust and inconsistent with the policy? It is ironic, but presently I am insured using Cigna as the TPA for our self-funded plan. I have no issues with my coverage or the whole plan.

Yes, I have costs. Yes, there are things not covered by the policy. Yes, copay and deductibles vary based on use of network providers. (Note: 95% of all facilities and providers are in network including the major medical research hospitals)

As a small business owner, what is most hindering to you is the inability to find group coverage. What you may not realize is that insurance companies sell the product companies or individuals want. No one size fits all policy. Group status enhances the bargaining power, and allows more tailoring of the policy. Insurance companies cannot provide a cost effective policy a la carte, but buffet-style (mid or large group) offers better value. If this bill as written passes, the outcome will not be more coverage choices for you, your friends, family or employees, but your customers, suppliers and any company you do business with which does enough business will start passing on the 8% increase in taxes to you. In return, you will get a federal health system subject to the whims of who won in any present or future November.

As for the insurance companies having decades to get things right, you seem to miss the very real aspect of the insurance industry being regulated by the government. Government actually dictates what policies can be written and what insurance companies can do business where. As cost have risen some less user friendly policy models or features have been tried, but the market quickly adapted. How many HMOs still exist? Very few in percentages. Why? It was a faulty means to control costs. It took too much control away from the consumer. PPOs with contracted networks and the choice to still go out of network if desired is the model most prevalent today. Why? It puts choice back to the consumer, and allow choice even if that choice bears consequences. Those consequences also help motivate healthier lifestyles, and individual cost containment measures.

Every individual and small business needs access to the group buying power at work for them, but like yourself, not every business is large enough to qualify alone. If present laws were changes to permit and better even, encourage the creation of alternative groups such as community organizations or chambers of commerce, etc., you would find more insurance policy options at less cost.

Of course, employment based plans are also highly influenced by the employer, who is buying on behalf of their employees. Some employers are more or less interested in the value of the plan. Some buy a ‘cheap’ policy, just to say they have one. Others shop frugally to get the maximum value in return for their employees. This is not a flaw in insurance companies. By opening the door for competing groups by non-employment based associations, individuals will have more choices for where to seek a policy. Present laws already provide protections against pre-existing conditions, etc. when changing policies, so no harm in dropping one for the better choice.

To make that work, we just need to allow these type associations the ability to form a group policy, and give them the same tax advantage for doing so that employers get.

By the way, I did not lose last November. Regardless of how one may have voted, we are still Americans living in the greatest nation on earth. The flag still flies reminding us of our history and the freedoms we enjoy and treasure. To lose would require the loss of those things more precious than the name or party of a single or group of politicians.

Actually, my distrust of the insurance companies comes from the experience of friends and family. Insurance companies charge us a ransom for premiums and then cancel policies, refuse treatment and deny claims.

If the insurance companies provided good coverage at a decent price, you and I wouldn’t even be discussing this and Congress wouldn’t be debating it. It’s only because the insurance companies have been so greedy and so deceitful that this is an issue.

The insurance company had decades to do the right thing. And they didn’t. They only had one priority; maximizing profits at the expense of every other type of business.

As a small business owner, I want an alternative to the insurance companies. If you want to pay them, that’s fine. Step aside and let we the majority who won last November get what we voted for. Go trust Cigna; I’m sure they’ll treat you accordingly.

Obviously, posting the entire bill would be unnecessary to discuss this one point. As the section title indicates, this is the section that “protects our right to coverage choice.” However, there is a major problem with that, as anyone can read, the section does not protect anything realistic long-term. It is crafted to appear as if protection is there, but as I pointed out in my notes, the title is quite misleading.

If it was as simple as “you do your thing, and I’ll do mine,” we wouldn’t be having this discussion. Fact though is, this bill takes away my choice and forces me to fund yours.

You are either influenced by frustration of trying to buy an individual health care policy, a participant in a small group policy, or just repeating rhetoric. Group health coverage is the most effective and efficient model available, unfortunately at present options for group policies other than through employment are very few and void of the tax advantage employers get for providing coverage. Change these two things, and many of the problems will go away without loss of choice or a costly expansion of government ineffective health care systems. By the way, I have decades of experience with U.S. Goverment health care, and it is very wasteful in nature and ineffective due to the way government works and thinks.

As a favor, here is the link to the whole bill: http://thomas.loc.gov/cgi-bin/query/z?c111:H.R.3200

Also, even with the part you provided, I don’t see the reason for fear and panic. What’s the problem, brother?

If you don’t want to enroll in a voluntary Public Health Care Option, I suggest you don’t. Now, leave we the majority alone as we’d like to consider what is offered and not be subject to the non-choice of only private, for-profit insurance. (If they’ll even write you a policy and if they’ll even pay your claims.)

Here’s the fine print:

SEC. 102. PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE.

(a) Grandfathered Health Insurance Coverage Defined- Subject to the succeeding provisions of this section, for purposes of establishing acceptable coverage under this division, the term `grandfathered health insurance coverage’ means individual health insurance coverage that is offered and in force and effect before the first day of Y1 if the following conditions are met:

(1) LIMITATION ON NEW ENROLLMENT-

(A) IN GENERAL- Except as provided in this paragraph, the individual health insurance issuer offering such coverage does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day of Y1.

(B) DEPENDENT COVERAGE PERMITTED- Subparagraph (A) shall not affect the subsequent enrollment of a dependent of an individual who is covered as of such first day.

(2) LIMITATION ON CHANGES IN TERMS OR CONDITIONS- Subject to paragraph (3) and except as required by law, the issuer does not change any of its terms or conditions, including benefits and cost-sharing, from those in effect as of the day before the first day of Y1.

(3) RESTRICTIONS ON PREMIUM INCREASES- The issuer cannot vary the percentage increase in the premium for a risk group of enrollees in specific grandfathered health insurance coverage without changing the premium for all enrollees in the same risk group at the same rate, as specified by the Commissioner.

(b) Grace Period for Current Employment-based Health Plans-

(1) GRACE PERIOD-

(A) IN GENERAL- The Commissioner shall establish a grace period whereby, for plan years beginning after the end of the 5-year period beginning with Y1, an employment-based health plan in operation as of the day before the first day of Y1 must meet the same requirements as apply to a qualified health benefits plan under section 101, including the essential benefit package requirement under section 121.

(B) EXCEPTION FOR LIMITED BENEFITS PLANS- Subparagraph (A) shall not apply to an employment-based health plan in which the coverage consists only of one or more of the following:

(i) Any coverage described in section 3001(a)(1)(B)(ii)(IV) of division B of the American Recovery and Reinvestment Act of 2009 (Public Law 111-5).

(ii) Excepted benefits (as defined in section 733(c) of the Employee Retirement Income Security Act of 1974), including coverage under a specified disease or illness policy described in paragraph (3)(A) of such section.

(iii) Such other limited benefits as the Commissioner may specify.

In no case shall an employment-based health plan in which the coverage consists only of one or more of the coverage or benefits described in clauses (i) through (iii) be treated as acceptable coverage under this division

(2) TRANSITIONAL TREATMENT AS ACCEPTABLE COVERAGE- During the grace period specified in paragraph (1)(A), an employment-based health plan that is described in such paragraph shall be treated as acceptable coverage under this division.

(c) Limitation on Individual Health Insurance Coverage-

(1) IN GENERAL- Individual health insurance coverage that is not grandfathered health insurance coverage under subsection (a) may only be offered on or after the first day of Y1 as an Exchange-participating health benefits plan.

(2) SEPARATE, EXCEPTED COVERAGE PERMITTED- Excepted benefits (as defined in section 2791(c) of the Public Health Service Act) are not included within the definition of health insurance coverage. Nothing in paragraph (1) shall prevent the offering, other than through the Health Insurance Exchange, of excepted benefits so long as it is offered and priced separately from health insurance coverage.

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Here is what they call protecting your choice!

No new enrollments! Whether this means new “policies” or the actual word used “enrollments” the result is devastating. If the traditional insurance industry term is applied, no existing plan (policy) can add new members except as dependents of existing members. If it means policies, then present employers without policies, will not be able to get one. How does either of these help the uninsured get coverage?

No updating of plan is like saying no oil changes or fill ups for your car. This will prevent inclusion of new coverages or types of care no presently covered. It prevents cost changes to deductibles and copays for inflation purposes. If your deductible is $500 per year now, it must remain the same forever. Any change to the policy in restricted areas as mentioned results in loss of the grandfathered status; which means the policy is unlawful.

In quick summary, you can keep your coverage if you want, but there will be #$@$# to pay if you do.

Just because the fox is going to watch the hen house, no one should be concerned, right?

Actually, I have an HSA and offer it (among other) to my employees. Those that are in it love it. I know that i do. I can go to whatever doctor I want, buy whatever health care items i need (including bandaids) on a pretax basis and if I don’t use the dollars right away, they are tax free for my whole life if I spend them on health care items. If not, i am taxed on it when I withdraw, just like a 401K. I can even invest any excess dollars. (which I have). I offer the other, more traditional plan to employees who aren’t as comfortable with an HSA. It’s more expensive but not bad and they are very happy with it. I’m sorry it hasn’t worked out for you but all in all, considering what the alternatives are (gov or socialized–real definition, not the exploited one), I’ll take the private companies. Nothing in life is free. There is a cost (whether dollars, time, whatever) to everything. Finite resources must be allocated. There’s no other way.

Ok…enough pontification from me. Have a good day everyone!

It is possible to create good government programs that aren’t corrupted by large corporations. It’s a matter of who is in office, and if they stand up to these interests or not. Arguing that we shouldn’t have any of these programs isn’t a realistic or desirable alternative.

The “free market” is wonderful for so many reasons. I don’t have to restate them all here. But it shouldn’t and can’t do everything, under any circumstances, at all times. That’s why we need both a strong and efficient private and public sector. It’s about making intelligent choices, hopefully, and not ideology.

For decades, the private insurance companies have given us a song and dance about “more competition” and “cafeteria style plans” (interesting and revealing terminology), HSA’s, etc. All of them are designed solely to fool the person who buys them and maximize profits for the industry.

If these companies were so efficient and so caring, they could have done away with this issue decades ago. The ONLY reason we’re even having this debate is because the insurance companies have failed so miserably. They didn’t deliver good quality health care to all citizens at a decent price; they’re not designed to. Their purpose is maximum ROI for shareholders and large executive compensation packages. They don’t exist to actually take care of people.

So, they’ve lost my trust, based on results. As a business person, Maggy, what do you do with companies or individuals who don’t perform and don’t produce results no matter how many chances you give them?

I just deleted what I was about to send. Sorry. In a nutshell, most of the people i talk with get their info from experience and iyears of observation and study on the topic. I’m not persuaded by big business, at least not since i reached about 35 years of age. The people objecting to gov care are quite informed and smart, just as you are. just for the record: I don’t like big business in general and don’t like big government…they are in bed together (not new news). With a gov option, you will soon see whose recent lobbying activities have been successful. You will see it by who they use to administrate and implement the program. You’ll really hate CIGNA then. Keep gov small and you reduce big business impact on every day lives. Make gov big and you almost ensure that big business will lobby their way in.

Have you looked closely at bringing in more competition, cafeteria-type plans and what I haven’t read in any bill yet, tort reform? Just wondering what you have found on those topics (they are my favorite solutions).