Gary Gross has begun to highlight Section 122 of H.R. 3200, which defines the benefits that any private plan must provide to be considered qualified. He actually bridges 122 and 123, and in this post I will include parts of Sec. 124; you need to see them together as a whole to understand this part of the bill. Below you will find ten questions (or sets of questions) that will help you define where your legislator is on controlling your health insurance.

Section 122 defines a list of benefits that any qualified plan would have. The rule would not apply to any plan you currently have -- that is the part the President is using to say "if you like your health insurance you can keep it," which is a vacuous promise, but not needed to discuss here. Let's read 122 in full:

(a) In General- In this division, the term `essential benefits package' means health benefits coverage, consistent with standards adopted under section 124 to ensure the provision of quality health care and financial security, that--

(1) provides payment for the items and services described in subsection (b) in accordance with generally accepted standards of medical or other appropriate clinical or professional practice;

(2) limits cost-sharing for such covered health care items and services in accordance with such benefit standards, consistent with subsection (c);

(3) does not impose any annual or lifetime limit on the coverage of covered health care items and services;

(4) complies with section 115(a) (relating to network adequacy); and

(5) is equivalent, as certified by Office of the Actuary of the Centers for Medicare & Medicaid Services, to the average prevailing employer-sponsored coverage.

(b) Minimum Services To Be Covered- The items and services described in this subsection are the following:

(1) Hospitalization.

(2) Outpatient hospital and outpatient clinic services, including emergency department services.

(3) Professional services of physicians and other health professionals.

(4) Such services, equipment, and supplies incident to the services of a physician's or a health professional's delivery of care in institutional settings, physician offices, patients' homes or place of residence, or other settings, as appropriate.

(5) Prescription drugs.

(6) Rehabilitative and habilitative services.

(7) Mental health and substance use disorder services.

(8) Preventive services, including those services recommended with a grade of A or B by the Task Force on Clinical Preventive Services and those vaccines recommended for use by the Director of the Centers for Disease Control and Prevention.

(9) Maternity care.

(10) Well baby and well child care and oral health, vision, and hearing services, equipment, and supplies at least for children under 21 years of age.

(c) Requirements Relating to Cost-sharing and Minimum Actuarial Value-

(1) NO COST-SHARING FOR PREVENTIVE SERVICES- There shall be no cost-sharing under the essential benefits package for preventive items and services (as specified under the benefit standards), including well baby and well child care.

(2) ANNUAL LIMITATION-

(A) ANNUAL LIMITATION- The cost-sharing incurred under the essential benefits package with respect to an individual (or family) for a year does not exceed the applicable level specified in subparagraph (B).

(B) APPLICABLE LEVEL- The applicable level specified in this subparagraph for Y1 is $5,000 for an individual and $10,000 for a family. Such levels shall be increased (rounded to the nearest $100) for each subsequent year by the annual percentage increase in the Consumer Price Index (United States city average) applicable to such year.

(C) USE OF COPAYMENTS- In establishing cost-sharing levels for basic, enhanced, and premium plans under this subsection, the Secretary shall, to the maximum extent possible, use only copayments and not coinsurance.

(3) MINIMUM ACTUARIAL VALUE-

(A) IN GENERAL- The cost-sharing under the essential benefits package shall be designed to provide a level of coverage that is designed to provide benefits that are actuarially equivalent to approximately 70 percent of the full actuarial value of the benefits provided under the reference benefits package described in subparagraph (B).

(B) REFERENCE BENEFITS PACKAGE DESCRIBED- The reference benefits package described in this subparagraph is the essential benefits package if there were no cost-sharing imposed.

That leads to a few questions right off the top.

1. Congressman/woman, Does the lack of cost-sharing for preventative services under 122(c)(1) help control costs? A CBO letter last Friday to Rep. Nathan Deal points to a study that shows "that slightly fewer than 20 percent of [preventative] services that were examined save money, while the rest add to costs."
2. Does the annual cap of $5000 for a single and $10,000 for a family come on TOP of my current premium? According to the pro-reform page put up by HHS, we currently pay $1,522 in cost-sharing. Does sec. 122(c)(2)(B) mean I am going to see higher co-pays and deductibles?
3. Do you favor a cafeteria plan for choosing benefits, as Gary highlighted in his interview of Rep. Paul Ryan? Why is it a better for cost control to define minimum benefits than it is to permit individuals to pick the services they want? Do you support the Patients' Choice Act?
   

Let's move on to Sec. 123, which creates a committee that decides on what is in the essential benefits package:

(a) Establishment-

(1) IN GENERAL- There is established a private-public advisory committee which shall be a panel of medical and other experts to be known as the Health Benefits Advisory Committee to recommend covered benefits and essential, enhanced, and premium plans.

(2) CHAIR- The Surgeon General shall be a member and the chair of the Health Benefits Advisory Committee.

(3) MEMBERSHIP- The Health Benefits Advisory Committee shall be composed of the following members, in addition to the Surgeon General:

(A) 9 members who are not Federal employees or officers and who are appointed by the President.

(B) 9 members who are not Federal employees or officers and who are appointed by the Comptroller General of the United States in a manner similar to the manner in which the Comptroller General appoints members to the Medicare Payment Advisory Commission under section 1805(c) of the Social Security Act.

(C) Such even number of members (not to exceed 8) who are Federal employees and officers, as the President may appoint.

Such initial appointments shall be made not later than 60 days after the date of the enactment of this Act.

(4) TERMS- Each member of the Health Benefits Advisory Committee shall serve a 3-year term on the Committee, except that the terms of the initial members shall be adjusted in order to provide for a staggered term of appointment for all such members.

(5) PARTICIPATION- The membership of the Health Benefits Advisory Committee shall at least reflect providers, consumer representatives, employers, labor, health insurance issuers, experts in health care financing and delivery, experts in racial and ethnic disparities, experts in care for those with disabilities, representatives of relevant governmental agencies. and at least one practicing physician or other health professional and an expert on children's health and shall represent a balance among various sectors of the health care system so that no single sector unduly influences the recommendations of such Committee.

(b) Duties-

(1) RECOMMENDATIONS ON BENEFIT STANDARDS- The Health Benefits Advisory Committee shall recommend to the Secretary of Health and Human Services (in this subtitle referred to as the `Secretary') benefit standards (as defined in paragraph (4)), and periodic updates to such standards. In developing such recommendations, the Committee shall take into account innovation in health care and consider how such standards could reduce health disparities.

(2) DEADLINE- The Health Benefits Advisory Committee shall recommend initial benefit standards to the Secretary not later than 1 year after the date of the enactment of this Act.

(3) PUBLIC INPUT- The Health Benefits Advisory Committee shall allow for public input as a part of developing recommendations under this subsection.

(4) BENEFIT STANDARDS DEFINED- In this subtitle, the term `benefit standards' means standards respecting--

(A) the essential benefits package described in section 122, including categories of covered treatments, items and services within benefit classes, and cost-sharing; and

(B) the cost-sharing levels for enhanced plans and premium plans (as provided under section 203(c)) consistent with paragraph (5).

(5) LEVELS OF COST-SHARING FOR ENHANCED AND PREMIUM PLANS-

(A) ENHANCED PLAN- The level of cost-sharing for enhanced plans shall be designed so that such plans have benefits that are actuarially equivalent to approximately 85 percent of the actuarial value of the benefits provided under the reference benefits package described in section 122(c)(3)(B).

(B) PREMIUM PLAN- The level of cost-sharing for premium plans shall be designed so that such plans have benefits that are actuarially equivalent to approximately 95 percent of the actuarial value of the benefits provided under the reference benefits package described in section 122(c)(3)(B).

Questions here:

1. The committee that decides what has to be in a qualified plan contains at least twenty (20) people, yet it only guarantees one physician is on the panel. Do you think this is the right level of participation of medical professionals?
2. The committee membership includes the words "shall at least reflect" various health insurance stakeholders. Isn't that vague? Would you want to change that?
3. Does Congress get any say in who's on this committee?
4. Borrowing from Gary: Senator or Congressperson, do you believe that this committee would unduly restrict the relationship between a patient and her or his doctor? Why or why not?

On to Section 124, which defines how the process works from recommendation by the Health Benefits Advisory Committee to action.

(a) Process for Adoption of Recommendations-

(1) REVIEW OF RECOMMENDED STANDARDS- Not later than 45 days after the date of receipt of benefit standards recommended under section 123 (including such standards as modified under paragraph (2)(B)), the Secretary shall review such standards and shall determine whether to propose adoption of such standards as a package.

(2) DETERMINATION TO ADOPT STANDARDS- If the Secretary determines--

(A) to propose adoption of benefit standards so recommended as a package, the Secretary shall, by regulation under section 553 of title 5, United States Code, propose adoption such standards; or

(B) not to propose adoption of such standards as a package, the Secretary shall notify the Health Benefits Advisory Committee in writing of such determination and the reasons for not proposing the adoption of such recommendation and provide the Committee with a further opportunity to modify its previous recommendations and submit new recommendations to the Secretary on a timely basis.

(3) CONTINGENCY- If, because of the application of paragraph (2)(B), the Secretary would otherwise be unable to propose initial adoption of such recommended standards by the deadline specified in subsection (b)(1), the Secretary shall, by regulation under section 553 of title 5, United States Code, propose adoption of initial benefit standards by such deadline.

This raises questions too:

1. Where is Congress' input into what shall be in the plan? Does your senator or congressperson think this plan vests too much power in the hands of the HHS Secretary?
2. In particular, can the Secretary decide to ignore the Health Benefits Advisory Committee and impose a minimum plan? (The answer is yes, only subject to the cost rules in Sec. 122.)
3. The rules for updating the benefits package is vague, only providing for "periodic updating". Do you think this should be that vague?

I urge you to read all of the posts done here for questions about the bill. Ask your legislator these questions and please post in comments any answers you receive. Also send them to me at comments at scsuscholars*dot*com. I'd like a diary of any of these you get.

Labels: economics, health care