Posted on 10/31/2013 6:17:41 PM PDT by ToastedHead
"The Departments recognize that plans may utilize multiple service providers to help administer benefits (such as one third-party administrator for major medical coverage, a separate pharmacy benefit manager, and a separate managed behavioral health organization). Separate plan service providers may impose different levels of out-of-pocket limitations and may utilize different methods for crediting participants' expenses against any out-of-pocket maximums. These processes will need to be coordinated under section 1302(c)(1), which may require new regular communications between service providers."
(This is found in the second paragraph of Question #2)
(Excerpt) Read more at dol.gov ...
A person has major surgery, and meets their out of pocket maximum while in the hospital. Upon discharge, they bring a prescription to the pharmacy for a continuation of care medication, say for example injectable Lovenox. This is often given after a stent is put in, for example, to prevent clotting, and is cash priced at over $1000 (even for the generic which is now available.)
In this case, the person should be able to get their prescription for the copay price.
However, because there exists no mechanism for the pharmacy benefits manager to "talk" to the medical claims administrator within the ACA, the copay given to the pharmacy when the claim is submitted will be the full cash price. There will be absolutely no way for the pharmacy to know the out of pocket maximum has been met.
Within this addendum to the 40,000+ pages of regulations, in this one small FAQ, the Dept of Labor/HHS/Treasury all admit "These processes will need to be coordinated under section 1302(c)(1)."
Obviously from watching the healthcare.gov website, the integration of legacy systems of data is a huge task. After they get that website working, how much will this one small process cost us, the taxpayer, to implement. Is it even possible?
***I've never posted before, and I can't tell if I am doing it right. Please edit as needed. I'm just throwing this out there because it will really affect me in my line of work. Thanks!***
Medical Doctor: "That's what we say about a stool sample."
I think we knew from day one this was a “full employment” bill for attorneys. Even over and above the 15,000 lawyers and accountants hired by the IRS to administer/enforce Obamacare.
Toast.....They are trying to baffle us with bullshiie.
It was really painful to watch the Sebelius hearing. I realized how little they could possibly understand the enormity of the mess they’ve made.
I read that Landrieu and others are considering a piece of legislation called “The If You Like It, You Can Keep It Act.” It’s way too late for that. The insurance companies have already made their projections and adjustments for 2014. There’s no going back, but there’s also no going forward it seems.
I can’t wait until the new premiums come out for January. Employer sponsored coverage is going to get killed, too. Is there anyone on the planet smart enough to fix this?
And doing a fabulous job! The regulations are written in such a way that they are just about impossible to make sense of. There is an exception to just about every exception.
I can’t wait to vote on Tuesday!
Great post, you done good.......even though the info is disturbing :(
Thank you! (I was nervous:)
The PWS (performance work statement) intends to be clever with "will and shall".
The Obama Admin has now applied this to your life. This Obamacare is no different. Believe me, it will be a nightmare to get through this socialism of the highest order.
"Give me your tired, your poor, Your huddled masses yearning to breathe free, The wretched refuse of your teeming shore. Send these, the homeless, tempest-tost to me, I lift my lamp beside the golden door!"
Give me your money that I may stay in control of your life
“and a separate managed behavioral health organization”
Probably off topic. But what the hell is that?
The contrast of then and now.
The phrase reads as if somebody is trying to regulate socialism in order to claim they are defending freedom in the marketplace. The only problem is that it creates more bureaucracy instead of promoting liberty.
“intends to be clever with “will and shall”
I hate will and shall, and may. Vague, open ended, and up for discussion. No work will get done while the “team” debates.
It sounds like the organization of “firearm allowance” to me.
I wasn't born in the USA to be a stinking slave.
I'll always be a free man 'til they put me in my grave.
(chorus)
Filling out your forms is just a giant hose!
I'll have to change my address and hide my assets I suppose.
Your Progressive commie paradise I'll have to leave behind,
and if you try to follow me I won't be very kind.
Loading my magazines. Loading my magazines
with 40,000 rounds to pass the time.
It sounds like “manageing my behavior” to me.
How can it be read any different?
“a separate managed behavioral health organization”
That part read to me like it was a byproduct of the “Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).”
(Lol!)
That entire section only seems to have come up for debate as a result of trying to reconcile this new law with that old law. Probably as a result of some special interest objection.
“Shall” is intended for the contractor, “will” is afforded to the fed.
They abuse the hell out of this. Hello Fed.
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