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It's Not An Option (IBD Exclusive Series: Government-Run Healthcare: A Prescription For Failure)
IBD Editorials ^ | July 15, 2009 | INVESTORS BUSINESS DAILY Staff

Posted on 07/15/2009 5:48:04 PM PDT by Kaslin

Congress: It didn't take long to run into an "uh-oh" moment when reading the House's "health care for all Americans" bill. Right there on Page 16 is a provision making individual private medical insurance illegal.


When we first saw the paragraph Tuesday, just after the 1,018-page document was released, we thought we surely must be misreading it. So we sought help from the House Ways and Means Committee.

It turns out we were right: The provision would indeed outlaw individual private coverage. Under the Orwellian header of "Protecting The Choice To Keep Current Coverage," the "Limitation On New Enrollment" section of the bill clearly states:

"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 the year the legislation becomes law.

So we can all keep our coverage, just as promised — with, of course, exceptions: Those who currently have private individual coverage won't be able to change it. Nor will those who leave a company to work for themselves be free to buy individual plans from private carriers.

From the beginning, opponents of the public option plan have warned that if the government gets into the business of offering subsidized health insurance coverage, the private insurance market will wither. Drawn by a public option that will be 30% to 40% cheaper than their current premiums because taxpayers will be funding it, employers will gladly scrap their private plans and go with Washington's coverage.

(Excerpt) Read more at ibdeditorials.com ...


TOPICS: Breaking News; Business/Economy; Constitution/Conservatism; Culture/Society; Editorial; Extended News; Front Page News; Government; News/Current Events; Philosophy
KEYWORDS: 111th; agenda; bho44; bhofascism; bhohealthcare; communism; congress; cwii; cwiiping; democratcongress; democrats; donttreadonme; economy; fascism; healthinsurance; ibd; lping; marxism; obama; obamacare; rationedhealthcare; rationing; socialism; socializedmedicine; takeover; taxes; universalhealthcare; youpayforhthis
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To: Cyber Liberty

What about changes to family member status— going from single to married/family, adding a baby, etc.? Will newborn babies go onto the gvt plan? Will a change in marital status be allowed?

Every year we have a ‘dual choice’ enrollment period, where we can change our health care plan, effective with the next calendar year— looks like that’s history, too.


81 posted on 07/16/2009 2:58:25 PM PDT by green pastures
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To: green pastures

I don’t know...I’m not a lawyer (nor do I play one on TV). The key word seems to be “enroll,” and I don’t think an addition of a dependent is an enrollment, but any other change at all, like adding a spouse, is an enrollment, so likely prohibited.


82 posted on 07/16/2009 3:02:43 PM PDT by Cyber Liberty (I AM JIM THOMPSON!)
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To: STARWISE

I just had a huge knock down drag out fight with my goofy liberal sister over this stuff. That is another thing that I blame Obama and the democrats for. They are not ‘governing from the center’..they are racing us into a full blown marxist/communist take-over when they have no mandate to do so. The polls don’t support such a mandate and neither did Obama’s win.

Now sisters are turning against sisters, mothers against sons, fathers against daughters. I really feel like we are heading for a civil war in this country if this insanity is not stopped. I usually blow her off but not this time..I took her down a country road and don’t feel bad about it one bit!

These people are destoying our country!


83 posted on 07/16/2009 3:24:12 PM PDT by penelopesire ("The only CHANGE you will get with the Democrats is the CHANGE left in your pocket")
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To: penelopesire

Destruction is their aim .. socialist takeover
of every segment of our lives is the game.

I can definitely relate to the family thing.

I think it’s been prophesized somewhere.


84 posted on 07/16/2009 3:43:41 PM PDT by STARWISE (The Art & Science Institute of Chicago Politics NE Div: now open at the White House)
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To: xzins
...My guess, then, is that Tri-Care will be replaced by Gov’t health care.

Anyone have anything authoritative on that?

Seen this?

Sen Roberts: Obamacare Bill includes the end of Medicare and TRICARE

85 posted on 07/16/2009 3:44:30 PM PDT by Red Steel
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To: Red Steel; P-Marlowe

That simply doesn’t surprise me. Why would they run competing health care delivery systems? (Other than “Congress Care”)

It will eventually incorporate all public health care policies from fed to state to local. Teachers will lose health care. Veterans will lose health care. Everyone will lose their health care and be enrolled in the gov’t plan.

Of course, that’s one less incentive to offer a young person pondering a military career, but liberals are not in the DoD growth business. They want to close her down except for a palace guard and a secret police, if they can get away with it.


86 posted on 07/16/2009 3:54:55 PM PDT by xzins (Chaplain Says: Jesus befriends all who ask Him for help.)
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To: Kaslin
Drawn by a public option that will be 30% to 40% cheaper than their current premiums because taxpayers will be funding it, employers will gladly scrap their private plans and go with Washington's coverage.

It will be cheaper. In the beginning...

87 posted on 07/16/2009 3:56:22 PM PDT by fhayek
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To: zot; Interesting Times; grey man; Hurtgen

Yep, we can keep our private health insurance, but after the bill is passed no new private health insurance policies can be written. So much for freedom of choice on health care.


88 posted on 07/16/2009 4:08:09 PM PDT by GreyFriar (Spearhead - 3rd Armored Division 75-78 & 83-87)
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To: ExTexasRedhead

I’v emailed my senators twice and will place a phone call to their offices tomorrow. If their interns tally the calls, I at least want to go on record as being against this and adding another slash in the NO column. This fiasco is nothing more than the “eugenics and euthanasia” bill, and conservatives should refer to it as such. But the average rank and file citizen probably doesn’t even know what those two words mean.


89 posted on 07/16/2009 4:13:24 PM PDT by 1951Boomer
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To: Kaslin

bump


90 posted on 07/16/2009 4:17:16 PM PDT by lowbridge (It's not that liberals are ignorant, it's that they know so much that isn't so - Ronald Reagan)
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To: Kaslin
Here's the section: (reformatted for readability)

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 (PL 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.

This seems to be talking about current existing health coverage, and making it not subject to any new regulations for a period of time.

The part that will influence private plans are here:

TITLE I—PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS

Subtitle A—General Standards
SEC. 101. REQUIREMENTS REFORMING HEALTH INSURANCE MARKETPLACE.
   (a) PURPOSE.—The purpose of this title is to establish standards to ensure that new health insurance coverage and
       employment-based health plans that are offered meet standards guaranteeing access to affordable coverage, 
       essential benefits, and other consumer protections.
   (b) REQUIREMENTS FOR QUALIFIED HEALTH BENEFITS PLANS.—On or after the first day of Y1, a health benefits plan 
       shall not be a qualified health benefits plan under this division unless the plan meets the applicable 
       requirements of the following subtitles for the type of plan and plan year involved:
      (1) Subtitle B (relating to affordable coverage).

Subtitle B—Standards Guaranteeing Access to Affordable Coverage

SEC. 111. PROHIBITING PRE-EXISTING CONDITION EXCLUSIONS.
A qualified health benefits plan may not impose any pre-existing condition exclusion (as defined in section 
2701(b)(1)(A) of the Public Health Service Act) or otherwise impose any limit or condition on the coverage under the 
plan with respect to an individual or dependent based on any health status-related factors (as defined in section 
2791(d)(9) of the Public Health Service Act) in relation to the individual or dependent.
 
SEC. 112. GUARANTEED ISSUE AND RENEWAL FOR INSURED PLANS.
The requirements of sections 2711 (other than subsections (c) and (e)) and 2712 (other than paragraphs (3), and (6) 
of subsection (b) and subsection (e)) of the Public Health Service Act, relating to guaranteed availability and 
renewability of health insurance coverage, shall apply to individuals and employers in all individual and group 
health insurance coverage, whether offered to individuals or employers through the Health Insurance Exchange, through 
any employment-based health plan, or otherwise, in the same manner as such sections apply to employers and health 
insurance coverage offered in the small group market, except that such section 2712(b)(1) shall apply only if, before 
nonrenewal or discontinuation of coverage, the issuer has provided the enrollee with notice of nonpayment of premiums 
and there is a grace period during which the enrollees has an opportunity to correct such nonpayment. Rescissions of 
such coverage shall be prohibited except in cases of fraud as defined in sections 2712(b)(2) of such Act.

SEC. 113. INSURANCE RATING RULES.
  (a) IN GENERAL.—The premium rate charged for an insured qualified health benefits plan may not vary except as   
      follows:
      (1) LIMITED AGE VARIATION PERMITTED.—By age (within such age categories as the Commissioner shall specify) so 
          long as the ratio of the highest such premium to the lowest such premium does not exceed the ratio of 2 to 
          1.
      (2) BY AREA.—By premium rating area (as permitted by State insurance regulators or, in the case of Exchange-
          participating health benefits plans, as specified by the Commissioner in consultation with such 
          regulators).
      (3) BY FAMILY ENROLLMENT.—By family enrollment (such as variations within categories and compositions of 
          families) so long as the ratio of the premium for family enrollment (or enrollments) to the premium for 
          individual enrollment is uniform, as specified under State law and consistent with rules of the 
          Commissioner.
  (b) STUDY AND REPORTS.—
      (1) STUDY.—The Commissioner, in coordination with the Secretary of Health and Human Services and the Secretary 
          of Labor, shall conduct a study of the large group insured and self-insured employer health care markets. 
          Such study shall examine the following:
            (A) The types of employers by key characteristics, including size, that purchase insured products versus 
                those that self-insure.
            (B) The similarities and differences between typical insured and self-insured health plans.
            (C) The financial solvency and capital reserve levels of employers that self-insure by employer size.
            (D) The risk of self-insured employers not being able to pay obligations or otherwise becoming 
                financially insolvent.
            (E) The extent to which rating rules are likely to cause adverse selection in the large group market or 
                to encourage small and mid size employers to self-insure
      (2) REPORTS.—Not later than 18 months after the date of the enactment of this Act, the Commissioner shall 
          submit to Congress and the applicable agencies a report on the study conducted under paragraph (1). Such 
          report shall include any recommendations the Commissioner deems appropriate to ensure that the law does not 
          provide incentives for small and mid-size employers to self-insure or create adverse selection in the risk 
          pools of large group insurers and self-insured employers. 
          
          Not later than 18 months after the first day of Y1, the Commissioner shall submit to Congress and the 
          applicable agencies an updated report on such study, including updates on such recommendations.

SEC. 114. NONDISCRIMINATION IN BENEFITS; PARITY IN MENTAL HEALTH AND SUBSTANCE ABUSE DISORDER BENEFITS.
  (a) NONDISCRIMINATION IN BENEFITS.—A qualified health benefits plan shall comply with standards established by the 
      Commissioner to prohibit discrimination in health benefits or benefit structures for qualifying health benefits 
      plans, building from sections 702 of Employee Retirement Income Security Act of 1974, 2702 of the Public Health 
      Service Act, and section 9802 of the Internal Revenue Code of 1986.
  (b) PARITY IN MENTAL HEALTH AND SUBSTANCE ABUSE DISORDER BENEFITS.—To the extent such provisions are not superceded 
      by or inconsistent with subtitle C, the provisions of section 2705 (other than subsections (a)(1), (a)(2), and 
      (c)) of section 2705 of the Public Health Service Act shall apply to a qualified health benefits plan, 
      regardless of whether it is offered in the individual or group market, in the same manner as such provisions 
      apply to health insurance coverage offered in the large group market.

SEC. 115. ENSURING ADEQUACY OF PROVIDER NETWORKS.
  (a) IN GENERAL.—A qualified health benefits plan that uses a provider network for items and services shall meet 
      such standards respecting provider networks as the Commissioner may establish to assure the adequacy of such 
      networks in ensuring enrollee access to such items and services and transparency in the cost-sharing 
      differentials between in-network coverage and out-of-network coverage.
  (b) PROVIDER NETWORK DEFINED.—In this division, the term "provider network" means the providers with respect to 
      which covered benefits, treatments, and services are available under a health benefits plan.

SEC. 116. ENSURING VALUE AND LOWER PREMIUMS.
  (a) IN GENERAL.—A qualified health benefits plan shall meet a medical loss ratio as defined by the Commissioner. 
      For any plan year in which the qualified health benefits plan does not meet such medical loss ratio, QHBP 
      offering entity shall provide in a manner specified by the Commissioner for rebates to enrollees of payment 
      sufficient to meet such loss ratio.
  (b) BUILDING ON INTERIM RULES.—In implementing subsection (a), the Commissioner shall build on the definition and 
      methodology developed by the Secretary of Health and Human Services under the amendments made by section 161 
      for determining how to calculate the medical loss ratio. Such methodology shall be set at the highest level 
      medical loss ratio possible that is designed to ensure adequate participation by QHBP offering entities, 
      competition in the health insurance market in and out of the Health Insurance Exchange, and value for consumers 
      so that their premiums are used for services.


      (2) Subtitle C (relating to essential benefits).

Subtitle C—Standards Guaranteeing Access to Essential Benefits

SEC. 121. COVERAGE OF ESSENTIAL BENEFITS PACKAGE.
  (a) IN GENERAL.—A qualified health benefits plan shall provide coverage that at least meets the benefit standards 
      adopted under section 124 for the essential benefits package described in section 122 for the plan year 
      involved.
  (b) CHOICE OF COVERAGE.—
    (1) NON-EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS.—In the case of a qualified health benefits plan that is not 
        an Exchange-participating health benefits plan, such plan may offer such coverage in addition to the essential 
        benefits package as the QHBP offering entity may specify.
    (2) EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS.—In the case of an Exchange-participating health benefits plan, 
        such plan is required under section 203 to provide specified levels of benefits and, in the case of a plan 
        offering a premium plus level of benefits, provide additional benefits.
    (3) CONTINUATION OF OFFERING OF SEPARATE EXCEPTED BENEFITS COVERAGE.—Nothing in this division shall be construed 
        as affecting the offering of health benefits in the form of excepted benefits (described in section 
        102(b)(1)(B)(ii)) if such benefits are offered under a separate policy, contract, or certificate of insurance.
  (c) NO RESTRICTIONS ON COVERAGE UNRELATED TO CLINICAL APPROPRIATENESS.—A qualified health benefits plan may not 
      impose any restriction (other than cost sharing) unrelated to clinical appropriateness on the coverage of the 
      health care items and services.

SEC. 122. ESSENTIAL BENEFITS PACKAGE DEFINED.
  (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.

SEC. 123. HEALTH BENEFITS ADVISORY COMMITTEE.
  (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 costsharing 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).
  (c) OPERATIONS.—
    (1) PER DIEM PAY.—Each member of the Health Benefits Advisory Committee shall receive travel expenses, including 
        per diem in accordance with applicable provisions under subchapter I of chapter 57 of title 5, United States 
        Code, and shall otherwise serve without additional pay.
    (2) MEMBERS NOT TREATED AS FEDERAL EMPLOYEES.—Members of the Health Benefits Advisory Committee shall not be 
        considered employees of the Federal government solely by reason of any service on the Committee.
    (3) APPLICATION OF FACA.—The Federal Advisory Committee Act (5 U.S.C. App.), other than section 14, shall apply to 
        the Health Benefits Advisory Committee.
  (d) PUBLICATION.—The Secretary shall provide for publication in the Federal Register and the posting on the Internet 
      website of the Department of Health and Human Services of all recommendations made by the Health Benefits 
      Advisory Committee under this section.

SEC. 124. PROCESS FOR ADOPTION OF RECOMMENDATIONS; ADOPTION OF BENEFIT STANDARDS.
  (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.
    (4) PUBLICATION.—The Secretary shall provide for publication in the Federal Register of all determinations made by 
        the Secretary under this subsection.
  (b) ADOPTION OF STANDARDS.—
    (1) INITIAL STANDARDS.—Not later than 18 months after the date of the enactment of this Act, the Secretary shall, 
        through the rulemaking process consistent with subsection (a), adopt an initial set of benefit standards.
    (2) PERIODIC UPDATING STANDARDS.—Under subsection (a), the Secretary shall provide for the periodic updating of 
        the benefit standards previously adopted under this section. 
    (3) REQUIREMENT.—The Secretary may not adopt any benefit standards for an essential benefits package or for level 
        of cost-sharing that are inconsistent with the requirements for such a package or level under sections 122 and 
        123(b)(5).
      
(3) Subtitle D (relating to consumer protection).

Subtitle D—Additional Consumer Protections

SEC. 131. REQUIRING FAIR MARKETING PRACTICES BY HEALTH INSURERS.

The Commissioner shall establish uniform marketing standards that all insured QHBP offering entities shall meet.

SEC. 132. REQUIRING FAIR GRIEVANCE AND APPEALS MECHANISMS.

  (a) IN GENERAL.—A QHBP offering entity shall provide for timely grievance and appeals mechanisms that the 
      Commissioner shall establish.
  (b) INTERNAL CLAIMS AND APPEALS PROCESS.— Under a qualified health benefits plan the QHBP offering entity shall 
      provide an internal claims and appeals process that initially incorporates the claims and appeals procedures 
      (including urgent claims) set forth at section 2560.503–1 of title 29, Code of Federal Regulations, as published 
      on November 21, 2000 (65 Fed. Reg. 70246) and shall update such process in accordance with any standards that 
      the Commissioner may establish.
  (c) EXTERNAL REVIEW PROCESS.—
    (1) IN GENERAL.—The Commissioner shall establish an external review process (including procedures for expedited 
        reviews of urgent claims) that provides for an impartial, independent, and de novo review of denied claims 
        under this division.
    (2) REQUIRING FAIR GRIEVANCE AND APPEALS MECHANISMS.—A determination made, with respect to a qualified health 
        benefits plan offered by a QHBP offering entity, under the external review process established under this 
        subsection shall be binding on the plan and the entity.
  (d) CONSTRUCTION.—Nothing in this section shall be construed as affecting the availability of judicial review under 
      State law for adverse decisions under subsection (b) or (c), subject to section 151.

SEC. 133. REQUIRING INFORMATION TRANSPARENCY AND PLAN DISCLOSURE.

  (a) ACCURATE AND TIMELY DISCLOSURE.—
    (1) IN GENERAL.—A qualified health benefits plan shall comply with standards established by the Commissioner for 
        the accurate and timely disclosure of plan documents, plan terms and conditions, claims payment policies and 
        practices, periodic financial disclosure, data on enrollment, data on disenrollment, data on the number of 
        claims denials, data on rating practices, information on cost-sharing and payments with respect to any 
        out-of-network coverage, and other information as determined appropriate by the Commissioner. The Commissioner
        shall require that such disclosure be provided in plain language.
    (2) PLAIN LANGUAGE.—In this subsection, the term "plain language" means language that the intended audience, 
        including individuals with limited English proficiency, can readily understand and use because that language 
        is clean, concise, well-organized, and follows other best practices of plain language writing.
    (3) GUIDANCE.—The Commissioner shall develop and issue guidance on best practices of plain language writing.
  (b) CONTRACTING REIMBURSEMENT.—A qualified health benefits plan shall comply with standards established by the 
      Commissioner to ensure transparency to each health care provider relating to reimbursement arrangements between 
      such plan and such provider.
  (c) ADVANCE NOTICE OF PLAN CHANGES.—A change in a qualified health benefits plan shall not be made without such 
      reasonable and timely advance notice to enrollees of such change.

SEC. 134. APPLICATION TO QUALIFIED HEALTH BENEFITS PLANS NOT OFFERED THROUGH THE HEALTH INSURANCE EXCHANGE.

The requirements of the previous provisions of this subtitle shall apply to qualified health benefits plans that are 
not being offered through the Health Insurance Exchange only to the extent specified by the Commissioner.

SEC. 135. TIMELY PAYMENT OF CLAIMS.

A QHBP offering entity shall comply with the requirements of section 1857(f) of the Social Security Act with respect 
to a qualified health benefits plan it offers in the same manner an Medicare Advantage organization is required to 
comply with such requirements with respect to a Medicare Advantage plan it offers under part C of Medicare.

SEC. 136. STANDARDIZED RULES FOR COORDINATION AND SUBROGATION OF BENEFITS.

The Commissioner shall establish standards for the coordination and subrogation of benefits and reimbursement of 
payments in cases involving individuals and multiple plan coverage.

SEC. 137. APPLICATION OF ADMINISTRATIVE SIMPLIFICATION.

A QHBP offering entity is required to comply with standards for electronic financial and administrative transactions 
under section 1173A of the Social Security Act, added by section 163(a).

There are a number of things to be concerned about here. A commissioner and health care advisory committee seem to have no limits on their recommendations of what should be covered and how much a company can charge for the coverage. The required unlimited free coverage of preventive care. The maximum cost-sharing amounts of $5,000 and $10,000 seem arbitrary as well.

91 posted on 07/16/2009 4:34:05 PM PDT by dan1123 (Gov't Healthcare Plan: Break it and Take it.)
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To: taildragger
If they are like H. saving accounts, you can expect them to be killed:

The legislation is also likely to finish off health savings accounts, a goal that Democrats have had for years. They want to crush that alternative because nothing gives individuals more control over their medical care, and the government less, than HSAs.

Actually, when we consider the real motives at work (Cheaper - no; Improved Quality - no; Preserved Choice - no; Efficiency - no; More Thorough Coverage - Maybe at the expense of the previous and your sovereignty), it become intuitive.

 Stick a fork in this country.

92 posted on 07/16/2009 4:57:08 PM PDT by Harrius Magnus (LIBERALS: We should invade their countries, kill their leaders and convert them to Christianity.)
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To: zot; Interesting Times; SeraphimApprentice

must read!!!!!


93 posted on 07/16/2009 5:28:12 PM PDT by GreyFriar (Spearhead - 3rd Armored Division 75-78 & 83-87)
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To: Kaslin

JUST WHERE IN THE CONSTITUTION WAS CONGRESS EMPOWERED TO MAKE HEALTH CARE CHOICES?


94 posted on 07/16/2009 5:58:15 PM PDT by omega4179 (Anti)
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To: Kaslin

Insanity. Pure insanity. Scares the hell out of me.


95 posted on 07/16/2009 6:15:27 PM PDT by RepublitarianRoger2
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To: Cyber Liberty

Another thing to consider is that policies are renewed once a year. Even if you do not change, would this renewal be considered “new” for that year and thus be automatically forfeit anyway?

I am trying to think like a statist snake trying to be extremely crafty and sly.


96 posted on 07/16/2009 6:48:56 PM PDT by DarkWaters ("Deception is a state of mind --- and the mind of the state" --- James Jesus Angleton)
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To: Deo volente

Not just Freedom but our country as we know it - is GONE!!!!!!! UNLESS THE FEW VOICES THAT ARE LEFT UNITE AND TELL THE COWARDLY SENATORS TO DEFEAT THIS BILL!!!


97 posted on 07/16/2009 6:54:19 PM PDT by Freedom'sWorthIt
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To: STARWISE

Thanks for making it even clearer - the devil is in the details.

Actually, the devil is in ALL of this nightmare of a bill. He authored it.


98 posted on 07/16/2009 6:56:22 PM PDT by Freedom'sWorthIt
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To: nutmeg

great article, thanks for the ping.


99 posted on 07/16/2009 7:04:35 PM PDT by Coleus (Abortion, Euthanasia & FOCA - - don't Obama and the Democrats just kill ya!)
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To: Deo volente

It did indeed


100 posted on 07/16/2009 7:26:17 PM PDT by Kaslin (Acronym for 0bama: One Big Ass Mistake America)
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