Summary of Benefits and Coverage under the Affordable Care Act
Posts Tagged White House
Today, the Supreme Court issued an opinion related to health care reform. A divided Supreme Court upheld the constitutionality of the Obama administration’s health-care law. The court said Congress was acting within its powers under the Constitution when it required most Americans to carry health insurance or pay a tax. Chief Justice Roberts’ vote saved the ACA.
The Affordable Care Act, including its individual mandate that virtually all Americans buy health insurance, is constitutional. There were not five votes to uphold it on the ground that Congress could use its power to regulate commerce between the states to require everyone to buy health insurance. However, five Justices agreed that the penalty that someone must pay if he refuses to buy insurance is a kind of tax that Congress can impose using its taxing power. That is all that matters. Because the mandate survives, the Court did not need to decide what other parts of the statute were constitutional, except for a provision that required states to comply with new eligibility requirements for Medicaid or risk losing their funding. On that question, the Court held that the provision is constitutional as long as states would only lose new funds if they didn’t comply with the new requirements, rather than all of their funding.
The bottom line is that the entire ACA is upheld, with the exception that the federal government’s power to terminate states’ Medicaid funds is limited.
Please see below for a detailed overview of each opinion.
- The individual mandate survives as a tax. The only effect of not complying with the mandate is that you pay the tax. The Court holds that the mandate violates the Commerce Clause, but that doesn’t matter b/c there are five votes for the mandate to be constitutional under the taxing power. The Court holds that the Anti-Injunction Act doesn’t apply because the label “tax” is not controlling.
- The Medicaid provision is limited, but not invalidated. A majority of the Court holds that the Medicaid expansion is constitutional but that it will be unconstitutional for the federal government to withhold Medicaid funds for non-compliance with the expansion provisions. Another way to think about Medicaid is that the Constitution requires that states have a choice about whether to participate in the expansion of eligibility; if they decide not to, they can continue to receive funds for the rest of the program.
Original Posted by Rick Lindquist on Thu, Jun 28, 2012 @ 09:15 AM
From the beginning of the Chief’s opinion: “We do not consider whether the Act embodies sound policies. That judgment is entrusted to the Nation’s elected leaders. We ask only whether Congress has the power under the Constitution to enact the challenged provisions.”
Posted @ Thursday, June 28, 2012 10:03 AM by Rick Lindquist
If you like your health care plan, tough luck – if you’re on a Medicare prescription drug plan:
More than 3 million seniors may have to switch their Medicare prescription plan next year, even if they’re perfectly happy with it, thanks to an attempt by the government to simplify their lives.
The policy change could turn into a hassle for seniors who hadn’t intended to switch plans during Medicare’s open enrollment season this fall.
And it risks undercutting President Barack Obama’s promise that people who like their health care plans can keep them….”As a result of this policy, there are going to be fewer plans offered in 2011,” said Bonnie Washington, a senior analyst with Avalere Health, which produced the study.
If you like your health care plan, better luck next time – if you’re a college student:
Along comes word that the bill “could make it impossible for colleges and universities to continue to offer student health plans.” That’s how the American Council on Education and a dozen other higher-ed lobbies put it in a recent letter to the Obama Administration, warning that the insurance coverage they offer may get junked by ObamaCare’s decrees.
Between 4.5 million to 5.5 million students annually are insured by short-term plans sponsored by their schools, which are tailored to upperclassman who have aged out of their parents’ coverage or to international and graduate students. These plans are very low cost because the benefits are designed for generally healthy young people and often organized around campus health services and academic medical centers.
All of which means these plans aren’t likely to qualify under ObamaCare’s “minimal essential coverage” rules that mandate rich benefit packages, even if colleges have the flexibility to make exceptions for special needs. And given that insurance must now be sold anytime to everyone, colleges may be required to continue to cover students after they’ve graduated-leaving this type of coverage unaffordable.
If you like your health care plan, cross your fingers and hope you’ll like your new one better – if your employer sponsored plan doesn’t meet the law’s strict grandfathering requirements:
While many U.S. companies initially hoped they could preserve much of their existing group health plans under the new grandfather provision, a new survey by Hewitt Associates, a global human resources consulting and outsourcing company, shows that almost all now believe they will not. Ninety percent of companies said they anticipate losing grandfathered status by 2014, with the majority expecting to do so in the next two years.
Under the “grandfather” provision of the U.S. Patient Protection and Affordable Care Act, companies can maintain many of their current health care coverage provisions and are required to make fewer changes to plan documents and administrative procedures in order to comply with the new law. Companies can lose their grandfather status if they take certain steps such as reducing benefits, significantly raising co-payment charges, significantly raising deductibles or changing insurance carriers.
According to Hewitt’s survey of 466 companies–representing 6.9 million employees–most companies expect to lose grandfather status because of health plan design changes (72 percent) and/or changes to company subsidy levels (39 percent).
None of this is exactly surprising—at least if you’ve been paying attention. Any health system overhaul as sweeping as the PPACA was bound to upset existing coverage arrangements, especially given the dominance of insurance in American health care. But given how disastrous the possibility of forced plan changes proved to HillaryCare in the 90s, the law’s supporters couldn’t admit that. So President Obama and congressional leadership and the progressive activist class had to promise, repeatedly, that no one would have to change plans if they didn’t want to.
Please watch this… some insight on what is going on in Healthcare.
As you may know, the health care reform law includes a provision requiring health insurers to cover preventive services with no member cost sharing. Recently-published interim final regulations clarify this provision. Non-grandfathered plans issued or renewed on or after September 23, 2010, will not include member cost sharing or copays for the following preventive care provided in-network:
- Evidence-based items or services that have a rating of A or B in the current recommendations of the United States Preventive Services Task Force.
- Immunizations for routine use in children, adolescents, and adults that are recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.
- For infants, children and adolescents, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration.
- For women, to the extent not otherwise addressed by the United States Preventive Services Task Force recommendations, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration.
Other key points:
- This impacts non-grandfathered plans issued or renewed on or after September 23, 2010.
- This applies to in-network services. Out-of-network services will have the same cost-sharing requirements as they do today.
- Most of the recommended screenings, immunizations and exam services are already on our preventive services list. We are adding the new, required preventive services to this existing list.
- An example of a new preventive service is counseling related to aspirin use, tobacco cessation, obesity and alcohol use.
- Some services currently covered as medical/maternity will now be considered preventive services. This includes several recommended screenings for pregnant women.
As with the other provisions in the health care reform law, we’re committed to implementing this provision in a manner that helps members have access to quality health care services. If you have any questions, talk with your sales representative.
Grandfathering allowed for most standard and non-standard plans
As we recently communicated with you, the federal government has issued Interim Final Regulations for the grandfathering provision. Because there are advantages to grandfathering, we will grandfather most standard and non-standard plans in our portfolio. To help you better understand what this means to you, we’ve put together this Grandfathering Fact Sheet. It explains:
£ More about grandfathering
£ What changes can be made without losing grandfathered status
£ What changes will result in losing the grandfathered status
This is an important provision for many individuals and group policyholders. You can expect more information about grandfathering, including how we will implement it. As always, please talk with your consultant if you have any questions.
Grandfathering Fact Sheet
Under the recently enacted federal health care reform legislation, health plans can be grandfathered. Interim Final Regulations have been published to provide further clarification on grandfathering. These rules are designed, according to the Obama administration, to allow grandfathered plans to “innovate and contain costs by allowing insurers and employers to make routine changes without losing grandfather status.” In general, grandfather status will be lost if there are significant reductions to benefits or increases in out-of-pocket spending for consumers, such as deductibles or co-pays.
We believe there are benefits to grandfathering for our groups and individual members who wish to maintain their existing health benefit coverage. For this reason, we will grandfather most group and individual plans. In a continued effort to simplify our plan offerings, we are reviewing our current options by state to determine which ones we will offer as grandfathered plans. More information explaining how we will implement grandfathering for our individual and group customers will be provided in the near future.
Additionally, in limited situations, the legislation allows clients that made benefit changes after March 23, 2010, that would not meet the grandfathering rules to regain grandfathered status at the next renewal in 2011. We are working to determine how to help plans possibly regain grandfathered status.
What is grandfathering?
Grandfathering allows groups and individual members that keep their existing plan from March 23, 2010, to January 1, 2014, to be exempt from the new product and rating framework that is effective in 2014. To maintain grandfathered status, a client must continue to keep the plan and the plan’s benefits essentially the same. Grandfathering also exempts plans from some of the requirements of the plan-related provisions effective September 23, 2010.
The following changes can be made without impacting grandfathered status:
Changes in premiums of a policy or plan
Changes required to comply with federal or state law
Changes to increase benefits, or voluntarily comply with provisions of the Patient Protection and Affordable Care Act
Changes to plan structure, for example, switching from a health reimbursement arrangement to major medical coverage, or from insured to self-funded coverage
Changes to a provider network
Changes to a prescription drug formulary
Changes to accommodate mergers and acquisitions (as long as the merger or acquisition is not done solely to allow a group to move from one grandfathered plan to another when the plan change would reduce benefits or increase cost sharing in excess of that allowed by the regulations)
Changes to an ASO plan’s third-party administrator
The following changes would cause a loss of grandfathered status:
Eliminate all (or substantially all) benefits to diagnose or treat a particular condition.
Increase coinsurance (or another percentage cost-sharing requirement) above the level at which it was set on March 23, 2010. In other words, any increase in an insurer or plan’s coinsurance will result in a loss of grandfathered status.
Increase fixed-amount cost-sharing requirements other than copayments, such as a deductible or an out-of-pocket limit, by a total percentage (measured from March 23, 2010) that is more than the sum of medical inflation plus 15%.
Increase copayments above the level in effect on March 23, 2010, by an amount that exceeds the greater of (a) the sum of medical inflation plus 15%, or (B) $5 increased by medical inflation.
Reduce employer contributions (calculated by cost or formula, such as hours worked) toward any tier of group health insurance coverage or a group health plan by more than 5% below the contribution rate on March 23, 2010.
Impose an annual limit on the dollar value of benefits if an annual or lifetime limit had not been previously imposed on all benefits or, for plans that previously imposed a lifetime limit of all benefits, impose an overall annual dollar limit that is lower than the lifetime limit, or, for plans that
previously imposed an annual limit on all benefits, decreases the dollar value of the annual limit.
Issuer or plan sponsor does not disclose to participants and beneficiaries that the plan or coverage is a grandfathered health plan.
Change from one insurer to another
New government website lets consumers compare insurance plans
The U.S. Department of Health and Human Services (HHS) has just launchedHealthCare.gov, a website designed to help individuals and small businesses compare both private and public health insurance plans. Through HealthCare.gov, consumers can find information on literally thousands of private and public health care products.
Important note about how some products appear on the site
Please note that the products are listed under the legal entities – not their brand names, which may cause confusion. Companies currently working with HHS to correct this matter, and they hope to have their familiar brand names appear on the website soon. Until then, please be aware of how our products are listed on the website, state by state:
£ California: Blue Cross of California, Anthem Blue Cross Life & Health Insurance Company
£ Colorado: Rocky Mountain Hospital and Medical Service, Inc.
£ Connecticut: Anthem Health Plans, Inc.
£ Georgia: Blue Cross and Blue Shield of Georgia, Inc., Blue Cross Blue Shield Healthcare Plan of Georgia, Inc.
£ Indiana: Anthem Insurance Companies, Inc.
£ Kentucky: Anthem Health Plans of Kentucky, Inc.
£ Maine: Anthem Health Plans of Maine, Inc.
£ Missouri: RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC),
£ Nevada: Rocky Mountain Hospital and Medical Service, Inc.
£ New Hampshire: Anthem Health Plans of New Hampshire, Inc.
£ New York: Empire HealthChoice HMO, Inc., Empire HealthChoice Assurance, Inc.,
£ Ohio: Community Insurance Company
£ Virginia: Anthem Health Plans of Virginia, Inc.
£ Wisconsin: Blue Cross Blue Shield of Wisconsin, Compcare Health Services Insurance Corporation
In October, HealthCare.gov will also start including rate estimates for private insurance plans. Insurance companies are working with the government to determine how small group information will appear in states with no community ratings.
HealthCare.gov can be a valuable tool for you, which is why Insurance Companies are working hard to have their recognizable names appear on it soon. We’ll keep you posted as more information becomes available to us. If you have any comments or questions, please talk with your sales representative.
Getting to the bottom of health care costs
Did you know: Only three cents of every premium dollar is profit?
On average, 87 cents of every premium dollar you pay is spent covering medical care and services that members receive like doctor visits, hospital costs, prescription drugs and more according to a PriceWaterhouseCoopers medical cost trend report for 2009. Another 10 cents funds services we provide like claims processing, enrollment and billing and provider credentialing. That leaves 3 cents of every premium dollar for profits. Kaiser Health news has reported that the combined annual profits of the top 10 health insurers are equal to just two days work of national health care expenditures or just 0.5% of the estimated $2.5 trillion the nation spent on health care in 2009.
Promises Made; Promises Broken. Senate Majority Leader Harry Reid is in full get-a-bill mode. Virtually every promise of reform has been thrown out the window, even as those willing to work with the president have been thrown under the bus. Just consider some of the promises broken.
- Family health insurance premiums will drop by $2,500 a year by the end of the president’s first term.
- Everyone will be covered.
- If you like your current health insurance plan you can keep it.
- Electronic medical records will save significant amounts of money.
- The president will sit down with members of Congress and go over the legislation line by line.
- Discussions will be an open process that even C-Span could broadcast.
- Health care reform will cost about $60 billion a year (which would only be $600 billion over 10 years).
All those promises and more have been broken; they aren’t even considered serious anymore. And yet reform efforts move on. That’s one of the reasons those of us opposing the reform effort are so frustrated. No one — and certainly not the media — appears to be holding the president accountable.
Déjà vu. Actually, this effort isn’t all that different than the 1993-4 Clinton health care reform debate. When Clinton was elected there was also a sense of inevitability about the success of the bill. Most of the various trade associations — the AMA, PMA (now PhRMA), the AHA, the big business groups, and even HIAA — wanted to work with the administration and have a “seat at the table.”
It wasn’t until January or February of the following year (1994) — about where we are now — that many of the major groups started turning against the plan. The business groups have been turning, and some of the associations are turning.
Of course, there are differences. The Democrats are much further along this time than in 1993-4. And some of the trade associations have continued their support, even when it’s clear they will be hammered by the legislation.
But don’t let people tell you things are completely different this time. There are a lot of similarities.
No More Cards. Last week Senator John McCain (R-AZ) went on the floor of the Senate to complain that AARP has opposed every past cut to Medicare, even as it supports the proposed new cuts to Medicare — which are substantially larger than anything the Republicans ever proposed. And so McCain urged seniors to cut up their AARP membership cards.
It’s an important point. The media regularly refer to AARP as a seniors’ lobby or a consumer group. It’s not. It has effectively become an arm of the Democratic Party. Yes, AARP supported the Republican-led Medicare prescription drug legislation that passed in 2003. But Democrats roundly chastised AARP for doing so — even though several Democrats voted for the bill — and AARP apparently learned its lesson. If Democrats say something’s good, AARP must say something’s good. I just wish the media would recognize the relationship.
One of the goals of health care reform is to make coverage more affordable, but the proposed annual $6.7 billion health insurance premium tax will have the opposite effect by increasing costs for families and employers across the country. The new health insurance premium tax will:
Increase premiums for families and small businesses: CBO has stated that new taxes on health plans will result in “higher premiums for private coverage.” These taxes would increase costs for families and employers at a time when they are already struggling with rising health care costs.
Cause immediate disruption for policyholders: While broader reforms will not begin until 2014, the new health insurance premium tax would go into effect in 2010 – after contracts have been negotiated and after individuals have enrolled in their plan for next year. Imposing new taxes next year that cannot be supported by current premium levels will cause significant disruption and higher costs for policyholders, and could impede the ability of health plans to meet promised benefits.
Create an unsustainable burden on health plans: Health plans will be required to pay a $6.7 billion tax beginning next year for the next 10 years, in addition to “stabilization‟ fees of $25 billion in 2013, 2014, and 2015. According to Fortune magazine‟s analysis of the companies listed under “Insurance and Managed Care‟, earnings in 2008 totaled $8.61 billion with a profit margin of 2.2% — ranking the industry 35th on the Fortune list.
The new tax is non-deductible and is layered on top of existing state and federal taxes paid by health insurance plans, including: premium taxes, assessments to support high risk pools, state and federal income taxes, employment taxes, sales and use taxes, and property taxes.
Put benefits at risk for families and employers: The new health insurance premium tax is assessed based on market share and is not tax deductible. As shown in this chart, the new tax will disproportionately impact health plans with the lowest net income, and for some health plans, could result in an effective tax rate of more than 100 percent. This would put at risk the reserves health plans are required by law to keep on hand to pay out benefits for families and businesses.