Health Reform

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Health Reform

  1. 1. on Health ReformAchieving comprehensive health reform has emerged as a leading priority of the President and Congress. This summary of the Senate Finance Committee America’s Healthy FutureAct of 2009, the Senate HELP Committee Affordable Health Choices Act (S. 1679) and the House Tri-Committee America’s Affordable Health Choices Act of 2009 (H.R. 3200) describesthe key components of these leading health reform proposals. The House Tri-Committee summary incorporates the major amendments to the legislation adopted by the threecommittees of jurisdiction during their mark-ups of the bill. These amendments are identified using an abbreviation for the House panel that approved it — “E&C” for the Committeeon Energy and Commerce; “E&L” for the Committee on Education and Labor; and “W&M” for the Committee on Ways and Means. Senate HELP Committee House Tri-Committee Senate Finance Committee Affordable Health Choices Act America’s Affordable Health Choices Act of 2009 America’s Healthy Future Act of 2009 (S. 1679) (H.R. 3200) Date plan announced September 16, 2009 June 9, 2009 June 19, 2009 (passed by Committee October 13, 2009) (passed by Committee July 15, 2009) Overall approach Require most U.S. citizens and legal residents Require individuals to have health insurance. Require all individuals to have health insurance. to expanding access to have health insurance. Create state-based Create state-based American Health Benefit Create a Health Insurance Exchange through to coverage health insurance exchanges through which Gateways through which individuals and small which individuals and smaller employers can individuals can purchase coverage, with businesses can purchase health coverage, purchase health coverage, with premium and premium and cost-sharing credits available to with subsidies available to individuals/families cost-sharing credits available to individuals/ individuals/families with income between 100- with incomes up to 400% of the federal poverty families with incomes up to 400% of the federal 400% of the federal poverty level (the poverty level (or $73,240 for a family of three in 2009). poverty level (or $73,240 for a family of three in level is $18,310 for a family of three in 2009) and Require employers to provide coverage to their 2009). Require employers to provide coverage create separate exchanges through which small employees or pay an annual fee, with exceptions to employees or pay into a Health Insurance businesses can purchase coverage. Assess a fee for small employers, and provide certain small Exchange Trust Fund, with exceptions for certain on certain employers that do not offer coverage employers a credit to offset the costs of providing small employers, and provide certain small for each employee who receives a tax credit for coverage. Impose new regulations on the employers a credit to offset the costs of providing health insurance through an exchange, with individual and small group insurance markets. coverage. Impose new regulations on plans exceptions for small employers. Impose new Expand Medicaid to all individuals with incomes participating in the Exchange and in the small regulations on health plans in the exchange up to 150% of the federal poverty level. group insurance market. Expand Medicaid to and in the individual and small group markets. 133% of the poverty level. Expand Medicaid to all individuals with incomes up to 133% of the federal poverty level.Health Care Reform Proposals — Last Modified: October 15, 2009
  2. 2. Senate HELP Committee House Tri-Committee Senate Finance Committee Affordable Health Choices Act America’s Affordable Health Choices Act of 2009 America’s Healthy Future Act of 2009 (S. 1679) (H.R. 3200)Individual mandate • Require U.S. citizens and legal residents to • Require individuals to have qualifying health • Require all individuals to have “acceptable have qualifying health coverage. Enforced coverage. Enforced through a minimum health coverage”. Those without coverage pay through a tax penalty of $750 per adult per tax penalty of $750 per individual per year a penalty of 2.5% of modified adjusted gross year. The penalty will be phased-in according (maximum penalty per family of 4 times income up to the cost of the average national to the following schedule: $0 in 2013; $200 in the individual penalty). Exemptions to the premium for self-only or family coverage under 2014; $400 in 2015; $600 in 2016; and $750 in individual mandate will be granted to residents a basic plan in the Health Insurance Exchange. 2017. Exemptions will be granted for financial of states that do not establish an American Exceptions granted for dependents, religious hardship, religious objections, American Health Benefit Gateway, members of Indian objections, and financial hardship. Indians, and if the lowest cost plan option tribes, those for whom affordable coverage is exceeds 8% of an individual’s income or if not available, those without coverage for fewer the individual has income below 133% of the than 90 days, and those with incomes below poverty level. 150% FPL.Employer requirements • Assess employers with more than 50 • Require employers to offer health coverage • Require employers to offer coverage to their employees that do not offer coverage a fee for to their employees and contribute at least employees and contribute at least 72.5% of each employee who receives a tax credit for 60% of the premium cost or pay $750 for each the premium cost for single coverage and 65% health insurance through an exchange. The uninsured full-time employee and $375 for of the premium cost for family coverage of penalty is the lesser of a flat dollar amount each uninsured part-time employee who is not the lowest cost plan that meets the essential equal to the average national tax credit for offered coverage. For employers subject to the benefits package requirements or pay 8% of each full-time employee receiving a tax credit assessment, the first 25 workers are exempted. payroll into the Health Insurance Exchange or $400 times the total number of full-time • Exempt employers with 25 or fewer employees Trust Fund. [EL Committee amendment: employees in the firm. from the requirement to provide coverage. Provide hardship exemptions for employers • Exempt employers with 50 or fewer employees that would be negatively affected by job losses from the penalty. as a result of requirement.] • Require employers with 200 or more • Eliminate or reduce the pay or play assessment employees to automatically enroll employees for small employers with annual payroll of less into health insurance plans offered by the than $400,000: employer. Employees may opt out of coverage if – Annual payroll less than $250,000: exempt they have coverage from another source. – Annual payroll between $250,000 and $300,000: 2% of payroll; – Annual payroll between $300,000 and $350,000: 4% of payroll; – Annual payroll between $350,000 and $400,000: 6% of payroll.Health Care Reform Proposals — Last Modified: October 15, 2009
  3. 3. Senate HELP Committee House Tri-Committee Senate Finance Committee Affordable Health Choices Act America’s Affordable Health Choices Act of 2009 America’s Healthy Future Act of 2009 (S. 1679) (H.R. 3200)Employer requirements [EC Committee amendment: Extend the(continued) reduction in the pay or play assessment for small employers with annual payroll of less than $750,000 and replace the above schedule with the following: – Annual payroll less than $500,000: exempt – Annual payroll between $500,000 and $585,000: 2% of payroll; – Annual payroll between $585,000 and $670,000: 4% of payroll; – Annual payroll between $670,000 and $750,000: 6% of payroll.] • Require employers that offer coverage to automatically enroll into the employer’s lowest cost premium plan any individual who does not elect coverage under the employer plan or does not opt out of such coverage.Expansion of public • Expand Medicaid to all individuals (children, • Expand Medicaid to all individuals (children, • Expand Medicaid to all individuals (children,programs pregnant women, parents, and adults without pregnant women, parents, and adults without pregnant women, parents, and adults without dependent children) with incomes up to 133% dependent children) with incomes up to 150% dependent children) with incomes up to 133% FPL (to be implemented in 2014). Adults with FPL. Individuals eligible for Medicaid will be FPL. Newly eligible, non-traditional (childless incomes between 100-133% FPL will have the covered through state Medicaid programs adults) Medicaid beneficiaries may enroll in option of obtaining coverage through Medicaid and will not be eligible for credits to purchase coverage through the Exchange if they were or with federal subsidies through the exchange. coverage through American Health Benefit enrolled in qualified health coverage during the All newly eligible adults will be guaranteed a Gateways. six months before becoming Medicaid eligible. benchmark benefit package that at least meets • Grant individuals eligible for the Children’s Provide Medicaid coverage for all newborns the minimum creditable coverage standards. Health Insurance Program (CHIP) the option who lack acceptable coverage and provide Require states to provide premium assistance of enrolling in CHIP or enrolling in a qualified optional Medicaid coverage to low-income to any Medicaid beneficiary with access to health plan through a Gateway. HIV-infected individuals and for family planning employer-sponsored insurance if it is cost- services to certain low-income women. In effective for the state. To finance the coverage for addition, increase Medicaid payment rates for the newly eligible (those who were not previously primary care providers to 100% of Medicare eligible for a full benchmark benefit package rates. [EC Committee amendment: Require or who were eligible for a capped program but states to submit a state plan amendment were not enrolled), states will receive an increase specifying the payment rates to be paid under in the federal medical assistance percentage the state’s Medicaid program.] The coverage (FMAP). Initially, the percentage point increase expansions (except the optional expansions) in the FMAP will be 27.3 for states that already and the enhanced provider payments will cover adults with incomes above 100% FPL and be fully financed with federal funds. [EC 37.3 for other states. These percentage point Committee amendment: Replace full federal increases will be adjusted over time so that by financing for Medicaid coverage expansions 2019, all states will receive an FMAP increase of with 100% federal financing through 2014 and 32.3 percentage points for the newly eligible. 90% federal financing beginning in year 2015.]Health Care Reform Proposals — Last Modified: October 15, 2009
  4. 4. Senate HELP Committee House Tri-Committee Senate Finance Committee Affordable Health Choices Act America’s Affordable Health Choices Act of 2009 America’s Healthy Future Act of 2009 (S. 1679) (H.R. 3200)Expansion of public High need states—those with total Medicaid • Require Children’s Health Insurance Programprograms (continued) enrollment that is below the national average (CHIP) enrollees to obtain coverage through for enrollment as a percentage of the state the Health Insurance Exchange (in the first population and unemployment rates of 12% year the Exchange is available) provided the or higher for August 2009—will receive full Health Choices Commissioner determines that federal funding for the newly eligible for five the Exchange has the capacity to cover these years. children and that procedures are in place to • Require states to maintain current income ensure the timely transition of CHIP enrollees eligibility levels for children in Medicaid and the into the Exchange without an interruption Children’s Health Insurance Program (CHIP) of coverage. [EC Committee amendment: until 2019. CHIP benefit package and cost- Require that CHIP enrollees not be enrolled in sharing rules will continue as under current an Exchange plan until the Secretary certifies law. Beginning in 2014, states will receive a 23 that coverage is at least comparable to percentage point increase in the CHIP match coverage under an average CHIP plan in effect rate up to a cap of 100% and a .15 percentage in 2011. The Secretary must also determine point increase in the Medicaid match rate. that there are procedures to transfer CHIP-eligible children who are unable to enroll CHIP enrollees into the exchange without in the program due to enrollment caps will be interrupting coverage or with a written plan of eligible for tax credits in the state exchanges. treatment.]Premium subsidies • Provide refundable and advanceable premium • Provide premium credits on a sliding scale basis • Provide affordability premium credits to eligibleto individuals credits to individuals and families with incomes to individuals and families with incomes up to individuals and families with incomes up to between 133-400% FPL in 2013, and including 400% FPL to purchase coverage through the 400% FPL to purchase insurance through the individuals and families with incomes between Gateway. The premium credits will be based on Health Insurance Exchange. The premium 100-133% FPL in 2014, to purchase insurance the average cost of the three lowest cost qualified credits will be based on the average cost of through the health insurance exchanges. The health plans in the area, but will be such that the three lowest cost basic health plans in the premium credits will be tied to the second individuals with incomes less than 400% FPL pay area and will be set on a sliding scale such that lowest-cost silver plan in the area and will no more than 12.5% of income and individuals the premium contributions are limited to the be provided on a sliding scale basis from 2% with incomes less than 150% FPL pay 1% of following percentages of income for specified of income for those at 100% FPL to 12% of income, with additional limits on cost sharing. income tiers: income for those between 300-400% FPL. • Limit availability of premium credits through 133-150% FPL: 1.5 - 3% of income • Exclude individuals with incomes below 100% the Gateway to U.S. citizens and lawfully 150-200% FPL: 3 - 5% of income FPL from eligibility for the premium credits. residing immigrants who meet income limits 200-250% FPL: 5 - 7% of income These individuals will be eligible for coverage and are not eligible for employer-based 250-300% FPL: 7 - 9% of income through the Medicaid program. coverage that meets minimum qualifying 300-350% FPL: 9 - 10% of income • Provide cost-sharing subsidies to eligible criteria and affordability standards, Medicare, Medicaid, TRICARE, or the Federal Employee 350-400% FPL: 10 - 11% of income individuals and families with incomes between 100-200% FPL. For those with incomes Health Benefits Program. Individuals with between 100-150% FPL, the cost-sharing access to employer-based coverage are subsidies will result in coverage for 90% of eligible for the premium credits if the cost of the benefit costs of the plan. For those with the employee premium exceeds 12.5% of the incomes between 150-200%, the cost-sharing individuals’ income. subsidies will result in coverage for 80% of the benefit costs of the plan.Health Care Reform Proposals — Last Modified: October 15, 2009
  5. 5. Senate HELP Committee House Tri-Committee Senate Finance Committee Affordable Health Choices Act America’s Affordable Health Choices Act of 2009 America’s Healthy Future Act of 2009 (S. 1679) (H.R. 3200)Premium subsidies • Limit availability of premium credits and cost- [EC Committee amendment: Replaces theto individuals (continued) sharing subsidies through the exchanges to above subsidy schedule with the following: U.S. citizens and legal immigrants who meet 133-150% FPL: 1.5 - 3% of income income limits. Employees who are offered 150-200% FPL: 3 – 5.5% of income coverage by an employer are not eligible for 200-250% FPL: 5.5 - 8% of income premium credits unless the employer plan 250-300% FPL: 8 - 10% of income does not have an actuarial value of at least 65% or if the employee share of the premium 300-350% FPL: 10 - 11% of income exceeds 10% of income. 350-400% FPL: 11 - 12% of income] • Require verification of both income and [EC Committee amendment: Increase the citizenship status in determining eligibility for affordability credits annually by the estimated the federal premium credits. savings achieved through adopting a formulary in the public health insurance option, pharmacy benefit manager transparency requirements, developing accountable care organization pilot programs in Medicaid, and administrative simplification.] [EC Committee amendment: Increase the affordability credits annually by the estimated savings achieved through limiting increases in premiums for plans in the Exchange to no more than 150% of the annual increase in medical inflation and by requiring the Secretary to negotiate directly with prescription drug manufacturers to lower the prices for Medicare Part D plans.] • Provide affordability cost-sharing credits to eligible individuals and families with incomes up to 400% FPL. The cost-sharing credits reduce the cost-sharing amounts and annual cost-sharing limits and have the effect of increasing the actuarial value of the basic benefit plan to the following percentages of the full value of the plan for the specified income tier: 133-150% FPL: 97% 150-200% FPL: 93% 200-250% FPL: 85% 250-300% FPL: 78% 300-350% FPL: 72% 350-400% FPL: 70%Health Care Reform Proposals — Last Modified: October 15, 2009
  6. 6. Senate HELP Committee House Tri-Committee Senate Finance Committee Affordable Health Choices Act America’s Affordable Health Choices Act of 2009 America’s Healthy Future Act of 2009 (S. 1679) (H.R. 3200)Premium subsidies • Limit availability of premium and cost-sharingto individuals (continued) credits to US citizens and lawfully residing immigrants who meet the income limits and are not enrolled in qualified or grandfathered employer or individual coverage, Medicare, Medicaid (except those eligible to enroll in the Exchange), TRICARE, or VA coverage (with some exceptions). Individuals with access to employer-based coverage are eligible for the premium and cost-sharing credits if the cost of the employee premium exceeds 11% of the individuals’ income [EC Committee amendment: To be eligible for the premium and cost-sharing credits, the cost of the employee premium must exceed 12% of individuals’ income.].Premium subsidies • Provide small employers with fewer than 25 • Provide qualifying small employers with a • Provide small employers with fewer than 25to employers employees and average annual wages of less health options program credit. To qualify for employees and average wages of less than than $40,000 that purchase health insurance the credit, employers must have fewer than $40,000 with a health coverage tax credit. The for employees with a tax credit. 50 full-time employees, pay an average wage full credit of 50% of premium costs paid by ­ Phase I: For tax years 2011 and 2012, provide of less than $50,000, and must pay at least employers is available to employers with 10 or a tax credit of up to 35% of the employer’s 60% of employee health expenses. The credit fewer employees and average annual wages of contribution toward the employee’s health is equal to $1,000 for each employee with $20,000 or less. The credit phases-out as firm insurance premium if the employer single coverage and $2,000 for each employee size and average wage increases and is not contributes at least 50% of the total premium with family coverage, adjusted for firm size permitted for employees earning more than cost or 50% of a benchmark premium. The (phasing out as firm size increases) and $80,000 per year. full credit will be available to employers number of months of coverage provided. Bonus • Create a temporary reinsurance program for with 10 or fewer employees and average payments are given for each additional 10% of employers providing health insurance coverage annual wages of less than $20,000. Tax- employee health expenses above 60% paid by to retirees ages 55 to 64. Program will exempt small businesses meeting these the employer. Employers may not receive the reimburse employers for 80% of retiree claims requirements are eligible for tax credits of up credit for more than three consecutive years. between $15,000 and $90,000. Payments from to 25% of the employer’s contribution toward Self-employed individuals who do not receive the reinsurance program will be used to lower the employee’s health insurance premium. premium credits for purchasing coverage the costs for enrollees in the employer plan. ­ Phase II: For tax years 2013 and later, for through the Gateway are eligible for the credit. Appropriate $10 billion over ten years for the eligible small businesses that purchase reinsurance program. coverage through the state exchange, provide a tax credit of up to 50% of the employer’s contribution toward the employee’s health insurance premium if the employer contributes at least 50% of the total premium cost or 50% of a benchmark premium. The credit will be available for two years. The full credit will be available to employers withHealth Care Reform Proposals — Last Modified: October 15, 2009
  7. 7. Senate HELP Committee House Tri-Committee Senate Finance Committee Affordable Health Choices Act America’s Affordable Health Choices Act of 2009 America’s Healthy Future Act of 2009 (S. 1679) (H.R. 3200)Premium subsidies 10 or fewer employees and average annual • Create a temporary reinsurance programto employers (continued) wages of less than $20,000. Tax-exempt for employers providing health insurance small businesses meeting these requirements coverage to retirees ages 55 to 64. Program are eligible for tax credits of up to 35% of the will reimburse employers for 80% of retiree employer’s contribution toward the claims between $15,000 and $90,000. Program employee’s health insurance premium. will end when the state Gateway is established. • Create a temporary reinsurance program Payments from the reinsurance program will for employers providing health insurance be used to lower the costs for enrollees in the coverage to retirees ages 55 to 64. Program employer plan. will reimburse employers or insurers for 80% of retiree claims between $15,000 and $90,000. Appropriate $5 billion to finance the program.Tax changes related • Impose a tax on individuals without qualifying • Impose a minimum tax on individuals without • Impose a tax on individuals without acceptableto health insurance coverage of $750 per adult per year to be qualifying health care coverage of $750 per health care coverage of 2.5% of modified phased-in beginning in 2014. individual per year (maximum family penalty of adjusted gross income. • Impose an excise tax in 2013 on insurers 4 times the individual penalty). of employer-sponsored health plans with aggregate values that exceed $8,000 for individual coverage and $21,000 for family coverage (these threshold values will be indexed to the consumer price index for urban consumers (CPI-U) plus 1%). The threshold amounts will be increased for retired individuals age 55 and up and for employees engaged in high-risk professions by $1,850 for individual coverage and $5,000 for family coverage. In the 17 states with the highest health care costs, the threshold amount is increased by 20% initially; this premium increase is subsequently reduced by half each year until it is phased out in 2015. The tax is equal to 40% of the value of the plan that exceeds the threshold amounts and is imposed on the issuer of the health insurance policy, which in the case of a self-insured plan is the plan administrator or, in some cases, the employer. The aggregate value of the health insurance plan includes reimbursements under a flexible spending account for medical expenses (health FSA) or health reimbursement arrangement (HRA), employer contributions to a health savings account (HSA), and coverage for dental, vision, and other supplementary health insurance coverage.Health Care Reform Proposals — Last Modified: October 15, 2009
  8. 8. Senate HELP Committee House Tri-Committee Senate Finance Committee Affordable Health Choices Act America’s Affordable Health Choices Act of 2009 America’s Healthy Future Act of 2009 (S. 1679) (H.R. 3200)Tax changes related • Conform the definition of medical expensesto health insurance for purposes of employer provided health(continued) coverage (including HRAs and health FSAs), HSAs, and Archer medical savings accounts to the definition for purposes of the itemized deduction for medical expenses. This change will exclude the costs for over-the-counter drugs not prescribed by a doctor from being reimbursed through an HRA or health FSA and from being reimbursed on a tax-free basis through an HSA or Archer MSA. • Increase the tax on distributions from a health savings account that are not used for qualified medical expenses to 20% (from 10%) of the disbursed amount. • Limit the amount of contributions to a flexible spending account for medical expenses to $2,500 per year. • Increase the threshold for the itemized deduction for unreimbursed medical expenses from 7.5% of adjusted gross income to 10% of adjusted gross income for regular tax purposes. Individuals age 65 and older are exempt from the increased threshold. • Impose new fees on segments of the health care sector: – $2.3 billion annual fee on the pharmaceutical manufacturing sector; – $4 billion annual fee on the medical device manufacturing sector; and – $6.7 billion annual fee on the health insurance sector.Creation of insurance • Provide immediate assistance until the new • Create state-based American Health Benefit • Create a National Health Insurance Exchange,pooling mechanisms insurance market rules go into effect for Gateways, administered by a governmental through which individuals and employers those with pre-existing conditions by creating agency or non-profit organization, through (phasing-in eligibility for employers starting a temporary high-risk pool. Individuals who which individuals and small employers can with smallest employers) can purchase have been denied health coverage due to a purchase qualified coverage. States may form qualified insurance, including from private pre-existing medical condition and who have regional Gateways or allow more than one health plans and the public health insurance been uninsured for at least six months will Gateway to operate in a state as long as each option. be eligible to enroll in the high-risk pool and Gateway serves a distinct geographic area. receive subsidized premiums. The high-risk pool will exist until 2013.Health Care Reform Proposals — Last Modified: October 15, 2009
  9. 9. Senate HELP Committee House Tri-Committee Senate Finance Committee Affordable Health Choices Act America’s Affordable Health Choices Act of 2009 America’s Healthy Future Act of 2009 (S. 1679) (H.R. 3200)Creation of insurance • Create state-based exchanges for the individual • Restrict access to coverage through • Restrict access to coverage through thepooling mechanisms market and small business health options the Gateways to individuals who are not Exchange to individuals who are not enrolled(continued) program (SHOP) exchanges for the small group incarcerated and who are not eligible for in qualified or grandfathered employer or market. Allow small businesses with up to 100 employer-sponsored coverage that meets individual coverage, Medicare, Medicaid (with employees to purchase coverage through the minimum qualifying criteria and affordability some exceptions), TRICARE, or VA coverage SHOP exchanges beginning in 2015 and permit standards, Medicare, Medicaid, TRICARE, (with some exceptions). [EC Committee states to allow businesses with more than 100 or the Federal Employee Health Benefits amendment: Permit members of the armed employees to purchase coverage in the SHOP Program. forces and those with coverage through exchange beginning in 2017. • Create a community health insurance option TRICARE or the VA to enroll in a health benefits • Restrict access to coverage through the to be offered through state Gateways that plan offered through the Exchange.] exchanges to U.S. citizens and legal immigrants. complies with the requirements of being a • Create a new public health insurance option • Create the Consumer Operated and Oriented qualified health plan and meets the same to be offered through the Health Insurance Plan (CO-OP) program to foster the creation requirements as other plans relating to Exchange that must meet the same of non-profit, member-run health insurance guarantee issue and renewability, insurance requirements as private plans regarding companies in all 50 states and District of rating rules, quality improvement and benefit levels, provider networks, consumer Columbia. To be eligible to receive funds, reporting, solvency standards, licensure, protections, and cost-sharing. Require the organizations must not be an existing and benefit plan information. Require the public plan to offer basic, enhanced, and organization, substantially all of its activities community health insurance plan to provide premium plans, and permit it to offer premium must consist of the issuance of qualified health the essential benefits package and offer plus plans. Finance the costs of the public benefit plans in each state in which it is licensed, coverage at all cost-sharing tiers. Require plan through revenues from premiums. For governance of the organization must be subject to that the costs of the community health the first three years, set provider payment a majority vote of its members, must operate with insurance plan be financed through revenues rates in the public plan at Medicare rates and a strong consumer focus, and any profits must from premiums, require the plan to negotiate allow bonus payments of 5% for providers that be used to lower premiums, improve benefits, payment rates with providers, and contract participate in both Medicare and the public or improve the quality of health care delivered to with qualified nonprofit entities to administer plan and for pediatricians and other providers its members. Require CO-OPs to meet the same the plan. Permit the plan to develop innovative that don’t typically participate in Medicare. requirements as private insurance plans in the payment policies to promote quality, efficiency, In subsequent years, permit the Secretary to exchanges related to solvency, licensure, provider and savings to consumers. Require each State establish a process for setting rates. [EC payments, network adequacy, and any applicable to establish a State Advisory Council to provide Committee amendment: Require the public state premium assessments. recommendations on policies and procedures health insurance option to negotiate rates with • Require all state-licensed insurers in the for the community health insurance option. providers so that the rates are not lower than individual and small group markets to • Require guarantee issue and renewability of Medicare rates and not higher than the average participate in the exchanges. health insurance policies in the individual and rates paid by other qualified health benefit • Require guarantee issue and renewability small group markets; prohibit pre-existing plan offering entities.] Health care providers and allow rating variation based only on age condition exclusions; prohibit insurers from participating in Medicare are considered (limited to 4 to 1 ratio), tobacco use (limited rescinding coverage except in cases of fraud; participating providers in the public plan unless to 1.5. to 1 ratio), family composition, and and allow rating variation based only on family they opt out. Permit the public plan to develop geography in the non-group and the small structure, geography, the actuarial value of the innovative payment mechanisms, including group market (new rules for small group health plan benefit, tobacco use (limited to 1.5 medical home and other care management market will be phased-in over five years). to 1 ratio), and age (limited to 2 to 1 ratio). payments, value-based purchasing, bundling Require risk adjustment in the individual and of services, differential payment rates, small group markets and prohibit insurers performance based payments, or partial from rescinding coverage. capitation and modify cost sharing andHealth Care Reform Proposals — Last Modified: October 15, 2009
  10. 10. Senate HELP Committee House Tri-Committee Senate Finance Committee Affordable Health Choices Act America’s Affordable Health Choices Act of 2009 America’s Healthy Future Act of 2009 (S. 1679) (H.R. 3200)Creation of insurance • Require the exchanges to develop a • Require plans participating in the Gateway payment rates to encourage use of high-valuepooling mechanisms standardized format for presenting insurance to provide coverage for at least the essential services. [EC Committee amendment: Clarify(continued) options, create a web portal to help consumers health care benefits, meet network adequacy that the public health insurance option must find insurance, maintain a call center for requirements, and make information regarding meet the same requirements as other plans customer service, and establish procedures for plan benefits service area, premium and cost relating to guarantee issue and renewability, enrolling individuals and businesses and for sharing, and grievance and appeal procedures insurance rating rules, network adequacy, and determining eligibility for tax credits. Permit available to consumers. transparency of information.] [EC Committee exchanges to contract with state Medicaid • Create three benefit tiers of plans to be offered amendment: Require the public health agencies to determine eligibility for tax credits through the Gateways based on the percentage insurance option to adopt a prescription drug in the exchanges. of allowed benefit costs covered by the plan: formulary.] • Create four benefit categories of plans plus a – Tier 1: includes the essential health benefits, • Create four benefit categories of plans to be separate “young invincible plan” to be offered covers 76% of the benefit costs of the plan, offered through the Exchange: through the exchange, and in the individual and and limits out-of-pocket costs to the Health – Basic plan includes essential benefits small group markets: Savings Account (HSA) current law limit package and covers 70% of the benefit costs – Bronze plan represents minimum creditable ($5,950 for individuals and $11,900 for of the plan; coverage and would cover 65% of the benefit families in 2010); – Enhanced plan includes essential benefits costs of the plan, with an out-of-pocket limit – Tier 2: includes the essential health benefits, package, reduced cost sharing compared equal to the Health Savings Account (HSA) covers 84% of the benefit costs of the plan, to the basic plan, and covers 85% of benefit current law limit ($5,950 for individuals and and limits out-of-pocket costs to 50% of the costs of the plan; $11,900 for families in 2010); HSA limit ($2,975 for individuals and $5,950 – Premium plan includes essential benefits – Silver plan includes minimum benefits, for families); and package with reduced cost sharing compared covers 70% of the benefit costs of the plan, – Tier 3: includes the essential health benefits, to the enhanced plan and covers 95% of the with the HSA out-of-pocket limits; covers 93% of the benefit costs of the plan, benefit costs of the plan; – Gold plan includes the minimum benefits, and limits out-of pocket costs to 20% of the – Premium plus plan is a premium plan that covers 80% of the benefit costs of the plan, HSA limit ($1,190 for individuals and $2,380 provides additional benefits, such as oral with the HSA out-of-pocket limits; for families). health and vision care. – Platinum plan includes the minimum • Require states to adjust payments to health • Require guarantee issue and renewability; benefits, covers 90% of the benefit costs of plans based on the actuarial risk of plan allow rating variation based only on age the plan, with the HSA out-of-pocket limits; enrollees using methods established by the (limited to 2 to 1 ratio), premium rating area, – Young Invincible plan available to those Secretary. and family enrollment; and limit the medical 25 years old and younger and provides • Require the Gateway to certify participating loss ratio to a specified percentage. catastrophic coverage only with the coverage health plans, provide consumers with • Require plans participating in the Exchange level set at the HSA current law levels except information allowing them to choose among to be state licensed, report data as required, that prevention benefits would be exempt plans (including through a centralized website), implement affordability credits, meet network from the deductible. contract with navigators to conduct outreach adequacy standards, provide culturally • Reduce the out-of-pocket limits for those with and enrollment assistance, create a single and linguistically appropriate services, incomes up to 400% FPL to the following levels: point of entry for enrolling in coverage through contract with essential community providers, – 100-200% FPL: one-third of the HSA limits the Gateway or through Medicaid, CHIP or and participate in risk pooling. Require ($1,983/individual and $3,967/family); other federal programs, and assist consumers participating plans to offer one basic plan for – 200-300% FPL: one-half of the HSA limits with the purchase of long-term care services each service area and permit them to offer ($2,975/individual and $5,950/family); and supports. additional plans. – 300-400% FPL: two-thirds of the HSA limits ($3,987/individual and $7,973/family).Health Care Reform Proposals — Last Modified: October 15, 2009 10
  11. 11. Senate HELP Committee House Tri-Committee Senate Finance Committee Affordable Health Choices Act America’s Affordable Health Choices Act of 2009 America’s Healthy Future Act of 2009 (S. 1679) (H.R. 3200)Creation of insurance • Permit states the option of creating a Basic • Prohibit plans participating in the Gateways [EC Committee amendment: Require planspooling mechanisms Health Plan for uninsured individuals with from discriminating against any provider to provide information related to end-of-life(continued) incomes between 133-200% FPL. States opting because of a willingness or unwillingness to planning to individuals and provide the option to provide this coverage will contract with provide abortions. to establish advance directives and physician’s multiple private plans to provide coverage at • Following initial federal support, the Gateway order for life sustaining treatment.] the level of plans in the exchanges. They are will be funded by a surcharge of no more than • Require risk adjustment of participating encouraged to include innovative features in 4% of premiums collected by participating Exchange plans. the contracts, such as care coordination and health plans. • Provide information to consumers to enable incentives for using preventive services and them to choose among plans in the Exchange, should seek to contract with managed care including establishing a telephone hotline and plans that meet specific performance measures. maintaining a website and provide information States will receive 85% of the funds that would on open enrollment periods and how to enroll. have been paid as federal premium and cost- • [EC Committee amendment: Prohibit sharing subsidies for eligible individuals in the plans participating in the Exchange from state with incomes between 133-200% FPL to discriminating against any provider because establish the Basic Health Plan. Individuals of a willingness or unwillingness to provide with incomes between 133-200% FPL in states abortions.] creating Basic Health Plans will not be eligible • [EC Committee amendment: Facilitate the for subsidies in the exchanges. establishment of non-for-profit, member- • Require that at least one plan in the exchanges run health insurance cooperatives to provide provide coverage for abortions beyond those for insurance through the Exchange.] which federal funds are permitted and require • Allow states to operate state-based exchanges that at least one plan in the exchange does not if they demonstrate the capacity to meet the provide coverage for abortions beyond those for requirements for administering the Exchange. which federal funds are permitted (in cases of rape or incest or to save the life of the woman). Prohibit plans participating in the exchanges from discriminating against any provider because of a willingness or unwillingness to provide, pay for, provide coverage of, or refer for abortions.Benefit design • Create minimum creditable coverage that • Create the essential health care benefits • Create an essential benefits package that provides a comprehensive set of services, package that provides a comprehensive array provides a comprehensive set of services, covers 65% of the actuarial value of the of services and prohibits inclusion of lifetime covers 70% of the actuarial value of the covered covered benefits, limits annual cost-sharing or annual limits on the dollar value of the benefits, limits annual cost-sharing to $5,000/ to $5,950/individual and $11,900/family, benefits. The essential health benefits must be individual and $10,000/family, and does not does not impose annual or lifetime limits on included in all qualified health plans and must impose annual or lifetime limits on coverage. coverage, and is not more extensive than the be equal to the scope of benefits provided by The Health Benefits Advisory Council, chaired typical employer plan. Require the Secretary to a typical employer plan. Create a temporary, by the Surgeon General, will make define and annually update the benefit package independent commission to advise the recommendations on specific services to be through a transparent and public process. (See Secretary in the development of the essential covered by the essential benefits package as description of benefit categories in Creation of health benefit package. well as cost-sharing levels. [EL Committee insurance pooling mechanism.) amendment: Require early and periodicHealth Care Reform Proposals — Last Modified: October 15, 2009 11
  12. 12. Senate HELP Committee House Tri-Committee Senate Finance Committee Affordable Health Choices Act America’s Affordable Health Choices Act of 2009 America’s Healthy Future Act of 2009 (S. 1679) (H.R. 3200)Benefit design • Prohibit abortion coverage from being required • Specify the criteria for minimum qualifying screening, diagnostic, and treatment (EPSDT)(continued) as part of the minimum benefits package; coverage for purposes of meeting the individual services for children under age 21 be included require segregation of public subsidy funds mandate for coverage, and an affordability in the essential benefits package.] from private premium payments for plans standard such that coverage is deemed [EC Committee amendment: Prohibit abortion that choose to cover abortion services beyond unaffordable if the premium exceeds 12.5% of coverage from being required as part of the Hyde—which allows coverage for abortion an individual’s adjusted gross income. essential benefits package; require segregation services to save the life of the woman and in of public subsidy funds from private premiums cases of rape or incest; and require there be no payments for plans that choose to cover effect on state or federal laws on abortions. abortion services beyond Hyde—which allows coverage for abortion services to save the life of the woman and in cases of rape or incest; and require there be no effect on state or federal laws on abortions.] • All qualified health benefits plans, including those offered through the Exchange and those offered outside of the Exchange (except certain grandfathered individual and employer- sponsored plans) must provide at least the essential benefits package.Changes to private • Impose the same insurance market regulations • Impose the same insurance market regulations • Prohibit coverage purchased through theinsurance relating to guarantee issue, premium rating, relating to guarantee issue, premium rating, individual market from qualifying as acceptable prohibitions on pre-existing condition prohibitions on pre-existing condition coverage for purposes of the individual exclusions, risk adjustment, and rescissions in exclusions, and prohibitions on insurance plan mandate unless it is grandfathered coverage. the individual market, in the exchange, and in rescissions in the individual and group markets Individuals can purchase a qualifying health the small group market, phasing in the new and in the American Health Benefit Gateways. benefit plan through the Health Insurance rules for small group market over five years. (See new rating and market rules in Creation of Exchange. (See new rating and market rules in Creation of insurance pooling mechanism). • Impose the same insurance market regulations insurance pooling mechanism.) • Require health insurers to report their medical relating to guarantee issue, premium rating, • Require health plans to report the proportion of loss ratio. and prohibitions on pre-existing condition premium dollars spent on items other than • Require health insurers to provide financial exclusions in the insured group market and medical care and require plans to compile incentives to providers to better coordinate in the Exchange (see creation of insurance information on coverage in a standard format. care through case management and chronic pooling mechanism). • Require all new policies (except stand-alone disease management, promote wellness and • Limit health plans’ medical loss ratio to a dental, vision, and long-term care insurance health improvement activities, improve patient percentage specified by the Secretary to be plans) to comply with one of the four benefit safety, reduce medical errors, and provide enforced through a rebate back to consumers. categories, including those offered through the culturally and linguistically appropriate care. [EL Committee amendment: Limit health exchanges and those offered outside of the • Provide dependent coverage for children up to plans’ medical loss ratio to at least 85%.] exchanges. Require health plans in the age 26 for all individual and group policies. • Improve consumer protections by establishing individual and small group markets to at least • Require insurers and group plans to notify uniform marketing standards, requiring fair offer coverage in the silver and gold categories. enrollees if coverage does not meet minimum grievance and appeals mechanisms, and Existing individual and employer-sponsored qualifying coverage standards for purposes of prohibiting insurers from rescinding health plans do not have to meet the new benefit satisfying the individual mandate for coverage. insurance coverage except in cases of fraud.Health Care Reform Proposals — Last Modified: October 15, 2009 12
  13. 13. Senate HELP Committee House Tri-Committee Senate Finance Committee Affordable Health Choices Act America’s Affordable Health Choices Act of 2009 America’s Healthy Future Act of 2009 (S. 1679) (H.R. 3200)Changes to private standards. (See description of benefit • Permit licensed health insurers to sell health • Adopt standards for financial andinsurance (continued) categories in Creation of insurance pooling insurance policies outside of the Gateway. States administrative transactions to promote mechanism.) will regulate these outside-the-Gateway plans. administrative simplification. • Require small employers to provide a plan with • Create the Health Choices Administration a deductible that does not exceed $2,000 for to establish the qualifying health benefits individuals and $4,000 for families unless standards, establish the Exchange, administer contributions are offered that offset deductible the affordability credits, and enforce the amounts above these limits. This deductible requirements for qualified health benefit plan limit will not affect the actuarial value of offering entities, including those participating bronze plans and does not apply to “young in the Exchange or outside the Exchange. invincible” plans. (See description of benefit categories in Creation of insurance pooling mechanism.) • Allow states the option of merging the individual and small group markets. • Create a temporary reinsurance program to help stabilize premiums during the first three years of operation of the exchanges when the risk of adverse selection due to enforcement of the new rating rules and market changes is greatest. Finance the reinsurance program through mandatory contributions by health insurers. • Allow insurers to offer a national health plan with a uniform benefits package in the states in which they are licensed. National plans would be required to offer plans with silver and gold benefit packages and would be exempt from state benefit requirements. Allow states to opt out of the national plan. • Permit states to form health care choice compacts and allow insurers to sell policies in any state participating in the compact. Insurers selling policies through a compact would only be subject to the laws and regulations of the state where the policy is written or issued.Health Care Reform Proposals — Last Modified: October 15, 2009 13
  14. 14. Senate HELP Committee House Tri-Committee Senate Finance Committee Affordable Health Choices Act America’s Affordable Health Choices Act of 2009 America’s Healthy Future Act of 2009 (S. 1679) (H.R. 3200)State role • Require states to create health insurance • Establish American Health Benefit Gateways • Require states to enroll newly eligible Medicaid exchanges for individuals and small businesses meeting federal standards and adopt individual beneficiaries into the state Medicaid programs and require state insurance commissioners to and small group market regulation changes. and to implement the specified changes with provide oversight of health plans with regard • Implement Medicaid eligibility expansions respect to provider payment rates, benefit to the new insurance market regulations, and adopt federal standards and protocols enhancements, quality improvement, and consumer protections, rate reviews, solvency, for facilitating enrollment of individuals in program integrity. reserve fund requirements, and premium federal and state health and human services • Require states to maintain Medicaid and taxes, and to define rating areas. programs. CHIP eligibility standards, methodologies, • Require states to enroll newly eligible Medicaid • Create temporary “RightChoices” programs to or procedures that were in place as of June beneficiaries into state Medicaid programs, provide uninsured individuals with immediate 16, 2009 as a condition of receiving federal coordinate enrollment with the new exchanges, access to preventive care and treatment for Medicaid or CHIP matching payments. and implement other specified changes to the identified chronic conditions. States will receive • Require states to enter into a Memorandum Medicaid program. Require states to maintain federal grants to finance these programs. of Understanding with the Health Insurance current Medicaid and CHIP eligibility levels for Exchange to coordinate enrollment of children until 2019. States must also maintain individuals in Exchange-participating health current Medicaid eligibility levels for adults plans and under the state’s Medicaid program. above 133% FPL until 2013 and until 2014 for • May require states to determine eligibility those with incomes at or below 133% FPL. A for affordability credits through the Health state is exempt from the maintenance of effort Insurance Exchange. requirement for non-disabled adults with incomes above 133% FPL from January 2011 if the state certifies that it is experiencing a budget deficit or will experience a deficit in the following year. • Require states to establish an ombudsman office to serve as an advocate for people with private coverage in the individual and small group markets. • Permit states to obtain a waiver of certain new health insurance requirements if the state can demonstrate that it provides health coverage to all residents that is at least as comprehensive as the coverage required under an exchange plan and that the state plan is budget-neutral to the federal government over 10 years.Health Care Reform Proposals — Last Modified: October 15, 2009 14
  15. 15. Senate HELP Committee House Tri-Committee Senate Finance Committee Affordable Health Choices Act America’s Affordable Health Choices Act of 2009 America’s Healthy Future Act of 2009 (S. 1679) (H.R. 3200)Cost containment • Restructure payments to Medicare Advantage • Establish a Health Care Program Integrity • Simplify health insurance administration plans to base payments on plan bids with Coordinating Council, a Fraud, Waste, and by adopting standards for financial and bonus payments for quality, performance Abuse Commission, and two new federal administrative transactions, including improvement, and care coordination. department positions to oversee and timely and transparent claims and denial Grandfather the extra benefits in MA plans in coordinate policy, program development, and management processes and use of standard areas where plan bids are at or below 75% of oversight of health care fraud, waste, and electronic transactions. traditional fee-for-service Medicare (these plans abuse in public and private coverage. • [EC Committee amendment: Limit annual are required to participate in the new competitive • Simplify health insurance administration increases in the premiums charged under any bidding process). Provide transitional extra by adopting standards for financial and health plans participating in the Exchange to benefits for MA beneficiaries in certain areas if administrative transactions, including no more than 150% of the annual percentage they experience a significant reduction in extra timely and transparent claims and denial increase in medical inflation. Provide benefits under competitive bidding. management processes and use of standard exceptions if this limit would threaten a health • Reduce annual market basket updates for electronic transactions. plan’s financial viability.] inpatient hospital, home health, skilled nursing • Modify provider payments under Medicare including: facility, hospice and other Medicare providers, – Modify market basket updates to account and adjust for productivity. for productivity improvements for inpatient • Freeze the threshold for income-related hospital, home health, skilled nursing facility, Medicare Part B premiums through 2019, and other Medicare providers; and and reduce the Medicare Part D premium – Reduce payments for potentially preventable subsidy for those with incomes above $85,000/ hospital readmissions. individual and $170,000/couples. • Restructure payments to Medicare Advantage • Establish an independent Medicare plans, phasing to 100% of fee-for-services Commission to submit proposals for reducing payments, with bonus payments for quality. excess Medicare cost growth by targeted • Increase the Medicaid drug rebate percentage amounts. Proposals submitted by the and extend the prescription drug rebate to Commission must be acted on by Congress Medicaid managed care plans. Require drug and if a legislative package with the targeted manufacturers to provide drug rebates for dual level of Medicare savings is not enacted, eligibles enrolled in Part D plans. the Commission’s proposal will go into • [EC Committee amendment: Require effect automatically. The Commission would the Secretary to negotiate directly with be prohibited from submitting proposals pharmaceutical manufacturers to lower drug that would ration care, increase revenues prices for Medicare Part D plans and Medicare or change benefits, eligibility or Medicare Advantage Part D plans.] beneficiary cost sharing (including Parts A and B premiums), but would not be prohibited • [EC Committee amendment: Authorize the from making recommendations to reduce Food and Drug Administration to approve premium subsidies for Medicare Advantage or generic versions of biologic drugs and grant stand-alone Part D prescription drug plans. biologics manufacturers 12 years of exclusive Hospitals and hospices would not be subject to use before generics can be developed.] cost reductions proposed by the Commission. • Reduce Medicaid DSH payments by $6 billion Beginning January 1, 2019, the growth target in 2019, imposing the largest percentage for Medicare spending would be set at GDP per reductions in state DSH allotments in states capita plus one percent. with the lowest uninsured rates and those that do not target DSH payments.Health Care Reform Proposals — Last Modified: October 15, 2009 15

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