Healthreform Sbs Full

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Healthreform Sbs Full

  1. 1. on Health Reform This side-by-side compares the leading comprehensive reform proposals across a number of key characteristics and plan components. Included in this side-by- side are proposals for moving toward universal coverage that have been put forward by the President and Members of Congress. In an effort to capture the most important proposals, we have included those that have been formally introduced as legislation as well as those that have been offered as principles or in White Paper form. This side-by-side will be regularly updated to reflect changes in the proposals and to incorporate major new proposals as they are announced. The House Tri-Committee summary incorporates the major amendments to the legislation adopted by the three committees 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 Committee on Energy and Commerce; “E&L” for the Committee on Education and Labor; and “W&M” for the Committee on Ways and Means. House Tri-Committee America’s Affordable Health Senate Finance Committee Senate HELP Committee Choices Act of 2009 President Obama Policy Options Affordable Health Choices Act (H.R. 3200) Principles for Health Reform Date plan announced April – May 2009 June 9, 2009 June 19, 2009 February 26, 2009 Overall approach The Senate Finance Committee Require individuals to have health Require all individuals to have President Obama outlined eight to expanding access released a series of papers laying insurance. Create state-based health insurance. Create a Health principles for health care reform to coverage out options for health reform. While American Health Benefit Gateways Insurance Exchange through which in his FY 2010 Budget overview. not a formal proposal, these papers through which individuals and small individuals and smaller employers The President has indicated that offer a framework for achieving businesses can purchase health can purchase health coverage, with comprehensive health reform should: health reform goals and present the coverage, with subsidies available to premium and cost-sharing credits • Reduce long-term growth of range of options the Committee will individuals/families with incomes up available to individuals/families health care costs for businesses consider as it works to draft health to 400% of the federal poverty level with incomes up to 400% of the and government. reform legislation. (or $73,240 for a family of three in federal poverty level (or $73,240 for • Protect families from bankruptcy or Require all individuals to have 2009). Require employers to provide a family of three in 2009). Require debt because of health care costs. health insurance. Create a Health coverage to their employees or employers to provide coverage to • Guarantee choice of doctors and Insurance Exchange through which pay an annual fee, with exceptions employees or pay into a Health health plans. individuals and small businesses for small employers, and provide Insurance Exchange Trust Fund, certain small employers a credit with exceptions for certain small • Invest in prevention and wellness. can purchase health coverage, with to offset the costs of providing employers, and provide certain • Improve patient safety and quality subsidies available to individuals/ coverage. Impose new regulations small employers a credit to offset care. families with incomes between 100 and 400% of the federal poverty on the individual and small group the costs of providing coverage. • Assure affordable, quality health level. Impose new regulations on insurance markets. Expand Impose new regulations on plans coverage for all Americans. the non-group and small group Medicaid to all individuals with participating in the Exchange and in • Maintain coverage when you insurance markets. Expand incomes up to 150% of the federal the small group insurance market. change or lose your job. Medicaid and CHIP and offer a poverty level. Expand Medicaid to 133% of the • End barriers to coverage for temporary Medicare buy-in for the poverty level. people with pre-existing medical pre-Medicare population. conditions. Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: august 5, 2009
  2. 2. House Tri-Committee America’s Affordable Health Senate Finance Committee Senate HELP Committee Choices Act of 2009 President Obama Policy Options Affordable Health Choices Act (H.R. 3200) Principles for Health Reform Individual mandate • Require all individuals to have • Require individuals to have • Require all individuals to have • The plan must put the country insurance that meets minimum qualifying health coverage. “acceptable health coverage”. on a clear path to cover all coverage standards. Enforced Enforced through a minimum Those without coverage pay Americans. through an excise tax equal to a tax penalty of no more than a penalty of 2.5% of modified percentage of the premium for $750 per year. Exemptions to the adjusted gross income up to the lowest cost option available individual mandate will be granted the cost of the average national through the Health Insurance to residents of states that do not premium for self-only or Exchange in the area where the establish an American Health family coverage under a basic individual resides. Exemptions will Benefit Gateway, members of plan in the Health Insurance be granted for financial hardship; Indian tribes, those for whom Exchange. Exceptions granted for if the lowest cost plan option affordable coverage is not dependents, religious objections, exceeds 10% of an individual’s available, and those without and financial hardship. income; and if the individual has coverage for fewer than 90 days. income below 100% of the poverty level. Employer requirements • Proposed Option A: Require • Require employers to offer health • Require employers to offer Not specified. employers with more than coverage to their employees and coverage to their employees and $500,000 in total payroll per contribute at least 60% of the contribute at least 72.5% of the year to offer coverage to their premium cost or pay $750 for premium cost for single coverage employees and contribute at each uninsured full-time and 65% of the premium cost for least 50% of the premium or pay employee and $375 for each family coverage of the lowest cost an assessment. The employer uninsured part-time employee plan that meets the essential assessment could be structured who is not offered coverage. For benefits package requirements or in several ways: 1) a set fee per employers subject to the pay 8% of payroll into the Health enrollee per month based on total assessment, the first 25 workers Insurance Exchange Trust Fund. annual payroll; 2) a tiered penalty are exempted. [EL Committee amendment: calculated as a percentage of • Exempt employers with 25 or Provide hardship exemptions payroll; or 3) a larger penalty only fewer employees from the for employers that would be on firms with annual payroll of requirement to provide coverage. negatively affected by job losses more than $1,500,000. as a result of requirement.] • Proposed Option B: No employer “pay or play” requirement. Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: august 5, 2009 2
  3. 3. House Tri-Committee America’s Affordable Health Senate Finance Committee Senate HELP Committee Choices Act of 2009 President Obama Policy Options Affordable Health Choices Act (H.R. 3200) Principles for Health Reform Employer requirements • Eliminate or reduce the pay (continued) or play assessment for small employers with annual payroll of less than $400,000: – Annual payroll less than $250,000: exempt – 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. [EC Committee amendment: Extend the 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. Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: august 5, 2009
  4. 4. House Tri-Committee America’s Affordable Health Senate Finance Committee Senate HELP Committee Choices Act of 2009 President Obama Policy Options Affordable Health Choices Act (H.R. 3200) Principles for Health Reform Expansion of public Medicaid • Expand Medicaid to all individuals • Expand Medicaid to all individuals • As a foundation for health programs • Expand Medicaid to all individuals (children, pregnant women, (children, pregnant women, reform, the President signed with incomes up to 115% FPL, parents, and adults without parents, and adults without the Children’s Health Insurance with a possible increase in dependent children) with incomes dependent children) with incomes Program Reauthorization eligibility for parents, pregnant up to 150% FPL. Individuals up to 133% FPL. Newly eligible, Act (CHIPRA), which provides women, and children to a eligible for Medicaid will be non-traditional (childless adults) coverage to 11 million children. higher level. Coverage could be covered through state Medicaid Medicaid beneficiaries may provided through the current programs and will not be eligible enroll in coverage through the program structure or by enrolling for credits to purchase coverage Exchange if they were enrolled children, pregnant women, through American Health Benefit in qualified health coverage parents, and childless adults in Gateways. during the six months before the Health Insurance Exchange. • Grant individuals eligible for becoming Medicaid eligible. Another alternative is to enroll the Children’s Health Insurance Provide Medicaid coverage for all all populations except childless Program (CHIP) the option of newborns who lack acceptable adults in Medicaid. Under this enrolling in CHIP or enrolling in coverage and provide optional approach, childless adults would a qualified health plan through a Medicaid coverage to low-income not be eligible for Medicaid but Gateway. HIV-infected individuals and for would be given tax credits to family planning services to certain purchase coverage through the low-income women. In addition, Exchange or to buy-in to Medicaid. increase Medicaid payment Children’s Health Insurance rates for primary care providers Program to 100% of Medicare rates. • After September 30, 2013, expand [EC Committee amendment: CHIP eligibility to 275% FPL. Once Require states to submit a state the Health Insurance Exchange is plan amendment specifying the fully operational, CHIP enrollees payment rates to be paid under would obtain coverage through the state’s Medicaid program.] the Exchange and states would The coverage expansions (except be required to continue to provide the optional expansions) and the services not covered by plans in enhanced provider payments the Exchange, including Early and will be fully financed with Periodic Screening, Diagnosis, federal funds. [EC Committee and Treatment (EPSDT) services. amendment: Replace full federal financing for Medicaid coverage Medicare expansions with 100% federal • Until the Health Insurance financing through 2014 and 90% Exchange is underway, allow federal financing beginning in year individuals aged 55-64 without 2015.] coverage to buy-in to Medicare at full-cost. • Phase-out or reduce the two- year waiting period for Medicare eligibility for people with disabilities. Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: august 5, 2009
  5. 5. House Tri-Committee America’s Affordable Health Senate Finance Committee Senate HELP Committee Choices Act of 2009 President Obama Policy Options Affordable Health Choices Act (H.R. 3200) Principles for Health Reform Expansion of public Public Health Insurance Option • Require Children’s Health programs (continued) • Proposed Option A: Create a new Insurance Program (CHIP) public plan to be offered through enrollees to obtain coverage the Exchange that will be subject through the Health Insurance to the same rating and risk Exchange (in the first year the adjustment rules as the private Exchange is available) provided plans. The public plan could the Health Choices Commissioner be administered by the federal determines that the Exchange government, by multiple third- has the capacity to cover these party administrators, or by the children and that procedures states. are in place to ensure the timely • Proposed Option B: Do not create transition of CHIP enrollees a public plan option. into the Exchange without an interruption of coverage. Premium subsidies • Provide refundable tax credits • Provide premium credits on a • Provide affordability premium • The plan must protect families’ to individuals to individuals and families with sliding scale basis to individuals credits to eligible individuals from bankruptcy or debt because incomes between 100 and 400% and families with incomes up to and families with incomes up to of health care costs. FPL to purchase insurance 400% FPL to purchase coverage 400% FPL to purchase insurance • The American Recovery and through the Health Insurance through the Gateway. The through the Health Insurance Reinvestment Act makes coverage Exchange. The level of the premium credits will be based Exchange. The premium credits more affordable for Americans premium tax credit could be set on the average cost of the three will be based on the average cost who lose their jobs and their as a percentage of income or as a lowest cost qualified health plans of the three lowest cost basic access to employer-based health percentage of the premium, with in the area, but will be such that health plans in the area and will coverage by offering a subsidy of additional limits on cost-sharing. individuals with incomes less be set on a sliding scale such 65 percent of the premium costs than 400% FPL pay no more than that the premium contributions for COBRA coverage. 12.5% of income and individuals are limited to the following with incomes less than 150% FPL percentages of income for pay 1% of income, with additional specified income tiers: limits on cost-sharing. 133-150% FPL: 1.5 - 3% of income • Limit availability of premium 150-200% FPL: 3 - 5% of income credits through the Gateway to 200-250% FPL: 5 - 7% of income individuals who are not eligible 250-300% FPL: 7 - 9% of income for employer-based coverage that 300-350% FPL: 9 - 10% of income meets minimum qualifying criteria and affordability standards, 350-400% FPL: 10 - 11% of income Medicare, Medicaid, TRICARE, or the Federal Employee Health Benefits Program. Individuals with access to employer-based coverage are eligible for the premium credits if the cost of the employee premium exceeds 12.5% of the individuals’ income. Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: august 5, 2009 5
  6. 6. House Tri-Committee America’s Affordable Health Senate Finance Committee Senate HELP Committee Choices Act of 2009 President Obama Policy Options Affordable Health Choices Act (H.R. 3200) Principles for Health Reform Premium subsidies [EC Committee amendment: to individuals (continued) Replaces the above subsidy schedule with the following: 133-150% FPL: 1.5 - 3% of income 150-200% FPL: 3 – 5.5% of income 200-250% FPL: 5.5 - 8% of income 250-300% FPL: 8 - 10% of income 300-350% FPL: 10 - 11% of income 350-400% FPL: 11 - 12% of income] [EC Committee amendment: Increase the affordability credits annually by the estimated 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.] Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: august 5, 2009
  7. 7. House Tri-Committee America’s Affordable Health Senate Finance Committee Senate HELP Committee Choices Act of 2009 President Obama Policy Options Affordable Health Choices Act (H.R. 3200) Principles for Health Reform Premium subsidies • Provide affordability cost-sharing to individuals (continued) 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% • Limit availability of premium and cost-sharing 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.]. Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: august 5, 2009
  8. 8. House Tri-Committee America’s Affordable Health Senate Finance Committee Senate HELP Committee Choices Act of 2009 President Obama Policy Options Affordable Health Choices Act (H.R. 3200) Principles for Health Reform Premium subsidies • Provide certain small employers • Provide qualifying small • Provide small employers with Not specified. to employers that purchase insurance for their employers with a health options fewer than 25 employees and employees with a tax credit. The program credit. To qualify for the average wages of less than full credit of 50% of the average credit, employers must have fewer $40,000 with a health coverage total premium cost paid by the than 50 full-time employees, pay tax credit. The full credit of 50% of employer would be available an average wage of less than premium costs paid by employers to employers with 10 or fewer $50,000, and must pay at least is available to employers with 10 employees and whose employees 60% of employee health expenses. or fewer employees and average have average annual wages of less The credit is equal to $1,000 annual wages of $20,000 or less. than $20,000. The tax credit would for each employee with single The credit phases-out as firm size be phased out as firm size and coverage and $2,000 for each and average wage increases and earnings increase. The tax credit employee with family coverage, is not permitted for employees would not be payable in advance adjusted for firm size (phasing earning more than $80,000 per or refundable. out as firm size increases) and year. number of months of coverage • Create a temporary reinsurance provided. Bonus payments are program for employers providing given for each additional 10% health insurance coverage to of employee health expenses retirees ages 55 to 64. Program above 60% paid by the employer. will reimburse employers for 80% Employers may not receive of retiree claims between $15,000 the credit for more than three and $90,000. Payments from the consecutive years. Self-employed reinsurance program will be used individuals who do not receive to lower the costs for enrollees in premium credits for purchasing the employer plan. Appropriate coverage through the Gateway are $10 billion over ten years for the eligible for the credit. reinsurance program. • Create a temporary reinsurance program for employers providing health insurance coverage to retirees ages 55 to 64. Program will reimburse employers for 80% of retiree claims between $15,000 and $90,000. Program will end when the state Gateway is established. Payments from the reinsurance program will be used to lower the costs for enrollees in the employer plan. Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: august 5, 2009
  9. 9. House Tri-Committee America’s Affordable Health Senate Finance Committee Senate HELP Committee Choices Act of 2009 President Obama Policy Options Affordable Health Choices Act (H.R. 3200) Principles for Health Reform Tax changes related • Considers several health • Impose a minimum tax on • Impose a tax on individuals Not specified. to health insurance insurance-related tax changes individuals without qualifying without acceptable health care affecting the tax preference for health care coverage of no more coverage of 2.5% of modified employer-sponsored insurance, than $750 per year. adjusted gross income. health savings accounts, flexible spending accounts, and deductions for medical expenses. Creation of insurance • Create one national or multiple • Create state-based American • Create a National Health Insurance • The plan should provide portability pooling mechanisms regional Health Insurance Health Benefit Gateways, Exchange, through which individuals of coverage and should offer Exchanges through which administered by a governmental and employers (phasing-in eligibility Americans a choice of health individuals and small employers agency or non-profit organization, for employers starting with smallest plans. can purchase qualified insurance. through which individuals and employers) can purchase qualified • Require all state-licensed insurers small employers can purchase insurance, including from private in the non-group and small group qualified coverage. States may health plans and the public health markets to participate in the form regional Gateways or allow insurance option. Health Insurance Exchange(s). more than one Gateway to operate • Restrict access to coverage • Require guarantee issue and in a state as long as each Gateway through the Exchange to renewability and allow rating serves a distinct geographic area. individuals who are not enrolled variation based only on age, • Restrict access to coverage in qualified or grandfathered tobacco use, family composition, through the Gateways to employer or individual coverage, and geography (not health status) individuals who are not Medicare, Medicaid (with some in the Exchange(s). incarcerated and who are not exceptions), TRICARE, or VA • Require the Exchange(s) to eligible for employer-sponsored coverage (with some exceptions). develop a standardized format coverage that meets minimum [EC Committee amendment: for presenting insurance qualifying criteria and affordability Permit members of the armed options, create a web portal to standards, Medicare, Medicaid, forces and those with coverage help consumers find insurance, TRICARE, or the Federal Employee through TRICARE or the VA to maintain a call center for Health Benefits Program. enroll in a health benefits plan customer service, and establish offered through the Exchange.] procedures for enrolling • Create a new public health individuals and businesses and insurance option to be offered for determining eligibility for tax through the Health Insurance credits. Exchange that must meet the same requirements as private plans regarding benefit levels, provider networks, consumer protections, and cost-sharing. Require the public plan to offer basic, enhanced, and premium plans, and permit it to offer premium plus plans. Finance the costs of the public plan through revenues from premiums. Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: august 5, 2009 9
  10. 10. House Tri-Committee America’s Affordable Health Senate Finance Committee Senate HELP Committee Choices Act of 2009 President Obama Policy Options Affordable Health Choices Act (H.R. 3200) Principles for Health Reform Creation of insurance • Create a community health For the first three years, set pooling mechanisms insurance option to be offered provider payment rates in the (continued) through state Gateways that public plan at Medicare rates complies with the requirements and allow bonus payments of of being a qualified health plan. 5% for providers that participate Require that the costs of the in both Medicare and the public community health insurance plan plan and for pediatricians be financed through revenues and other providers that don’t from premiums, require the typically participate in Medicare. plan to negotiate payment rates In subsequent years, permit the with providers, and contract Secretary to establish a process with qualified nonprofit entities for setting rates. [EC Committee to administer the plan. Permit amendment: Require the public the plan to develop innovative health insurance option to payment policies to promote negotiate rates with providers so quality, efficiency, and savings to that the rates are not lower than consumers. Require each State to Medicare rates and not higher establish a State Advisory Council than the average rates paid by to provide recommendations on other qualified health benefit policies and procedures for the plan offering entities.] Health community health insurance care providers participating option. in Medicare are considered • Create three benefit tiers of participating providers in the plans to be offered through the public plan unless they opt out. Gateways based on the percentage Permit the public plan to develop of allowed benefit costs covered by innovative payment mechanisms, the plan: including medical home and other – Tier 1: includes the essential care management payments, health benefits and covers 76% value-based purchasing, bundling of the benefit costs of the plan; of services, differential payment – Tier 2: includes the essential rates, performance based health benefits and covers 84% payments, or partial capitation of the benefit costs of the plan; and modify cost sharing and payment rates to encourage use – Tier 3: includes the essential of high-value services. [EC health benefits and covers 93% Committee amendment: Clarify of the benefit costs of the plan. that the public health insurance option must meet the same requirements as other plans relating to guarantee issue and renewability, insurance rating rules, network adequacy, and transparency of information.] Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: august 5, 2009 0
  11. 11. House Tri-Committee America’s Affordable Health Senate Finance Committee Senate HELP Committee Choices Act of 2009 President Obama Policy Options Affordable Health Choices Act (H.R. 3200) Principles for Health Reform Creation of insurance • Require guarantee issue and [EC Committee amendment: pooling mechanisms renewability of health insurance Require the public health (continued) policies in the individual and small insurance option to adopt a group markets; prohibit pre- prescription drug formulary.] existing condition exclusions; and • Create four benefit categories of allow rating variation based only plans to be offered through the on family structure, geography, Exchange: the actuarial value of the health – Basic plan includes essential plan benefit, tobacco use, and age benefits package and covers (with only 2 to 1 variation). 70% of the benefit costs of the • Require plans participating in plan; the Gateway to provide coverage – Enhanced plan includes for at least the essential health essential benefits package, care benefits, meet network reduced cost sharing compared adequacy requirements, and to the basic plan, and covers make information regarding plan 85% of benefit costs of the plan; benefits service area, premium – Premium plan includes essential and cost sharing, and grievance benefits package with reduced and appeal procedures available cost sharing compared to the to consumers. enhanced plan and covers 95% • Require states to adjust payments of the benefit costs of the plan; to health plans based on the – Premium plus plan is a premium actuarial risk of plan enrollees plan that provides additional using methods established by the benefits, such as oral health and Secretary. vision care. • Require the Gateway to certify • Require guarantee issue and participating health plans, provide renewability; allow rating variation consumers with information based only on age (limited to 2 to allowing them to choose among 1 ratio), premium rating area, and plans (including through a family enrollment; and limit the centralized website), contract with medical loss ratio to a specified navigators to conduct outreach percentage. and enrollment assistance, create a single point of entry for enrolling in coverage through the Gateway or through Medicaid, CHIP or other federal programs, and assist consumers with the purchase of long-term care services and supports. Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: august 5, 2009
  12. 12. House Tri-Committee America’s Affordable Health Senate Finance Committee Senate HELP Committee Choices Act of 2009 President Obama Policy Options Affordable Health Choices Act (H.R. 3200) Principles for Health Reform Creation of insurance • Following initial federal support, • Require plans participating pooling mechanisms the Gateway will be funded by in the Exchange to be state (continued) a surcharge of no more than licensed, report data as required, 4% of premiums collected by implement affordability credits, participating health plans. meet network adequacy standards, provide culturally and linguistically appropriate services, contract with essential community providers, and participate in risk pooling. Require participating plans to offer one basic plan for each service area and permit them to offer additional plans. [EC Committee amendment: Require plans to provide information related to end-of-life planning to individuals and provide the option to establish advance directives and physician’s order for life sustaining treatment.] • Require risk adjustment of participating Exchange plans. • Provide information to consumers to enable them to choose among plans in the Exchange, including establishing a telephone hotline and maintaining a website and provide information on open enrollment periods and how to enroll. • [EC Committee amendment: Prohibit plans participating in the Exchange from discriminating against any provider because of a willingness or unwillingness to provide abortions.] . • [EC Committee amendment: Facilitate the establishment of non-for-profit, member-run health insurance cooperatives to provide insurance through the Exchange.] Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: august 5, 2009 2
  13. 13. House Tri-Committee America’s Affordable Health Senate Finance Committee Senate HELP Committee Choices Act of 2009 President Obama Policy Options Affordable Health Choices Act (H.R. 3200) Principles for Health Reform Creation of insurance • Allow states to operate state- pooling mechanisms based exchanges if they (continued) demonstrate the capacity to meet the requirements for administering the Exchange. Benefit design • Create four benefit categories • Create the essential health care • Create an essential benefits Not specified. (lowest, low, medium, and high). benefits package that provides a package that provides a Require all plans to provide a comprehensive array of services comprehensive set of services, comprehensive set of services and and prohibits inclusion of lifetime covers 70% of the actuarial value prohibit inclusion of lifetime limits or annual limits on the dollar of the covered benefits, limits on coverage or annual limits on value of the benefits. The essential annual cost-sharing to $5,000/ benefits. health benefits must be included individual and $10,000/family, • All policies (except certain in all qualified health plans and and does not impose annual or grandfathered employer- must be equal to the scope of lifetime limits on coverage. The sponsored plans) must comply benefits provided by a typical Health Benefits Advisory Council, with one of the four benefit employer plan. Create a chaired by the Surgeon General, categories, including those offered temporary, independent will make recommendations on through the Exchange and those commission to advise the specific services to be covered by offered outside of the Exchange. Secretary in the development of the essential benefits package as the essential health benefit well as cost-sharing levels. [EL package. Committee amendment: Require • Specify the criteria for minimum early and periodic screening, qualifying coverage for purposes diagnostic, and treatment of meeting the individual mandate (EPSDT) services for children for coverage, and an affordability under age 21 be included in the standard such that coverage is essential benefits package.] [EC deemed unaffordable if the Committee amendment: Prohibit premium exceeds 12.5% of an abortion coverage from being individual’s adjusted gross income. required as part of the essential benefits package; require segregation of public subsidy funds from private premiums payments for plans that choose to cover 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.] Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: august 5, 2009
  14. 14. House Tri-Committee America’s Affordable Health Senate Finance Committee Senate HELP Committee Choices Act of 2009 President Obama Policy Options Affordable Health Choices Act (H.R. 3200) Principles for Health Reform Benefit design • All qualified health benefits plans, (continued) 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 • Require guarantee issue and • Impose the same insurance • Prohibit coverage purchased • The plan must end barriers to insurance renewability and allow rating market regulations relating through the individual market coverage for people with pre- variation based only on age, to guarantee issue, premium from qualifying as acceptable existing medical conditions. tobacco use, family composition, rating, and prohibitions on pre- coverage for purposes of the and geography (not health status) existing condition exclusions in individual mandate unless it in the non-group, micro-group the individual and small group is grandfathered coverage. (2-10 employees), and small group markets and in the American Individuals can purchase a markets. Require risk adjustment Health Benefit Gateways (see qualifying health benefit plan in all markets. creation of insurance pooling through the Health Insurance • Require all state-licensed insurers mechanism). Exchange. in the non-group and small group • Require health insurers to report • Impose the same insurance markets to participate in the their medical loss ratio. market regulations relating to Health Insurance Exchange. • Require health insurers to provide guarantee issue, premium rating, • Require all insurers to issue financial incentives to providers and prohibitions on pre-existing policies in each of the four new to better coordinate care through condition exclusions in the insured benefit categories. case management and chronic group market and in the Exchange • Allow states the option of merging disease management, promote (see creation of insurance pooling the non-group and small group wellness and health improvement mechanism). markets. activities, improve patient safety, • Limit health plans’ medical loss and reduce medical errors. ratio to a percentage specified • Provide dependent coverage by the Secretary to be enforced for children up to age 26 for all through a rebate back to individual and group policies. consumers. • Require insurers and group plans • Improve consumer protections by to notify enrollees if coverage does establishing uniform marketing not meet minimum qualifying standards, requiring fair grievance coverage standards for purposes and appeals mechanisms, of satisfying the individual and prohibiting insurers from mandate for coverage. rescinding health insurance • Permit licensed health insurers coverage except in cases of fraud. to sell health insurance policies • Adopt standards for financial outside of the Gateway. States and administrative transactions will regulate these outside-the- to promote administrative Gateway plans. simplification. Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: august 5, 2009
  15. 15. House Tri-Committee America’s Affordable Health Senate Finance Committee Senate HELP Committee Choices Act of 2009 President Obama Policy Options Affordable Health Choices Act (H.R. 3200) Principles for Health Reform Changes to private • Create the Health Choices insurance (continued) Administration to establish the qualifying health benefits standards, establish the Exchange, administer the affordability credits, and enforce the requirements for qualified health benefit plan offering entities, including those participating in the Exchange or outside the Exchange. State role • Allow states the option of merging • Establish American Health • Require states to enroll newly Not specified. the non-group and small group Benefit Gateways meeting eligible Medicaid beneficiaries insurance markets. federal standards and adopt into the state Medicaid • Require state insurance individual and small group market programs and to implement the commissioners to provide regulation changes. specified changes with respect oversight of health plans with • Implement Medicaid eligibility to provider payment rates, regard to consumer protections, expansions and adopt federal benefit enhancements, quality rate reviews, solvency, reserve standards and protocols for improvement, and program fund requirements, and premium facilitating enrollment of integrity. taxes and to define rating areas. individuals in federal and state • Require states to maintain health and human services Medicaid and CHIP eligibility programs. standards, methodologies, or • Create temporary “RightChoices” procedures that were in place as programs to provide uninsured of June 16, 2009 as a condition of individuals with immediate access receiving federal Medicaid or CHIP to preventive care and treatment matching payments. for identified chronic conditions. • Require states to enter into a States will receive federal grants Memorandum of Understanding to finance these programs. with the Health Insurance Exchange to coordinate enrollment of individuals in Exchange-participating health plans and under the state’s Medicaid program. • May require states to determine eligibility for affordability credits through the Health Insurance Exchange. Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: august 5, 2009 5
  16. 16. House Tri-Committee America’s Affordable Health Senate Finance Committee Senate HELP Committee Choices Act of 2009 President Obama Policy Options Affordable Health Choices Act (H.R. 3200) Principles for Health Reform Cost containment • Encourage adoption and use of • Establish a Health Care Program • Simplify health insurance • The plan should reduce high health information technology Integrity Coordinating Council administration by adopting administrative costs, unnecessary by expanding eligibility for and two new federal department standards for financial and tests and services, waste, and the Medicare HIT incentives positions to oversee policy, administrative transactions, other inefficiencies that consume in the American Recovery and program development, and including timely and transparent money with no added benefit. Reinvestment Act to include oversight of health care fraud, claims and denial management additional providers. waste, and abuse in public and processes and use of standard • Eliminate fraud, waste, and abuse private coverage. electronic transactions. in public programs through more • Simplify health insurance • [EC Committee amendment: intensive screening of providers, administration by adopting Limit annual increases in the the development of the “One PI standards for financial and premiums charged under any database” to capture and share administrative transactions, health plans participating in the data across federal and state including timely and transparent Exchange to no more than 150% programs, increased penalties claims and denial management of the annual percentage increase for submitting false claims and processes and use of standard in medical inflation. Provide violating EMTALA, and increase electronic transactions. exceptions if this limit would funding for anti-fraud activities. threaten a health plan’s financial • Restructure payments to Medicare viability.] Advantage plans to promote • Modify provider payments under efficiency and quality. Medicare including: • Require drug or device – Modify market basket updates manufacturers to disclose to account for productivity payments and incentives given improvements for inpatient to providers and any investment hospital, home health, skilled interest held by a physician. nursing facility, and other • Improve transparency of Medicare providers; and information about skilled nursing – Reduce payments for facilities. potentially preventable hospital • Allow providers organized as readmissions. accountable care organizations • Restructure payments to Medicare that voluntarily meet quality Advantage plans, phasing to 100% thresholds to share in the cost- of fee-for-services payments, with savings they achieve for the bonus payments for quality. Medicare program. • Increase the Medicaid drug rebate percentage and extend the prescription drug rebate to Medicaid managed care plans. Require drug manufacturers to provide drug rebates for dual eligibles enrolled in Part D plans. Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: august 5, 2009
  17. 17. House Tri-Committee America’s Affordable Health Senate Finance Committee Senate HELP Committee Choices Act of 2009 President Obama Policy Options Affordable Health Choices Act (H.R. 3200) Principles for Health Reform Cost containment • [EC Committee amendment: (continued) Require the Secretary to negotiate directly with pharmaceutical manufacturers to lower drug prices for Medicare Part D plans and Medicare Advantage Part D plans.] • Reduce Medicaid DSH payments by $6 billion in 2019, imposing the largest percentage reductions in state DSH allotments in states with the lowest uninsured rates and those that do not target DSH payments. • Require hospitals and ambulatory surgical centers to report on health care-associated infections to the Centers for Disease Control and Prevention and refuse Medicaid payments for certain health care-associated conditions. • Reduce waste, fraud, and abuse in public programs by allowing provider screening, enhanced oversight periods, and enrollment moratoria in areas identified as being at elevated risk of fraud in all public programs, and by requiring Medicare and Medicaid program providers and suppliers to establish compliance programs. Side-by-Side CompariSon of major HealtH Care reform propoSalS — last modified: august 5, 2009

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