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04 November 2009

Health Care Bill Breakdown - Part 1

Thanks to a good friend of ours, Trent Davidson, he has painstakingly read, and broken down EVERYTHING in the current Health Care Bill.

HHS = Health and Human Services. There are gaps in the numbered sections, that's because several sections were cut before the bill was published to the public. The numbering and ordering below is precisely how they appear in the version of the ironically titled "affordable health care for America Act" as published by the US House of Representatives. This is a 25-page condensation of a 1,990 page bill.

Section 101—sets up a “high risk” insurance pool -- provide health benefits starting jan 1 2010. costs no more than 125% of market rate????? Secretary of HHS determines if somebody was “dumped” from health plan by insurer or employer and recoup costs of covering that individual. Essential benefits: max deductible 1500, no annual limits allowed; maximum cost sharing 5000/ind., 10000 family. No pre-existing condition exclusion. State govts CANNOT cut funding from July 31 2009 levels
Pg 24 line 19 title 101 sec 6—no specifics for eliminating fraud, waste, and abuse
Creates $5 billion immediate slush fund. In the case of Insufficient funds, Secretary authorized to slash benefits = rationed care. Authorized to extend temporary high risk pool in order to avoid lapse of coverage during transition to “health exchange”

Section 102—attempt at lowering rates. Sec. HHS establishes a national Medical loss ratio for insurance companies, at least 85%- Any company who pays out less than the loss ratio of revenue from premiums to pay for medical costs of customers, the insurers must give money back to customers. This does not include the company’s operating costs, payroll, etc. Basically, it’s the federal govt telling an insurer how much profit they are allowed to have and how much money they are allowed to pay their employees—effective 1 jan 2010

Section 103--Amending previous legislation to make it harder for insurers to revoke coverage—they must demonstrate obvious fraud; they must provide written advanced notification of . Allow individuals to invoke federal watchdog (3rd party review) to force insurer to make the case for fraud, and insurer must provide coverage until review is complete—there is no provision for timeliness of this review, meaning that an individual can simply appeal and wait around with health insurance while the govt takes 3 to 33 years to review his case.

Section 104--Insurer must justify rate increases from year to year—must ask federal permission to increase premiums.
Section 105--Dependants up to age 27 are covered by parents’ coverage—mandatory
Section 106--Reduces pre-existing coverage “look-back” periods from 12 months to 3 months, making it harder for insurance companies to identify pre-existing conditions.
Section 107--Domestic Violence cannot be considered a pre-existing condition (pregnancy neither)
Section 108--Forcing insurers to provide surgical benefits for congenital or developmental deformities of minor children except cosmetic surgery
Section 109--Bans lifelong coverage caps
Section 110--Bans reduction of coverage or benefits of retirees—employers may apply for waiver
Section 111--Reimburse insurers that are providing coverage for retirees—anything over 15000 but less than 90000, can be reimbursed 80%. Insurer must use money to reduce premium costs, not as stated revenue or stock dividends. Creates $10 billion trust fund immediately

Section 112—incentives for employers to introduce health wellness programs—health awareness education, physical screenings, healthy living (tobacco, obesity, etc). Dept HHS and Dept Labor will validate a wellness program and certify it for a grant—equal to $150 x # of employees, but not more than $50,000 --1 jan 2010

Section 113—extends non-expired COBRA extension coverage until Health Exchange is stood up. Prohibits states from enforcing expiration dates, forcing state govts to keep paying.

Section 114—Grants for states to insure uninsured. States that already have a qualified program don’t get grants. States must pay 20% of the grant in order to get the grant --funding not specified

Section 115—Enforce standardized administrative actions electronically. Plan must be in place by 5 years later, and the plan must meet list of criteria, but no dollar estimate—cost determined by plan. Standardize claims processing procedures. Cost TBD. Free reign for HHS to penalize anyone that’s slow to adopt the standards

Section 201—Health plans have to meet new criteria (detailed later)
Section 202—Allows customers to keep the coverage they already have (i.e. allows private insurers to keep offering plans that people have already bought in to, they cannot enroll any new persons into those plans (if they don’t meet the later critieria) 5 yr grace period. After Y1, individual health insurance coverage MUST be participating in the Health Exchange.

Section 211—Qualified health benefits plan must have no pre-existing condition exclusion.
Section 212—continuations of coverage guaranteed. In order to axe anybody, there must be demonstrable fraud or notification of non-payment of premiums followed by grace period to allow person to pay up.
Section 213—Limits variance of premiums; For age, most expensive due to age cannot be more than twice as much as the cheapest due to youth and vigor. Rates can vary by area according to state insurance regulators. Uniform ratio of family price to indiv. price. Optional coverage prices will be determined by central commissioner. Requires a study and report within 18 mos
Section 214—Requires further research. Buffs up provisions of other bills, coverage/benefits cannot be limited or denied due to mental health or substance abuse.
Section 215—standards of provider network. Must have web portal
Section 216—Qualified health plan must insure dependant at option of customer, up to age 27
Section 217—Changes in coverage or costs must be notified 90 days in advance
Section 221—Exchange participants must adhere to standard detailed later, non-exchanged participants have more leeway.
Section 222—Qualified plan must cover: Hospitalization, out-patient, ER, professional services, equipment and supplies, prescriptions, rehabilitative services, mental health, substance abuse, behavioral health, preventive vaccines, maternity, well-baby, prosthetics and orthotics. There will be NO COST SHARING for maternity or well baby/child or vaccines.
Cost share total max 5000 for ind and 10000 for family per year. This increases proportional to the increase in premiums per year. Coverage is 70% of actuarial value.
Govt can’t mandate that a plan cover abortions, but does not prohibit federal funding of them (pg 110,) Dental care will be determined in a study to be conducted within 1 yr

Section 223—Health Benefits Advisory Committee. Consists of 21-27 people, 10-18 of which appointed by president. Determines benefit standards. Dictates cost sharing costs for enhanced and premium plans.
Section 224—procedures for adopting benefit standards. Bureaucratic crap
Section 231—Committee dictates uniform marketing standards for qualified health plans
Section 232—committee directs procedures for grievances due to denied claims. Findings of the panel are binding upon the insurance provider. Again, no provision for timeliness
Section 233—Standards for publication of plan information to the public. Contracting entities have a whole list of info they have to provide the committee or else face fines and other penalties. It is up to the insurer to make sure that their documentation is idiot-proof.
Section 234—the commissioner gets to decide the extent to which the standards apply to non-exchange participants.
Section 235—qualified plan must pay with same timeliness as Medicaid advantage.
Section 236—the committee determines standards for coordinating subrogation and reimbursements.
Section 237—Requires providers to simplify administrative processes as dictated by the Social Security Act ???
Section 238—Act does not interfere with state laws prohibiting discrimination against providers.
Section 239—Sec. HHS conducts study of pharmaceutical marketing practices and their use of physician prescribe information. Directs way to stop it and enforce “un-biased” marketing practices.
Section 240—Insurer must issue end-of-life counseling info, but Act will not interfere with state law in this regard.

Section 241—Establishes as independent agency in the executive branch the Health Choices Administration.
Section 242—implements and enforces plan standards; maintains health exchange, manages individual affordability credits; holds providers accountable through audits that the provider is then forced to pay for. Maintain stats and collect data; the commission punishes bad companies—fines, cutting off reimbursments for exchange participants, prevent the company from enrolling more people
Section 243—Agency has to communicate and collaborate with a whole list of orgs
Section 244—Ombudsman office to deal with RFIs, grievances, etc.

Section 251—Relationship to other acts. Bureaucratic crap.
Section 252—Non-discrimination of health care
Section 253—Whistleblower protection. Standard fare.
Section 254—Act does not infringe on collective bargaining agreements
Section 255—If one part of the bill is determined to be unconstitutional, that won’t impact the rest of the bill.
Section 256—Bill doesn’t impact state of Hawaii’s programs
Section 257—State attorneys general can sue on behalf of anyone in their state for monetary damages any provider that is found in violation of the act.
Section 258—Does not impact state or federal laws regarding abortion;
Section 259—Cannot discriminate against a medical service provider because they refuse to perform or refer patient for abortion
Section 260—FTC can prepare all kinds of reports on insurers regardless of for-profit status.
Section 261—act does not dictate in any way responsibilities of providers toward customers in any malpractice claim
Section 262—insurance providers no longer exempt from anti-trust laws
Section 263—Sec. HHS conducts a study on how to increase the use of electronic health records. Report NLT 31 DEC 2013.

Section 301—Health Insurance Exchange. Part of Health choices administration
302—Eligibles for Exchange—Everybody eligible so long as they are not maintaining coverage elsewhere. This is a gap coverage, enabling uninsured to get insured until they qualify for other coverage like medicare, Medicaid, tricare, etc.
303—In exchange, any provider can only offer one plan and one enhanced plan per area, if offer enhanced, can also offer premium, if premium, can offer premium-plus. Basic is 70% cost sharing, commission dictates the levels of other plans. Allowable 10% between tiers. States can add to minimum requirements and they will be in force.
304—bids and contracts for exchange participating insurers. The commissioner can waive federal contract standards that get in the way. Providers are responsible to be licensed in the state they offer in, provide data mandated by commission, be cheap, accept govt credits, and accept anybody—up to “capacity”, must include entities that provide services for low income and “medically under-served” people, and cater to culture and linguistic differences. Cannot discriminate service providers based on abortion
305—outreach and marketing for the exchange; enrollment from Sep to Nov; Automatic enrollment for people not eligible for Medicaid; enrollees pay insurer directly, are randomly reassigned if their plan gets axed; heavy reliance on state Medicaid system—the exchange determines state Medicaid eligibility and punts people off to the states; establish a plan to assist small businesses in dealing with the exchange; commission can provide coverage directly or through “nonprofit” providers selected by commission (huge corruption opportunity)
306—risk pooling adjustments—bureaucratic crap
307—Establishes Exchange trust fund—fed by taxes on people without acceptable coverage, taxes on employers not offering acceptable coverage, and taxes on providers who don’t pass muster
308—states are authorized to operate their own exchanges in lieu of the federal one, provided it meets minimum federal standards; states are also allowed to axe their own exchanges
309—Eff 1 Jan 2015 2 or more states can team up for interstate insurance compacts, subject to federal application approval; the commission can pay awards for states that do it, up to $1 million per state—NOTE*** authorizes money in the future without knowing how much money that will be.
310—Authorizes grants and loans for states to run non-profit insurance CO-Ops. The CO-OP cannot be state run or sponsored, must operate by popular vote of members, and be licensed. Appropriates $5 billion for this.
311—nothing in the bill impacts DoD or VA processes.

321—Public Option.---public option only available through the exchange. Can contract out to operate the administrative requirements. Create lots of bureaucrats (read: Ombudsmen). Acts as normal plan in the exchange, same rules apply, can offer enhanced and premium plans.
322—appropriates $2 billion in start up cash; the commission researches and sets premiums to cover all costs. The plan cannot be bailed out with federal funds.
323—health care providers that take Medicaid must take public option, can ask permission to opt out. Reimbursement rates are equal to medicare. NO ADMINISTRATIVE OR JUDICIAL REVIEW OF PUBLIC OPTION PAYMENTS IS ALLOWED
324—The commission must seek creative and more efficient ways to provide services, collect funds, provide payment options, etc. Standards do not have to be uniform in the public option across geographical regions.
325—There are preferred and non-preferred physicians. Preferred accept public option payment as “payment in full”. Non-preferred are the uppity ones. They agree to not impose charges greater than +15%. These physicians will get reimbursed less by the Public Option.
326—previously documented fraud and abuse provisions apply to the public option.
327—HIPAA insurance requirements apply
328—privacy act and other privacy legislation apply
329—Public Option is completely optional
330—members of Congress can enroll if they want
331—cooperate with VA to reimburse each other

341—Individual affordability credits—you get to apply to have your premiums reduced or your cost sharing proportion reduced; only citizens and legals are allowed, but verificationprocedures include a signature and a declaration they are legal. No database of illegals/legals is allowed. Starts off appropriating $30 million. Punts operating costs to social security administration. Amends social security act accordingly. It actually requires the administration to report conflicting records on citizenship status to the state, which is then required to ask the DHS for citizenship verification. Does not require any action be taken. Affordability credit cannot be used to help with abortion
342—Credits are available to individuals in the exchange program, not insured by employer, who makes less than 400% of poverty level. Also, if your employer offers insurance, but it would cost you more than 12% of your salary, you are eligible.
343—Premium credit. Chart on pg. 252,. Out of pocket cost caps max out at 5000/year.
344—Cost sharing credit—reduces cost sharing proportion, max out of pocket 5000/year
345—calculating and verifying income for applicants, penalties for liars.
346—special rules for US territories; lots of money allotted
347—No federal payments for illegal immigrants

401—individual responsibility; see section 501
411—employer must: offer indiv. and family Qualified Health Benefits Plan (QHPB), make contributions toward that coverage, if an employee declines coverage and gets insurance through the exchange, the employer must still make contributions to the health exchange.
412—employers required to pay 72.5% of premiums for indiv. and 65% of premiums for family. Part time employees also get coverage, and employer payment is proportional to the hours worked by the part time employee. Employers automatically enroll workers, but employee can opt out.
413—Employers can choose not to offer insurance, and instead pay 8% of payroll to health choices commission. This money is not counted as a proportion of the employee’s premiums. Employers with small payrolls can pay less according to chart on pg 276.
414—the commission can accuse and investigate employers if they feel they are encouraging employees to decline employer coverage in order to go to the exchange
415—calls for recurring annual study and report on the impact and status of employer contributions, making recommendations for possible adjustments
416—Call for study to investigate if employers should be elibible for exemption due to hardship.

421—massive amendment to the Employee retirement income security act of 1974—employer fails to pass muster, fined $100/day until rectified. Max $500,000. also excise taxes as listed in Internal Revenue Code of 1986—20% penalty
422—employers that fail to comply get taxed
423—amendment to Public Health Service Act to reflect section 421
424—Sec labor, treasury, HHS, and health choices commissioner pow-wow on making rules

501—Amendment to Internal Revenue Code of 1986—If at any time during a year you don’t have “satisfactory” health insurance, you are taxed 2.5% of gross income, maxed out at average national health care premium. Acceptable coverage is a QHBP, tricare, Medicare/aid, or a grandfathered pre-existing program

511—Amendment to Internal Revenue Code of 1986—taxes and punishments on employers that fail to pass muster.
512-- Amendment to Internal Revenue Code of 1986—8% tax on companies electing to not provide QHBP.—bureaucratic crap
521—assistance for small employers with low-paid employees. Lots of bureaucratic crap.

531—specification of govt. programs to cover insulin and prescription meds
532—more amendments—limitations on “cafeteria” plans—doesn’t count as QHBP unless salary reduction contributions are less than 2500
533—non-qualifying Health Savings Accounts are penalized a 20% excise tax (currently is 10%)
534—denies tax deduction for federal subsidies for prescriptions

541—sharing taxpayer information among depts. Of treasury and health choices commission
542-544—bureaucratic crap making required adjustments in wording to other bills.
545—Exclusion from gross income for medical care provided to American Indians.

551—additional tax of 5.4% of any adjusted gross income over $1 million for joint filers, $500k for individual filers.
552—2.5% tax on all sales of medical devices unless purchased at retail. i.e. tax on hospitals and doctors and patients that get their devices issued by them
553—expands reporting requirements to the IRS
554—Delays the Worldwide Application of Interest option for additional 9 years—2019. This is a tax option for people with overseas interests and accounts.

561—prevents treaties from reducing taxes
562—accountancy crap—nickels and dimes from state and local and taxpayers to make tax accounting more favorable to fed. Govt.
563—adjusting tax code to assume larger tax liabilities of large publically traded entities.

571—enabled self-employed individuals broad leeway in claiming health benefits for dependants for tax purposes.

Division B
Medicare/Medicaid “improvements”

1101—adjusts funding for nursing facilities under Medicaid, (guarantee it pushes payments downward)
1102—pushes back expiration date of pre-existing funding for inpatient rehabilitation facilitation coverage.
1103—massive adjustments to payment rate adjustment timelines. Very arcane and virtually impossible to understand.

1111—Adjustment in payment rates for sundry services; authorizes Sec. HHS to adjust rates in order to make these services “budget neutral”. Mandates 2% reduction in overall payments for ancillary services.
1112—mandates a report to Congress NLT 1 Jan 2016 on impact of reforms in reducing #of uninsured; results of report will push down funding to Medicaid starting FY2017; size of cuts TBD at that time.
1113—pushes off regulation of hospice care past 2010
1114—extending definitions of post-hospital care and physician care for coding and charging purposes

1121—calls for new feedback reports to be generated on how physicians use Medicaid/are.
1122—review and adjust periodically medical services that may be “misvalued” in the system. Authorizes to make adjustment to fee scheds as the dept. sees fit. Appropriated $20 billion for the project.
1123—incentive payments for efficiency (5% bonus). Regions that charge below reimbursement rates will get it, and region determined by zip code
1124—modification of physician rating program
1125—Redefines California fee schedule localities. Bureaucratic crap.

1131—more adjustments to fee schedules

1141—wheelchairs and other complex medical products—adjustments to wording and definitions, procedures for leasing and buying.
1142—extends payment for brachytherapy through 2012
1143—report to congress on fee-for-service medicare coverage NLT july 1 2011.—obviously trying to justify cutting the program or its funding
1144—requires surgical centers to submit service cost reports to keep on file in govt
1145—research costs of cancer hospitals and how the costs compare with others—authorizes adjustments to reimbursments.
1146—increases presumed utilization rate of imaging equipment from 50% to 75%--meaning less money for equipment, fewer devices. Currently, there’s 25% less payment for multiple uses on the same patient, the bill makes it 50% less payment
1147—further regulating medical devices, glasses, oxygen tanks, etc.
1148—bone mass measurement study—report on effectiveness and utility with an eye to kill it
1149—liberalizing payments for post-mastectomy thingies, biosimilar biological products; conduct study on setting up a mechanism for providing medical items via contracting bids

1151—cuts payments to hospitals for excess readmissions—if patients keep getting readmitted, pays out less each time, authorizes funds to study reasons for readmission and find ways to fix
1152—adjusting procedures for post-acute care by bundling services and consolidating processes. The pilot program gets $45 million 2010-2012
1153-1154 –adjustments to home health care payments. Bureaucratic crap
1155—making productivity improvements already in place in other legislation apply to home health services, calls for a study on variation in home health services, and standardizes procedures for making initial assessments
1156—provisions on tracking and reporting physician ownership or part ownership of medical facilities, I guess to deal with conflict of interest issues—physicians can’t make medicaire funded referrals to hospitals in which they have an ownsership interest. Funded $5 million per year every year starting 2010 and forever
1157—calls for study and report to Congress on geographic adjustment factors for medicare payments
1158—Revise medicare payment systems to respond to the geographic study, but can’t cost more than $8 billion a year in adjustment costs; the medicare improvement fund will be increased every year by the amount the Secretary deems necessary to implement adjustments.
1159—calls for study on geographic variation in health service utilization and promoting high-value health care; geographic influence on prices, health status, lifestyle, access to medical services, income and educational levels, etc. Make adjustments to pay schedules. $10 million appropriated for the study and analysis.
1160—implementing recommendations from 1159. Implementation plan must be budget neutral over 10 years. Dictates congressional procedures for implementation

1161—significant recalculation of Medicare Advantage benefits and payouts—downward push, with counties with high usage rates getting some extra attention. Gives govt free reign to axe Medicare Advantage plans that them deem noncompliant
1162—takes an administrative process in Medicare that was supposed to expire in 2010 and makes it permanent. My guess is it’s something that was pushing down reimbursments.
1163—2 week processing period for annual enrollments, shortens of annual enrollment season
1164—extends contracting process that was supposed to expire in 2010—thru 2012
1165—restricts employer group plan options for medicare advantage—can only be in group plan if 90% of eligibles are enrolled
1166—report due to congress within one year on how to improve risk and payment projections
1167—Kills the Medicare Advantage Plan Stabilization Fund and dumps the money into the Medical Insurance Trust fund.
1168—Calls for a study of changing the way medicare regions are tracked and managed.

1171—Limits cost sharing for individual health services; out of pocket expenses for individual services cannot be more than if they were part of larger plan
1172—modifies enrollment season if your medicare advantage plan gets axed
1173—requires MA providers to publish a laundry list of stats, including medical loss ratio. The plan must have a loss ration of at least 0.85, if lower, provider must refund money to customers. If they fail for 3 straight years, they cannot enroll anyone else. If for 5 years, the plan is axed
1174—Secretary can audit any MA plan provider they want, and provider pays the cost
1175—States can enforce federal standards, impose penalties, tattle on provider to govt.
1176—limits special circumstances under which outside-open-season enrollments can occur
1177—extends existing authorization for special need programs to restrict enrollment. Was slated to expire 2011, this pushes it out till 2016. Extends existing moratorium against certain geographic areas from 2010 to 2012.
1178—buffs up medicare senior housing plans—better plans for people living in retirement homes. Provides more incentive to put grandma in a home.

1181—buffs up Medicare part D by $500 in 2010 (per enrollee), increases medication coverage and reimbursement rates; starting 2011 thru 2019, each year must increase coverage total and decrease out-of-pocket threshold. Lists progressive % of increase in initial coverage limits for these years; Additional provision to force drug makers to provide rebates to individuals—for Part D or MA plans, anytime a manufacturer’s drug is paid for, that company must pay back to Medicare a portion of money proportional to the # of doses paid for. The rebate equals #doses x amount by which medicare rebate amount for that drug is greater than the average medicare rebate amount; fines companies big time if they delay or withhold information on pricing and dosage
1182—Forces pharmaceuticals to agree to discount certain drugs for Part D and MA and other federal drug plans. While individuals are in a gap in coverage, due to initial enrollment or other reason, 50% discount is forced.
1183—deletes a portion of the social security act limiting the timeframe a pharmacy in a hospital or clinic has to make claims
1184—eliminates a form of dual payment of claims by counting a claim as “paid” when it is covered by other programs. Brilliant and Revolutionary.
1185—substantive changes in drug plans, coverage, or cost sharing cannot take place mid-year—has to wait till next enrollment year
1186—Secretary will negotiate for lower costs for drugs and report results to congress
1187—Prescription plan providers are mandated to put in place controls to track dispensing and cut wasteful dispensing of drugs to enrollees living in long-term care housing
1188—PSPs have to offer to reduce or waive the co-pay for generic drugs in order to get people to take the generics instead of the name brand drugs
1189—secretary can accept state certification as interim licensing for PSP applicants

1191—Sets up bureaucratic committee (Telehealth Advisory Committee) to sit around and pretend to deal with rural issues with medicare. Adds Kidney Dialysis to a list of services afforded special reimbursement for rural areas; sets standards for accrediting “Telemedicine” physicians
1192—extends special funding for rural hospitals from 2010 to 2012
1193—extends “section 508” classification—higher payment rates for certain hospitals based on region.
1194—extends geographic floor criterion from 2010 to 2012, meaning that if the cost index (and therefore reimbursement rate) for a region is found to be below 1.00, it is assumed to be 1.00.
1195—extends payment for certain pathology services that were supposed to expire this year through 2011.
1196—Extends special bonus rate for ambulance service in rural areas from 2010 to 2012

1201—raises the monetary level below which people qualify for special perks Medicaid. You now have to be less poor to be considered poorest for Medicaid.
1202—eliminates cost sharing for a narrow group of people—free health care for people who probably should be in a permanent care facility
1203—waters down verification procedures for people trying to get low-income special treatment.
1204—Enhanced oversight for retro-active reimbursements for people who get the low-income subsidy. Must justify by line-item any reimbursement to the enrollee.
1205—dumbest thing so far. It calls for the use of an “intelligent process” to assign new enrollees to PSPs. But does not detail it—just tasks the secretary to actually take logistics and cost into account when enrolling people.
1206—more liberal enrollment policies for low-income subsidy people
1207—low income subsidy is not counted as income when making low-income subsidy decision

1221—SEC HHS conducts a study on medicare paying for interpreters for English-impaired enrollees, or some other way of funding them; the study evaluates which providers are providing what kind of language services. Appropriates $2 million for the study; authorizes the secretary to sanction/fine providers that do not provide “adequate” language services
1222—After the study is complete, provide at least 24 3-year grants ($500k) to medicare service providers to improve language services in communities that are “underserved”. Grant priority is given to providers with partnerships with Community Organizations. This program is a proof-of concept study that will be used to determine Medicare payments to providers of linguistic services; the three year program is appropriated $16million per year for 3 years ($48 million)
1223—Call for a report from Institute of Medicine on the health impact of language access services
1224—defines some critical language-related terms

1231—a waiver on cap of coverage for physical therapy is extended from 2009 to 2011
1232—extends eligibility for dialysis and immuno-supressive drugs for kidney transplant patients
1233—Medicare pays for end-of-life counseling (now called “advance care planning consultation”)
1234—Special enrollment period for enrollees, and Tricare beneficiaries can waive enrollment penalties
1235—normally you use two years ago for computing your income-related premium, but this creates a special circumstance allowing you to use last year if your income for that year is less due to the selling of your home at a loss.
1236—Conduct a fancy little science project trying to help enrollees make treatment decisions. Developing a “decision aid” for the enrollee to look at. Can be web portal, video, you name it. Money is authorized to pay for this, but the amount is not specified—“all costs”.

1301—Pilot program to find way to reduce the growth of expenditures. “Redesigned care practices”, rewards for best practices among physicians. Participants in the program don’t have to be medical practices—it has to be “organized at least in part for the purpose of providing physician’s services”. Participants report to a “best practices” website maintained by the secretary. Program pays out awards for participating care organizations that do things cheaply. Also measures “quality of care” in considering best practices. These measurements are not defined and are left up to the Secretary’s discretion. Program must start NLT 1Jan 2012. No administrative or judicial review of the program is allowed, including on the criteria of and to whom “awards” are paid. The Secretary can establish different performance standards for different kinds of participating organizations. The Secretary is authorized to limit participants’ exposure to “high cost patients”. Nudge nudge. Appropriated $25 million per year 2010-2014 and $20 million for 2015. ($120 million).

1302—5 year Pilot program for medical homes. Incentivize, test, and track different kinds of care facilities—Independent (operated and directed by physicians) vs. Community based (not-for profit local or state-run); medicare will pay these facilities per patient per month, as determined by the bureaucracy. The secretary can fund the start-up of community based facilities. $6 millino per year for 5 years just for operating and administering the program. $200 million per year 2010-2014 for the independent project, $125 million per year 2012-2016 for community based ($1.625 billion) plus initial implementation costs of $2.5 million per year 2010-2012.

1303—incentive payment of 5% above normal medicare reimbursement for certified primary care providers (10% bonus if you are in a registered shortage region)
1304—increases reimbursement rate for certified midwives
1305—waiver of cost-sharing for preventative services (cancer screenings, diabetic self-care training, screening for glaucoma, physical exams, vaccines, diabetic screening, etc, etc.) If medicare currently pays anything for these, it now pays 100%. For others, coverage will be determined later. Deductible is waived for these services.
1306—universal waiver of deductible for colorectal cancer screenings.
1307—excludes social worker services from medicare coverage under the skilled nursing facility payment system
1308—medicare coverage of marriage and family therapist services, mental health care provider.
1309—extends existing modification of fee schedule for mental health providers from 2009 to 2011.
1310—expands federal coverage of vaccines. Removes list of approved ones and replaces list with “federally approved and recommended vaccines”. Manufacturers of vaccines must enter into rebate agreement to pay to govt. any payment the receive that is above the average cost of vaccines
1311—expands medicare covered preventive services at qualified health centers
1312—Another science project. This is to see if they can make things cheaper by relying on in-home care providers. Sets target expenditure levels, and pays out rewards if the home-based provider in the study beats that level by 5%. $5 million per year 2010-2015.
1313—classifies a “certified diabetes educator” as a care provider under medicare and therefore eligible for payment/reimbursement. Sounds like some Congressman has a brother in law who is a certified diabetes educator.
1401—creates a new executive bureaucracy under the Agency for Healthcare Research and Quality, called “Center for Comparative Effectiveness Research”. This will poke, prod, and shake health care data in order to make it look like the reform plan is working. Er…I mean in order to identify most effective practices, procedures, practitioners, etc. Tasked to issue grants for research projects that fall within its mandate. Creates a commission to lead the direction of health care research in the country. Commission is 3 bureaucrats, 10 practicing physicians, and 6 more leeches drawing a government salary for pretending to work. For funding, see section 1802

1411—mandates that nursing facilities publish information to become more transparent—ownership details, governance/administration,
organizational structure, people who lease or sublease parts of the facility, exert financial or operational control, or donates/lends over 50,000 to the facility
1412—mandates that nursing facilities have in place an ethics program to prevent and detect civil, criminal, and administrative violations. Develop and publish regulations on employees. Dictates the minimum standards of the regulations of this program. Also mandates the Secretary to implement a Quality Assurance and Performance Improvement program for nursing facilities. The facilities must report plans to comply with the program
1413—mandates certain information be present on a govt website to compare nursing homes. Mandates issuing guidance to states on how they can interface state services with federal web portal.
1414—reporting procedures of nursing facilities reporting their costs and expenditures. Separate cost of care providers from administrative and operating costs.
1415—Secretary must generate and provide for universal use a standardized complaint form for nursing facility residents. Mandates that States develop a documented complaint resolution process.
1416—nursing facilities have to report in a uniform manner all staffing and payroll information.
1417—Establish federal program that enables nursing facilities to check the backgrounds of direct patient access employees. Requires fingerprint check. Federal agency must report results to State officials, who then report to facility. To pay for it, states must put forward some money, and the fed govt matches 3x that amount. Federal appropriations are unspecified, but maxed out at $160 million.

1421—Authorizes massive fees against nursing facilities that are found in violation of any federal standards/regulations regarding them (including these new ones). Violation leading to death--$100k. violations resulting in harm – between $3k and $25k. And so forth.
1422—Science project!!! Sets up an independent monitoring agency to provide oversight of large nursing facilities or chains of facilities. Report management structures, staffing levels, conditions, staff turnover, yadda yadda yadda. Study will see if this oversight yields any savings due to augmented efficiency and/or any improvement in care.
1423—Administrator of a nursing facility must notify federal agency, state, and legal representation of residents of intent to close a facility. Must provide 60-day advance notice. The state must ensure relocation of residents.

1431—facilities are mandated to provide training on preventing abuse of patients suffering from dementia
1432—call for a study on what kind of training is required for nursing facility staff.
1433—documents the qualifications required of a director of food services at a nursing facility.

1441 through 1445 document the standards for measuring quality—the processes for developing the processes for developing the metrics for measuring the quality. I don’t care to elaborate—These 15 pages just may have crushed my soul.

1451—Requires drug manufacturers to report all financial relationships and transactions with prescribing physicians, covered recipients, or other entities in the health services chain for that drug. This also includes the provision and pushing of “free samples” of medications. Also requires medical facilities to report on physician ownership of those facilities. Demands a study on the use and medicare billing of diagnostic imagery and radiation oncology services. MASSIVE fines for failure to report information.

1461—Hospitals and other care facilities can only participate in govt health programs if they report to the govt all treatment-related infections that occur. This information is to be posted and publically available on govt websites. Secretary has to report aggregate results annually to Congress, and make recommendations on how to reduce such infections.

1 comment:

Anonymous said...

Great post. I was going to write something similar. Will check this blog more often I think.