Learn about the Public Option here.. Please rec this diary so others will have a chance to read it later in the day. If you rec’d the first diary, please rec again. Thanks. Or you have my permission to copy/paste and post as your diary.

An Analysis of The House Bill called: “America’s Affordable Health Choices Act of 2009”

Is below. I thought, if we are fighting for the Public Option, we could read it. It’s not that long. It’s a short read. However, the Public Option is so dependent on another Section, I was bummed to learn I had to read that, too.

So the PART I of the diary is an overview of The Health Insurance Exchange (HIE), which will probably be what each State offers, in my opinion. Will the HIE and non-HIE premiums cost the same if the Bill passes?

In PART II the Public Option has been copied and pasted and commented on. It’s a short read folks. I hope you will take this chance, this weekend to learn in greater detail what we are fighting for and to raise important questions for our Congress.

reflect questions raised and a desire to better understand. The diary is an invitation to professionals here to help us all know what we are fighting for. However, much effort was made to share the questions that came to mind when reading the Bill sections below. My apologies for any hints of cynicism and/or snarks.

If you do have some suggestions and information, please include a clear reference to the section you are commenting on. I will include your information in future updates. Thank you.

“America’s Affordable Health Choices Act of 2009”

You can read the whole Bill here:
http://edlabor.house.gov/documents/111/pdf/publications/AAHCA-BillText-071409.pdf

The Public Health Option is found on page 116.

HOWEVER, what becomes immediately understood is that the Public Option is subject to the stipulations under Division A, Title II, Subtitle A or the Health Insurance Exchange which are the rules for all insurance providers allowed to provide insurance within the Exchange.

So, in order to understand the Public Option, we need to understand the rules for The Health Insurance Exchange.

OK, I read it for you. Each paragraph below is what I felt were the important points. I also included the questions and ideas raised when reading this.

I will say, however, that I did not find any language referring to our coverage. Here is a list of important points in the Health Exchange:

The Bill seems more about who can play, who gets paid and how, and THE MANDATES rules including the Excise Taxes fining those who don’t comply. But I haven’t read the rest yet, either.

PART I Health Insurance Exchange Overview – Commentary

I think this is sort of like the Congress’ basket of choices. The Health Choices Commissioner is established under section 141 along with a Health Insurance Ombudsman.

Quite frankly, there is a huge bureaucracy created under this Bill that seems to duplicate what Medicare already does. Obviously, there would need to be an exponential addition of human resources for newly included insureds.

However, both the Federal and State Insurance commissioners will oversee it.

Actually, States may create their own Health Insurance Exchanges either singularly, or in conjunction with other states, pgs. 111-114.

Health Insurance is mandated in the America’s Affordable Health Choices Act of 2009 for employers and employees, pg. 110. Both individuals and employers will have to pay an Excise Tax, payable to the US Treasury, for non-compliance.

6. The individual will pay 2.5% of adjusted income, not to exceed the annual average insurance premium. The employer pays less. Can’t remember or find where I gleaned this so it may not be true.

7. All individuals and employers without insurance are eligible for the Health Exchange beginning in 2013. Those with insurance are not eligible until the first 3 years pass or after 2016, or so it seems.

8. In 2016, larger employers and their employees become eligible for Health Exchange options, but not before, or so it seems. This protects the Insurers interests for almost 7 years.

9. On page 78, it appears an individual can be considered a non-traditional Medicaid eligible if there is no gap in coverage prior to applying, in order to cover a period between loss of coverage and the upcoming open enrollment for the Exchange between September and November (pg. 96) each year.

10. Once enrolled in the Health Exchange, you remain eligible for the exchange, p. 79. Towards the end of page 90, item (III) gives the Commissioner an opening for determination re: Medicaid/Exchange eligibility.

11. The Employer size breakdown is outlined on page 80. Under 10 employees, under 20 employees, and all other employers. Not sure why they have these three categories.

12. The Employer mandate is outlined on page 81. On page 144 the Employer contribution states the employer will pay 72.5% of individual premiums and 65% of family premiums. The employer pays the rest and it appears this amount will be taxed as income, although I am not sure on this.

13. The Employer must give the employee 30 days to decide and then, if employee fails to choose, the Employer will auto enroll the employee.

14. Insurance providers, including the Public Option, are called QHBP offering entities. On page 84, it states that to qualify the QHBP must offer three plans: Basic, Enhanced, and Premium for the area of operation.

15. The Basic plan has the highest out-of-pocket expense, the Enhanced less out-of-pocket expense, and the Premium the least.

16. This seems to be much like our current three tier programs. Sadly, those in most need will be sacked with the most out-of-pocket expense again, or so it seems.

17. On page 86 it is clear that no dental or vision is included in these plans. Another FAIL in my opinion. There will be a Premium-Plus option that includes dental and vision for those who can afford the premiums.

18. On page 87, there is a hint of some health care services that will require no co-pay in the Basic plan.

19. On page 88, the Commissioner will review and negotiate the Insurer bids in the same manner that Medicare review is done, I think.

20. The Federal Acquisition Regulation will not apply to QHBP contracts, pg. 89.

21. All QHBP will be licensed within the state they operate under State law. Will any States not authorize the Public Option?

22. A QHBP can notify the Commissioner of a “capacity limitation”. What will that mean?

23. The Commissioner will require risk pooling.

24. Contracts for outpatient services with covered entities will be defined in the Public Health Service Act, July 1, 2009, section 340(a)(4) and specified by the Commissioner. I couldn’t find the specifics online.

However, if you go to www.thomas.gov and search for

“Public Health Service Act” 2009.

You will get a list of awesome of health improvement coverage made this year. You can be proud of some of the work our Congress has done! I hope the 100+ list of health laws are funded.

Back to the Health Care bill.

25. HMO’s are included on page 91. However, on pg. 92 the co-pay for going out-of-network has to be equal to the co-pay for going in- network. This is a good change.

26. Pg. 97 hints that the Health Exchange polices are NOT portable; however, if you move out of coverage area, the Commissioner can grant Special Enrollment into a new Exchange. Other special enrollment criteria are here as well.

27. We can be auto-enrolled and randomly assigned as well. Pgs. 97-98.

28. This is foggy and, quite frankly troubling because the Public Option is not mentioned. Individuals not covered by an employer will pay “the plans directly”. Page 99. There is not mention of who to pay for the Public Option.

29. We will communicate via an 1800 number and the Internet, pg. 99. On pg. 100 there is an opening to outsource assistance. Go privatization!

30. Page 102 has language that could indicate an Schip sunset and a move to Medicaid. I know my state keeps cutting back funding for Medicaid so this concerns me, but I don’t know much about Schip or Medicaid. This is an important question to ask. I hope I am wrong here.

31. AFFORDABILITY CREDITS, pg. 106. The Commissioner will coordinate. However, the Treasury will hold our Public Option premiums. Some details are on page 120.

32. Adverse Selection. Will be minimized, not rooted out. Disappointing. Pg. 107.

33. A new Bureaucracy will be created. Pages 107-109. The Office of the Special Inspector General for the Health Insurance Exchange, headed by a Special Inspector General, appointed by the President with Senate approval. The Office of the Special Inspector General shall terminate after 5 years of the enactment of this bill, and two years after it begins operating, pg. 109.

34. APPROPRIATIONS TO COVER GOVERNMENT CONTRIBUTIONS.
“There are hereby appropriated, out of any moneys in the Treasury not otherwise appropriated, to the Trust Fund, an amount equivalent to the amount of payments made from the Trust Fund under subsection (b) plus such amounts as are necessary reduced by the amounts deposited under paragraph (1).

OK, does anyone anticipate any problems here? Here’s what I see as a potential problem. We are running deep deficits, so what money is there that the “Treasury not otherwise appropriated”. A good question to raise.

Page 109

35. Trust Fund and Excise Taxes for the Americans who choose to not comply. Ok. I am quite liberal; however, WHAT IS WRONG with a system that FINES people who can’t or choose not to join this HUGE social experiment? If all is affordable, who in their right mind wouldn’t comply? I can’t seem to muster any faith in a system that allows Health Care for Profit to continue. But, maybe that’s just me.

36. Here you can read about the Health Insurance Exchange money matters:

37. SEC. 207. HEALTH INSURANCE EXCHANGE TRUST FUND.
(a) ESTABLISHMENT OF HEALTH INSURANCE EX-
CHANGE TRUST FUND.—There is created within the
Treasury of the United States a trust fund to be known
as the ‘‘Health Insurance Exchange Trust Fund’’ (in this
section referred to as the ‘‘Trust Fund’’), consisting of
such amounts as may be appropriated or credited to the
Trust Fund under this section or any other provision of
law.

Can we demand protection of this Trust Fund so another President doesn’t dip into it to finance another "off the books" war like Iraq?

38. (b) PAYMENTS FROM TRUST FUND.—The Commis-
sioner shall pay from time to time from the Trust Fund
such amounts as the Commissioner determines are nec-
essary to make payments to operate the Health Insurance
Exchange, including payments under subtitle C (relating
to affordability credits).

Is this written in anticipation of costs that may not have to be considered if we just made it simple and had two plans: The One You Have and Medicare for Uninsured

39. (c) TRANSFERS TO TRUST FUND.—

(1) DEDICATED PAYMENTS.—There is hereby
appropriated to the Trust Fund amounts equivalent
to the following:

110

40. (A) TAXES ON INDIVIDUALS NOT OBTAIN-
ING ACCEPTABLE COVERAGE
.—The amounts re
ceived in the Treasury under section 59B of the
Internal Revenue Code of 1986 (relating to re-
quirement of health insurance coverage for indi-
viduals).

Are they expecting a windfall? I sure hope not because only the uninsured have to pay this.

41. (B) EMPLOYMENT TAXES ON EMPLOYERS
NOT PROVIDING ACCEPTABLE COVERAGE.—The
amounts received in the Treasury under section
3111(c) of the Internal Revenue Code of 1986
(relating to employers electing to not provide
health benefits).

42. (C) EXCISE TAX ON FAILURES TO MEET
CERTAIN HEALTH COVERAGE REQUIRE-
MENTS.—The amounts received in the Treasury
under section 4980H(b) (relating to excise tax
with respect to failure to meet health coverage
participation requirements).

43. (2) APPROPRIATIONS TO COVER GOVERNMENT
CONTRIBUTIONS.—There are hereby appropriated,
out of any moneys in the Treasury not otherwise ap-
propriated, to the Trust Fund, an amount equivalent
to the amount of payments made from the Trust
Fund under subsection (b) plus such amounts as are
necessary reduced by the amounts deposited under
paragraph (1).

44. Most of the remaining Title II discusses how the States can set up and operate their own Health Insurance Exchanges. Well, don’t they already have “pools”? The big concern in the language is on page 113.

As one of the criteria for acceptance by the Commissioner “The State provides assurances..WILL NOT RESULT IN ANY NET INCREASE IN EXPENDITURES TO THE FEDERAL GOVERNMENT”.

45. What does that mean, and as most States are near bankruptcy, do you want to be forced into a mandated State Exchange? If a State runs an Exchange, will we be able to opt for the Federal Public Option. It is just not clear in the Bill, to me anyway.

PART II – THE PUBLIC OPTION

So, as you now read the Public Health Insurance Option, you will have some idea of what they mean when they refer to QHBP and Health Care Exchange compliance.

So, here is the Bill’s Public Health Insurance Option. It doesn’t take all that long to read, guys!

Again, you can read the whole bill here:
http://edlabor.house.gov/documents/111/pdf/publications/AAHCA-BillText-071409.pdf

Page 116: Subtitle B—Public Health Insurance Option

SEC. 221. ESTABLISHMENT AND ADMINISTRATION OF A
PUBLIC HEALTH INSURANCE OPTION AS AN
EXCHANGE-QUALIFIED HEALTH BENEFITS
PLAN.

(a) ESTABLISHMENT.—For years beginning with Y1,
the Secretary of Health and Human Services (in this sub-
title referred to as the ‘‘Secretary’’) shall provide for the
offering of an Exchange-participating health benefits plan
(in this division referred to as the ‘‘public health insurance
option’’) that ensures choice, competition, and stability of
affordable, high quality coverage throughout the United
States in accordance with this subtitle. In designing the
option, the Secretary’s primary responsibility is to create
a low-cost plan without comprimising quality or access to
care.

The program won’t go into effect until 2013.

(b) OFFERING AS AN EXCHANGE-PARTICIPATING
HEALTH BENEFITS PLAN.—

(1) EXCLUSIVE TO THE EXCHANGE.—The pub-
lic health insurance option shall only be made avail-
able through the Health Insurance Exchange.

If you are insured at the time it goes into effect, you won’t qualify for the Public Option, if I understand this correctly.

(2) ENSURING A LEVEL PLAYING FIELD.—Con-
sistent with this subtitle, the public health insurance
option shall comply with requirements that are ap-

Pg. 117
plicable under this title to an Exchange-participating
health benefits plan, including requirements related
to benefits, benefit levels, provider networks, notices,
consumer protections, and cost sharing.

(3) PROVISION OF BENEFIT LEVELS.—The pub-
lic health insurance option—
(A) shall offer basic, enhanced, and pre-
mium plans; and

(B) may offer premium-plus plans.

Remember, a Basic, Enhanced, and Premium program with no dental/vision. Also, I found no language stating any regulation on how competitive or not competitive this program will be allowed to be. It will still cost money so I remain concerned for so many of us who don’t qualify for Medicaid, but can’t afford health insurance either. Lot’s of details need to be learned.

(c) ADMINISTRATIVE CONTRACTING.—The Secretary
may enter into contracts for the purpose of performing
administrative functions (including functions described in
subsection (a)(4) of section 1874A of the Social Security
Act) with respect to the public health insurance option in
the same manner as the Secretary may enter into con-
tracts under subsection (a)(1) of such section. The Sec-
retary has the same authority with respect to the public
health insurance option as the Secretary has under sub-
sections (a)(1) and (b) of section 1874A of the Social Se-
curity Act with respect to title XVIII of such Act. Con-
tracts under this subsection shall not involve the transfer
of insurance risk to such entity.

Is this the open door to the furthur privatization of the Public Option. If so, good grief~

(d) OMBUDSMAN.—The Secretary shall establish an
office of the ombudsman for the public health insurance
option which shall have duties with respect to the public

Pg. 118
health insurance option similar to the duties of the Medi-
care Beneficiary Ombudsman under section 1808(c)(2) of
the Social Security Act.

Another Ombudsman! That’s two new Ombudsmen so far.

(e) DATA COLLECTION.—The Secretary shall collect
such data as may be required to establish premiums and
payment rates for the public health insurance option and
for other purposes under this subtitle, including to im-
prove quality and to reduce racial, ethnic, and other dis-
parities in health and health care.

I like the sound of this. Hope it means affordable premiums and out of pockets. Although, somewhere in the Bill I read of the familiar $5,000 for individual, $10,000 family out-of-pocket deductibles. Maybe I misread it.

(f) TREATMENT OF PUBLIC HEALTH INSURANCE OPTION.—
With respect to the public health insurance option,
the Secretary shall be treated as a QHBP offering entity
offering an Exchange-participating health benefits plan.

This is good reason why I included an overview of the Exchange.

(g) ACCESS TO FEDERAL COURTS.—The provisions
of Medicare (and related provisions of title II of the Social
Security Act) relating to access of Medicare beneficiaries
to Federal courts for the enforcement of rights under
Medicare, including with respect to amounts in con-
troversy, shall apply to the public health insurance option
and individuals enrolled under such option under this title
in the same manner as such provisions apply to Medicare
and Medicare beneficiaries.

Recourse for those who have legal resources. Good idea!

SEC. 222. PREMIUMS AND FINANCING.

(a) ESTABLISHMENT OF PREMIUMS

Page 119

(1) IN GENERAL.—The Secretary shall establish
geographically-adjusted premium rates for the public
health insurance option in a manner—

Not a "One Price Fit’s All". Darn!

(

A) that complies with the premium rules
established by the Commissioner under section
113 for Exchange-participating health benefit
plans; and

(B) at a level sufficient to fully finance the
costs of—

(i) health benefits provided by the
public health insurance option; and

(ii) administrative costs related to op-
erating the public health insurance option.

Don’t we already know that we Can’t Afford Medical Care in the USA. It’s too expensive. There needs to be some price gouging legislation!

(2) CONTINGENCY MARGIN.—In establishing
premium rates under paragraph (1), the Secretary
shall include an appropriate amount for a contin-
gency margin.

Anyone want to guess what this might actually mean?

(b) ACCOUNT.—

(1) ESTABLISHMENT.—There is established in
the Treasury of the United States an Account for
the receipts and disbursements attributable to the
operation of the public health insurance option, in-
cluding the start-up funding under paragraph (2).

Section 1854(g) of the Social Security Act shall
apply to receipts described in the previous sentence

Page 120
in the same manner as such section applies to pay
ments or premiums described in such section.

The same rules/regs for Medicare payments found here:
Sec. 1854. [42 U.S.C. 1395w–24] (a) Submission of Proposed Premiums, Bid Amounts,[347] and Related Information.—
http://www.ssa.gov/OP_Home/ssact/title18/1854.htm

(2) START-UP FUNDING.—

(A) IN GENERAL.—In order to provide for
the establishment of the public health insurance
option there is hereby appropriated to the Sec-
retary, out of any funds in the Treasury not
otherwise appropriated, $2,000,000,000.
In
order to provide for initial claims reserves be
fore the collection of premiums, there is hereby
appropriated to the Secretary, out of any funds
in the Treasury not otherwise appropriated,
such sums as necessary to cover 90 days worth
of claims reserves based on projected enroll-
ment.

(B) AMORTIZATION OF START-UP FUND-
ING.—The Secretary shall provide for the re-
payment of the startup funding provided under
subparagraph (A) to the Treasury in an amor-
tized manner over the 10-year period beginning
with Y1.

(C) LIMITATION ON FUNDING.—Nothing in
this section shall be construed as authorizing
any additional appropriations to the Account,
other than such amounts as are otherwise pro-

Page 121
vided with respect to other Exchange-partici-
pating health benefits plans.

Rats. Are special fund authorizations for just the Public Option Fund disallowed? Is this to protect the private insurers from UNJUST competition?

SEC. 223. PAYMENT RATES FOR ITEMS AND SERVICES.

(a) RATES ESTABLISHED BY SECRETARY.—

(1) IN GENERAL.—The Secretary shall establish
payment rates for the public health insurance option
for services and health care providers consistent with
this section and may change such payment rates in
accordance with section 224.

(2) INITIAL PAYMENT RULES.—

(A) IN GENERAL.—Except as provided in
subparagraph (B) and subsection (b)(1), during
Y1, Y2, and Y3, the Secretary shall base the
payment rates under this section for services
and providers described in paragraph (1) on the
payment rates for similar services and providers
under parts A and B of Medicare.

This changes around a bit further down the page. However, there are many doctors who don’t take Medicare patients in my area. How about your area? Keep reading. This becomes quite interesting. As I said in the beginning, a lot of the bill is about HOW people can play and how they will be paid!

(B) EXCEPTIONS.—

(i) PRACTITIONERS’ SERVICES.—Payment
rates for practitioners’ services other-
wise established under the fee schedule
under section 1848 of the Social Security
Act
shall be applied without regard to the
provisions under subsection (f) of such sec-
tion and the update under subsection

Page 122
(d)(4) under such section for a year as ap
plied under this paragraph shall be not less
than 1 percent.

Well, that clears things up a bit? Ok, I am snarking. Here is the SSA site where you can read about PAYMENT FOR PHYSICIANS’ SERVICES, Sec. 1848. [42 U.S.C. 1395w–4] (a) Payment Based on Fee Schedule.—
https://www.socialsecurity.gov/OP_Home/ssact/title18/1848.htm

And here’s the original Social Security Act 1935. Note that it is only maybe 11 pages. Back when Congress KEPT IT SIMPLE!
http://www.nationalcenter.org/SocialSecurityAct.html

(ii) ADJUSTMENTS.—The Secretary
may determine the extent to which Medi-
care adjustments applicable to base pay-
ment rates under parts A and B of Medi-
care shall apply under this subtitle.

WIGGLE ROOM!

(3) FOR NEW SERVICES.—The Secretary shall
modify payment rates described in paragraph (2) in
order to accommodate payments for services, such as
well-child visits, that are not otherwise covered
under Medicare.

(4) PRESCRIPTION DRUGS.—Payment rates
under this section for prescription drugs that are not
paid for under part A or part B of Medicare shall
be at rates negotiated by the Secretary.

You may be noticing that Medicare is being used as the foundation. So why not just sign people up for Medicare!

Again, if you go to www.thomas.gov and search for “Public Health Service Act” 2009,
you will find a list of awesome of health improvement coverage made this year. You can be proud of some of the work our Congress has done! I hope the 100+ list of health laws are funded. I am assuming these were passed for inclusion in covered services under the Reform Bill to fill in some of the egregious exclusions by the present insurers. I am just guessing, however.

NOTICE that the Pharma Windfall here is that all the drugs covered under Medicare part A and/or part B will NOT BE NEGOTIATED. BS!

OK, back to Doctor payments. Remember I mentioned above some policy shifting. Here it is:

(b) INCENTIVES FOR PARTICIPATING PROVIDERS.—

(1) INITIAL INCENTIVE PERIOD.—

(A) IN GENERAL.—The Secretary shall
provide, in the case of services described in sub-
paragraph (B) furnished during Y1, Y2, and
Y3, for payment rates that are 5 percent great-
er than the rates established under subsection
(a).

That’s nice! So Docs will be paid 5% more to treat non-Medicare patients? Maybe I am reading this wrong. Otherwise, could the elderly have an even harder time finding a participating doctor?

Page 123
(B) SERVICES DESCRIBED.—The services
described in this subparagraph are items and
professional services, under the public health in-
surance option by a physician or other health
care practitioner who participates in both Medi-
care and the public health insurance option.

(C) SPECIAL RULES.—A pediatrician and
any other health care practitioner who is a type
of practitioner that does not typically partici-
pate in Medicare (as determined by the Sec-
retary) shall also be eligible for the increased
payment rates under subparagraph (A)

.
PLEASE add the following: "IF the practitioner will also take Medicare patients for non-gerintological treatments". Please!

(2) SUBSEQUENT PERIODS.— Beginning with
Y4 and for subsequent years, the Secretary shall
continue to use an administrative process to set such
rates in order to promote payment accuracy, to en-
sure adequate beneficiary access to providers, and to
promote affordablility and the efficient delivery of
medical care consistent with section 221(a). Such
rates shall not be set at levels expected to increase
overall medical costs under the option beyond what
would be expected if the process under subsection
(a)(2) and paragraph (1) of this subsection were
continued.

The Bill could use more cost-containment language!

Page 124

(3) ESTABLISHMENT OF A PROVIDER NET-
WORK.—Health care providers participating under
Medicare are participating providers in the public
health insurance option unless they opt out in a
process established by the Secretary.

THIS IS IMPORTANT. A provider will earn 5% more treating non-Medicare patients. The low percentage of doctors treating Medicare patients surely shouldn’t be invited to opt out of being a Medicare doctor. Can someone from AARP chime in here, please?

(c) ADMINISTRATIVE PROCESS FOR SETTING
RATES.
—Chapter 5 of title 5, United States Code shall
apply to the process for the initial establishment of pay-
ment rates under this section but not to the specific meth-
odology for establishing such rates or the calculation of
such rates

.
RED ALERT: There doesn’t appear to be a Chapter 5 of title 5, United States Code? There are three (3) sections under Title 5:
http://frwebgate.access.gpo.gov/cgi-bin/usc.cgi?ACTION=BROWSE&title=5usc&PDFS=YES

And there is a Title 5 Appendix that has a Section 5 here:
http://frwebgate.access.gpo.gov/cgi-bin/usc.cgi?ACTION=BROWSE&title=5uscApp.&PDFS=YES

ADMINISTRATIVE PROCESS FOR SETTING RATES is very important. I think this refers to what premiums we will pay. Are they going to surprise us? I have some rumblings that the Public Option will cost 20% or so less than existing premiums. That’s a rumor.

(d) CONSTRUCTION.—Nothing in this subtitle shall
be construed as limiting the Secretary’s authority to cor-
rect for payments that are excessive or deficient, taking
into account the provisions of section 221(a) and the
amounts paid for similar health care providers and serv-
ices under other Exchange-participating health benefits
plans.

LAWYER ALERT! Does this sound like an open door to an end of the year bill? Or maybe a refund, although that would probably shock us to death! I don’t see how provider fees can be similar nationwide. Could some providers actually improve their profit margins? And why the Secretary and not the Commissioner who runs the Exchange for which the Public Option is part and parcel, or so we hope? This clause raises more questions than it answers, in my opinion.

(e) CONSTRUCTION.—Nothing in this subtitle shall be
construed as affecting the authority of the Secretary to
establish payment rates, including payments to provide for
the more efficient delivery of services, such as the initia-
tives provided for under section 224.

(f) LIMITATIONS ON REVIEW.—There shall be no ad-
ministrative or judicial review of a payment rate or meth-

Page 125
odology established under this section or under section
224.

That’s a lot of power for just the Secretary. And no review? Curious.

SEC. 224. MODERNIZED PAYMENT INITIATIVES AND DELIV-
ERY SYSTEM REFORM. Page 125

(a) IN GENERAL.—For plan years beginning with Y1,
the Secretary may utilize innovative payment mechanisms
and policies to determine payments for items and services
under the public health insurance option. The payment
mechanisms and policies under this section may include
patient-centered medical home and other care manage-
ment payments, accountable care organizations, value-
based purchasing, bundling of services, differential pay-
ment rates, performance or utilization based payments,
partial capitation, and direct contracting with providers.

(b) REQUIREMENTS FOR INNOVATIVE PAYMENTS.—
The Secretary shall design and implement the payment
mechanisms and policies under this section in a manner
that—

(1) seeks to—
(A) improve health outcomes;
(B) reduce health disparities (including ra-
cial, ethnic, and other disparities);
(C) provide efficent and affordable care;
(D) address geographic variation in the
provision of health services; or

Page 126
(E) prevent or manage chronic illness; and
(2) promotes care that is integrated, patient-
centered, quality, and efficient.

There goes that $2,000,000,000 start up capital. Ok, I get silly after working too hard.

(c) ENCOURAGING THE USE OF HIGH VALUE SERV-
ICES.—To the extent allowed by the benefit standards ap-
plied to all Exchange-participating health benefits plans,
the public health insurance option may modify cost shar-
ing and payment rates to encourage the use of services
that promote health and value.

Oh, more privatization. I just wish I knew someone on the inside. But good for jobs. High paying?

(d) NON-UNIFORMITY PERMITTED.—Nothing in this
subtitle shall prevent the Secretary from varying payments
based on different payment structure models (such as ac
countable care organizations and medical homes) under
the public health insurance option for different geographic
areas.

Prices and payments will vary geographically. I hope they give some incentive to serve the non-served areas so health care becomes available to rural America.

SEC. 225. PROVIDER PARTICIPATION. Page 126

(a) IN GENERAL.—The Secretary shall establish con-
ditions of participation for health care providers under the
public health insurance option.

(b) LICENSURE OR CERTIFICATION.—The Secretary
shall not allow a health care provider to participate in the
public health insurance option unless such provider is ap-
propriately licensed or certified under State law.

Could some language be added to ban doctors who have lost their license in any State? I can just see a doctor moving from state to state.

(c) PAYMENT TERMS FOR PROVIDERS.—

Page 127
(1) PHYSICIANS.—The Secretary shall provide
for the annual participation of physicians under the
public health insurance option, for which payment
may be made for services furnished during the year,
in one of 2 classes:

(A) PREFERRED PHYSICIANS.—Those phy-
sicians who agree to accept the payment rate
established under section 223 (without regard
to cost-sharing) as the payment in full.

(B) PARTICIPATING, NON-PREFERRED
PHYSICIANS.—Those physicians who agree not
to impose charges (in relation to the payment
rate described in section 223 for such physi-
cians) that exceed the ratio permitted under
section 1848(g)(2)(C) of the Social Security
Act.

You can read the fees here:
PAYMENT FOR PHYSICIANS’ SERVICES
Sec. 1848. [42 U.S.C. 1395w–4] (a) Payment Based on Fee Schedule.—
http://www.ssa.gov/OP_Home/ssact/title18/1848.htm

(2) OTHER PROVIDERS.—The Secretary shall
provide for the participation (on an annual or other
basis specified by the Secretary) of health care pro-
viders (other than physicians) under the public
health insurance option under which payment shall
only be available if the provider agrees to accept the
payment rate established under section 223 (without
regard to cost-sharing) as the payment in full.

Dare we dream? Will there be preferred physicians happy with the Medicare payments, or with 5% above Medicare? And no co-pays from us? Am I interpreting this correctly?

Page 128
(d) EXCLUSION OF CERTAIN PROVIDERS.—The Sec-
retary shall exclude from participation under the public
health insurance option a health care provider that is ex-
cluded from participation in a Federal health care pro-
gram (as defined in section 1128B(f) of the Social Secu-
rity Act).

http://www.ssa.gov/OP_Home/ssact/title11/1128.htm
Excludes individuals and entities from participating on the basis of prior convictions for fraud, patient abuse, felony conviction relating to a controlled substance, etc. (Thanks to triv33 for this contribution)

SEC. 226. APPLICATION OF FRAUD AND ABUSE PROVI-
SIONS.
Provisions of law (other than criminal law provisions)
identified by the Secretary by regulation, in consultation
with the Inspector General of the Department of Health
and Human Services, that impose sanctions with respect
to waste, fraud, and abuse under Medicare, such as the
False Claims Act (31 U.S.C. 3729 et seq.), shall also
apply to the public health.

End of Bill

Under the False Claims Act, 31 U.S.C. §§ 3729-3733, those who knowingly submit, or cause another person or entity to submit, false claims for payment of government funds are liable for three times the government’s damages plus civil penalties of $5,500 to $11,000 per false claim.

http://www.taf.org/whyfca.htm
You can read the law here: http://www.taf.org/federalfca.htm

The entities providing insurance coverage are called "QHBP offering entities". They include (found on page 12):

Employer Sponsored Group Plan as defined by section 733(a)(1)(d) of the Employee Retirement Income Security Act of 1974;

Health Insurance Coverage from Private Insurer;

Public Health Insurance Option via the Secretary of HHS (must follow the rules of the Health Insurance Exchange);

Non-Federal Governmental Plan (or State(s) Plan), as defined in the Public Health Service Act, section 2791(d). (A quick read through the Health Exchange language indicates that a State or group of States may create their own Health Exchange under the approval of the Secretary of HHS); and

A Federal governmental plan as defined in the Public Health Service Act in section 2791(d), overseen by the appropriate Federal official.

"(F) DEPOSIT OF PENALTY COLLECTED.—
Any amount of penalty collected under this paragraph shall be deposited as miscellaneous receipts in the Treasury of the United States.’


I think the Excise Taxes (fines for non-participation) should go into the Public Option Trust for payment of health care services to others, not "miscellaneous receipts" that will be sucked Down the National Debt Drain. I don’t get this clause.

Done! Don’t you think we should familiarize ourselves with this MONSTER SIZED BILL?

FYI. Here are some websites that we can use in the future as we try to solve another proposed legislative puzzle:

Cornell University Law School has a great search engine for free:
http://www.law.cornell.edu/

Social Security Law, etc. You can search for a specific section, which is very helpful with the health care issue.
http://www.ssa.gov/

US Government Printing Office, a great resource!
http://www.gpoaccess.gov/index.html

WarOnError

WarOnError

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