THEY PASSED THE HEALTHCARE BILL YAY!! Wait...what does that actually mean? (PART 3)

***There are computer errors that are showing up on this post! They don't show however, when I edit so I'm sure this is a skirt problem that will be fixed soon. Thanks!!

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**Hey I hope you ladies are still with me on this! I know it's a lot to read..try not to give up! I'm picking up right where I left off in Part 2**

F. Protection Against Dumping Risks by Insurers:

(1) IN GENERAL. - The Secretary shall establish criteria for determining whether health insurance issuers and employment-based health plans have discouraged an individual from remaining enrolled in prior coverage based on that individual's health status.

(2) SANCTIONS. - An issuer or employment-based health plan shall be responsible for reimbursing the program for the medical expenses incurred by the program for an individual who, based on criteria established by the Secretary, the secretary finds was encouraged by the issuer to disenroll from health benefits coverage prior to enrolling in the program. The criteria shall include at least the following circumstances:

(A) In the case of prior coverage obtained through an employer, the provision by the employer, group health plan, or the issuer of money or other financial consideration for disenrolling from the coverage.

(B) In the case of prior coverage obtained directly from an issuer or under an employment-based health plan - (i) the provision by the issuer or plan of money or other financial consideration for disenrolling from the coverage; or (ii) in the case of an individual whose premium for the prior coverage exceeded the premium required by the program (adjusted based on the age factors applied to the prior coverage) -

(I) The prior coverage is a policy that is no longer being actively marketed (as defined by the Secretary) by the issuer; or (II) the prior coverage is a policy for which duration of coverage form issue or health status are factors that can be considered in determining premiums at renewal.

(3) CONSTRUCTION. - Nothing in this subsection shall be construed as constituting exclusive remedies for violations of criteria established under paragraph (1) or as preventing States from applying or enforcing such paragraph or other provisions under law with respect to health insurance issuers.

G. Covered Benefits, Cost-Sharing, Premiums, and Consumer Protections. -

(1) PREMIUM. - The monthly premium charged to eligible individuals for coverage under the program - (A) may vary by age so long as the ratio premium does not exceed the ratio of 2 to 1; (B) shall be set at a level that does not exceed 125 percent of the prevailing standard rate for comparable coverage in the individual market; and (C) shall be adjusted for geographic variation in costs.

Health insurance issuers shall provide such information as the Secretary may require to determine prevailing standard rates under this paragraph. The Secretary shall establish standard rates in consultation with the National Association of Insurance Commissioners.

(2) COVERED BENEFITS. - Covered benefits under the program shall be determined by the Secretary and shall be consistent with the basic categories in the essential benefits package described in section 222. Under such benefits package -

(A) The annual deductible for such benefits may not be higher than $1,500 for an individual or such higher amount for a family as determined by the Secretary; (B) there may not be annual or lifetime limits; and (C) the maximum cost-sharing with respect to an individual (or family) for a year shall not exceed $5,000 for an individual (or $10,000 for a family).

(3) NO PREEXISTING CONDITION EXCLUSION PERIODS. - No preexisting condition exclusion period shall be imposed on coverage under the program.

(4) APPEALS. - The Secretary shall establish an appeals process for individuals to appeal a determination of the Secretary - (A) with respect to claims submitted under this section; and  (B) with respect to eligibility determinations made by the Secretary under this section.

(5) STATE CONTRIBUTION, MAINTENANCE OF EFFORT. - As a condition of providing health benefits under this section to eligible individual residing in a State - (A) in the case of a State in which a qualified high-risk pool (as defined under section 2744(c)(2) of the Public Health Service Act) was in effect as of July 1, 2009, the Secretary shall require the State make a maintenance of effort payment each year that the high-risk pool is in effect equal to an amount not less than the amount of all sources of funding for high-risk pool coverage made by that State in the year ending July 1, 2009; and (B) in the case of a State which required health insurance issuers to contribute to a State high-risk pool  or similar arrangement for the assessment against such issuers for pool losses, the State shall maintain such a contribution arrangement among such issuers.

 **(2) QUALIFIEDHIGHRISKPOOL. —For purposes of subsection (a)(1)(D)(ii), a ‘‘qualified high risk pool’’ described in this paragraph is a high risk pool that— (A) provides to all eligible individuals health insurance coverage (or comparable coverage) that does not impose any preexisting condition exclusion with respect to such coverage for all eligible individuals, and (B) provides for premium rates and covered benefits for such coverage consistent with standards included in the NAIC Model Health Plan for Uninsurable Individuals Act (as in effect as of the date of the enactment of this title). <----From the Public Health Service Act. www.fda.gov

(6) LIMITING PROGRAM EXPENDITURES. - The Secretary shall, with respect to the program - (A) establish procedures to protect against fraud, waste, and abuse under the program; and (B) provide for other program integrity methods.

(7) TREATMENT AS CREDITABLE COVERAGE. - Coverage under the program shall be treated, for purposes of applying the definition of "credible coverage" under the provisions of title XXVII of the Public Health Service Act, Part 6 of subtitle B of Title I of Employee Retirement Income Security Act of 1974, and chapter 100 of the Internal Revenue Code of 1986 (and any other provision of law that references such provisions) in the same manner as if it were coverage under a State health benefits risk pool described in section 2701(c)(1)(G) of the Public Health Service Act.

(h) FUNDING; TERMINATION OF AUTHORITY. – (1) IN GENERAL. – There is appropriated to the Secretary, out of any moneys in the Treasury not otherwise appropriated, $5,000,000,000 to pay claims against (and administrative costs of) the high-risk pool under this section in excess of the premiums collected with respect to eligible individuals enrolled in the high-risk pool. Such funds shall be available without fiscal year limitation. (2) INSUFFICIENT FUNDS. – If the Secretary estimates for any fiscal year that the aggregate amounts available for payment of expenses of the high-risk pool will be less than the amount of the expenses, the Secretary shall make such adjustments as are necessary to eliminate such deficit, including reducing benefits, increasing premiums, or establishing waiting lists.

(3) TERMINATION OF AUTHORITY. – (A) IN GENERAL. – Except as provided in subparagraph (B), coverage of eligible individuals under a high-risk pool shall terminate as of the date on which the Health Insurance Exchange is established. (B) TRANSITION TO EXCHANGE. – The Secretary shall develop procedures to provide for the transition of eligible individuals who are enrolled in health insurance coverage offered through a high-risk pool established under this section to be enrolled in acceptable coverage. Such procedures shall ensure that there is no lapse in coverage with respect to the individual and may extend coverage offered through such a high-risk pool beyond 2012 if the Secretary determines necessary to avoid such a lapse.

SEC. 102. ENSURING VALUE AND LOWER PREMIUMS.

(A) 

GROUP HEALTH INSURANCE COVERAGE. – Title XXVII of the Public Health Service Act is amended by inserting after section 2713 the following new section:

SEC. 2714. ENSURING VALUE AND LOWER PREMIUMS.

“(a) IN GENERAL. – Each health insurance issuer that offers health insurance coverage in the small or large group market shall provide that for any plan year in which the coverage has a medical loss ratio below a level specified by the Secretary (but not less than 85 percent), the issuer shall provide in a manner specified by the Secretary for rebates to enrollees of the amount by which the issuer’s medical loss ratio is less than the level so specified.

“(b) IMPLEMENTATION. – The Secretary shall establish a uniform definition of medical loss ratio and methodology for determining how to calculate it based on the average medical loss ratio in a health insurance issuer’s book of business for the small and large group market. Such methodology shall be designed to take into account the special circumstances of smaller plans, different types of plans, and newer plans. In determining the medical loss ratio, the secretary shall exclude State taxes and licensing or regulatory fees. Such methodology shall be designed and exceptions shall be established to ensure adequate participation by health insurance issuers, competition in the health insurance market, and value for consumers so that their premiums are used for services.

“© SUNSET. – Subsections (a) and (b) shall not apply to health insurance coverage on and after the first date that health insurance coverage is offered through the Health Insurance Exchange.”.

(B) 

INDIVIDUAL HEALTH INSURANCE COVERAGE. – Such title is further amended by inserting after section 2753 the following new section:

SEC. 2754. ENSURING VALUE AND LOWER PREMIUMS.

“The provisions of section 2714 shall apply to health insurance coverage offered in the individual market in the same manner as such provisions apply to health insurance coverage offered in the small or large group market except to the extent the Secretary determines the application of such section may destabilize the existing individual market.”.

© IMMEDIATE IMPLEMENTAION. – The amendments made by this section shall apply in the group and individual market for plan years beginning on or after January 1, 2010, or as soon as practicable after such date.

SEC. 103. ENDING HEALTH INSURANCE RECESSION ABUSE.

(A) 

CLARIFICATION REGARDING APPLICATION OF GUARANTEED RENEWABILITY OF INDIVIDUAL AND GROUP HEALTH INSURANCE COVERAGE. – Sections 2712 and 2742 of the Public Health Service Act (42 U.S.C. 300gg-12, 300gg-42) are each amended –

(1) 

in its heading, by inserting “ AND CONTINUATION IN FORCE, INCLUDING PROHIBITION OF RECISSION,” “GUARANTEED RENEWABILITY; and

(2) 

in subsection (a), by inserting “, including without rescission,” after “continue in force”.

(b) SECRETARIAL GUIDANCE REGARDING RESCISIONS. –

(1) 

GROUP HEALTH INSURANCE MARKET. – Section 2712 of such Act (42 U.S.C. 300gg – 12) is amended by adding at the end the following:

(f) RESCISSION. – A health insurance issuer may rescind group health insurance coverage only upon clear and convincing evidence of fraud described in subsection (b) (2), under procedures that provide for independent, external third-party review.”.

(2) 

INDIVIDUAL HEALTH MARKET. – Section 2742 of such Act (42 U.S.C. 300gg-42) is amended by adding at the end of the following:

“(f) RESCISSION. – A health insurance issuer may rescind individual health insurance coverage only upon clear and convincing evidence of fraud described in subsection (b)(2), under procedures that provide for independent, external third-party review.”

(3) 

GUIDANCE. – The Secretary of Health and Human Services, no later than 90 days after the date of the enactment of this Act, shall issue guidance implementing the amendments made by paragraphs (1) and (2), including procedures for independent, external third-party review.

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