NEO-LIBERAL POLITICAL PUNDIT EJ DIONNE JOKED A FEW YEARS AGO THAT THE AFFORDABLE CARE ACT IS A SINGLE-PAYER-----IT WILL PUSH EVERYONE TO MEDICAID AND THEN END MEDICAID. NEO-LIBERALS RUNNING AS DEMOCRATS WORKING AS HARD AS REPUBLICANS TO MAKE HEALTH CARE ALL ABOUT PROFITS!
Why do Republicans call it ObamaCare and why does Obama embrace that? Republicans need to hide that much of the Affordable Care Act is Republican policy ----the mandated insurance---the state-run private health systems to end and deregulate the public health system that will allow no protection for the American people in how health care is delivered. Bye-Bye Medicare and Medicaid----all Republican policies. Know who is as mad about these policies as labor and justice-----Republican voters. So, Republican pols love Affordable Care Act but give neo-liberals cover by pretending to hate it. The Democratic base of labor and justice will be literally killed by 'ObamaCare' as they are the 80% that will not longer access any health care than preventative if ACA stays in place. This is why neo-liberals need women and people of color as the face of these policies---WOMEN AND PEOPLE OF COLOR ARE MUCH OF THAT 80%.
INSTEAD OF RECEIVING ALL THE HEALTH CARE YOU NEED AT YOUR LOCAL HOSPITAL ----YOU WILL NOW TRAVEL SOMEWHERE ELSE, NATIONALLY OR INTERNATIONALLY, TO FIND ROUTINE HEALTH CARE YOU CAN AFFORD.
This is the key to the promise made by neo-liberals that no one would be denied coverage for 'pre-existing conditions' and 'your child can stay on your plan until 27 years old'. The fact that most people with strong health plans today will be pushed into these Bronze and Medicaid-level coverage does not bode well for that 27 year old only able to access the same. THAT WAS SIMPLE PROPAGANDA DRESSED AS A PROGRESSIVE BONE. The loopholes left in the ACA were designed to encourage corporations to shed strong health plans for preventative care and designed to build health systems with insurance consolidated that can move people with pre-existing health issues to clinic and hospital care far away from where they live.
THEY ARE USING HEALTH CARE REFORM AS THEY ARE EDUCATION REFORM TO FORCE PEOPLE TO LIVE IN CERTAIN PLACES TO RECEIVE ORDINARY ACCESS TO HEALTH CARE.
The ACA states all plans must take people with pre-existing conditions and so now we see health plans with coverage areas that look like a gerrymandered political district with the final destination for that patient sometimes 100 miles away.....at the least across town. The ACA also allows for a broad definition of 'pre-existing condition' so as to send many people into plans just like this. So, the coverage is indeed there-----it has simply been made hard to access. Sadly, even a shortage of children's cancer drugs pre-emptied what the ACA was supposed to protect against. Keep in mind people with chronic illness will quickly fall into medical bankruptcy and with that Medicaid-level coverage. Seniors today are already seeing their retirement savings blown on medical payments not covered by Medicare and having to fall into bankruptcy. Below you see reference to continuous health coverage as a pre-requisite for pre-existing care coverage and one thing that costs will do is have people leaving policies for others.
Let's look at what these issues actually look like....remember, if you are thinking this will only affect people with bad health habits and good riddance------think again:
Key Regulation Concepts
Pre-existing Conditions
What are pre-existing conditions? Millions of Americans live with chronic conditions like asthma, heart disease and depression, and millions more seek care each year for shorter-term medical conditions such as back injuries or pregnancy. When a person applies for a health insurance plan, these conditions are referred to as "pre-existing" because they existed before the plan was purchased. Many people have been denied treatment - or payment of treatment - by insurance companies because of pre-existing conditions, and the insurers had broad discretion in defining pre-existing condition. Two federal laws protect people from these practices: the Affordable Care Act (ACA) and the Health Insurance Portability and Accountability Act (HIPAA).
What is current law on pre-existing conditions? The ACA prohibits insurers from excluding children under 19 from coverage because they have a pre-existing condition. This prohibition, which began September 2010, includes both pre-existing condition exclusions (i.e., an insurance company cannot refuse to pay for chemotherapy for a child with cancer because the child had the cancer before obtaining insurance) and outright coverage denials (i.e., an insurance company cannot refuse to cover a child because of the child's cancer). This rule applies to all group plans and new plans in the individual market, but does not pertain to grandfathered individual plans. Beginning January 1, 2014, the ACA requires new and grandfathered group plans to eliminate pre-existing condition exclusions for everyone.
Prior to 2014, HIPAA still restricts a health insurer's ability to limit coverage of pre-existing medical conditions for adults. HIPAA rules apply to all employer-sponsored health plans and to some plans purchased by some individual consumers. States may have stronger protections.
Rules for different types of plans:
'NARROW NETWORKS' .....that is how Affordable Care Act works to eliminate all public community hospitals and health centers and bring all health to large health systems. It is how as well costly patients are networked into what will be lower quality health systems and/or systems outside the community and/or even region. They have to provide a plan for pre-existing conditions but loopholes allow these insurance plans to make it as difficult as possible to make it cheap as possible. We have insurance plans with networks that make political gerrymandering of districts look like child's play all to undermine the coverage for what will become most Americans. What defines pre-existing health is now being broadened and left vague so insurance corporations can continue to throw the most costly patients into these networks. MAYBE YOU WANT TO FLY TO INDIA FOR YOUR HEALTH CARE SAY THESE GLOBAL CORPORATE POLS BUILDING WALL STREET-LIKE HEALTH SYSTEMS THAT WILL PREY ON PEOPLE, NOT CARE FOR THEM.
Hmmmmmmmm.......narrow networks affect the people receiving that insurance subsidy while Medicaid patients have more access. Sounds like they are making people lose income to get better insurance coverage!
Obamacare health plans leave out some community health centers
By Guy Boulton of the Journal Sentinel March 22, 2014
One of the law's key goals is to expand health insurance coverage. Yet community health centers, which are located in neighborhoods with the highest concentration of uninsured people, often are not included in the networks of health plans sold on the federal marketplace.
Only one of the health plans available in Milwaukee includes all of the community health centers. It is the most expensive plan, limiting its appeal to people with low incomes. And when a community health center is included in a plan's network, the hospital that the health center refers patients to often isn't.
For example, Molina Healthcare has contracted with Sixteenth Street Community Health Centers and Progressive Community Health Centers, but not with Columbia St. Mary's or Froedtert Hospital and the Medical College of Wisconsin.
The doctors and midwives at Sixteenth Street practice at Columbia St. Mary's Hospital-Milwaukee. Progressive has a close working relationship with Froedtert Hospital and the Medical College, whose specialists see the health center's patients.
Part of this stems from the efforts of health insurers to keep the cost of the health plans as low as possible.
The regulations imposed on health insurers — such as being required to cover a standard package of benefits and to cover people with pre-existing health conditions — were intended to increase price competition among health plans sold on the marketplace.
The limited or narrow networks, in theory, enable health insurers to negotiate better prices, enabling them to offer health plans that cost less.
The plans' networks of doctors and hospitals had to be deemed adequate by the federal government to be sold on the marketplace. But the networks have drawn criticism. The National Association for Community Health Centers reportedly has lobbied for two years to require insurers to include health centers in their networks.
Relationship problems Nearly all of the health plans sold on the federal marketplace in Milwaukee have narrow networks.
Anthem Blue Cross and Blue Shield in Wisconsin, Arise Health Plan, an affiliate of WPS Health Insurance, and Common Ground Healthcare Cooperative all offer plans tied to Aurora Health Care's hospitals and doctors.
But at least three of the four community health centers, which provide care to almost 1 in 8 people in Milwaukee, almost all of them with low incomes, are affiliated with a specific health system.
"We have no relationship with the Aurora specialists," said John Bartkowski, president and chief executive of Sixteenth Street. "We have no relationship with the Aurora hospitals."
Sixteenth Street has ties to Columbia St. Mary's, Progressive to Froedtert Health and the Medical College, and Milwaukee Health Services to Aurora and Wheaton Franciscan Healthcare.
That could change.
Progressive is working to arrange for its doctor who specializes in obstetrics and gynecology and its midwife to get privileges to practice at Aurora Sinai Medical Center, said Jenni Sevenich, chief executive of the community health center.
The narrow networks will affect only adults eligible for subsidized coverage on the marketplace. They have household incomes above the federal poverty threshold, or $11,670 for an individual this year, and are not eligible for affordable insurance through an employer.
Adults with incomes below the threshold will be eligible for BadgerCare Plus, the state's largest Medicaid program. They will have access to all hospitals and to physicians who agree to accept them as patients.
Covering children Children and pregnant women who live in households with incomes of up to 300% of the federal poverty level — $71,550 for a family of four — are eligible for BadgerCare Plus when affordable insurance is not available through an employer.
This may be why only two of the health insurers selling plans on the marketplace — Anthem and Arise — include Children's Hospital of Wisconsin and the physicians group that includes specialists from the Medical College of Wisconsin in their networks.
Molina and one of Common Ground’s two health plans do not have contracts with the hospital or physicians but said they will pay for the care of children who need to be hospitalized.
The narrow networks probably mean less to people who have been uninsured. The community health centers provide primary care to people without insurance, charging them fees tied to their income. But they have always had difficulty getting access to hospitals and specialists for care not deemed a medical emergency.
The narrow networks will affect adults now covered by BadgerCare Plus, those with incomes between 100% and 200% of the federal poverty level with children under 19. They now must get coverage through the subsidized plans sold on the marketplace.
How many of them are aware of the limited networks when picking a health plan is unknown.
"They are learning a whole lot in the beginning," said Sevenich of Progressive.
________________________________________
Obama is fast privatizing all of the Federal Medicare and Medicaid agencies and pushing all program funding to the states as they work to end public health care. Outsourcing everything Medicare and Medicaid while placing the next head of Health and Human Services-----a Gates Foundation executive openly saying she thinks block grants work for Medicaid and wants the same for Medicare. So, the idea that this Federal subsidy for pre-existing conditions was real was simply a lie.
Another thing to consider is that Medicaid spending is gutted with fraud and corruption because of this 'block grant' status----no doubt the reason the new HHS appointee thinks it is working great----it moves billions of dollars to health institutions in fraud every year and she is determined that this same block grant format do the same with Medicare!
Neo-liberals and neo-cons intend to end these Federal health programs so Medicaid will simply be looted and defunded out of existence just as 80% of Americans are moved to Medicaid because corporate plans and union plans will end.
I DIDN'T KNOW THAT SAY INCUMBENT NEO-LIBERALS HAVING CREATED AFFORDABLE CARE ACT AND THE NATIONAL LABOR AND JUSTICE ORGANIZATIONS THAT SUPPORTED IT! YES, THEY DID KNOW THAT JUST AS I DID.
GAO: HHS Already Rationing Enrollment in Obamacare’s Pre-Existing Condition Plan
May 31, 2013 - 1:10 PM By Michael W. Chapman
President Barack Obama signs the Patient Protection and Affordable Care Act into law, Mar. 23, 2010. (AP)
(CNSNews.com) – A pre-existing condition health insurance program established by Obamacare is already straining its own budget and, to control costs, the administration’s Health and Human Services Department (HHS) has stopped enrolling any new people in the program, according to an audit by the General Accountability Office (GAO).
In addition, to further control spending, HHS has directed the program to shift more of the costs onto the current enrollees, thus raising the out-of-pocket health care expenses for the people with pre-existing conditions.
“Finally, due to growing concerns about the rate of PCIP [Pre-existing Condition Insurance Program] spending, in February 2013, CCIIO [under HHS] suspended PCIP enrollment to ensure the appropriated funding would be sufficient to cover claims for current enrollees through the end of the program,” states the GAO report, Patient Protection and Affordable Care Act: Enrollment and Spending in the Early Retiree Reinsurance and Pre-existing Condition Insurance Plan Programs.
The rationing or denial of health care coverage in the marketplace for people with pre-existing conditions, or insurers charging higher premiums to people with pre-existing conditions were among the reasons cited by President Barack Obama and most congressional Democrats for implementing Obamacare, the Patient Protection and Affordable Care Act.
“This year, tens of thousands of uninsured Americans with preexisting conditions, the parents of children who have a preexisting condition, will finally be able to purchase the coverage they need. That happens this year,” said Obama when he signed the Affordable Care Act into law on Mar. 23, 2010.
“This year, insurance companies will no longer be able to drop people’s coverage when they get sick,” said the president.
President Barack Obama and Health and Human Services Secretary Kathleen Sebelius. (AP)
As Obamacare went into effect, two temporary programs were established in March 2010, the Early Retiree Reinsurance Program and the Pre-existing Condition Insurance Plan (PCIP) program. Each program is supposed to operate through Dec. 31, 2013, after which their respective enrollees are supposed to transition into the health insurance Exchanges established by Obamacare.
Each program was allotted $5 billion.
Retirees and people with pre-existing conditions, said the GAO, “historically have faced challenges obtaining health insurance in the individual market due, among other things, to being charged higher premiums than younger or healthier individuals on the basis of age or health status, or to being denied coverage altogether.”
The Pre-existing Condition Insurance Plan (PCIP) is overseen by the Center for Consumer Information and Insurance Oversight (CCIIO), which is part of the Department of Health and Human Services, which is headed by Secretary Kathleen Sebelius.
To be eligible for the PCIP, “individuals must have a pre-existing condition and have been without creditable coverage for at least 6 months prior to application,” explained the GAO. That limits “the program to individuals who likely have been unable to access insurance because of their pre-existing condition.”
The $5 billion for the PCIP is distributed state-by-state based upon population, the number of uninsured people, and variations in the cost of care by location.
The PCIP programs cannot impose waiting periods for coverage “based on the enrollee’s preexisting condition, and plan benefits must cover at least 65 percent of the total cost of coverage until enrollees hit a statutory out-of-pocket spending limit, at which point PCIP covers 100 percent of the cost,” said the GAO.
(AP)
Under Obamacare, enrollment in the PCIP started in July 2010. However, given that the program had a fixed $5 billion to operate, the costs of enrollment and how long funding would last were ongoing concerns, said the GAO.
“For example, while enrollment in the PCIP program has been lower than initially projected, per member per month claim costs have been higher than expected, leading some to question whether spending could exhaust its $5 billion appropriation as enrollment continues to grow,” reported the GAO.
Under the law, if HHS determines that spending for the PCIP is too much and it might run out of funds, it can make “adjustments as are necessary” and “stop PCIP enrollment.”
The GAO audit found that enrollment in the PCIP was substantial: Between July 2010 and the end of December 2012, enrollment had hit 103,160, which was up more than 50,000 over the 2011 enrollment of 48,862.
Enrollment varied widely. Vermont had 1 enrollee, for example, and California had 15,101.
By the end of January 2013, the GAO found that PCIP spending had reached $2.6 billion, more than half of its $5 billion budget.
(AP Photo)
To control those costs, the HHS, through its Center for Consumer Information and Insurance Oversight (CCIIO), implemented changes. For example, in August 2012, reimbursement rates to the health care provider were lowered in some areas. In addition, some of the federally run PCIP hospital facility fees were renegotiated to match the same fee-rate as Medicare. About 25 percent of the hospitals approached agreed to this renegotiation, said the GAO.
Further, the CCIIO “instituted benefit changes for the federally run PCIP that shifted more costs onto enrollees starting in January 2013,” reported the GAO. “For example, it increased enrollees’ out of pocket maximum for in-network services from $4,000 to $6,250 and for out-of-network services from $7,000 to $10,000.”
The report concluded, “Finally, due to growing concerns about the rate of PCIP spending, in February 2013, CCIIO suspended PCIP enrollment to ensure the appropriated funding would be sufficient to cover claims for current enrollees through the end of the program.”
The GAO noted that, according to HHS officials, if they think they will not run out of money as quickly as projected “they might reinstate PCIP enrollment to use remaining funds.”
__________________________________________
First, Krugman is a neo-liberal economist and not a liberal. Below you see what the goal for Affordable Care Act was-----truly a single-payer plan-----Medicaid for All. Krugman thinks sending 80% of the American people to preventative care only is a liberal thing to do even after most of these same people spent 40 years paying income and payroll taxes to fund all of the medical advances we have today. He doesn't tell you that Congress gutted Medicaid and turned it into a block grant program that is filled with such a level of fraud and corruption that people are getting the worst of access and quality of care in modern history from Medicaid. After Congress gutted funding for Medicaid to pay down the national debt created by massive corporate fraud----the states like California and Maryland further cut funding to Medicaid because they are neo-liberal states and not liberal ......making Medicaid funding so low as to dismantle it....which is the next step. Ending Medicare and Medicaid completely. Krugman goes so far as to lie about this US Medicaid for All being like the European national health care WHEN IT HAS ABSOLUTELY NO SIMILARITIES....HE IS LYING.
We need everyone shouting and voting for candidates running and supporting EXPANDED AND IMPROVED MEDICARE FOR ALL or our children and grandchildren will have access to none of the routine medical procedures we have had for decades.
'But it turns out that many of the newly insured are in fact being covered under a single-payer system — Medicaid. And as I’ve pointed out before,
Medicaid is actually the piece of the US system that looks most like European health systems, which cost far less than ours while delivering comparable results'.
California by the way is largely neo-liberal----not Democratic!
Stealth Single Payer
July 30, 2014 11:56 amJuly 30, 2014 11:56 am
The Kaiser Family Foundation has a new survey (pdf) on Obamacare in California, and it’s full of remarkably good news. For those who haven’t been following this, CA — with its now-dominant Democratic Party — is where Obamacare was implemented the way it was supposed to be implemented: the website worked pretty well from the beginning, Medicaid expansion was implemented, and the state worked hard on outreach. It was also a place that really needed reform: the uninsured were a high percentage of the population, and an individual market without community rating meant that the mere hint of a preexisting condition was enough to prevent coverage.
So it now appears that most of California’s uninsured — 58 percent of the total, or well over 60 percent of those eligible (because undocumented immigrants aren’t covered) have gained insurance in the first year. Considering the complexity of the scheme, that’s really impressive, and it strongly suggests that next year, once those who missed out have had a chance to learn via word of mouth, California will have gotten much of the way toward universal coverage for legal residents.
But there’s something else the Kaiser report drives home: most of those gaining coverage are doing so not via the exchanges (although those are important too) but via Medicaid. And that’s important as an answer to critics of Obamacare from the left.
There have always been critics complaining that what we really should have is single-payer, and angry that subsidies were being funneled through the insurance companies. And in principle they’re right; the trouble was that cutting the insurers out of the loop would have made the plan politically impossible, both because of the industry’s power and because of the unwillingness of people with good coverage to take a leap into a completely new system. So we got this awkward public-private hybrid, which I supported because it was what we could get and despite its impurity it dramatically improves many people’s lives.
But it turns out that many of the newly insured are in fact being covered under a single-payer system — Medicaid. And as I’ve pointed out before,
Medicaid is actually the piece of the US system that looks most like European health systems, which cost far less than ours while delivering comparable results.
All in all, liberals really should be celebrating. California shows how Obamacare can and should work, and it’s looking pretty good.
Neo-liberals are not liberals Krugman!
Why do Republicans call it ObamaCare and why does Obama embrace that? Republicans need to hide that much of the Affordable Care Act is Republican policy ----the mandated insurance---the state-run private health systems to end and deregulate the public health system that will allow no protection for the American people in how health care is delivered. Bye-Bye Medicare and Medicaid----all Republican policies. Know who is as mad about these policies as labor and justice-----Republican voters. So, Republican pols love Affordable Care Act but give neo-liberals cover by pretending to hate it. The Democratic base of labor and justice will be literally killed by 'ObamaCare' as they are the 80% that will not longer access any health care than preventative if ACA stays in place. This is why neo-liberals need women and people of color as the face of these policies---WOMEN AND PEOPLE OF COLOR ARE MUCH OF THAT 80%.
INSTEAD OF RECEIVING ALL THE HEALTH CARE YOU NEED AT YOUR LOCAL HOSPITAL ----YOU WILL NOW TRAVEL SOMEWHERE ELSE, NATIONALLY OR INTERNATIONALLY, TO FIND ROUTINE HEALTH CARE YOU CAN AFFORD.
This is the key to the promise made by neo-liberals that no one would be denied coverage for 'pre-existing conditions' and 'your child can stay on your plan until 27 years old'. The fact that most people with strong health plans today will be pushed into these Bronze and Medicaid-level coverage does not bode well for that 27 year old only able to access the same. THAT WAS SIMPLE PROPAGANDA DRESSED AS A PROGRESSIVE BONE. The loopholes left in the ACA were designed to encourage corporations to shed strong health plans for preventative care and designed to build health systems with insurance consolidated that can move people with pre-existing health issues to clinic and hospital care far away from where they live.
THEY ARE USING HEALTH CARE REFORM AS THEY ARE EDUCATION REFORM TO FORCE PEOPLE TO LIVE IN CERTAIN PLACES TO RECEIVE ORDINARY ACCESS TO HEALTH CARE.
The ACA states all plans must take people with pre-existing conditions and so now we see health plans with coverage areas that look like a gerrymandered political district with the final destination for that patient sometimes 100 miles away.....at the least across town. The ACA also allows for a broad definition of 'pre-existing condition' so as to send many people into plans just like this. So, the coverage is indeed there-----it has simply been made hard to access. Sadly, even a shortage of children's cancer drugs pre-emptied what the ACA was supposed to protect against. Keep in mind people with chronic illness will quickly fall into medical bankruptcy and with that Medicaid-level coverage. Seniors today are already seeing their retirement savings blown on medical payments not covered by Medicare and having to fall into bankruptcy. Below you see reference to continuous health coverage as a pre-requisite for pre-existing care coverage and one thing that costs will do is have people leaving policies for others.
Let's look at what these issues actually look like....remember, if you are thinking this will only affect people with bad health habits and good riddance------think again:
Key Regulation Concepts
Pre-existing Conditions
What are pre-existing conditions? Millions of Americans live with chronic conditions like asthma, heart disease and depression, and millions more seek care each year for shorter-term medical conditions such as back injuries or pregnancy. When a person applies for a health insurance plan, these conditions are referred to as "pre-existing" because they existed before the plan was purchased. Many people have been denied treatment - or payment of treatment - by insurance companies because of pre-existing conditions, and the insurers had broad discretion in defining pre-existing condition. Two federal laws protect people from these practices: the Affordable Care Act (ACA) and the Health Insurance Portability and Accountability Act (HIPAA).
What is current law on pre-existing conditions? The ACA prohibits insurers from excluding children under 19 from coverage because they have a pre-existing condition. This prohibition, which began September 2010, includes both pre-existing condition exclusions (i.e., an insurance company cannot refuse to pay for chemotherapy for a child with cancer because the child had the cancer before obtaining insurance) and outright coverage denials (i.e., an insurance company cannot refuse to cover a child because of the child's cancer). This rule applies to all group plans and new plans in the individual market, but does not pertain to grandfathered individual plans. Beginning January 1, 2014, the ACA requires new and grandfathered group plans to eliminate pre-existing condition exclusions for everyone.
Prior to 2014, HIPAA still restricts a health insurer's ability to limit coverage of pre-existing medical conditions for adults. HIPAA rules apply to all employer-sponsored health plans and to some plans purchased by some individual consumers. States may have stronger protections.
Rules for different types of plans:
- Group Health Plans.
A group plan can only refuse to pay for treatment of a condition if the insurer can prove that the patient received medical advice, diagnosis, care, or treatment for the condition within the last six months prior to coverage. This is called the objective standard. Group health plans can never count pregnancy as a pre-existing condition. In addition, pre-existing condition exclusions cannot be imposed on newborn babies, newly adopted children, and children placed for adoption. In addition, the Genetic Information Non-Discrimination Act (GINA) prohibits a plan from excluding a person for a pre-existing condition because of genetic information, in the absence of a diagnosis of a condition.
When a group plan determines that a person has a pre-existing condition, the insurer can refuse to pay for treatment of that condition for a maximum of 12 months (called a pre-existing condition exclusion period). Some people might face an 18-month exclusion period if they sign up late for their group health plan (after they are first eligible). Group health plans must give written notice of pre-existing condition exclusion periods, and these exclusion periods must be consistent.
The amount of time an insurer can refuse to pay for treatment of a pre-existing condition is reduced if a person had prior health coverage without a significant lapse in that coverage.
- Individual Health Plans. HIPAA prohibits insurers from imposing pre-existing condition exclusions on federally eligible individuals when they enroll in coverage. This holds for all pre-existing conditions, including pregnancy. Federally eligible individuals must have at least 18 months of prior health plan coverage, the last of which must have been in a group plan. Also, federally eligible individuals must use up any Consolidated Omnibus Budget Reconciliation Act (COBRA) or state continuation coverage they may have from their prior health plans, and they must not be eligible for new group coverage or Medicare.
- Insured Group Plans. In some states, the maximum pre-existing condition period that fully-insured group health plans can impose is up to six months. In a few states, certain group health plans are not allowed to impose pre-existing condition exclusion periods at all.
- Individual Plans. Some states limit the imposition of pre-existing condition exclusion time periods in individual coverage. However, in most states that impose such limits, insurers are permitted to impose exclusionary riders, or amendments to an individual's health plan that permanently exclude a pre-existing condition. Sometimes exclusionary riders will eliminate coverage not only for a condition (such as asthma), but for the body part or system (e.g., the lungs or the upper respiratory system).
In many states, the definition of pre-existing condition is different for people in the individual market than in the group market. For example, insurers in the individual market often are permitted to look back much farther than six months for evidence of a pre-existing condition. Any health problem someone as ever had in the past might be counted. Also, in most states, individual market insurers can use a subjective standard for determining whether a condition is pre-existing. They can count conditions for which a person received treatment in the past, or conditions for which someone had symptoms and the insurer thinks should have sought treatment, even if he or she didn't. Some insurers maintain lists of up to 400 different health conditions that could trigger a pre-existing condition exclusion.
- State high-risk pool coverage. Many states have established high-risk pools for people who are unable to find other coverage, typically due to a pre-existing condition. Under HIPAA, states can guarantee coverage to federally eligible individuals through their high-risk pool, instead of through the traditional private health insurance market, and many have done so.
While all state high-risk pools impose pre-existing condition exclusion periods, HIPAA prohibits state high-risk pools from imposing such exclusionary periods on federally eligible individuals.
- Federal high-risk pool coverage. The ACA also established a temporary federal high-risk pool, the Pre-existing Condition Insurance Plan (PCIP). Unlike state high risk pools, the PCIP program is not designed for federally eligible individuals. Instead, PCIP is for people who had been excluded from the individual insurance market, typically due to a pre-existing health condition, for at least six months, without other access to health coverage. Federally eligible individuals are not eligible for PCIP because HIPAA guarantees them portable coverage with no exclusions. PCIPs also differ from state high-risk pools in that they are prohibited from imposing any waiting periods for coverage of pre-existing conditions.
'NARROW NETWORKS' .....that is how Affordable Care Act works to eliminate all public community hospitals and health centers and bring all health to large health systems. It is how as well costly patients are networked into what will be lower quality health systems and/or systems outside the community and/or even region. They have to provide a plan for pre-existing conditions but loopholes allow these insurance plans to make it as difficult as possible to make it cheap as possible. We have insurance plans with networks that make political gerrymandering of districts look like child's play all to undermine the coverage for what will become most Americans. What defines pre-existing health is now being broadened and left vague so insurance corporations can continue to throw the most costly patients into these networks. MAYBE YOU WANT TO FLY TO INDIA FOR YOUR HEALTH CARE SAY THESE GLOBAL CORPORATE POLS BUILDING WALL STREET-LIKE HEALTH SYSTEMS THAT WILL PREY ON PEOPLE, NOT CARE FOR THEM.
Hmmmmmmmm.......narrow networks affect the people receiving that insurance subsidy while Medicaid patients have more access. Sounds like they are making people lose income to get better insurance coverage!
Obamacare health plans leave out some community health centers
By Guy Boulton of the Journal Sentinel March 22, 2014
One of the law's key goals is to expand health insurance coverage. Yet community health centers, which are located in neighborhoods with the highest concentration of uninsured people, often are not included in the networks of health plans sold on the federal marketplace.
Only one of the health plans available in Milwaukee includes all of the community health centers. It is the most expensive plan, limiting its appeal to people with low incomes. And when a community health center is included in a plan's network, the hospital that the health center refers patients to often isn't.
For example, Molina Healthcare has contracted with Sixteenth Street Community Health Centers and Progressive Community Health Centers, but not with Columbia St. Mary's or Froedtert Hospital and the Medical College of Wisconsin.
The doctors and midwives at Sixteenth Street practice at Columbia St. Mary's Hospital-Milwaukee. Progressive has a close working relationship with Froedtert Hospital and the Medical College, whose specialists see the health center's patients.
Part of this stems from the efforts of health insurers to keep the cost of the health plans as low as possible.
The regulations imposed on health insurers — such as being required to cover a standard package of benefits and to cover people with pre-existing health conditions — were intended to increase price competition among health plans sold on the marketplace.
The limited or narrow networks, in theory, enable health insurers to negotiate better prices, enabling them to offer health plans that cost less.
The plans' networks of doctors and hospitals had to be deemed adequate by the federal government to be sold on the marketplace. But the networks have drawn criticism. The National Association for Community Health Centers reportedly has lobbied for two years to require insurers to include health centers in their networks.
Relationship problems Nearly all of the health plans sold on the federal marketplace in Milwaukee have narrow networks.
Anthem Blue Cross and Blue Shield in Wisconsin, Arise Health Plan, an affiliate of WPS Health Insurance, and Common Ground Healthcare Cooperative all offer plans tied to Aurora Health Care's hospitals and doctors.
But at least three of the four community health centers, which provide care to almost 1 in 8 people in Milwaukee, almost all of them with low incomes, are affiliated with a specific health system.
"We have no relationship with the Aurora specialists," said John Bartkowski, president and chief executive of Sixteenth Street. "We have no relationship with the Aurora hospitals."
Sixteenth Street has ties to Columbia St. Mary's, Progressive to Froedtert Health and the Medical College, and Milwaukee Health Services to Aurora and Wheaton Franciscan Healthcare.
That could change.
Progressive is working to arrange for its doctor who specializes in obstetrics and gynecology and its midwife to get privileges to practice at Aurora Sinai Medical Center, said Jenni Sevenich, chief executive of the community health center.
The narrow networks will affect only adults eligible for subsidized coverage on the marketplace. They have household incomes above the federal poverty threshold, or $11,670 for an individual this year, and are not eligible for affordable insurance through an employer.
Adults with incomes below the threshold will be eligible for BadgerCare Plus, the state's largest Medicaid program. They will have access to all hospitals and to physicians who agree to accept them as patients.
Covering children Children and pregnant women who live in households with incomes of up to 300% of the federal poverty level — $71,550 for a family of four — are eligible for BadgerCare Plus when affordable insurance is not available through an employer.
This may be why only two of the health insurers selling plans on the marketplace — Anthem and Arise — include Children's Hospital of Wisconsin and the physicians group that includes specialists from the Medical College of Wisconsin in their networks.
Molina and one of Common Ground’s two health plans do not have contracts with the hospital or physicians but said they will pay for the care of children who need to be hospitalized.
The narrow networks probably mean less to people who have been uninsured. The community health centers provide primary care to people without insurance, charging them fees tied to their income. But they have always had difficulty getting access to hospitals and specialists for care not deemed a medical emergency.
The narrow networks will affect adults now covered by BadgerCare Plus, those with incomes between 100% and 200% of the federal poverty level with children under 19. They now must get coverage through the subsidized plans sold on the marketplace.
How many of them are aware of the limited networks when picking a health plan is unknown.
"They are learning a whole lot in the beginning," said Sevenich of Progressive.
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Obama is fast privatizing all of the Federal Medicare and Medicaid agencies and pushing all program funding to the states as they work to end public health care. Outsourcing everything Medicare and Medicaid while placing the next head of Health and Human Services-----a Gates Foundation executive openly saying she thinks block grants work for Medicaid and wants the same for Medicare. So, the idea that this Federal subsidy for pre-existing conditions was real was simply a lie.
Another thing to consider is that Medicaid spending is gutted with fraud and corruption because of this 'block grant' status----no doubt the reason the new HHS appointee thinks it is working great----it moves billions of dollars to health institutions in fraud every year and she is determined that this same block grant format do the same with Medicare!
Neo-liberals and neo-cons intend to end these Federal health programs so Medicaid will simply be looted and defunded out of existence just as 80% of Americans are moved to Medicaid because corporate plans and union plans will end.
I DIDN'T KNOW THAT SAY INCUMBENT NEO-LIBERALS HAVING CREATED AFFORDABLE CARE ACT AND THE NATIONAL LABOR AND JUSTICE ORGANIZATIONS THAT SUPPORTED IT! YES, THEY DID KNOW THAT JUST AS I DID.
GAO: HHS Already Rationing Enrollment in Obamacare’s Pre-Existing Condition Plan
May 31, 2013 - 1:10 PM By Michael W. Chapman
President Barack Obama signs the Patient Protection and Affordable Care Act into law, Mar. 23, 2010. (AP)
(CNSNews.com) – A pre-existing condition health insurance program established by Obamacare is already straining its own budget and, to control costs, the administration’s Health and Human Services Department (HHS) has stopped enrolling any new people in the program, according to an audit by the General Accountability Office (GAO).
In addition, to further control spending, HHS has directed the program to shift more of the costs onto the current enrollees, thus raising the out-of-pocket health care expenses for the people with pre-existing conditions.
“Finally, due to growing concerns about the rate of PCIP [Pre-existing Condition Insurance Program] spending, in February 2013, CCIIO [under HHS] suspended PCIP enrollment to ensure the appropriated funding would be sufficient to cover claims for current enrollees through the end of the program,” states the GAO report, Patient Protection and Affordable Care Act: Enrollment and Spending in the Early Retiree Reinsurance and Pre-existing Condition Insurance Plan Programs.
The rationing or denial of health care coverage in the marketplace for people with pre-existing conditions, or insurers charging higher premiums to people with pre-existing conditions were among the reasons cited by President Barack Obama and most congressional Democrats for implementing Obamacare, the Patient Protection and Affordable Care Act.
“This year, tens of thousands of uninsured Americans with preexisting conditions, the parents of children who have a preexisting condition, will finally be able to purchase the coverage they need. That happens this year,” said Obama when he signed the Affordable Care Act into law on Mar. 23, 2010.
“This year, insurance companies will no longer be able to drop people’s coverage when they get sick,” said the president.
President Barack Obama and Health and Human Services Secretary Kathleen Sebelius. (AP)
As Obamacare went into effect, two temporary programs were established in March 2010, the Early Retiree Reinsurance Program and the Pre-existing Condition Insurance Plan (PCIP) program. Each program is supposed to operate through Dec. 31, 2013, after which their respective enrollees are supposed to transition into the health insurance Exchanges established by Obamacare.
Each program was allotted $5 billion.
Retirees and people with pre-existing conditions, said the GAO, “historically have faced challenges obtaining health insurance in the individual market due, among other things, to being charged higher premiums than younger or healthier individuals on the basis of age or health status, or to being denied coverage altogether.”
The Pre-existing Condition Insurance Plan (PCIP) is overseen by the Center for Consumer Information and Insurance Oversight (CCIIO), which is part of the Department of Health and Human Services, which is headed by Secretary Kathleen Sebelius.
To be eligible for the PCIP, “individuals must have a pre-existing condition and have been without creditable coverage for at least 6 months prior to application,” explained the GAO. That limits “the program to individuals who likely have been unable to access insurance because of their pre-existing condition.”
The $5 billion for the PCIP is distributed state-by-state based upon population, the number of uninsured people, and variations in the cost of care by location.
The PCIP programs cannot impose waiting periods for coverage “based on the enrollee’s preexisting condition, and plan benefits must cover at least 65 percent of the total cost of coverage until enrollees hit a statutory out-of-pocket spending limit, at which point PCIP covers 100 percent of the cost,” said the GAO.
(AP)
Under Obamacare, enrollment in the PCIP started in July 2010. However, given that the program had a fixed $5 billion to operate, the costs of enrollment and how long funding would last were ongoing concerns, said the GAO.
“For example, while enrollment in the PCIP program has been lower than initially projected, per member per month claim costs have been higher than expected, leading some to question whether spending could exhaust its $5 billion appropriation as enrollment continues to grow,” reported the GAO.
Under the law, if HHS determines that spending for the PCIP is too much and it might run out of funds, it can make “adjustments as are necessary” and “stop PCIP enrollment.”
The GAO audit found that enrollment in the PCIP was substantial: Between July 2010 and the end of December 2012, enrollment had hit 103,160, which was up more than 50,000 over the 2011 enrollment of 48,862.
Enrollment varied widely. Vermont had 1 enrollee, for example, and California had 15,101.
By the end of January 2013, the GAO found that PCIP spending had reached $2.6 billion, more than half of its $5 billion budget.
(AP Photo)
To control those costs, the HHS, through its Center for Consumer Information and Insurance Oversight (CCIIO), implemented changes. For example, in August 2012, reimbursement rates to the health care provider were lowered in some areas. In addition, some of the federally run PCIP hospital facility fees were renegotiated to match the same fee-rate as Medicare. About 25 percent of the hospitals approached agreed to this renegotiation, said the GAO.
Further, the CCIIO “instituted benefit changes for the federally run PCIP that shifted more costs onto enrollees starting in January 2013,” reported the GAO. “For example, it increased enrollees’ out of pocket maximum for in-network services from $4,000 to $6,250 and for out-of-network services from $7,000 to $10,000.”
The report concluded, “Finally, due to growing concerns about the rate of PCIP spending, in February 2013, CCIIO suspended PCIP enrollment to ensure the appropriated funding would be sufficient to cover claims for current enrollees through the end of the program.”
The GAO noted that, according to HHS officials, if they think they will not run out of money as quickly as projected “they might reinstate PCIP enrollment to use remaining funds.”
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First, Krugman is a neo-liberal economist and not a liberal. Below you see what the goal for Affordable Care Act was-----truly a single-payer plan-----Medicaid for All. Krugman thinks sending 80% of the American people to preventative care only is a liberal thing to do even after most of these same people spent 40 years paying income and payroll taxes to fund all of the medical advances we have today. He doesn't tell you that Congress gutted Medicaid and turned it into a block grant program that is filled with such a level of fraud and corruption that people are getting the worst of access and quality of care in modern history from Medicaid. After Congress gutted funding for Medicaid to pay down the national debt created by massive corporate fraud----the states like California and Maryland further cut funding to Medicaid because they are neo-liberal states and not liberal ......making Medicaid funding so low as to dismantle it....which is the next step. Ending Medicare and Medicaid completely. Krugman goes so far as to lie about this US Medicaid for All being like the European national health care WHEN IT HAS ABSOLUTELY NO SIMILARITIES....HE IS LYING.
We need everyone shouting and voting for candidates running and supporting EXPANDED AND IMPROVED MEDICARE FOR ALL or our children and grandchildren will have access to none of the routine medical procedures we have had for decades.
'But it turns out that many of the newly insured are in fact being covered under a single-payer system — Medicaid. And as I’ve pointed out before,
Medicaid is actually the piece of the US system that looks most like European health systems, which cost far less than ours while delivering comparable results'.
California by the way is largely neo-liberal----not Democratic!
Stealth Single Payer
July 30, 2014 11:56 amJuly 30, 2014 11:56 am
The Kaiser Family Foundation has a new survey (pdf) on Obamacare in California, and it’s full of remarkably good news. For those who haven’t been following this, CA — with its now-dominant Democratic Party — is where Obamacare was implemented the way it was supposed to be implemented: the website worked pretty well from the beginning, Medicaid expansion was implemented, and the state worked hard on outreach. It was also a place that really needed reform: the uninsured were a high percentage of the population, and an individual market without community rating meant that the mere hint of a preexisting condition was enough to prevent coverage.
So it now appears that most of California’s uninsured — 58 percent of the total, or well over 60 percent of those eligible (because undocumented immigrants aren’t covered) have gained insurance in the first year. Considering the complexity of the scheme, that’s really impressive, and it strongly suggests that next year, once those who missed out have had a chance to learn via word of mouth, California will have gotten much of the way toward universal coverage for legal residents.
But there’s something else the Kaiser report drives home: most of those gaining coverage are doing so not via the exchanges (although those are important too) but via Medicaid. And that’s important as an answer to critics of Obamacare from the left.
There have always been critics complaining that what we really should have is single-payer, and angry that subsidies were being funneled through the insurance companies. And in principle they’re right; the trouble was that cutting the insurers out of the loop would have made the plan politically impossible, both because of the industry’s power and because of the unwillingness of people with good coverage to take a leap into a completely new system. So we got this awkward public-private hybrid, which I supported because it was what we could get and despite its impurity it dramatically improves many people’s lives.
But it turns out that many of the newly insured are in fact being covered under a single-payer system — Medicaid. And as I’ve pointed out before,
Medicaid is actually the piece of the US system that looks most like European health systems, which cost far less than ours while delivering comparable results.
All in all, liberals really should be celebrating. California shows how Obamacare can and should work, and it’s looking pretty good.
Neo-liberals are not liberals Krugman!
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