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View Diary: Senate Quietly Curtailed HCR limits on Insurer Profits (71 comments)

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  •  Why would the summary from the Democratic (2+ / 0-)
    Recommended by:
    tikkun, 2laneIA

    Senate Caucus read as follows: link here:

    http://dpc.senate.gov/...

    Sec. 2711. No lifetime or annual limits. Prohibits all plans from establishing lifetime or unreasonable annual limits on the dollar value of benefits.

    And then there's this:

    Section 2718 of the Senate bill provides that

       

    Health insurance companies will be required to report publicly the percentage of total premium revenue that is expended on clinical services, and quality rather than administrative costs. Health insurance companies will be required to refund each enrollee by the amount by which premium revenue expended by the health insurer for non-claims costs exceeds 20 percent in the group market and 25 percent in the individual market. The requirement to provide a refund expires on December 31, 2013, but the requirement to report percentages continues.[1]

    •  The text you quote from (1+ / 0-)
      Recommended by:
      icemilkcoffee

      in Section 2718 does not exist in the Manager's Amendment which is the text that replaces the passage you are citing in the original bill.

    •  Well the beautiful thing about thomas.gov (2+ / 0-)
      Recommended by:
      NoisyWithdrawal, icemilkcoffee

      is that it lets you see what the legislation actually says, not what politicians are saying it says.

      What's more, since no law can be copyrighted, I can even reproduce it in full for those too lazy to follow links provided.

      So, the active text concerning annual limits is section 10101(a) of the bill (amending section 2711 of the Public Health Act - I think you've gotten confused with your section numbering, which is entirely understandable because it's very confusing). Anyway, here's the active text for lifetime and annual limits, with page numbers:

      Page 2034:

      22 ‘‘SEC. 2711. NO LIFETIME OR ANNUAL LIMITS.
      23 ‘‘(a) PROHIBITION.—

      Page 2035:

      1 ‘‘(1) IN GENERAL.—A group health plan and a
      2 health insurance issuer offering group or individual
      3 health insurance coverage may not establish—
      4 ‘‘(A) lifetime limits on the dollar value of
      5 benefits for any participant or beneficiary; or
      6 ‘‘(B) except as provided in paragraph (2),
      7 annual limits on the dollar value of benefits for
      8 any participant or beneficiary.
      9 ‘‘(2) ANNUAL LIMITS PRIOR TO 2014.—With re
      10 spect to plan years beginning prior to January 1,
      11 2014, a group health plan and a health insurance
      12 issuer offering group or individual health insurance
      13 coverage may only establish a restricted annual limit
      14 on the dollar value of benefits for any participant or
      15 beneficiary with respect to the scope of benefits that
      16 are essential health benefits under section 1302(b) of
      17 the Patient Protection and Affordable Care Act, as de
      18 termined by the Secretary. In defining the term ‘re
      19 stricted annual limit’ for purposes of the preceding
      20 sentence, the Secretary shall ensure that access to
      21 needed services is made available with a minimal im
      22 pact on premiums.
      23 ‘‘(b) PER BENEFICIARY LIMITS.—Subsection (a) shall
      24 not be construed to prevent a group health plan or health
      25 insurance coverage from placing annual or lifetime per ben-

      Page 2036:

      1 eficiary limits on specific covered benefits that are not es
      2 sential health benefits under section 1302(b) of the Patient
      3 Protection and Affordable Care Act, to the extent that such
      4 limits are otherwise permitted under Federal or State
      5 law.’’.

      So, starting immediately, lifetime limits are prohibited. From enactment to 2014, annual limits are allowed only within parameters set by the Sec. HHS. From 2014 on, annual limits are forbidden.

      Now, with respect to the too-low-MLR rebates, that's section 10101(f) of the Senate bill. Here it's a little harder to understand your mistake, since the Senate bill didn't include MLR limits before the Manager's Amendment, so this only appears once. Anyway, subsection (f) is quite long so I'll only quote the relevant part, which is to become section 2718(b)(1) of the Public Health Service Act:

      Page 2041:

      6 ‘‘(1) REQUIREMENT TO PROVIDE VALUE FOR
      7 PREMIUM PAYMENTS.—
      8 ‘‘(A) REQUIREMENT.—Beginning not later
      9 than January 1, 2011, a health insurance issuer
      10 offering group or individual health insurance
      11 coverage (including a grandfathered health plan)
      12 shall, with respect to each plan year, provide an
      13 annual rebate to each enrollee under such cov
      14 erage, on a pro rata basis, if the ratio of the
      15 amount of premium revenue expended by the
      16 issuer on costs described in paragraphs (1) and
      17 (2) of subsection (a) to the total amount of pre
      18 mium revenue (excluding Federal and State
      19 taxes and licensing or regulatory fees and after
      20 accounting for payments or receipts for risk ad
      21 justment, risk corridors, and reinsurance under
      22 sections 1341, 1342, and 1343 of the Patient
      23 Protection and Affordable Care Act) for the plan
      24 year (except as provided in subparagraph
      25 (B)(ii)), is less than—

      Page 2042:

      1 ‘‘(i) with respect to a health insurance
      2 issuer offering coverage in the large group
      3 market, 85 percent, or such higher percent
      4 age as a State may by regulation deter
      5 mine; or
      6 ‘‘(ii) with respect to a health insurance
      7 issuer offering coverage in the small group
      8 market or in the individual market, 80 per
      9 cent, or such higher percentage as a State
      10 may by regulation determine, except that
      11 the Secretary may adjust such percentage
      12 with respect to a State if the Secretary de
      13 termines that the application of such 80
      14 percent may destabilize the individual mar
      15 ket in such State.
      16 ‘‘(B) REBATE AMOUNT.—
      17 ‘‘(i) CALCULATION OF AMOUNT.—The
      18 total amount of an annual rebate required
      19 under this paragraph shall be in an amount
      20 equal to the product of—
      21 ‘‘(I) the amount by which the per
      22 centage described in clause (i) or (ii) of
      23 subparagraph (A) exceeds the ratio de
      24 scribed in such subparagraph; and

      Page 2043:

      1 ‘‘(II) the total amount of pre
      2 mium revenue (excluding Federal and
      3 State taxes and licensing or regulatory
      4 fees and after accounting for payments
      5 or receipts for risk adjustment, risk
      6 corridors, and reinsurance under sec
      7 tions 1341, 1342, and 1343 of the Pa
      8 tient Protection and Affordable Care
      9 Act) for such plan year.
      10 ‘‘(ii) CALCULATION BASED ON AVER
      11 AGE RATIO.—Beginning on January 1,
      12 2014, the determination made under sub
      13 paragraph (A) for the year involved shall be
      14 based on the averages of the premiums ex
      15 pended on the costs described in such sub
      16 paragraph and total premium revenue for
      17 each of the previous 3 years for the plan.
      18 ‘‘(2) CONSIDERATION IN SETTING PERCENT
      19 AGES.—In determining the percentages under para
      20 graph (1), a State shall seek to ensure adequate par
      21 ticipation by health insurance issuers, competition in
      22 the health insurance market in the State, and value
      23 for consumers so that premiums are used for clinical
      24 services and quality improvements.

      Page 2044:

      1 ‘‘(3) ENFORCEMENT.—The Secretary shall pro
      2 mulgate regulations for enforcing the provisions of
      3 this section and may provide for appropriate pen
      4 alties.

      That's it. Nothing about sunsetting. The fact that the basis for calculating the rebate amount is slightly altered starting in 2014, provides a strong hint that the rebate policy does not end in 2013. It doesn't phase out.

      In America, 60% of bankruptcies are because of medical bills, and 80% of those people had health insurance

      by sullivanst on Tue Feb 09, 2010 at 03:18:02 PM PST

      [ Parent ]

      •  Read my addendum... (0+ / 0-)

        it's a document from the Senate Democratic Caucus that claims to describe the bill.   It should not be necessary to go through pages of documents and have a law degree to understand this.

        I stand by the document on the addendum.  Just why would the Democrats say something that is a control over profits of insurers, the stated enemy of the working class, is to be ended.

        There is no logic to why this would appear in an official summary.  

        If you recall, my reaction was to refute this, but it's there.

        •  OK I was very slightly wrong (2+ / 0-)
          Recommended by:
          NoisyWithdrawal, icemilkcoffee

          When describing the Senate bill I said:

          Here it's a little harder to understand your mistake, since the Senate bill didn't include MLR limits before the Manager's Amendment, so this only appears once.

          This is not actually true. The MLR limit did appear in the pre-Manager's Amendment text - I just missed it because it places an upper limit on the inverse of MLR (i.e. how much money the insurers may keep for non-medical purposes) rather than a lower limit on MLR. And it entirely explains the confusion. The expiration does exist in Section 1001(5) of the bill. But Section 1001(5) is overridden by Section 10101(f) - the bill is self-amending:

          [10101](f) Section 2718 of the Public Health Service Act, as added by section 1001(5), is amended to read as follows

          Suffice it to say, Byron Dorgan's summary document on which you're basing your assertions does not describe the final bill, and, in particular, the expiration it describes is removed by the Manager's Amendment.

          You don't need a law degree to understand the legislative text (I don't have one) - but you do need to take the time to read it. Summaries are secondary sources, and should be avoided for this kind of analysis because the primary source is available and manageable.

          In America, 60% of bankruptcies are because of medical bills, and 80% of those people had health insurance

          by sullivanst on Tue Feb 09, 2010 at 03:33:24 PM PST

          [ Parent ]

          •  You defend sloppy work from a Senator.... (1+ / 0-)
            Recommended by:
            tikkun

            and place the burden on a citizen, whom it will affect, to go through the entire bill, as you just did, after first making an error.

            This was not Bryon Dorgan's summary, but the summary of the majority party of the United States Senate.

            Did you read ever one of the 2000 plus pages of the bill to see if there isn't a section that does what the summary says it does.

            As you say, you are not a lawyer, and not a part of the Senate.   Yet, you ask to believe your interpretation rather than a document that has been on line for weeks, with plenty of time to rectify if it is in error.

            If the summary is wrong, just what gives you confidence that the actual bill, written by the same people, does what it claims to do.

            •  I don't ask you to trust my interpretation (1+ / 0-)
              Recommended by:
              NoisyWithdrawal

              I ask you to read the damned text, and offer my interpretation.

              Did you ever strip the URL for your summary down to the domain name? dpc.senate.gov is the website for the Democratic Policy Committee, not the Democratic Party. That political Committee is chaired by Byron Dorgan. What's more, from its about page, one sees that its mission is not to inform the general public, but to provide "services for Democratic Senators and staff".

              In America, 60% of bankruptcies are because of medical bills, and 80% of those people had health insurance

              by sullivanst on Tue Feb 09, 2010 at 03:47:09 PM PST

              [ Parent ]

              •  This is a rather absurd conversation... (1+ / 0-)
                Recommended by:
                tikkun

                if it was for a limited audience it should have been password protected.  I won't continue the pissing match.

                You seem to be an inside player in this, yet you defend such sloppy work by those who are making profound laws for our country.

                If they just let this stand, open to the public, it is reprehensible.  And the fact that you don't see this negates your contribution to this discusion.

                I have placed the caveat of the potential inaccuracy of their statement on the diary.  If you give a damn, you should have this corrected, and then contact me that it has been done.

                •  What? (1+ / 0-)
                  Recommended by:
                  NoisyWithdrawal

                  Why on earth should it be password protected? When the Democratic party is touting themselves as the party of open government?

                  Look, my college textbooks were directed at a limited audience. That doesn't mean I should have kept them in a locked case and only let other physics majors read them.

                  Trust me on this, I'm a very long way from an inside player (I'm a software engineer). Hell, I'm not even a citizen yet. But when I do become a citizen, I'm sure as hell going to be an informed one.

                  Anyway, the description in the DPC document is a fair representation of the text of the bill. But what you have to understand is that anything that is touched by the Manager's Amendment has two versions in the bill, and the Manager's Amendment version always wins. So, the version of the MLR restriction which expires is replaced by the later version of the MLR restriction which does not expire. The Exchange which includes a public option is replaced by the later version of the Exchange which does not include a public option. The Manager's Amendment is Title X of the bill, and the description of it starts on page 57 of the DPC document. Everything before that point is subject to re-interpretation based on what comes after.

                  In America, 60% of bankruptcies are because of medical bills, and 80% of those people had health insurance

                  by sullivanst on Tue Feb 09, 2010 at 04:12:24 PM PST

                  [ Parent ]

                •  Sullivanst is right- you should amend your diary (0+ / 0-)

                  I agree with Sullivanst's understanding of the senate bill and the all-important 'Manager's amendment' tacked on at the end of the process. In fact I had written a diary on this exact sunset clause back in Dec:
                  http://www.dailykos.com/...

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