Make no mistake, I am in favor of single payer and have thrown my support behind the Stark bill in my correspondence with my congressman and the president. Realism forces me to consider the compromise in reform that we will see come out of congress this summer. Given the apparent outcome of "If you like what you have (in health insurance) you can keep it" and "we are going to build on and improve our current healthcare system" as the starting point for any discussion of reform, I propose the following "New Rules" for the private health insurance industry.
Additions to list based on "negotiations" with Actuary4Change.
These rules would have the force of federal law, applying in all states and jurisdictions. The private health insurance industry can continue to do business but would have to play by these rules. If we are giving up single payer or even a robust Medicare for all public option, then we should at least get rules for private insurance that make sense for the health consumer and small business.
Rule 1. No exclusion for pre-existing conditions. Any one applying for enrollment is accepted.
Rule 2. No risk rating of premiums.
Rule 3. For any plan in any region offered by the insurer, all of the members who purchase into that plan are in the risk pool. No more individual policies, small group policies and large group policies. The insurer is allowed do devise the plan and its covered services (within the constraints of state and federal regulations) and must offer each of the plans to the public for the same AGE RATED premium without regard to the status of the individual or business.
Rule 4. No waiting periods for enrollment or coverage, except in the case of uninsured patients presenting to an emergency room without health insurance coverage. These persons would be responible for payment for their "emergency related episode of illness" until such time as they are then eligible for insurance enrollment.
Rule 5. The insurance plan must agree to pay for covered services performed by any willing provider. No penalty or increase in co-pay shall be applied to the individual if they seek care from an entity without a contractual arrangement (ie preferred provider) with the insurer.
Rule 6. The insurer must give the provider and the patient an "assumption of coverage" for emergency and urgent services. The insurer must provide payment for these services in a timely fashion. The insurer is allowed to review the services provided on a retroactive basis, but cannot automatically deny payment without review.
Rule 7. All insurers will accept one uniform method of submission of bills by providers.
Rule 8. All insurers agree to make public the rules for coverage of services under their plans.
Rule 9. All insurers must pay "clean claims" (charges submitted without apparent errors) within 30 calendar days.
Rule 10. Medicare Advantage plans will receive payment at 100%, or less, of the average traditional Medicare cost for the region for their enrollees. No more "bonus payments" to Medicare Advantage.
Rule 11. Health insurance coverage would be mandatory in the same fashion that auto insurance is mandatory. If you present for Emergency Room care without health insurance coverage you would face civil penalties.
Amend and flame as you wish.