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Legislative News

Healthcare Reform Act at a Glance

Healthcare Reform Act at a Glance
Steve Verno, CMBS, CMSCS, CEMCS
March 24, 2010
 
(Disclaimer: I am not a lawyer, I do not give legal advice. This article is presented by a layperson for training and informational purposes only. The reader is free to seek legal advice from an attorney at their own expense)
 
Yesterday was a BFD when President Obama signed healthcare reform into Law. Those of us, in the trenches see things patients and the average person doesn’t see. We see claims denials for frivolous reasons, we get refund demands because the patient’s insurance company retroactively denied benefits, years after the patient was seen and the claim was paid. I’ve read the Twitters from the uninformed. Some people say that anyone can get healthcare but this is not so. People with preexisting medical conditions cannot get healthcare, people who are overweight are denied coverage. People who don’t have preexisting conditions have their medical histories under an electron microscope so that a preconceived preexisting condition can be used to terminate coverage. Several years ago, I fell on a homemade set of stairs that gave away. An insurance company investigator came to my home. She asked me one question: “Have you ever fallen in your life?” I can’t say no because we all fall at some time in our life. The moment I said yes, workers compensation coverage was denied. Why? My fall was deemed to be preexisting. 
 
So, now we have a new Law. One that is very controversial and is set to be fought at the state level and by those opposed to it. HR 3590 is a 2,074 page document. Here are a few items from this lengthy document:
 
BILLING:
 
SEC. 9007. ADDITIONAL REQUIREMENTS FOR CHARITABLEHOSPITALS.
 
‘‘(A) FINANCIAL ASSISTANCE POLICY.—A written financial assistance policy which includes—
 ‘‘(i) eligibility criteria for financial assistance, and whether such assistance includes free or discounted care, ‘‘
   (ii) the basis for calculating amounts charged to patients,
   (iii) the method for applying for financial assistance,
   (iv) in the case of an organization which does not have a separate billing and collections policy, the actions the organization may take in the event of non-payment, including collections action and reporting to credit agencies, and
   (v) measures to widely publicize the policy within the community to be served by the organization.
 
(B) POLICY RELATING TO EMERGENCY MEDICAL CARE.—A written policy requiring the organization to provide, without discrimination, care for emergency medical conditions (within the meaning of section 1867 of the Social Security Act (42 U.S.C. 1395dd)) to individuals regardless of their eligibility under the financial assistance policy described in subparagraph (A).
 
 
 
(3) COST-SHARING.—In this title (A) IN GENERAL.—The term ‘‘cost-sharing’’ includes—
(i) deductibles, coinsurance, copayments, or similar charges; and
(ii) any other expenditure required of an insured individual which is a qualified medical expense (within the meaning of section 223(d)(2) of the Internal Revenue
Code of 1986) with respect to essential health benefits covered under the plan.
 
(B) EXCEPTIONS.—Such term does not include premiums, balance billing amounts for
non-network providers, or spending for non-covered services.
 
(5) LIMITATION ON CHARGES.—An organization meets the requirements of this paragraph if the organization—‘‘(A) limits amounts charged for emergency or other medically necessary care provided to individuals eligible for assistance under
the financial assistance policy described in paragraph (4)(A) to not more than the lowest
amounts charged to individuals who have insurance covering such care, and (B) prohibits the use of gross charges.
 
(6) BILLING AND COLLECTION REQUIREMENTS.—An organization meets the requirement of this paragraph only if the organization does not engage in extraordinary collection actions before the organization has made reasonable efforts to determine whether the individual is eligible for assistance under the financial assistance policy described in paragraph (4)(A).
 
SEC. 6503. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE PAYEES REQUIRED TO REGISTER UNDER MEDICAID.
 
(a) IN GENERAL.—Section 1902(a) of the Social Security Act (42 U.S.C. 42 U.S.C. 1396a(a)), as amended by section 6502(a), is amended by inserting after paragraph (78), the following:
\
(79) provide that any agent, clearinghouse, or other alternate payee (as defined by the Secretary) that submits claims on behalf of a health care provider must register with the State and the Secretary in a form and manner specified by the Secretary;’’.
 
SEC. 6506. OVERPAYMENTS.
(a) EXTENSION OF PERIOD FOR COLLECTION OF OVERPAYMENTS DUE TO FRAUD.—
(1) IN GENERAL.—Section 1903(d)(2) of the Social Security Act (42 U.S.C. 1396b(d)(2)) is amended— (A) in subparagraph (C)—(i) in the first sentence, by striking
‘‘60 days’’ and inserting ‘‘1 year’’; and (ii) in the second sentence, by striking
‘‘60 days’’ and inserting ‘‘1-year period’’; and (B) in subparagraph (D)—(i) in inserting ‘‘(i)’’ after ‘‘(D)’’; and 1787(ii) by adding at the end the following:
‘‘(ii) In any case where the State is unable to recover a debt which represents an overpayment (or any portion thereof) made to a person or other entity due to fraud
within 1 year of discovery because there is not a final determination of the amount of the overpayment under an administrative or judicial process (as applicable), including as a result of a judgment being under appeal, no adjustment shall be made in the Federal payment to such State on account of such overpayment (or portion thereof) before the date that is 30 days after the date on which a final judgment (including, if applicable, a final determination on an appeal) is made.’’.
(2) EFFECTIVE DATE.—The amendments made by this subsection take effect on the date of enactment of this Act and apply to overpayments discovered on or after that date.
(b) CORRECTIVE ACTION.—The Secretary shall promulgate regulations that require States to correct Federally identified claims overpayments, of an ongoing or re22
curring nature, with new Medicaid Management Information System (MMIS) edits, audits, or other appropriate corrective action.
 
CODING
 
SEC. 3203. APPLICATION OF CODING INTENSITY ADJUSTMENT DURING MA PAYMENT TRANSITION.
 
Section 1853(a)(1)(C) of the Social Security Act (42 U.S.C. 1395w–23(a)(1)(C)) is amended by adding at the end the following new clause:
1 ‘‘(iii) APPLICATION OF CODING INTENSITY ADJUSTMENT FOR 2011 AND SUBSEQUENT YEARS.—
(I) REQUIREMENT TO APPLY IN 2011 THROUGH 2013.—In order to ensure payment accuracy, the Secretary shall conduct an analysis of the differences described in clause (ii)(I). The Secretary shall ensure that the results of such analysis are incorporated into the risk scores for 2011, 2012, and 2013.
(II) AUTHORITY TO APPLY IN 2014 AND SUBSEQUENT YEARS.—The Secretary may, as appropriate, incorporate the results of such analysis into the risk scores for 2014 and subsequent years.’’.
 
SEC. 6507. MANDATORY STATE USE OF NATIONAL CORRECT CODING INITIATIVE.
 
Section 1903(r) of the Social Security Act (42 U.S.C.1396b(r)) is amended—
(1) in paragraph (1)(B)—
(A) in clause (ii), by striking ‘‘and’’ at the end;
(B) in clause (iii), by adding ‘‘and’’ after the semi-colon; and
(C) by adding at the end the following new clause:
(iv) effective for claims filed on or after October 1, 2010, incorporate compatible methodologies of the National Correct Coding Initiative administered by the Secretary (or any successor initiative to promote correct coding and to control improper coding leading to inappropriate payment) and such other methodologies of that Initiative (or such other national correct coding methodologies) as the Secretary identifies in accordance with paragraph (4);’’; and (2) by adding at the end the following new paragraph: 1789
(4) For purposes of paragraph (1)(B)(iv), the Secretary shall do the following:
(A) Not later than September 1, 2010:
(i) Identify those methodologies of the National Correct Coding Initiative administered
by the Secretary (or any successor initiative to promote correct coding and to control improper coding leading to inappropriate payment) which are compatible to claims filed under this title.
(ii) Identify those methodologies of such Initiative (or such other national correct coding
methodologies) that should be incorporated into claims filed under this title with respect to items or services for which States provide medical assistance under this title and no national correct coding methodologies have been established under such Initiative with respect to title XVIII.
(iii) Notify States of—(I) the methodologies identified under subparagraphs (A) and (B) (and of any other national correct coding methodologies identified under subparagraph
(B)); and 1790
(II) how States are to incorporate such methodologies into claims filed under
this title.
(B) Not later than March 1, 2011, submit a report to Congress that includes the notice to States under clause (iii) of subparagraph (A) and an analysis supporting the identification of the methodologies made under clauses (i) and (ii) of subparagraph (A).’’.
 
PROHIBITIONS
 
‘‘SEC. 2712. PROHIBITION ON RESCISSIONS.
 
A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not rescind such plan or coverage with respect to an
enrollee once the enrollee is covered under such plan or coverage involved, except that this section shall not apply to a covered individual who has performed an act or practice that constitutes fraud or makes an intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage. Such plan or coverage may not be cancelled except with prior notice to the enrollee, and only as permitted under section 2702(c) or 2742(b).
 
(Personal Note: Group Health Plans fall under the jurisdiction of ERISA as defined by 29 USC 18, 1003(a). The above section can be used to fight back when an insurance company retroactively denies benefits and demands a refund.)
 
‘‘SEC. 2704. PROHIBITION OF PREEXISTING CONDITION EXCLUSIONS OR OTHER DISCRIMINATION BASED ON HEALTH STATUS.
 
(a) IN GENERAL.—A group health plan and a health insurance issuer offering group or individual health insurance coverage may not impose any preexisting condition
exclusion with respect to such plan or coverage.’’; and (B) by transferring such section (as amended by subparagraph (A)) so as to appear after the section 2703 added by paragraph (4);(3)(A) in section 2702 (42 U.S.C. 300gg-1)—
(i) by striking the section heading and all that follows through subsection (a);
(ii) in subsection (b)—(I) by striking ‘‘health insurance issuer offering health insurance coverage in connection with a group health plan’’ each place that such appears and inserting ‘‘health insurance issuer offering group or individual health insurance coverage’’; and (II) in paragraph (2)(A)—(aa) by inserting ‘‘or individual’’
 after ‘‘employer’’; and (bb) by inserting ‘‘or individual health coverage, as the case may be’’ before the semicolon; and (iii) in subsection (e)— (I) by striking ‘‘(a)(1)(F)’’ and inserting ‘‘(a)(6)’’;(II) by striking ‘‘2701’’ and inserting‘‘2704’’; and (III) by striking ‘‘2721(a)’’ and inserting ‘‘2735(a)’’; and (B) by transferring such section (as amended by subparagraph (A)) to appear after section 2705(a) as added by paragraph (4); and
(4) by inserting after the subpart heading (as added by paragraph (1)) the following:
‘‘SEC. 2701. FAIR HEALTH INSURANCE PREMIUMS.
 
SEC. 2708. PROHIBITION ON EXCESSIVE WAITING PERIODS.
‘‘A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not apply any waiting period (as defined in section
2704(b)(4)) that exceeds 90 days.’’.
 
SEC. 6505. PROHIBITION ON PAYMENTS TO INSTITUTIONS
OR ENTITIES LOCATED OUTSIDE OF THE UNITED STATES.
Section 1902(a) of the Social Security Act (42 U.S.C.1396b(a)), as amended by section 6503, is amended by inserting after paragraph (79) the following new paragraph:
‘‘(80) provide that the State shall not provide any payments for items or services provided under the State plan or under a waiver to any financial institution or entity located outside of the United States;’’.
 
APPEALS
 
‘‘SEC. 2719. APPEALS PROCESS.
‘‘A group health plan and a health insurance issuer offering group or individual health insurance coverage shall implement an effective appeals process for appeals of coverage determinations and claims, under which the plan or issuer shall, at a minimum—
‘‘(1) have in effect an internal claims appeal process;
‘‘(2) provide notice to enrollees, in a culturally and linguistically appropriate manner, of available internal and external appeals processes, and the availability of any applicable office of health insurance consumer assistance or ombudsman established under section 2793 to assist such enrollees with the appeals processes;
‘‘(3) allow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process; and‘‘(4) provide an external review process for such plans and issuers that, at a minimum, includes the consumer protections set forth in the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners and is binding on such plans.’’.
 
(Note: The appeals process identified above is identical to the appeals process outlined in ERISA, specifically 29 CFR 2560.503-1)
 
 
‘‘SEC. 2793. HEALTH INSURANCE CONSUMER INFORMATION.
‘(a) IN GENERAL.—The Secretary shall award grants to States to enable such States (or the Exchanges operating in such States) to establish, expand, or provide support for—
‘‘(1) offices of health insurance consumer assistance; or‘‘(2) health insurance ombudsman programs.
‘‘(b) ELIGIBILITY.—
(1) IN GENERAL.—To be eligible to receive a grant, a State shall designate an independent office of health insurance consumer assistance, or an ombudsman, that, directly or in coordination with State health insurance regulators and consumer assistance
organizations, receives and responds to inquiries and complaints concerning health insurance coverage with respect to Federal health insurance requirements and under State law.
‘‘(2) CRITERIA.—A State that receives a grant under this section shall comply with criteria established by the Secretary for carrying out activities under such grant.
‘‘(c) DUTIES.—The office of health insurance consumer assistance or health insurance ombudsman shall—
‘(1) assist with the filing of complaints and appeals, including filing appeals with the internal appeal or grievance process of the group health plan or health insurance issuer involved and providing information about the external appeal process;
‘‘(2) collect, track, and quantify problems and inquiries encountered by consumers;
‘‘(3) educate consumers on their rights and responsibilities with respect to group health plans and health insurance coverage;
‘‘(4) assist consumers with enrollment in a group health plan or health insurance coverage by providing information, referral, and assistance; and ‘‘(5) resolve problems with obtaining premium tax credits under section 36B of the Internal Revenue Code of 1986.
‘(d) DATA COLLECTION.—As a condition of receiving a grant under subsection (a), an office of health insurance consumer assistance or ombudsman program shall be required to collect and report data to the Secretary on the types of problems and inquiries encountered by consumers. The Secretary shall utilize such data to identify areas where more enforcement action is necessary and shall share such information with State insurance regulators, the Secretary of Labor, and the Secretary of the Treasury for use in the enforcement activities of such agencies.
‘‘(e) FUNDING.—
‘‘(1) INITIAL FUNDING.—There is hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, $30,000,000 for the first fiscal year for which this section applies to carry out this section. Such amount shall remain
available without fiscal year limitation.
(2) AUTHORIZATION FOR SUBSEQUENT 20 YEARS.—There is authorized to be appropriated to the Secretary for each fiscal year following the fiscal year described in paragraph (1), such sums as may be necessary to carry out this section.’’.
 
(Note: Whether we need to take on the appeals process and perform the reporting to the State or place the appeals and reporting process into the hands of the insured needs to be discussed. Will Maximus be awarded the task of complying with this requirement?)
 
 
 
EMERGENCY CARE
 
SEC. 1302. ESSENTIAL HEALTH BENEFITS REQUIREMENTS.
(a) ESSENTIAL HEALTH BENEFITS PACKAGE.—In this title, the term ‘‘essential health benefits package’’ means, with respect to any health plan, coverage that—
(1) provides for the essential health benefits defined by the Secretary under subsection(b);
(2) limits cost-sharing for such coverage in accordance with subsection (c); and
(3) subject to subsection (e), provides either the bronze, silver, gold, or platinum level of coverage described in subsection (d).
(b) ESSENTIAL HEALTH BENEFITS.—
(1) IN GENERAL.—Subject to paragraph (2), the Secretary shall define the essential health benefits, except that such benefits shall include at least the following general categories and the items and services covered within the categories:
(A) Ambulatory patient services.
(B) Emergency services.
(C) Hospitalization.
(D) Maternity and newborn care.
(E) Mental health and substance use disorder services, including behavioral health treatment.
(F) Prescription drugs.
G) Rehabilitative and habilitative services and devices.
H) Laboratory services.
(I) Preventive and wellness services and chronic disease management.
(J) Pediatric services, including oral and vision care.
 
(2) LIMITATION.—
A) IN GENERAL.—The Secretary shall ensure that the scope of the essential health benefits under paragraph (1) is equal to the scope of benefits provided under a typical employer plan, as determined by the Secretary. To inform this determination, the Secretary of Labor shall conduct a survey of employer-sponsored coverage to determine the benefits typically covered by employers, including multiemployer Plans, and provide a report on such survey to the Secretary.
(B) CERTIFICATION.—In defining the essential health benefits described in paragraph
(1), and in revising the benefits under paragraph (4)(H), the Secretary shall submit a report to the appropriate committees of Congress containing a certification from the Chief Actuary of the Centers for Medicare & Medicaid Services that such essential health benefits meet the limitation described in paragraph (2).
 
SEC. 1303. SPECIAL RULES.
(c) APPLICATION OF EMERGENCY SERVICES LAWS.—Nothing in this Act shall be construed to relieve any health care provider from providing emergency services as required by State or Federal law, including section 1867 of the Social Security Act (popularly known as ‘‘EMTALA’’).
 
 
 
 
DEFINITIONS
 
(1) LARGE EMPLOYER.—The term ‘‘large employer’’ means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 101 employees on business days during the preceding calendar year and who employs at least 1 employee on the first day of the plan year.
 
(2) SMALL EMPLOYER.—The term ‘‘small employer’’ means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 1 but not more than 100 employees on business days
during the preceding calendar year and who employs at least 1 employee on the first day of the plan year.
 
(3) STATE OPTION TO TREAT 50 EMPLOYEES AS SMALL.—In the case of plan years beginning before January 1, 2016, a State may elect to apply this subsection by substituting ‘‘51 employees’’ for ‘‘101 employees’’ in paragraph (1) and by substituting
‘‘50 employees’’ for ‘‘100 employees’’ in paragraph 16 (2).
 
EMERGENCY MEDICAL CONDITION.—The term ‘‘emergency medical condition’’ means, with respect to an individual, an individual who expresses suicidal or homicidal thoughts or gestures, if determined dangerous to self or others.
 
EMERGENCY SERVICES.—The term ‘emergency services’ includes acute, prehospital, and trauma care.
 
MISELLANEOUS
‘‘(F) PROCEDURE ROOMS.—In this subsection, the term ‘procedure rooms’ includes
rooms in which catheterizations, angiographies, angiograms, and endoscopies are performed, except such term shall not include emergencyrooms or departments (exclusive of rooms in which catheterizations, angiographies, angiograms, and endoscopies are performed).
 
 
 
Healthcare Reform Act at a Glance
Steve Verno, CMBS, CMSCS, CEMCS
March 24, 2010
 
(Disclaimer: I am not a lawyer, I do not give legal advice. This article is presented by a layperson for training and informational purposes only. The reader is free to seek legal advice from an attorney at their own expense)
 
Yesterday was a BFD when President Obama signed healthcare reform into Law. Those of us, in the trenches see things patients and the average person doesn’t see. We see claims denials for frivolous reasons, we get refund demands because the patient’s insurance company retroactively denied benefits, years after the patient was seen and the claim was paid. I’ve read the Twitters from the uninformed. Some people say that anyone can get healthcare but this is not so. People with preexisting medical conditions cannot get healthcare, people who are overweight are denied coverage. People who don’t have preexisting conditions have their medical histories under an electron microscope so that a preconceived preexisting condition can be used to terminate coverage. Several years ago, I fell on a homemade set of stairs that gave away. An insurance company investigator came to my home. She asked me one question: “Have you ever fallen in your life?” I can’t say no because we all fall at some time in our life. The moment I said yes, workers compensation coverage was denied. Why? My fall was deemed to be preexisting. 
 
So, now we have a new Law. One that is very controversial and is set to be fought at the state level and by those opposed to it. HR 3590 is a 2,074 page document. Here are a few items from this lengthy document:
 
BILLING:
 
SEC. 9007. ADDITIONAL REQUIREMENTS FOR CHARITABLEHOSPITALS.
 
‘‘(A) FINANCIAL ASSISTANCE POLICY.—A written financial assistance policy which includes—
 ‘‘(i) eligibility criteria for financial assistance, and whether such assistance includes free or discounted care, ‘‘
   (ii) the basis for calculating amounts charged to patients,
   (iii) the method for applying for financial assistance,
   (iv) in the case of an organization which does not have a separate billing and collections policy, the actions the organization may take in the event of non-payment, including collections action and reporting to credit agencies, and
   (v) measures to widely publicize the policy within the community to be served by the organization.
 
(B) POLICY RELATING TO EMERGENCY MEDICAL CARE.—A written policy requiring the organization to provide, without discrimination, care for emergency medical conditions (within the meaning of section 1867 of the Social Security Act (42 U.S.C. 1395dd)) to individuals regardless of their eligibility under the financial assistance policy described in subparagraph (A).
 
 
 
(3) COST-SHARING.—In this title (A) IN GENERAL.—The term ‘‘cost-sharing’’ includes—
(i) deductibles, coinsurance, copayments, or similar charges; and
(ii) any other expenditure required of an insured individual which is a qualified medical expense (within the meaning of section 223(d)(2) of the Internal Revenue
Code of 1986) with respect to essential health benefits covered under the plan.
 
(B) EXCEPTIONS.—Such term does not include premiums, balance billing amounts for
non-network providers, or spending for non-covered services.
 
(5) LIMITATION ON CHARGES.—An organization meets the requirements of this paragraph if the organization—‘‘(A) limits amounts charged for emergency or other medically necessary care provided to individuals eligible for assistance under
the financial assistance policy described in paragraph (4)(A) to not more than the lowest
amounts charged to individuals who have insurance covering such care, and (B) prohibits the use of gross charges.
 
(6) BILLING AND COLLECTION REQUIREMENTS.—An organization meets the requirement of this paragraph only if the organization does not engage in extraordinary collection actions before the organization has made reasonable efforts to determine whether the individual is eligible for assistance under the financial assistance policy described in paragraph (4)(A).
 
SEC. 6503. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE PAYEES REQUIRED TO REGISTER UNDER MEDICAID.
 
(a) IN GENERAL.—Section 1902(a) of the Social Security Act (42 U.S.C. 42 U.S.C. 1396a(a)), as amended by section 6502(a), is amended by inserting after paragraph (78), the following:
\
(79) provide that any agent, clearinghouse, or other alternate payee (as defined by the Secretary) that submits claims on behalf of a health care provider must register with the State and the Secretary in a form and manner specified by the Secretary;’’.
 
SEC. 6506. OVERPAYMENTS.
(a) EXTENSION OF PERIOD FOR COLLECTION OF OVERPAYMENTS DUE TO FRAUD.—
(1) IN GENERAL.—Section 1903(d)(2) of the Social Security Act (42 U.S.C. 1396b(d)(2)) is amended— (A) in subparagraph (C)—(i) in the first sentence, by striking
‘‘60 days’’ and inserting ‘‘1 year’’; and (ii) in the second sentence, by striking
‘‘60 days’’ and inserting ‘‘1-year period’’; and (B) in subparagraph (D)—(i) in inserting ‘‘(i)’’ after ‘‘(D)’’; and 1787(ii) by adding at the end the following:
‘‘(ii) In any case where the State is unable to recover a debt which represents an overpayment (or any portion thereof) made to a person or other entity due to fraud
within 1 year of discovery because there is not a final determination of the amount of the overpayment under an administrative or judicial process (as applicable), including as a result of a judgment being under appeal, no adjustment shall be made in the Federal payment to such State on account of such overpayment (or portion thereof) before the date that is 30 days after the date on which a final judgment (including, if applicable, a final determination on an appeal) is made.’’.
(2) EFFECTIVE DATE.—The amendments made by this subsection take effect on the date of enactment of this Act and apply to overpayments discovered on or after that date.
(b) CORRECTIVE ACTION.—The Secretary shall promulgate regulations that require States to correct Federally identified claims overpayments, of an ongoing or re22
curring nature, with new Medicaid Management Information System (MMIS) edits, audits, or other appropriate corrective action.
 
CODING
 
SEC. 3203. APPLICATION OF CODING INTENSITY ADJUSTMENT DURING MA PAYMENT TRANSITION.
 
Section 1853(a)(1)(C) of the Social Security Act (42 U.S.C. 1395w–23(a)(1)(C)) is amended by adding at the end the following new clause:
1 ‘‘(iii) APPLICATION OF CODING INTENSITY ADJUSTMENT FOR 2011 AND SUBSEQUENT YEARS.—
(I) REQUIREMENT TO APPLY IN 2011 THROUGH 2013.—In order to ensure payment accuracy, the Secretary shall conduct an analysis of the differences described in clause (ii)(I). The Secretary shall ensure that the results of such analysis are incorporated into the risk scores for 2011, 2012, and 2013.
(II) AUTHORITY TO APPLY IN 2014 AND SUBSEQUENT YEARS.—The Secretary may, as appropriate, incorporate the results of such analysis into the risk scores for 2014 and subsequent years.’’.
 
SEC. 6507. MANDATORY STATE USE OF NATIONAL CORRECT CODING INITIATIVE.
 
Section 1903(r) of the Social Security Act (42 U.S.C.1396b(r)) is amended—
(1) in paragraph (1)(B)—
(A) in clause (ii), by striking ‘‘and’’ at the end;
(B) in clause (iii), by adding ‘‘and’’ after the semi-colon; and
(C) by adding at the end the following new clause:
(iv) effective for claims filed on or after October 1, 2010, incorporate compatible methodologies of the National Correct Coding Initiative administered by the Secretary (or any successor initiative to promote correct coding and to control improper coding leading to inappropriate payment) and such other methodologies of that Initiative (or such other national correct coding methodologies) as the Secretary identifies in accordance with paragraph (4);’’; and (2) by adding at the end the following new paragraph: 1789
(4) For purposes of paragraph (1)(B)(iv), the Secretary shall do the following:
(A) Not later than September 1, 2010:
(i) Identify those methodologies of the National Correct Coding Initiative administered
by the Secretary (or any successor initiative to promote correct coding and to control improper coding leading to inappropriate payment) which are compatible to claims filed under this title.
(ii) Identify those methodologies of such Initiative (or such other national correct coding
methodologies) that should be incorporated into claims filed under this title with respect to items or services for which States provide medical assistance under this title and no national correct coding methodologies have been established under such Initiative with respect to title XVIII.
(iii) Notify States of—(I) the methodologies identified under subparagraphs (A) and (B) (and of any other national correct coding methodologies identified under subparagraph
(B)); and 1790
(II) how States are to incorporate such methodologies into claims filed under
this title.
(B) Not later than March 1, 2011, submit a report to Congress that includes the notice to States under clause (iii) of subparagraph (A) and an analysis supporting the identification of the methodologies made under clauses (i) and (ii) of subparagraph (A).’’.
 
PROHIBITIONS
 
‘‘SEC. 2712. PROHIBITION ON RESCISSIONS.
 
A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not rescind such plan or coverage with respect to an
enrollee once the enrollee is covered under such plan or coverage involved, except that this section shall not apply to a covered individual who has performed an act or practice that constitutes fraud or makes an intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage. Such plan or coverage may not be cancelled except with prior notice to the enrollee, and only as permitted under section 2702(c) or 2742(b).
 
(Personal Note: Group Health Plans fall under the jurisdiction of ERISA as defined by 29 USC 18, 1003(a). The above section can be used to fight back when an insurance company retroactively denies benefits and demands a refund.)
 
‘‘SEC. 2704. PROHIBITION OF PREEXISTING CONDITION EXCLUSIONS OR OTHER DISCRIMINATION BASED ON HEALTH STATUS.
 
(a) IN GENERAL.—A group health plan and a health insurance issuer offering group or individual health insurance coverage may not impose any preexisting condition
exclusion with respect to such plan or coverage.’’; and (B) by transferring such section (as amended by subparagraph (A)) so as to appear after the section 2703 added by paragraph (4);(3)(A) in section 2702 (42 U.S.C. 300gg-1)—
(i) by striking the section heading and all that follows through subsection (a);
(ii) in subsection (b)—(I) by striking ‘‘health insurance issuer offering health insurance coverage in connection with a group health plan’’ each place that such appears and inserting ‘‘health insurance issuer offering group or individual health insurance coverage’’; and (II) in paragraph (2)(A)—(aa) by inserting ‘‘or individual’’
 after ‘‘employer’’; and (bb) by inserting ‘‘or individual health coverage, as the case may be’’ before the semicolon; and (iii) in subsection (e)— (I) by striking ‘‘(a)(1)(F)’’ and inserting ‘‘(a)(6)’’;(II) by striking ‘‘2701’’ and inserting‘‘2704’’; and (III) by striking ‘‘2721(a)’’ and inserting ‘‘2735(a)’’; and (B) by transferring such section (as amended by subparagraph (A)) to appear after section 2705(a) as added by paragraph (4); and
(4) by inserting after the subpart heading (as added by paragraph (1)) the following:
‘‘SEC. 2701. FAIR HEALTH INSURANCE PREMIUMS.
 
SEC. 2708. PROHIBITION ON EXCESSIVE WAITING PERIODS.
‘‘A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not apply any waiting period (as defined in section
2704(b)(4)) that exceeds 90 days.’’.
 
SEC. 6505. PROHIBITION ON PAYMENTS TO INSTITUTIONS
OR ENTITIES LOCATED OUTSIDE OF THE UNITED STATES.
Section 1902(a) of the Social Security Act (42 U.S.C.1396b(a)), as amended by section 6503, is amended by inserting after paragraph (79) the following new paragraph:
‘‘(80) provide that the State shall not provide any payments for items or services provided under the State plan or under a waiver to any financial institution or entity located outside of the United States;’’.
 
APPEALS
 
‘‘SEC. 2719. APPEALS PROCESS.
‘‘A group health plan and a health insurance issuer offering group or individual health insurance coverage shall implement an effective appeals process for appeals of coverage determinations and claims, under which the plan or issuer shall, at a minimum—
‘‘(1) have in effect an internal claims appeal process;
‘‘(2) provide notice to enrollees, in a culturally and linguistically appropriate manner, of available internal and external appeals processes, and the availability of any applicable office of health insurance consumer assistance or ombudsman established under section 2793 to assist such enrollees with the appeals processes;
‘‘(3) allow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process; and‘‘(4) provide an external review process for such plans and issuers that, at a minimum, includes the consumer protections set forth in the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners and is binding on such plans.’’.
 
(Note: The appeals process identified above is identical to the appeals process outlined in ERISA, specifically 29 CFR 2560.503-1)
 
 
‘‘SEC. 2793. HEALTH INSURANCE CONSUMER INFORMATION.
‘(a) IN GENERAL.—The Secretary shall award grants to States to enable such States (or the Exchanges operating in such States) to establish, expand, or provide support for—
‘‘(1) offices of health insurance consumer assistance; or‘‘(2) health insurance ombudsman programs.
‘‘(b) ELIGIBILITY.—
(1) IN GENERAL.—To be eligible to receive a grant, a State shall designate an independent office of health insurance consumer assistance, or an ombudsman, that, directly or in coordination with State health insurance regulators and consumer assistance
organizations, receives and responds to inquiries and complaints concerning health insurance coverage with respect to Federal health insurance requirements and under State law.
‘‘(2) CRITERIA.—A State that receives a grant under this section shall comply with criteria established by the Secretary for carrying out activities under such grant.
‘‘(c) DUTIES.—The office of health insurance consumer assistance or health insurance ombudsman shall—
‘(1) assist with the filing of complaints and appeals, including filing appeals with the internal appeal or grievance process of the group health plan or health insurance issuer involved and providing information about the external appeal process;
‘‘(2) collect, track, and quantify problems and inquiries encountered by consumers;
‘‘(3) educate consumers on their rights and responsibilities with respect to group health plans and health insurance coverage;
‘‘(4) assist consumers with enrollment in a group health plan or health insurance coverage by providing information, referral, and assistance; and ‘‘(5) resolve problems with obtaining premium tax credits under section 36B of the Internal Revenue Code of 1986.
‘(d) DATA COLLECTION.—As a condition of receiving a grant under subsection (a), an office of health insurance consumer assistance or ombudsman program shall be required to collect and report data to the Secretary on the types of problems and inquiries encountered by consumers. The Secretary shall utilize such data to identify areas where more enforcement action is necessary and shall share such information with State insurance regulators, the Secretary of Labor, and the Secretary of the Treasury for use in the enforcement activities of such agencies.
‘‘(e) FUNDING.—
‘‘(1) INITIAL FUNDING.—There is hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, $30,000,000 for the first fiscal year for which this section applies to carry out this section. Such amount shall remain
available without fiscal year limitation.
(2) AUTHORIZATION FOR SUBSEQUENT 20 YEARS.—There is authorized to be appropriated to the Secretary for each fiscal year following the fiscal year described in paragraph (1), such sums as may be necessary to carry out this section.’’.
 
(Note: Whether we need to take on the appeals process and perform the reporting to the State or place the appeals and reporting process into the hands of the insured needs to be discussed. Will Maximus be awarded the task of complying with this requirement?)
 
 
 
EMERGENCY CARE
 
SEC. 1302. ESSENTIAL HEALTH BENEFITS REQUIREMENTS.
(a) ESSENTIAL HEALTH BENEFITS PACKAGE.—In this title, the term ‘‘essential health benefits package’’ means, with respect to any health plan, coverage that—
(1) provides for the essential health benefits defined by the Secretary under subsection(b);
(2) limits cost-sharing for such coverage in accordance with subsection (c); and
(3) subject to subsection (e), provides either the bronze, silver, gold, or platinum level of coverage described in subsection (d).
(b) ESSENTIAL HEALTH BENEFITS.—
(1) IN GENERAL.—Subject to paragraph (2), the Secretary shall define the essential health benefits, except that such benefits shall include at least the following general categories and the items and services covered within the categories:
(A) Ambulatory patient services.
(B) Emergency services.
(C) Hospitalization.
(D) Maternity and newborn care.
(E) Mental health and substance use disorder services, including behavioral health treatment.
(F) Prescription drugs.
G) Rehabilitative and habilitative services and devices.
H) Laboratory services.
(I) Preventive and wellness services and chronic disease management.
(J) Pediatric services, including oral and vision care.
 
(2) LIMITATION.—
A) IN GENERAL.—The Secretary shall ensure that the scope of the essential health benefits under paragraph (1) is equal to the scope of benefits provided under a typical employer plan, as determined by the Secretary. To inform this determination, the Secretary of Labor shall conduct a survey of employer-sponsored coverage to determine the benefits typically covered by employers, including multiemployer Plans, and provide a report on such survey to the Secretary.
(B) CERTIFICATION.—In defining the essential health benefits described in paragraph
(1), and in revising the benefits under paragraph (4)(H), the Secretary shall submit a report to the appropriate committees of Congress containing a certification from the Chief Actuary of the Centers for Medicare & Medicaid Services that such essential health benefits meet the limitation described in paragraph (2).
 
SEC. 1303. SPECIAL RULES.
(c) APPLICATION OF EMERGENCY SERVICES LAWS.—Nothing in this Act shall be construed to relieve any health care provider from providing emergency services as required by State or Federal law, including section 1867 of the Social Security Act (popularly known as ‘‘EMTALA’’).
 
 
 
 
DEFINITIONS
 
(1) LARGE EMPLOYER.—The term ‘‘large employer’’ means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 101 employees on business days during the preceding calendar year and who employs at least 1 employee on the first day of the plan year.
 
(2) SMALL EMPLOYER.—The term ‘‘small employer’’ means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 1 but not more than 100 employees on business days
during the preceding calendar year and who employs at least 1 employee on the first day of the plan year.
 
(3) STATE OPTION TO TREAT 50 EMPLOYEES AS SMALL.—In the case of plan years beginning before January 1, 2016, a State may elect to apply this subsection by substituting ‘‘51 employees’’ for ‘‘101 employees’’ in paragraph (1) and by substituting
‘‘50 employees’’ for ‘‘100 employees’’ in paragraph 16 (2).
 
EMERGENCY MEDICAL CONDITION.—The term ‘‘emergency medical condition’’ means, with respect to an individual, an individual who expresses suicidal or homicidal thoughts or gestures, if determined dangerous to self or others.
 
EMERGENCY SERVICES.—The term ‘emergency services’ includes acute, prehospital, and trauma care.
 
MISELLANEOUS
‘‘(F) PROCEDURE ROOMS.—In this subsection, the term ‘procedure rooms’ includes
rooms in which catheterizations, angiographies, angiograms, and endoscopies are performed, except such term shall not include emergencyrooms or departments (exclusive of rooms in which catheterizations, angiographies, angiograms, and endoscopies are performed).
 
 
 
Healthcare Reform Act at a Glance
Steve Verno, CMBS, CMSCS, CEMCS
March 24, 2010
 
(Disclaimer: I am not a lawyer, I do not give legal advice. This article is presented by a layperson for training and informational purposes only. The reader is free to seek legal advice from an attorney at their own expense)
 
Yesterday was a BFD when President Obama signed healthcare reform into Law. Those of us, in the trenches see things patients and the average person doesn’t see. We see claims denials for frivolous reasons, we get refund demands because the patient’s insurance company retroactively denied benefits, years after the patient was seen and the claim was paid. I’ve read the Twitters from the uninformed. Some people say that anyone can get healthcare but this is not so. People with preexisting medical conditions cannot get healthcare, people who are overweight are denied coverage. People who don’t have preexisting conditions have their medical histories under an electron microscope so that a preconceived preexisting condition can be used to terminate coverage. Several years ago, I fell on a homemade set of stairs that gave away. An insurance company investigator came to my home. She asked me one question: “Have you ever fallen in your life?” I can’t say no because we all fall at some time in our life. The moment I said yes, workers compensation coverage was denied. Why? My fall was deemed to be preexisting. 
 
So, now we have a new Law. One that is very controversial and is set to be fought at the state level and by those opposed to it. HR 3590 is a 2,074 page document. Here are a few items from this lengthy document:
 
BILLING:
 
SEC. 9007. ADDITIONAL REQUIREMENTS FOR CHARITABLEHOSPITALS.
 
‘‘(A) FINANCIAL ASSISTANCE POLICY.—A written financial assistance policy which includes—
 ‘‘(i) eligibility criteria for financial assistance, and whether such assistance includes free or discounted care, ‘‘
   (ii) the basis for calculating amounts charged to patients,
   (iii) the method for applying for financial assistance,
   (iv) in the case of an organization which does not have a separate billing and collections policy, the actions the organization may take in the event of non-payment, including collections action and reporting to credit agencies, and
   (v) measures to widely publicize the policy within the community to be served by the organization.
 
(B) POLICY RELATING TO EMERGENCY MEDICAL CARE.—A written policy requiring the organization to provide, without discrimination, care for emergency medical conditions (within the meaning of section 1867 of the Social Security Act (42 U.S.C. 1395dd)) to individuals regardless of their eligibility under the financial assistance policy described in subparagraph (A).
 
 
 
(3) COST-SHARING.—In this title (A) IN GENERAL.—The term ‘‘cost-sharing’’ includes—
(i) deductibles, coinsurance, copayments, or similar charges; and
(ii) any other expenditure required of an insured individual which is a qualified medical expense (within the meaning of section 223(d)(2) of the Internal Revenue
Code of 1986) with respect to essential health benefits covered under the plan.
 
(B) EXCEPTIONS.—Such term does not include premiums, balance billing amounts for
non-network providers, or spending for non-covered services.
 
(5) LIMITATION ON CHARGES.—An organization meets the requirements of this paragraph if the organization—‘‘(A) limits amounts charged for emergency or other medically necessary care provided to individuals eligible for assistance under
the financial assistance policy described in paragraph (4)(A) to not more than the lowest
amounts charged to individuals who have insurance covering such care, and (B) prohibits the use of gross charges.
 
(6) BILLING AND COLLECTION REQUIREMENTS.—An organization meets the requirement of this paragraph only if the organization does not engage in extraordinary collection actions before the organization has made reasonable efforts to determine whether the individual is eligible for assistance under the financial assistance policy described in paragraph (4)(A).
 
SEC. 6503. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE PAYEES REQUIRED TO REGISTER UNDER MEDICAID.
 
(a) IN GENERAL.—Section 1902(a) of the Social Security Act (42 U.S.C. 42 U.S.C. 1396a(a)), as amended by section 6502(a), is amended by inserting after paragraph (78), the following:
\
(79) provide that any agent, clearinghouse, or other alternate payee (as defined by the Secretary) that submits claims on behalf of a health care provider must register with the State and the Secretary in a form and manner specified by the Secretary;’’.
 
SEC. 6506. OVERPAYMENTS.
(a) EXTENSION OF PERIOD FOR COLLECTION OF OVERPAYMENTS DUE TO FRAUD.—
(1) IN GENERAL.—Section 1903(d)(2) of the Social Security Act (42 U.S.C. 1396b(d)(2)) is amended— (A) in subparagraph (C)—(i) in the first sentence, by striking
‘‘60 days’’ and inserting ‘‘1 year’’; and (ii) in the second sentence, by striking
‘‘60 days’’ and inserting ‘‘1-year period’’; and (B) in subparagraph (D)—(i) in inserting ‘‘(i)’’ after ‘‘(D)’’; and 1787(ii) by adding at the end the following:
‘‘(ii) In any case where the State is unable to recover a debt which represents an overpayment (or any portion thereof) made to a person or other entity due to fraud
within 1 year of discovery because there is not a final determination of the amount of the overpayment under an administrative or judicial process (as applicable), including as a result of a judgment being under appeal, no adjustment shall be made in the Federal payment to such State on account of such overpayment (or portion thereof) before the date that is 30 days after the date on which a final judgment (including, if applicable, a final determination on an appeal) is made.’’.
(2) EFFECTIVE DATE.—The amendments made by this subsection take effect on the date of enactment of this Act and apply to overpayments discovered on or after that date.
(b) CORRECTIVE ACTION.—The Secretary shall promulgate regulations that require States to correct Federally identified claims overpayments, of an ongoing or re22
curring nature, with new Medicaid Management Information System (MMIS) edits, audits, or other appropriate corrective action.
 
CODING
 
SEC. 3203. APPLICATION OF CODING INTENSITY ADJUSTMENT DURING MA PAYMENT TRANSITION.
 
Section 1853(a)(1)(C) of the Social Security Act (42 U.S.C. 1395w–23(a)(1)(C)) is amended by adding at the end the following new clause:
1 ‘‘(iii) APPLICATION OF CODING INTENSITY ADJUSTMENT FOR 2011 AND SUBSEQUENT YEARS.—
(I) REQUIREMENT TO APPLY IN 2011 THROUGH 2013.—In order to ensure payment accuracy, the Secretary shall conduct an analysis of the differences described in clause (ii)(I). The Secretary shall ensure that the results of such analysis are incorporated into the risk scores for 2011, 2012, and 2013.
(II) AUTHORITY TO APPLY IN 2014 AND SUBSEQUENT YEARS.—The Secretary may, as appropriate, incorporate the results of such analysis into the risk scores for 2014 and subsequent years.’’.
 
SEC. 6507. MANDATORY STATE USE OF NATIONAL CORRECT CODING INITIATIVE.
 
Section 1903(r) of the Social Security Act (42 U.S.C.1396b(r)) is amended—
(1) in paragraph (1)(B)—
(A) in clause (ii), by striking ‘‘and’’ at the end;
(B) in clause (iii), by adding ‘‘and’’ after the semi-colon; and
(C) by adding at the end the following new clause:
(iv) effective for claims filed on or after October 1, 2010, incorporate compatible methodologies of the National Correct Coding Initiative administered by the Secretary (or any successor initiative to promote correct coding and to control improper coding leading to inappropriate payment) and such other methodologies of that Initiative (or such other national correct coding methodologies) as the Secretary identifies in accordance with paragraph (4);’’; and (2) by adding at the end the following new paragraph: 1789
(4) For purposes of paragraph (1)(B)(iv), the Secretary shall do the following:
(A) Not later than September 1, 2010:
(i) Identify those methodologies of the National Correct Coding Initiative administered
by the Secretary (or any successor initiative to promote correct coding and to control improper coding leading to inappropriate payment) which are compatible to claims filed under this title.
(ii) Identify those methodologies of such Initiative (or such other national correct coding
methodologies) that should be incorporated into claims filed under this title with respect to items or services for which States provide medical assistance under this title and no national correct coding methodologies have been established under such Initiative with respect to title XVIII.
(iii) Notify States of—(I) the methodologies identified under subparagraphs (A) and (B) (and of any other national correct coding methodologies identified under subparagraph
(B)); and 1790
(II) how States are to incorporate such methodologies into claims filed under
this title.
(B) Not later than March 1, 2011, submit a report to Congress that includes the notice to States under clause (iii) of subparagraph (A) and an analysis supporting the identification of the methodologies made under clauses (i) and (ii) of subparagraph (A).’’.
 
PROHIBITIONS
 
‘‘SEC. 2712. PROHIBITION ON RESCISSIONS.
 
A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not rescind such plan or coverage with respect to an
enrollee once the enrollee is covered under such plan or coverage involved, except that this section shall not apply to a covered individual who has performed an act or practice that constitutes fraud or makes an intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage. Such plan or coverage may not be cancelled except with prior notice to the enrollee, and only as permitted under section 2702(c) or 2742(b).
 
(Personal Note: Group Health Plans fall under the jurisdiction of ERISA as defined by 29 USC 18, 1003(a). The above section can be used to fight back when an insurance company retroactively denies benefits and demands a refund.)
 
‘‘SEC. 2704. PROHIBITION OF PREEXISTING CONDITION EXCLUSIONS OR OTHER DISCRIMINATION BASED ON HEALTH STATUS.
 
(a) IN GENERAL.—A group health plan and a health insurance issuer offering group or individual health insurance coverage may not impose any preexisting condition
exclusion with respect to such plan or coverage.’’; and (B) by transferring such section (as amended by subparagraph (A)) so as to appear after the section 2703 added by paragraph (4);(3)(A) in section 2702 (42 U.S.C. 300gg-1)—
(i) by striking the section heading and all that follows through subsection (a);
(ii) in subsection (b)—(I) by striking ‘‘health insurance issuer offering health insurance coverage in connection with a group health plan’’ each place that such appears and inserting ‘‘health insurance issuer offering group or individual health insurance coverage’’; and (II) in paragraph (2)(A)—(aa) by inserting ‘‘or individual’’
 after ‘‘employer’’; and (bb) by inserting ‘‘or individual health coverage, as the case may be’’ before the semicolon; and (iii) in subsection (e)— (I) by striking ‘‘(a)(1)(F)’’ and inserting ‘‘(a)(6)’’;(II) by striking ‘‘2701’’ and inserting‘‘2704’’; and (III) by striking ‘‘2721(a)’’ and inserting ‘‘2735(a)’’; and (B) by transferring such section (as amended by subparagraph (A)) to appear after section 2705(a) as added by paragraph (4); and
(4) by inserting after the subpart heading (as added by paragraph (1)) the following:
‘‘SEC. 2701. FAIR HEALTH INSURANCE PREMIUMS.
 
SEC. 2708. PROHIBITION ON EXCESSIVE WAITING PERIODS.
‘‘A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not apply any waiting period (as defined in section
2704(b)(4)) that exceeds 90 days.’’.
 
SEC. 6505. PROHIBITION ON PAYMENTS TO INSTITUTIONS
OR ENTITIES LOCATED OUTSIDE OF THE UNITED STATES.
Section 1902(a) of the Social Security Act (42 U.S.C.1396b(a)), as amended by section 6503, is amended by inserting after paragraph (79) the following new paragraph:
‘‘(80) provide that the State shall not provide any payments for items or services provided under the State plan or under a waiver to any financial institution or entity located outside of the United States;’’.
 
APPEALS
 
‘‘SEC. 2719. APPEALS PROCESS.
‘‘A group health plan and a health insurance issuer offering group or individual health insurance coverage shall implement an effective appeals process for appeals of coverage determinations and claims, under which the plan or issuer shall, at a minimum—
‘‘(1) have in effect an internal claims appeal process;
‘‘(2) provide notice to enrollees, in a culturally and linguistically appropriate manner, of available internal and external appeals processes, and the availability of any applicable office of health insurance consumer assistance or ombudsman established under section 2793 to assist such enrollees with the appeals processes;
‘‘(3) allow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process; and‘‘(4) provide an external review process for such plans and issuers that, at a minimum, includes the consumer protections set forth in the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners and is binding on such plans.’’.
 
(Note: The appeals process identified above is identical to the appeals process outlined in ERISA, specifically 29 CFR 2560.503-1)
 
 
‘‘SEC. 2793. HEALTH INSURANCE CONSUMER INFORMATION.
‘(a) IN GENERAL.—The Secretary shall award grants to States to enable such States (or the Exchanges operating in such States) to establish, expand, or provide support for—
‘‘(1) offices of health insurance consumer assistance; or‘‘(2) health insurance ombudsman programs.
‘‘(b) ELIGIBILITY.—
(1) IN GENERAL.—To be eligible to receive a grant, a State shall designate an independent office of health insurance consumer assistance, or an ombudsman, that, directly or in coordination with State health insurance regulators and consumer assistance
organizations, receives and responds to inquiries and complaints concerning health insurance coverage with respect to Federal health insurance requirements and under State law.
‘‘(2) CRITERIA.—A State that receives a grant under this section shall comply with criteria established by the Secretary for carrying out activities under such grant.
‘‘(c) DUTIES.—The office of health insurance consumer assistance or health insurance ombudsman shall—
‘(1) assist with the filing of complaints and appeals, including filing appeals with the internal appeal or grievance process of the group health plan or health insurance issuer involved and providing information about the external appeal process;
‘‘(2) collect, track, and quantify problems and inquiries encountered by consumers;
‘‘(3) educate consumers on their rights and responsibilities with respect to group health plans and health insurance coverage;
‘‘(4) assist consumers with enrollment in a group health plan or health insurance coverage by providing information, referral, and assistance; and ‘‘(5) resolve problems with obtaining premium tax credits under section 36B of the Internal Revenue Code of 1986.
‘(d) DATA COLLECTION.—As a condition of receiving a grant under subsection (a), an office of health insurance consumer assistance or ombudsman program shall be required to collect and report data to the Secretary on the types of problems and inquiries encountered by consumers. The Secretary shall utilize such data to identify areas where more enforcement action is necessary and shall share such information with State insurance regulators, the Secretary of Labor, and the Secretary of the Treasury for use in the enforcement activities of such agencies.
‘‘(e) FUNDING.—
‘‘(1) INITIAL FUNDING.—There is hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, $30,000,000 for the first fiscal year for which this section applies to carry out this section. Such amount shall remain
available without fiscal year limitation.
(2) AUTHORIZATION FOR SUBSEQUENT 20 YEARS.—There is authorized to be appropriated to the Secretary for each fiscal year following the fiscal year described in paragraph (1), such sums as may be necessary to carry out this section.’’.
 
(Note: Whether we need to take on the appeals process and perform the reporting to the State or place the appeals and reporting process into the hands of the insured needs to be discussed. Will Maximus be awarded the task of complying with this requirement?)
 
 
 
EMERGENCY CARE
 
SEC. 1302. ESSENTIAL HEALTH BENEFITS REQUIREMENTS.
(a) ESSENTIAL HEALTH BENEFITS PACKAGE.—In this title, the term ‘‘essential health benefits package’’ means, with respect to any health plan, coverage that—
(1) provides for the essential health benefits defined by the Secretary under subsection(b);
(2) limits cost-sharing for such coverage in accordance with subsection (c); and
(3) subject to subsection (e), provides either the bronze, silver, gold, or platinum level of coverage described in subsection (d).
(b) ESSENTIAL HEALTH BENEFITS.—
(1) IN GENERAL.—Subject to paragraph (2), the Secretary shall define the essential health benefits, except that such benefits shall include at least the following general categories and the items and services covered within the categories:
(A) Ambulatory patient services.
(B) Emergency services.
(C) Hospitalization.
(D) Maternity and newborn care.
(E) Mental health and substance use disorder services, including behavioral health treatment.
(F) Prescription drugs.
G) Rehabilitative and habilitative services and devices.
H) Laboratory services.
(I) Preventive and wellness services and chronic disease management.
(J) Pediatric services, including oral and vision care.
 
(2) LIMITATION.—
A) IN GENERAL.—The Secretary shall ensure that the scope of the essential health benefits under paragraph (1) is equal to the scope of benefits provided under a typical employer plan, as determined by the Secretary. To inform this determination, the Secretary of Labor shall conduct a survey of employer-sponsored coverage to determine the benefits typically covered by employers, including multiemployer Plans, and provide a report on such survey to the Secretary.
(B) CERTIFICATION.—In defining the essential health benefits described in paragraph
(1), and in revising the benefits under paragraph (4)(H), the Secretary shall submit a report to the appropriate committees of Congress containing a certification from the Chief Actuary of the Centers for Medicare & Medicaid Services that such essential health benefits meet the limitation described in paragraph (2).
 
SEC. 1303. SPECIAL RULES.
(c) APPLICATION OF EMERGENCY SERVICES LAWS.—Nothing in this Act shall be construed to relieve any health care provider from providing emergency services as required by State or Federal law, including section 1867 of the Social Security Act (popularly known as ‘‘EMTALA’’).
 
 
 
 
DEFINITIONS
 
(1) LARGE EMPLOYER.—The term ‘‘large employer’’ means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 101 employees on business days during the preceding calendar year and who employs at least 1 employee on the first day of the plan year.
 
(2) SMALL EMPLOYER.—The term ‘‘small employer’’ means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 1 but not more than 100 employees on business days
during the preceding calendar year and who employs at least 1 employee on the first day of the plan year.
 
(3) STATE OPTION TO TREAT 50 EMPLOYEES AS SMALL.—In the case of plan years beginning before January 1, 2016, a State may elect to apply this subsection by substituting ‘‘51 employees’’ for ‘‘101 employees’’ in paragraph (1) and by substituting
‘‘50 employees’’ for ‘‘100 employees’’ in paragraph 16 (2).
 
EMERGENCY MEDICAL CONDITION.—The term ‘‘emergency medical condition’’ means, with respect to an individual, an individual who expresses suicidal or homicidal thoughts or gestures, if determined dangerous to self or others.
 
EMERGENCY SERVICES.—The term ‘emergency services’ includes acute, prehospital, and trauma care.
 
MISELLANEOUS
‘‘(F) PROCEDURE ROOMS.—In this subsection, the term ‘procedure rooms’ includes
rooms in which catheterizations, angiographies, angiograms, and endoscopies are performed, except such term shall not include emergencyrooms or departments (exclusive of rooms in which catheterizations, angiographies, angiograms, and endoscopies are performed).
 
 
 

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