Brain Injury Blog | Traumatic Brain Injury TBI

On November 7, 2009, the House of Representatives approved their health care reform overhaul package by a vote of 220-215. The bill includes the provisions below: (provided by Congressional Quarterly, CQ Today)

Coverage Requirements

Individual Mandate

• Requires nearly all individuals to obtain health care coverage beginning in 2013.
• Permits individuals to keep their current health plan as a “grandfathered” plan.
• Excludes from the mandate those exempt from filing income tax returns and others who receive a hardship waiver.
• Subjects those who do not obtain coverage to a penalty tax of 2.5 percent of adjusted gross income above a threshold.

Employer Mandate

• Requires employers to offer their employees health care insurance, or make an insurance contribution on their behalf, starting in 2013.
• Exempts firms with payrolls of $500,000 or less.
• Subjects businesses that fail to provide coverage to penalties of up to 8 percent of their payroll.

Purchase of Coverage

Health Insurance Exchange

• Creates a federal exchange, to begin operation in 2013, that would allow individuals and small businesses to purchase health insurance from insurers participating in the exchange.
• Allows states to apply to operate their own state-based health insurance exchanges.

Public Option

• Requires the establishment of a public health insurance option within the insurance exchange by 2013.
• Directs the Health and Human Services Department to run the public option and negotiate with providers to determine rates.
• Requires those rates to be no lower than those under Medicare and no higher than the average for private plans.

Additional Options

• Authorizes loans to entities that want to create health insurance cooperatives.
• Permits states to enter into compacts that allow for the sale of insurance across state lines.

Affordability

Individual Subsidies

• Provides affordability credits to individuals and families with incomes of up to 400 percent of the federal poverty level.
• Requires that subsidies would be used to reduce premiums and out-of-pocket costs.

Small Businesses

• Provides tax credits for certain small businesses that offer health insurance to their employees.

Requirements for Insurance Companies

Pre-Existing Conditions

• Bars insurance companies from denying or reducing coverage based on pre-existing medical conditions, beginning in 2013.
• Restricts how long insurers can continue to limit coverage for pre-existing conditions until the full ban takes effect.
• Prohibits companies from considering domestic violence a pre-existing condition.

Coverage Caps

• Prohibits annual or lifetime coverage limits.

Premiums

• Limits variations on premiums based on the age of the beneficiary to a ratio of 2-to-1.
• Permits variations on premiums based on geography and family size.

Out-of-Pocket Expenses

• Limits annual out-of-pocket expenses to $5,000 for an individual and $10,000 for a family.
• Guarantees no out-of-pocket costs for preventive care.

Essential Benefits Package

• Requires all qualified health benefits plans to provide coverage that meets or exceeds the standards of an “essential benefits package.”
• Requires an essential benefits package to, at a minimum, cover hospitalization, outpatient hospital and clinic services, professional services of physicians and other health professionals, prescription drugs, rehabilitative services; mental health and substance use disorder services; preventive services, maternity care, well-baby and well-child care, and medical equipment.
• Establishes a Health Benefits Advisory Committee, chaired by the surgeon general, to make recommendations to HHS regarding the details of covered health benefits included in the essential benefits plan.

Medicare and Medicaid

Medicaid Expansion

• Expands eligibility for Medicaid by allowing enrollment for those making up to 150 percent of the poverty level, beginning in 2013.
• Beginning in 2015, states would pay 9 percent of costs associated with the expanded coverage.
• Requires Medicaid to cover newborns during the first 60 days of life.

Medicare Advantage

• Reduces payments under the Medicare Advantage program over a three-year period beginning in 2011.
• Makes the rates for Medicare Advantage the same as those for traditional fee-for-service Medicare by 2014.
• Provides bonus payments to insurance plans in the program that offer high-quality insurance plans in low-cost areas.

As part of the debate, Congressman Bill Pascrell, Jr., Co-Chairman of the Congressional Brain Injury Task Force, offered a statement including BIAA’s guiding principles for health care reform. Also included in the statement, which can be viewed by clicking on the link below, was language regarding payment initiatives such as the bundling of services.

http://www.biausa.org/elements/policy/2009/house_cr_statement_bp.pdf

The statement detailed BIAA’s position that “post-acute payment systems must facilitate, not impede, improvements in functional status of individuals with brain injury and their ability to return to their homes and communities. BIAA supports a deliberative planning process and rigorous pilot testing.”

Congressman Pascrell has been a true champion in the fight for securing access to care for persons with brain injury during the health care reform debate. Please take a minute to click on the link below and thank him for his dedication to this important issue:

http://pascrell.house.gov/contact/

It is also important to note that BIAA’s Business and Professional Council was integral in creating the content of BIAA’s health care reform guiding principles.

Now that the House has passed its measure, BIAA is monitoring Senate activity closely. Senate Majority Leader Harry Reid has alluded to Senate action on their leadership bill as soon as next week.

BIAA will alert grassroots advocates if action is needed.