The following provides a brief description of the provisions for individuals obtaining health insurance in the Health, Education, Labor and Pensions ("HELP") Committee and the House Tri-Committee Health Reform Packages.
Senate HELP Committee Package
The HELP Committee package would address the concerns of the APsaA by prohibiting insurers from imposing pre-existing condition limitations on individuals and groups. The legislation would also limit the ability of insurers to rate individuals and groups on the basis of health status, medical conditions, including physical and mental illness, claims experience, medical history, genetic information, receipt of health care, evidence of insurability and disability. The legislation would also impose guaranteed issue and guaranteed renewability rules in the group and individual markets. Plans may impose special enrollment or "open" periods to limit enrollment and renewability to specified times.
The other significant provision for individuals in the HELP Committee bill is the creation of "State Health Benefit Gateways" which would create an insurance exchange through which individuals and qualified employer groups could purchase health insurance. The gateways would also offer a public insurance option as well as qualified private insurance plans. The bill lays out 11 requirements that each gateway must meet in order to qualify for Federal grants. Among these provisions, the most relevant are that each gateway must offer one affordable access plan. These gateways will facilitate enrollment in qualified health insurance plans by establishing procedures for certification and providing information to consumers on benefit, premium and out of pocket expenditures. A qualified individual may enroll in any qualified health plan through the gateway but may also enroll in plans not offered through the state exchange. The bill also creates a "Medical Advisory Council" to create recommendations on the development of an essential benefits package that will serve as the basis for developing the minimum qualifying criteria to meet an individual mandate as well as the benefits package offered through the public plan.
The HELP committee package also provides certain subsidies for individuals to purchase health insurance through the state Gateways. These subsidies are based on income on a sliding scale. There is also an individual mandate which requires all qualified individuals to certify that they have health insurance coverage that satisfies the minimum qualified criteria set by the Medical Advisory Council.
House Tri-Committee Package
The House Ways and Means, Energy and Commerce and Education Labor Committees issued the House Tri-Committee Health Reform Discussion on June 19, 2009. This bill also creates a health insurance exchange through which individuals and small employers can purchase health insurance. The Exchange may operate as a national entity or states may choose to operate the exchange so long as they adhere to federal requirements. The Exchange would also offer a public plan option. The package establishes an "Independent Advisory Committee" to develop a basic benefits package that will eventually become the minimum standard for coverage in the exchange and in employer plans.
The Tri-committee reform package also creates sliding scale subsidies to allow individuals to purchase health insurance through the Exchange, enabling them to satisfy the individual health insurance mandate.
The House Tri-Committee package also reforms the group and individual insurance markets to ensure greater access to insurance. These reforms include a prohibition on excluding individuals and groups on the basis of health status and pre-existing health conditions. Similar to the HELP Committee bill, the package limits insurers from engaging in insurance rating based on health status and gender, limiting premium rating to age, geography and family size.
Next Steps
In terms of going forward, the APsaA should express their support by writing letters to the Chairman of the HELP Committee, Senator Kennedy, as well as Senator Dodd, who is currently in charge of the HELP Committee markup, to thank them for the inclusion of the insurance market reforms and creation of the insurance gateways which will expand individual access to the private market as well as create an affordable public insurance option. A similar letter may be submitted to the Chairman of the House Ways and Means Committee, Representative Rangel as well as the Chairman of the Subcommittee on Health, Representative Stark. Additionally, letters of support may be sent to the Chairman of the Energy and Commerce Committee, Representative Henry Waxman, and Chairman of the House Education and Labor Committee, Representative George Miller.
Given that the Senate Finance Committee has not introduced their health reform package, it may be helpful to send a letter to the Chairman, Senator Baucus and Ranking Member, Senator Grassley to express the APsaA’s support for provisions which expand individual access to the private and public insurance options as well as insurance market reforms which prohibit excluding individuals and groups on the basis of health status or pre-existing conditions and prohibit insurers from engaging in discriminatory insurance rating practices.
The following provides a brief description of the provisions for individuals obtaining health insurance in the Health, Education, Labor and Pensions ("HELP") Committee and the House Tri-Committee Health Reform Packages.
Senate HELP Committee Package
The HELP Committee package would address the concerns of the APsaA by prohibiting insurers from imposing pre-existing condition limitations on individuals and groups. The legislation would also limit the ability of insurers to rate individuals and groups on the basis of health status, medical conditions, including physical and mental illness, claims experience, medical history, genetic information, receipt of health care, evidence of insurability and disability.The legislation would also impose guaranteed issue and guaranteed renewability rules in the group and individual markets. Plans may impose special enrollment or "open" periods to limit enrollment and renewability to specified time.
The other significant provision for individuals in the HELP Committee bill is the creation of "State Health Benefit Gateways" which would create an insurance exchange through which individuals and qualified employer groups could purchase health insurance. The gateways would also offer a public insurance option as well as qualified private insurance plans. The bill lays out 11 requirements that each gateway must meet in order to qualify for Federal grants. Among these provisions, the most relevant are that each gateway must offer one affordable access plan. These gateways will facilitate enrollment in qualified health insurance plans by establishing procedures for certification and providing information to consumers on benefit, premium and out of pocket expenditures. A qualified individual may enroll in any qualified health plan through the gateway but may also enroll in plans not offered through the state exchange. The bill also creates a "Medical Advisory Council" to create recommendations on the development of an essential benefits package that will serve as the basis for developing the minimum qualifying criteria to meet an individual mandate as well as the benefits package offered through the public plan.
The HELP committee package also provides certain subsidies for individuals to purchase health insurance through the state Gateways. These subsidies are based on income on a sliding scale. There is also an individual mandate which requires all qualified individuals to certify that they have health insurance coverage that satisfies the minimum qualified criteria set by the Medical Advisory Council.
[1] Information in this document comes from the HELP Committee Bill and the CRS Summary. |