Sec. 113, Pg. 21-22 of the Health Care (HC) Bill MANDATES a government audit of the books of ALL EMPLOYERS that self-insure in order to “ensure that the law does not provide incentives for small and mid-size employers to self-insure”!

Sec. 113, Pg. 21-22 of the Health Care (HC) commissions a STUDY and a REPORT regarding employers who self-insure as well as those who are in large group coverage. See applicable text below:

“….shall conduct a study of the large group insured and self-insured employer health care markets.”
“…Commissioner shall submit to Congress and the applicable agencies a report on the study conducted under paragraph (1).”

Sec. 122, Pg. 29, Lines 4-16 - YOUR HEALTH CARE WILL BE RATIONED!

Sec. 122, Pg. 29, lines 4-16 – Establishes out-of-pocket maximums of $5000 per person/$10000 per family. It also outlines increases in OOP max adjusted for inflation based on the CPI. See applicable text below:

“(A) ANNUAL LIMITATION.—The cost-sharing incurred under the essential benefits package with respect to an individual (or family) for a year does not exceed the applicable level specified in subparagraph (B).
(B) APPLICABLE LEVEL.—The applicable level specified in this subparagraph for Y1 is
$5,000 for an individual and $10,000 for a family. Such levels shall be increased (rounded to the nearest $100) for each subsequent year by the annual percentage increase in the Consumer Price Index (United States city average) applicable to such year.”

Sec. 123, Pg. 30 - THERE WILL BE A GOVERNMENT COMMITTEE deciding what treatments and benefits you get.

Sec. 123, Pg. 30 - It establishes guidelines and responsibilities for the Health Care Advisory Committee. Members are from a variety of aspects, not merely governmental areas. Additionally, the Committee is not a paid governmental body. The primary goal is to establish what the primary benefits are that will be included in the basic, enhanced, and premium plans. See applicable text below:

“(5) PARTICIPATION.—The membership of the Health Benefits Advisory Committee shall at least reflect providers, consumer representatives, employers, labor, health insurance issuers, experts in health care financing and delivery, experts in racial and ethnic disparities, experts in care for those with disabilities, representatives of relevant governmental agencies. and at least one practicing physician or other health professional and an expert on children’s health and shall represent a balance among various sectors of the health care system so that no single sector unduly influences the recommendations of such Committee.”
“(1) RECOMMENDATIONS ON BENEFIT STANDARDS.—The Health Benefits Advisory Committee shall recommend to the Secretary of Health and Human Services (in this subtitle referred to as the ‘‘Secretary’’) benefit standards (as defined in paragraph (4)), and periodic updates to such standards. In developing such recommendations, the Committee shall take into account innovation in health care and consider how such standards could reduce health disparities.”
“(2) MEMBERS NOT TREATED AS FEDERAL EMPLOYEES.—Members of the Health Benefits Advisory Committee shall not be considered employees of the Federal government solely by reason of any service on the Committee.”

Sec. 142, Pg. 42 - The Health Choices Commissioner will choose your benefits for you. You have no choice!

Sec. 142, Pg. 42 – The Commissioner is responsible for establishing minimum requirements for benefits, as well as the establishment of the health care exchange. See applicable text below:

“(a) DUTIES.—The Commissioner is responsible for carrying out the following functions under this division:
(1) QUALIFIED PLAN STANDARDS.—The establishment of qualified health benefits plan standards under this title, including the enforcement of such standards in coordination with State insurance regulators and the Secretaries of Labor and the Treasury.
(2) HEALTH INSURANCE EXCHANGE.—The establishment and operation of a Health Insurance Exchange under subtitle A of title II.
(3) INDIVIDUAL AFFORDABILITY CREDITS.—
The administration of individual affordability credits under subtitle C of title II, including determination of eligibility for such credits.”

Sec. 152, Pg. 50-51 - HC will be provided to ALL NON-US citizens.

Sec. 152, Pg. 50-51- States that healthcare will be provided to EVERYONE regardless of extraneous factors. This does allow for the possibility of non-US citizens receiving healthcare. (Proof of citizenship was not required for Medicaid until 2006). See applicable text below:

”(a) IN GENERAL.—Except as otherwise explicitly permitted by this Act and by subsequent regulations consistent with this Act, all health care and related services
(including insurance coverage and public health activities) covered by this Act shall be provided without regard to personal characteristics extraneous to the provision of high quality health care or related services.”

Sec. 163, Pg. 58-59 beginning at line 5 - Government will have real-time access to individual’s finances & a National ID health care card will be issued!

Sec. 163, Pg. 58-59 beginning at line 5 – Seeks to establish a method of determining a patient’s financial responsibility at the point of service. Similar to the pre-approval of services required by some private health-care plans. This may include a machine-readable ID card. See applicable text below:

‘‘(D) enable the real-time (or near real-time) determination of an individual’s financial responsibility at the point of service and, to the extent possible, prior to service, including whether the individual is eligible for a specific service with a specific physician at a specific facility, which may include utilization of a machine-readable health plan beneficiary identification card;”

Sec. 163, Pg. 59, Lines 21-24 - Government will have direct access to your bank accounts for electronic funds transfer.

Sec. 163, Pg. 59, Lines 21-24 – Electronic funds transfer will be established for payments and remittance. (The government already has your bank account details. See FDIC). See applicable text below:

‘‘(C) enable electronic funds transfers, in order to allow automated reconciliation with the related health care payment and remittance advice;”

Sec. 164, Pg. 65 is a payoff subsidized plan for retirees and their families in unions & community organizations (ACORN).

Sec. 164, Pg. 65 – Defines a reinsurance program for retirees (and family) covered by employer-based group health plans. This includes unions, but also includes non-union employers who offer healthcare benefits to retirees, such as Allstate Insurance and IBM. It also includes retired fire and police personnel, as well as other state and local governmental bodies. See applicable text below:

“…establish a temporary reinsurance program (in this section referred to as the ‘‘reinsurance program’’) to provide reimbursement to assist participating employment-based plans with the cost of providing health benefits to retirees and to eligible spouses, surviving spouses and dependents of such retirees.”

(A) The term ‘‘eligible employment-based plan’’ means a group health benefits plan that—
(i) is maintained by one or more employers, former employers or employee associations, or a voluntary employees’ beneficiary association, or a committee or board of individuals appointed to administer such plan, and
(ii) provides health benefits to retirees.

Sec. 201, Pg. 72, Lines 8-14 - Government is creating an HC Exchange to bring private plans under government control.

Sec. 201, Pg. 72, Lines 8-14 - The health care exchange is designed to allow consumers a range of plan offerings from which to choose. It also indicates that the commissioner will define standards for participation, accept bids from and negotiate with private plan providers. See applicable text below:

“(a) ESTABLISHMENT.—There is established within the Health Choices Administration and under the direction of the Commissioner a Health Insurance Exchange in order to facilitate access of individuals and employers, through a transparent process, to a variety of choices of affordable, quality health insurance coverage, including a public health insurance option.”

“(1) under section 204 establish standards for, accept bids from, and negotiate and enter into contracts with, QHBP offering entities for the offering of health benefits plans through the Health Insurance Exchange, with different levels of benefits required under section 203, and including with respect to oversight and enforcement;”

Sec. 203, Pg. 84 - Government mandates ALL benefit packages for private Health Care plans in the exchange.

Sec. 203, Pg. 84 – The HC Commissioner will establish which benefits are available through the HC Exchange. All providers must include one plan that meets the guidelines of the “essentials” plan, which is comparable to the average employer sponsored plan. If the provider offers a basic plan, they may also offer (1) enhanced plan, and if they offer an enhanced plan, they can also offer (1) premium plan. See applicable text below:

“(a) IN GENERAL.—The Commissioner shall specify the benefits to be made available under Exchange-participating health benefits plans during each plan year, consistent with subtitle C of title I and this section.”

“(1) REQUIRED OFFERING OF BASIC PLAN.—The entity offers only one basic plan for such service area.
(2) OPTIONAL OFFERING OF ENHANCED PLAN.—If and only if the entity offers a basic plan for such service area, the entity may offer one enhanced plan for such area.
(3) OPTIONAL OFFERING OF PREMIUM PLAN.— If and only if the entity offers an enhanced plan for such service area, the entity may offer one premium plan for such area.”

Sec. 203, Pg. 85, Line 7 - Specifications of benefit levels for plans means that the government will define your HC plan and has the ability to ration your health care!

Sec. 203, Pg. 85, Line 7 – Defines the benefits offered in each level (basic, enhanced, and premium) of health care coverage. The basic level of coverage is defined in Sec. 122 of the plan. See the below referenced text from both Sec. 203 and Sec. 122.

“Sec. 122 Established Minimum Coverage
(b) MINIMUM SERVICES TO BE COVERED.—The items and services described in this subsection are the following:
(1) Hospitalization.
(2) Outpatient hospital and outpatient clinic services, including emergency department services.
(3) Professional services of physicians and other health professionals.
(4) Such services, equipment, and supplies incident to the services of a physician’s or a health professional’s delivery of care in institutional settings, physician offices, patients’ homes or place of residence, or other settings, as appropriate.
(5) Prescription drugs.
(6) Rehabilitative and habilitative services.
(7) Mental health and substance use disorder services.
(8) Preventive services, including those services recommended with a grade of A or B by the Task
Force on Clinical Preventive Services and those vaccines recommended for use by the Director of the Centers for Disease Control and Prevention.
(9) Maternity care.
(10) Well baby and well child care and oral health, vision, and hearing services, equipment, and
supplies at least for children under 21 years of age.”

Sec. 203
“(1) IN GENERAL.—The Commissioner shall establish the following standards consistent with this subsection and title I:
(A) BASIC, ENHANCED, AND PREMIUM PLANS.—Standards for 3 levels of Exchange
participating health benefits plans: basic, enhanced, and premium (in this division referred to as a ‘‘basic plan’’, ‘‘enhanced plan’’, and ‘‘premium plan’’, respectively).
(B) PREMIUM-PLUS PLAN BENEFITS.— Standards for additional benefits that may be
offered, consistent with this subsection and subtitle C of title I, under a premium plan (such a plan with additional benefits referred to in this division as a ‘‘premium-plus plan’’).”

Sec. 205, Pg. 95, Lines 8-18 - The government will use groups (i.e., ACORN & AmeriCorps) to “inform and educate” (sign up) individuals for government plan.

Sec. 205, Pg. 95, Lines 8-18 - The commissioner will provide outreach services, particularly to at-risk populations through the use of appropriate entities. The dissemination of information is likely to include mental health facilities, local disability boards, unemployment offices, and similar groups. It may also include ACORN and AmeriCorps.

“(1) OUTREACH.—The Commissioner shall conduct outreach activities consistent with subsection (c), including through use of appropriate entities as described in paragraph (4) of such subsection, to inform and educate individuals and employers about the Health Insurance Exchange and Exchange-participating health benefits plan options. Such outreach shall include outreach specific to vulnerable populations, such as children, individuals with disabilities, individuals with mental illness, and individuals with other cognitive impairments.”

“(C) ENROLLMENT INFORMATION.—The Commissioner shall provide for the broad dissemination of information to prospective enrollees on the enrollment process, including before each open enrollment period. In carrying out the previous sentence, the Commissioner may work with other appropriate entities to facilitate such provision of information.”

“(A) provide for the operation of a toll-free telephone hotline to respond to requests for assistance and maintain an Internet website through which individuals may obtain information on coverage under Exchange-participating health benefits plans and file complaints;
(B) develop and disseminate information to Exchange-eligible enrollees on their rights and responsibilities;
(C) assist Exchange-eligible individuals in selecting Exchange-participating health benefits plans and obtaining benefits through such plans; and
(D) ensure that the Internet website described in subparagraph (A) and the information described in subparagraph (B) is developed using plain language (as defined in section 133(a)(2)).”

Sec. 205, Pg. 102, Lines 12-18 - Medicaid-eligible individuals will be automatically enrolled in Medicaid. No freedom to choose.

Sec. 205, Pg. 102, Lines 12-18 – Establishes an automatic enrollment process for exchange-eligible individuals who have opted not to enroll in the exchange-participating plan. This only applies to individuals classified as Non-Traditional Medicaid Eligible Individuals, as described in Sec. 202 (d)(3). Applicable text for both sec. 205 and sec. 202 are included below.

“(3) AUTOMATIC ENROLLMENT OF MEDICAID ELIGIBLE INDIVIDUALS INTO MEDICAID.—The Commissioner shall provide for a process under which an individual who is described in section 202(d)(3) and has not elected to enroll in an Exchange-participating health benefits plan is automatically enrolled under Medicaid.”

Sec. 202 (d)(3)
”(3) TREATMENT OF CERTAIN NON-TRADITIONAL MEDICAID ELIGIBLE INDIVIDUALS.—An individual who is a non-traditional Medicaid eligible individual (as defined in section 205(e)(4)(C)) in a State may be an Exchange-eligible individual if the individual was enrolled in a qualified health benefits plan, grandfathered health insurance coverage, or current group health plan during the 6 months before the individual became a non-traditional Medicaid eligible individual. During the period in which such an individual has chosen to enroll in an Exchange-participating health benefits plan, the individual is not also eligible for medical assistance under Medicaid.”

Sec. 223, Pg. 124, Lines 24-25 - No company can sue the government for price-fixing. No “administrative of judicial review” against a government monopoly.

Sec. 223, Pg. 124, Lines 24-25 – This section of the bill establishes that payment rates are based on items covered under Medicaid Parts A and B, and that any services/drugs outside of Medicaid’s current system are subject to negotiation with the provider. It is possible that this could be viewed as a protection of a monopoly, if it were a monopoly. Included is the relevant text with a definition of the term monopoly. However, as the government is establishing a health-care exchange that includes a variety of providers, including a public option, then there is by definition no monopoly. (As an aside, as Medicaid is the only provider of no-cost healthcare coverage, it IS by definition a monopoly. In order to fix prices, there has to be collusion between the government and ALL health-care providers to artificially increase, decrease, or hold constant the price of goods and services. Instead, the legislation outlines how payment rates made BY THE GOVERNMENT to the PROVIDER are calculated. If a provider does not wish to accept the payment rate, then they do not have to participate in the program.

“(f) LIMITATIONS ON REVIEW.— There shall be no administrative or judicial review of a payment rate or methodology established under this section or under section 224.”

“Monopoly : exclusive ownership through legal privilege, command of supply, or concerted action” – Merriam-Webster Dictionary

Sec. 225, Pg. 127, Lines 1-16 - Doctors – the government will tell YOU what you can make. “The Secretary shall provide for the annual participation of physicians under the public health insurance option, for which payment may be made for services furnished during the year.”

Sec. 225, Pg. 127, Lines 1-16 – Defines the two classes of participating physicians who will be reimbursed for services rendered. Similar to restrictions outlined in private and group health care plans. Again, providers have three options: accept the payment terms set forth, agree to the ratio stipulations set forth in the Social Security Act, or do not participate. PPO’s, HMO’s, etc. are structured in much the same way. (E.g. formulary drugs, preferred physicians, etc. in an employer based plan.)

“(A) PREFERRED PHYSICIANS.— Those physicians who agree to accept the payment rate established under section 223 (without regard to cost-sharing) as the payment in full.
(B) PARTICIPATING, NON-PREFERRED PHYSICIANS.—Those physicians who agree not
to impose charges (in relation to the payment rate described in section 223 for such physicians) that exceed the ratio permitted under section 1848(g)(2)(C) of the Social Security Act.”

Sec. 312, Pg. 145, Lines 15-17 - Employers MUST auto-enroll employees into public option plan.

Sec. 312, Pg. 145, Lines 15-17 – Employer provides auto-enrollment for employees, if the employer participates in the healthcare exchange AND if the employee does not opt out of coverage.

“(1) OFFERING OF COVERAGE.—The employer offers the coverage described in section 311(1) either through an Exchange-participating health benefits plan or other than through such a plan.”

“(4) AUTOENROLLMENT OF EMPLOYEES.—The employer provides for autoenrollment of the employee in accordance with subsection (c).”

“(1) IN GENERAL.—The requirement of this subsection with respect to an employer and an employee is that the employer automatically enroll such employee into the employment-based health benefits:plan for individual coverage under the plan option with the lowest applicable employee premium.(2) OPT-OUT.—In no case may an employer automatically enroll an employee in a plan under paragraph (1) if such employee makes an affirmative election to opt out of such plan or to elect coverage under an employment-based health benefits plan offered by such employer. An employer shall provide an employee with a 30-day period to make such an affirmative election before the employer may automatically enroll the employee in such a plan.”

There are many days when I wake up and wonder why I'm dragging myself in to work. All it takes is one look at my little monkey, and it all comes rushing back. My sole purpose in life is to make sure that he has everything he will ever need, and at least a little bit of what he wants.

His infectious smile is what gets me through the day. It doesn't hurt that he's darned cute in ugly shirts (just like his dear old dad.) This is my son's tribute to summer. Hope you enjoy.

http://princeliamthebrave.blogspot.com

Liam Witt is the bravest person I've NEVER met. His parents are former colleagues of mine, and Larry is the only one of the three with whom I have spoken. Since February of 2007, Prince Liam has been battling neuroblastoma. I have been following his progress for the past two years, and though I know him only from photos and his parents blog, I celebrate his good times and I am saddened by his bad times. His story touches me everytime I sit down at my computer.

Today he is in surgery, as he suffered a relapse in mid-June. I cannot begin to understand how his parents must be feeling at this point, but I am writing this to ask that everyone out there remembers the Witt family in your thoughts and prayers.

I would also ask that the generous amongst you pay a visit to www.cookiesforkidscancer.org. Gretchen, Liam's mother, founded the charity to help raise funds for pediatric cancer research, as it is severely underfunded. It started out as an idea to help raise money during the holiday season, but they will turning 1 this September. The cookies they sell are fabulous, but you can also show your support by hosting a bake sale. I was able to raise a few hundred dollars, but with the help of other like-minded folks, I believe we can do better than that. I am trying to spread the word about their charity, because I believe Prince Liam and other children like him deserve every shot at life that they can get.

Everyday, I look around and see a commercial for Autism. Or for Cerebal Palsy. Or some Irritable Bowel Syndrome. Do you know the last time I saw an ad to bring awareness to the public regarding Down syndrome? Never. I am not saying they don't exist, but rather they are not at the forefront of our attention. Which, in my opinion, is an issue for our population who happen to have Down syndrome.

I believe a portion of the issue is that the Down syndrome population is so fragmented. There are currently ~400,000 individuals with Down syndrome living in the United States. There are three (or four) national organizations representing these individuals, and a host of local Down syndrome associations representing them in their communities. However, we do not have one voice when it comes time to approach the NIH for research funding, nor do we have one voice when it comes to fundraising for our own research objectives.

There is no central organization to lobby for funds. There is no central "mouthpiece" to coordinate public relations. There is no concerted effort to re-educate and re-arm clinicians with the proper tools to adequately prepare potential new parents on how to handle a child with Down syndrome. This is a major disservice to our own children, and the children for the forseeable future. We can continue to fight and struggle as a fragmented population, and we can bring change. But it will be small, and it will go unnoticed.

Clinicians will continue to recommend abortion, and misinformed potential parents will continue to take the advice of said clinicians. Individuals with Ds will continue to be excluded from clinical trials and mainstream medical research. And we will continue to battle for research on something other than prenatal diagnosis. In my opinion. to no avail.

In February of this year, the ABLE Act of 2009 was introduced to Congress. For those interested, you can track it down as S.493 (Senate) and H.R.1205 (House of Representatives). For those who do not wish to wade through the legalese, I'll provide a brief synopsis.

Basically, the ABLE Act would create a tax free savings account for those with disability. The funds would be used to provide for things like housing, medical care, education, transportation, and employment support. There are limits to annual contributions and additional funds cannot be added after the beneficiary reaches age 65. The best part (in my opinion) is that the funds do disqualify the beneficiary from receiving other government funding (Medicaid, SSDI, etc.)

I don't often say nice things about the government in general, but it is refreshing to see something like this making its way through Congress. At present, it has been referred to the House Ways and Means Committee and the House Energy and Commerce Committee. as well as the Senate Finance Committee. I will be waiting anxiously to see if this passes, as it provides financial security to those who need it most.

If anyone would like to read the legislation in its entirety, it can be viewed at the following link:
http://www.govtrack.us/congress/billtext.xpd?bill=s111-493

Welcome to the first official post of my blog. I will not make any sort of promises or random predictions about the frequency or quality of my posts. The only thing I will guarantee is that I WILL post SOMETHING SOMETIME. Nothing more, nothing less.

So it begins.....Regardless, on to my ponderings. This past weekend, I had the opportunity to attend a research and awareness conference in Cincinnati, Ohio. One of the topics covered during the weekend was future planning. Suprisingly, our government has made that one a bit more challenging for those of us who happen to have the "enhanced" models running around underfoot. Up until this point, I always assumed I'd tuck some money away, take out a life insurance policy, grow old, die and leave my kid some money. Survey says: WRONG.

Because my son has Down syndrome and has/will receive some sort of governmental aid in his lifetime, any inheritance/savings, etc. becomes fair game for the good ol' boys. Based on my understanding, the only way to protect anything I leave to my monkey is to set up a special needs trust. Anything contributed to the TRUST of the monkey is untouchable by our greedy old uncle. This is the balliwack of a lawyer, and it's not something you can do with Word, a bottle of wine, and thirty minutes of down time. However, in order to secure the future of your mini-me, I'd recommend getting in touch with your friendly local legal counsel and making things all official like. I'm doing it now.

And while you're at it, remind mom, dad, grandma, grandpa, cousin earl, aunt buelah and cousin tillie to update any policies, wills or checks they'd like to give your crumbsnatcher. Everything goes to the TRUST of Sunny Bubba Junebug Johnson Jr. Otherwise, it goes to the politicos, and we don't want that.

See, it wasn't all that painful. We'll see if it goes uphill or downhill from here.