(if you delete this line and set your printer's margins at one-half inch top, bottom and sides, this should fit on 4 pages)

HR-3962 Excerpts - The Facts:  IT'S NOT FREE

Bolded for easier reading.  Italics are my comments.

Pg 4 - (4) HEALTH DELIVERY REFORM.—This division institutes health delivery system reforms both to increase quality and to reduce growth in health spending so that health care becomes more affordable for businesses, families, and Government. 

Pg 9 - (4) COST-SHARING.—The term ‘‘cost-sharing’’ includes deductibles, coinsurance, copayments, and similar charges, but does not include premiums, balance billing amounts for non-network providers, or spending for non-covered services. (You still pay all of these)

Pg 16 - SEC. 101. NATIONAL HIGH-RISK POOL PROGRAM. 

Pg 18 - (d) MEDICALLY ELIGIBLE REQUIREMENTS.—For purposes of subsection (c)(1)(B)(ii), an individual described in this subsection is an individual—(1) who, during the 6-month period ending on the date the individual applies for high-risk pool coverage under this section applied for individual health insurance coverage and— A) was denied such coverage because of a preexisting condition or health status; or (B) was offered such coverage— (i) under terms that limit the coverage for such a preexisting condition; or (ii) at a premium rate that is above the premium rate for high risk pool coverage under this section;

Pg 19 - the Secretary shall make adjustments to offset differences in premium rating that are attributable solely to differences in age rating.  ("High risk" people will still pay a higher rate under the new system - the only adjustments will be for age...older people will pay up to twice as much as younger ones. Age not yet specified in the bill)

Pg 22 - (g) COVERED BENEFITS, COST-SHARING, PREMIUMS, AND CONSUMER PROTECTIONS

(1) PREMIUM.—The monthly premium charged to eligible individuals for coverage under the program— (A) may vary by age so long as the ratio of the highest such premium to the lowest such premium does not exceed the ratio of 2 to 1; (B) shall be set at a level that does not exceed 125 percent of the prevailing standard rate for comparable coverage in the individual market; and (C) shall be adjusted for geographic variation in costs.  

The Secretary shall establish standard rates in consultation with the National Association of Insurance Commissioners. 

(Just like private insurance now, older people pay higher premiums.  Rates will be determined by the same people who decide the rates for private insurance)

Pg 23 - (4) APPEALS.—The Secretary shall establish an appeals process for individuals to appeal a determination of the Secretary--(A) with respect to claims...B) with respect to eligibility determinations made by the Secretary (no outside  recourse) 

Pg 24 - 5) STATE CONTRIBUTION, MAINTENANCE OF EFFORT...the Secretary shall require the State make a maintenance of effort payment each year that the high-risk pool is in effect equal to an amount not less than the amount of all sources of funding for high-risk pool coverage... (Where will your state get the money for its payments?)

Pg 25 - (h) FUNDING; TERMINATION OF AUTHORITY.— (1) IN GENERAL.—There is appropriated to the Secretary, out of any moneys in the Treasury not otherwise appropriated, $5,000,000,000 to pay claims against (and administrative costs of) the high-risk pool under this section in excess of the premiums collected with respect to eligible individuals enrolled in the high-risk pool. Such funds shall be available without fiscal year limitation.   (2) INSUFFICIENT FUNDS.—If the Secretary estimates for any fiscal year that the aggregate amounts available for payment of expenses of the high-risk pool will be less than the amount of the expenses, the Secretary shall make such adjustments as are necessary to eliminate such deficit, including reducing benefits, increasing premiums, or establishing waiting lists. 

Pg 26 - (3) TERMINATION OF AUTHORITY.— (A) IN GENERAL.—Except as provided in subparagraph (B), coverage of eligible individuals under a high-risk pool shall terminate as of the date on which the Health Insurance Exchange is established. (B) TRANSITION TO EXCHANGE.—The Secretary shall develop procedures to provide for the transition of eligible individuals who are enrolled in health insurance coverage offered through a high-risk pool established under this section to be enrolled in acceptable coverage.

Pg 31 - SEC. 104. SUNSHINE ON PRICE GOUGING BY HEALTH INSURANCE ISSUERS.  The Secretary of Health and Human Services, in conjunction with States, shall establish a process for the annual review of increases in premiums for health insurance coverage. Such process shall require health insurance issuers to submit a justification for any premium increases prior to implementation of the increase.  (Your rates will increase, just as they do now; only the government will decide if your insurer can raise rates and by how much- denials can mean less coverage)

Pg 54 - SEC. 717. PROTECTION AGAINST POSTRETIREMENT REDUCTION OF RETIREE HEALTH BENEFITS. (b) NO REDUCTION.—Notwithstanding that a group health plan may contain a provision reserving the general power to amend or terminate the plan or a provision specifically authorizing the plan to make post-retirement reductions in retiree health benefits...(If your health plan had a clause allowing amendments, reductions or terminations, this Section will still not ensure your coverage will remain unchanged.  If not, your employer can still apply for and be granted a hardship waiver.)

Pg 72 - SEC. 114. STATE HEALTH ACCESS PROGRAM GRANTS. (2) COMMUNITY COVERAGE PROGRAM.—Community coverage with shared responsibility between employers, governmental or nonprofit entity, and the individual. (NOT FREE)  (c) ELIGIBILITY AND ADMINISTRATION.— (1) IMPLEMENTATION OF KEY STATUTORY OR REGULATORY CHANGES.—In order to be awarded a grant under this section for a program, a State shall demonstrate that— (B) it will be able to sustain the program without Federal funding after the end of the period of the grant.  (That means the State has to get the money from somewhere...a state income tax? a higher sales tax? increase in property tax?)

Pg 75 - (B), no grant may be awarded to a State unless the State demonstrates the seriousness of its effort by matching at least 20 percent of the grant amount through non-Federal resources, which may be a combination of State, local, private dollars from insurers, providers, and other private organizations. 

Pg 77 - (2) GOALS FOR FINANCIAL AND ADMINISTRATIVE TRANSACTIONS. (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, on a specific date or range of dates,... (Your financial records are immediately accessible in order to determine if you are allowed certain services and if so when, where, and by which doctor.)

Pg 79 - (B) require paper versions of standardized transactions... (D) require timely and transparent claim and denial management processes

Pg 91 - SEC. 201. REQUIREMENTS REFORMING HEALTH INSUR17ANCE MARKETPLACE.SEC. 202. PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE. (1) LIMITATION ON NEW ENROLLMENT.— (A) IN GENERAL.—Except as provided in this paragraph, the individual health insurance issuer offering such coverage does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day of Y1.  (You cannot buy private insurance after the government plan starts) (2) LIMITATION ON CHANGES IN TERMS OR CONDITIONS.—Subject to paragraph (3) and except as required by law, the issuer does not change any of its terms or conditions, including benefits and cost-sharing, from those in effect as of the day before the first day of Y1.  (With the exception of raising your premiums as allowed by the gov't, your insurance policy cannot change at all once the government plan starts; otherwise it is not considered "acceptable coverage")

Pg 92 - (b) GRACE PERIOD FOR CURRENT EMPLOYMENT-BASED HEALTH PLANS. (A) IN GENERAL.—The Commissioner shall establish a grace period whereby, for plan years beginning after the end of the 5-year period beginning with Y1, an employment-based health plan in operation as of the day before the first day of Y1 must meet the same requirements as apply to a qualified health benefits plan under section 201, including the essential benefit package requirement under section 221.  (After 5 years, private insurance must conform to the government’s required coverage)

Pg 94 - (c) LIMITATION ON INDIVIDUAL HEALTH INSURANCE COVERAGE.— (1) IN GENERAL.—Individual health insurance coverage that is not grandfathered health insurance coverage under subsection (a) may only be offered on or after the first day of Y1 as an Exchange-participating health benefits plan. (Again, if you don’t have private insurance when the government plan goes into effect, you cannot buy it - you must enroll in the government insurance.  Dental and vision  insurance are not included in your health plan - you must buy it separately)

Pg 96 - SEC. 213. INSURANCE RATING RULES.  a) IN GENERAL.—The premium rate charged for a qualified health benefits plan that is health insurance coverage may not vary except as follows:  (1) LIMITED AGE VARIATION PERMITTED.—By age (within such age categories as the Commissioner shall specify) so long as the ratio of the highest such premium to the lowest such premium does not exceed the ratio of 2 to 1. (2) BY AREA.

(c) STUDY AND REPORTS.— (A) The types of employers by key characteristics, including size, that purchase insured products versus those that self-insure.  (C) The financial solvency and capital reserve levels of employers that self-insure by employer size.  (2) REPORTS. (1). Such report shall include any recommendations the Commissioner deems appropriate to ensure that the law does not provide incentives for small and midsize employers to self-insure.

Pg 100 - SEC. 215. ENSURING ADEQUACY OF PROVIDER NETWORKS.  (b) INTERNET ACCESS TO INFORMATION.  The Commissioner shall also establish an on-line system whereby an individual may select by name any medical provider (as defined by the Commissioner) and be informed of the plan or plans with which that provider is contracting.  (Not all doctors will take all insurance plans - just like the current system)

Pg 104 - SEC. 222. ESSENTIAL BENEFITS PACKAGE DEFINED.  (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... (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... (11) Durable medical equipment, prosthetics, orthotics and related supplies. 

(1) NO COST-SHARING FOR PREVENTIVE SERVICES.—There shall be no cost-sharing under the essential benefits package for— #8 and #10 above only. (Cost sharing does not mean premiums or balance billing)

Pg 107 - (A) ANNUAL LIMITATION.—The cost-sharing incurred under the essential benefits package with respect to an individual (or family) for a year...is not to exceed $5,000 for an individual and not to exceed $10,000 for a family. Such levels shall be increased (rounded to the nearest $100) for each subsequent year (Sounds just like private insurance, doesn't it? Only after this bill passes, you won't have the choice to pick the plan that is right for you)

Pg 110 -  (4) ABORTION SERVICES.— (A) ABORTIONS FOR WHICH PUBLIC FUNDING IS PROHIBITED.—The services described in this subparagraph are abortions for which the expenditure of Federal funds appropriated for the Department of Health and Human Services is not permitted, based on the law as in effect as of the date that is 6 months before the beginning of the plan year involved. (B) ABORTIONS FOR WHICH PUBLIC FUNDING IS ALLOWED.—The services described in this subparagraph are abortions for which the expenditure of Federal funds appropriated for the Department of Health and Human Services is permitted, based on the law as in effect as of the date that is 6 months before the beginning of the plan year involved. 

Pg 147 - (a) NO PREEMPTION OF STATE LAWS REGARDING ABORTION. (b) NO EFFECT ON FEDERAL LAWS REGARDING ABORTION.

Pg 110 -  SEC. 223. HEALTH BENEFITS ADVISORY COMMITTEE.  (a) ESTABLISHMENT.— (1) IN GENERAL.—There is established a private-public advisory committee which shall be a panel of medical and other experts to be known as the Health Benefits Advisory Committee to recommend covered benefits and essential, enhanced, and premium plans. 

Pg 129 - SEC. 240. DISSEMINATION OF ADVANCE CARE PLANNING INFORMATION. (a) IN GENERAL.—The QHBP offering entity — (1) shall provide for the dissemination of information related to end-of-life planning to individuals seeking enrollment in Exchange-participating health benefits plans offered through the Exchange

Pg 132 - SEC. 242. DUTIES AND AUTHORITY OF COMMISSIONER.  (2) COMPLIANCE EXAMINATION AND AUDITS.— (B) RECOUPMENT OF COSTS IN CONNECTION WITH EXAMINATION AND AUDITS.—The Commissioner is authorized to recoup from qualified health benefits plans reimbursement for the costs of such examinations and audit of such QHBP offering entities.  (Costs to your insurer are usually passed on to you. With new gov't interference, if costs rise but the company can't cover that with higher premiums they will likely end up out of business which forces you on to the govt plan)

Pg 167 - SEC. 303. BENEFITS PACKAGE LEVELS. b) LIMITATION ON HEALTH BENEFITS PLANS OFFERED BY OFFERING ENTITIES.—The Commissioner may not enter into a contract with a QHBP offering entity under section 304(c) for the offering of an Exchange-participating health benefits plan in a service area unless the following requirements are met: (1) REQUIRED OFFERING OF BASIC PLAN. (2) OPTIONAL OFFERING OF ENHANCED PLAN. (3) OPTIONAL OFFERING OF PREMIUM PLAN. (4) OPTIONAL OFFERING OF PREMIUM-PLUS PLANS

Pg 169 - ...plan is a premium plan that also provides additional benefits, such as adult oral health and vision care, approved by the Commissioner.

Pg 184 - (2) ENROLLMENT PERIODS.— (A) OPEN ENROLLMENT PERIOD. Such periods shall be during September through November of each year...

Pg 185 - 3) AUTOMATIC ENROLLMENT FOR NON-MEDICAID ELIGIBLE INDIVIDUALS.

Pg 195 - SEC. 307. HEALTH INSURANCE EXCHANGE TRUST FUND.  (a) ESTABLISHMENT OF HEALTH INSURANCE EXCHANGE TRUST FUND.  (c) TRANSFERS TO TRUST FUND.— (A) TAXES ON INDIVIDUALS NOT OBTAINING ACCEPTABLE COVERAGE. (B) EMPLOYMENT TAXES ON EMPLOYERS NOT PROVIDING ACCEPTABLE COVERAGE. (C) EXCISE TAX ON FAILURES TO MEET CERTAIN HEALTH COVERAGE REQUIREMENTS. (2) APPROPRIATIONS TO COVER GOVERNMENT CONTRIBUTIONS. (they're going to tax us all to death)

Pg 216 - regarding the “public option”: SEC. 323. PAYMENT RATES FOR ITEMS AND SERVICES.  (3) INNOVATIVE PAYMENT METHODS. (c) LIMITATIONS ON REVIEW.—There shall be no administrative or judicial review of a payment rate or methodology established under this section or under section 324.  SEC. 324. MODERNIZED PAYMENT INITIATIVES AND DELIVERY SYSTEM REFORM.  The payment mechanisms and policies under this section may include patient-centered medical home and other care management payments, accountable care organizations, value-based purchasing, bundling of services (currently illegal in Florida), differential payment rates, performance or utilization based payments, partial capitation, and direct contracting with providers. 

Pg 256 -SEC. 345. INCOME DETERMINATIONS. (2) INCOME VERIFICATION.— (i) the Commissioner shall request from the Secretary of the Treasury the disclosure to the Commissioner of such information as may be permitted to verify the information contained in such application;  (tax returns; guidelines for reporting to the gov’t changes to your income)

Pg 283 - (b) ENFORCEMENT OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS. (Monetary penalties charged to employers who “fail to satisfy the health coverage participation requirements” will not go into the healthcare fund to help offset expenses): (F) DEPOSIT OF PENALTY COLLECTED.— Any amount of penalty collected under this paragraph shall be deposited as miscellaneous receipts in the Treasury of the United States. (Don't you think those fines should go into the healthcare fund instead?)

Pg 298 - SEC. 501. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE COVERAGE.  (1) TAX LIMITED TO AVERAGE PREMIUM.— (A) IN GENERAL.—The tax imposed under subsection (a) with respect to any taxpayer for any taxable year shall not exceed the applicable national average premium for such taxable year. 

Pg 304 - (6) NOT TREATED AS  TAX IMPOSED BY THIS CHAPTER FOR CERTAIN PURPOSES.—The tax imposed under this section shall not be treated as tax imposed by this chapter for purposes of determining the amount of any credit under this chapter or for purposes of section 55. (You have to pay a penalty called a “tax” but can’t deduct it on your tax return for credit as a tax paid.)

Pg 305 - SEC. 6050X. RETURNS RELATING TO HEALTH INSURANCE COVERAGE. (a) REQUIREMENT OF REPORTING.—Every person who provides acceptable coverage (as defined in section 59B(d)) to any individual during any calendar year shall, at such time as the Secretary may prescribe, make the return described in subsection (b) with respect to such individual.  (Your employer is required to file a return with an as yet unnamed government dept containing your personal info and social security number or be penalized - undoubtedly that will cause some kind of reconciliation on our private returns, too)

Pg 313 - (c) EMPLOYERS ELECTING NOT TO PROVIDE HEALTH BENEFITS.— (1) IN GENERAL.—In addition to other taxes, there is hereby imposed on every nonelecting employer an excise tax, with respect to having individuals in his employ, equal to 8 percent of the wages... 

Pg 318 - SEC. 45R. SMALL BUSINESS EMPLOYEE HEALTH COVERAGE CREDIT. (1) IN GENERAL.—For purposes of this section, the applicable percentage is 50 percent. (2) PHASEOUT BASED ON AVERAGE COMPENSATION OF EMPLOYEES.—In the case of an employer whose average annual employee compensation for the taxable year exceeds $20,000, the percentage specified in paragraph (1) shall be reduced by a number of percentage points which bears the same ratio to 50 as such excess bears to $20,000.  (The small employer’s credit for paying your premiums is only 50% of his cost, which means less money for raises, improvements, new hires, etc and is further reduced or phased out the higher your salary is)

(2) CREDIT NOT ALLOWED WITH RESPECT TO CERTAIN HIGHLY COMPENSATED EMPLOYEES (making $80,000 or more) (3)CREDIT ALLOWED FOR ONLY 2 TAXABLE YEARS.

Pg 324 - PART 3—LIMITATIONS ON HEALTH CARE RELATED EXPENDITURES.  

SEC. 531. DISTRIBUTIONS FOR MEDICINE QUALIFIED ONLY IF FOR PRESCRIBED DRUG OR INSULIN. 

Pg 337 - SEC. 59C. SURCHARGE ON HIGH INCOME INDIVIDUALS.

Pg 339 - SEC. 552. EXCISE TAX ON MEDICAL DEVICES.  (a) IN GENERAL.—There is hereby imposed on the first taxable sale of any medical device a tax equal to 2.5 percent of the price for which so sold. (2) LEASE TREATED AS SALE. (3) USE TREATED AS SALE.  (Your doctors or hospitals will pay an EXTRA tax when they purchase devices and equipment to be used to treat you)

Pg 429 - D) ADJUSTMENT IN TECHNICAL COMPONENT DISCOUNT ON SINGLE-SESSION IMAGING INVOLVING CONSECUTIVE BODY PARTS. III) ADDITIONAL REDUCED PAYMENT FOR MULTIPLE IMAGING PROCEDURES. (When you have more than one body part scanned on a visit, the facility discounts the second test by 50%; the gov’t will change that to 75%  and pay the facility even less) 

Pg 441-446 - SEC. 1151. REDUCING POTENTIALLY PREVENTABLE HOSPITAL READMISSIONS.  (1) IN GENERAL.—With respect to payment for discharges from an applicable hospital (as defined in paragraph (5)(C)) occurring during a fiscal year beginning on or after October 1, 2011, in order to account for excess readmissions in the hospital, the Secretary shall reduce the payments that would otherwise be made to such hospital... (Penalizing hospitals, doctors, skilled nursing and rehab facilities, and home health agencies for additional if a patient has to be readmitted after being discharged - timeframe determined by the gov’t; and there is no challenge allowed.  Life happens - human beings aren’t machines!) (6) LIMITATIONS ON REVIEW.—There shall be no administrative or judicial review..

If you would like a copy of the original bill in PDF format, or any other information, please contact me at

MissJaneQPublic@gmail.com

Feel free to forward this information – Knowledge is Power