Pre-Existing Conditions

[Emit]

Side-by-Side Comparison:

Changes to Private Insurance:

Senate Bill
Patient Protection and Affordable Care Act
(H.R. 3590)

Establish a temporary national high-risk pool to provide health coverage to individuals with pre-existing medical conditions. U.S. citizens and legal immigrants who have a pre-existing medical condition and who have been uninsured for at least six months will be eligible to enroll in the high-risk pool and receive subsidized premiums. Premiums for the pool will be established for a standard population and may vary by no more than 4 to 1 due to age; maximum cost-sharing will be limited to the current law HSA limit ($5,950/individual and $11,900/family in 2010). Appropriate $5 billion to finance the program. (Effective within 90 days of enactment until January 1, 2014)

~snip~

Prohibit individual and group health plans from placing lifetime limits on the dollar value of coverage and prohibit insurers from rescinding coverage except in cases of fraud. Prohibit pre-existing condition exclusions for children. (Effective six months following enactment) Beginning in January 2014, prohibit individual and group health plans from placing annual limits on the dollar value of coverage. Prior to January 2014, plans may only impose annual limits on coverage as determined by the Secretary.

House Bill
Affordable Health Care for America Act
(H.R. 3962)

Establish a temporary national high-risk pool to provide health coverage to individuals (and spouses and dependents) with pre-existing medical conditions. Individuals who have been denied coverage, offered unaffordable coverage, have an eligible medical condition or who have been uninsured for at least six months will be eligible to enroll in the national high-risk pool. Premiums for the high-risk pool will be set at not higher than 125% of the prevailing rate for comparable coverage in the state and could vary by no more than 2:1 due to age; annual deductibles will be limited to $1,500 for an individual; and maximum cost-sharing will be limited to $5,000 for individuals. (Effective January 1, 2010 and until the Health Insurance Exchange is established)

~snip~

Limit pre-existing condition exclusions for group policies prior to implementation of the insurance market reforms by shortening the period plans can look back for pre-existing conditions from six months to 30 days and shortening the period plans can exclude coverage of certain benefits from 12 months to three months. (Effective January 1, 2010)

~snip~

Impose the same insurance market regulations relating to guarantee issue, premium rating, and prohibitions on pre-existing condition exclusions in the insured group market and in the Exchange. (See creation of insurance pooling mechanisms.) (Effective January 1, 2013)

White House/Congressional Leadership Reconciliation Bill
Health Care and Education Affordability Act of 2010
(H.R. 4872)

(Note: The reconciliation bill makes changes to the Patient Protection and Affordable Care Act passed by the Senate. The summary below includes the Senate bill language and incorporates changes to particular provisions made by the new legislation. The changes are identified by italicized text. If a provision was not addressed by the reconciliation bill, the Senate bill language has remained unchanged.)

Establish a temporary national high-risk pool to provide health coverage to individuals with pre-existing medical conditions. U.S. citizens and legal immigrants who have a pre-existing medical condition and who have been uninsured for at least six months will be eligible to enroll in the high-risk pool and receive subsidized premiums. Premiums for the pool will be established for a standard population and may vary by no more than 4 to 1 due to age; maximum cost-sharing will be limited to the current law HSA limit ($5,950/individual and $11,900/family in 2010). Appropriate $5 billion to finance the program. (Effective within 90 days of enactment until January 1, 2014)

~snip~

Prohibit individual and group health plans from placing lifetime limits on the dollar value of coverage and prohibit insurers from rescinding coverage except in cases of fraud. Prohibit pre-existing condition exclusions for children. (Effective six months following enactment) Beginning in January 2014, prohibit individual and group health plans from placing annual limits on the dollar value of coverage. Prior to January 2014, plans may only impose annual limits on coverage as determined by the Secretary.

Grandfather existing individual and group plans with respect to new benefit standards, but require these grandfathered plans to extend dependent coverage to age 26, prohibit rescissions of coverage, and eliminate waiting periods for coverage of greater than 90 days. Require grandfathered group plans to eliminate lifetime limits on coverage and beginning in 2014, eliminate annual limits on coverage. Prior to 2014, grandfathered group plans may only impose annual limits as determined by the Secretary. Require grandfathered group plans to eliminate pre-existing condition exclusions for children within six months of enactment and by 2014 for adults. (Effective six months following enactment, except where otherwise specified)

~snip~

Impose the same insurance market regulations relating to guarantee issue, premium rating, and prohibitions on pre-existing condition exclusions in the individual market, in the Exchange, and in the small group market (See new rating and market rules in Creation of insurance pooling mechanism.) (Effective January 1, 2014)

http://www.kff.org/healthreform/sidebyside.cfm

[girl gone mad]

1. I don't understand how they can tout "no lifetime limits" while there are still annual caps.

Unless I've been misinformed, humans all have an expiration date.

[Warren Stupidity]

3. an annual cap is not a lifetime limit.

You can exceed a lifetime limit and still be alive. You can exceed an annual cap, and start again the next year at zero. I think annual caps are another disgrace in this bill that should be undone as soon as possible, but removing lifetime caps is definitely a good thing not undone by annual caps.

[girl gone mad]

4. Okay, but as long as there are still finite annual caps...

and as long as humans still have a finite lifespan, there are effectively lifetime limits.

[hobbit709]

11. It's capped and you can't afford the treatment for the rest of that year

Then it's an END of life cap.

[Warren Stupidity]

12. That is possible.

Like I said, I think it is wrong. However claiming that it is a lifetime cap is dishonest. This bill ends lifetime caps and that is a good thing.

[joycean]

5. Annual caps WILL also be eliminated (for group plans)

According to the three House committees that prepared a summary of H.R. 4872, annual limits will be restricted after 6 months, and prohibited in 2014 for adults.

Sec. 2301. Insurance Reforms. Extends the prohibition of lifetime limits, prohibition on rescissions, and a requirement to provide coverage for non-dependent children up to age 26 to all existing health insurance plans starting six months after enactment. Starting in 2014, extends the prohibition on excessive waiting periods to existing health plans. For group health plans, prohibits pre-existing condition exclusions in 2014 (for children, they are prohibited starting six months after enactment), restricts annual limits beginning six months after enactment, and prohibits them starting in 2014. For coverage of non-dependent children prior to 2014, the requirement on group health plans is limited to those adult children without an employer offer of coverage

summary can be found at http://www.rules.house.gov/111_hr4872_secbysec.html

[Emit]

7. For both individual and group plans according to the info in the OP

Senate Bill
Patient Protection and Affordable Care Act
(H.R. 3590)
... Beginning in January 2014, prohibit individual and group health plans from placing annual limits on the dollar value of coverage. Prior to January 2014, plans may only impose annual limits on coverage as determined by the Secretary. ...


White House/Congressional Leadership Reconciliation Bill
Health Care and Education Affordability Act of 2010
(H.R. 4872)
... Beginning in January 2014, prohibit individual and group health plans from placing annual limits on the dollar value of coverage. Prior to January 2014, plans may only impose annual limits on coverage as determined by the Secretary. ...

... Require grandfathered group plans to eliminate lifetime limits on coverage and beginning in 2014, eliminate annual limits on coverage. Prior to 2014, grandfathered group plans may only impose annual limits as determined by the Secretary. ...

[EFerrari]

2. Emit, you and I disagree on this bill but I appreciate your efforts

to keep the discussion civil and factual.

[Emit]

6. Thanks, EFerrari, for the kind words

I think we probably disagree only somewhat, though, because it's not what I wanted, it's hardly what anyone here really wanted (assuming most here are in fact progressives, democrats, liberals, etc. and not freeper and James O'Keefe plants, lol). We all wanted more.

But, it's what we have now, and it needs to pass, imho, or we may never have the chance again in my lifetime.

During my time in the trenches at state voc rehab and mental health, I have sat across from far too many desperate clients ~ clients who have lost everything, who need basic health care, who are caught between a rock and a hard place all too often. I have worked in the trenches too long to turn my back on what may be a foot in the door, I think, at least.

With regard to keeping the discussion civil and factual, I don't like the dissension since I have been back at DU ~ the separation into camps, the petty bickering and mean name calling, and the increasing hyperbolic disinformation. I find it worse than the primaries! I am far less a cheerleader than just trying to point out the pros and cons, as factually as possible, and to keep us honest, or ... perhaps just to convince myself that this bill may provide something positive in the midst of chaos, waning hope and growing disappointment.

:hi:

[eridani]

8. Fuck your high risk pool garbage! States already have these shitty alternatives

--and they help no one. You pay more than a typical mortgage payment for very high deductibles. Totally worthless.

[eomer]

9. What's your basis for that?

The new federal high-risk pool requires premiums charged to be at standard rates for standard populations (in other words, not high-risk rates).

Premiums currently charged by state high-risk pools are capped at anywhere from 125% to 200% of standard rates.

What's your basis for saying the federal pool will be too expensive? Am I missing something?

Here's the relevant section from the Senate bill:

(C) ensures that with respect to the pre-
mium rate charged for health insurance coverage
offered to eligible individuals through the high
risk pool, such rate shall—

.
.
.

(iii) be established at a standard rate
for a standard population; and


.
.
.

http://democrats.senate.gov/reform/patient-protection-affordable-care-act-as-passed.pdf

edit: clarity of wording

[eridani]

13. And the "standard rate" is already outrageously high

It is going to be unaffordable to the people who need it.

[eomer]

14. Just like it is unaffordable to everyone else.

Agreed then. People in the high-risk pool will be in the same boat as the rest of us, which is not good for them or for us.

[gleaner]

10. My husband had MRSA in 2008 ...

It is an antibiotic resistant strain of staph. It was all through his body. It nearly destroyed his heart and left him with lung damage, liver damage, and damage to his bone marrow so that his blood does not clot properly. It took away his ability to walk and the doctors told us that no one knows if he will ever recover from it beyond being bedridden and nearly helpless because people usually die of it. They don't have experience with survivors.

I write this by way of explaining why an annual cap would have killed him and left us even closer to complete and utter poverty than we are. His room cost alone at the non profit hospital which helped make his insurance pay it was. $1,500,000. That did not include doctors and tests and medication. But without acute care he would never have survived. So in 2008 a yearly cap would have been a death sentence for him. I am still waiting to see what other shoe will drop when it comes to a lifetime max. Most insurance polices already have that and I cannot see them giving it up easily.

I appreciate the time and care you took with your post, and I have tried to answer it in the spirit in which it was written, as an attempt to be helpful. But I do not like this bill. I do not trust the President and I always thought single payer would have helped a lot more people a lot sooner. I regret that this bill is probably going to pass because it will never be revisited. There is no impetus to do so for anyone except the people who want health care instead of health just health insurance. And we are not rich enough to have much influence.

One thing that everyone considering annual caps as an acceptable risk should be aware of is that illnesses like MRSA are no longer rare or confined to medical settings. As the ICU contagion nurse told me it is "in the wild." Which means it is out in the community for everyone. It passes as easily as a case of flu, by hand to hand contact or sneezing on someone. And there are many more catastrophic health conditions like it that no one ever thinks they will get, but somehow they do. Another victim in our area was a high school wrestler who was only 17 and in robust health. He died in three days of MRSA. The doctor of course told us while my husband was waiting for his open heart surgery. You can always trust a healer to say just the right thing at the wrong time.