Category News

HHS has commissioned the Institute of Medicine to conduct  a study on the Essential health Benefits of the health care law.  They are to recommendations will lead to how Essential health benefits are determined. This is a huge aspect of the law. Right now we have an idea of what these essential benefits are.  Anthem Essential Health Benefits   There is real concern on transparency with the HHS on this topic. When these benefits are determined it will have a huge impact on Health Insurance. 

1. Elimination of lifetime limits on essential health benefits (effective for plan years starting on or after September 23, 2010)

2. Restricted annual limits on essential health benefits (effective for plan years starting on or after September 23, 2010)

3. Requirement that employers of 50 or more employees provide minimum essential coverage that includes the essential health benefits package (effective in 2014)

4. Requirement that qualified health plans offered in exchanges include the essential health benefits package (effective in 2014)

Allergy injections and/or testing


Ambulatory surgical services

Asthma education

Bariatric surgery

Cardiac rehab

Chiropractic manipulation services and/or osteopathic manipulation

Diabetic supplies and glucometers

Diagnostic services

Dialysis and kidney disease treatment

Durable medical equipment, medical equipment and supplies, oxygen

Emergency room services

Enteral formula and modified low protein food products

Hearing aid

Home health care


Infusion therapy, home infusion therapy

Inpatient or outpatient facility services

Inpatient rehab/physical therapy


Mental health/substance abuse inpatient and/or outpatient

Office visits

Ostomy supplies

Outpatient occupational therapy

Outpatient physical therapy

Outpatient speech therapy

Pharmacy and prescription drugs/injections

Preventive care and preventive screenings

Prosthetic devices or limbs

Pulmonary or respiratory rehab/therapy

Skilled nursing

Surgical and anesthesia services

Transplant service

Treatment of TMJ


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The Administration of the new health law sent a memo out giving  Flexibility for State Run Exchanges. This is in response to the Governor’s Letter to HHS early this week.

The memo is stating that the states already have the power to set up the exchanges as they see fit. The Governors letter points out some serious issue and there need to be more than just memo addressing them.

The exchanges are going to change the way people purchase health insurance and what option they have available. There is real concerns that the exchanges will not be competitively priced. There is also some fear that the carriers could decide not to participate in the exchanges but compete against it.

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Most universities offer some type of health insurance plan to the students. Most of these plans would be consider Limited liability health plans. The usually are guaranteed issue. Well now under the new health care law all of these plans will have to adapt to the new health care laws. College Students Health Insurance

This will create some very interesting situations. The first impact will be a huge increase in premium.  Once these plans become true health insurance products they will no longer be able to offer low premiums.  There are many college student groups that are praising this measure but will they still be happy when they see the new premiums?

It will be very interesting to see what kind of changes these plans adopt.

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Right now there is a lot of confusion on how the health insurance exchanges are going to be set up. There are states like South Carolina that have told the Federal Gov. they will not set up an exchange because they do not believe the law is constitutional. Then there are states like California that are on the fast track to set up an exchange. State Health Exchange

Then we here from conservative states that they want full control over how the exchanges are set up. They want waivers to the health care law so they can make plans affordable.Governor’s Letter to HHS

Now all of sudden we hear politicians talking about removing funding for the health care law so that implementation has to stop. Defund Health Law

Next the white house is stating that they are not backing down from the individual mandate. White House Supports Mandate

It’s very hard at this time to get a clear picture of where health insurance and health care is going.

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Governor’s Letter to HHS

Here is the Governor’s letter to  Kathleen Sebelius Secretary U.S. Department of Health and Human Services.

This letter is stating that the states should have the right to setup the health exchange without the federal governments mandates.  This is a huge statement!  These governors realize that the federal mandates will make the plans in the exchange unaffordable. So the states want to develop the plans with cost in the equation. Not everyone needs or wants the same level of benefits.

The other major factor here is the medicaid. The states cannot afford the expansion of medicaid either in enrollment or increased benefits.

The list of Governor’s that signed
Governor Rick Perry of Texas
Governor Gary R. Herbert of Utah
Governor Scott Walker of Wisconsin
Governor Dennis Daugaard of South Dakota
Governor Bill Haslam of Tennessee
Governor Tom Corbett of Pennsylvania
Governor Nikki Haley of South Carolina
Governor Terry E. Branstad of Iowa
Governor Sam Brownback of Kansas
Governor Bobby Jindal of Louisiana
Governor Paul R. LePage of Maine
Governor Haley Barbour of Mississippi
Governor David Heineman of Nebraska
Governor Brian Sandoval of Nevada
Governor Susana Martinez of New Mexico
Governor John R. Kasich of Ohio
Governor Mary Fallin of Oklahoma
Governor Robert J. Bentley of Alabama
Governor Nathan Deal of Georgia
Governor C.L. “Butch” Otter of Idaho
Governor Mitch Daniels of Indianapolis

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The monthly option helps you pay for health insurance as you go.

  • You pay 20% of your premiums to the IRS each month
  • The IRS adds 80% and sends the full payment to your health plan

The health coverage tax credit (HCTC) began in 2002 as an effort to make health care affordable for certain families by allowing taxpayers to pay only 20% of health insurance premiums. The HCTC was expanded in 2009 under the American Recovery and Reinvestment Act and is available on a monthly basis to help pay for health insurance as you go, or on a yearly basis when you file your federal income tax return. If you opt to receive the credit on your federal income tax return, you’ll need to file a federal form 8885, Health Coverage Tax Credit together with your return. Like the adoption credit for 2010, the HCTC is refundable. To qualify for the credit, you must be receiving Trade Adjustment Assistance (TAA) benefits — including Reemployment (RTAA) or Alternative (ATAA) — or receiving pension payments from the Pension Benefit Guaranty Corporation (PBGC) and be 55 years old or older. To see if you qualify, check out the IRS website.

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 Judge Roger Vinson, in Pensacola, FlaVinson wrote 

“I must reluctantly conclude that Congress exceeded the bounds of its authority in passing the act with the individual mandate. That is not to say, of course, that Congress is without power to address the problems and inequities in our health care system. The health care market is more than one-sixth of the national economy, and without doubt Congress has the power to reform and regulate this market. That has not been disputed in this case. The principal dispute has been about how Congress chose to exercise that power here,”

It looks like this issue will go to the Supreme Court.

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Here at Nefouse and Associates we know how everyone enjoys watching C-Span especially when it comes to health insurance.  So I have watched it for you and will give you the update.

Health and Human Services Secretary Kathleen Sebelius testified on the impact of the 2010 health care law. The Secretary job is to interpret, clarify and install the health care law. She was asked specific questions by Senators about the law.

The chairman of the committee helped right the law so he was very happy to praise the law and not ask any difficult questions.
The next Senator was Mike Enzi  and his questions were geared towards the child stand alone policies. Under the law children under 19 are guaranteed issue and many carriers have pulled out of this market. So the Senator goes on to ask what is the Secretary doing to address the issue.  The Secretary responded that the states should force carriers to cover these markets.  The Senator asked specific questions about parents gaming the system by waiting until the child needs care to take out a policy.  The Secretary did not give a clear answer on this.

Senator All Franken was up next. He really tried to simplify the health care law by comparing it to a 3 legged stool.  There was not a lot of substance there. Almost to the point you wanted to ask him had he done his homework? The Senator did speak about Medical Loss Ratio and how it was his idea.

Senator John McCain was very prepared for this hearing. He asked about all the waivers that had been given to companies and why not make them permanent.  The Secretary assured the Senator that these companies just need time to adapt to the health care law. The Senator then asked about waivers for Medicaid so states could reach their budgets. The Secretary stated certain areas of Medicaid would not be eligible for waivers. Then The Senator ask if Malpractice caps could be introduced and if the Secretary would support it. She said Yes.

Senator Jeff Bigaman talked about the Work Force Commission and how those resources would help stream line health care services.  The Secretary spoke of the potential role this commission would have.

Senator Michael Bennett addressed the costly issue of readmission of Medicare Beneficiary. This was addressing the cost of Seniors on Medicare having multiple admissions to a hospital. He stressed the issue of Transitional Care  and a more Effective delivery model. The Secretary spoke on progress of these areas.

Senator Pat Roberts spoke about his past history with the Secretary and her family.  Then he addressed the head of the CMS and then talked about Independent Advisory Boards with regards to the Emergency Access centers in his home state.  The Senator was making statement rather than asking about questions.  There was no explanation on why this board needed to address ER access and who is even on this board.

Senator Jack Reed was stressing that the Mandatory coverage aspect of the law was pushed by the Insurance Industry.  He was stressing maybe even blaming the insurance industry for this mandate. The Secretary then “schooled” the Senator on how a Private Insurance Market stays Solvent and without the mandate the market would incur adverse selection.

Senator Richard Burr talked about the cost of the reform law. He pointed out that CMS had recently released a $200 billion short fall on the health care reform. The Secretary very calmly recognized that loss and did not dispute that. The Senator then asked a tough question about the Medical Device Tax that will lead to increase cost.  The Secretary did not agree the tax would increase the overall costs.

Senator Bernie Sanders talked about community health centers and how investing into them will lower cost down the road.  The Secretary agreed.

Senator Kay Hagan talked about children being allowed to stay on a parents group health plan until 26. She spoke about her personal experience and then the Secretary talked about her personal experience of finding her adult child a health insurance policy.

Senator Patty Murray spoke about how the law is going to make premium increases more transparent. The Secretary went on to explain that premium increases have to be justified by the carriers and the federal Gov. is giving resources to review those areas. The Secretary also explained how more information about the insurance company was going to be public record. So you can look up how many claims have denied by a carrier and so on.

So there you have a hour and half of testimony summarized into a blog posting.

I thought the Secretary was prepared for this hearing she did a good job explaining certain aspects of the law.  Where I feel she is letting the country down is on the cost of the law. There was only one Senator that asked about the cost.  Only 3 Senators really asked tough questions the rest were set up questions for the Secretary to explain. There is 2,700+ pages of this law and then 1,000’s more  pages clarifying the law.  The Senate should have asked much deeper questions.

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