Healthcare reform, Part 2

The US military:

• Armed Forces retirees should be provided full coverage for all medical expenses from any available care provider.

• Active-duty Armed Forces members should be offered the best public coverage available with minimal copays ($10/visit), low patient percentage (90/10), low out-of-pocket maximum ($1,000/year), no lifetime maximums, and all the frills (included annual wellness exam, vision exam and correction, dental exam, dental correction shares percentage/maximum OoP with medical).

• Effects of duties should be covered in their entirety and separately from personal insurance for the life of the member. For example, a member who suffered loss of hearing in the performance of duties should be provided associated regular exams, correction, and any recommended supplies for life, without regard to length of service or discharge status.

Any reforms should be first enacted at a state level.

Any federal reforms must only be enacted after this point for the purpose of standardization ("regulation").

Public options of healthcare insurance:

• Any public insurance options should compete with private insurance with no subsidies or tax-based funding. No legislation should favor public options, restrict private options, or limit access to private options in any manner.

• Low-income households should be provided the lowest option offered in place of Medicaid.

• Unemployed individuals with a history of employment who are actively seeking employment should be provided the lowest option in addition to any unemployment insurance .

• Government employees under the jurisdiction of the coverage will be provided the lowest option. They may elect to increase their coverage level at their own expense. State representatives will be included in any state option, and federal representatives (United States Senate and Congress members) will be in cluded in any federal option..

• Coverage must be provided for all licensed service providers, whether they be public or private, and for any procedure such service provider advises as medically prudent or necessary. If such a licensed provider does not accept insurance, coverage must provide prompt reimbursement to the insured of any reasonable and customary costs when accompanied by an itemized bill.

• Precertification may be required for non-emergent situations. Procedures may not require more than one day (24 hour) precertification.

Private insurance reforms:

• Individuals and businesses may obtain insurance from providers in any state, provided such coverage meets or exceeds state minimum requirements.

• Lifestyle-oriented coverages should not be mandated. Examples include coverage for maternity, sexually-transmitted diseases, alcohol or drug rehabilitation, counseling, and elective abortion. Such coverages should be at the option of the insurer or subscriber.

• Pre-existing conditions may not prevent coverage or increase premiums.

• Any individual who leaves his/her present employment with employer-provided insurance may transfer any or all coverages to private plans at the same premium rates charged by the insurance provider. In clarification, in the event the employer paid all or part of any premiums, the individual will assume payments of the full premium amounts unless alternative arrangements are made between the parties.

Public and private options:

• If a procedure requires a second opinion, the insurer may not require specified providers be used for the second opinion. The expert opinion of the insured's medical service provider must be accepted and may not be overruled by employees, agents, or contractors of the insurer.

• New and experimental procedures must be accepted on the recommendation and second opinion of the medical service providers of the insured.

• Insurance providers must provide payment to service providers within thirty (30) days of billing.

• Rates billed or negotiated between the insurer and the service provider as part of a business relationship must be accepted as payment in full. If the insurer and the service provider are business affiliates, no portion of any bill may be passed to the insured as being in excess of reasonable and customary. Any disputes in relation to bill details or costs must be resolved between the insurer and the service provider. As an example, if an insurance provider partners with a certain healthcare organization, the details and fees of any member service provider must be accepted as reasonable.

• A service provider who operates in a relationship with a business partner of the insurer must be accepted as in-network with that business partner. As an example, services provided by an anesthesiologist in a partner hospital for a service provided by that hospital cannot be considered out-of-network. A doctor operating in a member office must be deemed in-network with the office unless such separation is clearly stated.

• In cases multiple networks may apply, the greater benefits to the insured will prevail.

• Details of precertified services may not be refused payment unless the care provider specifies such products or services were elective.

Edited 2009/08/16