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MEDLIB-L  September 1993

MEDLIB-L September 1993

Subject:

Clinton Health Plan

From:

Fox Lynne <[log in to unmask]>

Reply-To:

Medical Libraries Discussion List <[log in to unmask]>

Date:

Tue, 21 Sep 1993 09:56:18 MDT

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (1618 lines)

--------- The following is a converted OFFICEPOWER mail message ----------
 
 
       To:  medlib-l
 
       CC:
 
 
  Subject:  Clinton Health Plan              New [*]       Codes:  [        ]
  Message:  I came across the attached on SNURS-L, a student nurse's list,
            and hadn't seen this posted on MEDLIB-L yet.  Hope I'm not
            duplicating something that has already been posted.  WARNING:
            This document is 28 pages long.
 
            Lynne M. Fox, Univ. of Northern CO, Greeley, CO  80639
 
 Priority:  2                Delivery Acknowledge [ ]    View Acknowledge [ ]
 
     From:  Fox Lynne              By:  lfox@GoldnG8           Attachment [*]
 
-------------------------------- ATTACHMENT ------------------------------
 
 Date:         Thu, 16 Sep 1993 00:22:59 -0500
Sender: Student Nurses's List <[log in to unmask]>
From: Jenny Jacobson <[log in to unmask]>
Subject:      AMA Synopsis of Clinton Health System Proposal (20-25 pages) (fwd
              by Jenny)
To: Multiple recipients of list SNURSE-L <[log in to unmask]>
 
Forwarded From: Soumen Nandy <[log in to unmask]>
Subject: AMA synopsis of leaked report
Sender: Med Student Organization/Policy Forum
 <[log in to unmask]>
To: Multiple recipients of list MEDFORUM <[log in to unmask]>
 
===============================================================================
WARNING: THE FOLLOWING IS A VERY LONG POSTING (20-25 PAGES) WHICH I HAVE
         PASSED ON TO MEDFORUM ONLY BECAUSE OF ITS EXTREME CURRENCY.
         IF YOU ARE NOT INTERESTED IN THIS ADVANCE NOTICE OF CLINTON'S
         PLAN, PLEASE TERMINATE THIS LETTER NOW
===============================================================================
                       AMERICAN MEDICAL ASSOCIATION
                   Synopsis of Clinton Health System Proposal
 
                  Provided by the American Medical Association
                                     13 September 1993
 
=================================================
 
        This is a synopsis of the draft of the President's proposal
and not an analysis, which will be developed as further intensive
review/discussion proceeds. Some items are given more detailed
attention than others in this synopsis, depending on relative
importance and due to the brief time for preparation.
 
 
--------------------------------------------------------------------------------
COVERAGE
--------------------------------------------------------------------------------
 
*       All American citizens and legal residents
 
*       A health security card entitles each eligible person to obtain
coverage through a health plan covering a nationally defined
comprehensive benefit package.
 
*       Eligible individuals enroll through health alliances
established by each state, unless covered under designated
government-sponsored programs, which continue
        --      Medicare, DOD, VA, IHS
 
*       Medicaid eligibiles receive coverage through alliances
 
*       Large employers (5,000 employees nationally), Taft-
Hartley plans and rural electric and telephone coops (which cover
5,000 employees), and U.S. Post Office may choose to be their
own self-funded alliance
 
 *       Government employees (federal, state, local) obtain
coverage through state-established alliances
 
*       AFDC/SSI eligibles, whether employed or unemployed,
obtain coverage through state-established alliances paid for by
Medicaid
 
*       Medicare continues for over 65 and disabled, secondary
payor for working 65+ remains, over 65 non-Medicare eligible join
alliances
 
*       Retired under 65 enroll in alliances, pay only 20% share
of premium (presumably government pays rest, unless individual
eligible for employer/pension fund payment of the 80%)
 
*       Obligation of all individuals to enroll in a health plan; those
not enrolling are automatically enrolled when seeking service,
assigned by alliance; newborns assigned if not enrolled through
parent's plan.
 
*       No health plan may cancel person until enrolled in another
plan.
 
 
Employer Mandate
-------------------------
*       Employer pays 80% of weighted-average premium (pro-
rata contribution for part-time employees under 30 hours per
week)
 
*       Self-insured employers (over 5,000 employees) may self-
fund, contract with certified health plan, or join state-established
alliance; they must ensure employees are enrolled in health plan
 
        --      may be required to continue to pay for coverage
for 6 months for terminated employees
        --      may have to pay 1% of payroll to cover
unemployed workers
 
If number of employees fall below 4,800, must join state-
established alliance
 
 
*       Employees pay 20% of weighted average premium for an
average-cost plan chosen through alliance, pay less if chooses
less expensive plan, more for selecting more expensive plan;
employer may pay some or all of employee portion
 
*       Self-employed and unemployed pay both employer and
employee shares, unless eligible for income-based assistance.
 
Enforcement
-----------------
*       By Secretary of Labor
 
Out of Area Coverage
-----------------------------
*       Plan pays under arrangements among alliances
 
 Undocumented Persons and Others
--------------------------------------------------------------------------------
*       Undocumented persons are not eligible for guaranteed
benefits. Employers must still pay premiums for all employees,
regardless of immigration status. Federal funding to continue to
institutions serving large numbers of undocumented persons.
 
        --      states must address in their plans needs of
migrant workers
        --      students obtain coverage through regional alliance
where they attend school, but are covered by parents' policies if
dependents
        --      prisoners remain responsibility of prison system
 
--------------------------------------------------------------------------------
NATIONALLY DEFINED BENEFIT PACKAGE
--------------------------------------------------------------------------------
 
Comprehensive medical, some dental, no lifetime limit except for
orthodontia.
 
*       Hospital, ER, physician services, preventive, mental
health/substance abuse, family planning, pregnancy-related,
hospice, home health, extended care, ambulance, outpatient
lab/diagnostic, outpatient prescription drugs and biologicals,
outpatient rehab, DME and prosthetic and orthotic devices,
vision/hearing care, preventive dental for children, health
education classes.
 
*       Services of physicians and other health professionals
        --      all settings
        --      covers those services a health professional is
legally authorized to perform in state
        --      no state may limit practice of any class of health
professionals except as justified by skill or training of such
professional
        --      benefit package does not require any plan to
reimburse any particular provider or type or category of provider,
but to provide sufficient mix to provide access
 
*       Clinical preventive services
        --      As specified in periodicity schedule, targeted
screening tests and immunizations, periodic medical exams (20-
39/3 yrs; 40-65/2 yrs; 65+/1 yr)
 
*       SNF/Rehab facility
        --      100 days per year
 
*       Vision/hearing
        --      routine eye/ear exams, including refraction
        --      eyeglasses/contact lenses only for children under
18
        --      eye exams limited to one every 2 years for those
over 18
 
 *       Mental health/substance abuse
        --      30 days per episode/inpatient, 60 days per year
        --      inpatient hospital for substance abuse only for
medical detox as needed for psychiatric or medical complications
of withdrawal
        --      outpatient 30 visits per year for psychotherapy
        --      intensive non-residential services - 120 per year
        --      broader coverage by 2001
 
Investigational Treatments
-----------------------------------
*       Covered during an approved research trial
 
Cost Sharing
-----------------
*       Low cost sharing
        --      no deductible
        --      $10 copay for outpatient services
        --      no copay for inpatient
        --      40% coinsurance for point-of-service option
        --      $1,500/$3,000 maximum for out-of-pocket
        --      prescription drugs $5/prescription
 
*       High cost sharing
 
        --      $200/$400, 20% coinsurance
        --      $1,500/$3,000 out-of-pocket maximum
        --      above amounts include both inpatient and
outpatient, but deductible and coninsurance do not apply to
preventive care
        --      prescription drugs $250 per year deductible; 20%
coinsurance; out-of-pocket maximum applies
 
*       Combination
        --      low cost sharing if use preferred providers; higher
cost sharing (20% coinsurance) for out-of-network providers;
same out-of-pocket maximum
 
--------------------------------------------------------------------------------
NATIONAL HEALTH BOARD
--------------------------------------------------------------------------------
 
Independent board to set national standards and oversee
establishment and administration of new system.
 
*       establishes requirements for state plans, monitors
compliance
 
*       interprets/updates benefit package and issues
regulations, recommends changes to President/Congress
 
*       issues regulations for implementation of national health
spending budget and enforces budget
 
 *       establishes and manages a quality management and
improvement system
 
*       makes public declarations on reasonableness of "launch
prices" of breakthrough drugs; no authority to set or control drug
prices
 
*       applies performance standards and accountability to
state-established and corporate alliances
 
*       Membership
 
        --      Seven members appointed by President; one
representing the states, chair appointed by President to serve
maximum of three four-year terms; others serve maximum of two
four-year terms; serve as federal employees and no other
employment during term; "may not have a pecuniary interest in or
hold an official relation to any health care plan, health care
provider, insurance company, pharmaceutical company, medical
equipment company or other affected industry."
 
*       National Administration
 
        --      Reviews alliance plans submitted by states
(corporate alliances supervised through ERISA and Department
of Labor). Secretary of HHS can withhold federal health dollars to
states not in compliance, also can establish one or more alliances
or contract with private parties to do so. Secretary of Treasury will
impose a payroll tax on all employers in state not in compliance
to fund federally established state alliance.
 
--------------------------------------------------------------------------------
STATE RESPONSIBILITIES
--------------------------------------------------------------------------------
 
*       State Plans
 
        --      states submit plans for implementation of health
reform to National Health Board.  States must:
                --      administer subsidies
                --      certify health plans
                --      financially regulate plans
                --      administer data collection, quality
management/improvement
                --      establish and provide for governance of
health alliances and advisory bodies.
 
*       Establishment of Alliances
 
        --      by no later than January 1, 1997, each state must
establish one or more health alliances, assure that all eligible
individuals enroll and are provided the comprehensive benefit
package
        --      alliance size must ensure "it controls adequate
market share to negotiate effectively with health plans."
        --      states may establish only one alliance if they
choose
 
 *       State Regulation of Plans
 
        --      states ensure that alliances establish risk-
adjustment mechanisms meeting federal standards
        --      states qualify health plans to participate in
alliances (measure quality, financial stability, capacity, must
disclose criteria necessary to become a qualified health plan)
        --      states ensure all individuals have plan available at
a price equal to or less than weighted-average premium
        --      states may not regulate premium rates, except for
budget or solvency purposes
        --      state establishes capital standards (minimum of
$500,000), financial reporting, auditing, and guaranty fund if plan
fails
        --      if plan fails, providers must continue services until
person enrolled in new plan
 
*       Single-Payor Option
 
        --      a state may establish a single-payor health care
system rather than an alliance system; state may establish a
single-payor alliance for portion of state. Single payor system
would need to comply with benefit package, coinsurance, and
out-of-pocket maximums
 
        --      if states establish a single-payor system, federal
government may waive any provisions so self-insured companies
and Medicare come under single payor
 
--------------------------------------------------------------------------------
HEALTH ALLIANCES
--------------------------------------------------------------------------------
 
*       May operate as non-profit corporation, independent state
agency, or agency of state executive branch. Board of directors
of non-profit corporation alliances are to be equal number of
consumers and employers who purchase coverage through that
alliance. States establish mechanism for selecting members of
alliance boards.
 
*       Board of alliance may not include health care providers or
their employees, owners of health plans or their employees, or
persons who derive substantial income from health plans or
provision of health care, nor members of associations, law firms
or other organizations representing providers, plans, or others in
health field. Likewise for drug and medical equipment/device or
service companies.
 
*       Each alliance must establish a provider advisory board.
 
*       Each alliance enrolls all eligible persons; annual open
enrollment in which each individual/family may choose among
health plans offered through alliance.
 
*       Alliances control health plan marketing to consumers.
 
*       Alliances publish information for consumers on cost,
providers, any restrictions on access, and quality of health plans
 
 *       Alliances may not bear insurance risk
 
*       Relations with Plans
 
        --      each alliance negotiates with plans to provide
benefit package; must offer contract to each qualified plan unless
                --      proposed premium exceeds weighted-
average premium by over 20%
                --      quality is unsatisfactory as determined by
state
                --      plan discriminates
                --      plan does not comply with contract
                --      "plan is a fee-for-service plan that is not a
successful bidder. Through competitive bidding process, alliance
may limit to three the number of plans that pay any willing
provider on a fee-for-service basis and have no network of
providers operating under a contract with the plan."
 
        --      an alliance may decline contract with any plan if
plan's proposed premium would cause alliance to exceed its
budget target
        --      alliances use a risk-adjustment mechanism to
account for variations in enrollment across health plans
 
*       Fee-for-Service Plans
 
        --      Alliance must offer at least one fee-for-service
plan, unless the state, with approval of National Health Board,
waives requirement after alliance demonstrates that
                -- fee-for-service plan not financially viable
                -- insufficient provider interest
                -- insufficient enrollment to sustain plan
 
        --      each alliance, after negotiations with providers,
establishes a fee schedule for the fee-for-service component of
health plans in that alliance. Each plan uses the same schedule
and must reimburse providers up to the fee schedule level.
Providers may collectively negotiate the fee schedule with the
alliance. (See apparent antitrust limits later.) A state may choose
to adopt a statewide fee schedule.
 
*       Balance Billing
 
        --      a provider may not charge or collect from a patient
a fee in excess of the fee schedule adopted by the alliance. A
plan and its participants are not legally responsible for payment
of any amount in excess of the allowable charge.
 
*       Prospective Budgeting of Fee-for-Service
 
        --      states have authority to impose prospective
budgeting on fee-for-service plans offered through alliances
 
*       Enforcement
 
        --      Department of Labor oversees the financial
operation of alliances
 
 --------------------------------------------------------------------------------
CORPORATE ALLIANCES
--------------------------------------------------------------------------------
 
*       Employers with over 5,000 employees (nationwide), Taft-
Hartley plans and rural electric and telephone cooperatives with
over 5,000 covered employees, may be their own self-funded
alliance or join a state-established alliance
 
*       A state adopting a single payor approach may require all
employers and individuals to be in the single payor system
 
*       Large employers have a one-time opportunity to enroll
workers in state-established alliance in area where less than 100
of employer's workers reside
 
*       Large employers periodically have opportunity to switch to
state-established alliance under designated conditions. If they
switch, they must then stay in state-established alliance.
 
*       Corporate alliance must offer plans providing nationally
established benefit package, either through certified self-funded
plan or through contracts with state-certified health plans.
 
*       Corporate alliance/health plan contracts may have
community, experience, or combination rating; must provide for
acceptance of all eligible employees/families regardless of health
or other reasons; and may not terminate, restrict, or limit
coverage; no preexisting conditions/waiting periods and may not
cancel coverage until employee enrolls in another plan.
 
*       If coverage is terminated for failure to pay premiums,
corporate alliance remains liable.
 
*       Corporate alliances must provide same type of information
about health plans to employees as do state-established
alliances.
 
*       Secretary of Labor approves corporate alliance plans.
 
*       Choice of Plans
 
        --      corporate alliance must contract with at least one
fee-for-service plan, unless exempted due to waiver granted to
state-established alliance in same area, and must contract with at
least two other plans, unless such plans are unavailable or
unwilling to contract with the corporate alliance
 
        --      employees covered in corporate alliance pay a
community rate for their portion of premiums
 
--------------------------------------------------------------------------------
ERISA
--------------------------------------------------------------------------------
 
*       Establishes new ERISA fiduciary and enforcement
requirements for employers establishing corporate alliances,
regarding
 
         --      national benefit package
        --      fiduciary requirements
        --      plan information requirements
        --      uniform claims form, data reporting, electronic
billing, grievance and benefit dispute procedures
 
*       Self-funded plans establish trust fund for benefit
payments, special protection in bankruptcy if employer fails
 
*       A new national guaranty fund to operate similar to state
insurance guaranty funds
 
*       ERISA preemption of state laws modified to
 
        --      apply preemption only to employers in corporate
alliances
        --      permit nondiscriminatory taxes/assessment on
corporate alliance employers
        --      permit states to adopt all-payer hospital rates or
all-payer rate setting
        --      permit states to include corporate alliances in any
requirement to reimburse essential community providers
 
--------------------------------------------------------------------------------
HEALTH PLANS
--------------------------------------------------------------------------------
 
Health Plans required to offer a national guaranteed
comprehensive benefit package.
 
*       Plans certified by state and offered through health
alliances. Plans required to have open enrollment period and not
allowed to cancel or reduce benefits of an enrollee, even for
nonpayment of premiums. A plan cannot cancel an individual
until the patient is enrolled in another plan. The program prohibits
preexisting condition limitations and disease-specific exclusions.
The plan must take all comers, though states can limit enrollment
based on the capacity of the plan to deliver the full array of
services. Health plans use community rating to determine
premiums.
 
*       In August of each year, alliance negotiates premium rates
with each plan and publishes the negotiated rates for individual
and family coverage. The employer and employee will pay the
community rate to the alliance, but the health alliance will be
allowed to adjust payments to plans based on risks, using a
formula developed by the national health board. Also, the plans
will be allowed to reinsure if they are carrying high-risk
populations.
 
*       Each health plan is required to provide information to the
health alliance that makes the information available to consumers
and health care professionals. The information includes costs,
quality and availability of providers, utilization review procedures,
procedures for improving quality of care, rights and
responsibilities of consumers and plans. Plans are to provide
 
 consumers information regarding risks, benefits, and costs of
medical procedures so as to improve patient autonomy and
decision-making in clinical issues. Plans will also be required to
provide patients information on state laws concerning advance
directives. Plans must have grievance procedures and an
alternative dispute resolution process that is operated with neutral
third parties. (The grievance procedure is to be enforced by the
Department of Labor.)
 
*       State laws are preempted (except for fee-for-service
plans) if they would interfere with a plan's ability to limit the
number and type of providers, that would limit the ability of a plan
to require beneficiaries to get all services in plan from plan
providers except in emergency conditions, that would limit the
plan's ability to require referral for specialty services, that would
limit the plan's ability to have differential payment rates for the
participating providers and providers out of plan; and that would
limit the plan's ability to create incentives to use participating
providers. The program also preempts corporate practice of
medicine and ownership laws and restricts the ability of plans to
own facilities or offer medical services.
 
*       Out-of-service-area emergency and urgent care services
must be provided and they will be paid on a fee-for-service basis,
using the fee-for-service rate schedule set by the alliance. Plans
must also cover services provided by existing community
providers, using Medicare's community health center method.
Plans are prohibited from discriminating on the basis of race,
ethnicity, gender, religion, or medical condition.
 
*       Plans must have advisory boards of providers (selected
by the providers). The plan is to consult with such advisory
boards "frequently" and the plan must respond to the board's
concerns. The advisory board has access to plan information .
 
*       The plan establishes loans and guarantees for
community-based plans. Plans must meet conditions of
participation that are developed by the national health board.
Such conditions include fiscal solvency, truth in marketing, verify
credentials of practitioners in facilities (by annual check) and
licensure, disclose information as required concerning the plan's
performance, maintain patient bill of rights, due process for
patient appeals, ensure confidentiality, and have a complaint
resolution process for patients.
 
*       Other conditions include the ability of a consumer to leave
a plan at any time for cause, requirement for disclosure of
utilization management controls, including methods used to
manage, selection of providers, including selection criteria, and
internal performance standards, compensation methods,
incentives to control utilization, utilization review criteria, and
procedures for managing high cost patients. Finally, all AHPs
must participate in a data management and reporting system to
regional data centers.
 
 --------------------------------------------------------------------------------
EMPLOYER CONTRIBUTIONS
--------------------------------------------------------------------------------
 
*       Each alliance will establish four categories for premiums:
Single, couple with no children, single-parent family, and two-
parent family. For full-time employees, the employer pays 80% of
the average premium for the category of family for the employee.
The employee pays 20% of the average cost plus any actual
premium for selecting a higher cost plan. Individuals with incomes
under 150% of the poverty level can get assistance from the
alliance. The subsidy is paid for by the federal government. No
employer will be required to pay more than 7.9% of payroll for
health benefits.
 
*       Employers with less than 50 employees have a lower cap,
based on the employer's average annual payroll per employee,
so that for small employers with an average annual wage of
$12,000 or less, the cap is 3.5% of payroll; $12,000-$15,000, the
cap is 3.8% of payroll; $15,000-$18,000 is 4.4% of payroll;
$18,000-$21,000 is 5.5% of payroll; $21,000-$24,000 is 6.5% of
payroll; and $24,000 and above is 7.9% of payroll. Employers
can pay the employee's share, but they cannot discriminate
against classes of employees. If an employee chooses a less
expensive option, they receive a taxable rebate of the difference.
 
*       For individuals under 150% of the poverty line, there is a
subsidy to cover the individual's contribution. The individual self-
declares estimated annual income and there is a reconciliation at
the end of the year with filing of a tax return.
 
*       Corporate alliances for the large employer contribute to a
subsidy for those wage earners under $15,000 per year. Large
employers in regional alliances are risk-adjusted the first five
years they join the regional alliance and will pay the greater of
either the community rate or the risk-adjusted rate. After five
years there is a blended phase-out of their risk-adjusted rate.
 
*       Part-time employees are covered by regional alliances,
and employers contribute a share of the employer contribution,
using a ratio of the number of hours worked per week to a 30-
hour week. Individuals and self-employed paying their own
premiums have that amount fully deductible from income tax.
 
--------------------------------------------------------------------------------
GLOBAL BUDGETS AND PRICE CONTROLS
--------------------------------------------------------------------------------
 
*       A national health care budget is described as being a
"backstop" for market action, to ensure health care costs do not
rise faster than other sectors of the economy. The plan uses a
weighted-average premium for the guaranteed benefit package
as a target for future increases in premiums by health plans and
health alliances.
 
*       It does not appear that cost-sharing or out-of-pocket
expenses for noncovered services are included in the global
 
 budget. Coverage applies to premiums for guaranteed benefits.
Medicare and Medicaid will have their own separate budgets.
Also excluded from the national budget are workers'
compensation and auto injury health payments (WC/auto insurers
pay health plans directly).
 
*       Target rate of increase for premiums for 1996 is consumer
price index (CPI) plus 1.5; 1997, CPI plus 1; 1998, CPI plus 0.5;
and 1999 and beyond, CPI (plus increases for population).
Introductory overview stated goal of getting health spending in
line with GDP by 1997. A national health board will develop a
system for adjustments at the alliance level for factors such as
age and changes in demographics. There will be a national per
capita based premium. The first year will take the current per
capita expenses and trend it to 1996, with adjustments for
increased UR by uninsured/underinsured and to recapture
currently uncompensated care.
 
*       The plans will submit bids to alliances (either blind, or with
knowledge of a target premium rate provided the alliance by the
national health board). Each alliance receives an average
premium from the national health board. A weighted average of
all the alliance target premiums then equals the national target
premium. Each alliance then submits its negotiated premiums to
the national health board that computes the weighted premiums
and tells the alliance if its average premium is acceptable or not.
If not, the alliance must renegotiate with its plans.
 
*       Enforcement in the first year. If the estimated weighted
average exceeds the target average, an assessment is imposed
on each plan whose bid exceeds the target, and an assessment
is imposed on providers who provide services to those plans.
Revenues from the assessment to plans are used to reduce
employer premium contributions and amounts collected from
providers under the assessment are returned to the plans. A
base-line premium is established in year one for each alliance
and then just updated by inflation (CPI).
 
*       If the alliance exceeds its target, there is a two-year
recoupment. The national health board is to appoint an advisory
commission to make recommendations on the target.
Congressional action is required to adjust the target, once it has
been set.
 
*       States can comply with the target by promulgating
premium and payment regulations, limiting enrollment in high cost
plans, establishing a surcharge for high cost plans, providing a
rebate to individuals who choose low-cost plans, establishing
payment rates for providers, and controlling investments and
capital through planning.
 
*       Corporate alliances use a target which is based on a
methodology developed by the National Health Board for
calculating an annual premium equivalent. If they fail two out of
three years, they are terminated and their employees move to the
regional alliances.
 
 --------------------------------------------------------------------------------
ADMINISTRATIVE SIMPLIFICATION
--------------------------------------------------------------------------------
 
*       Standard Forms
 
        --      The national health board is to develop/supervise
administrative simplification of forms. Standard forms are to be
used by January of 1995 are the UB92 for institutional services,
the standard health insurance claim form (similar to HCFA 1500)
for noninstitutional services, the HCFA 1500 for dentists, and the
universal drug claim form for pharmacies.
 
*       Insurance Transactions
 
        --      The national health board will set standards for
automated transactions. Also, standards will be set for coding
systems. Private payers will be required to adopt standards for
electronic transactions by January 1, 1995, and federal programs
as soon as possible upon enactment. Providers are to be
automated within six months of the standardization being
established, with medical groups of over 20 professionals being
included in that requirement. States can deny payments to plans
that are not utilizing electronic data transfer.
 
*       Medicare Simplification
 
        --      Consolidation of contractors contracting by
function as compared to area.
        --      Eliminate balance billing for durable medical
equipment.
        --      Development of a national data file on Medicare
beneficiaries.
        --      Medigap coverage terminations will take place as
part of a national data file.
        --      A presumptive waiver of co-insurance for financial
reasons upon physician's acknowledgement.
        --      Physician input required in carrier performance
evaluation.
        --      Integrate Part A and Part B claim processing.
        --      Eliminate attestation requirement, except once
when getting hospital medical staff privileges.
        --      Repeal of a pre-approval requirement for ten
surgical procedures.
        --      Prohibit system changes more often than once
every 120 days.
        --      PROs are to focus their view on patterns and not
individual cases.
 
--------------------------------------------------------------------------------
QUALITY ISSUES
--------------------------------------------------------------------------------
 
*       The program establishes a national quality management
program. This program is overseen by an advisory council to the
national health board of 15 members, including consumers, plan
representatives, states, experts in public health, quality of care.
 
 *       This program will be used to develop performance
measures and continuous quality improvement. It will be
"customer-focused" and involve surveys on satisfaction, as well
as outcomes. The national quality program will set national goals
for performance, establish minimum standards, support research,
and report on quality.
 
*       The program will publish results of all plans annually.
States will enforce national quality standards, monitor AHPS, and
develop comparative reports. States will also be able to establish
consumer advocate programs.
 
*       The alliances collect information provided to providers and
consumers. The goal is to be able to compare plans and data
from providers and practitioners and to conduct educational
programs.
 
*       The program establishes regional data centers. There will
also be a national program to develop practice guidelines,
scientific standards, and priorities to be set by the national
advisory council. Institutions will have to meet national standards
on quality.
 
*       This national regulation will preempt local regulation
except concerning items such as fire  safety, building codes, etc.
Interventions will focus on problems, with targeted reviews and
randomly selected validation sites to assure compliance.
Demonstration program in this area must be established by
January 1, 1996. Medicare PROs remain in place until the HHS
Secretary determines that the national quality review program
makes PRO no longer necessary.
 
--------------------------------------------------------------------------------
SCOPE OF PRACTICE
--------------------------------------------------------------------------------
 
*       HHS Secretary is to develop and encourage the adoption
by states of a national model professional practice statute for
advanced practice nurses and physician assistants. State
Practice Acts are allowed to restrict the practice of a health care
practitioner only based on competency, skills, and training.
 
--------------------------------------------------------------------------------
PHYSICIAN WORKFORCE
(Medical Education and Incentives)
--------------------------------------------------------------------------------
 
*       After a five-year transition, 50% of physicians in training
must be in primary care (defined as family medicine, general
internal medicine, and general pediatrics). During the five-year
transition, each year the number of filled primary slots must
increase by 7% and specialty slots decrease by 10%.
 
*       HHS will allocate positions based on recommendations of
a new national council on graduate medical education. Positions
will be allocated to regional councils, with these councils
distributing the positions to programs.
 
 *       The national commission on graduate medical education
will include members representing educators, practicing
physicians, hospital administrators, program directors, nurses,
and others. The council is to seek the views of national
professional associations. Programs in institutions that have more
slots than have been assigned will receive no national graduate
education funding. The regional councils will include
representation from health alliances, teaching programs, and
consumers. The allocation of physicians will be based on
program quality, relevance of the training programs to actual
practice, and its curriculum to actual practice, participation of
underrepresented minorities, and participation of locally
coordinated plans.
 
*       The HHS Secretary has veto over allocations granted by
the graduate council and allocations of positions are good for up
to three years.
 
*       Financing
 
        --      All insurers and Medicare who pool explicit funds
for graduate medical education ($6 billion dollars) payments will
be made to programs, not institutions, and this will encourage
out-of-institution programs. There will be a transition payment for
hospitals that have positions reduced in order to replace
residents with other staff, and the first year that transition
payment will be 150% of average resident amount. That figure
will be lowered each year until the subsidy is eliminated.
 
*       Incentives for Primary Care
 
        --      Loan forgiveness for primary practice.
 
        --      Programs to retrain specialists for primary care will
be developed.
 
        --      Special emphasis for minorities and special
emphasis on community training at the undergraduate medical
education level, as well as part of continuing medical education.
 
        --      There will be expansion for nurse practitioners,
nurse mid-wives, and physician assistants, by doubling the
number of training positions now being funded.
 
        --      There will be special emphasis in training for
mental health, substance abuse prevention, and geriatrics.
Programs will be developed in school-based health care,
community care, and managed care.
 
*       Primary Care Incentives/Medicare
 
        --      Reduction in payment rates for office consultations
with the savings transferred to increase reimbursement for office
visits.
 
        --      Increased office visit RVUs to cover pre- and post-
visit time. Reduce the RVUs for all non-primary care services to
maintain neutrality.
 
         --      Resource based overhead component.
 
        --      Increase the MPVS for primary care to gross
domestic product per capita plus 5% in 1995.
 
        --      Eliminate the 10% bonus for nonprimary care in
urban shortage areas and double the bonus to 20% for primary
care in all shortage areas.
 
        --      Reduce out-lier intensity procedures.
 
--------------------------------------------------------------------------------
ACADEMIC HEALTH CENTERS
--------------------------------------------------------------------------------
 
*       A national pool of funds will be established to support
institution slots for research for specialized care.
 
*       Medicare funds plus a surcharge of private premiums ($6
billion in 1994) to be allowed at a fixed percentage add-on to help
academic hospitals. Medicare payments to teaching hospitals to
compensate for uninsured and disproportionate share are
reduced.
 
*       Health plans must cover routine costs associated with
approved clinical protocols. Plans must have agreements with
academic health centers to provide care for certain diseases in
patient populations to assure access to academic health centers.
This access is to be monitored by the regional health alliance.
 
--------------------------------------------------------------------------------
INFORMATION SYSTEMS
--------------------------------------------------------------------------------
 
*       Every eligible individual will receive a health security card,
like an automatic-teller machine card.
 
*       The card will not carry much information but will be used
to access specially stored information. The national health board
is to develop a national uniform minimum health data set.
 
*       Electronic data interchange standards are also to be
developed for information transfer. These standards are to
ensure privacy and security.
 
*       Unique identifiers will be established for plans,
practitioners, providers, and patients. The system is based on
collecting data from all encounters, using a standard format with
an emphasis on electronic records being phased in. All encounter
data is to be transmitted to a regional information network.
 
*       Ultimately, this data will be used to establish national
information trends. Ultimately, the plan would anticipate a point-
of-service information entry system. The national network of
regional providers will provide information on encounters,
enrollment, and utilization.  There will be a local option for state or
alliance networks. There will be a national data advisory
committee for research.
 
 *       New funding priorities will be established at the National
Institutes of Health for prevention and health research services
will be expanded. There will be an increased emphasis on
effectiveness and outcomes based on quality. There will be a
program to evaluate reform and a program to study how
consumer choice and decision-making take place.
 
--------------------------------------------------------------------------------
PUBLIC HEALTH INITIATIVES
--------------------------------------------------------------------------------
 
*       Public health departments will be able to shift away from
delivery of care since most patients they now provide services to
will have private coverage. There will be state formula grants that
will allow state health departments and local health departments
to do data collection, surveillance, protection of the environment,
housing, food and water supply, epidemiology monitoring, and
response to public health emergencies. Also states will be
encouraged to develop state health education programs to
assure proper levels of licensure, training, and community focus.
 
--------------------------------------------------------------------------------
RURAL HEALTH
--------------------------------------------------------------------------------
 
*       Alliances can sponsor plans in rural areas to assure
cooperation and provide linkages between incentives to practice
in rural areas. Additional incentives include:
 
        --      a nonrefundable personal $1,000/month tax credit
for physicians who practice in rural areas ($500/month for nurse
practitioners and physician assistants)
        --      Exclude national health service corps loan
payback from income
        --      provide an allowance of $10,000 per year for
equipment purchased for use in a health profession shortage
area
        --      deduct student loan interest up to $5,000 per year
for physicians, physician assistants, advance practice nurses,
and residents.
 
--------------------------------------------------------------------------------
WORKERS' COMPENSATION/AUTO INJURY ROLL-IN
--------------------------------------------------------------------------------
 
*       Health plans would provide treatment for medical services
related to compensation plans and auto injury policies. The
health plan would be reimbursed for the services by the auto or
compensation insurer at the negotiated fee-for-service alliance
schedule with no copayments.
 
*       Under workers' compensation, state freedom-of-choice
provider laws are preempted. The health plans must establish
that they can provide the type of services necessary for returning
compensation beneficiaries back to employment. Benefits are
determined by the state, and there is no coinsurance, no
deductibles, and no balance billing.
 
 --------------------------------------------------------------------------------
SUPPLEMENTARY INSURANCE
--------------------------------------------------------------------------------
 
*       There are two types of supplementary insurance,
beneficiary benefit supplemental insurance and cost sharing
supplemental insurance. (These provisions do not cover long-
term care insurance, Medigap coverage, hospital or nursing home
indemnity coverage, or accidental coverage.)
 
--------------------------------------------------------------------------------
COST-SHARING SUPPLEMENTAL COVERAGE
--------------------------------------------------------------------------------
 
*       The national health board will establish two standard
policies for cost sharing - a standard and a maximum cost
sharing policy. Only these two kinds of plans can be offered to
offset cost sharing. Plans that have high cost sharing options
must offer both supplemental plans. Only plans with high cost
sharing options can offer supplements for cost sharing. There
must be an annual open enrollment period, and the plan must be
priced to cover not only the benefits paid, but also the expected
increased utilization caused by reduction in coinsurance and
deductibles. The national health board is to regulate this
insurance and loss ratios must be a minimum of 90%.
 
--------------------------------------------------------------------------------
ADDED BENEFITS SUPPLEMENTAL INSURANCE
--------------------------------------------------------------------------------
 
*       No duplicate coverage allowed for basic benefits. Six-
month maximum limit on waiting periods and no exclusions
allowed. Same price and premium for all enrollees with the
exception for trade association, fraternal, and employee plans.
The national health board is to develop marketing standards that
will prohibit additional coverage tied to the basic benefit plan,
compensation to agents for promoting supplemental coverage,
and for disclosure of health status to the sales force.
 
-------------------------------------------------------------------------------
RISK ADJUSTMENTS
--------------------------------------------------------------------------------
 
*       The national health board will set standards for health
alliances to determine premiums for health plans based on risk
adjustments. The system is to be developed nine months prior to
the first enrollment. Plans with high risk will get a higher premium
and will be allowed to reinsure. States may provide incentives to
plans to cover disadvantaged groups. States are required to
assure that alliances use the federal risk-adjustment system,
unless state is granted a waiver by the National Health Board for
a state-established alliance.
 
--------------------------------------------------------------------------------
CLINICAL LABORATORY IMPROVEMENT
--------------------------------------------------------------------------------
 
 *       Inspections will be required for labs that perform 50,000 or
more tests per year, that does critical testing where the answer is
needed quickly, or where erroneous results would lead to serious
harm, and where testing is done to monitor care.
 
*       Other changes: exempt labs that do waiver tests or only
microscopic tests would no longer have to register or be involved
at all.
 
        --      limited license practitioners would be allowed to be
added to the microscopic category; more tests would be added to
the waiver category;
 
        --      existing personnel would be grandfathered, even if
they don't meet new credential requirements as long as there is
no demonstrated problem in quality;
 
        --      proficiency testing programs would be educational
with action only if extremely poor.
 
        --      there will be study to work with Congress to modify
the cytology proficiency standard.
 
        --      focus of inspections will shift from all labs to high
risk labs.
 
        --      inspections will be announced. (under review)
 
--------------------------------------------------------------------------------
LONG TERM CARE
--------------------------------------------------------------------------------
 
The Administration's plan includes a home and community care
program for all ages, administered by the states, and paid for by
savings in the system, not premiums.
 
*       To become eligible a person must require assistance with
three or more of five activities of daily living, evidence severe
cognitive or mental impairment, have severe or profound mental
retardation, or for children under six, be dependent on technology
and otherwise require hospital or institutional care.
 
*       States have the flexibility to design and define their
community based services system and may also elect to offer
vouchers or cash directly to eligible individuals or to capitate
benefits to health plans or other providers.
 
*       Eligible individuals pay co-insurance to cover a portion of
the costs of all services according to a sliding scale.
 
*       HHS establishes a national budget for home and
community based services and allocates funds to the states. The
maximum budgeted amount increases annually consistent with
the rate of increase allowed in the national budget for health care
and changes in the number of people over age 75.
 
 
 *       Some people now receiving Medicaid community LTC do
not meet the functional eligibility requirements of the new
program and current Medicaid programs are replaced with a new
community based LTC program for low income people. Funding
for this low income program is based on each state's 1993
Medicaid expenditures. At full implementation, expenditures
under the low income program are pooled with the funds for the
new LTC program for people with severe disabilities and are
subject to the national budget ceiling.
 
*       For private long-term care insurance, the plan provides for
state grants for consumer information, minimum long term care
insurance product and business standards, federal regulations for
long-term care insurance offerings, and amends IRS code to deal
with tax treatment of premiums for long-term care insurance.
 
*       HHS also conducts a demonstration program for
integrated models of acute and long-term care services for
individuals with disability and chronic illnesses.
 
--------------------------------------------------------------------------------
MALPRACTICE REFORM
--------------------------------------------------------------------------------
 
The malpractice reform section of the President's proposal
involves both changes in tort law and the development of
alternative approaches to resolving claims against providers.
Reforms are:
 
*       Patients are required to submit claims through an
alternative dispute resolution system established by each plan
using one or more of several models developed by the National
Health Board. At completion of the alternative dispute process,
patients can pursue the complaint in court.
 
*       Malpractice suits must include a certificate of merit
affidavit signed by a medical specialist in field relevant to claimed
injury attesting that the care deviated from established standards
of care.
 
*       Attorneys' fees for malpractice are limited to a maximum
of 33 1/3 percent of an award or lower limits if imposed by states.
 
*       HHS will establish rules for public access to information
contained in the National Practitioner Data Bank.
 
*       New collateral source rules will require reduction of any
malpractice case by the amount of recovery from other sources.
 
*       Either party may request an award to be made payable in
periodic installments.
 
*       Federal funds will support state demonstration projects to
establish enterprise liability.
 
 
 *       The Maine experiment is expanded by authorizing HHS to
develop a pilot program to determine the effect of using practice
guidelines adopted by the new National Quality Management
Program. A physician able to demonstrate that he/she has
complied with guidelines is not liable for medical malpractice.
HHS has the authority to work with states to invest practice
guidelines with the force of law for physicians and other providers
participating in the pilot program.
 
--------------------------------------------------------------------------------
ANTITRUST REFORM
--------------------------------------------------------------------------------
 
*       Hospitals smaller than a certain size will not be challenged
by the federal government if they attempt to merge. The DOJ and
FTC will publish guidelines that provide safety zones for such
mergers and expedited reviews and advisory opinions.
Guidelines also will provide the analysis the agencies use to
evaluate mergers among larger hospitals.
 
*       The DOJ and FTC will publish guidelines that provide
safety zones for hospital joint ventures and purchasing
arrangements, examples of ventures that would not be
challenged, and an expedited review or advisory opinion
procedure (within 90 days).
 
*       The DOJ and FTC will publish guidelines that provide:
safety zones for physician network joint ventures that do not
possess market power (must be below 20 percent) and that share
financial risk; examples of networks that would not be challenged
by the agencies; and an expedited business review or advisory
opinion procedure through which the parties that do not fall within
the safety zones can obtain timely (90 days) advice and
assurance as to whether their network will be challenged. Within
the safety zones, physicians may bargain collectively with health
plans about payment, coverage, decisions about medical care,
and other matters without fear of federal enforcement of the
antitrust laws.
 
*       During the transition to the new health care system,
physicians and other providers may require some protection to
negotiate effectively with health plans and to form their own
plans. To protect physicians and other providers from the market
power of third party payers forming health plans, providers are
provided a narrow safe harbor to establish and negotiate prices if
the providers share financial risk. The financial risk may not be
simply fee discounting. Physicians who provide health services
for the benefit package may combine to establish or negotiate
prices for the health services offered if the providers share risk
and if the combined market power of the providers does not
exceed 20 percent. This safe harbor does not apply to the implicit
or explicit threat of a boycott.
 
 
 *       The DOJ and FTC will publish guidelines that apply that
"state action doctrine" where a state seeks to grant antitrust
immunity to hospitals and other institutional health providers. If a
state establishes a clearly articulated and affirmatively expressed
policy to replace competition with regulation and actively
supervises the arrangements, the hospitals and other institutional
providers involved will have certainty that they will not face
enforcement action by the federal government.
 
*       The DOJ and FTC will publish guidelines that describe
under existing law the ability of providers to collectively negotiate
fee schedules with the alliances. All alliances, as established and
supervised under state law, are required under federal law to
establish a fee schedule for fee-for-service plans, and providers
in order to participate in the negotiation process need certainty
that their action will not violate the antitrust laws.
 
*       The current McCarran-Ferguson exemption from the
antitrust laws enjoyed by health insurers is repealed, thereby
eliminating the ability of health plans to collectively determine the
rates they charge, and other terms of their relationships with
providers.
 
--------------------------------------------------------------------------------
FRAUD AND ABUSE
--------------------------------------------------------------------------------
 
The President's proposal establishes an all-payer health care
fraud and abuse enforcement program and increases funding for
and coordinates activities of various branches of government for
enforcement against fraud and abuse in the health care system.
 
*       The DOJ and HHS will jointly direct the program to
coordinate federal, state and local law enforcement activities
directed at health care fraud and abuse. Fines and penalties for
fraud or abuse will be put in a trust fund to supplement additional
federal efforts to combat fraud and abuse.
 
*       The current anti-kickback statute covering Medicare and
Medicaid will be expanded to include all payers. The statute will
provide a new administrative remedy involving civil monetary
penalties for kickback violations.
 
*       Exceptions to the kickback provision will include payment
for items or services furnished to patients paid for on an at-risk
basis to the provider furnishing the item or service, such as
capitated payments. The exception covers all "downstream"
payments made to  providers by such an at-risk plan, even fee-
for-service payments and current "safe harbor" exceptions will
apply to the expanded kickback statute.
 
*       All self referrals are prohibited except when items or
services are paid for on an at-risk basis to that provider, such as
capitated payments. Exceptions are the same as for the anti-
kickback provisions above, except that the exception for group
practices is narrowed to prevent the creation of sham groups,
and exceptions for investment by large entities require that the
company hold $100 million in shareholder equity.
 
 *       Current federal authority is amended to allow forfeitures of
proceeds derived from health care fraud, allowing the federal
government to use either criminal or civil remedies to seize
assets derived from fraudulent or illegal activities.
 
*       A new health care fraud statute, modeled after existing
mail and bank fraud statutes will set penalties for schemes to
defraud public or private health care programs. Civil monetary
penalties of $10,000 per item or service claimed can be assessed
for the following:  false claims; routine waiver of co-payment if co-
payments are required; "upcoding"; unbundling or fragmenting
charges; unnecessary multiple admissions; false statements
submitted to a data bank, the National Health Board, health
alliance or plan; failing to provide medically necessary services
required under law or contract to be provided to an individual;
engaging in discrimination against those with preexisting
conditions; failing to cooperate with quality or utilization review;
failing to report violations of federal law.
 
*       The basis for exclusion from Medicare and state health
programs serves as the basis for exclusion from all other health
programs, and exclusion is mandatory in the case of criminal
conviction relating to fraud, theft, embezzlement, breach of
fiduciary responsibility or other financial misconduct and criminal
conviction relating to the neglect or abuse of patients. Exclusions
on other bases will be decided by HHS given the facts of the
case, including, for example, failing to meet professional
recognized standards in a gross and flagrant manner or in a
substantial number of cases, or defaulting on student loans.
 
*       Standard of knowledge in these cases is "knows or should
know."
 
--------------------------------------------------------------------------------
HEALTH CARE ACCESS INITIATIVES
--------------------------------------------------------------------------------
 
*       The National Health Service Corps is expanded to reduce
the shortage of primary care practitioners in underserved areas.
 
*       Categorical programs and formula grants continue to pay
for personal health services for specific populations such as
community and migrant health centers, family planning clinics,
etc.
 
*       New grants and loans will support capacity expansion;
new funds will be supplemented by funds for existing programs.
Funds to be used for ensuring adequate choice of providers and
health plans in underserved areas, supporting the development
of networks of care providers, and overseeing the integration of
federally funded providers into the new system.
 
*       New formula grants will be provided to states to ensure
access to health care for low-income, underserved, hard-to-reach
populations.
 
 
 *       During the first five years of reform, health plans will be
required to contract with and reimburse established community-
based providers at a rate no less than that paid to other providers
or at rates based on Medicare payment principles. At the end of
five years, providers either become integrated into health plans or
join together to create new, community-based health plans.
 
*       An adolescent and school-aged youth initiative supports
the delivery of clinical services through school-based or school-
linked sites.
 
*       Mental health and substance abuse initiatives refocus
existing formula grants to encourage development of community-
based programs by restricting existing grants to treatment in
excess of the comprehensive benefit, funds for the support of
improved outreach strategies for hard-to-reach populations,
training and staff development, and capital assistance for
additional non-acute, residential treatment centers.
 
--------------------------------------------------------------------------------
MEDICARE
--------------------------------------------------------------------------------
 
States are permitted to integrate Medicare beneficiaries into
health alliances if they have the same or better coverage as
Medicare and if federal financial liability is not increased.
Alliances must offer at least one fee-for-service option that offers
the Medicare benefit package at no greater cost than traditional
Medicare. States are permitted to discontinue a Medicare
integration program at the end of any fiscal year. To obtain a
waiver, states must assure that Medicare beneficiaries have
access to services comparable to Medicare, and equal or better
protection against balance billing. States must operate within a
capitation rate consistent with budget limits on growth of federal
spending for Medicare. Savings accruing to the state are shared
with the federal government and/or Medicare beneficiaries.
 
*       After establishment of health alliances, individuals have
the right to elect to remain in an alliance when they reach age 65,
but they must continue to receive the nationally guaranteed
package with the full range of options available for those younger
than 65. During an annual enrollment period, those over 65 may
return to Medicare or choose a new plan through the alliance.
Alliances can make risk adjustments to premiums using methods
prescribed by the National Health Board.
 
*       Changes in payment methodology to improve the
Medicare managed care program includes discretionary authority
to establish a ceiling and floor for payments and to create a
special pool for high-cost cases. Within three years, all health
plans are required to enter into a cost contract as a condition for
participation in health alliances. A Medicare Point-of-Service
option is created within fee-for-service Medicare for those not
choosing a managed care plan.
 
 --------------------------------------------------------------------------------
MEDICARE OUTPATIENT PRESCRIPTION DRUG BENEFIT
--------------------------------------------------------------------------------
 
No later than July 1, 1996, Medicare will cover outpatient
prescription drugs as part of the Part B program, with
beneficiaries paying 25% of the cost. There will be a $250
deductible, with a 20% co-pay, capped at $1,000. As a condition
of participation in Medicare and Medicaid, drug manufacturers
must sign rebate agreements with the Secretary based on the
difference between the average manufacturer retail price and
weighted average of the prices of the drug in the non-retail
market, with additional rebates required for drug prices that
increase at a higher rate than inflation. Reimbursement for brand
name drugs is the lower of the 90th percentile of actual charges
in a previous period or the estimated acquisition cost plus a
dispensing fee. Manufacturers of drugs would have to offer
discounts to all purchasers on equal terms.
 
--------------------------------------------------------------------------------
MEDICARE COST SAVINGS
--------------------------------------------------------------------------------
 
The following are proposed to reduce the rate of growth in the
Medicare program and allow Medicare to operate within the
constraints of the budget:
 
*       Reduce the Hospital Market Basket Index update by a
further 0.5% in 1997 and 1% in 1998-2000.
 
*       Reduce IME Adjustment to 5.65% in 1995 and 3.0% in
1996 and thereafter.
 
*       Reduce payments for hospital inpatient capital.
 
*       Phase down the Disproportionate Share Hospital
adjustment by 1998.
 
*       Expand centers of excellence.
 
*       Lower home health cost limits to 100% of median by July
l, 1999.
 
*       Delete volume and intensity from the MVPS formula.
 
*       Establish cumulative expenditure goals for physician
expenditures.
 
*       Reduce the Medicare fee schedule conversion factor by
3% in 1996, with primary care services exempt.
 
*       Establish prospective payment for hospital outpatient
radiology, surgery, and diagnostic services.
 
*       Competitively bid for all part B Laboratory services, except
in rural areas, and other medicare Part B services.
 
 
 *       Extend Medicare Secondary Payor Provision for ESRD
patients.
 
*       Increase Part B premiums for individuals with income
above $100,000 and for couples with incomes above $125,000.
 
*       10% coinsurance for home health visits more than 20
days after discharge; 20% coinsurance for lab services.
 
*       Subject all state and local employees to hospital
insurance tax.
 
*       Set Part B premium into law.
 
--------------------------------------------------------------------------------
MEDICAID ACUTE CARE
--------------------------------------------------------------------------------
 
Under 65 Medicaid recipients not on AFDC or SSI will no longer
receive insurance through Medicaid. They will enter regional and
corporate alliances, with the exception of undocumented persons
who will continue to receive Medicaid coverage for emergency
services. Medicaid will make capitated payments to regional
alliance health plans, instead of the current practice of providing
payment directly to providers. Recipients will choose from among
plans participating in the regional alliance. Just like other
members of the alliance, AFDC and SSI recipients with incomes
below 150% of poverty will receive subsidies for copayments and
deductibles if no plan with low cost sharing is available at or
below the weighted average premium. Health plans submit
premium bids to alliances for the non-AFDC, non-SSI population.
Following negotiations with the alliance, premiums are adjusted if
necessary to comply with the requirements of the budget. There
will be "blended premiums" and alliances will pay health plans
based on the blended premium for all enrollees, so a plan
receives the same payment for a person of a given risk class
regardless of the persons welfare status.
 
--------------------------------------------------------------------------------
GOVERNMENT PROGRAMS
--------------------------------------------------------------------------------
 
The Department of Defense will coordinate the military health
system with national health reform and will develop a plan for
implementation. Military health plans may contract with civilian
health providers and may offer plans within the regional alliance
in which the military medical center is located. Military plans will
provide the nationally guaranteed benefit package.
 
The Department of Veterans Affairs may organize its health
centers and hospitals into health plans or allow them to function
as health providers contracting with health plans or other
providers to deliver services. Health plans organized within the
VA system must conform to the requirements and standards for
all other health plans, and the VA will provide the nationally
guaranteed comprehensive benefit package to every eligible
person who enrolls.
 
 The Indian Health Service clinics and hospitals, tribal health
centers, etc., will operate outside regional health alliances.
Enrollment in a health plan offered through the alliance, but there
will be no federal subsidies because of their status. Individuals,
whether enrolled in a health plan in an alliance or enrolled with
the Indian Health Service are eligible for financial subsidies on
the same basis as other Americans. After a five year transition
period, the Indian Health Service will begin to deliver the full array
of services guaranteed in the comprehensive benefit package.
 
Those covered under the Federal Employee Health Benefits Plan
will purchase coverage through state-established alliances that
serve the area in which they live. Coverage under FEHBP ends
as regional health alliances begin operation.
 
--------------------------------------------------------------------------------
TRANSITION
--------------------------------------------------------------------------------
 
States can begin the new system as early as January, 1995, with
federal subsidizes and limitation on balance billing taking place.
States must have plans approved by the National Health Board
by January 1, 1997. States implementing reform prior to 1997 will
receive special start-up funds, subsidies, and expedited federal
consideration. States become eligible for federal support for
administrative costs in three phases. Support for Medicaid must
continue at current levels.
 
*       Those eligible to form corporate alliances must do so by
January 1, 1997.
 
*       Interim insurance reforms will be implemented and apply
to ERISA plans, MEWAs, and HMOs.
 
*       There are restrictions on insurers so that they do not
discriminate and so that they increase rates only on a uniform
basis for various covered groups.
 
*       Insurers are prohibited from applying exclusions to pre-
existing conditions, or for imposing waiting conditions, or reducing
any benefits.
 
*       HHS may establish a national risk pool for those who are
unable to obtain coverage because of health status.
 
--------------------------------------------------------------------------------
SHORT-TERM VOLUNTARY COST CONTAINMENT
--------------------------------------------------------------------------------
 
*       The President will announce a program urging all sectors
of the health care system to limit price and expenditure increases
to a specified amount, with HHS monitoring prices and advising
the President on compliance. HHS will issue public reports on
levels of compliance in each sector.
 
 
 --------------------------------------------------------------------------------
RETIREES (under review)
--------------------------------------------------------------------------------
 
Retirees not yet eligible for Medicare who are over 55 and who
meet the Social Security requirements for quarters of work are
eligible for a subsidy for the employer share of their premium.
Alliances administer the retiree subsidies. The retiree and his or
her family are also responsible for the family share of the
premium, with subsidies to those whose income is below 150% of
poverty. Where an agreement exists for employers to pay retiree
health benefits, the employer's responsibility will shift to paying
the 20% family share on behalf of the retiree. Employers who
realize a reduction in retiree health costs may be assessed a
one-time payment for the extra costs associated with induced
early retirements due to the retiree subsidy program.
 
--------------------------------------------------------------------------------
MANAGEMENT OF REGIONAL ALLIANCE FUNDS AND
RECORDS
--------------------------------------------------------------------------------
 
Alliances will periodically request payment from HHS to make up
shortfalls as a result of employer and family subsidies. States
make Medicaid maintenance of effort payments to offset subsidy
costs. States set standards, at least at the federal minimum, for
procedures, policies, due diligence,  record-keeping, budgeting,
internal controls, internal audit, bonding, etc. THE DOL and HHS
develop standardized forms and data field for use by alliances,
employers and consumers.
 
--------------------------------------------------------------------------------
TAX SUBSIDIES
--------------------------------------------------------------------------------
 
Employer contribution toward the premium and toward cost
sharing for the nationally guaranteed comprehensive benefit
package and for additional benefits phased in by the year 2000
are tax deductible to the employer and not counted as income to
the employee. Once alliances are established, contributions
continue to be tax-preferred only if made through an alliance.
Benefits that exceed the fully phased-in benefit package are
taxable to the employee, but they continue to be fully tax
preferred for 10 years after enactment if provided as of January
1, 1993.
( AMA Synopsis of Clinton Health System Proposal Page 41 )
_______________________________________________________________________________
Soumen Nandy [log in to unmask] |That which does not destroy| 617-275-3402 voice/fax
Computers in Medicine      |    us makes us stronger   | THE OPINIONS EXPRESSED
AMSA Nat'l Coordinator     |That which DOES destroy us | ARE SOLELY MY OWN...
MA Med. Society Comm. Chair| ...makes us physicians    | ...IF EVEN THAT...

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October 2000, Week 1
September 2000, Week 5
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April 2000, Week 1
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March 2000, Week 1
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February 2000, Week 1
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January 2000, Week 3
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January 2000, Week 1
December 1999, Week 5
December 1999, Week 4
December 1999, Week 3
December 1999, Week 2
December 1999, Week 1
November 1999, Week 5
November 1999, Week 4
November 1999, Week 3
November 1999, Week 2
November 1999, Week 1
October 1999, Week 5
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October 1999, Week 3
October 1999, Week 2
October 1999, Week 1
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May 1999, Week 1
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April 1999, Week 3
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April 1999, Week 1
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January 1999, Week 1
December 1998, Week 5
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December 1998, Week 1
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October 1998, Week 5
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October 1998, Week 1
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September 1998, Week 1
August 1998, Week 5
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August 1998, Week 1
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July 1998, Week 3
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July 1998, Week 1
June 1998, Week 5
June 1998, Week 4
June 1998, Week 3
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June 1998, Week 1
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April 1998, Week 5
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April 1998, Week 1
March 1998, Week 5
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March 1998, Week 3
March 1998, Week 2
March 1998, Week 1
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February 1998, Week 2
February 1998, Week 1
January 1998, Week 5
January 1998, Week 4
January 1998, Week 3
January 1998, Week 2
January 1998, Week 1
December 1997, Week 5
December 1997, Week 4
December 1997, Week 3
December 1997, Week 2
December 1997, Week 1
November 1997, Week 5
November 1997, Week 4
November 1997, Week 3
November 1997, Week 2
November 1997, Week 1
October 1997, Week 5
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October 1997, Week 3
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October 1997, Week 1
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August 1997, Week 1
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July 1997, Week 1
June 1997, Week 5
June 1997, Week 4
June 1997, Week 3
June 1997, Week 2
June 1997, Week 1
May 1997, Week 5
May 1997, Week 4
May 1997, Week 3
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May 1997, Week 1
April 1997, Week 5
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April 1997, Week 3
April 1997, Week 2
April 1997, Week 1
March 1997, Week 5
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March 1997, Week 3
March 1997, Week 2
March 1997, Week 1
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February 1997, Week 1
January 1997, Week 5
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January 1997, Week 3
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January 1997, Week 1
December 1996, Week 5
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December 1996, Week 3
December 1996, Week 2
December 1996, Week 1
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November 1996, Week 4
November 1996, Week 3
November 1996, Week 2
November 1996, Week 1
October 1996, Week 5
October 1996, Week 4
October 1996, Week 3
October 1996, Week 2
October 1996, Week 1
September 1996, Week 5
September 1996, Week 4
September 1996, Week 3
September 1996, Week 2
September 1996, Week 1
August 1996, Week 5
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August 1996, Week 1
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April 1996, Week 1
March 1996, Week 5
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March 1996, Week 2
March 1996, Week 1
February 1996, Week 5
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February 1996, Week 3
February 1996, Week 2
February 1996, Week 1
January 1996, Week 5
January 1996, Week 4
January 1996, Week 3
January 1996, Week 2
January 1996, Week 1
December 1995, Week 5
December 1995, Week 4
December 1995, Week 3
December 1995, Week 2
December 1995, Week 1
November 1995, Week 5
November 1995, Week 4
November 1995, Week 3
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October 1995, Week 4
October 1995, Week 3
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October 1995, Week 1
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September 1995, Week 1
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July 1995, Week 3
July 1995, Week 2
July 1995, Week 1
June 1995, Week 5
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June 1995, Week 3
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June 1995, Week 1
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May 1995, Week 1
April 1995, Week 5
April 1995, Week 4
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April 1995, Week 1
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March 1995, Week 3
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March 1995, Week 1
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February 1995, Week 2
February 1995, Week 1
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December 1994, Week 5
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December 1994, Week 3
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December 1994, Week 1
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October 1994, Week 5
October 1994, Week 4
October 1994, Week 3
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October 1994, Week 1
September 1994, Week 5
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September 1994, Week 1
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July 1994, Week 1
June 1994, Week 5
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May 1994, Week 2
May 1994, Week 1
April 1994, Week 5
April 1994, Week 4
April 1994, Week 3
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April 1994, Week 1
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