Skip to comments.One Small Example out of 40,000+ pages of Regulations on ACA
Posted on 10/31/2013 6:17:41 PM PDT by ToastedHead
"The Departments recognize that plans may utilize multiple service providers to help administer benefits (such as one third-party administrator for major medical coverage, a separate pharmacy benefit manager, and a separate managed behavioral health organization). Separate plan service providers may impose different levels of out-of-pocket limitations and may utilize different methods for crediting participants' expenses against any out-of-pocket maximums. These processes will need to be coordinated under section 1302(c)(1), which may require new regular communications between service providers."
(This is found in the second paragraph of Question #2)
(Excerpt) Read more at dol.gov ...
A person has major surgery, and meets their out of pocket maximum while in the hospital. Upon discharge, they bring a prescription to the pharmacy for a continuation of care medication, say for example injectable Lovenox. This is often given after a stent is put in, for example, to prevent clotting, and is cash priced at over $1000 (even for the generic which is now available.)
In this case, the person should be able to get their prescription for the copay price.
However, because there exists no mechanism for the pharmacy benefits manager to "talk" to the medical claims administrator within the ACA, the copay given to the pharmacy when the claim is submitted will be the full cash price. There will be absolutely no way for the pharmacy to know the out of pocket maximum has been met.
Within this addendum to the 40,000+ pages of regulations, in this one small FAQ, the Dept of Labor/HHS/Treasury all admit "These processes will need to be coordinated under section 1302(c)(1)."
Obviously from watching the healthcare.gov website, the integration of legacy systems of data is a huge task. After they get that website working, how much will this one small process cost us, the taxpayer, to implement. Is it even possible?
***I've never posted before, and I can't tell if I am doing it right. Please edit as needed. I'm just throwing this out there because it will really affect me in my line of work. Thanks!***
Medical Doctor: "That's what we say about a stool sample."
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I think we knew from day one this was a “full employment” bill for attorneys. Even over and above the 15,000 lawyers and accountants hired by the IRS to administer/enforce Obamacare.
Toast.....They are trying to baffle us with bullshiie.
It was really painful to watch the Sebelius hearing. I realized how little they could possibly understand the enormity of the mess they’ve made.
I read that Landrieu and others are considering a piece of legislation called “The If You Like It, You Can Keep It Act.” It’s way too late for that. The insurance companies have already made their projections and adjustments for 2014. There’s no going back, but there’s also no going forward it seems.
I can’t wait until the new premiums come out for January. Employer sponsored coverage is going to get killed, too. Is there anyone on the planet smart enough to fix this?
And doing a fabulous job! The regulations are written in such a way that they are just about impossible to make sense of. There is an exception to just about every exception.
I can’t wait to vote on Tuesday!
Great post, you done good.......even though the info is disturbing :(
Thank you! (I was nervous:)
The PWS (performance work statement) intends to be clever with "will and shall".
The Obama Admin has now applied this to your life. This Obamacare is no different. Believe me, it will be a nightmare to get through this socialism of the highest order.
"Give me your tired, your poor, Your huddled masses yearning to breathe free, The wretched refuse of your teeming shore. Send these, the homeless, tempest-tost to me, I lift my lamp beside the golden door!"
Give me your money that I may stay in control of your life
“and a separate managed behavioral health organization”
Probably off topic. But what the hell is that?
The contrast of then and now.
The phrase reads as if somebody is trying to regulate socialism in order to claim they are defending freedom in the marketplace. The only problem is that it creates more bureaucracy instead of promoting liberty.
“intends to be clever with “will and shall”
I hate will and shall, and may. Vague, open ended, and up for discussion. No work will get done while the “team” debates.
It sounds like the organization of “firearm allowance” to me.
I wasn't born in the USA to be a stinking slave.
I'll always be a free man 'til they put me in my grave.
Filling out your forms is just a giant hose!
I'll have to change my address and hide my assets I suppose.
Your Progressive commie paradise I'll have to leave behind,
and if you try to follow me I won't be very kind.
Loading my magazines. Loading my magazines
with 40,000 rounds to pass the time.
It sounds like “manageing my behavior” to me.
How can it be read any different?
“a separate managed behavioral health organization”
That part read to me like it was a byproduct of the “Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).”
That entire section only seems to have come up for debate as a result of trying to reconcile this new law with that old law. Probably as a result of some special interest objection.
“Shall” is intended for the contractor, “will” is afforded to the fed.
They abuse the hell out of this. Hello Fed.
“Separate plan service providers may impose different levels of out-of-pocket limitations”
That doesn’t even make sense. The medical side has its own out of pocket, which has nothing to do with any level of anything on the pharmacy side. Is the policy out of pocket max determined individually per provider, or is it aggregate?
I’d like to see a Navigator Of Excellence prune through that fine print. Right after they put down the bong.
I used to have a post about those rules that I put up many times in 2009.
I found a few of those in your last rowboat tip over. Thanks :^)
Seems like they are writing the unwritten.
Different medical insurance policies have different organizational structures coordinating between 7 to 20 entities, each with massive relational databases to operate in the industry. (e.g. within one regional healthcare system commonly accessed service providers in an outpatient surgical procedure might include: Patient, Dr., Dr’s Group, Pharmacy, Lab, Admissions, Insurance Provider, Radiology, Anesthesia, Emergency Room/Trauma Center, Ambulance, Physical Therapy).
Different plans group those services in different fashions based upon local economies of service. Any two or more of those groups may also engage in “co-pay” systems.
The clause seems to be allowing all the different plans to implement their operations in their own fashion, but failing to recognize their ‘granting’ of that freedom, might be encroaching upon the contractual relationships between service providers within their systems.
I haven’t seen a model showing the difference in ACA and the relationships in standard healthcare systems.
“The only problem is that it creates more bureaucracy instead of promoting liberty.”
At some level this amount of bureaucracy has to implode on itself and suck the planet in with it. How many lifetimes could it ever take to sort out 40,000 pages of unreadable regulations? Not to mention that Dingle fossil needed an assistant to turn his mike on and off.
Learn from my mistake. Never carry more than 10,000 rounds in a row boat. They just ain’t built for it. ;^)
The problem is that the Repubs want to save Obamacare instead of ridding the
monstrous catastrophe that's about to ruin our economy and jobs. Any delay will
also allow the full implementation of Zerocare and allow the Feds to save their
ass' after the titanic has sailed without a radio. In a year nobody will remember
the Titanic-care send off. They'll only know that the Repubs helped create the
failure and will be blamed for all of it. They must not touch one rivet!
“and that’s the TEA Party”
It is my observation that anyone who calls themselves a Tea Party person has a very great sense of personal responsibility, and is a joy to work with.
“Never carry more than 10,000 rounds in a row boat. They just aint built for it. ;^)”
You might want to think about a diet. Row boats are constructed to carry a large person.
I'm just a rare exception! lol
“I havent seen a model showing the difference in ACA and the relationships in standard healthcare systems.”
I think the biggest difference is that the usual models were designed by people driven by profit (good thing.)
These regulations are being written to shut people up, or make someone happy, or push a goal forward. The final cost is irrelevant. Other people’s money, and all.
That’s funny and a little ironic. If I wanted to do Halloween as a skeleton all I’d need to do is take my shirt off. ;-)
I appreciate your efforts but that’s the first I’ve heard of that kinda bullshit. I knew it was coming but that is my first actual evidence I can point to in regards to my “head in the sand” family members.
And get this. I know you know but this is for anyone who doesn’t.You think your excercise habits, what you drink, what you smoke, how far you drive to work, what your weight is, how much weight you’ve gained or lost, who you’ve screwed in the past, who you associate with, who those you associate with, how many stairs in your house, HOW YOU DISCIPLINE YOUR CHILDREN, who’s staying in your house, etc. etc. etc......THEY WILL CONTROL EVERY FACET OF YOUR LIFE.
And get this. You lie. About anything. And guess what? That’s Insurance Fraud AND YOU GO TO JAIL. Or re-education camps
“the Repubs want to save Obamacare”
Aren’t there some business oriented Republicans up there who can see the obvious economic black hole this thing is? The website alone looks like it will top a billion dollars before it gets fired up.
In that case, you need to next consider buying a new row boat:)
Aren’t you cold??
It can't be "fixed" -- not in the conventional meaning of the word. Obamacare is irrepairable; a total loss.
Consequently, the best fix would be to repeal it, in toto. Then,, start all over again.
There will be massive problems with this approach, too -- as you suggest. But every day of delay, part of the healthcare infrastructure erodes away -- and risks being lost forever.
Push the "re-set" button -- tomorrow, if possible -- and let the market figure out how to adapt and re-gain something like the status quo ante. Markets are really, really good at this -- and the less "guidance", the better.
They will never be able to reliably implement this. Literally dozens of private companies and government agencies trying to link all these legacy and proprietary systems will make the website launch look like a massive success.
I wish the whole thing would go away. You can accommodate for the relatively small number of people who have “enrolled” in an exchange. (Real enrollments or not, who knows.) They can invent a “Gold/Silver/Bronze Come All Ye Exchange People” plan to cover a couple thousand people.
It’s the 10-15 million people left scrambling who have an immediate need for some way to protect themselves. There’s not enough time left to put them somewhere. The day the insurers knew they’d lose that revenue and acquire all these new additional costs, affordable policies vanished.
I wonder who gets sued on January 3rd when someone cannot afford their injectable clot busting drug, and then goes home and dies.
Will it be me? I’m the little guy on the totem pole in my faux scenario. CVS/Walgreens/Kroger/RiteAid won’t protect me. If I tell someone “Nope, sorry, it’s gonna be $1000” and they do not have $1000, am I the “licensed evil man” who gets the lawsuit?
My guess at this moment in time is yes, and that’s why I’ve decided to not engage in “retail” again until at least mid 2015, when there is some semblence of law and order again. I carry my own malpractice insurance, but it’s puny compared to the big guns. And I have to think of my kids.
Then there's a ultimate security threat of the world having every American's information
being sold to every thief in the world market. Maybe that's in the plan too, because it
absolutely will happen. Then the fix will be a national ID, accept for illegals.
Who writes all this crap?
Who takes the time?
We know why.
I guess that’s what they breed the kids to do in college now. Write completely nonsensical (but intimidating) legislation, all in the name of marching towards a utopia where no one ever has to do anything. “Healthcare is a right!”
Any bill brought up by congress needs to be made available on the web for the people to read. Didn’t Obummer say he was going to do just that? We should demand that of any candidate.
Would make for some interesting reading.
TostedHead noob poster. You did good.
If you pushed the button tomorrow -- and all those Obamacare coverage mandates vanished into thin air -- the insurers would be offering those 10-15 million people their old policy (or something akin to it) within hours.
They would jump thru hoops not to lose these customers.
Problem is, of course, nobody's going to push that button...tomorrow.
“TostedHead noob poster. You did good.”
I appreciate you! I am starting to relax. Now I need to post something highly controversial and cause mayhem.
You’re probably right about that. I got my first divorce letter from BCBS, dated Oct 2nd, telling me my policy would no longer exist after Dec 1, 2014. I got a second letter, dated Oct 22nd, reminding me they will have tons of other options and thanking me for my business. It had a feel to it of “we see we’re gonna get screwed because no one we can make money of off is enrolling, so please keep us in mind.”