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One Small Example out of 40,000+ pages of Regulations on ACA
Dept of Labor Website ^ | 02/20/2013 | Dol/HHS/Treasury

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 ...


TOPICS: Health/Medicine
KEYWORDS: lawlessnation; obama; obamacare; obamalies
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What this means:

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!***

1 posted on 10/31/2013 6:17:41 PM PDT by ToastedHead
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To: ToastedHead
Nancy Pelosi: "We have to pass it to see what's in it."

Medical Doctor: "That's what we say about a stool sample."

2 posted on 10/31/2013 6:20:37 PM PDT by From The Deer Stand
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To: ToastedHead; All
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3 posted on 10/31/2013 6:20:42 PM PDT by musicman (Until I see the REAL Long Form Vault BC, he's just "PRES__ENT" Obama = Without "ID")
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To: ToastedHead

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.


4 posted on 10/31/2013 6:20:53 PM PDT by nascarnation (Frequently wrong but rarely in doubt....)
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To: ToastedHead

Toast.....They are trying to baffle us with bullshiie.


5 posted on 10/31/2013 6:29:00 PM PDT by willibeaux (de ole Korean War vet age 83)
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To: nascarnation

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?


6 posted on 10/31/2013 6:37:23 PM PDT by ToastedHead
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To: willibeaux

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!


7 posted on 10/31/2013 6:42:50 PM PDT by ToastedHead
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To: ToastedHead

Great post, you done good.......even though the info is disturbing :(


8 posted on 10/31/2013 6:48:15 PM PDT by LuvFreeRepublic
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To: LuvFreeRepublic

Thank you! (I was nervous:)


9 posted on 10/31/2013 6:51:29 PM PDT by ToastedHead
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To: ToastedHead
Welcome to the US Government. I had to navigate through many projects and service contracts from the Fed.

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

10 posted on 10/31/2013 6:52:16 PM PDT by eyedigress ((zOld storm chaser from the west)/ ?s)
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To: ToastedHead

“and a separate managed behavioral health organization”

Probably off topic. But what the hell is that?


11 posted on 10/31/2013 6:55:57 PM PDT by saleman
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The contrast of then and now.


12 posted on 10/31/2013 6:57:13 PM PDT by eyedigress ((zOld storm chaser from the west)/ ?s)
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To: ToastedHead
Whoa........aside from your scenario about the benefits managers not being updated on a timely basis which could cost more, how about this..... Separate plan service providers may impose different levels of out-of-pocket limitations ....... Reads to me like even the 'out of pocket' which is quoted can actually be a lie as well!
13 posted on 10/31/2013 6:57:16 PM PDT by liberalh8ter (The only difference between flash mob 'urban yutes' and U.S. politicians is the hoodies.)
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To: ToastedHead

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.


14 posted on 10/31/2013 6:59:44 PM PDT by Cvengr (Adversity in life and death is inevitable. Thru faith in Christ, stress is optional.)
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To: eyedigress

“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.


15 posted on 10/31/2013 7:00:29 PM PDT by ToastedHead
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To: saleman

It sounds like the organization of “firearm allowance” to me.


16 posted on 10/31/2013 7:02:47 PM PDT by eyedigress ((zOld storm chaser from the west)/ ?s)
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To: ToastedHead
40,000 pages couldn't make me change my mind
if I had to make the choice between the insurance or the fine.
I know just where my fee should go
and that's the TEA Party.

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.

(chorus)

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.


17 posted on 10/31/2013 7:03:54 PM PDT by TigersEye (Stupid is a Progressive disease.)
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To: eyedigress

It sounds like “manageing my behavior” to me.

How can it be read any different?


18 posted on 10/31/2013 7:04:15 PM PDT by saleman
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To: saleman

“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).”

(Lol!)

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.


19 posted on 10/31/2013 7:04:26 PM PDT by ToastedHead
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To: ToastedHead

“Shall” is intended for the contractor, “will” is afforded to the fed.

They abuse the hell out of this. Hello Fed.


20 posted on 10/31/2013 7:05:48 PM PDT by eyedigress ((zOld storm chaser from the west)/ ?s)
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To: saleman

They “will”!!!!


21 posted on 10/31/2013 7:06:28 PM PDT by eyedigress ((zOld storm chaser from the west)/ ?s)
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To: liberalh8ter

“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.


22 posted on 10/31/2013 7:10:05 PM PDT by ToastedHead
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To: saleman
Yes, something like that was in the original Senate version. Neighborhood "minders" will be checking on your lifestyle and recommending diet and exercise programs for you. Non-compliance will mean higher rates.

I used to have a post about those rules that I put up many times in 2009.

23 posted on 10/31/2013 7:10:08 PM PDT by TigersEye (Stupid is a Progressive disease.)
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To: TigersEye

I found a few of those in your last rowboat tip over. Thanks :^)


24 posted on 10/31/2013 7:13:18 PM PDT by eyedigress ((zOld storm chaser from the west)/ ?s)
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To: liberalh8ter

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.


25 posted on 10/31/2013 7:13:33 PM PDT by Cvengr (Adversity in life and death is inevitable. Thru faith in Christ, stress is optional.)
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To: Cvengr

“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.


26 posted on 10/31/2013 7:17:40 PM PDT by ToastedHead
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To: eyedigress

Learn from my mistake. Never carry more than 10,000 rounds in a row boat. They just ain’t built for it. ;^)


27 posted on 10/31/2013 7:19:06 PM PDT by TigersEye (Stupid is a Progressive disease.)
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To: ToastedHead
The If You Like It, You Can Keep It Act.”

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!

28 posted on 10/31/2013 7:19:32 PM PDT by MaxMax (Pay Attention and you'll be pissed off too! FIRE BOEHNER, NOW!)
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To: TigersEye

“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.


29 posted on 10/31/2013 7:22:37 PM PDT by ToastedHead
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To: TigersEye

“Never carry more than 10,000 rounds in a row boat. They just ain’t built for it. ;^)”

You might want to think about a diet. Row boats are constructed to carry a large person.


30 posted on 10/31/2013 7:25:55 PM PDT by ToastedHead
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To: ToastedHead
That doesn't surprise me at all.

I'm just a rare exception! lol

31 posted on 10/31/2013 7:30:00 PM PDT by TigersEye (Stupid is a Progressive disease.)
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To: Cvengr

“I haven’t 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.


32 posted on 10/31/2013 7:30:14 PM PDT by ToastedHead
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To: ToastedHead

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. ;-)


33 posted on 10/31/2013 7:32:46 PM PDT by TigersEye (Stupid is a Progressive disease.)
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To: TigersEye

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


34 posted on 10/31/2013 7:34:14 PM PDT by saleman
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To: MaxMax

“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.


35 posted on 10/31/2013 7:34:48 PM PDT by ToastedHead
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To: TigersEye

In that case, you need to next consider buying a new row boat:)

Aren’t you cold??


36 posted on 10/31/2013 7:36:28 PM PDT by ToastedHead
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To: saleman
I guess your family members will have to find out the hard way. I have some of those too. My sympathy for them is gone. All they will get from me now is this...

If you voted for it. You deserve it!

37 posted on 10/31/2013 7:49:03 PM PDT by TigersEye (Stupid is a Progressive disease.)
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To: ToastedHead
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?

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.

38 posted on 10/31/2013 7:49:36 PM PDT by okie01 (The Mainstream Media: Ignorance On Parade)
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To: ToastedHead

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.


39 posted on 10/31/2013 7:57:45 PM PDT by matt04
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To: okie01

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.


40 posted on 10/31/2013 7:58:12 PM PDT by ToastedHead
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To: matt04

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.


41 posted on 10/31/2013 8:06:33 PM PDT by ToastedHead
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To: ToastedHead
The answer is the obvious question about why McCain and Boehner want Amnesty, also.
They are on the wrong side of the future standing by the RATs.
42 posted on 10/31/2013 8:13:31 PM PDT by MaxMax (Pay Attention and you'll be pissed off too! FIRE BOEHNER, NOW!)
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To: matt04
The quagmire of making it all work together has not even been implemented.
All means all the Data coming from all sources converging to make it possible.
Making the site work is small potatoes compared to that.

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.

43 posted on 10/31/2013 8:18:30 PM PDT by MaxMax (Pay Attention and you'll be pissed off too! FIRE BOEHNER, NOW!)
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To: ToastedHead

Who writes all this crap?

Who takes the time?

We know why.


44 posted on 10/31/2013 8:19:35 PM PDT by Sequoyah101
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To: Sequoyah101

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!”


45 posted on 10/31/2013 8:25:47 PM PDT by ToastedHead
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To: ToastedHead

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.


46 posted on 10/31/2013 8:27:19 PM PDT by CodeJockey (Christian, Freeper, Tea Party Member, Bitter Clinger, Creepy White Cracker)
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To: ToastedHead
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. <

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.

47 posted on 10/31/2013 8:27:23 PM PDT by okie01 (The Mainstream Media: Ignorance On Parade)
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To: CodeJockey

“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.


48 posted on 10/31/2013 8:34:36 PM PDT by ToastedHead
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To: okie01

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.”


49 posted on 10/31/2013 8:39:47 PM PDT by ToastedHead
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To: ToastedHead
***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!***

You did well. I fractured my neck a couple years ago and it took months before corrective surgery was finally performed. I have a clotting disorder which complicated the scheduling and am very familiar with the self-injection of Lovenox over a very extended period of time (it sucked). Out of pocket was high enough without the destructive effects of the "Affordable Care Act."

Please keep pointing out the disaster.
50 posted on 10/31/2013 9:24:27 PM PDT by PA Engineer (Liberate America from the Occupation Media. No Blood For Ego!)
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