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Plain Meaning Rule

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How to read and figure out the law or Insurance Policy Provisions – Evidence of Coverage

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Read the Statute,  Read the Statute,  Read the Statute
!”

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Justice

Felix Frankfurter

said that –   The language of the text of the statute should serve as the starting point for any inquiry into its meaning.    To properly understand and interpret a statute,

[first] you must read the text closely

, keeping in mind that your initial understanding of the text may not be the only plausible interpretation of the statute or even the correct one.

Guide to Reading & Interpreting

*

American Society of Healthcare Risk Management
and *
Wikipedia

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.
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The way I heard it, either in my one year of correspondence law school or two years of beginners

Talmud

was:
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Read the law three times, then when you think you understand it, read it again.

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.
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The starting point in

statutory construction is the language of the statute itself

. The Supreme Court often recites the

“plain meaning rule,”

as in,

King vs Burwell

Subsidies in Health Care.Gov upheld, that, if the language of the statute is clear, there is no need to look outside the statute to its legislative history in order to ascertain the statute’s meaning.
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Felix Frankfurther – Wikipedi
a\r\n\r\nTry these links for youtube video https://youtu.be/ryx0OX5pAQ4 *** https://youtu.be/q2pbVhxHZWw\r\n\r\nI\’m just not this quick to make policy determinations and interpretations. With so few documents in front of the Insurance Agent on TV how does he know?\r\n\r\nEpisode Notes
IMDB
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King v Burwell – Subsidies Upheld – ScotusCare –
Plain Meaning Rule – Interpretive Jiggery Pokery
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President Trump says no one knew healthcare would be so complicated
.
He could have asked me.
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 Tools to Read a Statute
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A cardinal rule of construction is that a statute should be read as a
harmonious whole
, with its various parts being interpreted within their broader statutory context in a manner that furthers statutory purposes.  A provision that may seem ambiguous in isolation is often clarified by the remainder of the statutory scheme — because the same terminology is used elsewhere in a context that makes its meaning clear, or because only one of the permissible meanings produces a substantive effect that is compatible with the rest of the law.”
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In
Edgar v. MITE Corp.
, 457
U.S.

624
(1982), the Supreme Court ruled: “A state statute is void to the extent that it
actually conflicts
with a valid Federal statute.” In effect, this means that a State law will be found to violate the
supremacy clause
when either of the following two conditions (or both) exist:
[3] \r\n\r\n
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Compliance with both the Federal and State laws is impossible, or
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“…state law stands as an obstacle to the accomplishment and execution of the full purposes and objectives of Congress…”
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Supreme Court – FINAL Ruling – Plain Meaning – No
Jiggery Pokery
\r\n47 Pages,
view our highlights, annotations & bookmarks
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Resources & Links

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Wikipedia

PDF

Congressional Research Service

on plain meaning rule
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Our webpage on mandated privacy notices
– scroll down to section on writing in plain English.\r\n\r\nC
alifornia Civil Code 1635 et seq – Interpretation of Contract
s\r\n\r\n
Caminetti_v._United_States
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Thomas v Quintero
\r\n\r\nGeorgetown University 21 pages on how to read, interpret and apply statutes\r\n\r\nParol Evidence Rule
Wikipedia
– Contract stands by itself – can\’t bring up discussions or agreements that were prior to actually signing the written Contract\r\n

Related Web Pages

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King V Burwell Subsidies Held in Health Care.Gov

\r\n\r\n\r\n \r\n\r\n \r\n\r\n ‘,’Plain Meaning Rule – Read the statute 3 times’,”,’publish’,’open’,’closed’,”,’plain-meaning-rule’,”,”,’2018-10-27 14:38:31′,’2018-10-27 14:38:31′,”,0,’http://healthlaw.healthreformquotes.com/?page_id=5′,0,’page’,”,0),(7,1,’2014-12-04 07:02:07′,’2014-12-04 07:02:07′,”,’PPACA & Health Insurance Law’,”,’publish’,’open’,’closed’,”,’introduction’,”,”,’2017-03-09 17:18:59′,’2017-03-09 17:18:59′,”,0,’http://healthlaw.healthreformquotes.com/?page_id=7′,0,’page’,”,0),(8,1,’2014-12-04 16:35:44′,’2014-12-04 16:35:44′,’

All health plans and insurers to are now required to
offer
(
make something available for those who want it
) coverage for
orthotic
and
prosthetic
devices and services as follows:

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Annual and lifetime maximums for orthotic and prosthetic devices and services cannot be lower than the maximums applicable to other plan benefits; and

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Copayments, coinsurance, deductibles, and maximum out-of-pocket amounts cannot be higher than the most common amounts on the benefit plan.\r\nAB 2012  Health and Safety Code §1367.18 Insurance Code §
10123.7

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\r\nA removable
shoe insert
, otherwise known as a
foot orthoses
, accomplishes many number of purposes, including daily wear comfort, foot and joint pain relief from
arthritis
, overuse, injuries, and other causes such as
orthopedic
correction, smell reduction and athletic performance.
wikipedia.org/Shoe_insert
\r\n\r\n \r\n\r\nFoot orthoses comprise a custom made insert or footbed fitted into a shoe. Commonly referred to as \”orthotics\” these orthoses provide support for the foot by redistributing ground reaction forces as well as realigning foot joints while standing, walking or running. A great body of information exists within the orthotic literature describing the sciences that might be used to aid people with foot problems as well as the impact \”orthotics\” can have on foot, knee, hip, and spine deformities. They are used by everyone from athletes to the elderly to accommodate biomechanical deformities and a variety of soft tissue inflammatory conditions such as plantar fasciitis.

[8]

wikipedia.org/Orthotics#Foot_orthoses

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Consumer Resources

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San Pedro Shoes
\r\nExcellent Orthotics\r\n\r\n
spenco.com/ insoles
\r\n\r\nVideo Istep digital foot analysis\r\n
vimeo.com
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thorlo.com
Socks\r\n\r\n
Medicare
on Orthotic & Prosthetic\’s\r\n\r\nBefore AB 2012, health plans and insurers were required to offer group coverage for orthotic and prosthetic devices under terms agreed upon between the employer and the health plan or insurer. AB 2012 revised the existing \”mandate to offer\” to stipulate that this coverage may be subject only to maximums and limitations on coverage that apply to the plan’s basic health care services. The new provision is effective July 1, 2007.\r\n

Related Pages

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\r\n ‘,’Orthotics’,”,’publish’,’open’,’closed’,”,’orthotics’,”,”,’2017-04-18 00:27:30′,’2017-04-18 00:27:30′,”,30,’http://healthlaw.healthreformquotes.com/?page_id=8′,0,’page’,”,0),(10,1,’2014-12-04 18:08:40′,’2014-12-04 18:08:40′,’
Blue Cross settlement

5/11/2007

proposal to only rescind or cancel if the error was

intentional

(
LA Times 2/23/2008 $9 million award
more
Calif Health Line
Anderson Cooper Newscast
$15 Million Settlement
on CA DOI Website)

Sacramento Bee 6.20.2013

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Insurance Company employees encouraged to drop sick policyholders per

LA times.com

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PROHIBITION ON RESCISSIONS
PPACA
SEC. 2712
.

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A group health plan and a health insurance issuer offering group or individual health insurance coverage
shall not rescind
such plan or coverage with respect to an enrollee once the enrollee is covered under such plan or coverage involved, except that this section shall not apply to a covered individual who has performed an act or practice that constitutes
fraud
or makes an
intentional misrepresentation of
material fact
as prohibited by the terms of the plan or coverage. Such plan or coverage may not be cancelled except with prior notice to the enrollee, and only as permitted under section 2702(c) or 2742(b).

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Rescission of Membership

Top
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Rescission of Membership\r\n

Every applicant age 18 or older acknowledges the following:

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I have provided true and complete answers to all questions in the application to the best of my knowledge and understand that all answers are important and will be considered in the acceptance or denial of this application.

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I understand that all information I know, that is responsive to a question on this application, must be provided in my answers consistent with California law. If Anthem Blue Cross and/or Anthem Blue Cross Life and Health Insurance Company discovers that you committed an act, practice, or omission that constitutes fraud, or intentional misrepresentation of material fact is found in this application, Anthem Blue Cross and/or Anthem Blue Cross Life and Health Insurance Company may rescind my plan/policy within the first 24 months from my effective date.

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I understand this means that Anthem Blue Cross and/or Anthem Blue Cross Life and Health Insurance Company will revoke my plan/policy as if it never existed back to the original Effective Date. Rescission may occur even if we review your medical records or seek medical confirmation of your health information as part of our processing of your application.

\r\nThe primary applicant additionally acknowledges the following:\r\n

All of my dependents listed on this application who are 18 years of age or older have read this application and have provided complete and accurate information for this application to the best of my knowledge and have signed the application below.

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Also, to the best of my knowledge and belief, I have done everything necessary to be able to assure you that all information about all applicants, including my children under the age of 18, listed on this application is true and complete. Anthem Blue Cross and/or Anthem Blue Cross Life and Health Insurance Company may deny or rescind the entire plan/policy if it discovers that you committed an act, practice, or omission that constitutes fraud, or intentional misrepresentation of material fact is found in this application. Enrollees/insured\’s other than the individual(s) whose information led to the rescission on such plans/policies may be able to obtain coverage as set forth in the section

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Eligibility following Rescission
.  Top
\r\nI understand that if my plan/policy is rescinded, I will be sent written notice that will explain the basis for the decision and my appeal rights.
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I have the option to submit a new application in the future to be underwritten and considered for  benefits.

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I also understand that, consistent with California law, I will be required to pay for any services Anthem Blue Cross and/or Anthem Blue Cross Life and Health Insurance Company paid on my behalf and that Anthem Blue Cross and/or Anthem Blue Cross Life and Health Insurance Company will refund any premium paid by me, less my medical expenses that Anthem Blue Cross and/or Anthem Blue Cross Life and Health Insurance Company

(Blue Cross Application Section 7)

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Q7: The Affordable Care Act (through Public Health Service Act section
2712
) generally provides that plans and issuers must not rescind coverage unless there is fraud or an individual makes an intentional misrepresentation of material fact.

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A rescission is defined as it is commonly understood under the law – a cancellation or discontinuance of coverage that has a retroactive effect, except to the extent attributable to a failure to pay timely premiums towards coverage.
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Is the exception to the statutory ban on rescission limited to fraudulent or intentional misrepresentations about prior medical history?
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What about retroactive terminations of coverage in the “normal course of business”?
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The statutory prohibition related to rescissions is not limited to rescissions based on fraudulent or intentional misrepresentations about prior medical history.
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An example in the Departments’ interim final regulations on rescissions clarifies that some plan errors (such as mistakenly covering a part-time employee and providing coverage upon which the employee relies for some time) may be cancelled prospectively once identified, but not retroactively rescinded unless there was some fraud or intentional misrepresentation by the employee.
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On the other hand, some plans and issuers have commented that some employers’ human resource departments may reconcile lists of eligible individuals with their plan or issuer via data feed only once per month. If a plan covers only active employees (subject to the COBRA continuation coverage provisions) and an employee pays no premiums for coverage after termination of employment, the Departments do not consider the retroactive elimination of coverage back to the date of termination of employment, due to delay in administrative record-keeping, to be a rescission.
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Similarly, if a plan does not cover ex-spouses (subject to the COBRA continuation coverage provisions) and the plan is not notified of a divorce and the full COBRA premium is not paid by the employee or ex-spouse for coverage, the Departments do not consider a plan’s termination of coverage retroactive to the divorce to be a rescission of coverage. (Of course, in such situations COBRA may require coverage to be offered for up to 36 months if the COBRA applicable premium is paid by the qualified beneficiary.)\r\n

(dol.gov

)

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Recession in CA

– IRMI.com
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Blue Cross FAQ\’s
concerning
Obama\’s Plan
\r\n\r\nPost Claim Underwriting The Federation.org\r\n\r\n
Recent news articles
Calif. Health line\r\n

Limitations on Recission

Top
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Insurance Companies are getting more & more limited if they want to cancel coverage. Policy holders, who had coverage improperly cancelled have the right to get their policy back.  Agents and brokers attest that they explained the importance of filling out an application correctly.

(AB 2569 (2008)

1389.7 and 1389.8
Health and Safety Code,
10119.2 and 10119.3
Insurance Code.)
lawsuits pending to limit insurer ability to cancel

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Existing law prohibits a plan or insurer from rescinding, canceling, or limiting a health plan contract or health insurance policy due to the plan\’s or
insurer\’s failure to complete medical underwriting and resolve all reasonable questions
arising from written information on or with an application before issuing a contract or policy
(Legislative digest of AB 2569 medical news today.com)

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Insurance Companies can no longer cancel for minor or unintentional mistakes in a member\’s application.  Consumers may sue insurers over policy rescissions.  The cancellation  must give 30 days notice and advise members of their  right to appeal

(
AB 2470

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What if another company refused to write my coverage?
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CA Dept of Insurance Survey

does not show this as a reason. Insurance Code

10133.95

‘,’Rescission’,”,’publish’,’open’,’closed’,”,’rescission’,”,”,’2018-07-13 22:22:08′,’2018-07-13 22:22:08′,”,12,’http://healthlaw.healthreformquotes.com/?page_id=10′,0,’page’,”,0),(11,1,’2014-12-04 18:09:58′,’2014-12-04 18:09:58′,’

How does the Insurance Company know, (investigate) if the application wasn\’t filled out correctly?

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They can
write to your MD
, before a claim is even turned in.

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Video on denials for \”minor\” issues?\r\n
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Sample

Permissions

and

Information Practices

on what the Insurance Companies can look into, to make their decision.
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Visit our Page on
Wrong Information

on your application
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Los Angeles Times 5.13.2012

Lenders Tools to Prevent Fraud

‘,’Investigation’,”,’publish’,’open’,’closed’,”,’investigation’,”,”,’2017-01-05 19:08:32′,’2017-01-05 19:08:32′,”,12,’http://healthlaw.healthreformquotes.com/?page_id=11′,0,’page’,”,0),(12,1,’2014-12-04 18:16:13′,’2014-12-04 18:16:13′,’‘,’Insurance Application – Errors – What must be disclosed’,”,’publish’,’open’,’open’,”,’insurance-application-errors-must-disclosed’,”,”,’2017-01-05 19:08:32′,’2017-01-05 19:08:32′,”,0,’http://healthlaw.healthreformquotes.com/?page_id=12′,0,’page’,”,0),(13,1,’2014-12-04 18:18:07′,’2014-12-04 18:18:07′,’

What information must be disclosed on an Insurance Application?

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What happens if the information is wrong?

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The falsity of any statement in the application for any policy covered by this chapter shall not bar the right to recovery under the policy unless such false statement was made with actual

intent to deceive

or unless it

materially affected

either the acceptance of the risk or the hazard assumed by the insurer

§
10380.

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§

The insured shall not be bound by any statement made in an application for a policy unless a copy of such application is attached to or endorsed on the policy when issued as a part thereof. …
10381.5

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No insurer issuing or providing any policy of disability insurance covering hospital, medical, or surgical expenses shall engage in the practice of
post claims underwriting.

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For purposes of this section, \”post claims underwriting\” means the rescinding, canceling, or limiting of a policy or certificate due to the insurer\’ s failure to complete medical underwriting and resolve all reasonable questions arising from written information submitted on or with an application before issuing the policy or certificate.
§10384.

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Yale Law School Scholarship Paper

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Please note, when reviewing codes, you may have to check what \”Chapter\” it\’s in.  The code cited, might be taken out of context.  This website is not legal advise, contact an

attorney

.
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NEGOTIATIONS BEFORE EXECUTION\r\nArticle 1.  Concealment ..
330-339
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§ 330. Concealment defined
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§ 331. Effect of concealment
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§ 332. Required disclosure
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§ 333. Required inquiry
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§ 334. Materiality
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§ 332

. Required disclosure – Each party to a contract of insurance shall communicate to the other, in good faith,

all facts within his knowledge

which are or which he believes to be material to the contract and as to which he makes no warranty, and which the other has not the means of ascertaining.\r\nCase Law
\r\nRepresentation ….
350-361
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§ 350. Oral or written representations
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§ 358. Falsity
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§ 359. Material false representations; effect
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§ 360. Materiality
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Ambiguity

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In cases of uncertainty not removed by the preceding rules, the language of a contract should be interpreted most strongly against the party who caused the uncertainty to exist.
Cal.Civ.Code § 1654

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Generally, when an applicant for life insurance is asked for material information about his medical history and does not give the specific information requested, the insurer is entitled to void the policy. (
Ins. Code, §§ 331
,
10380.)

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Under California law, where insured fails to fulfill his or her obligation to marine insurer under
uttermost good faith
duty of disclosure, insurer is entitled to rescind and void contract.

Article 2.  Concealment and Representations–Rules Peculiar to  Marine Insurance …

1900-1905

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Under California law, applicant for marine insurance was bound by application form which he signed, even though form was filled out by insurer\’s agent and applicant chose not to read it.

Pacific Ins. Co. v. Kent

120 F.Supp.2d 1205C.D.Cal.,2000.

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Marine insurance application\’s request for \”purchase price\” unambiguously referred to price paid for boat, not to applicant\’s subjective view of market value of boat, and thus applicant\’s knowing misstatement of amount he had paid for boat constituted misrepresentation warranting rescission under California law, even absent showing of materiality.

1900-1905

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Under California law, insurance
agent
was under no duty to investigate marine insurance
application
to determine whether applicant\’s representations were false.

1900-1905

.

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Under California law, insurance
agent
assumes duties of reasonable care, diligence, and judgment in procuring insurance requested by an insured.\r\n

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Case Examples  Knowledge of insured–In general
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Generally where insurer makes no inquiry, and insured makes no representations as to facts in question, in absence of actual fraud such concealment is not ground for avoiding a policy, but in California there must first be actual knowledge of fact alleged to be concealed, and extent of such knowledge is tested by insured\’s good faith belief at the time of application, and subsequent events proving it to be unfounded or false are not sufficient to allow insurer to void the policy.

Ashley v. American Mut. Liability Ins. Co., N.D.Cal.1958, 167 F.Supp. 125

.
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If applicant for insurance had no present knowledge of facts sought, or failed to appreciate significance of information related to him, his incorrect or incomplete responses on application would not constitute grounds for rescission.

Thompson v. Occidental Life Ins. Co. of California (1973) 109 Cal.Rptr. 473, 9 Cal.3d 904, 513 P.2d 353

.
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Failure to mention, in application for insurance, existence of condition of which applicant has no knowledge or appreciation is not misrepresentation affecting validity of policy.

MacDonald v. California-Western States Life

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Ins. Co. (App. 2 Dist. 1962) 21 Cal.Rptr. 659, 203 Cal.App.2d 440
.

\r\nFailure to disclose facts of which applicant for insurance is ignorant will not warrant avoiding policy.

Travelers\’ Ins. Co. of Hartford, Conn., v. Byers (App. 1932) 123 Cal.App. 473, 11 P.2d 444

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Are you having
problems
getting through the
Blue Cross
or
other Companies
Quote and Enrollment Links
?

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Wonder
why YOU must complete the application
and can\’t just tell us, send me the policy, like when you order a pizza?

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Are you concerned about what happens if you make a
mistake on  your application
, either by accident or intentionally?

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Here\’s some hints (be sure to scroll the entire page) from when we helped some of our clients get through these problems.

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Please call or
email
us to discuss 310.519.1335,

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we are working on having more detail on this page.

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With a little sarcasm, being as coverage is now guaranteed issue

§2701

. and the companies are mandated to put you on a

preventative care

maintenance program, (

Covered CA Brochure Page 6

)  along with more rate regulation,

80% loss ratio,

etc, one of the tools for preventative health maintenance is the smart phone

LA Times 12.5.2014

so having you fill out an application online, prepares you to use all the other modern 21st century tools.
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A

Pediatric Dental Plan

is required even if you don\’t have children under 18
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After you get the quotes, you must create a password and login credentials
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Then log in
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This is why we can\’t just do the application for you.\r\n\r\n \r\n\r\n

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What happens if you didn\’t tell with complete honesty the Insurance Company about a pre existing condition or disease that you knew, should have  KNOWN about or disclosed?

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Covered CA Application
– Agent Certification\r\n

\r\nClick on image to enlarge\r\n
That is, what if there is wrong, false, misleading or incomplete information on your

application

?
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The Insurance company can cancel or rescind the policy, give back the premium – force the agent/broker to give back the commission or service fees, even if the condition has NOTHING to do with the claim that arises.
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This in fact happened to us back in the early 80\’s,  the start of the

AIDS epidemic

.   We had someone who was in a bar fight in Haiti, got stabbed and was given multiple blood transfusions.  His policy was

cancelled

, when he turned in a claim for some kind of stomach hospitalization.
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FAQ\’s    –        Historical\r\n

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Is there a
ONE page simple form
to find out if an Insurance Company
will write me
, without answering all the questions on a
full application
?  – This question and most of the others are no longer relevant under Guaranteed Issue Health Care Reform along with no Pre X clause!
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What if I have a
(Pre-Existing)
condition, but the application does not ask about it?\r\n
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What is Medical Underwriting
?
Why don\’t Insurance Companies write coverage for anyone willing to pay the premium?
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What if my Agent says it\’s OK, not to list a condition? Does he have to attest that he explained how to properly complete the application?
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What does to the best of my knowledge mean?
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Can the Insurance Company cancel my coverage, even if the claim had NOTHING to do with the
pre-existing condition
that was not listed on the application?
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Where can I get more
MEDICAL information
on my health conditions and how to keep them under control?
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What if the Insurance Company cancels me in
Bad Faith
?  Do I have a right to appeal?
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What does it mean if the Insurance Company says I concealed a
Material Fact?
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What does the California Insurance Code
§
330 – 339 require an applicant to disclose or tell the Insurance Company?\r\nHow about Long Term Care
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Does the site have further links to \”wrong info that I can review?
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Where can I get coverage, if no Insurance Company wants me?
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Hagan v Blue Shield
– upheld.
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What are
some things Insurance Companies might look at
to wonder if my application is correct or that I didn\’t something?
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Can an insurance company refuse to write my coverage, if another company cancelled me or refused to write me?
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Tell me more about recent legislation restricting Insurance Companies ability to rescind coverage, AB 2740 Guidance
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Blue Cross FAQ
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Email us
your question?
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Consumer Resources\r\nSee FAQ\’s Above

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US Military Enlistment Disclosures

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Answers to FAQ\’s

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What Information did the application ask for?

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6A. Health History Questionnaire – ALL QUESTIONS MUST BE ANSWERED OR THE APPLICATION WILL BE RETURNED. Give COMPLETE details of any \”Yes\” answers in Section 6C on the following page.
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Has any person listed on this application, in the last 10 years, had any signs or symptoms, seen a health care provider, had treatment recommended including prescription medications, received treatment, or been hospitalized for any of the following conditions as stated in questions 1 through 14?

(
Blue Cross Individual Application
.)

\r\n
I have provided a complete history of material information that will be considered in the acceptance or denial of this application. I understand that if I intentionally provided incomplete or false material information Blue Cross may revoke my coverage. This means Blue Cross will cancel membership as if it never existed. Also, after approval for membership, if material information is discovered by Blue Cross that was not provided to the Plan prior to the effective date of the policy, Blue Cross may deny coverage.
\r\n
I understand and agree that I alone am responsible for the accuracy and completeness of this application.
\r\n

I have personally read and completed this application.
If I am accepted, this application will become part of the contract between Blue Cross and me.

(Blue Cross Individual Application)

\r\n

How does the Insurance Company know, if the application wasn\’t filled out correctly?   Do they investigate?

\r\n

Attestation

\r\n
Your Insurance Agent/Broker MUST sign this form, that he informed you of the importance of completing the application properly.  The agent can get in a lot of trouble for improperly advising you on how to complete the application.
\r\n

6.

\r\n

Review and select one of the following:

\r\n\r\n
\r\n

I did not assist the applicant in any way in completing or submitting this application. All information was completed by the applicant with no assistance or advice of any kind from me.

\r\n

I assisted the applicant in submitting this application. All information in the health questionnaire was provided by them. I advised the applicant that they should answer all questions completely and truthfully and that no information requested on the application should be withheld. I explained that, if information is withheld, that could result in their coverage being cancelled later. The applicant indicated to me that they understood these instructions and warnings. To the best of my knowledge, the information on the application is complete and accurate. I understand that, if any portion of this statement by me is false, I may be subject to civil penalties of up to $10,000.

(
Blue Shield Individual Application
, Insurance Code

\r\n
\r\n
10119.3.  (a) Notwithstanding any other provision of law, an agent or broker who assists an applicant in submitting an application to a health insurer has the duty to assist the applicant in providing answers to health questions accurately and completely.\r\n(b) An agent or broker who assists an applicant in submitting an application to a health insurer shall

attest

on the written application to both of the following:\r\n(1) That to the , the information on the application is complete and accurate.\r\n(2) That he or she explained to the applicant, in easy-to-understand language, the of providing inaccurate information and that the applicant understood the explanation.\r\n(c) If, in an attestation required by subdivision (b), a declarant willfully states as true any material fact he or she knows to be false, that person shall, in addition to any applicable penalties or remedies available under current law, be subject to a civil penalty of up to ten thousand dollars ($10,000). Any public prosecutor may bring a civil action to impose that civil penalty. These penalties shall be paid to the Insurance Fund.\r\n(d) A health insurance application shall include a statement advising declarant\’s of the civil penalty authorized under this section.
\r\n
\”

to the best of my knowledge

\”
\r\n

Definition: 1.
information in mind:
general awareness or possession of information, facts, ideas, truths, or principles — Her knowledge and interests are extensive.  2.
specific information:
clear awareness or explicit information, e.g. of a situation or fact —I believe they have knowledge of the circumstances.\r\n

Encarta

\r\n

To render life policy void for falsity of warranty that answers in application therefore are true to
best of applicant\’s knowledge and belief
, they must be substantially untrue, not merely in fact,
but to best of applicant\’s knowledge and belief.

St.1917, p. 964,  6 (West\’s Ann. Insurance Code,  10380);  West\’s Ann.Civ.Code, ? 1572.

\r\n
Combs v. Burbank Mut. Life & Benefit Ass\’n
140 Cal.App. 139, 35 P.2d 132 (Cal.App. 2 Dist. 1934)\r\n

Applicant\’s failure to disclose diagnosis of leukemia and thereby correct misstatements in application for life insurance policy breached continuing duty of good faith and provided basis for rescission under statute requiring each party to contract of insurance to communicate to the other, in good faith, all facts within knowledge which are or are believed to be material to contract, as to which no warranty is made, and which cannot be ascertained by other party, even if insurer could have discovered disease by complete blood count (CBC) during application process.

CA Ins.Code  332 .Lunardi v. Great-West Life Assurance Co.  37 Cal.App.4th 807, 44 Cal.Rptr.2d 56 (Cal.App. 6 Dist.,1995)

\r\n

Retroactive Action

\r\n
Blue Cross has 24 months to initiate retroactive action due to false or omitted health history information on the application. Claims submitted during that period are audited to ensure that preexisting conditions not listed on the application were not diagnosed, evaluated, or treated prior to enrollment. If a preexisting condition that should have been disclosed is discovered, the contract may be retroactively canceled, or it may be re-underwritten and placed into coverage that would have been offered based upon complete

original information.Source – Blue Cross Confidential Agent\’s Manual

\r\n
Employers and employees who commit

fraud

or

misrepresentation

to circumvent the

law

or rules governing PacAdvantage will be disqualified, possibly retroactive to the initial enrollment date. In cases of fraud, individuals may be financially responsible for their own medical care, even care provided while improperly enrolled through PacAdvantage. Page 6 Pac Advantage Employer Manual 7/04
\r\n
AB 1945 – California Proposed Law to Prohibit Post Claims Underwriting – Didn\’t pass – vetoed by Governor\r\nArticle 6.  Interpretation of Policy  10380-10390
\r\n

What if another company refused to write my coverage?
\r\n

CA Dept of Insurance Survey

does not show this as a reason. Insurance Code 10133.95
\r\n

\r\n

‘,’Disclosure’,”,’publish’,’open’,’open’,”,’disclosure’,”,”,’2017-08-26 14:13:58′,’2017-08-26 14:13:58′,”,12,’http://healthlaw.healthreformquotes.com/?page_id=13′,0,’page’,”,0),(14,1,’2014-12-04 18:19:41′,’2014-12-04 18:19:41′,’

Pre-existing conditions (Uninsurable)

clauses\r\nare pretty much no longer revelant as they are prohibited under Health Care Reform 4

5 CFR §147.10

8 and all coverage is GUARANTEED ISSUE

§2701

\r\n
Commonwealth Fund –

Report ACA helped those with Pre

X
\r\n
See Comments & FAQ\’s below about the

case pending in court

to do away with this guarantee
\r\n

Jump to Pre ObamaCare Rules\r\n

\r\n

Donald Care vs Mandate & Keeping Pre X Clause Debate – Status – Fist Pounding

\r\n

AHCA Continous Coverage Requirement

\r\n

Preexisting condition exclusion
means
a
limitation or exclusion of benefits
(including a denial of coverage) based on the fact that the condition was present before the effective date of coverage (or if coverage is denied, the date of the denial) under a group health plan or group
or individual health insurance coverage
(or other coverage provided to federally eligible individuals pursuant to 45 CFR part
148
), whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that day. A preexisting condition exclusion includes any limitation or exclusion of benefits (including a denial of coverage) applicable to an individual as a result of information relating to an individual\’s health status before the individual\’s effective date of coverage (or if coverage is denied, the date of the denial) under a group health plan, or group or individual health insurance coverage (or other coverage provided to Federally eligible individuals pursuant to 45 CFR part
148
), such as a condition identified as a result of a pre-enrollment questionnaire or physical examination given to the individual, or review of medical records relating to the pre-enrollment period.
5
4.9801-
2   H
ealth Care Reform Facts Q 33
5
\r\n

\r\n
*****
\r\n

Are you repealing patient protections, including for people with pre-existing conditions?

\r\n
No. Americans should never be denied coverage or charged more because of a pre-existing condition.
\r\n
We preserve vital patient protections, such as (1) prohibiting health insurers from denying coverage to patients based on pre-existing conditions, and (2) lifting lifetime caps on medical care.

housegop.leadpages.co/healthcare

\r\n
***
\r\n

Get FREE Quotes Here for CA

Nationwide

\r\n

Child Pages

\r\n
\r\n

Obamacare PROHIBITS discrimination or different rates based on health!

\r\n
§

2701 Page 37

HR 3590 FAIR HEALTH INSURANCE PREMIUMS.
\r\n

‘‘(a) P

ROHIBITING

D

ISCRIMINATORY

P

REMIUM

R

ATES

.—

\r\n

‘‘(1) I

N GENERAL

.—With respect to the premium rate

charged by a health insurance issuer for health insurance coverage offered in the individual or small group market—
\r\n
(A) such rate shall vary with respect to the particular plan or coverage involved only by—
\r\n
(i) whether such plan or coverage covers an individual or family;
\r\n
(ii)

rating area

, as established in accordance with paragraph (2);
\r\n
S

mall Biz Rating Methods AB 108

3
\r\n
(iii) age, except that such rate shall not vary by more than 3 to 1 for adults (consistent with section 2707(c)); and
\r\n
(iv) tobacco use, [Doesn’t apply in CA] except that such rate shall not vary by more than 1.5 to 1; and
\r\n
(B) such rate shall not vary with respect to the particular plan or coverage involved by any other factor not described in subparagraph (A).
\r\n
So does CA Law §

10965.3 (g) (1

)
A health insurer shall not establish rules for eligibility, including continued eligibility, of any individual to enroll under the terms of an individual health benefit plan based on any of the following factors:\r\n
(A)

Health status.

\r\n
(B)

Medical condition

, including physical and mental illnesses.
\r\n
(C) Claims experience.
\r\n
(D) Receipt of health care.
\r\n
(E)

Medical history.

\r\n
(F) Genetic information.
\r\n
(G)

Evidence of insurability

, including conditions arising out of acts of domestic violence.
\r\n
(H)

Disability.

\r\n

Get
Private Disability Coverage

Social Security Disability

SDI – CA State Disability

\r\n
(I) Any other health status-related factor as determined by any federal regulations, rules, or guidance issued pursuant to Section 2705 of the federal Public Health Service Act.
\r\n
Thus, the rest of this  page is pretty much

Historical\r\n

\r\n

\r\n
Pre – X existing conditions deal with those
medical problems
that you\’ve been treated for in the past or in some cases even a condition you\’ve never been treated for, but know or should know that you have, paid cash or somehow think that it\’s not on your record.  The three main issues are:\r\n
\r\n

Can you get coverage?

\r\n

If you do get coverage, can and if so, for how long can the Insurance Company exclude coverage?

\r\n

If they can exclude coverage, must they cover you after a certain period of time and must they give you credit for time under your prior coverage?

\r\n

What about
Health Care Reform and GUARANTEED Issue
with no – pre X Clause?

\r\n
\r\nSee the FAQ\’s below.  If you are in California,
email us
a copy of your policy, application, etc. and we can help you.
Not in CA?
\r\n

FAQ\’s

\r\n

F

requently

A

sked

Q

uestions
\r\n

How can I get Affordable Individual or Family Coverage?

\r\n\r\n
\r\n

Is there a simple
ONE page form
that I can fill out to see if my Medical conditions will still allow me to get
Preferred Rates
for
Individual Coverage
?\r\n
California Residents ONLY.

\r\n

What about Guaranteed Issue plans, like:\r\n
Health Care Reform\’s Pre-Existing Condition Plan
\r\n
Mr. MIP
or limited benefit plans like Get Med 360?

\r\n

What about BMI and
weight
?

\r\n

What if I do not tell the Insurance company about my medical conditions?

\r\n

What if I was healthy when I filled out the application,
but something happened later?

\r\n

Does the Government have any
tools
to help me find coverage?

\r\n

What about the new rule that
kids under 19
cannot have a Pre X clause?

\r\n

What if I\’m
pregnant
?

\r\n

What about Life Insurance?

\r\n

Can I
email you a question
that I don\’t see listed here?

\r\n
\r\n

What is a Pre Existing Condition?

\r\n\r\n
\r\n

What
medical issues
might be considered  Pre – Existing?

\r\n

What State or Federal Laws Define \”Pre-Existing Condition
?\”

\r\n

What if I paid cash and there is no record of my illness or treatment?

\r\n

Does the Dept of Labor have a brochure to explain how HIPAA protects on Pre-X conditions?

\r\n

wikipedia.org

\r\n
\r\n
Affordable

Employer Group Coverage?

\r\n\r\n
\r\n

Does AB 1672 in CA require Employer\’s Group health plans, including if I
start my own business
have to write my coverage
, and waive the Pre-existing Condition clause?

\r\n

Are there any rules or laws  that say the Insurance Company must cover my Pre-X immediately if I pass underwriting or the Insurance Company is
mandated to issue coverage
to me?
(employee in an Employer Group Plan,
AB 1672
, AB 1790)

\r\n

If I lost my coverage from my job, are there any guarantees?
\r\n
COBRA
\r\n
Cal COBRA
\r\n
HIPAA
When Cal Cobra is all used up.

\r\n
\r\n

Seniors &
Medicare Supplements
\r\n

Medicare Advantage Plans

\r\n

Part D – Rx – Prescriptions

\r\n\r\n
\r\n

What about Medicare Advantage & Medi Gap (Supplement) plans?

\r\n
\r\n

Waiving the Pre X Clause – Once I\’m able to get coverage

\r\n\r\n
\r\n

If I have prior medical insurance
\”Credible Coverage\”
and I get new health coverage will my  pre-existing conditions be covered?

\r\n

If I do not have prior
Credible Coverage
will  my pre-x be excluded forever, or just for
say 6 months or a year

\r\n

What about the
Pre X clause
in
visitor and travel policies
?

\r\n
\r\n

Claims Issues?

\r\n\r\n
\r\n

What if something else makes the Pre-X worse
, my pre-x causes a new problem, that is, how does the Insurance Company decide if the medical expense claim was from the Pre-X?

\r\n

What if I have say
Hypertension
– how would it be
determined
if that was the
nexus
or aggravation of say a
Heart Attack?

\r\n

If I have a policy in force and then I get sick or develop a Pre – X
can they cancel me or raise my rates
?

\r\n

How can I appeal, complain or file a grievance?

\r\n

Does
Obama\’s Plan
prohibit recessions Nationally?

\r\n

\r\n
\r\n

Misc.

\r\n\r\n
\r\n

Where can I find Federal Regulations §146.111 or §
2590.701-3
on Pre-X limitations?

\r\n

How will Obama\’s Plan affect Pre-Existing Conditions?

\r\n

How do I get help if I\’m not in California?

\r\n

Are there any
Federal
, State
AB 88
or protections in
Obama\’s plan
for
Mental Illness
?

\r\n
\r\n

State & Federal Laws that Define Pre-Existing Conditions

\r\n
\”Pre-existing condition provision\” means
a policy provision that excludes coverage for charges or expenses incurred during a specified period following the insured\’s effective date of coverage, as to a condition for which medical advice, diagnosis, care, or treatment was recommended or received during a specified period immediately preceding the effective date of coverage.
California

Small Group Employer Plans AB 1672

CA Ins. Code  §

10700 (q)

Appears to be exact same definition as in CA  Ins. Code §

10198.6 c

Federal Definition Title 42 300 gga

wikipedia.org

UHC Policy Extract

\r\n\r\nPre X cannot include reasonable or prudent person would have sought treatment – Insurance Dept Bulletin
93.04 A
\r\n\r\nAlso check the
application
for a definition of Pre X or what the health questions are.\r\n\r\n
19a.
Within the last 2 years, have you had any serious illness or serious physical injury
not mentioned elsewhere
on this application
that has not been evaluated by a licensed health practitioner?
\r\n\r\n
19b.
Within the last 2 years, have you visited a physician, psychiatrist, chiropractor, physician assistant, nurse practitioner, physical therapist or other licensed health practitioner
that has not been disclosed elsewhere on this application?

Blue Cross 3.2013 Application

\r\n\r\n
Knox Keene Health Care Act
\r\n

Underwriting

\r\nIn Individual plans Insurance Companies generally have the right to decide to give you a policy on not.  This is called
Underwriting
.\r\n\r\nCA Department of Insurance
Listing
of  typical Pre-existing conditions\r\n\r\nIf there are any waiting periods in your new coverage, they are
generally waived
if 63 days of terminating your Insurance with another
\”creditable\”
health care plan.\r\n

One Page – Pre Underwriting FORMS

\r\nDo NOT miss your HIPAA
63 day
deadline!\r\n

Pre-Clause Waived if you had Prior Coverage

\r\nIf you apply for coverage within 63 days of terminating your membership with another
\”creditable\”
health care plan, then
you can use your prior coverage for credit toward the six-month waiting period.

CA Insurance Code for

Small Group Plans

10708 c

Individual Plans CA Insurance Codes §10198.6-10198.9 (might not be on point)

Blue Shield FAQ\’s

PPO Share Brochure – Page 12   Federal Guarantees

HIPAA

Health
I
nsurance
P
ortability and
A
ccountability
A
ct

\r\n

When must a health plan write me?

\r\nIn CA under
AB 1672 Small Employer Health Act

§10705 j

you can not be excluded as an employee or dependent in a group plan for health status.
Employer group of 2
or more are
guaranteed coverage.
\r\n\r\n
Mr. MIP
Guaranteed coverage for individuals rejected from
standard plans.
\r\n\r\n
Obama\’s Interim High Risk Guaranteed Pool
However, this plan just ran out of funding.\r\n\r\nGuaranteed Issue & Plans for Uninsured\r\n\r\nFederal Law
1182
– Group Plans must treat all similarly situated employees the same, regardless of health status.\r\n\r\n
Steve, you\’re website is the

greatest

, but I don\’t live in California
\r\n

Guarantees for those who lost Employer Group Health Insurance

\r\n
COBRA
\r\nand when that expires in 18 months or
36 months in California
,\r\nthen you can get a
\”HIPAA\”
policy\r\n\r\nHIPAA Matrix\r\n

Weight Chart

\r\nThis is NOT an Insurance Company Chart.  We just have it here for guidance.  Check our
Pre-Underwriting Page
for a more specific answer to your medical situation.\r\n
www.health.harvard.edu/
\r\n

How long is the Pre-X clause?

\r\nIn CA Group Plans, not more than 6 months 10198.7\r\n\r\nThis clause can often be waived!\r\n

Government Tools to help find coverage

\r\n

Case Law on Pre-Existing Conditions

\r\n
What if a don\’t tell the Insurance Company about my medical history?
\r\n\r\nBe sure to
disclose
whatever is asked for in the application, so that there isn\’t a
recession – cancellation later
.  Just because you paid cash or were treated by someone whose records are not available, doesn\’t mean that just because it\’s not on your \”record\” that it doesn\’t count.  In some cases, the Insurance Company will have your doctor
verify your conditions
on your first visit with your new coverage.\r\n\r\nDo NOT call or contact us in any way,  if you plan to misrepresent yourself on an
application for Insurance.
We do not need the grief or the fine.   We are mandated by law to certify that we do not know anything negative that is not on the application and that we explained to you how important it is to fill out an application correctly.  We pride ourselves on helping the public get paid on
LEGITIMATE claims and issues.
\r\n

Preexisting conditions, proximate cause

\r\nWhen two causes join in causing injury, one of which is insured against, insured is covered by policy.
Zimmerman v. Continental Life Ins. Co. (App. 1 Dist. 1929) 99 Cal.App. 723, 279 P. 464.

Wiki Answers

Ins.Code

§ 10320

exclusions must be listed in the policy itself.
\r\n\r\n10198.6.  Preexisting Condition Provisions and
Late
Enrollees
\r\n10198.7.  (a)\r\n\r\n
top
\r\n\r\n \r\n\r\n \r\n
29 USC

§ 1182.

Prohibiting discrimination against individual participants and beneficiaries based on health status
\r\n(a)
In eligibility to enroll
\r\n\r\n(1)
In general
\r\n\r\nSubject to paragraph (2), a group health plan, and a health insurance issuer offering group health insurance coverage in connection with a group health plan, may not establish rules for eligibility (including continued eligibility) of any individual to enroll under the terms of the plan based on any of the
following health status-related factors
in relation to the individual or a dependent of the individual:\r\n
(A) Health status.
\r\n
(B) Medical condition (including both physical and mental illnesses).
\r\n
(C) Claims experience.
\r\n
(D) Receipt of health care.
\r\n
(E) Medical history.
\r\n
(F) Genetic information.
\r\n
(G) Evidence of insurability (including conditions arising out of acts of domestic violence).
\r\n
(H) Disability.
\r\n(2)
No application to benefits or exclusions
\r\n\r\nTo the extent consistent with section 1181 of this title, paragraph (1) shall not be construed—\r\n
(A) to require a group health plan, or group health insurance coverage, to provide particular benefits other than those provided under the terms of such plan or coverage, or
\r\n
(B) to prevent such a plan or coverage from establishing limitations or restrictions on the amount, level, extent, or nature of the benefits or coverage for

similarly situated individuals

enrolled in the plan or coverage.
\r\n(3)
Construction
\r\n\r\nFor purposes of paragraph (1), rules for eligibility to enroll under a plan include rules defining any applicable waiting periods for such enrollment.\r\n
(b)

In premium contributions

\r\n
(1)

In general

\r\n
A group health plan, and a health insurance issuer offering health insurance coverage in connection with a group health plan, may not require any individual (as a condition of enrollment or continued enrollment under the plan) to pay a premium or contribution which is greater than such premium or contribution for a

similarly situated individual

enrolled in the plan on the basis of any health status-related factor in relation to the individual or to an individual enrolled under the plan as a dependent of the individual.
\r\n
(2)

Construction

\r\n
Nothing in paragraph (1) shall be construed—
\r\n
(A) to restrict the amount that an employer may be charged for coverage under a group health plan; or
\r\n
(B) to prevent a group health plan, and a health insurance issuer offering group health insurance coverage, from establishing premium discounts or rebates or modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention.
\r\nIs one condition the nexus or aggravation of another?
top
\r\n\r\nLastly, the veteran must have a nexus [connection]  between the current disability and the in service disease injury or incident.\r\n\r\nIn other words, there must be a link between the present disability and the veterans time during his period of active military service.\r\n\r\nThere are many ways in which the veterans present disability can be connected to his disease, injury or incident in service. The VA is required to consider all the possible ways to disability could be service-connected.\r\n\r\nProbably the most common is
direct service connection
. This is when a disease, injury or incident in service directly caused the veteran\’s present disability. These cases are usually won when you have a letter from a doctor stating that the in service disease, injury or incident was the cause of the veteran\’s present disability. Because the veteran is given the benefit of the doubt a doctor only needs to be 50% sure that the in service condition caused the present disability. The language the VA accepts is that it is \”at least as likely as not\” that the veterans present disability is a result of the specified disease injury or incident in service. If the doctor uses the terminology that it is less likely than not he or she is saying they are less than 50% sure there is a connection. And if the doctor uses the terminology that \”it is more likely than not\” then he or she is saying there is a greater than 50% chance that the in service disease injury or incident caused the veterans present disability. These opinions from doctors are often called
Nexus letters
. If you are seeking a nexus opinion from your doctor it is extremely important the doctor is aware of the terminology used by the VA. It is also important for these opinion letters that the doctor have access to, review and state that he has reviewed your file and service medical records. If the doctor references the file in service medical records it strengthens the opinion even more. These opinion letters are even more important when you\’re trying to prove service connection for a present condition many years after service.\r\n\r\n \r\n\r\nA veteran will have to show
aggravation of a condition
in service if the condition preexisted his service time. If the veteran can show his condition has worsened as a result of his time in service than the VA has the burden to prove that the worsening of the condition was due to \”the natural progression of the disease.\” One presumption in VA law that helps in these types of cases is the \”presumption of soundness.\” This means the veteran is presumed to be in sound condition when he entered service in less shown otherwise usually by the service entrance exam
icdri.org/
\r\n\r\n \r\n\r\nrbs law.com/\r\n\r\n
veterans disability lawyer site.com
\r\n
Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections
\r\n
\r\n

Regulation

\r\n

Fact Sheet

\r\n

Patient Protection Model Notice

\r\n

Lifetime Limits Model Notice

\r\n

Public Comments

\r\n
\r\n \r\n\r\n \r\n\r\nWith Guaranteed Issue Coverage coming 1.1.2014 many employees may leave their jobs to start new businesses.  www.SteveShorr.com has been helping Small Biz with 2 or more employees in CA get guaranteed coverage since 1992 under
AB 1672
,
Mr. Mip
for individuals if they had no place else to go and
HIPAA
for those who have exhausted
COBRA
.    We welcome NEW start ups.  Free
Individua
l
Business
Quotes\r\n\r\nIt’s our opinion that under Health Care Reform that ONE employee business, even if it’s just the owner can get GROUP coverage.  There is  some dissenting opinion.  We’ve sent a email to Covered CA for clarification.\r\n\r\n \r\n\r\nReferences\r\n
‘Employment Lock’ May Be Coming to an End
\r\nMeanwhile, a new paper explores the phenomenon of “employment lock” — where workers stay in jobs they don’t like because of the health benefits — and concludes that given the new security of coverage expansion under the ACA, as many as 940,000 Americans will leave their jobs.\r\n(
CA Healthline)
\r\n\r\n \r\n\r\n \r\n\r\n

\r\n
claire
says:
\r\n
February 3, 2016 at 12:44 AM
Edit
\r\n

\r\n

\r\n\r\nIs there a waiting period for treating pre existing condition?\r\n\r\n

\r\n

Reply

\r\n
\r\n
\r\n

\r\n

Steve Shorr
says:
\r\n
February 3, 2016 at 6:36 AM
Edit
\r\n
\r\n
\r\n\r\nNo. The ObamaCare prohibition against P
re-Exisitng Condition
s includes any limitation or exclusion.\r\n\r\n
\r\n

\r\n
‘,’Pre-Existing Conditions’,”,’publish’,’open’,’closed’,”,’pre-existing-conditions’,”,”,’2018-07-13 22:26:56′,’2018-07-13 22:26:56′,”,0,’http://healthlaw.healthreformquotes.com/?page_id=14′,0,’page’,”,2),(16,1,’2014-12-04 18:21:31′,’2014-12-04 18:21:31′,’
\r\n\r\n\r\nPresident Obama\’s Speech after decision\r\n\r\n
Kaiser Foundation 10 page summary – ACA Upheld as Tax\r\n\r\n
Full Text of Supreme Court Decision – 193 pages – Our bookmarks and annotations\r\n\r\n
Actual Ruling – Stating Mandated Health Insurance Violates Commerce Act\r\n\r\n
Motion to Dismiss\r\n\r\n
\r\n

Health Care Reform UPHELD as a TAX

\r\n \r\n\r\n
Guide to Decision to uphold ACA as a Tax – 10 pages
Kaiser Family Foundation\r\n\r\n
FULL decision
193 pageswith Steve\’s Annotations & Bookmarks\r\n
PPACA Litigation

Blog

\r\n

Aetna Video

Need even more reforms – pay MD\’s for HEALTHIER patients
\r\n

Argument FOR Constitutionality

(New York Review of Books)
\r\n

2.21.2012 Court might delay ruling till 2014, as a tax can\’t be declared unconstitutional till it\’s been collect

.
\r\n
9.13.2011 Pennsylvania Judge Rules Mandate Unconstitutional

cnn.com
washingtonpost.com/

\r\n
Appeal won\’t be fast tracked in the US Supreme Court, announced 4/25/2011.

KHI.org

\r\n
U.S. District

Judge Henry Hudson

ruled

that the provision in the new law that

forces individuals to purchase health care insurance

is unconstitutional.
\r\n
White House and outgoing House Speaker Nancy Pelosi expressed confidence that the law would remain intact. Pelosi noted that Judge Hudson\’s decision does not stand in the way of

other parts of the reform

, which are moving forward.
\r\n
\”Contrary to what opponents argue (10th Amendment states\’ rights)

the new law

falls well within Congress\’s power to regulate economic activity under the:
\r\n\r\n
\r\n

Commerce Clause

\r\n

Necessary and Proper Clause

\r\n

General Welfare Clause,\”

\r\n
\r\n
– according to Whitehouse adviser Stephanie Cutter (Time.com 12/14/2010)
\r\nU.S. District Court Judge Roger Vinson on 1/31/2011 ruled that the federal health reform law\’s individual mandate is unconstitutional, as the mandate exceeds Congress\’ power to regulate interstate commerce, the

Washington Post

reports (Aizenman/Goldstein,

Washington Post

, 2/1)
.\r\n\r\nVinson also voided the entire law because he concluded that the mandate is \”inextricably bound\” to other provisions in the law
(Sack,

New York Times

, 1/31).
\r\n\r\nThe Judge refused to grant the request to suspend further implementation of the law, saying that such an order is unnecessary because of a \”long-standing presumption\” that the federal government will comply with judicial rulings.
(

Washington Post

, 2/1). (

California Healthline.org

)
\r\n

Explanation

from Dorsey & White LLP\r\n

McGuireWoods

\r\n

States Rights

\r\n
Constitution\’s principle of

federalism

by providing that powers not granted to the

federal government

nor prohibited to the

states

by the Constitution of the United States are reserved to the states or the people under the 10th amendment.

(wikipedia.org)

\r\n

Necessary & Proper Clause

\r\n
The

Congress

shall have Power – To make all Laws which shall be necessary and proper for carrying into Execution the

foregoing Powers

, and all other Powers vested by this Constitution in the Government of the United States, or in any Department or Officer thereof.

(
Article One of the United States Constitution
, section 8, clause 18)

\r\n

General Welfare Clause

\r\n
A governing bodies constitution generally allows them to enact laws as they see fit to promote or provide for the general welfare of the people. In some countries, this has been used as a basis for legislation promoting the health, safety, morals, and well-being of the people governed thereunder (also known as the

police power

).
\r\n
Such clauses are generally interpreted as granting the state broad power to regulate for the general welfare that is independent of other powers specified in the governing document.

(
wikipedia.org)

\r\n

Commerce Clause

\r\n
According to the Tenth Amendment, the government of the United States has the power to regulate only matters delegated to it by the Constitution. Other powers are reserved to the states, or to the people (and even the states cannot alienate some of these).
\r\n
In modern times,

the
Commerce Clause
has become one of the most frequently-used sources of Congress\’ power

, and thus its interpretation is very important in determining the allowable scope of federal government.
\r\n
In the 20th century, complex economic challenges arising from the

Great Depression

triggered a reevaluation in both Congress and the Supreme Court of the use of Commerce Clause powers to maintain a strong national economy.
\r\n
In

Wickard v. Filburn

(1942), in the context of

World War II

, the Court ruled that federal regulations of

wheat production

could constitutionally be applied to wheat grown for \”home consumption\” on a farm — that is, wheat grown to be fed to farm animals or otherwise consumed on the farm. The rationale was that a farmer\’s growing \”his own wheat\” can have a

substantial cumulative effect on interstate commerce

, because if all farmers were to exceed their production quotas, a significant amount of wheat would either not be sold on the market or would be bought from other producers.

Hence, in the aggregate, if farmers were allowed to consume their own wheat, it would affect the interstate market in wheat.

\r\n
In

Garcia v. San Antonio Metropolitan Transit Authority

(1985), the Court changed the analytic framework to be applied in Tenth Amendment cases. Prior to the Garcia decision, the determination of whether there was state immunity from federal regulation turned on whether the state activity was \”traditional\” for or \”integral\” to the state government. The Court noted that this analysis was \”unsound in principle and unworkable in practice,\” and rejected it without providing a replacement. The Court\’s holding declined to set any formula to provide guidance in future cases. Instead, it simply held \”…we need go no further than to state that we perceive nothing in the overtime and minimum-wage requirements of the FLSA … that is destructive of state sovereignty or violative of any constitutional provision.\” It left to future courts how best to determine when a particular federal regulation may be \”destructive of state sovereignty or violative of any constitutional provision.\”
\r\n
In

United States v. Lopez

514
U.S.
549
(1995)

, a federal law mandating a \”

gun-free zone

\” on and around public school campuses was struck down because, the Supreme Court ruled, there was no clause in the Constitution authorizing it.

This was the first modern Supreme Court opinion to limit the government\’s power under the Commerce Clause.

The opinion did not mention the Tenth Amendment, and the Court\’s 1985

Garcia

opinion remains the controlling authority on that subject.
\r\n
Most recently, the Commerce Clause was cited in the 2005 decision

Gonzales v. Raich

. In this case, a California woman sued the

Drug Enforcement Administration

after her

medical marijuana

crop was seized and destroyed by Federal agents. Medical marijuana was explicitly made legal under California state law by

Proposition 215

; however,

marijuana

is prohibited at the federal level by the

Controlled Substances Act

. Even though the woman grew the marijuana strictly for her own consumption and never sold any, the Supreme Court stated that growing one\’s own

marijuana
affects
the interstate market of marijuana.

The theory was that the marijuana

could

enter the stream of interstate commerce, even if it clearly wasn\’t grown for that purpose and it was unlikely ever to happen (the same reasoning as in the

Wickard v. Filburn

decision). It therefore ruled that this practice may be regulated by the federal government under the authority of the Commerce Clause.

(wikipedia.org

)

\r\n
The

McCarran–Ferguson Act

, 15

U.S.C.

§§ 1011-1015, is a

United States federal law

that exempts the business of insurance from most federal regulation, including federal

anti-trust

laws to a limited extent. The McCarran–Ferguson Act was passed by Congress in 1945 after the

Supreme Court

ruled in

United States v. South-Eastern Underwriters Association

that the federal government could regulate insurance companies under the authority of the

Commerce Clause

in the

U.S. Constitution

.
\r\n
The Act was sponsored by Senators

Pat McCarran

(D-

Nev.

) and

Homer Ferguson

(R-

Mich.

)

(wikipedia.org)

.
\r\n

Links

\r\n
White House.Gov  Affordable Health Care Act

YouTube Channel

\r\n

Issue under Clinton\’s Health Security Act

\r\n

Summary by O\’Neill Institute

\r\n

Mark Hall JD

\r\n

View Actual Ruling
\r\n

\r\n

New Law effective 2014

\r\n

\r\n
Commonwealth of Virginia\r\nComplaint for Declaratory & Injunctive Relief
\r\n
Commonwealth of Virginia v Sebelius\r\nSebelius

Points & Authorities

to Dismiss
\r\n
Cato Institute

amici curiae
brief

\r\nWashington Legal Foundation
\r\n ‘,’Heath Reform Upheld as a tax’,”,’publish’,’open’,’closed’,”,’heath-reform-upheld-tax’,”,”,’2018-10-06 18:54:54′,’2018-10-06 18:54:54′,”,8037,’http://healthlaw.healthreformquotes.com/?page_id=16′,0,’page’,”,0),(22,1,’2014-12-04 18:51:12′,’2014-12-04 18:51:12′,’
\r\n\r\nPlaylist on Health Care Reform from

Health Reform.Gov

\r\n\r\n
\r\n

Resources
Consumer Links

\r\n
Affordable Care Act –

California

CHCF.org
\r\n
CA Health Care Foundation –

ACA 411 Tracking Health Care Reform

in CA
\r\n
What Californian\’s should know.
\r\n

UHC Resource Center

\r\n\r\n
\r\n

Excerpt of changes
as noted in actual group policy

\r\n
\r\n
DOL

FAQ\’s Implementation

\r\nCMS.Gov
Health Reform for Consumers
\r\n

Aetna Health Reform Weekly

\r\n
Health Net

Pamphlet

22 Pages\r\n

\r\n
\r\n

health Care.gov/time line

\r\n

\r\n
The Kaiser Foundation has a new timeline detailing when specific provisions of the health reform law are scheduled to take effect. It reflects the provisions of the Patient Protection and Affordable Care Act, as modified by the Health Care & Education Reconciliation Act. A separate

summary of the law

is also available, as is an

interactive calculator

to illustrate the subsidies in the law and a brief explaining how the new law will close the Medicare drug benefit\’s coverage gap. These resources and more are found on the

Health Reform Gateway

.
\r\nLecture on President Obama\’s Plan\r\n

LA Times Graphic Summary

\r\n

\r\n
Blue Cross/Anthem\’s Summary 4/7/2010
\r\n
Summary for Employers
\r\n\r\n
Summary of Changes
(NAHU) but this site took off their logo\r\nLos Angeles Times
4/4/2010
\r\n\r\nCleaning up ambiguities –
LA Times 4/4/2010
\r\n

Senate Passes Bill

\r\n

Key Points of L.A. Times Article 3/22/2010

\r\n
Health Care Fraud – President Obama\’s Plan
\r\n

Kaiser Permanente\’s Summary

\r\n
Assess employers with

50 or more

employees that do not offer coverage and have at least one full-time employee who receives a premium tax credit a fee of $2,000 per full-time employee, excluding the first 30 employees from the assessment.
\r\n
Employers with 50 or more employees that offer coverage but have at least one full-time employee receiving a premium tax credit, will pay the lesser of $3,000 for each employee receiving a premium credit or $2,000 for each full-time employee, excluding the first 30 employees from the assessment.
\r\n
Require employers with more than 200 employees to automatically enroll employees into health insurance plans offered by the employer.  Employees may opt out of coverage.
\r\n\r\n
\r\n

\r\n
Broker Links
\r\n
Health Net
Broker Guide
to Health Care Reform 1/2011
\r\n\r\n

\r\n
‘,’PPACA Resources’,”,’publish’,’open’,’closed’,”,’ppaca-resources’,”,”,’2018-07-27 18:17:33′,’2018-07-27 18:17:33′,”,8129,’http://healthlaw.healthreformquotes.com/?page_id=22′,0,’page’,”,0),(23,1,’2014-12-04 19:04:20′,’2014-12-04 19:04:20′,’

Workers\’ compensation

is the oldest social insurance program; it was adopted in
most states
, including
California
, during the second decade of the 20th century. It is a
no-fault system
, meaning that
injured employees need not prove the injury was someone else\’s fault
in order to receive workers\’ compensation benefits for an
on-the-job injury
.

\r\n
There are

six basic

types of workers\’ compensation

benefits

available, depending on the nature, date and severity of the worker\’s injury:
\r\n

1.
medical care
,

all medical care reasonably required to cure or relieve the effects of the injury
\r\n
Get quotes for

24/7 coverage for your employees

.

Individuals & Self Employed

\r\n

2. t
emporary
disability benefits,

two-thirds of the lost wages, up to a maximum of $728 per week.
\r\n

3.
permanent
disability benefits,

rating schedule

up to $728 per week — for life
\r\n

\r\n

4. vocational rehabilitation services, &

\r\n

5. supplemental job displacement benefits, and

education-related retraining or skill enhancement, up to $10,000
\r\n

6.
death benefits
.

Up to $160,000

(DWC Website)

\r\n
Get

Life Insurance Quotes

no matter where or how G-d forbid you leave us\r\n

\r\n

24 Hour Worker\’s Comp with
Medical Insurance

\r\n

\r\nBrochure

16 Pages, including Application

email us

for the most recent version.
\r\n
Acceptable Industries
\r\n
Class Codes
\r\n\r\n
Fillable Application
Word 2010\r\n

Get a quote

for Worker\’s Compensation from

Harbor Insurance
.

an associate of ours

\r\n

\r\n \r\n

Resources, Main
Workers Compensation
, Child & Related Pages

\r\n

Nolo Guide to Worker\’s Compensation

\r\n

Employer Small Group Health Insurance

\r\n
Human Resource Tools –

HR Wow

\r\n
\r\n

Broker ONLY

\r\n

How to complete application

‘,’Worker\’s Compensation’,”,’publish’,’open’,’closed’,”,’workers-compensation’,”,”,’2017-04-06 00:18:06′,’2017-04-06 00:18:06′,”,0,’http://healthlaw.healthreformquotes.com/?page_id=23′,0,’page’,”,0),(24,1,’2014-12-04 19:05:10′,’2014-12-04 19:05:10′,’

FAQ\’s – Workers Compensation\r\n

\r\n

What happens if you\’re
Self Employed and you\’re asked to provide a Certificate of Worker\’s Compensation?

\r\n

Sole Proprietors
can generally submit a signed affidavit that they are not required under
state law
to have workers\’ compensation insurance.

It would be a good idea to get an

individual

or

small group

health insurance plan for

24/7 coverage.

\r\nSample Worker\’s Compensation Waiver Form\r\nSan Diego City Attorney\r\n\r\n
Contractors Board
\r\n
Q.

My spouse and I are the sole owners of our business. We have

no employees

. Are we required to obtain workers\’ compensation coverage?
\r\n
A.
Generally, if you are the sole owners of the business, coverage for yourselves, is optional if you wish to pursue it. You would need to have workers\’ compensation coverage for any employees you may hire. You should consult with your
attorney,
insurance agent or broker
, or carrier regarding the specifics of you situation and your options.\r\n
What is an

Independent or sub Contractor

?
\r\n
Use this worksheet is to be used by the proprietor of a business to determine whether a worker is most likely an employee or an independent contractor.
\r\n
CA EDD –

DE 38

7 Pages
\r\nView our
main page on 1099 vs Employee
\r\n

Must
Corporate Officer\’s be covered?

\r\n
California Labor Code Section

3351,

partners and corporate officers, or members of boards of directors are employees for Workers’ Compensation purposes except under limited circumstances.
\r\n
In order for individuals holding the above-mentioned positions to fall outside the Workers’ Compensation laws, they must be shareholders of the corporation, and all stock of the corporation must be held by persons who are either officers or members of the board of directors of the corporation.\r\nBlue Cross

Employer Application

Question # 12
\r\n
*******************
\r\n

Can you ever go without workers’ compensation insurance

\r\nThe short answer is NO.\r\n
Sole business owners are not required to have coverage but may get it for themselves alone, if an insurer is willing to provide it. Business partners or corporate officers must be covered in some cases. Source –

CA Employers Guide to Worker\’s Comp

. Page 13
\r\n
***************************************
\r\n

What\’s an On The Job Injury?\r\nIf two employees fight over a girl friend, is that covered?

\r\n

\”In the course of\”

means that the injury must occur at work and during work hours. For example, an injury that occurs during the work day while the employee is crossing the street to buy a donut as a personal snack is probably not compensable. Activities that are completely non-work-related are also outside the course of employment even if they occur at work. These include horseplay, violation of company rules, or

a non-work-related dispute (e.g., a fight at work over a girlfriend)

.

(rkmlegal.com)

\r\n

State of CA Background Paper on Causation

Points out that

Labor Code 3600

excludes initial aggressor of physical altercation and requires service in the course of employment and proximately caused by the employment

Mathews v Worker\’s Compensation Bureau

deals with constitutional issues and that the initial aggressor only has to commit assault, not battery.
\r\n

The Taneka Talley Case – When Does Injury or Death “Arise” Out of Employment?

lexisnexis.com/

Transactron v Worker\’s Comp Appeals Board

Job duties must contribute to the danger.
\r\n

Conway v Gobin

– Compensation denied where injuries are the result of personal grievances, unconnected with employment.
\r\n

Globe v Industrial Accident

– Marmurowicz v Miss Marshall – argument about preparing the ice cream in a restaurant – arose out of employment, thus compensable, no clear cut aggressor, if personal grievance not related to employment, no compensation.
\r\n

Azevedo v Industrial Acc. Commission

\r\n

O\’Conner Brothers – Hull

– Aggressor get\’s paid, unless it\’s willful & serious Labor Code 4551 and even then one get\’s paid 1/2
\r\n

Gunnell v Metrocolor Lab

\r\n

insurance journal.com

\r\n

AOE/COE Alicia Hoffman Esq

\r\n

Investigation

\r\n

lexis nexis.com

\r\n

Labor Code 3200 Et Seq Course of Employment

\r\n

MORE FAQ\’s

\r\n
CA Dept of Industrial Relations
\r\n
FAQ\’s
\r\n\r\n
FAQ
for Employers\r\n\r\n
Injured workers
\r\n
FAQ\’s on Workers Comp.
\r\n
19 pages Quotit
\r\n\r\n \r\n

Main
Workers Compensation
, Child & Related Pages

\r\n

\r\n
\r\n

\r\n ‘,’FAQ\’s’,”,’publish’,’open’,’closed’,”,’faqs’,”,”,’2017-10-20 23:04:11′,’2017-10-20 23:04:11′,”,23,’http://healthlaw.healthreformquotes.com/?page_id=24′,0,’page’,”,0),(25,1,’2014-12-04 19:06:06′,’2014-12-04 19:06:06′,’
This is a technical page as part of our Main

Workers Compensation

Section.
\r\n

Technical Links

\r\n

Permanent Disability Rating Schedule

\r\n
Insurance Code
, excerpts\r\n\r\n
PART 3.  LIABILITY, WORKERS\’ COMPENSATION, AND COMMON CARRIER
\r\n
LIABILITY INSURANCE
\r\n\r\n \r\n

CA Ins. Code

109

.  Workmen\’s compensation insurance includes insurance against loss from liability imposed by law upon employers to compensate employees and their dependents for injury sustained by the employees arising out of and in the course of the employment, irrespective of negligence or of the fault of either party.
\r\n

Labor Code
excerpts

\r\n \r\n\r\nRules –
Code of Regulations
\r\n\r\nWorkers\’ Compensation Insurance Fraud Reporting
1877-1877.5
\r\n\r\n \r\n

Definitions

\r\n

3300.

As used in this division,

\”employer\” means:\r\n(a) The State and every State agency.\r\n(b) Each county, city, district, and all public and quasi public\r\ncorporations and public agencies therein.\r\n(

c) Every person including any public service corporation, which has any natural person in service.

\r\n(d) The legal representative of any deceased employer.
\r\n

Definition of Employee

\r\n

Blue Cross Glossary

\r\nLABOR CODE  SECTION 3350 et seq.
Definition of Employee
3352.  \”Employee\” excludes the following:\r\n(a) Any person defined in subdivision (d) of Section 3351 who is employed by his or her parent, spouse, or child\r\n
3353.

\”Independent contractor\”
[view our page on employee vs independent contractor 1099]

means any person who renders service for a specified recompense for a specified result, under the control of his principal as to the result of his work only and not as to the means by which such result is accomplished.
\r\n

Labor Code 3600

.  (a) Liability for the compensation provided by this division, in lieu of any other liability whatsoever to any person except as otherwise specifically provided in Sections 3602, 3706, and 4558, shall, without regard to negligence, exist against an employer for any injury sustained by his or her employees arising out of and in the course of the employment and for the death of any employee if the injury proximately causes death, in those cases where the following conditions of compensation concur:\r\n(1) Where, at the time of the injury, both the

employer

and the

employee

are subject to the compensation provisions of this division.
\r\n(2) Where, at the time of the injury, the employee is performing\r\nservice growing out of and incidental to his or her employment and is\r\nacting within the course of his or her employment.\r\n(3) Where the injury is proximately caused by the employment,\r\neither with or without negligence.\r\n(4) Where the injury is not caused by the intoxication, by alcohol\r\nor the unlawful use of a controlled substance, of the injured\r\nemployee.  As used in this paragraph, \”controlled substance\” shall\r\nhave the same meaning as prescribed in Section 11007 of the Health\r\nand Safety Code.\r\n(5) Where the injury is not intentionally self-inflicted.\r\n(6) Where the employee has not willfully and deliberately caused his or her own death.\r\n(7) Where the injury does not arise out of an altercation in which\r\nthe injured employee is the initial physical aggressor.\r\n(8) Where the injury is not caused by the commission of a felony,\r\nor a crime which is punishable as specified in subdivision (b) of\r\nSection 17 of the Penal Code, by the injured employee, for which he\r\nor she has been convicted.\r\n(9) Where the injury does not arise out of voluntary participation\r\nin any off-duty recreational, social, or athletic activity not\r\nconstituting part of the employee\’s work-related duties, except where\r\nthese activities are a reasonable expectancy of, or are expressly or\r\nimpliedly required by, the employment.  The administrative director\r\nshall promulgate reasonable rules and regulations requiring employers\r\nto post and keep posted in a conspicuous place or places a notice\r\nadvising employees of the provisions of this subdivision.  Failure of\r\nthe employer to post the notice shall not constitute an expression\r\nof intent to waive the provisions of this subdivision.\r\n(10) Except for psychiatric injuries governed by subdivision (e)\r\nof Section 3208.3, where the claim for compensation is filed after\r\nnotice of termination or layoff, including voluntary layoff, and the\r\nclaim is for an injury occurring prior to the time of notice of\r\ntermination or layoff, no compensation shall be paid unless the\r\nemployee demonstrates by a preponderance of the evidence that one or\r\nmore of the following conditions apply:\r\n(A) The employer has notice of the injury, as provided under\r\nChapter 2 (commencing with Section 5400), prior to the notice of\r\ntermination or layoff.\r\n(B) The employee\’s medical records, existing prior to the notice\r\nof termination or layoff, contain evidence of the injury.\r\n(C) The date of injury, as specified in Section 5411, is\r\nsubsequent to the date of the notice of termination or layoff, but\r\nprior to the effective date of the termination or layoff.\r\n(D) The date of injury, as specified in Section 5412, is\r\nsubsequent to the date of the notice of termination or layoff.\r\nFor purposes of this paragraph, an employee provided notice\r\npursuant to Sections 44948.5, 44949, 44951, 44955, 44955.6, 72411,\r\n87740, and 87743 of the Education Code shall be considered to have\r\nbeen provided a notice of termination or layoff only upon a district\’\r\ns final decision not to reemploy that person.\r\nA notice of termination or layoff that is not followed within 60\r\ndays by that termination or layoff shall not be subject to the\r\nprovisions of this paragraph, and this paragraph shall not apply\r\nuntil receipt of a later notice of termination or layoff.  The\r\nissuance of frequent notices of termination or layoff to an employee\r\nshall be considered a bad faith personnel action and shall make this\r\nparagraph inapplicable to the employee.\r\n(b) Where an employee, or his or her dependents, receives the\r\ncompensation provided by this division and secures a judgment for, or\r\nsettlement of, civil damages pursuant to those specific exemptions\r\nto the employee\’s exclusive remedy set forth in subdivision (b) of\r\nSection 3602 and Section 4558, the compensation paid under this\r\ndivision shall be credited against the judgment or settlement, and\r\nthe employer shall be relieved from the obligation to pay further\r\ncompensation to, or on behalf of, the employee or his or her\r\ndependents up to the net amount of the judgment or settlement\r\nreceived by the employee or his or her heirs, or that portion of the\r\njudgment as has been satisfied.\r\n\r\n109.  Workmen\’s compensation insurance includes insurance against loss from\r\nliability imposed by law upon employers to compensate\r\nemployees and their dependents for injury sustained by the employees arising\r\nout of and in the course of the employment, irrespective of negligence\r\nor of the fault of either party.\r\n\r\n \r\n

Main
Workers Compensation
, Child & Related Pages

\r\n\r\n
\r\n

FAQ’s
\r\n
\r\n
Domestic Workers
\r\n
\r\n

\r\n

Links & Resources

\r\n

Technical & Actual Law

\r\n
‘,’Technical & Actual Law’,”,’publish’,’open’,’closed’,”,’technical-actual-law’,”,”,’2017-06-21 14:53:05′,’2017-06-21 14:53:05′,”,23,’http://healthlaw.healthreformquotes.com/?page_id=25′,0,’page’,”,0),(26,1,’2014-12-04 19:06:52′,’2014-12-04 19:06:52′,’

Links & Resources for Worker\’s Compensation Insurance

\r\n

Employer Resources

\r\n
Department of Industrial Relations – Worker\’s Comp Division –
\r\n\r\n
Employer Info.
\r\n\r\n
Forms
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Links to view other Employer Mandated Benefits
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California Department of Worker\’s Compensation

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Wikipedia

on Worker\’s Comp.
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Workers Comp &

ADA Americans with Disabilities Act
\r\nLA District Attorney Worker\’s Comp. Fraud\r\n\r\n \r\n

Employee Resources

\r\n
Guidebook for Injured Workers
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DIR Injured Employee Workshops
\r\n\r\n
Fact sheets and instructions for injured workers
\r\n\r\n
Basic information
for employees\r\n\r\n
Attorney Referrals
\r\n
What to bring and discuss
for the Injured Worker\r\n\r\n
Glossary of workers\’ compensation terms for injured workers
or\r\n\r\n
Fact Sheet B
\r\n\r\n
Worker\’s Comp.com
\r\n\r\nGet your own Private Disability Insurance\r\n\r\n
Longshore & Harbor Workers Act
Explanation on Attorney Naylor\’s Site\r\n\r\nFree Advise.com on Worker\’s Comp.\r\n\r\n
Law Help.org
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I CURRENTLY AM ON WORKER\’S COMPENSATION.

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CAN MY EMPLOYER MAKE ME PAY  FOR MY OWN HEALTH INSURANCE WHILE I\’M OFF?

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Main
Workers Compensation
, Child & Related Pages

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‘,’Links & Resources’,”,’publish’,’open’,’closed’,”,’links-resources’,”,”,’2018-06-02 14:47:46′,’2018-06-02 14:47:46′,”,23,’http://healthlaw.healthreformquotes.com/?page_id=26′,0,’page’,”,0),(27,1,’2014-12-04 19:08:34′,’2014-12-04 19:08:34′,’
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Health Insurance Dictionary
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Dictionary – Photo Credit Wikipedia\r\n

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A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X Y Z\r\n\r\n
Health Reform Glossary
(UHC)
\r\n\r\n
Numerous other Medical, Legal & Insurance Dictionaries
\r\n
View our
other Glossary Page
\r\n
CA Dept of Insurance Glossary
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Legal Dictionary
Lectlaw
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Medicare Glossary

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Acupuncture
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Acupuncture coverage, including coverage for traditional Chinese herbal supplements, is an option available to employer groups. Health Net has contracted with American Specialty Health Plans (ASHP) to administer acupuncture services and traditional Chinese herbal supplements to Health Net members. Members who have the coverage may obtain acupuncture services through the ASHP network of participating acupuncturists without a referral from the participating physician group (PPG). All acupuncture services, except the initial examination and emergency services, require authorization by ASHP.
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Adjudication
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The process used by health plans to determine the amount of payment for a claim.
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Allergy Treatment
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Allergy testing, allergy immunotherapy, and allergy injection services are covered under all plans. Some plans also cover allergy serum. Allergy treatment is covered when it is indicated by standard medical practice and is subject to scheduled copayments.
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Allowable Charge
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The maximum fee that a health plan will reimburse a provider for a given service.
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Ambulatory Services
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Services performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed medical center. Also called Outpatient Services.
See also: Outpatient.
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Ambulatory Surgery
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Surgical procedures performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called Outpatient Surgery.
See also: Outpatient Surgery.
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Appeals
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The process used by a member to request that the health plan re-considers a previous authorization or denial decision.
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Authorization
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See Prior Authorization.
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Balance Billing
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is when an insurance plan covers less than what a doctor, hospital, or lab service
wants
to be paid.. The health-care provider demands, bills the balance from the patient. Uncertain and fearing the calls of a debt collector, the patient pays up.
business week.com/
ama-assn.org/
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Visit our
NEW website
on ER prohibition of Balance Billing.
\r\nWhile \”balance billing\” is regulated in eight states, legislation to regulate the practice in California has \”repeatedly died\” in the state Legislature
medical news today.com
\r\n\r\nCalifornia
DMHC

Press Release
on Prohibition of Balance Billing in Emergency Rooms 10/2008\r\n
See also:
Negotiated Fees – Rates
\r\n
SB 981 This bill would also prohibit a noncontracting emergency physician from seeking payment from individual enrollees for covered emergency medical services he or she rendered, except for allowable co payments and deductibles, and would require the physician to seek reimbursement solely from the enrollee\’s health care service plan or the plan\’s contracting risk-bearing organization. The bill would require a health care service plan that becomes aware that one of its enrollees has been billed in violation of these provisions to report that violation to the department. The bill would also provide that an enrollee shall have no obligation to pay an amount billed in violation of these provisions.
.leginfo.legislature.ca.gov/
\r\n
Bill Number: SB 697\r\nTopic:
Provider Balance Billing for Members of Healthy Families and AIM\r\n
Statute(s) Impacted:
Added
12693.55
and
12698.26
to the Insurance Code\r\n
Effective Date:
January 1, 2009\r\n
Summary:
This bill prohibits providers of health care from seeking to collect any amounts from Healthy Families and Aid for Infants and Mothers Program enrollees for covered services, except authorized copayments.
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Balance Billing americanbar.org/l
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See also
Dual Coverage
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Benefit
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Payments provided for covered services under the terms of the policy. The benefits may be paid to the insured, or on his behalf, to the medical provider. Benefit design includes the types of benefits offered and any applicable limits to those benefits, e.g., number of visits, percentage paid or dollar maximums applied, subscriber responsibility (cost sharing components), or subscriber incentives to use network providers.
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Benefit Period
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Payments provided for covered services under the terms of the policy. The benefits may be paid to the insured, or on his behalf, to the medical provider. Benefit design includes the types of benefits offered and any applicable limits to those benefits, e.g., number of visits, percentage paid or dollar maximums applied, subscriber responsibility (cost sharing components), or subscriber incentives to use network providers.
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Brand Name Drug
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A prescription drug that has been patented and is only available through one manufacturer.
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Case Management
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A program that assists the member-patient in determining the most-appropriate and cost effective treatment plan. Case management is usually provided to patients who have prolonged expensive or chronic conditions. The program helps determine the treatment location (hospital, other institution or home) and may authorize payment for such care if it is not covered under the member’s benefit agreement.
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Certification
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See Pre-Certification.
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Certificate of Creditable Coverage
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Chemotherapy
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Treatment of malignant disease by chemical or biological antinoeplastic agents.
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Chiropractic Care
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An alternative medicine therapy administered by a licensed Chiropractor. The Chiropractor adjusts the spine and joints to treat pain and improve general health.
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Claim
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A request for payment for benefits received or services rendered.
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Co-payment (or co-pay)
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A way in which the enrollee shares in the cost of health care. The benefit plan requires the enrollee to pay a flat dollar amount per unit of service. An example of a common co-pay is $10 per physician office visit.
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Q41. What is the difference between deductibles and co-payments?\r\nA41.
Co-payment is a type of member cost sharing that requires a flat amount per unit of service or unit of time. This is may be a percentage of the charges or a dollar amount for specified services.
\r\nDeductible is an amount the insured person must pay before benefit payments for covered services begin. The deductible is usually a set amount or a percentage determined by the member\’s contract. For example, a plan might require the insured to pay the first $500 of covered expenses during a calendar year before any benefits are payable.\r\n\r\n
Q42. How does my out-of-pocket maximum work?
\r\n\r\nA42.
Out-of-pocket maximum refers to the most you pay for covered expenses during the year before your plan begins paying 100% of covered expenses for the remainder of the year. It is a sum of deductible and coinsurance amounts. Only covered expenses, as determined by your contract, count toward the maximum. Other costs, such as amounts you pay for non-covered services or charges in excess of our allowances, don\’t count.
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COBRA
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Consolidated Omnibus Budget Reconciliation Act: a federal law that requires most employers with 50 or more employees to provide continuation of coverage for members as prescribed by current federal law.
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Coinsurance
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An arrangement under which the insured person pays a fixed percentage of the cost of medical care after the deductible has been paid. For example, a health plan might pay 80% of the allowable charge, with the enrollee responsible for the remaining 20%; the 20% amount is then referred to as the coinsurance amount.
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Coinsurance maximum OOP
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This is the maximum dollar amount of Covered Expenses for which the Member is responsible in a Calendar Year. After that maximum is reached, this plan will pay 100% of Covered Expenses incurred during the remainder of that Calendar Year.
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Q42. How does my out-of-pocket maximum work?
\r\nA42.
Out-of-pocket maximum refers to the most you pay for covered expenses during the year before your plan begins paying 100% of covered expenses for the remainder of the year. It is a sum of deductible and coinsurance amounts. Only covered expenses, as determined by your contract, count toward the maximum. Other costs, such as amounts you pay for non-covered services or charges in excess of our allowances, don\’t count.
\r\n\r\nBlue Cross FAQ\’s
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Continuation
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When a former plan member has lost eligibility because of a
qualifying event
(as defined by law), coverage identical to that currently being provided to \”similarly situated\” (
AB 1672)
active employees must be continued without a lapse if requested by the member. To illustrate, a member, who had Plan A previously, would continue to have the benefits of Plan A as a COBRA member. Examples of
qualifying events
include: termination of the subscribing member’s employment, divorce or legal separation from the subscribing member, loss of eligibility of the subscribing member’s dependent child, death of the subscribing member.
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Contraception
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The use of contraceptive devices or services and supplies that prevent pregnancy.
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Contract or Subscriber Contract
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A legal agreement between an individual subscriber or an employer group and a health plan that describes the benefits and limitations of the coverage. One subscriber may have coverage under two contracts e.g., one for health and one for dental. Contract or Subscriber contract may also be referred to as Benefit Certificate or Certificate of Insurance, Evidence of Coverage, Health Benefit Contract or Policy.
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Conversion Option
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The exercise of an option to purchase individual coverage at a negotiated rate by a person who is leaving an employee group, typically at retirement.
This may cause you to lose
COBRA
and
HIPAA
rights
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Coordination of Benefits (COB)
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The provision which applies when an enrollee is covered by two health plans at the same time. The provision is designed so that the payments of both plans do not exceed 100% of the covered charges. The provision also designates the order in which the multiple health plans are to pay benefits. Under a COB provision, one plan is determined to be primary and its benefits are applied to the claim first. The unpaid balance is usually paid by the secondary plan to the limit of its responsibility. Benefits are thus \”
coordinated
\” between the two health plans.
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Covered Services
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Hospital, medical, and other health care services incurred by the enrollee that are entitled to a payment of benefits under a health benefit contract. The term defines the type and amount of expense, which will be considered in the calculation of benefits.
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Custodial Care
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Care that is provided primarily to meet the personal needs of the patient. Such care includes help in walking, bathing or dressing. It also includes preparing food or special diets, feeding, administering medicine, or any other care, that does not require continuing services of medical-trained personnel.
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Customary and Reasonable (C&R)
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The amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient after medical review of the case. Also called \”Usual, Customary and Reasonable\” (UCR).
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Day Treatment Center
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An outpatient psychiatric facility, which is licensed to provide outpatient care and treatment of mental or nervous disorders or substance abuse under the supervision of physicians.
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Deductible
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An amount the insured person must pay for covered services during a calendar year, January 1 through December 31, before health benefit payments begin.
What is the difference between deductibles and co-payments?\r\n
Co-payment is a type of member cost sharing that requires a flat amount per unit of service or unit of time. This is may be a percentage of the charges or a dollar amount for specified services.
Deductible is an amount the insured person must pay before benefit payments for covered services begin. The deductible is usually a set amount or a percentage determined by the member\’s contract. For example, a plan mightrequire the insured to pay the first $500 of covered expenses during a calendar year before any benefits are payable.Blue Cross FAQ\’s
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Deductible Carryover
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Many plans offer a provision called a deductible carryover. This provision allows you to carry over to the next year any unmet portion of the deductible that you, or your family, run up in October, November and December. For example, assume you had no medical claims in the first part of the year. In November, you run up $350 worth of claims. If your deductible was $500, you would start the next year with $350 of your $500 deductible already me\r\n
afchealth.com/
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Dental Care
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Covered Services which are necessary and appropriate for the treatment of your teeth and gums and supporting structures according to a licensed professional dentist or dental policies which meet professionally recognized standards of practice.
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Dependent
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Person (spouse or child) other than the subscribing member who is covered under the subscriber\’s evidence of coverage or benefit certificate. May also be referred to simply as \”Member\” or \”Beneficiary\”.
See also: Member.
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Dictionaries
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law.com
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Court Site
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Legal Dictionary
Lectlaw
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Department of Labor – Health Benefits Advisor
Glossary
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Texas DOI Glossary
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Insurance Web
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Glossary of Employee Benefit Terms
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State of CA Insurance Dept.
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CA DOI – Health Insurance Terms
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Glossary
– Annuity Advisors LOMA
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Diagnostic Tests
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Tests and procedures ordered by a physician to determine if the patient has a certain condition or disease based upon specific signs or symptoms demonstrated by the patient. Such diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory, pathology services or tests.
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Disability Insurance
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Insurance Code Definition
benefits and how to obtain coverage
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Domestic Partner
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Drug
Formulary or Recommended Drug List (RDL)
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A list of preferred pharmaceutical products that health plans, working with pharmacists and physicians, have developed to encourage greater efficiency in the dispensing of prescription drugs without sacrificing quality. See: /general/plans/supplemental/drug.asp
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Durable Medical Equipment (DME)
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Mechanical devices, equipment and supplies, which enable a person to maintain functional ability. Also called Medical Equipment.

Medicare Brochure
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Effective Date
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The date that you become covered or entitled to receive the benefits provided under the Plan.
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Emergency Care
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An injury or sudden, unexpected illness (including severe pain and active labor) of sufficient severity that if the member does not receive immediate treatment, it could present a serious threat to his or her health, could seriously impair physical functions, or could cause a serious dysfunction of any organ or body part if immediate medical treatment is not received.
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Enrollee
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An individual who is enrolled and eligible for coverage under a health plan contract. This term encompasses both the subscriber and any of his/her covered dependents, each of whom may also be referred to as a \”Member\”.
\r\nSee also: Member.
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Evidence of Coverage (EOC)
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Exclusions
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Specific conditions or circumstances that are not covered under the health plan benefit agreement. It is very important to consult the health plan benefit agreement (may also be called the Evidence of Coverage, Certificate, or Subscriber Contract) to understand what services are not covered benefits.
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Experimental Procedures
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Procedures that are mainly limited to laboratory research.
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Expiration Date
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The date indicated in the contract as the date coverage expires.
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Explanation of Benefits (EOB)
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A form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim. This explanation usually includes the amount paid, the benefits available, reasons for denying payment, and the claims appeal process.
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Formulary
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See Drug Formulary or Recommended Drug List (RDL).
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A drug, which is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand drug. Read more about Generic Drugs here: http://www.healthnet.com/calpers/faq2.asp#4.
See also: Brand Name Drug.
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H
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Health Benefit Plan
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The plan described and is defined in the health plan benefit contract (may also be referred to as Evidence of Coverage, Subscriber Contract or Certificate), which contract delineates the set of covered health care services and benefits offered, and the health care provider network available, to the member.
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Health Maintenance Organization (
HMO)
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A type of health care plan under which the enrollees receive all the medical services under a Health Benefit Plan through a specific group of participating doctors and hospitals.
From Page 2 of
Blue Shields Individual
50 Page Brochure
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HMO
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See Health Maintenance Organization (HMO).
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Home Health Care
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Health services rendered in the home to an individual who is confined to the home. Such services are provided to aged, disabled, sick or convalescent individuals who do not need institutional care, but who do need nursing services or therapy, medical supplies and special outpatient services.
See also: Outpatient.
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Home Infusion Therapy
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The administration of intravenous drug therapy in the home. Home infusion therapy includes the following services: solutions and pharmaceutical additives; pharmacy compounding and dispensing services; durable medical equipment; ancillary medical supplies; and, nursing services.
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Hospice
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A facility or service that provides care for the terminally ill patient and who provides support to the family. The care, primarily for pain control and symptom relief, can be provided in the home or in an inpatient setting.
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Hospital
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An institution whose primary function is to provide inpatient services, diagnostic and therapeutic, for a variety of medical conditions, both surgical and non-surgical. In addition, most hospitals provide some outpatient services, particularly emergency care.
See also: Emergency Care, Inpatient, Outpatient.
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I.D. Card / Identification Card
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A card issued to a subscriber and possibly his/her dependents, which allows the subscriber to identify himself or his covered dependents to a provider for health care services. The card is subsequently used by the provider to determine benefit levels and to prepare the billing statement.
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Immunizations
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Immunizations and injections that are recommended by guidelines published by the Advisory Committee on Immunization Practices (ACIP) of the U.S. Public Health Service or the American Academy of Pediatrics (AAP).
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In-Network
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Refers to the use of providers who participate in the health plan’s provider network. Many benefit plans encourage enrollees to use participating (in-network) providers to reduce the enrollee’s out-of-pocket expense.
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Indemnity
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A tradition health insurance plan that reimburses for medical services provided to patients based on bills submitted after the services are rendered. Also know as fee-for-service plans. These plans generally do not have a specific provider network.
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Independent Contractor 1099
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Check out
employee definition AB 1083 Health Care Reform
IRS Guidelines
\r\nIRS
SS-8
Worksheet to determine status\r\nCA EDD
DE 38
Determination Guide\r\nEDD Guide
DE 44
see Page 7\r\n
Worker\’s Compensation
\r\nEDD
Pamphlet
Instructions
to Complete the
1099 form
Willful misclassification SB 459 1/1/2012\r\n
Commentary by our CPA
Nolo
Contract With Independent Contractor
\r\n
How to Safely & Legally Hire Independent Contractors
Small Group EmployER AB 1672 – DE 6 & 9 Rules
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Infertility
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Term used to describe the inability to conceive or an inability to carry a pregnancy to a live birth after a year or more of regular sexual relations without the use of contraception. Also includes the presence of a condition recognized by a physician as the cause of infertility.
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Infusion Therapy
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Treatment accomplished by placing therapeutic agents into the vein, including intravenous feeding. Such therapy also includes enteral nutrition which is the delivery of nutrients into the gastrointestinal tract by tube.
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Inpatient
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Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.
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Investigational Procedures
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Procedures that have progressed to limited use on humans but are not widely accepted as proven and effective procedures within the organized medical community.
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K
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Knox-Keene Health Care Service Plan Act of 1975
The Knox-Keene Health Care Service Plan Act of 1975, as amended, is the set of laws passed by the State Legislature to regulate
HMOs
within the State
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Late Enrollment
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M
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Managed Care
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Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires pre-authorization of certain services.
See also: Health Maintenance Organization (HMO).
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Material Fact
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CA Insurance Code on Disclosure
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Maternity Care
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Health care provided during pregnancy, including care rendered during the pre and post-natal phase of pregnancy, as well as care rendered throughout the entire course of pregnancy, continuing through to infant delivery and circumcision.
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Medical Equipment (DME)
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See Durable Medical Equipment (DME).
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Medically Necessary
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Services or supplies provided by a licensed health facility or health professional,whichare determined by the health plan company and its contracting or employedPhysicianGroupto be: Appropriate and necessary for the symptoms, diagnosis, or treatment of a condition, illness or injury.\r\n
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Not Experimental or Investigational.
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Member
An individual or dependent who is enrolled in and covered by a managed health care plan. Also called Enrollee or Beneficiary.
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Mental Health / Behavioral Health
Conditions that affect thinking and the ability to figure things out and that affect perception, mood and behavior. Such disorders are recognized primarily by symptoms or signs that appear as distortions of normal thinking or distortions of the way things are perceived (seeing or hearing things that are not there.) Disorders can also be recognized by moodiness, sudden or extreme changes in mood, depression, and highly agitated or unusual behavior.

California Mental Health Parity Act

Federal
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N

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Network
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The doctors, clinics, hospitals and other medical providers that a health plan contracts with to provide health care to its members. In a PPO or HMO, members are generally limited to network providers for full coverage of their health costs.
See also:
Health Maintenance Organization (HMO)
,\r\nOut of Network,\r\n
Preferred Provider Organization (PPO).
How Aetna Pays Out of Network Providers
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Network Provider
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Physicians, Hospitals or other providers of health care who have a written agreement with the health plan to participate in the network. Providers are listed in the Preferred Provider Directory given to each Member upon enrollment and periodically updated.
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Negotiated Rates
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Negotiated Rates
\r\nNegotiated Fee Rate
is the amount of payment that Anthem has negotiated with the Participating Provider under a Prudent Buyer Participating Agreement.
Page 52
Blue Cross EOC
More explanation
calhealth.net
– Can MD\’s charge more?  Uninsured?\r\n

Balance Billing
This means that you pay the full cost of … care (at our negotiated rates) until your annual deductible has been met.
Health Net Brochure
page 9Medicare Allowances – CPT Codes\r\n\r\nSecrecy
Insure Me Kevin.com
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Balance Billing
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Pending Legislation AB 1321 2005-2006 Session – MD\’s must bill through hospital, when hospital is a contracted (HMO – PPO) provider and can\’t send separate bills
PDF
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Analyses
Assembly Committee
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MEWA\’s
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If it seems too good to be true, it probably is. Nationwide, the health insurance marketplace is facing tough times. The cost of health insurance is rising. Those seeking to make a profit by selling fraudulent health insurance claim that state insurance laws don’t apply. These entities recruit insurance agents to sell
\”ERISA plans\”
or \”union plans\” that falsely claim to be exempt from state law. Click on link to find information from
National Association of Insurance Commissioners (NAIC)
to help you protect yourself against illegal health insurance plans
DOL Site on MEWA
DOL Investigations & Enforcement
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Non-Participating Provider
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A medical provider who has not contracted with a health plan as a participating provider.
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O
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Occupational Therapy
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Treatment to restore a physically disabled person’s ability to perform activities such as walking, eating, drinking, dressing, toileting, and bathing.
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Open Enrollment
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Out of Network
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The use of health care providers who have not contracted with the health plan to provide services. HMO members are generally not covered for out-of-network services except in emergency situations. Members enrolled in preferred provider organizations (PPO) and point-of-service (POS) coverage\’s can go out-of-network, but will pay some additional costs.
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Out-of-Pocket Maximum
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Refers to the
maximum amount
that an enrollee will have to pay for expenses covered under the health plan. The maximum is a sum of all paid deductible and co-payment or coinsurance amounts.
out-of-pocket maximum
. This means that once your expenses reach a certain amount in a given calendar year, the reasonable and customary fee for covered benefits will be paid in full by the insurer.
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anthem.com/
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Outpatient
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A patient who is receiving care at a hospital, physician office or other health facility without being admitted to the facility for an overnight stay. The term “ambulatory” is often used to describe outpatient care.
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Outpatient Surgery
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Surgical procedures performed that do not require an overnight stay in the hospital or ambulatory surgery facility. Such surgery can be performed in the hospital, a surgery center, or physician office.
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Partial Day Treatment
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A program offered by appropriately-licensed psychiatric facilities that include either a day or evening treatment program for mental health or substance abuse. Such care is an alternative to inpatient treatment.
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Participating Provider
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A physician, hospital, pharmacy, laboratory, or other appropriately licensed facility or provider of health care services or supplies, that has entered into an agreement with a managed care entity, or HMO, to provide services or supplies to a patient enrolled in a health benefit plan.
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PCP
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See Primary Care Physician (PCP).
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Physical Therapy
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Treatment involving physical movement to relieve pain, restore function and prevent disability following disease, injury, or loss of limb.
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Point of Service (POS)
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A type of health benefit plan that allows enrollees to go outside the health plan’s provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do.
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Pre-Authorization
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A procedure used to review and assess the medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided.
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Pre-Certification
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Applies to specified services that require review and approval prior to the expense for such services being incurred. If a service is not Pre-Certified, benefits paid for that service will be reduced in accordance with the provisions of your Certificate of Insurance or Evidence of Coverage.
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Pre-Existing Condition
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Preferred Provider Organization
(PPO)
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A type of health benefit plan designed to give enrollees incentives to use health care providers designated as “preferred providers”, but that also give substantial coverage for services received from other health care providers. PPO plans can also be distinguished from HMO plans by the ability of PPO members to see any specialty physician without referral from a PCP, although some HMOs with a POS feature may allow this as well.
See also
HMO
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Prescription
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A written order or refill notice issued by a licensed medical profession for drugs which are only available through a pharmacy.
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Preventive Care
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Office visits for the evaluation and management of the member’s physical development for prevention of future medical problems.
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Primary Care Physician (PCP)
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A doctor selected by the enrollee to be the first physician contacted for any medical problem. The doctor acts as the patient\’s regular physician and coordinates any other care the patient needs, such as a visit to a specialist or hospitalization.
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Prior Authorization
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The process of obtaining advance approval before receiving certain health care services covered under a Certificate of Insurance or Evidence of Coverage.
See also: Pre-Authorization.
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Prosthetic Devices
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A device which replaces all or portion of a part of the human body. These devices are necessary because a part of the body is permanently damaged, is absent or is malfunctioning.
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Provider
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A licensed health care facility, program, agency, physician or other health professional that delivers health care services.
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Provider Network
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The set of providers contracted with a health plan to provide services to the enrollees.
See also: Network.
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Qualifying Event
\r\n
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See late enrollee
\r\n
Special Enrollment
\r\n
AB 1672 Requirements
\r\n
DOL  HIPAA Q & A

ERISA
\r\n
TITLE 29
CHAPTER 18SUBCHAPTER I
Subtitle B
part 6 1163
\r\nWestlaw Cases
1163
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Qualified Beneficiary
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Qualified Beneficiary
1167
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Radiation Therapy
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Treatment of disease by x-ray, radium, cobalt or high energy particle sources.
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Reasonable and Customary
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A charge that falls within the common range of services by a majority of providers for any procedure in a given geographic region, or which is justified based on the complexity or the severity of the treatment for a specific case.
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Referral
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A recommendation by a physician that an enrollee receive care from a specialty physician or facility.
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Respiratory Therapy
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Treatment of illness or disease that is accomplished by introducing dry or moist gases into the lungs.
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Qualifying Event
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Certain events that would ordinarily cause an individual to lose health coverage. The type of qualifying event will determine who the qualified beneficiaries for the qualifying event are and the length of time COBRA continuation coverage is available.   See also
Special Enrollment
For more information, see
Questions and Answers: Recent Changes in Health Care Law
.
Source
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Second Opinion
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The voluntary option or mandatory requirement to visit another physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed.
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Service Area
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The geographic area in which a health plan is prepared to deliver health care through a contracted network of participating providers.
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Similarly Situated Non-COBRA Beneficiaries
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The group of
covered employees
, their spouses or dependent children who are covered under a
group health plan
maintained by the employer or
employee organization
. This group is receiving their benefits under the group plan and not through
COBRA continuation coverage
. They are most similarly situated to the circumstances of the
qualified beneficiary
immediately before the
qualifying event
.
Source
\r\n
AB 1672
def. similar
\r\n\r\n
DOL Explanation of
HIPAA
Protections
Similarly Situated Individuals – Protections
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Skilled Nursing Facility (SNF)
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A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services.
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Speech Therapy
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Treatment of the correction of a speech impairment which resulted from birth, or from disease, injury, or prior medical treatment.
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Special Enrollment
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\r\n
Special Enrollment
under Health Care Reform\r\n
Click here for the links to work
\r\n
The opportunity to enroll in a
group health plan
when certain work or life events occur, regardless of the plan’s regular enrollment dates. Generally, if certain conditions are met, special enrollment is available when you, your spouse or your dependents lose other coverage (including
exhaustion of COBRA continuation coverage
), when you marry or when you have a new child by birth,
adoption or placement for adoption
. The plan must give you at least 30 days–from the loss of coverage or from the date of the marriage, birth, adoption or placement for adoption–to request special enrollment. The maximum
pre-existing condition exclusion
that may be applied to a person upon special enrollment is 12 months (reduced by the person\’s prior
creditable coverage
). However, if enrolled within 30 days of birth, adoption or placement for adoption, children may be exempt from any pre-existing condition exclusion. A description of a plan\’s special enrollment rules must be given to the employee on or before the time the employee is offered the opportunity to enroll in the plan. For more information, see Questions and Answers: Recent Changes in Health Care Law
pdf
Page 16
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Federal Definition Title 42 300 gg  f
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See also\r\n
late enrollee
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Qualifying Event
\r\n
AB 1672 Requirements
\r\nFederal Code of Regulations 146.117 Special Enrollment Periods
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Spin-Off Group:
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New company formed by employees leaving an established group to form a new company with a new owner, and potentially, some additional employees who are not from the established group.
If two or more employees they are
GUARANTEED issue
under Ins. Code
10700
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Subscriber
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The individual in whose name a contract is issued or the employee covered under an employer’s group health contract. The subscriber can enroll dependents under family coverage.
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Subscriber Contract
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See Contract or Subscriber Contract.
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Substance Abuse / Chemical Dependency
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Alcoholism, drug addiction, or other chemical dependency problems.
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Tier Rating
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Letter T
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U
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Top
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Urgent Care
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Services received for an unexpected illness or injury that is not life threatening but requires immediate outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering or sever pain, such as a high fever. urgent
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Underwriting
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Usual, Customary and Reasonable
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A \”usual\” charge is the amount that is most consistently charged by an individual physician for a given service. A \”customary\” charge is the amount that falls within a specified range of usual charges for a given service billed by most physicians with similar training and experience within a given geographic area. A \”reasonable\” charge is a charge that meets the Usual and Customary criteria, or is otherwise reasonable in light of the complexity of treatment of the particular case. Under an UCR Program, the payment is the lowest of the actual billed charge, the physician\’s usual charge or the area customary charge for any given covered service.
\r\nSee also: Customary and Reasonable (C&R).
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Utilization Management
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The entire program of systems designed to ensure that members receive quality, medically necessary health care services at the appropriate level of care in a timely, effective, and cost efficient manner. It includes pre certification, concurrent review, discharge planning, care management and retrospective review.
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W
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Top
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wages
\r\n
\r\n
Employment Development Department
EDD
web site:\r\n
What are wages?
\r\nAll money, the value of meals and lodging, or other goods and services provided to an employee as payment for personal services are \”wages.\” Payment may be by private agreement, consent, or mandated by law.\r\n\r\nThe method of payment does not change the taxability of wages paid to employees, no matter what terminology is used. Payments by the day, by the hour, by \”piece rate,\” or any other measurement are wages, even if the employee is a casual worker, day or contract laborer, part-time, or temporary worker.\r\n\r\n
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Well Baby / Well Child Care
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Routine care, testing, checkups and immunizations for a generally healthy child from birth through the age of six.
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Wellness Program
\r\n
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A health management program which incorporates the components of disease prevention, medical self-care, and health promotion. It utilizes proven health behavior techniques that focus on preventive illness and disability which respond positively to lifestyle related interventions. See http://www.healthnet.com/ for more information.
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The above Glossary was copied from
Health Net\’s Site
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Material Fact
More on
UCR  A
rticle on MD\’s site
\r\n
The respondents contend that their fee schedules are pro competitive because they make it possible to provide consumers of health care with a uniquely desirable form of insurance coverage that could not otherwise exist. The features of the foundation-endorsed insurance plans that they stress are a choice of doctors, complete insurance coverage, and lower premiums. The first two characteristics, however, are hardly unique to these plans. Since only about 70% of *352 the doctors in the relevant market are members of either foundation, the guarantee of complete coverage only applies when an insured chooses a physician in that 70%. If he elects to go to a nonfoundation doctor, he may be required to pay a portion of the doctor\’s fee. It is fair to presume, however, that at least 70% of the doctors in other markets charge no more than the \”usual, customary, and reasonable\” fee that typical insurers are willing to reimburse in full.
[FN24] Thus, in Maricopa and Pima Counties as well as in most parts of the country, if an insured asks his doctor if the insurance coverage is complete, presumably in about 70% of the cases the doctor will say \”Yes\” and in about 30% of the cases he will say \”No.\”
\r\n\r\n
Arizona v. Maricopa County Medical Soc.\r\n
102 S.Ct. 2466\r\nU.S.Ariz.,1982.\r\nJun 18, 1982 (Approx. 18 pages)
What are customary and reasonable charges?\r\nCustomary and reasonable charges, as determined by Health Net Life, are charges that fall within the common range of fees billed by a majority of physicians for a procedure in a given geographic region, or which are justified based on the complexity or the severity of treatment for a specific case.
Health Net.com/
Customary and Reasonable (C&R)
(see
negotiated rates
)
The amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient after medical review of the case. Also called \”Usual, Customary and Reasonable\” (UCR).   See also
Medicare RBRVS
See also: Usual, Customary and Reasonable.
\r\n
\r\n
www.steveshorr.com/
\r\nOPS offers many different policies to its subscribers, with varying terms. Under a majority of these policies, OPS offers a two-tier system covering health care costs. OPS conducts a survey of the fees for various services submitted to it by individual member physicians. Once the data has been compiled, the fees are referred to as the \”usual, customary and reasonable\” rates (UCR). OPS then determines the 90th percentile of such fees–that is, the rate at which 90 percent of the sample group charges the same or less.\r\nWhen a member physician treats an OPS subscriber, OPS pays the physician directly up to the 90th percentile rate. The member physician must accept the OPS payment as payment in full and may not bill the subscriber for any extra amount. Nonmembers, on the other hand, may bill subscribers at whatever rate they choose. A subscriber pays a nonmember\’s bill and is then reimbursed by OPS, but generally at a rate no more than at the 60th percentile of the UCR. Nonmembers, unlike members, may bill subscribers for the balance of their fees. Appellants produced evidence that, on average, OPS members received from OPS 76 cents on the dollar billed, while OPS paid podiatrists only 50 cents on the dollar billed. OPS subscribers were free to seek treatment from members or nonmembers as they wished.\r\n
Hahn v. Oregon Physicians\’ Service\r\n
860 F.2d 1501\r\nC.A.9 (Or.),1988.\r\nNov 04, 1988 (Approx. 6 pages)
\r\n

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Bookmarks
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Independent Contractor
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\r\n ‘,’Dictionary – Glossary’,”,’publish’,’open’,’closed’,”,’dictionary-glossary’,”,”,’2017-01-05 19:08:33′,’2017-01-05 19:08:33′,”,28,’http://healthlaw.healthreformquotes.com/?page_id=27′,0,’page’,”,0),(28,1,’2014-12-04 19:09:34′,’2014-12-04 19:09:34′,’
Rating Organizations
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A.M. Best Ratings
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National Association of Insurance Commissioners
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Dictionaries
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California LAW
Dept. of Insurance
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California Insurance Code\r\n
All CA Laws
Los Angeles Municipal Code
dmhc.ca.gov/regulations/
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Knox-Keene Health Care Service Plan Act of 1975
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Office of Patient Advocate –
HMO Survey
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Managed Health Care
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Health Care Rights
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Pending Legislation
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Federal Law
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Federal Register GPO
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UScode.house.gov/
Library of Congress
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Dept. of Labor – Health Plans Section
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COBRA
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HIPAA
Premiums for coverage
, after COBRA expires
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Employee Benefits Institute of America
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Magazines
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California Broker

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Surveys
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HMO

PPO
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Business Insurance
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Insurance Journal
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hr.blr.com/
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Labor Law Newsletters
Attorney\’s Site
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Declarations & Exclusions
– Attorney Site
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Websites – Guides
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California Health Care Foundation.org
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Health Care Costs 101
\r\nMarket Report 2004
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Consumer Guides for Getting and Keeping Health Insurance
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America\’s Health Insurance Plans
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BC/BS Health Care Issues
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Lorman Seminars
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Insurance Fraud.org/
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National Coalition of Healthcare
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Associations
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Calif. Assoc. of Health Underwriters
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Los Angeles Health Underwriters
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Small Group Guaranteed
Issue  AB 1672 Insurance Code 10700…
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ICD Codes
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\r\n
\r\n ‘,’Research & Legal Tools’,”,’publish’,’open’,’closed’,”,’research-legal-tools’,”,”,’2018-05-20 02:32:12′,’2018-05-20 02:32:12′,”,0,’http://healthlaw.healthreformquotes.com/?page_id=28′,0,’page’,”,0),(29,1,’2014-12-04 19:22:00′,’2014-12-04 19:22:00′,’
\r\n\r\n
Cochlear Implant Activation – Click to view Video\r\n\r\n
Cochlear Implant – Learn More – Cochlear.com\r\n\r\n
\r\n

Cochlear Implants &\r\n
Small Group Guaranteed Issue Health Insurance
\r\n

\r\n \r\n
A

cochlear implant

is a small electronic device that can help \”make\” sound if you have severe or total hearing loss. The implant does the job of the damaged or absent nerve cells that in a normal ear make it possible to hear (auditory nerves). Cochlear implants can be programmed according to your specific needs and degree of hearing loss.

Web MD

\r\n

Complementary
Individual Quotes CA

Nationwide

Employer Group

\r\n

Will an implant be covered on your Medical Insurance?

\r\n

Aetna\’s Bulletin

on Cochlear Implants, includes billing codes.
\r\n

Pre-Existing Condition Clause

\r\n
Is the implant

Medically Necessary

\r\n
Did the employee have

Credible Coverage

within the past 63 days?  If not PPO would have a 6 month Pre-X and HMO would not have a Pre-X waiting period.
\r\n
Guaranteed Issue for

Employer Groups

AB 1672

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Rules to get Covered

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Consumer Resources

\r\n

Individual & Family Guaranteed Issue 1.1.2014 – Covered CA

\r\n
Cochlear Americas.com/
\r\n

Insurance FAQ\’s

\r\n
hearing loss.org/
\r\n\r\nWhat about hearing aids?\r\n
Send us a copy
of your policy and we will check.\r\n\r\n\”Inventor?\” William F House Obituary LA Times 12.13.2012\r\n

Related Pages in
Misc. Coverages
Section

\r\n
\r\n \r\n\r\n ‘,’Cochlear Implants’,”,’publish’,’open’,’closed’,”,’cochlear-implants’,”,”,’2018-06-02 14:39:24′,’2018-06-02 14:39:24′,”,30,’http://healthlaw.healthreformquotes.com/?page_id=29′,0,’page’,”,0),(30,1,’2014-12-04 19:22:41′,’2014-12-04 19:22:41′,’‘,’Misc. Coverages’,”,’publish’,’open’,’open’,”,’misc-coverages’,”,”,’2017-01-05 19:08:32′,’2017-01-05 19:08:32′,”,0,’http://healthlaw.healthreformquotes.com/?page_id=30′,0,’page’,”,0),(31,1,’2014-12-04 19:27:11′,’2014-12-04 19:27:11′,’

Legislative History

\r\n

Affordable Health Care Act

\r\n
Now, Democrats must steer a package of fixes to the healthcare bill through the Senate by using the arcane budget reconciliation process.
\r\n
Party leaders designed their healthcare overhaul to preserve the

employer-based healthcare system

in which most Americans get their insurance.  IRS Website on Small Biz Tax Credit

3 step worksheet

\r\nBut the legislation would dramatically expand federal regulation of healthcare. Federal law would for the first time require insurance companies to cover all Americans, regardless of their health status, and would prohibit insurers from denying coverage to people who become sick.\r\n\r\nI
ndividuals would also be required to buy insurance.
And large employers would have to
provide employees with health benefits
or in some cases face penalties.\r\n\r\nThe bill would open the nation\’s 45-year-old
Medicaid insurance program
for the poor to all Americans earning less than 133% of the federal poverty line — $14,404 for an individual or $29,327 for a family of four.\r\n\r\nThe government would also create new state-based insurance marketplaces for millions who do not get coverage through work.\r\n\r\nCommercial insurers would offer plans in these marketplaces, or exchanges, and be required to provide a minimum set of benefits, including
mental health services,
maternity care and preventive care.\r\n\r\nThe most expensive feature is a commitment by the federal government to provide nearly
$500 billion in subsidies over the next decade to help millions of low- and moderate-income Americans buy insurance in an exchange.
\r\n\r\nTo pay for their legislation, Democrats approved a new 3.8% tax on investment income for individuals earning more than $200,000 and couples earning more than $250,000. In 2018, people with high-end \”Cadillac\” health plans would be subject to a new tax on their benefits.\r\n\r\nAnd medical device makers, pharmaceutical companies and insures would be subject to new excise taxes.\r\n\r\nThe bill would also
cut more than $400 billion over the next decade in what Medicare pays to hospitals
, nursing homes and insurance companies that provide
Medicare Advantage plans
, a provision that proponents hope would ultimately help make the system more efficient.\r\n\r\nNAHU
Comparison
of HR 3590 & Reconciliation Package\r\n\r\n
Library of Congress  H R 4872
\r\n
Text of HR 4872
– 55 Pages\r\n

House Approves Senate Health Reform, \’Corrections\’ Bills

\r\nLast night, the House voted 219-212 to approve the Senate health reform bill, which now goes to President Obama to be signed into law. Thirty-four Democrats and all Republicans voted against the legislation. The House also approved the so-called \”corrections\” legislation, which makes a series of changes to the Senate bill.
New York Times
et al.\r\n\r\n \r\n
This webpage reviews Obama\’s Health plan as promoted on HIS website

@
Barack Obama.com

and his

FAQ\’s

we simply cut and pasted them in.  I put in my comments by interlineation  with an indent and

italicized

them

.

We have added hyperlinks to further information, both in Obama\’s proposal and our comments.
\r\n
Please

email

your comments to Steve if you would like them incorporated on this page or need a specific answer or consultation.  For general comments, please post to our blog @

http://steveshorr.blogspot.com/

\r\n\r\n
\r\n

Health care costs are skyrocketing. Health insurance premiums have doubled in the last 8 years, rising 3.7 times faster than wages in the past 8 years, and increasing co-pays and deductibles threaten access to care.
1

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View our Website on Why Premiums are rising
\r\n
Congressional Budget Office
Review
of the Affordable Health Choices Act 10 pages
\r\n

\r\n

Many insurance plans cover only a limited number of doctors’ visits or hospital days, exposing families to unlimited financial liability.

\r\n\r\n

\r\n
Check the OOP – Out of Pocket Maximum
\r\n

\r\n

Over half of all personal bankruptcies today are caused by medical bills.
2

\r\n\r\n

\r\n
View our website on
Medical Bankruptcy
Medi-Cal
\r\n

\r\n

Lack of affordable health care

\r\n\r\n

\r\n
Click here for FREE California Quotes
from $10 visit HMO\’s to High Deductible
Health Savings Accounts
\r\n
\r\n

\r\n

is compounded by serious flaws in our health care delivery system. About 100,000 Americans die from medical errors in hospitals every year.
3
One-quarter of all medical spending goes to administrative and overhead costs, and reliance on antiquated paper-based record and information systems needlessly increases these costs.
4

\r\n\r\n

\r\n
I\’m all for that.  Just check out THIS website.  NO PAPER!!!  Check out all the other places that are going electronic, even
Court Forms
. Appellate
Briefs
can be filed
electronically
Even
CA law
says that electronic filings are the same as paper.

This is what
HIPAA privacy law
is trying to keep up with – how much easier it is for ANYONE to get your medical records, when they are available electronically, emailed or posted on the Internet vs. just on paper.
\r\n
Kaiser
,
Anthem Blue Cross
,
Health Ne
t
Take the tour
and many Insurance Companies
already have electronic records.
\r\n
CHCF Article on using Stimulus Funds to improve Information Technology in Health Care
\r\n

\r\n

Tens of millions of Americans are uninsured because of rising costs. Over 45 million Americans
5
— including over 8 million children
6
—lack health insurance.

\r\n\r\n

\r\n
Try
Healthy Families
in CA
\r\n

\r\n

Eighty percent of the uninsured are in working families.
7
Even those with health coverage are struggling to cope with soaring medical costs. Skyrocketing health care costs are making it increasingly difficult for employers, particularly small businesses, to provide health insurance to their employees.

\r\n\r\n

\r\n
Click here for Small Biz Proposals
AB 1672 Guaranteed Issue Pre-X is usually waived.\r\n
\r\n

\r\n

Underinvestment in prevention and public health. Too many Americans go without high-value preventive services, such as cancer screening and immunizations to protect against flu or pneumonia. The nation faces epidemics of obesity

\r\n\r\n

\r\n
We must change our opinion of exercise.  When I ride my bike rather than drive, I rarely see anyone else on a bike or even on the sidewalk.  Restaurants often have portions that are too big.  Do not be shy to ask for a take home box or split a meal.   I have had people tell me that if you take a woman on a date, you must buy TWO meals.  Here\’s
more on diet, nutrition and exercise.
\r\n

\r\n

and chronic diseases

\r\n\r\n

\r\n
CHCF articles on\r\nCalifornians struggling to care for their chronic conditions\r\nBetter Chronic Disease Care
\r\n

\r\n

as well as new threats of pandemic flu and bioterrorism. Yet despite all of this less than 4 cents of every health care dollar is spent on prevention and public health.
8
Our health care system has become a disease care system, and the time for change is well overdue.

\r\n\r\n

\r\n
OBAMA-BIDEN PLAN TO PROVIDE AFFORDABLE, ACCESSIBLE HEALTH CARE TO ALL
\r\n
Barack Obama and Joe Biden’s plan strengthens employer–based coverage,
\r\n\r\n
\r\n
See our page on
how to qualify
for AB 1672
\r\n
\r\n
makes insurance companies accountable and ensures patient choice of doctor and care without government interference.
\r\n\r\n
\r\n
What percent of providers are opting out of
Medicare
, because of  paperwork and low reimbursement levels?
\r\n
\r\n
Under the plan, if you like your current health insurance, nothing changes, except your costs will go down by as much as $2,500 per year. If you don’t have health insurance, you will have a choice of new, affordable health insurance options.
\r\n\r\n
\r\n
This sounds REALLY GREAT.  A chicken in every pot. (President Herbert Hoover)
King Henry IV
\r\n
No loss to my business.  We will have to look and see if the details will work.
\r\n
\r\n

\r\n

\r\n
LOWER COSTS TO MAKE OUR HEALTH CARE SYSTEM WORK FOR PEOPLE AND BUSINESSES – NOT JUST INSURANCE COMPANIES
\r\n
Inefficient and poor quality care costs the nation at least $50 to $100 billion every year.
9
Billions more are wasted on administration and overhead because of inefficiencies in the health care system.
10
And given current trends, this problem will only get worse as health care spending is expected to double within the next decade.
11
\r\n
A growing body of research points to substantial opportunities to improve quality while reducing the costs of care. Health care systems in many parts of the country deliver high quality care to the populations they serve at half the cost of other equally renowned academic medical centers in other parts of the country.
12
The key is to provide information, incentives and support to help physicians and others work together to improve quality of care while reducing costs.
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Barack Obama and Joe Biden believe we must redesign our health system to reduce inefficiency and waste and improve health care quality, which will drive down costs for families and individuals. The Obama-Biden plan will improve efficiency and lower costs in the health care system by: (1) adopting state-of-the-art health information technology systems;
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Competition is doing that
right now
.
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How about if Obama\’s as a \”Test Run\” lowers US Postal Service Costs.  \”
Go Postal First\” by Dave Petno
NAHU 6/2009\r\n
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(2) ensuring that patients receive and providers deliver the best possible care, including prevention and chronic disease management services;
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How much
\”Big Brother\” 1984
do we want.  We are all adults here, shouldn\’t we be responsible for our own health care treatment?
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How many forms will doctors have to fill out to be able to treat you?  What if a citizen does not comply with preventative care?  What if he refuses to eat the proper diet to prevent obesity? Does that mean he will not get treatment?
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Big Brother
is a
fictional character
in
George Orwell
\’s novel
Nineteen Eighty-Four
, the enigmatic
dictator
of Oceania, a
totalitarian
state taken to its utmost logical consequence – where the ruling elite (\’the Party\’) wield total power for its own sake over the inhabitants.
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In the society that Orwell describes, everyone is under complete
surveillance
by the authorities, mainly by
telescreens
. The people are constantly reminded of this by the phrase \”Big Brother is watching you\”, which is the core \”truth\” of the
propaganda
system in this state. Big Brother\’s physical characteristics are intended to resemble
Joseph Stalin
(citation needed
] , although in the film his moustache more closely resembles
Adolph Hitler
\’s.
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(3) reforming our market structure to increase competition;
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Click here for competitive quotes.
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and offering federal reinsurance to employers to help ensure that unexpected or catastrophic illnesses do not make health insurance unaffordable or out of reach for businesses and their employees.
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I do not understand what Obama is talking about.  Here\’s more from his FAQ\’s
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Obama’s plan includes a
reinsurance pool
for employers. If employer health care costs exceed a certain amount, the federal government will pick up the tab,
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How much will that cost us?
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as long as the employer agrees to pass the savings onto their employees.
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I think we already have that in Employer Plans in CA as the best discount an employer can have is 10% off standard rates and the worst surcharge for having a lot of claims is 10%.  This is known as the RAF factor.
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That helps businesses who have that one sick employee to be able to continue offering health insurance to their employees and keep their doors open
Barack Obama.com/
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(1)
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INVEST IN ELECTRONIC HEALTH INFORMATION TECHNOLOGY SYSTEMS.
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Most medical records are still stored on paper, which makes them difficult to use tocoordinate care, measure quality, orreduce medical errors.\r\n
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Insurance Companies & HMO\’s are
already working on this!
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Processing paper claims also costs twice as much as processing electronic claims.13 Barack Obama and Joe Biden will invest $10 billion a year over the next five years to move the U.S. health care system to broad adoption of standards-based electronic health information systems, including electronic health records.\r\n
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Private Enterprise is
already doing this
.  If nothing else, check out THIS website!
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They will also phase in requirements for full implementation of health IT and commit the necessary federal resources to make it happen. Barack Obama and Joe Biden willensure that these systemsare developedin coordination with providers and frontline workers, including those in rural and underserved areas. Barack Obama and Joe Biden willensure that patients’ privacy is protected.\r\n
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We already have
HIPAA Privacy Laws.
\r\nCHCF.org article on the Stimulus Bill & Privacy of Health Information in CA
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A study by the Rand Corporation found that if most hospitals and doctors offices adopted electronic health records, up to $77 billion of savings would be realized each year through improvements such as reduced hospital stays, avoidance of duplicative and unnecessary testing, more appropriate drug utilization, and other efficiencies.14
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(2)
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IMPROVE ACCESS TO PREVENTION AND PROVEN DISEASE MANAGEMENT PROGRAMS.
\r\n
Experts agree that several steps should be taken immediately to help patients get the care they need and to help providers improve medical practice. Barack Obama and Joe Biden will expand and support these and other efforts to lower costs and improve health outcomes.
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HELP PATIENTS
\r\nSupport disease management programs.\r\n
Over seventy-five percent of total health care dollars are spent on patients with one or more chronic conditions, such as diabetes, heart disease, and high blood pressure.
15
Many patients with chronic diseases benefit greatly from disease management programs, which help patients manage their condition and get the care they need.
16
Barack Obama and Joe Biden will require that plans that participate in the new public plan,
Medicare
or the
Federal Employee Health Benefits Program
(FEHBP) utilize proven disease management programs. This will improve quality of care and lower costs, as well.
\r\nCoordinate and integrate care.\r\n
Rates of chronic diseases have skyrocketed in the last 2 decades.
17
Over 133 million Americans have at least one chronic disease.
18
With proper care, the onset and progression of these diseases can be contained for many years. In addition to the needless suffering and early death they cause, these chronic conditions cost a staggering $1.7 trillion yearly.
19
Barack Obama and Joe Biden will support providers to put in place care management programs and encourage team care through implementation of medical home type models that will improve coordination and integration of care of those with chronic conditions.
\r\nRequire full transparency regarding quality and costs.\r\n
Health care quality and costs can vary tremendously among hospitals and providers; however, patients have limited access to this information.
20
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I\’ve been complaining about that for a LONG time.
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Cal Hospital Compare.org/
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Barack Obama and Joe Biden will require hospitals and providers to collect and publicly report measures of health care costs and quality, including data on preventable medical errors, nurse staffing ratios, hospital-acquired infections, and disparities in care and costs. Health plans will be required to disclose the percentage of premiums that actually goes to paying for patient care as opposed to administrative costs.
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That is already in every sales brochure in CA.  The average is 80%.
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\r\nENSURE PROVIDERS DELIVER QUALITY CARE ¾ Promote patient safety.\r\n
Barack Obama and Joe Biden will require providers to report preventable medical errors, and support hospital and physician practice improvement to prevent future errors.
\r\nAlign incentives for excellence.\r\n
National Health Insurance Exchange,\r\n
\r\n Comparative effectiveness reviews and research.\r\n
One of the keys to eliminating waste and missed opportunities is to increase our investment in comparative effectiveness reviews and research. This information is developed by reviewing existing literature, analyzing electronic health care data, and conducting simple, real world studies of new technologies. Barack Obama and Joe Biden will establish an independent institute to guide reviews and research on comparative effectiveness, so that Americans and their doctors will have accurate and objective information to make the best decisions for their health and well-being.
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Tackle disparities in health care. Although all Americans are affected by problems with our health care delivery system, an overwhelming body of evidence demonstrates that certain populations are significantly more likely to receive lower quality health care than others. Barack Obama and Joe Biden will tackle the root causes of health disparities by addressing differences in access to health coverage and promoting prevention and public health, both of which play a major role in addressing disparities. They will also challenge the medical system to eliminate inequities in health care by requiring hospitals and health plans to collect, analyze and report health care quality for disparity populations and holding them accountable for any differences found; diversifying the workforce to ensure culturally effective care; implementing and funding evidence-based interventions, such as patient navigator programs; and supporting and expanding the capacity of safety-net institutions, which provide a disproportionate amount of care for underserved populations with inadequate funding and technical resources.
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¾ Reform medical malpractice while preserving patient rights. Increasing medical malpractice insurance rates are making it harder for doctors to practice medicine
22
and raising the costs of health care for everyone.
23
Barack Obama and Joe Biden will strengthen antitrust laws to prevent insurers from overcharging physicians for their malpractice insurance. Barack Obama and Joe Biden will also promote new models for addressing physician errors that improve patient safety, strengthen the doctor-patient relationship, and reduce the need for malpractice suits.
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(3) LOWER COSTS BY TAKING ON ANTICOMPETITIVE ACTIONS IN THE DRUG AND INSURANCE COMPANIES. It is not right that Americans families are paying skyrocketing premiums while drug and insurance industries are enjoying record profits. These companies benefit most from the status quo and in many cases are the greatest obstacles to reform. The Obama-Biden plan will tackle needless waste and spiraling costs by increasing competition in the insurance and drug markets.
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Increasing competition in the insurance industry. The insurance business today is dominated by a small group of large companies that has been gobbling up their rivals. In recent years, for-profit companies have bought up not-for-profit insurers around the country. There have been over 400 health care mergers in the last 10 years and just two companies dominate a full third of the national market.
24
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These changes were supposed to make the industry more efficient, but instead premiums have skyrocketed, increasing over 87 percent over the past six years.
25
Over the same time period, insurance administrative overhead has been the fastest-growing component of health spending. The 2007 Commonwealth Fund Commission on a High Performance Health System reported that between 2000 and 2005, administrative overhead – including both administrative expenses and insurance industry profits – increased 12.0 percent per year, 3.4 percentage points faster than the average health expenditure growth of 8.6 percent.
26
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And while health care costs continue to rise for families, CEOs of these insurance companies have received multi-million dollar bonuses.
27
Barack Obama and Joe Biden will prevent companies from abusing their monopoly power through unjustified price increases. In markets where the insurance business is not competitive, their plan will force insurers to pay out a reasonable share of their premiums for patient care instead of keeping exorbitant amounts for profits and administration. Barack Obama and Joe Biden’s new National Health Insurance Exchange will also help increase competition by insurers.
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Prevent private insurance waste and abuse in Medicare. Medicare’s private plan alternative, called Medicare Advantage, was established to increase competition and reduce costs. But independent reports show that on average the government pays 12 percent more than it costs to treat comparable beneficiaries through traditional Medicare.
28
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Does this have anything to do with the EXTRA benefits that Medicare Advantage Plans have, like Preventative, Dental, Vision, lower Co-Pays, and
Prescriptions Part D
?   These plans are generally FREE to the client.   Click here to view
Blue Shield Benefits,
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These excessive subsidies cost the government billions of dollars every year and create an incentive structure that has led to fraudulent abuses of seniors. Barack Obama and Joe Biden believe we need to eliminate the excessive subsidies to Medicare Advantage plans and pay them the same amount it would cost to treat the same patients under regular Medicare.
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Health Care Fraud – President Obama\’s Plan
\r\n
Allow consumers to import safe drugs from other countries.
The second-fastest growing type of health expenses is prescription drugs.
29
Pharmaceutical companies should profit when their research and development results in a groundbreaking new drug. But some companies are exploiting Americans by dramatically overcharging U.S. consumers. These companies are selling the exact same drugs in Europe and Canada but charging Americans a 67 percent premium.
30
Barack Obama and Joe Biden will allow Americans to buy their medicines from other developed countries if the drugs are safe and prices are lower outside the U.S.
\r\n
Prevent drug companies from blocking generic drugs from consumers.
Some drug manufacturers are explicitly paying generic drug makers not to enter the market so they can preserve their monopolies and keep charging Americans exorbitant prices for brand name products.
31
The Obama-Biden plan will work to ensure that market power does not lead to higher prices for consumers. Their plan will work to increase use of generic drugs in the new public plan, Medicare, Medicaid, FEHBP and prohibit large drug companies from keeping generics out of markets.
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Allow Medicare to negotiate for cheaper drug prices.
The 2003 Medicare Prescription Drug Improvement and Modernization Act bans the government from negotiating down the prices of prescription drugs, even though the Department of Veterans Affairs’ negotiation of prescription drug prices with drug companies has garnered significant savings for taxpayers.
32
Barack Obama and Joe Biden will repeal the ban on direct negotiation with drug companies and use the resulting savings, which could be as high as $30 billion,
33
to further invest in improving health care coverage and quality.
\r\n(4) REDUCE COSTS OF CATASTROPHIC ILLNESSES FOR EMPLOYERS AND THEIR EMPLOYEES.\r\n
Catastrophic health expenditures account for a high percentage of medical expenses for private insurers.
34
In fact, the most recent data available reveals that the top five percent of people with the greatest health care expenses in the U.S. account for 49 percent of the overall health care dollar.
35
For small businesses, having a single employee with catastrophic expenditures can make insurance unaffordable to all of the workers in the firm. The Obama-Biden plan would reimburse employer health plans for a portion of the catastrophic costs they incur above a threshold if they guarantee such savings are used to reduce the cost of workers\’ premiums. Offsetting some of the catastrophic costs would make health care more affordable for employers, workers and their families.
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AFFORDABLE, ACCESSIBLE COVERAGE OPTIONS FOR ALL
\r\nBarack Obama and Joe Biden will guarantee affordable, accessible health care coverage for all Americans. Currently, there are over 45 million Americans lacking health insurance, and millions more are at risk of losing their coverage due to rising costs.
36
Rising costs are also a burden on employers, particularly small businesses, which are increasingly unable to provide health insurance coverage for their employees and remain competitive. Nearly two million fewer Americans receive health insurance coverage through their employers now compared to eight years ago,
37
and this trend shows no sign of slowing down. It is simply too expensive for individuals and families to buy insurance directly on the open market and impossible for many with pre-existing conditions.\r\n
The Obama-Biden plan both builds on and improves our current insurance system, which most Americans continue to rely upon, and leaves Medicare intact for older and disabled Americans. Under the Obama-Biden plan, Americans will be able to maintain their current coverage, have access to new affordable options, and see the quality of their health care improve and their costs go down. The Obama-Biden plan provides new affordable health insurance options by: (1) guaranteeing eligibility for all health insurance plans; (2) creating a National Health Insurance Exchange to help Americans and businesses purchase private health insurance; (3) providing new tax credits to families who can’t afford health insurance and to small businesses with a new Small Business Health Tax Credit;
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Sec. 3112.
Small business health options program credit. Page 94 –
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(4) requiring all large employers to contribute towards health coverage for their employees or towards the cost of the public plan; (5) requiring all children have health care coverage; (5) expanding eligibility for the Medicaid and SCHIP programs; and (6) allowing flexibility for state health reform plans.
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(1)
\r\n
GUARANTEED ELIGIBILITY. Obama and Biden will require insurance companies to cover pre-existing conditions so all Americans, regardless of their health status or history, can get comprehensive benefits at fair and stable premiums.
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(2)
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NEW AFFORDABLE, ACCESSIBLE HEALTH INSURANCE OPTIONS.
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The Obama-Biden plan will create a National Health Insurance Exchange to help individuals purchase new affordable health care options if they are uninsured or want new health insurance. Through the Exchange, any American will have the opportunity to enroll in the new public plan or an approved private plan, and income-based sliding scale tax credits will be provided for people and families who need it. Insurers would have to issue every applicant a policy and charge fair and stable premiums that will not depend upon health status. The Exchange will require that all the plans offered are at least as generous as the new public plan and meet the same standards for quality and efficiency. Insurers would be required to justify an above-average premium increase to the Exchange. The Exchange would evaluate plans and make the differences among the plans, including cost of services, transparent.
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The Exchange will have the following features
:\r\n
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(3)
\r\n
TAX CREDITS FOR FAMILIES AND SMALL BUSINESSES.
\r\n
Barack Obama and Joe Biden understand that too many families that do not qualify for public health programs like
Medicaid
and
SCHIP
have trouble finding affordable health insurance.\r\n
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Video\’s Explanations
on how to get your
FREE Quotes

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Sec. 3112.
Small business health options program credit. Page 94 –
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\r\nThey know from talking to small business owners across the nation that the skyrocketing cost of healthcare poses a serious competitive threat to America’s small businesses. The Obama-Biden health care plan willprovide tax credits\r\n
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View our website on
Taxation
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Sec. 3112.
Small business health options program credit. Page 94 –
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\r\nto all individuals who need it for their premiums. They will also create a new
Small Business Health Tax Credit toprovide small businesses with a refundable tax credit of up to 50 percent on premiums paid by small businesses on behalf of their employees.\r\n
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Sec. 3112.
Small business health options program credit. Page 94 –
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\r\n \r\n\r\nTo be eligible for the credit, small businesses will have to offer a quality health plan to all of their employees\r\n\r\n \r\n
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\r\nand cover a meaningful share of the cost of employee health premiums.\r\n
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Video\’s Explanations

on how to get your

FREE Quotes

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(4)
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EMPLOYER CONTRIBUTION.
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Large employers that do not offer meaningful coverage or make a meaningful contribution to the cost of quality health coverage for their employees will be required to contribute a percentage of payroll toward the costs of the national plan. Small businesses will be exempt from this requirement.
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(5)
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REQUIRE COVERAGE OF CHILDREN.
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Barack Obama and Joe Biden will require that all children have health care coverage. Barack Obama and Joe Biden will expand the number of options for young adults to get coverage by allowing young people up to age 25 to continue coverage through their parents’ plans.
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(6)
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EXPANSION OF MEDICAID AND SCHIP. Barack Obama and Joe Biden will expand eligibility for the Medicaid and SCHIP programs and ensure that these programs continue to serve their critical safety net function.
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(7)
\r\n
FLEXIBILITY FOR STATE PLANS. Due to federal inaction, some states have taken the lead in health care reform. Under the Obama-Biden plan, states can continue to experiment, provided they meet the minimum standards of the national plan.
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\r\n
PROMOTING PREVENTION & STRENGTHENING PUBLIC HEALTH
\r\n
Covering the uninsured and modernizing America’s health care system are urgent priorities, but they are not enough. This nation is facing a true epidemic of chronic disease. An increasing number of Americans are suffering and dying needlessly from diseases such as obesity, diabetes, heart disease, asthma and HIV/AIDS, all of which can be delayed in onset if not prevented entirely. One in 3 Americans—133 million—have a chronic condition, and children are increasingly being affected.
38
Five chronic diseases—heart disease, cancer, stroke, chronic obstructive pulmonary disease, and diabetes—cause over two-thirds of all deaths each year.
39
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In addition to the tremendous human cost, chronic diseases exact a tremendous financial toll on our health care resources. Care for patients with diabetes costs $130 billion each year alone, and this amount is growing.
40
Tackling chronic diseases is also straining our public health departments and finances, which are already stretched too thin carrying out traditional public health functions, which include ensuring our water is safe to drink, the air is safe to breathe, and our food is safe to eat.
\r\n
Barack Obama and Joe Biden believe that protecting and promoting health and wellness in this nation is a shared responsibility among individuals and families, school systems, employers, the medical and public health workforce, and federal and state and local governments. All parties must do their part, as well as collaborate with one another, to create the conditions and opportunities that will allow and encourage Americans to adopt healthy lifestyles.
\r\n\r\n
\r\n
(1)
\r\n
EMPLOYERS. Reduced workforce productivity from illness and disability represents an additional drain on business. To address employee health, an increasing number of employers are offering worksite health promotion programs, onsite clinical preventive services such as flu vaccinations, nutritious foods in cafeterias and vending machines, and exercise facilities. Equally important, many employers choose insurance plans that cover preventive services for their employees. Barack Obama and Joe Biden believe that worksite interventions hold tremendous potential to influence health and they will expand and reward these efforts.
\r\n
(2)
\r\n
SCHOOL SYSTEMS.
\r\n
Childhood obesity is nearly epidemic,
41
particularly among minority populations,
42
and school systems can play an important role in tackling this issue. For example, only about a quarter of schools adhere to nutritional standards for fat content in school lunches.
43
Barack Obama and Joe Biden will work with schools to create more healthful environments for children, including assistance with contract policy development for local vendors, grant support for school-based health screening programs and clinical services, increased financial support for physical education, and educational programs for students.
\r\n
(3)
\r\n
WORKFORCE.
\r\n
Primary care providers and public health practitioners have and will continue to lead efforts to protect and promote the nation’s health. Yet, the numbers of both are dwindling,
44
and the existing workforce is further challenged by inadequate training for new health threats such as bioterrorism and avian flu, antiquated funding and reimbursement mechanisms, and limited access to real-time information and technical support. Barack Obama and Joe Biden will expand funding—including loan repayment, adequate reimbursement, grants for training curricula, and infrastructure support to improve working conditions— to ensure a strong workforce that will champion prevention and public health activities.
\r\n
(4)
\r\n
INDIVIDUALS AND FAMILIES.
\r\n
Preventive care only works if Americans take personal responsibility for their health and make the right decisions in their own lives – if they eat the right foods, stay active, and stop smoking.\r\n
\r\n
EXACTLY!!!!!
\r\n
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Barack Obama and Joe Biden will ensure that all Americans are empowered to monitor their health by ensuring coverage of essential clinical services in all federally supported health plans, including
Medicare
,
Medicaid
,SCHIP\r\n
\r\n
Healthy Families
CMS Website
Wikipedia
\r\n
\r\n
\r\n
and the
new public plan
. Americans also benefit from healthy environments that allow them to pursue healthy choices and behaviors that can help ward off chronic and preventable diseases. Healthy environments include sidewalks, biking paths and walking trails;\r\n
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I do not see what we  already have being used.
\r\n
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local grocery stores with fruits and vegetables; restricted advertising for tobacco and alcohol to children; and wellness and educational campaigns. In addition, Barack Obama and Joe Biden will increase funding to expand community based preventive interventions to help Americans make better choices to improve their health.
\r\n
(5)
\r\n
FEDERAL, STATE, AND LOCAL GOVERNMENTS.
\r\n
The federal government and state and local governments play critical roles across the full range of disease prevention and health promotion activities. First, working together, governments at all levels should lead the effort to develop a national and regional strategy for public health and align funding mechanisms to support its implementation. Second, the field of public health would benefit from greater research to optimize organization of the 3,000 health departments in this nation,
45
collaborative arrangements between levels of government and its private partners, performance and accountability indicators, integrated and interoperable communication networks, and disaster preparedness and response. Third, the government must invest in workforce recruitment as well as modernizing our physical structures, particularly our public health laboratories. And finally, the government must examine its own policies, including agricultural, educational, environmental and health policies, to assess and improve their effect on public health in this nation. Barack Obama and Joe Biden will prioritize all of these activities, to ensure a 21
st
century public health system and healthy America.
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\r\nPaid for by Obama for America\r\n\r\nPrinted in House\r\n
1 Kaiser Family Foundation and Health Research and Educational Trust. (2008). Employer Health Benefits 2008,
http://kff.org/insurance/7527/index.cfm
; Bureau of Labor Statistics, Sept. 2008
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2 David U. Himmelstein, Elizabeth Warren, Deborah Thorne, and Steffie Wooldhandler (February 2005). “Illness and Injury as Contributors to Bankruptcy,” Health Affairs, http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.63v1
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3 Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors; Committee on Quality of Health Care in America, Institute of Medicine (2000). To Err is Human. Washington, DC: National Academy Press.
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4 Steffie Woolhandler, Terry Campbell, and David U. Himmelstein (2003) “Costs of Health Care Administration in the United States and Canada.” New England Journal of Medicine.
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5Census Bureau, August 2008,

Click to access p60-235.pdf


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6 Id.
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7 Kaiser Family Foundation, The Uninsured: A Primer (2006),

Click to access 7451-021.pdf


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8 Jeanne M. Lambrew, (April 2007). A Wellness Trust to Prioritize Disease Prevention. The Hamilton Project, Brookings Institution. brookings.edu/
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9 Commonwealth Fund, Why Not the Best? Results from a National Scorecard on U.S. Health Systems Performance, September 2006,
http://www.cmwf.org/publications/publications_show.htm?doc_id=401577
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10 Steffie Woolhandler, Terry Campbell, and David U. Himmelstein (2003) “Costs of Health Care Administration in the United States and Canada.” New England Journal of Medicine.
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11 Office of the Actuary. (February 2007). National Health Expenditures http://www.cms.hhs.gov/
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12 Dartmouth Atlas Project (2006), The Care of Patients with Severe Chronic Illness,

Home


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13 Federico Girosi, Robin Meili, and Richard Scoville (2005), Extrapolating Evidence of Health Information Technology Savings and Costs. RAND, page 79.
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14 Federico Girosi, Robin Meili, and Richard Scoville (2005), Extrapolating Evidence of Health Information Technology Savings and Costs. RAND, page 36.
\r\n
15 Gerard Anderson, Robert Herbert, Timothy Zeffiro, and Nikia Johnson
Chronic Conditions: Making the Case for Ongoing Care
(2004). Partnership for Solutions (Johns Hopkins and Robert Wood Johnson Foundation).
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16 Center on an Aging Society at Georgetown University, Disease Management Programs: Improving Health and while Reducing Costs?, p4, (January 2004).

Click to access management.pdf


\r\n
17 Gerard Anderson, Robert Herbert, Timothy Zeffiro, and Nikia Johnson
Chronic Conditions: Making the Case for Ongoing Care
(2004). Partnership for Solutions (Johns Hopkins and Robert Wood Johnson Foundation).
\r\n
18 Gerard Anderson, Robert Herbert, Timothy Zeffiro, and Nikia Johnson
Chronic Conditions: Making the Case for Ongoing Care
(2004). Partnership for Solutions (Johns Hopkins and Robert Wood Johnson Foundation).
\r\n
19
CMS. (February 2007). National Health Expenditures; Gerard Anderson, Robert Herbert, Timothy Zeffiro, and Nikia Johnson
Chronic Conditions: Making the Case for Ongoing Care
(2004). Partnership for Solutions (Johns Hopkins and Robert Wood Johnson Foundation).
20
National Committee for Quality Assurance (2006), The State of Health Care 2006,
ncqa.org
\r\n
21
Jeanne M. Lambrew, (April 2007). A Wellness Trust to Prioritize Disease Prevention. The Hamilton Project, Brookings Institution. http://www3.brookings.edu/views/papers/200704lambrew.pdf
\r\n
22
Kenneth Thorpe (January 21, 2004), The Medical Malpractice ‘Crisis’: Recent Trends and the Impact of State Tort Claims, Health Affairs, http://content.healthaffairs.org/cgi/content/full/hlthaff.w4.20v1/DC1#39
\r\n
23
Department of Health and Human Services (March 3, 2003), Addressing the New Health Care Crisis: Reforming the Medical Litigation System to Improve the Quality of Care,
http://aspe.hhs.gov/daltcp/reports/medliab.htm
\r\n
24
Edward Langston, “Statement of the American Medical Association to the Senate Committee on the Judiciary, United States Senate” (September 6, 2006). Testimony.
25
Kaiser Family Foundation and Health Research and Educational Trust. (2006). Employer Health Benefits 2006,
http://kff.org/insurance/7527/index.cfm
\r\n
26
Karen Davis, Cathy Schoen, Stuart Guterman et al. (January 2007), Slowing the Growth of U.S. Health Care Expenditures: What are the Options? Commonwealth Fund
\r\n
27
Forbes.com, 2007 CEO Executive Compensation – Health Care Equipment & Services, forbes.com/li
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28
Glenn Hackbarth, Medicare Payment Advisory Commission (April 11, 2007), Testimony: The Medicare Advantage Program and MedPAC Recommendations, U.S. Senate Committee on Finance,
medpac.gov/
\r\n
29
Karen Davis, Cathy Schoen, Stuart Guterman et al. (January 2007), Slowing the Growth of U.S. Health Care Expenditures: What are the Options? Commonwealth Fund.
30
Patented Medicine Prices Review Board, Annual Report (Ottawa, Ontario: PMPRB, 2002), p. 23.
31
Marc Kaufman (April 25, 2006), “Drug Firms’ Deals with Allowing Exclusivity,” Washington Post,
http://www.washingtonpost.com/wp-dyn/content/article/2006/04/24/AR2006042401508.html
\r\n
32
Families USA (December 2005), Falling Short: Medicare Prescription Drug Plans Offer Meager Savings, http://www.familiesusa.org/assets/pdfs/PDP-vs-VA-prices-special-report.pdf
\r\n
33
Roger Hickey & Jeff Cruz (April 2007), Waste and Inefficiency in the Bush Medicare Prescription Drug Plan: Allowing Medicare to Negotiate Lower Prices Could Save $30 Billion a Year, Institute for America’s Future, http://cdncon.vo.llnwd.net/
\r\n
34
Mark W. Stanton and Margaret Rutherford (June 2006), The High Concentration of U.S. Health Care Expenditures. Agency for Healthcare Research and Quality. Research in Action Issue 19.
35
Mark W. Stanton and Margaret Rutherford (June 2006), The High Concentration of U.S. Health Care Expenditures. Agency for Healthcare Research and Quality. Research in Action Issue 19.
36
Census Bureau, “Census Bureau Revises 2004 and 2005 Health Insurance Coverage Estimates,” March 23, 2007.
http://www.census.gov/Press-Release/www/releases/archives/health_care_insurance/009789.html
\r\n
37
Census Bureau (2008), Income, Poverty, and Health Insurance Coverage in the United States: 2007. Table C-1.
38
Gerard Anderson, Robert Herbert, Timothy Zeffiro, and Nikia Johnson
Chronic Conditions: Making the Case for Ongoing Care
(2004). Partnership for Solutions (Johns Hopkins and Robert Wood Johnson Foundation).
\r\n
39
CDC, http://www.cdc.gov/nccdphp/overview.htm
40
CDC, http://www.cdc.gov/nccdphp/press/index.htm
\r\n
41
NIH, Childhood Obesity, June 2002 Word on Health http://www.nih.gov/news/WordonHealth/jun2002/childhoodobesity.htm
42
CDC National Center for Health Statistics,
http://www.cdc.gov/nchs/pressroom/06facts/obesity03_04.htm
\r\n
43
GAO (2003), School Lunch Program: Efforts Needed to Improve Nutrition and Encourage Healthy Eating,

Click to access d03506.pdf


\r\n
44
The Robert Graham Center (October 2003), http://www.graham-center.org/x468.xml; Institute of Medicine (2002), The Future of the Public’s Health in the 21
st
Century, p.364.
\r\n
45
Bob Prentice and George Flores (December 15, 2006), Local Health Departments and the Challenge of Chronic Disease: Lessons From California, NIH,
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1832141
\r\n\r\ncbsnews.com/\r\n
A Quick Summary of the Affordable Health Choices Act
\r\n
Senator Edward M. Kennedy, Chairman of the Health, Education, Labor and Pensions Committee (HELP), today released
The Affordable Health Choices Act
, legislation that aims to reduce health care costs, protect individuals? choices of doctors, hospitals and insurance plans  and guarantee, quality and affordable health care for all Americans.
\r\n
The Affordable Health Choices Act
includes the following five major elements:\r\n\r\n
CHOICE
: An important foundation of
The Affordable Health Choices Act
is the following  principle: If you like the coverage you have now, you keep it. But if you don\’t have health insurance or don\’t like the insurance you have, our bill will give you new, more affordable options.\r\n\r\n
COST REDUCTION:
The Affordable Health Choices Act
will reduce health care costs through stronger prevention, better quality of care and use of information technology. It will also root out fraud and abuse and reduce unnecessary procedures.\r\n\r\n
PREVENTION:
The best way to treat a disease is to prevent it from ever striking, which is exactly why
The Affordable Health Choices Act
will give citizens the information they need to take charge of their own health. The bill will make information widely available in medical settings, schools and communities. It will also promote early screening for heart disease, cancer and depression and give citizens more information on healthy nutrition and the dangers of smoking.\r\n\r\n
HEALTH SYSTEM MODERNIZATION:
The Affordable Health Choices Act
will take strong steps to see that America has a 21st-century workforce for a modern and responsive healthcare system. America must make sound investments in training the doctors, nurses, and\r\nother health professionals who will serve the needs of patients in the years to come. It will make sure that patients? care is better coordinated so they see the right doctors, nurses and other health practitioners to address their individual health needs.\r\n\r\n
LONG TERM CARE AND SERVICES:
The Affordable Health Choices Act
will also make it possible for the elderly and disabled to live at home and function independently. It will help them afford to put ramps in their homes, pay someone to check in on them regularly, or any of an array of supports that will enable them to stay in their communities instead of in nursing homes.
help.senate.gov/
\r\n
Affordable Health Choices Act
\r\n
Press Release  22 page
\r\n
Full Text of Senate Bill
___  (615 pages)
\r\n
‘America’s Affordable Health Choices Act of 2009’\r\nFull Text  246 pages
\r\n
Comparison
of Senate Affordable Health  Choices Act & HR 3200 America\’s  Health Choices Act of 2009
\r\n
\”SEC. 3112. SMALL BUSINESS HEALTH OPTIONS PROGRAM CREDIT.
\r\n
Summary:
\r\n
Small Business Health Tax Credit to provide small businesses with a refundable tax credit of up to 50 percent on premiums paid by small businesses on behalf of their employees.  Source:
Text of Obama\’s Summary
\r\n
\r\n
\”(a) CALCULATION OF CREDIT.?For each calendar year beginning in calendar year 2010, in the case of an employer that is a qualified small employer, the Secretary shall make a payment in the amount described in sub14 section (b).\r\n\”(b) GENERAL CREDIT AMOUNT.  For purposes of this section:\r\n\”(1) IN GENERAL.  The credit amount described in this subsection shall be the product of?\r\n\”(A) the applicable amount specified in paragraph (2);\r\n\”(B) the employer size factor specified in paragraph (3); and\r\n\”(C) the percentage of year factor specified in paragraph (4).
\r\n\”(2) APPLICABLE AMOUNT.  For purposes of paragraph (1):\r\n\”(A) IN GENERAL.  The applicable amount shall be equal to?\r\n\”(i) $1,000 for each employee of the employer who receives self-only health in surance coverage through the employer;\r\n\”(ii) $2,000 for each employee of the employer who receives family health insurance coverage through the employer; and\r\n\”(iii) $1,500 for each employee of the employer who receives health insurance coverage for two adults or one adult and one or more children through the employer.\r\n\”(B) BONUS FOR PAYMENT OF GREATER PERCENTAGE OF PREMIUMS.  The applicable amount specified in  subparagraph (A) shall be increased by $200 in the case of subparagraph\r\n(A)(i), $400 in the case of subparagraph\r\n(A)(ii), and $300 in the case of subparagraph\r\n(A)(iii), for each additional 10 percent of the qualified employee health insurance expenses exceeding 60 percent which are paid by the qualified small employer.\r\n\r\n\”(3) EMPLOYER SIZE FACTOR.?\r\nFor purposes of paragraph (1), the employer size factor shall be the percentage determined in accordance with the following:\r\n\”(A) With respect to an employer with more than 10, but not more than 20, full-time employees, the percentage shall be 80 percent.\r\n\”(B) With respect to an employer with more than 20, but not more than 30, full-time employees, the percentage shall be 50 percent.\r\n\”(C) With respect to an employer with more than 30, but not more than 40, full-time employees, the percentage shall be 40 percent.\r\n\”(D) With respect to an employer with more than 40, but not more than 50, full-time employees, the percentage shall be 20 percent.\r\n\”(E) With respect to an employer with more than 50 full-time employees, the percent\r\nage shall be 0 percent.\r\n
\”(4) PERCENTAGE OF YEAR FACTOR.?\r\nFor purposes of paragraph (1), the percentage of year factor shall be equal to the ratio of?\r\n\”(A) the number of months during the tax able year for which the employer paid or incurred qualified employee health insurance expenses; and\r\n\”(B) 12.\r\n\”(c) DEFINITIONS AND SPECIAL RULES.  For purposes of this section:\r\n\”(1) QUALIFIED SMALL EMPLOYER.?\r\n\”(A) IN GENERAL.  The term ?qualified small employer? means an employer (as defined in section 3001(a)(4) of the Public Health Service Act) that?\r\n\”(i) purchases health insurance coverage for its employees in a small group market in a State that meets the requirements of subparagraph (B) for the year involved;\r\n\”(ii) pays or incurs at least 60 percent of the qualified employee health insurance expenses of such employer, or who is self-employed; and\r\n\”(iii) was?\r\n\”(I) an employer that?\r\n\”(aa) employed an average of 50 or fewer full-time employees during the preceding taxable year; and
\r\n\”(bb) had an average wage of less than $50,000 for full time employees in the preceding taxable year; or\r\n\”(II) a self-employed individual that had?\r\n\”(aa) not less than $5,000 in net earnings or not less than $15,000 in gross earnings from self-employment in the preceding taxable year; and\r\n\”(bb) not greater than $50,000 in net earnings or not greater than $150,000 in gross earnings from self-employment in the preceding taxable year.\r\n\”(B) LIMITATION.  An employer may not receive a credit under this section for more than three consecutive years.\r\n
\”(2) QUALIFIED EMPLOYEE HEALTH INSURANCE EXPENSES.?\r\n\”(A) IN GENERAL.  The term ?qualified employee health insurance expenses? means any amount paid by an employer or an employee of such employer for health insurance coverage under this Act to the extent such amount is for coverage?\r\n\”(i) provided to any employee (as defined in subsection 3001(a)(3) of such Act), or\r\n\”(ii) for the employer, in the case of a self-employed individual.\r\n\”(B) EXCEPTION FOR AMOUNTS PAID UNDER SALARY REDUCTION ARRANGEMENTS.?\r\nNo amount paid or incurred for health insurance coverage pursuant to a salary reduction arrangement shall be taken into account for purposes of subparagraph (A).\r\n\”(3) FULL-TIME EMPLOYEE.  The term ?full time employee? means, with respect to any period, an employee (as defined in section 3001(a)(3)) of an employer if the average number of hours worked by such employee in the preceding taxable year for such employer was at least 35 hours per week.\r\n\”(d) INFLATION ADJUSTMENT.?\r\n\”(1) IN GENERAL.  For each calendar year after 2009, the dollar amounts specified in subsections (b)(2)(A), (b)(2)(B), and (c)(1)(A)(iii) (after the application of this paragraph) shall be the amounts in effect in the preceding calendar year or, if greater, the product of?\r\n\”(A) the corresponding dollar amount specified in such subsection; and \”(B) the ratio of the index of wage inflation (as determined by the Bureau of Labor Statistics) for August of the preceding calendar year to such index of wage inflation for August of 2008.\r\n\”(2) ROUNDING.  If any amount determined under paragraph (1) is not a multiple of $100, such amount shall be rounded to the next lowest multiple of $100.\r\n\”(e) APPLICATION OF CERTAIN RULES IN DETERMINATION OF EMPLOYER SIZE.  For purposes of this section:\r\n\”(1) APPLICATION OF AGGREGATION RULE FOR EMPLOYERS.  All persons treated as a single employer under subsection (b), (c), (m), or (o) of section 414 of the Internal Revenue Code of 1986 shall be treated as 1 employer.\r\n\”(2) EMPLOYERS NOT IN EXISTENCE IN PRECEDING YEAR.  In the case of an employer which was not in existence for the full preceding taxable year, the determination of whether such employer meets the requirements of this section shall be based on the average number of full-time employees that it is reasonably expected such employer will employ on business days in the EmployER\’s first full taxable year.\r\n\”(3) PREDECESSORS.  Any reference in this subsection to an employer shall include a reference to any predecessor of such employer.\”.\r\n(b) DISCLOSURE OF INFORMATION TO PROVIDE PREMIUM PAYMENTS.?\r\n(1) IN GENERAL.  Subsection (l) of section 6103 of the Internal Revenue Code of 1986 is amended by adding at the end the following new paragraph:\r\n\”(21) VOLUNTARY AUTHORIZATION FOR INCOME VERIFICATION.?\r\n\”(A) VOLUNTARY AUTHORIZATION.  The Secretary shall provide a mechanism for each taxpayer to indicate whether such taxpayer authorizes the Secretary to disclose to the Secretary of Health and Human Services (or, pursuant to a delegation described in subsection (d)(4)(B), to a State or a Gateway (as defined in section 3101 of the Public Health Service Act) return information of a taxpayer who may be eligible for credits under section 3111 of the Public Health Service Act.\r\n\”(B) PROVISION OF INFORMATION.  If a taxpayer authorizes the disclosure described in subparagraph (A), the Secretary shall disclose to the Secretary of Health and Human Services (or, pursuant to a delegation described in subsection (d)(4)(B), to a State or a Gateway) the minimum necessary amount of information necessary to establish whether such individual is eligible for credits under section 3111 of the Public Health Service Act.\r\n\”(C) RESTRICTION ON USE OF DISCLOSED INFORMATION.  Return information disclosed under subparagraph (A) may be used by the Secretary (or, pursuant to a delegation described in subsection (d)(4)(B), a State or a\r\nGateway) only for the purposes of, and to the extent necessary in, establishing the appropriate amount of any payments under section 3111 of the Public Health Service Act.\”.\r\n(2) CONFORMING AMENDMENTS.?\r\n(A) Paragraph (3) of section 6103(a) of such Code is amended by striking \”or (20)\” and inserting \”(20), or (21)\”.
\r\n(B) Paragraph (4) of section 6103(p) of such Code is amended by striking \”(l)(10), (16), (18), (19), or (20)\” each place it appears and inserting \”(l)(10), (16), (18), (19), (20), or (21)\”.\r\n(C) Paragraph (2) of section 7213(a) of such Code is amended by striking \”or (20)\” and inserting \”(20), or (21)\”.\r\n
lifetime max
\r\n
early retirees\’
\r\n
Pre X
\r\n
recessions
\r\n
appeals
\r\n
Health care costs 10
1\r\n
Salary Discrimination
\r\n
Web Portal Consumer Info
\r\n
grandfather
\r\n
2014 Mandatory to have health Insurance
\r\nr
esources on health reform law
\r\n
Exchange
\r\n
Small Biz Health Credit
\r\n
Summary
\r\n
value for premium payments
\r\n
Free Preventative Care
\r\n\r\n

\r\n

\r\n
\r\n
Comments
\r\nThere is a negative undercurrent to your posts regarding the Obama healthcare plan. I’m a big fan of President Obama and credit him for passing a healthcare plan of any sort against tremendous opposition. Obviously the opposition still exists, judging by your comments.\r\n\r\nI would like to see a healthcare plan like that of Canada. I’ve read about how awful it is in the American press, but have nothing but kudos from friends in Canada who enjoy it.\r\n\r\n
\r\n
Reply
\r\n

\r\n

\r\n
\r\n
Steve Shorr
says:
\r\n
July 19, 2013 at 10:48 AM
Edit
\r\n
\r\n
\r\n\r\nYes, but I try to be fair and link to my sources. You are welcome to link to authoritative sources to support Canadian Health Care. Note that I link to the ACTUAL video from the White House of the President’s speech.\r\n\r\n
\r\n
\r\n

\r\n
‘,’Legislative History’,”,’publish’,’open’,’closed’,”,’legislative-history’,”,”,’2018-03-01 19:24:38′,’2018-03-01 19:24:38′,”,8129,’http://healthlaw.healthreformquotes.com/?page_id=31′,0,’page’,”,0),(35,1,’2015-01-08 19:21:03′,’2015-01-08 19:21:03′,”,’Abstract-Green-Waves-Vector-Background[1]’,”,’inherit’,’open’,’open’,”,’abstract-green-waves-vector-background1′,”,”,’2015-01-08 19:21:03′,’2015-01-08 19:21:03′,”,0,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2015/01/Abstract-Green-Waves-Vector-Background1.jpg’,0,’attachment’,’image/jpeg’,0),(41,1,’2015-01-13 19:26:39′,’2015-01-13 19:26:39′,’
A

B 214 9.2013
Domestic Worker

\’s – Compensation

\r\n (1) …\r\n
\r\n

This bill would enact the Domestic Worker Bill of Rights
to, until January 1, 2017, regulate the hours of work of certain domestic work employees and provide an overtime compensation rate for those employees. The bill would define various terms for the purposes of the act, including defining domestic work to mean services related to the
care of persons in private households
or maintenance of private households or their premises, which would include childcare providers,
caregivers of people with disabilities, sick, convalescing, or elderly persons
, house cleaners, housekeepers, maids, and other household occupations.

\r\n

.

\r\n
\r\n
\r\n
\r\n

Main
Workers Compensation
, Child & Related Pages

\r\n

\r\n

\r\n\r\n
‘,’Domestic Workers’,”,’publish’,’closed’,’closed’,”,’domestic-workers’,”,”,’2017-01-05 19:08:33′,’2017-01-05 19:08:33′,”,24,’http://healthlaw.healthreformquotes.com/?page_id=41′,0,’page’,”,0),(46,1,’2015-03-23 21:11:58′,’2015-03-23 21:11:58′,’ ‘,”,”,’publish’,’open’,’closed’,”,’46’,”,”,’2016-11-09 16:07:18′,’2016-11-09 16:07:18′,”,0,’http://healthlaw.healthreformquotes.com/?p=46′,8,’nav_menu_item’,”,0),(47,1,’2015-03-23 21:11:59′,’2015-03-23 21:11:59′,”,’Worker\’s Compensation’,”,’publish’,’open’,’closed’,”,’workers-compensation’,”,”,’2016-11-09 16:07:18′,’2016-11-09 16:07:18′,”,0,’http://healthlaw.healthreformquotes.com/?p=47′,11,’nav_menu_item’,”,0),(48,1,’2015-03-23 21:11:58′,’2015-03-23 21:11:58′,’ ‘,”,”,’publish’,’open’,’closed’,”,’48’,”,”,’2016-11-09 16:07:18′,’2016-11-09 16:07:18′,”,0,’http://healthlaw.healthreformquotes.com/?p=48′,2,’nav_menu_item’,”,0),(50,1,’2015-03-24 01:21:25′,’2015-03-24 01:21:25′,’

The California Confidentiality of Medical Information Act\r\n
(CA Civil Code §56 et seq)

\r\n
understands  that Private Information about your health and healthcare is perhaps the most sensitive and personal kind of information collected.  California  State &

Federal HIPAA

laws give us many rights to limit those who see our medical records.
\r\n
Businesses are forbidden from trying to obtain

medical information

directly from an individual

for direct marketing purposes

without clearly and conspicuously disclosing how it will use and share that information, and without obtaining the consumer’s consent. (

SB 1633

Civil Code

§1798.91)

\r\n \r\n
\r\n

\r\n
\r\n
\r\n\r\n
Covered CA Privacy Course\r\n\r\n
Flow Chart – Private Entity \r\n
\r\n\r\n
Safeguarding Taxpayer Data – A guide for your business\r\n\r\n \r\n\r\n
HIPAA Summary \r\n
\r\n

\r\n
\r\n

Consumer Links

\r\nCalifornia Patients Guide\r\n\r\n
wikipedia.org
\r\n\r\nCalifornia State Office of Privacy Protection Website\r\n\r\n
CA Office of HIPAA Implementation
\r\n\r\n
CA Healthcare Foundation
15 Page Pdf Rights & Requirements\r\n\r\n
Federal HIPAA
\r\n

California CONFIDENTIALITY OF MEDICAL INFORMATION Act
\r\n
§56 – §56.37
\r\n

\r\n

Technical & Research Links

\r\nUse of
Social Security Number
§
1798.85
\r\nCalifornia Senate Bill 168\r\nHealth Net\’s FAQ\’s\r\n\r\n
Family Law Code
§
3751.5 Right of Other Parent to Obtain Medical Information
\r\n\r\n
Covered CA Agent Agreement Exhibit # D on Privacy & Security
\r\n\r\n \r\n

Insurance Information and Privacy Protection Act
§
791-791.27

\r\nCalifornia Code of Regulations Section §2689.1 et seq.\r\nwww.calregs.com/\r\n

Related Pages in
Privacy – HIPAA
Section

\r\n
\r\n

‘,’CA Privacy’,”,’publish’,’open’,’closed’,”,’ca-privacy’,”,”,’2018-10-06 18:58:15′,’2018-10-06 18:58:15′,”,53,’http://healthlaw.healthreformquotes.com/?page_id=50′,0,’page’,”,0),(51,1,’2015-03-24 01:23:05′,’2015-03-24 01:23:05′,”,’Site Map’,”,’publish’,’open’,’open’,”,’site-map’,”,”,’2017-01-05 19:08:33′,’2017-01-05 19:08:33′,”,0,’http://healthlaw.healthreformquotes.com/?page_id=51′,0,’page’,”,0),(52,1,’2015-03-24 01:23:33′,’2015-03-24 01:23:33′,’ ‘,”,”,’publish’,’open’,’closed’,”,’52’,”,”,’2016-11-09 16:07:18′,’2016-11-09 16:07:18′,”,0,’http://healthlaw.healthreformquotes.com/?p=52′,12,’nav_menu_item’,”,0),(53,1,’2015-04-02 17:33:34′,’2015-04-02 17:33:34′,’
\r\n\r\n
HIPAA Summary\r\n\r\n
\r\n

Federal –
HIPAA Privacy
(HHS.gov)
and
Calif. Civil Code
\r\nprovides  in a one sentence summation that:

\r\n

Any  [medical] records  which contain
individually identifiable (PHI) Protected Health
Information must be secured,  so that they are not readily available to those who do not need them.
(HSS Q & A)

Thus, the people who can see your medical records is very limited.   HHS

Summary

of HIPAA Privacy Rule  (25 Pages)

Each covered entity, with certain exceptions, must provide a notice of its privacy practices.\r\n

\r\n\r\n
\r\n

\r\n
\r\n
\r\n\r\nSafeguarding Taxpayer Data – A guide for your business\r\n\r\n
CMS Webinar 56 pages on Privacy
2017\r\n\r\n \r\n
Hints on writing the notice in
Plain English
\r\n
Plain Language.Gov
\r\n
Videos
\r\n
Our Quote Engines

Privacy Policy
\r\n
Plain Language Instructional Video Minnesota DHS Training
\r\n
\r\n
\r\n\r\nFlow Chart – Private Entity\r\n\r\n
Privacy Practices Notice
\r\n\r\n
The Privacy Rule requires that the notice contain certain elements.
\r\n
\r\n
The notice must describe the ways in which the covered entity may use and disclose protected health information.
\r\n
The notice must state the covered entity’s duties to protect privacy, provide a notice of privacy practices, and abide by the terms of the current notice.
\r\n
The notice must describe individuals’ rights, including the right to complain to HHS and to the covered entity if they believe their privacy rights have been violated.
\r\n
The notice must include a point of contact for further information and for making complaints to the covered entity.
\r\n
Covered entities must act in accordance with their notices.
(

hhs.gov

)
\r\n
\r\n
\r\n
\r\n

\r\n
\r\n

\r\n\r\n \r\n

Steve\’s personal thoughts

\r\nI think if people just followed the 1
0 Commandments
, the
7 Noahide Laws
, and the Golden Rule, and be careful about
Gossip
,  we wouldn\’t have to have ALL these pages and tons of paperwork.\r\n

1st HIPAA Privacy Conviction

\r\n
Defendant Richard Gibson obtained the demographic information of a cancer patient from his employer, Seattle Cancer Care Alliance. Gibson then used this data to obtain credit cards in the patient’s name, eventually incurring over $9,000 in debt for items such as video games, apparel, and jewelry.

(Attorney\’s Corwel & Moring

)

\r\n

Consumer Links
\r\n

Summaries

and Links
\r\n

Our page on how to read law

– 3 times and when you think you understand it, read it again.
\r\n
Office for Civil Rights –

HIPAA

H & HS Website – has a ton of information and links
\r\n
Blue Cross Data Breach, Identity Theft, etc.
\r\n
California Privacy
\r\n\r\nPrivacy
wikipedia.org/
\r\n\r\n
wikipedia.org   HIPAA
\r\n\r\n
harvard.edu  privacy  Torts
\r\n\r\n
Privacy Rights.org
\r\n\r\n
ACLU
\r\n\r\nCA Patients Guide\r\n\r\nHow and why to
get your medical records
– Center for Democracy & Technology Website\r\n\r\n
Health Privacy . Org
HIPPA  Myths and Facts
Lot\’s of Information in Simple to Understand Format\r\n\r\n
Anti-Phishing Act of 2005
Phony Websites & Email to gather identity theft information\r\n\r\n
Jewish Thought on Gossip, Tale Bearing
JewFAQ.org\r\n\r\n
Online Education
Torah.org\r\n\r\n
CMS Webinar 56 pages on Privacy
\r\n
How to comply –

Solutions

\r\n
Paubox.com
\r\n\r\n
Sample Business Associates Agreement
– from
HHS/OCR
Site\r\n\r\nFor members of NAHU -\r\n
National Association of Health Underwriters

Compliance Guide
\r\n

Insurance Company Forms

\r\n
Blue Cross\’s Privacy Statement
\r\n\r\nBlue SHIELD Privacy Statement –
Release Form
\r\n

FAQ\’s

\r\n
CIGNA FAQ\’s
\r\n\r\n
hhs.gov faq
\r\n

What does the HIPAA Privacy Rule do?

\r\n

\r\n
Most health plans and health care providers that are covered by the new Rule must comply with the new requirements by April 14, 2003.
\r\nThe HIPAA Privacy Rule for the first time creates national standards to protect individuals’ medical records and other personal health information.\r\n\r\n- It gives patients more control over their health information.\r\n\r\n- It sets boundaries on the use and release of health records.\r\n\r\n- It establishes appropriate safeguards that health care providers and others must achieve to protect the privacy of health information.\r\n\r\n- It holds violators accountable, with civil and criminal penalties that can be imposed if they violate patients’ privacy rights.\r\n\r\n- And it strikes a balance when public responsibility supports disclosure of some forms of data – for example, to protect public health.\r\n\r\nFor patients – it means being able to make informed choices when seeking care and reimbursement for care based on how personal health information may be used.\r\n\r\n- It enables patients to find out how their information may be used, and about certain disclosures of their information that have been made.\r\n\r\n- It generally limits release of information to the minimum reasonably needed for the purpose of the disclosure.\r\n\r\n- It generally gives patients the right to examine and obtain a copy of their own health records and request corrections.\r\n\r\n- It empowers individuals to control certain uses and disclosures of their health information.\r\n

When is an authorization required from the patient before a provider or health plan engages in marketing to that individual?

\r\n
The HIPAA Privacy Rule expressly requires an authorization for uses or disclosures of protected health information for ALL marketing communications, except in two circumstances: (1) when the communication occurs in a face-to-face encounter between the covered entity and the individual; or (2) the communication involves a promotional gift of nominal value.
\r\nIf the marketing communication involves direct or indirect remuneration to the covered entity from a third party, the authorization must state that such remuneration is involved.\r\n
Can contractors (business associates) use protected health information for its own marketing purposes?
\r\n
No. While covered entities may share protected health information with their contractors who meet the definition of “business associates” under the HIPAA Privacy Rule, that definition is limited to contractors that obtain protected health information to perform or assist in the performance of certain health care operations on behalf of covered entities. Thus, business associates, with limited exceptions, cannot use protected health information for their own purposes. Although, under the HIPAA statute, the Privacy Rule cannot govern contractors directly, the Rule does set clear parameters for how covered entities may contract with business associates. See 45 CFR 164.502(e) and 164.504(e), and the definition of “business associate” at 45 CFR 160.103.
\r\nFurther, the Privacy Rule expressly prohibits health plans and covered health care providers from selling protected health information to third parties for the third party’s own marketing activities, without authorization. So, for example, a pharmacist cannot, without patient authorization, sell a list of patients to a pharmaceutical company, for the pharmaceutical company to market its own products to the individuals on the list.\r\n\r\n \r\n

Sample business associate agreement

\r\n
Blog Text of Law
\r\n

Related Pages in
Privacy – HIPAA
Section

\r\n
\r\n
Summaries and Links
\r\n

Text of law

\r\n

faq

\r\n

phi

‘,’Privacy – HIPAA’,”,’publish’,’open’,’closed’,”,’privacy-hipaa’,”,”,’2018-10-27 14:37:25′,’2018-10-27 14:37:25′,”,0,’http://healthlaw.healthreformquotes.com/?page_id=53′,0,’page’,”,0),(56,1,’2015-04-11 20:34:07′,’2015-04-11 20:34:07′,”,’privacy law’,’CA Privacy Law – Click to view actual code on State Website’,’inherit’,’open’,’open’,”,’privacy-law’,”,”,’2015-04-11 20:34:52′,’2015-04-11 20:34:52′,”,50,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2015/03/privacy-law.jpg’,0,’attachment’,’image/jpeg’,0),(60,1,’2015-04-13 15:09:34′,’2015-04-13 15:09:34′,”,’Privacy – HIPAA’,”,’publish’,’open’,’closed’,”,’60’,”,”,’2016-11-09 16:07:18′,’2016-11-09 16:07:18′,”,7,’http://healthlaw.healthreformquotes.com/?p=60′,9,’nav_menu_item’,”,0),(61,1,’2015-04-13 15:09:34′,’2015-04-13 15:09:34′,”,’HIPAA Privacy Blog’,”,’publish’,’open’,’closed’,”,’hipaa-privacy-blog’,”,”,’2016-11-09 16:07:18′,’2016-11-09 16:07:18′,”,0,’http://healthlaw.healthreformquotes.com/?p=61′,10,’nav_menu_item’,”,0),(63,1,’2015-04-25 18:13:31′,’2015-04-25 18:13:31′,”,’felix’,’Felix Frankfurther – Wikipedia’,’inherit’,’open’,’open’,”,’felix’,”,”,’2015-04-25 18:14:11′,’2015-04-25 18:14:11′,”,5,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2014/12/felix.jpg’,0,’attachment’,’image/jpeg’,0),(66,1,’2015-05-02 13:31:57′,’2015-05-02 13:31:57′,”,’Search’,”,’publish’,’open’,’closed’,”,’search’,”,”,’2016-11-09 16:07:18′,’2016-11-09 16:07:18′,”,0,’http://healthlaw.healthreformquotes.com/?p=66′,13,’nav_menu_item’,”,0),(74,1,’2015-06-09 14:40:25′,’2015-06-09 14:40:25′,”,’workers-compensation-coverage-resized-600[1]’,”,’inherit’,’open’,’open’,”,’workers-compensation-coverage-resized-6001′,”,”,’2015-06-09 14:40:25′,’2015-06-09 14:40:25′,”,24,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2014/12/workers-compensation-coverage-resized-6001.png’,0,’attachment’,’image/png’,0),(77,1,’2015-06-25 14:09:07′,’2015-06-25 14:09:07′,”,’Dictionary_Icon[1]’,’Dictionary – Photo Credit Wikipedia’,’inherit’,’open’,’open’,”,’dictionary_icon1′,”,”,’2015-06-25 14:09:37′,’2015-06-25 14:09:37′,”,27,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2014/12/Dictionary_Icon1.png’,0,’attachment’,’image/png’,0),(82,1,’2015-06-25 23:05:05′,’2015-06-25 23:05:05′,”,’scotus.care’,’King v Burwell – Subsidies Upheld – ScotusCare’,’inherit’,’open’,’open’,”,’scotus-care’,”,”,’2015-06-25 23:05:43′,’2015-06-25 23:05:43′,”,5,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2014/12/scotus.care_.jpg’,0,’attachment’,’image/jpeg’,0),(86,1,’2015-07-04 15:50:49′,’2015-07-04 15:50:49′,’supreme.court[1] mandate upheld as a tax’,’supreme.court[1] mandate upheld as a tax’,”,’inherit’,’open’,’open’,”,’supreme-court1′,”,”,’2015-07-04 15:51:14′,’2015-07-04 15:51:14′,”,16,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2014/12/supreme.court1_.jpg’,0,’attachment’,’image/jpeg’,0),(87,1,’2015-07-04 15:59:12′,’2015-07-04 15:59:12′,’Kaiser Foundation 10 page summary – ACA Upheld as Tax’,’summary.supreme.court.aca.upheld.as.a.tax’,’Kaiser Foundation 10 page summary – ACA Upheld as Tax’,’inherit’,’open’,’open’,”,’summary-supreme-court-aca-upheld-as-a-tax’,”,”,’2015-07-04 16:00:05′,’2015-07-04 16:00:05′,”,16,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2014/12/summary.supreme.court_.aca_.upheld.as_.a.tax_.jpg’,0,’attachment’,’image/jpeg’,0),(94,2,’2015-08-03 22:22:22′,’2015-08-03 22:22:22′,”,’Large Blog Image’,”,’inherit’,’open’,’open’,”,’large-blog-image’,”,”,’2015-08-03 22:22:22′,’2015-08-03 22:22:22′,”,0,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2015/08/steve-shorr-favicon-01-55bfe99ev1_site_icon.png’,0,’attachment’,’image/png’,0),(98,1,’2015-10-15 14:41:33′,’2015-10-15 14:41:33′,’Cochlear Implant Activation’,’little.miracles’,’Cochlear Implant Activation – Click to view Video’,’inherit’,’open’,’closed’,”,’little-miracles’,”,”,’2015-10-15 14:42:22′,’2015-10-15 14:42:22′,”,29,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2014/12/little.miracles.jpg’,0,’attachment’,’image/jpeg’,0),(140,1,’2016-04-16 17:21:10′,’2016-04-16 17:21:10′,’

This page is informational and historical only.

\r\n
Do not contact us for information.  We do not have anything current!
\r\n
It appears these plans are no longer allowed to be sold, as they do not meet the

Essential Benefits

Requirements of PPACA.
\r\n

They might come back under a 7.5.2016  Big Fines! —  In August 2012, DMHC issued a cease-and-desist order against Accountable Health for allegedly conducting illegal utilization reviews and
making medical necessity decisions for insurers.
DMHC accused the group\’s vice president and another employee of engaging in utilization reviews on behalf of nine health plans, even though the employees are not licensed physicians.

\r\n

Learn More
CA Health Line 9.10.2015

\r\n

Wikipedia

\r\n\r\n

References

\r\n

\r\n
\r\n
\r\n
See
42 U.S.C. §
1395y(a)(1)(A)
\r\n
See

http://www.cms.hhs.gov/mcd/overview.asp
\r\n
For more information, see
Certificate of medical necessity
,
\r\n
\r\n
\r\n

\r\n

External links

\r\n

\r\n
Your Medicare Coverage
from medicare.gov
\r\n
Medicare Coverage Database
which includes NCDs, LMRP/LCDs, as well as NCAs & CALs, from cms.hhs.gov
\r\n
Physician Fee Schedule lookup
at cms.hhs.gov
\r\n
What is medical necessity?
by Nancy W. Miller, as found in the Physician\’s News Digest
\r\n
Defining Medical Necessity Under the Patient Protection and Affordable Care Act
at academia.edu., by Daniel R. Skinner, published in the journal
Public Administration Review
(2013).
\r\n
Charles Martin, \”Medical Use of Cannabis in Australia: \’Medical necessity\’ defences under current Australian law and avenues for reform\” (2014) 21(4)
Journal of Law and Medicine
875.
\r\n
Florida\’s Medical Necessity Defense, Reconsidered
by Miami attorney Jared H. Beck
\r\n

\r\n

Kantor & Kantor Law Firm

\r\n

Medical Policies & Clinical UM Guidelines

\r\nto determine if a procedure is

Medically Necessary

.  Does Company X Y Z pay for this or that surgery?  Like Lap Band\r\n\r\nAetna Bulletin on

Obesity Surgery

(Gastric Bypass) (Lap Band)\r\n\r\n

Cochlear Implants

– Hearing\r\n\r\n

Clinical Policy Bulletin Index

\r\n\r\n

Blue Cross

\r\n\r\n

Blue Shield Clinical Policies

\r\n

Spine Policy & Pain Intervention

\r\n

Lap Band – Severe Obesity

\r\n\r\n

PacifiCare – United HealthCare

\r\nHow do I

find a code.com

ICD 9, 10, DRG, CPT, (Current Procedural Terminology) diagnosis code, Medical Billing,  coding\r\n\r\n

Magellan – Medical Necessity Guidelines

Mental Health? 190 pages\r\n\r\n

Utilization Review

\r\n

Oscar  Clinical Guidelines

\r\n\r\n

\r\n
\r\n
\r\n
\r\n
\r\nNoninvasive Positive Pressure Ventilation (CG003)\r\n
English PDF
\r\n
\r\n
\r\nOxygen Therapy (CG005)\r\n
English PDF
\r\n
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\r\nHospital Beds and Accessories (CG006)\r\n
English PDF
\r\n
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\r\nPressure-Reducing Support Surfaces (CG007)\r\n
English PDF
\r\n
\r\n
\r\nBariatric Surgery (Adults) (CG008)\r\n
English PDF
\r\n
\r\n
\r\nBariatric Surgery (Adolescents) (CG009)\r\n
English PDF
\r\n
\r\n
\r\nMedical Nutrition Therapy (CG010)\r\n
English PDF
\r\n
\r\n
\r\nOral Liquid Nutritional Supplements (CG011)\r\n
English PDF
\r\n
\r\n
\r\nNon-Covered Experimental, Investigational, and Unproven Services (CG012)\r\n
English PDF
\r\n
\r\n
\r\nAcupuncture (CG013)\r\n
English PDF
\r\n
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\r\nHyperbaric Oxygen Therapy (CG014)\r\n
English PDF
\r\n
\r\n
\r\nTreatment and Removal of Benign Skin Lesions (CG015)\r\n
English PDF
\r\n
\r\n
\r\nSex Reassignment Surgery (Gender Affirmation Surgery) (CG017)\r\n
English PDF
\r\n
\r\n
\r\nBalloon Ostial Dilation (CG018)\r\n
English PDF
\r\n
\r\n
\r\nWearable Cardioverter-Defibrillator Devices (CG019)\r\n
English PDF
\r\n
\r\n
\r\nHome Care – Skilled Nursing Care (RN, LVN/LPN) (CG020)\r\n
English PDF
\r\n
\r\n
\r\nHome Care – Physical Therapy (PT) and Occupational Therapy (OT) (CG021)\r\n
English PDF
\r\n
\r\n
\r\nHome Care – Home Health Aides (HHA) (CG022)\r\n
English PDF
\r\n
\r\n
\r\nHome Care – Speech Language Pathology (SLP) Services (CG023)\r\n
English PDF
\r\n
\r\n
\r\nColorectal Cancer Screening (CG024)\r\n
English PDF
\r\n
\r\n
\r\nOptical Coherence Tomography (OCT) (CG025)\r\n
English PDF
\r\n
\r\n
\r\nAutonomic Testing (CG026)\r\n
English PDF
\r\n
\r\n
\r\nBreast Imaging (CG027)\r\n
English PDF
\r\n
\r\n
\r\nDiabetes Equipment and Supplies (CG028)\r\n
English PDF
\r\n
\r\n
\r\nInsulin Delivery Systems and Continuous Glucose Monitoring (CG029)\r\n
English PDF
\r\n
\r\n
\r\nBioengineered Skin and Soft Tissue Substitutes (CG030)\r\n
English PDF
\r\n
\r\n
\r\nBPH Treatment (CG031)\r\n
English PDF
\r\n
\r\n
\r\nAmbulatory Cardiac Event Monitoring (CG032)\r\n
English PDF
\r\n
\r\n
\r\nBotulinum Toxin (CG033)\r\n
English PDF
\r\n
\r\n
\r\nGlaucoma Surgery (CG034)\r\n
English PDF
\r\n
\r\n
\r\nTranscranial Doppler (CG035)\r\n
English PDF
\r\n
\r\n
\r\nBreast Procedures (CG036)\r\n
English PDF
\r\n
\r\n
\r\nErectile Dysfunction (CG037)\r\n
English PDF
\r\n
\r\n
\r\nHome Births (CG038)\r\n
English PDF
\r\n
\r\n
\r\nContact Lenses and Eyeglasses (CG039)\r\n
English PDF
\r\n
\r\n
\r\nPotentially Preventable Hospital Readmissions (CG040)\r\n
English PDF
\r\n
\r\n
\r\nAnesthesia and Sedation in Endoscopy (CG041)\r\n
English PDF
\r\n
\r\n
\r\nSkilled Nursing Facility Care (CG042)\r\n
English PDF
\r\n
\r\n
\r\nPrenatal Testing (CG043)\r\n
English PDF
\r\n
\r\n
\r\nOutpatient Physical Therapy & Occupational Therapy (CG044)\r\n
English PDF
\r\n
\r\n
\r\nIntraoperative Neuromonitoring (CG045)\r\n
English PDF
\r\n
\r\n

\r\n

\r\n
\r\n

\r\n \r\n\r\n \r\n

Child & Related Pages

\r\n

View our Appeals & Grievances Page

\r\n

IMR – Independent Medical Review

\r\n

10 Essential Health Benefits in ObamaCare

\r\n\r\n\r\n \r\n\r\nThe Benefits of this Plan are provided only for Services which are Medically Necessary as defined in this section.\r\n\r\n \r\n

\r\n
Services which are Medically Necessary include only those which have been established as safe and effective, are furnished under generally accepted professional standards to treat illness, injury or medical condition, and which are:
\r\n

\r\n \r\n

\r\n
Consistent with the Plan’s medical policy;
\r\n
Consistent with the symptoms or diagnosis;
\r\n
Not furnished primarily for the convenience of the patient, the attending Physician or other provider; and
\r\n
Furnished at the most appropriate level which can be provided safely and effectively to the patient.
\r\n

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\r\n

\r\n
If there are two (2) or more Medically Necessary Services that may be provided for the illness, injury, or medical condition, Blue Shield Life will provide benefits based on the most cost-effective Service.
\r\n

\r\n \r\n\r\n

\r\n

\r\n
Hospital Inpatient Services which are Medically Necessary
include only those Services which satisfy the above requirements, require the acute bed-patient (overnight) setting,
and which could not have been provided
in the Physician\’s office, the Outpatient department of a Hospital, or in another lesser facility without adversely affecting the patient\’s condition or the quality of medical care rendered. Inpatient services not Medically Necessary include hospitalization:
\r\n

\r\n \r\n

\r\n
For diagnostic studies that could have been provided on an Outpatient basis;
\r\n
For medical observation or evaluation;
\r\n
For personal comfort;
\r\n
In a pain management center to treat or cure chronic pain; and
\r\n
For Inpatient Rehabilitation that can be provided on an Outpatient basis.
Copied from Blue Shield EOC
\r\n

\r\n

‘,’Medical Necessity – reasonable and necessary’,”,’publish’,’open’,’closed’,”,’medical-necessity’,”,”,’2018-10-06 18:52:43′,’2018-10-06 18:52:43′,”,0,’http://healthlaw.healthreformquotes.com/?page_id=149′,0,’page’,”,0),(151,1,’2016-05-10 08:06:05′,’2016-05-10 08:06:05′,’

\r\n\r\n\r\n\r\n

\r\n

\r\n
When can I get coverage, regardless of any Pre-Existing Conditions?
\r\n
Do I have to pay you a fee to help me with my coverage?
\r\n
Will premiums be lower under Health Care Reform?
\r\n
How do I know how much of a tax credit or subsidy I will get?
\r\n
Tell me more about
how I use the credit to pay for my coverage
?
\r\n
Is there a
simple 10 minute video I can watch to have Health Care Reform
explained to me?
\r\n
Does Covered CA have a list of FAQ\’s?\r\n
\r\n

\r\n \r\n\r\n \r\n

\r\n

The Pre-Exisiting conditions are no longer an issue on 1.1.2014.  Signups, brochures & rates will be available 10.1.2013
\r\n
Agent Webinar Slides
\r\n

No, all rates and benefits are the same, as filed with the Department of Insurance  or Managed Care.  We are compensated for our time and expertise by Covered CA or the Insurance Companies.
\r\n

I really don\’t know.  There are arguments going both ways.  We will know on 10.1.2013.  Here\’s the
\”summary\” brochure from Covered CA
showing that rates are less.  View the
Covered CA
page for HHS Report that prices will be lower.   The proof in the pudding will be in a few years, when we have the claims experience and see if
Preventative Care
and Case Management truly keep the costs down.
\r\n
See our page on
increasing medical costs
– (we started this page, way before Health Care Reform – HCR)
\r\n
UHC Health Reform Website
\r\n

\r\n \r\n

Instant Health & Subsidy Quote
\r\n
ONLINE Enrollment

\r\n

Child Pages

\r\n\r\n\r\n

InsuBuy International Medical Coverage –
Instant Quotes & Enrollment

\r\n ‘,’Health Care Reform FAQs’,”,’publish’,’open’,’closed’,”,’health-care-reform-faqs’,”,”,’2018-02-07 05:24:10′,’2018-02-07 05:24:10′,”,0,’http://healthlaw.healthreformquotes.com/?page_id=151′,0,’page’,”,0),(152,1,’2016-05-10 08:08:23′,’2016-05-10 08:08:23′,’

Right to view FULL Policy – E O C (Evidence of Coverage) prior to purchase Health Insurance

\r\n

California Insurance Code §10276
.  Every individual accident and health policy or contract, except single premium nonrenewable policies or contracts, issued for delivery in this state on or after July 1, 1962, by an insurance company, nonprofit hospital service plan or medical service corporation,
shall have printed thereon
or attached thereto a notice stating that the person to whom the policy or contract is issued
shall be permitted to return the policy
or contract after its delivery to the purchaser and to have the
premium paid refunded
if, after examination of the policy or contract, the purchaser
is not satisfied with it for any reason
. The period time set forth by the insurer, nonprofit hospital service plan or medical service corporation for return of the policy or contract shall be clearly stated on the notice and such period
shall not be less than 10 days nor more than 30 days
. The policyholder or purchaser may return the policy or contract to the insurer, plan or corporation at any time during the period specified in the notice. If a policyholder or purchaser pursuant to such notice, returns the policy or contract to the company or association at its home or branch office or to the agent through whom it was purchased,
it shall be void from the beginning
and the parties shall be in the same position as if no policy or contract had been issued.

\r\n

This section shall apply to all policies or contracts subject to this section and issued, amended, delivered, or renewed in this state on or after January 1, 1981. All policies or contracts subject to this section which are in effect on January 1, 1981, shall be construed to be in compliance with this section, and any provision in any such policy or contract which is in conflict with this section shall be of no force or effect.

\r\n\r\n
\r\n

Every policy of individual life insurance shall have a notice stating that after receipt of the policy by the owner, the policy may be returned by the owner for  cancellation by delivering it or mailing it to the insurer or to the agent through whom it was purchased.  This period shall not be less than 10 days nor more than 30 days.
CIC
10127.9
.

\r\n

\r\n

Sample Policy Provision

\r\n

YOU HAVE THE RIGHT TO VIEW THE AGREEMENT PRIOR TO ENROLLMENT.

\r\n

ONCE ENROLLED, YOU HAVE
THIRTY (30) DAYS
FROM THE DATE OF DELIVERY TO EXAMINE THIS AGREEMENT.
IF YOU ARE NOT SATISFIED, FOR ANY  REASON
WITH THE TERMS OF THIS AGREEMENT, YOU MAY RETURN THE AGREEMENT TO US WITHIN THOSE THIRTY (30) DAYS. YOU, CONSISTENT WITH CALIFORNIA LAW, WILL BE REQUIRED TO PAY FOR ANY SERVICES ANTHEM BLUE CROSS PAID ON YOUR BEHALF DURING THE THIRTY (30) DAY PERIOD AND ANTHEM BLUE CROSS WILL REFUND ANY PREMIUM PAID BY YOU, LESS YOUR MEDICAL AND PHARMACY EXPENSES THAT ANTHEM BLUE CROSS PAID. IF NO SERVICES WERE RENDERED, YOU WILL BE ENTITLED TO RECEIVE A
FULL REFUND
OF ANY PREMIUMS PAID. THIS AGREEMENT WILL THEN BE NULL AND VOID.
(
Page 18 Specimen Policy
)

\r\n

Free look

\r\n\r\n \r\n

Covered CA has a different Opinion.  IMHO they are in violation of law!

\r\n \r\n\r\nThank you for contacting Covered California™.  I apologize about the link.  Please see below for the article regarding the 14 Day Notice of Termination.\r\n14 Day Notice for Terminations\r\n\r\nThis article clarifies the policy for 14 Day Notice for Terminations and give examples.\r\n

\r\n
Enrollees must generally provide 14 days advance notice to process requests to terminate enrollment in a health or dental plan through Covered California, with some exceptions.
\r\n
Covered California may apply exceptions in some cases and terminate with less than 14 days’ notice as long as the termination date is end of the month.
\r\n
Regardless of how many days of advance notice enrollees give Covered California, they are strongly recommended to make thier termination effective the end of a month, for the following reasons.  Before consumers terminate or attempt to terminate, inform them of the following:
\r\n

\r\n

\r\n
\r\n
Consumer usually pay in advance for coverage for the following month.  For example, you are billed in May for coverage in the month of June. If you terminate your coverage with less than 14 days advance notice, your health plan carrier may have already billed you for the following month’s premium or may not have enough time to cancel your payment for the following month if the monthly payments are automatically withdrawn from your bank account.
\r\n
There is no legal obligation for the health or dental plan carrier to refund prorated premiums.  So if you call on June 1st and request a plan termination on June 15, your plan carrier is not required to refund you for the remaining days of June.
\r\n
If you request a termination date in the middle of a month, you may have a gap in coverage because most health plans start on the first day of the next month.
\r\n
For these reasons, if you need to terminate your health or dental plan, it’s strongly recommended that you request termination 14 days in advance so that it can be effective at the end of the month. The day of the call is counted as the first day of the request for termination.
\r\n
\r\n
Except in rare cases, terminations are always made with a future effective date.  State and Federal regulations allow Covered California to process requests to terminate past months of coverage in very limited circumstances, such as death and fraud.  If this is the case, follow the Escalations process. If this is not the case, review the 14 Day Termination Rule Talking points in this document and assist the caller in selecting a future termination date.
\r\n

\r\nLess than 14 Day Notice for Termination of Health or Dental Plans\r\n\r\nThere are some exceptions to the 14-day advance notice requirement.\r\n

\r\n
If enrollees request an end–of-month termination with less than 14 days advance notice, inform them that while a 14-day advance notice is required in most cases, you will terminate the plan at the end of the month.
\r\n
If enrollees request a mid-month termination with less than a 14-day notice, inform them that Covered California is unable to process this request without carrier approval and he/she must contact the carrier to receive an authorization.
\r\n

\r\nExamples:\r\n

\r\n
The enrollee contacts Covered California on…
\r\n

\r\n

\r\n
\r\n
September 25th to request termination of coverage.  He explains that his employer-sponsored coverage begins on October 1st and he wishes to cancel as of/before the new coverage goes into effect.  This would result in an end-of-month termination, and SCRs have been granted permission to terminate less than 14 days, if the enrollee requests it, and it results in an end-of-month termination.  You can process this termination with a termination date of September 30th.
\r\n
September 25th to request a termination of coverage on the day of contact, September 25th. In this case, the consumer can choose to terminate at the end of month, September 30th, or 14 days from the date of the contact, October 8th. Covered California does not have the authority to terminate with less than 14 days’ notice if the result is not the end of the month termination.
\r\n
September 1st to request termination of coverage.  The enrollee wants his/her coverage to be terminated on September 15th, which meets the 14-day advance notice requirement.  The regulations provide that the enrollee is only required to give a 14-day advance notice, even if this results in a mid-month termination date.  Before proceeding, the SCR should explain the implications of a mid-month termination as explained above and recommend the September 30th termination date.  If the enrollee insists on September 15th termination date, however, the SCR should process the termination as requested.
\r\n
May 1st to request termination of coverage on May 10th.  This request for a termination date with less than 14 days advance notice results in a mid-month termination. Explain to the enrollee that Covered California does not have the authority to waive the 14-day noticing requirement unless the effective termination date is the last day of the month. So the earliest termination date allowed would be May 15th, although that is not recommended due to the above reasons.  Explain the termination policies including that only the carrier can approve less than 14-day, mid-month termination requests and that the enrollee would need to contact his/her carrier for approval if he/she still wants May 10th termination but the SCR can terminate the coverage either on May 15th or May 31st, which is the recommended termination date.  Email dated (01/24/2017 09:43 AM)
\r\n
\r\n

\r\n

\r\n
\r\n
\r\n
\r\n
Sorry, the links below do not work properly.
\r\n
Use the
search feature on the State\’s Website
\r\n
INS – 10113.6. – ARTICLE 1. General Provisions [10110. – 10127.19.]…(a)An insurer that is required to deliver a life insurance policy to the owner of the policy in order to start the period running during which the owner may exercise any statutory
right
to
return

\r\n
\r\n
\r\n
\r\n
INS – 10164.2. – ARTICLE 3a. Standard Nonforfeiture Law for Life Insurance [10159.1. – 10167.5.]… shall be construed to limit an existing statutory
right
to
return
a policy for surrender, nor shall…
\r\n
\r\n
\r\n
\r\n
INS – 10192.17. – ARTICLE 6. Medicare Supplement Policies [10192.1. – 10192.24.]… insurance company.” (E)THIRTY-DAY
RIGHT
TO
RETURN
THIS POLICY. The text shall… type, stating in substance that the policyholder or certificate holder shall have the
right

\r\n
\r\n
\r\n
\r\n
INS – 10232.7. – ARTICLE 3. General Provisions [10232. – 10233.9.]… in subdivisions (a) and (b) of Section 10231.6, shall have the
right
to
return
the policy…
\r\n
\r\n
\r\n
\r\n
INS – 10233.5. – ARTICLE 3. General Provisions [10232. – 10233.9.]… (a)Provide a brief description of the
right
to
return
—“free look” provision of the policy. (b…
\r\n
\r\n
\r\n
\r\n
INS – 10295.8. – ARTICLE 2.1. Accelerated Death Benefits [10295. – 10295.19.]…(a)An applicant for an accelerated death benefit shall have the
right
to
return
the accelerated death benefit policy or certificate by first-class United States mail within 30 days of its delivery…
\r\n
\r\n
\r\n
\r\n
INS – 786. – ARTICLE 6.3. Senior Insurance [785. – 789.10.]… the
right
to
return
the policy or certificate within 30 days after its receipt via regular mail…
\r\n
\r\n
\r\n

\r\nSee Obama Care on

Mandatory Summary of Benefits

\r\n\r\n \r\n\r\n ‘,’30 Day Free Look – Right to view EOC’,”,’publish’,’open’,’closed’,”,’30-day-free-look-right-view-eoc’,”,”,’2017-01-25 18:54:45′,’2017-01-25 18:54:45′,”,151,’http://healthlaw.healthreformquotes.com/?page_id=152′,0,’page’,”,0),(153,1,’2016-05-10 08:09:05′,’2016-05-10 08:09:05′,’

\r\n\r\n\r\n\r\n

\r\n

How does Health Reform affect\r\nIndividuals & Families?

\r\n

Summary AHIP
Millman
Comprehensive Analysis
27 Pages of
Health Reform Factors
that will affect
premiums
in 2014
pdf with our comments

\r\nParody of

Affordable Health Care Act compared to the Plumbing Act

\r\n

Blue Cross
Guide
Individuals & Families Health Care Reform
Rev 12/2011

\r\n

\r\n

Consumer Resources & Links

\r\n

Main Health Reform Page

\r\n

\r\nSmall Employer
Timeline
including  hyperlinks to MORE detail

\r\n

No Rescission\’s
Blue Cross FAQ\’s

\r\n

Dependents to Age 26

\r\n\r\n

AB 1461

(Insurance Code 10965.3) Open and

Special Enrollment Periods

Rates only by Age & Zip Code\r\n\r\n

Aetna\’s Website on Health Reform

Uniform Summary of Benefits

starting 9/23/2012

Preventative Services

\r\n\r\n

Health Net

\r\n\r\nHealth Net

Pamphlet

22 Pages\r\n

\r\n

PPACA More Info

\r\n

Dependent Definitions

\r\n

Medical Loss Ratio (MLR)

\r\n

Exchanges

\r\n

Grandfathering

\r\n

Constitutionality
Health Reform upheld as a tax, rather than a penalty

\r\n\r\n

\r\n
\r\n
Health Care Reform Repeal?
\r\n
\r\n

\r\n

EmployER Mandate over 50 lives

\r\n\r\n

ObamaCare Suvival Guide Review – Washington Post

\r\n

Free Instant Subsidy, Premium and Benefits Calculator

\r\n

PPACA Resources

\r\n

Summary of Benefits
– Mandated uniform so that it\’s easier to compare plans

\r\n

Preventative Services
– Free – no co-pays

\r\n

Essential Benefits
all Insurance plans must include these 10 benefits

\r\n

Annual & Lifetime Limits are no longer allowed

\r\n

Individual Mandate

\r\n

Technical & Research Resources

\r\n

ABX1-2 Pan 2013
brings CA Law into compliance with Federal Affordable Care Act

\r\n\r\n

\r\n
Non-Grandfathered Members
\r\n
\r\n
Members will receive new certificates and new ID cards in the mail beginning mid December.
\r\n
MembersreceivethefollowingPPACA provisions:\r\n
\r\n
Expanded Dependent Coverage
\r\n
No Annual Dollar or Lifetime Limits
\r\n
Expanded Preventive Care
\r\n
No Pre-existing Condition Waiting Period for Children under 19
\r\n
New Patient Protections
\r\n
New Limitations on Rescission
\r\n
\r\n
\r\n
\r\n
\r\n
Grandfathered Members
\r\n
\r\n
Members will  receive new amendments in the future, but will not receive new ID cards.
\r\n
MembersreceivethefollowingfourPPACA provisions:\r\n
\r\n
Expanded Dependent Coverage
\r\n
No Lifetime Limits
\r\n
New Patient Protections
\r\n
New Limitations on Rescission (BC
12/17/2010
Bulletin)   More on
Grand Fathering

Grand Mothering
\r\n
\r\n
\r\n
\r\n
\r\n

\r\n

Related Pages – FAQ\’s

\r\n\r\n\r\n

\r\n\r\n \r\n

\r\n

Historical

\r\n

CIGNA and probably the other Companies will follow suit by keeping current plans IN FORCE, so that current clients do NOT have to change anything in 2014
CIGNA 5.9.2013 Bulletin
, as the policies won\’t be renewing
1399.855
till 12.31.2013.  The only advantage we see at this time would be if qualify for
Tax Credits
or have a
HIPAA
or surcharged or limited policy, due to Pre Existing Conditions.

\r\n

Health Net Brochure, Introduction and Explanation Rev 9.2013
healthnet.com

\r\n

‘,’Background of PPACA’,”,’publish’,’closed’,’closed’,”,’health-reform-background’,”,”,’2017-12-18 17:05:29′,’2017-12-18 17:05:29′,”,31,’http://healthlaw.healthreformquotes.com/?page_id=153′,0,’page’,”,0),(154,1,’2016-05-10 08:10:12′,’2016-05-10 08:10:12′,’

What if my Covered CA bill has my spouses name, but it\’s ONLY me that\’s covered?

\r\n

On  Exchange records displays the name of the Responsible Party instead of the main applicant. The Responsible Party is the person who set up the Covered CA   application and indicated that they are responsible for the payment and   oversight of the account. Before   the binder payment is processed, the Responsible Party name will show up on   the Individual List Bill (ILB), but the SSN and DOB will show as the main applicant.   The main applicant is different from the Responsible Party. This will   typically happen when the Responsible Party applies for a dependent or a   spouse through On Exchange Covered California plans. All   correspondence sent out will be addressed to the Responsible Party, including   the initial binder payment letter. Once   the binder payment is processed, the main applicant and additional dependents   will be visible.
Blue Shield Email Dated 1.13.2013

‘,’Bill in wrong name?’,”,’publish’,’closed’,’closed’,”,’bill-wrong-name’,”,”,’2017-01-05 19:08:31′,’2017-01-05 19:08:31′,”,0,’http://healthlaw.healthreformquotes.com/?page_id=154′,0,’page’,”,0),(155,1,’2016-05-10 08:10:44′,’2016-05-10 08:10:44′,’

ERISA–
E
mployee
R
etirement
I
ncome
S
ecurity
A
ct —
1974

\r\n

\r\n
sets minimum standards for most voluntarily established
pension
and
health plans
(self insured) in private industry to provide protection for employees and their dependents.

\r\n

ERISA requires plans to provide participants with
plan information
including important information about plan features and funding; provides
fiduciary responsibilities
for those who manage and control plan assets; requires plans to establish a
grievance and appeals process
for participants to get benefits from their plans; and gives participants the right to sue for benefits and breaches of fiduciary duty.

\r\n

In general,
ERISA does not cover
group health plans
established or maintained by
governmental entities
, churches for their employees, or plans which are maintained solely to comply with applicable
workers compensation
, unemployment, or
disability
laws. ERISA also does not cover plans maintained outside the United States primarily for the benefit of nonresident aliens or unfunded excess benefit plans.
(
Department of Labor\’s Web Site
)  *  poynerspruill.com

\r\n

ERISA Enhancements

\r\n\r\n

\r\n
\r\n
COBRA
(Consolidated Omnibus Budget Reconciliation Act)
provides some workers and their families with the right to continue their health coverage, in general for 18 months after losing their job.  See also
Cal COBRA
, which provides a total of 36 months for CA Residents.\r\n
\r\n
\r\n
\r\n
HIPAA
(Health Insurance Portability and Accountability Act)
provides important protections for working Americans and their families who have preexisting medical conditions or might otherwise suffer discrimination in health coverage based on factors that relate to an individual\’s health.
\r\n
\r\n
\r\n
Newborns\’ and Mothers\’ Health Protection Act
\r\n
\r\n
\r\n
Mental Health Parity Act,
\r\n
\r\n
\r\n
Women\’s Health and Cancer Rights Act 1988.
\r\n
\r\n

\r\n

Consumer Resources

\r\n

DOL Overview Page

\r\n\r\n

dol.gov/EBSA/

\r\n

CNA
Third Party ERISA
coverage reimburses covered plans for loss due to fraud by a trustee, officer, employee, administrator or a manager
including
administrators or managers who are independent contractors

\r\n

wikipedia.org

\r\n

Technical & Research Resources

\r\n

Definitions

(DOL)\r\n

USC
(United States Code)
Chapter 18 ERISA

\r\n\r\n

\r\n
\r\n
§ 1001. Congressional findings and declaration of policy
\r\n
§ 1001a. Additional Congressional findings and declaration of policy
\r\n
§ 1001b. Findings and declaration of policy
\r\n
§ 1002. Definitions
\r\n
§ 1003. Coverage\r\n…any employee benefit plan …except …
governmental plan
or … church plan
\r\n
\r\n

\r\n

\r\n
\r\n
part 1
—reporting and disclosure (§§ 1021—1031)
\r\n
§ 1022.
Summary plan descriptio
n
\r\nWorkers\’ Right to Health Plan Information
\r\n
part 2
—participation and vesting (§§ 1051—1061)
\r\n
part 3
—funding (§§ 1081—1085a,_1085b,_1086)
\r\n
part 4
—fiduciary responsibility (§§ 1101—1114)
\r\n
part 5
—administration and enforcement (§§ 1131—1148)
\r\n
part 6
—continuation coverage and additional standards for group health plans (§§ 1161—1169)
\r\n
part 7

group health plan requirements
(§§ 1181—1191c)\r\n
\r\n
\r\n
\r\n
\r\n
§ 1181. Increased portability through limitation on
preexisting condition
exclusions
\r\n
§ 1182. Prohibiting discrimination against individual participants and beneficiaries based on
health status
\r\n
§ 1183. Guaranteed renewability in multiemployer plans and multiple employer welfare arrangements
\r\n
§ 1185. Standards relating to benefits for
mothers and newborns
\r\n
§ 1185a. Parity in
mental health
and substance use disorder benefits
\r\n
§ 1185b. Required coverage for reconstructive surgery following mastectomies
\r\n
§ 1185c. Coverage of
dependent students
on medically necessary leave of absence\r\n§ 1191. Preemption; State flexibility; construction\r\n§ 1191a. Special rules relating to
group health plans
\r\n§ 1191b. Definitions\r\n§ 1191c. Regulations\r\n
\r\n
\r\n
\r\n
Cross Reference USC vs. ERISA
\r\n
\r\n\r\n \r\n\r\n

\r\n

Code of Federal Regulations

\r\n \r\n

ERISA Enforcement
, Civil & Criminal  DOL Site

\r\n

TITLE 29 – LABOR
(Findlaw)\r\n
CHAPTER 18 – EMPLOYEE RETIREMENT INCOME SECURITY PROGRAM

\r\n

Sec. 1182
ERISA . – a
group health plan
, and a health insurance issuer offering group health insurance coverage in  connection with a group
health plan, may not establish rules for eligibility (including continued eligibility) of any individual to enroll under the terms of the plan based on any of the
following health status-related factors

\r\n

Sec. 1182
(b)
(1)
In general
A group health plan, and a health insurance issuer offering health insurance coverage in connection with a group health plan, may not require any individual (as a condition of enrollment or continued enrollment under the plan) to pay a premium or contribution which is greater than such premium or contribution for a
similarly situated individuals see also
AB 1672

\r\n

\r\n
‘,’ERISA Employee Retirement Income Security Act — 1974′,”,’publish’,’open’,’closed’,”,’erisa’,”,”,’2018-07-27 18:16:05′,’2018-07-27 18:16:05′,”,0,’http://healthlaw.healthreformquotes.com/?page_id=155′,0,’page’,”,2),(156,1,’2016-05-10 08:11:34′,’2016-05-10 08:11:34′,’

\r\n
\r\n
\r\n
\r\n
FAQ\’s from
Free Advise.com
on Health Insurance Law
\r\n
\r\n
\r\n
\r\n
\r\n
Please note that the answers are VERY GENERAL in nature and
IMHO
they don\’t necessarily reflect California Law.\r\n
\r\n\r\n
\r\n\r\n
\r\n\r\n
\r\n\r\n
\r\n\r\n
HOW DO I DETERMINE WHAT MY HEALTH CARE COVERAGE OR BENEFITS ARE?
SUPPOSE THE CONTRACT OR BOOKLET IS AMBIGUOUS OR UNCLEAR?
WHAT ARE \”DEFINITIONS,\” \”BENEFITS,\” \”LIMITATIONS,\” AND \”EXCLUSIONS?\”
WILL ONE OF THESE MANY AGENCIES BE ABLE TO HELP ME?
IS A BUSINESS REQUIRED TO PROVIDE HEALTH INSURANCE TO EMPLOYEES?
HOW DO I OBTAIN HEALTH INSURANCE?
\r\n\r\n
Call Steve Shorr  310.519.1335 or
click here to get rates & benefits
\r\n\r\n
\r\n\r\n
\r\n\r\n
\r\n\r\nSee also –
Wrong or Incomplete Info.
\r\n\r\n
\r\n\r\n
\r\n\r\n
\r\n\r\n
\r\n\r\n
\r\n\r\nSee also –
Wrong or Incomplete Info.
\r\n\r\n
\r\n\r\n
\r\n\r\n
\r\n\r\n
\r\n\r\n
\r\n\r\n
\r\n\r\n
\r\n\r\n
\r\n\r\n
CAN A HEALTH INSURANCE COMPANY OR HEALTH SERVICE PLAN CANCEL MY POLICY FOR MEMBERSHIP FOR ANY REASON?
CAN I CANCEL MY HEALTH INSURANCE, AND WILL THERE BE A PENALTY OR ADVERSE CONSEQUENCE?
IF I CANCEL DO I GET MY UNUSED PREMIUM BACK?
ARE THERE DANGERS IN CANCELLING HEALTH INSURANCE?
I CURRENTLY AM ON WORKER\’S COMPENSATION. CAN MY EMPLOYER MAKE ME PAY FOR MY OWN HEALTH INSURANCE WHILE I\’M OFF?
WHAT ARE TYPICAL PROBLEMS THAT ARISE IN GETTING HEALTH CARE BENEFITS PROVIDED OR PAID?
I CURRENTLY AM ON WORKER\’S COMPENSATION. CAN MY EMPLOYER MAKE ME PAY FOR MY OWN HEALTH INSURANCE WHILE I\’M OFF?
WHAT IS PRIVATE INDEMNITY INSURANCE?
HOW LONG WILL MY MEDICAL INSURANCE ALLOW MY NEW BABY AND MYSELF REMAIN IN THE HOSPITAL FOLLOWING CHILDBIRTH?
MY FATHER WHO HAS CONGESTIVE HEART FAILURE AND TYPE 2 DIABETES RECENTLY UNDERWENT A QUINTUPLE HEART BYPASS. HIS MEDICAL BILLS ARE STAGGERING AND HE HAS NO HEALTH INSURANCE. SHORT OF FILING BANKRUPTCY, WHAT ARE HIS OPTIONS IN GETTING THESE AMOUNTS REDUCED?
\r\n\r\n
You might try
Medi-Cal
\r\n\r\n
See
Cobra
Get quotes
WHAT CAN, OR MUST, I DO WHEN A HEALTH INSURANCE COMPANY OR PLAN REFUSES TO PAY A CLAIM OR PROVIDE A BENEFIT OR SERVICE?
WHAT IS THE APPEALS AND GRIEVANCE PROCESS LIKE?
\r\n\r\n
See also Cal Broker Magazine
12/04 Article
WHAT IF THE INSURED LIED ABOUT A HEART ATTACK?
\r\n
\r\n\r\n
WHAT IS PRIVATE INDEMNITY INSURANCE?
I CURRENTLY AM ON WORKER\’S COMPENSATION. CAN MY EMPLOYER MAKE ME PAY FOR MY OWN HEALTH INSURANCE WHILE I\’M OFF?
ARE THERE ANY GOVERNMENT AGENCIES THAT REGULATE HOW HEALTH INSURANCE COMPANIES OR PLANS OPERATE?
\r\n\r\n
Government sponsored plans
\r\n\r\n
\r\n\r\n
HMOs
\r\n\r\n
\r\n\r\n
Premiums
\r\n\r\n
\r\n\r\n
\r\n\r\n
Private indemnity policies
\r\n\r\n
\r\n\r\n
\r\n\r\n
Purpose
\r\n\r\n
\r\n\r\n
For Group Plans 20% variance see CIC
10700
HOW DO I OBTAIN HEALTH INSURANCE?
\r\n\r\n
Call Steve Shorr  310.519.1335 or
email him
HOW DO I OBTAIN HEALTH INSURANCE?
\r\n\r\n
See our page on
Medi Gap Policies
\r\n91 Charged in Federal Health Care Fraud Sting
Kaiser News
\r\n\r\nIndividual Plans – Health Care Reform – Abuse of Special Enrollment Period – B
log Insure Me Kevin.co
m\r\n
File a complaint
CA Dept of Insurance
Enforcement Branch Overview
\r\nInsurance Journal
Fraud Search
\r\n\r\nBlue Shield –
Fraud
Unit
(800) 221-2367
\r\n\r\n
Report Fraud Waste or Abuse to Blue Cross
\r\n\r\nwww.nicb.org/\r\n
Consumer Resources
\r\n\r\n
\r\n
\r\n
\r\n

\r\n\r\n
Abuse\r\n\r\n
More Resources

\r\n

\r\n\r\n
Resources

\r\n
\r\n
\r\n
\r\n
How to Avoid Becoming a Victim of Insurance Fraud
\r\nAn illustrated brochure describing the warning signs of insurance fraud and some concrete steps you can take to avoid becoming a victim. This brochure contains information helpful to all consumers. It details several types of insurance fraud, such as fake policies, premium fraud, unlicensed agents, unnecessary services, and insurance scams. It also describes how to get your money back and where to complain about insurance fraud.
\r\n

N

ational

H

ealth

C

are

A

nti-Fraud

A

ssociation
is the leading national organization focused exclusively on the fight against health care fraud. We are a private-public partnership — our members comprise more than 100 private health insurers and those public-sector law enforcement and regulatory agencies having jurisdiction over health care fraud committed against both private payers and public programs. Established in 2000,
\r\n
The NHCAA Institute for Health Care Fraud Prevention
is a separately incorporated, tax-exempt educational foundation that provides education and training to private- and public-sector health care anti-fraud personnel.
\r\n
Preventing Credit Card Fraud: Learn How to Protect Yourself
\r\nA brochure, available in English and Spanish that describes how crooks steal and use credit cards and card numbers and explains how to protect your credit card and what to do if your card has been stolen.\r\nBy Consumer Action.
\r\n
California Court Website on Fraud & Cyber Crime
\r\n
Report

Worker\’s Compensation
Fraud\r\n\r\n \r\n
\r\n
THE INSURANCE

FRAUDS PREVENTION ACT
\r\n
\r\n
False and Fraudulent Claims
1871-1871.8
\r\nBureau of Fraudulent Claims
1872-1872.96
\r\nInsurance Fraud Reporting
1873-1873.4
\r\nMotor Vehicle Theft and Motor Vehicle Insurance\r\nFraud Reporting
1874-1874.81
\r\nInsurer Inspections
1874.85-1874.87
\r\nAuto Insurance Fraud Crisis Areas
1874.90-1874.91
\r\nArson Investigations .
1875-1875.8
\r\nInsurance Claims Analysis Bureaus
1875.10-1875.18
\r\nInsurer Fraud Investigation
1875.20-1875.23
\r\nDeposit of Automobile Insurance Claims                   Information .
1876-1876.5
\r\nWorkers\’ Compensation Insurance Fraud Reporting
1877-1877.5
\r\nInsurance Fraud Prevention  §1879-1879.8
\r\nUSC 1347 Federal Law on  Health Care Fraud\r\n\r\nMedicare – Part D Fraud – Final Rules – Federal Register\r\n
More FAQ\’s & Related Pages
\r\n
Hospital Billing Inconsistencies
\r\n

Combating Fraud to keep rates low   InsureMeKevin.com
\r\n
Our Webpage on
Medicare Fraud, Waste & Abuse
\r\n
\r\n
‘,’Fraud, Waste, Abuse & Scams’,”,’publish’,’open’,’closed’,”,’fraud’,”,”,’2018-06-02 14:31:51′,’2018-06-02 14:31:51′,”,0,’http://healthlaw.healthreformquotes.com/?page_id=157′,0,’page’,”,1),(158,1,’2016-05-10 08:12:27′,’2016-05-10 08:12:27′,’
\r\n

Grandfathering Exemption

\r\n
Grandfathering means
that if your coverage was in place on 9.23.2010, when the
Affordable Care Act
was enacted, President Obama promised that you could keep it, as long as there were
no \”major\” changes
to your coverage.
\r\n
8 questions to determine Grandfathered status
Health Net Flyer if health plans significantly raise co-payments or deductibles, or if they significantly reduce benefits – for example, if they stop covering treatment for a disease like HIV/AIDS or cystic fibrosis – they’ll lose their grandfathered status and their customers will get the same full set of consumer protections as new plans.
(healthreform.gov)
\r\n
View this  chart
for the
differences
in the Mandates for NEW plans and for the Older Grandfathered Plans.
\r\n
GET Quotes on NEW ACA Plans
\r\n
Individual CA

Nationwide

Small Employer CA
\r\n
Advantage of a Grandfathered Plan\r\n
SB 1446 Grandmothering
for Group Plans
\r\n
The primary one  is that in 2014 the rating for the nongrandfathered plans will be subject to

additional taxes and fees
.

These could total upwards of 50% higher than a comparable grandfathered plans. Since the rates will be so much higher than the grandfathered plans we feel it would be a good idea to keep those plans until at least we see how the rates look like in 2014.
Excerpt of Email Rec\’d 1.25.2013 from a Major Insurance Company
\r\n
However, the
Government says NO
in Q & A on their website at
healthreform.gov
\r\n\r\n
\r\n
\r\n

Individual Grandfathered plans are \”closed\” plans, no longer sold to new applicants. It is possible that premiums or costs may increase because new, healthy applicants are no longer being added to the closed \”pool\” of members. Premium changes for all plans, whether \”closed\” or open to new sales, are driven by several factors. These include increased consumer demand for services, rising prescription drug costs, advances in medical technology, and benefits and/or taxes required by state and federal legislation.

Blue

Cross Flyer

\r\n
\r\n
make some changes to the benefits their plans offer,
\r\n
raise premiums or change employee cost-sharing to keep pace with health costs within some limits, and
\r\n
continue to enroll new employees and their families.
\r\n
\r\n
The bottom line is that under the Affordable Care Act, if you like your doctor and plan, you can keep them, subject to \”
Narrow Lists
.\”    But if you aren’t satisfied with your insurance options today, the Affordable Care Act provides for better, more affordable health care choices through new consumer protections.
(

healthreform.gov)

\r\n
Wikipedia on Health Reform & Grandfathering
\r\n
No more RAF – Rating Adjustment Factor  §10753.14 in
Employer Group Plans
\r\n
Insurance Companies NOT offering Plans?\r\nThus the End of Grand Fathering?
\r\n
It looks like Grandfathering is OVER for Individual Plans in 2015.
Blue Cross
is
dropping 79 plans
.
California Health Line 10.3.2014
reports
Blue Cross
,
Kaiser
and various other insurers are not renewing pre ACA plans, that don\’t have the
10 essential benefits
and other provisions of ACA.
Reasoning – Washington Post?
\r\n\r\n
\r\n
\r\n
\r\n

\r\n\r\nUHC Grandfathering Video\r\n
Decision Flow Charge
\r\n\r\n\r\n
Eight Questions to determine Grandfathered Statu
s\r\n\r\n

\r\n

\r\n\r\n
Grandfathered vs New ObamaCare Differences Chart\r\n\r\n All White House You Tube Video\’s on ObamaCare

\r\n
\r\n
\r\n
\r\n
FAQ\’s
\r\n\r\n
\r\n
Which will be

less expensive

Grandfathered or Not?
\r\n
Is there any difference in

Premium Taxes or other fees or taxes

imposed by Health Care Reform?
\r\n

Blue Shield Info and Tools on Grandfathering

\r\n
\r\n

General Client  Resources & Links
\r\n
grand fathered-plans (health care.gov)
\r\n\r\n
Blue Cross Health Reform Website
\r\n\r\n5.2013 Anthem Blue Cross
Press Release 6/25/2010
\r\n\r\n
List
of Grandfathered Plans\r\n\r\nM
akingHealthCareReformWork.com
\r\n
Keeping the Health Plan you have – Grandfathered… Rules HealthReform.Gov
\r\n
Research & Technical Links
\r\n\r\n
\r\n

Fact Sheet on Regulation

Health Care Reform Provisions Summary Chart

Model Notice

for Grand Fathered Plans
Talk about allowing non-grand fathered plans to go three more years?  california health line.org/2014/3/5/  but this didn\’t happen in CA due to Covered CA contract regulations
Page 14 Section e
Group Health Plans CAN change Insurer\’s without affecting Grand Father Status. (
HHS.gov Amendment
)
\r\n
\r\n

\r\n
Child & Related Pages
\r\n\r\n
Blue Shield
\r\n\r\n
\r\n
Grand Fathered Plan – Non Renewal
\r\n
\r\n
Blue Shield Grandfathering WebPage   FAQ
4.1.2015 one time 25% credit on monthly bill
\r\n
Blue Cross
\r\n\r\n
\r\n
Grandfathered Plans – Non Renewal 2.2018
\r\n
Which plans are grandfathered?
\r\n
\r\n

Grand Fathered 4.2017 Rate Change
\r\n
\r\n
Grandfathered April 2016 Rate Increase
\r\n
\r\n
Grandfathered Plan vs 2017 Offerings?
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\r\n

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‘,’Grand Fathered Plans’,”,’publish’,’open’,’closed’,”,’grand-fathered-plans’,”,”,’2018-07-20 17:18:20′,’2018-07-20 17:18:20′,”,151,’http://healthlaw.healthreformquotes.com/?page_id=158′,0,’page’,”,0),(159,1,’2016-05-10 08:13:01′,’2016-05-10 08:13:01′,’

Historical Info

\r\n
Grandfathered Plans
\r\n
View Main
Grand Fathered
Information
\r\n
You could get HIPAA, if the prior plan is Grandfathered….
leginfo.legislature.ca.gov/
\r\n\r\n
11.14.2013 Video
–  President Obama announces that Insurance Companies can keep you enrolled for an additional year.  Are we in 1984?  Why is the above video now PRIVATE?   Here\’s information from the online print press.
\r\n\r\n

\r\n\r\n
Covered CA won\’t do it, but extends dealine to 12.23.2013
. It\’s up toCoveredCAtodeceide for CA  Modern Health Care 11.21.2013
\r\n
Latest Major Action:
11/15/2013 House floor actions. Status: Mr. Andrews moved to recommit with instructions to Energy and Commerce.
\r\n
Latest Action:
11/15/2013 DEBATE – The House proceeded with 10 minutes of debate on the Andrews motion to recommit with instructions, pending the reservation of a point of order. The instructions contained in the motion seek to require the bill to be reported back to the House with an amendment to give insurance companies the option to continue offering non-Affordable Care Act compliant plans through 2014 to current enrollees only, as long as those plans were in effect as of October 1, 2013. The motion also requires insurance companies to notify consumers of the differences between these extended plans and the options, credits, and subsidies available through the Affordable Care Acts exchanges, as well as instructions on how to receive them. Thomas.Gov Legislative Digest
Congress.Gov
\r\n
Covered CA Contract – Requires Cancellation Page 14 Section e
\r\n
NPR written updates – transcript
\r\n
Keep your Health Plan Act HR 3350 Fred Upton (Wikipedia)
Thomas.Gov
GovTrack.US
MSNBC
\r\n
Why is your policy being cancelled and you must roll over to an ACA compliant plan?
\r\n
Did President Obama have his
fingers crossed behind his back
, holding these rules when he said, If you like your plan you can keep it?
\r\n \r\n
How would I know if my plan is grandfathered?
\r\n
The simple answer is has it been in force since March 2010
without
any significant changes
which can be verified by  ask the insurance agent of your employer or  their HR department
\r\n\r\n

‘,’Historical’,”,’publish’,’closed’,’closed’,”,’historical’,”,”,’2018-10-06 18:46:10′,’2018-10-06 18:46:10′,”,158,’http://healthlaw.healthreformquotes.com/?page_id=159′,0,’page’,”,0),(160,1,’2016-05-10 08:13:35′,’2016-05-10 08:13:35′,’
Rhonda Royalty says:\r\nFebruary 17, 2014 at 11:20 AM (Edit)
\r\n
This process of applying for this supposedly money saving health care reform is utterly a complete nightmare. Insurance companies have let go of health plans that used to be offered that were nothing to brag about but yet would keep the average hard working American from filing bankruptcy because of medical debts.
\r\n
I was on a plan that seemed a bit high for what I was actually getting from it. I was paying $464.00 in monthly premiums with a $14,000 total out of pocket ( which is easier to foresee paying off in payments than hundreds of thousands of dollars), if something major might have happened to cover myself, my son and two daughters; this plan was no longer offered when Obama care/ Covered Ca. took effect.
\r\n
Now this process of trying to get Health Insurance coverage has been stressful and frustrating and an utterly disappointing process that has gone on since December 2013. Talking with different representatives that have no idea what is going on, so they think they are trying to help and change things on your application. Now my application has been through the ringer numerous of times and still no affordable rates for the amount of my income. You are not assigned one person to handle your case so it turns into one hand does not know what the other hand is doing. From the start of applying Dec. 2013 there has been obstacles thrown at us from left to right, first application we used our taxes from 2012, they had to verify it no problem, than verify kids birthdays, citizenships, residency, and etc… This seemed to be a lengthy process and we ended up going to an Insurance agent that was trained to handle Covered CA. / Obama Care for help in Jan. 2014 submitted everything by the Jan 15th deadline so we could get insurance by Feb. 1, 2014. Had a plan chosen still no replies? I made numerous calls to Covered Ca. and the Insurance Company that I chose Blue Shield Silver 87 PPO, supposedly Covered Ca. did not send the papers for approval over to them; called Covered Ca. they said that they did. Then all of a sudden now they cannot use my taxes, so I gave them my husband’s 2013 W-2 amounts Gross income they adjusted everything and again still no communication from the insurance company. So I called again now they cannot use the W- 2’s from 2013, they needed an estimated amount of what we think we might be making for 2014 income. We submitted what we calculated with one of the representatives she was having a hard time with making adjustments to the application and said she would have to call me back later. When I received the call back it was that they could not use those number amounts and was figuring our income on one pay stub for a monthly income and calculated it for the year of 2014. My husband’s paychecks fluctuate and as of the end of May 2014 he will be fully retired.
\r\n
A $601.00 monthly insurance payment, plus $40.00 per visit for a general doctor, $65 for a specialist, this policy will only cover three of us because my husband is on Medicare and my other daughter is only seventeen, so they said everyone under eighteen enrolls in Medi-Cal. Now if I due a Bronze plan it will cost $462 plus a month but co-pays to the doctors are outrageous and before you can get any medications that would be $19.00 dollars one person would have to pay $5,000 towards the deductible or if there is more than one it is $10,000.
\r\n
This whole Covered Ca. Obama Care backed program is totally out of control and hurts the average hard working American. Have you really looked at what these insurance companies are really offering people? We are receiving a lot less than what was offered before. This is supposed to be better than what we had before, no way is this benefiting the average hard working American. We will have to put more money up front before we get any justifiable medical help. Insurance Companies have found even a better opportunity to take advantage of ripping off the American people. Maybe before you ever had an idea of putting this health care reform in action you really should have looked at the big picture of who is this going to affect. Our Government legislation from the President, to Senator’s, House of Representatives, and Governors of our States and etc…, are all sitting in their luxurious comforts with the best Insurance policies that the people of the United States are funding through all of our taxes we pay. . Remember people of the United States voted for everyone in these offices, it is our money that pays for the legislator’s paychecks, insurance, and etc… So they approve a health care reform that they will not even accept to sign up for. This is a health reform that is not a benefit to all people because still it gears towards helping low income, and illegals. Everyone else that works hard for their money will still be paying for everyone that is in lower income brackets. Truth is what happens if a lower income person gets hurt or someone that does not have citizenship they will automatically get the heath bills paid for? The working consumer may receive health care but will be paying the health debt off for many years. This is not to say we want free health care, but we need something we can afford with the benefits that are affordable. What happened to our Constitutional Rights, we now are told you will be on a health plan or you will be fined. The Subsidies they say are federal subsidies the consumer’s tax dollars pay for all of this. Maybe the government should realize what is good for one is good for all; they need to be on this Obama Care too.
‘,’Horror Stories’,”,’publish’,’closed’,’closed’,”,’horror-stories’,”,”,’2017-01-05 19:08:32′,’2017-01-05 19:08:32′,”,151,’http://healthlaw.healthreformquotes.com/?page_id=160′,0,’page’,”,0),(161,1,’2016-05-10 08:14:05′,’2016-05-10 08:14:05′,’
Problems in Bankruptcy caused by high medical bills
\r\n
With
Health Reform
,
mandates, tax penalties
and
Subsidies, tax credits
– This shouldn\’t happen anymore!\r\nPlease note that a lot of the information is Pre-Health Care Reform
\r\n\r\n
Here are 10 statistics and findings on medical debt.
\r\n1. One in five working-age Americans with insurance
encountered
problems paying medical bills in the past year, which often led to serious financial challenges and changes in employment and lifestyle, according to a comprehensive Kaiser Family Foundation/
New York Times

survey
. Among the uninsured, 53 percent reported problems paying medical bills.\r\n\r\n2. Among those facing problems paying medical bills, almost identical shares of the insured (44 percent) and uninsured (45 percent) said the bills had a major impact on their families.\r\n\r\n3. Of insured individuals who reported problems paying medical bills, 26 percent received unexpected claim denials; and 32 percent received care from an out-of-network provider their insurance wouldn\’t cover.\r\n\r\n4. Among those with private insurance, those enrolled in higher deductible plans were more likely to report medical bill problems than those in plans with lower deductibles (26 percent compared to 15 percent).\r\n\r\n5. Among the insured and uninsured with medical bill problems, 31 percent said the total amount of the bills they had problems paying reached at least $5,000, including 13 percent who say the total hit at least $10,000. One in four (24 percent) said their bills totaled less than $1,000.\r\n\r\n6. Thirty-one percent of insured Americans took money out of retirement, college or other long-term savings accounts to pay medical bills in the past year; 17 percent of uninsured reported the same. An additional 17 percent of insured and 11 percent of uninsured patients took out another type of loan to pay medical bills.\r\n\r\n7. Although more than 90 percent of patients reported satisfaction with their primary care physician across several categories in a
survey
commissioned by the Physicians Foundation, many communicated concern regarding healthcare costs and medical debt.\r\n\r\n8. According to the survey, 62 percent of participants reported concern regarding their ability to pay for medical care if they were to fall ill or become injured. More than a quarter — 28 percent — reported skipping a medical test, missing a follow-up appointment or not seeking treatment for a medical problem in the last year due to insecurities regarding the cost of care.\r\n\r\n9. Medical debt is
sold
very cheap because it is difficult to collect on. Craig Antico, co-founder of RIP Medical Debt, a nonprofit based in Rye, N.Y., told
STAT
a dollar of debt can be bought for less than a cent. \”It only takes $14.45 million to abolish $1 billion in debt,\” he said.\r\n\r\n10. Men and women in the armed forces are nearly twice as likely to
file
complaints about debt collection than the general population, according to a
report
from the Consumer Financial Protection Bureau. Of the roughly 19,200 complaints from servicemembers the CFPB received last year, about 8,900 were related to debt collection. In 2015, medical debt concerns comprised 13 percent of servicemember debt collection complaints, with a majority of the medical debt complaints coming from the veteran population.
https://www.beckershospitalreview.com/finance/10-statistics-and-findings-on-medical-debt.html
*\r\n
The percentage of U.S. residents who have difficulty paying medical bills declined from about
22%
in September 2013, before the
Affordable Care Act
fully took effect, to about
17%
in March 2015
\r\n
In 2001, 1.458 million American families filed for
bankruptcy.
About half of debtors cited medical causes
,… Among individuals whose illness led to bankruptcy, out-of-pocket costs averaged $11,854 since the start of illness; 75.7% had insurance at the onset of illness. Medical debtors were 42% more likely than other debtors to experience
lapses
in medical coverage. Even middle class, insured families often fall prey to financial catastrophe when sick.
\r\n
The average debtor was a 41 year old woman with children, and at least some college education. Most debtors owned homes; their occupational prestige scores place them predominantly in the middle or working classes.
\r\n
Medical debt was also associated with mortgage problems.
\r\n
\r\n
Medical Debt Survivor Guide
\r\n
Nolo – Bankruptcy
\r\n
2007 Six Page Study
American Journal of Medicine
\r\n
Medical debtors reported particular problems paying mortgages/rent and utilities (Exhibit 4). Although our interviews occurred soon after the bankruptcy filings (7 months, on average) many debtors had already been turned down for jobs (3.1% of debtors), mortgages (5.8%), apartment rentals (4.9%) or car loans (9.3%) because of the bankruptcy on their credit reports.
\r\n
Illness begot financial problems both directly – due to medical costs – and through lost income. 59.9% of families bankrupted by medical problems indicated that medical bills (i.e. from medical providers) contributed to bankruptcy; 47.6% cited drug costs; 35.3% had curtailed employment due to illness – often (52.8%) to care for someone else. Many families had problems with both medical bills and income loss. Click on link for
Disability
and
Supplemental plans
Families bankrupted by medical problems cited varied, and sometimes multiple, diagnoses. Cardiovascular disorders were reported by 26.6%; trauma/orthopedic/back problems by nearly one-third; and cancer, diabetes, pulmonary or mental disorders, and childbirth-related and congenital disorders by about 10% each. 51.7% of the medical problems involved ongoing chronic illnesses.
\r\n
The co-occurrence of medical and job problems was a common theme. For instance one debtor underwent lung surgery and suffered a heart attack. Both hospitalizations were covered by his
employer-paid insurance
, but he was unable to return to his physically-demanding job. He found new employment, but was denied coverage due to his pre-existing conditions
\r\n
(I don\’t think this is correct click and view our
COBRA
page – Also see our
Pre-X page
and check out the guarantees on
Employer Provided coverage
.
\r\n
which required costly ongoing care. Similarly, a school-teacher who suffered a heart attack was unable to return to work for many months, and hence her coverage lapsed. A hospital wrote off her $20,000 debt, but she was nonetheless bankrupted by doctor bills and the
cost of medications
. even brief lapses in insurance coverage may be ruinous and should not be viewed as benign.
\r\n
Steve\’s Note – This would be a reason to have your premiums paid AUTOMATICALLY from your checking account or credit card
automatic payments
even good
employment-based
coverage sometimes fails to protect families because illness may lead to job loss and the consequent loss of coverage.
\r\n
Check
COBRA
,
Cal COBRA
36 Months,
HIPAA (pre health Care Reform),
Temporary Plans and of course Private Coverage
\r\n
Lost jobs, of course, also leave families without health coverage when they are at their financially most vulnerable.
View entire article
PNHP Study
Summary page
– I don\’t agree with them though
\r\n
Five Mistakes that Will Land You in Medical Debt
, written by Elizabeth Cohen, CNN\’s Medical News correspondent. Highlights of the story include:
\r\n\r\n
\r\n
\r\n
A 2007 report stating that 28 percent of the population is paying off medical debt.
\r\n
\r\n
\r\n
How medical debt usually happens quickly and is a surprise to many.
\r\n
\r\n
\r\n
How agencies can help you negotiate with providers and insurance companies.
\r\n
\r\n
\r\n
Furthermore, Cohen highlights the FHCE\’s tools and services eligibility quiz,
state-by-state guide of health care choices
and
24-hour helpline
as resources to those who currently do not have insurance. To take advantage of our online tools and services we provide, please visit our Web site,
www.Coverage For All.org
. It is a rich and educational resource designed for consumers, agents and organizations alike.
\r\n
Illness often leads to financial catastrophe through loss of income, as well as high medical bills. Hence,
disability insurance
and paid sick leave are also critical to financial survival of a serious illness.
\r\n
WebMD on Medical Bankruptcy
\r\n
Posting on another agent’s website about repairing Medical Debt
insure me kevin.com
\r\n\r\n

Get Subsidy Quotes & Programs for the Uninsured Guaranteed Issue!

\r\n
Related Pages
\r\n
\r\n

\r\n
‘,’Medical Bankruptcy’,”,’publish’,’open’,’closed’,”,’medical-bankruptcy’,”,”,’2018-09-27 21:32:33′,’2018-09-27 21:32:33′,”,151,’http://healthlaw.healthreformquotes.com/?page_id=161′,0,’page’,”,0),(162,1,’2016-05-10 08:14:42′,’2016-05-10 08:14:42′,’
\r\n\r\n
NEW Health Reform Fix\r\n\r\n
\r\n
The Patient Choice, Affordability, Responsibility, and Empowerment Act
\r\n
(A failed attempt to repeal ObamaCare)
\r\n
Executive Summary
\r\n
In 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act (PPACA). The law was presented to the American people as health care reform that would lower costs for families and taxpayers alike, allow individuals to keep the doctor and the health plans they already had, and increase choices for all Americans.
\r\n
.\r\nUnfortunately, the President’s health care law has disrupted health care for millions of Americans in many ways.  The law sent premiums and out-of-pocket costs skyrocketing, forced limited networks, cancelled health plans, reduced workers’ hours, hurt jobs, and threatened the safety nets of Medicare and Medicaid that protect some of our nation’s most vulnerable.  Today, just seven percent of Americans say they expect the law to reduce their health care costs.  Further, a Gallup poll shows that one in three Americans report putting off medical treatment that they or their family need because of cost — the highest response rate in the 14-year history of Gallup asking consumers about this issue.
\r\n
The country needs a better path forward, which is why we are advancing the Patient Choice, Affordability, Responsibility, and Empowerment (Patient CARE) Act. Our proposal provides needed relief to those hurt by the President’s broken health care promises.  Our plan outlines policies and reforms that will lower health care costs, and increase choices, access, and quality. We are committed to advancing these reforms without adding a dollar to our deficit.
\r\n
The American people expect responsible health care reforms that will not only fix what is broken, but build on what works, such as continuing to foster the medical innovation that has been the envy of the world. Our proposal will not return to the failed policies that existed before the President’s health care law.  Nor will our plan force American families, job creators, workers, seniors, and taxpayers to continue living with the dire consequences of the President’s health care law.
\r\n
We are charting a better path forward by offering our vision for America —one that empowers patients, families, small businesses and states instead of Washington bureaucrats. Our plan would:
\r\n
Provide relief to Americans hurt by the President’s health care law;
\r\n
Advance quality care for patients;
\r\n
Empower patients, families, small businesses, and states with more choices;
\r\n
Better serve some of our most vulnerable by modernizing Medicaid;
\r\n
Lower the costs of health through increasing competition and choice;
\r\n
Strengthen the transparency, delivery, and sustainability in health care.
\r\n
The President and his Democratic allies jammed a large, flawed, partisan bill through Congress. The American people deserve better. Our proposal embraces a step-by-step approach to truly reform health care by lowering costs and improving access—the very reforms the American people were promised and deserve
\r\n
Learn More⇒
Our copy
with bookmarks & annotations
Original
\r\n
Related Pages
\r\n\r\n\r\n‘,’Patient Choice, Affordability, Responsibility & Empowerment Act – Historical’,”,’publish’,’closed’,’closed’,”,’patient-choice-affordability-responsibility-empowerment-act’,”,”,’2017-04-19 12:25:23′,’2017-04-19 12:25:23′,”,8037,’http://healthlaw.healthreformquotes.com/?page_id=162′,0,’page’,”,0),(227,1,’2013-07-01 17:36:39′,’2013-07-02 00:36:39′,’
\r\n
\r\n\r\n
2017 Factors in Calculating the Premiums\r\n\r\n
\r\n
Why are my
\r\n\r\n
medical insurance premiums increasing
,
\r\n
getting higher and expensive every year?
\r\n
What about the
high price of Health Care
?
\r\n
What about the impact
Health Reform
?
\r\n
Can I
shop & Compare Prices
?
\r\n
Latest News Articles & Insurance Company Blasts
\r\n\r\n
\r\n
CHCF Health Care Costs 101 Sept. 2017
\r\n
Unfortunately, rates overall are going up 13%  Learn More==>  Covered CA Press Release 7.19.2016\r\n
\r\n

Rate Booklet for 2017

\r\n
\r\n
\r\n
7 to 8% in CA for 2017
Kaiser Health News 5.11.2016
\r\n
\r\n
Major drivers of 2017 premium changes include: the underlying growth in health care costs, the sunset of reinsurance program funds, how assumptions regarding the composition of the 2017 risk pool differ from those assumed for 2016, and the one-year moratorium on the health insurance provider fee.
\r\n
Other factors potentially contributing to premium changes include the repeal of the expansion of the small group market and the shift to narrower provider networks.

Actuary.org May 2016

\r\n
The New York Times: Newest Policyholders Under Health Law Are Sicker And Costlier To Insurers
\r\n
The Associated Press: Report Details Costs, Challenges Of ACA\’s Newly Insured
\r\n
The
Washington Post
: They’re Sicker, Plus ACA Enrollees Cost More In Care, Major Insurer Finds
\r\n
The
Wall Street Journal
: Affordable Care Act Enrollee Spending Is Increasing
CA Health Line – Increases for 2016 12.18.2015
\r\n
\r\n

\r\n\r\n
\r\n
Medical Cost Trends – Behind the Numbers
– with bookmarks
\r\n
\r\n\r\n
California Healthcare Compare website
is a collaboration among the state Department of Insurance, UC San Francisco and Consumers Union, the publisher of Consumer Reports. Those groups built the site using $3.9 million in federal grant money made available through the Affordable Care Act.
LA Times 9.21.2015

PART 154–HEALTH INSURANCE ISSUER RATE INCREASES:
\r\nOther subparts are in
MLR Page
\r\n\r\n
Medical Loss Ratio

Regulations & Guidance
\r\n
CA DOI Guidance for 2010 Legislation
\r\n
CA DOI Guidance Unreasonable Rate Increases
\r\n
SB 1163
\r\n
Article 4.5.  Review of Rate Increases ……………….
10181-10181.13
\r\n
10181. For purposes of this article, the following
definitions
shall apply:
\r\n
(a) \”Large group health insurance policy\” means a group health insurance policy other than a policy issued to a small employer, as defined in
Section 10700
.
\r\n
(b) \”Small group health insurance policy\” means a group health insurance policy issued to a small employer, as defined in
Section 10700
.
\r\n
(c)
\”PPACA\”
means Section 2794 of the federal Public Health Service Act (42 U.S.C. Sec. 300gg-94), as amended by the federal Patient Protection and Affordable Care Act (P.L. 111-148), and any subsequent rules, regulations, or guidance issued pursuant to that law.
\r\n
(d) \”Unreasonable rate increase\” has the same meaning as that term is defined in PPACA.
\r\n
10181.2. This article shall apply to health insurance policies offered in the
individual or group market
in California. However, this article shall not apply to a specialized health insurance policy; a
Medicare supplement
policy subject to Article 6 (commencing with Section 10192.05); a health insurance policy offered in the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code); a health insurance policy offered in the Healthy Families Program (Part 6.2 (commencing with Section 12693)), the
Access for Infants and Mothers Program
(Part 6.3 (commencing with Section 12695)), the
California Major Risk Medical Insurance Program
(Part 6.5 (commencing with Section 12700)), or the
Federal Temporary High Risk Pool
(Part 6.6 (commencing with Section 12739.5)); a health insurance conversion policy offered pursuant to Section 12682.1; or a health insurance policy offered to a federally eligible defined individual under Chapter 9.5 (commencing with Section 10900)
\r\n
.
\r\n
10181.3. (a) (1) All health insurers
shall file
with the department
all required rate information
for individual and small group health insurance policies at least 60 days prior to implementing any rate change.
\r\n
(2) For individual health insurance policies, the filing shall be concurrent with the notice required under Section 10113.9.
\r\n
(3) For small group health insurance policies, the filing shall be concurrent with the notice required under Section 10199.1.
\r\n
(b) An insurer
shall disclose
to the department all of the following for each individual and small group rate filing:
\r\n
(1) Company name and contact information.
\r\n
(2) Number of policy forms covered by the filing.
\r\n
(3) Policy form numbers covered by the filing.
\r\n
(4) Product type, such as indemnity or preferred provider organization.
\r\n
(5) Segment type.
\r\n
(6) Type of insurer involved, such as for profit or not for profit.
\r\n
(7) Whether the products are opened or closed.
\r\n
(8) Enrollment in each policy and rating form.
\r\n
(9) Insured months in each policy form.
\r\n
(10) Annual rate.
\r\n
(11) Total
earned premiums
in each policy form.
\r\n
(12) Total
incurred claims
in each policy form.
\r\n
(13)
Average rate increase initially requested
.
\r\n
(14) Review category: initial filing for new product, filing for existing product, or resubmission.
\r\n
(15)
Average rate of increase.
\r\n
(16) Effective date of rate increase.
\r\n
(17) Number of policyholders or insured\’s affected by each policy form.
\r\n
(18) The insurer\’s overall
annual medical trend factor
assumptions in each rate filing for all benefits and by aggregate benefit category, including hospital inpatient, hospital outpatient, physician services, prescription drugs and other ancillary services, laboratory, and radiology. An insurer may provide aggregated additional data that demonstrates or reasonably estimates year-to-year cost increases in specific benefit categories in major geographic regions of the state. For purposes of this paragraph, \”major geographic region\” shall be defined by the department and shall include no more than nine regions.
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(19) The amount of the
projected trend attributable to the use of services, price inflation,
or fees and risk for annual policy trends by aggregate benefit category, such as hospital inpatient, hospital outpatient, physician services, prescription drugs and other ancillary services, laboratory, and radiology.
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(20) A comparison of claims cost and rate of changes over time.
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(21) Any changes in insured cost-sharing over the prior year associated with the submitted rate filing.
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(22) Any changes in insured benefits over the prior year associated with the submitted rate filing.
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(23) The certification described in subdivision (b) of Section 10181.6.
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(24) Any changes in administrative costs.
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(25)
Any other information required for rate review under PPACA.
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(c) An insurer subject to subdivision (a)
shall also disclose
the following aggregate data for all rate filings submitted under this section in the individual and small group health insurance markets:
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(1) Number and percentage of rate filings reviewed by the following:
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(A) Plan year.
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(B) Segment type.
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(C) Product type.
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(D) Number of policyholders.
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(E) Number of covered lives affected.
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(2) The insurer\’s average rate increase by the following categories:
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(A) Plan year.
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(B) Segment type.
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(C) Product type.
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(3) Any
cost containment and quality improvement efforts
since the insurer\’s last rate filing for the same category of health benefit plan. To the extent possible, the insurer shall describe any significant new health care cost containment and quality improvement efforts and provide an estimate of potential savings together with an estimated cost or savings for the projection period.
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(d) The department may require all health insurers to submit all rate filings to the
National Association of Insurance Commissioners\’ System for Electronic Rate and Form Filing (SERFF).
Submission of the required rate filings to SERFF shall be deemed to be filing with the department for purposes of compliance with this section.
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(e) A health insurer shall submit any other information required under
PPACA
. A health insurer shall also submit any other information required pursuant to any regulation adopted by the department to comply with this article.
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10181.4. (a) For
large group health insurance policies
, all health insurers shall file with the department at least 60 days prior to implementing any rate change all required rate information for unreasonable rate increases. This filing shall be concurrent with the written notice described in Section 10199.1.
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(b) For large group rate filings, health insurers shall submit all information that is required by PPACA. A health insurer shall also submit any other information required pursuant to any regulation adopted by the department to comply with this article.
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(c) A health insurer subject to subdivision (a) shall also disclose the following aggregate data for all rate filings submitted under this section in the large group health insurance market:
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(1) Number and percentage of rate filings reviewed by the following:
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(A) Plan year.
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(B) Segment type.
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(C) Product type.
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(D) Number of insured\’s.
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(E) Number of covered lives affected.
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(2) The insurer\’s average rate increase by the following categories:
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(A) Plan year.
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(B) Segment type.
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(C) Product type.
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(3) Any cost containment and quality improvement efforts since the health insurer\’s last rate filing for the same category of health insurance policy. To the extent possible, the health insurer shall describe any significant new health care cost containment and quality improvement efforts and provide an estimate of potential savings together with an estimated cost or savings for the projection period.
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(d) The department may require all health insurers to submit all rate filings to the National Association of Insurance Commissioners\’ System for Electronic Rate and Form Filing (SERFF). Submission of the required rate filings to SERFF shall be deemed to be filing with the department for purposes of compliance with this section.
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10181.5. Notwithstanding any provision in a contract between a health insurer and a provider, the department may request from a health insurer any information required under this article or PPACA.
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10181.6. (a) A filing submitted under this article
shall be actuarially sound.
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(b) (1) The health insurer shall contract with an
independent actuary
or actuaries consistent with this section.
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(2) A filing submitted under this article shall include a
certification by an independent actuary or actuarial firm that the rate increase is reasonable or unreasonable
and, if unreasonable, that the justification for the increase is based on accurate and sound actuarial assumptions and methodologies. Unless PPACA requires a certification of actuarial soundness for each large group health insurance policy, a filing submitted under Section 10181.4 shall include a certification by an independent actuary, as described in this section, that the aggregate or average rate increase is based on accurate and sound actuarial assumptions and methodologies.
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(3) The actuary or actuarial firm acting under paragraph (2) shall not be an affiliate or a subsidiary of, nor in any way owned or controlled by, a health insurer or a trade association of health insurers. A board member, director, officer, or employee of the actuary or actuarial firm shall not serve as a board member, director, or employee of a health insurer. A board member, director, or officer of a health insurer or a trade association of health insurers shall not serve as a board member, director, officer, or employee of the actuary or actuarial firm.
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(c) Nothing in this article shall be construed to permit the commissioner to establish the rates charged insured\’s and policyholders for covered health care services.
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10181.7. (a) Notwithstanding Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code, all information submitted under this article shall be made publicly available by the department except as provided in subdivision (b).
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(b) Any contracted rates between a health insurer and a provider shall be deemed confidential information that shall not be made public by the department and are exempt from disclosure under the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code). The contracted rates between a health insurer and a large group shall be deemed confidential information that shall not be made public by the department and are exempt from disclosure under the California Public Records Act (Chapter 3.5 (commencing with Section 6250) of Division 7 of Title 1 of the Government Code).
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(c) All information submitted to the department under this article shall be submitted electronically in order to facilitate review by the department and the public.
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(d) In addition, the department and the health insurer shall, at a minimum, make the following information readily available to the public on their Internet Web sites, in plain language and in a manner and format specified by the department, except as provided in subdivision (b). The information shall be made public for 60 days prior to the implementation of the rate increase. The information shall include:
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(1) Justifications for any unreasonable rate increases, including
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all information and supporting documentation as to why the rate increase is justified.
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(2) An insurer\’s overall annual medical trend factor assumptions in each rate filing for all benefits.
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(3) An insurer\’s actual costs, by aggregate benefit category to include, hospital inpatient, hospital outpatient, physician services, prescription drugs and other ancillary services, laboratory, and radiology.
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(4) The amount of the projected trend attributable to the use of services, price inflation, or fees and risk for annual policy trends by aggregate benefit category, such as hospital inpatient, hospital outpatient, physician services, prescription drugs and other
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ancillary services, laboratory, and radiology.
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10181.9. (a) On or before July 1, 2012, the commissioner may issue guidance to health insurers regarding compliance with this article. This guidance shall not be subject to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code).
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(b) The department shall consult with the Department of Managed Health Care in issuing guidance under subdivision (a), in adopting necessary regulations, in posting information on its Internet Web site under this article, and in taking any other action for the purpose of implementing this article.
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10181.11. (a) Whenever it appears to the department that any person has engaged, or is about to engage, in any act or practice constituting a violation of this article, including the
filing of inaccurate or unjustified rates or inaccurate or unjustified rate information, the department
may review rate filing
to ensure compliance with the law.
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(b) The department may review other filings.
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(c) The department shall accept and post to its Internet Web site any public comment on a rate increase submitted to the department during the 60-day period described in subdivision (d) of Section 10181.7.
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(d) The department shall report to the Legislature at least quarterly on all unreasonable rate filings.
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(e) The department shall post on its Internet Web site any changes submitted by the insurer to the proposed rate increase, including any documentation submitted by the insurer supporting those changes.
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(f) If the department finds that an unreasonable rate increase is not justified or that a rate filing contains inaccurate information, the department shall post its finding on its Internet Web site.
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(g) Nothing in this article shall be construed to impair or impede the department\’s authority to administer or enforce any other provision of this code.
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10181.13. The department shall do all of the following in a manner consistent with applicable federal laws, rules, and regulations:
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(a) Provide data to the United States Secretary of Health and Human Services on health insurer rate trends in premium rating areas.
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(b) Commencing with the creation of the Exchange, provide to the Exchange such information as may be necessary to allow compliance with federal law, rules, regulations, and guidance.
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Insurance.CA.GOV Health Guidance
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Rate Increases must be certified by an Actuary\r\n
CA SB 1163
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The rates and rating factors for most types of insurance must be filed with the insurance regulatory agency for each state where the insurance is to be sold. In some states and for some types of insurance, the rates must get regulatory approval before they can be used.
law.freeadvice.com/
\r\nCHAPTER 9.  RATES AND RATING AND OTHER ORGANIZATIONS\r\nArticle 1.  Purpose and Scope of Chapter ………………
1850.4-1851.1
\r\nArticle 2.  Making and Use of Rates …………………..
1853.5-1853.9
\r\nArticle 2.5.  Making and Use of Rates–Insurance of\r\nProperties Being Purchased From\r\nDepartment of Veterans Affairs …………
1853.95-1853.97
\r\nArticle 4.  Advisory Organizations ……………………..
1855-1855.5
\r\nArticle 5.  Joint Underwriting and Joint Reinsurance ………….
1856
\r\nArticle 6.  Records and Examinations ……………………
1857-1857.4
\r\nArticle 6.5.  Recording and Reporting of Loss and Expense\r\nExperience …………………………….
1857.7-1857.9
\r\nArticle 7.  Hearings, Procedure and Judicial Review ………
1858-1858.7
\r\nArticle 8.  Penalties …………………………………
1859-1859.1
\r\nArticle 9.  Miscellaneous ……………………………..
1860-1860.3
\r\nArticle 10.  (Reduction and Control of Insurance Rates)
1861.01-1861.16
\r\n
\r\n \r\n\r\n ‘,’CA Rate Regulation’,”,’publish’,’open’,’closed’,”,’ca-rate-regulation’,”,”,’2017-09-25 21:48:52′,’2017-09-25 21:48:52′,”,887,’http://individuals.healthreformquotes.com/?page_id=7577′,0,’page’,”,0),(7578,1,’2014-12-04 18:55:03′,’2014-12-04 18:55:03′,’
Health Reform CFR – Code of Federal Regulations on Rate Regulation
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TITLE 45–Public Welfare
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SUBTITLE A–DEPARTMENT OF HEALTH AND HUMAN SERVICES
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SUBCHAPTER B–REQUIREMENTS RELATING TO HEALTH CARE ACCESS
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PART 154–HEALTH INSURANCE ISSUER RATE INCREASES:\r\nDISCLOSURE AND REVIEW REQUIREMENTS
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If the links below do not work… Try \”googling\” Federal Code of Regulations and the code #.
\r\n \r\n
Subpart A–GENERAL PROVISIONS
\r\n§154.101Basis and scope.§154.102\r\n\r\nDefinitions.§154.103Applicability.\r\n
Subpart B–DISCLOSURE AND REVIEW PROVISIONS
\r\n§154.200Rate increases subject to review.\r\n\r\n§154.205
Unreasonable rate increases.\r\n\r\n§154.210Review of rate increases subject to review by CMS or by a State.\r\n\r\n§154.215Submission of disclosure to CMS for rate increases subject to review.\r\n\r\n§154.220Timing of providing the Preliminary Justification.\r\n\r\n§154.225Determination by CMS or a State of an unreasonable rate increase.\r\n\r\n§154.230Submission and posting of Final Justifications for unreasonable rate increases.\r\n
Subpart C–EFFECTIVE RATE REVIEW PROGRAMS
\r\n§154.301\r\n
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CMS\’s determinations of Effective Rate Review Programs.
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TITLE 45–Public Welfare
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SUBTITLE A–DEPARTMENT OF HEALTH AND HUMAN SERVICES
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SUBCHAPTER B–REQUIREMENTS RELATING TO HEALTH CARE ACCESS
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PART 158–ISSUER USE OF PREMIUM REVENUE: REPORTING AND REBATE REQUIREMENTS
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§158.101
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Basis and scope.
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§158.102
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Applicability.
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§158.103
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Definitions.
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Subpart A–DISCLOSURE AND REPORTING
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§158.110
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Reporting requirements related to premiums and expenditures.
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§158.120
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Aggregate reporting.
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§158.121
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Newer experience.
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§158.130
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Premium revenue.
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§158.140
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Reimbursement for clinical services provided to enrollees.
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§158.150
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Activities that improve health care quality.
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§158.151
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Expenditures related to Health Information Technology and meaningful use requirements.
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§158.160
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Other non-claims costs.
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§158.161
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Reporting of Federal and State licensing and regulatory fees.
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§158.162
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Reporting of Federal and State taxes.
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§158.170
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Allocation of expenses.
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\r\n \r\n\r\nB –
Calculating the Rebate
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Subpart C–POTENTIAL ADJUSTMENT TO THE MLR FOR A STATE\’S INDIVIDUAL MARKET
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§158.301
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Standard for adjustment to the medical loss ratio.
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§158.310
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Who may request adjustment to the medical loss ratio.
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§158.311
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Duration of adjustment to the medical loss ratio.
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§158.320
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Information supporting a request for adjustment to the medical loss ratio.
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§158.321
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Information regarding the State\’s individual health insurance market.
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§158.322
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Proposal for adjusted medical loss ratio.
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§158.323
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State contact information.
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§158.330
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Criteria for assessing request for adjustment to the medical loss ratio.
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§158.340
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Process for submitting request for adjustment to the medical loss ratio.
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§158.341
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Treatment as a public document.
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§158.342
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Invitation for public comments.
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§158.343
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Optional State hearing.
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§158.344
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Secretary\’s discretion to hold a hearing.
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§158.345
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Determination on a State\’s request for adjustment to the medical loss ratio.
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§158.346
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Request for reconsideration.
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§158.350
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Subsequent requests for adjustment to the medical loss ratio.
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‘,’CFR Rate Regulation’,”,’publish’,’open’,’closed’,”,’cfr-rate-regulation’,”,”,’2017-01-05 19:08:30′,’2017-01-05 19:08:30′,”,7576,’http://individuals.healthreformquotes.com/?page_id=7578′,0,’page’,”,0),(7579,1,’2014-12-04 18:59:00′,’2014-12-04 18:59:00′,’
The

rate review process of

Medical Loss Ratio

\r\n
does not presume that an increase above 80% is unreasonable, nor does it prevent issuers from increasing rates.
The process only requires such increases be reviewed and that certain information be made public.   When HHS reviews a rate increase, HHS will determine that the rate increase is
unreasonable
if the increase is:
\r\n
\r\n
Excessive
– meaning the increase causes the premium charged for the health insurance coverage to be unreasonably high in relation to the benefits provided.
\r\n
Unjustified
– meaning the data or documentation the issuer provides to HHS in connection with the increase is incomplete, inadequate or otherwise does not provide a basis upon which the reasonableness of an increase may be determined.
\r\n
Unfairly discriminatory
– meaning the increase results in premium differences between insured\’s within similar risk categories that (1) are not permissible under applicable state law or (2) in the absence of an applicable state law, do not reasonably correspond to differences in expected costs.
\r\n
\r\n
The examination must include an analysis of all of the following:
\r\n\r\n
\r\n
The impact of medical trend changes by major service categories
\r\n
The impact of utilization changes by major service categories
\r\n
The impact of cost-sharing changes by major service categories
\r\n
The impact of benefit changes
\r\n
The impact of changes in enrollee risk profile
\r\n
The impact of any overestimate or underestimate of medical trend for prior year periods related to the rate increase
\r\n
The impact of changes in reserve needs
\r\n
The impact of changes in administrative costs related to programs that improve health care quality
\r\n
The impact of changes in other administrative costs
\r\n
The impact of changes in applicable taxes, licensing or regulatory fees;
\r\n
Medical loss ratio
\r\n
The issuer’s risk-based capital status relative to national standards
(Blue Cross Memo on

Rate Review

)

6/2011 Update

154.205 Federal Regulation
\r\n
\r\n
\r\n
\r\n
\r\n
\r\n\r\nWhite House – YouTube Channel on Health Care Reform
\r\n
\r\n

Plain Language Rate Filings

\r\n

Health Care.Gov  Tool
to find out about Rate Increases or Loss Ratio for each Insurance Company

\r\n

dmhc.ca.gov/rate review

/\r\n\r\n

CA Dept of Insurance

\r\n

United Health Care

\r\n

\r\n
\r\n
\r\n
\r\n
\r\n \r\n\r\n ‘,’Rate Regulation’,”,’publish’,’open’,’closed’,”,’rate-regulation’,”,”,’2018-10-06 18:51:17′,’2018-10-06 18:51:17′,”,7577,’http://individuals.healthreformquotes.com/?page_id=7579′,0,’page’,”,0),(7693,1,’2015-03-17 06:44:26′,’2015-03-17 06:44:26′,”,’Cost of Ebola Treatment’,”,’publish’,’open’,’closed’,”,’cost-of-ebola-treatment’,”,”,’2017-01-05 19:08:31′,’2017-01-05 19:08:31′,”,227,’http://individuals.healthreformquotes.com/?page_id=7693′,0,’page’,”,0),(7713,1,’2015-04-09 18:55:11′,’2015-04-09 18:55:11′,’
\r\n\r\n 4.14.2016 Ways & Means Committee Hearing –
Transcripts
Sound is missing for the 1st minute or two\r\n\r\n
Cadillac Tax\r\n\r\n
\r\n
The
Cadillac Tax
, set to begin in
2018
– 2020
C
A Health Line 12.21.201
5
as part of the ACA, is a
40% tax on benefits over certain thresholds
. HRAs, HSAs, Major Medical coverage and other items are included in the coverage that counts towards this tax.  The tax will hit insurance and related perks valued at more than $10,200 for singles and $27,500 for families. So for family benefits worth $30,000, the tax would apply to the $2,500 that’s above the limit.  The administration has long argued it is a modest step to get health care costs under control. It “will affect only a small portion of the very highest-cost health plans — a total of 3 percent of premiums in 2013,”  About one-third of employers will be hit by the tax in 2018 if they do nothing to change their plans
4.7.2015 Word & Brown from Politic
o
\r\n
January 2017 – Senators Dean Heller (R-NV) and Martin Heinrich (D-NM) introduced
S. 58
, after Representatives Mike Kelly (R-PA) and Joe Courtney (D-CT) introduced
H.R. 173
,
legislation to repeal the ACA\’s
Cadillac/excise Tax
, which will impose a 40% excise tax on health plans that exceed certain cost thresholds beginning in 2020
\r\n
H
ealth Net Update 11.24.201
5
1.19.2016
\r\nWhy Employers are really cutting benefits? Not the Cadillac Tax
Los Angeles Times 8.27.2015
\r\n\r\nNext Big ObamaCare Battle – Cadillac Tax
CA Health Line 9.17.2015
\r\n\r\n
4.29.2015 – Legislation introduced to eliminate Cadillac Tax
\r\n\r\nA
CA Times.com  Planning for Cadillac Tax
\r\n\r\n
Wikipedia on Cadillac Tax
\r\n
26 U.S. Code § 4980I – Excise tax on high cost employer-sponsored health coverage
\r\n
American Health Care Act
– Donald Care
retain
the ACA\’s so-called
Cadillac tax
on high-value plans but delay it until 2025 –
page 85 3.6.2017 Revision
\r\n
Check out
Group Supplemental Plans
to avoid the tax!
\r\n
Related Pages in
Financial Impact of Health Care Reform on Premiums
Section
\r\n

\r\n
‘,’Cadillac Tax’,”,’publish’,’open’,’closed’,”,’cadillac-tax’,”,”,’2017-03-07 21:57:27′,’2017-03-07 21:57:27′,”,893,’http://individuals.healthreformquotes.com/?page_id=7713′,0,’page’,”,0),(7729,1,’2015-04-16 23:03:15′,’2015-04-16 23:03:15′,’
Increasing Health Care Costs
\r\n \r\n\r\nhave been an issue for a LONG time.  See our main page for the most current information, namely after Health Care Reform – ObamaCare.\r\n
This is historical information.
\r\n
Paying More Getting Less
(2008) Joel A Harrison
\r\n\r\n
Organ Transplants
Joel A Harrison – East County San Diego Magazine 1.2009\r\n\r\n
Kaiser\’s Premium Rates – Employer Backlash – LA Times  7.24.2013\r\n
\r\n
SB 746 – I\’d link to the State of CA, but their site is down today.    I don\’t understand why we need this law, considering the  Medical Loss Ratio  MLR mandate of 80%  in Health Care Reform.  If you have a thought, please post it in comments, including a URL if you state any facts.
\r\n
The part that concerns me is that Kaiser is the \”model\” of preventive care, \”case management,\” etc.  If their rates are going up…   How will Health Care Reforms mandate of Preventative Care and Case Management work?
\r\n
Wellpoint – Anthem Blue Cross have higher earnings – costs are down
LA Times 7.25.2013
\r\n
Millman Study 4.2013 on Health  Reform and Premiums
pdf (click on bookmark icon)
\r\n
Anthem Blue Cross 4.2013
MORE detailed explanation of why Medical costs are rising
. 7 Pages pdf
\r\n
Full Report
data.cms.gov/
\r\n
Inpatient Prospective Payment System (IPPS) Provider Level Charges and Medicare Payments for the Top 100 Diagnosis-Related Groups (DRG)
\r\n
Cedar\’s doesn\’t really charge as much as the report shows – LA Times 5.2013
\r\n
CMS just release study on pricing
\r\n
Medicare Supplement Increases
Blue Cross Flyer 11.2010
\r\n
Medical Cost Trend: 2013 (PWC)
\r\n
Los Angeles Times – Steve Lopez
\r\n
$5K Emergency Room for Stomach Ache!
\r\n
Recent News and Insurance Company Bulletins
\r\n
New York Times 1.5.2013
\r\n
Premiums still increasing despite
Medical Loss Ratio (MLR)
&
Rate Regulation
\r\n
12.13.2012
LA Times\r\nBlue Shield Rate Hike 12%
\r\n \r\n
New legislation.   http://www.steveshorr.com/405/pending_legislation.htm  use our search engine\r\n
Proposed government mandates–such as the
\r\n
Medicare
\r\nreform, and\r\nhealth care
tax
changes–will continue to drive health care costs up.
\r\n
AB 88
\r\n
Maternity
\r\n
Small Group Reform
\r\n
COBRA
,\r\n
HIPAA
,\r\n
Privacy
\r\n
Infertility
\r\n
Costs of Infertility Treatment
\r\n
cal health reform.org/
\r\n
CHFC
Articles
\r\nIn the private insurance market, cost containment is largely left to market forces. Insurers compete with one another for customers partly on the basis of price. When the insurers are managed care plans, they have some influence on medical costs through their contractual relationships with
participating providers
, who may agree to fee constraints because of their desire to be included in the plan\’s provider networks and to have access to that source of business. Health plans often also implement various utilization controls to limit service use.\r\n\r\nPrice competition among
providers
is less intense, since most consumers of health care are covered by insurance and are thus relatively insensitive to provider prices. However, various forms of
patient cost-sharing
are designed to give consumers incentives to avoid excess utilization and to choose less expensive medical alternatives.\r\n\r\nThe public-sector buyers achieve cost control primarily through administered prices for providers. The state sets the fees it will pay
Medi-Cal
providers and health plans participating in either Medi-Cal or
Healthy Families
, and has other features in place to control utilization.\r\n\r\nAlthough there is no consensus about what proportion of our resources should be devoted to medical care, many believe the present system does not adequately contain costs. Health expenditures have risen more rapidly than wages and represent an increasing proportion of total spending.\r\n\r\n
20 percent of Californians remain Uninsured More than half of California’s uninsured children are eligible for
public health insurance
\r\n\r\n
Cost Containment
\r\n
health affairs.org/
\r\n
ahcpr.gov/

\r\n
Study of 10 health plans in CA and how they actually perform – Georgetown University
\r\n
https://www.healthcarebluebook.com
\r\nmy medical costs.com\r\nI haven\’t figured out who sponsors them or where they get their data from
\r\nVideo
Samples of Accidents
covered by medical insurance\r\n\r\n
Video\’s of Surgeries
NIH\r\n\r\n
NIH Health Topics
\r\n\r\n
Blue Cross Statement on Employers rising costs
\r\n\r\nAgency for Health Care Research & Quality\r\n
Health reform is high on the political agenda in California, and things are moving fast. Cal Health Reform.org  was created to help keep Californians up-to-date on the major proposals, analyses, hearings, and news. We also provide resources to help explain the issues and a discussion forum where you can share your ideas.
\r\n
Blue Cross Provider Quality Finder Links
\r\n
America\’s Health Insurance Plans – merged with Health Insurance Institute of America
\r\n
State Health Facts.org
\r\n
Blue Cross
letter to Employers
\r\n
\r\n\r\n \r\n
***********************************Comments**********************************************
\r\n2.1.2013\r\n\r\nHi,\r\n\r\nJust when I was so thankful that the
Grandfathered Plans
(if you like your plan, you can keep it) were great for 2014 and beyond.  The plans allowed many of our clients to stay out of the 1.1.2014 Covered CA SNAFU fiasco of no ID cards or invoices, narrow networks, glitch ridden websites and rollover to
Metal Level Plans
.     I just found out from a prospect and the
LA Times
that there is a rate increase (
why?
) of up to 25%.   With almost daily bulletins and changes, a lot of my new information is from the LA Times rather than Insurance Company bulletins.  Now the Times requires registration and/or a subscription, as if the barrage of advertising on their website isn’t enough.\r\n\r\nIf you want to look at new Obama Care coverage, check our
ONLINE instant quote engine
.  If you think you might qualify for tax credits – premium subsides, send us your  household income and we will do the calculation for you.
Click here for an explanation
, including a
video explanation
.\r\n\r\nAccording to the LA Times, the CA Department of Insurance must review the
rate regulation
(our
new website
)  filing.   Here’s the ACTUAL filing around 500 pages, on the CA DOI website.  It’s quite possible that you might get a rate decrease!  If you have any comments, the DOI has a spot for that on their filing page.  You may also post them on our
Premium Increases web page
.\r\n\r\nPlease email or call us for further information.  We have NO call holding wait times.   If we are in the middle of something, send an email or leave a message.  We will respond within 2 working hours.\r\n\r\nSteve\r\n\r\n \r\n\r\nExchange Enrollees – Covered CA? Sicker than on employer group plans
californiahealthline.org
\r\n\r\nKaiser only company to cut rates for 2015
atimes.com/
\r\n\r\nAverage rate increase for all exchanges 7.5%c
aliforniahealthline.org/
\r\n\r\nAverage rate increase for 2015\r\n
latimes.com
\r\n\r\nMore details

Get and understand your Health Coverage now!


\r\n\r\n \r\n\r\nExchange Rates might increase in 2015
californiahealthline.org/
\r\n\r\nTrans Union survey shows more than 1/2 of consumers surprised by amount of medical bills
californiahealthline.org
\r\n\r\n \r\n\r\nCovered CA rates for 2015 to be released Thursday. No increases expected?
http://www.californiahealthline.org
\r\n\r\nAnthem predicts 10% or less premium increase for 2015\r\n\r\nLast week, Anthem and other insurers filed their proposed rates for 2015 with Covered California\r\n\r\nThe final rates are expected to be disclosed publicly in late July when health insurers submit them to state regulators for review\r\n\r\n
http://www.insurance.ca.gov
\r\n\r\n“These narrow networks are making a huge difference on affordability,” Morgan said. “People value price above all else…. These narrow networks are really here to stay.”\r\n\r\n

Get and understand your Health Coverage now!


\r\n\r\n
http://www.latimes.com/
\r\n\r\nHunkered down in conference rooms, insurance actuaries are parsing prescriptions, doctor visits and hospital stays for clues about how expensive these new patients may be. By May, insurance companies must file next year’s rates with California’s state-run exchange so negotiations can begin.\r\n\r\n“I probably neglected my health the last few years because of the expense,” Davidson said. “Now I’m going to have every test known to man.”\r\n\r\nShe plans to undergo lab tests for her diabetes, a mammogram, a bone density scan and a colonoscopy — everything she put off while she went without comprehensive insurance.\r\n\r\nclaims information is usually a better guide to future costs than a customer’s age, sex and other demographic data.
latimes.com/
\r\n\r\nRate Increases for 2015 – Insurance Mandatory Filings coming up soon\r\n\r\nInsurers’ short turnaround time, coupled with regulatory uncertainties, has led some industry officials and outside experts to predict that double-digit rate hikes could be in the works. That would be bad news for consumers, the administration and Democrats running for election in November. The fear is that if premiums rise significantly, fewer healthy but uninsured Americans will sign up in 2015, leading to more rate hikes. Still, many observers say the exchange market would survive rate increases because the law’s re-insurance and risk-adjustment mechanisms protect plans with higher-than-expected costs.\r\n\r\n“There will undoubtedly be remarkable price increases,” WellPoint CEO Joseph Swedish said. He added that the prospect of double-digit hikes “appears as if it’s likely,” but he was uncertain about specific numbers. His company—the biggest commercial insurer in the exchanges, with 500,000 members as of the end of January—will study the demographics and medical utilization of its new members to figure that out\r\n\r\nthree-year phase-out of re-insurance and risk-corridor protections established under the ACA, said Hans Leida, a consulting actuary with Milliman. The phase-out of re-insurance would contribute about 6% to 12% in rate increases alone, spread out over the next few years. The risk-corridor program built in some certainty for insurers on the exchanges by limiting both potential gains and losses.\r\n\r\n
http://www.modernhealthcare.com
\r\n\r\nReinsurance….

Get and understand your Health Coverage now!


\r\n\r\nHere’s an attorney’s thought on why Rx have increased so much. Prescription Benefit Managers? I really wish she had citations for your statements.  constantcontact.com\r\n\r\nSibling Pages\r\n

‘,’Historical’,”,’publish’,’closed’,’closed’,”,’historical’,”,”,’2018-10-06 19:09:31′,’2018-10-06 19:09:31′,”,227,’http://individuals.healthreformquotes.com/?page_id=7729′,0,’page’,”,0),(7737,1,’2015-04-17 18:44:20′,’2015-04-17 18:44:20′,’
Resources to find out the costs of Medical Services
\r\n
Charge Master – Coding
– Optum 360
\r\n
fair health consumer.org/
\r\n
health care blue book.com
\r\n
transplant.org – costs
per transplant
\r\n
Kaiser Family Foundation
– Tons of Information
\r\n
Blue Shield\’s Make Coverage Affordable Website
\r\n \r\n\r\n
Blue Cross
2010 Medical Cost Trends 4 pages\r\n
Samples of Accidents
covered by medical insurance
\r\nLooking at premiums as an INVESTMENT, rather than an expense.’,’Tools to find costs of Health Care’,”,’publish’,’open’,’open’,”,’tools-to-find-costs-of-health-care’,”,”,’2018-10-06 19:08:24′,’2018-10-06 19:08:24′,”,462,’http://individuals.healthreformquotes.com/?page_id=7737′,0,’page’,”,0),(7756,1,’2015-05-04 17:22:12′,’2015-05-04 17:22:12′,’89.3 KPPC
4.29.2015 article
on agents who can\’t provide post sales service with Obamacare Commissions – many going out of the Health Insurance Business.\n\nSee also agent compensation for
Medi-Cal
.’,’Agent Compensation’,”,’publish’,’open’,’closed’,”,’agent-compensation’,”,”,’2017-01-05 19:08:31′,’2017-01-05 19:08:31′,”,893,’http://individuals.healthreformquotes.com/?page_id=7756′,0,’page’,”,0),(7764,1,’2015-05-07 15:46:59′,’2015-05-07 15:46:59′,’
Latest News Articles on Health Insurance Premiums
\n\n
Dozens of Insurers are asking for 2016 rate increases of more than 10 %, some as high as 26%.    The Insurance Companies now have a full year of data, not partial.  Contributing factors are emergency room, heart and cancer treatments and
specialty Rx drugs
.  Learn More ⇒Los Angeles Times 6.2.2015   See also,
Medical Loss Ratio
,
Rate Regulation
.
\n\nC
A Health Line 5.7.2015
DMHC slams Aetna for 20% rate increase\n\nSB 746 is pending to make insurers have more transparency in their rate calculations.
CA Healthline
\n\n \n\n \n\n
Other pages in this section
\n\n \n\n‘,’Latest Articles on Premiums’,”,’publish’,’open’,’closed’,”,’latest-articles-on-premiums’,”,”,’2017-01-05 19:08:31′,’2017-01-05 19:08:31′,”,227,’http://individuals.healthreformquotes.com/?page_id=7764′,0,’page’,”,0),(8010,1,’2015-09-16 18:34:49′,’2015-09-16 18:34:49′,’
This final rule sets forth payment parameters and provisions related to the risk adjustment, reinsurance, and risk corridors programs; cost sharing parameters and cost-sharing reductions; and user fees for Federally-facilitated Exchanges. It also finalizes additional standards for the individual market annual open enrollment period for the 2016 benefit year, essential health benefits, qualified health plans, network  adequacy, quality improvement strategies, the Small Business Health Options Program, guaranteed availability, guaranteed renewability, minimum essential coverage, the rate review program, the medical loss ratio program, and other related topics.
\n\n
Final Market Rules 45 CFR Parts 144, 147, 153, 154, 155, 156 and 158
\n\n ‘,’Final Market Rules 45 CFR Parts 144, 147, 153, 154, 155, 156 and 158′,”,’publish’,’closed’,’closed’,”,’final-market-rules-45-cfr-parts-144-147-153-154-155-156-and-158′,”,”,’2017-01-05 19:08:31′,’2017-01-05 19:08:31′,”,893,’http://individuals.healthreformquotes.com/?page_id=8010′,0,’page’,”,0),(8011,1,’2015-09-16 21:40:13′,’2015-09-16 21:40:13′,’
\r\n\r\n\r\n\r\n \r\n\r\n
Market Stabilization PDF\r\n\r\n
The Rule Making Process
11 pages pdf\r\n\r\n
\r\n
What is
actuarial value
and how does it affect premiums?
\r\n
The
actuarial value
of a health insurance policy is the
percentage of the total covered expenses that the plan covers, on average for a typical population
. [Age & Zip Code] For example, a plan with a 70% actuarial value means that consumers would on average pay 30% of the cost of health care expenses through features like deductibles and coinsurance. The amount that each enrollee pays will vary substantially by the amount of services they use.
\r\n
The health reform law specifies a benchmark level of coverage for the purposes of premium subsidies using actuarial values. Premium subsidies will be tied to
Silver plans
, which have an actuarial value of
70%
. Additional subsidies for people making between 100 and 250% of the poverty level limit cost sharing and raise the actuarial value of Silver plans. The
calculator
also illustrates premiums and subsidies for Bronze plans, which have an actuarial value of 60%. Bronze plans represent the minimum level of coverage most people are required to maintain under health reform, and these plans will have higher cost sharing on average. Regardless of the level of actuarial value, insurers will have to cover a
defined set of health care services
and cap the total amount of cost sharing required of consumers at defined levels, but can generally otherwise vary the structure and degree of cost sharing so long as minimum actuarial value thresholds are met.   Learn More
Kaiser Family Foundation
\r\n
Proposed Changes to CFR Code of Federal Regulations
\r\n
Executive Summary
\r\n
1.
Levels of coverage (actuarial value) (§156.140)
\r\n
Section 2707(a) of the PHS Act and section 1302 of the Affordable Care Act direct issuers of non-grandfathered individual and small group health insurance plans, including QHPs, to ensure that these plans adhere to the levels of coverage specified in section 1302(d)(1) of the Affordable Care Act. A plan’s coverage level, or actuarial value (AV), is determined based on its coverage of the EHB for a standard population. Section 1302(d)(1) of the Affordable Care Act requires a bronze plan to have an AV of 60 percent, a silver plan to have an AV of 70 percent; a gold plan to have an AV of 80 percent; and a platinum plan to have an AV of 90 percent. Section 1302(d)(2) of the Affordable Care Act directs the Secretary to issue regulations on the calculation of AV and its application to the levels of coverage. Section 1302(d)(3) of the Affordable Care Act authorizes the Secretary to develop guidelines to provide for a de minimis variation in the actuarial valuations used in determining the level of coverage of a plan to account for differences in actuarial estimates.
\r\n
In the EHB Rule, at §156.140(c), HHS established that the allowable variation in the AV of a health plan that does not result in a material difference in the true dollar value of the health plan is +/ ?2 percentage points. As finalized in the 2018 Payment Notice, §156.140(c) permits a de minimis variation of +/ ? 2 percentage points, except if a bronze health plan either covers and pays for at least one major service, other than preventive services, before the deductible or meets the requirements to be a high deductible health plan within the meaning of 26 U.S.C. 223(c)(2), the allowable variation in AV for such plan is ?2 percentage points and +5 percentage points. We established this additional flexibility for certain bronze plans in the 2018 Payment Notice to provide a balanced approach to ensure that a variety of bronze plans can be offered, including high deductible health plans, while ensuring that bronze plans can remain at least as generous as catastrophic plans. As discussed in the EHB Rule, our intention with the de minimis variation of +/?2 percentage points was to give issuers the flexibility to set cost-sharing rates that are simple and competitive while ensuring consumers can easily compare plans of similar generosity. While the de minimis range is intended to allow plans to float within a reasonable range and is not intended to freeze plan designs preventing innovation in the market, it was also intended to mitigate the need for annual plan redesign, allowing plans to retain the same plan design year to year while remaining at the same metal level.\r\nAt this time, we believe that further flexibility is needed for the AV de minimis range for metal levels to help issuers design new plans for future plan years, thereby promoting competition in the market. In addition, we believe that changing the de minimis range will allow more plans to keep their cost sharing the same from year to year. Although the AV Calculator is not a pricing tool, changing the de minimis range could also put downward pressure on premiums. Thus, we anticipate that this flexibility could encourage healthier consumers to enroll in coverage, improving the risk pool and increasing market stability. For these reasons, we believe that changing the AV de minimis range would help retain and attract issuers to the nongrandfathered individual and small group markets, which would increase competition and help consumers. Therefore, we propose amending the definition of de minimis included in §156.140(c), to a variation of – 4/+2 percentage points, rather than +/- 2 percentage points for all non-grandfathered individual and small group market plans that are required to comply with AV. Under the proposed standard, for example, a silver plan could have an AV between 66 and 72 percent. We believe that a de minimis amount of -4/+2 percentage points would provide the necessary flexibility to issuers in designing plans while striking the right balance between ensuring comparability of plans within each metal level and allowing plans the flexibility to use convenient and competitive cost-sharing metrics.
\r\n
We also note that as established at §156.135(a), to calculate the AV of a health plan, the issuer must use the AV Calculator developed and made available by HHS for the given benefit year. The AV Calculator represents an empirical estimate of the AV calculated in a manner that provides a close approximation to the actual average spending by a wide range of consumers in a standard population. For the 2018 AV Calculator, we made several key updates to the AV Calculator, including updating the claims data underlying the continuance tables that represent the standard population to reflect more current claims data. For example, all previous versions of the AV Calculator had been using 2010 (pre-Affordable Care Act) claims data and the 2018 AV Calculator is using 2015 (post-Affordable Care Act) claims data. As discussed in the 2018 AV Calculator Methodology, due to the scope and number of updates in the 2018 AV Calculator, the impact on current plans’ AVs will vary.13 Indeed, issuers have reported that the AV of 2017 plans have varied in unexpected ways when entered into the 2018 AV Calculator. Therefore, the proposed flexibility in the de minimis range is also intended to help provide some stability to those plans that are being impacted by the updates to the AV Calculator.
\r\n
We are
proposing
to provide the increased flexibility in the de minimis range starting with the 2018 AV Calculator. We seek comment on whether making the change effective for the 2019 plan year would be preferable, given the lead time issuers require to design plans.
\r\n
While we are proposing to modify the de minimis range for the metal level plans (bronze, silver, gold, and platinum), we are not proposing to modify the de minimis range for the silver plan variations (the plans with an AV of 73, 87 and 94 percent) under §§156.400 and 156.420 at this time. The de minimis variation for a silver plan variation of a single percentage point would still apply. In the Actuarial Value and Cost-Sharing Reductions Bulletin we issued on February\r\n24, 2012,14 we explained why we did not intend to require issuers to offer a cost-sharing
\r\n
13 2018 AV Calculator Methodology is available at https://www.cms.gov/cciio/resources/regulations-andguidance/#Plan.\r\n14 Available at https://www.cms.gov/CCIIO/Resources/Files/Downloads/Av-csr-bulletin.pdf.\r\nreduction plan variation with an AV of 70. However, given our proposal, we also are considering whether the ability for an issuer to offer a standard silver level plan at an AV of 66 would require a plan variation to be offered at an AV of 70 or some other mechanism to provide for cost-sharing reductions for eligible individuals with household incomes that are more than\r\n250 percent but not more than 400 percent of the poverty line for a family of the size involved.\r\nWe also would maintain the bronze plan de minimis range policy finalized in the 2018 Payment Notice at §156.140(c) with one modification. We propose to change the de minimis range for the expanded bronze plans from +5/-2 percentage points to +5/-4 percentage points to align with the policy in this rule. Therefore, for those bronze plans that either cover and pay for at least one major service, other than preventive services, before the deductible or meet the requirements to be a high deductible health plan within the meaning of 26 U.S.C. 223(c)(2), we are proposing the allowable variation in AV would be ?4 percentage points and +5 percentage\r\npoints. 10\r\nWe seek comment on this proposal, including on the appropriate de minimis values for metal level plans and silver plan variations, and whether those values should differ when increasing or decreasing AV.
\r\n
To implement the amended AV de minimis range in this proposed rule, we would update the 2018 AV Calculator in accordance with this policy.
\r\n
7. Section 156.140 is amended by revising paragraph (c) to read as follows:\r\n§156.140 Levels of coverage.\r\n* * * * *\r\n(c) De minimis variation. The allowable variation in the AV of a health plan that does not result in a material difference in the true dollar value of the health plan is –
4 percentage points and + 2 percentage points
, except if a health plan under paragraph (b)(1) of this section (a bronze health plan) either covers and pays for at least one major service, other than preventive services, before the deductible or meets the requirements to be a high deductible health plan within the meaning of 26 U.S.C. 223(c)(2), in which case the allowable variation in AV for such plan is ?4 percentage points and +5 percentage points.
\r\n
Related Pages in the
Metal Levels – Platinum, Gold, Bronze – Silver & Enhanced
»\r\n
80% Medical Loss Ratio (MLR)
»
CA Rate Regulation
Section
\r\n
Donald Care on Market Stabilzation
– Actuaril Value
\r\n
\r\n
‘,’Actuarial Value’,”,’publish’,’open’,’closed’,”,’actuarial-value’,”,”,’2017-05-03 03:14:20′,’2017-05-03 03:14:20′,”,7577,’http://individuals.healthreformquotes.com/?page_id=8011′,0,’page’,”,0),(8014,1,’2016-05-10 08:59:09′,’2016-05-10 08:59:09′,’
The Agents Role – Part in the Medical Loss Ratio Calculation
\r\n
Loss of Agent Services under Health Care Reform? Forbes 6.29.2012
\r\n
\r\n
MLR
(Medical Loss Ratio)   define their commissions as part of the medical expense and failed.  The argument by insurance agents was a senseless argument.  healthcare exchanges under the new law.
\r\n
These exchanges are not yet up and running but it is easy to picture them to be akin to Amazon.com (AMZN) by necessity and by law, insurance companies will have to display their products in easy to understand and easy to compare formats.  In some ways, the migration will be similar to the migration of retail from the likes of
Best Buy
(BBY), Barnes &
Noble
(BKS), and Borders to Amazon.com.  At least in retail there are numerous good reasons for the masses to go to the brick and mortar stores. With regard to health insurance the argument for procurement through agents is very weak.
Forbes
\r\n
The hope of the insurance agents had risen because of the recent backing  by the National Association of Insurance Commissioners.
\r\n
In a recent ruling, the Department of Health and Human Services dashed all hopes.
\r\n
Now the only hope left is
H.R.1206, the Professional Health Insurance Advisors Act
, a pending bill in Congress that would exclude compensation paid to independent insurance producers for the purposes of MLR.
forbes.com
\r\n
THE MEMBERS OF THE NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS, THEREFORE RESOLVE THAT:
\r\n
Congress should expeditiously consider legislation amending the MLR provisions of the PPACA in order to preserve consumer access to agents and brokers, and;
\r\n
The Department of Health and Human Services should take whatever immediate actions are available to the Department to mitigate the adverse effects the MLR rule is having on the ability of insurance producers to serve the demands and needs of consumers and to more appropriately classify producer compensation in the final PPACA MLR rule.
naic.org
\r\n
The insurer has no incentive to operate more efficiently or to reduce premiums. Companies would pay brokers as much or as little as they want because any amount would be paid from increased premiums, and the 7.2 points of \”excess\” MLR could be shaved to please investors by further raising premiums.
\r\n
The impact of the broker payment exclusion cannot be considered in a vacuum.
\r\n
If broker commissions are not subject to those limits, insurance companies have every incentive to shift as much administrative burden to brokers as they can, because broker commissions would be subject to no limits.
naic.org/
\r\n \r\n
Main Benefits of Broker Page
, Sibling and Child Pages
\r\n
\r\n
‘,’Medical Loss Ratio – Agent Role’,”,’publish’,’open’,’closed’,”,’medical-loss-ratio-agent-role’,”,”,’2017-01-05 19:08:31′,’2017-01-05 19:08:31′,”,7756,’http://healthlaw.healthreformquotes.com/?page_id=8014′,0,’page’,”,0),(8015,1,’2016-05-10 09:01:06′,’2016-05-10 09:01:06′,’
\r\n\r\n
\r\n\r\n
Sample Appeal Letter – 62 page guide – DOI Washington State\r\n\r\n
\r\n
The process of
\r\n\r\n
appeals & grievances
\r\n
gets very technical, legal, etc.  I won\’t even attempt to summarize it here.  Please
follow the links below
, check your policy – evidence of coverage and check the law.
\r\n
Medical Procedures
?
\r\n
Was your procedure
Medically  Necessary
?
\r\n
Blue Cross Clinical UM (Utilization Management) Guidelines
,
\r\n
Did you use the Correct
MD or hospital – Provider List
and
\r\n
Did you Review the procedures in your actual policy, evidence of coverage?
\r\n
Here\’s a
sample Speciment EOC Evidence of Coverage – Platinum Plan
Page 151
\r\n \r\n\r\n \r\n
Reasons why the Claim might be denied
\r\n
Did you tell the truth on your application?
\r\n
How does the Insurance Company know, if the application wasn\’t filled out correctly?\r\nHere\’s where they
write to your MD
, before a claim is even turned in.
\r\n\r\n
Billing Codes
– Satire or how it really works?\r\n

\r\n

Consumer Links
\r\n\r\n
\r\n
\r\n
\r\n
\r\n\r\nMaytag Repairman\r\n\r\n
Gather documents, cancelled checks, warnings, late notice, emails, phone logs\r\n\r\n \r\n
\r\n\r\n
Navigating the Appeals Process – Patient Advocate Foundation\r\n\r\n
Specimen EOC Evidence of Coverage – Appeals – Grievances\r\n\r\n\r\n\r\n Understanding what you pay and when
\r\n
\r\n
\r\n
\r\n
Grievance procedures
Free Advise.com
\r\n\r\n
Insurer\’s Bad Faith
\r\n\r\nFree Advice.com
WHAT IS THE APPEALS AND GRIEVANCE PROCESS LIKE?
\r\n\r\nBlue Cross Specimen Policy –
Sample Appeals Procedures
Page 151\r\n\r\nHow to gather documents to prove your case –
Small Claims Manual
\r\n
Prove you never got a letter
?
\r\n
How to tell your story, timeline and background –
actual attorney brief
to the court.
\r\nHow to create a
TIMELINE in Word, Excel, PowerPoint
\r\n\r\n
Fines against PacifiCare for improper claims handling 1/30/2008
CHFC
\r\n\r\n
Health Net faces suit over refusal to cover treatments
LA Times 9.13.2012
\r\n\r\n
Appeal Guide – Washington State
62 pages pdf\r\n\r\n
Todd Friedman, Esq.
can help if debt collectors are harassing you when you don\’t owe the $$$\r\n
Insurance Company & Regulatory Agency Grievance Procedures & Forms\r\n
\r\n
K
aiser, & Blue Shield Grievance Form
s
\r\n
Aetna
\r\n\r\n
Blue Cross
Grievance Procedures
\r\n
Notice
\r\nBlue Shield – General Info.
Appeals & Grievances

PO Box 629007
El Dorado Hills , CA 95762 – 9007  Fax: (916) 350 – 7585
\r\n\r\n
CA Department of Insurance

\r\n
IMR – Independent Medical Review

\r\n

\r\n
Enforcement
\r\n
Anthem Blue Cross Fined $415K since the California Department of Managed Health Care said it found 40 cases in which Anthem deprived members of their grievance and appeal rights. –
CA Healthline 5.3.2016
\r\n \r\n
\r\n
Other Pages in
Appeals & Grievances
Section
\r\n
Medicare Appeals & Grievances
\r\n
I
nsure Me Kevin.co
m
\r\n
\r\n
Historical
\r\n
Blue Cross Summary 6/2011
on how Health Care Reform mandates will be complied with
\r\n
Blue Cross Anthem Summary 10/22/2010
\r\n\r\n
Anthem Blue Cross Fact Sheet
\r\n\r\n

\r\n\r\n
CA Small Claims Court Guide
56 Pages\r\n\r\n
‘,’Appeal & Grievances?’,”,’publish’,’open’,’closed’,”,’appeal-grievances’,”,”,’2018-11-01 14:01:19′,’2018-11-01 14:01:19′,”,0,’http://healthlaw.healthreformquotes.com/?page_id=8015′,0,’page’,”,5),(8016,1,’2016-05-10 09:06:20′,’2016-05-10 09:06:20′,’
Technical Links – Appeals & Grievances
\r\n
Page 19 Section §2719 of Health Care Reform -Appeals Process
\r\n
45 CFR Part 147
Interim Final Rules for Group Health Plans and Health Insurance Issuers – Appeals\r\n
\r\n
§ 147.136 — Internal claims and appeals and external review processes.
\r\n\r\n
7/26/2011

Final Rules

EBSA

Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals and External Review Processes; Correction
[PDF]\r\n\r\nMore Final Rules for EBSA\r\n\r\n
§10123.13. (a) Every insurer…shall reimburse claims …, whether in state or out of state, … as soon as practical, but no later than 30 working days after receipt…
\r\n\r\n(b) If an uncontested claim is not reimbursed … within 30 working days…interest shall accrue and shall be payable at the rate of 10 percent per annum …\r\n\r\nSearch & Find
CPT Current Procedural Terminology codes and their relative values at
CPT Code/Value Search
– Medicare Billing Codes
This is a free site for patients and consumers.
\r\n
See also
Medical Necessity
\r\n
California Insurance Code
§
790.03 (h)
Knowingly committing or performing with such frequency as to indicate a general business practice any of the following
unfair claims settlement practices:

Calif. Code of Regulations TITLE 10. CHAPTER 5 ADOPT SUBCHAPTER 7.5 with new 2004 amendments
on CA Department of Insurance Site
\r\n
(1) Misrepresenting to claimants pertinent facts or insurance policy provisions relating to any coverage\’s at issue.\r\n(2) Failing to acknowledge and act reasonably promptly upon communications with respect to claims arising under insurance policies.\r\n(3) Failing to adopt and implement reasonable standards for the prompt investigation and processing of claims arising under insurance policies.\r\n(4) Failing to affirm or deny coverage of claims within a reasonable time after proof of loss requirements have been completed and submitted by the insured.
\r\n
(5) Not attempting in good faith to effectuate prompt, fair, and equitable settlements of claims in which liability has become reasonably clear.\r\n(6) Compelling insured\’s to institute litigation to recover amounts due under an insurance policy by offering substantially less than the amounts ultimately recovered in actions brought by the insured\’s, when the insured\’s have made claims for amounts reasonably similar to the amounts ultimately recovered.\r\n(7) Attempting to settle a claim by an insured for less than the amount to which a reasonable person would have believed he or she was entitled by reference to written or printed advertising material accompanying or made part of an application.\r\n(8) Attempting to settle claims on the basis of an application which was altered without notice to, or knowledge or consent of, the insured, his or her representative, agent, or broker.\r\n(9) Failing, after payment of a claim, to inform insured\’s or beneficiaries, upon request by them, of the coverage under which payment has been made.\r\n(10) Making known to insured\’s or claimants a practice of the insurer of appealing from arbitration awards in favor of insured\’s or claimants for the purpose of compelling them to accept settlements or compromises less than the amount awarded in arbitration.\r\n(11) Delaying the investigation or payment of claims by requiring an insured, claimant, or the physician of either, to submit a preliminary claim report, and then requiring the subsequent submission of formal proof of loss forms, both of which submissions contain substantially the same information.\r\n(12) Failing to settle claims promptly, where liability has become apparent, under one portion of the insurance policy coverage in order to influence settlements under other portions of the insurance policy coverage.\r\n(13) Failing to provide promptly a reasonable explanation of the basis relied on in the insurance policy, in relation to the facts or applicable law, for the denial of a claim or for the offer of a compromise settlement.\r\n(14) Directly advising a claimant not to obtain the services of an attorney.\r\n(15) Misleading a claimant as to the applicable statute of limitations.\r\n(16) Delaying the payment or provision of hospital, medical, or surgical benefits for services provided with respect to acquired immune deficiency syndrome or AIDS-related complex for more than 60 days after the insurer has received a claim for those benefits, where the delay in claim payment is for the purpose of investigating whether the condition preexisted the coverage. However, this 60-day period shall not include any time during which the insurer is awaiting a response for relevant medical information from a health care provider.\r\n(i) Canceling or refusing to renew a policy in violation of Section 676.10.
\r\n
Main Appeals & Grievances Page
– Other Pages in this Section
\r\n

\r\n
‘,’Technical Links – Appeals & Grievances’,”,’publish’,’closed’,’closed’,”,’technical-links-appeals-grievances’,”,”,’2018-10-06 18:44:17′,’2018-10-06 18:44:17′,”,8015,’http://healthlaw.healthreformquotes.com/?page_id=8016′,0,’page’,”,0),(8017,1,’2016-05-10 09:07:01′,’2016-05-10 09:07:01′,’
\r\n\r\n
Covered CA Appeals Form\r\n\r\n
\r\n
How do I file a Covered CA Appeal?
\r\n
Check out the forms and procedures on Covered CA\’s website, the materials below and to the right, our main page on
Appeal & Grievances?
and the child & sibling pages.
\r\n
Appeals Procedure on Covered CA\’s Website
\r\n
Eligibility Grievance Form
Rev 7.2016
\r\n
We also need you to
write out your story
and including all the proofs – evidence & exhibits. See also our
main page on appeals
, namely
how to gather your evidence and exhibits
.   Here\’s an
example of a decision
from the Administrative Law Judge for Covered CA.
\r\nWe
might
be able to help you
appeal
(click for form)

errors in your application
, IF you appoint us (Steve Shorr) as your Certified Insurance Agent, by
following these instructions
as we are paid by Covered CA to help you, if you ask them to!\r\n
\r\n
\r\n
\r\n
\r\n\r\n
Sample Letter for Appeal\r\n\r\n \r\n
\r\n\r\n
Covered CA Appeals Decision\r\n\r\n \r\n
\r\n
\r\n
\r\n \r\n
Subpart F—Appeals of Eligibility Determinations for Exchange Participation and Insurance Affordability Programs
\r\n
§155.500   Definitions.
\r\n
§155.505   General eligibility appeals requirements.
\r\n
§155.510   Appeals coordination.
\r\n
§155.515   Notice of appeal procedures.
\r\n
§155.520   Appeal requests.
\r\n
§155.525   Eligibility pending appeal.
\r\n
§155.530   Dismissals.
\r\n
§155.535   Informal resolution and hearing requirements.
\r\n
§155.540   Expedited appeals.
\r\n
§155.545   Appeal decisions.
\r\n
§155.550   Appeal record.
\r\n
§155.555   Employer appeals process.
\r\nJuly 23, 2010 OCIIO-9993-IFC: Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Internal Claims and Appeals and External Review Processes Under the Patient Protection and Affordable Care Act – Opens in a new window (PDF – 257 KB)\r\n
\r\n
June 22, 2011
CMS-9993-IFC2: Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals and External Review Processes – Opens in a new window
\r\n
July 26, 2011
CMS-9993-CN: Group Health Plans and Health Insurance Issuers: Rules Relating to Internal Claims and Appeals and External Review Processes; Correction – Opens in a new window
(PDF – 184 KB)
\r\n
\r\n
Resources, Child Pages & Links
\r\n
I
nsure Me Kevin.co
m
\r\n
Prove you never got a letter
?
\r\n
Medicare Appeals & Grievances
\r\n
Medical Necessity Grievances
\r\n
\r\n \r\n
Historical
\r\n
Their service is the worst I have seen since earning my Degree in Insurance at San Diego State University in 1975.  I learned the word SNAFU from a guy I knew in the Dorm.  This is the first time, I\’ve been able to use the word in \”real\” life.   Please note how many of the 8,000 certified agents are now refusing to deal with Covered CA.  See screen shots below from Ehealth Insurance and another agent.  It\’s twice the work, for less than 1/2 of what we were paid last year and \”criminal\” support and customer service!
\r\n
However, if you qualify for
Medi-Cal
we do not get compensated and it appears we are supposed to refer you to your
local County
Medi Cal Agency.
\r\n
Hurry, we may well soon be FORCED to
charge a fee for appeals and consultation
for Covered CA.
\r\n
1.29.2015 Update – Through the Covered CA Agent Portal & Email, I\’m now getting pretty good service & response.
\r\n\r\n\r\nOne of our friendly competitors is leaving the market\r\n

\r\n \r\n\r\n \r\n\r\n ‘,’Covered CA Appeals’,”,’publish’,’open’,’closed’,”,’covered-ca-appeals’,”,”,’2018-10-06 18:41:21′,’2018-10-06 18:41:21′,”,8015,’http://healthlaw.healthreformquotes.com/?page_id=8017′,0,’page’,”,0),(8018,1,’2016-05-10 09:07:35′,’2016-05-10 09:07:35′,’
What happens when one enrolls in a plan shown on the exchange, but doesn\’t really exist?
\r\n
These screen shots show that Covered CA quoted a woman born February 1958 and lives in Zip Code 90732  to be able to enroll in a
Blue Cross HMO plan
which doesn\’t exist!   Check this out on
Quotit
and
Blue Cross
.  We\’ve emailed Covered CA, etc.  asking for an explanation.  They are welcome to reply in the comments section.
\r\n
Is the
7.1 million enrollments
calculated like million man math (
Mad TV Video

Wikipedia
) ?
\r\n
Here\’s a response from Blue Cross – We are offering
HMO plans
, however we experienced a glitch with the online process and temporarily turned if off, I\’ll check and see if it\’s back up and running.
\r\n
\r\n

\r\n
\r\n

‘,’Enrollment in non existant plans?’,”,’publish’,’closed’,’closed’,”,’enrollment-non-existant-plans’,”,”,’2017-01-05 19:08:31′,’2017-01-05 19:08:31′,”,8017,’http://healthlaw.healthreformquotes.com/?page_id=8018′,0,’page’,”,0),(8019,1,’2016-05-10 09:08:02′,’2016-05-10 09:08:02′,’
\r\n\r\n
Sample Complaint to Department of Insurance\r\n\r\n
\r\n
Sample Grievance Letters we\’ve written
\r\n
Confusing Employee Enrollment Forms
\r\n
Balance Billing Problem
\r\n
We would
charge
a non client maybe $150 to draft something like this.  Please note we are NOT
attorneys
and cannot give legal advise or represent you in court.
\r\n
wikipedia.org
\r\n
We love to  help.
We enjoy our clients inquiries via
email
and scanned documents in .pdf.  Otherwise, we are like the Maytag Repairman waiting for problems to solve.
\r\n
Main Appeals & Grievances Page
– Other Pages in this Section
\r\n

\r\n
‘,’How we can help you with your grievance’,”,’publish’,’open’,’closed’,”,’steve-shorr-insurance-can-help’,”,”,’2017-09-09 10:20:56′,’2017-09-09 10:20:56′,”,8015,’http://healthlaw.healthreformquotes.com/?page_id=8019′,0,’page’,”,0),(8020,1,’2016-05-22 18:21:36′,’2016-05-22 18:21:36′,’Gather documents, cancelled checks, warnings, late notice, emails, phone logs’,’gather.documents’,’Gather documents, cancelled checks, warnings, late notice, emails, phone logs’,’inherit’,’open’,’closed’,”,’gather-documents’,”,”,’2016-05-22 18:22:03′,’2016-05-22 18:22:03′,”,8015,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2016/05/gather.documents.jpg’,0,’attachment’,’image/jpeg’,0),(8022,1,’2016-05-27 13:24:14′,’2016-05-27 13:24:14′,”,’SMFBadge_English[1]’,”,’inherit’,’open’,’closed’,”,’smfbadge_english1′,”,”,’2016-05-27 13:24:14′,’2016-05-27 13:24:14′,”,157,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2016/05/SMFBadge_English1.gif’,0,’attachment’,’image/gif’,0),(8026,1,’2016-06-04 15:52:46′,’2016-06-04 15:52:46′,’Covered CA Appeals Form’,’appeals.form’,’Covered CA Appeals Form’,’inherit’,’open’,’closed’,”,’appeals-form’,”,”,’2016-06-04 15:53:17′,’2016-06-04 15:53:17′,”,8017,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2016/05/appeals.form_.jpg’,0,’attachment’,’image/jpeg’,0),(8027,1,’2016-06-05 14:41:26′,’2016-06-05 14:41:26′,’Covered CA Appeals Decision’,’proposed.decesion’,’Covered CA Appeals Decision’,’inherit’,’open’,’closed’,”,’proposed-decesion’,”,”,’2016-06-05 14:43:42′,’2016-06-05 14:43:42′,”,8017,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2016/05/proposed.decesion.jpg’,0,’attachment’,’image/jpeg’,0),(8028,1,’2016-06-05 14:45:25′,’2016-06-05 14:45:25′,’Sample Letter for Appeal’,’statement.of.facts’,’Sample Letter for Appeal’,’inherit’,’open’,’closed’,”,’statement-of-facts’,”,”,’2016-06-05 14:46:28′,’2016-06-05 14:46:28′,”,8017,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2016/05/statement.of_.facts_.jpg’,0,’attachment’,’image/jpeg’,0),(8030,1,’2016-06-08 16:31:28′,’2016-06-08 16:31:28′,’
Patriot Act
\r\n\r\n
Insurance Companies required to establish Anti Money Laundering Programs
\r\n
\r\n
Placement is the initial stage in which money from criminal activities is placed in financial institutions. One of the most common methods of placement is structuring—breaking up currency transactions into portions that fall below the reporting threshold for the specific purpose of avoiding reporting or recordkeeping requirements. Because most carriers do not accept cash payments, insurance producers should be on the lookout for cash equivalents. Gene’s opening of multiple accounts and making payments with bank checks of less than $10,000 are examples of placement and structuring.
\r\n
Layering is the process of conducting a complex series of financial transactions, with the purpose of hiding the origin of money from criminal activity and hindering any attempt to trace the funds. In this scenario, Gene’s movement of money between accounts and his exercise of the 10-day free-look provision are examples of layering.
\r\n
Integration is the final stage in which an apparently legitimate transaction is used to return the now-laundered funds back to the criminal. Gene’s request to take redemptions from his mutual funds is considered integration as he now has checks from financial institutions.
knowledge.limra.com
\r\n
‘,’Money Laundering’,”,’publish’,’open’,’closed’,”,’money-laundering’,”,”,’2017-01-05 19:08:32′,’2017-01-05 19:08:32′,”,157,’http://healthlaw.healthreformquotes.com/?page_id=8030′,0,’page’,”,0),(8033,1,’2016-06-17 21:06:36′,’2016-06-17 21:06:36′,’
\r\n\r\n
Questions to ask that could cause a plan to lose grandfathering\r\n\r\n
\r\n
If you
change to a different plan
, but with the same Insurance Company and the same rules in your Employee Handbook,
is the plan still grandfathered
?
\r\n
***
Grandfathering means
that if your coverage was in place on 9.23.2010, when the
Affordable Care Act
was enacted, President Obama promised that you could keep it, as long as there were no
“major” changes
to you coverage.  See
8 Questions
to see.
Learn More
\r\n
******
\r\n
We have, per our [
Employee] Handbook
, carved out a [
Management] carve outs
, class of covered employees.  this has been in force well before 2010
\r\n
We are a small business,  less than 10 employees
\r\n
the covered employees have always been just 2.  One of the employees recently went into
medicare
.  since needed 2 employees to make a group
\r\n
***That\’s not exactly correct, see
§10753
(q) (1) “Small employer”
\r\n
we converted to an
individual plan
for the remaining employee.  The plan stayed with the
same insurance co.
but not in our companies name.
\r\n
So, would this still be be considered “
grandfathered
?
\r\n
***No.  Sounds like major changes to me.   Check this links for details about cutting or lowering coverage, coinsurance, payments, deductibles, employer contributions, annual limits.
HealthCare.gov
*
BlueShieldCA.com
*
Our Page on Grandfathering
*
HN Flyer
\r\n
While it doesn\’t appear that
Salary Discrimination under Section 2716
is being enforced, you can\’t call an Individual Plan a Group plan,
nor can your company take the deduction
under IRC
Section 106
!
\r\n \r\n
Related Pages in
Grand Fathered Plans
Section
\r\n\r\n\r\n\r\n
Blue Shield
\r\n\r\n
\r\n
Grand Fathered Plan – Non Renewal
\r\n
\r\n
Blue Shield Grandfathering WebPage   FAQ
4.1.2015 one time 25% credit on monthly bill
\r\n
Blue Cross
\r\n\r\n
\r\n
Grandfathered Plans – Non Renewal 2.2018
\r\n
Which plans are grandfathered?
\r\n
\r\n

Grand Fathered 4.2017 Rate Change

\r\n

\r\n
Grandfathered April 2016 Rate Increase
\r\n
\r\n
Grandfathered Plan vs 2017 Offerings?
\r\n
\r\n
\r\n

\r\n
\r\n
\r\n
\r\n
\r\n \r\n
‘,’Grandfathered if plans changed?’,”,’publish’,’open’,’closed’,”,’grandfathered-plans-changed’,”,”,’2018-07-20 17:16:16′,’2018-07-20 17:16:16′,”,158,’http://healthlaw.healthreformquotes.com/?page_id=8033′,0,’page’,”,0),(8035,1,’2016-06-17 21:58:22′,’2016-06-17 21:58:22′,’Questions to ask that could cause a plan to lose grandfathering’,’health.net.grandfathering’,’Questions to ask that could cause a plan to lose grandfathering’,’inherit’,’open’,’closed’,”,’health-net-grandfathering’,”,”,’2016-06-17 21:58:56′,’2016-06-17 21:58:56′,”,8033,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2016/06/health.net_.grandfathering.jpg’,0,’attachment’,’image/jpeg’,0),(8037,1,’2016-06-24 17:53:52′,’2016-06-24 17:53:52′,’
Repeals and challenges to Obamacare are fading
LA Times 6.21.2016
\r\n
Pending Legal/Constitutional Challenges
us health policy gateway.com
\r\n
Child Pages
\r\n
Supreme Court – FINAL Ruling – King vs Burwell Subsidies Upheld in Federal Exchange
\r\n\r\n‘,’Challenges to ObamaCare’,”,’publish’,’open’,’closed’,”,’challenges-to-obamacare’,”,”,’2017-04-19 12:06:37′,’2017-04-19 12:06:37′,”,8129,’http://healthlaw.healthreformquotes.com/?page_id=8037′,0,’page’,”,0),(8040,1,’2016-06-24 18:10:27′,’2016-06-24 18:10:27′,’A Better Way – Republication Ideas to Improve Health Care’,’better.way’,’A Better Way – Republication Ideas to Improve Health Care’,’inherit’,’open’,’closed’,”,’better-way’,”,”,’2016-06-24 18:11:17′,’2016-06-24 18:11:17′,”,8037,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2016/06/better.way_.jpg’,0,’attachment’,’image/jpeg’,0),(8044,1,’2016-07-01 13:53:31′,’2016-07-01 13:53:31′,”,’Contact Us’,’[email protected] 310.519.1335′,’publish’,’closed’,’closed’,”,’contact-us’,”,”,’2016-11-09 16:07:18′,’2016-11-09 16:07:18′,”,0,’http://healthlaw.healthreformquotes.com/?p=8044′,14,’nav_menu_item’,”,0),(8053,1,’2016-07-17 18:09:23′,’2016-07-17 18:09:23′,’ ‘,”,’Insurance Companies must pay at last 80% in medical claims and can keep 20% for profit and administrative expense’,’publish’,’closed’,’closed’,”,’8053′,”,”,’2016-11-09 16:07:18′,’2016-11-09 16:07:18′,”,0,’http://healthlaw.healthreformquotes.com/?p=8053′,3,’nav_menu_item’,”,0),(8054,1,’2016-07-17 18:11:52′,’2016-07-17 18:11:52′,”,’Dual Coverage – Who pays 1st? Collect Twice?’,”,’publish’,’closed’,’closed’,”,’dual-coverage-who-pays-1st-collect-twice’,”,”,’2016-11-09 16:07:18′,’2016-11-09 16:07:18′,”,457,’http://healthlaw.healthreformquotes.com/?p=8054′,4,’nav_menu_item’,”,0),(8055,1,’2016-07-17 20:14:46′,’2016-07-17 20:14:46′,’ ‘,”,”,’publish’,’closed’,’closed’,”,’8055′,”,”,’2016-11-09 16:07:18′,’2016-11-09 16:07:18′,”,12,’http://healthlaw.healthreformquotes.com/?p=8055′,5,’nav_menu_item’,”,0),(8056,1,’2016-07-17 20:14:46′,’2016-07-17 20:14:46′,”,’Appeal & Grievances?’,”,’publish’,’closed’,’closed’,”,’appeal-grievances’,”,”,’2016-11-09 16:07:18′,’2016-11-09 16:07:18′,”,0,’http://healthlaw.healthreformquotes.com/?p=8056′,6,’nav_menu_item’,”,0),(8058,1,’2017-01-05 19:08:30′,’0000-00-00 00:00:00′,”,’2017 Individual & Family Rate Increase’,”,’draft’,’closed’,’closed’,”,”,”,”,’2017-01-05 19:08:30′,’2017-01-05 19:08:30′,”,0,’http://healthlaw.healthreformquotes.com/?page_id=8058′,0,’page’,”,0),(8059,1,’2016-08-08 22:38:49′,’2016-08-08 22:38:49′,’
What are the rules with dual coverage in regards to\r\nCOBRA for the husband & a group plan for wife?
\r\nThe Primary (person A)\r\n
***[How do I know, who is primary? I need to see the documents] \r\n
If you are covered as an employee, member or subscriber under more than one plan, but are covered under state or federal continuation (COBRA) under one of the plans, then:
\r\n
The plan covering you as an employee, member or subscriber is
primary over
the plan covering you under state or federal continuation (
COBRA
).
illinois.gov
\r\nhas health insurance through their job, loses job, continues COBRA coverage for the family, meets the maximum deductible of $4000, [individual and/or family deductible] they have 0% out of pocket expenses now except for the
monthly premium of $1,442
.\r\n\r\nMid-year the
spouse
(person B) now
gets a job with health insurance coverage
through their employer.\r\n\r\nThe premium is much less $338, deductible of $3,000 with 80% coverage for in-network.\r\n\r\nIf they cancel the COBRA, then they pay a new deductible +20% of medical charges incurred. If they overlap and have dual-coverage, then they are really paying extra money for the second medical plan $338/month with little benefit\r\n
***I don\’t quite follow, sounds like more benefit
\r\n-since they\’ve met their deductible and pay 0% out of pocket.\r\n\r\nWhat if the family has dual coverage for 1 month, then after the second month they cancel COBRA?\r\n\r\nDo they still have to meet the new deductible of $3,000?\r\n
***I\’d have to see the new policy. I doubt there is any take over provision.  Thus, yes.
\r\nDoes the insurance company only look at charges that have occurred within that month of dual coverage in order to determine if deductible B $3,000 has been met?\r\n
***Deciding what medical bills go to the deductible has nothing to do with having other coverage.
\r\nHow do they determine when it\’s beneficial to have dual coverage?\r\n
***The Insurance Company doesn\’t decide if it\’s better for you. That\’s your decision. Why pay $1,442 to have dual coverage? In two months, you have the $3k deductible taken care of.  Also, the $338 contribution as the employer is paying the rest of the premium, is probably tax deductible, if the employer has set up a
Section 125 POP Plan
.
‘,’COBRA and Spousal Coverage – Two inforce policies – Web Vistor Q & A’,”,’publish’,’open’,’closed’,”,’8059-2′,”,”,’2017-08-26 14:12:42′,’2017-08-26 14:12:42′,”,5521,’http://healthlaw.healthreformquotes.com/?page_id=8059′,0,’page’,”,0),(8062,1,’2016-09-05 14:43:30′,’2016-09-05 14:43:30′,’California
Statutes are the Chaptered Bills
. A bill is \”chaptered\” by the Secretary of State after it has passed through both houses of the Legislature and has been
signed by the Governor
or becomes law without the Governor\’s signature. Statutes are available starting from 1993.
Legal.info.ca.gov
\r\n
\r\n
ENROLLED BILL
\r\n
Whenever a bill passes both Houses of the Legislature, it is ordered enrolled. Upon enrollment, the bill is again proofread for accuracy and then delivered to the Governor. The enrolled bill contains the complete text of the bill with the dates of passage certified by the Chief Clerk of the Assembly and the Secretary of the Senate.
Legal info.CA.Gov
\r\n
‘,’Chaptered – Enrolled’,”,’publish’,’open’,’closed’,”,’chaptered-enrolled’,”,”,’2017-04-06 00:17:02′,’2017-04-06 00:17:02′,”,28,’http://healthlaw.healthreformquotes.com/?page_id=8062′,0,’page’,”,0),(8064,1,’2016-09-12 17:53:27′,’2016-09-12 17:53:27′,’ ‘,”,’Read the law 3 times and then when you think you understand it, read it again’,’publish’,’closed’,’closed’,”,’8064′,”,”,’2016-11-09 16:07:18′,’2016-11-09 16:07:18′,”,0,’http://healthlaw.healthreformquotes.com/?p=8064′,7,’nav_menu_item’,”,0),(8068,1,’2016-09-30 17:52:58′,’2016-09-30 17:52:58′,’Sample Appeal Letter ‘,’sample-appeal-letter’,’Sample Appeal Letter ‘,’inherit’,’open’,’closed’,”,’sample-appeal-letter’,”,”,’2016-09-30 17:53:33′,’2016-09-30 17:53:33′,”,8015,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2016/05/sample.appeal.letter.jpg’,0,’attachment’,’image/jpeg’,0),(8069,1,’2016-09-30 17:58:27′,’2016-09-30 17:58:27′,’Navigating the Appeals Process – Patient Advocate Foundation’,’appeals-procedure-manual-patient-advocate’,’Navigating the Appeals Process – Patient Advocate Foundation’,’inherit’,’open’,’closed’,”,’appeals-procedure-manual-patient-advocate’,”,”,’2016-09-30 17:59:19′,’2016-09-30 17:59:19′,”,8015,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2016/05/Appeals.procedure.manual.patient.advocate.jpg’,0,’attachment’,’image/jpeg’,0),(8076,1,’2016-11-15 15:57:51′,’2016-11-15 15:57:51′,’CA Health Line’,’ca-health-line’,’CA Health Line’,’inherit’,’open’,’closed’,”,’ca-health-line’,”,”,’2016-11-15 15:58:24′,’2016-11-15 15:58:24′,”,8037,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2016/06/ca.health.line_.jpg’,0,’attachment’,’image/jpeg’,0),(8078,1,’2016-11-16 21:52:07′,’2016-11-16 21:52:07′,’
This wildest presidential election possibly ever is now in the books. Donald Trump, a man who has never held political office and has no military background, stands ready to head to the Oval Office in roughly two months to become the 45th president of the United States.
\r\n
But what\’s most notable about this election is that the Republican Party also held on to the majority of both houses of Congress. This essentially means that we have a government unified under a single party, which could allow for new laws to be passed with greater ease compared with the Washington gridlock we\’ve witnessed for many years.
\r\n
According to President-elect Trump, who released his 100-day plan once he\’s in office shortly after his victory, repealing and replacing Obamacare (officially known as the Affordable Care Act), the flagship healthcare law of Barack Obama\’s presidency, sits near the top of his list. With a Congressional majority that has also shared an unfavorable view of Obamacare behind him, a repeal and replace seems quite possible.
\r\n\r\n
Donald Care – Trumpcare vs. Obamacare
\r\n
What might \”Trumpcare,\” as we\’ll affably call it, look like next to Obamacare? Let\’s take a closer look by examining Trump\’s seven-point plan.
\r\n\r\n
1. Repeal Obamacare
\r\n
The first point, which needs no comparison, involves repealing and
replacing Obamacare in its entirety
. Chances are that any sort of repeal and replace
wouldn\’t involve a sudden loss of insurance
for the millions of Americans currently insured through Obamacare. More than likely we\’d see a
one- or two-year transition
away from Obamacare and toward Donald Care – Trumpcare.
\r\n\r\n
2. Allow insurance to be purchased across state lines
\r\n
Trumpcare
: Under Trump\’s proposal, consumers would be allowed to shop for health insurance beyond just the boundaries of their state. The idea is that if more health insurers were competing for members, then premiums are less likely to head higher.
\r\n
But, each state has their own Department of Insurance to regulate the Insurance Companies….  Any Insurance Company can sell in CA if they file and get
authorization from the CA Department of Insurance
.  How many companies in CA are domiciled outside of CA?
\r\n
Obamacare
: Under Obamacare, and the status quo that preceded the Affordable Care Act, insurers tailored their health insurance plans to each individual state (and sometimes even counties and towns). The reason health insurance is sold within a state\’s borders has to do with demographics and medical access for people within each state.
\r\n
For example, people living in Wyoming, a state with a sparse population and relatively few specialized medical-care facilities, are expected to pay higher premiums than highly populous states, such as California, where there are more hospitals and plenty of specialized medical equipment. Insurers operating in Wyoming have to take into account the added costs of potentially getting people who live far away from hospitals and other specialized care facilities to the care they need.
\r\n
The
McCarran–Ferguson Act
, 15
U.S.C.
§§ 1011-1015, also known as Public Law 15,
[1] is a
United States federal law
that exempts the business of insurance from most federal regulation, including federal
antitrust
laws to a limited extent. The McCarran–Ferguson Act was passed by the 79th Congress in 1945 after the
Supreme Court
ruled in
United States v. South-Eastern Underwriters Association
that the federal government could regulate insurance companies under the authority of the
Commerce Clause
in the
U.S. Constitution
.   Learn More==>
Wikipedia
\r\n\r\n
3. Full premium tax deductions
\r\n
Trumpcare
: According to Trump\’s proposal, one of the primary incentives of purchasing health insurance would be the ability to
write off the full amount of your premiums come tax time
. Admittedly, this also means wealthier individuals who can afford costlier, but more encompassing, health coverage would get a bigger tax break than lower-income adults who could presumably only afford a lower-cost plan.
\r\n
Business can do it under
Section 106
.
Self – Employed Line 29
of 1040.
\r\n
Obamacare
: Under Obamacare, medical expenses have to
exceed 10% of your adjusted gross income
before you can claim them as a deduction. Taxpayers need to fill out a Schedule A should they claim this exemption.
\r\n\r\n
4. Emphasize the use of
Health Savings Accounts
\r\n
Trumpcare
: Another component of Trump\’s healthcare plan involves emphasizing the use of Health Savings Accounts, or HSAs. To be crystal clear, HSAs already exist, so what Trump is proposing is something most Americans already have access to. An HSA is a tax-deferred plan open to individuals and families enrolled in high-deductible health plans. The allure of these plans is that withdrawals can be made
at any age
for qualifying medical expenses on a tax-free, penalty-free basis.
\r\n
Obamacare
: HSAs are also available right now for Obamacare enrollees, so there\’s nothing essentially different from what Trump has proposed and what\’s currently available under Obamacare.
\r\n\r\n
5. Require price transparency from health insurers
\r\n
Trumpcare
: Trump\’s proposal also vaguely calls for increased pricing transparency from health insurers so that consumers can make more educated purchasing decisions. No specific mention is made as to what aspects of the health insurance buying process would need to be more transparent.
\r\n
Obamacare
: Obamacare
does the exact same thing
through its online marketplace exchanges. In other words, Obamacare and Trumpcare are identical in calling for better price transparency. It should be noted, though, that having better transparency doesn\’t mean consumers are using the data afforded to them very well. Well over a million people
automatically enrolled in Obamacare
last year, possibly signifying that they didn\’t take the time to shop around for the best deal.
\r\n
Shop with our quote engine
.
\r\n\r\n
6. Block-grant Medicaid –
Medi-Cal
to the states
\r\n
Trumpcare
: One of Trump\’s unique healthcare proposals involves block-granting Medicaid to the states. Trump believes that state and local governments have a far better idea of what their needs are than the federal government, meaning block-granting federal money should result in less waste.
\r\n
Obamacare
: Under Obamacare, states have the right to decide whether they want to accept federal aid to expand their Medicaid programs — 31 states have chosen to do so. This
Medicaid expansion covers people earning less than 138% of the federal poverty level
. By 2020, the federal government is expected to phase down its contribution to 90%, putting the onus of the remaining 10% of revenue generation on the participating states.
\r\n\r\n
7. Remove barriers to entry for overseas drug providers
\r\n
Trumpcare
: Finally, Trump\’s healthcare plan involves breaking down the barriers to entry for overseas drugmakers. It\’s no secret that pharmaceutical companies rely on high branded-drug pricing in the U.S. to subsidize their ventures in less profitable countries. If Americans were able to look outside the U.S. to, say,
Canada,
for their pharmaceutical purchases, they may be able to save money.
\r\n
Obamacare
: Obamacare has no specific provision designed to reduce prescription-drug prices. However, its transparent marketplace platform, and the introduction of the
risk corridor
[which ended 12.31.2016?] — a type of risk-pooling fund that collected money from profitable insurers and redistributed it to money-losing insurers that priced their premiums too low — were aimed at keeping premium inflation to a minimum.
\r\n\r\n
Three more
big
differences
\r\n
Beyond Trump\’s seven-point healthcare plan, there are three other, potentially major, differences between Obamacare and Trumpcare.
\r\n
First
, Obamacare\’s
individual mandate
, which is the actionable component of the health law of the land, requires consumers to purchase health insurance or face a
penalty
come tax time. This penalty, known as the Shared Responsibility Payment, works out to the greater of $695, or 2.5% of your modified adjusted gross income in 2016.
If Obamacare is repealed, there would presumably no longer be a penalty imposed for not purchasing health insurance
.
\r\n
Secondly
, Obamacare requires insurers to accept all applicants, even if they have
pre-existing medical conditions
. Repealing Obamacare would, in theory, mean that insurers would be allowed to once again pick and choose whom they insure. It\’s possible Trumpcare could add in a similar provision, but Trump hasn\’t suggested that one would be in his health plan.
\r\n
Finally
, Obamacare ensures that Americans earning less than 400% of the federal poverty level (about $47,500) have access to the
Advanced Premium Tax Credit (APTC)
, and that those earning less than 250% of the federal poverty level receive
cost-sharing reductions (CSR) [Enhanced Silver] if they purchase a silver level plan.
\r\n
Adverse Ruling on Cost Shareing Reductions
– Enhanced Silver – House v Burwell
\r\n
Get a free quote and benefit calculation here.
\r\n
The APTC is the subsidy that lowers what low- and middle-income individuals and families pay for their premium, while CSRs help cover the cost of receiving medical care (i.e., deductibles, copays, and coinsurance).
\r\n
Trump has signaled via his Medicaid block grant proposal that lower-income folks would still be taken care of, but
anyone earning between 138% and 400% of the federal poverty level
could
(note the emphasis) lose the financial assistance
they\’ve become accustomed to with Obamacare.
\r\n
Again, it\’s important to point out that
Trump\’s proposals could change
between now and his first 100 days in office. Even
members of Trump\’s own party in Congress have been critical of his healthcare plan
, so some degree of compromise may be in order. But, it\’s pretty clear that Trumpcare is headed down a markedly different path from where President Obama took healthcare over the past few years.   Donald Trump.com  1984? https://www.donaldjtrump.com/positions/healthcare-reform
‘,’Donald Care – Trumps 7 point plan’,”,’publish’,’open’,’closed’,”,’trumps-7-point-plan’,”,”,’2017-04-05 23:35:24′,’2017-04-05 23:35:24′,”,8037,’http://healthlaw.healthreformquotes.com/?page_id=8078′,0,’page’,”,0),(8081,1,’2016-11-18 00:02:36′,’2016-11-18 00:02:36′,’Guide to Reading Statutes – George Town University 21 pages’,’guide-to-reading-statutes’,’Guide to Reading Statutes – George Town University 21 pages’,’inherit’,’open’,’closed’,”,’guide-to-reading-statutes’,”,”,’2016-11-18 00:03:45′,’2016-11-18 00:03:45′,”,5,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2014/12/guide.to_.reading.statutes.jpg’,0,’attachment’,’image/jpeg’,0),(8082,1,’2016-11-19 13:46:06′,’2016-11-19 13:46:06′,’
Licensed Attorney Referrals
\r\n
We are no longer maintaining this page
.
\r\n
See specific pages on our website and see what attorney\’s we\’ve linked to.
\r\n
Insurance – Bad Faith
\r\n
Michael Bidart
\r\n
Condo Law\r\n

\r\n

Davis-Stirling.com

\r\n
Criminal Law
\r\n
\r\n
Joe Medina, Esq.
\r\n\r\n
Marc Legget, Esq.
\r\n\r\n
David Haas, Esq.
\r\n\r\n
Shouse Law.com/
I don\’t know them, but their website is 2nd to none
\r\n\r\n
Azar Elihu, Esq.
\r\n\r\n
Los Angeles County Bar Referrals
Criminal-Felony
\r\n
Misdemeanor
\r\n\r\n
Nolo\’s Lawyer Directory: Find a Criminal Defense Lawyer
\r\n
E-Commerce, Intellectual Property,
Copy write
Civil

Insurance Litigation
\r\n
\r\n
Gauntlett & Assoc.
\r\n
Marv Schlackman, Esq.
is an excellent attorney.  I use to share office space with him. He can also answer questions via email
\r\n
Gallegos Law Firm.com/
\r\n
Marc Legget, Esq. Personal Injury both  -plaintiff and defendant, usually for companies that are self insured, business litigation matters of many types, appeals and also some probate litigation
\r\n\r\n
Baute Law.com/
I saw one of their Attorney\’s Gerry Fox, in action in the Courtroom and he is even better that the best Attorney\’s on Law & Order in Oral Argument!
\r\n
Estate Planning  & Conservatorships\r\n
\r\n
Philip J. Hoskins
, Esq.
\r\n
Byron Lane,Esq.
\r\n
Anthony Vulin, Esq.
(310) 548-0746
\r\n\r\n
Mark Miller, Esq.
Torrance, CA
\r\n\r\n
LA County Bar
Estate, Trust and Estate Tax Planning
\r\n\r\n
Philip McCarthy, Esq.
\r\n\r\n
Dennis Sandoval, Esq.
\r\n\r\n
special needs alliance.org
National Referral\’s
\r\n

Family Law,\r\n
\r\n
Joe Medina, Esq.
\r\n
attorney aid.com
\r\n
LA County Bar
Dissolution-Family Law
\r\n
Military Law
\r\n
psyclaw.com/
\r\n\r\n
military lawyers.org
\r\n
Attorney Services –
Process Server\’s
\r\n
Dale Dombrowski\r\nLicensed & Registered Process Server # 3738, Skip Tracing\r\n(562) 310-6346\r\nLong Beach, CA
\r\n\r\n
Los Angeles Attorney Service.com
\r\n\r\n
certified mobile notary.com/
\r\n
Referral Services
\r\n
California
State Bar Attorney Referral Service

\r\n
Legal Match
actually saves you time in the end. The alternative to Legal Match is calling each lawyer individually and scheduling 30-minute consultations, which may not happen for several days in the future. You may also have to speak with 5-10 different lawyers before you not only find someone who has the experience to handle your case, but is also willing to take your matter at the dollar rate you require. Plus, we provide more background information about the lawyers then you could ever get from a consultation.\r\n
\r\n
law quote.com/ similar to Legal Match above
\r\n\r\n
Nolo\’s Legal Referral Service
\r\n\r\n
Los Angeles County Bar Association – Lawyer Referral
\r\n\r\n
smartlaw.org
\r\n\r\nNew York State –
Attorney Search
\r\n
Worker\’s Compensation
\r\n
Cantrell, Green, Pekich, Cruz, & McCort
– who represents the worker.\r\n\r\n
Wai & Connor
Worker\’s Comp. Defense (For Employer\’s or Insurance Companies) Attorney\’s\r\n\r\n
comp lawyers.net
\r\n\r\n

1 800 jones act.com
\r\n\r\n
What to bring and discuss
\r\n\r\n
Wrongful Termination-Labor and Employment Law
\r\n\r\n \r\n\r\nBookmarks\r\n\r\n
Criminal Law
\r\n\r\n
Referral
\r\n\r\n
Estate Planning
‘,’Attorney Referral – Historical – No longer Updated’,”,’publish’,’closed’,’closed’,”,’attorney-referral’,”,”,’2018-07-03 18:07:10′,’2018-07-03 18:07:10′,”,8019,’http://healthlaw.healthreformquotes.com/?page_id=8082′,0,’page’,”,0),(8089,1,’2016-12-11 14:35:31′,’2016-12-11 14:35:31′,’
\r\n\r\n President Obama 12.10.2016 Weekly Address – Sign Up\r\n\r\nSorry, this video disappeard. 1984? Skip to 4:09 10.20.2016 President Obama on ACA
Transcript
\r\n\r\n
\r\n
President Obama\’s Main Points of
\r\n
signing up by Thursday\’s Deadline
\r\nWhy does the President only mention HealthCare.gov, not Covered CA or going through your own agent at
no additional charge
?\r\n\r\nGood change you will find a Plan that  will cost less than $75/month\r\n
Maybe if you earn $17k and barely can afford groceris.  Click here for complementary quote, benefit and subsidy calculation.  Please note the difference between the \”real\” premium and the net premium after the Advance Premium Tax Credit.
\r\nDecember 15th deadline for 1.1.2017 effective date\r\n\r\nObama Care deadline doesn\’t apply to
Medi-Cal
, Medicaid,
Medicare
or
Employer Coverage
\r\n
Consumer Protections
\r\n
Patient Bill of Rights
*
Specimen Policy
\r\n\r\n
Essential Benefits
\r\n
Preventative Care
\r\n
Mammogram
\r\n
Contraception
\r\nNo
annual or lifetime limits
\r\n\r\nRates are the same regardless of sex or gender\r\n\r\nCoverage on parents plan to
age 26
\r\n\r\n
Medicare Donut Hole
Discounts\r\n\r\n
Guaranteed Issue and no pre-x clause
\r\n\r\nSince 2010
slowest healthcare premium increases
in 50 years\r\n\r\nGoal of Health Care Reform to get people better coverage\r\n
Ideas on how to approve ACA Affordable Care Act – Obama Care
\r\n
What are they?
\r\n
HHS.Gov
\r\n
Advancing the Health, Safety, and Well-Being of the Nation
|
Building Upon the Success of the Affordable Care Act
|
Delivery System Reform
|
Keeping People Healthy and Safe
\r\n
10.20.2016 Remarks
by President Obama
\r\n
Expand Medi-Cal – Medi Caid
\r\n
More Insurance Companies to compete in the Marketplace – not just a single insurer
\r\n
Outreach to citizens – get healthier people to enroll
\r\n
Tax Subsidies offset premium increases
\r\n
Repeal is not the answer
\r\n
More tax credits – subsidiy as overall cost to Federal Government is billions less than anticipated
\r\n
Tweak the law to help those who are not benefiting now
\r\n
Obama Care doesn\’t affect employer coverage
\r\n
I disagree!!!  Look at all the
changes ACA did for Employer Group
plans!
\r\n
Educate the public on Obama Care and then the legislators
\r\n \r\n\r\nRepublicans want to undo all of it… if they change someting, will we still have the improvements?\r\n
30M Americans could lose their coverage.  4 out of 5 from working families
\r\n
9m would not get subsidies
\r\nMake sure you since up by Thursday, that\’s one of the best ways to insure we keep the improvements of ACA’,’Sign up by Thursday 12.15.2016′,”,’publish’,’open’,’closed’,”,’obama-weekly-address-sign-up-by-thursday’,”,”,’2017-04-05 23:33:01′,’2017-04-05 23:33:01′,”,146,’http://healthlaw.healthreformquotes.com/?page_id=8089′,0,’page’,”,0),(8094,1,’2016-12-13 21:24:36′,’2016-12-13 21:24:36′,’
\r\n\r\n Watch your sugar intake\r\n\r\n
Covered CA Eligiblity Appeals starting on Page 280\r\n\r\n
\r\n
2.
Covered California Eligibility Appeals
\r\n
a. Notice: Content and Time Requirements
\r\n
b. Request for Hearing c. Expedited Appeals
\r\n
d. Eligibility Pending Appeal – Continuing Enrollment
\r\n
e. Informal Resolution
\r\n
f. Notification of Hearing and Position Statement
\r\n
g. The Fair Hearing
\r\n
h. Hearing Decision and Other Post-Hearing Processes
\r\n
3. Dual Agency Appeals
\r\n
a. Shared Appeals Entity
\r\n
b. Informal Resolution Process
\r\n
c. The Fair Hearing
\r\n
4. Medi-Cal Access Program (MCAP) Eligibility Appeals
\r\nC. Moving Between Programs\r\n
1. Covered California to Medi-Cal
\r\n
2. Medi-Cal to Covered California
\r\n
FAQ\’s
\r\nWhat if Covered CA says they can\’t write you because they say Medi-Cal is covering you, but Medi-Cal lapsed your coverage over a year ago?\r\n
If the county determines that a beneficiary is no longer eligible for Medi-Cal, the county must issue a Notice of Action to the beneficiary ten days prior to the date of termination.391
\r\n
391. 42 C.F.R. § 431.213; 22 CCR §§ 50179(d). The requirements for termination notices are discussed in detail at
Section B.1.a of this Chapter
‘,’Eligibilty Appeals – Medi-Cal or Covered CA?’,”,’publish’,’open’,’closed’,”,’eligibilty-appeals-medi-cal-covered-ca’,”,”,’2017-01-05 19:08:31′,’2017-01-05 19:08:31′,”,8017,’http://healthlaw.healthreformquotes.com/?page_id=8094′,0,’page’,”,0),(8095,1,’2016-12-13 21:21:58′,’2016-12-13 21:21:58′,’Covered CA Eligiblity Appeals starting on Page 280′,’health.coverage.for_.low_.income[1]’,’Covered CA Eligiblity Appeals starting on Page 280′,’inherit’,’open’,’closed’,”,’health-coverage-for_-low_-income1′,”,”,’2016-12-13 21:23:44′,’2016-12-13 21:23:44′,”,8094,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2016/12/health.coverage.for_.low_.income1.jpg’,0,’attachment’,’image/jpeg’,0),(8102,1,’2016-12-21 19:06:58′,’2016-12-21 19:06:58′,’Safeguarding Taxpayer Data – A guide for your business’,’tax.payer.data.privacy’,’Safeguarding Taxpayer Data – A guide for your business’,’inherit’,’open’,’closed’,”,’tax-payer-data-privacy’,”,”,’2016-12-21 19:07:36′,’2016-12-21 19:07:36′,”,53,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2015/04/tax.payer_.data_.privacy.jpg’,0,’attachment’,’image/jpeg’,0),(8110,1,’2017-01-15 01:20:06′,’2017-01-15 01:20:06′,’

Actual Text of the Law
\r\n
GENERAL ADMINISTRATIVE REQUIREMENTS
45 -CFR  160GPO.Gov
\r\n
SECURITY AND PRIVACY
45 CFR – 164GPO.gov
\r\n
gpo.gov/
\r\n
\r\n
45 CFR Parts 160, 162, and 164 SUMMARY:\r\n
This final rule adopts standards for the
security of electronic protected health information
to be implemented by health plans, health care clearinghouses, and certain health care providers.
(HIPAA).
\r\n
Health Insurance Reform: Security 45 CFR Parts 160, 162, and 164 Standards; Final Rule Federal Register
\r\n
§ 164.312 Technical safeguards.
(iv) (c) (2)
(d) (page 46)
Standard: Person or entity authentication.
Implement procedures to verify that a person or entity seeking access to electronic protected  health information is the one claimed.
Sample implementation  1
2
Voice Recognition
\r\n
Code of Federal Regulations\r\nSubpart C—Security Standards for the Protection of Electronic Protected Health Information
\r\n\r\n
§ 164.302   Applicability.\r\n§ 164.304   Definitions.\r\n§ 164.306   Security standards: General rules.\r\n§ 164.308   Administrative safeguards.\r\n§ 164.310   Physical safeguards.\r\n§ 164.312   Technical safeguards.\r\n§ 164.314   Organizational requirements.
\r\nSec. 164.506
Consent for uses or disclosures to carry out treatment, payment, or health care operations.\r\n\r\n \r\n
Sec. 164.502 Uses and disclosures of
Protected health information:
\r\n
general rules.
\r\n(a) Standard. A covered entity may not use or disclose
protected
\r\n
health
information
, except as permitted or required by this subpart or\r\nby subpart C of part 160 of this subchapter.\r\n(1) Permitted uses and disclosures.
A covered entity is permitted to use or disclose
protected
health
information
as follows:
\r\n(i) To the individual;\r\n(ii) Pursuant to and in compliance with a consent that complies with\r\nSec.
164.506
, to carry out
treatment, payment, or
health
care operations;\r\n
Sec. 160.103

Individually identifiable health information
PHI)
is information that is a subset of health information, including demographic information collected from an individual, and:\r\n(1) Is created or received by a health care provider, health plan, employer, or health care clearinghouse; and\r\n(2) Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and\r\n(i) That identifies the individual; or\r\n(ii) With respect to which there is a reasonable basis to believe the information can be used to identify the individual.
\r\n
TITLE 45–PUBLIC WELFARE
\r\n\r\nAND HUMAN SERVICES\r\n
PART 164–SECURITY AND PRIVACY–
\r\nTable of Contents\r\n\r\nSubpart E–Privacy of Individually Identifiable Health Information\r\n\r\nSec.
164.506

Consent for uses or disclosures to carry out treatment, payment, or health care operations.\r\n\r\n(a) Standard: Consent requirement. (1) Except as provided in\r\nparagraph (a)(2) or (a)(3) of this section, a covered health care\r\nprovider must obtain the individual\’s consent, in accordance with this\r\nsection, prior to using or disclosing protected health information to\r\ncarry out treatment, payment, or health care operations.\r\n(2) A covered health care provider may, without consent, use or\r\ndisclose protected health information to carry out treatment, payment,\r\nor health care operations, if:\r\n(i) The covered health care provider has an indirect treatment\r\nrelationship with the individual; or\r\n(ii) The covered health care provider created or received the\r\nprotected health information in the course of providing health care to\r\nan individual who is an inmate.\r\n(3)(i) A covered health care provider may, without prior consent, use or disclose protected health information created or received under paragraph (a)(3)(i)(A)-(C) of this section to carry out treatment, payment, or health care operations:\r\n(A) In emergency treatment situations, if the covered health care provider attempts to obtain such consent as soon as reasonably practicable after the delivery of such treatment;\r\n(B) If the covered health care provider is required by law to treat\r\nthe individual, and the covered health care provider attempts to obtain\r\nsuch consent but is unable to obtain such consent; or\r\n(C) If a covered health care provider attempts to obtain such consent from the individual but is unable to obtain such consent due to substantial barriers to communicating with the individual, and the covered health care provider determines, in the exercise of professional\r\njudgment, that the individual\’s consent to receive treatment is clearly inferred from the circumstances.\r\n(ii) A covered health care provider that fails to obtain such consent in accordance with paragraph (a)(3)(i) of this section must document its attempt to obtain consent and the reason why consent was not obtained.\r\n(4) If a covered entity is not required to obtain consent by\r\nparagraph (a)(1) of this section, it may obtain an individual\’s consent\r\nfor the covered entity\’s own use or disclosure of protected health\r\ninformation to carry out treatment, payment, or health care operations,\r\nprovided that such consent meets the requirements of this section.\r\n(5) Except as provided in paragraph (f)(1) of this section, a\r\nconsent obtained by a covered entity under this section is not effective\r\nto permit another covered entity to use or disclose protected health\r\ninformation.\r\n(b) Implementation specifications: General requirements. (1) A\r\ncovered health care provider may condition treatment on the provision by\r\nthe individual of a consent under this section.\r\n(2) A health plan may condition enrollment in the health plan on the\r\nprovision by the individual of a consent under this section sought in\r\nconjunction with such enrollment.\r\n(3) A consent under this section may not be combined in a single\r\ndocument with the notice required by Sec. 164.520.\r\n(4)(i) A consent for use or disclosure may be combined with other\r\ntypes of written legal permission from the individual (e.g., an informed\r\nconsent for treatment or a consent to assignment of benefits), if the\r\nconsent under this section:\r\n(A) Is visually and organizationally separate from such other\r\nwritten legal permission; and\r\n(B) Is separately signed by the individual and dated.\r\n(ii) A consent for use or disclosure may be combined with a research\r\nauthorization under Sec. 164.508(f).\r\n\r\n[[Page 701]]\r\n\r\n(5) An individual may revoke a consent under this section at any\r\ntime, except to the extent that the covered entity has taken action in\r\nreliance thereon. Such revocation must be in writing.\r\n(6) A covered entity must document and retain any signed consent\r\nunder this section as required by Sec. 164.530(j).\r\n(c) Implementation specifications: Content requirements. A consent\r\nunder this section must be in plain language and:\r\n(1) Inform the individual that protected health information may be\r\nused and disclosed to carry out treatment, payment, or health care\r\noperations;\r\n(2) Refer the individual to the notice required by Sec. 164.520 for\r\na more complete description of such uses and disclosures and state that\r\nthe individual has the right to review the notice prior to signing the\r\nconsent;\r\n(3) If the covered entity has reserved the right to change its\r\nprivacy practices that are described in the notice in accordance with\r\nSec. 164.520(b)(1)(v)(C), state that the terms of its notice may change\r\nand describe how the individual may obtain a revised notice;\r\n(4) State that:\r\n(i) The individual has the right to request that the covered entity\r\nrestrict how protected health information is used or disclosed to carry\r\nout treatment, payment, or health care operations;\r\n(ii) The covered entity is not required to agree to requested\r\nrestrictions; and\r\n(iii) If the covered entity agrees to a requested restriction, the\r\nrestriction is binding on the covered entity;\r\n(5) State that the individual has the right to revoke the consent in\r\nwriting, except to the extent that the covered entity has taken action\r\nin reliance thereon; and\r\n(6) Be signed by the individual and dated.\r\n(d) Implementation specifications: Defective consents. There is no\r\nconsent under this section, if the document submitted has any of the\r\nfollowing defects:\r\n(1) The consent lacks an element required by paragraph (c) of this\r\nsection, as applicable; or\r\n(2) The consent has been revoked in accordance with paragraph (b)(5)\r\nof this section.\r\n(e) Standard: Resolving conflicting consents and authorizations. (1)\r\nIf a covered entity has obtained a consent under this section and\r\nreceives any other authorization or written legal permission from the\r\nindividual for a disclosure of protected health information to carry out\r\ntreatment, payment, or health care operations, the covered entity may\r\ndisclose such protected health information only in accordance with the\r\nmore restrictive consent, authorization, or other written legal\r\npermission from the individual.\r\n(2) A covered entity may attempt to resolve a conflict between a\r\nconsent and an authorization or other written legal permission from the\r\nindividual described in paragraph (e)(1) of this section by:\r\n(i) Obtaining a new consent from the individual under this section\r\nfor the disclosure to carry out treatment, payment, or health care\r\noperations; or\r\n(ii) Communicating orally or in writing with the individual in order\r\nto determine the individual\’s preference in resolving the conflict. The\r\ncovered entity must document the individual\’s preference and may only\r\ndisclose protected health information in accordance with the\r\nindividual\’s preference.\r\n(f)(1) Standard: Joint consents. Covered entities that participate\r\nin an organized health care arrangement and that have a joint notice\r\nunder Sec. 164.520(d) may comply with this section by a joint consent.\r\n(2) Implementation specifications: Requirements for joint consents.\r\n(i) A joint consent must:\r\n(A) Include the name or other specific identification of the covered\r\nentities, or classes of covered entities, to which the joint consent\r\napplies; and\r\n(B) Meet the requirements of this section, except that the\r\nstatements required by this section may be altered to reflect the fact\r\nthat the consent covers more than one covered entity.\r\n(ii) If an individual revokes a joint consent, the covered entity\r\nthat receives the revocation must inform the other entities covered by\r\nthe joint consent of the revocation as soon as practicable.\r\n\r\nEffective Date Note: At 67 FR 53268, Aug. 14, 2002, Sec. 164.506 was\r\nrevised, effective Oct. 15,\r\n\r\n[[Page 702]]\r\n\r\n2002. For the convenience of the user, the revised text is set forth as\r\nfollows:\r\n\r\nSec. 164.506  Uses and disclosures to carry out treatment, payment, or\r\nhealth care operations.\r\n\r\n(a) Standard: Permitted uses and disclosures. Except with respect to\r\nuses or disclosures that require an authorization under\r\nSec. 164.508(a)(2) and (3), a covered entity may use or disclose\r\nprotected health information for treatment, payment, or health care\r\noperations as set forth in paragraph (c) of this section, provided that\r\nsuch use or disclosure is consistent with other applicable requirements\r\nof this subpart.\r\n(b) Standard: Consent for uses and disclosures permitted. (1) A\r\ncovered entity may obtain consent of the individual to use or disclose\r\nprotected health information to carry out treatment, payment, or health\r\ncare operations.\r\n(2) Consent, under paragraph (b) of this section, shall not be\r\neffective to permit a use or disclosure of protected health information\r\nwhen an authorization, under Sec. 164.508, is required or when another\r\ncondition must be met for such use or disclosure to be permissible under\r\nthis subpart.\r\n(c) Implementation specifications: Treatment, payment, or health\r\ncare operations.\r\n(1) A covered entity may use or disclose protected health\r\ninformation for its own treatment, payment, or health care operations.\r\n(2) A covered entity may disclose protected health information for\r\ntreatment activities of a health care provider.\r\n(3) A covered entity may disclose protected health information to\r\nanother covered entity or a health care provider for the payment\r\nactivities of the entity that receives the information.\r\n(4) A covered entity may disclose protected health information to\r\nanother covered entity for health care operations activities of the\r\nentity that receives the information, if each entity either has or had a\r\nrelationship with the individual who is the subject of the protected\r\nhealth information being requested, the protected health information\r\npertains to such relationship, and the disclosure is:\r\n(i) For a purpose listed in paragraph (1) or (2) of the definition\r\nof health care operations; or\r\n(ii) For the purpose of health care fraud and abuse detection or compliance.\r\n(5) A covered entity that participates in an organized health care arrangement may disclose protected health information about an individual to another covered entity that participates in the organized health care arrangement for any health care operations activities of the organized health care arrangement.\r\n\r\n \r\n\r\n
Title 45: Public Welfare
\r\n
\r\n\r\nBrowse Previous | Browse Next\r\n
PART 5b—PRIVACY ACT REGULATIONS
\r\n
Section Contents
\r\n§ 5b.1   Definitions.\r\n§ 5b.2   Purpose and scope.\r\n§ 5b.3   Policy.\r\n§ 5b.4   Maintenance of records.\r\n§ 5b.5   Notification of or access to records.\r\n§ 5b.6   Special procedures for notification of or access to medical records.\r\n§ 5b.7   Procedures for correction or amendment of records.\r\n§ 5b.8   Appeals of refusals to correct or amend records.\r\n§ 5b.9   Disclosure of records.\r\n§ 5b.10   Parents and guardians.\r\n
§ 5b.11   Exempt systems.
\r\n§ 5b.12   Contractors.\r\n§ 5b.13   Fees.\r\nAppendix A to Part 5b—Employee Standards of Conduct\r\nAppendix B to Part 5b—Routine Uses Applicable to More Than One System of Records Maintained by HHS\r\nAppendix C to Part5b—Delegations of Authority [Reserved] \r\n\r\n \r\n
Related Pages in
Privacy – HIPAA
Section
\r\n
\r\n

\r\n \r\n\r\n
‘,’Federal Privacy Law – Actual Text’,”,’publish’,’closed’,’closed’,”,’federal-privacy-law-actual-text’,”,”,’2018-10-06 19:02:17′,’2018-10-06 19:02:17′,”,53,’http://healthlaw.healthreformquotes.com/?page_id=8110′,0,’page’,”,0),(8111,1,’2017-01-15 01:19:42′,’2017-01-15 01:19:42′,’
Privacy Issues in Email
\r\n
First, the technology used to communicate via
e-mail
is extraordinarily
analogous to a telephone conversation
. Indeed, e-mail is transmitted from one computer to another via telephone communication, either hard line or satellite. We have recognized that \”[t]elephone conversations are protected by the Fourth Amendment if there is a
reasonable expectation of privacy
.\”
United States v. Sullivan,
42 MJ 360, 363 (1995).
\r\n
E-mail transmissions are not unlike other forms of modern communication. We can draw parallels from these other mediums. For example, if a sender of
first-class mail
seals an envelope and addresses it to another person, the sender can reasonably expect the contents to remain private and free from the eyes of the police absent a search warrant founded upon probable cause
. Cf. Gouled v. United States, supra
. However, once the letter is received and opened, the destiny of the letter then lies in the control of the recipient of the letter, not the sender, absent some legal privilege.
See
Mil.R.Evid. 501-06, Manual for Courts-Martial, United States, 1984.
Cf. Gouled v. United States,
255 U.S. at 302.
\r\n
The fact that an unauthorized \”hacker\” might intercept an e-mail message does not diminish the legitimate
expectation of privacy
in any way.
Expectations of privacy in e-mail transmissions depend in large part on the type of e-mail involved and the intended recipient
U.S. v Maxwell
\r\n
Standard Reply from Covered CA
\r\nPlease ensure that you are encrypting any email that includes
PII (Personally Identifiable Information)
(
Wikipedia
) or
PHI (Protected Health Information
).\r\n
Under the US
Health Insurance Portability and Accountability Act
(HIPAA), PHI that is linked based on the following list of 18 identifiers must be treated with special care:
[1] \r\n\r\n
\r\n
\r\n
Names
\r\n
All geographical identifiers smaller than a state, except for the initial three digits of a zip code if, according to the current publicly available data from the Bureau of the Census: the geographic unit formed by combining all zip codes with the same three initial digits contains more than 20,000 people; and the initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000
\r\n
Dates (other than year) directly related to an individual
\r\n
Phone numbers
\r\n
Fax numbers
\r\n
Email
addresses
\r\n
Social Security numbers
\r\n
Medical record numbers
\r\n
Health insurance
beneficiary numbers
\r\n
Account numbers
\r\n
Certificate/license numbers
\r\n
Vehicle identifiers and serial numbers, including license plate numbers;
\r\n
Device identifiers and serial numbers;
\r\n
Web
Uniform Resource Locators
(URLs)
\r\n
Internet Protocol (IP) address numbers
\r\n
Biometric
identifiers, including finger, retinal and voice prints
\r\n
Full face photographic images and any comparable images
\r\n
Any other unique identifying number, characteristic, or code except the unique code assigned by the investigator to code the data
Learn More==> Wikipedia
\r\n
\r\n
\r\n \r\n\r\nThis is information that can be used to distinguish or trace an individual’s identity, either alone or when combined with other personal or identifying information that is linked or linkable to a specific individual.\r\n\r\n \r\n
Microsoft Trust Center –
Explanation of HIPAA and HITECT Act
\r\n
Currently there is no official certification for HIPAA or HITECH Act compliance. However, those Microsoft services covered under the BAA have undergone audits conducted by accredited independent auditors for the
Microsoft ISO/IEC 27001 certification
.
\r\n
How can I learn more about complying with HIPAA and the HITECH Act?
\r\n
To assist customers with this task, Microsoft has published these guides:
\r\n
HIPAA/HITECH Act Implementation Guidance
for
Azure
and for
Dynamics 365 and Office 365
. Written for privacy, security, and compliance officers and others responsible for HIPAA and HITECH Act implementation, they describe concrete steps your organization can take to maintain compliance.
\r\n
paubox.com/hipaa-compliance
\r\n\r\nstartmail.com/question–answer-encryption-method
\r\n
Outlook 365
\r\n
support.office.com/Encrypt-email-messages
\r\n\r\n
microsoft.comCompliance/HIPAA
\r\n\r\n
zixcorp.com/encryption
\r\n\r\n \r\n
Using a service that claims (at least that
reasonably
claims) to be HIPAA-compliant could potentially insulate you, to some degree, from liability in the event of a breach. Their Terms (and the included “disclaimer”) leave something to be desired:
\r\n
“8.2 For breach of the express warranty set forth above, Customer’s exclusive remedy shall be the re-performance of the deficient Services. If Paubox cannot re-perform such deficient Services as warranted, Customer shall be entitled to recover a pro-rata portion of the fees paid to Paubox for such deficient Services, and such refund shall be Paubox’s entire liability.”
\r\n
Of course, it isn’t unreasonable to believe that a judge might choose to throw out that provision if they were ever hauled into court. After all, claiming to provide a service and then
explicitly
disclaiming any duty to provide that very service is
at least
questionable.
\r\n
I also cannot say that I am
fond
of section 8.5:
\r\n
“8.5 Customer shall defend at its expense any Claim brought against Paubox alleging that Customer Data, or Customer’s use of the Services in violation of this Agreement, infringes the intellectual property rights of, or has otherwise harmed, a third party or violates any law or regulation, and Customer shall pay all costs and damages finally awarded against Paubox by a court of competent jurisdiction as a result of any such Claim; provided that Paubox (i) promptly gives written notice of the Claim to Customer; (ii) gives Customer sole control of the defense and settlement of the Claim (provided that Customer may not settle or defend any Claim unless it unconditionally releases Paubox of all liability); and (iii) provides to Customer, at Customer’s cost, all reasonable assistance.”
\r\n
The foregoing notwithstanding, I am insufficiently familiar with the provisions of HIPAA to know what precisely is required in terms of security, but, again, contracting the services of a reputable company that claims to provide HIPAA compliance is likely insulation against
at least
a claim that you were negligent in your handling of confidential information.
\r\n
As for the technology of Paubox, it seems they are simply enforcing SSL/TLS use on their IMAP/SMTP services
and
additionally providing detection of whether or not the recipient servers do the same. If the recipient servers do not provide SSL/TLS, then a plaintext email is sent instead of the actual email and that plaintext email has a link to the actual email, which will be delivered over a secure link.
\r\n
From a technology standpoint, this provides no additional benefits. From a
legal
standpoint, that may not matter.
paubox.com/terms
\r\nFundamentally, the problem with using email as a ‘secure’ means of communication is that email was
not
designed to be secure. Email is, in fact,
never
secure. You can secure the
content
of an email, but you cannot secure the email itself.\r\n\r\nIn general, I would
not
suggest sending sensitive data via email. There are simply too many security risks (and those risks are ongoing as emails are often retained for weeks, months, or even years after they are sent). A far better solution is to use a secure-messaging system of some kind (for client matters, something hosted on your own site would probably be optimal as that keeps everything under your control and under your brand).\r\n\r\nWhen I need to send secure messages, I typically use
Telegram
. For sending documents and larger files, I prefer
Dropbox
. These solutions are
sufficiently
secure for
most
matters.\r\n\r\nWordPress
can
serve as a platform for delivering files and such securely. The easiest way to accomplish this would probably be a client portal (e.g., xxx/) and a page for each client (e.g., hxxx). You could then add files to the client page that
only
the client would be able to access (either via account-based permissions or a simple password), and incorporate an upload form so that the client could securely send you files.\r\n\r\nFor the sake of completeness:\r\n
\r\n
Generating and installing a certificate in your email client provides
some
security, but in order for such a setup to provide
encryption
, the client would also need to obtain a certificate (and you would need to send an initial email to establish the ability of your clients to communicate using encryption). Another drawback to this setup is that you would need to install the certificate on
every
device you use and your emails would become inaccessible if you should happen to lose the certificate.
\r\n
Encrypting the content prior to transmission (e.g., with GPG) and then sending the encrypted data will secure your information. However, the client will need to have similar facilities to decrypt the information and you will need to provide your public key in advance. Most users are not sufficiently technically savvy for this option to be viable.
\r\n
\r\n \r\n
Related Pages in
Privacy – HIPAA
Section
\r\n
\r\n
‘,’Email Privacy’,”,’publish’,’open’,’closed’,”,’email-privacy’,”,”,’2017-05-15 18:34:16′,’2017-05-15 18:34:16′,”,53,’http://healthlaw.healthreformquotes.com/?page_id=8111′,0,’page’,”,0),(8112,0,’2017-01-15 01:19:14′,’2017-01-15 01:19:14′,’
‘,’January 15, 2017 1:19 am’,”,’publish’,’closed’,’closed’,”,’january-15-2017-119-am’,”,”,’2017-01-15 09:59:20′,’2017-01-15 09:59:20′,”,0,’https://healthlaw.healthreformquotes.com/?post_type=wdscan_result&p=8112′,0,’wdscan_result’,”,0),(8116,1,’2017-01-24 23:47:51′,’2017-01-24 23:47:51′,’I have pretty good
Cobra Insurance
(Health Net PPO, eligibility expires 12/17), however, I am concerned with the
current political climate, Obama Care may go away
\r\n
***Here\’s where I\’m keeping up on the status.
donaldcare.healthreformquotes.com
\r\nand when I am no longer eligible for Cobra, it might be difficult to get insurance due to
pre-existing condition
or other medical related risk factors becoming a factor as they were in the past. To protect against that, I would like to get a Blue Cross PPO now\r\n
***Click here to get
proposals, benefits, subsidy calculation
etc.
\r\n
In the past we had
HIPAA
for those who lost COBRA.  There was also MR. MIP – High Risk Pools.
\r\nand just continue it until my Cobra expires.\r\n
***Losing COBRA gives you a Special Enrollment Period
\r\nSo therefore, I would have
two health plans
. My current
Cobra
group plan and an
individual/family Blue Cross PPO
plan.\r\n\r\nThe questions I have are:\r\n
\r\n
Can I have two health plans (I’m not trying to commit fraud, I understand I cannot get paid more than the bill).\r\n
\r\n
Dual Coverage & Co-ordination Rules
\r\n
Let\’s see if the question is asked on the
paper application
–  I\’m looking at doing this direct, no Covered CA no subsidies.  For subsidies, the answer would definately be NO.
\r\n
\r\n

Question G 2 asks about other coverage and if you plan to cancel it.  So yes, you would have to disclose other coverage.   I doubt they would write you.  If it\’s that important to you I could email them and ask.  I could also check the ACA rules and see if the
ACA law
says you can buy coverage, even if you have other coverage.

\r\n
\r\n
\r\n
\r\n
\r\n
Do I need to tell Blue Cross?\r\n
\r\n
Yes, since they ask.
\r\n
\r\n
\r\n
Can I pick and choose who I want to use, if Blue Cross\r\n
\r\n
Please get a quote
proposals, benefits, subsidy calculation
.   I don\’t think Blue Cross has a PPO in your area.  Try Blue Shield.
\r\n
\r\n
\r\n
has a doctor I like or pays more benefits for a particular procedure, can I only use them.\r\n
\r\n
These questions are quite complex and I think I\’m going to have to charge a research fee for them.  Under ACA, I practically have to work for free.  See our page on
Dual Coverage
, see also the rules in the current
evidence of coverage
, if we can even get you an extra policy, that we do NOT recommend that you purchase!
\r\n
\r\n
\r\n
The same for Health Net PPO, use them if they are more beneficial for the procedure I have. – Please answer for Blue Cross, I have already got Health Net’s comment.\r\n
\r\n
Verbal comments are worthless!!!
\r\n
See the rules on dual coverage, basically the 2nd company pays up to 100% of what the first one didn\’t.  It may well be that there is NO co-ordination of benefits clause on two INDIVIDUAL policies.  Thus, you could collect more than 100%, which is why I don\’t think you will get a policy issued, if you plan to keep the first one.
\r\n
Note too, that I won\’t give an answer, unless I can show it too you in writing or the law.   I don\’t want to have to pay the claim out of my pocket.
\r\n
\r\n
\r\n
My intent it to cancel my Health Net policy down the road\r\n
\r\n
I think you should keep it, till you really want to move and it expires.  There is also
Cal COBRA
, which gives you another 18 months of coverage.
\r\n
\r\n
\r\n
but I have had it for 15 years and am leery just to let it go.
\r\n
Also, I go to doctors who do not take insurance. Can I go to doctors who do not take insurance and not let Blue Cross know I am having a procedure done?\r\n
\r\n
If you have a PPO, you could still turn in the claim.  When  a MD says they don\’t take insurance, that just means they don\’t agree to the
negotiated rate
, they still will cash the check.
\r\n
\r\n
\r\n
Usually the bills are below the deductible or I don’t want to wait for an approval – like an MRI)\r\n
\r\n
The question is beyond my pay grade.
\r\n
\r\n
\r\n
\r\n \r\n\r\nOk this might be an unusual question, also the extra money for premium payments is not material to me right now.’,’COBRA, Donald Care & Dual Coverage – Web Vistor\’s Question’,”,’publish’,’open’,’closed’,”,’cobra-new-aca-plan-concerned-donald-care’,”,”,’2017-09-25 18:02:24′,’2017-09-25 18:02:24′,”,5521,’http://healthlaw.healthreformquotes.com/?page_id=8116′,0,’page’,”,0),(8121,1,’2017-03-01 22:24:45′,’2017-03-01 22:24:45′,”,’cadillac.tax_-300×150[1]’,”,’inherit’,’open’,’closed’,”,’cadillac-tax_-300×1501′,”,”,’2017-03-01 22:24:45′,’2017-03-01 22:24:45′,”,7713,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2015/04/cadillac.tax_-300×1501.jpg’,0,’attachment’,’image/jpeg’,0),(8123,1,’2017-03-07 23:27:10′,’2017-03-07 23:27:10′,’
\r\n\r\nPublished on Feb 25, 2017 Details of potential Obamacare replacements\r\n\r\n
Congress.Gov HR 1628 AHCA of 2017
\r\n\r\n
American Health Care Act Rev. 3.6.2017\r\n\r\n
\r\n
AHCA – Trump Care – Pre X?
\r\n
Personally I resent all the news articles and especially all the Facebook posts that say things about the technical legal aspects of law, without citing the actual law.  Even when one has the actual law, you still need to
read it three times and then when you thing you understand it, read it again
.  I guess especially egregious is Congress passing ACA and now AHCA without time to read the law first.   Below, I will attempt to find the citations mentioned in various news articles and then we can sort fact from fiction.
\r\n
If you take a quick read into
American Health Care Act
, it would appear as though the
provision on pre-existing conditions
has remained untouched. But when you take a closer look, the AHCA requires \”
continuous coverage
\” §133  for patients with pre-existing conditions and those with perfect health, meaning that if a patient goes
63 days
continuously without coverage, they must pay a
30 percent premium penalty
.
\r\n

SEC. 2710A
.
ENCOURAGING CONTINUOUS HEALTH INSURANCE COVERAGE
.
\r\n\r\n
“(a)
Penalty Applied
.—
\r\n
“(1)… a
health insurance issuer
offering health insurance coverage in the individual or small group market
shall
, …
increase the monthly premium rate

\r\n
“(2)
30 percent
\r\n
“(b)
Definitions
.
\r\n
“(1)
‘applicable policyholder’ means
,
\r\n
“(A) is a policyholder
\r\n
“(B) cannot demonstrate ….there was not a period of
at least 63 continuous days
during which the individual did not have
creditable coverage
\r\n
If you have a pre-existing condition and
no gap in coverage, great
! You\’re just groovy. But, here\’s the big
problem with \”continuous coverage\” requirements for pre-existing condition
s: If you lose your job or lose coverage because of missed premium payments, your rate will be increased 30 percent if you want a health insurer to take you on if you have a pre-existing condition. Anyone? To put it plainly: The continuous coverage stipulation is
not
the same as requiring health insurance companies to cover individuals with pre-existing conditions, as the Affordable Care Act did. Instead, those with pre-existing conditions who are struggling financially will, in many cases, be charged more for their insurance.  So, will everyone else.
Romper.com 3.7.2017
\r\nAs
we described yesterday
, there are some concerning policy elements of the House-passed American Health Care Act, which the Senate would be wise to
explore and rectify
over the coming weeks. The bill — and that\’s
all
it is at this point: a work in progress — repeals and alters significant portions of the Democratic Party\’s
failing experiment
in \”affordability.\”  But based on rhetoric from
elected Democrats
and the Left generally, one might assume that Obamacare was called the \”Pre-existing Conditions Coverage Act\” (side-stepping the whole \”choice and affordability\” fairy tale they peddled), and that the Republican bill obliterates those protections. The proposed law would be a \”
death warrant
\” for sick women and children, they shriek, casting Obamacare opponents as the moral equivalent of accessories
to murder
. This is demagogic, hyperbolic, inaccurate nonsense. To review the actual facts, even under an exceedingly unlikely scenario in which the Senate passed the House bill without making a single alteration, people with pre-existing conditions are offered
several layers
of protection:\r\n
Layer One
: Insurers are required to sell plans to all comers, including those with pre-existing conditions. This is known as \”guaranteed issue,\” and it\’s mandated in the AHCA. No exceptions, no waivers. I spoke with an informed conservative news consumer earlier who was stunned to learn that this was the case, having been subjected to 24 hours of unhinged rhetoric from the Left.\r\n\r\n
Layer Two
: Anyone with a pre-existing condition and who lives in a state that does not seek an optional waiver from the AHCA\’s (and Obamacare\’s) \”community rating\” regulation cannot be charged more than other people for a new plan when they seek to purchase one — which, as established above, insurers are also required to sell them.\r\n
MacArthur Amendment
?
\r\n
Layer Three
: Anyone who is insured and remains continuously insured cannot be dropped from their plan due to a pre-existing condition, and cannot be charged more after developing one. So if you\’ve been covered, then you change jobs or want to switch plans, carriers must sell you the plan of your choice at the same price point as everyone else. Regardless of your health status. This is true of people in non-waiver and waiver states alike.\r\n\r\n
Layer Four
: If you are uninsured
and
have a pre-existing condition
and
live in a state that pursued (and obtained after jumping through hoops) a \”community rating\” waiver, your state is required to give you access to a \”high risk pool\” fund to help you pay for higher premiums. The AHCA earmarks nearly $130 billion for these sorts of patient stability funds over ten years.
\r\nIt is simply a lie to say that the AHCA guts protections for people with pre-existing conditions. One can argue that perhaps $130 billion (not $8 billion, as some are dishonestly pretending) might at some point prove insufficient to covering the people described in layer four, but I think any such assessment is
at best
hypothetical and premature.  Either way, it\’s a very different critique than the scare-mongering going around right now.  Also, I\’ll repeat: The number of \”uninsurable\” Americans with pre-existing conditions within the individual market represents
a tiny sliver
of the overall population.  Helping these people was one of the few credibly-popular selling points and actual achievements of Obamacare.  But the
existing law\’s track record
on this front helps illustrate how limited the scope of that particular problem is:\r\n\r\n \r\n\r\nObamacare created a \”bridge\” program that allowed previously-uninsurable consumers with pre-existing conditions to get coverage in between the law\’s 2010 passage and full implementation a few years later. At its peak, it attracted less than 115,000 takers. Those people matter, and they were helped. But that statistic helps contextualize the problem, especially compared to Obamacare\’s overriding flaw: Unaffordability, leading to lack of participation, leading to unsustainable risk pools, leading to insurers
pulling out and hiking premiums
, leading to unaffordability, leading to further lack of participation, etc.  As for the moral bullying about the AHCA supposedly leading to thousands of deaths (with these pronouncements coming from the
very same people
who lied incessantly and made spectacularly wrong predictions about Obamacare, by the way), consider this
data-based evidence
:\r\n
Public-health data from the Centers for Disease Control confirm what one might expect from a health-care reform that expanded Medicaid coverage for adults: no improvement. In fact, things have gotten worse.
Age-adjusted death rates in the U.S. have consistently declined for decades, but in 2015 — unlike in 19 of the previous 20 years — they increased. For the first time since 1993, life expectancy fell.
Had mortality continued to decline during ACA implementation in 2014 and 2015 at the same rate as during the 2000–13 period,
80,000 fewer Americans would have died in 2015 alone.
Of course, correlation between ACA implementation and increased mortality does not prove causation. Researchers hypothesize that increases in obesity, diabetes, and substance abuse may be responsible. But thanks to the roughly half of states that refused the ACA’s Medicaid expansion, a good control group exists. Surely the states that expanded Medicaid should at least perform better in this environment of rising mortality? Nope.
Mortality in 2015 rose more than 50 percent faster in the 26 states (and Washington, D.C.) that expanded Medicaid during 2014 than in the 24 states that did not.
\r\nIf conservatives wanted to turn liberals\’ demagoguery against them, they could cite these numbers to claim that Obamacare is
killing tens of thousands of people
— especially in Medicaid expansion states — and that Democrats have blood on their hands.
Murderers!
Let\’s not match their repugnant hackery. But we should make them aware of evidence that could build that deeply uncharitable and specious narrative. And speaking of Medicaid, I\’ve seen a lot of hyperventilating about \”deep cuts\” to the program, which was already suffering
poor health outcomes
and
restricted access
before Obamacare\’s huge expansion of it. The AHCA does eventually transition to a major reform of the dysfunctional program, but it does so via a gradual tapering and eventual halt of Medicaid\’s expansion several years from now, with existing recipients (including
new additions
under the continued expansion) grandfathered in. May
I repeat
: There are flaws in the bill that need to be addressed. But the fact-challenged, emotional, manipulate meltdown on the Left is designed to scare people, not inform them. And it has the side effect of distracting from the spiraling betrayals of Obamacare, a program the Left put in place last time they were in charge. I\’ll leave you with this
strong editorial from the
Wall Street Journal
:
Town Hall.com

\r\n
‘,’Pre-Existing Conditions? AHCA Donald Care’,”,’publish’,’open’,’closed’,”,’ahca-pre-x-donald-care’,”,”,’2018-06-15 17:19:40′,’2018-06-15 17:19:40′,”,9457,’http://healthlaw.healthreformquotes.com/?page_id=8123′,0,’page’,”,0),(8125,1,’2017-03-08 18:17:49′,’2017-03-08 18:17:49′,’
Taxes
\r\n
How it works now:
Obamacare’s architects cobbled together a mix of taxes to offset the cost of subsidizing insurance for tens of millions of low- and moderate-income Americans.\r\n\r\nThat has meant some new taxes on insurance companies and medical device makers (both of which, it was reasoned, were benefiting from getting new customers through the law).\r\n\r\nWealthy Americans are paying more too. Families making more than $250,000 a year have seen their Medicare payroll taxes increase because of Obamacare.\r\n\r\n
How it would change:
The House Republican plan scraps the taxes.\r\n\r\nThat’s a big tax cut for the medical device and insurance industry. Insurers say lower taxes will allow them to charge lower premiums.\r\n\r\nIt’s also a very large tax cut for the wealthiest taxpayers, who would no longer be subject to the Medicare payroll surtax.\r\n\r\nThe House legislation does not include any new tax to offset the loss of revenue from cutting the Obamacare taxes.
LA Times 3.8.2017
‘,’AHCA – Donald Care – No more taxes!’,”,’publish’,’closed’,’closed’,”,’ahca-donald-care-no-taxes’,”,”,’2017-03-08 18:17:49′,’2017-03-08 18:17:49′,”,893,’http://healthlaw.healthreformquotes.com/?page_id=8125′,0,’page’,”,0),(8126,1,’2017-03-09 14:58:37′,’2017-03-09 14:58:37′,’
Case Law –
Fioretti v. Mass. General Life
\r\nVisit our new website at

Get and understand your Health Coverage now!


\r\n
What must be
disclosed on an Insurance Application
\r\nMassGen agreed to underwrite Anthony Fioretti\’s life insurance policy, contingent only upon his execution of the Statement of Good Health.\r\n\r\nEven after the expiration of the contestability period, an insurer may deny a claim if the insured committed fraud in the policy application.  To rescind a policy, an insurer need not show that the insured actually intended to deceive.
Even an innocent misrepresentation can constitute equitable fraud justifying
rescission.
(even after lapse of contestability period, a health insurer may deny coverage based on insured\’s nondisclosure of a serious illness in his insurance application);  (recession authorized when insured knowingly misrepresents material health information to health insurer); (same when misrepresentations made to life insurer).\r\n\r\nat the time he completed this\r\n\r\n
Statement of Good Health
, Anthony Fioretti knew:\r\n
(1) that he was HIV- positive;\r\n(2) that he had previously been declined life insurance by another carrier (Columbian Mutual); and\r\n(3) that he had previously consulted with at least two doctors concerning his HIV status.
\r\nIn short, every representation made by Anthony Fioretti in the Statement of Good Health was false\r\n
The California Court of Appeal, for the first time since 1988, has agreed that when an insured misrepresents or conceals, in an application for insurance, facts subjectively material to the underwriter who agreed to the risk, the insurer may effectively rescind the policy
\r\n
The rule that an insurer is estopped to claim misrepresentation in an insurance
application
caused by the insurance
agent\’s
negligence does not apply where the applicant receives a copy of his
application
,
unless some action by the
agent
prevents the applicant from reading the policy or
leads the applicant to believe that the misstated or omitted answers are not material.
Rutherford v. Prudential Ins. Co. of America
234 Cal.App.2d 719
Cal.App.1.Dist.,1965.
\r\n
Question in application for life insurance as to whether applicant had ever had headaches, chest pains, above normal blood pressure, and whether applicant had consulted physician during past five years for any other cause,
called for matters of fact normally within knowledge of every layman,
and there was substantial, though mainly indirect, evidence that answers of deceased in application constituted both knowing misrepresentations and concealment of truth.
Anaheim Builders Supply, Inc. v. Lincoln Nat. Life Ins. Co. (App. 5 Dist. 1965) 43 Cal.Rptr. 494, 233 Cal.App.2d 400
.
Insurance
\r\n
This case may no longer be VALID law.  Check with your attorney and review the other pages on this website, namely, prohibitions on recission.
‘,’Fioretti v Mass General Life’,”,’publish’,’open’,’closed’,”,’fioretti-v-mass-general-life’,”,”,’2017-04-05 23:29:04′,’2017-04-05 23:29:04′,”,10,’http://healthlaw.healthreformquotes.com/?page_id=8126′,0,’page’,”,0),(8127,1,’2017-03-09 15:01:50′,’2017-03-09 15:01:50′,’
Must read your policy
\r\n
A court \”must hold the insured bound by clear and conspicuous provisions in the policy even if evidence suggests that the insured did not read or understand them.\”
\r\n
The Hadlands, having
failed to read the policy and having accepted it without objection,
cannot
be heard to
complain it was not what they expected. Their reliance on representations about what they were getting for their money was unjustified as a matter of law.
Sarchett v. Blue Shield of California
(1987) 43 Cal.3d 1, 15, 233 Cal.Rptr. 76, 729 P.2d 267
\r\n
Hadland v. NN Investors Life Ins. Co. (1994) 24 Cal.App.4th 1578 , 30 Cal.Rptr.2d 88
(Findlaw.com requires free registration)
\r\n
STORY of what happened in this lawsuit
\r\n
In the fall of 1985, the Hadland\’s were notified of a 10 percent increase in the premiums for their health insurance under a policy with Reliance Standard Life Insurance Company. The Reliance major medical policy paid
80 percent
of medical and hospital expenses, subject to a $250 deductible. The Hadland\’s began to look for less expensive coverage. When they received a mailing from NASE describing low-cost group hospital insurance available to NASE members through NN, they sent in a postcard asking for further information. Kevin Winn, associated with NASE, NN and United Group Association (UGA) (a company that markets NN insurance), contacted the Hadland\’s and, on December 5, came to their place of business to make a sales presentation.
According to the Hadland\’s, Winn told them coverage under the NN policy was \”as good if not better\” than coverage under the Reliance policy, at half the premium cost.
Promotional materials described the policy as offering major hospital benefits. The Hadland\’s joined NASE and applied for NN coverage. As it turned out, the NN policy was, as Winn had stated, half as expensive as the Reliance policy, but it did not cover most outpatient medical expenses. Moreover, NN\’s benefits were paid according to a maximum benefit schedule which, in some cases, covered less than 50 percent of the actual charge for a surgical procedure. For instance, the maximum surgical benefit available under the policy was $6,000, regardless of the actual cost, and the maximum hospital room and board benefit for nonintensive care was $300 a day.
\r\n
In January 1986, the Hadland\’s received a certificate of insurance indicating their coverage benefits under the NASE group policy. In an attached letter, they were asked to read the certificate and call the NN office if they had any questions. The first page of the certificate advised them that if the policy did not meet their needs, they could return it within 10 days for a full refund. fn. 1 NN sent the Hadland\’s a second letter to confirm their receipt of the certificate and to ask them to contact the insurer if they had any questions concerning coverage.
The Hadland\’s did not read the insurance contract.
In November, Mary Jane Hadland was hospitalized for a surgical procedure. She incurred nearly $26,000 in medical and hospital bills.
NN paid less than one-half
, which, the Hadland\’s concede, was the total of benefits due under the policy.
\r\n
To take their fraud cause of action to the jury, the Hadland\’s had to prove not only defendants\’ false representations, but their own justifiable reliance
\r\n
\’A reasonable person will read the coverage provisions of an insurance policy to ascertain the scope of what is covered. [Citation.]\’ … Generally the insured is \’bound by clear and conspicuous provisions in the policy even if evidence suggests that the insured did not read or understand them.\’
\r\n
NN
(NASE prior Insurance Company)
policy\’s schedule of benefits expressly provided, for instance: an entirely unambiguous
maximum
surgical benefit of $6,000, regardless of whether the surgery consisted of an organ transplant, a partial or radical mastectomy or the amputation of a toe; [FN12] a
maximum
nonintensive care hospital room and board benefit of $300 a day; and a
maximum
benefit of
**95
$300 a day for outpatient hospital charges. The Reliance (the company the Hadland\’s had before NASE) policy provided unqualified benefits of 80
*1589
percent of covered expenses.
Thus, any representations by defendants of \”full protection\” under the NN policy, or coverage \”as good or better\” as the Reliance policy, were patently at odds with the express provisions of the written contract. If the Hadland\’s had read it,
they would have discovered its limitations, rejected it, and continued to pay the higher premium for the increased security of Reliance\’s more comprehensive coverage.\r\n
\r\n
View Entire Case on Findlaw.com
Hadland v. NN Investors Life Ins. Co.
\r\n\r\n
\r\n
(NASE\’s prior Carrier, as pointed out by UICI\’s
4/6/2006
letter
)
This case shows that one must read the ACTUAL policy and can\’t rely on Agent\’s statements or brochures.  There are some exceptions…  This doesn\’t just apply to NASE, but to ANY Insurance Contract.  See attorney
Keler.com
for more explanation.
\r\n
\r\n
\r\n\r\n
Plain Language – Read Policy THREE times
‘,’Must read your policy’,”,’publish’,’open’,’closed’,”,’must-read-policy’,”,”,’2018-10-06 18:49:41′,’2018-10-06 18:49:41′,”,10,’http://healthlaw.healthreformquotes.com/?page_id=8127′,0,’page’,”,0),(8129,1,’2017-03-09 17:16:24′,’2017-03-09 17:16:24′,’
Patient Protection and Affordable Care Act
\r\n
Key Provisions of PPACA – Health Reform
\r\n
Private Health Insurance Provisions in the Patient Protection and Affordable Care Act (PPACA)
Congressional Research Service
\r\n
UHC 14 page summary of Health Reform
2014 Rev
\r\n
PPACA/Health Care Reform_What\’s Next_050213.webinare
\r\n\r\n
\r\n
\r\n
Guaranteed Issue and NO Pre Existing Condition Clause!
\r\n
PHSA 2704 (a),
42 USC 300 gg
IRC
9815
ERISA 715
national underwriter.com
Health Reform Facts Q & A 252
\r\n
2014 – Requirement to have Health Insurance
\r\nRequire U.S. citizens and legal residents to have qualifying health coverage (phase-in tax penalty for those without coverage).\r\nAn insurance-less person would have to pony up whichever is greater: $695 for each uninsured family member, up to a maximum of $2,085; or 2.5 percent of household income.
(
Christian Science Monitor,

Section 1501, 5000A,  HR 3590 Page 124,

Section 1002 HR 4872 Page 4
)
\r\n
Constitutionality?
\r\n
Government Subsidy & CA Premium
calculator
\r\n
\r\n
SMALL BUSINESS
TAX CREDITS
\r\n
Offers tax credits to small businesses to make employee coverage more affordable.  Tax credits of up to 35 percent of premiums will be available to firms that choose to offer coverage.
Effective beginning calendar year 2010.
(Beginning in 2014, the small business tax credits will cover 50 percent of premiums.)\r\n
\r\n
NO DISCRIMINATION AGAINST CHILDREN under 19 WITH
PRE-EXISTING CONDITIONS
—Prohibits new health plans in all markets plus grandfathered group health plans from denying coverage to children with pre-existing conditions.
Effective 6 months after enactment.
(Beginning in 2014, this prohibition would apply to all persons.)
CA Assembly Bill 2244
\r\n
\r\n
HELP FOR UNINSURED AMERICANS WITH
PRE-EXISTING CONDITIONS
UNTIL
EXCHANGE
IS AVAILABLE (INTERIM HIGH-RISK POOL)
—Provides access to affordable insurance for Americans who are uninsured because of a pre-existing condition through a temporary subsidized high-risk pool.
Effective in 2010.
\r\n
\r\n
National Conference of State Legislatures
\r\nMr. MIP CA Page\r\n
Choice Administrators on Exchanges
\r\n
Christian Science Monitor
\r\n
Our Website for information quotes
\r\n
Individuals & Families
\r\n
Employer Groups 2 – 50
\r\n
ENDS RESCISSIONS
—Bans insurance companies from dropping people from coverage when they get sick.
Effective 6 months after enactment.
\r\n
Blue Cross FAQ\’s
\r\n
Blue Cross FAQ\’s for Small Employer Groups
\r\nAB 2470 De La Torre 2010
\r\n
BEGINS TO CLOSE THE
MEDICARE PART D
DONUT HOLE
—Provides a $250 rebate to Medicare beneficiaries who hit the donut hole in 2010.
Effective for calendar year 2010.
(Beginning in 2011, institutes a 50% discount on prescription drugs in the donut hole; also completely closes the donut hole by 2020.)\r\n
medicare.gov/
\r\n
\r\n
FREE
PREVENTIVE CARE
UNDER
MEDICARE
\r\n—Eliminates co-payments for preventive services and exempts preventive services from deductibles under the Medicare program.
Effective beginning January 1, 2011.
\r\n
\r\n
EXTENDS COVERAGE FOR YOUNG PEOPLE UP TO
26TH BIRTHDAY THROUGH PARENTS’ INSURANCE
\r\n—Requires new health plans and certain grandfathered plans to allow young people up to their 26th birthday to remain on their parents’ insurance policy, at the parents’ choice.
Effective 6 months after enactment.
\r\n
\r\n
HELP FOR
EARLY RETIREES
—Creates a temporary re-insurance program (until the Exchanges are available) to help offset the costs of expensive premiums for employers and retirees for health benefits for retirees age 55-64.

Effective in 2010.
\r\n
\r\n
\r\n
BANS LIFETIME LIMITS ON COVERAGE

\r\nProhibits health insurance companies from placing lifetime caps on coverage.
Effective 6 months after enactment.
health care.gov
Blue Cross Flye
r HHS Memo 12/9/2010
\r\n
\r\n
Los Angeles Times
$21m claim to Medi-Cal poses huge challenge
7.17.2017\r\n
\r\n
\r\n
\r\n
\r\n
BANS RESTRICTIVE ANNUAL LIMITS ON COVERAGE
\r\n—Tightly restricts the use of annual limits to ensure access to needed care in all new plans and grandfathered group health plans.  (Beginning in 2014, the use of any annual limits would be prohibited for all new plans and grandfathered group health plans.)
health care.gov
* Blue Shield – info – NOTE definition of
Essential Benefits
Blue Cross Flyer
\r\n
FREE PREVENTIVE CARE
UNDER NEW PRIVATE PLANS
—Requires new private plans to cover preventive services with no co-payments and with preventive services being exempt from deductibles.\r\n
\r\n
NEW, INDEPENDENT
APPEALS PROCESS
—Ensures consumers in new plans have access to an effective internal and external appeals process to appeal decisions by their health insurance plan.
Effective 6 months after enactment.
\r\n
\r\n
ENSURES VALUE FOR PREMIUM PAYMENTS
—Requires plans in the individual and small group market to
spend 80 percent
of premium dollars on medical services, and plans in the large group market to spend 85 percent.\r\n
\r\n
COMMUNITY HEALTH CENTERS
—Increases funding for Community Health Centers to allow for nearly a doubling of the number of patients seen by the centers over the next 5 years.
Effective beginning in fiscal year 2011.
\r\n
INCREASES THE NUMBER OF PRIMARY CARE PRACTITIONERS

Provides new investments to increase the number of primary care practitioners, including doctors, nurses, nurse practitioners, and physician assistants.
Effective beginning in fiscal year 2011.
\r\n
\r\n
PROHIBITS
DISCRIMINATION BASED ON SALARY
\r\n—Prohibits new group health plans from establishing any eligibility rules for health care coverage that have the effect of discriminating in favor of
higher wage employees.

Effective 6 months after enactment.
\r\n
FAQ\’s BC/BS
\r\n
Management Carve Out
\r\n
\r\n
Page 17 Section 2716 HR 3590
\r\n
HEALTH INSURANCE CONSUMER INFORMATION (Web Portal)
—Provides aid to states in establishing offices of health insurance consumer assistance in order to help individuals with the filing of
complaints and appeals.
Effective beginning in fiscal year 2010.
\r\n
How to Get & Keep your Health Insurance\r\n
\r\n
Section 2793 Page 20 HR 3590
\r\n
More info on Web Portals
Health Care.gov
\r\n
\r\n
HOLDS INSURANCE COMPANIES ACCOUNTABLE FOR UNREASONABLE
RATE HIKES
\r\n—Creates a grant program to support States in requiring health insurance companies to submit justification for all requested premium increases, and insurance companies with excessive or unjustified premium exchanges may not be able to participate in the new
Health Insurance Exchanges
.
Starting in plan year 2011.
\r\nRate Review SB 1163\r\n
Medical Loss Ratio
\r\n
\r\n
Grandfathering Exemption
\r\n
\r\n
individual.tax.credit.36BFactSheet
\r\n
\r\n \r\n
\r\n
\r\n
\r\n
\r\n\r\n Hitler\’s plot to put ObamaCare on the American People – Parody\r\n\r\n
\r\n
\r\n\r\n
\r\n
\r\n
\r\n
\r\n \r\n
Resources on the New Health Reform Law
\r\n
ObamaCareFacts.com
\r\n
Tax Facts on Health Reform\r\n
Questions can be viewed
\r\nto get answers you must subscribe or
email us
\r\n\r\n
\r\n
\r\n
Consumer Links
\r\n
cal health plans.org
\r\n
small business majority.org/
\r\n
\r\n\r\n
\r\n
\r\n
//
‘,’PP-ACA Obamacare Introduction’,”,’publish’,’open’,’closed’,”,’pp-aca-obamacare-introduction’,”,”,’2018-10-06 18:53:57′,’2018-10-06 18:53:57′,”,0,’http://healthlaw.healthreformquotes.com/?page_id=8129′,0,’page’,”,0),(8219,1,’2017-03-29 17:09:40′,’2017-03-29 17:09:40′,’
\r\n\r\n
Specimen Policy – Platinum\r\n\r\n
\r\n
How long does one have to report a mistake?
\r\n
That is, if the Insurance Company wrote up the wrong policy and no one noticed for a long time?
\r\n
INTRODUCTION
\r\n
For a mistake to affect the validity of a contract it must be an \”
operative mistake
\”, ie, a mistake which operates to make the contract void. The effect of a mistake is:
\r\n
At common law, when the mistake is operative the contract is usually void ab initio, ie, from the beginning. Therefore, no property will pass under it and no obligations can arise under it.
\r\n
Even if the contract is valid at common law, in equity the contract may be voidable on the ground of mistake. Property will pass and obligations will arise unless or until the contract is avoided. However, the right to
rescission
may be lost.
\r\n
Unfortunately, there is
no general doctrine of mistake
– the rules are contained in a disparate group of cases. This is also an area of
confusing terminology
.
No two authorities seem to agree
on a common classification, and often the same terminology is used to cover different forms of mistake.
\r\n
MUTUAL MISTAKE
\r\nA mutual mistake is one where both parties fail to understand each other.\r\n
Learn More ===>
LawTeacher.net
\r\n
How does this apply to an Insurance Contract?
\r\nThe rescission agreement
page 36 of our specimen policy
allows the Insurance Company two years to find an error and be able to cancel the policy.\r\n
Rights & Responsibilities
Page 177 of Specimen Policy
\r\nGive the Insurance Company your thoughts and ideas about any of the rules of this plan and in the way it works.\r\n\r\nMake complaints or appeal about: our organization, any benefit or coverage decisions we make, Your coverage,\r\nor care received\r\n
Responsiblilies?
\r\n
Read and understand, to the
best of Your ability
, all information about Your health benefits or ask for help if You need it.
\r\n
Ambiquity?
\r\n
Interpretation of Contracts
\r\n
In cases of uncertainty not removed by the
preceding rules
,  [1635 – 1663
] the language of a contract should be
interpreted most strongly against the party who caused the uncertainty to exist
.
Cal.Civ.Code § 1654
\r\n1636.   A contract must be so interpreted as to give effect to the mutual intention of the parties as it existed at the time of contracting, so far as the same is ascertainable and lawful.\r\n\r\n1639.   When a contract is reduced to writing, the
intention of the parties
is to be ascertained from the writing alone, if possible; subject, however, to the other provisions of this Title.\r\n\r\n1640.   When, through fraud,
mistake, or accident
, a written contract fails to express the
real intention
of the parties, such intention is to be regarded, and the erroneous parts of the writing disregarded.\r\n
1644.   The
words
of a contract are to be understood in their
ordinary and popular sense
, rather than according to their strict legal meaning; unless used by the parties in a technical sense, or unless a special meaning is given to them by usage, in which case the latter must be followed.
\r\n
1649.   If the terms of a promise are in any respect
ambiguous or uncertain, it must be interpreted in the sense in which the promisor believed, at the time of making it, that the promisee understood it
.
\r\n
Statue of Limitations?
\r\n
4 years on a written contract –
\r\n
Learn More ===> Attorney Tony Liu
\r\n
Related Pages
\r\n
Insurance Application – Errors – What must be disclosed
\r\n\r\n
\r\n
Disclosure
\r\n
Investigation
\r\n
Pre-Existing Conditions
\r\n
Rescission
\r\n
\r\n
Fioretti v Mass General Life
\r\n
Must read your policy
\r\n
\r\n
\r\n
‘,’Mistake? Deadline to Report?’,”,’publish’,’open’,’closed’,”,’mistake-deadline-report’,”,”,’2018-07-13 22:13:07′,’2018-07-13 22:13:07′,”,8015,’http://healthlaw.healthreformquotes.com/?page_id=8219′,0,’page’,”,0),(8222,1,’2017-03-29 23:22:08′,’2017-03-29 23:22:08′,’2017 Factors in Calculating the Premiums’,’increasing.health.care.costs’,’2017 Factors in Calculating the Premiums’,’inherit’,’open’,’closed’,”,’increasing-health-care-costs’,”,”,’2017-03-29 23:24:27′,’2017-03-29 23:24:27′,”,227,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2013/07/increasing.health.care_.costs_.jpg’,0,’attachment’,’image/jpeg’,0),(8236,1,’2017-04-03 22:30:14′,’2017-04-03 22:30:14′,’
Insurance Companies cannot discriminate against victims of domestic abuse, regardless of sex.
(Woods v Horton * Woods v Sherry

pdf

)
npr.org
\r\n
\r\n
\r\n
\r\n
\r\n
Women\’s Law Project – Insurance\r\nDiscrimination – Domestic Violence\r\n
Women\’s Rights in Medical Insurance
ag.ca.gov
\r\n
\r\n\r\n
\r\n
\r\n
\r\n
\r\n
\r\n

\r\n
CA Insurance Code § 10144.2
.
\r\n
(a) No disability insurer covering hospital, medical, or surgical expenses
shall deny, refuse to insure
, refuse to renew, cancel, restrict, or otherwise terminate, exclude, or limit coverage or charge a different rate for the same coverage, on the basis that the applicant or insured person is, has been, or may be a
victim of
domestic violence
.
\r\n
(b) Nothing in this section shall prevent a disability insurer covering hospital, medical, or surgical expenses from
underwriting
coverage on the basis of the
medical condition
of an individual so long as the consideration of the condition
\r\n
(1) does not take into account whether such an individual\’s medical condition was caused by an act of
domestic violence
,
\r\n
(2) is the same with respect to an applicant or insured who is not the subject of
domestic violence
as with an applicant or insured who is the subject of
domestic violence
, and
\r\n
(3) does not violate any other act, regulation, or rule of law. The fact that an individual is, has been, or may be the subject of
domestic violence
shall not be considered a medical condition.

\r\n
(c) As used in this section, \”
domestic violence
\” means
domestic violence
, as defined in Section 6211 of the Family Code.
\r\n
See also Health & Safety Code
1374.75
\r\n

\r\n
CA Insurance Code 676.9.  (a) This section applies to policies covered by Sections 675 and 675.5.
\r\n
(b) No insurer issuing policies subject to this section shall deny or refuse to accept an application, refuse to insure, refuse to renew, cancel, restrict, or otherwise terminate, or charge a different rate for the same coverage, on the basis that the applicant or insured person is, has been, or may be, a victim of domestic violence.
\r\n
(c) Nothing in this section shall prevent an insurer subject tothis section from taking any of the actions set forth in subdivision(b) on the basis of criteria not otherwise made invalid by thissection or any other act, regulation, or rule of law. If discrimination by an insurer is not in violation of this section butis based on any other criteria that are allowable by law, the fact that the applicant or insured is, has been, or may be the subject ofdomestic violence shall be irrelevant.
\r\n
(d) For purposes of this section, information that indicates thata person is, has been, or may be a victim of domestic violence ispersonal information within the meaning of …Section 791)
\r\n
(e) No insurer that issues policies subject to this section, andno person employed by or under contract with an insurer that issues policies subject to this section, shall request any information theinsurer or person knows or reasonably should know relates to acts ofdomestic violence or an applicant\’s or insured\’s status as a victimof domestic violence, or make use of this information however obtained, except for the limited purpose of complying with legal obligations, verifying a person\’s claim to be a subject of domestic violence, or cooperating with a victim of domestic violence in seeking protection from domestic violence or facilitating the treatment of a domestic violence-related medical condition. Thissubdivision does not prohibit an insurer from asking an applicant orinsured about a property and casualty claim, even if the claim isrelated to domestic violence, or from using information therebyobtained in evaluating and carrying out its rights and duties under the policy, to the extent otherwise permitted by this section and other applicable law.
\r\n
(f) As used in this section, \”domestic violence\” means domesticviolence as defined in Section 6211 of the Family Code.
\r\n

‘,’Domestic Abuse – Can\’t be used in underwriting’,”,’publish’,’open’,’closed’,”,’domestic-abuse-cant-used-underwriting’,”,”,’2018-10-06 18:56:14′,’2018-10-06 18:56:14′,”,14,’http://healthlaw.healthreformquotes.com/?page_id=8236′,0,’page’,”,0),(8349,1,’2017-04-25 15:33:56′,’2017-04-25 15:33:56′,’
\r\n\r\n
Unsolicited Emails
§17529-17529.
9\r\n\r\n
\r\n
Telemarketing Harassment?
\r\nSee the links below for our research on how to comply with the laws on telemarketing and emails.\r\n\r\n
Guide for Business
– Can Spam Act\r\n\r\nCA Law – Restrictions On Unsolicited Commercial E-mail Advertisers Business & Professions §
17529-17529.9
\r\n\r\n
Todd Friedman, Esq.
can help stop the calls.\r\n
Federal Trade Commission Telemarketing Sales Rule,
16 C.F.R. Part 310
\r\n
The National Do Not Call Registry is only for personal phone numbers.
Business to business calls are not covered
by the National Do Not Call Registry.
FTC.Gov
\r\n
cell.phone.maps
\r\nUnsolicited and Unwanted Telephone Solicitations 17590-17594\r\n\r\nunsolited.emails.  bpc_17529-17529\r\n\r\n
\r\n\r\n \r\n
\r\n
\r\n
\r\n
\r\n\r\nGet Garcia – News Cast – Harassing Debt Collection\r\n\r\n
Todd Friedman, Esq
\r\n
\r\n
\r\n
\r\n
\r\n
Historical Info
\r\nFTC Do NOT call list –
is NOT valid
2003\r\n\r\n ‘,’Telemarketing Harassment? Unsolicited Email?’,”,’publish’,’open’,’closed’,”,’telemarketing-harassment’,”,”,’2018-10-06 19:03:17′,’2018-10-06 19:03:17′,”,53,’http://healthlaw.healthreformquotes.com/?page_id=8349′,0,’page’,”,0),(8353,1,’2017-04-25 16:44:43′,’2017-04-25 16:44:43′,’Hi,\r\n\r\nIt’s unfortunate that with all the problems with getting the poor, those with pre existing conditions, etc. covered, that there are scammers out there committing fraud.\r\n\r\nWe offer our website to help you keep informed, with aninimoty and no obligation.  Please email us your questions or post them on each web page.\r\n\r\nHere are some excerpts on how to keep safe.\r\n
\r\n
“Confusion is the scammer’s best friend,” said James Quiggle, a spokesman for the
Coalition Against Insurance Fraud
, a consumer protection group.
\r\n
“If something sounds too good to be true, it probably is,” said Michael T. McRaith, director of the Illinois Department of Insurance,
\r\n
\r\n
\r\n\r\nposing as
federal employees
, trying to get your personal and financial details for suspected identity theft.\r\n\r\nScammers also know that whenever there’s a change or even discussion about possible changes in government programs or policy, the time is ripe to capitalize on consumers’ uncertainty by trying to get them to reveal personal information.\r\n\r\n \r\n
\r\n
Government agencies already have your personal information on file. Unless you initiate contact, you will never be asked to provide or verify that data.
\r\n
Don’t be fooled if your
Caller ID screen
indicates that a call is from an agency you recognize. Scammers have technology that lets them display any number or organization name on your screen.
\r\n
Government agencies do not send
unsolicited emails
. Official correspondence is typically delivered by U.S. mail. If you get such a letter, you can authenticate it by looking up the agency’s phone number yourself in a directory and calling the agency.
\r\n
Don’t expect government employees to make unannounced door-to-door visits about new or revised programs. You’ll typically receive advance notification of any official knock on your door, and your personal information will already be known to legitimate federal employees.
\r\n
\r\n
http://www.aarp.org/money/scams-fraud/info-07-2012/affordable-care-act-scam.html
‘,’Scams’,”,’publish’,’open’,’closed’,”,’scams’,”,”,’2017-04-25 16:44:43′,’2017-04-25 16:44:43′,”,157,’http://healthlaw.healthreformquotes.com/?page_id=8353′,0,’page’,”,0),(8422,1,’2017-05-11 16:49:45′,’2017-05-11 16:49:45′,’AHIP Graph of Medical Loss Ratio 80% Claims – 20% Operating Costs & Profit’,’mlr’,’AHIP Graph of Medical Loss Ratio 80% Claims – 20% Operating Costs & Profit’,’inherit’,’open’,’closed’,”,’mlr’,”,”,’2017-05-11 16:51:01′,’2017-05-11 16:51:01′,”,887,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2013/07/mlr.jpg’,0,’attachment’,’image/jpeg’,0),(8469,1,’2017-05-20 13:30:48′,’2017-05-20 13:30:48′,’Medicare Guide to who pays first # 02179′,’medicare.guide.who.pays.first’,’Medicare Guide to who pays first # 02179′,’inherit’,’open’,’closed’,”,’medicare-guide-who-pays-first’,”,”,’2017-05-20 13:31:28′,’2017-05-20 13:31:28′,”,5521,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2014/05/medicare.guide_.who_.pays_.first_.jpg’,0,’attachment’,’image/jpeg’,0),(8470,1,’2017-05-20 13:34:08′,’2017-05-20 13:34:08′,”,’dual.coverage.rules’,”,’inherit’,’open’,’closed’,”,’dual-coverage-rules’,”,”,’2017-05-20 13:34:08′,’2017-05-20 13:34:08′,”,5521,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2014/05/dual.coverage.rules_.jpg’,0,’attachment’,’image/jpeg’,0),(8471,1,’2017-05-20 13:38:33′,’2017-05-20 13:38:33′,’NAIC Summary on Co-Ordination of Benefits’,’naic.dual.coverage’,’NAIC Summary on Co-Ordination of Benefits’,’inherit’,’open’,’closed’,”,’naic-dual-coverage’,”,”,’2017-05-20 13:39:33′,’2017-05-20 13:39:33′,”,5521,’http://healthlaw.healthreformquotes.com/wp-content/uploads/sites/11/2014/05/naic.dual_.coverage.jpg’,0,’attachment’,’image/jpeg’,0),(8481,1,’2017-05-24 12:19:07′,’2017-05-24 12:19:07′,’
Do Individual Health Insurance Plans cover on the Job Injuries?
\r\nYes, if you are not covered by workers compensation:\r\n\r\nLet\’s take a look at the typical
exclusions
for Worker\’s Compensation\r\n
Any condition for which
benefits are recovered or can be recovered
either
by any workers’ compensation law
or similar law even if You do not make a claim for those benefits. If there is a dispute or substantial uncertainty as to whether benefits may be recovered for those conditions pursuant to workers’ compensation law or similar law, we will provide the benefits of this plan for such conditions, subject to our right to a
lien
or other recovery under section 4903 of the California Labor Code or other applicable law.
Specimen Policy
Exclusions Page 105
*  if you are covered by
Worker\’s Compensation
Page 119
\r\n
I do not see any exclusion that says that if you are doing something and getting paid, it\’s excluded.
\r\nSo, if you\’re self employed or a C
orporate Office
r and are
NOT required to have
Workers Compensation
, nor can you probably get it.  You would be COVERED by  virtually ALL Individual Medical Plans.\r\n\r\nGroup Medical Plans will typically make you sign off that you are excluded under the Worker\’s Compensation Laws.\r\n
Blue Cross Employer Medical Application Section 12
\r\n\r\nDefinition of employee CA Labor Code

§
3351
‘,’Self Employed – Covered by Health Insurance?’,”,’publish’,’open’,’closed’,”,’self-employed-covered-health-insurance’,”,”,’2017-05-24 12:34:07′,’2017-05-24 12:34:07′,”,24,’http://healthlaw.healthreformquotes.com/?page_id=8481′,0,’page’,”,0);