Veterans 2nd Amendment Protection Act (H.R. 1181)

It’s no secret that the mental health of our Veterans is a hot topic; not only how to manage it, but also the consequences of it. As a Veteran and a caregiver to my Veteran husband who was injured in Iraq, I understand first-hand why it is so important that we study and improve on services for our men and women in the military. That being said, the rights of some Veterans are being taken away because the VA has determined they are “mentally incompetent” to manage their own finances. This determination could be for many different reasons but it results in the appointment of someone to oversee their VA compensation (often a loved one or friend) and the denial to own a firearm. You read that properly. A man or woman who has served our country honorably and fought to keep them safe could potentially lose the right to bear arms, a right afforded to them in the 2nd Amendment.

Enter H.R. 1181, the Veterans 2nd Amendment Protection Act. With a vote of 240-175, the bill was passed in the House today. The bill seeks to correct language about gun ownership that is too broad. The U.S. Code which outlines criminal acts, makes owning a gun a crime for anyone who has been “adjudicated as a mental defective.” Under this new bill, if passed, a judge, magistrate, or someone “of judical authority” must determine that a Veteran is a danger to themself or others.

I am not going to slam the VA here. After five years in Army administration, I know how hard it can be to ensure that you are following regulation to the letter of the law (there is rarely room for “spirit of the law”). However, in an attempt to do so, the VA has reported thousands of names of Veterans to the FBI’s National Instant Background Check System which would prevent them from buying a gun. This may not seem like a bad idea, except a Veteran who can’t manage their bills properly are now kept from claiming a right that they, ironically, had to make use of during their service.  Some reports say that 167,000 Veterans are listed because of their inability to manage finances; still others list it at 257,000. Whatever the number, it is unfair to take away such a right under these circumstances. Forgetting that your cable bill is due every month does not equal being a danger to anyone.

I thoroughly support background checks and preventing those who are dangerous from owning a gun. I will add that where there is a will, there is, unfortunately sometimes, a way. We cannot prevent all gun violence, or violence using any weapon, however, laws are an important defense against it. Nevertheless, we have to give our Veterans a fair chance. Just because you are bruised, doesn’t mean you are broken.

 

 

 

 

 

 

 

American Health Care Act: Premium Tax Credits (Proposed Bill)

We start today’s installment of the health care bill translation with discussion about advanced tax credits. I know, that sent chills of excitement down your spine, didn’t it!?! Either way, under the Affordable Care Act, any tax credits for health care that were advanced and overpaid had to be paid back to the government. There is no real surprise there and it seems only fair, right? Well, there was a plan in place on how much the government would get back, a limit on repayment. For the years 2018 and 2019, there will now be no limit. If you are given an advanced tax credit for health care, you will be required to pay back any and all over-payments, regardless of the amount and personal income. This still seems fair but perhaps it would also be a good idea to work on calculating payments and credits more accurately.

For the purposes of this tax credit, the term “Qualified Health Plan” would now include plans that are not offered on State exchanges. It would not include a grandfathered or grandmothered health plan or one that includes coverage for abortions unless it was necessary to save the life of the mother. Women can still opt to buy separate insurance that would cover abortion but they cannot use or claim any tax credits for that plan. Should any side effects, illness, or injury occur because of an abortion, the treatment of those things would be able to be treated by a health plan that is paid for by credits.

Advanced payments of tax credits will not be made for any health insurance plan that is not part of the State exchange. If you wish to claim the credits for non-exchange plans, you will need to include a statement with your tax return showing that it is a qualified health plan, the months you were covered, the adjusted monthly premium for a silver plan at the second lowest cost (wow that is getting specific), and any other information requested in the  future. These requirements for information will not apply to any coverage starting in January 2020.

Seniors are seeing another raise in their health care premiums through this bill starting in the 2019 tax year. Should they be eligible to receive any premium tax credits, the percentage of personal income that they are required to pay towards premiums increases with age once you get income above 150% of the poverty line.

Screenshot (7)

And really, this doesn’t just affect seniors. The older you are, the more  you will pay. Have a younger spouse? Well that won’t help either! My husband is 12 years older than me. Filing a joint return means that his age is the one they base the required percentage off of. That could mean 2% or more difference and it would be another 30 years before we are both in the same bracket and that won’t matter because the premium tax credits will be gone after the 2019 tax year. Why does age matter for tax credits anyway? Isn’t a dollar still a dollar no matter whose pocket it is in?

Next up… Small Business Tax Credit…

American Health Care Act: Buh-Bye Random Taxes (Proposed Health Care Bills)

Several pages of the American Health Care Act repeal a few taxes and even a deduction. Unfortunately, only a couple of them will directly affect the American consumer. If the bill passes, we can say buh-bye to the so-called “Tanning Tax.” The 10% tax is paid by the person who actually hops inside the tanning bed. The 3.8% Investment Income Tax will go away as well. According to businessinsider.com, just over 40% of Americans are invested in the stock market, but it really depends on how much each person holds in stock as to whether or not they really feel a boost. As with all of the other repeals discussed in this post, these taxes will end December 31, 2017.

The IRS code does not allow health insurance companies to deduct pay paid to an  employee that goes over $500k. There are a few exceptions but now this won’t be a problem. They can pay a CEO a buttload of money and deduct it as a payroll expense. In case you are wondering, buttload is a technical term…

Screenshot (5)

Now that we can all legitimately use “buttload,” let’s get back to all of the fun money that companies will be saving after 2017!

Prescription drug makers and importers will no longer be paying the special tax imposed upon them. Could this lead to lower prescription drug costs? We can only hope.

And finally, health insurance companies pay another tax that has to do with how much they collect in monthly premiums. The tax was suspended for this year and if this bill makes it through without changing this, the tax will formally end at the end of the year.

These tax cuts could be a positive thing, as long as they translate to lower costs to the consumer. I’ll be honest, I’m not entirely sure why the Investment Income Tax is addressed in health care legislation, but random stuff happens like this all the time.Perhaps you could argue that the tax that would have been paid could be used to pay monthly insurance premiums but I just don’t see Americans who need help the most carrying a stock portfolio that makes that kind of money. But, I’ve been wrong before.

‘Til tomorrow, when I will bring you another buttload of information!

American Health Care Act, Subtitle D: Patient & Health Insurance Market Stability

This subtitle of the American Health Care Act (AHCA) may possibly be the most important part that I have reviewed thus far. I can finally see where the drafters of this legislation can support their call for “Repeal and Replace.” That is exactly what this section does.

Section 1402 of the Affordable Care Act (Obamacare) will be repealed. This section covers the decrease of “cost-sharing” for insured Americans. Things like copays and deductibles are reduced but premiums and out of network services are not.

This is to be replaced with a new title section added to the Social Security Act which governs medical assistance programs and payments. This new section will be:

Title XXII – Patient and State Stability Fund

For the period of January 1, 2018 to December 31, 2026, funds will be given to each state for the following purposes:

  1. Financial assistance for “high-risk” people who don’t have health care coverage through their employer. The term “high-risk” was not defined anywhere in the subtitle and poses a concern because it can mean many things to different people.Do they mean high-risk financially or medically? And what would the criteria be to fall into that category. Implementation gets sketchy when details are left out.
  2. States can provide “incentives” to “appropriate entities” that enter into arrangements with the State to help level off the cost of premiums (the bill you get to pay to the insurance companies… ).
  3. The funds can be used to reduce the cost to insurance companies for people who are  expected to need a lot of medical care. Although it isn’t stated, I can see where this could be a good idea. Premiums go up when insurance companies think they will have to pay more for your care. There should probably be some oversight here to make sure the insurance companies follow through completely on this.
  4. States can use the money to promote participation in the health insurance market and to increase the number of options available in the individual/small group market.
  5. They can promote access to preventive services, dental and vision care, and services mental health or substance use disorders.
  6. Payments can be made directly or indirectly to health care providers
  7. Finally, and perhaps what families will notice the most, these funds from the federal government to the States can be used to reduce out of pocket costs to those who are insured to include copays, premiums, and deductibles.

State Eligibility and Approval; Default Safeguard

States will need to formally tell the federal government how these funds will be used before they can receive them. They will also need to certify that they will use their own State money to supplement the federal money in the percentage required by law (discussed a little later). If a State doesn’t have and approved application for funding for the year, the Administrator of the Centers for Medicare and Medicaid Services will work with the State Insurance Commissioner and spend the money for the State for the purposes stated above.

For insurance claims that exceed $50k, but less than $350k, part of the State funds will be used to pay 75% of those claims to the insurer. This will be done in hopes of stabilizing the price of insurance. $15 billion in total will be given to the States in 2018 and 2019 and 10 billion for every year after  that through 2026.Any funds that are not used each year can be applied to payment of insurance claims that exceed $1 million or they can be rolled over to the next year.

Beginning in 2020, States must also agree to use a portion of their own money for the same seven reasons listed above that the federal money is used for. It starts at 7% in 2020 and increases by 7% each year until it jumps by 8% in 2026 to make an even 50%. So for every $1 million that the federal government gives the States for this section in 2026, the States will have to use $500k of their own money for the same activities. If they do not agree to this, they will only receive a portion of the money they would otherwise get.

The penalty for not having health care doesn’t seem to be going away. Instead of a flat penalty for being uninsured that many Americans enjoy so much… the punishment will be 30% of the monthly premiums you would have paid if you remain uninsured for more than 63 days continuous days. My thoughts on this are best described in this quote from B.F. Skinner:

“A person who has been punished is not thereby simply less inclined to behave in a given way; at best, he learns how to avoid punishment.”

I would confidently say that the majority of people who are uninsured do not remain that way because they want to. It’s a matter of “Do I eat today” or “Do I pay my insurance bill” more than anything. No one likes to be surprised by hospital and doctor bills, just like we don’t like to be surprised by natural disasters and car wrecks. The difference is the cost. Car and home insurance can be had fairly cheaply as long as you are take precaution and follow the applicable laws. If this – or any – health care bill works to control the spiraling costs of health care, then – and only then – will you see people happy to have a law requiring them to buy health insurance.

Section 134 Increasing Coverage Options

This section takes away the mandate for basic “Health Benefit Packages” in order for health insurance to be part of an approved plan by the government. If you have read my previous posts, this may sound familiar to you… and it should. This section takes away the mandate within the Affordable Care Act. There was a similar removal from the Social Security Act under Subtitle B of this bill.

Finally, and probably a really terrible note to end on, age related premiums have gone from a ration of 3:1 to 5:1. Basically, if you are 22 year old woman and are charged $200 for a health insurance plan, it would be legal for an insurance company to charge a 64 year old woman $1000 for the exact same plan.

What a crappy note to end on. There better be some serious help for that 64 year old woman…

,

American Health Care Act, Title 1, Subtitle C – Per Capita Allotment for Medical Assistance (Medicaid)

If you are still reading this after seeing the title, you are an inspiration to me TUH-DAY! I hated to put it there but it’s mostly necessary so you know what this post is about. Overall, Subtitle C of the AHCA (American Health Care Act) bill was much easier to translate for you. It’s not so much because it was worded to be easily understood, but rather because I understood enough to realize that it mostly dealt with outlining formulas for how much should be spent on medical assistance per person (aka per capita).

The simplest summary is that it actually adds a new section to the Social Security Act, the legislation that actually governs Medicaid. The new section gives instructions calculating how much IS spent per person for Medicaid and how much SHOULD be spent. This will be different from year to year and from State to State. If a state exceeds how much should have been spent per person, the they will receive less money each quarter for the next year. In other words, if they overspend by $100,000, they will receive $25,000 less in Medicaid allotments every three months the following year.

Continue reading “American Health Care Act, Title 1, Subtitle C – Per Capita Allotment for Medical Assistance (Medicaid)”

American Health Care Act, Title 1, Subtitle B – Medicaid Program Enhancement (Proposed Bill)

Let me first just say… wow. Subtitle B was a lot to take in. In case you have been living under a rock, I imagine you won’t be shocked to hear that the changes do not favor Medicaid expansion at all. Just in case you don’t know exactly how it was expanded, all people who earn an income of 138% (or less) of the poverty level are included now instead of just low-income persons who are seniors, children, pregnant women, and those with certain disabilities. Basically, if the poverty level were $100, you could make $138 and still qualify for Medicaid.

Sec 111: Right out of the gate, hospitals who elect to be qualified to determine medical assistance eligibility (so that patients can be treated during a time that it is assumed they will be formally approved) will not be able to do so beginning January 1, 2020 and any hospitals who have already made this election will no longer be qualified.

The income eligibility limits of 133% of poverty level for children between 6 and 19 will end on December 31, 2019.

The 6% funding increase for home and community based services and support will end January 1, 2020. As a caregiver myself, I find this funding cut hard to swallow. In the event that I were not able to care for my husband, at any age, I would be particularly worried about how much care he would actually be able to receive. A friend of mine recently experienced this very situation. She was torn between working to support their family and staying at home to care for him. Everyday presented a new problem, a new requirement, a new task for her to complete. My heart goes out to her and all of those who care for a loved one while working outside the home. Suddenly, that “rock and a hard place” we always hear about seems very real.

States can currently elect to grant “presumptive eligibility”for Medicaid for pregnant women and children based on income. This period will no longer be allowed beginning January 1, 2020.

Section 112: Repeal of Medicaid Expansion (go ahead… tell me you didn’t see this coming…)

The first change puts into legislation what the Supreme Court has already decided: that States can decide whether or not they want to join the Medicaid expansion plan.

Next, the percentage of funds given to the States, for the cost of medical assistance for people newly eligible under the expansion, will be equal to previously stated amounts. The percentage is 95% in 2017. Fun fact: the word “such” is used 9 times in this amendment. NINE! It really was unnecessary.

The expansion clause which allows for non-pregnant, childless adults to be enrolled for medical assistant will end January 1, 2020. However, anyone who falls into that category before that date will continue to be covered unless they have a break in eligibility for more than one month.

Federal medical assistance is capped at 80% this year and beyond (instead of increasing to 100% by 2019).

The clause which established the Essential Health Benefits requirements for government sponsored health care and HMOs will no longer be in effect after December 31, 2019. The listed essential benefits are:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity/Newborn care
  5. Mental Health / Substance Abuse / Behavioral Health care
  6. Prescription Drugs
  7. Rehabilitative services and devices
  8. Lab services
  9. Prevention / Wellness Services / Chronic Disease Management
  10. Pediatric Services (including oral / vision care)

Wow. I don’t really know if there is anything left! It will truly become a “you get what you pay for” health care marker. Perhaps that will be a good thing for some but I can already see disaster strike when someone purchases health benefits a la carte, thinking that they will not need long-term prescription benefits, etc. Yes, we are supposed to “adult” these days but take a second to think about some of your loved ones. I am pretty sure you can think of at least a couple of them who aren’t so consistent with adulting…

Section 113: Elimination of DSH Cuts

There are hospitals who provide care for a disproportionate amount of low income families and they are referred to as Disproportionate Share Hospitals (DSH). A reduction in the amount of money they receive from medical assistance was already scheduled to be reduced during this fiscal year. This reduction will now end in fiscal year 2018 instead of 2024. Note: The proposed bill strikes through “2025” in the Social Security Act but after quadruple checking, “2024” is really the fiscal year specified. Seriously… if someone find where this clause currently reads “2025,” you will get a gold star for the day! lol

A subparagraph is also added that says when a State does not have Medicaid expansion for a fiscal year, the reduction in DSH allotments will not apply to that State for that fiscal year. And then the next subparagraph added pretty much just says that if the previous subparagraph doesn’t apply to you, your reduction for that fiscal year stands. I thought that last part was pretty pointless. After the reduction period, the DSH allotments will go back to being determined by the previous year’s allotment and the percentage changes in the consumer price index. Basically, it will apply to fiscal year 2019 only.

Section 114: Reducing State Medicaid Costs

I think this next bit will be supported by pretty much everyone! If someone receives Medicaid because of income level, and they win big (lottery, sweeps, etc), that money will be counted as income but will affect their eligibility a little different depending on the circumstances. A lump sum payment of less than $80k will affect their eligibility for Medicaid for the month it is received only. An $80k to less than $90k will prevent eligibility for 2 months. $90k to less than $100k will make them ineligible for 3 months. Add an additional month to that for every $10k increase in the lump sum. The max ineligibility will before 120 months. Winnings that are paid in equal installments will be counted as income every month that they are received. My question is… how is this not already a thing! Shouldn’t have this been identified as an issue by now? Sure, most Americans will not be winning the lottery this year – or ever- but with as much nitpicking as we see in legislation, one would think this would have already been taken care of.

There are “hardship exemptions” for people who exceed the income limits but the standards for approving the exemption may vary by State.

Next, there is an addition requiring notification of loss of eligibility and that it be made before the date that the individual loses coverage. The notification must specify the date coverage will end and when they can reapply. Again… I feel like this should already be mandated and it’s really a no-brainer. I’m pretty sure Dear Abby would explain this is really just good manners and not very difficult.

The bill also reminds us that none of these provisions should be taken to mean that a State cannot intercept State lottery winnings to recoup and money paid for that individuals medical assistance. Also, the winnings will be counted as income only for the individual in the household who won and their spouse if they have one.

Under current health care laws, medical assistance coverage can be granted for up to three months prior to the application. So if Johnny applies for coverage and he broke his leg a month ago, medical assistance could pay for the care he received even though he hadn’t applied yet. It is proposed that this retroactive eligibility be canned and all effective dates of coverage be on the date of application or after. This change would take effect October 1, 2017. I can certainly see the idea behind removing this practice. A lot of medical care can happen in three months and I imagine  that it is more difficult to process claims the longer it has been since the service occurred. However, the need for prolonged, intense medical care can interrupt a person’s income and it’s pretty easy to end up broke even with insurance. After all of that, Medicaid might be their only option to not go bankrupt. With hospitals not being able to determine presumptive eligibility soon, the need for emergency medical care just became even more inconvenient.

Along the lines of presumptive income eligibility, applicants were also given the benefit of the doubt when it comes to their citizenship. A statement from the individual was all that was needed to start coverage until they had been given a satisfactory amount of time to produce valid documentation to prove citizenship. Not surprisingly, beginning six months after this bill is passed, no one will be eligible for coverage until they can prove citizenship. For most, this probably doesn’t seem like a big deal since a social security number is considered valid proof. If States do elect to offer coverage while waiting for proof, they will not receive Federal funds for any medical assistance they provide during that period. If you are curious just how much money is spent on medical coverage for illegal aliens, I found an interesting article from PolitiFact on this topic.

For people in nursing homes or long-term care facilities, States will not be able to increase the home equity allowance from $500k to $750k. It will now just be $500k plus a yearly increase based on the consumer price index in increments of $1000. This increase began in 2011 and will remain in effect.

If States must pass legislation to comply with any of these changes, they will have one regular legislative session to do so. The example they used is if a State has a 2-year legislative session, each year will be counted as a different regular session and they will only have one of those to complete the work needed.

Section 115: Safety Net for Non-Expansion States

During the years of 2018 – 2021, non-expansion States (in regards to Medicaid expansion) will receive funds equal to 100% of their medical assistance expenditures and 95% every year after that. This could certainly be a financial incentive for States to resist expanding their Medicaid coverage and I think it would be hard to argue that it isn’t.

There is a formula to cap these payments, however, and it is based on total population and population at 138% of the poverty income level. Payments to providers will not exceed the cost of the services but, again, did that really need to be said? Perhaps the frustration for that sentence should stick with whomever is responsible for the outrageous prices for hospital services.

Once a State offers expanded coverage, it will not be treated as a non-expansion State under this section in subsequent years.

Section 116: Providing Incentives for Increased Frequency of Eligibility Determination

The moment I got to this section, I dreaded. I am blessed to not be on Medicaid but I have sat with someone during an eligibility interview because they moved to a new state. It wasn’t even my medical coverage and I was nervous! They ask you pretty much everything besides how much your frying pan is worth… I get why they do that but I feel like the following addition to the health care law could be abused by States who are looking for additional funding.

Beginning October 1, 2017, anyone now eligible for medical assistance because of the expansion plan and if their income was determined by their modified adjusted gross income, they must be reevaluated for eligibility at least every six months. Money paid to States for activities related to these reevaluations will be increased by 5%. If they spend $100 for a reevaluation interview, they will receive $105. Do you see where this could be abused? If the words “at least” weren’t in there , wouldn’t be so concerned but more reevaluations equal extra paper Lincolns.

Civil monetary penalties for any person or entity (besides the beneficiary of medical assistance) have increased when it comes to intentionally committing fraud by claiming services that weren’t provided, medically necessary or completed outside of the eligibility period and presenting patients to physicians who aren’t properly licensed or certified. This applies to individuals that are “knowingly enrolled” on or after October 1, 2017. Each case identified will bring a heft $20k penalty.

We made it through. My brain hurts. We should go take a Tylenol together. ‘Til next time when venture into Subtitle C of the proposed health care bill!