EATING THE DONUT HOLE

Considering the statistics on the image provided (Wikipedia reports US literacy rate is 99%), here are selected sections from the ACA. Feel free to comment.

“Fruitcakes in the kitchen

Fruitcakes on the bus

There’s a little bit of Fruitcake left in every one of us”

                -Jimmy Buffett

 

 literacy

1. ESTABLISHED STANDARD BENEFITS PACKAGE DEFINED (NOT REALLY)

§ 1302 [42 U.S.C. 18022]. ESSENTIAL HEALTH BENEFITS REQUIREMENTS.

(a) ESSENTIAL HEALTH BENEFITS PACKAGE. — In this title, the term ‘‘essential health benefits package’’ means, with respect to any health plan, coverage that—

(1) provides for the essential health benefits defined by the Secretary under subsection (b);

(2) limits cost-sharing for such coverage in accordance with subsection (c); and

(3) subject to subsection (e), provides either the bronze, silver, gold, or platinum level of coverage described in subsection (d).

(b) ESSENTIAL HEALTH BENEFITS.—

(1) IN GENERAL.—Subject to paragraph (2), the Secretary shall define the essential health benefits, except that such benefits shall include at least the following general categories and the items and services covered within the categories:

(A) Ambulatory patient services.

(B) Emergency services.

(C) Hospitalization.

(D) Maternity and newborn care.

(E) Mental health and substance use disorder services, including behavioral health treatment.

(F) Prescription drugs.

(G) Rehabilitative and rehabilitative services and devices.

(H) Laboratory services.

(I) Preventive and wellness services and chronic disease management.

(J) Pediatric services, including oral and vision care.

 2. BENEFITS AND ABILITY TO PAY. YOU STILL GET WHAT YOU PAY FOR.

§ 1302 (d) LEVELS OF COVERAGE.—

(1) LEVELS OF COVERAGE DEFINED. — The levels of coverage described in this subsection are as follows:

(A) BRONZE LEVEL.— A plan in the bronze level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 60 percent of the full actuarial value of the benefits provided under the plan.

(B) SILVER LEVEL.— A plan in the silver level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 70 percent of the full actuarial value of the benefits provided under the plan.

(C) GOLD LEVEL.— A plan in the gold level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 80 percent of the full actuarial value of the benefits provided under the plan.

(D) PLATINUM LEVEL. — A plan in the platinum level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 90 percent of the full actuarial value of the benefits provided under the plan.

(2) ACTUARIAL VALUE.—

(A) IN GENERAL. — Under regulations issued by the Secretary, the level of coverage of a plan shall be determined on the basis that the essential health benefits described in subsection (b) shall be provided to a standard population (and without regard to the population the plan may actually provide benefits to).

 3. CHILD BENEFITS AND AGE 27 COVERAGE:

§ 1302 (f) CHILD-ONLY PLANS.—If a qualified health plan is offered through the Exchange in any level of coverage specified under subsection

(d), the issuer shall also offer that plan through the Exchange in that level as a plan in which the only enrollees are individuals who, as of the beginning of a plan year, have not attained the age of 21, and such plan shall be treated as a qualified health plan.

 4. CATASTROPHIC PLAN COVERAGE IF YOU HAPPEN TO BE OVER 30

§ 1302 (e) CATASTROPHIC PLAN.—

(1) IN GENERAL.—A health plan not providing a bronze, silver, gold, or platinum level of coverage shall be treated as meeting the requirements of subsection (d) with respect to any plan year if—

(A) the only individuals who are eligible to enroll in the plan are individuals described in paragraph (2); and

(B) the plan provides—

(i) except as provided in clause (ii), the essential health benefits determined under subsection (b), except that the plan provides no benefits for any plan year until the individual has incurred cost-sharing expenses in an amount equal to the annual limitation in effect under subsection (c)(1) for the plan year (except as provided for in section 2713); and

(ii) coverage for at least three primary care visits.

(2) INDIVIDUALS ELIGIBLE FOR ENROLLMENT.—An individual is described in this paragraph for any plan year if the individual—

(A) has not attained the age of 30 before the beginning of the plan year;

(B) has a certification in effect for any plan year under this title that the individual is exempt from the requirement under section 5000A of the Internal Revenue Code of 1986 by reason of—

(i) section 5000A(e)(1) of such Code (relating to individuals without affordable coverage); or

(ii) section 5000A(e)(5) of such Code (relating to individuals with hardships).

5. SAVINGS (REDUCED COST?). MATH SIMPLIFIED FOR SENIOR CITIZENS. Less than  0 = 0?

§ 3403\1899A SSA

‘‘(B) MEDICARE PER CAPITA GROWTH RATE.—

‘‘(i) IN GENERAL.—[As revised by section 10320(a)(1)(G)]

For purposes of this section, the Medicare per capita growth rate for an implementation year shall be calculated as the projected 5-year average (ending with such year) of the growth in Medicare program spending (calculated as the sum of per capita spending under each of parts A, B, and D).

‘‘(ii) REQUIREMENT.—The projection under clause (i) shall—

‘‘(I) to the extent that there is projected to be a negative update to the single conversion factor  applicable to payments for physicians’ services under section 1848(d) furnished in the proposal year or the implementation year,  assume that such update for such services is 0 percent rather than the  negative percent that would otherwise apply; and

(II) take into account any delivery system reforms or other payment changes that have been enacted or published in final rules but not yet implemented as of the making of such calculation.

Frog bat -Mediguano

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