Well, it appears the office of U.S. Senator Bob Menendez, D-N.J.,  didn’t take long to respond to yesterday’s blog about whether New Jersey’s senators could have gotten more sweet deals for the state in the health care bill if they played harder-to-get, as holdout Democrat Ben Nelson did when he got the federal government to permanently pay for Nebraska’s Medicaid increases.

I got a phone call — and then this release — from Menendez press aide Afshin Mohamadi saying that the senator did, indeed, get some good deals for the state. Here’s what I received:

First, here are the provisions he got in the bill that are NJ-focused.

Approx $70 million per year in savings for New Jersey hospital (top priority of the New Jersey Hospital Association). Current law ensures that hospitals in highly-urban states, like New Jersey, are protected from receiving unfairly low Medicare reimbursements. Provision would ensure that the costs associated with this protection are shared by hospitals nationwide, rather than shared exclusively within these states, as the Center for Medicare and Medicaid Services is proposing.

AUTISM - Require insurance plans to provide behavioral health treatments. Plans in the exchange must cover behavioral health treatments as part of the minimum benefits standard. For example, applied behavior analysis is a behavioral health treatment for people with autism. Unless behavioral health treatment is explicitly spelled out as a covered benefit, people with autism are not likely to receive comprehensive healthcare.

Tax credit for biotechnology. Creates a credit that would encourage investments in new therapies to prevent, diagnose, and treat acute and chronic disease, lower health care costs.

New Jersey funding for Medicare Advantage transition (as part of amendment by Sen. Ron Wyden). Amendment would include parts of New Jersey as one of only an estimated 5 states that will receive funding to help seniors in the transition of Medicare Advantage from “fee-for-serivce” reimbursements to competitive bidding.

Out-of-pocket cost limit for families between 300-400 percent of the federal poverty level - IMPORTANT FOR HIGH COST OF LIVING STATES. For those between 300-400 percent of FPL, within the same actuarial value, the benefit will include an out-of-pocket limit equal to two-thirds of the Health Savings Account (HSA) current law limit.

Excluding middle-class families, seniors from excise tax on high-value insurance plans – IMPORTANT FOR HIGH COST OF LIVING STATES (joined Sen. Kerry on amendment). Successfully fought to raise tax thresholds for retirees and high-risk workers so that their additional health needs could be recognized. Successfully fought to raise the indexing of the high premium excise tax threshold to save millions of family policies from being hit.

Urban Medicare Hospitals. Some urban hospitals are highly dependent on Medicare payments because they serve high proportions of Medicare patients, but, unlike many otherwise similar hospitals, they do not receive any special add-on payments. This would provide for a study for a special add-on payment to be afforded this select group of hospitals that could be designated as urban Medicare-dependent hospitals.

 

Here’s the full list of what Sen. Menendez got in the Senate bill – beyond the NJ-focused provision, all of these consumer protection are going to benefit millions across the country and in NJ. This breaks down what he got included in the Finance Committee and what he got included in the full Senate.

IN FINANCE COMMITTEE:

Require insurance plans to provide behavioral health treatments. Plans in the exchange must cover behavioral health treatments as part of the minimum benefits standard. For example, applied behavior analysis is a behavioral health treatment for people with autism. Unless behavioral health treatment is explicitly spelled out as a covered benefit, people with autism are not likely to receive comprehensive healthcare.

Tax credit for biotechnology. Creates a credit that would encourage investments in new therapies to prevent, diagnose, and treat acute and chronic disease, lower health care costs.

Excluding middle-class families, seniors from excise tax on high-value insurance plans (joined Sen. Kerry on amendment). Successfully fought to raise tax thresholds for retirees and high-risk workers so that their additional health needs could be recognized. Successfully fought to raise the indexing of the high premium excise tax threshold to save millions of family policies from being hit.

Require private insurers to fully reimburse Federally-Qualified Health Centers in the exchange (offered amendment with Sen. Lincoln). This amendment would ensure that FQHCs, which are a primary health care option for millions, would not lose revenue when treating newly insured patients gaining coverage through the new health insurance exchanges.

 Out-of-pocket cost limit for families between 300-400 percent of the federal poverty level. For those between 300-400 percent of FPL, within the same actuarial value, the benefit will include an out-of-pocket limit equal to two-thirds of the Health Savings Account (HSA) current law limit.

Women’s Medical Home (included in bill prior to markup). Legislation creates an Innovation Center within CMS to test and evaluate different structures to increase patient care and lower cost. The center is required to test a number of different models, including a “medical home that addresses women’s unique health care needs.” 

Child-only insurance option and subsidies in the exchange.  Ensures that minor children qualify as exchange eligible individuals and would also provide for the availability of child-only health insurance coverage in the exchanges.

Consumer protection for emergency services. Requires that each health care plan and insurance issuer offering coverage in the exchange must provide enrolled individuals coverage for emergency services without regard to prior authorization.

Guaranteeing consumers a fair appeal for a denial of coverage. Requires that each health care plan and health care insurance issuer offering coverage in the exchange must provide an internal claims appeal process and each state must provide an external review process for plans in the individual and small group markets.

Ombudsman assistance with internal appeals. Allows policyholders to access the ombudsman created in the legislation for help with internal appeals.

Ombudsman assistance with tax credit appeals. Allow policyholders to access the ombudsman for assistance in resolving problems with their premium and cost-sharing credits, and with assistance in filing appeals as needed.

Support, education, and research for postpartum depression. Provides support services to women suffering from postpartum depression and psychosis and helps educate mothers and their families about these conditions.  In addition, supports research into the causes, diagnoses and treatments for postpartum depression and psychosis.

Approx $70 million per year in savings for New Jersey hospital (top priority of the New Jersey Hospital Association). Current law ensures that hospitals in highly-urban states, like New Jersey, are protected from receiving unfairly low Medicare reimbursements. Provision would ensure that the costs associated with this protection are shared by hospitals nationwide, rather than shared exclusively within these states, as the Center for Medicare and Medicaid Services is proposing.

New Jersey funding for Medicare Advantage transition (as part of amendment by Sen. Ron Wyden). Amendment would include parts of New Jersey as one of only an estimated 5 states that will receive funding to help seniors in the transition of Medicare Advantage from “fee-for-serivce” reimbursements to competitive bidding.

Urban Medicare Hospitals. Some urban hospitals are highly dependent on Medicare payments because they serve high proportions of Medicare patients, but, unlike many otherwise similar hospitals, they do not receive any special add-on payments. This would provide for a study for a special add-on payment to be afforded this select group of hospitals that could be designated as urban Medicare-dependent hospitals.

Value-Based Purchasing for Hospital Acquired Infections. This measure includes healthcare-associated infections, as measured by the prevention metrics and targets established in the Department of Health and Human Services’ HHS Action Plan to Prevent Healthcare-Associated Infections or any successor plan.

 

AFTER FINANCE COMMITTEE:

Clarification and strengthening of provision guaranteeing consumers a fair appeal for a denial of coverage. All health insurers would be required to implement an internal appeals process for coverage denials, and states will ensure the availability of an external appeals process that is independent and holds insurance companies accountable.

Clairification and strengthening provision expanding access to health care through community health centers. Private insurers would be required to fully reimburse Federally-Qualified Health Centers in the insurance exchange. This amendment would ensure that FQHCs, which are a primary health care option for millions, would not lose revenue when treating newly insured patients gaining coverage through the new health insurance exchanges.

Holding health insurance companies accountable. The Government Accountability Office would conduct a study on the rate of denial of coverage and enrollment by health insurance issuers and group health plans.

 

Locations