HR3200/Section 132

I would like to post part of my reply to Elizabeth of yesterday. She has been very helpful in supplying information regarding the Congress's Health Care Bill. I have read all the articles and in some instances agree in kind. Some authors are known to be or professed "far left". They have their right to express their opinion also. That is what makes this the greatest country on Earth.

My partial response:

.....it was a good article from a used to be insider. I firmly believe no one wants anybody to do with out health care. For me that would be against my beliefs and morals. What I don't want is to pay for some schmuck that won't get a job or keep a job to help himself and help pay for his/her own insurance.

What I don't want is another Medicare/Medicaid entitlement!

On with:

SEC. 132. REQUIRING FAIR GRIEVANCE AND APPEALS MECHANISMS.

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(a) In General- A QHBP offering entity shall provide for timely grievance and appeals mechanisms that the Commissioner shall establish.CommentsClose CommentsPermalink


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(b) Internal Claims and Appeals Process- Under a qualified health benefits plan the QHBP offering entity shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures (including urgent claims) set forth at section 2560.503-1 of title 29, Code of Federal Regulations, as published on November 21, 2000 (65 Fed. Reg. 70246) and shall update such process in accordance with any standards that the Commissioner may establish.CommentsClose CommentsPermalink



(c) External Review Process-CommentsClose CommentsPermalink



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(1) IN GENERAL- The Commissioner shall establish an external review process (including procedures for expedited reviews of urgent claims) that provides for an impartial, independent, and de novo* review of denied claims under this division.CommentsClose CommentsPermalink



(2) REQUIRING FAIR GRIEVANCE AND APPEALS MECHANISMS- A determination made, with respect to a qualified health benefits plan offered by a QHBP offering entity, under the external review process established under this subsection shall be binding on the plan and the entity.CommentsClose CommentsPermalink




(d) Construction- Nothing in this section shall be construed as affecting the availability of judicial review under State law for adverse decisions under subsection (b) or (c), subject to section 151.




On its face this sounds like a very, very good section of the bill. Unfortunately as with anything written by an attorney/legislator one must look deeply into the wording. Being a retired union member but, not very pro union, I like anything that has a grievance and appeals policy.

1(a) In General- A QHBP offering entity shall provide for timely grievance and appeals mechanisms that the Commissioner shall establish.

Who is establishing the "timely grievance and appeals mechanisms"? The QHBP or the Commissioner? This sentence says both. Could/would someone in Congress please explain this to me?

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(b) Internal Claims and Appeals Process- Under a qualified health benefits plan the QHBP offering entity shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures (including urgent claims)

Great! An appeals process is established (by someone) that will address even "urgent claims". Would someone in Congress please explain what "urgent is". As many of you know my wife passed away a short 5 months ago. Due to the rapid spreading of the Cancer she applied for Disability under some section of Social Security. An appointment was set and she was granted benefits within 3 weeks. We felt the situation was urgent and apparently so did the lady who helped with the paperwork. We felt a little less than disappointed when the lady said my wife would have to wait for 6 months to receive her first disability check. Being a Christian two income family we were still very thankful she would be receiving some funds in 6 months. She passed away March 30,2009.

Her first check was due on or about April 10,2009. Needless to say that check never hit the bank. The Federal government stopped payment on it within approximately 48 hours of her death certificate being issued. Is that the way "urgent claims" are going to be processed? Could/would someone in Congress please explain this to me?

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Nothing in this section shall be construed as affecting the availability of judicial review under State law for adverse decisions under subsection (b) or (c), subject to section 151.

When was the last time you heard of some poor schmuck suing and winning against the Federal Government. In my life time NEVER!!!

What troubles me most about Congress's bill is two fold. A. No where in the bill does it say "everyone without health insurance will get health insurance". Isn't that what this was suspose to be about, health care for ALL Americans. B. The cost. This bill will take $500 million from Medicare to help pay for it. What happens to the Medicare recipients? My dad called that, "robbin' Peter to pay Paul" Say what you will but I call it rationing health care to Medicare recipients.

Finally, "the Commissioner shall" this phrase is used so many times in this bill I quit counting. Just who is this "commissioner", what are his qualifications, how does he get this job, will he be cabinet level or another CZAR? There are just too many loopholes in this bill to pass any form of it.

Let's all just take a deep breath, relax, and start over with "we the people" in mind, not we the Congress.

*Law Encyclopedia: De Novo Top

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This entry contains information applicable to United States law only.

[Latin, Anew.] A second time; afresh. A trial or a hearing that is ordered by an appellate court that has reviewed the record of a hearing in a lower court and sent the matter back to the original court for a new trial, as if it had not been previously heard nor decided.