The Health Security Plan

Coverage

All American citizens and legal residents are guaranteed a nationally defined, comprehensive package of benefits and enroll in a health plan. Coverage continues without interruption regardless of a change of employer, employment status, marital status or medical condition.

Coverage goes into effect -- state by state -- beginning in 1995 and is fully implemented by 1997.

The vast majority of Americans continue to receive their health coverage at work, as they do today. All workers have a choice of health plans, each of which must be certified as meeting quality standards. Unlike today, however, all employers contribute to the purchase of health coverage for their employees, both full and part-time.

Employed individuals receive information about enrollment and health plans either at work or directly from the alliance. Small business owners and their families, employees of small business, the self-employed and the unemployed sign up for the health plan of their choice through the regional alliance office in their area.

Firms or Taft-Hartley Plans with more than 5000 employees may fulfill their obligation to provide coverage for their employees by establishing a corporate alliance or joining the regional alliances. Corporate alliances must meet federal standards for benefits, choice and quality.

Medicare beneficiaries continue to receive all current benefits and, in 1996, receive a new benefit covering outpatient prescription drugs. New long-term care programs also expand access to home and community-based care.

Those people who receive health care through the Department of Defense, the Department of Veterans Affairs and the Indian Health Service may continue to do so.

Medicaid beneficiaries receive coverage through the regional health alliance, choosing among the health plans it offers.

Benefits

The health benefits guaranteed to all Americans contain no lifetime limits on coverage, and provide a comprehensive package of medical services delivered in hospitals, clinics, professional offices and other sites. One uniform, comprehensive benefit package replaces hundreds of different insurance products in the market today.

When medically necessary or appropriate, covered services include hospital care, emergency services, preventive care, mental health and substance-abuse services, family planning, pregnancy-related care, hospice care, home health and extended-care services following an acute illness, ambulance services, outpatient laboratory and diagnostic services, prescription drugs and biologicals, outpatient rehabilitation, durable medical equipment, vision and hearing care, periodic medical checkups and preventive dental services for children.

The plan includes coverage for a full range of preventive screening and care often not covered in traditional health insurance policies. Covered preventive care includes well-baby checkups and immunizations for children, periodic physical examinations, routine laboratory work and screening tests, with no charge to the patient.

Additional benefits, including preventive dental care for adults and a more comprehensive mental health and substance-abuse benefit, are phased into the nationally guaranteed benefits by the year 2001.

Individuals or employers who wish to purchase benefits beyond the nationally guaranteed package may do so.

All individuals in a health plan pay the same premium for the nationally guaranteed comprehensive benefits regardless of health status, age, place of residence or employment status. Health plans are prohibited from discriminating based on existing medical conditions and other individual characteristics.

Medicare beneficiaries continue to receive all current benefits and, in 1996, receive a new benefit covering outpatient prescription drugs. Financial support for long-term care also expands.

Cost-Sharing

Health plans adopt one of three standard cost-sharing arrangements:

Choice Of Health Plans

The Health Security plan allows individuals, rather than employers, to choose their health plans on the basis of quality and price. Today, only half of employed individuals have a choice of health plans. For the rest, employers choose their health plans, locking individuals and families into a system of care delivery and determining how much they pay out of pocket.

Because the Health Security plan requires that alliances provide at least one traditional fee-for-service plan, it preserves consumers' ability to choose their own doctors and other health providers -- an option that is not available to many today.

Likewise, doctors and other health providers may choose to participate in as many or as few of an alliance's health plans as they want.

Individuals whose employers provide more generous benefits than the nationally defined comprehensive benefits may continue those benefits at their current level without any change in coverage or cost.

Supplemental Insurance

Health plans may offer standardized supplemental insurance policies to cover cost-sharing or health benefits above and beyond the comprehensive benefits package. Employers may contribute to purchase supplemental coverage for their employees. Health plans that adopt the high-cost sharing option must offer their participants the opportunity to purchase supplemental insurance policies that cover cost sharing.

Supplemental insurance policies may not duplicate coverage of any services provided under the nationally guaranteed comprehensive benefit package.

Long-Term Care

Existing nursing home coverage under Medicaid continues. Disabled Americans of all ages gain access to a wider variety of home and community-based support services, making it possible to continue to live at home. The Health Security plan also provides the following expansions and improvements in coverage for long-term care:

Medicare

Medicare recipients experience no change in how and where they obtain health care or their existing benefits. In 1996, Medicare benefits expand to include coverage for prescription drugs under the Medicare Part B policy.

Medicare continues as a federally run program for individuals over age 65. Once the new health care system is in place, individuals have the option of enrolling in Medicare or remaining in their health plan when they turn 65.

Medicare beneficiaries have a broader range of choice through the expansion of managed care plans.

As the alliance system is fully implemented, states may provide Medicare benefits through alliances, provided the interests of Medicare beneficiaries and the Federal Treasury are safeguarded, and there is no reduction in benefits.

Medicaid

Medicaid recipients under the age of 65 who are not eligible for cash assistance either through Aid to Families with Dependent Children or Supplemental Security Income no longer enroll in Medicaid. They choose a health plan through their area alliance, with 80 percent of the premium covered by employer contributions if they are employed, or premium discounts if they are unemployed and have low incomes.

Medicaid continues to pay the cost of health insurance for recipients of AFDC and SSI, who also pick a plan offered by the regional alliance. They may choose any plan priced at or below the weighted-average premium without making additional payments.

Like other members of the alliance, former Medicaid recipients with incomes below 150 percent of poverty are eligible for discounts to cover a portion of the cost of co-payments and deductibles if no plan with low cost sharing is available at or below the average premium. Health plans receive the same payment for Medicaid recipients as for other participants, reducing any stigma associated with obtaining coverage through Medicaid.

To pay for services covered in the comprehensive benefits to families that receive Aid to Families with Dependent Children and Supplemental Security Income payments, Medicaid pays health plans a fixed rate for each participant. Payments from the alliance to health plans are risk adjusted.

Medicaid coverage for other services, including nursing home coverage and special services for the severely disabled and supplemental services, continue as a public program.

Retirees

Americans who retire before age 65 and were employed for at least the amount of time used as a standard to qualify for Social Security purchase health coverage through their regional alliance and pay only the employee share of the premium for their health plan. The federal government pays the 80 percent employer share.

Although they may choose to pay more, employers whose retirement plans cover health insurance premiums for retired workers are responsible for paying only the employee's share, or 20 percent of the average premium.