Washington - This morning, the U.S. Senate passed historic health insurance reform legislation in a 60-39 vote. The legislation would institute major health insurance reforms to protect consumers, cover an estimated additional 30 million Americans, bring Medicare back from the brink of insolvency, provide Medicare Part D prescription drug cost relief for seniors and cut the budget deficit by a projected $132 billion over the first ten years and as much as $1.3 trillion over the next ten. The Senate bill and House of Representatives bill will be reconciled in a conference committee over the next few weeks before a vote on final approval, likely in January.

U.S. Senator Robert Menendez (D-NJ) had a key role in helping to craft the legislation as a member of the crucial Finance Committee. Through his committee seat, he was able to gain inclusion of numerous amendments to the bill, a number of which contain particular benefits for New Jersey. Today, he celebrated the passage of the historic legislation.

"This is an historic moment for an historic reform that will protect the health and wealth of our nation," said Menendez. "For too many years, too many families have wondered why something so basic as health insurance takes so much out of their paychecks and why their insurance is unreliable when they need it the most. This legislation, forged through the hard work and vigorous debate of many Senators, will finally end the tug-of-war between families and their insurance companies, will curb the ballooning cost of health insurance and will significantly reduce our budget deficit. For seniors, it will bring Medicare back from the brink of insolvency, fully preserve Medicare benefits and provide badly-needed Medicare Part D prescription drug cost relief.

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"In our state, millions of families will benefit from the cost control provisions, consumer protections and expanded access to insurance that come with this reform. I worked hard as a member of the Finance Committee to include priority provisions to the bill that are focused on benefitting our state. As a result, our hospitals, which have experienced tough times, will save an estimated $70 million per year, thousands of New Jersey families dealing with autism will have guaranteed coverage for treatment, and the legislation is fairer to moderate-income families in high cost-of-living states, like ours.

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"Through the rigors of debate, the moments of optimism and the moments of pessimism, 59 of my colleagues and I believed that we could get this done, because we knew that we must get it done. Our generation is rising to the challenge that has confronted generations before us, and that will make ours a stronger nation."

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Complete information on the legislation is available here: http://dpc.senate.gov/dpcdoc-responsiblereform.cfm

MENENDEZ PROVISIONS INCLUDED IN THE LEGISLATION

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New Jersey-focused provisions:

  • Approx $70 million per year in savings for New Jersey hospitals (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 - Requiring 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 critical biotechnology research performed by small firms. 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 a handful of states that will receive funding to help seniors in the transition of Medicare Advantage from "fee-for-service" 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 more 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. Successfully included high-cost state transition rules which would give states like New Jersey higher thresholds than the rest of the country for the first three years.
  • 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.

Full list of Menendez provision in the legislation

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Provisions included during Finance Committee work

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  • 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.
  • 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 critical biotechnology research performed by small firms. Creates a credit that would encourage investments in new therapies to prevent, diagnose, and treat acute and chronic disease, lower health care costs.
  • Excluding more 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. Successfully included high-cost state transition rules which would give states like New Jersey higher thresholds than the rest of the country for the first three years.
  • 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.
  • 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.

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  • 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-service" 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.

Provisions included during full Senate debate

  • 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.
  • Clarification 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.

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