What is a “qualified” plan?

As you know, beginning in 2014, all individuals must have a “qualified” insurance plan, or pay a tax. Congressman Weiner’s protestations to the contrary notwithstanding, that tax will be enforced by the Internal Revenue Service as the tax imposed “shall be included in a taxpayer’s return”.  And, we all know who enforces information on tax returns.

But, I digress.  We don’t have the specifics, as the Secretary of Health and Human Services hasn’t written them yet, but we do know some things about a “qualified plan”.

A “qualified” plan must include, at a minimum, ambulatory, emergency, hospital, maternity, prescription drugs, rehabilitation services, laboratory services, preventive and wellness care, pediatric care (including dental and vision), mental health and new born care.  And, the scope of benefits must at least equal that provided under a “typical employer plan”.

Other than those requirements, the Secretary has complete discretion to add as many mandates as she wants either within the above categories, or as brand new categories.

Once all the Secretary’s mandates have been established, you will have a choice of plans each of which must contain all of the mandates.

The plans are labeled Bronze, Silver, Gold and Platinum.  A Bronze plan must include “benefits actuarially equivalent to 60% of the full actuarial value of the benefits”, a Silver plan must have benefits equal to 70%, a Gold plan must have benefits equal to 80%, and a Platinum plan, 90%.

Obviously, a Bronze plan will cost less than a Platinum plan, but, it is impossible to predict even a range of costs until the Secretary determines what services must be covered.  In other words, must hair transplants be covered, or not, must in vitro fertilization be covered, or not, must tattoo removal be covered or not?  Until those, and other coverage questions are answered by the Secretary, determining an actual cost is elusive.

But, whether you believe the Congressional Budget Office or not, the CBO states that

… premiums in the individual market will rise by 10% to 13% more than if Congress did nothing. Family policies under the status quo are projected to cost $13,100 on average, but under ObamaCare will jump to $15,200.

If the CBO is correct (and their historical track record isn’t exactly”spot on”), regardless of what must be in a “qualified plan”, expect to spend considerably more than you do now for insurance.

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The Sound Off Sister was an Assistant United States Attorney for the Southern District of Florida, and special trial attorney for the Department of Justice, Criminal Division; a partner in the Florida law firm of Shutts & Bowen, and an adjunct professor at the University of Miami, School of Law. The Sound Off Sister offers frequent commentary concerning legislation making its way through Congress, including the health reform legislation passed in early 2010.


  1. Dimsdale on March 27, 2010 at 5:33 am

    I think "qualified" would be best defined as "moving target" or "at the whim of polititicians".


    When they want a public option, who is to stop them from saying that no plan is "qualified", and force us all on the dole.  The precedent for ignoring the Constitution has been set.

  2. Dimsdale on March 27, 2010 at 6:04 am

    Part deux: when they fully control the financing of health care, what do you think will happen when the budget runs into deficit again (or continuously)?   They will do like cities and towns do, but instead of teachers, firemen and police, they will threaten to close hospitals, fire doctors and cut coverage to cover the losses.



  3. Anne-EH on March 30, 2010 at 5:45 am

    Posted it over at Free Republic.

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