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Assisted Plan. --The assisted plan would make coverage available to low-income families regardless of employment status and to families and employment groups who are high medical risks, and to non-employed families regardless of income status. The plan would be administered under Federal regulations by the States using private carriers to process benefits.

The maximum cost sharing amounts are the same as for the employee plan, but are reduced according to family income.

The plan would be financed by premium payments from enrollees accord

The

ing to family income, but with none for lower income groups.
balance of costs would be paid from Federal and State general revenues,
The State share would vary primarily according to State per capita
income and 1975 Medicaid spending and would account for about 25
percent of the plan's revenues.

Plan for the Aged.--The plan for the aged would cover aged persons insured under social security and would be administered by the Federal Government as under the present Medicare program,

Benefits would be subject to a deductible of $100 per person and 20
percent coinsurance, but with maximum costsharing limited to $750 per
person. Reduced costsharing, according to individual income, would
be provided for the low-income aged.

The program would be financed by continuation of the present Medicare payroll taxes and by premium payments by the aged, but with no premiums for the low-income aged. Federal and State general revenues would finance the reduced costsharing and premiums for the low-income aged.

The costsharing under the three plans is shown on table 4.

Reimbursement Methods.--Reimbursement rates would be established by the States, according to Federal procedures and criteria. Two classes of providers are established. "Full participating" providers would be paid the State-established rates, including the costsharing, as full payment of their charges, The costsharing would be collected from the patient. "Associate participating" providers could charge more than the State rate for employee plan patients, but must collect the extra charges and costsharing from the patients. All hospitals and SNP's must be full participating providers.

Other Provisions.--(1)

Under all plans, an option would be available

to enroll in approved prepaid plans as an alternative to the regular coverage. (2) The States would regulate insurance carriers including approval of their premium rates and requirements against insolvency of carriers. (3) The States would also regulate providers, including approval of proposed capital expenditures.

(4) Professional Standards

Review Organization (PSRO) would apply to all outpatient and inpatient

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TABLE 4.--Hills-Schneebeli-Packwood Bill:

Premium rates and cost sharing requirements, by type of plan

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services. (5) The Medicaid program would be limited to long-term care

benefits.

Estimating Assumptions

(1) In accordance with the general methodology, employer contributions are at least 75 percent of their premium costs. The

temporary Federal premium subsidy for certain high-cost employers

is not shown.

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(2) The benefits which are to be determined by regulation for pre-natal care, well-child care, family planning services and supplies, eye examinations, eyeglasses, hearing examinations and hearing aids are assumed to be limited by generally accepted medical standards.

(3) The definition of income for the purpose of determining premiums and costsharing under the assisted plan is assumed to be a broad definition, including earned and unearned income.

(4) It is assumed that many States will continue to pay for the services excluded from the assisted plan but previously supported under medical assistance programs.

(5) While there would of course be variations, the reimbursement rates established by the States for fiscal year 1975 are assumed to approximate Medicare levels. Payments will take into account

that bad debts for participating providers are eliminated under the healthcard system.

(6) The requirement for PSRO review of all services is assumed to

The following tabulation presents the estimated number of persons electing coverage under the three plans (as of January 1975), as well as those who would elect to have other private coverage or to be uninsured. Persons electing coverage under the assisted plan include employees whose employer has brought his entire employment group under the assisted plan for themselves and their families.

Table 5 shows the average premium rates for the employer plan by type

of medical service.