#1. Determine if health care reform rules apply to your plan(s).
- Apply to most group health plans.
- Do not apply to retiree-only group health plans.
- Do not apply to limited scope dental or vision plans.
- Do not apply to specified disease plans.
#2. Decide if your plans can and should be grandfathered.
- In effect on March 23, 2010?
- Applies to each benefit package.
- Certain market reform rules apply whether or not grandfathered.
- Certain cost sharing limits required to remain grandfathered.
- Exempt from certain coverage and benefit changes if grandfathered.
- Exempt from new claims procedures if grandfathered.
#3. Adopt design changes that apply whether or not plans are grandfathered.
- Expansion of coverage to adult children to age 26.
- Elimination of lifetime maximums on essential health benefits.
- Phase out of annual limits on essential health benefits.
- Elimination of certain pre-existing condition limitations.
- Prohibition on rescissions of coverage.
#4. Recognize the benefit changes you can make and remain grandfathered.
- Changes to comply with health care reform or other federal or state law.
- Benefit increases.
- Add new hires or new enrollees.
- Change TPA.
#5. Understand the benefit changes you cannot make and remain grandfathered.
- Issued a new policy, certificate, or contract of insurance.
- Eliminate all or substantially all benefits for a condition, including necessary elements to diagnose or treat.
- Plans without annual or lifetime limits cannot add an annual limit, annual limits that
- are less than existing lifetime limits cannot be added, and existing annual limits may
- not be decreased.
#6. Appreciate the cost sharing limits that apply to grandfathered plans.
- No coinsurance increases.
- Increases in deductible and out-of-pocket limits and co-pays are limited.
- Decreases in employer contributions are limited.
#7. Consider the new coverage and benefit rules that apply to non-grandfathered plans.
- First dollar preventive care.
- Emergency care without pre-authorization and out-of-network emergency care without increased cost sharing.
- Selection of any primary care provider and pediatrician.
- Access to OB/GYN without referral.
#8. Comprehend the new internal claims procedures that apply to non-grandfathered plans.
- Strict adherence to regulatory requirements.
- Non-English notices required in certain circumstances.
- Required content of notices increased.
- 24 hour notice on urgent care claims.
- Flesh out full and fair review.
- No conflicts.
- Concurrent care reduction limits.
- Adverse benefit determinations include rescissions.
#9. Understand the new external appeals procedures that apply to non-grandfathered plans.
- Two types, state and federal.
- Federal applies to self-insured ERISA governed plans.
- If state external review process is available, fully-insured plans must comply. If not, fully-insured plans must comply with the federal process.
- If the state external process applies to plans not governed by ERISA, those plans must comply with the state process. If not, those plans must comply with the federal process.
- Two safe harbors.
- Voluntary compliance with available state external process.
- Meet the criteria for standard and expedited external appeals.
- Standard external appeal.
- Four months to request review.
- Preliminary review by plan.
- Referral to an independent review organization (IRO).
- Detailed contractual provisions with IRO.
- Thorough IRO review within 45 days.
- Immediate provision of benefits if reversed.
- Expedited external appeal.
- Same steps as standard.
- IRO decision in 72 hours.
#10. Use cost containment measures to offset increased group health plan costs.
- 2011 average expected medical inflation is 8% to 9%.
- Consider benefit reductions in plans not subject to health care reform.
- Consider restructuring plans to avoid health care reform.
- Begin or enhance wellness programs.
- Create disciplined, systematic and automated model vendor contract review processes.
- Negotiate cost plus pharmacy benefit manager contracts that fully account for all discounts, rebates and other monies paid by drug companies.