Health insurers, employers and providers are facing a dizzying array of changes wrought by the health reform law, and the regulations and guidance issued to implement it.

In Health Reform 2011: Impact on Health Plans, Hospitals, Providers and Purchasers, insiders close to HHS and in leadership positions at health plans, provider organizations and PBMs identify the strategic impact of the reform law across all sectors of the industry, and the business implications and compliance issues raised by new rules covering dozens of topics — from dependent coverage expansions and high-risk pools to bans on pre-existing condition exclusions and annual and lifetime limits.

Packed with articles and illustrations, this comprehensive report outlines the likely impact of health reform on coverage, benefit designs, medical costs, providers and pharmacy benefits. Special sections also address the impact on employers, the transformation of the Medicare and Medicaid programs and the radical changes to fraud, abuse and compliance initiatives.

Order Health Reform 2011: Impact on Health Plans, Hospitals, Providers and Purchasers today, and learn tactics to limit risks and maximize opportunities amid the massive changes under way.

Table of Contents

• Impact on Benefit Design
  • Coverage for Children
    • Insurers Pull Out of Child-Only Coverage, But Consultants, States See Possible Fixes
    • Regulatory Actions on ‘Child Only’ May Not Allay Insurer Concerns
    • States Seek to Work With Insurers On Child-Only Enrollment Options
    • Regence Mulls Legal Response to Order to Resume Child-Only Sales
  • Grandfathering Rules
    • Many Large Employers Will Change Plans Despite Losing ‘Grandfather’
    • Formulary Changes Could Lead to Loss of Grandfathered Status
    • Sponsors Remain Perplexed Over What Grandfathered Plans Can Do
    • Federal-State Debate on Association Plans Forces AHPs To Re-evaluate Grandfathering
    • New HHS Break for Grandfathered Plans May Have Come Too Late
  • Preventive Services
    • Preventive-Services Rule Perplexes Plans With Coverage Mandates Open to Questions
    • HHS Issues Final Preventive Rule; Surgeons Doubt ‘Shortage Areas’
• Insurance Exchanges
  • Adverse Selection Is Seen as Big Issue for Exchanges, but Decisions Could Cut Risks
  • Schwarzenegger Signs Exchanges Bills, Vetoes Limits on Rate Hikes
  • HHS Grants to States Accelerate Work With Insurers on Exchanges
  • Jury Is Out: Will Exchanges Shift Administrative Costs to Consumers?
  • Direct Medical Home Practices Want to Be In Exchanges, ‘Be Like Starbucks or Costco’
  • States Mull Requiring Medicaid Plans to Participate in Exchanges
  • States Show Drive on Exchanges As HHS Offers Health IT Grants
  • Exchanges to Cause Seismic Market Shift, But Preparations Now Will Help Plans Thrive
  • States Consider Basic Health Program for Low-Income Coverage Outside Exchanges
  • Exchanges Aren’t on Top of GOP Repeal List; Concerns Over Subsidies, Abuses Remain
  • Health Insurers Must Be Part of Dialogue As States Begin To Build Exchanges
• Medical Loss Ratio Rules
  • Iowa Seeks MLR Individual-Market Phase-in; Florida May Too
  • Strict MLR Floors Could Prompt Plans to Flee Unprofitable Small-Group Markets
  • MLRs May Have Bigger Impact on Plans Than Expected, Analyst Says
  • HHS Gives ‘Mini-meds’ MLR Relief; More States May Ask For Phase-in
  • With HHS MLR Rule Now Out, More States Will Seek Waivers; Bar for Approval Is High
  • Insurers Alter Sales Commissions, Partly to Help Meet MLR Rules
• Rate-Setting Practices
  • Rate Review Grants: Strategy to Control Premium Hikes or HHS PR Maneuver?
  • As HHS Funds State Rate Review, Former State Regulator Urges Care
  • Insurers Cite Cost Pressures From Reform As Contributing To Rate Hikes in Fall 2010
  • Plans Will Provide More Info to Denied Applicants in California
  • HHS Says It’s ‘Surprised’ by Conn. Rate-Hike Approval for Anthem
  • New California Insurance Commissioner Jones Seeks to Rein In Premium Increases
  • Conn., Wash. Reject Individual-Market Rate Hikes; HHS Regs Are Likely to Be Tough
• Accountable Care Organizations and Other Provider Issues
  • ACOs
    • Hospitals Fear Financial Impact of ACOs, Seek Clarifications on Legal Issues, Pay
    • Global Cap Dominates Some Private-Sector Payment Models; Others Seek Partial Cap
    • ACO Antitrust Worries May Be Addressed By ‘Safe Harbors’ Coming From FTC
    • MD Groups Move Forward With ACO Development Despite Risks
    • Advocate Makes Moves Toward ACOs
    • Accountable Care Organizations Won’t Work Without Real Provider Accountability
    • CMS Seeks Input Mainly on ACO Structure, But Market Power Issues Remain a Concern
    • New PHOs Are Being Structured as Stepping Stones to ACOs
    • CMS Delays Issuing ACO Rule, Setting Up Very Tight Timeline
  • Other Provider Issues
    • Physicians Must Inform Patients of Imaging Machinery Ownership
    • OIG Calls for Bigger Crackdowns on Infections as Penalty Looms
    • HHS Calls for 13-Month SGR Fix; Docs Worry About Reform Offsets
    • Groups Seek More Clarity on Judge’s MD-Owned Hospital Ruling
    • Hospitals See Flaws in Readmission Policy Under Reform, Wait for Fix From Congress
• Impact on Employers
  • ‘Creative’ Employers Are Raising Copays, Using Mandatory Mail, Generics Programs
  • ‘Cadillac Tax’: Though Years Away, Employers Are Already Tinkering Under the Hood
  • Rate Hikes, Reform Fears May Force Employers to Target Worker Health
  • Employers Laud ‘More Freedom’ In Defining Dependent Coverage
• Impact on Medicare Advantage and Part D
  • Debate Heats Up on MA Plan Member Costs as Election Nears
  • Employers Are Still Unsure About Future of Retiree Drug Benefits
  • Part D Plans Are Not Charged With Collecting Additional Premium
  • Almost All Manufacturers Sign 50% Gap Discount Agreements for 2011
  • Health Reform: For Part D Plans It Feels Like 2006 Again
  • Part D Reform Provisions Will Likely Escape Republican Overhaul
• Impact on Medicaid
  • With Millions of New Potential Customers At Stake, More Insurers Will Eye Medicaid
  • Talk of State Withdrawals From Medicaid Fails to Sway Berwick at Senate Hearing
  • Study: Top States for Medicaid Managed Care Growth Are In South
• Compliance, Enforcement and Fraud and Abuse
  • Compliance
    • With Reform, Providers Need More Board Oversight of Compliance
    • Health Reform Law Has Far-Reaching Impact on the Compliance World
  • Self-Disclosure
    • State Inspectors General Brace for Busy Self-Disclosure Processes With Reform
    • Self-Disclosures to N.Y. Pave the Way for New Federal Mandate
    • Providers Wary of Self-Disclosure Protocol, But 60-Day Repayment Rule Ups the Ante
  • Fraud
    • New CMS Rule Sets Stage for Use of New
    • Program-Integrity Powers Under Reform
    • Medicaid RACs Gear Up While MICs Find Significant Recoveries in Some States
    • CMS: States Should Coordinate Audits, Ensure Medicaid RACs Report Fraud Cases
• Impact on Pharmacy
  • PBMs, Plan Sponsors Weigh Implications of OTC Changes
  • CMS Proposes Changes to AMP Rule on Medicaid Drug Reimbursement
  • PBMs Expect Gains as Reform Leads to More Management Of Broader Population
  • Reform’s Impact on Drug Pricing May Vary From CBO’s Analysis
• Other Issues Affecting Health Reform
  • Is CLASS Program ‘Different’ or ‘Inferior’ to Private LTC Options?
  • Medical-Device Makers Fret That Reform Tax May Harm Small Firms
  • Plans Get Till July for New Claims-Review Processes, Allowing Focus on 2011 Benefits
  • Insurers Make Big Investments to Gear Up for Implementing Reform Law Provisions
  • HealthCare.gov Portal Adds Info; Insurers Dispute Site’s Denial Data
  • Rural Health Makes Strides Under Reform, but Challenges Remain
  • Biotech Gets $1B Under Reform, But Firms Sought Bigger Shares
• Impact on Brokers
  • Some Insurers Are Already Paring Down Broker Commissions Due to MLR Reg
  • Aetna’s Change to Broker Fees Could Prompt Others to Follow