Aetna 2012 Annual Report Download - page 43

Annual Report- Page 37
• Imposing assessments on (or to be collected by) health plans or health carriers, which may or may not be
passed onto their customers. These assessments may include assessments for insolvency, uninsured or
high-risk pools, uncompensated care, or defraying health care provider medical malpractice insurance costs.
• Reducing federal and/or state government funding of government-sponsored health programs in which we
participate including Medicare and Medicaid programs.
• Restricting or mandating health plan or life insurer claim processing, review, payment and/or related
procedures.
• Extending malpractice and other liability exposure for decisions made by health plans.
• Mandating coverage for additional conditions and/or specified procedures, drugs or devices (for example,
experimental pharmaceuticals).
• Mandating expanded employer and consumer disclosures and notices.
• Regulating e-connectivity.
• Mandating or regulating the disclosure of health care provider fee schedules and other data about our
payments to providers.
• Mandating or regulating disclosure of health care provider outcome and/or efficiency information.
• Imposing substantial penalties for our failure to pay claims within specified time periods.
• Assessing the medical device status of health information technology (“HIT”) products and/or solutions,
mobile consumer wellness tools and clinical decision support tools, which may require compliance with
FDA requirements in relation to some of these products, solutions and/or tools.
• Imposing payment levels for services rendered to our members by health care providers who do not have
contracts with us.
• Mandating additional internal and external grievance and appeal procedures (including expedited decision
making and access to external claim review).
• Enabling the creation of new types of health plans or health carriers, which in some instances would not be
subject to the regulations or restrictions that govern our operations.
• Allowing individuals and small groups to collectively purchase health care coverage without any other
affiliations.
• Imposing requirements and restrictions on the administration of pharmacy benefits, including restricting or
eliminating the use of formularies for prescription drugs; restricting our ability to make changes to drug
formularies and/or our clinical programs; limiting or eliminating rebates on pharmaceuticals; restricting our
ability to configure our pharmacy networks; and restricting or eliminating the use of certain drug pricing
methodologies.
• Creating or expanding state-sponsored health benefit purchasing risk pools, in which we may be required to
participate.
• Imposing requirements and restrictions on certain plan designs and funding options, including consumer
driven health plans and/or health savings accounts.
• Restricting the ability of health plans to establish member financial responsibility.
• Further regulating individual insurance coverage by restricting or mandating premium rate levels,
restricting our underwriting discretion or restricting our ability to rescind coverage based on a member's
misrepresentations or omissions.
• Providing members the right to receive information about anyone who has accessed their electronic PHI,
even where such access was permitted (such as access by our authorized employees in the course of claims
administration or medical management).
• Exempting physicians from the antitrust laws that prohibit price fixing, group boycotts and other horizontal
restraints on competition.
Some of the changes, if enacted, could provide us with business opportunities. However, it is uncertain whether we
can counter the potential adverse effects of such potential legislation or regulation, including whether we can
recoup, through higher premium rates, expanded membership or other measures, the increased costs of mandated
coverage or benefits, assessments or other increased costs, including the cost of modifying our systems to
implement any enacted legislation or regulations.