Aetna 2015 Annual Report Download - page 39

Annual Report- Page 33
• 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, the uninsured,
uncompensated care, Medicaid funding 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.
• Mandating coverage for additional conditions and/or specified procedures, drugs or devices (for example,
high cost pharmaceuticals, experimental pharmaceuticals and oral chemotherapy regimens).
• 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 require members to obtain
drugs through a mail order or specialty pharmacy; restricting our ability to place certain specialty or other
drugs in the higher cost tiers of our pharmacy formularies; 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.
• Regulating electronic 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.
• Prescribing or limiting members’ financial responsibility for health care or other covered services they
utilize.
• 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
U.S. Food and Drug Administration (“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.
• Restricting the ability of employers and/or health plans to establish or impose member financial
responsibility.
• Imposing additional requirements on the processing of claims for disability benefits.
• Amending or supplementing the Employee Retirement Income Security Act of 1974 (“ERISA”) to impose
greater requirements on the administration of employer-funded benefit plans or limit the scope of current
ERISA pre-emption, which would among other things expose us and other health plans to expanded
liability for punitive and other extra-contractual damages and additional state regulation.
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.
Our business also may be affected by other legislation and regulations. The Dodd-Frank Wall Street Reform and
Consumer Protection Act (the “Financial Reform Act”) was signed into law in July 2010. The Financial Reform Act
creates incentives for whistleblowers to speak directly to the government rather than utilizing internal compliance
programs, reduces the burden of proof under the Foreign Corrupt Practices Act of 1977 (the “FCPA”) and creates a
Federal Insurance Office (“FIO”) within the U.S. Department of the Treasury (the “Treasury”) with powers that
include information-gathering and subpoena authority. Although the FIO does not have authority over health
insurance, it may have authority over other parts of our business, primarily life insurance. In December 2013, the
FIO released a Financial Reform Act mandated report to Congress on how to modernize and improve the system of
insurance regulation in the United States. The report includes recommendations for reforms to the existing state-