Aetna 2006 Annual Report Download - page 33

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Page 31
Legislative and Regulatory Initiatives
There has been a continuing trend of increased health care regulation at both the federal and state levels. The
federal government and many states have enacted or are considering additional legislation or regulation related to
health care plans. Legislation, regulation and initiatives relating to this trend include among other things, the
following:
• Amending or supplementing 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.
• 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, assessments for
uninsured or high-risk pools, assessments for uncompensated care, or assessments to defray provider medical
malpractice insurance costs.
• Mandating minimum medical cost ratios.
• Extending malpractice and other liability exposure for decisions made by health plans.
• Mandating coverage for certain conditions and/or specified procedures, drugs or devices (e.g., infertility
treatment and experimental pharmaceuticals).
• Mandating direct access to specialists for patients with chronic conditions, and direct access to OB/GYNs,
chiropractors or other practitioners.
• Mandating expanded employer and consumer disclosures and notices.
• Mandating expanded coverage for emergency services.
• Prohibiting or limiting certain types of financial arrangements with providers, including among other things
incentives based on utilization of services.
• Imposing substantial penalties for failure to pay claims within specified time periods.
• Regulating the composition of provider networks, such as any willing provider and pharmacy laws (which
generally provide that providers and pharmacies cannot be denied participation in a managed care plan where
the providers and pharmacies are willing to abide by the terms and conditions of that plan).
• Imposing payment level limits for out-of-network care.
• Exempting physicians from the antitrust laws that prohibit price fixing, group boycotts and other horizontal
restraints on competition.
• Restricting health plan claim processing, review, payment and related procedures.
• Requiring the application of treatment and financial parity between mental health benefits and medical benefits
within the same health plan.
• Extending benefits available to workers who lose their jobs and other uninsured individuals.
• Mandating liberalized definitions of medical necessity.
• Mandating internal and external grievance and appeal procedures (including expedited decision making and
access to external claim review).