Aetna 2009 Annual Report Download - page 33

Annual Report – Page 27
 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.
 Mandating 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 operations of pharmacy benefit managers, including restricting or
eliminating the use of formularies for prescription drugs or the use of average wholesale price.
 Creating or expanding state-sponsored health benefit purchasing pools, in which we may be required to
participate.
 Creating a single payer system where the government oversees or manages the provision of health care
coverage.
 Imposing requirements and restrictions on consumer-driven health plans and/or health savings accounts.
 Restricting the ability of health plans to establish member financial responsibility.
 Regulating the individual coverage market by restricting or mandating premium levels, restricting our
underwriting discretion or restricting our ability to rescind coverage based on a member’ s misrepresentations
or omissions.
 Requiring employers to provide health care coverage for their employees.
 Assisting individuals in retaining access to employer-based coverage, for example, through government
subsidies for terminated workers.
 Requiring individuals to purchase health care coverage.
 Allowing significantly expanded access to Medicaid, Medicare, the Federal Employees Health Benefit Plan or
other government-based health insurance programs, or creating other government-run insurance programs that
would compete with commercial health plans.
For example, on October 3, 2008, the Paul Wellstone-Pete Domenici Mental Health Parity and Addiction Equity Act
2008 (the “Mental Health Parity Act”) was enacted into law as part of an end-of-session package that included the
Emergency Economic Stabilization Act of 2008. The Mental Health Parity Act became effective for plan years
beginning on or after October 3, 2009 and requires that financial requirements and treatment limitations applicable to
mental health or substance abuse disorder benefits be no more restrictive than those imposed on medical/surgical
benefits. The Mental Health Parity Act does not require plans to offer mental health or substance use disorder benefits.
The regulations implementing the Mental Health Parity Act are more stringent than anticipated and will require us to
revise our benefit offerings.
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 premiums, expanded membership or other measures, the increased costs of mandated coverage or
benefits, assessments or other increased costs.
We also may be adversely impacted by court and regulatory decisions that expand the interpretations of existing
statutes and regulations or impose medical malpractice or bad faith liability. Among other issues, federal and state
courts continue to consider cases addressing group life insurance payment practices and the pre-emptive effect of
ERISA on state laws. In general, limitations to ERISA pre-emption have the effect of increasing our costs, liability
exposures, or both. The legislative initiatives discussed above include proposals in the U.S. Congress to restrict the
pre-emptive effect of ERISA and state legislative activity in several states that, should it result in enacted legislation
that is not pre-empted by ERISA, could increase our liability exposure and could result in greater state regulation of
our operations.
The Employee Retirement Income Security Act of 1974 (“ERISA”)
The provision of services to certain employee benefit plans, including certain Health Care, Group Insurance and Large
Case Pensions benefit plans, is subject to ERISA, a complex set of laws and regulations subject to interpretation and
enforcement by the Internal Revenue Service and the Department of Labor (the “DOL”). ERISA regulates certain