A Guide to Health Insurance Reform: Benefit Design Regulation Under Federal Reform

Table of Contents

Benefit Design

• Coverage of Preventive Services
• Elimination of Lifetime and Annual Limits
• Patient Protections
• Grandfathering Rules
• Essential Health Benefits
• Limits on Cost Sharing
• Wellness Program Incentives
• Changes to Spending Account Rules
• Access to Care Requirements

Eligibility and Guaranteed Issue

• Pre-existing Condition Exclusions
• Dependent Coverage
• Student Health Insurance Coverage
• Nondiscrimination Based on Health Status and Gender
• Waiting Periods

Premium Rate and Profit Regulations

• Medical Loss Ratio and Rebate Requirements
• Rate Increase Regulation
• Ratings Bands

Health Insurance Exchanges

• Risk Adjustment
• Definition of “Qualified Health Plans”
• Enrollment Procedures
• Small Business Health Options Program

Administrative Issues

• Prohibition on Rescissions
• Early Retiree Reinsurance Program
• Appeals and Reviews
• Co-Op Health Plans
• Uniform Explanation of Coverage Documents
• Quality Reporting
• Executive Compensation
• Health Care Choice Compacts
• Multistate Qualified Health Plans

Written By

The Guide is written and managed by Francie Fernald, J.D., who is the managing editor of AIS's diverse line of looseleaf services and has decades of experience covering complex regulatory issues, and Executive Editor Jill Brown, who manages AIS’s health business products and has been covering every beat in the passage and implementation of health reform. Commentary and Analysis is provided by members of the Advisory Board.

Advisory Board

• Angela M. Bohmann, Shareholder, Leonard, Street and Deinard P.A., Minneapolis
• Sander Domaszewicz, Principal and Senior Consultant, Mercer Health & Benefits Services, Newport Beach, Calif.
• Bruce Merlin Fried, Partner, SNR Denton, Washington, D.C.
• Amy Gordon, Partner, McDermott Will & Emery LLP, Chicago
• Mark S. Joffe, Owner, Law Offices of Mark S. Joffe, Washington, D.C.
• Edward A. Kaplan, Senior Vice President and National Health Practice Leader, The Segal Co., New York
• Kurt L. Lawson, Partner, Hogan Lovells US LLP, Washington, D.C.
• Johann Lee, Alston & Bird, Washington, D.C.
• Mark E. Lutes, EpsteinBeckerGreen, Washington, D.C.
• William MacBain, Senior Vice President, Finance, Gorman Health Group, LLC, Washington, D.C.
• Joseph Paduda, Principal, Health Strategy Associates, Madison, Conn.
• Jack Rovner, Founding Principal, The Health Law Consultancy, Chicago
• Chantel Sheaks, Principal, Government Affairs, Buck Consultants, Washington, D.C.
• Dave Tuomala, Director of Actuarial Consulting, Ingenix Consulting, Eden Prairie, Minn.

Written For

Managers at:

• Health plans
• Pharmaceutical companies
• Employers
• Hospitals, health systems and other providers
• Attorneys, consultants and other advisers

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