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Health Care Reform: Implementation Update

January 11, 2011

Today, the first health care reform requirements go into effect. Here's a quick review of the changes and what we're doing to make sure your customers' plans are ready when they renew.

Covering dependent children to age 26

All plans must cover dependent children up to the age of 26. This is regardless of the dependent's marital status, financial dependence, student status, or employment status. Grandfathered plans do not have to cover dependents who are eligible for employer coverage other than through their parents. Our insured plans also will comply with any state laws that already require coverage beyond age 26.

100 percent coverage of preventive care services

All plans (except grandfathered plans) will provide coverage with no member cost sharing for recommended preventive care services, when provided in network.

We have developed a list of covered preventive services. The list is based on our interpretation of the preliminary final guidance released by the Department of Health and Human Services (HHS) in July 2010. We will cover services on this list without cost sharing in our insured plans. We're also sharing the list with our self-funded plan sponsors.

Finally, we're providing doctors in our network with information. This will help make sure they know about our preventive health coverage.

Annual and lifetime limits

We have removed lifetime and annual dollar limits for essential benefits, both in and out of network, from all of our plans. (See the exception below for limited benefit plans). Annual frequency limits can still apply.

We have based these changes on our assessment of which benefits are essential. We will update this assessment as needed once HHS provides additional information.

Limited Benefit Plans:There is an exception for limited benefit plans (such as Aetna's Affordable Health Choices plans). HHS has agreed to waive the restricted annual benefit limits for qualified limited benefit plans until other affordable options become available in 2014. We are applying for an annual waiver for our Affordable Health Choices plans. We expect to get word soon.

Emergency services out of network

We foresee little change in the way we cover emergency services in most of our plans. Aetna already applies an in-network cost-share to out-of-network emergency services. We also don't require preauthorization for these services.

HHS had originally defined a payment formula for out-of-network emergency claims. However, in guidance issued September 20, 2010, HHS accepted our proposal that the formula not apply if the member is held harmless for any balance billing. This will enable us to continue our current payment practices. Today, we pay the out-of-network provider based on the plan's out-of-network allowance. This allowance varies by plan. We hold the member responsible only for the in-network cost share. We tell members to contact us if an out-of-network provider balance bills them for an emergency service. If this happens, we reimburse the member for the balance billed amount.

We are expanding this hold harmless approach to our Traditional Choice and Open Choice plans. These are the only plans where it was not previously in effect. We are making our EOB messaging clearer regarding the fact we will hold member harmless. We also are developing appropriate language for our plan documents.

Grievance and appeals

The law has a number of requirements around grievances and appeals. These include turnaround times for urgent care claims, expanded availability of external review, providing notices in a culturally/linguistically appropriate manner, and other provisions. Grandfathered plans are not required to meet these requirements.

Aetna is working on updates to our systems and processes to bring our plans into compliance. We are working with our language vendor to identify language needs and provide information in a culturally/linguistically appropriate manner. We are also expanding the availability of external reviews as required.

In guidance issued September 20, 2010, HHS granted a good faith grace period until July 1, 2011 for the implementation of changes to urgent care claim turnaround times, EOBs and language requirements for notices. Those changes require system and process modifications which were not possible by the September 23, 2010 effective date. While enforcement action will not occur prior to July of 2011, we will become compliant as soon as possible.

Pre-existing conditions

We are removing the ability for plans (except grandfathered plans) to limit or exclude benefits or coverage based on pre-existing conditions for enrollees under the age of 19.

Choice of health care professionals

The law says health plans must allow members to choose any participating primary care provider. Plans must allow women to access ob/gyn's without a referral or preauthorization, and allow pediatricians to be named as a child's primary care provider. Aetna plans already include all of these provisions, and no changes are needed.

We hope this is a helpful summary of the changes coming to ensure your customers' plans are ready at renewal. Please contact your Aetna representative if you have any questions.


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