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Health Insurance Answer Book, Twelfth Edition

Health Insurance Answer Book, Twelfth Edition

By John C. Garner
Format
Looseleaf
$489.00

Looseleaf

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Overview

From designing a cost-effective new health care plan…to administering an existing plan…to complying with the many state and federal rules that govern health benefit plans - you know how difficult it is to manage your company's group health insurance.

With Health Insurance Answer Book, you get expert guidance and practice-based answers to all types of questions about today's health insurance marketplace, including:

  • Are there any guidelines on medical tourism?
  • What are the issues related to implementation of a "full flex" plan?
  • What is the role of an intermediary?
  • Can onsite health clinics save money?
  • Are there any new developments regarding the use of captives for retiree health insurance?
  • What is electronic prescribing?
  • What is comparative effectiveness research?

Last Updated 01/16/2018
Update Frequency Updated annually
Product Line Wolters Kluwer Legal & Regulatory U.S.
ISBN 9781454842606
SKU 10044874-7777
Table of Contents
  • 1. An Overview of Group Insurance
    • Group Health Insurance
    • The Uninsured
    • Group Insurance
    • Types of Insurance Professionals
    • Intermediaries
    • Blue Cross/Blue Shield Plans
  • 2. State and Federal Laws
    • Legal Factors Affecting Design
    • State Law
    • Federal Law
    • Pregnancy Discrimination Act
    • Family and Medical Leave Act
    • Americans with Disabilities Act
    • Taxation of Group Health Plans
    • Reservists' Benefits
  • 3. Health Care Reform
    • Overview
    • Small Employer Tax Credit
    • Special Programs
    • Grandfathered Plans
    • Dependent Coverage to Age 26
    • Patient's Bill of Rights
    • Preventive Services
    • Guaranteed Availability and Renewal
    • Exchanges
    • Transparency
    • Vouchers
    • Taxes and Fees
    • Penalties
    • Other Rules
  • 4. Eligibility
    • Employees
    • Dependents
  • 5. Types of Medical Plans
    • Traditional Plans
    • Managed Care
    • Health Maintenance Organizations
    • Adverse Selection
    • Legal Standards
    • Evaluating HMOs
    • Preferred Provider Organizations
    • POS
    • Managed Care Backlash
  • 6. Factors Influencing Plan Design
    • Strategies
    • Contributions
    • Covered Expenses
    • Essential Health Benefits
    • Restrictions on Coverage
    • Deductibles, Copayments, and Reimbursement
    • Cost Containment
    • Managed Competition
  • 7. Flexible Benefits
    • Tax Advantages
    • Cost Control
    • Types of Plans
    • Flexible Spending Accounts
    • Mid-Year Plan Changes
    • Flexible Benefit Options
    • Implementation
    • Health Care Reform Changes
    • Simple Cafeteria Plans
  • 8. Consumer-Driven Health Plans
    • Health Savings Accounts
    • Health Reimbursement Arrangements
    • Medical Savings Accounts
    • Consumer-Driven Dental Care
    • Defined Contribution Health Care
  • 9. Plan Implementation and Administration
    • Setting Up the Plan .
    • Reporting and Disclosure
    • Health Care Reform Reporting Requirements
    • Uniform Standards
    • Enrollment
    • Billing
    • Coverage, Renewal, and Changes
    • Termination of Coverage .
    • Computerized Administration .
    • Outsourcing
  • 10. Claim Administration
    • Claims
    • Health Care Reform Changes
    • Coordination of Benefits
    • Billing Codes
    • Third-Party Administrators
  • 11. Health Insurance Portability and Accountability Act
    • Portability
    • Electronic Data Interchange
    • Health Care Reform Changes
    • Privacy
    • Security
  • 12. COBRA
    • The Basics
    • Covered Employers
    • Covered Plans
    • General Requirements
    • Notification Requirements
    • Premiums
    • Election and Grace Periods
    • Qualified Beneficiaries
    • Retiree Medical Coverage
    • Miscellaneous
  • 13. Form 5500
    • Plan Years
    • Administration
    • Completing the Form
    • Electronic Filing
    • Summary Annual Report
  • 14. Nondiscrimination Rules
    • Accident and Health Plans
    • Cafeteria Plans
    • Voluntary Employees’Beneficiary Associations
    • Nondiscriminatory Classification
    • Nondiscrimination Rules for Archer MSAs
    • Comparability Rules for Health Savings Accounts (HSAs)
    • Controlled Group Rules
    • Tax-Exempt Organizations
    • Comparisons
  • 15. Plan Rating and Funding
    • Plan Funding
    • Fully Insured Plans
    • Health Care Reform
    • Alternatives to Fully Insured Plans
    • Deferred Premium Arrangements
    • Shared Funding Arrangements
    • Retrospective Premium Arrangements
    • Reserve Reduction Agreements
    • Minimum Premium Plans
    • Captives
  • 16. Self-Funding
    • Reasons for Self-Funding
    • Decision to Self-Fund
    • Administration
    • The Marketplace
    • Self-Funding and Legal Requirements
    • Stop-Loss Insurance
    • Voluntary Employees’ Beneficiary Associations
  • 17. Vendor Selection
    • Types of Vendors
    • Selection Process
    • Role of the Intermediary
    • Choosing Intermediaries
    • Choosing Other Specific Types of Vendors
  • 18. Managing Health Insurance Costs
    • Factors Affecting Costs
    • Health Care Data
    • Utilization Review and Case Management
    • Additional Cost-Management Strategies
    • Rationing Health Care
    • The Employer's Role
    • Review of Premium Increases
  • 19. Wellness Plans
    • Health Promotion and Wellness
    • Health Care Reform
    • Health and Productivity Management
  • 20. Pharmacy Benefit Management
    • The Basics
    • Pharmaceutical Pricing
    • Pharmacy Benefit Design
    • Cost Control
    • Coverage Disclosure Considerations
    • Cost Considerations
    • The Global Drug Market
    • Pharmacy Benefit Managers
    • Choosing a Pharmacy Benefit Manager
    • Ensuring Quality
    • Cost-Management Concepts
    • Utilization Management Concepts
    • Formularies
    • Prior Authorization Programs
    • Disease State Management
    • Quality Management/Oversight
  • 21. Retiree Health Benefits
    • Regulatory Issues
    • Eligibility and Plan Design
    • Determining and Allocating Costs
    • Retiree Medical Liabilities
    • Pre-Funding
    • Medicare Solutions to Retiree Challenges
    • Early Retiree Reinsurance Program
  • 22. Medicare
    • The Basics
    • Medicare Order of Benefit Determination
    • Medicare Cost Containment
    • Medigap
    • Medicare Advantage
    • Health Care Reform Changes
  • 23. Medicare Part D Benefit
    • Enrollment
    • Employer Incentives to Participate
    • Standard Benefit
    • Pharmacy Network Contracting
    • Formularies and Part D
    • Medication Therapy Management (MTM)
    • Skilled Nursing Facility (SNF)/Nursing Facility (NF) Impact
    • Quality Measures
    • Audit Issues
    • Coordination of Benefit (COB) Issues
  • 24. Quality Assurance
    • Quality Measures
    • Report Cards
    • The Joint Commission and HEDIS
    • Outcomes Measurement
    • Health Care Reform Changes
  • 25. Mental Health
    • Mental Health Benefits
    • Mental Health Parity and Addiction Equity Act
    • Controlling Costs
    • Substance Abuse
    • Managed Mental Health
    • Employee Assistance Programs
    • Outcome Measurements
    • Americans with Disabilities Act
  • 26. Dental, Vision, and Other Benefits
    • Dental Benefits
    • Vision Benefits
    • Hearing Benefits
    • Long-Term Care
    • CLASS Act
  • 27. Communication
    • Developing Communication Strategies
    • Benefit Statements
    • Periodic Benefit Reports
    • Interactive and Online Systems
    • Open Enrollments
  • APPENDIX A. Model COBRA General Notice
  • APPENDIX B. Notice of Unavailability of COBRA Continuation Coverage
  • APPENDIX C. Model COBRA Election Notice upon Occurrence of a Qualifying Event
  • APPENDIX D. Model Certificate of Creditable Coverage
  • APPENDIX E. Sample QMCSO Procedure
  • APPENDIX F. Model Beneficiary Notices of Part D Creditable Coverage Status

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