Health Insurance Answer Book, Twelfth Edition

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?

• 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