Healthcare reform isn't a done deal ... until they say it is

Correction: Because of a reporting error, a story in Wednesday's Business section about the implementation of healthcare reform gave the incorrect title for Amy M. Lischko. She is the state commissioner of the Division of Health Care Finance and Policy, part of the Executive Office of Health and Human Services.

The battle to shape the state's plan to extend health insurance to about 500,000 residents who lack coverage isn't over.

There's no time to waste. The law sets an ambitious timetable that began with Romney's signature -- new low-cost policies for the uninsured must be ready by October.

``It's going to be a terrific seven months for people in the lobbying business," said Dan Roble , a partner in the healthcare practice of Ropes & Gray LLP, a Boston law firm. ``There's going to be lobbying at a high level."

In fact, it's already started. Two weeks ago, Richard C. Lord , chief executive of the Associated Industries of Massachusetts, the state's largest business group, met with Timothy R. Murphy , state secretary of health and human services, and Brian Wheelan , deputy director of Medicaid.

``We feel our work only just began on April 12 when the governor signed the bill," Lord said. ``The next 12 months are going to be key as to how this actually works."

Businesses are trying to influence many facets of healthcare reform. At the top of their list are the rules that will determine which employers have to pay a $295 annual assessment for each employee if they do not offer a ``fair and reasonable" premium contribution to workers.

The Division of Health Care Finance and Policy, a little-known agency within the Department of Health and Human Services, is charged with defining ``fair and reasonable." The agency will also determine what costs businesses will be responsible for if they don't offer health insurance and one of their employees receives free medical care .

Lord said he discussed those issues in the meeting with Murphy and during a meeting with Amy M. Lischko , assistant commissioner of the state Division of Health Care Finance and Policy.

But there are many other issues to discuss . For example, the healthcare reform law allows employees at businesses that don't offer health insurance to pay for their insurance premiums with pre-tax dollars, similar to the way employees use flexible-spending accounts at some companies.

Lord and his group's members want to know who will be eligible for such pre-tax deductions, called 125 plans after a section of the Internal Revenue Code .

``We spent the last 12 months lobbying members of the Legislature," said Lord. ``Now the action has moved over to the administration. I'm sure everybody is doing what we are, which is advocating for our position."

The reform law hinges on a combination of a personal mandate -- individuals are required to buy insurance or face penalties -- and insurance policies that will be designed for low-income residents.

There will be subsidies for families earning less than three times the federal poverty threshold, or about $60,000 for a family of four.

The sheer volume of rules that must be established, and the number of parties involved in writing them, is overwhelming. At least nine state offices will be crafting regulations.

``There'll be lobbying at all levels of the executive branch, from the governor to his key aides to the secretary of health and human services to the agencies with key implementation responsibility," said John McDonough , executive director of Health Care for All, an advocacy group that helped push healthcare reform through the Legislature.

For instance, the law created the Health Care Quality and Cost Council, which is charged with devising a system for insurers and healthcare providers to report quality and cost information. The system is intended to enable consumers to seek out the lowest-cost, highest-quality care. But the specifics of what will be reported haven't been spelled out, and the council itself hasn't yet been formed.

Another newly created entity, the MassHealth Payment Policy Advisory Board, will recommend reimbursement rates for Medicaid services, and the Division of Insurance will issue regulations for plans intended to cover young adults such as recent college graduates.

The most influential group created by the law is the Commonwealth Health Insurance Connector, which has not yet convened. An independent authority, it will define the minimum requirements for low-cost policies. Jon Kingsdale , a senior vice president at Tufts Health Plan, is expected to be named to head the connector.

Chris Murphy , a spokesman for Blue Cross Blue Shield of Massachusetts, the state's dominant health insurer with nearly 3 million members, said he cannot predict what policies might be offered until the rules are completed.

``Product design is all about specifics, but what we have right now in the law is general," he said.

Hospitals are also working to shape the reform details.

Joe Kirkpatrick , vice president of healthcare finance and managed care policy for the Massachusetts Hospital Association, said his group is concerned about the minimum requirements for low-cost policies. It worries that such plans won't offer substantial coverage, and that caregivers will once again be stuck with unpaid bills.

``We want to make sure it's real coverage," Kirkpatrick said.

Kirkpatrick said he plans to meet Tuesday with Murphy , the secretary of health and human services, to discuss that concern and others affecting hospitals. ``When the insurance connector has an executive director aboard, we'll communicate our concerns and suggestions to them as well," he said.

Philip W. Johnston , a former health and human services secretary under Governor Michael Dukakis who now heads the state Democratic Party and operates a healthcare consulting firm, said, ``The rule-making process will be central to the success of the legislation. Everyone is eager to get in on the act."

Jeffrey Krasner can be reached at krasner@globe.com.