Even before the first member is enrolled, consumer operated and oriented plans (CO-OPs) will invest thousands of hours in developing the operational infrastructure that will provide healthcare coverage for their members. Conventional approaches to managing cost such as contract negotiations with network providers for competitive unit costs and implementing medical management models to curb excessive utilization are important starting points for controlling the cost of claims. However, recent changes to the nation’s healthcare system have created a few additional items for CO-OPs to consider as they prepare for October 2013 and enrolling their first members.