Phia GroupPhia Group Mediahttps://www.phiagroup.com/Media/PostsConsiderations Regarding the Exclusion of Gender-Affirming Carehttps://www.phiagroup.com/Media/Posts/PostId/1305/considerations-regarding-the-exclusion-of-gender-affirming-careBlog,Health Insurance,Healthcare Costs,PlanTue, 16 Jan 2024 20:33:52 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">By: Kendall Jackson, Esq. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Gender-affirming care was a particularly popular topic throughout 2023. As we enter the new year, the prevalent discussion concerning plan coverage of such care will certainly continue. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">For self-funded health plans, the decision of whether to cover or exclude gender-affirming care is quite multilayered. Specifically for plans that exclude gender-affirming care within their plan documents, there are several potential discrimination concerns. An important element when evaluating these concerns is what law applies to the plan. For instance, certain state laws may not apply to a self-funded plan governed by the Employee Retirement Income Security Act (ERISA) due to ERISA preemption. ERISA preemption operates to preempt state insurance laws as they relate to employee benefit plans. Accordingly, any state laws that may require coverage or ban coverage for gender-affirming care would not apply to an ERISA plan. This is noteworthy as ERISA affords an employer the broad discretion to construct and design the coverage and benefits for its employees. As there is no federal requirement for plans to cover gender-affirming care, an ERISA plan may choose to cover or exclude benefits for gender-affirming care. Alternatively, non-ERISA plans, such as self-funded church plans or non-federal governmental plans, have slightly less flexibility and must adhere to both state and federal law. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Federal protections against discrimination have been, and will continue to be, integral to filling the gaps in health coverage for marginalized groups. Consequently, the potential compliance concerns outlined below apply particularly to plans that elect to exclude gender-affirming care. The first consideration is whether the plan is subject to Section 1557 of the Affordable Care Act (ACA), which hinges on whether the plan sponsor receives any federal financial assistance through the Department of Health and Human Services (HHS). Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, or disability. HHS provided guidance in a notice in March 2022 that clarified the extent of Section 1557’s protections.<a href="#_ftn1" name="_ftnref1" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[1]</span></span></span></span></span></a> HHS opined that Section 1557’s protection against sex discrimination encompassed an individual’s right to access health programs that are free from discrimination based on gender identity. HHS stated that a plan categorically excluding benefits due to an individual’s gender identity was discrimination and prohibited by Section 1557. At the time, this guidance had a significant impact because if a plan was subject to Section 1557, generally, any exclusion of benefits or services related to, for example, transgender care, would be deemed a categorical exclusion and would be prohibited. Although HHS’s viewpoint was contested, nevertheless, it demonstrates the movement to protect against the exclusion of benefits based on gender identity. Accordingly, to avoid allegations of discrimination, self-funded plans subject to Section 1557 should consider removing gender-affirming care exclusions.</span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:105%"><span style="font-family:"Calibri",sans-serif">Even if a plan is not subject to ACA Section 1557, there are still significant discrimination concerns for plans with gender-affirming care exclusions if they create a disparity in coverage for certain individuals. These concerns stem from scrutiny from the Equal Employment Opportunity Commission and the protection against discrimination based on gender identity under Title VII of the Civil Rights Act of 1964. There have been several lawsuits brought forth by transgender individuals under these laws and Section 1557 about gender-affirming care exclusions, and courts have ruled in their favor on some occasions. An example of an exclusion that could create a disparity in coverage is a sex reassignment exclusion. In this case, while it does not exclude care for transgender individuals specifically, it is possible it could be viewed as discriminatory because it functions to categorically exclude services which will overwhelmingly be needed only by transgender individuals. As a result, while self-funded health plans are not mandated to cover gender-affirming care, the compliant approach with regard to all applicable laws would be to remove exclusions for gender-affirming care from the plan. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Pivoting to a different perspective, for self-funded non-ERISA plans subject to state law, there have been many changes surrounding gender-affirming care over the past year. For example, in Texas, on September 1, 2023, a<a name="_Hlk155366211"> law</a> banning gender-affirming care, such as treatments for gender dysphoria, transitioning, and reassignment for minors took effect. The law prohibits health plans from covering services “that are intended to transition a child’s biological sex as determined by the child’s sex organs, chromosomes, and endogenous profiles.”<a href="#_ftn2" name="_ftnref2" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[2]</span></span></span></span></span></a> In Ohio, governor Mike DeWine signed an executive order on January 5, 2024, that banned hospitals and ambulatory surgical facilities from performing gender-affirming surgeries on minors.<a href="#_ftn3" name="_ftnref3" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[3]</span></span></span></span></span></a> In New Hampshire, the New Hampshire House recently passed a bill that will now be sent to the New Hampshire Senate. This bill proposes to ban gender-affirming procedures for minors.<a href="#_ftn4" name="_ftnref4" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[4]</span></span></span></span></span></a> The bill also proposes to prohibit health care workers from referring minors to out-of-state facilities that may perform gender-affirming procedures. These are only a few examples of the recent developments in state legislation that concern gender-affirming care. As of November 2023, 22 states had a law or policy banning gender-affirming care.<a href="#_ftn5" name="_ftnref5" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[5]</span></span></span></span></span></a> There will likely be more development in state legislation in the new year and plans subject to state law should be mindful of how these laws and policies may influence their plan structure.</span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">The decision of whether to cover or exclude gender-affirming care is a multilayered matter and will likely depend on the intent of the employer. There are varying considerations depending on the type of plan and applicable law. As the landscape is constantly changing in regard to gender-affirming care laws, it is essential that plans consider plan document compliance, the potential for discrimination allegations, and, if applicable, what is mandated or banned by relevant states. </span></span></span></p> <p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <div>  <hr align="left" size="1" width="33%" /> <div id="ftn1"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref1" name="_ftn1" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[1]</span></span></span></span></span></a> HHS Notice and Guidance on Gender Affirming Care, Civil Rights, and</span></span></p> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif">Patient Privacy, https://www.hhs.gov/sites/default/files/hhs-ocr-notice-and-guidance-gender-affirming-care.pdf</span></span></p> </div> <div id="ftn2"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref2" name="_ftn2" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[2]</span></span></span></span></span></a> Senate Bill 14, https://capitol.texas.gov/tlodocs/88R/billtext/html/SB00014I.htm</span></span></p> </div> <div id="ftn3"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref3" name="_ftn3" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[3]</span></span></span></span></span></a> Ohio Gov. DeWine signs executive order banning hospitals from gender transition surgeries on minors, https://ohiocapitaljournal.com/2024/01/05/ohio-gov-dewine-signs-executive-order-banning-hospitals-from-gender-transition-surgeries-on-minors/</span></span></p> </div> <div id="ftn4"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref4" name="_ftn4" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[4]</span></span></span></span></span></a> House Bill 619, https://gencourt.state.nh.us/bill_status/legacy/bs2016/billText.aspx?sy=2024&id=71&txtFormat=pdf&v=current</span></span></p> </div> <div id="ftn5"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref5" name="_ftn5" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[5]</span></span></span></span></span></a> HRC Foundation, https://www.hrc.org/resources/attacks-on-gender-affirming-care-by-state-map</span></span></p> </div> </div> 1305Expanding Protections for Breastfeeding Mothershttps://www.phiagroup.com/Media/Posts/PostId/1265/expanding-protections-for-breastfeeding-mothersBlog,Affordable Care Act,Health Insurance,PlanThu, 03 Aug 2023 19:55:52 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: Kendall Jackson </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">So far this year, we have seen two notable advancements in protections for breastfeeding mothers in the workplace. The first of which includes the expansion of women’s preventive services under the Affordable Care Act (ACA). Based on new recommendations by the Health Resources and Services Administration (HRSA), breastfeeding mothers will no longer have to pay out-of-pocket costs for particular breast pumps and related supplies. The HRSA specifically noted that access to double electric breast pumps should be prioritized and should not be treated as a secondary step if manual pumps are unsuccessful. In addition to the double electric breast pumps, the preventive service recommendation includes coverage for the pump parts, maintenance of the pumps, and supplementary equipment for women needing additional services or for women who have faced breastfeeding complications. Plans subject to the ACA and its preventive care mandate must cover these new additions to women’s preventive services with no cost sharing.</span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">The second protection is an employment law that governs nursing mothers’ access to areas to express breast milk while at work. The Providing Urgent Maternal Protections (PUMP) For Nursing Mothers Act expanded the Fair Labor Standards Act (FLSA) and took effect on April 28, 2023. Under the PUMP Act, for one year following the birth of the child, the nursing mother must be allowed to take a break for a reasonable time to express breast milk. The frequency and duration of the breaks are dependent on the mother’s needs. Additionally, the employer must provide a space for the nursing mother to pump that is not a bathroom, is shielded from view, and will not expose the mother to the intruding staff or public. Employers are not required to compensate the mothers during this break unless the mother is not fully relieved from work duties or if the break would have otherwise been paid. The PUMP Act applies to all employers with 50 or more employees. If an employer with fewer than 50 employees can demonstrate that adhering to the requirements of the Act would impose undue hardship on the employer, then the employer would be exempt from the Act’s requirements. Currently, flight attendants and pilots are the only occupations excluded from the Act.</span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">With any new development in law, it is important to know how it will affect the employer and their plan. The new preventive service recommendation for breastfeeding mothers specifically impacts coverage for health plans that are subject to the ACA. The PUMP Act, meanwhile, is an employment law which directly impacts the employer. If applicable, employers must provide breaks for nursing mothers according to the standards set out in the Act. As always, please do not hesitate to reach out to our consulting teams to assist with any questions you may have relating to these expanded protections for mothers in the workplace. </span></span></span></span></span></span></p> 1265IDR Entities Still Struggling with Volume – Highlights from the Q4 2022 Reporthttps://www.phiagroup.com/Media/Posts/PostId/1260/idr-entities-still-struggling-with-volume-highlights-from-the-q4-2022-reportBlog,Cost Containment,Plan,Supreme CourtMon, 17 Jul 2023 16:57:15 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><b></b>By: Andrew Silverio<b></b></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><b>IDR Entities Still Struggling with Volume – Highlights from the Q4 2022 Report</b></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Under the No Surprises Act (NSA), the Departments of Health and Human Services, Labor, and Treasury are required to post quarterly data on the Federal Independent Dispute Resolution (IDR) process.  In response to the federal court decision in <i>Texas Medical Association, et al. v. United States Department of Health and Human Services</i>, portions of the governing regulations were vacated, resulting in a February 10, 2023 order for IDR entities to cease issuing new payment determinations (see <a href="https://www.cms.gov/nosurprises/help-resolve-payment-disputes/payment-disputes-between-providers-and-health-plans" style="color:#0563c1; text-decoration:underline">https://www.cms.gov/nosurprises/help-resolve-payment-disputes/payment-disputes-between-providers-and-health-plans</a>).  This was lifted as of February 24, 2023 for services furnished before October 25, 2022, and as of March 17, 2023 for services furnished on or after October 25, 2022.   Because there was essentially a freeze on IDR proceedings for a good portion of Quarter 1 of 2023, the report issued for Quarter 4 of 2022, available at <a href="https://www.cms.gov/files/document/partial-report-idr-process-octoberdecember-2022.pdf" style="color:#0563c1; text-decoration:underline">https://www.cms.gov/files/document/partial-report-idr-process-octoberdecember-2022.pdf</a>, is the most recent and complete picture we have of how the process is performing.  The full report is certainly worth reviewing, but here are some noteworthy data points:</span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><b>110,034 disputes were initiated in Q4 2022</b></span></span></span></p> <ul> <li style="margin: 0in 0in 0in 0.5in; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">This is a 53% increase from Q3 2022<b></b></span></span></span></li> <li style="margin: 0in 0in 8pt 0.5in; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">The vast majority were for OON Emergency or non-Emergency items or services, with just around 6% (6,864 in total) being for OON air ambulance services<b></b></span></span></span></li> </ul> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><b>IDR entities closed our 31,714 disputes in Q4 2022</b></span></span></span></p> <ul> <li style="margin: 0in 0in 0in 0.5in; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Over three times more payment determinations were made (12,662) than in the prior quarter</span></span></span></li> <li style="margin: 0in 0in 0in 0.5in; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">However, the total number of closed disputes is still just around 29% of the number of new disputes submitted in this same time period</span></span></span></li> <li style="margin: 0in 0in 8pt 0.5in; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Of the 31,714 closed disputes, 12,662 (40%) reached a payment determination, while 9,525 (30%) were found ineligible for IDR proceedings</span></span></span></li> </ul> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><b>The overwhelming majority of proceedings (>99%), not surprisingly, were initiated by providers</b></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><b>A few entities are dominating the IDR Submission process, both as complainant and respondent </b></span></span></span></p> <ul> <li style="margin: 0in 0in 0in 0.5in; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">One entity, SCP Health, initiated 30% of all disputes for OON emergency and non-emergency items or services<b></b></span></span></span> <ul style="list-style-type:circle"> <li style="margin:0in 0in 0in 0.5in"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">United Healthcare was the most frequent non-initiating party, at 25% of disputes<b></b></span></span></span></li> </ul> </li> <li style="margin: 0in 0in 0in 0.5in; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">One entity, Global Medical Response, initiated 42% of all air ambulance disputes<b></b></span></span></span> <ul style="list-style-type:circle"> <li style="margin:0in 0in 8pt 0.5in"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Zelis was the most frequent non-initiating party, at 12% of disputes<b></b></span></span></span></li> </ul> </li> </ul> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">It will be important to keep an eye on how these data trends develop, and how the backlog caused by the work stoppage in quarter one of this year will impact new numbers. </span></span></span></p> 1260One Year Post-Dobbs Decisionhttps://www.phiagroup.com/Media/Posts/PostId/1256/one-year-post-dobbs-decisionBlog,Health Insurance,Plan,Supreme CourtWed, 05 Jul 2023 13:36:05 GMT<p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:">By: Kelly Dempsey</span></span></p> <p> </p> <p style="margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:">June 27, 2023 marked one year since the Supreme Court of the United States (SCOTUS) overturned the constitutional right to abortion in the case of Dobbs v. Jackson Women’s Health Organization. Over the last 12 months, half of the states have passed some type of abortion restriction or complete ban and many more are in the process of creating legislation. Some of these laws include the possibility for civil or criminal penalties against women who obtain abortions, doctors who perform abortions, or even individuals who, broadly, facilitate abortions. </span></span></p> <p> </p> <p style="margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:">It may be a year old now, but the Dobbs case seems as controversial now as it did the week it came out. While the landscape has continued to evolve state-by-state, with different states reacting in different ways, the various areas of concern for health plans remain the same as they have been since the Dobbs decision. </span></span></p> <p> </p> <p style="margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:">From a federal law perspective, aside from the preventive care requirement imposed on health plans to cover FDA-approved birth control methods, the Affordable Care Act does not require health plans to cover an abortion procedure. To contrast, the Pregnancy Discrimination Act of 1978 does require health plans to cover abortion where the life of the mother would be endangered if the fetus is carried to term and where there are medical complications. In the post-Dobbs landscape, self-funded plans that want to cover abortion (including related travel) face significant challenges, and ERISA preemption does not apply as clearly as many expect it to (or hope it does, anyway). ERISA preemption does not, for instance, extend to state criminal laws such as those banning the facilitation of abortion.</span></span></p> <p> </p> <p style="margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:">Compliance with state abortion law isn't the only compliance consideration, though. For instance, some plans have explored increasing their abortion benefits, in particular by adding travel benefits; it is important to keep in mind that the requirement to perform an NQTL analysis (to uncover mental health parity issues) may highlight that abortion travel benefit as a way that mental health and substance abuse claims are perhaps not afforded the same benefits as medical and surgical benefits, since most plans do not offer travel benefits for MH/SUD claims. Additional considerations include the impact to HSA qualified HDHPs, telemedicine, and stop-loss. </span></span></p> <p> </p> <p style="margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:">It would be absurd to suggest that the self-funded industry has had an easy time navigating all the changing laws, but the Dobbs decision – especially coming out at the same time as other complex laws like the No Surprises Act (which presents yet another, albeit very different type of, landmark change to the self-funded universe) – requires a great deal of extra caution and consideration related to benefit offerings. As we see it, it stresses the importance of making informed decisions by working with claims administrators, brokers, and consultants (like The Phia Group) prior to making decisions about controversial or legally-complex plan provisions.</span></span></p> <p> </p> <p style="margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif"></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:">Phia has always recommended that plan documents be reviewed on an annual basis, and every year we seem to be proven right all over again. Our goal is to help ensure that yours or your clients’ plans provide robust benefits without running afoul of applicable laws, but that gets harder and harder all the time! Luckily, we’re up to the challenge, and we know you are too.</span></span></p> 1256What Happens When Auto and Health Insurance Collide?https://www.phiagroup.com/Media/Posts/PostId/1251/what-happens-when-auto-and-health-insurance-collideBlog,Health Insurance,Healthcare Costs,PlanTue, 20 Jun 2023 14:23:44 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">By: Cindy Merrell, Esq. </span></span></span></span></span></p> <p> </p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">I remember when I graduated college, I was in the early stages of adulthood and my parents told me that I needed to get my own car insurance. Beyond knowing that my monthly bills were going up, I had little understanding about car insurance other than it was required and it provided protection in the event of an accident. After over a decade of practicing<span style="color:red">,</span> law I have found that most adults (not just recent college graduates) do not actually know or understand their own auto coverage. Even fewer adults know how auto insurance and health benefits may intersect in the event of an auto collision.  </span></span></span></span></span></p> <p> </p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""><span style="color:#0070c0">Who pays medical expenses immediately after a car wreck?</span></span></span></b><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">The answer depends on many factors including applicable state law; the terms of the auto insurance; and terms of the health plan. The starting place is to review the injured party’s auto coverage policy. If someone else caused the wreck, many people are offended by the idea of their own auto carrier footing the medical bill. However, many states have mandatory coverages called personal injury protection (also known as PIP) coverage or medical payment coverage. These coverages require auto carriers to provide benefits (an amount usually $10,000.00 or less) that can be used to pay medical expenses regardless of fault. The public policy behind these laws is to provide access to medical treatment in a timely fashion because determining who is at-fault can take years. The auto carrier may even recoup these expenses from the at-fault party once fault has been determined.</span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">Depending on the terms and funding status of a health plan, the health plan may coordinate health benefits with PIP or medical payment coverages. Each state has various coordination of benefits laws. Typically, the single most important deciding factor are the terms of the health plan document. Most health plans have coordination of benefits provisions that specify the order of benefits requiring the auto coverage to pay primary.</span></span></span></span></span></p> <p> </p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""><span style="color:#4472c4">What if the plan member is not at-fault for the motor vehicle wreck?</span></span></span></b><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">The next layer of coverage we look to is the at-fault party’s auto coverage. Unfortunately, many states do not require the at-fault party’s insurance carrier to disclose policy limits until after a lawsuit has been filed. Typically, parties attempt to resolve their claims without litigation as it gives both parties more control of the outcome. Therefore, it is very common for injured parties to pursue claims against the at-fault party without knowing the policy limits. During this prelitigation period the injured party and the at-fault party are typically trying to determine who is at-fault (liability) and the extent of the injured party’s damages. It is important to remember the at-fault party’s auto coverage is intended to compensate the member for more than just medical expenses. The injured party may suffer other damages such as lost wages, pain and suffering, impaired ability to earn income in the future. </span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">If the at-fault party policy limits are tendered, then we look to the injured party’s underinsured motorist coverage. This coverage is intended to provide another source of recovery.  Each state has different laws governing underinsured motorist coverage. If the health plan is a self-funded ERISA plan and has the appropriate plan language, the health plan may also seek recovery from the injured party’s underinsured motorist coverage. </span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">If the at-fault party does not have insurance, the injured party may make a claim against their own insurance for uninsured motorist coverage. This coverage is like underinsured motorist coverage as it provides coverage to the injured party for their damages, but without the requirement of settlement with the at-fault party.</span></span></span></span></span></p> <p> </p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><b><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times=""><span style="color:#0070c0">Why does the health plan pursue a recovery from the auto coverages? </span></span></span></b><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">The simple answer is because the health plan is not responsible for medical expenses which resulted from the action(s) of the at-fault driver. However, the health plan may have advanced the benefits on behalf of the member immediately providing the member access to medical treatment without waiting years for litigation to resolve. In addition, subrogation and reimbursement keeps premiums lower as the health plan can recover funds from the auto coverages and keeps a self-funded health plan viable and healthy for all members.</span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">When health plan benefits and auto insurance collide, it is important to look to plan language and state law to determine who is responsible for payment medical expenses. If the health plan has strong recovery and coordination of benefits plan language, the answers become much clearer. The Phia Group can assist plans ensuring they have the proper plan language to maximize recoveries. </span></span></span></span></span></p> <p> </p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span new="" roman="" style="font-family:" times="">Please note this article is not intended to be a comprehensive review of auto coverage benefits as state law could impact the applicability of the above statements.  For a more detailed analysis of a specific matter please contact The Phia Group.  </span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:normal"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></p> 1251