Phia Group

MAHP 2023 Annual Health Care Conference: Health Care Affordability, Quality and Equity in a Post Pandemic World

On November 28, 2023
Last November, the Massachusetts Association of Health Plans (MAHP) Annual Conference focused on healthcare challenges and opportunities – both from a regional and national perspective -- amidst a receding pandemic. The 2022 conference, headlined by then-Governor Charlie Baker, homed in on two topics: a.) healthcare equity and b.) regulation of provider prices. Twelve months later, on November 17, 2023, the MAHP 2023 Annual Conference, held once again at the Seaport Hotel in downtown Boston, had an eerily familiar theme: “Health Care Affordability, Quality and Equity in a Post Pandemic World.”

Minor Members and Third Party Settlements

On November 27, 2023
Does a self-funded ERISA plan have a right of recovery from a minor’s third-party liability claim? The answer is yes. However, there are various factors that can influence the Plan’s recovery in these circumstances. Federal courts across the country have recently considered a few challenges to a health plan’s right of recovery and clarified an ERISA plan’s right of recovery through reimbursement. What is abundantly clear is good plan language is vital to a health plan’s recovery.

Being Mindful of Telemedicine Access

On November 9, 2023
From a healthcare standpoint, two of the most significant byproducts of the COVID-19 pandemic have been the exploding popularity of Telemedicine, the practice of providing medical and mental health services remotely, and a heightened awareness of many Americans’ longstanding mental health issues. Due to a confluence of prolonged extenuating circumstances, it became readily apparent to healthcare providers, politicians, social workers, employers, teachers, and parents on both sides of the Mississippi that a.) the inimitable convenience of virtual healthcare does not compromise quality (at least for some patients and practitioners) and b.) many Americans experiencing emotional distress have long been suffering in silence.

Update on the Federal IDR Process

On October 27, 2023
Recently there has been significant discussion about the federal IDR process. The IDR process is an important tool of the No Surprises Act (“NSA”) as it resolves claims for payment for out-of-network items and services. It not only provides a procedure for settling disputed claims but is also an integral mechanism for supporting the NSA’s protection for plan members against potentially crippling expenses from balance billing for high-cost out-of-network claims.

Empowering the 2023 SIIA National Conference

On October 26, 2023
Earlier this month, the self-insurance industry’s most prominent thought-leaders, innovative service providers, and esteemed subject matter experts convened at the 2023 Self-Insurance Institute of America (SIIA) National Conference at the JW Marriott Phoenix Desert Ridge Resort & Spa. The SIIA National Conference, which this year covered such pressing topics as artificial intelligence, surprise billing, emerging trends impacting the employer stop-loss market, and recent legislative and regulatory updates, is widely considered to be the self-insurance industry’s annual marquee event, bringing together hundreds of industry professionals including TPAs, vendors (there were over 950 booths representing industry vendors stationed in the exhibitor hall), brokers, captive managers, stop-loss carriers, and solution providers.

District Court Strikes a Blow to Copay Accumulator Programs

On October 11, 2023
Many of our clients are aware of, or even utilize, “copay accumulator” programs – these programs create plan savings by not counting amounts received by patients from manufacturer assistance programs toward annual deductibles and out-of-pocket maximums. Some programs go a step further by actually increasing the applicable copayment for certain drugs to maximize the amount a patient may be eligible to receive from manufacturers.

Fall Is Here & So Are the Cold-Weather Germs – New CDC Recommendations

On September 26, 2023
Fall is officially here as the fall equinox has passed and with fall comes the impending “flu season” which also brings a bunch of other germs – new strains of COVID-19 and a rise in RSV cases. If you have children who have headed back to school (even college kids), you’ve probably noticed an uptick in stuffy noses and tummy aches already.

Three Shots for Autumn

On September 18, 2023
It’s a daunting Venn diagram – the interplay of three potentially fatal diseases: Respiratory Syncytial Virus (“RSV”), COVID-19, and influenza. And with summer slipping into fall, this triple-headed monster is (once again) threatening to rear its ugly head. But, thanks to modern medicine, could this cold-weather season have a less devastating toll on humanity than what transpired a year ago?

The First Ten: The Initial Round of Drugs Subject to Medicare Price Negotiations

On August 30, 2023
On August 29, President Biden unveiled the first ten prescription drugs that will be subject to price negotiation with Medicare (Jardiance, Xarelto, Januvia, Farxiga, Entresto, Enbrel, Imbruvica, Stelara, Fiasp and NovoLog), representing a watershed moment for Democrats who have spent years clamoring for lower prescription costs.

Protecting the Most Vulnerable

On August 24, 2023
In February 2022, we received a balance bill referral that was truly exceptional, but for all the wrong reasons. Our client received a staggering bill of over $675,000.00 after a premature delivery with major complications resulted in a two-month stay in the NICU. It was an unjust financial burden exacerbating an already challenging situation.

Wegovy: The Heart of the Matter

On August 18, 2023
Obesity adversely impacts upwards of 100 million adults in the US and accounts for nearly $150 billion in annual health care spending, yet health insurers have been reluctant to cover high-priced weight loss drugs, ones they frequently label as “cosmetic” or “lifestyle” medications. But, given what transpired earlier this month, is it possible that there could be an impending sea change in the medical field’s perception of such treatment?

The Power Dynamics of Gag Clauses

On August 14, 2023
In the already-intricate world of health benefits, Congress passed the Consolidated Appropriations Act, 2021, which is notable to the self-funded industry for three main reasons: it expanded the Mental Health Parity and Addiction Equity Act to require health plans to proactively document their compliance via the nonquantitative treatment limitation (NQTL) analysis; it introduced the No Surprises Act, which fundamentally changed how claims disputes are handled; and it prohibited health plans from entering into contracts containing gag clauses. This particular blog post focuses on gag clauses. The implications of this prohibition on transparency and patient rights are immense, and it’s worth looking into the power dynamics at play since it’s not quite as simple as saying that plans can no longer have these gag clauses.

Expanding Protections for Breastfeeding Mothers

On August 3, 2023
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.

Diapers & Wipes Reflection

On August 3, 2023
As my family and I look forward to celebrating our daughter Kinsley’s first birthday this Sunday, we have revisited some of our fond memories and challenges in our first year as a family of five. In doing so, we have discussed how helpful Phia’s “Diapers and Wipes” program has been to our family.

Benefest 2023: Talking Costs and Laws with Carriers

On July 31, 2023
By March, amidst the snowbanks contracting and days growing incrementally longer, conference season – at least for the healthcare industry -- is in full bloom. One of the marquee Massachusetts-based healthcare conferences, Benefest 2023, focused on “shaping the future of healthcare” in the commonwealth, was held earlier this summer at Worcester’s Polar Park -- during the peak of conference season.