Phia Group

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.

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.

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.

One Year Post-Dobbs Decision

On July 5, 2023
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.

Merck vs. Biden

On June 23, 2023
The globally recognized, multi-billion-dollar pharmaceutical company Merck & Co. sued the U.S. government on June 6th in an effort to halt the Medicare drug price negotiation program contained in the Inflation Reduction Act. The drug negotiation program aims to form agreements with drugmakers to lower costs on their most expensive drugs, which will save billions of dollars for Americans, particularly those on Medicare, while sapping Big Pharma of billions in potential revenue. In the first attempt by a drugmaker to challenge the law, Merck is pushing to be declared exempt from the drug price negotiation program, which they claim would lower their drug prices by 25 to 60 percent below market value.

What Happens When Auto and Health Insurance Collide?

On June 20, 2023
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, 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.

A Weight Off My Chest

On June 6, 2023
Insurance is supposed to be something you purchase to protect yourself against unforeseen – but costly – losses. You don’t “expect” to be involved in a motor-vehicle accident, but you purchase automobile insurance to protect yourself against the costs incurred in an accident. You don’t expect your home to flood or burn down, but you purchase homeowner’s insurance to protect yourself against the costs incurred in such incidents. Automobile insurance does not pay to fill your car’s gas tank or change the oil. These are foreseen, planned costs of automobile ownership and maintenance. Homeowner’s insurance does not pay to replace the filters in your HVAC or power wash mold from the siding. These are foreseen, planned costs of home ownership and maintenance. Why, then, does health insurance pay for foreseen, planned costs of your body’s maintenance? More importantly, how have recent trends taken advantage of our addiction to health insurance, and the expectation that it will pay for everything?

Unwrapping the Benefits to Your Plan

On May 4, 2023
On January 1, 2022, the No Surprises Act (NSA) officially went into effect, affording protection to patients against surprise medical bills on certain types of claims, including out-of-network emergency services, ancillary out-of-network professional services rendered at in-network facilities, and air ambulance services. While the NSA has spared countless patients from potentially devastating balance bills, its complex and ever-evolving dispute resolution process has created headaches for plans and providers alike. Luckily, Phia Unwrapped includes NSA support services during the Open Negotiation period and, if necessary, Independent Dispute Resolution.

Marty Walsh Goes to Bat for NHL Retirees

On April 11, 2023
The National Hockey League’s collective bargaining agreement (“CBA”) is not set to expire until September of 2026, but it was still a hot topic during NHLPA Executive Director Marty Walsh’s introductory media conference last month in Toronto. In particular, there were several questions directed to the erstwhile Boston mayor and US Secretary of Labor about the union’s plans for managing the health benefits of retired players. Judging by his response, he didn’t appear to be blindsided.