Phia Group Media


Phia Group Media

HIPAA Compliance Audits – Good News and Bad News

On February 1, 2021

By: Andrew Silverio, Esq.

In December 2020, the Department of Health and Human Services (“HHS”) Office for Civil Rights (“OCR”) released the findings of an extensive audit of Covered Entities and Business Associates, performed in 2016 and 2017 for compliance with various HIPAA requirements.  This data, available at, provides valuable insight into what Covered Entities are doing right, and what they’re doing wrong, when it comes to HIPAA compliance (of the Covered Entities audited, 90% were health care providers, 9% were health plans, and 1% were health care clearinghouses).

Rather than a general audit for compliance with all of HIPAA’s requirements, the audit focused on seven provisions.  It looked at compliance with the notice of privacy practices and content requirements, provision of notice – electronic notice (website posting), and right of access requirements (from the Privacy Rule), the timeliness of notification and content of notification requirements (from the Breach Notification Rule), and the security management process – risk analysis and risk management requirements (from the Security Rule).  For Business Associates, the scope of the audit was more narrow, focusing only on the notification by a business associate requirements (from the Breach Notification Rule), and the security management process – risk analysis and risk management requirements (from the Security Rule).

Overall, the audit found that compliance with requirements that come into play after a security issue or breach occur, such as breach notification requirements, is generally good.  Compliance with the requirement to make the applicable Notice of Privacy Practices online was also good.  However, the results were less positive in regard to other requirements which represent more of the “groundwork” in setting up proper safeguards and procedures.  For example, “… OCR also found that most covered entities failed to meet the requirements for other selected provisions in the audit, such as adequately safeguarding protected health information (PHI), ensuring the individual right of access, and providing appropriate content in their NPP. OCR also found that most covered entities and business associates failed to implement the HIPAA Security Rule requirements for risk analysis and risk management.”

These findings make sense from an intuitive standpoint – it’s easy to simply not think about HIPAA’s requirements until a problem arises.  However, this audit underscores the importance of creating proper safeguards proactively – doing so can result in less damage when and if a breach occurs, both financially and when it comes to preserving client and participant good will.

Energage Names The Phia Group a Winner of the 2021 Top Workplaces USA Award

On January 28, 2021

For Immediate Release


Canton, MA – Energage Names The Phia Group, LLC a Winner of the 2021 Top Workplaces USA Award.

Today The Phia Group announced that it has earned a 2021 Top Workplaces USA award, issued by Energage.  Energage, an organization that develops solutions to build and brand a vast array of companies, leveraged their 14-year history of surveying more than 20 million employees across 54 markets, to award this prize during what is the prestigious honor’s inaugural year.

Earning this accolade was no small task.  Several thousand organizations from across the country were invited to participate, and winners of the Top Workplaces USA were chosen based solely on employee feedback gathered through an employee engagement survey, issued by Energage.  These results were then calculated by comparing the survey’s research-based statements, including 15 Culture Drivers that are proven to predict high performance against industry benchmarks.

“The Phia Group’s mission is to reduce medical costs and improve the quality of health care.  That mission starts and ends with our people.  Our job is to help other employers secure the best benefits for their employees and families; it behooves us to do the same for our own team,” The Phia Group’s CEO, Adam Russo, remarked.  “This award is proof that our focus on benefits, opportunities, and general employee satisfaction is not misguided.  While employee satisfaction is valuable in and of itself, it is equally important as a crucial element of improving our company’s overall value.  If our team doesn’t share our passion or buy into our principles, that reflects in the work product.  Employer success is therefore built upon a foundation of employee success.  By emphasizing an atmosphere of employee satisfaction, we generate better outcomes, satisfied clients and success for all.”

To learn more about The Phia Group, what it is doing to empower plans and enable all employers to be best places to work, please contact Garrick Hunt by email at or by phone at 781-535-5644.

About The Phia Group:

The Phia Group, LLC, headquartered in Canton, Massachusetts, and with offices in Hartford, Boise, and Louisville, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets.  By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans.

About Energage:

Making the world a better place to work together.™

Energage is a purpose-driven company that helps organizations turn employee feedback into useful business intelligence and credible employer recognition through Top Workplaces. Built on 14 years of culture search and the results from 22 million employees surveyed across more than 66,000 organizations,  Energage delivers the most accurate competitive benchmark available. With access to a unique combination of patented analytic tools and expert guidance, Energage customers lead the competition with an engaged work force and an opportunity to gain recognition for their people-first approach to culture. For more information or to nominate your organization, visit or

The Hefty Price Tag of Covid-Related Substance Abuse Disorders

On January 27, 2021

By: Philip Qualo, J.D.

Life as we know it came to a halt in February of last year due to the quick and vicious spread of the COVID-19 virus. Although the US has made significant strides in slowing the spread, and pharmaceutical companies have manufactured vaccines, employees across the country continue to struggle with the realities of working from home. Whether due to stress associated with juggling work and family within an eight-hour workday at the kitchen table, or the inherent loneliness of performing job functions without peers or colleagues to interact with, working remotely and isolation orders have taken a toll on the American psyche. COVID-19 continues to be an uncertain, ever-evolving reality, and its impacts are particularly being felt among those with addiction and those in recovery from substance use disorders. As a result, health plans are already experiencing an influx of costly claims associated with substance abuse.

In order to combat the spread of the virus, the government, the media, and even our employers have told us “stay at home”. The bars and restaurants we frequented are all shut down, or only accessible via curbside pickup. Although these orders are intended to enhance public and workplace safety, complying with these orders has presented unique challenges for people with substance use disorders and in recovery. The stress from social isolation and other COVID-19 related life changes can lead to or worsen substance use and abuse. Widespread shutdowns and social distancing mandates have made it difficult for those seeking guidance and treatment for substance abuse issues to secure resources. Because of this, the US has experienced a surge in alcohol sales and drug addiction relapses as substance abuse becomes more prominent.

In the 12 months prior to May 2020, the US recorded 81,230 drug overdose deaths, an 18.2% increase over the previous 12-month period, according to the Centers for Disease Control and Prevention. The CDC announced this past December that overdose deaths had already accelerated in the months before COVID-19 came to the U.S., but had sped up even more during the pandemic. The rationale is before the pandemic; employees didn’t have much opportunity to do drugs or drink while working in an office location. With remote work, they are even more isolated from society and nobody is around to see them drinking or taking drugs.

It is common knowledge that substance abuse costs employers a lot of money every year in the form of healthcare treatments and missed work. These costs are dramatically increasing, however, due to the inevitable feelings of isolation and despair inherent in isolation that can lead to substance abuse disorders. More importantly, there are also health risks resulting from chronic substance abuse as it weakens the immune system and puts stress on the body’s cardiovascular and respiratory systems. All of these factors combined equal a rapidly escalating and expensive problem for employer-sponsored health plans. This is especially troubling as health plan expenditures are already expected to rise in 2021 due to Americans foregoing preventive care in 2020 out of fear of catching the virus in healthcare settings.

There is no question that social distancing and stay-at-home orders are a necessity at this time due to soaring infection rates. It is important, however, to keep sight of the larger picture when assessing the toll of this pandemic on Americans and our health plans that goes far beyond the illness itself. COVID-19 has dropped a grenade on our efforts to combat substance abuse disorders, and as a result, health plans can expect to carry the hefty price tag. Some strategies plan sponsors may want to consider to reduce the impact on their own workforce is to offer programs to help plan participants overcome and prevent substance abuse. These programs may include an employee assistance program, narcotics therapy management programs, and designated centers of excellence for substance use.

Empowering Plans: P100 – President Biden's First 100 Days - What to Expect

On January 22, 2021

In this episode of the Empowering Plans podcast, Ron and Brady discuss the inauguration of President Biden and what his presidency could mean for healthcare policy. With Democrats in control of government, a lot could get done in the first 100 days - on COVID-19 relief, the ACA, and rolling back Trump-era rules. Join us as we break it all down.

Click here to check out the podcast!  (Make sure you subscribe to our YouTube and iTunes Channels!)

The “No Surprises Act,” COVID Relief, and Plan Design Changes Impacting Your Business in 2021

On January 20, 2021

After a hectic political showdown, the president has signed legislation which includes comprehensive protection from surprise medical billing. This 5,000-page bill, along with a raging pandemic and a new administration, is certain to have our industry scrambling to keep up. Join The Phia Group in a new webinar format as they discuss the COVID-19 relief bill, the impact on the industry, and everything in between. From plan design changes to updates on fiduciary duties and subrogation, we have got you covered as we ring in the New Year. Following the one-hour webinar, there will be two 30-minute breakout sessions, addressing plan design changes, stop-loss issues, and legal and regulatory updates affecting claims.

Click Here to View Our Full Webinar

To obtain a copy of our webinar slides, please reach out to

To obtain a recording of our Breakout Sessions, please reach out to

The Phia Group's 1st Quarter 2021 Newsletter

On January 19, 2021

Phone: 781-535-5600 |


The Book of Russo:

When asked whether I believe the “glass is half empty, or half full,” I’m “positive” that I am an optimist. I realize that it can annoy people, but I assume it’s in a good way. Whoops; there I go again.

Looking at 2020, I can’t help but note the positives that emerged from the previous year. Though I wasn’t able to travel (and my stockpile of hotel pens and miniature bottles of shampoo have reached an all-time low), The Phia Group still saw its client base expand, and retained the talents of many new Phia Group team members. That in turn means I got to meet and spend time with so many new employees and clients (albeit over Zoom, Skype, Ring Central, and a million other programs with which I’m not yet familiar). In truth – this led to me likely spending even more time with those great people than I would have spent pre-pandemic.

Perhaps, most important, I truly got to enjoy more quality time with my four kids and incredible wife. I saw how my children have persevered through the pandemic and rolled with the punches. They did the best they could with virtual birthday parties, distanced Halloween trick or treating, and intimate Christmas celebrations.

So – in addition to positivity – I also feel pride. Pride in my family. Pride in my colleagues. Pride in our industry.

Speaking of The Phia Group, and how it too has rolled with the punches – our Friday “Staff Zoom Meetings” will never go away; even after we’ve all been vaccinated and are once again occupying the same physical space. People love them, especially when the kids (including the furry four legged ones) join the calls. You can only truly get to know your employees by examining what is in their “home office” backgrounds!

Additionally, in 2020 we moved into two new beautiful offices, we already hired almost 40 people, we added close to 3 million lives of business, we more than doubled our technological power and added two successful service lines.

This experience and our ability to keep pushing forward, showed me that The Phia Group is truly a family that can conquer anything.

Oh! I almost forgot to mention that we were named a 2020 Best Place to Work by the Boston Globe. This would be a tremendous honor any other year, but this year – it’s “next level” amazing. While other employers are cutting staff, pulling back benefits, withholding information, and always a little “too late” to respond to the needs of their team – The Phia Group approached how it deals with its own staff in the same way it approaches its clients and services. With innovation, and thinking ahead; with empathy and generosity, speed and customization.

This, then, was one of my proudest moments and verified for me that our emphasis on amazing benefits and employee satisfaction proved successful. If your staff is happy, their worst product will still be better than the competitions’ best. Your clients will feel the love, and remain beyond satisfied. Internally and externally, that is the foundation of loyalty.

I truly thank all of you – partners and Phia team members – for believing in Phia and partnering with us; it means the world to me. Be well. Be safe. Happy reading.


The Phia Group Named as a Top Place to work 2020

It is with great honor and humility that The Phia Group announces it has been named by The Boston Globe as one of the Top Places to Work in Massachusetts. In its 13th annual employee-based survey, The Boston Globe – having assessed anonymous employee feedback, and details about the company – determined that The Phia Group provides one of the most rewarding, meaningful employment experiences in the Commonwealth of Massachusetts.



Enhancements of the Quarter: Patient Defender
Phia Fit to Print
From the Blogosphere
The Phia Group’s 2021 Charity
The Stacks
Employee of the Quarter & Year
Phia News


Enhancement of the Quarter: Patient Defender Value Reports

Clients of Patient Defender will be excited to hear that we have created a brand new report for them. Clients of The Phia Group’s innovative Patient Defender service can access this quarterly snapshot of the service and the client’s activity. It contains a myriad of data, including both currently active and historical items.

While the Patient Defender service itself can be a life-saver for groups subject to claims being balance-billed, this report provides information that demonstrates the true value of the service, allowing users to continue to make informed decisions about their actions.

With over 35,000 employee lives represented in these reports, we have already received positive feedback, and we will continue to monitor clients’ usage and feedback!

To learn more about these reports or to receive a sample report, please contact our Sales Manager, Garrick Hunt, at 781-535-5644 or Likewise, to learn more about Patient Defender, Phia Unwrapped, balance-billing support services or any other services The Phia Group offers, Garrick is available to you.




Service Focus of the Quarter: Phia Unwrapped

If you’re not familiar with reference-based pricing (or “RBP”), get familiar. RBP started as an outlier in the industry, but it’s getting more and more popular, even being embraced by many networks and providers as the new norm. As helpful as RBP can be for non-contracted claims, however, it is not without the risk of balance-billing and member disruption – which is why many TPAs and groups that would otherwise embrace RBP instead shy away from it.

To anyone who sees the value in RBP but can’t tolerate the risks: The Phia Group is here to help!

The Phia Group has for decades provided services meant to supplement and enhance RBP programs; from balance billing support – which is plugged into plans that choose not to use any network, to Phia Unwrapped. Phia Unwrapped is designed to pair with plans that opt to supplement, rather than replace, a primary PPO, targeting out of network claims and allowing a health plan to shed its wrap network … and with it the meager but expensive discounts it allows providers to charge (or requires plans to pay, depending upon how you look at it).

Phia Unwrapped is anything but traditional; by replacing wrap network access and modifying non-network payment methodologies, this service enables health plans to secure payable amounts that are unbeatably low. Phia Unwrapped places no minimum threshold on claims to be repriced, and sets no limit on balance bills eligible for negotiation. Looking at those instances in particular, The Phia Group attempts to secure sign-off, ensuring providers will accept the plan’s payment as payment in full.

Out-of-network claims run through The Phia Group's Unwrapped program yield an average savings of 74% off billed charges (three times the average wrap discount). There’s very little member disruption to boot, since the plan would keep its existing PPO and use Phia Unwrapped only for non-contracted claims. Phia Unwrapped can also be a way for a plan to switch from a traditional ”mega” network, with no meaningful steerage and therefore no meaningful discounts, to a narrower network with real steerage and real discounts, recognizing that a narrow network potentially means more non-network claims – which is exactly what Phia Unwrapped is designed to not only address, but leverage.


Success Story of the Quarter: Reviewing Proposed Service Agreements

The Phia Group’s consulting department (via was recently asked by a broker to review a proposed service agreement between an employer group and a vendor. After the broker confirmed our written scope of work and flat fee quote, we got to work, and immediately noticed some odd provisions in the vendor’s draft agreement.

Chief among them was a provision that guaranteed the vendor a certain PEPM fee per contract that the vendor was able to enter into with any medical provider. Percentage-of-savings fees are the norm as payment for obtaining contracts, since payment should ideally depend on the value added, but the PEPM fee increase per contract seemed unusual. Although there is a possible world in which that provision benefitted the group, there were no provisions whatsoever to qualify the extent of this requirement. The example we provided to the group (based in New York) when discussing the language was that if the vendor calls fifty doctors in California and negotiates 1% discounts with all of them, that’s fifty contracts, and fifty separate additions to the PEPM cost of the vendor’s service – despite the fact that the CA-based doctors would be unusable by the NY-based employees, and, maybe more importantly, that those negotiated discounts would be a joke.

We provided the broker with a full explanation of our issues with this language, as well as numerous other problematic or otherwise notable things we saw within the agreement. The broker subsequently requested from the vendor a list of its contracted discounts, with which it received and was thoroughly dissatisfied. The vendor refused to change its payment model to a percent-of-savings, and the deal was terminated.


Phia Case Study: A Common Claim with Complications

A plan participant was involved in a motor vehicle accident while riding a motorcycle, and suffered severe injuries. The Plan suspended payment until the police report was received, after which the Plan excluded claims due to the report indicating that the participant had been driving recklessly, and based on witness testimony, may have been intoxicated. Worth note is that this exclusion was applied despite the accident apparently being primarily caused by another driver rather than the plan participant’s own recklessness.

The police report also noted that the participant’s injuries were too emergent for the officer on scene to be able to determine the participant’s sobriety (or lack thereof), so the police report was not conclusive on the question of intoxication. As a result, the Plan sought the medical records.

The ER physician’s report vaguely mentioned that intoxication was a possibility, but the physician did not have concrete evidence. Subsequently, the lab results came back and lacked any evidence of intoxication.

The Plan felt that the physician’s initial comment about possible intoxication was sufficient to allow the Plan Administrator to deny the claims on the basis of DUI, but the TPA sought out the opinion of The Phia Group regarding whether the claims were deniable on this basis. The TPA correctly noted that while the Plan did not need evidence that proved intoxication “beyond a reasonable doubt,” it did need “some” evidence.

After a review of the file and relevant facts, we concluded that the physician’s initial speculation absent any real basis would not likely constitute evidence upon which a decision could be based without risking arbitrariness; it does not constitute a medical opinion that the patient was in fact intoxicated, nor is it substantiated by the physical evidence provided. We therefore opined that it would likely not be reasonable for the Plan to deny the claim on the basis of intoxication, since there was no evidence of intoxication upon which the Plan Administrator could reasonably rely.

Ultimately, based on this information, the Plan paid the claims, and the participant’s attorney subsequently agreed to reimburse the Plan from any settlement ultimately received from the driver who caused the accident.


Fiduciary Burden of the Quarter: Complaint Remark Codes

Adjudicating health claims is hard work. It can get complicated, especially in light of what can sometimes be tight timeframes within which EOBs must be provided. For that reason, in the face of numerous possibilities for why certain line items might be denied, it can difficult to comply with ERISA’s regulations requiring certain information within a remark code. Compliance with those regulations, however, is still very important.

The Plan Administrator has a duty to ensure that the plan provides reasonable claim procedures, in accordance with regulations found at 29 CFR §2560.503-1. Among other things, these regulations provide that an EOB must provide both “The specific reason or reasons for the adverse determination” and “Reference to the specific plan provisions on which the determination is based.” We often encounter EOBs that identify a given line item as denied or partially denied with a justification such as “denied pursuant to the Plan Document”, and generally something so vague would tend to not satisfy these regulations. It’s also somewhat common for plans utilizing reference-based pricing methodologies to use a remark code to the effect of “denied due to reference-based pricing,” which in our opinion is similarly vague and likely noncompliant. Remark codes like these fail to identify the plan language to justify the denial, and they fail to provide the required level of specificity in rendering a denial.

The purpose of these claims regulations is to promote a “meaningful dialogue” between the plan and claimant such that the claimant may formulate an appeal of a denial if necessary; for that reason, a remark code like “denied pursuant to the Plan Document” cannot possibly suffice, since it does not provide nearly enough information to allow the claimant to have that “reasonable dialogue” and formulate any meaningful appeal of a denial.

The practical effect of issuing remark codes that are too broad or vague to meet the requirements of the claims regulations is that the plan will have failed to provide reasonable claims procedures, and the claimant will be deemed to have exhausted its administrative remedies (i.e. the claimant can jump straight to a lawsuit, since the plan has effectively denied the claimant its right to appeal), effectively nullifying the plan’s internal appeals requirements.

For those of you with children, remark codes like the examples here roughly equate to the classic “because I said so.” That can work well in the parenting context, but not so well under ERISA; luckily, parents are not required by law to provide the child proper reasoning and an opportunity to appeal the decision – but health plans are.

If your remark codes include “denied because the plan said so”, please don’t hesitate to have them reviewed. The Phia Group is here to help!



• On December 16, 2020, The Phia Group presented, “A Transparent 2021 - Further Analysis of the Year to Come,” where we discussed the rules that will impact 2021, including the recently released transparent pricing rules.

• On November 16, 2020, The Phia Group presented, “Desperately Looking Forward to 2021,” where we discussed hot topics, forecasting what we expect to see in 2021, and giving you a head start as you – like we – plan, and look forward, to 2021.

• On October 19, 2020, The Phia Group presented, “New Opportunities to Save, Create Revenue & Avoid Scary Practices,” where we discussed some of the industry’s scariest blunders and gruesome practices.

Be sure to check out all of our past webinars!



Empowering Plans

• On December 23, 2020, The Phia Group presented, “Balance Billing During COVID-19 and Beyond,” where our hosts, Brady Bizarro and Mitch Hilbert, discuss how balance billing has been on an uptick during COVID, and how patients can possibly prevent this from occurring.

• On November 30, 2020, The Phia Group presented, “COVID-19 Vaccine Candidates – What Health Plans Need to Know,” where our hosts, Brady Bizarro Andrew Silverio, discuss current COVID-19 vaccine candidates and everything health plans and employers need to know about them.

• On November 13, 2020, The Phia Group presented, “Election Aftermath – Where Things Stand,” where our hosts, Ron Peck, Brady Bizarro, and Nick Bonds reunite to discuss their developing thoughts on the presidential election results.

• On November 9, 2020, The Phia Group presented, “2020 Election Results (So Far) – Our Takeaways,” where our hosts, Ron Peck and Brady Bizarro, are joined by Nick Bonds, to discuss the 2020 election results.

• On October 26, 2020, The Phia Group presented, “The Final Debate & Election Predictions,” where our hosts, Brady Bizarro and Nick Bonds, break down the final presidential debate of the campaign season, focusing in on the candidates’ healthcare plans.

• On October 19, 2020, The Phia Group presented, “Behind the Scenes – Town Halls, Nominees & Medicare-for-All,” where our hosts, Ron Peck and Brady Bizarro take you behind the scenes, avoiding the bright lights of presidential town halls and Supreme Court confirmation hearings.

• On October 13, 2020, The Phia Group presented, “Healthcare on Stage & COVID-19 in the White House,” where our hosts, Ron Peck and Brady Bizarro guide you through a chaotic week for healthcare news, including the first presidential debate, COVID-19 infecting the President and much of the West Wing, and more.

Be sure to check out all of our latest podcasts!


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Phia Fit to Print:

• BenefitsPro – – December 17, 2020

• BenefitsPro – Hispanic and Latino health and the Affordable Care Act – December 07, 2020

• Self-Insurers Publishing Corp. – Best Practices For Updating The Employee Handbook In A Pandemic – December 3, 2020

• BenefitsPro – Remembering why we do it: Employer-sponsored health plans – November 20, 2020

• BenefitsPro – ACA in court: Reactions from around the industry – November 11, 2020

• Self-Insurers Publishing Corp. – Cobra Coverage and COVID-19 – November 5, 2020

• Self-Insurers Publishing Corp. – Planning Ahead: COVID-19 And Other Considerations For 2021 Health Plan Renewals – October 2, 2020

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From the Blogoshpere:

Offer More for More! If and when private health benefits cannot compete with a public option on price, they will need to re-invent the industry.

Updating the Employee Handbook in Unprecedented Times. Have you made your updates yet?

There is no Such Thing as a 1099 Employee. A 1099 employee isn’t an employee of yours at all!

FFCRA Leave Entitlements Set to Expire December 31, 2020. How much do you know about the Families First Coronavirus Response Act?

I Hate Surprises! Surprise billing expected to come to a halt.

To stay up to date on other industry news, please visit our blog.

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The Stacks:

Best Practices For Updating The Employee Handbook In A Pandemic

By: Philip Qualo, J.D. – December 2020 – Self-Insurers Publishing Corp.

For many employers, the start of the holiday season usually brings forth the time of year to brush the dust off of the employee handbook and determine what changes are desired, and required, for the upcoming year. Although employers have generally been quick to adopt and enforce policies addressing COVID-19, the rapidly changing guidance and onslaught of personal and professional restrictions necessitate swift revisions as best practices and requirements continue to change from day to day.

In general, employers should review and revise their employee handbooks at least annually to account for changes in local, state, and federal laws and workplace safety requirements. After an unprecedented year that unleashed a pandemic on the world, however, employers and their compliance teams are scanning their employee handbooks, scratching their heads, and wondering where to begin. In finalizing our own employee handbook for a hopefully better 2021, I thought it would be helpful to share some lessons I learned on updating an employee handbook in challenging times..

Click here to read the rest of this article

Cobra Coverage and COVID-19

By: Kevin Brady, Esq. – November 2020 – Self-Insurers Publishing Corp.

It is an unfortunate, but well-known, fact that the COVID-19 pandemic has had a significant impact on the U.S. economy. With the unemployment rate reaching a high of 14.7% in April, it is no surprise that many hard-working Americans lost their jobs. Given that many Americans rely on those jobs for their health plan coverage, the loss of income, combined with the loss of health coverage, has been and could continue to be catastrophic for many.

Click here to read the rest of this article

Planning Ahead: COVID-19 And Other Considerations For 2021 Health Plan Renewals

By: Jennifer M. McCormick, Esq – October 2020 – Self-Insurers Publishing Corp.

As summer fades away and the leaves start to fall, many of us must start planning for 2021. The expectations and goals we set in January of 2020 have likely required review and adaptation. As a result of COVID-19, employers encountered unprecedented hurdles. In addition to the economic costs facing employers due to this pandemic, employers need action plans to address the logistical and morale challenges of COVID-19. While financial considerations are typically on the list of perpetual concerns, employers must now ensure they have action plans for employees needing to balance work and childcare, workplace safety, and the continually evolving regulations regarding COVID-19. Thankfully, with 2021 around the corner, employers have an amazing opportunity to boost employee morale and mitigate costs with thoughtful plan design. Employers can (and should) use the upcoming renewal opportunity to let their health benefits shine and invite excitement for employees about their 2021 health benefits.

Click here to read the rest of this article

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The Phia Group's 2021 Charity

At The Phia Group, we value our community and everyone in it. As we grow and shape our company, we hope to do the same for the people around us.

The Phia Group's 2021 charity is the Boys & Girls Club of Metro South.

The mission of The Boys & Girls Club is to nurture strong minds, healthy bodies, and community spirit through youth-driven quality programming in a safe and fun environment.

The Boys & Girls Club of Metro South (BGCMS) was founded in 1990 to create a positive place for the youth of Brockton, Massachusetts. It immediately met a need in the community; in the first year alone, 500 youths, ages 8-18, signed up as club members. In the 25 years since, the club has expanded its scope exponentially by offering a mix of Boys & Girls Clubs of America (BGCA) nationally developed programs and activities unique to this club.

Since their founding, more than 20,000 youths have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through the academic year and summertime programming.

Thanksgiving Dinner Delivery

Thanksgiving dinner delivery to The Boys & Girls Club of Metro South was a little different this year. The Phia Family was out and about the week of Thanksgiving, delivering dinners to the The Boys and Girls Club of Metro South, so the families could pick up their meals when they picked up their children. Additionally, our Phia Family in Idaho and Louisville were out and about spreading the same cheer to five families in the Boise area and five families in the Louisville area. In total, we delivered 32 meals this year! Check out the great picture we were able to get from that special day! We hope everyone had a wonderful Thanksgiving!

Angel Tree

Each year employees of The Phia Group pick nametags from the Angel Tree that sits in our main lobby. On those tags are names, ages and the wish lists of children from The Salvation Army. This year we had over 130 nametags! The Phia family loves to give back to the community; our greatest joy is providing these children with all of their holiday wishes.

Christmas Came Early

The Phia Group had the pleasure of bringing Christmas joy to the Boys & Girls Club of Metro South. Adam Russo and his helpers virtually passed out hundreds of gifts to over 130 children. We hope these children enjoy their new toys as much as they enjoyed spending time with virtual Santa!

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Get to Know Our Employee of the Quarter:

Kaitlyn Lucier

To be designated as an Employee of the Quarter is an achievement that is reserved for Phia employees who truly go above and beyond their day to day responsibilities. This person must not only transcend their established job expectations, but also demonstrate with fervency a dedication to The Phia Group and its employees that is so unparalleled that it cannot go without recognition.

The Phia Explore team has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Kaitlyn Lucier, The Phia Group’s Q4 Employee of the Quarter!

Kaitlyn has been able to handle any challenge that has been thrown at her with ease. She has done a phenomenal job training the new hires in CSD. She is always available to help others in need and being able to rapidly answer a question along with giving informative answers, so others are not lost. She is a valuable asset to CSD and is an outstanding hard worker.

Congratulations Kaitlyn, and thank you for your many current and future contributions.

Get to Know Our Employees of the Year: Philip Qualo

To be designated as an Employee of the Year is an achievement that is reserved for Phia employees who truly go above and beyond their day to day responsibilities. This person must not only transcend their established job expectations, but also demonstrate with fervency a dedication to The Phia Group and its employees that is so unparalleled that it cannot go without recognition.

The Phia Explore team has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Philip Qualo, The Phia Group’s 2020 Employee of the Year!

Philip has done a phenomenal job with the Diversity Inclusion Committee- conducting the meetings, putting together all of the plans, reviewing with the Executive team & providing staff with the information. He has put in a lot of extra hours working late many nights, to ensure that everything was completed along with his PGC tasks. He definitely deserves recognition for all of his hard work!


Job Opportunities:

• Chief Financial Officer

• Customer Service Representative

• Senior Vice President, Sales

• Claim Analyst

See the latest job opportunities, here:



• Liz Pereira has been promoted from Case Investigator to Case Analyst


New Hires

• Nathan Letourneau was hired as a Claim and Case Support Analyst

• Alexander Araujo was hired as a Customer Care Representative

• Brittany Farr was hired as a Customer Care Representative

• Thalea Gauthier was hired as a Customer Care Representative

• Alexia Holloway was hired as a Customer Care Representative

• Catherine Villanueva was hired as a Customer Care Representative

• Lisa Hill was hired as a Sr. Subrogation Attorney

• Anthony Jean was hired as an Accounting Administrator I

• Thomas Cole was hired as a Claim Analyst

• Skyla Mrosk was hired as a Claim Analyst

• Andrew Mead was hired as an IT Intern

• Alexandre Houle was hired as a Provider Relations Clinical Claims Specialist

• Aastha Vats was hired as an ETL Specialist

• Julie Padden was hired as an Executive Assistant

• Sheena Roberts was hired as a Sr. Administrative Assistant

• Kristen Melanson was hired as a Claim and Case Support Analyst

• Hillary Burmester was hired as a Claim Recovery Specialist

• Kaitlyn MacDonald was hired as a Health Benefit Plan Consultant I



Phia News:

Candy Corn Contest

We set up our annual Candy Corn Contest in the front lobby of our Canton office and asked everyone to guess how many pieces of candy corn were in the jar! For those working from home, we sent out pictures of the candy jar with measurements, and had over 100 submissions. The winner of this contest was Lisa Decristoforo, and the total count was 811. Lisa guessed that there were 803 pieces of candy corn. It’s hard to believe that all of those pieces of candy fit into that small jar!

Pumpkin Carving Contest

In October, The Phia Group held its first Pumpkin Carving contest. We had over 20 submissions and it was a tough decision to make, but the Phia family had to pick one. Congratulations to the winner, Catherine Baskerville. We are all so impressed with your creativity and carving skills. We look forward to our next Pumpkin Carving contest!


Mask Contest

With everyone being asked to work from home, we wanted to make sure we kept all employees engaged and entertained. We put our thinking caps on and asked everyone to submit photos of their most creative masks, and we had the Phia family vote for their favorite mask during a virtual staff meeting. We are proud to announce that Regina Cattel was the winner of this contest, with her super fun tiger mask!

The Phia Group Reaffirms Commitment to Diversity & Inclusion

At The Phia Group, our commitment to fostering, cultivating, and preserving a culture of diversity and inclusion has not wavered from the moment we opened our doors 20 years ago. We realized early on that our human capital is our most valuable asset, and fundamental to our success. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent that our employees invest in their work, represents a significant part of not only our culture, but also our company’s reputation and achievements.

We embrace and encourage our employees’ differences, including but not limited to age, color, ethnicity, family or marital status, gender identity or expression, national origin, physical and mental ability or challenges, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique.

The Phia Group’s diversity initiatives are applicable to all of our practices and policies, including recruitment and selection, compensation and benefits, professional development and training, promotions, social and recreational programs, and the ongoing development of a work environment built on the premise of diversity equality.

We recognize that the success of our company is a direct reflection of each team member’s drive, creativity, diversity, and willingness to exercise initiative. With this in mind, we always seek to attract and develop candidates who share our passion for the healthcare industry and our commitment to diversity and inclusion.

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The Stacks – 1st Quarter 2021

On January 19, 2021

Best Practices for Updating the Employee Handbook in a Pandemic

By Philip Qualo, J.D.

For many employers, the start of the holiday season usually brings forth the time of year to brush the dust off of the employee handbook and determine what changes are desired, and required, for the upcoming year. Although employers have generally been quick to adopt and enforce policies addressing COVID-19, the rapidly changing guidance and onslaught of personal and professional restrictions necessitate swift revisions as best practices and requirements continue to change from day to day.

In general, employers should review and revise their employee handbooks at least annually to account for changes in local, state, and federal laws and workplace safety requirements. After an unprecedented year that unleashed a pandemic on the world, however, employers and their compliance teams are scanning their employee handbooks, scratching their heads, and wondering where to begin. In finalizing our own employee handbook for a hopefully better 2021, I thought it would be helpful to share some lessons I learned on updating an employee handbook in challenging times


Avoid Non-Static COVID-19 Provisions

As updating an employee handbook multiple times within a fiscal year can be an administratively burdensome task, a best practice is to ensure all policies included or updated in the handbook are relevant, as well as static, for the duration of the applicable fiscal year. This has been simple in most years, however, in response to the COVID-19 pandemic, the federal government passed a series of comprehensive laws, with rapidly approaching expiration dates, aimed at protecting American workers by regulating group health plans and imposing new leave paid entitlements on covered employers, such as the Families First Coronavirus Response Act (FFCRA). In addition to the FFCRA, state and local laws guidance continue to be updated at an unpredictable frequency that often necessitates a quick and temporary change to workplace rules in order to comply safety requirements. For employers that sponsor self-funded plans, it is also important to keep in mind that for any newly enacted leave entitlements that continue coverage, the applicable Plan Document should be amended to reflect this continuation of coverage and communicated to the stop-loss carrier so ensure no gaps in coverage.

In order to avoid the challenge of updating and re-distributing an employee handbook multiple times within a single year, it may be helpful to limit specific references to COVID-19. For example, I chose to use terms such as “Public Health Emergency” and “Pandemic” where possible. If COVID-19 has taught us anything, it is that life is unpredictable. Now that we have collectively experienced and continue to endure this pandemic, we now know that public health emergencies and pandemics can happen to us… yes, even to us. As such, including language in an employee handbook referencing an employer’s responsibility to contain a public health emergency or pandemic would apply to COVID-19 and other critical health crisis that poses a threat to workplace safety.

For policies with an approaching expiration date, or that are likely to change frequently based on changing guidance, it may be helpful to generally reference them in the employee handbook and detail them in a separate platform or notice that can be updated and re-distributed with ease. For example, we use an intranet platform to house our most up to date COVID-19 policies. This allows for quick enhancements of relevant policies and immediate notification to employees. Although any platform accessible to all employees may be appropriate, an employer should take the additional step of distributing, announcing, or where applicable, requiring sign-off for each and every change to document compliance with notification requirements.

For example, I expanded the handbook to include language that referenced the “Direct Threat Exception” to Americans with Disabilities Act (ADA) limitations to explain my employer’s ability to temperature check and inquire about health status. In this provision, I chose to leave out the term “COVID-19” because the direct threat exception would likely apply to any other declared public health emergency that may arise. The temperature check policies, on the other hand, may not be applicable in a different type of pandemic.


So You’re Saying Not to Include Any COVID-19 Language?

Employee handbooks are more than just a collection of policies for most employers, they are a snapshot of that year, a yearbook of sorts. Although some memories are better left … not remembered…employers may one day want to reminisce on challenging year. On the other hand, as COVID-19 is likely not going anywhere as soon as we hoped for, it may be a good idea to include some static references to COVID-19. So I would not recommend pretending COVID-19 does not exist when it comes to the employee handbook.

For example, in our own employee handbook, I developed a paragraph that describes COVID-19, briefly, and details our companies commitment to follow all state, local, federal and Centers for Disease Control (CDC) guidance. As this guidance is subject to change, and has from day to day since the start, I did not include specific references to our face mask policy. Is this important? – absolutely. Is the handbook, however, the best place to house a policy that may be outdated by the time it is distributed? – probably not.

In summary, there are rarely two employee handbooks that are entirely alike in this world. There are not many rules surrounding what needs to go in one, or what needs to go out. For the most part, employee handbooks are not even legally required. It is, however, a strongly recommended best practice for an employer to maintain one and ensure appropriate policies as determined by their specific compliance needs. Therefore, employers are free to include any and every COVID-19 policy and language they desire. In minimizing the non-static language, however, employers can demonstrate compliance with all applicable rules while sparing the administrative burden involved in reconciling existing handbook provisions with the day to day changes to mandated workplace safety guidance.


COBRA Coverage and COVID-19

By: Kevin Brady, Esq.

It is an unfortunate, but well-known, fact that the COVID-19 pandemic has had a significant impact on the U.S. economy. With the unemployment rate reaching a high of 14.7% in April, it is no surprise that many hard-working Americans lost their jobs. Given that many Americans rely on those jobs for their health plan coverage, the loss of income, combined with the loss of health coverage, has been and could continue to be catastrophic for many.

On the (somewhat) bright side of things, those who lose their jobs are not always left optionless, as most individuals who lose their employer-sponsored health coverage will generally be eligible for continued coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA). COBRA provides workers and their families the option to continue group health plan coverage (for a limited period of time) under certain circumstances which cause a loss in group health plan coverage. Further, the employee, rather than a combination of the employee and employer, bears the full cost of coverage when enrolled in COBRA. From the individual’s perspective, the cost alone, especially in the midst of the pandemic and the resulting economic uncertainty makes COBRA a tough sell for former employees, especially those who have other coverage options available. 

From an employer’s perspective, administering COBRA coverage effectively- and most importantly, correctly is a difficult task. Employers have strict obligations under COBRA. They must provide adequate notice of a “qualifying event” to ensure that their former employees and their dependents are offered coverage. What makes things even more complicated, is that employers who self-fund their health plan coverage actually serve as both the employer under COBRA (subject to certain obligations), and the plan administrator (subject to a distinct set of obligations) as well. This nuance only adds to the multitude of obligations and the resulting confusion that an employer must contend with. As is this case with a great many other things, those obligations have become even more difficult to understand and satisfy in the wake of the COVID-19 pandemic.

As mentioned above, COBRA provides the opportunity to continue group health plan coverage if certain criteria are satisfied. Private employers who employ 20 or more workers, are generally subject to COBRA if they offer if a group health plan. COBRA must be made available for the “covered employees” of the employer, and their dependents, if they experience what is known as a qualifying event.

The COBRA regulations provide that a qualifying event may be any of the following occurrences:

  • Voluntary or involuntary termination of the covered employee’s employment other than by reason of gross misconduct;
  • Reduction of hours of the covered employee’s employment; Divorce or legal separation of the covered employee from the employee’s spouse;
  • Death of the covered employee;
  • A dependent child ceases to be a dependent under the generally applicable requirements of the plan;
  • A covered employee becomes entitled to benefits under Medicare; and
  • An employer’s bankruptcy, but only with respect to health coverage for retirees and their families.

While the situations and occurrences which are considered qualifying events may be widely known, what is often overlooked is that the qualifying event must also cause a loss of coverage under the plan. Therefore, if plan coverage does not terminate as a result of the qualifying event, then the individual does not become eligible for an offer of COBRA coverage from the employer.

One instance where this principle is becoming more and more relevant, relates to employees who are furloughed or laid off. Given the economic uncertainty surrounding the COVID-19 pandemic, an unprecedented number of employers have turned to workforce reduction measures such as furloughs and/or layoffs to ensure business continuity.

On the surface, a layoff or furlough may appear to be a qualifying event which triggers an offer of COBRA coverage to the affected individuals. While it may very well be a qualifying event, it very much depends on the facts and circumstances of the given case. For example, many health plans choose to continue plan coverage in the event of a leave of absence, or even a temporary layoff or furlough. This approach is actually quite common. Although typically outlined within an employer handbook or policy manual, effectively outlining the instances in which plan coverage will be continued within the plan document can mitigate the risk of a potential dispute with the stop loss carrier.

In essence, the employer must review the plan document to determine whether it properly allows for continued coverage while an individual is furloughed or laid off. If the plan outlines said continuation, then the individual has not experienced a qualifying event and the employer’s obligation to offer COBRA coverage has not been triggered.

Of course, the individual may become eligible for COBRA continuation coverage if they do not ultimately return to work or if their continued plan coverage expires during the maximum coverage period of COBRA. If that is the case, the employer’s obligations would then be triggered, and the employer would be required to offer coverage in accordance with COBRA’s requirements. Fortunately for employers, there is some flexibility in the timeframe in which the offer of coverage must be made.

The Internal Revenue Service (IRS) along with the Department of Labor (DOL) issued final rules which extend a number of important benefit plan timeframes. As it relates to COBRA, plan administrators do have some flexibility as it relates to their obligation to notify the individual of COBRA coverage.

On the other hand, the rules also extend the period in which individuals can elect COBRA coverage, as well as the period of time in which an individual must pay their premiums. These extensions are sure to make administering COBRA eligibility another difficult task for the foreseeable future.

Any way you look at it, COBRA continuation coverage generally imposes a number of obligations on employers, plan administrators, and those who would enroll in COBRA coverage as well. Determining what those obligations are, how to apply them, and who may be eligible for them is no small feat even without the regulatory and economic uncertainty of the COVID-19 pandemic factored in. In order to avoid potential compliance issues, as well as mitigating the risk of reimbursement issues down the road, plan administrators should pay special attention to these COVID-19 related issues. Review the plan document to determine whether individuals furloughed and laid off are eligible to continue coverage under the plan, or alternatively under COBRA. Until the economic consequences of the pandemic dissipate, the complications and nuances associated with COBRA continuation coverage are sure to persist along with it.


Planning Ahead:  COVID-19 and Other Considerations for 2021 Health Plan Renewals

By: Jennifer M. McCormick, Esq.

As summer fades away and the leaves start to fall, many of us must start planning for 2021.  The expectations and goals we set in January of 2020 have likely required review and adaptation. As a result of COVID-19, employers encountered unprecedented hurdles. In addition to the economic costs facing employers due to this pandemic, employers need action plans to address the logistical and morale challenges of COVID-19.  While financial considerations are typically on the list of perpetual concerns, employers must now ensure they have action plans for employees needing to balance work and childcare, workplace safety, and the continually evolving regulations regarding COVID-19. Thankfully, with 2021 around the corner, employers have an amazing opportunity to boost employee morale and mitigate costs with thoughtful plan design.  Employers can (and should) use the upcoming renewal opportunity to let their health benefits shine and invite excitement for employees about their 2021 health benefits.

In planning for the upcoming benefit year, design modifications can generally be categorized into two categories: (1) regulatory changes; and (2) recommended changes.  Lingering uncertainty and future unknowns make both categories of design modifications equally important. 

Regulatory Changes 

While the list of regulatory items that must be changed may seem overwhelming, some of the changes may ultimately be welcomed by employers or employees.

For example, benefit updates for COVID-19 related services and modified rules regarding continuation coverage were likely well received by employees.  In addition to the benefits and continuation coverage provided for by The Coronavirus Aid, Relief, and Economic Security (CARES) Act and Families First Coronavirus Response Act (FFCRA), the Department of Labor (DOL) and Internal Revenue Service (IRS) issued regulations offering additional relief for participants.  Specifically, the regulations allow additional time for participants to take actions such as electing (or paying premiums for) continuation coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) and filing an appeal of an adverse benefit determination or requesting an external review.  Relief will apply retroactively from March 30, 2020 until 60 days after the end of the national emergency.  

Relevant regulations did specify that penalties would not be imposed if plans were administered in compliance with the extended timeframes, even if contrary to the specific terms of the underlying plan document materials.  Ambiguity surrounding deadlines, however, leads to unnecessary confusion for individuals enrolled in the health plan.   To eliminate this concern, plan materials should be updated and include details regarding the extended timeframes.  Disclosure and inclusion of such information will also function to mitigate potential gaps that may arise between plan materials and stop loss policies.

In addition to the tolling of certain timeframes, employees may also welcome the updated Summary of Benefits and Coverage (SBC) templates for 2021, also requiring revision and implementation.  The SBC is intended to provide uniform and consistent information regarding available plan benefits.  While modifications to the 2021 SBC template are not extensive, they do include updates to the coverage examples and the removal of information pertaining to the individual mandate.

Regarding employers, however, certain review and revision may be needed pertaining to plan out-of-pocket maximums.  Specifically, on an annual basis the Department of Health and Human Services (HHS) determines the adjustments for the Affordable Care Act (ACA) in-network out-of-pocket maximums for non-grandfathered plans.  In addition, the IRS sets the standard for high-deductible health plans. These iterations are expected annually and should be reviewed and applied in alignment with employer intentions.   

The interesting twist on out-of-pocket maximums that employers may be contemplating (or have already addressed) is the policy change on drug manufacturer assistance calculations for non-grandfathered plans.  An employer plan is not required, but may, count toward the out-of-pocket maximum drug manufacturer assistance, coupons, or other cost reductions. This is true even if the assistance in question is available on a drug without a generic equivalent.  This update may create an opportunity for cost-savings as plan out-of-pocket maximums are reviewed; however, employers should examine whether any other state laws require consideration.

Another regulatory update seemingly well received by both employers and employees is the relief contained within IRS Notice 2020-29. This relief, while temporary until December 31, 2020, relaxed the rules for mid-year election changes offered under Section 125 cafeteria plans.  Pursuant to this guidance, employees (if the employer decides to offer this optional election, and documents the offering accordingly by way of amendment) could revoke an existing health plan election if certain factors were met.  For employees, this opportunity might be the flexibility needed to reduce or modify coverage as finances face greater and continued uncertainty. For employers, this offering might foster goodwill among employees anxious to make plan modifications as a result of less certain financial times.

Recommended Changes

Since the list of 2021 required regulatory changes may not be as extensive as in prior years, employers may want to consider modifying benefits to account for the evolving needs of their workforce.

Health benefits remain valuable during the pandemic.  Employers who consider implementation of 2021 updates that coalesce with employee needs and wants will only enhance goodwill.  For example, as part of end of year discussions, an employer should consider polling employees to identify benefits they consider absent or not robust enough.  It is possible the stress of a pandemic means more employees are desirous of holistic health options such as acupuncture or nutritional counseling. Identifying benefit enhancements that most effectively promote employee wellness and have the greatest potential to improve employee happiness and productivity is of paramount importance.

Incentivization of certain behaviors under the plan is one avenue employers might explore. It is evident that certain benefits were more heavily accessed than others during this past year. Heeding feedback regarding the needs of employees during this trying time poses an opportunity to incentivize utilization that benefits both the employer and the employee.  For example, many appointments with primary care physicians were postponed due to limited availability, discouraged, or canceled, and employees did not have access to care as they would under traditional circumstances.  An alternative, offering focused medical care for employees while promoting financial predictability (i.e. potential cost savings) for the health plan, is direct primary care.  As permissible per other plan agreements, the addition of a direct primary care benefit should be considered.  This additional benefit would create direct access for employees to connect with a physician and receive the customized, tailored care needed during these challenging times, simultaneously easing ‘access to care’ anxiety during a pandemic.

In addition to direct primary care, technology offers availability of greater connections to care via telehealth and telemedicine.  Telehealth services have been valuable as this option reduces the risk of exposure or transmission of COVID-19, while still providing the necessary virtual care. For example, telehealth has been useful for screening and accessing whether potential COVID-19 patients need to be seen in a hospital setting or care can be managed from home. Over the course of the pandemic, eased restrictions encouraged providers and patients to utilize telehealth services. Employers should revisit their benefit designs to determine whether and to what extent telehealth services are currently available to participants, and whether further modifications are necessary. By way of illustration, employers should review whether telehealth is a current standalone benefit or offered only through a specific vendor.  The availability of telehealth services should be clearly addressed and denoted within the plan materials to eliminate coverage related confusion under the health plan.

At the outset of COVID-19, many individuals feared limited supplies, supply chain disruptions, or quarantine status restrictions would impact the ability to access necessary medications.  It is very common, and for myriad reasons, however, for health plans to impose prescription refill restrictions. Limited access has the potential of leaving employees in a situation where they are without life-saving medications.  With the continued unknowns of the pandemic, employers may consider relaxing refill protocols, ensuring access to critical prescriptions.  As permissible by the relevant plan agreements, employers could allow a 90-day supply instead of a 30-day supply in certain circumstances, investigate the availability of home delivery for prescription drugs, or evaluate mail-order pharmacy services. Prescription drug design flexibility not only has the potential to safely improve employee access to medication, but also create alternative prescription options that save money for the health plan.

Employees continue to face uncertainty as it relates to COVID-19, and this likely creates additional worry, stress and anxiety.  Many employees are parents and caregivers and entering another school year with distance and remote learning, presents challenges for everyone. Pandemic related hardships and disruptions have had a negative impact on mental and behavioral health. As a result, taking care of mental and behavioral health needs is essential.  Enhanced benefits should be prioritized as employees need access to resources to address any mental and behavioral health concerns they face during these challenging times.  Employers should examine the current health plan to determine whether revised benefits are necessary to offer increased support.

Next Steps

With the end of the year rapidly approaching, employers must soon make critical decisions about employee benefit offerings.  Once solidified, a review and update of the current health plan materials is necessary to ensure these benefit modifications are described accurately.

In addition to updating plan document materials, employers must review and revise other corresponding agreements and policies to ensure seamless and gap free benefit administration. For example, the updated plan document materials should be compared against the stop loss policies, network agreements, and vendor agreements to identify (and eliminate) coverage gaps.

It may seem like an overwhelming task, but by proactively revising employee benefit materials to address these items employers can generate employee enthusiasm for the upcoming 2021 benefit year. 

Resolution to Become an Educated Consumer of Healthcare

On January 14, 2021

By: Bryan M. Dunton

Many people use the beginning of a new year as a reason to better themselves physically and emotionally, often setting goals for themselves in the process. After the pandemic of 2020 altering everyone’s plans, there’s sure to be a renewed dedication to personal goals this year. When deciding what types of personal goals to accomplish, it is important to ask yourself why these specific things are so important to you. Why do you want this change? How will it help you emotionally or physically? What’s stopping you from achieving it and how can you move beyond those obstacles?

Year after year, one of the most prominent goals is to be healthier. Two Years Ago, for example, 28% of people resolved to lose weight, 54% wanted to eat healthier, and 59% wanted to exercise more. Certainly, these are great goals to set for yourself, especially in the wake of 2020, when many people were locked down in their homes for extended periods of time and many of our favorite activities were closed. Some employers have taken a very proactive approach in encouraging their employees to be active despite the conditions created by the pandemic. Over the summer and early fall of 2020, Phia Group employees participated in a three-month long virtual race from our Canton, MA headquarters to Progressive Field (CEO Adam Russo is a huge Cleveland sports fan) as a way to get teammates moving and have some cross-department fun while many worked remotely.

Employers can make a positive difference in the health and wellness of their employees by providing the tools to become educated consumers of healthcare. Here at the Phia Group, we encourage employees to be healthy and provide them with the information and tools to do so. This includes both mental wellness as well as physical health through services such as direct primary care. We believe in educating employees about being proactive in self-care and how it factors into cost-containment for their own health expenses and that of the health plan itself. Phia often holds informational meetings for employees to discuss existing and new services being offered to maximize our opportunities for quality care at an affordable price. We have found that providing that targeted education and promoting the atmosphere of being consumers of healthcare, has led to significant cost savings for the plan.

While resolving to lose weight, eat healthier, and exercise more are important goals in the effort to having a healthy new year, we should also resolve to be educated about out health and healthcare and in so doing become consumers in the healthcare industry.

As always, we are happy to discuss these and the multiple other programs we use to contain costs with any employer who seeks to introduce similar methods to their health plans.

With an eye towards the new year, there is a strong desire for most of us that it will be different than how 2020 turned out. We hope that you take time to set some achievable goals for your own personal health and self-care this year. Here’s to 2021!

Empowering Plans: P99 – Balance Bills, Medical Tourism, and Vaccines – Oh My!

On January 13, 2021

In this episode of the Empowering Plans Podcast, Ron Peck is joined by Corey Crigger, an attorney in the Provider Relations Department. Ron and Corey discuss balance billing in the COVID world, medical tourism, and vaccine passports. What can we expect in the not so distant future? No one has a crystal ball, but Ron and Corey offer an insight on the implications of a tiered vaccine rollout that may not be uniform and business requiring proof of passport. Also, what parts of the pandemic does Corey see as a positive? Tune in to find out!

Click here to check out the podcast!  (Make sure you subscribe to our YouTube and iTunes Channels!)

Addition By Division

On January 11, 2021

By: Jon Jablon, Esq.

Business is complicated, and a recent consulting inquiry from a client recently reminded me just how complicated it can be, especially when health plans are involved. In the course of a given health plan’s lifespan, there is the potential for numerous different things to happen, and one such possibility is called a “spinoff”, which is the term used when one benefit plan is split into more than one benefit plan.

When a health plan “spins off” into two health plans, neither plan is considered an “original” or “existing” plan, but each plan effectively becomes a brand new plan. Effecting a spinoff can be beneficial if an employer wants to treat classes of employees differently, which often becomes relevant as the employer expands its business, enters new sectors or new industries, widens its employee base, or otherwise changes its needs or mindset. If one section of a company grows much faster than another, for instance, it could be a good idea to separate the two into different companies, and different corporate structures could be used for different purposes and to achieve different results. A health plan being “spun off” into two (or more) plans can help insulate the assets of one plan from the other, which can be useful for stop-loss purposes (for instance to have different plans underwritten differently) or for funding purposes.

Since health plans have assets, in the form of money paid in by employees and the plan sponsor and paid out in benefits, there must be a way to allocate those plan assets accordingly. It may be intuitive to think “well, if individuals paid into Plan A while they were members of Plan A, then that money belongs to Plan A, and the new Plan B will start fresh”, that is not the approach the regulators have taken. If some employees moved from Plan A to the brand new Plan B but assets did not get transferred from the old plan to the new plan, then the new plan would have no assets, and could not pay claims!

To account for this, the applicable regulations tend to require the plans to allocate Plan A’s assets to Plan B based proportionately upon the plan assets attributable to their membership. If you think that sounds complicated, don’t forget that Plan A’s pool of assets is far from static; Plan A constantly gains and spends money, and attributing every dollar to an individual can be extremely complex (and it can even change day-to-day). In classic DOL and IRS fashion, plans are given the instruction to make “reasonable actuarial assumptions” to calculate these things – which does not really help explain much at all. It’s the same as when the regulators tell health plans to use a “good faith, reasonable interpretation” of the guidance they publish; in a way, it allows plans to have a safety net as long as they exercised good faith, but I for one would much rather have some actual guidance. Maybe even a calculator with specific fields, like for Minimum Value calculations!

Employers sometimes view health plans as a handicap to achieving more efficient corporate structures, or they worry that their health plans will suffer as a result of certain factors that are apparently beyond their control. This “spinoff” is one example of a tool that is within an employer’s control; in fact, employers are given a very wide latitude to structure their health plan (or plans) as they see fit, and with a little creativity and a lot of math, that latitude can be used to an employer’s advantage.