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4th Quarter 2015 Newsletter – Phia News
New Faces at Phia

• Joseph Huddleston – Claims Support

• Alex Theberge – Office Management Assistant

Movers & Shakers!!!!

• Christopher M. Aguiar – Now licensed to practice law

• Sean N. Donnelly – Now licensed to practice law

• Jen Marsh – Customer Service Manager

• Christine Sands – Team Leader, Claims & Case Support

• Ashley Schramm – Advanced to CRS IV and now handles worker’s compensation cases

• Jason Kemp – Transition to CRS IV handling Bodily Injury Cases

• Danielle Bates – Transitioned from Assistant to Case Investigator

• Amanda Grogan – Advanced to Claims Recovery Specialist II

• Nick Murphy – Advanced to Manager, Claim Analysis

• Mike Mears – Advanced to Senior Claims Analyst

• Jason Thibodeaux – Advanced to Senior Claims Analyst

• Todd Geiger – Joined Claims Analysis as a Senior Claim Auditor

• Lisa Tamulynas – Moved from Recovery Department to Phia Group Consulting

• Tumi Gugushe – Transition to Legal Assistant

Phia Gives Back in 2014

JFS of Metrowest – Christmas came early for this bunch of great kids at JFS, to whom The Phia Group dedicated a year of service and support!!!

The 2015 Charity is …Susan J. Komen of Massachusettes – The Komen Promise

The Komen Promise– To save lives and end breast cancer forever by empowering people, ensuring quality care, and energizing science to find the cures.

For more information visit www.komenmass.org/site/c.6oIEJTPxGcISF/b.7453505/k.BDD2/Home.htm

Additions to the Phamily

Danasha Reddick’s New Baby … Dariyah
Elizabeth Welcome’s New Baby … Ryliegh

"In Reference To The FAQ"... The DOL FAQ Dissected - Part Deux!

On October 10, 2014, the Department of Labor, in conjunction with other regulatory agencies, released its “FAQ XXI.” In response, during its October Webinar, The Phia Group tore through the FAQ, sharing its concerns regarding the FAQ’s questionable verbiage and provisions. The support shown for The Phia Group’s October Webinar, “Creeping Around Pitfalls on the Way to Scary Savings! – How to Avoid Horror When Implementing Cost Containment Schemes!” was overwhelming! Not only did we enjoy an incredible turnout, but our attendees responded by providing some thought provoking insight to consider. Many of our industry’s greatest minds have since joined The Phia Group in assessing the FAQ’s meaning, impact, and steps we need to take to continue down the path of Reference Based Pricing. In November, we will share these ideas and conclusions with you.

Join The Phia Group’s CEO, Adam V. Russo; Sr. VP & General Counsel, Ron E. Peck; and other members of the legal team as we continue to dissect the FAQ, its key provisions, and how it impacts “RBP Plans .

View PDF here

View Webinar


Phia Group Consulting Addresses Regulatory Compliance

Braintree, MA – For years, The Phia Group’s team of consultants have been dealing with various regulatory inquiries. In response to the impending influx of regulation bound to follow the recent election and rollout of PPACA’s most complex provisions, The Phia Group announced this week the official formation of its Regulatory Compliance team.

Click here


FAQs about Affordable Care Act Implementation (Part XXII)
United States Department of Labor
Employee Benefits Security Administration

November 6, 2014

Set out below are additional Frequently Asked Questions (FAQs) regarding implementation of the Affordable Care Act. These FAQs have been prepared jointly by the Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury (collectively, the Departments). Like previously issued FAQs (available at http://www.dol.gov/ebsa/healthreform/ and http://www.cms.gov/cciio/resources/fact-sheets-and-faqs/index.html), these FAQs answer questions from stakeholders to help people understand the new law and benefit from it, as intended.

Read more…


Creeping Around Pitfalls on the Way to Scary Savings? - How to Avoid Horror When Implementing Cost Containment Schemes
Creeping Around Pitfalls on the Way to Scary Savings? - How to Avoid Horror When Implementing Cost Containment Schemes

DON’T MISS OUT! Whether you’re embarking on a new cost containment adventure in-house, or with the help of a vendor, most programs are not simple “plug and play” affairs. Those who head into the dark unprepared will undoubtedly find themselves spooked by what hides around the corner.

Are regulatory nightmares keeping you up at night? Just last week the federal government announced some gory changes to their regulations, sure to have a scary impact on reference based pricing. Nervous the path you’re headed down will lead to certain doom? Many are questioning how far they can go with dialysis carve-outs, without running afoul of the Medicare Secondary Payer Act. Are the tricks piling up, but no treats are in sight? The HHS has announced a scheme to crush skinny plans. If that isn’t enough to scare you straight, someone had better check for a heartbeat!

Now is not the time to explore the regulatory wilderness alone! If you are looking to create some sweet savings, join The Phia Group’s own CEO, Adam Russo, Sr. VP & General Counsel, Ron Peck, and other members of the legal team, as they review the hottest topics and biggest news to impact our industry in the recent weeks.
Don’t be left “holding the bag;” add this free webinar to your calendar; October 30 at 1 PM and fear no more!

Click here for PDF version!

Click here to view webinar


The Phia Group, LLC Comments on Recent Industry Developments
October 22, 2014; Braintree, MA

Friends & Colleagues:

These last few weeks have brought with them a whirlwind of controversy and concern.  The Phia Group, LLC is pleased to announce that it will be addressing three of the hottest topics during its monthly webinar.  If you have not yet signed up for our FREE webinar, to be held on Thursday, October 30th, 2014, from 1:00 – 2:00 PM EST, then you will most certainly be missing out!  Hear our assessment of the following major topics:

The Regulatory FAQ Addressing Reference Based Pricing (“RBP”)

Recently, a regulatory FAQ addressing RBP programs was released, regarding “reasonable” access to providers willing to accept the RBP rate, and RBP’s impact on patient out of pockets; (limited by the Patient Protection and Affordable Care Act [“PPACA”]).  Attendees of our October webinar will hear from our legal team, as we discuss the FAQ, what it means for RBP programs, and the steps we believe you can take to protect yourself and your program.

Recent Concerns with the HHS Minimum Value Calculator

As employers are preparing their plans for the upcoming year, some are looking at other plan options that will meet most of the requirements of the Affordable Care Act (ACA) but will perhaps not meet the minimum value requirement of the Employer Shared Responsibility Mandate (Employer Mandate). However, as some employers have discovered, there appears to be a flaw in the Federal Minimum Value (MV) Calculator, a tool used to determine if a plan meets the minimum value requirement of the Employer Mandate. The MV Calculator is indicating, in some cases, that plans that do not offer basic benefits such as hospitalization coverage still meet the minimum value requirement of the ACA but this calculation contradicts the IRS guidance in IRS Notice 2012-31.

Our legal team will discuss the different types of plan designs that employers are looking at for 2015 (i.e. Preventive Only (“Skinny”) Plans and Minimum Value Plans) as well as our considerations when using the MV Calculator for these types of plans.

Pressing Our Luck When Administering Dialysis Carve-Outs In The Face Of The Medicare Secondary Payer Act (“MSPA”)

Dialysis carve-outs are common, and work very well.  Many benefit plans have taken advantage of this excellent process, and are maximizing benefits while minimizing costs.  Unfortunately, the rate of success has been “all over the map,” largely dependent upon vendors and their clientele ensuring that the applicable plan language matches the process, and doesn’t run afoul of applicable law.  Newly brought to the industry’s attention are theories and procedures, reflected in widely adopted plan language, that may come too close to violating the MSPA.  Our team will discuss what some vendors are promoting, and what concerns many have shared in response.

Join us on October 30th at 1PM to discuss these issues!

SIIA State Legislative/Regulatory Update Report
October 21, 2014 — This is your weekly update of state legislative/regulatory developments affecting companies involved in the self-insurance/alternative risk transfer marketplace. Should you have any questions on information provided in these reports and/or would like to alert SIIA to new state legislative/regulatory activity (health care, workers’ compensation and/or captive insurance matters) we may have missed, please contact Adam Brackemyre, Director of State Government Relations directly at 202/463-8161, or via e-mail at abrackemyre@siia.org.


Colorado- Exchange Assessment Regulations Published
At long last, the Colorado Division of Insurance has published draft regulations addressing outstanding questions about the Colorado exchange’s assessment. The regulations can be viewed here. The link should open the rules in a Word document.

A hearing on the proposed rules has been schedule on November 5th. SIIA will be reviewing the proposed rules to see if it needs to submit comments or questions by this date.

If you have any questions or would like the proposed rule emailed to you, please contact Adam Brackemyre, SIIA’s Director of State Government Relations at abrackemyre@siia.org.

DC- Stop-Loss Legislation
On Friday, October 10th, the Business, Consumer and Regulatory Affairs (BCRA) Committee passed the DC stop loss language contained in B20-0797 to the full DC Council without any changes.

As previously reported, SIIA and other stakeholders testified at a public hearing and met with Department of Insurance Securities and Banking (DISB) staff responsible for writing the legislation and submitted amended language and justifications for those amendments, per DISB staff request. SIIA also worked with other industry lobbyists to request that members of the BCRA committee introduce the amendments, too.

There are still opportunities to seek amendments from the full DC Council. SIIA will continue to work with stakeholders to improve the legislation, which contains a minimum $40,000 individual attachment point and effective prohibition on employers of 50 and fewer from purchasing stop loss.

Illinois- Legislation Repealing Captive Tax Increase Introduced
Since the last SIIA state update, House Bill (HB) 6302, legislation repealing the recent Illinois captive tax increase, has been introduced.

There are two short legislative periods between now and the end of the year and nobody really knows how much will be accomplished because, as one Illinois insider told SIIA, legislative matters are taking a back seat to the close gubernatorial race.

Viewing this realistically, the best chance of repealing the tax will rest with a new legislature and new governor. There are two major barriers for HB 6302 in the lame duck period. First, the legislation is co-sponsored by members of the minority political party. Second, if HB 6302 were to be passed during the lame duck session, the governor would probably veto it, as he recently referred to the tax increase as “closing a loophole” during a recent debate.

In the meantime, SIIA will continue to work with the business community, support the repeal efforts and prepare to work with elected leaders next year who may be more favorable to the business community.

New York State- Advocacy Day in Albany
SIIA has tentatively planned an advocacy day in Albany next February in support of legislation that would protect small business access to stop loss insurance.

While SIIA has professional lobbyist resources in place, we need SIIA members who are New York State residents and business owners to attend. You are the best messenger to discuss how your clients, the legislators’ constituents, would be impacted if businesses with 51-100 covered lives would lose access their current health plan. If you could take one day to travel to Albany and educate legislators, it would be an invaluable service to your clients and your industry.

More information will be coming as the event details are finalized.

Supreme Court of California Case Notification for Children’s Hospital Central California v. Blue Cross of California
In an important legal development in the healthcare cost debate, the California Supreme Court has denied a petition for review of the recent decision in Children’s Hospital of Central California v. Blue Cross of California, 226 Cal. App.4th 1260 (2014). You’ll recall that a few months ago, a California appellate court reversed a decision by the trial court holding Blue Cross responsible for the full billed charges because the jury found that an implied-in-fact contract existed between the Hospital and Blue Cross. In so doing, the jury awarded the hospital $6.6 million in addition to the $4.2 million Blue Cross had already paid, totaling a payment of $10.8 million. This decision set up a potential showdown in the California Supreme Court; but the showdown is not to be. As a result benefit plans get important legal support for the proposition that a hospital cannot be paid an amount simply because they charge for it.

See the full appellate decision here.

Stay tuned as the the California courts try to determine on remand what should be considered when determining the “reasonable and customary” value of services rendered.

Final Part of Self-Funded White Paper Series Released
American Association of Payers, Administrators & Networks

This is the third and final installment of a three-part series examining the self-funded insurance market. Part one took a look at the benefits of self-funding, the significant role the self-funded market plays in the healthcare arena, and current statistics, including the substantial increase in self-funding since the enactment of the Affordable Care Act. Part two outlined the important role the TPA provides in administrating self-funded plans. Part three outlines the business practices of the stop-loss carrier in providing coverage for self-funded plans. The white paper in its’ entirety is attached or you may access it here.