Health Insurance Reform (aka Obamacare, aka PPACA, aka Healthcare Reform) has not enjoyed a smooth implementation. In fact, its birth has been quite turbulent. Are you surprised? Like many in our industry, The Phia Group’s CEO – Adam V. Russo, Esq. – as well as its Sr. VP & General Counsel – Ron E. Peck, Esq. – were not shocked to see the many issues developing in the law’s rollout, but even we have been impressed by some of the hurdles. From the “Pay or Play” employer mandate being delayed by a year, to a complete lack of guidance regarding the many costs, fees, and expenses of the law, join us as we – along with our special guest – The Phia Group’s legal counsel and VP of Consulting, Jennifer McCormick, Esq., analyze the volatile evolution of this controversial law.
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As always, thank you for your support of The Phia Group. We promise to keep you informed so you can protect yourselves and your clients. Happy reading.
August 26, 2013 – Comments made by regulators over the weekend at the summer meeting of the National Association of Insurance Commissioners (NAIC) in Indianapolis made it clear that ongoing pushback by SIIA and other stakeholder groups has dampened enthusiasm for new stop-loss regulation.
As an alternative, the NAIC ERISA Working Group agreed to move forward with the preparation of a white paper discussing regulatory issues associated with small employer self-insurance and the use of stop-loss insurance. To initiate this project, the Working Group recently surveyed all 50 states to obtain preliminary data regarding perspectives on regulatory activity.
Survey results included the following:
It was reported that work will continue on this White Paper, with the goal of completion by the end of the year. Individual states could then utilize the findings on an advisory basis.
In Other ERISA Working Group News….
DOL Presentation on New Employee Benefits Security Administration Final Rule on Ex Parte Cease and Desist and Summary Seizure Orders for MEWAs. The DOL made a presentation to the Working Group and reminded them that the ACA authorizes the DOL to issue a cease and desist order ex parte (without prior notice or hearing), and the DOL may issue a summary seizure order when it appears that a MEWA is in a financially hazardous condition. The DOL talked about MEWA regulations, and there was significant discussion regarding insolvent plans and the need to identify and police these better. The DOL mentioned with regard to cease and desist orders and summary seizures that it has expanded its breadth of financial review to include the brokers as well as the fiduciaries of the plans. However, the DOL noted the distinction between unfunded health plans, which pay claims out of their operating budgets, and self-funded health plans, which pay claims from a trust or separate account. The DOL noted that it does not have a good method to locate these unfunded plans prior to an insolvency event. Members of the Working Group asked if the DOL could develop regulations to address this deficiency, but the DOL said it did not think it was feasible to write such regulations.
Sham MEWA Plan Investigations. The regulators then met afterwards in a private session to discuss sham MEWA plan investigations.
We are all familiar with the contractual restrictions, limitations, and prohibitions imposed upon independent benefit plans and third party administrators utilizing major PPO networks. Whether it is restrictive deadlines, an inability to negotiate directly with providers, a prohibition on audits, or an obligation to pay in accordance with terms you’ll never see, many have complained about the apparent inequity established by these contracts. Few, however, have analyzed the network contracts existing between major carriers and their own network providers. One might be surprised to learn that these major carriers and ASOs not only recognize the importance of these items, but assert these rights for themselves! Join The Phia Group’s CEO – Adam V. Russo, Esq. – as well as its Sr. VP & General Counsel – Ron E. Peck, Esq. – as they dissect contractual terms existing between carriers and their network providers, and share the realization that they know exactly what is important to you.
On July 31st at 1 PM EST, The Phia Group’s CEO – Attorney Adam V. Russo – and The Phia Group’s Sr. VP and General Counsel – Attorney Ron E. Peck – will address one of the most pressing issues facing our industry today – balance billing. In particular, they will discuss what benefit plan administrators can do to assist their participants and push back against this problem.
To maintain benefit program viability, employers are cracking down on excessive spending through auditing and implementing new methodologies, such as cost based reimbursement and Medicare pricing, in addition to traditional network policies. In this new environment, participants will be thrust into the fray like never before; exposed to the threat of balance billing.
Topics that will be discussed include, but are not limited to –
• When strict enforcement of the plan terms and preventing balance billing may not be harmonious goals
• Undertaking efforts on behalf of benefit plans to resolve disputes with providers so that participants benefit as well, compared to “patient advocacy”
• Providing support to participants facing balance billing by explaining why the payments were capped, describing the appeals process in detail, and providing arguments they can raise against the provider
A Delay In Play (or Pay) – The News Isn’t As Good As You May Think
The Obama administration announced that it is postponing the requirement that employers provide employees robust, affordable health plans; also known as “pay or play.” You may think that this is good news… It’s another year to consider options, prepare funds, and study the intricacies of PPACA. DON’T BE FOOLED!
Regulatory officials have stated that the delay was prompted by so-called “compliance complexity concerns.” Employers have attacked the rule from every angle; targeting unrealistic expectations, costs, and difficulties in reporting. In addition, many employers have threatened to “trim” their employment rosters. Employers with fewer than 50 employees (or full-time equivalent employees) are exempt from the rule. It should have come as no surprise, then, that some employers were going to cut employees’ hours or terminate staff, dropping below 50 lives. With all of this in mind, the administration – “thankfully” – pulled back on the reins. Great news, right? Wrong!
At The Phia Group, we hope for the best but plan for the worst. For the following reasons, now is not the time to disregard cost containment efforts. – Read More