Join Ron Peck as he interviews Desmond Campbell; the man, the myth, the legend. Desmond has spent time crunching numbers over the past 4 years – first for clients, now for The Phia Group. A man with experience elsewhere in the industry, Desmond will share what brought him to The Phia Group, and what keeps him here.
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As players in the self-funded industry have found out the hard way, keeping business often isn’t easy. Fiduciary obligations and other difficult situations can arise when we all least expect them, and when we are worst-equipped to deal with them (such as in the height of renewal season). By popular demand, this month’s webinar will focus on when fiduciary duties can arise, who needs to be careful, and how those duties might affect your 2020 renewals.
Join The Phia Group’s legal team as they provide the education needed to help you meet your obligations and keep your business safe – and provide the information you need to earn a “passing grade” during renewal season!
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In this episode, learn more about the life and background of Andrew Fine, Phia’s Lead Intake Specialist. Listen in as Andrew discusses his family, the fan club behind him, compliance being the number one priority for plans, and the bittersweet nature of the Celtics. Listen in closely, as the former sports analyst might give you some insider tips!
By: Kevin Brady, Esq.
In May of this year, the Federal Drug Administration (FDA) approved the most expensive drug in the world, Zolgensma. The drug was developed by Swiss drug maker, Novartis, and costs $2.1 million for the one-time single dose. The drug maker will spread the burden of the high cost by allocating payments for the drug over a 5- year plan at $425,000 a year.
Zolgensma is a new gene therapy drug used to treat spinal muscular atrophy (SMA). SMA is a rare, genetic neuromuscular disease caused by a defective or missing gene. Infants with the missing or defective gene will lose motor function control and are likely to lose the ability to breath, speak, swallow and walk. Essentially, Zolgensma can be used to treat all types of SMA in newborns and toddlers up to age two (2).
Not only is this the most expensive drug in the world, the drug maker, Novartis, has recently come under scrutiny by the FDA for allegedly manipulating pre-clinical data prior to FDA approval. For now, the FDA is not inclined to take Zolgensma off the market, as they still believe in the safety and efficacy of the drug. However, the FDA is likely to take action against the drug maker, most likely in the form of civil and criminal penalties.
With all the scrutiny around this new drug, plan sponsors should be aware of the high-price tag associated with this drug and the alleged misrepresentations of data by the drug maker in its seeking of FDA approval. Plan sponsors should carefully consider their options when drafting their plans. Gene Therapy is always a hot topic as it is typically associated with a high cost. For Zolgensma, while there may be a high up-front cost, if the drug is effective, most importantly, it will save lives and potentially years of expensive, demanding, and less effective alternative treatments.
By: Jon Jablon, Esq.
If you draft, administer, or otherwise manage self-funded health plans, you are likely very familiar with the appeals submission timeframe requirements within the SPD. The relevant regulations prescribe certain timeframes within which a health plan must allow an appeal, and a health plan is certainly free to allow longer periods of time, but abiding by the legal minimums tends to be the common practice.
That’s all well and good, and relatively simple to administer, but they tend to fall flat when applied to balance-billing. Let me explain:
I received an email the other day from a very angry medical provider with whom I had been attempting to resolve a balance-billing scenario, in which the attorney explained that the TPA said to him (and I quote): “On page 83 the plan document says that all payment appeals must be submitted within twelve months of the date of the adverse benefit determination. You have billed the patient seventeen months following the determination. Therefore you are prohibited from billing the patient for the balance.”
A provider’s appeal is to the Plan itself, saying, essentially, “you have underpaid this claim,” whereas balance-billing is to the member, saying “you are responsible for the balance that your health plan has not paid.” While it is certainly possible for a provider to simultaneously appeal to the Plan and balance-bill the member, they constitute two very different demands, and only one – the appeal to the Plan – falls under the purview and limitations of the Plan Document.
I want to do my part to dispel the popular misconception that balance-billing can be eradicated with the right plan language in place. Balance-billing, by definition, is outside the terms of the Plan, and therefore nothing written in the Plan Document can change a provider’s rights. The Plan Document’s terms can and should be used as arguments against balance-billing, of course, and the Plan needs strong language to defend itself – but even the strongest Plan Document language cannot legally prohibit a provider from balance-billing.
Feel free to contact PGCReferral@phiagroup.com, and we’ll do our best to answer all your appeal and balance-billing questions!
In this episode, prepare to be enchanted by Mattie Sesin, our Director of Recovery Services. Like a toad kissed by a princess, her career has transformed – and we invite you to join the journey. Marvel at the tales of family, festivities, and food. Miss this one, and you’ll likely turn into a pumpkin.
By: Nick Bonds, Esq.
On July 17, 2019 the Internal Revenue Service issued Notice 2019-45, and, if our consulting question inbox is any indication, caused quite a stir in our community. At least among the groups offering HSA-qualified high deductible health plans.
We have been inundated with a deluge of inquiries, ranging from the vaguely curious to the slightly manic: Are they changing the definition of preventive services? Does this change what we have to cover? How do we account for this in our plan document? What is the airspeed velocity of an unladen swallow?
Okay, that last one might be from Monty Python, but seriously everyone – relax.
This new rule essentially stems from an executive order President Trump issued on June 24, his “Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First,” which tasked the Treasury Department with a few homework assignment. Among these was Section 6(a), which called for guidance to expand the ability of patients to select high-deductible health plans (HDHPs) that can be used alongside an (HSA), and that these plans cover low-cost preventive care, before the deductible, to help maintain the health of people with chronic conditions, all within 120 days.
Five weeks later, the Treasury delivered, and the IRS introduced Notice 2019-45 to the world. The notice’s stated purpose is to “expand the list of preventive care benefits permitted to be provided by a high deductible health plan (HDHP) . . . without a deductible, or with a deductible below the applicable minimum deductible (self-only or family) for an HDHP.”
Our interpretation of this notice is fairly straightforward: it does not create any requirements for an HDHP to cover the listed services differently. Rather it gives HDHPs the ability to cover fourteen new services and items at 100% without applying their deductible, and without endangering their HDHP status.
The whole point of this notice is to help individuals utilizing an HDHP to manage their chronic conditions, like asthma, diabetes, and heart disease. A growing majority of employers are offering their employees HDHPs in tandem with a Health Savings Account. This rule offers those employers greater flexibility and eases the strain high deductibles put on the wallets of employees with chronic conditions.
Section 6(b) gave us something else to look forward to: Treasury has 180 days to propose regulations that could potentially expand eligible medical expenses under Section 213(d) to include direct primary care and healthcare sharing ministries. Forthcoming regulations could open some exciting possibilities for employers contemplating on-site clinics. So stay tuned.
By: Philip Qualo, J.D.
The U.S. House of Representatives recently voted to abolish the so-called "Cadillac Tax" on employer-sponsored, high-value health plans, which was scheduled to take effect in 2022. If the Senate passes the measure, and the president signs it into law, the threat employers have faced from the tax will finally be over. The House passed H.R. 748, the Middle Class Health Benefits Tax Repeal Act, with an overwhelming bipartisan vote of 419 to 6. The Senate will now decide whether to vote on the measure.
The Cadillac Tax, part of the Affordable Care Act (ACA) passed in 2010, is a 40 percent excise tax on the cost of employer health plans in excess of annual cost thresholds. The tax, originally intended to take effect in 2018, was intended to help generate tax revenue to help fund ACA subsidies for marketplace plans. Due to heavy opposition, the effective date of the Cadillac Tax has been delayed twice by Congress and had now been scheduled to go into effect in 2022. It is calculated based on: the costs of plan premiums (regardless of whether employer- or employee-paid); employer contributions and employee-elected payroll deductions to health savings accounts and flexible spending accounts; employer contributions to health reimbursement arrangements; the cost of group wellness programs; the value of coverage in onsite medical clinics; and certain other health benefits. The Cadillac Tax would have applied to both fully-insured and self-funded health plans.
According to a new analysis by the nonprofit Kaiser Family Foundation, the tax would have affected 1 in 5 employers offering health benefits in 2022 unless employers reduced the value of their health plans. As currently projected, if the average plan cost to cover employees and dependents was more than $11,200 for individual coverage and $30,150 for family coverage, employers would have had to pay the tax on plan costs for each covered person above those threshold amounts.
Employers and advocacy groups have vehemently opposed the Cadillac Tax, noting that although this tax was intended to only hit Americans with “gold-plated” plans, modest plans covering low and moderate-income working families were projected to trigger the tax. The Alliance to Fight the 40 has argued that this tax would have disproportionately taxed the health plans of women, seniors, working middleclass families, the sick, and the disabled. They also noted that that small businesses that already struggle to offer health care coverage would have also been heavily penalized.
We will continue to provide updates on the Cadillac Tax as the bill makes its way through the Senate.
On June 24, 2019, President Trump issued his “Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First.” This Order requires hospitals to publicly post their prices, and is designed to give healthcare consumers more choice and better decision-making capabilities.
Join The Phia Group’s legal team as they discuss the executive order point by point; they’ll touch on what they like and don’t like about it, and – more importantly – what this all means for you.
By: Andrew Silverio, Esq.
Recently, the Trump administration released a finalized rule establishing the conditions under which employers can utilize HRAs to subsidize their employees’ purchase of individual coverage, including coverage on the Exchange.
Under the rule, employers are able to provide enrollees with a fixed dollar amount, tax exempt, which can be used to buy individual coverage. While the rule doesn’t relieve the employer’s obligations to provide group coverage, if applicable, participation in the individual coverage HRA is conditional upon having individual coverage, which includes Medicare. This requirement is applicable for the employee and any dependents. Additionally, the individual coverage must satisfy certain requirements to qualify under the rule, allowing an individual to utilize the ICHRA, and individuals must attest that they have suitable individual coverage.
Notably, the model notice and attestation (available at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Downloads/HRA-Model-Notice-PDF.pdf and https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Downloads/HRA-Model-Attestations-PDF.pdf) provided by the administration contain no disclosure or explanation that certain coverage, such as certain limited-benefit plans or health sharing ministries, would not satisfy the rule’s requirements relating to the suitability of other coverage.
Critics of the rule have pointed to a few plausible factors in arguing that it will raise the price of individual coverage in the exchanges, both by incentivizing sicker employees within a workforce and employers with sicker employee populations overall to feed high risk lives into the individual markets. Additionally, it has been noted that older participants may not benefit sufficiently from the ICHRAs, because the limitations on how much the contribution amounts can differ based on age will be insufficient to compensate for the naturally disproportionate premiums those participants will encounter in the individual market.
Finally, the content of the rule aside, the quick turnaround time of a 01/01/2020 effective date is leaving state marketplaces scrambling, with many saying it will be simply impossible to implement sufficient changes in just a few months to be equipped to manage enrollment accurately under the new rule.
This is a significant development, with implications in the ACA, tax code, employment law, and other fields. Court challenges are likely, but as of now the rule stands to go “live” in just a few months. Reach out to The Phia Group at PGCReferral@phiagroup.com with any questions or for more detailed information on any of the rule’s contents.