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Empowering Plans: P62 - Obamacare is Still the Law, Right?

Ron and Brady dissect the Texas decision that challenges the legality of the ACA, what it actually means, and what is next – as well as what you could (should?) be doing now.

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


The Phia Group's 1st Quarter 2019 Newsletter


Phone: 781-535-5600 | www.phiagroup.com



The Book of Russo:
From the Desk of the CEO

With 2018 in the rear view, it's important that we look back at such a historical year, while also moving forward to fine-tune our focus here at The Phia Group. In 2019, we will hone in on the highest priorities on behalf of our industry, to make certain that the momentum of innovation continues on. All of you must begin to empower your benefit plans. Healthcare has been, and continues to be the number one issue when discussing politics, law, and the economy. It is important to stay aware of change and the most cutting edge options, while also addressing each employer’s unique attributes and specific needs. We must create an understanding of what the best administrators are offering, so that we can in turn identify the best options for your benefit plan and all parties involved. Make it your resolution to understand the various types of plan components that are needed to stay competitive, while maximizing benefits and minimizing costs. I truly believe, we here at The Phia Group, have the tools to empower you to take control of your plan. Happy reading!


Service Focus of the Quarter: Independent Consultation & Evaluation (ICE)
Phia Group Case Study: Subrogation
Phia Fit to Print
From the Blogosphere
Webinars
Podcasts
The Phia Group’s 2019 Charity
The Stacks
Phia’s Speaking Events
Employee of the Quarter
Phia News

 

Service Focus of the Quarter: Independent Consultation & Evaluation (ICE)

Here at The Phia Group, we are not a TPA, but we know TPAs like the back of our hand. That is why we developed our Independent Consultation and Evaluation service, colloquially known as ICE.

We know how difficult processing claims can be, especially when those claims involve complex situations. Asking Plan Administrators for guidance to avoid potential liability is always a good idea, but is sometimes not feasible due to time constraints or simply the fact that most plan administrators are not well-versed in the art and science involved in claims processing. Your clients are school districts, or textile manufacturers, or labor unions; what can they reasonably be expected to know about the law related to when an illegal acts exclusion can be applied, and when it cannot?

Enter The Phia Group’s ICE service. We are experts in the law related to health benefit offerings, and we know plan documents like Tom Brady knows a pigskin. ICE was created to ensure that health plans and the TPAs that work with them have a resource to tap when things get hairy – and since it is billed on a predictable PEPM rate, rather than on an hourly basis, it is affordable and accessible, and there are no surprises.

Contact our Vice President of Sales & Marketing Tim Callender, to learn more. Tim can be reached at 781-535-5631 or tcallender@phiagroup.com.

 

Phia Case Study: Subrogation

A TPA client of The Phia Group had been unable to resolve a $62,000 lien with the patient’s attorney. The patient was in a motor vehicle accident, and subsequently retained an attorney to pursue the other driver for damages. The Plan Administrator attempted to place the attorney on notice of the plan’s right to reimbursement, but received no response whatsoever from the attorney, despite numerous letters and phone calls. The TPA had given up, and mentioned this failed recovery to one of The Phia Group’s attorneys in passing, who promptly volunteered that we would revive this file for them and attempt a recovery.

The Phia Group essentially started over by sending letters and calling the attorney, which again garnered no responses, as expected. The Phia Group’s legal team elected to take a different approach: after researching state law and decisions rendered by the state’s bar association, The Phia Group’s next correspondence focused on the attorney’s own ethical obligations, rather than only the patient’s reimbursement obligations.

The Phia Group not only received a prompt (and somewhat repentant) response from the attorney, but secured an agreement signed by the attorney to hold all settlement proceeds in trust and to honor the health plan’s rights in full. About two years later, the TPA recovered 90% of its lien.

 


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Fiduciary Burden of the Quarter: Whether You Are A Fiduciary!

Simply put, federal law provides that with very limited exceptions, entities acting as fiduciaries may not disclaim such a designation. The law is fairly straightforward when it provides that “…any provision in an agreement or instrument which purports to relieve a fiduciary from responsibility or liability for any responsibility, obligation, or duty under this part shall be void as against public policy.” To elaborate on that, the U.S. Supreme Court has stated that, “not only the persons named as fiduciaries by a benefit plan…but also anyone else who exercises discretionary control or authority over the plan's management, administration, or assets, is an ERISA fiduciary.”

Keep in mind, however, that the fact that an entity such as a TPA may be a fiduciary, under the reasoning spelled out above, does not necessarily mean that the TPA has breached a fiduciary duty when/if a breach occurs.

Fiduciary status is determined on a case-by-case basis; the courts have been clear that fiduciary status is triggered by the exercise of any discretionary authority over the management of a plan’s disposition of its assets. Practically speaking, the main purpose of fiduciary duties is money; the U.S. Court of Appeals for the Sixth Circuit has summed it up very well by noting that “[a]n entity such as a third-party administrator becomes an ERISA fiduciary when it exercises practical control over an ERISA plan’s money.”

If you control money, you owe fiduciary duties to the beneficiaries or potential beneficiaries of that money. So…be careful! Consult a neutral third-party expert when you face difficult claims or benefits decisions.

 

Success Story of the Quarter: Independent Consulting & Evaluation (ICE)

A third-party administrator presented The Phia Group with the facts of a situation wherein one of their incoming groups, previously serviced by another administrator, had a great deal of antiquated and weak language in its Plan Document. Erin Hussey, an attorney at The Phia Group, reviewed the Plan and noticed particular issues within its “eligibility” section.

The first issue Erin spotted was language that incentivized Medicare-eligible employees to not enroll in their group health plan, and to enroll in Medicare instead. Erin noted that this provision was in violation of the Medicare Secondary Payer Act (“MSP”), which explicitly prohibits such incentives.

Second, the Plan Document explained that retiree coverage was not offered to non-executive employees. Erin noticed that this may run afoul of §105(h) non-discrimination rules; these rules prohibit group health plans from treating highly-compensated individuals (“HCIs”) more favorably than non-HCIs. Therefore, by providing retiree coverage to only executives (who are far more likely to be HCIs), this language seemed to violate the 105(h) rules.

Erin communicated these findings to The Phia Group’s client, who was understandably concerned with the language issues. Erin explained the applicable law, the TPA’s responsibilities, and potential issues and penalties that could arise, and she provided a set of best practices for the TPA to follow in such circumstances. Based on the information Erin imparted, The Phia Group’s client was able to work with the employer group to correct the language and avoid likely MSP and 105(h) penalties in the face of a federal government that has been cracking down on violations of federal law such as these.

This is a perfect example of a way that health plans can avoid problems before they arise! The Phia Group’s ICE service helps TPAs, plans, and brokers with issues with claims, appeals, and other concrete issues – but where ICE can help the most is by preventing tough problems before they arise!
 

 


 

Phia Fit to Print:

• Money Inc. – A Conflict of Intent: Why We Can’t Achieve a Meeting of the Minds on Healthcare – December 12, 2018

• Self-Insurers Publishing Corp. – The Modernization of Health Savings Accounts – December 3, 2018

• Free Market Healthcare Solutions – Prescription Drug Prices Bridge a Divided Electorate in Election Season – November 28, 2018

• Money Inc. – Dialysis Providers Withstand Regulatory Haymaker – November 26, 2018

• The Inquirer: Daily Philly News – Main Line Hospital Charges $63 for Olive Oil Used to Turn a Breech Baby – November 20, 2018

• Self-Insurers Publishing Corp. – Don't Let Your Loss Leave You DOA: Part II - States Speak Up! – November 2, 2018

• Self-Insurers Publishing Corp. – Explanations That Benefit – October 4, 2018

• Money Inc. – Why Does Reform Always Seem to Favor the Wrongdoer? – October 1, 2018

 



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From the Blogosphere:

A Texas Judge Strikes Down Obamacare – Our Take. Don’t miss out on this great blog post!

You Down with RBP? (You May Already Be!) Reference-based pricing is one of the most mysterious self-funding structures out there.

OSHA Publishes Guidance on Post-Accident Drug Testing. Here’s an explanation to these requirements and how they apply to particular circumstances.

Healthcare on the Ballot, and a Free Side of Fries! Let’s take a step back and assess the big picture.

Is Your Life Insurance Policy Subject to ERISA? You may think this is a ridiculous question; however, Plan Sponsors and employers may want to reconsider this inquiry in light of a recent Seventh Circuit ruling...

 

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



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Webinars

Click HERE to Register!

• On December 12, 2018, The Phia Group presented, “What to Expect in 2019 – Part 2,” where we discussed current industry happenings and our predictions to help you look forward to the coming year.

• On November 13, 2018, The Phia Group presented, “What to Expect in 2019 - Part 1,” where we discussed current industry happenings and our predictions to help you look forward to the coming year.

• On October 18, 2018, The Phia Group presented, “Specialty Drugs: Trends and Issues Affecting Self-Funded Plans,” where we discussed the rising costs of specialty drugs.

Be sure to check out all of our past webinars!



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Podcasts:Featuring Video Podcasts!

• On November 20, 2018, The Phia Group presented, “Politics With Brady,” where Brady and Ron analyze the recent election results, and determine how they will impact the health benefits and health care industries.

• On November 16, 2018, The Phia Group presented, “Talkin’ with TPAC,” where our hosts, Ron and Brady, enjoy chatting with Michael Meloch, President of TPAC Underwriters and valued member of The Phia Group’s own advisory board

• On November 1, 2018, The Phia Group presented, “Special Edition: Talking Politics, Elections, and Healthcare,” where our hosts discuss healthcare on the ballot.

• On October 22, 2018, The Phia Group presented “AHPs: Will They Live Up to the Hype,” where our hosts discuss the benefits and hurdles the final rules have created for these new AHPs.

• On October 15, 2018, The Phia Group presented “2019 - Fly Ball or Home Run,” where Ron and Adam discuss the many issues, changes and challenges 2018 has lined up for 2019.

• On October 1, 2018, The Phia Group presented “Learn from the Past to Shape the Future,” where our hosts sit down with industry legend and innovative leader, Jerry Castelloe of Castelloe Partners.

Be sure to check out all of our latest podcasts!

 

Face of Phia

• On November 29, 2018, The Phia Group presented, “Flying High with Judy,” where Ron and Adam sit down with a member of The Phia Group’s Customer Service team, Judith McNeil.

• On November 16, 2018, The Phia Group presented, “Not Your “Norma-l” Employee,” where our hosts, Adam Russo and Ron Peck, sit down with a member of The Phia Group’s Accounting team, Norma Phillips.

• On October 24, 2018, The Phia Group presented, “A Chat With Matt,” where Adam Russo and Ron Peck sit down with The Phia Group’s Marketing & Accounts Manager, Matthew Painten.

 



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The Phia Group’s 2019 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 2019 charity is the Boys & Girls Club of Brockton.

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 Brockton (BGCB) 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 Brockton youths have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through academic year and summertime programming.

 

Thanksgiving – A Special Delivery

On Wednesday, November 21st, the Phia family went out to our local grocery store and purchased a total of 20 Thanksgiving dinners for the families of The Boys & Girls Club of Brockton. Once we loaded them up in our cars, we personally delivered them to the families. Words cannot express the feeling we got when we saw the looks on those families’ faces.

 

Christmas Tree Angel

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 Boys & Girls Club of Brockton. This year we had over 100 nametags! The Phia family loves to give back to the community; our greatest joy is providing these children with all of their holiday wishes.

 

Unwrapping Christmas

Santa and his elves made a surprise visit to the Boys & Girls Club of Brockton, one week before Christmas. Santa had sent a special elf to the Boys & Girls Club a couple of weeks prior to their visit to ask each child what they wanted most for Christmas. Santa and his elves gave out over 100 gifts to these amazing and talented children. We love giving gifts, but we really love receiving those smiles in return.  



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The Stacks

The Modernization of Health Savings Accounts

By: Krista J. Maschinot, Esq. – December 2018 – Self-Insurers Publishing Corp.

HSAs are highly regulated, tax-exempt savings accounts that both individuals and employers may contribute to on behalf of individuals covered by certain high-deductible health plans (HDHPs). These accounts are designed to help individuals set aside funds to be used for the qualified medical expenses of the individuals, their spouses, and their tax dependents. Unlike flexible spending accounts (FSAs), HSAs are not subject to mandatory “use it or lose it rules” and while FSAs are not portable, HSAs are portable as they are owned by the individual, not the employer, and can follow the individual as he or she changes jobs similar to a 401(k) or an individual retirement account (IRA). HSAs can be invested similar to a retirement account and have the ability to grow over time making them a valuable retirement vehicle. They are funded on a pretax basis through a cafeteria plan and result in a triple tax savings for the individual as they are funded with pretax dollars, grow tax-free, and are not taxed upon withdrawal so long as they are used to pay for qualified medical expenses.

Click here to read the rest of this article


Don't Let Your Loss Leave You DOA: Part II - States Speak Up!

By: Kelly E.Dempsey, Esq. – November 2018 – Self-Insurers Publishing Corp.

Remember that scenario from Spring of 2017 where an employer was attempting to do right by an employee and offered a continuation of coverage during an employer-approved leave of absence? If not, let’s quickly refresh our memories.

An employer’s long-time trusted employee had a stroke of bad luck and was diagnosed with stage four cancer after being relatively asymptomatic and having never been diagnosed with cancer previously. As the employee’s treatment plan became more aggressive, the employee ultimately needed to take a leave of absence – but leave under The Family and Medical Leave Act (FMLA) was exhausted due to the employee’s recent addition of a new baby. The employer subsequently continued to provide coverage, pursuant to 2016 guidance issued by the United States Equal Employment Opportunity Commission regarding employer-provided leave in accordance with The Americans with Disabilities Act (ADA).

Click here to read the rest of this article

 

Explanations That Benefit

By: Jon Jablon, Esq. – October 2018 – Self-Insurers Publishing Corp.

In the course of working with many different third-party administrators, it has become clear that every TPA operates differently. Claims processes are no exception; although federal law prescribes certain rules and regulations for the basics of what must be done and how, TPAs and health plans are left to their own devices to figure out the nuts and bolts of their particular processes. The only real requirement is that those processes fit in with the regulators’ rules and vision for how the industry should operate.

Click here to read the rest of this article

 

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

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Phia’s Q4 Speaking Events:

Phia’s Speaking Engagements:

• 1/9/2019 – FMMA Conference – Austin, TX

• 2/27/2019 – Sunlife 2019 MVP Academy – Denver, CO

• 3/8/2019 – UnitedAg Conference – Anaheim, CA

• 3/21/2019 – CGI Business Solutions Seminar – Woburn, MA

• 3/26/2019 – HFTA Broker Meeting – Tyler, TX

• 4/3/2019 – BenefitsPRO Broker Expo – Miami, FL

• 4/5/2019 – Pareto Conference – Nashville, TN

• 4/7/2019 – Captive Symposium – Cayman Islands

• 4/11/2019 – FMMA Conference – Dallas, TX

• 4/24/2019 – Sunlife 2019 MVP Academy – Kansas City, MO

• 4/25/2019 – Best Practices Workshop – Orlando, FL

• 5/30/2019 – Contrarian Captive – Austin, TX

• 6/11/2019 – Leavitt Conference – Big Sky, MT

• 7/31/2019 – 2019 MVP Academy – Wellesley, MA

• 8/24/2019 – Well Health Workshop – Chicago, IL

• 10/27/2019 – 2019 Annual NASP Conference – Washington DC

 

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Get to Know Our Employee of the Quarter:
Philip Qualo

Congratulations to Philip Qualo, The Phia Group’s Q4 2018 Employee of the Quarter!

Since he started just over 6 months ago, Philip has proven himself instrumental to our compliance team. He has shown a passion for and commitment to ensuring that our company remains compliant with state and federal laws as we have continued to grow and thus become subject to new and increasingly complex regulations. In particular, he played a lead role in updating and revising our Employee Handbook, even tackling the rather arduous process of researching state law and creating supplements for each of the 11 states in which we now have remote employees. In addition to internal compliance efforts, Philip has produced high-quality consulting work for our clients. Successfully functioning in a dual-role is never easy for a new employee, especially when those roles involve sensitive human resources and compliance matters. Philip has performed admirably, and for that, he has earned our trust, and earned my Passion Award nomination.

 

 

Congratulations Philip and thank you for your many current and future contributions.

 

Get to Know Our Employee of the Year:
Brady Bizarro

Congratulations to Brady Bizarro, The Phia Group’s 2018 Employee of the Year!

Brady has made his mark here at The Phia Group. Between traveling, speaking on our webinars and gracing industry leaders with his knowledge of politics and D.C. happenings at conferences around the United States, we would like to thank him for all that he has done. You truly exemplify what Phia employees should strive to be.

 

Congratulations Brady and thank you for your many current and future contributions. 

 

 


Phia News

 

Announcement of SIIA’s Next Chairman

Adam V. Russo, CEO of The Phia Group, will serve as the chairman of SIIA’s board of directors. Adam has been a long-time active SIIA member and will be concluding five years of service as a director. Congratulations to Adam and thank you for all fo the hard you and dedication.

 

A Phia Halloween

How great are these costumes? This year, the Phia Halloween Costume Contest was truly a nail-biter. Who would win? Rafiki? The clown? The fan favorite “Gambina the Unicorn riding Sprinkles the Unicorn,” bravely worn by Gambit Hunt, ultimately took home the gold. Thank you to all who participated, you truly made it a stellar Halloween!

 

Ugly Sweater Contest

Our Phia Family is so festive! Our “Ugly Sweater Day” was a hit and we thank all those who participated; congratulations to Norma (pictured below sporting a green and red number, with gold shoulders) for winning “Ugliest Sweater”!

 

 


 

Job Opportunities:

• Accounting Manager

• Staff Attorney, Provider Relations

• Case Investigator I

• Claims Analyst

• Health Benefit Plan Drafter

See the latest job opportunities, here: https://www.phiagroup.com/About-Us/Careers

 

Promotions

• Ekta Gupta was promoted from ETL Specialist to Manager, Data Services Group

• Gambit Hunt was promoted from Sales Coordinator to Sales Executive

 

New Hires

• Tammy Tran was hired as an Accounts Payable Coordinator

• Christina Veneto was hired as a Talent Acquisition Specialist

• Brittany Grueter was hired as a Case Investigator I

• Elise Mulready was hired as a Claim and Case Support Analyst

• Nicholas Bonds was hired as a Health Benefit Plan Admin - Attorney I

• Danijela Stanic was hired as a Health Benefit Plan Consultant I

• Michael Vaz was hired as a Sales and Accounts Coordinator



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info@phiagroup.com
781-535-5600

Faces of Phia: Episode 4 – Dishing with Delaney

Take a moment to meet Katie Delaney, Phia's Senior Training & Development Specialist who has been with the company since 2007.  Responsible for training employees, you can thank Katie anytime a team member succeeds.  Really?  Listen to learn how we got to this point!

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


The Stacks - 1st Quarter 2019

The Modernization of Health Savings Accounts

By: Krista Maschinot, Esq.

 

Health Savings Accounts (HSAs) were originally introduced as part of the Medicare Prescription Drug, Improvement, and Modernization Act that was signed into law by President George W. Bush on December 8, 2003.  While the contribution amounts have increased gradually since this time, no other significant changes have occurred.  Congress is addressing this issue and attempting to help individuals and families afford the ever increasing medical expenses plaguing the United States.

HSAs are highly regulated, tax-exempt savings accounts that both individuals and employers may contribute to on behalf of individuals covered by certain high-deductible health plans (HDHPs).   These accounts are designed to help individuals set aside funds to be used for the qualified medical expenses of the individuals, their spouses, and their tax dependents.  Unlike flexible spending accounts (FSAs), HSAs are not subject to mandatory “use it or lose it rules” and while FSAs are not portable, HSAs are portable as they are owned by the individual, not the employer, and can follow the individual as he or she changes jobs similar to a 401(k) or an individual retirement account (IRA).  HSAs can be invested similar to a retirement account and have the ability to grow over time making them a valuable retirement vehicle.  They are funded on a pretax basis through a cafeteria plan and result in a triple tax savings for the individual as they are funded with pretax dollars, grow tax-free, and are not taxed upon withdrawal so long as they are used to pay for qualified medical expenses.

The House of Representatives passed the Restoring Access to Medication and Modernizing Health Savings Account Act of 2018 (HR 6199) and the Increasing Access to Lower Premium Plans and Expanding Health Savings Accounts Act of 2018 (HR 6311) on July 25, 2018.   As the names imply, the bills focus on updating and modernizing the current laws surrounding the use of Health Savings Accounts (HSAs).  These updates include increasing the contribution limits for both individuals and families, expanding coverage to include qualified medical expenses that were previously omitted, and allowing for direct primary care physician arrangements to be accessed by individuals covered under an HDHP.

Contribution limits increased

For 2018, the contribution limit (for employer and employee combined) for an individual is $3,450, while the limit for a family is $6,900 (increased from the original $2,600 for individuals and $5,150 for families).  One modernization that HR 6311 will make is to increase to the contribution limits for individuals and families to $6,900 and $13,300 respectively.  These amounts are the current annual limits on deductibles and out-of-pocket expenses for HSA-eligible HDHPs.  In addition, individuals with HSA-qualifying family coverage who were previously deemed ineligible due to their spouse being enrolled in a medical FSA will now be permitted to contribute to an HSA.

Coverage expanded

Under the current law, the funds in an HSA may only be used to pay for qualified medical expenses pursuant to IRC Section 213(d), which include amounts paid:

“(A) for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body,

(B) for transportation primarily for and essential to medical care referred to in subparagraph (A),

(C) for qualified long-term care services (as defined in section 7702B(c)), or

(D) for insurance (including amounts paid as premiums under part B of title XVIII of the Social Security Act, relating to supplementary medical insurance for the aged) covering medical care referred to in subparagraphs (A) and (B) or for any qualified long-term care insurance contract (as defined in section 7702B(b)).

In the case of a qualified long-term care insurance contract (as defined in section 7702B(b)), only eligible long-term care premiums (as defined in paragraph (10)) shall be taken into account under subparagraph (D).”

HR 6199 further expands the permissible eligible expenditures to also include gym memberships and certain physical exercise programs (up to $500 for individual and $1,000 for family) along with feminine care products and other over-the-counter medical products.

Direct Primary Care permitted

A Direct Primary Care service arrangement (DPC) is an alternative to a tradition health care plan wherein individuals pay a flat fee each month, similar to a membership fee, to a primary care physician that covers all of the individual’s primary care service needs.  For services that are outside the realm of primary care, additional fees will apply.  At the current time, individuals cannot use their HSA funds to pay for the DPC monthly fee as they do not qualify as medical expenses under IRC Section 213(d).

Other issues surrounding DPC arrangements include the fact that when a DPC is offered outside of the employer’s health plan it is considered to be a second health plan and impermissible other coverage as Section 223(c) of the Internal Revenue Code (IRC) states:

“[S]uch individual is not, while covered under a high deductible health plan, covered under any health plan-

  • which is not a high deductible health plan, and
  • which provides coverage for any benefit which is covered under the high deductible health plan.”

As a result of this Code section, individuals are not permitted to be covered under an HDHP and to also be offered other coverage, include a DPC, outside of the employer’s self-funded health plan as (1) a DPC is not an HDHP and (2) a DPC offers benefits that are already covered under the employer’s HDHP.  Further, individuals are not permitted to use their HSA funds for services related to DPCs, as DPCs are considered to be health plans and use of such funds would be deemed impermissible other coverage.

If the DPC is a benefit under the employer’s self-funded health plan, the following consideration applies. An HDHP is not permitted to provide any first dollar coverage for benefits until a minimum deductible has been satisfied with the exception of preventive care services. Since the services provided by DPCs and other primary care physicians are not always considered preventive care, there will be times where the patient's care is still subject to the deductible. As a DPC does not typically include a fee for service, there is no fee to apply to the deductible which is problematic.

If enacted, HR 6311 will help solve the issues surrounding the ability of DPCs to be used along with HSA-eligible HDHPs.  Specifically, it would permit DPC service arrangements to no longer be treated as health plans, thus no longer disqualifying an individual from contributing to an HSA.  Additionally, the monthly DPC fees would qualify as medical expenses, meaning individuals would be permitted to use their HSA funds to pay for such fees (with a cap of $150 per individual and $300 per family per month). 

Other changes

The bills, again, if enacted, would also:

  • Allow up to $250 for individuals and $500 for families to be covered for non-preventive services under HDHPs;
  • Permit the use of employment-related health services and employer sponsored onsite medical clinics for limited use without violating HSA eligibility restrictions;
  • Allow for rollovers of health FSA balances from year to you (up to three times the contribution limit);
  • Allow for transfers of up to $2,650 for individuals and $5,300 for families from FSAs and HRAs to HSAs when enrolling in a qualifying high-deductible health plan with an HSA;
  • Allow spouses to make annual catch-up contributions of up to $1,000 to an HSA; and
  • Permit working seniors currently enrolled in Medicare Part A to contribute to an HAS when covered by a qualifying HDHP.

While these bills passed the House in July of this year, there has been no action on either in the Senate and December is quickly approaching.  As the tax advantages offered in each are beneficial to both employees and employers, employers should monitor the bills as the year comes to a close.

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Don’t Let Your LOAs Leave You DOA (Part II): States Speak Up!

By: Krista Maschinot, Esq.

Remember that scenario from Spring of 2017 where an employer was attempting to do right by an employee and offered a continuation of coverage during an employer-approved leave of absence? If not, let’s quickly refresh our memories.

An employer’s long-time trusted employee had a stroke of bad luck and was diagnosed with stage four cancer after being relatively asymptomatic and having never been diagnosed with cancer previously. As the employee’s treatment plan became more aggressive, the employee ultimately needed to take a leave of absence – but leave under The Family and Medical Leave Act (FMLA) was exhausted due to the employee’s recent addition of a new baby. The employer subsequently continued to provide coverage, pursuant to 2016 guidance issued by the United States Equal Employment Opportunity Commission regarding employer-provided leave in accordance with The Americans with Disabilities Act (ADA)1.

Although the employee ended up making a miraculous recovery, the claims poured in, and the employer soon realized there was a “gap” between the plan document and the employer’s decision to provide ADA leave, such that the plan document did not actually allow this continued coverage. Of course, the employer was free to provide whatever leave it saw fit – but the employer’s stop-loss carrier was not keen on reimbursing these claims, since this continued coverage was not contemplated when the carrier underwrote the policy. The employer was facing stop-loss reimbursement denials and potentially skyrocketing renewal rates for the upcoming plan year.

Part I of the story ended as a cliffhanger: the employer’s bank account looked bleak, and the employer was scrambling to figure out how to continue offering benefits to its employees without going bankrupt. “How did I end up here? All I wanted was to take care of my employees and give them the best benefits possible. Where did I go wrong?” 

As you may recall, we put ourselves in the shoes of employers. It’s intuitive to think that a health-related leave of absence from employment is coupled with a continuation of health plan coverage. Unfortunately, though, plan documents and employee handbooks are as prone to “gaps” as any other two documents, if not more; you’d be amazed at how antiquated some employee handbooks can be, and even when they’re updated, it occurs to alarmingly few employers that the two documents must be harmonized.

Similar to “surprise billing” legislation, the last year or so has seen a boom in state legislation that is designed to protect employees, and much of the legislation focuses on – you guessed it – leaves of absence and continuation of coverage. Some state laws address whether or not leave must be paid, others address whether benefits must be continued while on leave, and others still address both issues. Two interesting recent examples are California and New York.

California’s leave laws have been in place for decades, but have undergone various changes, including revisions in 1999, 2004, 2011, 2012, and most recently, 2017. California Senate Bill No. 63 implemented the New Parent Leave Act (NPLA) as of January 1, 2018. Affording protected leave to employees of employers with 20 or more employees, this marked a significant change from the state’s previous requirement laws that applied only to employers with 50 or more employees. Employers subject to California law must consider the interaction of all state and federal leave laws, including the NPLA, FMLA, California Family Rights Act (bonding leave), and Pregnancy Disability Leave (PDL). 

Unlike California’s law, which expanded an existing law, New York passed a brand new leave law, and it happens to be the most generous paid leave law in the United States to date. Effective January 1, 2018, New York’s Paid Family Leave Benefits Law (PFLBL) is being phased in over four years with full implementation in 2021. The law requires privately-owned employers to provide paid leave to employees in three situations: (1) for a father or mother to bond with a new child (birth, adoption, or foster); (2) to care for a close relative with a serious health condition; or (3) to care for a close relative when another close relative has been called to active military service. The length of leave in 2018 has been limited to eight weeks, but will increase over time to become 12 weeks upon full implementation in 2021. Interestingly, in addition to creating the requirements, the law requires employee handbook modifications, conspicuous posting of specific information (similar to FMLA), the need to coordinate with paid time off and FMLA, and of course the tax treatment of the benefits.

I don’t know about you, but my head is spinning. For employers subject to a myriad of laws such as FMLA, the various state leave laws, and ERISA, it’s no surprise that complying with all of them simultaneously is a serious headache, and sometimes details are overlooked.

Now, wait a minute. If a self-funded ERISA plan is protected by ERISA, aren’t state laws like these inapplicable? The short answer is no. The longer answer is no way. At a high level, ERISA protects a health plan from being subject to state insurance laws – but laws such as paid leave and continuation of coverage laws have been found to not actually be insurance laws, but employment laws, and therefore ERISA can’t shield anyone from compliance with such laws.

As an attorney, I can tell you that following state and federal laws is crucial to the viability of a health plan and the employer’s business. As a health care professional, I can tell you that full compliance is not an easy task. Laws that protect employees tend to have intricate details and nuances; we’ve picked on California and New York, but five other states and the District of Columbia have introduced legislation to offer or expand leave laws. Those states include Washington, New Jersey, Rhode Island, New Hampshire, and Maryland. Although most federal and state laws do not currently require a continuation of coverage, we may soon see an upheaval in the status quo.

In the absence of applicable state laws, employers can choose whether or not to provide the benefit of continued coverage – but of course an employer’s generosity must be spelled out in the plan document, not just the employee handbook, in order to avoid stop-loss denials. Ultimately, the interaction of applicable state laws, FMLA, and any other type of employer-sponsored leave of absence will need to be assessed on case-by-case basis to determine the rights of an individual employee in any particular circumstance. As with everything else in the self-funded world, if the relevant documents aren’t kept up-to-date and compliant, how can an employer expect to be able to solve the compliance Rubik’s Cube?

The alarming reality is that many gaps between plan documents and employee handbooks are only discovered once a disaster has already ensued. All it takes is one catastrophic event to discover that the various documents aren’t airtight, and may not even align with the employer’s intent.  

In sum, employers need to do their homework on a regular basis. As we enter renewal season, now is the perfect time for employers to look at their plan documents and the employee handbooks. Do the two documents reference the same types of leave? Do the documents clearly indicate under what circumstances, and for how long, coverage under the health plan is maintained during a leave? Has the employer assessed the need to comply with a new or revised state law? Are the employer and employee obligations and coverage options laid out clearly? Do the terms of these documents meet the intent of the employer? What does the stop-loss policy say about eligibility determinations? Can the handbook be used to document eligibility in the health plan? Do changes need to be made to minimize or eliminate gaps?

Don’t let your LOAs leave you DOA. Do the leg work now, and figure out what needs to be done to avoid being caught by surprise.

Kelly E. Dempsey is an attorney with The Phia Group. She is the Director of Independent Consultation and Evaluation (ICE) Services. She specializes in plan document drafting and review, as well as a myriad of compliance matters, notably including those related to the Affordable Care Act. Kelly is admitted to the Bar of the State of Ohio and the United States District Court, Northern District of Ohio.

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Explanations that Benefit

By: Jon Jablon, Esq. 

In the course of working with many different third-party administrators, it has become clear that every TPA operates differently. Claims processes are no exception; although federal law prescribes certain rules and regulations for the basics of what must be done and how, TPAs and health plans are left to their own devices to figure out the nuts and bolts of their particular processes. The only real requirement is that those processes fit in with the regulators’ rules and vision for how the industry should operate.

As a form that is given to a claimant along with payment (or, perhaps more relevantly, without payment), the Explanation of Benefits (or EOB) form is often the first,  and sometimes the only, document a claimant sees that explains why the claim was adjudicated as it has been. For that reason, although it would probably not be accurate to suggest that the regulators treat EOBs as “special” compared to any other regulations, in practical matters the EOB can be considered to be perhaps more important to get right than certain other things. That’s because it’s the first line of defense when denying or partially denying a claim, and the primary vehicle for a health plan’s justification of its denial.

29 USC § 1133 and accompanying regulations address a plan’s internal appeals procedures and require that claimants must be notified of the reasons why a claim has been denied and must be given a reasonable opportunity for a full and fair internal review of a claim1. The regulations go on to require that a group health plan provide – among other things – the specific reason for the denial, reference to the specific plan provisions upon which it has been based, a description of the plan’s appeals procedures, and a way to connect an applicable clinical judgment to the plan’s provisions.

Those rules seem fairly straightforward – but due to the numerous situations that courts and regulators have encountered through the years, there are some nuances in this language that are perhaps not quite clear, and which TPAs should be acutely aware of when addressing matters such as EOB compliance. As usual, the black-letter law leaves room for interpretation.

In one particular case, for instance, a health plan required arbitration as a mandatory stage of plan appeal, after the initial written appeal was denied. The EOB, however, was silent on that requirement. The court in that case applied the normal doctrine that courts use to rectify cases of inadequate notice: the health plan was directed to allow the claimant to file a late appeal, despite the timeframes stated within the applicable plan document and the fact that those timeframes had run out. Known as “tolling,” this remedy effectively stops the “countdown” of the appeal time requirement due to inadequate notice from the plan. In this case, then, the timeframes for appeal stated in the plan document were deemed inapplicable, since the plan did not adequately communicate them.

One can argue that the plan document’s inclusion of the relevant information should be sufficient to convey the information to a claimant – but according to courts, plan members can only reasonably be expected to know what is shown to them with respect to a specific case, rather than in the Plan Document in general. As one court put it, “[j]ust as a fiduciary must give written notice to a plan participant or beneficiary of the steps to be taken to obtain internal review when it denies a claim, so also, we believe, should a fiduciary give written notice of steps to be taken to obtain external review through mandatory arbitration when it denies an internal appeal2.” Even though the arbitration itself is not explicitly governed by ERISA, once it was made a part of the plan’s claim procedures, it became a provision that must be brought to the claimant’s attention. This case and others like it demonstrate that simply including a provision in the Plan Document is sometimes not enough to adequately inform a claimant of that provision.

That’s an example of a situation where plan provisions (timelines, specifically) were actually ignored by a court, because the plan and TPA failed to adequately disclose certain plan requirements on the EOB.

Where does it end, though? Surely the regulations can’t list every conceivable item that must be present on the EOB; even if a very long list were created, there would always be some new situation not previously contemplated. Hence, there is case law like this, that is designed to both give guidance in this specific instance, but also help inform future interpretations of these same rules. For instance, if a health plan required mediation rather than arbitration, surely the case law described above would still apply, even though it’s not an identical situation. It’s close enough, though, that the required “good faith, reasonable interpretation” of unclear regulations can be colored by this example.

In a longstanding series3 of somewhat more egregious examples of deficient EOBs, courts have opined that the regulations explaining the EOB requirements are not designed to invite “conclusions,” but instead “reasons” or “explanations.” So, rather than state that a claim is denied because pre-authorization was not given, the EOB should state why pre-authorization was not given, and therefore the conclusion4. Put simply, and again parroting the established regulations, “[a]n ERISA fiduciary must provide the beneficiary with the specific reasons for the denial of benefits5.”

Noncompliance, or an instance of a questionable nature, is somewhat common with reference-based pricing. The prevailing attitude seems to be that since reference-based pricing is such a fundamental change to the plan itself, there’s so much else going on that an EOB note such as “claim denied due to reference-based pricing” is somehow sufficient. Based on courts’ interpretations of the prevailing regulations, a remark this generic would neither be literally compliant with the text of the regulations, nor satisfy the intent of the regulations (which is to provide the claimant with information sufficient to file a meaningful appeal on the merits, or ultimately file suit to enforce benefits pursuant to ERISA)6.

My mention of the intent of the regulations was deliberate. In the legal system, intent is not always necessary to be held liable; at the risk of going on a tangent, there’s something called “strict liability” which imposes legal liability even without intent or even knowledge of wrongdoing. In the process of interpreting ERISA, this country’s courts have in some situations refused to apply a comparable doctrine of strict liability to violations of ERISA. In other words, sometimes a violation occurs, but the offending fiduciary is not held liable, due to other actions of that fiduciary.

To illustrate this, consider a situation where a claimant is given a compliant EOB containing one denial reason, the claimant appeals, and the health plan or its TPA denies the appeal, and also cites additional reasons for the denial that were not provided on the original EOB. For some context, it isn’t compliant with ERISA to provide additional denial reasons after the claimant has already exhausted or “used up” the available appeals, since that wouldn’t afford the claimant the opportunity to actually appeal the newly-given denials reasons7.

In some situations, though – when the claimant is given the opportunity to appeal the other denial reasons, despite already having exhausted appeals for the initial denial reason – compliance with one provision of ERISA has actually saved the fiduciary from noncompliance in another area. In a situation like this, the health plan is not in compliance when it issues a separate denial reason after already denying appeals for the initial denial reason – but the fiduciary was able to “cure” its noncompliance by providing the claimant ample opportunity to appeal the new denial reasons. Sometimes referred to as “substantial compliance8,” courts have noted that certain instances of technical noncompliance can be excused as long as the purpose of the regulations9 is not frustrated. In this case, that purpose is ensuring that claimants receive adequate recourse to appeal claims denials, which has been done.

As a final note, although the majority of this article discusses procedural matters related to EOBs, it’s worth taking a brief look into the substance of denials. Although the relevant regulations provide that the claimant must be given the “specific reasons” for the denial of benefits, an interesting nuance of this rule apparently involves a sort of meta-reasoning: as one court put it, “The administrator must give the ‘specific reasons’ for the denial, but that is not the same thing as the reasoning behind the reasons...10

Admittedly, that sounds very odd. The nuance is that although the Plan Administrator must provide a reason for denial, the Plan Administrator, oddly, isn’t required to provide a good reason. The fiduciary duty extends to providing a reason, and then the law places the burden on the claimant to refute that reason. Of course, the regulations explaining what must be present on an EOB are designed to give the claimant the tools it needs to refute the denial – but the fact remains that the Plan Administrator may provide a nonsensical reason for denial, and the Plan Administrator has then literally satisfied its duty to compliantly notify the claimant of the specific reason for the denial. After all, the law does not assume that Plan Administrators are perfect, or even logical; only that they explain themselves.

According to one particular court, requiring the Plan Administrator to explain its ‘reasoning behind the reasons’ “would turn plan administrators not just into arbitrators, for arbitrators are not usually required to justify their decisions, but into judges, who are.11” Interestingly, despite the doctrine of “substantial compliance” noted above, perhaps courts should adopt a doctrine of “substantial noncompliance,” which can place a fiduciary out of compliance for providing an egregiously poor reason for denial, and thus violating the spirit of the law, despite following the black letter of the law.

Regardless, the regulations are neither clear nor all-inclusive – but there is case law designed to educate Plan Administrators regarding things that must be on an EOB, and what doesn’t need to be. The rules are not as intuitive as the regulations make them out to be…but then again, in this industry, what is?

1Chappel v. Lab. Corp. of Am., 232 F.3d 719, 726 (9th Cir. 2000).

2Id.

3Accord VanderKlok v. Provident Life and Accident Ins. Co., 956 F.2d 610 (6th Cir. 1992); Wolfe v. J.C. Penney Co., 710 F.2d 388 (7th Cir. 1983); Richardson v. Central States, Southeast and Southwest Areas Pension Fund, 645 F.2d 660, 665 (8th Cir. 1981)

4Weaver v. Phx. Home Life Mut. Ins. Co., 990 F.2d 154, 158 (4th Cir. 1993)

5Makar v. Health Care Corp. of Mid-Atlantic (CareFirst), 872 F.2d 80, 83 (4th Cir. 1989) (dicta), emphasis preserved.

6See Halpin v. W.W. Grainger, Inc. 962 F2d 685 (CA7 Ill, 1992)

7Urbania v Cent. States, Southeast & Southwest Areas Pension Fund, 421 F3d 580 (CA7 Ill 2005).

8Lacy v. Fulbright & Jaworski, 405 F.3d 254, 256-257 & n.5 (5th Cir. 2005).

9Robinson v. Aetna Life Ins., 443 F.3d 389, 393 (5th Cir. 2006).

10Gallo v. Amoco Corp., 102 F.3d 918, 923 (7th Cir. 1996), internal citations omitted.

11Id.

 


Empowering Plans: P61 - Leather Patches & Pipes

The Phia Group’s foray into higher learning!  Ron discusses with professors Silverio and Jablon the forthcoming master’s degree program in plan development they will be teaching.  If you’re up for the challenge, prepare to learn!

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


EEOC Vacates ADA and GINA Wellness Incentive Rules

By: Erin M. Hussey, Esq.

On the verge of a potential government shutdown, the Equal Employment Opportunity Commission (“EEOC”) was quick to issue final rules December 19th on the Americans with Disabilities Act (“ADA”) and the Genetic Information Nondiscrimination Act (“GINA”). Issuing final rules at the end of the year is not a new trend, but the unique situation is that the final rules are vacating current provisions on wellness program incentives. With an effective date of January 1, 2019, we are left with less guidance than we had on December 18th.

By way of background, in 2016 the American Association of Retired Persons (“AARP”) sued the EEOC claiming that the EEOC’s wellness incentive rules, for wellness programs that implicate the ADA and GINA, were coercive and not truly voluntary. A wellness program would implicate the ADA if medical examinations or disability-related inquiries were involved (i.e., biometric screenings), and a wellness program would implicate GINA if there were inquiries about genetic information. Before recent events, the EEOC’s ADA and GINA rules capped the wellness program incentive at 30%.

In a 2017 opinion, the judge determined that the EEOC had never defined the term voluntary thus the court found that the EEOC "failed to adequately explain" the 30% maximum and how a plan can still be considered voluntary with that incentive. The EEOC was directed to re-write their workplace wellness rules related to incentives for an effective date of January 1, 2019 or the old rules would be vacated. Obviously the EEOC did not re-write the ADA and GINA incentive-related rules as they have now been vacated effective January 1, 2019. However, the EEOC had indicated at their Fall 2018 Unified Agenda of Federal Regulatory and Deregulatory Actions, that they intend to issue new regulations in June 2019.

In order to ensure compliance until new rules are issued, the quick solutions are to remove medical testing, questions about genetics, and lower the amount of the incentive (though it is unclear what amount will truly be considered voluntary). While frustrating to say the least, this limbo situation for employers and plans is more of the same uncertainty that we have been dealing with for the past eight years. Employers that choose not to make changes should be aware of the compliance risks they may face due to the lack of rules.

*Please note: the above-mentioned EEOC wellness rules are separate from the Health Insurance Portability and Accountability Act (“HIPAA”) and the Affordable Care Act (“ACA”) wellness rules and the above ruling has no effect on these rules.


Stop-Loss: The Forgotten Player in the Reference Based Pricing Game

By: Jon Jablon, Esq.

Plan sponsors of self-funded health plans have a lot to think about. From deciding which services to cover to making tough claims determinations, there are lots of moving parts to consider and be mindful of. Plans that utilize reference-based pricing are in the same boat, of course, except they have added even more moving parts to their benefits programs.

As many plans that use reference-based pricing are aware, some claims need to be settled with providers to eradicate balance-billing. A claim initially paid at 150% of Medicare may need to be ultimately paid at 200%, for instance, pursuant to a signed negotiation between the health plan and the medical provider. Fast-forward two months later, to when the plan receives notice from its stop-loss carrier that the carrier is only considering 150% of Medicare to be payable on the claim, and the extra 50% of Medicare (which can be a significant amount!) is excluded.

When the plan asks why it isn’t receiving its full reimbursement, the carrier quotes its stop-loss policy and the plan document. The former provides that the carrier will only reimburse what is considered Usual and Customary – and the latter provides that Usual and Customary is defined as 150% of Medicare, by the Plan Document’s own wording. The carrier’s liability, therefore, is limited to 150% of Medicare. The plan’s has chosen to pay more than that. Even though it’s for a very good cause, the stop-loss insurer may deny that excess payment amount. In this example, there is a “gap” between the plan document and stop-loss policy such that the plan has paid a higher rate than what the carrier is obligated to pay.

For this reason, it is so incredibly important for plans that are using reference-based pricing to talk to their stop-loss carriers. Some carriers will say “we don’t care – your SPD says 150%, so we’ll reimburse 150%,” but other carriers will say “we understand that reference-based pricing saves us money, and we understand that it’s not always as simple as paying 150% and walking away – so we’ll work with you in terms of reimbursement.” Other carriers still will agree to place a cap on reimbursements higher than what’s written in the Plan Document; in other words, if the plan provides that it’ll pay 150% of Medicare, the carrier may agree to reimburse settlements up to 200% of Medicare, if applicable and if necessary.

There are lots of options for how a stop-loss carrier might react to reference-based pricing, and the only way to find out is to have a conversation. If you don’t ask, you’ll never know (until it’s too late, that is).

Moral of the story? If you’re going to adopt reference-based pricing – whether full network replacement, carve-outs, out-of-network only, or any other type – put stop-loss high up on the laundry list of considerations.


A Texas Judge Strikes Down Obamacare – Our Take

By: Brady Bizarro, Esq.

We have been covering Texas v. United States since the case was filed in February of this year. The suit, brought by 18 state attorneys general and 2 Republican governors, represented the most serious threat to the Affordable Care Act (“ACA”) since the GOP’s efforts to repeal the healthcare law failed last summer. On Friday, Judge Reed O’Connor of the U.S. District Court for the Northern District of Texas ruled that the entire ACA is unconstitutional since Congress eliminated the individual mandate in a 2017 tax bill. His decision has rattled the markets, Democratic political leaders, advocacy groups, and the broader healthcare industry. After taking a closer look at this ruling, however, we agree with the many legal experts who have concluded that this ruling is not as earth shattering as the headlines make it appear.

First, Judge O’Connor’s ruling did not block enforcement of the ACA. All of the existing provisions of the ACA with which employers, fully insured plans, and self-funded plans must comply are still in effect. This decision has no effect whatsoever on plan design, on cost containment, on employee incentives, or on regulatory compliance. A quick check of Healthcare.gov reveals that federal officials have even added this reassuring message: “Court’s decision does not affect 2019 enrollment coverage.”

Second, a spokeswoman for the California attorney general has already confirmed that the 16 states (and D.C.) that defended the law will appeal this ruling to the Fifth Circuit Court of Appeals in New Orleans. That means there is a chance that this decision could be overturned before the case reaches the Supreme Court. That possibility brings us to our third point; that legal scholars across the ideological spectrum have found the legal arguments made by the plaintiffs in this case to be remarkably unpersuasive. To understand why, let us break down the court’s opinion (which sided with those arguments).

Judge O’Connor’s opinion had two major elements. First, he contended that since Congress reduced the ACA’s individual mandate penalty to $0, the mandate to purchase insurance must be invalidated. Then, he argued that since the individual mandate is essential to and inseverable from the remainder of the ACA, the entire healthcare law must be struck down. This issue of “severability,” or whether one provision of a law can be severed without invalidating the entire law, is key.

When the ACA was passed in 2010, the bill contained a requirement that all Americans purchase health insurance or pay a penalty. The Supreme Court ruled in 2012 that this requirement, known as the individual mandate, was a legitimate exercise of Congress’s constitutional authority to tax. Nothing in the original 2010 bill spoke to the severability of the individual mandate. Importantly, however, Congress did in 2017 when it eliminated the individual mandate in the Tax Cuts and Jobs Act (“TCJA”) of 2017 and preserved the rest of the ACA. Judge O’Connor’s explanation for this fact is that the 2017 Congress was unable to repeal the individual mandate because of budget rules and it therefore had no intent with respect to the individual mandate’s severability. In fact, Judge O’Connor spends most of his 55-page opinion attempting to discern the intent of the 2010 Congress instead of interpreting this later legislative act.

The political response to this ruling has been rather expressive. One prominent Democratic senator remarked, “This is a five alarm fire – Republicans just blew up our healthcare system.” Indeed, we could go on at length about the consequences if this ruling were to stand; the impact on employer-sponsored plans, the effect on those with pre-existing conditions, the potential loss of health insurance coverage for millions of individuals, and the end of the Medicaid expansion. Yet, based on the response from the legal community and our own legal analysis, our position is that this decision rests on shaky ground. This decision also goes much further than even the Trump administration had wanted. In short, we should all hold our collective horses and conduct business as usual for the time being.


The Phia Group Announces the Formation of Legal Compliance & Regulatory Affairs Team

December 14, 2018 - For Immediate Release

Braintree, MA -- The Phia Group LLC, one of the health benefit industry’s leading cost-containment service providers, announced that it has completed the formal creation of its internal Legal Compliance and Regulatory Affairs (“LCARA”) team.

The members of this Phia Group Consulting (“PGC”) subdivision will handle the most complex Independent Consultation and Evaluation (“ICE”) queries while performing in-depth research meant to benefit both The Phia Group, and its partners. Led by its Director of Legal Compliance & Regulatory Affairs, Brady Bizarro, Esq., as well as Compliance & Oversight Counsel, Andrew Silverio, Esq. and Compliance & Regulatory Affairs Consultant, Philip Qualo, J.D., the LCARA team will diligently track statutory and regulatory changes, to ensure both the continued compliance of The Phia Group as well as its clientele. By focusing both on the company’s own internal needs as well as the needs of its clients, the LCARA team represents a new stage in “crowd sourcing” information and experience.

“There are certainly a few individuals here or there who include this type of work in their list of responsibilities,” The Phia Group’s CEO Adam Russo remarked, “But we are confident that no team has ever been so focused on remaining ahead of legal challenges, and ensuring that both The Phia Group and its allies learn – and benefit – from each other’s growth, wins, and losses.”

To learn more about The Phia Group, its regulatory compliance services, or any of its offerings, please contact The Phia Group’s Sales Executive, Garrick Hunt, at 781-535-5644 or Info@PhiaGroup.com.

About The Phia Group

The Phia Group, LLC, headquartered in Braintree, Massachusetts, 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. Visit www.PhiaGroup.com.


What to Expect in 2019 – Part 2

To build on last month’s webinar (Part 1), join The Phia Group’s legal team for an hour on December 12, 2018, as they present the second part of this two-part series on What to Expect in 2019. Touching on topics such as appeals, stop-loss trends, reference-based pricing, and much more, this webinar will highlight current industry happenings and our predictions to help you look forward to the coming year. Just like last month: miss this one, and you’ll be left behind.

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