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The Irony of Equity – It’s Almost Never Fair
By: Chris Aguiar, Esq.

Self-funded benefit Plans are offered an exclusive equitable remedy.  Equity is really just a fancy word for “fair”, but most of the time – the outcomes in equitable claims aren’t really viewed as fair by anyone involved.  This week I handled a $3.5 million case for which the recovery was limited to $250,000.00.  I couldn’t help but think that no matter the outcome on this case, there is no way for anyone to feel like they got a fair share.

From the Plan’s perspective, It paid $3.5 million and even if It’s are able to recover the entire $250,000.00, it’s not fair that the party at fault for the accident is allowed to walk away without any loss except for those policy insurance limits, which to the insured only really means a premium increase for the next few years.  This sense of a lack of fairness is rooted in a very basic concept – that is, health insurance in a health care reform world is effectively unlimited while auto insurance minimums are governed by the states, with maximums decided by those who purchase the policies; they are really just looking to protect themselves from financial ruin, not those they may harm.

Of course, the Plan participant doesn’t feel like the outcome is fair, either.  This injured party was the son of a plan participant whose life was forever changed for the worse the day he found himself in the wrong place at the wrong time.  Certainly, after being resuscitated 4 times in the emergency room, he and his family are thankful he is still alive, but the stark reality that the responsible party doesn’t really have to suffer for the pain they caused that day, and that they may also lose out on any of the small pool of funds available because it may be taken completely by the Plan cannot be easy to swallow.

No matter what, someone leaves the table unhappy – but parties should to be sure they don’t throw good money after bad.  Doubling down on a bad situation only makes it worse.  If that same participant above gets a lawyer, for example, he likely gives away 1/3 of the $250,000.00, but hasn’t really changed his rights at all – so what was the point?  Benefits plans may have legal doctrine that limit their ability to push for more money – after all, ERISA requires plan fiduciaries to be prudent with Plan assets.  

I can’t stress the importance of having advisors who truly understand the rules of the game and, most importantly, that you trust.  Experienced, trusted advisors are in the best position to maximize the Plan’s recoveries as prudently as possible so that plans don’t end up spending valuable plan assets for nothing.  Equity isn’t always fair, but it is the law, and what’s the point of equity if it leaves you worse off than if you had done nothing at all?


Empowering Plans Segment 20 - Trumping Costs and Climbing the Hill
With this episode, Adam and Ron welcome back a fan favorite – guest star Brady Bizarro – and discuss the wild and crazy happenings in DC.  From contraceptives to cost containment; the impact of fully insured subsidies on self funded plans; and everything in between – this is one lively podcast you cannot afford to miss.

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

More Rule Changes?
By: Kelly Dempsey, Esq.

Just when you thought the 2018 renewal season would be uneventful, the federal agencies and the Trump administration have been busy pumping out rule changes in the last two weeks.  If you tuned into our webinar on Tuesday, October 17, we touched briefly on the changes that have been released, including:

1.    Narrowing of the ACA’s Contraceptive Mandate;
2.    The executive order on Associations and short-term insurance; and
3.    Ending the cost-sharing reductions.

Shortly after the webinar, an apparent deal was reached regarding the funding of the cost-sharing reductions to health insurers which means the cost-sharing reductions will likely continue for another few years.  We’ll be discussing these changes in more detail in an upcoming podcast – so stay tuned.  

As we’ve seen several attempts at repeal and replace fail to come to fruition, it’s possible that we’ll see more rule changes, making the renewal season even more fun.  So for now, don’t fall asleep at the wheel - run to the store and stock up on your favorite form of caffeine to help keep your eyes peeled and tune into our podcasts and webinars for more information.  


Best Practices for Today's Plan Documents

 

 

There’s a reason the law governs how plan documents must be formed and distributed – and it’s that the plan document remains the be-all-end-all of the plan’s and member’s rights. For this reason, it is crucial to ensure that the plan document is compliant to a T, is clear and comprehensible, and is able to contain costs.
 
A plan document can, however, also be a tool that employers can use to improve their businesses as a whole, and a way for TPAs and brokers to distinguish themselves in the marketplace. Join The Phia Group’s legal team as they discuss best and worst plan document practices, provide some creative ideas for plan formation, and suggest some concepts to help perfect plan document drafting.

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An Appealing Option - Affordable Care Act Review

By: Ron Peck, Esq.

Lately, I’ve caught myself talking (often) about fiduciary duty, appeals, and how they relate to each other.  In response to my commentary; that everyone needs to decide who is going to handle appeals and/or function as a fiduciary in that regard… some industry experts have asked how severe is the threat?  How likely is it that they will face a final appeal – make a bad decision – see that decision appear before a court – and be held liable for breaching their duty?  Indeed, in years past, second (final) appeals and external appeals were rare.  To this, I remind folks that as of March 23, 2010, Federal Law entitles all plan members to appeal health benefit plan decisions through an “internal appeal” process. If a benefit plan still denies payment or coverage, the law permits the member to have an independent third party decide to uphold or overturn the plan’s decision. This final process is often referred to as an “external review;” https://www.hhs.gov/healthcare/about-the-law/cancellations-and-appeals/appealing-health-plan-decisions/index.html.

Most benefit plans offer two appeals “internally,” before an “external” appeal can be filed.  The first internal appeal involves the plan administrator or its representative reviewing its initial claim denial.  The second internal appeal – often called the “final” internal appeal (since it is the last “bite at the apple” before a denial is submitted to an external reviewer for an external appeal), usually involves the plan administrator or its representative reviewing their response to the first internal appeal.  The repetitiveness and fact that the same entity is reviewing its own work over and over led lawmakers to include in the Affordable Care Act (“ACA”) provisions enabling participants to demand an external appeal.  Today, any denial that involves medical judgment where the patient or their provider disagree with the health insurance plan’s decision may be externally appealed, as well as any denial that involves a determination that a treatment is experimental or investigational, or cancellation of coverage based on an insurer’s claim that the insured gave false or incomplete information when they applied for coverage.  In 2016, the DOL released a denied claims report (https://www.oig.dol.gov/public/reports/oa/2017/05-17-001-12-121.pdf) indicating that more than 2 million denied claims will be appealed in the next year.  Of that, more than half of those denials are overturned.

Insurance companies in all states must participate in an external review process that meets the consumer protection standards of the health care law, and the cost to the participant (requesting the appeal) can’t be more than $25 per external review; https://www.healthcare.gov/appeal-insurance-company-decision/external-review/.

Prior to these ACA reforms, success rates for appeals have been documented at more than 50% and these reforms provide an even greater likelihood of success when appealing denials; Government Accountability Office (US) Washington: GAO; 2011. Mar, [cited 2012 Mar 10]. Report to the Secretary of Health and Human Services and the Secretary of Labor: private health insurance: data on application and coverage denials. Also available from: URL: http://www.gao.gov/new.items/d11268.pdf.

In light of the low cost to the participant, likelihood of achieving payment (overturn of a denial), and absolute legal right to demand one, the rate of final level internal appeals and external appeals is skyrocketing.  Indeed, many providers of medical services are coaching their patients regarding how to file appeals, and supporting them through the process, as they are incentivized to see denials appealed as well.  As mentioned, the maximum cost to the participant is $25.  Most Independent Review Organizations charge a lot more than that per appeal, with some complex appeals costing thousands of dollars to review.  As a result, benefit plans will be the ones paying the lion’s share of the cost of external appeals; a cost they will incur regardless of whether the denial is upheld or overturned.  Take note: this cost (to utilize an IRO) is not paid once, but twice, by most plans.  Indeed, benefit plans will ordinarily hire an IRO to assist with the final, internal appeal – and if the claim remains denied – hire another IRO for the external appeal.  

Finally, if a claim is denied by the plan – both when first received, again upon first appeal, and again upon final appeal – and the matter is externally appealed… if the external reviewer determines that the claim is not only payable, but that the decision to deny was arbitrary – that plan may be penalized up to treble damages for fiduciary breach.  In other words, if the unpaid (but eventually payable) claims were $100,000.00, the plan may be forced to pay up to another $300,000.00 to the aggrieved parties – for a total payment of $400,000.00.  

So… In response to those who say that, in the past, final appeals, external appeals, and fiduciary liability were never major issues… they may be in for a rude awakening, as providers and patients continue to awaken themselves to the opportunities available to them, to fight denials – at no cost or risk to them.

Contact The Phia Group today about an affordable care act external review!


Empowering Plans Segment 19 - The Man with the Plan
In this episode Adam and Ron discuss the oft overlooked but – in their opinion – all important plan document.  From its purpose to best practices, they discuss why legal compliance, interaction with third parties, and cost containment efforts all start (and end) with the plan terms.  Bring a pen and paper – these tips cannot be missed.

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

The Phia Group's 4th Quarter 2017 Newsletter
Phia Group Newsletter 2nd Quarter

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


The Book of Russo:
From the Desk of the CEO

The fall season is here and that means cooler weather, shorter days, changing leaves… and lots of travel for those of us in the self funding space.  The airport terminal is starting to get to me, but as we all know, once October ends, we have a few months at home before the spring events.   But that doesn't mean that it's not busy; in fact, with the amount of new business that so many of you are bringing to the table, it's busier than ever here at The Phia Group. 

We are talking about new plan documents to write, new stop loss policies to assess, more data to scrub for recovery opportunities, and more claims to review.  But all of this growth comes with potential land mines. We cannot take our eyes off the ball and must continue to innovate while being cautious of not overstepping.  There are so many ways we can empower our plans but we need to ensure that we do it right.

Speaking of right, I am excited about the release of our flagship template.  I spoke to our clients and one thing you wanted was our full template plan document, but with the variables pre-selected… a best practices plan document that had our chosen provisions in place already, saving you 75% of your time filling out long checklists.  Consider it done!  That’s just one example of the news we have to share.  So, without further ado, enjoy the season and happy reading.

Reducing Questionnaires:

Thanks to evolving technology and new resources, The Phia Group can identify subrogation opportunities without sending questionnaires to plan participants.  These recent upgrades to The Phia System™ and advancements in our investigational techniques lead to faster identification of third party liability claims and quicker engagement by The Phia Group’s team, without communicating with the plan participants – identifying opportunities more often, while reducing the volume of accident questionnaires we send to plan participants.  While accident questionnaires are still a useful tool – they are no longer the only tool.  That’s why I am pleased to provide you with the ability to decrease or cease the use of accident questionnaires.  To discuss these new customization capabilities, or our other services, please contact Garrick Hunt at ghunt@phiagroup.com or call (781) 535-5644.



Service Focus of the Quarter: The Phia Group Flagship Template
New Services and Offerings
Phia Group Case Study
Phia Fit to Print
From the Blogosphere
Webinars
Podcasts
The Phia Group’s 2017 Charity
The Stacks
Phia’s Speaking Events
Employee of the Quarter
Phia News


Service Focus of the Quarter: The Phia Group Flagship Template

Our plan document can now be yours in a fraction of the time. Taking the guesswork out of best practices and utilizing optimal provisions, The Phia Group Flagship Template offers an unrivaled plan document, with time and cost effectiveness in mind.

Let us make your life easier and your plan document drafting experience more accurate. With minimal time or monetary investment, you can now take advantage of the industry's most thorough yet efficient plan document production tool. Despite having 75% fewer questions than any other customizable plan document template, The Phia Group Flagship Template is both compliant with federal law, as well as innovative in its use of cost-containment tools and participant incentivizing provisions.

It should therefore come as no surprise that following in-depth review and assessment, The Phia Group Flagship Template is supported by many leading stop loss carriers.

Contact Garrick Hunt at ghunt@phiagroup.com or 781-535-5644 to learn more about how The Phia Flagship Template can help you.


New Services and Offerings:

New Phia Tableau Reporting Portal Tool now available:

At The Phia Group, we value transparency and customer satisfaction above all else. In recognition of those priorities, we routinely improve our client facing reports and reporting capabilities. To that end, we are proud to announce that we will be further expanding our reporting service features. Through the use of Tableau (https://www.tableau.com/), reports will now offer a new level of customization, enabling you and The Phia Group to collaborate like never before. These features are not only available to our Subrogation and Third Party Claim Recovery clients, but also customers utilizing any of our Provider Relations services (such as Phia Unwrapped, Balance Bill Support, and Claim Negotiation and Signoff).

For more information regarding the new Phia Tableau Reporting Tool and pricing, please contact Garrick Hunt at ghunt@phiagroup.com or call him at (781) 535-5644


Cutting back on Questionnaires:

It is The Phia Group’s mission to reduce the cost of healthcare through the use of innovative legal techniques and the most sophisticated technology. In keeping with this goal The Phia Group is always taking steps to improve all of our services, including our earliest: subrogation. Recent upgrades to The Phia System™ and advancements in our investigational techniques have led to faster identification of third party liability claims and quicker engagement by The Phia Group’s team, without relying upon or otherwise communicating with the plan participants. These new resources allow us to identify opportunities more often and more effectively, while at the same time reducing the volume of accident questionnaires we send to plan participants. While accident questionnaires are still a useful tool when investigating and collecting accident details – they are no longer the only tool. As such, we are pleased to now provide all of our subrogation clients with the ability to increase, decrease, or cease the use of plan participant accident questionnaires. Clients can also opt to utilize their own letters, or have the employer communicate directly with plan participants.

The Phia Group is committed to ensuring you and your clients are provided with nothing but the highest quality service, best-in-class performance, and a member first approach. That is why we are continuously improving our services to provide the best performance (and most options) possible.

To discuss these new customization capabilities, or our other services, please contact Garrick Hunt at
ghunt@phiagroup.com or call (781) 535-5644.

 


Phia Group Case Study:

The Phia Group was presented with a case where a self-funded health plan paid a claim based on a network rate; the billed charges were $211,500, and the network rate was 51% of billed charges – netting payment of $107,865. When submitted to stop-loss the group’s carrier denied a portion of the claim paid, citing the stop-loss policy exclusion of all amounts in excess of Usual and Customary amounts, as determined by the carrier.

The kicker: that was all the stop-loss policy’s exclusion said - Usual and Customary was not defined anywhere within the policy.

The carrier was of the opinion that 150% of the Medicare rate was Usual and Customary, and upon that basis allowed only $22,000 – denying reimbursement of nearly $87,000 that the Plan paid pursuant to its PPO contract. The group attempted to appeal the denial, but the carrier stood firm; the group was all but ready to give up the fight, when the group changed brokers and the new broker’s first order of business was to consult The Phia Group.

The Phia Group got in touch with the stop-loss carrier on the group’s behalf and attempted to explain the group’s position. The existence of the PPO contract and required payment amount combined with the carrier’s lack of explicit, supporting policy language in the stop-loss policy (along with other arguments – legal and common sense) formed the basis of our position. After many rounds of discussions, the carrier agreed to reimburse the entire claim paid except for $2,073 in “ineligible” charges.

The plan’s liability for the denied stop-loss claim was $87,000, and The Phia Group’s intervention helped save $85,000.


Fiduciary Burden of the Quarter:

Traditionally, we have discussed fiduciary burdens in terms of companies that perform “plan” functions– such as repricing claims or administering appeals – but this quarter has seen certain instances in which those that perform “settlor” functions (most prominently a broker placing stop-loss or network coverage) have encountered some fiduciary issues. For example: a recent dispute between a plan, its broker, a network administrator, and stop-loss carrier in which the broker apparently placed inadequate or insufficient stop-loss coverage to support a network’s standard policies. The issue is that the network contract required payment of claims that the carrier did not cover; caught in the cross-fire is the broker, who placed this business, and who allegedly should have been aware of the potential discrepancy.

The allegation? That the broker simply provided bad guidance regarding the choice of which network/carrier combination the plan should use. It is a very easy mistake to make and one that can potentially be made by anyone placing business. Our advice to brokers, TPAs, and other advisors, is to make sure you are as diligent as possible when making decisions for, or even making suggestions to, your clients. Self-funded plan sponsors and plan administrators rely heavily on their advisors; when they are given questionable advice, the backlash can be huge – and it can be unexpected.

Our popular services: plan document review, stop loss policy review, and Gap-Free Analysis  (which compares the stop-loss policy to a plan document, network contract, or other materials), can help identify issues and potential “gaps” in coverage before they happen. This can mean the difference between spending $120,000 on a new Maserati, and spending $120,000 to indemnify your client from an unexpected stop-loss denial.

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Phia Fit to Print:

• Money Inc. – “Affordable” Health Insurance Is Not “Affordable” Health Care – May 11, 2017

• Boston Voyager – Meet Ron E. Peck of The Phia Group in Braintree – August 7, 2017

• Money Inc. – All Against One and One Not for All: A Case Against a Single Payer System – August 21, 2017

• Bloomberg – Employers Taking Action to Control Health-Care Costs – September 5, 2017

• California Broker Magazine – Even as “Repeal and Replace” Falters Self-funding Remains Strong September 7, 2017

• Self-Insurers Publishing Corp. – State-mandated Continuation of Coverage and ERISA Preemption: What Self-funded Employers Need to Know – August 4, 2017

• Self-Insurers Publishing Corp. – Taking Health Care International - The Growing Trends of Importing Care and Exporting Patients – July 3, 2017



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From the Blogosphere:

Stop Loss and My Infinite Sadness. You get what you pay for.

Uncertainty Prevails in the Health Care Debate. The dog days of summer have come and gone.

Reverse Medical Tourism. US patients are seeking services abroad to obtain services and care at more affordable rates.

Spinning the Web of the Plan Document. No, this isn’t about spiders.

 

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



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Webinars

Best Practices for Today's Plan Documents

On October 17, 2017, The Phia Group will present “Best Practices for Today's Plan Documents,” where our legal team will discuss best and worst plan document practices, provide some creative ideas for plan formation, and suggest some concepts to help perfect plan document drafting.

Click HERE to Register!

On September 21, 2017, The Phia Group presented “It’s Time To Renew – Revisiting Stop Loss Trends,” where we discussed understanding procedures preemptively, reviewing a plan document side-by-side with the stop loss policy, and agreeing upon language interpretations.

On August 22, 2017, The Phia Group presented “A True Impact on the Bottom Line – Identifying Current Issues, Implementing Solutions & Seeing Results,” where we discussed the biggest issues impacting the health benefits industry today.

On July 13, 2017, The Phia Group presented “Consulting Headlines – The Hottest Topics in Benefit Plan Administration,” where our legal team discussed how laws are changing, regulations are shifting, and benefit plans are scrambling to keep up.



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Podcasts:

On September 11, 2017, The Phia Group presented “Cutting Out Conflict,” where our legal team explained what plan administrators can do to cut out conflict and tie up loose ends before they suffer a costly loss.

On August 21, 2017, The Phia Group presented “In Reference to reference Based Pricing,” where Adam Russo and Ron Peck picked apart the method for containing costs, identified the pros and cons of an “RBP” plan, and discussed options to customize such a program.

On August 11, 2017, The Phia Group presented “Stopping the Bleeding,” where The Phia Group’s CEO, Adam Russo and Attorney Brady Bizarro interviewed Garrick Hunt, Phia’s Sales Executive.

On August 7, 2017, The Phia Group presented “Repeal & Replace Fails: What’s Next,” where The Phia Group's CEO, Adam Russo, Sr. VP, Ron Peck, and Attorney Brady Bizarro discussed the dramatic events on Capitol Hill and the shocking failure of Senate Republicans to repeal and replace Obamacare.

On July 17, 2017, The Phia Group presented “Your Friendly Neighborhood Provider,” where Ron Peck, Jon Jablon and Andrew Silverio shared stories and examples of providers working with payers to preserve the private employer based group health plan industry.

On July 10, 2017, The Phia Group presented “The Cost of Care,” where The Phia Group's CEO, Adam Russo and Sr. VP, Ron Peck, interviewed Attorney Jon Jablon - Director of Provider Relations

Be sure to check out all of our latest podcasts!

 



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The Phia Group’s 2017 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 2017 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 youth 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.

On Friday, August 24th, employees of The Phia Group participated in the annual volunteer day at The Boys & Girls club of Brockton. Employees of The Phia Group hosted a number of activities that all of the children truly enjoyed. This year, The Phia Group collected and donated $4,500 to help keep this program running and enjoyable for years to come!  


The Phia Group invites its staff to donate various items for the benefit of The Boys and Girls Club of Brockton. For more information or to get involved, visit www.bgcbrockton.org.



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The Stacks

Aid-in-dying Laws and the Implications for Self-Funded Plans

By: Maribel E. McLaughlin, Esq. – September 2017 - Self-Insurers Publishing Corp.


Two years ago, a woman close to my mother was diagnosed with an aggressive form of brain cancer. Along with her two daughters, she went through the various treatment options presented to her and determined that she was going to try all of them. She wanted to put her best foot forward for her daughters and her granddaughter, and she found the strength to fight the cancer with every cell in her body.

Click here to read the rest of this article


State-mandated Continuation of Coverage and ERISA Preemption: What Self-funded Employers Need to Know

By: Brady Bizarro, Esq. – August 2017 - Self-Insurers Publishing Corp.

According to one prominent health law attorney, “Although in its text ‘hospital’ appears only once and ‘physician’ not all, ERISA may be the most important law [prior to the Affordable Care Act] affecting health care in the United States.” William Sage, “Health Law 2000”: The Legal System and the Changing Health Care Market, 15(3) Health Aff. 9 (Aug. 1996). Understanding the intricacies of the Employee Retirement Income Security Act of 1973 (“ERISA”) and its preemption clause can be a challenge for even the most assiduous attorney. The statute supersedes any and all state laws insofar as they “relate to” any employee benefit plan. It also contains a “savings clause” which preserves the state’s traditional role of regulating insurance. That clause is then qualified by the “deemer clause,” which acts as a kind of escape hatch through the savings clause. For employers, that escape hatch is key because it allows them to avoid state insurance regulations by self-funding their health plans rather than by purchasing health insurance. Increasingly, however, states are testing the limits of preemption by passing leave laws which mandate that employers continue health insurance coverage for eligible employees out on leave.

Click here to read the rest of this article.


Taking Health Care International – The Growing Trends of Importing Care and Exporting Patients

By: Andrew Silverio, Esq. – July 2017 – Self-Insurers Publishing Corp.


Esteemed physicist Richard Feynman is remembered by many for the phrase “If you think you understand quantum mechanics, you don’t understand quantum mechanics.” This sentiment rings true for the continually evolving landscape of our healthcare system as well, and the problems facing all of us, particularly as insurers, employers, and patients. For those of us within the healthcare or health risk industries, the more we learn about the problems we face and what is causing them, the more we realize just how complex the landscape is and what an impossible task it would be for any single solution to reel in the cost of care.

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:

• 7/12/17 – Montana Captive Conference – Whitefish, MT “High Performing Self-Insured Health Plans – The Key to Successful Stop-loss Captive Programs”

• 8/9/17 – NAHU Region 1 Meeting – Stamford, CT “The Best gets Better: Getting the Most out of Your Self-Funded Plans”

• 9/19/17 – Custom Design Benefits – Cincinnati, OH “The Top 10 Innovations in Self-Funding”

• 9/27/17 – TABA’s 2017 Fall Conference and Membership Meeting - The Woodlands, TX “Gap Traps: Avoiding Variances between the Employee Handbook and the Plan Document”

• 10/3/17 – NHAHU – Bedford, NH “Top 10 Do’s & Don’ts of Self-Funding”

• 10/4/17 – Hewitt Coleman Broker Meeting – Greenville, SC “The Future of Self-Funding & Reference Based Pricing”

• 10/16/17 – Captivated Health Membership Meeting – Woburn, MA “Empower & Engage Through Your Handbook”

Ron Peck’s 2017 Speaking Engagements:

• 9/19/17 – CIC-DC 2017 Annual Conference – Washington, D.C. “Cost Containment Strategies”

Tim Callender’s 2017 Speaking Engagements:
• 7/17/17 – Health Care Administrator’s Association TPA Summit – St. Louis, MO “Conference Emcee”

• 8/17/17 – FMMA 2017 Annual Conference – Oklahoma City, OK “Critical Strategies in Self-Funding to Promote the Free Market”

• 9/21/17 – Metro Detroit Association of Health Underwriters, Annual Conference – Troy, MI “The Real Causes of High Healthcare Costs & True Cost-Containment Strategies to Combat Cost.”

• 10/10/17 – SIIA, National Educational Conference & Expo – Phoenix, AZ “Through the Looking Glass – a Non-Vendor Take on Reference Based Pricing”

Brady Bizarro's 2017 Speaking Engagements:
• 7/18/17 – HCAA TPA Summit 2017 – St. Louis, MO “Ethics”

• 8/9/17 – TPAC 2017 Conference – Philadelphia, PA “Most Common Mistakes Employers Make in Their Plan Documents.”

• 9/26/17 – TABA’s 2017 Fall Conference and Membership Meeting - The Woodlands, TX “Gap Traps: Avoiding Variances between the Employee Handbook and the Plan Document”

 

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Get to Know Our Employee of the Quarter:
Kerri Sherman

Congratulations to Kerri Sherman, The Phia Group’s Q3 2017 Employee of the Quarter!

“Kerri consistently goes above and beyond to help all of us when help is needed. Kerri is always around to provide assistance and help out wherever she can! Whether it be training, or making sure we have all the tools we need to complete our work. She has been in the training room at times working with new people, but always keeps us informed of where she will be and what she is doing, so if any issues arise, we know how to proceed. We think she is a fantastic multi-tasker and is always supportive. She always provides quick feedback if something requires immediate attention and always provides detailed explanations of everything that needs to be done in order to solve the issue. We have appreciated all the hard work she has done to help me keep my case load at bay especially while we were preparing to go on vacation. We think she has been phenomenal and we are happy to have her on our team. She is reasonable and fair, while maintaining professionalism.”



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


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Phia News

    Catherine Dowie’s Latest Win

    We would like to congratulate Catherine Dowie on her latest win! Phia’s own Catherine Dowie won a $25,000 prize in the Philip Shawe Scholarship Competition, tying for second place in a pool of 240 applicants who submitted briefs to the crowd sourcing contest. We are proud to have you on our team. Get all of the details in recent article published by Suffolk University Law School.


    Job Opportunities:

    • Customer Service Representative

    • Claims Specialist

    • Medical Bill Negotiator

    • Health Benefit Plan Consultant I

    • Health Benefit Plan Administration – Attorney II

    • Product Development Manager

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

     

    Babies

    • Jamie Johnson gave birth to Miles and Kaia on 7/10/2017


    Promotions

    • Ulyana Bevilacqua was promoted from Consultant to Supervisor, PGC

    • Elizabeth Pels was promoted from Legal Assistant to Claim Recovery Specialist

    • Joseph Bacon was promoted from Legal Assistant to Claim Recovery Specialist


    • Vourneen O’Donovan was promoted from Legal Assistant to Claim Recovery Specialist

    • Cheyenne Fonseca was promoted from Legal Assistant to Claim Recovery Specialist

    New Hires

    • Joseph Bacon was hired as a Legal Assistant

    • Naveen Omkar was hired as an IT Technologist

    • Trevor Schramn was hired as a Sales and Accounts Coordinator

    • Jeff Booth was hired as a Training and Development Manager

    • Jen Montalto was hired as a Case Investigator/Stop Loss

    • Mike Mears was hired as a Claim Analyst

    • Gordon Glenn was hired as an IT Technologist

    • Olesya Avramenko was hired as a Consultant I


    • Michelle Rowland was hired as a Consultant I

    • Alexandra Simboski was hired as a Consultant I

    • Patrick Ouellette was hired as a Juris Doctor

    • Andrew Fine was hired as an Intake Specialist

    • Erin Hussey was hired as an Attorney I

    • Catina Griffiths was hired as a Case Investigator

    • Samad Khan was hired as a Contract Administrator


    • Zackery McLaren was hired as a Case Investigator

    • Kaley Dennison was hired as a Case Investigator

    • Ekta Gupta was hired as an ETL Specialist

    • Kathy baker was hired as a Claim Recovery Specialist IV-WC

    • Annie Heskin was hired as a Talent Acquisition Specialist

    Fun at Phia:

    Solar Eclipse of 2017




    Rock Star Recognition:

    The Phia Group was recently awarded the “Rock Stars of Health GOLD Award” during The Rock Stars of Health Summit held in Missoula, Montana on September 29, 2017.




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info@phiagroup.com
781-535-5600

The Stacks - 4th Quarter 2017

Aid-in-dying laws and the Implications for Self-Funded Plans
By: Maribel E. McLaughlin, Esq.

Two years ago, a woman close to my mother was diagnosed with an aggressive form of brain cancer. Along with her two daughters, she went through the various treatment options presented to her and determined that she was going to try all of them.  She wanted to put her best foot forward for her daughters and her granddaughter, and she found the strength to fight the cancer with every cell in her body.  After sixteen months of treatment, losing her hair, the inability to eat properly, and her body being riddled with the toxins that were used to fight the cancer, she decided that she wanted to end her life; her way, on her own terms.  She had a lengthy discussion with her daughters about her choice, and as sad as they were that they would soon be losing their mother, they understood that their mother wanted to live every moment to its fullest, but, when she was ready, she would make the decision to die on her own terms.  One particularly difficult night, she pushed herself to take one last walk through the Newport Cliff Walk with her daughters and granddaughter, enjoyed her last Del’s lemonade, savored the final clam chowder she was going to have, and decided that this was her chance to end her life on a high note.  That night, she took a higher dose of the medicine that she had been taking for the last sixteen months, and never woke up.  She purposely overdosed; or, as many would call it, she committed suicide.

D.C.’s New Death with Dignity Act
The Death with Dignity Act went into effect on February 18, 2017 in Washington D.C., and last month, doctors were able to begin the process of prescribing life-ending drugs to terminally ill patients; adding the District to six states that currently authorize that practice.  

The D.C. Health Department launched a website where physicians can register to participate in the “Death with Dignity” program, where doctors, pharmacists, and patients can learn about the law’s requirements and patients and doctors can download required forms.  Patients must be older than eighteen with a prognosis of less than six months to live in order to be eligible. In addition, they must have made two requests at least fifteen days apart for life-ending medications. They must ingest the drugs themselves, and two witnesses must attest that the patient is making the decision voluntarily.

Affordable Cara Act & Physician-Assisted Suicide
According to Section 1553 of the Affordable Care Act (“ACA”) , a health plan may not discriminate against an individual or institutional healthcare entity because the entity does not provide any healthcare item or service that causes, or assists in causing, the death of any individual, such as by assisted suicide, euthanasia, or mercy killing.  Put another way, if terminally ill patient requests that his doctor help him end his life, and the doctor refuses for moral or other reasons, that doctor is protected against discrimination by federal law.  This protects the doctor that may be targeted by insurance company because of their refusal to help patients end their lives.

California’s Election of Death of Dignity Law
In California, one of the six states, the law does not make it easy for a patient to elect death with dignity; the patient must be terminally ill to request a doctor’s prescription for medications intended to end their lives peacefully.  The End of Life Option Act creates a long list of administrative obstacles that both patients and doctors must overcome. At the time of the law’s enactment, it became the fifth state to implement an aid-in-dying law, and it is currently also the most stringent.  Patients must get a prescription from a participating physician.  This is not as easy as it may seem A coordinator may connect the patient with a physician that participates; but, if the patient is a U.S. military veteran that receives healthcare from the U.S. Department of Veterans Affairs, that patient will not be able to utilize this state law since federal law prohibits the use of federal funds for this purpose.  Additionally, the forty-eight Catholic and Catholic-affiliated hospitals located in California will not provide patients with the option to end their lives.   

Cost of Death vs. Cost of Healthcare
Another obstacle that patients may come across is the cost of the drugs involved with the assisted suicide practice.  The patient’s health plan may not cover them - and the states that have allowed the practice of assisted suicide do not require health insurers to cover the medications.  Under The Employee Retirement Income Security Act of 1974 (ERISA), there are minimum standards for voluntarily established health plans in private industry to provide protection for individuals in these plans; plans must provide participants with information about plan features and funding, and furnish information regularly and free of charge.  Nothing about the Acts requires that a self-funded plan under ERISA, cover the cost of the death-with-dignity practice. Luckily under ERISA, a Plan still has the liberty to create their health benefits. A health plan, when drafting their Plan Document, can choose to either allow this practice, or not. The ACA prohibits the discrimination of a provider that does not provide assisted suicide services.  The Act does not require health plans to allow the practice. The option is left to the Plan.

Healthcare costs in the United States have risen astronomically over the past decade and many people fear that insurance companies may look to assisted suicide as a way for a health plan to save money of expensive medical care.  One report concluded that it would save approximately $627 million dollars in 1995.   Some, who oppose assisted suicide, argue that insurance companies may begin to limit expensive procedures for patients who are suffering from terminal illnesses such as cancer, AIDS, and multiple sclerosis.  Others argue that even though the aggregate savings is small, the impact on an individual company or an individual family would be a powerful enough financial incentive to encourage the practice even where it was not intended.   Many fear that patients would be more likely to consider physician-assisted suicide as a better alternative with the added bonus of saving their family money and the burden of prolonged, expensive care. Insurance companies may try to exclude life-saving or life-extending drugs and pressure people into thinking about the practice of physician assisted suicide.

Collins and the Suicide Exclusion
Health plans are permitted to include a suicide exclusion that would enable the plan administrator to deny claims associated with the suicide. In Collins v. Unum Life Insurance Co., 185 F. Supp.3d 860 (2016),  the Supreme Court held that “Unum reasonably interpreted the suicide exclusion to encompass insane suicide, [and that] Mr. Collins' sanity at death has no bearing on the outcome.”  The issue in this case involved a state law which stated that a suicide exclusion would be only be valid if liability was limited to an insured “who, whether sane or insane, dies by his own act.”  Former Navy SEAL David M. Collins served this country for seventeen years, during which he was deployed to Iraq, Afghanistan, and Kuwait. He served in dangerous and stressful situations, many of which exposed him to enemy gunfire and blasts from mortar fire.   Despite seeking treatment, Mr. Collins was found dead in the driver's seat of his car with a gunshot wound to his head on March 12, 2014. The death was ruled a suicide.  Prior to his death, Mr. Collins had been working for Blackbird Technologies, where he participated in an employee benefit plan that provided basic and supplemental life insurance through group policies funded and administered by Unum Life Insurance Company of America.  When Mr. Collins died, his widow, Jennifer Mullen Collins, applied for benefits under both policies. Unum granted benefits under the basic policy, but denied benefits under the supplemental policy's suicide exclusion.  In addition, the Court held that it found “substantial evidence in the administrative record to support Unum's conclusion that the suicide exclusion applied.”

Option to Elect or Exclude Suicide
Plan administrators can take the position of either excluding assisted-suicide claims or paying them.  They can allow the practice, and give the power to the patient to make the decision for themselves, and ultimately save the Plan money for care that the patient would have ultimately not wanted; or, they can exclude the practice and have the peace of mind that everything that should have been covered was covered.  Whether you’re a broker, a health plan sponsor, third-party administrator, or reinsurer, this is something that should not only spike an interest, but also it should worry you if you have health plans in the states that allow physician assisted suicide practices.  Specialists in plan document drafting can provide assistance in reviewing your plan document and ensuring that the plan document addresses this issue specifically.
_________________________________________
1 HHS Office of the Secretary & Office for Civil Rights (OCR), Section 1553 - Refusal to provide assisted suicide services HHS.gov (2015), https://www.hhs.gov/civil-rights/for-individuals/refusal-provide-assisted-suicide-services/index.html (last visited Aug 9, 2017).
2 42 U.S. Code § 18113 (2010)
3 AB-15 End of life.(2015-2016), Bill Text - ABX2-15 End of life. (2015), https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201520162AB15 (last visited Aug 9, 2017).
4 Id.
5 Emily Bazar, Aid-In-Dying: Not So Easy Kaiser Health News (2017), http://khn.org/news/aid-in-dying-not-so-easy/ (last visited Aug 9, 2017).
6 29 U.S.C. 18 § 1001
7 Physician Assisted Suicide and Health Care Costs, Low Fat Diet Plan, http://lowfatdietplan.com/weight-loss-routine/end-of-life-care/physician-assisted-suicide-and-health-care-costs (last visited Aug 9, 2017).
8 Id
9 Id.
10 Collins v. Unum Life Insurance Co., 185 F. Supp.3d 860 (2016)
11 Id. at 882
12 Id. at 871
13 Id. at 863
14 Id. at 864
15 Id. at 863
16 Id. at 865
17 Id. at 880
________________________________________________________________________________________________________________________
State-mandated Continuation of Coverage and ERISA Preemption: What Self-funded Employers Need to Know
By: Brady Bizarro, Esq.

According to one prominent health law attorney, “Although in its text ‘hospital’ appears only once and ‘physician’ not all, ERISA may be the most important law [prior to the Affordable Care Act] affecting health care in the United States.” William Sage, “Health Law 2000”: The Legal System and the Changing Health Care Market, 15(3) Health Aff. 9 (Aug. 1996). Understanding the intricacies of the Employee Retirement Income Security Act of 1973 (“ERISA”) and its preemption clause can be a challenge for even the most assiduous attorney. The statute supersedes any and all state laws insofar as they “relate to” any employee benefit plan. It also contains a “savings clause” which preserves the state’s traditional role of regulating insurance. That clause is then qualified by the “deemer clause,” which acts as a kind of escape hatch through the savings clause. For employers, that escape hatch is key because it allows them to avoid state insurance regulations by self-funding their health plans rather than by purchasing health insurance. Increasingly, however, states are testing the limits of preemption by passing leave laws which mandate that employers continue health insurance coverage for eligible employees out on leave.

Perhaps the best known leave law is the federal Family and Medical Leave Act of 1993 (“FMLA”). The statute, like most other federal laws, applies regardless of the source of insurance. It requires employers to provide twelve weeks of unpaid, job-protected leave for an employee’s own serious health condition, for the birth or adoption of a child, or to care for a spouse, parent, or child with an illness. Significantly, the law also requires employers to maintain group health benefits for employees who take FMLA leave. Even though this continuation of coverage requirement clearly impacts self-funded ERISA plans, federal laws such as the FMLA are outside the scope of ERISA preemption.

At the state level, five states have now passed laws to address a perceived gap in the FMLA, granting eligible employees paid family leave: California, New Jersey, Rhode Island, Washington, and New York. Rhode Island law requires four weeks of paid leave, California and New Jersey each offer six weeks of paid leave, and Washington offers up to twelve weeks per year. New York’s Paid Family Leave Act (“PFL”), scheduled to take effect on January 1, 2018, offers one of the longest and most comprehensive paid family leave laws in the country. What makes the PFL unique is not just that it requires employers to provide twelve weeks of paid family leave; it also requires employers to continue health insurance coverage to employees out on leave. While this state-mandated employer obligation would seem to fall squarely under the purview of ERISA preemption, it turns out that determining the scope of ERISA preemption is an arduous task.

The key question to answer is whether the state law at issue “relates to” an ERISA plan.  The U.S. Supreme Court has said that a state law “relates to” an employee benefit plan covered by ERISA if it refers to or has a connection with that plan, even if the law is not designed to affect the plan or the effect is only indirect. See, e.g., Ingersoll-Rand Co. v. McClendon, 498 U.S. 133, 139 (1990). This implies that there is no relevant distinction between obligations imposed on the employer versus on the employee benefit plan for purposes of determining whether ERISA preemption applies. Simply put, state laws which impose obligations on employers, and not specifically plans, may still be preempted. In addition, the Court has held that ERISA does not preempt state laws which have only a tenuous, remote, or peripheral connection with an ERISA plan, as is typically the case with laws of general applicability.

The Court directly addressed ERISA preemption and a state law which mandated the extension of health insurance coverage in District of Columbia v. Greater Washington Bd. of Trade, 506 U.S. 125 (1992). In Greater Washington, the Court reviewed a Washington, D.C. law which required employers who provided health insurance for their employees to provide equivalent health insurance coverage for employees eligible for workers’ compensation benefits. The Court explained that when a state law specifically refers to benefit plans regulated by ERISA, that provides a sufficient basis for preemption. It made no difference to the Court that the law also related to ERISA-exempt worker-compensation plans or non-ERISA plans. Once it is determined that a state law relates to ERISA plans, this is sufficient irrespective of whether the law also relates to ERISA-exempt plans.
 
In earlier cases, petitioners argued that ERISA preemption should be construed to require a two-step analysis: if the state law “related to” an ERISA-covered plan, they argued, it may still survive preemption if employers could comply with the law through separately administered plans exempt from ERISA (making the distinction between a plan requirement and an employer requirement). See generally Metropolitan Life Ins. Co. v. Massachusetts, 471 U.S. 724 (1985). In Greater Washington, the U.S. Supreme Court dismissed that analysis, stating, “We cannot engraft a two-step analysis onto a one-step statute.” See Greater Washington, at 133. Despite the Court’s rulings, the breadth of the “relate to” clause remained unclear and the question of state-mandated continuation of coverage was not directly addressed.

In 2005, the Department of Labor (“DOL”) seemed to put this issue to rest in an advisory opinion on the applicability of leave substitution provisions of the Washington State Family Care Act (“FCA”) to employee benefit plans. The FCA permits employees entitled to sick leave or other paid time off to use that paid time off to care for certain relatives of the employee who had health conditions or medical emergencies. As part of its analysis, the DOL analyzed section 401(b) of the FMLA, which provides that state family leave laws at least as generous as the FMLA are not preempted by “this Act or any amendment made by this Act.” 29 U.S.C. § 2651(b). Further, the DOL cited to a 1993 Senate report which recounts a colloquy between Senators Chris Dodd (D-CT) and Russ Feingold (D-WI). The discussion involved the leave substitution provisions of the Wisconsin FMLA and ERISA preemption. The record revealed that Senator Dodd, the chief sponsor of the FMLA, remarked, “The authors of this legislation intend to prevent ERISA and any other [f]ederal law from undercutting the family and medical leave laws of States that currently allow the provision of substitution of accrued paid leave for unpaid family leave…” The DOL relied on this exchange as additional support for the notion that state family leave laws at least as generous as the FMLA (including leave laws that provide continuation of health insurance or other benefits) are not preempted by ERISA or any other federal law.

As a result of the department’s guidance, it appeared as if state family leave laws enjoyed special protections from ERISA preemption. In 2014, the Sixth Circuit Court of Appeals considered the same issue and reached the opposite conclusion. In Sherfel v. Newson, 768 F.3d 561 (2014), the Court found that the leave substitution provisions of Wisconsin’s FMLA sufficiently “related to” an ERISA plan such that they were preempted by ERISA. Specifically, the Court held that the state law would “mandate the payment of benefits contrary to the [written] terms of an ERISA plan,” thus undermining one of ERISA’s chief purposes; achieving a uniform administrative scheme for employers. Newson, at 564. As part of its analysis of the preemption issue, the Court also dismissed the legislative history relied upon by the DOL in an uncommonly blunt (and borderline satirical) manner. Considering whether legislators intended to preclude the preemption of state family leave laws by ERISA, the Court observed, “[T]he idea that this colloquy ever passed the lips of any Senator is an obvious fiction. Colloquies of this sort get inserted into the Congressional Record all the time, usually at the request of a lobbyist…” Newson, at 570.

By ruling that a state family leave law was preempted by ERISA, the Sixth Circuit Court of Appeals aligned itself with the U.S. Supreme Court’s earlier jurisprudence on preemption. It remains to be seen how other Circuit Courts will address similar challenges to state leave laws; especially those that mandate continuation of coverage. The conservative approach for employers would be to continue health coverage when required by state law; however, the Sixth Circuit is the highest court to address this issue to date, and self-funded employers would be on solid footing to use ERISA preemption as a shield against state-mandated continuation of coverage.

Paid family leave is one of the few policies in Washington, D.C. that has bipartisan support, and employers should expect to see more states pass laws akin to New York’s Paid Family Leave Act. The President explicitly referred to paid family leave in a speech to a joint session of Congress on February 28, and his 2018 budget proposes six weeks of federal paid parental leave. While it remains unclear if that policy will become law, the trend is likely to continue at the state level, and as those laws impact self-funded health plans, the issue of continuation of coverage and ERISA preemption will increasingly attract the scrutiny of the courts.

Brady Bizarro, Esq. is an attorney with The Phia Group, LLC.
________________________________________________________________________________________________________________________
Taking Health Care International – The Growing Trends of Importing Care and Exporting Patients
By: Andrew Silverio, Esq.

Esteemed physicist Richard Feynman is remembered by many for the phrase “If you think you understand quantum mechanics, you don’t understand quantum mechanics.”  This sentiment rings true for the continually evolving landscape of our healthcare system as well, and the problems facing all of us, particularly as insurers, employers, and patients.  For those of us within the healthcare or health risk industries, the more we learn about the problems we face and what is causing them, the more we realize just how complex the landscape is and what an impossible task it would be for any single solution to reel in the cost of care.

In tow with the cost of care, health premiums as well as per capita healthcare spending in America steadily increase every year.  This should not be news to anyone, and countless strategies have been proposed to slow and eventually reverse this inflation.  But, for many, the immediate objective isn’t to “fix” healthcare or undo the decades of developments which brought us here.  For many, the immediate goal is just to get care for their employees and families in an affordable way.  Although this problem is not uniquely American, we spend more of our GDP on healthcare than any other country (by a wide margin), and care is more expensive here than anywhere else.  As such, several newer strategies for cost containment are reaching beyond our borders into the international market – and doing so with impressive results.

One strategy aims to avoid the exceedingly high prices of some prescription medications in America by simply getting them from elsewhere.  Countries designated as “Tier 1” countries (including Canada, the UK, Australia, and New Zealand) have safety and efficacy standards which equal or exceed American standards, and enjoy significantly lower prices for drugs which are often chemically identical.  So, why hasn’t the American prescription drug market self-corrected due to this international competition?  The simple answer, and the reason many employers are hesitant to take advantage of this option, is that the practice is illegal.  Under federal law, drugs which are manufactured for sale outside the country are not FDA approved, as there is no potential for oversight in the manufacturing process.  Additionally, even if the foreign version of the drug is chemically identical in every respect, FDA guidelines address more than just the chemical makeup of the drug – they relate to labeling, storage, and transportation as well.  So, even a drug manufactured within the United States for sale outside of the country would be considered illegal if it was later re-imported into the country.

So, if importing foreign drugs is illegal, how is it a viable option for cost containment?  It’s possible, under the right circumstances, due to a well documented FDA policy of “enforcement discretion”.  Under this policy, the FDA does not prosecute individuals who import a limited quantity of prescription medications from abroad for personal use.  This discretion is based on several factors, including that the drug is for personal use only and that the amount imported is no more than a 3 month supply. So, if a program is set up correctly, the savings on many costly medications can be huge, with very minimal risk to the employer.  Two important things to consider, though, are safety and plan document design.  Regarding safety, it’s important to remember that just because a drug comes from a “Tier 1” country does not mean it is safe.  Just as you (probably) wouldn’t buy prescription drugs from someone out of a suitcase on the street, it’s important to ensure that you are working with reputable people and pharmacies abroad when dealing with this type of program.  There have been incidents involving drugs which were imported from Tier 1 countries after being manufactured in other countries with more lax standards, as well as incidents were drugs were found to be outright counterfeits.  Regarding plan document design, any given plan document likely has some existing barriers to making a seamless transition into reimbursing for expenses such as these.  Any exclusions or language which would conflict must be removed, and these changes should be approved by the plan’s stop-loss carrier and TPA (and ideally the PBM as well).  But again, when set up and run properly, this type of program can generate significant savings with minimal risk to the employer or patient.

Another trend picking up steam is specialized medical tourism.  Medical tourism is certainly nothing new, both within the country and internationally, but we are seeing a new trend – providers gearing their business model to specifically target medical tourism, and sometimes even specific conditions/illnesses.  When a facility specializing in a certain surgical procedure or implant, or treating a disease with particularly costly treatment, sets up shop just over the boarder or just offshore, it’s surely no coincidence.

A prime example of this is Health City Cayman Islands. Health City is a brand new facility (they took their first patient in 2014) that offers a broad spectrum of healthcare services, but none illustrate the savings potential better than their hepatitis C program.  Of course, a medical tourism offering only helps an employer save money if patients want to utilize it.  Health City seems to understand this – along with the appeal of their tropical location they offer travel planning assistance, transportation, and concierge services including arranging local activities and excursions.  The leading prescription hepatitis C medications can cost nearly $100,000 in the United States for a single 12 week course of treatment.  Many employers may be surprised to hear that in light of this, as compared to simply purchasing the drug at the local pharmacy, it can actually be significantly less expensive to put a patient on a plane (with a companion) and fly them to the Caribbean for treatment, including all ancillary services and testing and prescription medications dispensed onsite, all as part of what is essentially a free vacation.  The same concept is being applied with increasing regularity to other treatment, including surgical procedures.

Just as with drug importation, there are some practical house cleaning tasks a plan must take care of before introducing any sort of medical tourism benefit, particularly if patients will be traveling internationally.  A common barrier could be any existing plan exclusions for international treatment.  This and any other conflicting exclusions must be removed and cleared with interested parties, just as with an importation reimbursement benefit.  Another consideration with a medical tourism benefit is potential conflicts with the employer’s network agreement.  Many such agreements require that the in-network incentive be the “best” available, so if the in-network coinsurance is 20%, and the plan offers a “zero out-of-pocket” option to incentivize patients to use the new program, there could be trouble.  By that same token, the limitation could only apply within the network’s service area, which would mean there is no problem.  It is important to have a professional review these agreements to make sure the employer isn’t creating any liability for itself.

While many great minds continue to grapple with the puzzle of bringing American health costs down, many patients and employers simply cannot afford to wait for a complete solution.  These globally-minded strategies are just a few of the creative ways employer plans, vendors, and providers are attempting to make care more affordable and accessible.  The potential for savings is huge, and the quality of care can be just as high as or higher than comparable treatment domestically. Ultimately, those who reap the benefits will be those who are willing to innovate, and utilize new methods and strategies outside of the traditional employee benefit playbook.


Trump Administration Birth Control Roll Back
By: Jen McCormick, Esq.

The Trump Administration announced an impactful change via an interim final rule, effective immediately (i.e. October 6, 2017) to the ACA’s contraceptive mandate for some self-funded plans and their third party administrators.

These new HHS regulations allow a larger pool of entities (i.e. employers) to opt out of the ACA preventive care contraception requirements. Specifically, the regulations allow (1) employers with contrary religious beliefs and (2) organizations and small businesses with objections based on their moral convictions to opt out of this women’s preventive care mandate.

Prior to October 6, 2017, this exemption was limited to certain houses of worship, nonprofits with religious affiliations and closely held for-profit entities. Now, a much broader scope of entities (i.e. nonprofit organizations, for-profit companies, publicly traded companies, and educational institutions) are permitted to claim a religious objection.  

This change will permit a much larger pool of companies to carve-out certain women’s preventive care benefit under their health plan.  Thus, with renewal season almost in full force, the applicability of this rule for self-funded plans and their administrators needs immediate clarification.

Prior to this interim final rule, the regulations required third party administrators who administered the self-funded medical plan for those entities who could opt out of the mandate (via an exemption or accommodation, etc) to otherwise arrange for these women’s preventive benefits.  While we have yet to see the finalized rules, it appears this requirement remains untouched.  As a result, it seems that this could have a big impact on groups wanting to make this modification to their current benefit structure (or even those wishing to make an immediate amendment to their plan design).  Third party administrators should be on the look-out and ensure they have processes and procedures in place to address this internally.

Note that this is still a pending issue and rescission of coverage is still not permitted under the ACA, and we do expect additional clarification and guidance.  For example, it is expected that Massachusetts Attorney General Maura Healy will push against this regulation.


The Phia Group, LLC is pleased to announce the integration of its Flagship Template
For Immediate Release
October 6, 2017
 
Braintree, MA – The Phia Group, LLC is pleased to announce the integration of its Flagship Template into its acclaimed Phia Document Management (“PDM”) software, and support for The Phia Group Flagship Template by many leading stop loss carriers.  
 
Recognizing that delays in plan drafting cause many plans to administer old plans – or in some cases – no plan, early in 2017 The Phia Group announced that it had compiled decades of experience servicing various types of plans to develop its Flagship Template.  The Phia Group’s Flagship Template is a complete version of its industry acclaimed, fully customizable plan document template, but users’ time commitment is substantially reduced thanks to The Phia Group having already created a nearly complete plan document.  By populating the document with what it deems to be the best provisions in every regard and applying best practices to create an almost-complete SPD, users enjoy a compliant and innovative plan in comparatively no time at all.  All that remains is for the plan sponsor or its named administrator to fill in their biographical information, insert their selected schedule of benefits, eligibility criteria, and review the language already provided to request edits or revisions.  
 
Building upon this foundation, The Phia Group is now proud to announce that its Flagship Template has been uploaded to its acclaimed Phia Document Management (“PDM”) software, ensuring subscribers can now use and offer The Phia Group Flagship Template to their clientele.  Further, following in-depth review and assessment, The Phia Group Flagship Template is now supported by many leading stop loss carriers as well.
 
“We continue to work towards the evolution of benefit plan documents and self-funding.  Each step we take in the advancement of The Phia Group Flagship Template is also a step forward for our industry.  We will not allow time constraints to limit the quality of our clients’ plan documents.  With The Phia Group Flagship Template, speed and quality are both possible.  Our mission was to reduce the number of questions users need to answer, and we did that – reducing them by 75%.” Remarked The Phia Group’s CEO, Adam V. Russo, Esq.
 
Regarding what’s next for The Phia Group Flagship Template, Mr. Russo advised, “Achieving buy-in from the stop loss industry, as well as adding it to our PDM program, is just the beginning.”   
 
For more information regarding The Phia Group’s Flagship Template, or to learn about any of The Phia Group’s other services, please contact Tim Callender by email at tcallender@phiagroup.com or by phone at 781-535-5631.
 
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.