Phia GroupPhia Group Mediahttps://phiagroup.com/Media/PostsEmpowering Plans: P185 – Weighing the Optionshttps://phiagroup.com/Media/Posts/PostId/1318/empowering-plans-p185-weighing-the-optionsPodcastsThu, 14 Mar 2024 17:51:40 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/pjE_-C_W3RU?si=aL4aDJGDAum1O2F_" title="YouTube video player" width="560"></iframe></p> <p style="margin: 0in; text-align: justify;"><span style="color:#000000;"><span style="font-size:12pt"><span aptos="" style="font-family:"><span arial="" style="font-family:">Over the last twelve months we have seen major interest in GLP-1s  (Semaglutide- Ozempic / Wegovy and Tirzepatide – Mounjaro / Zepbound). Although GLP-1s have been around for years as a treatment for diabetes, the recent popularity is due to their use as a weight loss drug. Join Ron Peck and Corey Crigger as they discuss the impact this surge in demand has had on health plans and consumers. Are health plans and consumers informed about the benefits and drawbacks of this drug?  Are consumers too focused on the benefits? Are health plans too focused on cost? Find out as Ron and Corey discuss one of the hottest topics in the industry. </span></span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="color:#000000;"><span style="font-size:12pt"><span aptos="" style="font-family:"><span style="font-family:"Arial",sans-serif"></span></span></span></span></p> <p style="margin: 0in; text-align: justify;"> </p> <p><span style="color:#000000;"></span></p> <p style="margin: 0in; text-align: justify;"><span style="color:#000000;"><span style="font-size:12pt"><span aptos="" style="font-family:"><span style="font-family:"Arial",sans-serif"></span></span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="color:#000000;"><span style="font-size:12pt"><span aptos="" style="font-family:"><span arial="" style="font-family:"><a href="https://youtu.be/pjE_-C_W3RU">Click here to check out the podcast!</a> (Make sure you subscribe to our <a href="https://youtu.be/pjE_-C_W3RU">YouTube</a> and <a href="https://podcasts.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#467886; text-decoration:underline">Apple Podcasts</a> Channels!)</span></span></span></span></p> <p style="margin: 0in; text-align: justify;"> </p> 1318The Indirect (But Significant) Impact of a Recent Massive Healthcare Breach on Benefit Planshttps://phiagroup.com/Media/Posts/PostId/1317/the-indirect-but-significant-impact-of-a-recent-massive-healthcare-breach-on-benefit-plansBlog,Health InsuranceMon, 11 Mar 2024 19:06:24 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: Andrew Silverio, Esq. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">It’s not often we see a healthcare/health benefit story so big that it crosses into the mainstream. The recent cyberattack in the healthcare industry is just that type of story, however, and the American Hospital Association has already called it “the most significant cyberattack on the U.S. health care system in American history.”  </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">At stake were over 14 billion yearly transactions and this attack has seriously disrupted provider billing, interfering with patient care, and even preventing some providers from paying their employees. On top of that, a massive amount of patient information, protected under HIPAA, has been compromised. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Most of the focus among news outlets has been on the impact to providers, which is of course enormous. Those using the affected claim systems have essentially no way to be paid for their services, and many have seen cash flow come to a prompt and complete halt. The government has advised Medicare plans and related entities to relax prior authorization and timely filing requirements and the entity involved has announced a program to actually offer loans to affected providers.  However, those of us in self-funding know that it’s no simple matter to simply waive requirements like prior authorization and timely filing limits, and we have heard no word from stop-loss carriers on what action it will take if plans provide some allowances to safeguard patient care.  Plans are still able to enforce timely filing limits and other plan terms, but most don’t want to leave patients in the lurch with unpaid claims due to system disruptions entirely outside their control.  A plan that chooses to accept a late claim or waive a preauthorization requirement will be at real risk, since the stop-loss carrier is always free to enforce the terms of the plan, and its own policy, strictly and as-written.  </span></span></span></span></span></span></span></p> <p style="text-align: justify;"><span style="color:#000000;"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">The industry is still scrambling to get the system “working” again and establish something resembling a normal claim submission pipeline and cash flow.  But once the dust settles, we would expect in the coming months to see some regulatory relief for plans and providers alike, to account for concessions and audibles that had to be made to keep the ship afloat. Looking ahead, hopefully precautionary systemic measures can be taken to account for future incidents. After all, healthcare and technology promise to be forever intertwined and there’s no telling when the next cybersecurity breach will rock the industry as it did last month. </span></span></span></span></p> 1317Empowering Plans: P184 – State of the Union, 2024https://phiagroup.com/Media/Posts/PostId/1316/empowering-plans-p184-state-of-the-union-2024PodcastsFri, 08 Mar 2024 18:16:40 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/TIadlrwCGp4?si=JlILNcL2Mo8D9xrt" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span aptos=""></span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"><span style="color:#000000;">In his third State of the Union address, President Biden touted his administration’s record and outlined the issues he and his team will likely be campaigning on heavily as the 2024 presidential race kicks off in earnest. Sprinkled throughout were a number of policy wish list items, including some key healthcare initiatives that we’ll be keeping a close eye on in the coming months. Attorneys Brady Bizarro and Nick Bonds bring you some of the highlights in this episode of the Empowering Plans podcast.  </span></span></span></p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"><span aptos=""></span></span></span></p> <p style="text-align: justify;"><span style="font-family:Arial,Helvetica,sans-serif;"><span style="font-size:16px;"><span aptos=""><a href="https://youtu.be/TIadlrwCGp4">Click here to check out the podcast!</a><span style="color:black"> (Make sure you subscribe to our </span><a href="https://youtu.be/TIadlrwCGp4">YouTube</a> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#467886; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span></a> <span style="color:black">Channels!)</span></span></span></span></p> 1316How the Recent Industry Cyberattack Impacts Youhttps://phiagroup.com/Media/Posts/PostId/1315/how-the-recent-industry-cyberattack-impacts-youBlog,Health Insurance,HIPAAThu, 07 Mar 2024 15:09:26 GMT<p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: David Ostrowsky</span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Late last month, an apparent massive cybersecurity incident involving the potential theft of patient data – this could entail personally identifiable information, sensitive health information, and financial information -- and encrypted company files seemingly paralyzed one of the nation’s largest pipelines for healthcare payments and prior authorization processing. Impacting a substantial percent of Americans’ medical claims (billions of claims totaling over a trillion dollars per year), millions have been affected. But perhaps the worst part is that many don’t even know it – and won’t be aware until they need to visit their physician or refill a prescription and face new hurdles in getting their customary treatment. </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Just this week, The Washington Post published stories of patients getting billed hundreds of dollars for prescriptions that had normally been fully covered by insurance. Meanwhile, others cannot get their prescriptions filled at all no matter how much they are willing to pay and still others have found that discount coupons are no longer effective (this can literally save a person hundreds of dollars per month on a given prescription). For Americans living on airtight budgets, which is certainly a great number of our fellow countrymen, they’ve had to forego taking medications for an untold number of physical and psychiatric conditions. While it’s by no means a long-term fix, some physicians have provided their patients with sample packs of pills or offered more affordable replacement prescriptions for those needing to pay out of pocket. But we all know this band-aid solution will only go so far. </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">As this horrific situation has been playing out across pharmacies throughout our country, physicians in both massive hospital networks and small clinics are struggling to obtain prior authorization for exams, medications, and procedures; subsequently, many patients have faced significant delays in receiving life-altering and/or life-prolonging medical care. Such delays have also been exacerbated by the unfortunate reality that some hospitals and medical providers have not received payments and thus lack the wherewithal to keep their employees. As it is, many medical practices throughout America do not carry significant cash reserves and entirely depend on healthy cash flow to execute claim submission and payment on a timely basis as well as keep up with payroll. For facilities that administer the most expensive services (i.e., chemotherapy and other forms of cancer drugs), burning through cash reserves can mean being unable to treat patients in dire need.  </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Simply put, the residual effects of this historically monumental data breach are endless – and, for many of the most vulnerable Americans who are already living on the margins of society, there appears to be no end in sight to physicians and hospitals not receiving adequate funding from private insurers, Medicare, and Medicaid. </span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">As Molly Fulton, the chief operating officer of Arlington Urgent Care, a chain of urgent care centers around Columbus, Ohio, that’s currently carrying over $650,000 in unpaid insurance reimbursements, told the New York Times, “This is worse than when Covid hit because even though we didn’t get paid for a while then either, at least we knew there was going to be a fix. Here, there is just no end in sight.”</span></span></span></span></span></span></p> 1315Empowering Plans: P183 – The Therapeutic Equivalence Approach: A New “Pill”ar of Contraceptive Coveragehttps://phiagroup.com/Media/Posts/PostId/1314/empowering-plans-p183-the-therapeutic-equivalence-approach-a-new-pillar-of-contraceptive-coveragePodcastsThu, 29 Feb 2024 20:12:15 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/yol0L4GWzN4?si=PbnGwcB6l784-ybp" title="YouTube video player" width="560"></iframe></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span aptos=""><span calibri=""><span style="color:#000000;">The DOL recently issued new guidance on the long-standing contraceptive coverage mandate, and this time they took a different approach. Instead of clarifying prior guidance or issuing novel interpretations of the law, the DOL is giving health plans an alternative way to comply with the contraceptive coverage mandate: either follow the prior guidance issued in 2022… or don’t! The DOL introduced the “therapeutic equivalence” approach, whereby plans can comply with the law in a different, potentially less-burdensome way. Join The Phia Group’s Kendall Jackson and Jon Jablon as they discuss this “therapeutic equivalence” approach to compliance, what it means for consumers, and what it means for health plans.</span></span></span><br /> <span aptos=""><br /> <a href="https://youtu.be/yol0L4GWzN4">Click here to check out the podcast!</a><span style="color:black"> (Make sure you subscribe to our </span><a href="https://youtu.be/yol0L4GWzN4">YouTube</a> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#467886; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span></a> <span style="color:black">Channels!)</span></span></span></span></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:12pt"><span aptos="" style="font-family:"><span style="font-size:11.0pt"><span calibri="" style="font-family:"></span></span></span></span></p> 1314Millions Saying Good-Bye to Medicaidhttps://phiagroup.com/Media/Posts/PostId/1313/millions-saying-good-bye-to-medicaidBlog,MedicaidThu, 22 Feb 2024 20:02:29 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: David Ostrowsky</span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">That millions of Americans have been losing Medicaid coverage over the past year may be unsurprising, but it doesn’t make it any less heartbreaking. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Some historical context: Normally, Medicaid recipients who receive federally funded health insurance due to disabilities or low incomes undergo eligibility reviews every year to see if they are eligible for renewed coverage. But, of course, March 2020 was far from a normal time and the feds froze the checks due to it being a public health emergency. Subsequently, Medicaid recipients would retain their enrollment for the following three years . . . until this past spring when President Biden terminated the public health emergency and an “unwinding” process soon ensued whereby millions have thus far been disenrolled from Medicaid. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">According to KFF, the renowned non-profit organization that bills itself as an independent source for health policy research, polling, and journalism, <span style="background:white">as of December 20, 2023, over thirteen million Americans had been taken off Medicaid since the spring.</span> Texas, perhaps understandably given its mammoth size, has been at the epicenter of this gargantuan development. Since the COVID-era coverage protections were stripped last spring, over two million Texans have been cut off from their state’s Medicaid program. For reference, Houston, Texas’ largest city population-wise, has 2.3 million residents. It also should be noted that Texas hasn’t finished assessing eligibility information for all Medicaid enrollees, meaning more residents will likely forfeit coverage. Nationwide, an untold number of Medicaid beneficiaries will be receiving such disheartening notifications through May, after which the pre-pandemic status quo is slated to resume.  </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">While there is not exactly a universal way to categorize the tens of millions who receive Medicare funds, some common profiles include: </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">--Single parents working multiple low-paying jobs while struggling to stay above the Federal Poverty Level </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">--Parents with children who have serious, perhaps even terminal, illnesses that require incredibly expensive, drawn-out treatment</span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">--Americans who may be unable to work in a full or part-time capacity due to incurring sudden debilitating injuries </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">The harsh reality is that for many of these Medicare recipients who lack robust employer-sponsored health benefits, being denied coverage – even for just a few weeks – can represent a life-or-death scenario (i.e., no longer having access to chemotherapy, radiation, and/or round-the-clock medical care.)</span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">In fairness, Texas officials have been responsive to outreach efforts on behalf of the Center for Medicaid and Children’s Health Insurance Program Services (CHIP) as they convened to review Texas’ eligibility evaluation procedures and examine cases of state residents becoming disenrolled. Ultimately, Texas reinstated over 90,000 people who were deemed falsely disenrolled from Medicaid. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">In a statement to NBC News, the <span style="background:white">Texas Health and Human Services Commission said it “planned this massive unwinding effort for more than a year,” and that if issues surfaced, the commission “works systematically to resolve any issues and reinstate recipients’ coverage if necessary.” And even for those who do not get coverage reinstated, it’s not Medicaid or nothing – there is also potential to </span><span style="background:white">qualify for no or low-cost premiums in the health insurance marketplace</span><span style="background:white"> or obtain coverage from a new employer. </span></span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Also in fairness, for virtually every single American alive, this decade’s pandemic was an unprecedented time in our country’s history with many systems, including Medicaid, being thrown out of whack. From spring 2020 to spring 2023, Medicaid enrollment spiked to historic highs (as in over ninety-seven million Americans) – a situation that may very well have been unsustainable going forward. This spring, meanwhile, state agencies will have their hands full playing catch-up in examining cases to determine who should and should not retain Medicaid coverage. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">On another level, this historic purge of Medicaid recipients has exposed longstanding administrative and technical problems in the systemic framework that covers the most vulnerable Americans. As New York Medicaid director Amir Bassiri recently told a national board of Medicaid advisers: “It would be a failure if we come out of this with the same old standards and processes we had in place prior to the public health emergency.” These antiquated standards and processes very well prevent many from enrolling (and re-enrolling) in Medicaid in the first place. </span></span></span></span></span></span></span></p> <p style="text-align: justify;"><span style="color:#000000;"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">For now, such shortcomings – not to mention persistent staffing challenges -- are also making it significantly harder for states to redetermine who is Medicaid eligible. </span></span></span></span></p> 1313The Skinny on Weight Loss Drugshttps://phiagroup.com/Media/Posts/PostId/1312/the-skinny-on-weight-loss-drugsWebinarsWed, 21 Feb 2024 16:05:50 GMT<p style="text-align:justify; margin:0in 0in 10pt"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:115%"><span calibri="" style="font-family:">From Contrave to Saxenda to Wegovy and beyond, society is being bombarded with messaging about weight loss drugs.  While many publicly debate their efficacy and long term viability, far fewer are openly asking who will pay for them – and how.  For those of us that sponsor and service health benefit plans, the costs arising from this trend are very real.  While we want to help people lose weight, get fit, and improve their overall health – the best way to approach this matter is still uncertain.  Join The Phia Group for another free webinar!  Our team will discuss this very relevant topic, including related issues such as off-label drug usage, international drug importation, defining medical necessity, plan drafting and exclusions.  Likewise, the importance of educating plan membership about the costs of healthcare, and what it means to be self-funded.   </span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 10pt"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:"Calibri",sans-serif"></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 10pt"><a href="https://attendee.gotowebinar.com/recording/4261639336946821292"><span style="color:#0071ce;"><span style="font-size:11pt"><span style="line-height:115%"><span calibri="">Click Here to View Our Full Webinar</span></span></span></span></a></p> <p style="text-align:justify; margin:0in 0in 10pt"><span style="font-size:11pt"><span style="line-height:115%"><span calibri="" style="font-family:"><span style="color:#000000;">To obtain a copy of our webinar slides, please reach out to</span> <a href="mailto:mpainten@phiagroup.com" style="color:blue; text-decoration:underline">mpainten@phiagroup.com</a>.</span></span></span></p> <p style="text-align:justify; margin:0in 0in 10pt"><span style="font-size:11pt"><span style="line-height:115%"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> 1312Empowering Plans: P182 – Navigating Post-Settlement Fund Pursuitshttps://phiagroup.com/Media/Posts/PostId/1311/empowering-plans-p182-navigating-post-settlement-fund-pursuitsPodcastsThu, 15 Feb 2024 21:11:27 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/fRX_QUf4ox8?si=Q7yOlslKZpT6jHk5" title="YouTube video player" width="560"></iframe></p> <p style="text-align: justify;"><span style="color:#000000;"> <span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span aptos=""> Attorneys Andrew Silverio and Cindy Merrell discuss a newly decided case which provides a roadmap for pursuing settlement funds after disbursement. Who has the burden of proof when the funds have been dissipated? What is lowest intermediate balance rule? </span></span></span></span><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"></span></span></p> <p style="text-align: justify;"><span style="font-size:14px;"><span style="font-family:Arial,Helvetica,sans-serif;"><span aptos=""><a href="https://youtu.be/fRX_QUf4ox8">Click here to check out the podcast!</a><span style="color:black"> (Make sure you subscribe to our </span><a href="https://youtu.be/fRX_QUf4ox8">YouTube </a><span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#467886; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span></a> <span style="color:black">Channels!)</span></span></span></span></p> 1311Welcome to the Subrogation Spherehttps://phiagroup.com/Media/Posts/PostId/1310/welcome-to-the-subrogation-sphereBlog,Health Insurance,Healthcare Costs,SubrogationFri, 09 Feb 2024 14:43:40 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">By: Cindy Merrell, Esq. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><b><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">The Subrogation Sphere Is a Place Where Opponents Become Allies  </span></span></b></span></span></span></span><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">Las Vegas does not have the only sphere that can provide an extraordinary experience for its participants. Let me introduce you to the subrogation sphere where participants may first appear to have conflicting interests but can become allies. When a health plan member is injured because of a third-party action it sets into motion a dance involving many players, potentially including the plan participant, at-fault party, medical providers, stop loss carrier, and the health plan. Each player is trying to determine which player is the proper payor of the plan participant’s medical expenses. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><b><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">The Alliance Begins </span></span></b></span></span></span></span><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">My primary duty as a subrogation attorney is to identify the proper payor of the health plan participant’s medical expenses. To successfully perform my job, I have regular contact with attorneys for both stop loss carriers, facilities, and plan participants’ attorneys. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">Just the other week, one of our third-party administrator clients reached out to us because they were having difficulty getting a group’s stop loss carrier to process a $500,000.00 trauma bill. When we took a deep dive into the facts, we found out the member had been involved in a motor vehicle wreck caused by a third party. In this case, the auto policy limits were minimal. The hospital lien and health plan reimbursement amount far exceeded the available auto policy limits. Given the size of the trauma bill, the hospital retained an attorney to pursue their interest. The injured plan participant retained an attorney. The general counsel for the stop loss carrier was involved and The Phia Group was pursuing the subrogation/reimbursement interest on behalf of the health plan. Everyone was at a stalemate. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">I knew that no one could “win” on this case. The plan participant was stressing over the $500,000.00 unpaid trauma bill. The self-funded health plan employer group was stressing over the same bill, not only because their valued employee was stressed and injured, but because this large of a claim without the stop loss reimbursement could be financially catastrophic to the health plan. The plan participant’s attorney could not resolve the plan participant’s claim against the auto carrier given the size of the provider lien and the health plan’s reimbursement interest. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><b><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">No One Wins, but Everyone Wins</span></span></b></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">When I talked to the plan participant’s attorney, I could hear the desperation in his voice as he simply did not know what to do. His client who had suffered a catastrophic injury was more worried about the large trauma bill than his own recovery. I asked the plan participant’s attorney if his client would consider entering into a pre-settlement agreement in which the health plan and the plan participant could both get at least some portion of the minimal limits. After the plan participant agreed to my proposal, I had to get the stop loss carrier on board. I quickly realized the stop loss carrier simply did not have all the facts and I was able to provide the missing information and get the trauma bill processed. Once the trauma bill was processed and paid, the hospital lien was withdrawn. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><b><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif">Why Does the Alliance Matter? </span></span></b></span></span></span></span></p> <p style="text-align: justify;"><span style="color:#000000;"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">The subrogation sphere can provide a meaningful impact for many people. In my example, the plan participant did not face the financial hardship of a $500,000.00 trauma bill. The hospital that provided the medical care received compensation for the services it provided. Finally, the health plan could remain self-funded. The health plan’s self-funded status allows its employees and their dependents to have comprehensive health care with lower premiums.</span></span></span></span></p> 1310Empowering Plans: P181 – Chevron Deference in Peril – What It Could Mean for Healthcare Regulationshttps://phiagroup.com/Media/Posts/PostId/1309/empowering-plans-p181-chevron-deference-in-peril-what-it-could-mean-for-healthcare-regulationsPodcastsThu, 01 Feb 2024 20:24:33 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/6CTWtTQNv1E?si=YLXHenv_4tukQhkj" title="YouTube video player" width="560"></iframe></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:12pt"><span aptos="" style="font-family:"><span style="font-size:11.0pt">In this episode of the Empowering Plans podcast, attorneys Brady Bizarro and Brian O’Hara discuss the legal doctrine involved in two cases now before the Supreme Court – <u>Chevron</u> deference. They’ll explain what it means, why it is important for federal agency action, and how it impacts the entire healthcare industry. With a decision expected by this summer, you do not want to miss our take on how the NSA, the Medicare drug price negotiations, and the ACA itself could be at stake.</span></span></span><br /> <span style="font-size:11.0pt"><span aptos="" style="font-family:"><br /> <a href="https://www.youtube.com/watch?v=6CTWtTQNv1E">Click here to check out the podcast!</a><span style="color:black"> (Make sure you subscribe to our </span><a href="https://www.youtube.com/watch?v=6CTWtTQNv1E">YouTube</a> <span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:#467886; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span></a> <span style="color:black">Channels!)</span></span></span></p> 1309Are Measles Making a Comeback?https://phiagroup.com/Media/Posts/PostId/1308/are-measles-making-a-comebackBlog,Health Insurance,Healthcare CostsWed, 31 Jan 2024 14:52:22 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">By: David Ostrowsky</span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">When Dr. Michael Osterholm speaks, people listen – even if many do so begrudgingly. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">The ever-serious epidemiologist out of Minnesota, who forewarned of a global pandemic years ago and has garnered the not-so-flattering nickname “Bad News Mike,” has a new dire message about the recent measles outbreak, one to which children are most susceptible, that has started to trickle through pockets of Europe and, more recently, the US:</span></span></span></span></span></span></span></p> <p class="gntarbp" style="margin: 10.5pt 0in; text-align: justify;"><span style="font-size:12pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="color:black">“We're going to start seeing more and more of these outbreaks,” Osterholm told <i>USA TODAY</i> last month. “We're going to see more kids seriously ill, hospitalized and even die. And what's so tragic about this, these are all preventable.”</span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">In late January, the World Health Organization (WHO) reported that measles cases spiked more than 40-fold in 2023 compared with 2022. Approximately 30 percent of those cases were in Kazakhstan, where there is an exceptionally high number of children who aren’t vaccinated. In England, there were 250 confirmed measles cases, most impacting children younger than ten. Although last year in the US, the number of measles cases reported was lower compared to most pre-COVID years, there have been ominous signs of trouble: Philadelphia has thus far recorded nine cases of measles, Washington State has identified three cases and investigated three others, while several other states have been tracing contacts of a single case. From a global perspective, 49 countries are experiencing what the WHO calls “large or disruptive outbreaks.”</span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">As Osterholms noted, an uptick in severe illnesses, hospitalizations, and even deaths will follow. Per the Centers for Disease Control and Prevention (CDC), approximately a fifth of those who contract measles will be hospitalized due to a range of issues including uncontrollable diarrhea, dehydration, fever, conjunctivitis, skin rash, pneumonia triggering long-term respiratory issues, and possibly even brain inflammation sparking neurological issues. More alarmingly, it is estimated that out of every thousand children who come down with measles, one to three will inevitably die. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">But, most maddeningly, as Osterholm also referenced, the vast majority of recent measles cases, which are incredibly contagious as the virus can drift in the air for a couple hours, could have been prevented. A single dose of the measles vaccine is 93 percent effective at stopping the virus, according to the CDC. For that reason alone, nearly every single parent alive has their children vaccinated (in the US, the measles vaccine is given twice, at 12-15 months old and then again at 4-6 years of age); but there’s always a small minority that doesn’t – and that is precisely what appears to be the root cause of the current problem. Generally speaking, for measles to remain in check, at least 95 percent of a given population needs to be immunized; in Europe, the percentage of people who had received a first dose dipped from 96 percent in 2019 to 93 percent in 2022. </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">“We actually knew this was going to happen, so it’s not news for us,” Dr. Natasha Crowcroft told the <i>New York Times</i> in regard to Europe’s current rise in measles cases. “There are times when there’s absolutely no pleasure in being right, and this is one of those.” </span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">In terms of the aforementioned stateside cases, <span style="background:white">most unsurprisingly involved young children and adolescents who didn’t receive the measles, mumps and rubella (MMR) vaccine, despite being eligible. (Undoubtedly, </span><span style="background:#fcfcfc">measles is far from the only vaccine-preventable disease that looms as a major public health threat; other such diseases include polio, mumps, diphtheria, tetanus, whooping cough, and hepatitis B.)</span><span style="background:white"> But it is important to note that the rising number of unvaccinated children may not solely be attributed to an increasing body of parents reluctant to comply with vaccine recommendations for their children – a problem that only becomes magnified when their children have returned from international travel. Another chief culprit may be the larger, socioeconomic force in play: the unfortunate reality that broad swaths of the American population, naturally those uninsured and living below the Federal Poverty Level, (never mind millions living in impoverished communities around the globe) simply don’t have access to proper healthcare, a dynamic more broadly known as health inequity. Even more so, it has been well documented that childhood vaccination rates have been on the decline in America since the onset of COVID, further broadening pre-existing gaps in vaccine participation. </span></span></span></span></span></span></span></span></p> <p style="text-align: justify;"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">This unjust situation speaks to many issues, not least of which is that health insurance remains prohibitively expensive for many Americans who are unemployed, self-employed, employed by companies that provide substandard coverage, or ineligible for Medicare and/or Medicaid. While immunizations, including those for measles, are considered preventive care and thus covered without cost-sharing under private health plans, millions of tax-paying Americans remain without adequate access to such plans. When will that change for the betterment of society?</span></span></span></span></span></p> 1308Empowering Plans: P180 – The Continuing Evolution of MHPAEAhttps://phiagroup.com/Media/Posts/PostId/1307/empowering-plans-p180-the-continuing-evolution-of-mhpaeaPodcastsThu, 18 Jan 2024 15:45:30 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/jcruONvPkxk?si=LL_VB5k3ZPnE_9_F" title="YouTube video player" width="560"></iframe></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="color:#000000;"><span style="font-size:11pt"><span style="line-height:107%"><span aptos="" style="font-family:"><span style="font-size:12.0pt"><span style="line-height:107%"><span calibri="" style="font-family:">One might think they’re listening to a broken record when hearing Jennifer McCormick and Kelly Dempsey discuss the ever-shifting landscape of the Mental Health Parity and Addiction Equity Act (MHPAEA), but alas, this is a brand new podcast! As we start 2024, we are reframing our mindset and are making some changes to address the evolving MHPAEA regulations and insights we have received from regulating bodies through the NQTL Comparative Analysis Process. In addition to highlighting the significance of how these issues should be addressed within an employer’s PD/SPD, there are three main changes discussed to create visibility for employers creating new 2024 PD/SPDs.</span></span></span></span></span></span></span></p> <p><span style="font-size:12.0pt"><span style="line-height:107%"><span calibri="" style="font-family:"><a href="https://www.youtube.com/watch?v=jcruONvPkxk"><span style="color:#0071ce">Click here to check out the podcast!</span></a><span style="color:black"> (Make sure you subscribe to our </span><a href="https://www.youtube.com/watch?v=jcruONvPkxk"><span style="color:#0071ce;">YouTube</span></a><span style="color:#0071ce;"> </span><span style="color:black">and </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span></a> <span style="color:black">Channels!)</span></span></span></span></p> 1307A New Year Brings New (Higher) Prescription Drug Priceshttps://phiagroup.com/Media/Posts/PostId/1306/a-new-year-brings-new-higher-prescription-drug-pricesBlog,Health Insurance,Healthcare Costs,Hospital BillsThu, 18 Jan 2024 15:32:49 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: David Ostrowsky</span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">It must be January. W-2 forms are hitting the mail. Fitness centers are packed to the brim. The NFL playoffs are in full force. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">And, yes, pharmaceutical companies are hiking prices on their drugs. This time of year,<span style="background:white"><span style="color:black"><span style="letter-spacing:.3pt"> when insurance plans turnover,</span></span></span> Big Pharma unveils its list of new (aka elevated) prices for drugs, which, particularly concerning newly launched ones, sparks sticker shock for consumers. Certainly, January 2024 does not appear to be an exception to this unpleasant trend. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">On December 29 -- as many were making last-minute New Year’s Eve plans – the unsettling news dropped: globally recognized drugmakers, including Pfizer, Sanofi, and Takeda Pharmaceutical (all multibillion-dollar, publicly traded companies), were gearing up for price hikes on <i>over 500</i> drugs, including over 140 different brands of drugs. For the second consecutive year, Pfizer declared the most price hikes in January as the New York-based drugmaker is responsible for more than a quarter of all the drugs with anticipated price hikes. Meanwhile, Takeda-owned Baxalta released the second-highest number of price increases, with 53 hikes planned thus far, and Sanofi plans to elevate prices on its typhoid fever, rabies and yellow fever vaccines each by 9% this month. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Why the markup for an exceptionally large number of medications this year? The expected culprits – lingering high inflation and supply chain backups, largely stemming from a drawn-out Middle East Conflict – account for some, but certainly not all, of the issues. At this moment in time, there are also notable political forces at play, namely Big Pharma bracing for the profound impact of healthcare cost reduction measures in President Biden’s <span style="background:white"><span style="color:black">Inflation Reduction Act (IRA) coming into effect. (This past August, the U.S. Department of Health and Human Services (HHS) publicly released the first ten drugs covered under Medicare Part D for negotiation; the negotiated prices will become effective beginning in 2026.) Not to oversimplify the matter, but Big Pharma is essentially anticipating lost revenue in the not-so-distant future and it feels it needs to compensate for the shortfall somehow, hence the hefty volume of upticks this month. </span></span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">In other words, in the coming weeks, millions of Americans, many of whom are of advanced age and living below the federal poverty level, will be walking up to their local pharmacy counter to pay for their respective medications and learn that their co-pays and/or out-of-pocket expenses have gone up at least moderately, and in some cases, dramatically. And they will be faced with the gut-wrenching decision: do they fork over the extra cash for life-altering or even life-prolonging medications at the expense of cutting back on groceries and turning off the heat in single-digit temperatures? </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Of course, this conundrum does not only apply to January as throughout the calendar year, Americans grapple with such dilemmas. But it’s certainly a problem that becomes particularly acute this time of year – one that already presents considerable challenges to many people’s physical and mental health. </span></span></span></span></span></span></p> <p style="text-align: justify;"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">While geopolitical events and policy decisions may be uncontrollable and unpredictable, there are cost containment techniques that employer-sponsored health plans can employ to alleviate said burden on their respective participants. There are, in fact, viable methods for lowering prescription drug costs even when the titans of the pharma industry inflate their prices. Certainly, prescription (and overall healthcare) cost containment programs are not necessarily easy to execute. They require ingenuity, extensive data benchmarking, and widespread participant engagement. But they do represent one effective means for countering what continues to be a dreaded January tradition: a surge in prescription drug prices across the board.</span></span></span></p> 1306Considerations Regarding the Exclusion of Gender-Affirming Carehttps://phiagroup.com/Media/Posts/PostId/1305/considerations-regarding-the-exclusion-of-gender-affirming-careBlog,Health Insurance,Healthcare Costs,PlanTue, 16 Jan 2024 20:33:52 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">By: Kendall Jackson, Esq. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Gender-affirming care was a particularly popular topic throughout 2023. As we enter the new year, the prevalent discussion concerning plan coverage of such care will certainly continue. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">For self-funded health plans, the decision of whether to cover or exclude gender-affirming care is quite multilayered. Specifically for plans that exclude gender-affirming care within their plan documents, there are several potential discrimination concerns. An important element when evaluating these concerns is what law applies to the plan. For instance, certain state laws may not apply to a self-funded plan governed by the Employee Retirement Income Security Act (ERISA) due to ERISA preemption. ERISA preemption operates to preempt state insurance laws as they relate to employee benefit plans. Accordingly, any state laws that may require coverage or ban coverage for gender-affirming care would not apply to an ERISA plan. This is noteworthy as ERISA affords an employer the broad discretion to construct and design the coverage and benefits for its employees. As there is no federal requirement for plans to cover gender-affirming care, an ERISA plan may choose to cover or exclude benefits for gender-affirming care. Alternatively, non-ERISA plans, such as self-funded church plans or non-federal governmental plans, have slightly less flexibility and must adhere to both state and federal law. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Federal protections against discrimination have been, and will continue to be, integral to filling the gaps in health coverage for marginalized groups. Consequently, the potential compliance concerns outlined below apply particularly to plans that elect to exclude gender-affirming care. The first consideration is whether the plan is subject to Section 1557 of the Affordable Care Act (ACA), which hinges on whether the plan sponsor receives any federal financial assistance through the Department of Health and Human Services (HHS). Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, or disability. HHS provided guidance in a notice in March 2022 that clarified the extent of Section 1557’s protections.<a href="#_ftn1" name="_ftnref1" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[1]</span></span></span></span></span></a> HHS opined that Section 1557’s protection against sex discrimination encompassed an individual’s right to access health programs that are free from discrimination based on gender identity. HHS stated that a plan categorically excluding benefits due to an individual’s gender identity was discrimination and prohibited by Section 1557. At the time, this guidance had a significant impact because if a plan was subject to Section 1557, generally, any exclusion of benefits or services related to, for example, transgender care, would be deemed a categorical exclusion and would be prohibited. Although HHS’s viewpoint was contested, nevertheless, it demonstrates the movement to protect against the exclusion of benefits based on gender identity. Accordingly, to avoid allegations of discrimination, self-funded plans subject to Section 1557 should consider removing gender-affirming care exclusions.</span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:105%"><span style="font-family:"Calibri",sans-serif">Even if a plan is not subject to ACA Section 1557, there are still significant discrimination concerns for plans with gender-affirming care exclusions if they create a disparity in coverage for certain individuals. These concerns stem from scrutiny from the Equal Employment Opportunity Commission and the protection against discrimination based on gender identity under Title VII of the Civil Rights Act of 1964. There have been several lawsuits brought forth by transgender individuals under these laws and Section 1557 about gender-affirming care exclusions, and courts have ruled in their favor on some occasions. An example of an exclusion that could create a disparity in coverage is a sex reassignment exclusion. In this case, while it does not exclude care for transgender individuals specifically, it is possible it could be viewed as discriminatory because it functions to categorically exclude services which will overwhelmingly be needed only by transgender individuals. As a result, while self-funded health plans are not mandated to cover gender-affirming care, the compliant approach with regard to all applicable laws would be to remove exclusions for gender-affirming care from the plan. </span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Pivoting to a different perspective, for self-funded non-ERISA plans subject to state law, there have been many changes surrounding gender-affirming care over the past year. For example, in Texas, on September 1, 2023, a<a name="_Hlk155366211"> law</a> banning gender-affirming care, such as treatments for gender dysphoria, transitioning, and reassignment for minors took effect. The law prohibits health plans from covering services “that are intended to transition a child’s biological sex as determined by the child’s sex organs, chromosomes, and endogenous profiles.”<a href="#_ftn2" name="_ftnref2" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[2]</span></span></span></span></span></a> In Ohio, governor Mike DeWine signed an executive order on January 5, 2024, that banned hospitals and ambulatory surgical facilities from performing gender-affirming surgeries on minors.<a href="#_ftn3" name="_ftnref3" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[3]</span></span></span></span></span></a> In New Hampshire, the New Hampshire House recently passed a bill that will now be sent to the New Hampshire Senate. This bill proposes to ban gender-affirming procedures for minors.<a href="#_ftn4" name="_ftnref4" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[4]</span></span></span></span></span></a> The bill also proposes to prohibit health care workers from referring minors to out-of-state facilities that may perform gender-affirming procedures. These are only a few examples of the recent developments in state legislation that concern gender-affirming care. As of November 2023, 22 states had a law or policy banning gender-affirming care.<a href="#_ftn5" name="_ftnref5" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:11.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[5]</span></span></span></span></span></a> There will likely be more development in state legislation in the new year and plans subject to state law should be mindful of how these laws and policies may influence their plan structure.</span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">The decision of whether to cover or exclude gender-affirming care is a multilayered matter and will likely depend on the intent of the employer. There are varying considerations depending on the type of plan and applicable law. As the landscape is constantly changing in regard to gender-affirming care laws, it is essential that plans consider plan document compliance, the potential for discrimination allegations, and, if applicable, what is mandated or banned by relevant states. </span></span></span></p> <p style="margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"></span></span></span></p> <div>  <hr align="left" size="1" width="33%" /> <div id="ftn1"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref1" name="_ftn1" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[1]</span></span></span></span></span></a> HHS Notice and Guidance on Gender Affirming Care, Civil Rights, and</span></span></p> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif">Patient Privacy, https://www.hhs.gov/sites/default/files/hhs-ocr-notice-and-guidance-gender-affirming-care.pdf</span></span></p> </div> <div id="ftn2"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref2" name="_ftn2" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[2]</span></span></span></span></span></a> Senate Bill 14, https://capitol.texas.gov/tlodocs/88R/billtext/html/SB00014I.htm</span></span></p> </div> <div id="ftn3"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref3" name="_ftn3" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[3]</span></span></span></span></span></a> Ohio Gov. DeWine signs executive order banning hospitals from gender transition surgeries on minors, https://ohiocapitaljournal.com/2024/01/05/ohio-gov-dewine-signs-executive-order-banning-hospitals-from-gender-transition-surgeries-on-minors/</span></span></p> </div> <div id="ftn4"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref4" name="_ftn4" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[4]</span></span></span></span></span></a> House Bill 619, https://gencourt.state.nh.us/bill_status/legacy/bs2016/billText.aspx?sy=2024&id=71&txtFormat=pdf&v=current</span></span></p> </div> <div id="ftn5"> <p class="MsoFootnoteText" style="margin:0in"><span style="font-size:10pt"><span style="font-family:"Calibri",sans-serif"><a href="#_ftnref5" name="_ftn5" title=""><span class="MsoFootnoteReference" style="vertical-align:super"><span class="MsoFootnoteReference" style="vertical-align:super"><span style="font-size:10.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">[5]</span></span></span></span></span></a> HRC Foundation, https://www.hrc.org/resources/attacks-on-gender-affirming-care-by-state-map</span></span></p> </div> </div> 1305Navigating 2024: The Latest, Most Innovative Plan Design Features & Stop-Loss Policy Updateshttps://phiagroup.com/Media/Posts/PostId/1304/navigating-2024-the-latest-most-innovative-plan-design-features-stop-loss-policy-updatesWebinarsTue, 16 Jan 2024 19:31:14 GMT<p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">In this first webinar of 2024, our crew will provide a rundown of 2024’s biggest plan document and stop-loss updates, including matters about which our team has been asked the most.  Stay ahead of the crowd, and join The Phia Group as we jump into the year with a head start. Together we will resolve lingering problems of the past and equip you with a list of changes to expect and topics you need to monitor in 2024 and beyond.</span></span></span></span></span></span></p> <p style="text-align:justify; margin:0in 0in 8pt"><a href="https://attendee.gotowebinar.com/recording/1761038732775148290"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">Click Here to View Our Full Webinar</span></span></span></span></span></span></a></p> <p style="text-align:justify; margin:0in 0in 8pt"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Aptos",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">To obtain a copy of our webinar slides, please reach out to mpainten@phiagroup.com.</span></span></span></span></span></span></p> 1304The Phia Group's 1st Quarter 2024 Newsletterhttps://phiagroup.com/Media/Posts/PostId/1303/the-phia-groups-1st-quarter-2024-newsletterNewslettersThu, 11 Jan 2024 21:06:50 GMT<meta http-equiv="Content-Type" content="text/html; charset=UTF-8" /> <title></title> <style type="text/css">.header { font-family: Verdana, Geneva, sans-serif; font-weight: normal; color: #000000; } a:link { color: #2d67a1; }a:visited { color: #2d67a1; } a:hover, a:active { color: #2d67a1; } .bodytext { font-size: 10px; } .bodytext { font-size: 12px; } .bodytext { font-family: Verdana, Geneva, sans-serif; } .heading1 { font-family: Verdana, Geneva, sans-serif; font-size: 18px; } hr.style1{ border-top-width: 4px; border-top-style: solid; border-top-color: #2d67a1; } .horiz { } .toc { font-family: Verdana, Geneva, sans-serif; color: #039; line-height: 24px; text-decoration: underline; } .whitetext { font-family: Verdana, Geneva, sans-serif; font-size: 12px; color: #FFF; } .horiz { border-top-width: 4px; border-top-style: solid; border-right-style: none; border-bottom-style: none; border-left-style: none; border-top-color: #2d67a1; border-right-color: #2d67a1; border-bottom-color: #2d67a1; border-left-color: #2d67a1; } .tocbkgd { background-attachment: scroll; background-image: url(images/tocbkgd.png); background-repeat: no-repeat; background-position: center center; } .boldtext { font-family: Verdana, Geneva, sans-serif; font-size: 12px; font-weight: bold; } .bodytextsm { font-size: 10px; } .fealinks { font-size: 16px; font-family: Verdana, Geneva, sans-serif; color: #FFF; text-decoration: none; } </style> <table align="center" border="0" cellpadding="0" cellspacing="0" width="650"> <tbody> <tr> <td bgcolor="#4a85d3" colspan="2"> <table border="0" cellpadding="0" cellspacing="0" width="90%"> <tbody> <tr> <td bgcolor="#4a85d3" class="whitetext" style="text-align: right" valign="bottom"> <p><br /> Phone: 781-535-5600 | <a class="whitetext" href="http://www.phiagroup.com" style="color: #FFFFFF">www.phiagroup.com</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2"><img src="/Portals/phiagroup/Newsletters/Q1 2024/phiaheader5.png?ver=XOzyzq4h5Bd5ffg65SNvsg%3d%3d" style="width: 650px; height: 451px;" /></td> </tr> <tr> </tr> <tr> <td valign="top" width="312"><a href="#russo4"><img src="/Portals/phiagroup/Newsletters/Q1 2024/block0422lx.png?ver=jvIEOEy4Wj5EcXfYcxjeLQ%3d%3d" style="width: 325px; height: 216px;" /></a></td> <td valign="top" width="323"><a href="#pace3"><img src="/Portals/phiagroup/Newsletters/Q1 2024/block0422rx.png?ver=LONdDU-bRb-KWNypd3DR3g%3d%3d" style="width: 325px; height: 216px;" /></a></td> </tr> <tr> <td colspan="2"> <table border="0" cellpadding="0" cellspacing="2" width="100%"> </table> </td> </tr> <tr> <td valign="top" width="47%"> <p><br /> <img src="/Portals/phiagroup/Newsletter 2018 Q2/adam.jpg?ver=_i23rT-3qUEFJFJPienk5A%3d%3d" style="width: 264px; height: 255px;" /></p> </td> <td valign="top" width="53%"> <p class="bodytext"><span class="heading1" style="font-size: 14px; font-weight: bold;"><br /> The Book of Russo: </span></p> <p class="bodytext" style="text-align: justify;">At industry events, we will frequently ask attendees for a word or quality they attribute to The Phia Group. We then take those words and phrases, and use them to illustrate a “word cloud,” where the more popular answers are larger and the unique responses are smaller. I love seeing what others think of us, and I always print the image and frame it in my office. On a consistent basis, phrases like “Passion,” “Loyalty,” and “Innovative” dominate the image. How wonderful it is to be appreciated for those types of qualities; things that are ingrained in our mentality and personality.</p> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="bodytext" style="text-align: justify;">Yet attitude is not enough. You must be able to “put your money where your mouth is.” It’s one thing to be a thought leader. It’s another thing entirely to be an action leader. Passion and loyalty lead us to care about the industry we serve. Caring about this industry in turn leads us to learn. Maybe that’s why my personal Phia Group word cloud features a different word – big, bold, and in the center of the image. That word is “KNOWLEDGE.” Without in-depth understanding of how our industry works, what our clients need, and how the various players interact, all the world’s passion, loyalty, and innovation wouldn’t amount to more than hot air. The Phia Group is knowledge. Yet, like attitude, so too knowledge is not enough.</p> <p class="bodytext" style="text-align: justify;">Whether it is Leonardo da Vinci who said, “I have been impressed with the urgency of doing. Knowing is not enough; we must apply. Being willing is not enough; we must do…” or, G.I. Joe that reminded us kids that, “Knowing is half the battle,” the real challenge is transforming all of The Phia Group’s knowledge into something tangible, transferable, and useful. Not only is it important to us that we enrich our clients, but even amongst our staff members we seek to deliver knowledge efficiently and effectively. </p> <p class="bodytext" style="text-align: justify;">Thankfully, technology continues to provide tools we can use to package and deliver knowledge. In the past, we would spend hundreds of hours gathering, organizing and updating our internal and industry communication materials and deliverables, but now with artificial intelligence (A/I) so much of the delay between gaining and sharing knowledge has been minimized. Today, every service we offer and every piece of technology we utilize in support of those services leverages technology (like A/I) to improve timing and quality of deliverables. Maybe the inclusion of “innovative” in the word cloud is justifiable after all? Importantly – we don’t view this as a justification for lay-offs or slowing growth. We see technology as a way to make each individual an even more valuable contributor, and at The Phia Group, we can rarely have too much of a great thing. We continue to grow and expand, while also offering much faster turnarounds and reduced costs. In fact, I can argue that because of this focus on leveraging technology to use and distribute knowledge, we have obtained more new business more quickly than ever before. That, in turn, results in more career opportunities for our existing team members, more openings for prospective team members, improved services and deliverables for our clients, and an even larger pool of clients from whom we can all learn. </p> <p class="bodytext" style="text-align: justify;">This year, 2024, will be the year that we take A/I and all of our latest innovations to the marketplace – combining our legal prowess and vast amount of industry expertise with the latest technical tools – in a fashion never seen before. This will in turn result in opportunities for success and growth for all. We are excited about this journey and see 2024 as the year The Phia Group takes it to a new level of breakthroughs. The self-funded health benefits industry has never been bigger, busier, or more complex – let us help you ride the wave and avoid getting soaked. Happy reading!</p> </td> </tr> <tr> <td bgcolor="#eeeeee" class="toc" colspan="2" valign="top"> <table border="0" cellpadding="5" cellspacing="10" width="100%"> <tbody> <tr> <td> <p><img src="/Portals/phiagroup/Newsletter Q2 2017/inthisissue.png?ver=MccyVIGCQMCOF4LSnwUjkQ%3d%3d" style="width: 101px; height: 18px;" /></p> <p class="tocbkgd"><a href="#pace3">Service Focuses of the Quarter</a><br /> <a href="#pftp">Phia Fit to Print</a><br /> <a href="#pblog">From the Blogosphere</a><br /> <a href="#pwebinars">Webinars</a><br /> <a href="#ppodcast">Podcasts</a><br /> <a href="#pcharity">The Phia Group’s 2024 Charity</a><br /> <a href="#pstacks">The Stacks</a><br /> <a href="#employ">Employee of the Quarter</a><br /> <a href="#pnews2">Phia News</a></p> </td> </tr> </tbody> </table> </td> </tr> <tr> <td colspan="2" valign="top"> <p class="heading1"><a name="russo4"></a><strong><br /> Enhancement of the Quarter: SoPhia</strong> </p> <p class="bodytext" style="text-align: justify;">Though it is not yet available directly to ICE users, Phia’s consulting department has begun to use our new artificial intelligence (AI) tool, affectionately named soPhia, to assist with certain tasks and information sharing. </p> <p class="bodytext" style="text-align: justify;">Maybe most importantly, soPhia gives our very own Jennifer McCormick a way to troubleshoot her own Microsoft Excel problems – so our consulting attorneys can spend more time on ICE users’ consulting submissions, and less time fixing Jen’s computer. </p> <p class="bodytext" style="text-align: justify;">We’re excited to keep expanding soPhia’s capabilities and eventually share it with our clients!</p> <a id="pace3" name="pace3"></a> <p class="bodytext"><strong>Service Focus of the Quarter: Unwrapped, BBR & Patient Defense</strong></p> <p class="bodytext" style="text-align: justify;">Through our Phia Unwrapped service – combined with Balance Bill Resolution and Patient Defense – The Phia Group offers a suite of comprehensive end-to-end balance bill resolution services, ensuring that benefit plans and plan participants alike have independent but coordinated advocacy. Phia’s team of over 30 specialists and attorneys, bolstered by in-house medical coding and clinical resources, provides regulatory and legal expertise and over 15 years of reference-based pricing support experience. These services also include plan member legal representation by an external law firm, as well as the Phia “Safeguard,” guaranteeing that groups will not pay more than 200% of Medicare rates. </p> <p class="bodytext" style="text-align: justify;">Clients can enjoy stability, simplified processes, and improved balance bill resolution by working directly with The Phia Group. We offer direct access to our unrivaled team for all balance bill issues at every stage, eliminating the need for complex middlemen arrangements or third-party escalations. </p> <p class="bodytext" style="text-align: justify;">Moreover, existing clients opting for The Phia Group's direct contract in 2024 will continue to enjoy 2023 rates, emphasizing our commitment to providing value and excellent service in the balance bill resolution domain.</p> <p class="bodytext"><strong>Phia Case Study: Hidden Gag Clauses </strong> </p> <p class="bodytext" style="text-align: justify;">A TPA recently engaged Phia to review certain health plan agreements for compliance with the gag clause prohibition. The TPA let us know that their counsel went through them and found nothing problematic, but that they’d appreciate a second set of eyes. </p> <p class="bodytext" style="text-align: justify;">For the most part, we found no prohibited gag clauses; the plan’s vendors had generally done a thorough job of removing any historical gag clauses. In one agreement, however, we found a questionable provision. </p> <p class="bodytext" style="text-align: justify;">Specifically, this provision did not explicitly identify information that constitutes a gag clause such that it was not glaringly obvious, but it did allow the vendor to unilaterally deem any information proprietary and subject to confidentiality at its discretion. Even though this is not an explicit gag clause, it is nonetheless a potential gag clause, which is sufficient to trigger the prohibition, since the vendor could simply decide to make it a gag clause! We pointed it out to the TPA who promptly relayed the information to the vendor, who stated their disagreement with our interpretation. </p> <p class="bodytext" style="text-align: justify;">We suggested that the TPA ask the vendor to simply remove the discretionary nature of the confidentiality clause, and though the vendor was hesitant, its general counsel eventually conceded that while she didn’t personally think it constituted a gag clause, it was “not impossible” that some could hold that opinion (a.k.a. the attorney equivalent of a “you’re right”). The vendor agreed to modify the provision by more clearly delineating what information was confidential and not allowing the vendor to deem information confidential other than what was identified in the agreement. </p> <p class="bodytext" style="text-align: justify;">Within 11 business days of sending us the request, the vendor and plan had signed an amendment, and the health plan was able to attest that that agreement in fact had no gag clauses! </p> <a name="russo55"></a> <p class="bodytext"><strong>Fiduciary Burden of the Quarter: Abiding by the No Surprises Act</strong></p> <p class="bodytext" style="text-align: justify;">The No Surprises Act, or NSA, is a sweeping piece of federal legislation that grants and imposes certain rights and responsibilities onto health insurers, medical providers, and individual patients. Given its breadth and the general public’s inability to read Congress’ mind, some parts of this law raise more questions than answers. This quarter’s Fiduciary Burden of the Quarter will focus on one oft-forgotten but incredibly important piece of guidance: the prohibition on applying plan exclusions. </p> <p class="bodytext" style="text-align: justify;">Yes, you read that right. </p> <p class="bodytext" style="text-align: justify;">According to a section of the Public Health Service Act as amended by the NSA <a href="https://www.law.cornell.edu/cfr/text/29/2590.715-2719A">(found here)</a>, a health plan is required to cover an emergency service “without regard to any other term or condition of the coverage, other than” cost-sharing, a permissible waiting period, or “the exclusion or coordination of benefits.” In other words, the plan must cover the emergency claim unless benefits are excluded. That seems intuitive, though, right? Coverage is required unless it’s excluded – the way health plans normally work. That should be simple enough to interpret. </p> <p class="bodytext" style="text-align: justify;">Apparently not. In a publication entitled “Requirements Related to Surprise Billing; Part I” <a href="https://www.federalregister.gov/documents/2021/07/13/2021-14379/requirements-related-to-surprise-billing-part-i">(found here)</a>, the relevant regulatory bodies got together and issued guidance that turns cost-containment on its head. Specifically, this guidance provides that health plans may not “deny benefits for a participant, beneficiary, or enrollee with an emergency medical condition that receives emergency services, based on a general plan exclusion that would apply to items and services other than emergency services.” That would render exclusions like, for instance, those related to illegal acts unenforceable with respect to emergency services. </p> <p class="bodytext" style="text-align: justify;">So there we have it: Congress explicitly wrote that a plan can enforce the “exclusion of benefits” in a given emergency case, but subsequent regulatory guidance interpreted this language as meaning that a “general plan exclusion” cannot be enforced. Where does this leave us? Well, confused, to be honest. Did Congress really intend for health plans to be required to pay for any emergency claim even if the circumstance is clearly subject to a plan exclusion? The regulators say “Yes, patients need to be protected!” To that, we say “But so do health plans!” </p> <p class="bodytext" style="text-align: justify;">For the time being, though – until there’s guidance or a lawsuit to the contrary – we’re left with the regulatory guidance prohibiting health plans from excluding emergency claims based on any exclusion deemed “general” within the plan document – that is, any exclusion that applies regardless of the emergency nature of the claim.</p> <a name="pace3"></a> <hr class="horiz" /><a name="pdef"></a> <p class="heading1"><a id="p5" name="p5"></a><a id="pwebinars" name="pwebinars"></a>Webinars:</p> <p class="bodytext" style="text-align: justify;">• On November 15, 2023, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/strategizing-for-2024-new-ai-regulations-and-transparency-rules-impacting-healthcare">“Strategizing for 2024: New AI Regulations and Transparency Rules Impacting Healthcare,”</a> in which we discussed technological and legal improvements that are sure to dictate how you survive and thrive in the coming year. </p> <p class="bodytext" style="text-align: justify;">• On October 18, 2023, The Phia Group presented<a href="https://www.phiagroup.com/Media/Posts/cell-and-gene-therapy-industry-and-claim-cost-impact"> “Cell and Gene Therapy: Industry and Claim Cost Impact,”</a> in which we discussed frightening trends in drug costs, defined the risks, and presented solutions you can implement today.</p> <p class="bodytext" style="text-align: justify;">Be sure to check out all of our <a href="https://www.phiagroup.com/Media/Webinars" target="_blank">past webinars</a>!</p> <hr class="horiz" /> <p class="heading1"><a id="ppodcast" name="ppodcast"></a>Podcasts:</p> <center> <p class="heading1">Empowering Plans</p> </center> <p class="bodytext" style="text-align: justify;">• On December 21, 2023, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p178-back-to-december-phias-version">“Back to December (Phia’s Version)”</a> in which our hosts, Kendall Jackson and Corey Crigger, discussed how everything in PGC and Provider Relations has changed in 2023. </p> <p class="bodytext" style="text-align: justify;">• On December 8, 2023, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p177-entering-the-danger-zone-cross-plan-offsetting">“Entering the Danger Zone: Cross-Plan Offsetting,”</a> in which our hosts, Jon Jablon and Cindy Merrell, discussed the practice of cross-plan offsetting and the recent settlement between the Department of Labor and EmblemHealth Inc. </p> <p class="bodytext" style="text-align: justify;">• On November 21, 2023, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p176-copay-accumulator-programs-take-a-hit-whats-next">“Copay Accumulator Programs Take a Hit: What’s Next?,”</a> in which our hosts, Brady Bizarro and Andrew Silverio, discussed a recent federal court decision that saw drug manufacturers and patients alike score a victory against copay accumulator programs – programs that help maximize the manufacturer assistance available to patients but decline to count those amounts toward deductibles and out-of-pocket maximums. </p> <p class="bodytext" style="text-align: justify;">• On November 9, 2023, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/no-surprises-act-brings-more-surprises-other-surprises-for-2024">“No Surprises Act Brings More Surprises & Other Surprises for 2024,”</a> in which our hosts, Brian O’Hara and Kelly Dempsey, discussed a couple lesser-known items hidden in some NSA proposed rules. </p> <p class="bodytext" style="text-align: justify;">• On October 26, 2023, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p174-pcori-and-parity-and-lawsuits-oh-my">“PCORI and Parity and Lawsuits, Oh My!,”</a> in which our hosts, Jennifer McCormick and Nick Bonds, discussed some of the scary issues creeping up on health plans: rising PCORI fees, proposed regulations on mental health parity rules, and two fascinating court cases that may have significant implications for ERISA plans going forward. </p> <p class="bodytext" style="text-align: justify;">• On October 12, 2023, The Phia Group presented <a href="https://www.phiagroup.com/Media/Posts/empowering-plans-p173-gene-y-in-a-bottle-a-magical-overview-of-cell-and-gene-therapy">“Gene-y in a Bottle: A Magical Overview of Cell and Gene Therapy,”</a> in which our hosts, Ron Peck and Corey Crigger, discussed how this emerging treatment can impact self-funded health plans.</p> <p class="bodytext">Be sure to check out all of <a href="https://www.phiagroup.com/Media/Podcasts">our latest podcasts!</a><br />  </p> <p class="bodytext"><a href="https://podcasts.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2020/apple.png?ver=HxKWI1vbMUjFQn5lPGMUHg%3d%3d" style="width: 491px; height: 121px;" /></a><br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pftp" name="pftp"></a>Phia Fit to Print:</span></p> <p class="bodytext" style="text-align: justify;">• Self-Insurers’ Publishing Corp. – <a href="https://www.sipconline.net/files/The_Self-Insured_Health_Plan_Compliance_Clock_Counts_Down_For_2023_by_David_Ostrowsky.pdf">The Self-Insured Health Plan Compliance Clock Counts Down For 2023</a> – December, 2023 </p> <p class="bodytext" style="text-align: justify;">• America’s Benefit Specialist – <a href="https://digitaledition.pub/wc/nahu/Americas-Benefit-Specialist/December-2023/">Dissecting the CAA Gag Clause Prohibition</a> – December, 2023 </p> <p class="bodytext" style="text-align: justify;">• Self-Insurers’ Publishing Corp. – <a href="https://www.sipconline.net/files/Navigating_Coverage_For_Weight_Loss_Medications_authored_by_Kevin_Brady_Esq.pdf">Navigating Coverage for Weight Loss Medications</a> – October, 2023 </p> <p class="bodytext" style="text-align: justify;">• BenefitsPro – <a href="https://www.benefitspro.com/2023/10/25/self-funding-plan-preparation-for-2023/">Self-funding plan preparation for 2024</a> – October, 2023<br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pblog" name="pblog"></a>From the Blogoshpere:</span><span class="heading1"></span></p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/is-artificial-intelligence-the-new-frontier-for-healthcare">Is Artificial Intelligence the New Frontier for Healthcare?</a> AI is not going anywhere – in the healthcare industry and beyond. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/minor-members-and-third-party-settlements">Minor Members and Third Party Settlements.</a> Does a self-funded ERISA plan have a right of recovery from a minor’s third-party liability claim? </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/being-mindful-of-telemedicine-access">Being Mindful of Telemedicine Access.</a> Telemedicine, being such a convenient and effective alternative to traditional in-person care, has helped meet the unprecedented demand for mental health services and more. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/update-on-the-federal-idr-process">Update on the Federal IDR Process.</a> Recently there has been significant discussion about the federal IDR process. </p> <p class="bodytext" style="text-align: justify;">• <a href="https://www.phiagroup.com/Media/Posts/district-court-strikes-a-blow-to-copay-accumulator-programs">District Court Strikes a Blow to Copay Accumulator Programs.</a> Several patient groups brought a legal challenge against HHS and CMS, challenging the NBPP as unlawful.</p> <p class="bodytext" style="text-align: justify;">To stay up to date on other industry news, please <a href="https://www.phiagroup.com/Media/Blog.aspx" target="_blank">visit our blog</a>.<br /> <br /> <a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pstacks" name="pstacks"></a>The Stacks:</span></p> <p class="bodytext"><strong>The Self-Insured Health Plan Compliance Clock Counts Down For 2023</strong></p> <p class="bodytext">By: David Ostrowsky – December, 2023 – <a href="https://www.sipconline.net/files/The_Self-Insured_Health_Plan_Compliance_Clock_Counts_Down_For_2023_by_David_Ostrowsky.pdf">Self-Insurers Publishing Corp.</a> </p> <p class="bodytext" style="text-align: justify;">For HR professionals, the fourth quarter invariably presents considerable challenges. In addition to handling daily operational work involving employee benefits, HR departments are bracing for the deadline-driven annual open enrollment process—while navigating the upcoming holiday season, no less. With all the looming federal and state deadlines and corresponding action items, it can be overwhelming, if not daunting, when it comes time to review self-funded health plan documents, whether they be summary plan descriptions (SPDs), plan documents (PDs), combined SPD/PDs, wrap documents, cafeteria documents, or SBCs. The following guide outlines several critical compliance deadlines and reminders germane to end-of-year planning, though it should be noted that this is not meant to be a complete and exhaustive list of compliance requirements deadlines.  </p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-3rd-quarter-2023-newsletter">Click here</a> to read the rest of this article</p> <p class="bodytext"><strong>Navigating Coverage for Weight Loss Medications</strong></p> <p class="bodytext">By: Kevin Brady, Esq. – October, 2023 – <a href="https://www.sipconline.net/files/Navigating_Coverage_For_Weight_Loss_Medications_authored_by_Kevin_Brady_Esq.pdf">Self-Insurers Publishing Corp.</a> </p> <p class="bodytext" style="text-align: justify;">In October of 2022, Elon Musk (one of the world’s wealthiest individuals) ignited headlines (a common occurrence for him) when he revealed that he used Wegovy as a primary method for losing weight. Wegovy and other drugs such as Ozempic and Mounjaro instantly became national news and intriguing weight loss options for people across the country. </p> <p class="bodytext" style="text-align: justify;">By all accounts, these drugs seem to show effectiveness in addressing weight loss concerns; however, it's important to note that they come with a significant cost. Specifically, Wegovy, Ozempic, and Mounjaro boast per-treatment list prices of $1,349, $936, and $1,023, respectively.</p> <p class="bodytext"><a href="https://www.phiagroup.com/Media/Posts/the-stacks-1st-quarter-2024-newsletter">Click here to read the rest of this article</a> </p> <p class="bodytext"><a href="#top">Back to top ^</a></p> <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pcharity" name="pcharity"></a>The Phia Group's 2024 Charity</span></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">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.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Group's 2024 charity is the Boys & Girls Club of Metro South.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;"><img alt="" src="/Portals/phiagroup/Newsletters/Newsletter Q1 2020/boysgirls.png?ver=f3_V6CCiOdTpBy6ZWIVK6g%3d%3d" style="width: 472px; height: 220px;" /><br /> <br /> 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.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Boys & Girls Club of Metro South (BGCMS) 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 to 18, signed up as club members. In the 30-plus years since then, 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.</p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Since their founding, more than 20,000 youths have been welcomed through their doors. Currently, they serve more than 1,000 boys and girls ages 5-18 annually through the academic year and summertime programs. </p> <p><span class="bodytext"></span></p> <p class="bodytext"><strong>Thanksgiving Delivery!</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The tradition continues! The night before Thanksgiving, The Phia Group once again had a large contingent of volunteers helping to hand out Thanksgiving meals at the Boys & Girls Clubs of Metro South. Twenty-six families received dinners and each child received a gift from Adam Russo. We hope everyone had a great Thanksgiving!</p> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/bandg.png?ver=1MUTkUpgvkdTKk3WiXMHvQ%3d%3d" style="width: 600px; height: 340px;" /> <p class="bodytext"><strong>Angel Tree at Phia</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Our Angel Tree was on display in our Canton office! We are thrilled to share that this marks our 10th consecutive year participating in the Salvation Army Angel Tree program. We had 150 tags on our tree this year, which means that we got to bring joy to 150 children this holiday season. Discover more about this heartwarming initiative that brings us so much joy in the link below: <a href="https://saangeltree.org/">https://saangeltree.org/</a>.</p> <p><br /> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/angeltree2.png?ver=1sOcyMzWiRqHf0voag5bWg%3d%3d" style="width: 600px; height: 422px;" /></p> <p class="bodytext"><strong>Senior Care Package Corner</strong></p> <p class="bodytext" style="font-weight: normal">Through the Angel Tree Program, The Phia Group spread holiday cheer to dozens of seniors in the Greater Boston area, many of whom do not have families who are local. Thanks to the generosity and dedication of our employees, a Senior Care Package Corner was set up for the collection of basic necessities such as hats and gloves as well as some tasty treats. The Phia Group continues to look forward to making a difference in our local community in the upcoming year.</p>   <p><img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/seniorcare.png?ver=nPYAaSgrxmeZ6l_nkd2yOw%3d%3d" style="width: 600px; height: 312px;" /></p> <p class="bodytext"><strong>Santa’s Special Delivery</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">On the evening of Tuesday, December 21, The Phia Group – with CEO Adam Russo serving as Santa, accompanied by a dozen elves – delivered gifts to 150 kids at the Brockton Clubhouse of the Boys & Girls Clubs of Metro South. We hope they enjoyed all of the gifts they received!</p> <p class="bodytext" style="font-weight: normal"> </p> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/santaelf.png?ver=-_yW7F2b6EpHC1SA5Q6jmA%3d%3d" style="width: 600px; height: 454px;" /> <p><a href="#top">Back to top ^</a></p> <hr class="horiz" /><a id="pnews2" name="pnews2"></a> <p class="bodytext"><span class="heading1"><a id="pemployee" name="pemployee"></a>Phia News: Ping-Pong Tournament</span></p> <p class="bodytext" style="text-align: justify;">The Phia Group would like to congratulate Tomasz Olszewski on winning Round Two of its inaugural Ping-Pong Tournament. Tomasz is a great ping-pong player and will look to defend his title during the next round of the exciting tourney.</p> <p class="bodytext"> </p> <strong><img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/pingpong2.png?ver=fPnmmkrBnI0WKETa65vLdg%3d%3d" style="width: 600px; height: 331px;" /></strong> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a></span></p> <p class="bodytext"><strong>Stein Holding Challenge</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Our arms may have been sore but at least our bellies were full. The Phia Group celebrated Oktoberfest in style with a stein holding challenge (congrats Pete Kotsifas) and barbeque under postcard weather in Canton. What a way to usher in October … even if it didn’t feel like it outside in the Northeast.</p> <br /> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/stein.png?ver=LnqbvwOfin5FHYcIP814sg%3d%3d" style="width: 466px; height: 535px;" /> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a></span></p> <p class="bodytext"><strong>Halloween at Phia</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Late in October, many of our employees brought in their children for the annual Halloween extravaganza at our Canton headquarters. Everyone – kids and adults alike – had a blast trick-or-treating around the office and then enjoying a delicious pizza party afterwards! On behalf of everyone here at The Phia Group, we would like to thank all those who made that day so special for the Phia Phamily kids!</p> <br /> <strong><img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/halloween3.png?ver=-_yW7F2b6EpHC1SA5Q6jmA%3d%3d" style="width: 600px; height: 487px;" /></strong> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/halloween4.png?ver=gsCwemdXUui5kfeSKTj9RA%3d%3d" style="width: 600px; height: 481px;" /> <p class="bodytext"><strong><br /> Halloween Staff Costume Winner – Rebekah McGuire-Dye</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">As is tradition, Phia held its annual Halloween costume contest. The Phia staff did not disappoint. We could only choose one winner from the group, but the winner was clear. Congratulations to Rebekah McGuire-Dye, who dressed up as Ursula! Check out her amazing costume below.</p> <br /> <strong><img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/halloweencos.png?ver=ZiV6A_GCmC3PQPz0cOFRGw%3d%3d" style="width: 600px; height: 606px;" /></strong> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a></span></p> <p class="bodytext"><strong>Candy Corn Contest</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">As is tradition, Phia held its annual Candy Corn Contest. The Phia Family made some great guesses, but there was one person who came particularly close to guessing the exact number. Congratulations to Matt Kramp on guessing 801 pieces of candy corn. This was a very close guess, as we had 800 pieces of candy corn in the jar!</p> <br /> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/candycorn5.png?ver=3uiqEWECj_D6wpAEHMWGKg%3d%3d" style="width: 354px; height: 460px;" /> <p class="bodytext"><span class="heading1"><a id="p11" name="p11"></a></span></p> <p class="bodytext"><strong>Ugly Sweater Contest</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Ugly Sweater Contest was in full swing the last week of December, and the Phia family came together to vote one person as the winner of the owner of the ugliest sweater. The winner of the Ugly Sweater Contest was Regina Cattel! Congratulations and wear that sweater proudly!</p> <br /> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/uglysweater5.png?ver=OuZvsIOUSuf9xxv-BX0rkQ%3d%3d" style="width: 545px; height: 545px;" /> <p class="bodytext"><strong></strong></p> <p class="bodytext"><strong>Get to Know Our Employee of the Quarter: Zach John<strong><a id="employ" name="employ"></a></strong></strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">To be designated as an Employee of the Year is an achievement that is reserved for Phia employees who truly go above and beyond their day-to-day responsibilities. This person must not only transcend their established job description but also demonstrate dedication and passion to The Phia Group and its employees that is so unparalleled that it cannot go without recognition. </p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Explore team has made the unanimous decision, without hesitation, that there is no one more deserving than our very own Zach John as The Phia Group’s 2023 Employee of the Year! Here is what someone at Phia had to say about him: “Zach John joined Phia in 2016 and has been a tremendous contributor since day one. We have grown from one enterprise application (TPS) to six different applications on which Phia business is running today. Zach has been enhancing and maintaining all these applications with his team and has been doing it with an excellent attitude. Zach has grown a lot as a leader, and his accountability on getting things done and owning it is phenomenal. </p> <p class="bodytext" style="font-weight: normal; text-align: justify;">He is a true Phia idol employee who walks the talk and is appreciated by everyone. There is one thing to do your job, but it is another to do it with patience and empathy. He shows a lot of respect and accountability with business and his team alike. I am proud to have him as part of my team. He has been called the Flash for getting things done so quickly.”</p> <strong><img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/zach5.png?ver=01NJtYgFD8lKdNe_EW5ycA%3d%3d" style="width: 470px; height: 533px;" /></strong> <p class="bodytext"><br /> Congratulations Zach, and thank you for your many current and future contributions.</p> <p class="bodytext"><strong>Get to Know Our Employee of the Quarter: Daiana Williams</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Being named Employee of the Quarter is an achievement that is for Phia employees who truly go above and beyond their responsibilities. This person must not only transcend their established job description but also demonstrate such unparalleled dedication and passion to The Phia Group and its employees that it cannot go without recognition. </p> <p class="bodytext" style="font-weight: normal; text-align: justify;">The Phia Explore team has unhesitatingly made the unanimous decision that there is no one more deserving than our very own Daiana Williams as The Phia Group’s 2023 Q4 Employee of the Quarter! </p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Here is one person’s comments about Daiana: “Daiana is the rock in the recovery team. Not only is she the go-to for daily questions and stats, but she is the go-to for projects. When new ideas are being brought to the development team, Daiana is heavily involved. Not only does she test the enhancements before they go live, but she also quite literally is writing the guidelines and what is needed for this enhancement to go to development. Daiana works endless hours to get these going and successful for the team, and I don't think she gets enough credit on how appreciative we are for this. In addition to everything else, she is also training new hires and working with them daily to guide them to success.”</p> <img alt="" src="/Portals/phiagroup/Newsletters/Q1 2024/daiana5.png?ver=rGg99QjkSnsUqe6LkJBsjg%3d%3d" style="width: 447px; height: 558px;" /> <p class="bodytext">Congratulations Daiana, and thank you for your many current and future contributions.</p> <p class="bodytext"><strong>Phia Attending the SIIA National Conference</strong></p> <p class="bodytext" style="font-weight: normal; text-align: justify;">Several of Phia’s industry experts will attend SIIA’s 2024 National Conference in Phoenix, Arizona, from September 22nd – 24th. If you are interested in attending or learning more about SIIA’s National Conference, visit their website: </p> <p class="bodytext" style="font-weight: normal">Get more details: <a href="https://siiaconferences.org/nationalconference/2024/Index.cfm">https://siiaconferences.org/nationalconference/2024/Index.cfm </a></p>   <hr class="horiz" /> <p class="bodytext"><span class="heading1"><a id="pnews" name="pnews"></a>Job Opportunities:</span></p> <p class="bodytext">• Claims Specialist </p> <p class="bodytext">• Client Success Manager </p> <p class="bodytext">• Contract Administrator </p> <p class="bodytext">• Claim and Case Support Analyst </p> <p class="bodytext">• Case Investigator </p> <p class="bodytext">• Senior Subrogation Attorney </p> <p class="bodytext">• Sr. Claim Recovery Specialist</p> <p class="bodytext">See the latest job opportunities, here: <a href="https://www.phiagroup.com/About-Us/Careers " target="_blank">https://www.phiagroup.com/About-Us/Careers </a></p> <p class="bodytext"><a id="pcert" name="pcert"></a></p> <span class="boldtext">Promotions</span> <p class="bodytext">• Bill Parlee has been promoted from Case Investigator to Claim Recovery Specialist IV. </p> <p class="bodytext">• Deonte Small has been promoted from Accounting Assistant to Accounting Administrator.</p> <p class="bodytext"><strong>New Hires</strong></p> <p class="bodytext">• David Patrick was hired as a KP Claim Recovery Specialist. </p> <p class="bodytext">• Alex Stoner was hired as a KP Claim Support Analyst. </p> <p class="bodytext">• Matthew McKenzie was hired as a KP Claim Recovery Specialist. </p> <p class="bodytext">• Amy Justice Isaacs was hired as a KP Claim Recovery Specialist. </p> <p class="bodytext">• Shane Kepley was hired as a Claim Specialist. </p> <p class="bodytext">• Whitney Hester was hired as a KP Recovery Manager and Training Specialist. </p> <p class="bodytext">• Kevin Nealon was hired as a Claim and Case Support Analyst. </p> <p class="bodytext">• Ryan Kramer was hired as a Project and Operations Coordinator. </p> <p class="bodytext">• Jackie Ryan was hired as an Accounting Administrator. </p> <p class="bodytext">• Lesly Chavez was hired as a Customer Service Representative. </p> <p class="bodytext">• Chasitie Bryce was hired as a Customer Service Representative. </p> <p class="bodytext">• Roshaun Jones was hired as a Sr. Customer Service Representative. </p> <p class="bodytext">• Neil McCarthy was hired as a Claim Analyst. </p> <p class="bodytext">• Vanessa Leurini was hired as a Case Investigator. </p> <p class="bodytext">• Matthew Robinson was hired as a Director, Recovery Service Onboarding and Support. </p> <p class="bodytext">• John Gullett was hired as a Subrogation Attorney. </p> <p class="bodytext">• Spencer Mahne was hired as an Accounting Admin. </p> <p class="bodytext">• Nikki Wheeler was hired as a Director, Customer Service and Case Evaluation.</p> <a name="story"></a> <hr class="horiz" /> <p class="bodytext" style="text-align: justify;"><strong>The Phia Group Reaffirms Commitment to Diversity & Inclusion</strong><br /> <br /> At The Phia Group, our commitment to fostering, cultivating, and preserving a culture of diversity and inclusion has not wavered from the moment we opened our doors 20 years ago. We realized early on that our human capital is our most valuable asset, and fundamental to our success. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent that our employees invest in their work, represents a significant part of not only our culture, but also our company’s reputation and achievements.</p> <p class="bodytext" style="text-align: justify;">We embrace and encourage our employees’ differences, including but not limited to age, color, ethnicity, family or marital status, gender identity or expression, national origin, physical and mental ability or challenges, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique.</p> <p class="bodytext" style="text-align: justify;">The Phia Group’s diversity initiatives are applicable to all of our practices and policies, including recruitment and selection, compensation and benefits, professional development and training, promotions, social and recreational programs, and the ongoing development of a work environment built on the premise of diversity equality.</p> <p class="bodytext" style="text-align: justify;">We recognize that the success of our company is a direct reflection of each team member’s drive, creativity, diversity, and willingness to exercise initiative. With this in mind, we always seek to attract and develop candidates who share our passion for the healthcare industry and our commitment to diversity and inclusion.<br /> <br /> <a href="#top">Back to top ^</a></p> <p class="bodytext" style="text-align: center"><img src="/Portals/phiagroup/Newsletter 2018 Q2/footerlogo.png?ver=iYwkNviyLE_yU_0lKTSyJQ%3d%3d" style="width: 372px; height: 346px;" /></p> </td> </tr> <tr> <td bgcolor="#4a85d3" colspan="2"> <table border="0" cellpadding="5" cellspacing="5" width="100%"> <tbody> <tr> <td class="whitetext"><a class="whitetext" href="mailto:info@phiagroup.com" style="color: #FFFFFF">info@phiagroup.com</a><br /> 781-535-5600</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> 1303Empowering Plans: P179 – Higher Healthcare Prices (Made From Concentrate)https://phiagroup.com/Media/Posts/PostId/1301/empowering-plans-p179-higher-healthcare-prices-made-from-concentratePodcastsThu, 04 Jan 2024 21:07:23 GMT<p><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/yxvGmRYSfIs?si=3SRQ2yJrW_cdGSAy" title="YouTube video player" width="560"></iframe></p> <p style="margin: 0in; text-align: justify;"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"><span style="color:#000000;">The trend of provider consolidation is primed to pick up pace in 2024, distilling some areas into even more highly concentrated healthcare markets. Ron Peck and Nick Bonds break down how this concentration impacts the costs of healthcare and can drive costs upward for employers and employees alike. With fewer provider options, higher prices, and patients caught in the middle, Ron and Nick outline just a few of their concerns and discuss some of the tools health plans have at their disposal.  </span></span></span></span><br />  </p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"><a href="https://youtu.be/yxvGmRYSfIs"><span style="color:#0071ce;"><u><span style="font-size:12.0pt">Click here to check out the podcast!</span></u></span></a><span style="font-size:12.0pt"><span style="color:#000000;"> (Make sure you subscribe to our <a href="https://youtu.be/yxvGmRYSfIs"><u>YouTube</u></a> and</span><span style="color:black"> </span><a href="https://itunes.apple.com/us/podcast/the-phia-groups-podcast/id1246462552?mt=2" style="color:blue; text-decoration:underline"><span style="color:#0071ce">Apple Podcasts</span></a> <span style="color:#000000;">Channels!)</span></span><span style="font-size:12.0pt"></span></span></span></p> <p style="margin:0in"><span style="font-size:11pt"><span calibri="" style="font-family:"></span></span></p> 1301Is the Department of Labor Offsetting a Major Problem?https://phiagroup.com/Media/Posts/PostId/1300/is-the-department-of-labor-offsetting-a-major-problemBlog,Affordable Care Act,Cost Containment,Health Insurance,Healthcare Costs,Healthcare Exchanges,Hospital BillsWed, 03 Jan 2024 18:05:56 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">By: David Ostrowsky</span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">As if Americans on employer-based health plans didn’t face enough obstacles in trying to obtain reasonably priced healthcare. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">The inconvenient truth is that many participants on ERISA self-funded health plans, ones who are often already paying high premiums and deductibles, have unknowingly fallen victim to the ethically questionable – although not technically outlawed -- practice of cross-plan offsetting over the years. In fact, only very recently, as in the past several months, has there been heightened awareness of the adverse effects of cross-plan offsetting on unsuspecting American plan participants. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">First, a quick primer on cross-plan offsetting: </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">There are times when a given health plan erroneously overpays a provider for a service rendered. Perhaps because of a human or AI-induced oversight or timing snafu or minor typo, the plan will pay the full charge when it should have paid the claim based on the (lower) usual and customary or maximum allowable charge, per the plan document. Whatever the source of the erroneous payment might have been, the provider now has the extra funds (this could be thousands of dollars) and, by law, does not have to refund the plan. And they almost never do. It sounds like an inequitable practice, but, as long as the provider did not receive more than the billed charges, it’s entirely legal. Plans have<span style="background:white"><span style="color:#212121"> no legal recourse and are often left with no choice but to close the file. </span></span> </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Naturally, the plan’s respective TPA that administered the claim feels that the provider owes it money. In some cases, said TPA tries to recoup the excess funds by not<i> </i>paying that same provider the full amount due for a plan participant’s claim on <i>another</i> one of its plans. Yes, this is a blatant breach of their fiduciary duties. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">But most importantly, the end result is that the participant on this second plan, through no fault of their own, will see their claim denied by reading a cryptically written note on their explanation of benefits; the TPA is trying to exact revenge on the provider, but it is the hard-working, often cash-strapped participant – one with zero knowledge of the overpayment backstory -- who gets shortchanged by either getting balance billed for the erroneously offset claims or having to pay a hefty out-of-pocket amount for services rendered. </span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif">Many TPAs have been engaging in cross-plan offsetting for years, but this past fall, one in particular, EmblemHealth Inc., <span style="background:white"><span style="color:black">a New York-based insurer and TPA of ERISA group health plans,</span></span> was caught red-handed and made an example of for all the world to see. On September 29, the Department of Labor (DOL) <span style="background:white"><span style="color:black">entered into a settlement agreement with EmblemHealth Inc., resolving claims that the company violated its fiduciary duties under federal law by engaging in cross-plan offsetting to recover alleged overpayments. The DOL’s </span></span><span style="background:white"><span style="color:#212121">Employee Benefits Security Administration</span></span><span style="background:white"><span style="color:black"> (EBSA) submitted that Emblem benefitted by wrongfully keeping money from one health plan for a debt owed by another health plan.</span></span></span></span></span></span></span></span></p> <p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">So, what were the repercussions for Emblem? Per the terms of the settlement, Emblem pledged to no longer practice cross-plan offsetting and modify its policies, procedures, and practices accordingly no later than January 1, 2024, or as soon as reasonably possible for insured plans prospectively. That the DOL essentially gave Emblem a three-month deadline is noteworthy. Traditionally, the DOL is known for working at a glacial pace in adjudicating matters. But not this time, not when a stern dictum is in order to TPAs across the country: no longer can they get away with committing </span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:#212121">blatant violations of ERISA by using one plan’s money to take care of another’s debt under the guise of (arbitrarily) denying claims. Meanwhile, regarding </span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">retrospective corrective actions dating back to July 16, 2015, Emblem has been mandated to reimburse present and past participants and dependents whose reimbursements were reduced via cross-plan offsetting. Should Emblem not abide by the terms of this agreement, the DOL could very well take the TPA back to court.</span></span></span></span></span> </span></span></span></p> <p style="text-align: justify;"><span style="font-size:12.0pt"><span style="background:white"><span style="line-height:107%"><span style="font-family:"Times New Roman",serif"><span style="color:black">To be clear, an untold number of other TPAs have long engaged in this practice, some possibly unaware of the legal issues caused by it. Clearly, the DOL has stepped up enforcement here and it will be interesting to see whether cross-plan offsetting continues to be a fairly commonplace practice now that Emblem has been put on notice.</span></span></span></span></span></p> 1300Time’s Up! It’s Gag Clause Attestation Seasonhttps://phiagroup.com/Media/Posts/PostId/1299/times-up-its-gag-clause-attestation-seasonBlog,Health Insurance,Healthcare Costs,Third Party AdministratorsTue, 26 Dec 2023 21:54:36 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:107%"><span style="font-family:"Calibri",sans-serif">By: Andrew Silverio, Esq.<br /> <br /> As the year wraps up and plans and TPAs around the country are scrambling to handle renewals, another challenge looms large in 2023 – the first annual gag clause attestation.  As a reminder, the Consolidated Appropriations Act, 2021 (CAA) prohibits plans from entering into any contracts with providers and certain other entities that contain “gag clauses” – and requires them to attest annually that their contracts are free of them. The first attestation is due at the end of 2023, and it will cover the period of December 27, 2021 through December 31, 2023. The goal of the legislation is transparency, but it has glaring holes – contracts can’t prohibit plans from sharing certain information with other entities, but nothing requires them to be granted access to this information in the first place.<br /> <br /> While payers have technically been on notice of this requirement since the CAA passed, we all know how things get put off, and we saw a furious uptick of questions and activity surrounding this requirement in the second half of 2023. Unfortunately, it’s because of the nature of how the industry and its contracts have developed over the years that it’s more likely to find gag clauses than not to – especially in network and pharmacy benefit agreements.  Unfortunately, many plans have been put in an unfortunate position by many big players – we won’t name names – who have simply issued broad statements that their contracts do not contain gag clauses (statements that are often proven false with a simple review of the actual agreements) and refused to entertain changes or even sometimes let plans review the contracts directly.  Plans in this situation face a difficult choice: submit an attestation knowing that these representations are questionable at best and that the compliance obligation ultimately falls on them, or fail to submit the attestation, risking whatever enforcement action might follow.  It’s not entirely clear how enforcement will play out, but penalties for failure to attest <i>could</i> come in the form of the $100 per day excise tax under ERISA or excise tax via the IRS.<br /> <br /> Given the widespread confusion, disagreement, and outright disregard of this requirement, it’s also not clear how much effort will go into enforcement and auditing plans for compliance.  We’ve been approached by countless clients inquiring about whispers and rumors of an enforcement delay.  Everyone has heard from someone who heard from someone that enforcement will be delayed - however we’ve seen no indication from any official source that any relief is coming.  At this point it’s safe to say relief in the form of delays or waivers, if it happens at all, won’t be coming in 2023.  So at this point, all plans can do is the best they can to get their existing agreements in order, submit the required attestation, and be on the lookout for gag clauses in any new contracts moving forward.</span></span></span></p> 1299For Sickle Cell Disease Patients, Hope Has Arrived – but at What Cost?https://phiagroup.com/Media/Posts/PostId/1298/for-sickle-cell-disease-patients-hope-has-arrived-but-at-what-costBlog,Cost Containment,Health Insurance,Healthcare Costs,Hospital BillsThu, 21 Dec 2023 16:32:52 GMT<p style="margin: 0in 0in 8pt; text-align: justify;"><span style="font-size:11pt"><span style="line-height:normal"><span style="font-family:"Calibri",sans-serif"><span style="font-size:12.0pt"><span style="font-family:"Times New Roman",serif"><span style="color:#000000;">By: Kelly E. Dempsey, Esq.</span></span></span><br /> <span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:.3pt"><br /> For generations of sickle cell disease (SCD) patients, the suffering has been unbearable – with no end in sight. SCD, an </span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif">inherited genetic red blood cell disorder that affects hemoglobin, the protein that carries oxygen throughout the body, torments nearly 100,000 Americans (20 million people worldwide), a disproportionate number of whom are African-American. Among other symptoms, SCD often triggers chronic bouts of excruciating pain that require regular hospitalization, organ failure, strokes, and shortened life expectancy. Meanwhile, the only known cure for the insidious disease has been a bone marrow transplant</span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:.3pt">. </span><br /> <br /> Until last month, that is. Developments in this area are exciting for patients, but may make some waves for employers and their self-funded health plans. </span></span></span></span><br /> <span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><br /> In the middle of the invariably hectic holiday season, some above-the-fold medical news dropped when the FDA announced approval of two gene-based treatments for SCD: </span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:.3pt">Casgevy, the first-ever therapy to incorporate the gene-editing technique CRISPR which enables scientists to make cuts in DNA, and Lyfgenia, grounded in an older gene therapy approach in which a virus is used to deliver a healthy copy of the gene that produces adult hemoglobin to compensate for the one producing the sickled form. Both Casgevy (produced by Vertex Pharmaceuticals and CRISPR Therapeutics) and Lyfgenia (generated by Bluebird Bio) have been cleared for patients 12 and older and are designed to serve as a one-time panacea. </span><span style="letter-spacing:.3pt"></span></span></span></span></span><br /> <span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:.3pt"><br /> Certainly, for those with sickle cell who have long felt they have been suffering in silence, the disease now being the focus of this dramatic new approach to therapy development is cause for celebration. In reality, the majority of sickle cell patients can’t find a matching bone marrow donor, so this scientific breakthrough could truly be life-changing for the masses dealing with the agonizing blood disorder. And the early signs are, in fact, promising: through rounds of clinical trials, Casgevy and Lyfgenia have proved to be so effective as one-time treatments that they have been widely considered to be “cures” by the scientific community. </span><span style="letter-spacing:.3pt"></span></span></span></span></span><br /> <span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:.3pt"><br /> But, like any cutting-edge therapy, these won’t be cheap. Consider that Casgevy will cost <i>$2.2 million</i> for the one-time treatment while Lyfgenia will cost <i>$3.1 million</i>. It also bears mentioning that these multimillion-dollar treatments will need to be administered in a monthslong process within large-scale medical systems that can perform stem cell transplants – systems that are inaccessible to millions of impoverished Americans living in states that have not broadened their Medicaid programs. The global picture is even bleaker. A recent <i>New York Times</i> story indicated that Vertex has been focusing on gaining approval in six wealthy nations – U.S., Italy, Britain, France, Germany, and Saudi Arabia – that represent merely 2 percent of the worldwide sickle cell population. Meanwhile, approximately 75 percent of the planet’s sickle cell patients reside in sub-Saharan Africa, where basic medical resources can often be scarce, to put it mildly. It should be noted that not all sickle cell patients have cases severe enough to warrant the new therapies; for reference, roughly only 20,000 in the US are believed to be sick enough to qualify for treatment. </span><span style="letter-spacing:.3pt"></span></span></span></span></span><br /> <span style="color:#000000;"><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="letter-spacing:.3pt"><br /> But back to the daunting financial numbers. Why are the price tags so ridiculously expensive? Those pursuing Casgevy and Lyfgenia will need to have their cells harvested and transported to a lab for manufacturing; undergo multiple rounds of rigorous chemotherapy, which very well can pose its own risks; and be hospitalized for months on end. As Vertex’s chief scientific officer, Dr. David Altshuler, was quoted as saying in the previously mentioned <i>New York Times</i> article, “</span></span></span></span></span><span style="font-size:12.0pt"><span style="background:white"><span style="font-family:"Times New Roman",serif"><span style="color:#000000;">A medicine that is so resource-intensive as this is may not be appropriate in many places where the amount of resources for health care is more limited.” </span><span style="color:#363636"></span><br /> <span style="color:#000000;"><br /> For employer-sponsored health plans, the multi-million-dollar question is whether they will have the resources to foot the bill. Will most plans simply be inclined to outright exclude this therapy? Will these new treatments be the most cost-effective method for providing services to those with sickle cell disease?  For those plans that do provide coverage, how will their respective stop-loss policies be impacted? What sort of coverage, if any, will be provided by Medicaid and/or Medicare?  </span><span style="color:#363636"></span><br /> <span style="color:black"><span style="letter-spacing:.3pt"></span></span><br /> <span style="color:#000000;"><span style="letter-spacing:.3pt">Gene therapy and cellular therapy have been hot topics in the last year, as well as the ever-increasing price tag on medical care and new treatments. It reminds me of the meme floating around social media about Kevin McCallister’s grocery list from <i>Home Alone</i>. In 1990 he purchased a half-gallon of milk, a half-gallon of orange juice, a TV dinner, bread, frozen mac and cheese, laundry detergent, cling wrap, toilet paper, a pack of army men, and dryer sheets all for $19.83. In 2022, that same grocery list cost $44.40 and in 2023 it’s now up to $72.28 … My intent was to make readers laugh, but if you need tissues, I understand as well (I’ll see if Matt has any Phia logo tissues on hand). <br /> <br /> Stay tuned. </span></span><span style="color:black"><span style="letter-spacing:.3pt"></span></span></span></span></span></span></span></span></p> 1298