A client came to us in need of a plan document that includes a PPO plan option and an EPO plan option.  The basics of the plan were the same – eligibility and benefits – the differences were plan coverage of out-of-network services and the out of pocket figures.  We were able to craft one plan document with two benefit grids to accomplish this plan drafting request.  The client could have also utilized our major medical template in PDM to craft this plan and pop in the customized grids. 

A client came to us because a broker prospect approached them needing 50 customized plan documents imminently on their specialized template. The client wanted to take on the business, but wasn’t sure they had the bandwidth to get all the documents completed – so they reached out to us.  The Phia team not only helped this client prepare a scope for handling these document projects, but also helped them secure the business!  When Phia got involved we were able to assist by automating this specific template and allowing access for the client to quickly craft plans on Phia’s PDM software.  

An employer’s plan was previously fully insured.  The employer realized the savings that could be had by self-funding, so the employer was looking for a self-funded plan that would mirror the fully insured HMO plan the employer had for years.  Phia explained that the self-funded equivalent to an HMO is an EPO plan (where the plan generally does not pay for out of network services with the few exceptions associated with the ACA).  Phia explained that the more traditional self-funded model is a PPO, and described more innovation options including reference based pricing for out of network services.  The employer opted to move to an EPO for the time being, but is evaluating additional innovation options for future plan years.

A TPA with whom The Phia Group has worked closely for many years recently began to utilize its proprietary reference-based pricing model, whereby the TPA would perform claims repricing and patient advocacy. Since reference-based pricing entails paying claims at Medicare rates, it follows that plan documents must be amended prior to a given plan being able to utilize the service. After all, if the plan does not have the rights to pay based on Medicare rates, the plan cannot compliantly do so.

Conveniently, the TPA was a client of The Phia Group’s Phia Document Management (PDM) service, through which plan documents can be efficiently and seamlessly created online, with access to The Phia Group’s template language materials. This TPA was adding five groups to its reference-based pricing platform, and needed plan documents completed within the week to manage some high-profile renewals.

Using the PDM service, the TPA was not only able to compile and draft the plan documents it needed, but it was able to ensure that those plan documents included some of the best reference-based pricing language in the industry. Built into The Phia Group’s template materials are options for reference-based pricing language, which gives the plan all the rights it needs to pay based on Medicare and other criteria, or pay negotiated rates as necessary as well. To this day, the TPA has not experienced a challenge to that reference-based pricing language.
 

A client reached out to us since they realized that many of their clients only had benefit booklets/certificates of insurance/evidence of coverage documents for their plans but did not have ERISA-compliant Summary Plan Descriptions (SPDs) or Plan Documents. The client asked us what was the most efficient way to make sure their clients have all the ERISA-required documentation, without having to create all new SPDs/Plan Documents for each benefit plan.

We recommended that these plans create a “Wrap Document” on our PDM software. In a wrap document, multiple plans offered by an employer (i.e., medical, dental, vision, life, long-term disability, short-term disability) are combined into one plan that “wraps” all the included benefits together. An ERISA wrap document containing both health benefits and other welfare benefits only needs to file one Form 5500. Phia’s Wrap Document template on PDM is a combined Plan Document/Summary Plan Description, so it meets ERISA’s documentation requirements.

Using this wrap document option, these particular clients did not have to create new SPDs/Plan Documents for all of their ERISA benefits. In other words, they could continue to use their current documents since the wrap document met the ERISA requirements. Not only did this streamline the process for our client, but it was a cost-effective way of making sure their clients were in compliance with ERISA.

A broker had a prospect that wanted to offer benefits to their employees, but wanted to offer more limited benefits (i.e. preventive care only).  The broker wasn’t sure about the requirements or hurdles that this prospect would face – so she reached out to Phia.  The Phia team was not only able to help answer questions and concerns for this prospect, but also ultimately ended up helping this prospect become a client and crafted all the preventive care only group documents!

The Phia Group has been providing the SBC (Summary of Benefits and Coverage) services for our clients since the ACA rules regarding SBCs came into effect , September 21, 2012. Even though it is a short document (only 4 double-sided pages), the SBC template is strictly regulated and most of its provisions and disclaimers must be replicated by the Plans with no changes. Plans and TPAs were often unsure as to the extent the template language can be modified and what plan specific language is permitted and should be included in the SBC.

Creation of the automated SBC template provided our clients using PDM services with clarity as to what information is variable and can be modified to better describe plans’ specific information. All the mandated provisions of the SBC template were made static with no option for updates while areas permitted for updates are provided as variables in the SBC checklist. The SBC checklist in PDM also includes every question for the information that will fully satisfy the SBC requirement if answered. Our clients are no longer confused as to what information should and should not be added in the SBC to ensure compliance as well as listing plan specific information.