In the ever-evolving landscape of health care compliance, staying informed about crucial topics is essential.
In his presentation, Ron E. Peck, Esq., Chief Legal Officer for The Phia Group, gave Custom Design Benefit customers and brokers a crash course in some of the issues that everyone involved in self-funded benefits plans needs to be aware of. Among the most pressing include:
Cellular Gene Therapy: While excluding Cellular Gene Therapy from benefits plans may be permissible, flatly denying or making reactionary mid-year exclusions may create unnecessary discrimination and other unwanted legal issues.
Mental Health Parity: Group health plans must provide mental health benefits on par with medical/surgical benefits. This can be assessed using non-quantitative treatment limitations (NQTLs) such as network composition and provider credentialing, and quantitative treatment limitations (QTLs), such as days of coverage, deductibles and co-pays.
Gag Clauses: The Consolidated Appropriations Act of 2021 prohibits the use of gag clauses in benefit plan contracts, which prevents the withholding of certain plan information related to the cost and quality of health care services, to patients and others. Many (if not most) provider and network agreements contain broad confidentiality clauses that qualify as gag clauses.
No Surprises Act: There are many misconceptions people have with the No Surprises Act including the idea that it makes balance billing illegal or that it forces payers to pay 100% of billed charges. However, if the dispute does not fall into one of three criteria, it’s most likely an adverse benefit determination that would need to be appealed.
Want to stay up-to-date on the latest compliance issues? Contact your Account Manager to learn more.