PDDRC 2018 Recommendation Overview: PHIA Language

Please review each item which includes:

1. Current Language (Red)
2. PHIA's Recommended Language (Green)
3. Reasoning for recommendation from PHIA. (Yellow)

Select "APPROVE" if you want this to move forward.
Select "DISCUSS FURTHER" if you want to discuss this item further at a PDDRC weekly meeting.

If you see blue text, that indicates new language being added to existing languge.

If you see red text, that indicates the language may vary based on plan design or intent in its final form.

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  1. GENERAL DEFINITIONS - ALLOWABLE EXPENSES AND OTHER PLAN:



    CURRENT LANGUAGE:
    ALLOWABLE EXPENSES - Shall mean the usual and customary charge for any medically necessary, reasonable eligible item of expense, at least a portion of which is covered under this Plan. When some other plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service rendered, in the amount that would be payable in accordance with the terms of the Plan, shall be deemed to be the benefit. Benefits payable under any other plan include the benefits that would have been payable had claim been duly made therefore.



    PHIA LANGUAGE:
    ALLOWABLE EXPENSES – Shall mean the Maximum Allowable Charge for any Medically Necessary, eligible item of expense, at least a portion of which is covered under this Plan. When some Other Plan pays first in accordance with the Application to Benefit Determinations provision in the Coordination of Benefits section, this Plan’s Allowable Expenses shall in no event exceed the Other Plan’s Allowable Expenses.

    When some “Other Plan” provides benefits in the form of services (rather than cash payments), the Plan Administrator shall assess the value of said benefit(s) and determine the reasonable cash value of the service or services rendered, by determining the amount that would be payable in accordance with the terms of the Plan. Benefits payable under any Other Plan include the benefits that would have been payable had the claim been duly made therefore, whether or not it is actually made.

    OTHER PLAN - Shall include, but is not limited to:

    1. Any primary payer besides the Plan.
    2. Any other group health plan.
    3. Any other coverage or policy covering the Participant.
    4. Any first party insurance through medical payment coverage, personal injury protection, no-fault coverage, uninsured or underinsured motorist coverage.
    5. Any policy of insurance from any insurance company or guarantor of a responsible party.
    6. Any policy of insurance from any insurance company or guarantor of a third party.
    7. Workers’ compensation or other liability insurance company.
    8. Any other source, including but not limited to crime victim restitution funds, any medical, disability or other benefit payments, and school insurance coverage.



    PHIA REASONING:
    Recommended updating the Allowable Expense definition.



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    ACCEPT, no discussion needed
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  1. GENERAL DEFINITIONS - CHEMICAL DEPENDENCY AND SUBSTANCE USE DISORDER:



    CURRENT LANGUAGE:
    Chemical Dependency - An illness characterized by a physiological or psychological dependency, or both, on a controlled substance and/or alcoholic beverages. It is further characterized by a frequent or intense pattern of pathological use to the extent you exhibit a loss of self-control over the amount and circumstances of use; develops symptoms of tolerance or physiological and/or psychological withdrawal if use of the controlled substance or alcoholic beverage is reduced or discontinued; and your health is substantially impaired or endangered or your social or economic function is substantially disrupted.

    SUBSTANCE USE DISORDER SERVICES - Eligible covered services for the diagnosis and treatment of alcoholism and substance use disorders that are listed in the current edition of International Classification of Diseases, published by the U.S. Department of Health and Human Services Diagnostic unless those services are specifically excluded. The fact that a disorder is listed in the current edition of International Classification of Diseases does not mean that treatment of the disorder is covered under this Plan. Substance Dependence: Substance use history which includes the following: (1) substance abuse; (2) continuation of use despite related problems; (3) development of tolerance (more of the drug is needed to achieve the same effect); and (4) withdrawal symptoms.



    PHIA LANGUAGE:
    Chemical Dependency - See Substance Use Disorder Services definition.

    SUBSTANCE USE DISORDER SERVICES - Eligible covered services for the diagnosis and treatment of alcoholism and substance use disorders that are listed in the current edition of International Classification of Diseases, published by the U.S. Department of Health and Human Services Diagnostic unless those services are specifically excluded. The fact that a disorder is listed in the current edition of International Classification of Diseases does not mean that treatment of the disorder is covered under this Plan.



    PHIA REASONING:
    In general, we recommend using the DSM-5 definitions. Instead of having a separate “Chemical Dependency” definition, we recommend referring to the “Substance Use Disorder Services” definition below.



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    ACCEPT, no discussion needed
    DISCUSS FURTHER


  1. GENERAL DEFINITIONS - DEDUCTIBLE:



    CURRENT LANGUAGE:
    DEDUCTIBLE - The deductible is the amount of eligible expenses each calendar year that you must incur before any benefits are payable by the Plan. The individual deductible amount is listed in the Schedule of Benefits .



    PHIA LANGUAGE:
    DEDUCTIBLE - The deductible is the amount of eligible expenses each calendar year that you must incur before any benefits are payable by the Plan. The individual deductible amount is listed in the Schedule of Benefits .

    However, certain covered benefits may be considered preventive care and paid first dollar. Your ability to contribute to a Health Savings Account (HSA) on a tax favored basis may be affected by any arrangement that waives this Plan’s Deductible.



    PHIA REASONING:
    Recommend adding this additional paragragh qualified HDHP's.



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    ACCEPT, no discussion needed
    DISCUSS FURTHER


  1. GENERAL DEFINITIONS - DISABILITY, TOTALLY DISABILITY, AND DISABLED:



    CURRENT LANGUAGE:
    DISABILITY, TOTAL DISABILITY AND DISABLED - The terms total disability and disabled mean for the:

    • Employee – Your inability to engage, as a result of accident or illness, in your normal occupation with the Participating Company on a full time basis.
    • Dependent - Your inability to perform the usual and customary duties or activities of someone in good health and of the same age.



    PHIA LANGUAGE:
    Recommend delete definition.



    PHIA REASONING:
    In general, we do not recommend that medical plans include this definition, as it may create gaps between this document and the plan’s disability benefits plan language, if any. The medical plan should clearly state if there is a continuation of coverage for employees who are on disability leave.



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  1. AUDIT AND REVIEW FEES:



    CURRENT LANGUAGE:
    AUDIT AND REVIEW FEES

    Reasonable charges made by an audit and/or independent or peer review organization firm when the services are requested by the Plan Supervisor and approved by the Plan Administrator shall be payable.



    PHIA LANGUAGE:
    AUDIT AND REVIEW FEES

    In addition to the Plan’s medical record review process, the Plan Administrator may use its discretionary authority to utilize an independent bill review and/or claim audit program or service for a complete claim. While every claim may not be subject to a bill review or audit, the Plan Administrator has the sole discretionary authority for selection of claims subject to review or audit.

    The analysis will be employed to identify charges billed in error and/or charges that are not Usual and Customary and/or Medically Necessary and Reasonable , if any, and may include a patient medical billing records review and/or audit of the patient’s medical charts and records.

    Upon completion of an analysis, a report will be submitted to the Plan Administrator or its agent to identify the charges deemed in excess of the Usual and Customary and Reasonable amounts or other applicable provisions, as outlined in this Plan Document. Cost containment fees may be charged as a percent of savings under the Plan due to the application of cost containment provisions and are considered covered expenses under the Plan.

    Despite the existence of any agreement to the contrary, the Plan Administrator has the discretionary authority to reduce any charge to a Usual and Customary and Reasonable charge, in accord with the terms of this Plan Document.



    PHIA REASONING:
    It is recommended that we update the Audit and Review Fees provision.

    Common line item exclusions or payable charges, modifier 26 and unbundling. Issue if we use Blue Card, we must abide by rules; or only reference to non-Blue Card clients. May want to caveat "limited to non-network charges or non-blue charges"



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    ACCEPT, no discussion needed
    DISCUSS FURTHER


  1. AUDIT INCENTIVES:



    CURRENT LANGUAGE:
    AUDIT AND REVIEW FEES

    If you or your dependent discovers an error in the provider's medical billing which is subsequently recovered or if the benefits payable are reduced due to the identification of the error, the medical plan will reimburse you[ #178c% of the recovered 178c][ or 178c & 178d][ reduced amount up to $#178d per incident 178d]. No benefit is payable for any errors made by the Plan Supervisor in processing the claim.



    PHIA LANGUAGE:
    CLAIM AUDIT REVIEW PROGRAM

    The Claim Audit Review Program is designed to reward you for identifying and recovering erroneous charges on bills for medical services and supplies furnished to you or your dependents.

    1. When you independently identify eligible overpayments for services, supplies and treatments not rendered or received the you will be awarded fifty percent (50%) of the recovered amount up to a $500 maximum on claims you report to the Plan Administrator that are successfully recovered by the Plan.
    2. The Plan Administrator will assist you with the determination of an eligible overpayment and will pursue the collection of the overpayment amount.
    3. A final determination letter will be sent to you after the status of the audit has been completed. The Plan Administrator shall make the final determination regarding all qualifications for eligible overpayment and awarded amounts.

    Submittal Procedures
    Information regarding an overpayment or potential overpayment must be submitted for Claims Audit Review within 15 days of identification. All considerations for eligible overpayment must be submitted in writing and accompanied by supporting documentation as listed below:

    • Claim number or copy of the Explanation of Benefits;
    • Any correspondence with the Provider; and
    • A statement that includes the reason for belief of an eligible overpayment.

    Payment of Awards
    Awards shall only apply to the first occurrence of each claim submitted for Claim Audit Review. Awards will be reflected on the employee’s payroll check (?? What is our process?) following the final determination and subsequent recovery of the overpayment.

    You shall only be eligible for award under the Claim Audit Review Program if eligible overpayments, actual or potential, are the result of services, supplies or treatments billed but not rendered or received.



    PHIA REASONING:
    It is recommended that we replace our Audit Incentive provision with a more detailed provision. This doesn't change the program, it only provides more information. The goal is to incentivize participants to review their claims. This is only applicable if the client has elected to allow audit incentives.



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    ACCEPT, no discussion needed
    DISCUSS FURTHER


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    ACCEPT, no discussion needed
    DISCUSS FURTHER


  1. REQUIREMENTS FOR SECOND APPEAL - PACE PLANS ONLY:



    CURRENT LANGUAGE: N/A



    PHIA LANGUAGE:
    Two Levels of Appeal
    This Plan requires two levels of appeal by you before the Plan’s internal appeals are exhausted. For each level of appeal, you and the Plan are subject to the same procedures, rights, and responsibilities as stated within this Plan. Each level of appeal is subject to the same submission and response guidelines.

    Once you receive an Adverse Benefit Determination in response to an initial claim for benefits, you may appeal that Adverse Benefit Determination, which will constitute the initial appeal. If you receive an Adverse Benefit Determination in response to that initial appeal, you may appeal that Adverse Benefit Determination as well, which will constitute the final internal appeal. If you receive an Adverse Benefit Determination in response to your second appeal, such Adverse Benefit Determination will constitute the final Adverse Benefit Determination, and the Plan’s internal appeals procedures will have been exhausted.



    PHIA REASONING:
    It is recommended that we describe the 2 levels of appeals for clients who have purchased PACE services.

    Does it make sense to include for all clients, not just PACE?



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    ACCEPT, no discussion needed
    DISCUSS FURTHER


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    DISCUSS FURTHER


  1. COORDINATION OF BENEFITS:



    CURRENT LANGUAGE: N/A



    PHIA LANGUAGE:
    Excess Insurance
    If at the time of Injury, sickness, disease or disability there is available, or potentially available any other source of coverage (including but not limited to coverage resulting from a judgment at law or settlements), the benefits under this Plan shall apply only as an excess over such other sources of coverage.

    The Plan’s benefits will be excess to, whenever possible, any of the following:

    1. Any primary payer besides the Plan.
    2. Any first party insurance through medical payment coverage, personal injury protection, no-fault coverage, uninsured or underinsured motorist coverage.
    3. Any policy of insurance from any insurance company or guarantor of a third party.
    4. Workers’ compensation or other liability insurance company.
    5. Any other source, including but not limited to crime victim restitution funds, any medical, disability or other benefit payments, and school insurance coverage.

    Vehicle Limitation
    When medical payments are available under any vehicle insurance, the Plan shall pay excess benefits only, without reimbursement for vehicle plan and/or policy deductibles. This Plan shall always be considered secondary to such plans and/or policies. This applies to all forms of medical payments under vehicle plans and/or policies regardless of its name, title or classification.



    PHIA REASONING:
    It is recommended to include an Excess Insurance and a Vehicle Limitation provision to our Coordination of Benefits provision.



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    ACCEPT, no discussion needed
    DISCUSS FURTHER


  1. HIPAA PRIVACY AND SECURITY:



    CURRENT LANGUAGE: N/A



    PHIA LANGUAGE:
    The Plan provides each Participant with a separate Notice of Privacy Practices. This Notice describes how the Plan uses and discloses a Participant’s personal health information. It also describes certain rights the Participant has regarding this information. Additional copies of the Plan’s Notice of Privacy Practices are available by calling [INSERT PHONE NUMBER].



    PHIA REASONING:
    For clarity and to provide additional information to plan participants, it is recommended that plans include a statement indicating how a plan participant can obtain a copy of the Plan’s Notice of Privacy Practices



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    ACCEPT, no discussion needed
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  1. (The first paragraph in both versions are the same; everything else is changed).
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