BAN Blog

Meet the Partner: Michael Grinnell

Posted on by Caroline Williams

As a Regional Sales Director at ProAct, Inc. Mike delivers a fresh perspective on pharmacy benefits. With his diverse experience in all areas of employee benefits, he understands the major roll pharmacy management plays in not only cost containment but also employee satisfaction. ProAct focuses on flexible solutions with high touch service. Working with Brokers and TPAs, they customize a PBM plan that fits an employer’s budget, and their employee’s needs.

What is your background and how did you get into the EB business?
I started in the insurance business in 1989. After college graduation, I joined Metropolitan Life as a sales representative selling individual life insurance policies at the kitchen table. It taught me the “Rule of 50” in prospecting. From there, I moved to an independent agency for 7.5 years selling employee benefits to small business employers. For the next 10 years, I moved to the health carrier side of the business working for Kaiser, Emblem Health, and United Healthcare. In the health carrier sector, I learned about large group underwriting and the complexity of provider networks and contracting.

I then chose to move back to the agency side for 14.5 years with responsibilities focused on sales and management. I managed an EB department for 5 years and doubled the revenue in the department by adding great sales talent.

Another opportunity appeared with the introduction of ACA. We built a team to help employers complete their 1095s and file their 1094s with the IRS.

Most recently, I had the opportunity to join ProAct, Inc., a 100% employee-owned Pharmacy Benefit Manager. With the complexity of employee benefits and specialty pharmacy in today’s healthcare landscape, I have the important task of helping brokers and consultants help their clients manage pharmacy cost of their employee benefit programs.

What are your leadership principals?
My core leadership principals are to lead by example; challenge the process; enable others to act; and develop future leaders.

What are you looking forward to as a BAN Partner?
I am looking forward to ProAct’s collaboration with BAN membership to provide PBM education and value.

How are you advising your clients regarding inflation, higher interest rates and a shaky economy?
All employers are feeling the pressure of inflation, higher interest rates, a shaky economy, and employee retention concerns.

Complex conditions represent significant costs within employer health plans. In 2022, specialty spend throughout the industry continued to outpace non-specialty and grew approximately 11.6% compared to non-specialty growth of 6.9%. These challenges in specialty spend are changing how brokers and consultants are helping employers manage their total spend for pharmacy benefits.

ProAct offers various solutions to assist employers (plan sponsors) in managing specialty drug spend; including percentage-based copay programs, utilization management edits, as well as funding assistance partnerships.

The introduction of biosimilars can also offer some relief. By monitoring upcoming biosimilar and generic launches, ProAct can strategize appropriately, and implement formulary changes to transition utilization toward the agent losing exclusivity or by evolving our clinical programs to increase utilization.

ProAct’s Clinical Optimization Program offers an opportunity to discuss alternative medication therapies aimed at lowering prescription drug expenditures for plan sponsors, while improving health outcomes for members.

Around the corner in 2025, there will be an introduction of many new medications for gene therapy. We work with our brokers and consultants on planning in advance for these innovations to help provide solutions in mitigating substantial increases in pharmacy spend.

Are you concerned about a recession?
A recession will greatly impact employers in operating their businesses. We will work with brokers and consultants to help mitigate excess pharmacy spend through education.

What is your outlook in 2024?
Over the past few years, we’ve seen an unprecedented level of legislation around health plans and pharmacy benefit managers, leading to over 2,800 new pieces of legislation introduced around pharmacy benefits. We look forward to being a resource for Benefit Advisors Network Partners on the changing marketplace to ensure compliance with both federal and state reporting requirements.

What is the industry’s largest challenge?
The industry’s largest challenge is innovation and the rising cost of pharmacy benefits. We look forward to developing and executing solutions to help BAN’s brokers and consultants find innovative ways to manage their employers’ total pharmacy spend.

What are two lessons that you learned during your career that you can pass along to future leaders in the insurance industry?
In sales, it took me about 20 years in my career to learn that joint team selling can generate substantially better results. As a leader, I learned the importance of taking care of my team members and showing them how important they are to the company and our goals.

Mike can be reached at mikegrinnell@proactrx.com.

Follow Mike on LinkedIn.

Meet the Partner: Ashley Inman

Posted on by Caroline Williams

Ashley Inman, a skilled business development and marketing professional, brings over a decade of experience in the tech and healthcare industries. As VP of Market Development at Truveris, she connects partner networks, benefits brokers, and self-funded employers with the right solutions to improve prescription drug pricing and contract transparency while driving vendor accountability.

Before Truveris, Ashley drove business growth in healthcare analytics, enterprise system consulting, competitive strategy spaces, and leading marketing and strategic client initiatives. With an MBA and undergraduate degree from Babson College, her academic background is rooted in entrepreneurship, management, and strategy. Ashley is based in New York City.

What is your background, and how did you get into this line of work?
As I’ve navigated my career across various roles in marketing, consulting, and business development, I’ve gravitated toward industries and teams where I can maximize contribution and impact both personally and vocationally. With so much inefficiency and costs in the healthcare space, it’s a natural fit for someone who loves to take a mission-driven approach to solving important issues while creating winning growth strategies. I also care a lot about people, so it’s important to me to be in a collaborative role working with like-minded people who are equally as passionate about using our unique skills and contributions to improve the lives of others by driving value and innovation in the space.

What are your leadership principles?
My leadership principles center on competition, teamwork, and a collective purpose. I thrive on data and results, channeling that energy to mobilize teams towards shared objectives. I care about authenticity and believe emotional intelligence is fundamental to building high-performing teams. Ultimately, my focus is on driving value for communities and utilizing my skills to make a meaningful impact. I try to lead by example, inspiring others to learn, grow, and challenge themselves, and the industry to build something great and make a difference.

Why are you passionate about BAN? What value has it brought you/your business?
We’ve long admired BAN and its member organizations, so to have the opportunity to join as an exclusive industry partner is a true honor. BAN and Truveris share a common purpose of using innovation to solve the most challenging issues facing the benefits community. We’re a recent member of the BAN network, yet we’re already busy meeting many agency members and forging new relationships. We’re excited to collaborate and partner with their clients’ pharmacy contracting needs.

Where do you see the industry headed for the balance of 2023 and 2024?
Truveris is exclusively focused on pharmacy, specifically PBM management and cost containment. We expect the trends in pharmacy that have received a lot of attention in 2023 will carry into 2024 with even greater significance. The role of specialty medications will continue to rise, fueled by the likes of biosimilars, gene therapies, and GLP-1s (diabetes drugs used for weight management). With a consistent rise in employer and member costs, the calls for transparency, regulation, and disruption in the supply chain will grow louder, especially entering an election year. PBM oversight and reform are key legislative agenda items receiving bipartisan support in Congress. Beginning January 1, 2024, the Medicaid AMP (average manufacturer price) cap will be removed as outlined in the American Rescue Plan Act of 2021. This will have sweeping impacts on drug manufacturers and PBMs seeking to preserve their profitability and will ultimately affect plan sponsors and their pharmacy contracts.

What are the industry’s biggest challenges?
We think of challenges through the eyes of our clients – i.e. the benefits agencies and the plan sponsors. The most obvious challenge facing the industry is rapidly rising pharmacy costs for plan sponsors, driven by the trends we mentioned before. Almost every employer sees this as a major issue, but they feel helpless to do anything about it. The root cause stems from a pervasive lack of transparency in pharmacy. The complexity and opacity of pharmacy contracts leave employers in the dark and lacking control over their own programs. The best thing that agencies and employers can do is not be complacent about it. There are things that can be done, and pharmacy is one of the only benefits that can be proactively negotiated to reduce costs.

How can you help BAN members address these challenges?
Partnering with agencies to support their clients is a real source of pride for us. As an objective third party, we can empower BAN members and their employer clients by giving them visibility and control of their pharmacy programs. We’ve built a tech platform for PBM procurement and oversight that creates pricing transparency and drives competition to reduce costs for employers. The technology replaces the traditional models of using spreadsheets or waiting to get renewal offers. On average, we can generate deal improvements of 20% against their current spend. We also readjudicate 100% of the claims against the contract terms throughout the life of the contract, so that both the employee benefits producer and the employer know if they’re getting everything that’s been outlined in the contract. Very often, we find errors or variances that result in a shortfall for the employer. Having that information gives them full visibility and allows them to reclaim those dollars and put them to use someplace else. It also helps them sleep at night, knowing that they’re holding their PBM accountable to all the terms in their contract.

Ashley can be reached at ainman@truveris.com.

Follow Ashley on LinkedIn.

Benefit Advisors Network Partners with ProAct to Offer Pharmacy Benefit Management to Members

Posted on by Benefit Advisors Network

CLEVELAND, OH and EAST SYRACUSE, NY (10/24/23) – Benefit Advisors Network (BAN), an international network of progressive and visionary employee benefit brokers and consulting firms from across the United States and Canada – announces it is partnering with ProAct, a fully integrated, employee-owned Pharmacy Benefit Management (PBM) company.

Under the terms of the new partnership, ProAct will offer BAN member firms affordable and flexible prescription drug benefit solutions for self-funded clients. They combine industry-leading client service with the latest in PBM technology.

“The ProAct team is a great addition to our bank of reputable partners. With overall prescription drug spending rising nearly 10% in 2023, our members will benefit from their expertise and custom-built plans as well as solutions to manage high-cost medications,” says Perry Braun, President & CEO of the Benefit Advisors Network.

Braun continues, “In addition, ProAct focuses on the mid-market sized employer group, making them a much better PBM partner for our members versus a mega-PBM vendor.”

“We recognize so many people can’t afford prescription medication and at times are forced to choose between necessities,” says Mike Grinnell, Sales Director at ProAct. “This is why we are excited to partner with BAN to support their member firms as they seek to provide employer clients with the most cost-effective pharmacy benefit needs.”

About Benefit Advisors Network
Founded in 2002, BAN is an exclusive, premier, international network of independent, employee benefit brokerage and consulting companies. BAN delivers industry leading tools, technology, and expertise to member firms so that they can deliver optimum results to their employee benefit customers. BAN intentionally limits membership because of the highly collaborative interactions. For more information, visit: www.benefitadvisorsnetwork.com or follow them on LinkedIn.

About ProAct

ProAct is a 100% employee-owned, fully integrated Pharmacy Benefit Management company providing benefits since 1999. Aiming to serve midmarket sized employers that are often underserved, ProAct offers flexible solutions for cost-effective prescription drug benefits. ProAct services a diversified client base consisting of manufacturers, unions, universities, municipalities, hospitals, corporations, not-for-profit organizations, long-term care facilities, financial institutions, and more. Through an organic growth strategy, ProAct has been able to provide clients with an offering that couples competitive pricing with a high-touch service model that only an employee-owned PBM could provide.

ProAct manages the dispensing of prescription drugs through its mail-order pharmacy, ProAct Pharmacy Services, as well as through its national retail pharmacy network consisting of over 64,000 pharmacies in the United States, Puerto Rico, Guam, and the Virgin Islands. For more information visit: https://proactrx.com.

IRS Releases PCORI Fee For Plan Years Ending Before October 1, 2024

Posted on by Stacy Barrow

The IRS has released Notice 2023-70, which sets the applicable PCORI fee for plan years ending between October 1, 2023, and September 30, 2024, at $3.22 per covered life.

As a reminder, the PCORI was established as part of the Affordable Care Act (ACA) to conduct research to evaluate the effectiveness of medical treatments, procedures, and strategies that treat, manage, diagnose, or prevent illness or injury.  Under the ACA, most employer sponsors and insurers were required to pay PCORI fees until 2019 or 2020, as it only applied to plan years ending on or before September 30, 2019.  However, the PCORI fee was extended to plan years ending on or before September 30, 2029, as part of the Further Consolidated Appropriations Act, 2020. 

The amount of PCORI fees due by employer sponsors and insurers is based upon the number of covered lives under each “applicable self-insured health plan” and “specified health insurance policy” (as defined by regulations) and the plan or policy year-end date.  The fee must be paid on or before July 31 each year.  The fees due by July 31, 2024, are for plan years ending in 2023 and are as follows:

Insurance carriers are responsible for calculating and paying the PCORI fee for fully insured plans.  The employer is responsible for paying the fee on behalf of a self-insured plan, including an HRA.  In general, health FSAs are not subject to the PCORI fee.

Employers that sponsor self-insured group health plans must report and pay PCORI fees using the second quarter IRS Form 720, Quarterly Federal Excise Tax Return.  The second quarter form is generally not released by the IRS until the second quarter of the applicable filing year (usually in or around May of the applicable filing year).  Therefore, the Form 720 used for the 2024 filing deadline will not likely be available until in or around May 2024, and employers who sponsor self-insured group health plans subject to the PCORI fee must wait to file until the correct Form 720 is available. 

The average number of covered lives for the plan year is generally calculated using the snapshot, snapshot factor, actual count, or Form 5500 method.  These counting methods will be described in more detail in a future alert as we approach the 2024 filing deadline. 

Also note that because the PCORI fee is assessed on the plan sponsor of a self-insured plan, it generally should not be included in the premium equivalent rate that is developed for self-insured plans if the plan includes employee contributions.  However, an employer’s payment of PCORI fees is tax deductible as an ordinary and necessary business expense.

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About the Author. This alert was prepared by Barrow Weatherhead Lent LLP, a national law firm with recognized experts on the Affordable Care Act. Contact Stacy Barrow or Nicole Quinn-Gato at sbarrow@marbarlaw.com or nquinngato@marbarlaw.com.
The information provided in this alert is not, is not intended to be, and shall not be construed to be, either the provision of legal advice or an offer to provide legal services, nor does it necessarily reflect the opinions of the agency, our lawyers, or our clients. This is not legal advice. No client-lawyer relationship between you and our lawyers is or may be created by your use of this information. Rather, the content is intended as a general overview of the subject matter covered. This agency and Barrow Weatherhead Lent LLP are not obligated to provide updates on the information presented herein. Those reading this alert are encouraged to seek direct counsel on legal questions.
© 2023 Barrow Weatherhead Lent LLP. All Rights Reserved.

Agencies Issue Additional FAQs Regarding the Transparency in Coverage Final Rules

Posted on by Stacy Barrow

On September 27, 2023, the DOL, IRS, and HHS released FAQs About Affordable Care Act Implementation Part 61 (“FAQ Part 61”) which addresses lingering questions about enforcement of the Transparency in Coverage Final Rules (TiC Final Rules), specifically the provisions of the TiC final rules requiring plans and carriers to post machine-readable files for in-network negotiated rates and historical net prices for all covered prescription drugs by plan or issuer at the pharmacy location level (“Rx rates”), and the status of a previously announced enforcement safe harbor applicable to in-network (“INN”) provider rates for covered items and services which allowed plans with percentage-of-billed-amount contracts or other alternative reimbursement arrangements to report this information differently if the dollar amount could not be determined in advance.

If you recall, the TiC Final Rules required non-grandfathered group health plans (other than those consisting of excepted benefits or account-based plans) to make available to the public three separate machine readable files (“MRFs”) including detailed pricing information related to (1) negotiated rates for all covered items and services between the plan or issuer and in-network providers (“INN provider rates”), (2) historical payments to, and billed charges from, OON providers (“OON allowed amounts”), and (3) the Rx rates.

Beginning on July 1, 2022, machine readable files for INN provider rates and OON allowed amounts were required to be posted by plans; however, in Q1 of FAQs About Affordable Care Act Implementation Part 49 released by the agencies in August of 2021 (“FAQ Part 49”), the agencies delayed the requirement to release Rx rates machine readable files as they evaluated whether the requirement would be duplicative of other transparency and reporting obligations related to prescription drugs, specifically the RxDC reporting required under the Consolidated Appropriations Act of 2021 (“CAA”). In FAQ Part 61, the agencies report that, after reviewing the Rx DC reporting results, they have determined “there is no meaningful conflict between the reporting requirements” under the RxDC reporting and the TiC Rx rates machine readable file requirement as the CAA requires disclosure of different and additional information than required in the TiC Final Rules.

Therefore, the agencies have rescinded Q1 of FAQ part 49 and intend to develop technical guidance and an implementation timeline for plans to post their Rx rates machine readable files. Thus, the machine readable files for prescription drugs will be due once that technical guidance and timeline are released. This does not impact the requirement for plans to continually update (on a monthly basis) their machine readable files for the OON allowed amounts and INN rates for covered items and services.

FAQ Part 61 also addresses another enforcement safe harbor, which was previously announced in FAQs About Affordable Care Act Implementation Part 53 (“FAQ Part 53”) released by the agencies in April 2022, which applied to INN provider rate MRFs for plans with alternative reimbursement arrangements (such as reference-based pricing) or percentage of billed charges contracts. Under FAQ Part 53, the agencies indicated that where contractual arrangements are for a percentage of the billed charge or use a different, alternative funding arrangement, then plans were to use the applicable percentage in the rate box or the open text box to describe the nature of the negotiated rate, respectively.

FAQ Part 61 clarifies that the agency did not intend to apply a “categorical exception” to this reporting requirement. Whether a plan can comply with the requirement to provide a specific dollar amount is a facts and circumstances test and a safe harbor only applies in circumstances where a plan can demonstrate it is extremely difficult or impossible for a plan or issuer to determine and report a rate for a specific item or service (for the reasons specified in FAQ Part 53). In these instances, plans may continue to follow the technical guidance on GitHub.

Conclusion
No action with regard to the prescription drug machine readable files is required right now. The FAQ was essentially a “heads up” from the agencies indicating that they will request this reporting be completed, but they intend to provide guidance and some lead time after the guidance is issued for plans to post the files. We will release another update once the technical guidance and timeline are released. In the meantime, plans must continue to update their INN rates and OON allowed amount machine readable files monthly.

Plans with percentage of billed charges contracts or other alternative reimbursement arrangements should consult with counsel to review the FAQ and TiC Final Rules in light of their funding arrangement to determine whether they may still be able to use the standard set forth in Q2 of FAQ Part 61 (i.e., that they can demonstrate it is extremely difficult or impossible to determine and report a rate for a specific item or service) for their INN rate machine readable files, and to ensure they understand whether there is any risk in doing so.
 

About the Author. This alert was prepared by Barrow Weatherhead Lent LLP, a national law firm with recognized experts on the Affordable Care Act. Contact Stacy Barrow or Nicole Quinn-Gato at sbarrow@marbarlaw.com or nquinngato@marbarlaw.com.

The information provided in this alert is not, is not intended to be, and shall not be construed to be, either the provision of legal advice or an offer to provide legal services, nor does it necessarily reflect the opinions of the agency, our lawyers or our clients. This is not legal advice. No client-lawyer relationship between you and our lawyers is or may be created by your use of this information. Rather, the content is intended as a general overview of the subject matter covered. This agency and Barrow Weatherhead Lent LLP are not obligated to provide updates on the information presented herein. Those reading this alert are encouraged to seek direct counsel on legal questions.

© 2023 Barrow Weatherhead Lent LLP. All Rights Reserved.