G. Funds advanced from Appendix B Funds by RMI

 

In December 2021, RMI learned from a Plan Sponsor that it had received notice from the managing general agent for a third party stop loss carrier of the cancellation of the Plan’s stop-loss policy for failure to pay stop-loss premiums.The Plan had insufficient funds in its bank account to pay such premiums.At RMI’s request, Verdegard sent RMI a list of Plans in similar circumstances, as well as information concerning whether those Plans were delinquent on payment of their monthly contributions.For those Plans that were delinquent in payment of their monthly contributions, demands were made upon them to come current, in order to pay Plan expenses including stop loss premiums. Some Plans paid and came current; others did not. During late 2021 and early 2022, for those Plans that were current on their monthly contributions, RMI, through Verdegard, advanced funds to the Plans’ bank account to fund stop-loss premiums from funds in accounts listed on Appendix B to the Consent Order (“Appendix B Accounts”). Such transfers were authorized by ¶ 1 of the Consent Order, which provides that RMI “shall have full and exclusive authority and control over the assets in the accounts listed in Appendix B,” and ¶ 8(b) of the Consent Order, which provides that RMI shall have “[a]uthority to pay reasonable and necessary expenses of the Plans, such as, but not limited to … insurance premiums necessary to protect the Plans’ participants or beneficiaries….”The balance due back to Appendix B for advances to Plans for stop loss premiums has been reduced to and remains at $160,265.59 as of this report. The line titled “Funds Advanced from Appendix B Funds by RMI” contains any amounts owed by a Plan for repayment of this advancement of funds.

 

14.         Claims Detail Tab.

 

The Claims Detail Tab contains the list of all paid/processed claims and unpaid claims. The paid/processed claims are broken out into three separate sections: Paid Claims, Zero Plan Payment Claims, and Not Covered Claims.

 

A. Paid Claims includes all claims that were processed and then paid by the Plan.

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B. Zero Plan Payment Claims includes all claims that were processed by the plan but had no Plan Responsibility due from the Plan for the claim.

​

C. Not Covered Claims includes all claims that were but were determined to not be covered by the Plan. Further, the full adjudication of all Unpaid Claims is listed on this tab at the bottom of the page.

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D. The column titled “Claimant” contains the patient which received the services for the claim.

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E. The columns titled “Date From” and “Date To” contain the date(s) of service for each claim.

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F. The column titled “Received Date” contains the date which the claim was received for processing.

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G. The column titled “Process Date” contains the date which the claim was processed.

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H. The column titled “Paid Date” contains the date which the claim was either paid or was issued an EOB for “Zero Plan Payment” or “Not Covered Claims”. Note, the claims listed in the Unpaid Claims section of this tab do not contain a Paid Date as the claim has not yet been paid.

 

I. The column titled “Service Provider” contains the name of the provider where the medical services were received.

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J. The column titled "Total Charges” contains the total billed charge amount for each claim line.

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K. The column titled "Allowable Charges” contains the amount of payment allowed for each claim line less any applicable discount after adjudication per the plan document.

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L. The column titled “Not Covered” contains any amounts adjudicated to not be covered by the Plan for each claim.

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M. The column titled “PPO Savings” contains any amounts of network discounts taken for each claim line.

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N. The column titled “Paid By Other Ins” contains any amounts which were covered by another insurance policy, if applicable.

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O. The column titled “Co-Ins” contains the amount of Patient Responsibility owed for the claim which was allocated to the Patient’s Co-Insurance portion under the Plan.

 

P. The column titled “Deduct” contains the amount of Patient Responsibility owed for the claim which was allocated to the Patient’s Deductible amount under the Plan.

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Q. The column titled “Copay” contains the amount owed of Patient Responsibility owed for the claim which was allocated to the Patient’s Copay portion under the Plan.

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R. The column titled “Paid” contains the amount of Plan Responsibility for the claim which was paid by the Plan (if the claim is a Paid Claim) or which is owed by the Plan (if the claim is unpaid).

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S. The column titled “Check” contains the check number for the payment issued to the provider when the claim was paid.

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T. The column titled “Claim Number” contains the claim number assigned to the claim by the CHS system.

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U. The column titled “Ineligible” contains any amounts of the claim which were ineligible for coverage by the Plan.

•  

15.    Unpaid Claims Tab.

 

The Unpaid Claims Tab contains the list of the claims reported by the CHS system to be unpaid for the Plan as of the date of the report.

 

A. The report date is listed in the top left corner.

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B. The column titled “Claim Number” is the Lifestyle Plan claim number for the claim in the CHS system. This claim number is likely different from any claim number given to the claim at the provider’s office.

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C. The column titled “Incurred” is the date of service for which the claim was incurred.

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D. The column titled “Processed” is the date for which the claim was processed by the CHS system under either Medova or Verdegard’s administration of the Plan, depending on when the claim was received.

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E. The column titled “Payee” contains the name of the provider where the medical services were incurred.

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F. The column titled “Claimant” contains the name of the patient which received the services for the claim.

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G. The column titled “Employee” contains the name of the Employee for which the patient was covered by the Lifestyle Plan under.

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H. The column titled “Payment” contains the total amount of adjudicated Plan responsibility owed for the claim. Please note, the amount listed under the “Payment” column is not the total billed charges due for the claim but is only the amount of funds due from the Plan Sponsor for the claim. This is the amount due from the Plan Sponsor for each unpaid claim. The full breakdown of each claim is listed on the Claims Detail tab of the liquidation report and contains the Total Billed Charges, any applicable network discount, and any applicable Patient Responsibility due for each claim.

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I. The column titled “Received” contains the date which the claim was received for processing.

 

 

16.    Stop Loss Tab.

 

The Stop Loss Tab contains information on any Specific or Aggregate stop loss filings for the Plan. Most Lifestyle Plans had both an Aggregate and a Specific Stop Loss policy. However, some Lifestyle Plans only had an Aggregate Stop Loss policy, only had a Specific Stop Loss policy, or had no stop loss policy at all. Plan Sponsors should review the Plan Documents and Stop Loss Policies for their Plan to determine what coverage their Plan had in place and which Stop Loss Carrier any policy was with.

 

  A. Specific Stop Loss

 

Specific Stop Loss refers to the specific stop loss policy. Specific stop loss insurance is triggered when a single participant of the Plan incurs claims up to the Specific stop loss deductible. To be eligible for any Specific stop loss reimbursement, the Plan needs to pay claims to the Specific stop loss deductible for that specific participant. The Stop Loss tab contains information as to what Specific stop loss filings, if any, were made for the Plan by Verdegard.

 

i. The Claimant is the name of the participant who incurred enough in claims to trigger a Specific stop loss filing.

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ii. The column titled “Specific” lists the Specific stop loss deductible for the Plan’s Specific stop loss policy.

 

iii. The column titled “Carrier” indicates the name of the Plan’s stop loss carrier and/or Managing General Underwriter.

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iv. The column titled “Filing Date” indicates the date that Verdegard initially submitted the Specific stop loss filing.

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v. The column titled “Filing Amount” indicated the amount of Specific stop loss reimbursement that Verdegard filed for this Specific stop loss claim.

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vi. The columns titled “Receive Date” and “Receive Amount” indicate the date and amount of which Verdegard received any approved Specific stop loss reimbursement for the Plan.

 

vii. The column titled “Denial Reason” indicates a summary of why all or any portions of the Specific stop loss filing was denied by the stop loss carrier. Additionally, a copy of the Specific stop loss determination and any correspondence from the stop loss carrier pertinent to this Specific stop loss filing will be listed below.

​

  B. Aggregate Stop Loss

 

Aggregate Stop Loss refers to the Aggregate Stop Loss policy for the Plan. Aggregate Stop Loss is intended to cover the claims incurred by the Plan that do not trigger a Specific Stop Loss filing. To be eligible for Aggregate Stop Loss reimbursement, the Plan must, at a minimum, pay claims up to the minimum aggregate attachment point set forth in the Plan’s Aggregate Stop Loss Policy. If a plan did not pay claims up to the minimum aggregate attachment point set forth in the policy, the aggregate stop loss claim will most likely be denied by the Stop Loss carrier. Please see the Stop Loss section below for additional information on stop loss coverage.

 

i. The Stop Loss Tab contains information as to what Aggregate Stop Loss filings, if any, were submitted by Verdegard to the Plan’s Stop Loss carrier.

 

ii. The column titled “MGU” contains the name of the Managing General Underwriter (“MGU”) utilized by the Plan’s Stop Loss Carrier.

 

iii. The columns titled “DOS Start Date” and “DOS End Date” indicate the effective beginning date and term date of the plan year for which the stop loss claim was filed. Some plans may have multiple plan years for which Verdegard filed a stop loss claim for the Plan. There will be separate sections for each plan year’s filing if this is the case.

 

iv. The column titled “Agg Amount Submitted” indicates the amount of Aggregate Stop Loss reimbursement which Verdegard submitted for the Plan’s Aggregate Stop Loss filing.

 

v. The column titled “Original Submission Date” indicates the date of the initial filing of the Plan’s Aggregate Stop Loss claim with the carrier.

 

 

vi. The column titled “Revised Submission Date” indicates the date when a revised aggregate stop loss submission or an appeal was submitted by Verdegard.

 

vii. The column titled “Agg Amount Denied” indicates any amounts of the Aggregate Stop Loss reimbursement that were denied by the Stop Loss carrier.

 

 

viii. The column titled “Denial Reason” indicates a summary of the reasons why any amounts were denied by the Stop Loss Carrier.

 

ix. The column titled “Amount Recovered” indicates the amount of Aggregate Stop Loss reimbursement funds which were approved by the Stop Loss carrier and received by Verdegard. Once Stop Loss reimbursement funds are received, the funds are deposited into the Plan’s bank account for payment of claims and plan expenses.

 

x. The column titled “Date Recovered” indicates the date on which Verdegard received the Aggregate Stop Loss Reimbursement funds.

 

xi. The columns titled “1st Appeal File Date” or “2nd Appeal File Date” indicate the dates which Verdegard submitted a first or second level appeal of the initial determination of the stop loss filing. The status of the appeal is listed in the “1st Appeal Status” or “2nd Appeal Status” columns.

 

xii. The column titled “Claim Status” indicates whether the stop loss filing is considered to be open or closed with Verdegard.

 

xiii. The column titled “Final Audit Notes” contains notes from Verdegard as to the status and current determination of the stop loss filing.

 

Additionally, the Stop Loss Tab will contain a copy of the determination of the stop loss filing issued by the Stop Loss carrier, any correspondence received by Verdegard from the Stop Loss carrier relevant to the stop loss filing, and/or a worksheet prepared by Verdegard containing additional notes and details on the stop loss filing. These items vary based on the Plan’s stop loss carrier and the circumstances that exist with each stop loss filing. These items should be reviewed carefully by the Plan Sponsor in correlation with the Plan’s stop loss policy to determine what steps, if any, the Plan Sponsor may wish to take to further pursue any potential stop loss benefit.

 

In some cases upon auditing a stop loss filing, a Stop Loss carrier may determine that funds may actually be due back to the Stop Loss carrier. This information, if applicable, will be listed in the “Stop Loss Carrier Refund Request” section of the Stop Loss tab.

 

17.    AZ Bank Trans Tab.

 

The AZ Bank Trans Tab contains a listing of all transactions in and out of the Plan’s bank account at Arizona Bank & Trust since its inception. As you may be aware, when Medova was administering the Lifestyle Plans as TPA, Medova utilized Simmons Bank for banking services for each Lifestyle Plan. When Verdegard took over as TPA from Medova on July 1, 2021, Simmons Bank would no longer work with RMI, and new bank accounts were opened for each Plan at Arizona Bank & Trust. Any amounts remaining in the Plan’s bank account at Simmons Bank were transferred over to the new Plan bank account at Arizona Bank & Trust. The bank transactions are in reverse chronological order. In other words, the most recent transaction from the Plan’s bank account will be at the top of the page and the first transaction – the transfer of the funds in the Plan’s Simmons Bank account to the Plan’s Arizona Bank & Trust account – is at the bottom of the page.

 

18.      TPA Fees.

 

Per the July 1, 2021 TPA agreement entered into by RMI and Verdegard, Verdegard is entitled to a monthly administrative fee from each of the Lifestyle Health Plans it is administering. The fee is broken down as follows:

 

A.      If the group is an active health plan, the TPA fee is $20.00 PEPM – Note, all Lifestyle Health Plans have now finished their run-out periods, so no plans are active at this time. For inactive groups, the initial agreement provides that the TPA fee to be charged to each group is $150.00 per month. This agreement expired on December 3, 2022.

 

B.      A new agreement was entered into effective January 1, 2023, providing a TPA fee of $200.00 per month to be charged for groups with unpaid claims or pending stop loss filings. The January 1, 2023 agreement provides a TPA fee of $75.00 per month for groups with no unpaid claims or pending stop loss filings. These fees cease to be charged once a final accounting has been prepared for the group and the group is approved for liquidation.

 

C.      The liquidation reports contain all TPA fees accrued for a plan. These TPA fees are owed to Verdegard. Sponsoring Employers who wish to discuss any potential settlement of TPA fees should contact Verdegard directly.

 

19.     Form 5500 Fee.

 

As part of its duties as IF, RMI is required to file a Form 5500 for each Plan it was appointed over – regardless of the size of the Plan. A one-time $500.00 fee is charged by RMI to each plan to cover the preparation and filing of this Form 5500. RMI files the Form 5500 for each Plan once the Plan’s bank account is closed out and all Plan expenses have been resolved. If you wish to obtain a copy of the Form 5500 filed for your plan, please contact Jacqui Lawson at RMI at jlawson@receivermgmt.com

 

20.     Stop Loss Coverage.

 

Stop Loss coverage for a plan is plan specific.  In many cases, the Stop Loss Carriers have denied claims and those claims have had to be appealed by Verdegard. As noted above, the current status of any Stop Loss filing submitted for your Plan (and appeal(s) if applicable) is included in the liquidation package issued to the Plan Sponsor. The Plan Sponsor is the policy holder of the Stop Loss policy. As the policy holder, any Plan Sponsor who wishes to further pursue any potential stop loss benefits for their Plan is entitled to do so. The Plan Sponsor should contact its Stop Loss carrier directly regarding any further pursuit of a stop loss benefit. Plan Sponsors should carefully review the stop loss policy in place for its rights as the policy holder regarding further appeals of any stop loss denials.

 

21.    Plans with Stop Loss Coverage with Midlands Casualty Insurance Company

 

After the July 1, 2021 transition from Medova to Verdegard occurred, and at RMI’s direction, Verdegard began submitting stop loss claims to Midlands Casualty Insurance Company (“MCIC”), a captive stop loss /reinsurance company (domiciled in the state of Hawaii) owned and controlled by Medova and a named party to the DOL’s litigation. To the best of RMI’s knowledge, prior to July 1, 2021, Medova never submitted an aggregate stop loss claim to MCIC on behalf of any plan being administered by Medova. As most MCIC stop loss policies were issued for plan years prior to 2021, by the time Verdegard took over claims administration, many stop loss claims to be submitted to MCIC would have already been too late to file. Nonetheless, RMI directed Verdegard to begin submitting stop loss claims to MCIC, and as of June 30, 2022, approximately $3.1 million of stop loss claims had been submitted.  Once claims were filed, MCIC informed RMI that stop loss claims submitted to MCIC were not likely to be paid for the foreseeable future, because the U.S. Department of Justice had seized its funds.

 

Given the passage of time and the present circumstances, RMI does not believe MCIC will ever pay any stop loss claims. All stop loss claims filed on behalf of plans where MCIC was the stop loss carrier are being considered as effectively denied. The current status of any stop loss filing submitted on behalf of a Plan with MCIC stop loss coverage will be included in the Liquidation Report issued with the liquidation package.

 

 

 

​ ALL WRITS ORDER INJUNCTION INFORMATION

 

 

22.    Notice To Medical Providers Affected by The All-Writs Order Injunction

 

It has come to RMI’s attention that many hospitals and medical providers are seeking to comply with Judge Crouse’s All Writs Order but may not have knowledge as to which of their patients may be covered by the Court’s Injunction. See “DOCUMENT D” for the Order. To that end, we have posted a searchable listing of Group Names, Group ID Numbers and Member ID Numbers to assist medical providers in their efforts to comply with the Court’s Injunction. Please see “DOCUMENT L” under Documents for this searchable listing.

 

23.    Summary of All Writs Order.

 

Generally speaking, the All-Writs injunction applies to the adjudicated, allowed Employer Health Plan Responsibility amounts for each claim covered by your Medova Health Plan. This means providers and collection agencies are prohibited from making or continuing to make any adverse credit reports against Members who were covered by a Medova Lifestyle Employer Health Plan under RMI’s authority for any unpaid Employer Health Plan responsibility amounts due for a claim. 

 

A. If an EOB is under appeal, by either a member or provider, the entire unpaid claim amount is protected from collection until a final determination of the appeal has been issued. Members are still responsible for any Patient Responsibility portion due for the claim. Patient Responsibility amounts include deductibles, co-pays, co-insurance, and non-covered services listed on the EOB unless they are under appeal. (See “Document R” for RMI’s Appeal Information Sheet under Documents.

 

B. The All-Writs Order also stays the tolling of any statutes of limitation. Lawsuits can be filed to preserve the party’s claim but must be stayed after filing until the All-Writs Order has been lifted.

 

C. Providers can send regular invoices to the patient, member or guarantor but cannot attempt to collect Employer Plan Responsibility amounts. The invoices cannot reflect amounts allocated to Employer Plan responsibility as owed by the Member or threaten to collect Employer Plan responsibility amounts from the member.

 

Information concerning the All-Writs Order and current actions regarding the Lifestyle Health Plans/Bridgewell Plans is discussed further below. See “DOCUMENT F” under Documents below for a copy of the All-Writs Order.

 

24.  What Is Not Covered by The All-Writs Order?

 

The All-Writs Order issued by the Court does not cover:

 

A. Claims incurred for participants covered by Plans not listed on Exhibit A to the Consent Order.

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B. The Member Responsibility portion of a claim, such as copays, deductibles, amounts above the maximum, non-covered items.

 

C. Claims when the Member or Patient was not covered.

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D. Claims which have already been paid by the Plan.

 

25.  RMI All Writs Notice.

 

Please review Notice to medical providers affected by the injunction issued by U.S. District Judge Toby Crouse Section 22, Collection Issues Section 27, Lawsuits Against Members, Section 28, and What is not covered by the All-Writs injunction, Section 24.

 

If, after reviewing the sections above, you would like RMI to review whether it is appropriate for RMI to issue an All Writs Notice (and you have not had one previously issued and your plan is listed on Exhibit A to the Consent Order), you should send an encrypted email with “Medova Collections” in the subject line to ckinser@receivermgmt.com or by fax to (615) 373-4336 and provide:

 

A. the Member’s full name, mailing and email address and telephone number.

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B. the Name of the Member’s Employer.

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C. a copy of the Health Plan Card or provide your Member ID Number.

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D. the Patient’s full name and date of birth.

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E. the Claim Number, if known.

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F. the Provider’s name, email and mailing address, telephone number and fax number.

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G. the Date of Service(s).

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H. the Amount Billed.

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I. Copies of any Explanation of Benefits (EOBs) or bills you have received.

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J. Have you been subjected to collection action regarding Medova’ s portion of bill?   If yes, please provide copies of the collection notices; and

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K. Have you filed an appeal?  If yes, please provide copies of the appeal documents.

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If you do not have all the documents listed above, you should send what you have available. The more information you provide the easier it is for RMI to identify your claim(s) and provide an accurate response.

 

26. What do I do if an All Writs Notice and copy of the All-Writs Order has been delivered to a collecting party and the collecting party is still trying to collect Plan Responsibility from me? 

 

The protections provided for the Members and their Dependents by the All-Writs Order are participant enforced protections which may require you, as the participant, to seek enforcement in federal district court. We recommend you speak to an attorney regarding your options. Remember, the Injunction protects the Member and their Dependents from collection of amounts due from the Plan. It does not protect the Member/Participant/Patient from collection actions relating to Member/Participant/Patient responsibility.

 

 

 

 

COLLECTIONS/LAWSUITS AGAINST MEMBERS

 

27.    Collection Issues.

 

Participants with unpaid claims owed by the Plan should do the following:

 

REVIEW EOBs. Carefully review your EOB and confirm you do not owe any amounts for Patient Responsibility. Prior to August 1, 2024, if you do not have an EOB for the claim, you should contact Verdegard to obtain one. After August 1, 2024, you will need to go to your employer website located at https://webportal.lifestylehealthbenefits.com/Member/MembLogin.asp

 

A. GATHER INFORMATION AND KEEP COPIES. Continue to gather and retain the information described above for any unpaid claims. Keep copies for yourself.

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B. CHECK YOUR CREDIT REPORT. Make sure that there is no incorrect reporting of the debt on your credit report.

 

C. EDUCATE YOURSELF. Review available consumer educational materials regarding debt collection and credit reporting. The Federal Trade Commission has excellent consumer information regarding how to dispute errors on credit reports and debt collection at www.consumer.ftc.gov. 

 

D. DISPUTE IN WRITING. You should notify the Provider and Collection Entities in writing that you dispute the debt. This dispute notification should be sent by Certified Mail, Return Receipt Requested. You will need to include proof the debt is not yours, such as a copy of the EOB and proof you have paid your portion of the debt. You should also notify the Provider and the Collection Entities of the All-Writs Injunction Order and provide them with a copy.   See “DOCUMENT S” under Documents for additional information.

 

28.    Lawsuits Filed Against Members.

 

If legal action is taken against a Member or Patient, the Member needs to respond within the legally required period and will likely need an attorney.  The person who is being sued should notify the Plaintiff (the party who filed the action against you) that the debt is owed by the Employer Plan to the Provider (if such is the case). This notification should be sent by Certified Mail, Return Receipt Requested.

 

You should:

 

A. Provide the party attempting to collect with proof that the debt is not yours, such as a copy of the explanation of benefits and proof you have paid your portion of the debt.

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B. Provide the collecting party with a copy of the All-Writs Order and demand the litigation to be stayed. 

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C. Provide a copy of the correspondence sent to the collecting party to the Provider.

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D.  Keep a copy of all correspondence for your records. The Participant/Member/Patient being sued will need their own attorney to represent them.

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E. Provide copies of any legal action taken and all correspondence listed above to RMI via encrypted email with “Medova Lawsuit” in the subject line to ckinser@receivermgmt.com or by fax to (615) 373-4336. Please place in the subject line: “Medova Lawsuit (YOUR NAME) (PROVIDER NAME).”

 

 

 

 

 GENERAL INFORMATION

 

 

Medova Plans are not Insurance Plans

 

29.   Why is my Medova Health Plan not considered insurance?

 

The Medova Lifestyle Health Plans are self-funded employer-sponsored benefit plans. Medova, in its administration of the Lifestyle Plans, was not the insurer of any Lifestyle Plan but was only the Third-Party Administrator (“TPA”) of the Plans. In a self-funded benefit plan, the Sponsoring Employer retains the ultimate liability to ensure that all medical claims incurred by the plan are paid.

 

30.   Should I contact my State Agency regarding Insurance or Consumer Issues? 

 

That decision of course is yours, but you may want to consider whether your state has an entity that handles ERISA health plans. ERISA refers to plans covered by the federal Employee Retirement Income Security Act of 1974, as amended (ERISA) and state insurance agencies do not have authority over ERISA Plans. Some state consumer agencies also do not have authority over actions authorized by federal law, regulation, or rule.

 

31.    Third Party Administrator (“TPA”)

 

On July 1, 2021, Medova Healthcare Financial (“Medova”) agreed to be replaced as the Third-Party Administrator (TPA) with Hawaii Mainland Administrators ("HMA") to provide TPA services to the Lifestyle Health Plans. An administrative services agreement was entered into by RMI and HMA for TPA services provided to the Lifestyle Plans under RMI’s authority. HMA is located in Tempe, AZ. HMA changed its name to Verdegard effective January 1, 2024.  Verdegard has notified RMI it is terminating the contract as of July 31, 2024.  

 

32.    All Plans Have Termed.

 

As of June 30, 2022, all Health Plans covered by Appendix A have termed. Any claim with a date of service after June 30, 2022, would not be covered by a Medova Lifestyle Health Plan as all Medova Lifestyle Health Plans termed on or before that date.

 

33.    Non-ERISA Medova Lifestyle Health Plans.

 

It is important to understand RMI has not been appointed to address non-ERISA health plans handled by Medova. It is RMI’s understanding that the claims data and accounting information for non-ERISA health plans were assumed by Verdegard (formerly HMA). Please contact Verdegard directly for information needed for any non-ERISA health plans. The listing of plans determined to be ERISA plans under RMI’s authority is located on “DOCUMENT L” under Documents.

 

34.    Plan Documents.

 

You should keep a copy of your Plan Documents. If needed, your employer can provide you with a copy of any relevant Plan Documents.

 

35.    How Often Should I Check on the Status of My Claims?

 

If you have received an EOB or otherwise know your claim is on file, you do not need to check on your claim’s status.

 

If you were previously notified your claim was not on file and have not received an EOB or other confirmation that the claim is on file, you should check to confirm the claim is on file 30 days after the claim was sent by your provider.

 

Until August 1, 2024, you should contact HMA/Verdegard at 866-827-6607 to obtain status updates.  After August 1, 2024, you should contact your employer.

 

36.    Explanation of Benefits (“EOBs”).

 

If you do not have an explanation of benefit for a claim, you should go to the Employer Plan website located at https://webportal.lifestylehealthbenefits.com/Member/MembLogin.asp  and download the information or contact Verdegard before July 31, 2024. 

 

EOBs are generally not issued until payment of the Plan Responsibility portion of the claim is issued to the Provider. If your claim remains unpaid, then an EOB likely has not been issued.  You will receive it when the claim is paid. In the event that your employer fails to pay your claim, RMI will issue a copy of this EOB along with notice of your rights against your employer under ERISA.

 

 

37.    What if I Paid Medova Plan Responsibility?

 

At this time, the HMA Reimbursement Program has expired as it only covered claims paid within six months of the date of service and all claims that would be covered by a Medova plan are past this time period. If you paid monies to your Provider for services that you believe were not your responsibility, you should ask the Provider to reimburse you by providing a copy of the EOB and the All-Writs Order which prohibited them from collecting payments on the Medova plans. If the Provider will not refund the amounts you paid:

 

A.   If it is before July 31, 2024, you should contact Verdegard (formerly HMA) and provide them with proof you paid the claim. Verdegard can notate that information in your file to ensure that any potential Medova plan reimbursement will be paid to you rather than your provider.

 

B.   If it is after July 31, 2024, you should notify your employer and provide them with proof that you paid the claim. Your employer should provide that information to RMI during the liquidation process to review whether any amounts owed for the claim are owed to you or the relevant provider.

 

38.    Appeals.

 

Appeals should be submitted pursuant to the appeal information listed on your EOB.

 

Once an EOB has been issued for the claim, the EOB provides 180 days for the determination listed on the EOB to be appealed. If the 180-day deadline has passed, your claim cannot be appealed.

 

You should consult an attorney regarding your appeal rights because this involves legal advice and fact-specific determinations.  An appeal information sheet is available at the bottom of this information under Additional Documents.

 

Prior to August 1, 2024, if you previously filed an appeal and have not received a determination, you should contact HMA/Verdegard by calling 866-827-6607 and select option #2.to obtain the status of your appeal.  The length of time it takes to issue an appeal determination varies with the complexity of the matter.

 

After August 1, 2024, if you have previously filed an appeal and have not received a determination, you should contact RMI at ckinser@receivershipmgmt.com

 

39.    “Check Ready to Release”

​

Many Members have asked why their claim has not been paid when an EOB issued indicates that the claim is in “ready to release” or “ready to pay” status. This language means that a check for payment of the claim will be issued when there are sufficient funds in the Plan’s bank account to pay the claim. This “ready to release” or “ready to pay” status does not mean that a check has been issued or that a check will be issued by a certain date or period. 

 

40.    Claims Not on File.

 

Since all plans have termed, if you have learned that a claim is not on file, it is now too late to file the claim.

 

 

 

PROVIDER INFORMATION

 

 

41.    Providers Refusing to Provide Service.

​

RMI has received inquiries regarding providers who have refused to provide medical services because of unpaid medical bills. Unfortunately, the All-Writs Order cannot legally require a provider to provide medical services to a patient. If you find yourself in this unfortunate situation, you should show the provider a copy of the All-Writs order and explain the situation that exists with your Medova Health Plan.  See also Sections 22 to 26 related to All Writs Order.

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42.    Providers Discounts.

 

Some of you have reported that providers and collectors are attempting to collect the “discount” listed on your EOB from the member or patient. You should review your Plan documents to confirm it provides that negotiated discounts cannot be collected from members/patients. Once you confirm that the “discount” cannot be collected from you, you should follow the dispute and collection information in these materials under Section 27. 

 

 

 

EMPLOYER PLAN INFORMATION

 

43.    ERISA Lifestyle Health Plans with Insufficient Funds in their Accounts to Pay Approved Claims.

 

In July 2021, RMI issued notice to plan sponsors whose plans were reported by Medova to be underfunded as of June 10, 2021. The Medova Lifestyle Health Plans are self-funded health plans that are funded by contributions from the Sponsoring Employer. As noted in the Liquidation section above, RMI and Verdegard are in the process of issuing liquidation packages to the Sponsoring Employers whose plans lack sufficient funds in the plan’s bank account to pay all remaining unpaid claims and other plan expenses. These unpaid claims can be resolved by the Sponsoring Employer by payment of the Plan Responsibility amount owed for the claim to the TPA, by negotiating a settlement directly with the owed provider, or by providing sufficient documentation that a claim has been written off by the owed provider. The liquidation package will contain an unpaid claims report identifying each individual claim that remains unpaid that needs to be resolved by the Sponsoring Employer.

 

Depending on the plan selected by the Sponsoring Employer, the Plan may also have Stop Loss Insurance intended to provide additional reimbursements for the Plan. The purchase of a Stop Loss Policy does not guarantee that a Plan will receive any amount of Stop Loss reimbursement. To be eligible for Stop Loss Insurance reimbursement, certain criteria must be met. Additionally, once a Stop Loss claim is filed with the Stop Loss carrier, the Stop Loss carrier will audit the stop loss filing to determine what amounts, if any, are owed to the Plan pursuant to the Stop Loss policy.

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To the extent that a plan’s Stop Loss filing is denied, or the amount of Stop Loss reimbursement does not cover all unpaid claims incurred by the plan, it is RMI’s position that the Sponsoring Employer remains ultimately liable for paying these unpaid medical claims.

 

Employers should notify their employees of the Plan’s status and that claims will not be paid until funded by the Employer. Employers should continue to update employees regarding the Plan’s status as the liquidation process progresses for the plan.

 

44.    What if an Employer Fails to Fund the Plan Responsibility of Members and Patients?

 

If a Plan Sponsor fails to fully resolve all unpaid claims and other plan expenses owed by the Plan within the time frame allowed, RMI will notify the plan participants of the Plan Sponsor’s failure to resolve the expenses and of the participants’ rights to further pursue their Plan Sponsor under ERISA for any unpaid medical claims. Due to the lack of current funding, RMI will not be instituting litigation against any additional Plan Sponsors, unless and until additional resources become available to RMI. RMI will continue to pursue any actions it already filed to attempt to enforce plan documents against Plan Sponsors.  See “DOCUMENT K” under Documents.

 

 

 

BROKER INFORMATION

 

45.    Will any Broker Commissions that have not been Paid Ultimately be back Paid? If so, When?

 

RMI is not issuing payment from any Medova plan bank accounts for any broker commissions. The obligation to pay commissions is considered to be an expense of the Sponsoring Employer, NOT the Plan. If a broker believes it is owed any commissions from a Sponsoring Employer for a Medova plan, the broker should contact the Sponsoring Employer directly.

 

46.    Why have non-ERISA accounts been withheld when the IF has no control or jurisdiction over them?

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In limited situations, the IF has jurisdiction over non-ERISA funds.  One reason is that in certain circumstances, non-ERISA plans are reliant upon payments from the applicable accommodation funds. It is RMI’s understanding that Medova has used accommodation funds for more than just medical expenses. Secondly, under the terms of the Consent Order, RMI previously had control of all accommodation funds. (These funds have since been returned to the Stop Loss Carriers.)  Medova failed to submit any supporting documentation or evidence of any procedure used to establish amounts to be deducted for plans (ERISA or non-ERISA) from the accommodation funds that were congruent with the aggregate stop loss policies that control this feature. Additionally, Medova represented certain plans to be ERISA when they were not and represented certain plans to be non-ERISA when they were not. 

 

47.    What is the procedure for a broker to obtain information from RMI or Verdegard regarding an Employer Sponsored Plan?

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Because of issues regarding alleged misrepresentation by parties of who they represent, RMI and Verdegard, are unable to communicate directly with ANY broker regarding ANY Medova Plan matter until the employer sponsor has executed and submitted a Broker of Record form to Robert Moore and RMI has confirmed its authenticity with the employer. A copy of the template Broker of Record letter is “DOCUMENT O” under Documents. This form MUST be on the Sponsoring Employer’s letterhead and notarized. Any Broker of Record form submitted that is not on the Sponsoring Employer’s letterhead or that has not been notarized will not be accepted as valid.  RMI has the authority as the Court-Appointed Independent Fiduciary to communicate directly with any employer sponsor of an ERISA plan, any employer member, and any stop loss carrier at any time, regardless of the involvement of a broker.

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TAX INFORMATION

 

48.    PCORI Tax Announcement.

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On July 15, 2022, Verdegard mailed out letters with enrollment numbers for each Medova Lifestyle Health Plan to assist each group in filing its form 720 with the IRS related to PCORI taxes owed. In addition to reviewing the information contained in this writing, RMI would strongly encourage you to consult with your tax advisor and/or visit the link below on the IRS site, to determine if you need to file these documents with the IRS. Instructions on completing the 720 Form are located on the following link starting with Part II on page 8 of the IRS document: https://www.irs.gov/pub/irs-pdf/i720.pdf

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The 720 forms must be filed by the plan sponsor, which is the employer as defined by the IRS.  See “DOCUMENT M” under Documents.

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The enrollment numbers provided in the letter dated July 15, 2022, were gathered using the "Snapshot Count Method", which is "the number of lives covered on a date equals the actual number of lives covered on the designated date". This method can combine employees of the group and spouses/children/family members covered. The IRS instructions to use these numbers are to add together the four quarters for which you are reporting, then divide by four to get the average count per quarter.

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The below example on how to determine the enrollment count to report for your group can be found on the IRS Website at https://www.irs.gov/newsroom/patient-centered-outcomes-research-institute-fee and on page 13 of the IRS document.

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Example one. (I) Employer B is the plan sponsor of the Employer B Self-Insured Health Plan, which has a calendar year plan year. Employer B uses the snapshot method to determine the average number of lives covered under the plan and uses the snapshot count method to determine the number of lives covered on a day in the first month of each calendar quarter of the plan year. (ii) On January 4, 2013, the Employer B Self-Insured Health Plan covers 2,000 lives, on April 5, 2013, 2,100 lives, on July 5, 2013, 2,050 lives, and on October 4, 2013, 2,050 lives. Under the snapshot method, Employer B must determine the average number of lives covered under the Employer B Self-Insured Health Plan for the plan year ending December 31, 2013, as 8,200 (2,000 + 2,100 + 2,050 + 2,050) divided by 4, or 2,050. To calculate the section 4376 fee under paragraph (c)(1) of this section for the plan year ending December 31, 2013, Employer B must determine the applicable dollar amount under paragraph (c)(3) of this section and multiply that amount by 2,050.

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For issuers of specified health insurance policies, the fee for a policy year ending on or after October 1, 2021, but before October 1, 2022, is $2.79 (line 133(b)) ($2.66 for a policy year ending on or after October 1, 2020, but before October 1, 2021 (line 133(a))), multiplied by the average number of lives covered under the policy for that policy year.

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PLEASE NOTE, Verdegard and RMI will NOT be completing these forms for any Medova Lifestyle Health Plan. Verdegard is only providing the enrollment numbers needed for each group and the information included with the July 15 letter. It is the Employer Plan Sponsor’s responsibility to use this information to determine whether it is required to complete a 720 form for its group. Again, RMI would strongly encourage you to consult with your tax advisor to determine if you need to file these 720 forms or for assistance in completing this Form if necessary. Inserts from the Form 720 have been linked below for your convenience.  Please contact HMA for additional questions at (480) 921-8944.

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DOCUMENTS

 

 

 

 

Click on link below for the information noted:

 

 

 

DOL/MEDOVA COURT FILINGS

 

 

A. The DOL/Medova Case Pacer link where the Monthly Reports of the Interim Independent Fiduciary can be found, and all Case Filings can be found. 

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B. Complaint filed by U.S. Department of Labor.

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C. Answer filed by the Medova Defendants.

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D. Consent Order Appointing the Interim Independent Fiduciary and Adding Additional Defendants.

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E. Reports of the Interim Independent Fiduciary to the Court.

 

Initial Report

 

36th Report

 

F. All Writs Act Injunction Order.

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G. Compared Appendix A to Motion to Amend Appendix A to Consent Order.

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H. Appendix A to Motion to Amend Appendix A to Consent Order.

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I. Independent Fiduciary's Agreed Motion to Amend Appendix A to the Consent Order to Remove Non-ERISA Plans.

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DOL

 

 

J. Press release issued by DOL regarding Medova litigation.

 

 

RMI LITIGATION AGAINST PLAN SPONSORS

 

 

K. RMI’s lawsuit against the Magnolia ________ Plan Sponsor.

 

 

LISTINGS

 

 

L. Searchable Excel Medova Member ID by Group

 

 

 

TAX INFORMATION

 

 

M. IRS Form 720.

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N. IRS Form 5500.

 

RMI FORMS

 

O. Broker of Record Form.

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P. Negotiated Release Template PDF.

 

Q. Instructions for submitting documentation of a claim resolved by negotiated settlement or zero balance statement.

 

 

INFORMATION SHEETS

 

 

R. RMI Appeal Information Sheet.

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S. RMI Collection Information Sheet

 

 

 

 

 

 

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