On April 17, 2023, U.S. Department of Health & Human Services (HHS) launched its remaining rule to replace necessities and requirements for well being insurers and Marketplaces underneath the Affordable Care Act (ACA) for plan yr (PY) 2024. In addition to this annual “Notice of Benefit & Payment Parameters,” (NBPP) the company launched a Fact Sheet in regards to the remaining rule, and the ultimate PY 2024 Actuarial Value (AV) Calculator and Methodology.
HHS acquired over 300 public feedback on its draft NBPP, and on this remaining rule advances proposals to ban Marketplace plans with no supplier community, restrict the profusion of non-standardized plans, encourage enrollment in plans with lowered cost-sharing for lower-income customers, cut back misleading advertising practices, and decrease administrative limitations to enrollment. It additionally finalizes modifications to danger adjustment, Advance Premium Tax Credit (APTC) coverage, market transitions, person charges, and different market requirements. Key themes underlying most of the 2024 guidelines are the administration’s dedication to advancing well being fairness, bettering the buyer expertise, and increasing Marketplace enrollment.
In this primary of three Forefront articles on the ultimate 2024 NBPP, we deal with market reforms and shopper help. The second and third articles deal with danger adjustment, proposed modifications to market operational requirements, and APTC insurance policies.
Network Adequacy And Essential Community Providers
The 2024 NBPP maintains the community adequacy requirements for Marketplace well being plans, applied by the Biden administration in plan yr 2023, with modest modifications. The administration can also be ratcheting up its expectations that Marketplace issuers embody important group suppliers (ECPs) of their plan networks.
Plans That Do Not Use A Provider Network
The ACA requires that Marketplace plans guarantee a “sufficient choice” of suppliers and supply data to enrollees in regards to the availability of in-network and out-of-network suppliers. The statute additionally requires that plans “include within health insurance plan networks those essential community providers, where available, that serve predominantly low-income, medically-underserved individuals.” In the proposed 2024 NBPP, HHS argued that issuers can’t adjust to the ACA requirements, and the company can’t successfully implement compliance, if a plan doesn’t use a supplier community. The company has noticed that plans with out supplier networks may end up in entry and affordability challenges for enrollees, together with substantial and sudden out-of-pocket prices. Under the ACA, the Marketplace has broad discretion to certify a plan for participation provided that determines that doing so is “in the interests” of customers.
The company due to this fact proposed to repeal a 2016 coverage that exempted Marketplace plans, stand-alone dental (SADP), and small enterprise well being possibility program (SHOP) plans that don’t preserve a supplier community from the ACA’s community adequacy necessities.
Since 2016, solely a single well being plan issuer on the federally facilitated Marketplace (FFM) has sought certification with no supplier community. For SADPs, solely 8 of the 672 taking part within the Marketplace in 2022 didn’t use a community of suppliers, a quantity that has declined annually since 2017. In this present plan yr, SADPs with no supplier community are concentrated in simply two frontier states, Alaska and Montana.
HHS is finalizing its requirement that Marketplace well being plan, SADP, and SHOP issuers preserve a supplier community starting in PY 2024. Most commenters supported the proposal.
However, HHS estimates that roughly 2,200 SADP enrollees could possibly be required to modify plans underneath this coverage. To attempt to mitigate this danger, HHS is making a “limited exception” for SADP issuers in areas the place it’s thought of “prohibitively difficult” to determine a community of dental suppliers. This dedication should be made primarily based on attestations from state insurance coverage regulators in states the place at the least 80 p.c of their counties are labeled as Counties with Extreme Access Considerations that at the least one in every of these components exists:
- A major scarcity of dental suppliers;
- A major variety of dental suppliers unwilling to contract with Marketplace SADPs; or
- Significant geographic limitations impacting shopper entry to dental suppliers.
Appointment Wait Time Standards
Beginning this yr, issuers providing plans on the FFM and the state-based Marketplaces utilizing the federal platform (SBM-FP) should be sure that enrollees can receive supplier companies inside a most time or distance from their properties. In its 2023 NBPP, HHS additionally required QHP issuers to satisfy most appointment wait time requirements however delayed implementation of that requirement to plan yr 2024, citing issues in regards to the compliance burden on issuers.
In this remaining rule, HHS will once more delay the imposition of appointment wait time requirements, this time to PY 2025. A majority of public feedback urged the company to not implement this requirement for PY 2024, arguing that issuers want extra steering and specificity about how HHS would assess wait instances and implement compliance. Commenters raised a number of limitations to implementation, together with:
- The burden on suppliers to report knowledge to issuers;
- Issuers’ operational challenges monitoring contracted suppliers;
- Difficulties receiving correct wait time knowledge from suppliers;
- Fluctuations in appointment wait instances over the course of the yr; and
- Workforce staffing, recruiting, and retention challenges.
In agreeing to delay the implementation timeline for appointment wait time requirements, HHS notes they’re pursuing wait time requirements in different authorities protection packages. The extension will allow them to higher guarantee alignment throughout packages.
Essential Community Providers
HHS is finalizing new necessities to develop the illustration of ECPs in Marketplace plan networks. First, the company will add two new stand-alone ECP classes to the present checklist of six classes of ECPs:
- Federally Qualified Health Centers (FQHC)
- Ryan White Program Providers
- Family Planning Providers
- Indian Health Care Providers
- Inpatient Hospitals
- Other ECP Providers (outlined to incorporate Substance Use Disorder Treatment Centers, Community Mental Health Centers, Rural Health Clinics, Black Lung Clinics, Hemophilia Treatment Centers, Sexually Transmitted Disease Clinics, and Tuberculosis Clinics).
The two new classes for 2024 will likely be: Mental Health Facilities and Substance Use Disorder (SUD) Treatment Centers, thus eradicating them from the “Other ECP Providers” class. This change implies that issuers should try and contract with at the least one SUD Treatment Center and at the least one Mental Health Facility of their service areas. HHS can also be including Rural Emergency Hospitals as a supplier sort underneath the “Other ECP Providers” class.
Second, HHS would require Marketplace plans to contract with at the least 35 p.c of accessible FQHCs and at the least 35 p.c of accessible Family Planning Providers that qualify as ECPs. This is along with the present requirement that plans meet the general 35 p.c threshold requirement for ECP participation in every service space. HHS is establishing particular thresholds for FQHCs and Family Planning Providers as a result of they’re the 2 largest ECP classes; collectively they symbolize nearly all of the ECPs on the checklist maintained by HHS. The company argues that making use of the 35 p.c threshold to those two supplier sorts may assist enhance entry in low-income areas to the broad vary of companies these suppliers provide.
HHS estimates that almost all of Marketplace issuers already meet or exceed the 35 p.c threshold for these suppliers. Specifically, if these thresholds have been in place at this time, 76 p.c of issuers within the FFM would be capable to meet the 35 p.c threshold for FQHCs, and 61 p.c would be capable to meet the brink for Family Planning Providers. Issuers who can’t meet the usual could submit written justifications. Most public feedback supported HHS’ proposals to extend ECP illustration in Marketplace plan networks, noting that they need to assist develop entry to psychological well being and SUD remedy companies.
Standardized Plan Options
The Biden administration re-introduced standardized plan choices for the FFM and SBM-FPs for plan yr 2023. The administration believes that standardized plans are vital to assist streamline and simplify the plan choice course of for Marketplace customers. These plans are additionally designed to incorporate pre-deductible protection for a number of high-value well being care companies, which HHS argues will cut back limitations to entry, fight discriminatory profit designs, and enhance well being fairness. The standardized plans additionally emphasize using copayments as an alternative of coinsurance, the latter a type of cost-sharing that may end up in sudden monetary legal responsibility for customers. For plan yr 2024, HHS proposed (and is now finalizing) a comparatively modest change to its standardized plans.
Specifically, HHS will now not require FFM and SBM-FP issuers to supply a standardized plan on the “non-expanded” bronze metallic stage, (“Expanded” bronze plans cowl at the least one non-preventive service pre-deductible or meet the IRS’ definition of a high-deductible well being plan and are permitted to have an actuarial worth of as much as 5 factors above the 60 p.c customary; “non-expanded” bronze plans don’t.) HHS has discovered that the low actuarial worth of the non-expanded bronze plans preclude the flexibility to incorporate any pre-deductible protection. They additionally be aware that few insurers have chosen to supply non-expanded bronze plans, making the choice to now not require a standardized model much less disruptive.
Issuers should proceed to supply standardized plans in each service space the place in addition they provide non-standardized plan choices on the following metallic ranges:
- One expanded bronze plan;
- One customary silver plan;
- One model every of the three income-based silver cost-sharing discount (CSR) plan variations;
- One gold plan; and
- One platinum plan
As they did for plan yr 2023, HHS has declined to increase this requirement to issuers within the SBMs and in Oregon, which has its personal standardized plan necessities; they’ve additionally created a set of standardized plan choices that may apply solely in Delaware and Louisiana, resulting from these two states’ cost-sharing requirements.
Public feedback have been blended on HHS’ resolution to now not require Marketplace issuers to supply a standardized plan on the non-expanded Bronze stage. Some supported the transfer, noting the lowered burden on issuers and the higher recognition of the expanded bronze plans. Others expressed issues that buyers at present enrolled in these plans must swap to a brand new plan.
HHS will proceed to require issuers of standardized plans to make use of solely 4 tiers of prescription drug cost-sharing of their formularies: (1) generic, (2) most popular model title, (3) non-preferred model title, and (4) specialty. Although the company acknowledges that 5-6 tiers of drug cost-sharing are frequent within the business market, they argue that 4 tiers will enable for extra “predictable and understandable” drug protection, lowering the chance of sudden monetary legal responsibility for enrollees.
In spite of HHS’ issues that Marketplace issuers aren’t together with sure medication at acceptable cost-sharing tiers (akin to inserting generic medication in the popular or non-preferred model drug tiers), the company determined to not finalize a proposal that each one standardized plans place generic medication within the generic drug tier and all lined model title medication both in the popular or non-preferred model title tiers. Commenters expressed issues, and HHS agrees, that such a requirement may inhibit competitors amongst producers for favorable placement on plan formularies, which might help cut back prices and enhance treatment adherence for customers.
The company will proceed to differentially show standardized plan choices, which they name “Easy Pricing” plans, on HealthCare.gov. Consumers can apply filters to the search engine on the location, and examine solely standardized plans. HHS additionally requires web-brokers and Marketplace issuers utilizing the direct enrollment pathway to differentially show the standardized plan choices, except HHS approves a deviation.
Limits On Non-Standardized Health Plans
A RAND Corporation assessment of over 100 analysis research discovered that having too many well being plan selections can result in poor enrollment selections resulting from customers’ problem processing advanced medical insurance data. Yet this yr, the typical variety of plans obtainable to Marketplace customers is 113.7.
HHS will due to this fact undertake a restrict on the variety of non-standardized plans that issuers within the FFM and SBM-FPs could provide. The proposed rule would have permitted issuers to supply solely two non-standardized plans per product community sort and metallic stage (not together with catastrophic plans) in any service space in PY 2024. In response to public feedback arguing for a extra gradual strategy, the ultimate rule locations the restrict at 4 non-standardized plans for plan yr 2024, dropping to 2 non-standardized plans starting in PY 2025.
HHS can even give issuers that provide plans with extra dental and/or imaginative and prescient advantages higher flexibility, considerably growing the variety of non-standardized plans they’ll provide at every metallic stage. For instance, in 2024, inside a single service space, issuers could provide:
- Four non-standardized gold HMOs with no extra dental or imaginative and prescient protection;
- Four non-standardized gold HMOs with extra dental protection;
- Four non-standardized gold HMOs with extra imaginative and prescient protection;
- Four non-standardized gold HMOs with extra dental and imaginative and prescient protection;
- Four non-standardized gold PPOs with no extra dental or imaginative and prescient protection;
- Four non-standardized gold PPOs with extra dental protection;
- Four non-standardized gold PPOs with extra imaginative and prescient protection; and
- Four non-standardized gold PPOs with extra dental and imaginative and prescient protection.
This flexibility permits issuers to supply as much as 32 non-standardized plans per metallic stage in every service space in PY 2024, plus the required standardized plans. Beginning in PY 2025, that quantity will likely be lowered to a most of 16 non-standardized plans per metallic stage, per service space, though HHS intends to suggest creating an exceptions course of to permit issuers to develop past the two-plan restrict. Thus, in service areas with a couple of issuer, customers will possible proceed to face a lot of plan choices.
Still, HHS estimates that these limits will cut back the typical whole variety of plans obtainable to every shopper from 113.7 to 90.5 in PY 2024. Once the cap drops to 2 non-standardized plans in PY 2025, the typical whole variety of plans will likely be 65.3 for every shopper. HHS views the standardized profit designs and the plan limits as components of a multi-pronged technique to “meaningfully simplify” customers’ plan choice course of, lowering suboptimal plan choice and sudden monetary legal responsibility for enrollees.
HHS will not be extending the non-standardized plan limits to issuers in SBMs as a result of many SBMs already restrict the variety of plan choices. HHS additionally believes that SBMs are finest positioned to know what customers of their markets want.
Many commenters help limiting the variety of plans, arguing that the variety of plan choices on the Marketplace has elevated “beyond a point that is productive.” Commenters noticed that buyers should not have the time, sources, or well being literacy to know and examine the overwhelming variety of plan choices.
Other commenters argue that HHS ought to spend money on enhancements to the HealthCare.gov person interface and selection structure, relatively than limiting the variety of plan choices or standardizing advantages. HHS agrees that bettering HealthCare.gov is vital however finds such efforts to be inadequate, by themselves, to meaningfully cut back the chance of plan selection overload. HHS additionally believes that lowering the variety of plans obtainable will assist advance well being fairness, noting that the extreme variety of plans, notably on the silver stage, locations the best burdens on low-income people who qualify for CSRs.
Commenters who opposed limiting the variety of plans additionally argued that doing so would pose a major burden on issuers who’ve already invested in creating merchandise for PY 2024, and that it could trigger disruption for customers who must be re-enrolled in plans they didn’t actively select. HHS estimates that of the 101,453 non-standardized plan choices at present obtainable, roughly 17,532 will have to be discontinued, with a projected 2.72 million enrollees required to vary plans for 2024. However, the company has additionally discovered that, on common, 71 p.c of every issuer’s enrollment is concentrated amongst simply two plans per product community sort and metallic stage. The remaining portion of every issuer’s enrollment is extra evenly distributed throughout much less common choices. Many plans have very small enrollment numbers. HHS argues that the plan limits will merely focus enrollment among the many hottest present product choices. They additionally imagine that phasing within the reductions in plan choices over two years, as an alternative of the one yr initially proposed, will cut back the burdens for issuers and disruption for customers.
Other commenters noticed that plan limits may “severely restrict” shopper selection in markets which have much less competitors amongst issuers and fewer plan choices. However, HHS argues that the cap on plan choices strikes an “appropriate balance” by lowering the chance of plan selection overload whereas preserving a level of shopper selection, even for customers in counties with low issuer participation.
As an alternative choice to limiting the variety of plans, HHS had proposed re-instating an Obama-era “meaningful difference” customary. If this strategy had been adopted, HHS would have grouped plans by issuer ID, county, metallic stage, product community sort, and deductible integration sort, after which evaluated whether or not plans inside every group have been meaningfully completely different primarily based on variations in deductible quantities. Deductibles would have needed to differ by greater than $1,000 to fulfill the brand new customary. Because HHS is finalizing the coverage to restrict the variety of non-standardized plan choices, they don’t seem to be finalizing the proposal to impose a significant distinction customary.
Standards For Navigators And Other Consumer Assisters
This rule repeals the present prohibitions on Marketplace Navigators, licensed utility counselors, and non-Navigator help personnel (collectively, Assisters), from going door-to-door or immediately contacting customers to offer enrollment help. HHS argues that permitting such direct contact will take away limitations to well timed and related enrollment help, and can enable Assisters to achieve extra doubtlessly eligible customers, together with those that have problem touring resulting from lack of mobility or transportation, or who’re immunocompromised.
Public feedback on the draft rule overwhelmingly supported this proposal, noting that it’ll assist cut back uninsured charges and well being disparities in addition to the burden on customers. Many noticed that lifting the ban on door-to-door outreach and direct contacts will likely be notably vital to assist preserve protection for individuals affected by the Medicaid unwinding. Some commenters supported the proposal however urged HHS to take steps to mitigate fraud. HHS responds by detailing their efforts to scale back fraud, together with updating privateness and safety necessities for all Assister organizations.
Rules For Brokers And Agents
Roughly half of all federal Marketplace enrollments are facilitated by medical insurance brokers and brokers, in line with a 2020 CMS report. One in 5 brokers help greater than 200 customers throughout the Marketplace’s annual open enrollment interval. Since the inception of the Marketplaces, HHS has had requirements of conduct for brokers and brokers who want to promote Marketplace plans.
Extension Of Review Times
Where there may be proof of fraud or abusive conduct, HHS has the ability to right away droop or terminate a dealer, agent, or web-broker’s Marketplace settlement. The dealer, agent, or web-broker could then submit rebuttal proof protesting the suspension or termination. The 2024 NBPP finalizes a proposal to present HHS an extra 15 calendar days to assessment rebuttal proof from brokers, brokers, or web-brokers within the case of a Marketplace suspension, and an extra 30 calendar days within the case of a Marketplace termination. HHS will thus have a complete of as much as 45 or 60 calendar days to assessment rebuttal proof.
The company has discovered that the method for reviewing rebuttal proof from brokers, brokers, and web-brokers can, notably in advanced conditions, take appreciable sources and time, typically requiring technical data and knowledge and outreach to customers. The company acquired a number of feedback agreeing that additional time is required for the assessment of advanced instances. However, a few of these commenters urged HHS to attempt to resolve suspension and termination instances as rapidly as attainable and never use the additional assessment time if not essential.
Accurate And Complete Documentation Of Consumer Assistance
HHS has acquired complaints from customers that the knowledge their dealer submitted of their Marketplace functions was incorrect, or that the dealer submitted the appliance with out their consent. For instance, the company notes that some functions embody an attestation that the applicant is a U.S. citizen alongside an attestation that the applicant has no Social Security Number (SSN). This discrepancy can set off a “data matching” issuer, and place the buyer susceptible to having their protection terminated. Inaccurate revenue or family data on functions may also place the buyer susceptible to having to pay again any premium tax credit for which they weren’t eligible.
HHS has additionally noticed that unauthorized enrollments via brokers impression underserved teams of customers, notably unhoused people and people with restricted English proficiency, in “greater numbers” than different teams. Each yr, HHS estimates that it investigates roughly 120 brokers, brokers, or web-brokers. However, it has discovered that complaints about inaccurate or unauthorized functions are tough to adjudicate as a result of typically the one proof is the phrase of the buyer towards the phrase of the dealer.
The company is thus finalizing a proposal to require brokers, brokers, and web-brokers within the FFM and SBM-FPs to doc that their shoppers (or approved representatives) have reviewed and confirmed their eligibility data earlier than they submit an utility. The documentation should embody the date the buyer reviewed the appliance, the buyer’s title (or approved consultant’s title), a proof of the attestations within the utility, and the title of the agent, dealer, or web-broker offering the help. Acceptable types of documentation may embody the signature of the buyer or approved consultant, verbal affirmation captured in an audio recording, or a written response from the buyer or approved consultant to a communication despatched by the agent, dealer, or web-broker.
The remaining NBPP can even require brokers, brokers, and web-brokers to doc that they’ve acquired a shopper’s consent to help them with a market eligibility utility. This consent should embody the date, the buyer’s title (or approved consultant), and the title of the agent, dealer, or web-broker. HHS will not be prescribing precisely how consent should be obtained, however it could possibly take the type of a signature or a recorded verbal authorization. Brokers, brokers, and web-brokers should preserve a document of the buyer’s consent and affirmation of the accuracy of their eligibility data for at the least 10 years and be capable to produce it for HHS upon request.
HHS acquired many feedback that the brand new documentation necessities will place a heavy burden on brokers, brokers and web-brokers, requiring them to spend extra time with particular person shoppers and doubtlessly lowering the numbers of individuals they’ll in the end enroll. While the company agreed that the brand new documentation necessities pose new burdens, they imagine the advantages of encouraging the submission of correct data outweigh the adverse impression on brokers, brokers, and web-brokers. They additionally be aware that they’re offering brokers, brokers, and web-brokers with a number of means by which to adjust to the documentation necessities.
Prohibiting Mid-Year Terminations For Dependent Children Who Reach Maximum Age
Health plans and insurance coverage issuers that provide protection to dependent kids should, underneath the ACA, enable these kids to remain on their guardian’s plan till age 26. Through its enterprise guidelines, the FFM at present requires Marketplace issuers that cowl dependent kids to keep up their protection on their guardian’s plan till the top of the plan yr by which they flip 26. To present extra readability for QHP issuers and to scale back enrollee uncertainty about their protection, the 2024 NBPP codifies this requirement into federal laws. State-based Marketplaces (SBMs) have the choice of implementing an identical rule. During the annual open enrollment interval, the FFM will robotically enroll enrollees who turned 26 throughout the plan yr into their very own, separate plans, if in any other case eligible.
Many commenters supported this coverage and none opposed it, though one commenter inspired HHS to increase the coverage to SBMs. HHS notes, nevertheless, that SBMs are allowed to determine their very own operational practices and guidelines.
Rating Rules For Stand-Alone Dental Plans
The draft 2024 NBPP included two proposals for stand-alone dental plans (SADPs) in all Marketplaces, together with SBMs. The first required that SADP issuers set premium charges and decide plan eligibility primarily based on an enrollee’s age on the time the coverage is issued or renewed, starting in 2024. Although they’ve had flexibility to set a distinct date, the overwhelming majority of SADP issuers use an enrollee’s age on the coverage efficient date to set charges. With public feedback uniformly in help of this proposal, HHS is finalizing this coverage with out modifications.
The second proposal requires SADP issuers, as a situation of Marketplace certification, to submit solely assured charges for the plan yr, not estimates. Requiring assured charges helps stop inaccurate determinations of APTCs for the pediatric dental portion of a shopper’s premium, which is able to primarily profit lower-income customers who qualify for APTCs. Public feedback all supported the proposal, and HHS is finalizing the coverage with out modifications.
Marketing Name Requirements For Qualified Health Plans
In the proposed NBPP, HHS reported receiving complaints from customers about deceptive and misleading plan advertising names. Upon investigation, HHS and state insurance coverage regulators discovered that many plans use advertising names with cost-sharing or different profit particulars which are incorrect or deceptive. For instance, some plans have advertising names that point out limits on cost-sharing quantities that in truth are solely obtainable for a sure prescription drug or supplier community tier, embody greenback quantities that don’t specify what they confer with, or use “HSA” within the plan title when the plan doesn’t enable the enrollee to arrange an HSA. HHS thus proposed to require that plan and plan variation advertising names embody right data, and never embody content material that’s deceptive.
In the ultimate rule, HHS is finalizing the coverage as proposed and intends to work with state insurance coverage regulators throughout the annual Marketplace plan certification course of to watch compliance. Most public feedback applauded the coverage, in addition to HHS’ intention to collaborate with state insurance coverage regulators on enforcement. Some additionally urged HHS to undertake a typical template for plan advertising names; though HHS declined to take action for PY 2024, the company agreed that clear and comparable data in plan names is vital to help knowledgeable shopper decision-making.
Just a few commenters opposed the proposal, arguing that insurance coverage issuers wanted flexibility within the advertising practices, and that states needs to be completely answerable for regulating plan advertising names. In response, HHS famous that their investigation uncovered a number of egregious examples of plan advertising names which are at finest deceptive and doubtlessly intentionally misleading, akin to plans that describe themselves as “$0 cost-sharing” with out noting that it solely applies to a restricted variety of visits.
Establishing A Timeliness Standard For Notices Of Payment Delinquency
When a plan enrollee will get behind in making premium funds, HHS requires Marketplace issuers to ship a discover to the enrollee in order that they have a chance to pay unpaid premiums and keep away from a termination of their protection. In conducting oversight of issuers, the company discovered that some have been delaying sending these notices, in excessive instances stopping the enrollee from correcting their fee delinquency. HHS is thus establishing a timeliness customary for issuers in FFM and SBM-FP Marketplaces. Those issuers should ship notices inside 10 enterprise days of the date the issuer ought to have found that the enrollee was in delinquency, though HHS notes that state insurance coverage regulators could set up a extra stringent customary, if they want. Most commenters supported the timeliness requirement.
Author’s Note
The Robert Wood Johnson Foundation supplied grant help for the writer’s time researching and scripting this submit.
Sabrina Corlette, “Final 2024 Payment Rule, Part 1: Insurance Market Rules and Consumer Assistance,” Health Affairs Forefront, April 19, 2023, https://www.healthaffairs.org/content/forefront/final-2024-payment-rule-part-1-insurance-market-rules-and-consumer-assistance Copyright © 2023 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.