Self Insurer May 2019

MAY 2 0 1 9

A S I P C P U B L I C AT I O N

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A PRIVATE MATTER

Rife with sensitive information, workers’ compensation data is an easy target for hackers, and while cyber

insurance hasn’t been widely adopted, steps have been taken to shore up systems security and protect claimant privacy.

strength in

AN INTEGRATED APPROACH TO SELF-INSURED SOLUTIONS

balance Experts in coverage solutions for single entities, groups and public entities, our integrated approach gives self-insureds greater stability and control over their self-funded plan. Unparalleled underwriting expertise, innovative risk management and in-house claims management, work in sync and in perfect balance for best possible outcomes.

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Table of contents

may 2019 VOL 127

W W W. S I P C O N L I N E . N E T

FEATURES

4 A PRIVATE MATTER Rife with sensitive information, workers’ compensation data is an easy

target for hackers, and while cyber insurance hasn’t been widely adopted,

steps have been taken to shore up systems security and protect

claimant privacy.

By Bruce Shutan

10

Captive Growth Restrained in 2018

By Karrie Hyatt

ARTICLES 16 ACA, HIPAA and Federal Health Benefit Mandates

The Affordable Care Act (ACA), the Health Insurance Portability and

Accountability Act of 1996 (HIPAA) and other federal health

benefit mandates

38 Self-Insurance Educational Foundation (SIEF)

$2,500 scholarship winner

40

SIIA ENDEAVORS

47

News from siia members

22 Transparency – A Clear and Almost-Present Danger?

30 Battling a Silent and Deadly Epidemic, Nearly 40 million Americans suffer from

kidney disease

The Self-Insurer (ISSN 10913815) is published monthly by Self-Insurers’ Publishing Corp. (SIPC).

Postmaster: Send address changes to The Self-Insurer Editorial and Advertising Office, P.O. Box 1237, Simpsonville, SC 29681,(888) 394-5688

Self-Insurer’s Publishing Corp.

PUBLISHING DIRECTOR Erica Massey, SENIOR EDITOR Gretchen Grote, CONTRIBUTING EDITOR Mike Ferguson, DIRECTOR OF OPERATIONS Justin Miller, DIRECTOR OF ADVERTISING Shane Byars, EDITORIAL ADVISORS Bruce Shutan and Karrie Hyatt, 2018 Self-Insurers’ Publishing Corp. Officers James A. Kinder, CEO/Chairman, Erica M. Massey, President, Lynne Bolduc, Esq. Secretary

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FEATURE

A PRIVATE MATTER Rife with sensitive information, workers’ compensation data is an easy target for hackers, and while cyber insurance hasn’t been widely adopted, steps have been taken to shore up systems security and protect claimant privacy

A A

dministering self-insured workers’ compensation programs is so fraught with complexity and confusion that data privacy could be compromised by inattentive administrators along the way to securing insurance coverage and mitigating claims.

The work comp area is a treasure trove of personal identifiable information (PII) such as name, date of birth and Social Security number, as well as personal health information (PHI). But there are systemic problems with attempts to secure this information.

Most businesses and insurance markets are structured in a way that can magnify privacy concerns, notes John Means Cooper, VP of excess workers’ compensation for AmWINS Brokerage of the Carolinas who moderated a SIIA national conference workshop on this topic. Since group health benefits are walled off from property and casualty insurance, risk managers and CFOs who handle the latter category aren’t as familiar as HR executives with the Health Insurance Portability and Accountability Act (HIPAA), which isn’t on their radar.

Work comp fund administrators already have their hands full fretting about the overall cost of medicine alongside a laundry list of other items. Data privacy concerns “won’t even make the top 25,” Cooper opines.

WRITTEN BY BRUCE SHUTAN

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A Private Matter Regulatory patchwork A similar disconnection also plays out along the regulatory landscape. For example, regulators in Pennsylvania’s Department of Labor and Industry or the Louisiana Workforce Commission are work comp experts who don’t understand other insurance lines, he says. Their concern is with ensuring that claims are properly handled and claimants are receiving the care they need. His point is that it would be up to state insurance commissioners to rule on cyber insurance or other matters related to protecting work comp data.

The regulatory landscape is daunting considering that in addition to complying with HIPAA, businesses also must still comply with statutes in all 50 states as well as industry-specific statutes and regulations. While some industry observers have suggested there will be some type of national data privacy breach law modeled after the General Data Protection Regulation in the European Union, it seems unrealistic in the U.S. John Mullen, Sr., a partner with Mullen Coughlin LLC, recalls how in recent years 47 attorneys general implored Congress not to void their state privacy laws if a federal statute were

“My bet is that states wouldn’t support a national law that knocked their laws off to the side,” he predicts. “They probably John Mullen would support one that, at some level, creates an awning effect in addition to their statutes.” passed.

Complying with a patchwork of state and federal data privacy laws is no easy undertaking. While there are a few federal laws that have some bearing as to data privacy and the handling of protected data, none have preemptive power, explains Megan North, AVP of professional liability for AmWINS Brokerage of Texas, Inc. “Each state actually has its own laws about data privacy and what constitutes personal identifiable information, how that has to be protected, and if there’s a potential breach of that data, then what actions need to be taken to rectify the situation,” she says.

State attorneys general are becoming more involved with data privacy breaches, North reports. Their efforts include determining how sensitive information was compromised, preventing further incidents from occurring and levying penalties based on state regulations.

“We’re going to see more scrutiny from regulators,” she predicts, noting how all 50 states have enacted data privacy laws and some are already making revisions.

While poorly securing sensitive personal data is an unwise practice, Mullen explains that it doesn’t necessarily violate privacy laws, calling it “more of a statutory compliance challenge if a privacy event occurs.”

Vulnerable cyber trails A huge obstacle for self-insured work comp programs is the sheer number of times sensitive information changes hands. When Cooper starts the process of quoting someone’s account, PII has been tossed from an insurance agent, carrier and third-party administrator through multiple email chains by the time it reaches him. It’s then again shared with one or more carriers. In the never-ending transport of PII, he cautions that data is exposed to tremendous cyber risk.

Work comp data is a ripe target for sophisticated cyber criminals. “Hackers are looking for the easiest route with the biggest payoff, and medical records are going for quite a bit on the black market,” North says.

Fewer than 20% of entities in the small to middle market (i.e., less than $500 million in revenue), depending on how it is defined, have purchased cyber insurance, according to Mullen, who ties that assessment to interactions with brokers and underwriters. “Five years ago, it was far lower,” he adds.

MAY 2019

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A Private Matter A baseline requirement in today’s business world, Mullen notes that modestly priced cyber insurance premiums can buy millions of dollars in coverage and protection from “a panel of experts who do it fast and for a living.” One reason why this product has such a low market penetration is because it’s still a new line about which there’s little awareness, Cooper notes.

Despite a muted market for cyber insurance, which some critics believe is overpriced, North Megan North notes that all industries are pushing to develop and test network security protocols or best practices to safeguard PII and PHI. She encourages companies to involve their employees in those activities, as well as empower them to speak up when something doesn’t feel right.

“I think people are starting to pay more attention to it, which is largely driven by expectations within our society,” she adds.

Public pressure is one influential factor behind this movement.

Another reason cyber security is top of mind is the need to protect an organization’s reputation, especially in the highly competitive work comp space.

mine of extensive amounts of that data, and they might allege that they have it in their care.”

Relying on expertise What’s crystal clear is that the selfinsured work comp space will need to prepare for cyber security breaches in the future. There are nearly endless ways that cyber criminals can cobble together sensitive personal information, Cooper says.

They have become increasingly creative and sophisticated about poaching sensitive information, “and they will always eventually figure out a different way into something,” he observes, noting how medical records are worth a fortune on the black market.

Ransomware is one rampant tactic that’s being employed across every part of the economy. Under this frightening approach, hackers will threaten to release sensitive personal information to the public unless a specified amount of money is paid as a ransom.

They do this by disguising a nefarious email that looks like it was generated by a legitimate source, but when a user clicks on the link, IT systems instantly freeze and can only be reactivated by the hacker or a cyber security expert who cracks the code.

“If you ask any of the major cyber insurers, they’re going to tell you that’s where they’re largely getting hit right now because it’s easy and quick,” she says. “[Thieves are] sitting on a

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A Private Matter three days of a crazy forensic effort” into weeks of mop-up operations that worsened “until they finally reached out to their cyber insurer for help,” Mullen reports.

Indeed, the need for specialization and independent expertise cannot be understated given the degree of complexity involved. “A lawyer who’s a general practitioner or a business lawyer shouldn’t be doing cyber breaches,” says Mullen, whose team field cases each week from customers that aren’t even aware that their servers are teeming with protected information.

John Means Cooper

Bruce Shutan is a Los Angeles freelance writer who has closely covered the employee benefits industry for more than 30 years.

While not aware of any significant event involving work comp records, he cautions that it’s only a matter of time before a TPA or other entity experiences

“some gigantic breach and loss, and that will wake everybody up.” The trouble is that “insurance, by nature, is reactive and not a proactive industry,” he adds.

The underwriting process helps corporate customers “become a better manager of data and better positioned to respond” to a data privacy event, Mullen says. Last year his law firm handled 1,200 such events alongside forensic teams of specialists who manage IT, insurance claims, credit and ID monitoring, public relations, etc., virtually any time of the day or night.

One common denominator he noticed in the self-insured workers’ comp space is that those whose systems were penetrated often relied on internal IT staffers and in-house counsel.

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FEATURE

Captive Growth Restrained

I

in 2018 WRITTEN BY KARRIE HYATT

I

n 2018, the captive industry saw slower growth than it had in recent years. While active captive domiciles still added new captives to their books, for most domiciles, there were not as many new formations as in 2017.

The lackluster increase in captives likely had several causes. The continued soft insurance market being one. Another being the continued scrutiny by the IRS into small captives electing the 831(b) tax designation. In fact, the IRS again named these captives to its annual “Dirty Dozen� list of potential tax scams this year. Captives redomiciling and mergers also played a part in the near flat numbers in 2018.

However, despite what the static figures seems to indicate, the captive sector is thriving. Captive owners are insuring more types of coverages through their captives and captives are bringing in more money to their domiciles. In 2018 in Tennessee, written premium rose by 20% over the previous year. North Carolina, one of the newest and most aggressive of captive domiciles, released a statement last year claiming that captives had a $30 million dollar impact on state finances in 2017, and over $70 million since 2013. When its 2018 numbers are released it will likely be much higher due to its rapid addition of captives.

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Captive Growth Restrained State-of-the-Captive

By Domicile

Of the state captive domiciles that have released their numbers from 2018, only four show an increase in formations over the previous year. For Vermont and Arkansas, the increase was only by one captive, bringing the total number of captives up to 558 for Vermont and six for Arkansas.

While Vermont remains the largest onshore captive domicile, Arkansas is working on building its captive industry. Vermont has already updated its captive law in 2019—as it does every year—with several minor changes and clarifications, including allowing captives to undergo examination every five years instead of three. Arkansas is also looking to update its own law this year as well. The southern state originally passed captive law in 2001, but it wasn’t until 2017, when the state legislature updated the law, that the domicile really began courting new captives. The bill introduced into the state legislature in February provides clarifications on types of captives; on capital, surplus, and reporting requirements; on sponsored and cell captives; and on risk retention groups. By seeking to further update its legislation in 2019, Arkansas is indicating its seriousness as a captive domicile.

The other two jurisdictions that had an increase in formations were Kentucky, with seven new captives, an increase from four in 2017, and the District of Columbia, which had the largest number of new formations, with 17 new captives over the previous year’s three. In fact, this was the domicile’s largest net gain of captives since 2015.

Arizona, Delaware, Georgia, Hawaii, Montana, South Carolina, Tennessee, Texas, and Utah all reported fewer captives licensed in 2018 than in 2017. Many of these licensing 40% to 50% fewer captives.

Delaware licensed only 46 captives last year, in contrast with the 117 licensed in 2017. Of the newly licensed captives, 30 were taking advantage of Delaware’s latest addition to its captive law—conditional licensing. Signed into law in October, H.B. 334 amends the state’s law to allow captive applicants to be granted a six-month

provisional license to operate while the application is processed by regulators.

The idea proved popular. In the last ten weeks of 2018, Delaware granted 30 conditional licenses, indicating that previous nine months, the domicile had only licensed 16 new captives. In a statement, Insurance Commissioner Trinidad Navarro said,

“Captive insurance formations faced a number of challenges in 2018, due to recent changes in tax law. Despite the headwinds, Delaware’s having knowledgeable captive regulators continues to attract quality applicants.”

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Captive Growth Restrained In Vermont, one of its newest captives is the first of its kind—an affiliated reinsurance company. Affiliated reinsurance captives were enabled by Vermont through legislation in 2018 in reaction to the Base Erosion and Anti-Abuse Tax (BEAT) that was included in the Tax Cuts and Jobs Act of 2017, which subjects some companies that reinsure offshore to additional taxation. Vermont’s law offers a viable onshore option for these companies.

In addition to Vermont and Arkansas updating their captive laws this year, so far Georgia and North Carolina are also considering updates. Georgia has been updating its captive law with regularity over the last few years to keep it competitive. The 2019 changes considered are clarifying technicalities and streamlining the tax reporting and the licensing processes.

H.B. 220 was introduced into the North Carolina legislature in March. This would be the captive law’s fourth update since it was originally passed in 2013. The latest update clarifies some technical issues and makes some changes to the premium tax charges. At the time of writing, only Vermont had signed the updated legislation into law.

Reasons Captive Numbers Are Static

The soft market, new taxation rules, tax court decisions, and an economy in flux work against forming captives. The effects of the Tax Cuts and Jobs Act of 2017 made forming a captive less beneficial due to decreased tax benefits.

When the law was signed in December of 2017, industry experts forecasted a reduction in new captive formations, which certainly played out in 2018.

The small growth in captives in 2018 might also be a reflection of the decision of the U.S. tax court in Avrahami v.

Commissioner—the 2017 court decision that said the 831(b) captive owned by the Avrahami family was being used as a tax dodge. This decision and other similar court decisions have slowed down the rapid growth of small captives that would be eligible for the 831(b) tax option.

There was a significant rise in mergers and acquisitions (M&A) activity in the global insurance sector in 2018, according to the Sidley Global Insurance Review 2019, released by Sidley Austin, LLP. On the captive side, M&A activity may stem from the recent tax court decisions regarding small captives, which has led to some brokers leaving the captive space.

Captives redomiciling has led to fewer captives in some domiciles, and more in others. There has been a movement over the last few years of U.S. companies

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Captive Growth Restrained with offshore captives redomiciling them onshore. There has also been a trend for captives to redomicile to the home state of their parent company. This trend might increase following last year’s highprofile captive tax cases—Washington Insurance Commissioner vs. Cypress Insurance Co. and Johnson & Johnson vs. New Jersey. These cases stemmed from different circumstances, but both saw a captive sued by their parent company’s home state for not paying certain kinds of taxes.

Some captive domiciles are actively seeking to bring in redomiciling captives.

In North Carolina’s 2019 captive legislation update, the domicile wants to offer a “premium tax holiday” to foreign captive’s who consider redomiciling to the state by the end of 2020.

While captives did not grow in huge numbers in 2018, captives were still being formed. There were some significant changes in the marketplace— mostly regarding taxation—that put a damper on companies developing a captive for their insurance needs. There are at least three more cases relating to captives waiting for decision from the U.S. Tax Court that are expected this year. As the conditions that saw smaller growth in the captive sector in 2018 have not changed, the growth of captives in the U.S. in 2019 is likely to again be flat.

Karrie Hyatt is a freelance writer who has been involved in the captive industry for more than ten years. More information about her work can be found at: www. karriehyatt.com.

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ACA, HIPAA AND FEDERAL HEALTH BENEFIT MANDATES:

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he Affordable Care Act (ACA), the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other federal health benefit mandates (e.g., the Mental Health Parity Act, the Newborns and Mothers Health Protection Act, and the Women’s Health and Cancer Rights Act) dramatically impact the administration of self-insured health plans. This monthly column provides practical answers to administration questions and current guidance on ACA, HIPAA and other federal benefit mandates.

Attorneys John R. Hickman, Ashley Gillihan, Carolyn Smith, and Dan Taylor provide the answers in this column. Mr. Hickman is partner in charge of the Health Benefits Practice with Alston & Bird, LLP, an Atlanta, New York, Los Angeles, Charlotte, Dallas and Washington, D.C. law firm. Ashley Gillihan, Carolyn Smith and Dan Taylor are members of the Health Benefits Practice. Answers are provided as general guidance on the subjects covered in the question and are not provided as legal advice to the questioner’s situation. Any legal issues should be reviewed by your legal counsel to apply the law to the particular facts of your situation.

Readers are encouraged to send questions by E-MAIL to Mr. Hickman at john.hickman@alston.com.

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DC Court Sends AHP Rule Back to DOL In June of 2018, the DOL issued its Final Rule on association health plans (AHPs) which expanded the types of employer groups that might be considered to be a bona fide association. In March, a DC district court overturned the final AHP rule, and sent it back to DOL for it to determine which parts may be severable. During the pendency of this case, the status of AHPs established under the Final Rule (“New Rule AHPs) is in question. AHPs established under the old (sub-regulatory) AHP guidance (“Pre Rule AHPs”) should not be adversely affected.

Background

AHPs have been in existence for many years. If the association is “bona fide” under the applicable rules, the association is considered the “employer” under ERISA, with the result that the AHP can sponsor a single health plan on behalf of its members. If applicable rules are not satisfied, then each participating employer is treated as the sponsor of a separate group health plan. Fully-insured small employer group health plans are subject to additional ACA requirements that do not apply to large group or self-funded plans, such as the ACA requirement to offer essential health benefits (EHBs) and modified community rating. Through an AHP, a small employer may be able to avoid these additional requirements by banding together with other employers, potentially resulting in lower cost coverage.

Before the Final Rule, guidance as to when an association was considered “bona fide” under ERISA was contained in DOL “sub-regulatory” guidance, such as opinion letters and bulletins, as well as case law. This Pre-Rule Guidance generally sets forth two tests that must be satisfied for an association to be considered the “employer” for health plan purposes. First, the employer members of the association must have sufficient “commonality of interest”. Second, the employers must exercise “control” over the association and AHP plan. Establishing a bona fide association under PreRule guidance is challenging. The Final Rule relaxed some of these requirements, particularly the “commonality of interest” rule, making it easier to form AHPs.

Key provisions under the DOL Final Rule

The DOL Final AHP Rule relaxed the requirements to establish a bona fide association in several regards:

Relaxed commonality of interest test allows for geographically based AHPs. The Final Rule retains a modified version of the pre-rule AHP commonality of interest test. Under the Pre-Rule guidance, employers in the same line of business and same geographic location have been found to have requisite commonality of interest; however, employers that share only a common general interest, size, or geographic location have been held not to demonstrate sufficient commonality.

Thus, for example, pre-rule, the DOL found that a local chamber of commerce was not the “employer” (and therefore was not the proper sponsor of an AHP), where the primary economic nexus between the member employers was a commitment to private business development in a common geographic area. Under the Final Rule, the employers participating in an AHP will have commonality of interest if they are in the same trade, industry, line of business or profession. Additionally, the employers will have a commonality of interest under the Final Rule if their “principal place of business” is in the same geographic region within a single state or metropolitan area. Those employers would not be required to share any additional business connection other than their location.

MAY 2019

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The primary purpose of the association may be to offer health coverage, but the association must also have at least one substantial business purpose unrelated to providing benefits. Whereas the Pre-Rule guidance required that the association NOT be primarily established to provide insurance, the Final Rule found that the primary purpose could be the provision of benefits as long as the association has at least one other substantial business purpose.

The Final Rule does not define the term “substantial business purpose,” but does provide a safe harbor under which a substantial business purpose is considered to exist if the association would be a viable entity even in the absence of sponsoring an employee benefit plan. Examples of what may be considered a business purpose include

providing conferences or other educational services to association members, acting as a standard setting organization to establish business standards or best practices, engaging in public relations activities on issues of interest to members unrelated to health benefits, and advancing the well-being of the industry in which association members operate through substantial activity in addition to providing health coverage. If an organization has operated with an active membership before offering benefits, the DOL considers that compelling evidence of a substantial business purpose.

“Working owners” such as sole proprietors and partners can participate if certain requirements are met (even if the business has no employees other than the owner and spouse). Under the Pre-Rule guidance, business owners could not participate unless they also had common law employees covered by the AHP. Under the Final Rule a working owner could participate if they work on average at least 20 hours per week or 80 hours per month in the business enterprise or have income from the trade or business at least equal to the cost of coverage under the AHP.

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DC District Court Weighs In

Eleven states and the District of Columbia filed suit against the DOL alleging that the final AHP Rules are unlawful under the Administrative Procedures Act (“APA”). The APA regulates the process by which the agencies, including the DOL, make rules. In this particular case, the plaintiffs argued that the DOL’s definition of “employer” in the AHP rules extended beyond the authority granted to it by Congress in ERISA, which violates the APA. The Court agreed—noting that the AHP rules, which broadened the definition of “bona fide association” and also allowed working owners without employees to participate in plans maintained by the expanded bona fide associations-- scrapped ERISA’s careful statutory scheme that focuses on employee benefit plans and the inherent employment relationship at the core of such plans. It further noted that the AHP Rules were an “end-run around the ACA”. The Court vacated the Final Rule bona fide association definition and the

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working owner provision rules and then sent the rule back to the DOL to assess what parts of the final rule are severable.

The DOL, of course, has a right to appeal. In this regard, the DOL issued a set of FAQs addressing the ruling, including its potential impact on currently covered individuals. With regard to an appeal, the DOL noted as follows:

Will the Department appeal the decision?

We disagree with the District Court’s ruling and are considering all available options in consultation with the Department of Justice. The Administration will continue to fight for sole proprietors and small businesses so that they can have the freedom to band together to obtain more affordable, quality healthcare coverage.

If an appeal is filed, there will likely be a stay of the holding pending the appeal and there may not be final resolution for some time.

Regardless of whether the DOL appeals or not, the future of AHPs founded and maintained based solely on the new rules is uncertain at best. Those who were considering establishing a new association based solely on the new rules (a New Rule AHP) will likely rethink moving forward until there is final resolution. Those that have already established a New Rule AHP are in a much more precarious position.

States have significant flexibility to regulate the insurance market in their state and some may still afford the New Rule AHPs established in or covering individuals in their state large group market treatment despite the court’s holding; however, such treatment may not be too beneficial if federal law remains consistent with the court decision.

Also, the court ruling reinforces the status of Pre-Rule AHPs established under the bona fide association rules in effect prior to the New Rule. This path is limited because the association will not be bona fide under the prior rules unless there is a common employment or industry connection among the members and the primary purpose of the association is other than to provide health coverage to its members. Also, working owners would not be permitted to participate in a bona fide association health plan.

The Court’s Reasoning

At the core of the DC court’s holding was ERISA’s statutory definition of employer, which it defines as an employer or a group or association of employers that “act in the interests of an employer.

The court noted that because ERISA plans arise from a special relationship between employers and employees, “a plan is not an ERISA plan unless the entity providing benefits and the individuals receiving the benefits demonstrate the ‘economic or representational’ ties or protective ‘nexus’ that characterizes an employment relationship.”

Ultimately, the court essentially held that the Final Rule AHP definition failed to identify an organization that characterizes an employment relationship.

In making its decision, the court analyzed each of the 3 prongs of the Pre-Rule AHP bona fide association definition: purpose, commonality of interest and control.

First, the court held that the primary purpose of the association under the Final Rule could be to provide benefits to its members and that merely forming to provide benefits was not enough to act in the interest of employers.

The court noted that the Final Rule required that there be one substantial business purpose other than the provision of benefits; however, the court further noted that this did not set any meaningful limits on the character and activities of an association.

CONCLUSION

At this point, every AHP should examine its status under the Pre-Rule AHP analysis. New Rule AHPs will need to carefully watch how this case progresses and, absent an appeal and reversal, likely restructure their operations. Even Pre-Rule AHPs can expect additional scrutiny by many state authorities seeking to evaluate their status under the old bona fide association test (e.g., control requirement).

Even the Final Rule safe harbor describing “substantial purpose”, which indicated that the other purpose is substantial if the association would be viable in the absence of the health plan, is just that- a safe harbor, suggesting that some associations would still meet the purpose test if they didn’t meet the safe harbor.

Second, the court rejected the notion that an association of employers connected solely by geography would be acting in the common “interests” of employers, noting that that there was nothing “intrinsic in common geography that would generate the types of economic or reputational ties that courts have deemed essential for a plan to be covered by ERISA.” Finally, the court noted that the control requirement did reflect an employment connect but that the “control test alone, however, does not mean that the employer members are united in interest.”

Given the above analysis, it is not surprising—in light of the court’s focus on employment connection-- that the court also rejected the Final AHP Rule’s working owner provision, noting that Congress did not intend for working owners without employees to be included within ERISA.

MAY 2019

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Transparency – A Clear and AlmostPresent Danger?

By Ron Peck

T T

ransparency in healthcare, and pricing of care, has been a hot topic – especially for those in our industry – for quite some time. That flame has been fed recently by an increase in regulatory and legislative attention. About one year ago, a bipartisan group of Senators unveiled their intention to launch a healthcare price and quality information transparency initiative, and the feedback has been all over the map.

I recently published a blog post regarding failed attempts at transparency in retail.

The two examples I shared therein I’ve also described below. The response I received was passionate – from support, to opposition; it seems as if everyone feels “something” when it comes to “transparency.”

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Before you read any further, let me state clearly and unequivocally that I am a staunch supporter of transparency – as a concept, as well as a tool to be used in our never-ending quest to minimize costs while maximizing benefits in health coverage and care. Like so many other useful tools, however, transparency in overabundance or without other key ingredients will not only fail to move the needle (as it relates to the cost of health care) but may result in an increase in spending.

To get you up to speed, the examples of transparency (gone wrong) that I love to share are as follows –

Exhibit A: JC Penney’s.

Recall in 2011, when JC Penney’s made what most experts have deemed a catastrophic, strategic mistake, regarding its pricing strategy. What horrific miscalculation did the retail giant make? It replaced “sales” (a/k/a “discount”) and “coupons” with everyday low prices.

JC Penney’s told consumers: “Hey! We aren’t going to bamboozle you by inflating prices, and then throwing arbitrary discounts at you.

Instead, we’ll offer you fair prices without any games.” This was one example where transparency failed miserably.

Exhibit B: Payless. If you want to buy some sneakers from Payless, you’d better do it soon. Payless ShoeSource, Inc. is closing for good. I’ve never shopped at Payless myself, but they hold a special place in my heart by virtue of something they did in November of 2018. Yes indeed; it was only a few months ago that they supported my theory that transparency without quality awareness is not only useless, but potentially dangerous. Payless opened a fake luxury store, dubbed “Palessi.” At this “boutique,” they displayed shoes (for which they normally charge $20 at their Payless stores), with price tags that ranged up to $600+ (a 1,800% markup).

Shoppers saw the higher prices and assumed that – if it costs more, it must be better.

Another example of transparency that not only fails to reduce spending, but increases it, is also tethered to healthcare. Unlike many other expenses about which we industry members are dealing, (expenses for which the lion’s share of the cost is borne by the benefit plan and as such, the patient has no “skin in the game”), one example of healthcare costs for which plan participants are fully responsible to pay is over the counter pain medication.

Enter any retail pharmacy and you’ll see brand name medication, and identical store brand drugs, sharing shelf space. The store brand is clearly marked with a lower price than the brand name drug – who’s price is also clearly labeled. Additionally, both medications list the ingredients on the package; identical ingredients and percentages.

MAY 2019

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This is the ultimate cross-roads between healthcare, patient skin in the game, and transparency. So, of course people buy the store brand drug – it’s the same drug, costs less, and the patient is financially responsible to pay the price.

Transparency works, right? Wrong!

People overwhelmingly purchase the branded drug.

I’ve said it before, and I’ll say it again – people want the most expensive option.

People don’t want to pay for the most expensive option, but they want to have the most expensive option.

Look no further than the credit crisis bankrupting so many Americans. Credit cards made it so easy for people to buy more than they could afford, because they made it “feel” like it was someone else’s money.

Sound familiar?

People inherently want the most expensive option, because they are convinced price is an indicator of quality.

Additionally, luxury purchases are a status symbol.

So we (human beings) want the best. We assume the most expensive option must be the best option – ever hear someone say “you get what you pay

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for?” Additionally, we want other people to think we have the best (a/k/a the most expensive) stuff as well. The only roadblock is that we don’t always have enough money with which to buy the best (most expensive) stuff.

Drat.

But, when someone gives me a magical “card” and that “card” grants me access to deeper pockets than my own, I can now use that “card” to buy the best (a/k/a most expensive) stuff. The fact that I will tomorrow be asked to pay for that “stuff” later (either in the form of credit card payments … or … [assuming my metaphor didn’t go over your head] insurance premiums) won’t stop me from running up an unaffordable bill today.

Transparency did nothing to stop people from getting themselves into credit card debt. Transparency will do nothing to curb people’s health care spending, and I actually foresee it making things worse. Consider the proposals to have drug prices on TV advertisements.

I’m watching the Patriots beat another opponent, when a commercial for Viagra pops up; (pun intended). The commercial ends by telling me the cost of the drug is $400. Next, a commercial for Cialis appears, and tells me that drug costs $600.

Well – don’t I and my spouse deserve the best? Cialis it is!

I’d like to say that I am the first to spot these phenomena, but I’m not. In 2016, the Journal of the American Medical Association published a study1 that supports my assertion that transparency on its own doesn’t lead to savings. In this study, two employers offered web-based tools to their employee plan participants, providing them with “transparent” healthcare prices.

It empowered these participants to compare prices and “shop around” for their care. The result? The tools were rarely accessed, despite the introduction of high deductibles. In fact, as a side note, the high deductibles caused more participants to seek more costly care, in an effort to burn through the out of pocket maximum as quickly as possible.

Additionally, for the reasons already discussed earlier, researchers discovered that the participants with access to pricing ended up picking the more expensive options, more often than participants without access to pricing.

This report supports my theory above that patients always apply the type of rational behavior upon which traditional economic theory is based, especially when they are shopping for health care.

Rational behavior and economics would anticipate that a consumer will buy a less costly option unless the more expensive option includes additional features worth the added expense to the consumer.

That attitude, however, fails to take into account people’s need to “be seen” as affluent (and flaunt non-existent

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wealth), as well as their unfounded belief that if something costs more it must be better, and is worth the added expense. Consider, for instance, the blind taste tests where a person is given two glasses of wine, and they are told one is a $100 glass of wine, and the other is a $10 glass of wine. Without fail, the drinker claims the more expensive wine is better tasting – even though (you guessed it) the wine in the glasses is the same wine!

Looking at the impact of transparency on a broader scale, Professor David De Cremer of Cambridge University’s Judge Business School, published a fascinating article about transparency, and when it backfires.2 In it, he lists four negative side effects of transparency.

He discusses how it: creates a culture of blame (people become hyper-focused on what they are seeing and reacting to it, rather than identify bigger picture issues, causes for those issues, and solutions); increases distrust (those whose work is constantly under the microscope feel micro-managed and unable to take risks); increases cheating (those who are constantly being watched begin to look for, and take advantage of, any opportunity to game the system when the albeit rare opportunity arises); and sparks resistance (people refuse to do any work that will be hyper-examined, protesting the lack of faith)..

Finally, let’s not lose sight of the fact that not everyone agrees on what transparency in healthcare even is. Consider the Federation of American Hospitals which wrote to Congress that: “ …the healthcare price transparency initiative should focus on sharing out-of-pocket costs.

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Patients undergoing the same procedure could end up paying different amounts based on their health plan. Therefore, out-of-pocket cost information is more valuable to consumers … effective price transparency should involve the release of information that is clear, accessible, and actionable so that consumers easily can determine the cost of their premiums, deductibles, copayments, and non-covered services (out-of-pocket costs), prior to purchasing health insurance coverage as well as receiving medical services.” Yikes.

References 1 https://jamanetwork.com/journals/jama/ fullarticle/2518264 2 https://hbr.org/2016/07/when-transparency-backfires-and-how-to-prevent-it 3 https://www.kevinmd.com/

Dr. Niran S. Al-Agba, MD posted on the MedPage Today Professional “KevinMD Blog”3 – “Comprehensive transparency is only relevant if packaged in a reliable comparative context. Information regarding cost, value, and effectiveness should be readily accessible to patients enabling them to make meaningful comparisons across providers and specialists.

However, choices must be incentivized properly, so they are not only empowered but also motivated to use the information to make informed choices.” I totally agree.

Unless and until reliable quality measurements are included in the transparency discussion, and that information is delivered in such a way that the consumer will understand and appreciate that price has no relationship with quality, I fear “price transparency” on its own is not only a step too short, but potentially a step backwards, in Palessi boots.

Ron E. Peck has been a member of The Phia Group’s team since 2006. As an ERISA attorney with The Phia Group, Ron has been an innovative force in the drafting of improved benefit plan provisions, handled complex subrogation and third-party recovery disputes, healthcare direct contracting and spearheaded efforts to combat the steadily increasing costs of healthcare.

Attorney Peck obtained his Juris Doctorate from Rutgers University School of Law and earned his Bachelor of Science degree in Policy Analysis and Management from Cornell University. Attorney Peck now serves as The Phia Group’s Executive Vice President and General Counsel and is also a dedicated member of SIIA’s Government Relations Committee.

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Battling a Silent and Deadly Epidemic

Nearly 40 million Americans suffer from kidney disease, which often goes undetected for years and can lead to costly claims for self-insured plans.

While two leading players have been castigated for cornering the dialysis market and squelching competition, experts suggest early detection and carve-outs to improve outcomes and contain costs.

By Bruce Shutan

T T

he high cost of kidney dialysis appears to be reaching a tipping point of frustration and finger pointing across political, social and economic landscapes, including the self-insured marketplace. Clinics specializing in these treatments have been demonized alongside big pharma and the BUCAHs, accused of placing profits ahead of patients. But they have lobbied hard to argue their worth.

In California, for instance, an aggressive TV advertising campaign convinced voters to reject a 2018 mid-term election ballot initiative that would have required dialysis clinics to refund patients and payers revenue above 115% of the cost of direct care and health improvements. Clinic operators argued that the measure would have nearly choked off access to life-saving treatment.

Kidney disease is known as a silent epidemic “because most people don’t know they have chronic kidney disease until it gets into late stages, where it becomes very difficult to reverse the progression,� according to Lisa Moody, president and CEO of Renalogic, whose methodology and services support different approaches for reimbursing on dialysis claims.

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there’s always a possibility that “lurking in the weeds can be that one case involving an employee who’s not showing any symptoms but may have diabetes or prediabetes or high blood pressure.”

Rick Garrison

The price-tag associated with kidney disease has indeed skyrocketed with virtually no end in sight. Roughly a dozen monthly in-center hemodialysis treatments cost $50,000 or more, according to Sam Sletager, regional VP of sales at Zelis Healthcare, which helps payer clients manage the cost of kidney dialysis treatments.

Many of his referrals now exceed $80,000 per month with some well over $100,000.

The average billed charges per-treatment rate is $6,000 to $7,000, whereas he says it used to be around $2,000 to $3,000 less than 10 years ago.

Rising treatment costs The overall cost of renal dialysis is rising about 10% to 15% a year, reports Rick Garrison, president of Specialty Care Management, whose specialty is managing renal disease and end-stage renal disease.

“We’re finding that the average renal dialysis case can be now anywhere between $800,000 to $1 million on the low side, which without appropriate measures put into action, can be a killer to a small to midsize firm or even a large employer group,” he says, adding to that list the health plan’s reinsurer.

“We actually had a case that was $3 million annually down in Louisiana.”

When underwriting risk for stop-loss coverage for what appears to be a relatively healthy population, he says

Health care’s new whipping post The kidney dialysis sector has been demonized because “there just isn’t enough diversification, and that really holds true for kind of any area in healthcare,” Moody explains. There are only two main players, DaVita Inc. and Fresenius Medical Care. Critics consider them a duopoly whose Lisa Moody crushing domination of the market has created an unfair playing field in nearly every region of the U.S. Moody says these firms fly under the antitrust radar.

The fact is that there’s no focus on reducing the cost of kidney disease because these two companies, along with BUCAHs and PBMs that also play a role, are publicly traded and beholden to their shareholders, Moody laments.

Having cornered the market on dialysis, these providers aren’t inclined to do any direct contracting, she protests. “We’ve seen Blues contracts terminated because the providers just aren’t being reasonable about the rates that they negotiate with,” she says, noting there’s no blanket contract available to groups with a national company.

Both DaVita Inc. and Fresenius Medical Care declined an opportunity to respond to her comments.

Sletager believes that national and larger regional BUCAH networks also have proven to be obstacles to savings by not allowing employers to carve out services such as dialysis. Kidney dialysis has become a financial burden because many groups that leased smaller networks are now leasing BUCAH networks, he says.

“They’re based on contract language which many of them don’t even know they actually signed up for as part of the administrative agreement with their TPA,” he adds. “They’re bound to a PPO contract that doesn’t allow a carve-out, so they’re just stuck paying whatever the contract agreement is.”

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Roughly 60% of patients with comorbidity factors end up developing chronic kidney disease in low stages without even knowing it, Moody reports. “They don’t recognize, or are even informed by their PCPs, how their health and comorbid conditions are exacerbating their kidneys. That is just not something that gets focused on until it becomes too debilitating,” she observes.

The kidney disease management crisis isn’t lost on the federal government, which is developing a new payment approach for treating nearly 40 million Americans with kidney disease. In addition, the Department of Health and Human Services has sought to make more kidneys available for transplant.

That effort includes wearable and implantable artificial kidneys.

Moody cites advances in kidney transplantation, as well as use of artificial kidneys and wearable packs, as hopeful signs that innovation and technology will help mitigate costs and improve quality of life.

Preventive measures Meanwhile, the key to cost management is early identification of chronic kidney disease patients before they reach the end-stage renal disease and must go on dialysis, Sletager observes. He says most people who suffer from chronic kidney disease, which has never been a focus of the health care space, also have comorbid conditions such as hypertension, high blood pressure or cholesterol and diabetes.

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Her own husband of two years is a diabetic without other comorbid conditions that generally accompany that disease at age 41, so this issue obviously hits close to home. Without family support or health coaching to maintain a proper diet and exercise regimen, as well as stabilize blood sugars, Moody cautions that unmanaged diabetes will turn into kidney disease.

“It’s critical to identify those patients that may not know they have this disease and educate them about why it’s important to follow healthy behaviors and set goals for themselves to try to keep [chronic kidney disease] at bay,” she suggests.

Moody’s firm, formerly known as Dialysis Cost Containment, was founded in 2002 by her mother, Phyllis Langley, who noticed a serious gap in the marketplace with regard to managing kidney disease. When Moody came on board as an employee, her experience designing employee benefit plans and managing health care claims came in very handy. She took over the family business in 2008 when her mother retired and brought a proactive early intervention approach more upstream into the self-insured marketplace.

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The challenge is that there hasn’t been “a huge focus on prevention” among selffunded groups, she notes, while the fullyinsured model is more supportive of that approach. Much of what’s done in terms of cost containment in the self-funded space is more about risk management, she adds, though noticing a shift toward prevention over the past two years.

That’s somewhat understandable knowing that just one in 10,000 patients in any given employee population is on dialysis, Moody says. But self-insured employers risk bankruptcy from just one dialysis claim, she observes, which reinforces her argument to be proactive.

Keeping end-stage renal disease at bay can save millions of dollars on a claim.

Another issue worth noting is patients who are discharged from the hospital because of a diabetic foot ulcer or other episodic event no longer receive care after they’re discharged and the case manager is done getting them back on track, she adds.

Horror stories Sometimes the enemy is within the health care system and goes undetected.

Mark Wilcox, CEO and founder of Wellness Partners, has noticed that as much as one-third of the cases his firm manages are actually caused by prescribed medicine “and the doctor is not even checking kidney function to see what the impact is.”

But that phenomenon, which he describes as “shocking,” is just one of several horror stories Wilcox has encountered from the trench warfare of kidney dialysis management. He recalls one such example from 2012

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when, unable to stop the progression of kidney disease in a patient from one of his employer groups served by Blue Cross and Blue Shield of Nebraska (BCBSN), a direct contract was set up for full-treatment dialysis and care at about $9,000 a month.

Those efforts lowered the carrier and employer’s liability on that claim by about $800,000, but it all went sideways when he learned that the Blues plan viewed it as a 15% reduction of income. In a meeting with the carrier’s large group sales manager, as well as several service reps and IT staffers, Wilcox was chewed out for “diminishing the value and quality” of BCBSN and ordered to stop. The PPO operations and marketing people weren’t told that the arrangement was approved by the carrier’s underwriting department, he says. BCBSN later blacklisted his company to employer clients for engaging in what it considered illegal and immoral practices.

“What it comes down to is the carriers don’t care whether a claim is paid by the reinsurance carrier or employer in the form of premiums,” opines Wilcox, who says BCBSN pays about $76,000 per month for dialysis. “Either way, it’s revenue to the company.”

A BCBSN spokeswoman notes that “we pay claims for medically necessary and appropriate care” consistent with an agreement the carrier signed with Wellness Partners. She adds that BCBSN “is a steward of our members’ premium dollars.”

Carving out claims By carving dialysis out of the PPO contract, Sletager notes that self-funded plans working with Zelis save an average of more than 90% on billed charges.

Zelis provides dialysis language to its clients enabling them to carefully craft plan document language so that any reference-based price (RBP) chosen to maximize savings is usual, reasonable and customary. Put another way, the methodology used to reimburse providers cannot be arbitrary or capricious, he explains, referencing ERISA guidelines.

There are protections for patients on dialysis that prohibit balance billing by the providers if the member has the right Medicare coverage. Under Medicare’s secondary payer rule, he notes that if the primary insurer’s reimbursement is higher than what Medicare Part B would have paid as the primary insurance source, “then the provider is considered made whole and can’t balance bill the patient.”

Between ERISA and Medicare’s Secondary Payer Act protections, and “based on the components of our reimbursement database,” Sletager says, “we feel that our strategy is about as defensible as you can get.”

competitive provider marketplace. As such, there’s “limited ability to directly negotiate what is considered reasonable up front,” she adds. The danger of using RBP specific to renal dialysis is that “the potential for balance billing is quite large by virtue of high dollar amounts for renal dialysis, Garrison cautions. “The exposure to the patient is only enhanced with reference-based pricing,” he says.

Since the 1970s, anyone diagnosed with end-stage renal disease has been allowed to participate in Medicare, regardless of their age, Garrison points out. His firm helps self-funded entities allow patients access to such care and navigate their way through the federal program.

While the RBP model can help self-insured groups negotiate reasonable rates, Moody says it’s difficult applying it to the dialysis sector in the absence of a

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“But there are many other ways to manage end-stage renal disease, and more so, it’s through preventive measures,” he explains. “When someone has kidney disease, it’s not a fait accompli that you’re going to have end-stage renal disease.

There are many programs that can help either prevent or delay chronic kidney disease.”

Garrison suggests a multifold approach on the front end that includes case management, good plan design and wellness programs, as well as the use of appropriate analytics to better understand each patient population. Another critical step is to “set up a safety net on a prospective basis that would protect the plan from this type of exposure if it came up,” he adds, noting the importance of patient education.

Bruce Shutan is a Los Angeles freelance writer who has closely covered the employee benefits industry for more than 30 years.

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Faith R. Neale, Associate Professor of Risk Management and Insurance at UNC Charlotte, SIEF scholarship recipient Ryan McKellar, SIEF President Heidi Leenay and SIEF Board member Alex Giordano

Self-Insurance Educational Foundation (SIEF) $2,500 scholarship winner

T T

he first time Ryan McKellar set foot on a plane, he chose a destination befitting an aspiring actuary: London, where he visited what he referred to as the “holy ground” of Lloyd’s of London.

“I’ve always been good at math. I enjoyed the classes I’ve taken in statistics and data analytics. My dream is to be an actuary, but I’m also interested in learning about underwriting and risk management,” said Ryan, who said he learned about actuarial science while taking an Advanced Placement (AP) Statistics course in high school.

As this year’s Self-Insurance Educational Foundation (SIEF) $2,500 scholarship winner, Ryan is especially interested in “Big Data,” the art of analyzing extremely large data sets to identify patterns, trends, and associations. “I like looking for the meaning in the numbers, narrowing it down,” he explained.

A Junior majoring in Mathematics for Business with a concentration in Actuarial Sciences at the University of North Carolina, Ryan already is working toward the Associate in Actuarial Science designation and has passed the first exam in Financial Mathematics, a feat he attributes to his self-drive and focus. Given its complexity, “it’s

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not an easy exam to study for,” he explained. He is preparing to take the Society’s Probability exam this March.

Ryan also demonstrated his leadership capabilities by serving as captain of the UNC team that conducted a case study of Swedish furniture retailer IKEA’s risk management program for this year’s Spencer-RIMS Risk Management Challenge.

This 8-month-long competition, cosponsored by the Spencer Educational Foundation and the Risk & Insurance Management Society Inc., gives college students real-world risk management experience by analyzing data and developing a program for an actual company.

Ryan feels his greatest strengths as a leader are his communication skills and being able to delegate while still retaining some responsibilities for himself. Although Ryan’s team did not win the contest, it will be attending the 2019 RIMS Annual Conference & Exhibition in Boston this April to network with risk management professionals and potential employers.

Growing up in a military family in North Carolina, Ryan inherited his work ethic from his father, Charles, who taught him the value of diligence and perseverance. Ryan’s dad, who served as a truck driver during his first tour of duty in the U.S. Army, later attended college to obtain a computer science degree and now works in cyber security and network defense in the U.S. Air Force.

said his family—especially his mom, Lisa McKellar, have been very supportive of his decision to pursue a career as an actuary.

Ryan is the second recipient of the SIEF scholarship, which was introduced in 2018 to encourage college students to pursue careers in the self-insurance industry. Anna Petrides was last year’s scholarship recipient while a Junior at the University of South Carolina’s Darla Moore School of Business majoring in risk management/insurance.

“We are excited to support the selfinsurance industry through the SIEF scholarship fund and hope there will be many more talented students like Ryan to benefit from the program in the future,” said SIEF President Heidi Leenay.

Although his two brothers are following the family tradition—his older brother, Alden, is in the Army, while his younger brother, Charles, recently joined the Marines--Ryan

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MAY 2019

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ENDEAVORS

SIEF TopGolf participants

SIIA ENDEAVORS

S S

IIA held its annual Self-Insured Health Plans Executive Forum March 1820th at the Westin Charlotte in Charlotte, North Carolina. This event brings together senior executives representing key business partners supporting self-insured group health plans, including third party administrators (TPAs), stop-loss carriers/MGUs, brokers/consultants, captive managers and leading service providers, with the objective of promoting improved collaboration in order to grow the self-insurance marketplace in a responsible way.

The event kicked off with the Self-Insurance Educational Foundation’s (SIEF) TopGolf fundraising event. Participants supported the foundation dedicated to ensuring the development of tomorrow’s leaders in the self-insurance/ART industry, all while having a great time.

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ENDEAVORS Prior to the Self-Insured Health Plan Executive Forum’s main educational program was a special mini-program for the SIIA Future Leaders (SFL). SIIA launched the SIIA Future Leaders (SFL) initiative in fall of 2018, designed to encourage talented younger professionals to become involved with the association and the self-insurance industry.

SIEF TopGolf event

The special SFL mini-program sessions included:

• Power 90 Networking, where future leaders participated in a structured, 90-minute networking session.

• Working SIIA - What You Need To Know. Duke Niedringhaus, Senior Vice President of J.W. Terrill, a Marsh & McClennan Company shared his insights with the group on how to “work SIIA” to further their career advancement goals while adding current value to their employer.

If you have Future Leaders in your company that you would like to direct to this initiative, or if you are a future leader yourself, we invite you to join the SIIA Future Leaders LinkedIn Group at www.linkedin.com/groups/12098226. More information on SIIA’s Future Leaders initiative can also be found at www.siia.org.

The Self-Insured Health Plans Executive Forum’s main educational program began with “The Hot Industry Issues Audience Poll” moderated by SIIA President & CEO, Mike Ferguson. Key findings from the survey:

Participates

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ENDEAVORS

How was your company’s financial performance in 2018?

57% - Very Strong 25% - Somewhat Strong 13% - Marginal 0% - Poor 5% - Not sure

What is your outlook of the self-insurance industry over the next 5 years?

Attendees networking in the exhibit hall

47% - Very Positive 42% - Positive 11% - Mixed View 0% - Pessimistic

Biggest single biggest opportunity for the self-insurance industry? #1 - Transparency #2 - Innovation #3 - Resource-based Pricing

Biggest threats to the selfinsurance industry? #1 - Single Payor #2 - Regulation #3 - Government

What best describes your opinion about referenced-based pricing?

32% - True game-changing strategy that is a long-term solution 32% - Mostly positive in the short run, but longer-term is questionable 30% - Mixed short-term effectiveness and uncertain about future viability 2% - Overrated today and not likely to be viable in the future 4% - No opinion

SINGLE PAYOR

Is your company involved with stop-loss captive programs?

62% - Yes 35% - No 42

THE SELF-INSURER

Worried about large claims?

Get our advance funding feature and relax.

Anthem Stop Loss can help protect your cash flow.

Large-dollar medical and prescription drug claims can create havoc with your company’s cash flow. So consider the advance funding option from Anthem Stop Loss. Your company can get reimbursed before payment is released to the health care provider, helping control the funding of your medical plan.

As part of one of the nation’s leading stop loss carriers, our teams are ready from day one to put that size, strength and reputation to work for you.

For Stop Loss that’s safe, secure and surprisingly nimble, visit anthemstoploss.com.

Stop Loss coverage provided by Anthem Life Insurance Company. In New York, coverage provided by Anthem Life and Disability Insurance Company.

112173MUBENASL 12/18

ENDEAVORS Other educational sessions at the SelfInsured Health Plans Executive Forum included: Technology Strategies Shaping Tomorrow’s TPAs - Cheryl Kellond, CEO & Co-Founder of Apostrophe Health and Alex Arnet, Chief Commercial Officer of Lucent Health shared their insights on what successful TPAs of tomorrow will look like.

examples to provide practical advice on how best deal with “Third Wheel” situations.

Beyond Disruptors and Rock Stars – Let’s Talk Execution – presented by Mark Gaunya, Co-Owner and Chief Innovation Officer of Borislow Insurance, Kevin Trokey, Founder of Q4intelligence, Jim Rinere President of CWI Benefits, LLC, and Arlene Cayetano, FLMI, President & CEO, Managing Member of Greymatter Risk Management, LLC. The panel discussed what is going right and where there is room for improvement on how brokers/advisors, TPAs and stop-loss carriers work together in serving the interests of plan sponsors.

TPA Best Practices – Peer Review Session, an interactive session with Ron Dewsnup, President of Allegiance.

Stop-Loss Carrier/MGU Best Practices – Peer Review Session, an interactive session with Pat Campola of Windsor Strategy Partners, Inc. There was also an interactive “Audience Choice” Hot Topic Open Discussion.

Preparing Employers for Stop-Loss Captive Programs – Joe DiBella, EVP - Managing Director, Health & Benefits Practice for Conner Strong & Buckelew and Jesse Crary, Attorney at Primer Piper Eggleston & Cramer featured broker/advisor and legal perspectives on how employers should prepare and position themselves to optimize the upside of participating in a group medical stop-loss program.

Other upcoming SIIA Events Self-Insured Workers’ Compensation Executive Forum May 7-9, 2019 • The Westin Nashville • Nashville, TN SIIA’s Annual Self-Insured Workers’ Compensation Executive Forum is the country’s premier association sponsored conference dedicated exclusively to self-insured Workers’ Compensation. In addition to a strong educational program focusing on such

Self-Insurance Claims Classroom – an interactive session with Adam V. Russo, Esq., CEO of The Phia Group, LLC. Making it Work with the Third Wheel – Legacy Vendor Arrangements – presented by Brian Connelly, Director of Product Development & Strategy for Gilsbar, LLC, Jonathan Logan, President of Logan & Associates of Louisiana, Inc., Dan Myers, Vice President of Client and Business Development for EBMS, and Erin Weenum, Chief Strategist, Employee Benefits of Leavitt Group. The panel discussed real world

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Moderator Jonathan Socko, Joe DiBella and Jesse Crary

ENDEAVORS SIIA DC Fly-In May 22, 2019 • Washington, DC SIIA’s annual DC Fly-In provides a unique opportunity for SIIA members across the country to discuss important issues to the self-insurance and alternative risk industry with their elected representatives in Washington, D.C. This is a chance to discuss with policymakers the issues facing the self-insurance industry, while allowing participants to make important connections. The more SIIA members we have in attendance, the more of an impact we can make. So join us, tell your story and talk about the issues you face.

39th Annual National Educational Conference & Expo September 30 - October 2, 2019 • Marriott Marquis • San Francisco, CA

Adam Russo topics as risk management strategies and innovative ways to prevent and manage loss, this event will offer tremendous networking opportunities that are specifically designed to help you strengthen your business relationships within the self-insured/ alternative risk transfer industry.

The SIIA National Conference & Expo is the world’s largest event focused exclusively on the self-insurance/captive insurance marketplace and typically attracts more than 1,700 attendees from around the United States and from a growing number of countries around the world.

Registrants will enjoy a cutting-edge educational program combined with unique networking opportunities, and a world-class tradeshow of industry product and service providers guaranteed to provide exceptional value in four fast-paced, activity-packed days.

International Conference May 14-16, 2019 • JW Marriott • Miami, FL The goal of this event is to promote global networking, the exchange of selfinsurance and alternative risk strategies market knowledge, as well as effective emerging global health management trends.

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What are clients saying about our EmCap® program?

“You have become a key partner in our company’s attempt to fix what’s broken in our healthcare system.”

- CFO, Commercial Construction Company

“Our clients have grown accustomed to Berkley’s high level of customer service.”

- Broker

“The most significant advancement regarding true cost containment we’ve seen in years.”

- President, Group Captive Member Company

“EmCap has allowed us to take far more control of our health insurance costs than can be done in the fully insured market.”

- President, Group Captive Member Company

“With EmCap, our company has been able to control pricing volatility that we would have faced with traditional Stop Loss.”

- HR Executive, Group Captive Member Company

People are talking about Medical Stop Loss Group Captive solutions from Berkley Accident and Health. Our innovative EmCap® program can help employers with self-funded employee health plans to enjoy greater transparency, control, and stability.

Let’s discuss how we can help your clients reach their goals.

This example is illustrative only and not indicative of actual past or future results. Stop Loss is underwritten by Berkley Life and Health Insurance Company, a member company of W. R. Berkley Corporation and rated A+ (Superior) by A.M. Best, and involves the formation of a group captive insurance program that involves other employers and requires other legal entities. Berkley and its affiliates do not provide tax, legal, or regulatory advice concerning EmCap. You should seek appropriate tax, legal, regulatory, or other counsel regarding the EmCap program, including, but not limited to, counsel in the areas of ERISA, multiple employer welfare arrangements (MEWAs), taxation, and captives. EmCap is not available to all employers or in all states.

Stop Loss | Group Captives | Managed Care | Specialty Accident ©2017 Berkley Accident and Health, Hamilton Square, NJ 08690. All rights reserved. BAH AD2017-09 7/17

www.BerkleyAH.com

NEWS

NEWS FROM SIIA MEMBERS SIIA Diamond, Gold & Silver Member News SIIA Diamond, Gold, and Silver member companies are leaders in the self-insurance/captive insurance marketplace. Provided below are news highlights from these upgraded members. News items should be submitted to membernews@siia.org. All submissions are subject to editing for brevity. Information about upgraded memberships can be accessed online at www.siia.org. For immediate assistance, please contact Jennifer Ivy at jivy@siia.org. If you would like to learn more about the benefits of SIIA’s premium memberships, please contact Jennifer Ivy at jivy@siia.org.

MAY 2019 47

NEWS

Diamond Members Peter Mullen Named Artex Chief Executive Officer Artex is pleased to announce that Peter Mullen has re-joined the alternative risk management solutions provider as Chief Executive Officer, with David McManus assuming the new role of Chairman.

Peter, David and Artex North America President, Jennifer Gallagher, founded Artex in 1997. Peter spent more than 20 years with Artex and its parent company, Gallagher, before becoming CEO of Aon Captive & Insurance Management eight years ago. In 2016, Peter topped Captive Review magazine’s Power 50, a ranking of the most influential individuals in the captive insurance industry.

“I am thrilled to welcome Peter back to Artex and excited for what the future holds under his leadership,” states David McManus. “Innovation is at the core of his talents and is the foundation of our company. I’m confident that this innovation, together with Peter’s fresh perspective and energy, will drive Artex to even greater success in the years to come.”

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About Artex Artex provides a full range of alternative risk management solutions, customized for our clients’ individual challenges and opportunities. Powered by independent thought and an innovative approach, we empower our clients and partners to make educated risk management decisions with confidence.

Licensed in 32 jurisdictions around the globe, we are critically resourced to supply any alternative risk need. Artex is a solutions company, and we invite you to learn more about our breadth of services and depth of talent at www. artexrisk.com.

Stop Loss Insurance Services Inc., an AmWINS Group Company, Adds Certified Nurse Case Managers to its Professional Team Worcester, MA -- Stop Loss Insurance Services Inc., (“SLIS”), an AmWINS Group company, announced an important expansion of its professional services for brokers, consultants and their self-funded clients with the addition of a team of certified registered nurse case managers.

WANT TO IMPROVE THE HEALTH AND PRODUCTIVITY OF YOUR EMPLOYEES? YOU’LL NEED MORE THAN A WELLNESS PROGRAM AND SOME HEALTH DATA. You need a comprehensive view of workforce health & the systems and expertise to turn data into action.

YOU NEED IN-SIGHT FROM IPMG. In-Sight provides a single, integrated platform for all employee health, injury, workers’ compensation, absence and engagement activity — and the specialized teams that use your data to proactively minimize risks and promote productivity.

BECAUSE THRIVING COMPANIES RELY ON HEALTHY EMPLOYEES. JEFF WEBER • 314-293-9707 • IPMG.COM/IN-SIGHT

NEWS

Services provided by the registered nurse case managers will include:

• Large claim review and prediction of possible future claim occurrence based on prior claims history

• Information and education on disease states, treatment protocols and trends

• Advocacy with stop loss carrier staff for best case underwriting and possible reduction or removal of lasers

• Claim review and cost containment consultation

• Assistance with high claimant drugs and other cost savings

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THE SELF-INSURER

“SLIS has offered expertise in the self-funding industry for over 25 years, and our new nurse case review offers our clients additional education around stop loss and can provide insight into large claims, lasers, and potential cost reductions,” said Gerald Gates, President of SLIS. The new nurse case review capability adds to SLIS’ already extensive suite of products and services.

“This new program gives brokers and consultants the ability to educate their clients around stop loss underwriting and self-funding as a whole, while predicting risk and ultimately possible savings,” said Rebecca Bocek, President-National Sales Director of SLIS.

About Stop Loss Insurance Services Stop Loss Insurance Services (SLIS), an AmWINS Group Company, provides brokers, consultants and TPA’s a competitive edge by serving as a time-saving resource that is singularly focused on self-funded benefits solutions. Benefit professionals become more productive and successful in their core business by putting SLIS to work in this highly specialized segment of their practice. With more than 25 years of focused experience in self-funding, SLIS is known for deep expertise, strong market relationships and handson service, backed by the security of AmWINS Group, the largest insurance wholesaler in the U.S. Visit stoploss. amwins.com.

NEWS About AmWINS Group, Inc. AmWINS Group, Inc. is the largest independent wholesale distributor of specialty insurance products in the United States, dedicated to serving retail insurance agents by providing property and casualty products, specialty group benefit products and administrative services.

Based in Charlotte, N.C., the company operates through more than 115 offices globally and handles premium placements in excess of $15.3 billion dollars annually. Visit www.amwins.com.

Sun Life and Maxwell Health Launch New Digital Benefits Platform to Enhance Employee Enrollment and Ease Employer Administrative Burdens WELLESLEY, Mass. -- Sun Life and Maxwell Health have launched a combined benefits technology solution, providing employers and their employees with an intuitive digital benefits experience.

Not just an annual enrollment tool, the platform is a 24/7 benefits and HR command center that makes it easy for members and HR teams to access and manage employee benefits year-round. In addition to supporting a complete portfolio of Sun Life benefits, the new “Sun Life + Maxwell Health” platform enrolls medical insurance and includes distinct advantages for brokers and employers that result in less time spent on manual administrative tasks.

Sun Life acquired Maxwell Health in 2018 with aligned goals of helping employers and their employees achieve financial security and access the right benefits to live healthier, more productive lives. As an offering from one company, the Sun Life + Maxwell Health platform can provide a faster, simpler, more integrated experience than other benefits administration platforms.

“We believe in meeting clients where they are,” said Vinay Gidwaney, head of Maxwell Health. “Employers are looking for the time savings and additional employee engagement that comes from a digital benefits experience, plus dedicated technology support year-round. Offering their suite of Sun Life benefits within the enhanced Maxwell experience allows employers to administer the benefits enrollment process

in an efficient, paperless way, and at the same time offer employees the support and education they need to make the right benefits decisions and cover the financial gaps in their insurance.”

In a recent Sun Life broker survey, 32 percent of brokers said the most difficult part of the benefits platform discussion with their employer clients is effectively explaining how the platform can alleviate and integrate administrative tasks and processes. Since the Sun Life + Maxwell Health platform is working in real time throughout the year, HR administrators have access to a comprehensive benefits solution that reduces time spent on burdensome tasks and allows them to focus on adding more business value.

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51

Your

high expectations

Our

expert capabilities

Extra

peace of mind

We’ve got your back. Four words that anyone seeking to self-fund healthcare benefits needs to believe, particularly when contemplating the financial risks associated with catastrophic medical events.

That’s why we’re firm believers at Swiss Re Corporate Solutions in building strong relationships, understanding exactly what our partners expect of us, and creating innovative ways of fulfilling those expectations. By working closely together, we combine our expertise and capabilities with our brokers, payers and advisors to provide enhanced value for your clients – not to mention extra peace of mind.

When it comes to employer stop loss solutions, now, more than ever, we’ve got your back.

We’re smarter together.

Corporatesolutions.swissre.com/esl Insurance products underwritten by Westport Insurance Corporations and American Specialty Insurance Company. © Swiss Re 2018. All rights reserved.

NEWS

Key differentiators of the Sun Life + Maxwell Health offering include

• Full-service client implementation – Not an industry norm, full-service means less work for brokers and a dramatically shorter time to onboard new employer clients to the technology. According to a recent study by SelectHub, technology implementation is the biggest concern among HR decision makers;

• Streamlined data exchange – As a combined offering, the platform consolidates touchpoints for data intake and onboarding, streamlining the electronic data interface/exchange (EDI/EDX) with the employers’ medical carrier and other coverage providers;

• Real-time data – Since EDI is ongoing, employee data is kept up-to-date, accurate and accessible in real-time, allowing employers to better assess plan design and benefit offerings;

• Automation of HR tasks – The platform centralizes HR functions, handling tasks such as Evidence of Insurability (EOI) for enrollment, and ongoing eligibility management; and

• Easier payment and billing – One combined bill for the Maxwell platform and Sun Life coverages simplifies the payment process.

The platform allows consumers to access and review their benefits portfolio any time of the year through a web-based portal or the Maxwell Health mobile app, helping them fully utilize the value of their benefits package.

“In the U.S., much of the population is underinsured, and this results in burdensome out-of-pocket spending for healthcare,” said Joi Tillman, vice president of Voluntary Benefits at Sun Life Financial U.S. “It is vital to help employees approach their benefits decisions holistically. Choosing the right insurance to supplement high-deductible health plans with voluntary coverage such as critical illness and accident insurance can provide much-needed financial protection. We are excited to offer this new platform that provides a seamless decision support and enrollment experience for consumers.

Members can expect more innovative touchpoints as the platform continually evolves, as early as the 2019 enrollment season.

“A huge additional benefit for the Sun Life family is Maxwell Health’s talent, which gives us the edge in addressing brokers’ and employers’ top concerns in the insurtech space, such as advanced, data-driven solutions for underwriting and claims processing,” added Tillman.

“With Maxwell, we’ve gained a center of innovation that we will leverage to advance Sun Life’s digital capabilities throughout the company.”

The Sun Life + Maxwell Health platform supports products from any employerchosen insurance provider and is available for quoting by brokers April 1 for July 1 effective dates.

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NEWS Clients already using Maxwell’s direct platform will continue to do so and access the comprehensive benefits experience they already enjoy.

About Sun Life Financial Sun Life Financial is a leading international financial services organization providing a diverse range of insurance, wealth and asset management solutions to individuals and corporate Clients. Sun Life Financial has operations in a number of markets worldwide, including Canada, the United States, the United Kingdom, Ireland, Hong Kong, the Philippines, Japan, Indonesia, India, China, Australia, Singapore, Vietnam, Malaysia and Bermuda. As of December 31, 2018, Sun Life Financial had total assets under management of $951 billion. For more information, please visit www.sunlife.com.

vision, voluntary and medical stoploss. Sun Life employs approximately 6,000 people in its U.S insurance and asset management businesses. Group Insurance policies are issued by Sun Life Assurance Company of Canada (Wellesley Hills, Mass.) and Sun Life and Health Insurance Company (U.S.) (Lansing, Mich.). Contact Devon Fernald at 781-416-7151, Devon. portney.fernald@sunlife.com and visit www.sunlife.com/us.

In the United States, Sun Life Financial is one of the largest group benefits providers, serving more than 60,000 employers in small, medium and large workplaces across the country. Sun Life’s broad portfolio of insurance products and services in the U.S. includes disability, absence management, life, dental,

Artex provides a full range of alternative risk management solutions, customized for our clients’ individual challenges and opportunities. Powered by independent thought and an innovative approach, we empower our clients and partners to make educated risk management decisions with confidence.

Operating in over 30 domiciles and in more than 15 offices internationally, we have the proven capacity to supply any alternative risk need. For more information, please contact us at:

Stop-Loss Captives

Single-Parent Captives

Enterprise Risk Captives

Rent-a-Captive and Program Solutions

E: artexinfo@artexrisk.com T: 630.694.5050 W: artexrisk.com

Group and Association Captives

Bermuda Market Access

PROUD TO BE A DIAMOND MEMBER OF SIIA 29343B

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®

NEWS About Maxwell Health Maxwell’s mission is to make better health and financial security possible for all Americans by simplifying benefits and insurance. Maxwell Health is a marketplace that empowers consultants and employers to offer the best benefits to employees, helping them achieve better health and financial security.

The platform automates HR and benefits administration, providing a user-friendly experience for employees to understand, shop for, and use their benefits. Contact Sara Revsin at 814450-5527, sara@maxwellhealth.com and visit maxwellhealth.com.

Gold Members

From the comfort of your own home, you’ll learn more about the importance of AHPs and the impact of the Presidential Executive Order authorizing their development.

About HCAA Education Courses Courses are viewed online and materials can be printed from your browser. Best of all, you can study at your own pace, and then complete your final exam for each course online. All testing is from the course material only. No prior industry knowledge is required!

About HCAA The Health Care Administrators Association (HCAA) is the nation’s most prominent nonprofit trade association supporting the education, networking, resource and advocacy needs of benefit administrators (TPAs), stop loss insurance carriers, managing general underwriters, audit firms, medical managers, technology organizations, pharmacy benefit managers, brokers/agents, human resource managers, plan sponsors and health care consultants. For almost 40 years, HCAA has taken a leadership role in transforming the self-funding industry and increasing the importance of self-funding as an important alternative in the health care delivery systems of our country. Visit www.HCAA.org

HCAA Offers Course in Association Health Plans (AHPs) What are Association Health Plans (AHPs)? How do you set one up? What are the laws that govern them? Can anyone participate in them? HCAA has your answers!

Comprehensive and insightful, this advanced course covers every aspect that experienced life and health insurance brokers and producers, underwriters, actuaries, TPAs, attorneys, accountants and employee benefit specialists and other selffunding industry professionals need to consider when proposing to develop an Association Health Plan. Written by industry expert, Lawrence Thompson, you will find out what you need to know to stay current with developments in this important area of health care.

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NEWS Silver Members CareATC Receives Investment from LLR Partners Philadelphia, PA and Tulsa, OK -- LLR Partners announced it has completed a growth recapitalization of CareATC, Inc., a technology-driven employee population health management company.

The partnership with LLR Partners will support the continued growth of CareATC’s employer-sponsored clinic network and further investment in the Company’s market leading, proprietary population health technology platform.

“Employers are contending with skyrocketing costs of providing healthcare to their employees. At the same time, they’re seeing a decline in the quality and effectiveness of the traditional primary care model,” said Sasank Aleti, Principal at LLR Partners.

“Through robust, easy-to-use technology and high-quality clinical care, CareATC is making primary care more engaging, convenient and personalized, while helping employers achieve superior health outcomes and significantly lower healthcare costs. We’re excited to partner with the strong team at CareATC and invest in the Company’s continued growth.”

Corporations, labor unions and state and local governments across the U.S. rely on CareATC’s shared-site and onsite clinics to provide primary care, preventative health screenings, disease management, referral management and wellness for their employees, helping to improve health outcomes and lower the cost of care. The Company’s purpose-

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THE SELF-INSURER

built, proprietary technology platform also delivers analytics to improve clinical decisionmaking, drive more engaging patient experiences, and give employers better insights into the overall health and wellness of their employee populations.

“CareATC enables employers to deliver accessible and comprehensive primary care, lifestyle coaching and other ancillary healthcare services at little to no cost to their employees with a focus on addressing risk and preventing disease, resulting in a strong return on investment based on improved clinical outcomes,” said Philip Kurtz, CEO of CareATC.

“LLR’s experience with employer-based healthcare and technology will help us empower more businesses with the clinical and technology resources they need to inspire healthier, happier employees while reducing healthcare spend.”

Canaccord Genuity LLC acted as exclusive financial advisor to CareATC. PrayWalker served as legal counsel to CareATC. Morgan Lewis & Bockius LLP served as legal counsel to LLR Partners.

About CareATC, Inc. CareATC, Inc. is a leading innovator in the employer-sponsored healthcare marketplace. By leveraging groundbreaking technology, CareATC offers customized population health management solutions for employers that reduce healthcare costs by promoting health, preventing disease and providing a shorter path to care. CareATC manages more than 150 clients in 35 states and cares for more than 250,000 patients. Accredited by the Accreditation Association for Ambulatory Health Care Inc., CareATC is based in Tulsa, Oklahoma. Visit www. careatc.com.

20 Plus years of industry knowledge, expertise, and unsurpassed service Strength of Liberty Mutual which holds an A rating by both Best and S&P Plan Mirroring availability Disclosure statements no longer required on renewal business Liberty Mutual entered the Employer Stop Loss Market through its acquisition of TRU Services, LLC in April 2017.

Since then we have merged our brands and are issuing

Specific Advance Funding ability with enhanced features for qualified producers

the Liberty Insurance Underwriters Inc. (LIU) Policy.

You will receive the same service you have grown to

152 Conant Street

know of TRU, but with the strength of Liberty Mutual.

2nd Floor Beverly, MA 01915

For more information please contact: Rocko Robinson, Senior VP of Underwriting and Sales

Email: Robert.Robinson01@libertyIU.com

Phone: 978-564-0200 Fax: 978-564-0201 Website: www.truservices.com

NEWS About LLR Partners LLR Partners is a middle market private equity firm committed to creating long-term value by growing its portfolio companies. LLR invests in several industries, with a focus on technology, healthcare and services businesses.

Founded in 1999 and with more than $3.5 billion raised across five funds, LLR is a flexible provider of capital for growth, recapitalizations and buyouts.

Visit www.llrpartners.com.

ACS Benefit Services’ CEO, Kari L. Niblack, Named Outstanding Woman in

management, mentoring, and community and civic engagement.

Ms. Niblack will be honored at an awards gala at the Grandover Resort & Conference Center in Greensboro, NC on April 4, 2019.

“I am truly humbled and honored to have been nominated and selected as a recipient of the 2019 Outstanding Women in Business award. I am privileged to be surrounded by our passionate, innovative employees that make ACS shine and equally thankful to the great teams that I have had the good fortune to lead at the various stages of my career,” says Kari Niblack.

About ACS Benefit Services

Business 2019

ACS Benefit Services, founded in 1982, is a full service, customercentered third party administrator dedicated to creating value and delivering results. ACS emphasizes “high-touch” innovation with a state-ofthe-art product portfolio to positively affect our clients’ bottom line. Contact Kari L. Niblack, JD, SPHR, Chief

Winston-Salem, NC -- ACS Benefit Services, LLC, announced that Kari L. Niblack, Chief Executive Officer, is an award recipient for the Triad Business Journal’s Outstanding Women in Business 2019 award. The awards program recognizes entrepreneurs excelling in areas such as executive leadership, innovation, business

Executive Officer, at (336) 759.2013, KNiblack@ACSbenefitservices.com and visit www.acsbenefitservices.com.

AscellaHealth Provides High-Touch Specialty Pharmacy Solutions, Better Outcomes and Lower Costs BERWYN, PA -- AscellaHealth, a national Pharmacy Benefit Management (PBM) serving self-funded, commercial, Medicare and Medicaid segments, urges patients, families and communities to help raise awareness of prevention and screening as the best defenses against cancer and emphasize the importance of recognizing advances that progress toward effective cancer control.

Ascella points to the complexity and collaboration required in the management of cancer, highlighting the role of its clinical and educational programs to assist members with their prescribed therapy – beginning on day

You can make a lot of progress

with a single checkmark s

ion al revis s o op r p Submit s

report 1 Q w e Revi ards c e m i t e Updat to cut s y wa e Expnlor g spe din eam meeting et

Schedul

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Over 30 years ago, we resolved to help clients save money with advanced PBM solutions, limitless plan customization options and unparalleled experience. Three decades later and we’ve been succeeding in our goal every day since.

At Script Care, we believe that the unique requirements of every client matter and we’re committed to creating a plan that fits your organization.

SCRIPT CARE

Visit www.scriptcare.com to find out more !

Being Powerful.

Being Human.

Being PharmPix.

Partnership is within your grasp.

Discover why PharmPix has been revolutionizing PBM since 2009.

Schedule a personalized demo at www.onearksuite.com or call 404-566-2000.

POWERED BY ONEARK

NEWS one: helping with high deductible/co-insurance costs by utilizing financial assistance programs and partnering with physicians and pharmacists throughout the member’s course of treatment.

“Treating a cancer patient requires a strategic approach to specialty pharmacy that is designed to improve outcomes and care coordination for health plan members,” says Dea Belazi, president and CEO, AscellaHealth. “Our high-touch model includes clinical interventions, adherence counseling, psychosocial assessment, integrated nursing staff, refill reminders and delivery coordination as part of Ascella’s innovative specialty pharmacy strategy.”

In 2019, there will be approximately 140,690 cancer cases diagnosed and about 103,250 cancer deaths among the nation’s oldest individuals.

Ascella’s program is available on a standalone basis, or as part of a full-service pharmacy benefit management option that includes specialty drug management, formulary management services/rebates, competitive pricing and innovative discounting, drug utilization review, case management services/therapy management, clinical review/prior authorization, pharmacy and therapeutic management committee, flexible claims adjudication system, drug information and news reporting.

About AscellaHealth AscellaHealth, a national PBM serving commercial, Medicare and Medicaid segments offers high quality prescription drug management services along with other customizable services, such as carved-out specialty pharmacy services and cost-savings discount programs through its unique and proprietary service that extends discounts on prescription medications to customers more than any other PBM in the industry. Visit www.ascellahealth.com.

Do you aspire to be a published author? Do you have any stories or opinions on the self-insurance and alternati ve risk transfer industry that you would like to share with your peers?

We would like to in vite you to share your insight and submit an article to The Self-Insurer ! distributed in a digital and print format to reach over 10,000 readers around the world. The Self-Insurer has been delivering information to the self-insurance /alternative risk transfer community since 1984 to self-funded employ ers, TPAs, MGUs, reinsurers, stoploss carriers, PBM s and other service providers.

Articles or guideline to Editor Gretchen Grote at ggrote@sipconline.net also has advertising opportunities available. Please contact Shane

Byars at sbyars@sipconline.net for advertising information.

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SIIA 2019 BOARD of directors & committee chair ROSTER

Chairman of the Board*

Directors

Committee Chairs

Adam Russo Chief Executive Officer The Phia Group, LLC Braintree, MA

Kari L. Niblack, JD, SPHR CEO ACS Benefit Services Winston-Salem

President/CEO

Mary Catherine Person President HealthSCOPE Benefits, Inc. Little Rock, AR

CAPTIVE INSURANCE COMMITTEE John R. Capasso, CPA, CGMA, PFS President & CEO Captive Planning Associates, LLC Medford, NJ

Chairman Elect*

Kevin Seelman Senior Vice President Lockton Dunning Benefit CompanyDallas, TX

Mike Ferguson SIIA Simpsonville, SC

David Wilson President Windsor Strategy Partners, LLC Princeton, NJ

Treasurer and Corporate Secretary* Gerald Gates President Stop Loss Insurance Services AmWins Worcester, MA *Also serves as Director

SIEF Board of Directors Nigel Wallbank Chairman Heidi Leenay President Freda Bacon Director

Jeffrey K. Simpson Partner Womble Bond Dickinson (US) LLP Wilmington, DE Robert Tierney President StarLine East Falmouth, MA Peter Robinson Managing Principal Integro Re San Francisco, CA

GOVERNMENT RELATIONS COMMITTEE Steven B. Suter President & CEO Healthcare Management Admtrs., Inc. Bellevue, WA Chair, International Committee Liz D. Mariner Ford Senior Vice President Re-Solutions, a Risk Strategies Company Minneapolis, MN Chair, SIIA Future Leaders Committee Craig Clemente Chief Operating Officer Specialty Care Management Lahaska, PA Chair, TPA Best Practices Task Force Ron Dewsnup President Allegiance Benefit Plan ManagementMissoula, MT Chair, Workers’ Comp Committee Mike Zucco Business Development ATA Comp Fund Montgomery, AL

Les Boughner Director Alex Giordano Director

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SIIA new members MAY 2019

Regular Corporate Members April Lee Senior Vice President ARC Fertility Cupertino, CA

James Deren President/CEO Group Benefit Services, Inc. Springfield, MO

employer Corporate Members

Luke Berry Managing Director Collier Memphis, TN

Paul Kinson Consulting Actuary Liscord, Ward & Roy, Inc. Manchester, NH

Joe LaMantia, III Member Manager L&F Dist. LLC McAllen, TX

Julia Levin Events & Marketing Manager Confidio Towson, MD

Haywood Marsh GM NetClaim® Norcross, GA

Peter Analore VP of Customer Success FormFire LLC Cleveland, OH

Larry Klaahsen Executive Vice President Risk Administration Services Inc. Sioux Falls, SD

Reimagine · Rediscover Benefits Flexible, customized health plan options to meet the self-funded employer’s unique needs 62

THE SELF-INSURER

www.healthscopebenefits.com ● 800-884-0287

Pay it Right THE FIRST TIME

Through our integrated PREPAYMENT REVOLUTION Zelis is the market leader in integrating network solutions, payment integrity and electronic payments to deliver insights that drive even greater savings before a claim is paid. Working in a prepayment environment, we price the claim correctly before you pay, avoiding unnecessary costs, time and reducing member and provider abrasion.

In fact, 85% of the time we find claim savings that other vendors don’t. We do this by focusing on every step of the pre-payment claim cycle and delivering value-driven solutions from payment to reconciliation.

Contact Zelis today at 888.311.3505 or visit zelis.com to find out how our pre-payment solutions are helping control the rising cost of healthcare.

Better Service. Better Performance.

zelis.com

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Providing our clients with efficient solutions that reduce claim costs and promote quality healthcare. www.UnitedClaimSolutions.com www.NXHealthNetwork.com www.INETICO.com www.ZebuCompliance.com