Self Insurer November 2019 by SIPC

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TABLE OF CONTENTS

NOVEMBER 2019 VOL 133

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

FEATURES 4

SIIA ENDEAVORS A GOLDEN GATEWAY TO INNOVATION SIIA KEYNOTERS DRAW LAUGHS AND RAISE EYEBROWS

By Bruce Shutan

INDUSTRY REACTS TO IRS OFFER TO 831(B) CAPTIVES

By Karrie Hyatt

ARTICLES 28

OUTSIDE THE BELTWAY

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 BROKER/ADVISOR PERSPECTIVES INSIGHTS FOR AND ABOUT BROKERS/ADVISORS ACTIVE IN THE SELF-INSURANCE MARKETPLACE

ACA ROUND-UP FOR 2020: ITEMS AFFECTING EMPLOYER-SPONSORED GROUP HEALTH PLANS

NEWS FROM SIIA MEMBERS

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

NOVEMBER 2019

ENDEAVORS

FEATURE

SIIA ENDEAVORS

A GOLDEN GATEWAY TO INNOVATION

SIIA KEYNOTERS DRAW LAUGHS AND RAISE EYEBROWS

S S

IIA’s 39th annual National Conference & Expo in San Francisco offered a veritable gold rush of innovative solutions for an estimated 1,900 industry professionals.

The world’s largest self-insurance event featured nearly 40 educational workshops across five tracks and an exhibit hall floor teeming with 131 service providers. In addition, keynoters served up food for thought and comic relief.

Written by Bruce Shutan

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Greg Schwem, a renowned business humorist and award-winning Chicago Tribune syndicated humor columnist, stressed the importance of humor in the workplace and laughing at oneself. In a hilarious presentation entitled “Work, Laugh, Repeat: How Technology Contributes to a Funnier World,” he gently ribbed SIIA for showing up late to the Google game. Schwem cited identical acronyms belonging to others who surface in web-browser searches.

ENDEAVORS Vinnie Tortorich, one the country’s leading fitness and nutrition experts and creator of a new documentary questioning mainstream dietary guidance, weighed in on a serious topic – though often with humorous insight. In a compelling talk about rethinking the decades-old food pyramid, he said self-insured employers need to better educate their employees about nutrition. He warned that poor eating habits are causing or worsening numerous health conditions and spiking costs. In addition to dispelling popular myths about food, Tortorich shared his inspiring battle against leukemia.

BUNDLING DIRECT CONTRACTING WITH RISK PROTECTION

specific stop-loss on potentially large claims, he said.

Bundling direct contracting with risk protection helps drive competition by lowering price points “down to what we’re achieving in the market,” according to Hass. Employees benefit greatly from these programs when surgical case rates are zeroed out.

Direct contracting is all the rage, but when coupled with a robust layer of risk protection, one panel discussion showed how it can turbo-charge self-insurance.

While most elective surgeries are scheduled three to six weeks in advance, precert utilization review usually doesn’t happen until 24 to 48 hours before the procedure, explained Scott Haas, SVP of USI Insurance Services. The result is a narrow window to determine medical necessity, but no time to do anything about the price. This ties the hands of patients who have already made arrangements for family members and/or pets during their aftercare, creating a largely negative consumer experience.

But he’s wresting control of these scenarios by writing in plan documents that his employer clients reserve the right to deny any surgery that’s not prior authorized within 14 days of the procedure. “The plan sponsor has a fiduciary obligation to know what the surgery is going to be and what’s going to be paid prior to the surgery being delivered,” he said.

But there’s also something in it for providers for whom payment is expedited at the point of service. Under direct contracting arrangements, he said they’re paid up front and no longer need to chase accounts receivable.

Agreeing on price points in advance means providers don’t have to worry about billing, collections or bad debt,

His firm has created and placed a stop-loss mechanism inside the case rate that shields health plan members and plan sponsors from additional charges up to a certain amount related to surgery complications. The upshot is that it removes pressure off the overall

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ENDEAVORS Matosich said, but the trick is capturing all the data and making sure it’s transmitted to administrative partners for reporting, analytics, stop-loss purposes, etc.

In some cases, experts say travel may be appropriate for certain medical procedures. “The more complicated the service is that a plan member requires, the more you should be willing to look at regional or national options,” observed Korb Matosich, co-founder and president of Asserta Health, which enables cash payment for virtually any kind of health care service. “No one in their right mind should get a knee replacement done at a community hospital in a rural setting. It just doesn’t make any sense in the world. They don’t do enough volume.”

Haas provided a startling example of a patient in Pocatello, Idaho whose local medical center was going to charge him $85,000 for knee-replacement surgery. He ended up getting a round-trip ticket with his wife to a facility in Spokane, Wash., where they were taken to a surgical center by limo and stayed at the swanky Coeur d’Alene Resort on a per diem. The patient was discharged with no complications after the second night. Total expenses, including travel, were just $22,500.

Ensuring that direct contracting works as well as can be hinges on knowing the true cost of risk for a surgical episode or bundle. Regi Schindler, EVP and director of insurance operations for Leavitt Risk Partners, developed a quantitative insurance premium financing model to accurately price these procedures for the best possible risk protection.

“You hear about frequency in terms of mortality and morbidity,” he said. “We had to create the second half of that equation by effectively coming up with the severity part of it, which is the cost of the medical care when we have one of these known events happen. So the model becomes frequency times severity, and that allows us to come up with a price per case.”

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NOVEMBER 2019

ENDEAVORS Risk protection provides amazing insight into quality, Matosich added. For example, tracking loss ratios, complication rates and their cost narrows the range of acceptable surgeons so that risk is being taken intelligently.

Value plays a critical role in the convergence of direct contracting and risk protection Schindler’s firm rewards providers who exceed performance measures with lower premium charges and does the opposite for those who

Suzanne Delbanco, Ph.D., executive director of Catalyst for Payment Reform (CPR), which advocates value-based purchasing. Nearly half of Federal Trade Commission’s challenges to mergers between 2000 and 2008 involved the healthcare industry, according to Jaime King, associate dean and professor of law at the UC Hastings College of the Law.

The number of primary care physicians and specialists acquired by hospitals in the U.S. has nearly doubled between 2010 and 2018 to a point where almost half of all physician practices are now owned by a hospital, reported Richard Scheffler, a health economics and public policy professor at the University of California, Berkeley’s graduate school.

“Over 40,000 cases over a dozen years that’s proven to be probably the most valuable part of our process,” he noted.

In addition, he said there aren’t any good guidelines or methodology for judging a rash of vertical mega-mergers such as CVS/Aetna and Cigna/Express Scripts, both of which he opposed. Changes in the healthcare industry in the past decade or so have been the most profound and rapid he’s seen over the past 40 years.

FINDING VALUE AMID

The Alexander-Murray Lower Health Care Costs Act (S1895) is the most significant of six bills in Congress that address surprise billing, four of which are bipartisan, King said. Among the proposed reforms: creation of a federal all-payer claims database that would include self-insured health plans, surprise billing protections, and a ban on gag clauses and anti-competitive contract terms.

under-perform.

PROVIDER MARKET POWER Consolidation of U.S. health care providers is happening at an alarming rate and spiking prices with almost no end in sight, industry observers caution, but they also note that there are still ways to find value in the face of this trend.

“We heard a lot of nice stories over the years about how consolidation was going to lead to better continuity and coordination of care, more efficiency, less duplication of tests, but unfortunately, the evidence is about a mile high that it leads to higher prices,” lamented

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All three branches of the U.S. federal government, as well as scores of state houses, are responding to health care market consolidation in numerous ways.

President Trump’s June executive order on price transparency “would require all hospitals to release in a consumer-friendly format their negotiated rates for a series of shoppable services,” she explained. At the state level, King said 28 states have passed regulations over surprise billing, 13 of which are comprehensive, while15 other states offer some protection without arbitration or only in certain instances.

In addition, she noted that 20 states have passed most favored nation prohibitions, which allow insurers to negotiate just the lowest rate among their competitors.

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ENDEAVORS Another noteworthy development King cited is that the U.S. Supreme Court in Goveille v. Liberty Mutual held that “the state could not compel self-insured employer plans to submit their data to the state all-payer claims database, which is why the federal allpayer claims database is important.”

The prevailing view of industry thought leaders, however, is that there’s no use waiting for government solutions to systemic problems. Indeed, the panelists cited several examples of innovative responses to the challenges posed by anti-competitive behavior in the marketplace.

It’s important that self-insured employers pressure third-party administrators or other health insurers working on

“not to enter into contracts with providers that mask what’s really going on under the hood,” Delbanco said. “Pushing for price and quality transparency is sort of a fundamental building block of many of the things that we think employers can be trying to do.” their behalf

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She also recommended narrow networks that weed out 10% to 30% of the “most expensive, porous quality providers” and a center of excellence (COE) program that addresses areas that generate the biggest health care spend. In addition, she suggested waiving cost-sharing as a strategy that’s “better than having someone readmitted or having a complication” that requires additional surgery. Other solutions Delbanco believes will help bend the cost curve include telehealth, second opinions, reference-based pricing (RBP), and onsite clinics that “increase access to primary care and control referrals out to community providers.”

In a case study of Walmart’s Center COE program for spine surgery showing the value of second opinions, CPR found that half the patients who were referred by physicians at home for spine surgery were told they wouldn’t benefit from the procedure.

For RBP, Delbanco said the California Public Employee Retiree system known as CalPERS was able to reduce the average price it paid for joint replacements by 26%. The nation’s largest health care purchaser outside of Medicare decided to set a reference price of $30,000 after paying more than $100,000 and found plenty of providers willing to accept that price range.

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ENDEAVORS PATH TO VALUE MEANS PULLING COST, QUALITY LEVERS If value is an outcome achieved vs. a dollar spent, as one industry observer suggested during a panel discussion on value-based benefit design, then self-insured employers may need to rethink their purchasing strategies.

There are two levers to value-based insurance design and value-based payment plans that have to be pulled, according to Shane Wolverton, SVP of corporate development for Quantros, Inc., citing transparent prices and quality.

“If you can connect those two levers, then you can create the proper incentives and alignment to increase the probability that you’ll consume less in resources and that you will achieve far greater quality than you’ve been able to achieve thus far,” he said. Without such a connection, he suggested that plan sponsors are violating their “fiduciary responsibility to spend the resources wisely and help consumers, who are largely uneducated about this.”

Financial incentives associated with increasing quality and decreasing costs have both positive and negative effects, explained Jim Millaway, CEO of the Zero Card, Inc.

For example, he said health plan members could be subject to a much larger deductible for spinal fusion surgery done at a horribly low-performing health system or may have their annual deductible waived if they access care at a higher-performing facility. In short, his suggestion was that plans “make it exorbitantly expensive” to pursue the wrong choice and “totally free” to make the right decision.

Episodic care payment programs are designed to think prospectively priced and retrospectively reconciled strategies for engaging health plan members in “base shopper programs and positive incentives all the way to complete carveouts,” noted Francois De Brantes, SVP of Commercial business development for Remedy Partners.

One example he gave was maternity care, whose mortality rate in the U.S. “is the worst of all of the developing countries.” The objective is to ensure that clinicians have incentives to see patients on an ongoing basis, especially for risky pregnancies, “because it’s that prenatal engagement which is going to decide, ultimately, what the outcome of the case is going to be,” according to De Brantes.

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ENDEAVORS “If we’re going to change the way providers think and are motivated to give care,” he said, as well as “commensurately change the way in which consumers perceive their choices, then we’ve got to do things a little differently, and tying value-based insurance design to value-based payment is a way to get it done.”

While a solid, low-cost case rate for a vaginal delivery or C-section is important, he explained that the delivery method doesn’t matter “as much as what comes out as a process of the delivery,” which is a healthy birth weight.

De Brantes suggested changing the choice architecture for health care consumers. They will blow through their annual deductible and out-of-pocket maximum under a classic non-consumer-directed health plan, he cautioned. “But if you put the cost sharing or amount of money that ultimately you as an individual is responsible for above the episode price or budget for that particular procedure,” he said, “you have a completely different choice architecture.”

Noting that health care decisions are based on cost, quality and convenience, Millaway said “we made the cost point completely moot” by not charging patients who went to the best-performing providers for 27,000 unique bundles across 45 clinical categories.

Baseline savings in the bundled arena average about $40 per employee per month for self-insured employers whose mission is somewhat but not totally aligned, he reported. That number rises significantly when direct primary care is put in place from an onsite or near-site shared network, he added, while it’s $100 a month per employee per month when DPC and other attributes are combined with engaged HR departments and C-Suite executives “just by giving away everything for free.”

Today’s fee-for-service medicine is about cost-shifting, while a dearth of incentives to reward excellence means “you can be a hack or you can be amazing, and you get

“We’ve not done anything to fundamentally alter the provider. We value choice, and then we put the provider in the position to where they have to chase their money because we’ve offloaded that to the plan member.” paid the exact same rate,” Wolverton lamented.

However, managing poly-chronic patients who are more predisposed to hospitalizations and complicated surgeries is a far better way to have a meaningful impact, he suggested.

CAPTIVE REGULATORS TALK POT, PROCUREMENT TAXES

From medical and recreational marijuana and procurement taxes to blockchain technology and captive manager codes of conduct, regulators from leading captive domiciles examined several hot topics. The lively panel discussion was moderated by Martin Eveleigh, chairman of Atlas Insurance Management, who asked everyone what they see on the horizon in the next 18 to 24 months.

Steve Matthews, captive insurance coordinator for the Office of the Montana Commissioner of Securities & Insurance, is elated that his state legislature now allows public entities to form captives that his office regulates. “We’ve had some counties that are looking to pooling together to do some stop-loss programs and municipalities that have already formed a captive,” he reported.

While some small captives have dissolved in North Carolina, there has been an uptick in producer- or agencyowned medical stop-loss captives, as well as general liability and workers’ compensation, according to Debbie Walker, senior deputy commissioner for the North Carolina Department of Insurance’s Captive Insurance Companies Division.

NOVEMBER 2019

ENDEAVORS Mergers and acquisitions are driving the dissolution of Vermont captives, though new new entities have sprung up for traditional business, property/casualty, medical stop loss and employee benefits, said David Provost, deputy commissioner of the Vermont Department of Financial Regulation’s Captive Insurance Division. He also noted that tenant liability is a growing business.

Delaware saw the dissolution of 68 captives this year and 120 last year, reported

“You net that against 21 formations this year alone,” he said, “I’m already at a -47 if you look at certificates of authority counting.” Steve Kinion, director of the Delaware Captive Insurance Bureau.

But that’s expected to change. Delaware Insurance Commissioner Trinidad Navarro favors captives becoming involved in insuring hemp or even recreational cannabis, Kinion told attendees, noting the irony of Navarro’s background as a police officer. While Delaware state law only addresses medicinal marijuana, he said recreational use could be legalized within the next 24 months.

Noting that banks won’t accept money from medical marijuana distributors, one organization recently approached John Talley, J.D., captive program manager for the Missouri Insurance Department, about establishing a trust company with captive insurance that would issue an FDIC-type policy for each account. Talley described the idea as “brilliant” and said he would accept an application if it were filed. Missouri has legalized medical marijuana.

Another lucrative area for state captive regulators could be procurement taxes. Talley believes that one such proposal could arise during the next session of Washington’s state legislature. “What a great business model,” Kinion quipped, defending Mike Kreidler, Washington’s insurance commissioner.

“He doesn’t have a captive staff to pay, so he has no overhead. It’s all pure profit.” Knowing how scarce tax dollars are, Provost said “every state is looking for every opportunity they can to gain revenue.” He said $25 billion in premiums are going to

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Vermont alone, surmising the overall captive market must be $50 billion to $100 billion.

Panelists also weighed in on the use of emerging technology in the captive space. Provost, for example, cited a project in Vermont with the secretary of state to incorporate captives using blockchain technology. “Technically, it’s pretty straightforward,” he said. “Instead of a linear approach, it sort of goes through a web, and you can cut one piece of the web and all the other pieces stay in place, so it’s very tough to hack. When somebody does hack a blockchain, it will be a spectacular failure and very expensive, and they will be famous in their dark web community.”

The panel expressed concern about the role of cryptocurrency, which Provost said is usually built on a blockchain. While not having a problem with collecting premiums and paying claims in crypto, he cautioned against paying premiums in crypto and collecting claims in dollars “because there’s a moral hazard. Crypto’s way down, the dollar’s way up, I’m going to be a big winner.”

Kinion agreed, noting that cryptocurrency is very volatile. “About a year ago, remember, Bitcoin was at $19,000,” he said. “Now it’s below $10,000. It has lost more than 50% of its value, and anything like that makes me question whether that is a good currency to be using in the insurance industry.”

ENDEAVORS Another hot topic for discussion involved a professional code of conduct. Talley noted that CPAs and other professionals have to abide by their own codes. While liking the idea of applying it to captive managers, he’s not interested in policing their conduct.

“We want our service providers to work at the utmost of the ethical level necessary to do their job and to do it well for their customer,” he observed. “It’s not something that we want to regulate for two reasons.” They include the need for licensing and enforcement.

expensive hospitals earn more than 400% of Medicare with one facility raking in 782% on outpatient care. “All nine offer at least some services that are in the bottom quartile of all hospitals nationally” in terms of quality, he added, while most of the state’s nine most affordable facilities charge under 200% of Medicare with all offering virtually undistinguished quality.

This robust health care marketplace appears to be taking a terrible toll on some state residents. For example, Smith lamented the fact that as much as 25% of young teacher salaries in Colorado go toward health care, while the state’s average teacher pay is dead last in the U.S. However, steps are under way to reform the system.

“We intend to get the state of Colorado, some of the larger school districts and several counties to negotiate better prices, and then to make those prices available to the insurers to use,” he explained. But two conditions first must be in place: a promise to pass any savings onto small business customers and willingness to offer Affordable Care Act-compliant products on the state exchange.

USING RBP TO TAME THE HOSPITAL COST-SHIFT The key for self-insured health plans to lower hospital costs may be a combination of leveraged purchasing power and reference-based pricing (RBP), suggested an industry researcher and experts from Colorado and Montana who shared their success stories.

The intent is to not just reduce pricing and costs for self-funded employers, Smith said, but also for the fully-insured and individual insurance markets. As such, the CBGH is working with he governor’s office and has been asked to become a statewide purchasing coalition.

“Hospitals are charging what the market will bear,” explained Robert Smith, executive director of the Colorado Business Group on Health (CBGH) whose state markets he said “are consolidated not unlike the rest of the country.”

About 50% or 60% of physicians are owned by a health system across the state where Smith noted that the nine most

NOVEMBER 2019

ENDEAVORS In order to negotiate contracts on a reference-based price, Smith said payers need to know prices as a percent of Medicare and the best alternative to no deal. They also need scale. Unless employers have the size and/or moral standing in their community, he cautioned that they’re not going to get where they need to be and costs will be shifted onto patients. CBGH’s effort is similar to a number of coalitions across the nation that have banded together to significantly reduce hospital prices, he added.

Like business groups and private employers, state governments face the same pressures to revamp their health plans, especially since taxpayer dollars are at stake.

Montana’s largest self-funded plan, which covers 31,000 state employees and their dependents, found itself in deep trouble in 2014. That’s when a -$9 million actuarial projection of reserves for 2017 was issued assuming no meaningful plan design changes were made. An ultimatum was issued the following year when legislators passed Senate Bill 418: the plan would be dissolved if it was still mired in red ink two years later.

Marilyn Bartlett, special projects coordinator for the Montana Commissioner of Securities and Insurance, explained how she and her team eventually turned things around. At first, none of the nine respondents to a request for proposal would agree to a Medicare-plus RBP contract awarded to Allegiance Benefit Plan Management, a third-party administrator.

Negotiations began in the summer of 2015 with all state hospitals, since the governor didn’t want a narrow network, and the new plan went live a year later – but not without eye-popping revelations and hard-fought victories along the way.

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ENDEAVORS When claims were run through the plan’s re-pricer for the largest hospitals, for instance, Bartlett said the highest average price on outpatient care was was 611% of Medicare and around 500% for inpatient visits. Under the RBP program, she noted

“every hospital would have a different rate, but it would all be a percentage of Medicare.” that

The state also found other efficiencies and savings within the health plan. For example, she noted that numerous fees associated with spread pricing for pharmacy contracting were eliminated and replaced by a transparent pass-through pharmacy that saved $7.4 million in the first year. Another $5.5 million was trimmed by eliminating duplicate wellness services.

Other changes included beefing up a primary care focus with onsite health centers that didn’t charge any copays. “We put that particular contract on an admin fee, but a bonus to the vendor based on cohort outcomes,” Bartlett reported. In addition, the state rolled out Healthcare Bluebook quality measures for inpatient care so that members could also see the cost, moved to a cloud-based enrollment administration system and updated the summary plan description.

Bartlett credited RBP for saving Montana taxpayers and health plan members substantial amounts. By 2017, there were $112 million in reserves, which turned out to be higher than Montana’s general fund. Also, Montana hospital chargemasters didn’t rise more than 1% two years after RBP was put in place, whereas the average was 5% a year prior to that time.

The lessons learned in Colorado and Montana aren’t lost on Christopher Whaley, associate policy researcher with the RAND Corporation, who noted that RBI must be designed in a thoughtful manner.

That means being able to shop services, which eliminates emergency care from the equation, and measure quality.

He said setting a reasonable price cap, along with offering employees a financial incentive to use high-value and lower priced providers in a more targeted fashion than high-deductible health plans, will move employers from a passive to active purchaser of health care benefits.

Employers and health plans studied in 2017 by the RAND Corp. and Employers’ Forum of Indiana could have sliced their total payments to hospitals in half if they used Medicare’s payment formulas, according to Whaley. Instead, he said they ended up paying 241% more than what Medicare paid by negotiating a discount off hospital charges. Other RAND research suggests that employers could save an estimated 8.5% of their total medical spend if RBI were expanded to all procedures wherever appropriate.

HOW TO SMOOTH OUT STOPLOSS REIMBURSEMENT CLAIMS Friction associated with stop-loss reimbursement, particularly high-dollar claims, are unavoidable in self-insurance, but a panel of executives from third-party administrators and stop-loss carriers shared their recommendations for reducing or eliminating all the unwanted noise.

SIIA’s TPA taskforce has sought to address certain complications related to stop-loss claims reimbursement in a consistent manner and develop best practices to help “stay out of the courtroom and off the front page,” reported Dave Wilson, CEO of Windsor Strategy Partners, Inc., who moderated the panel discussion.

Ron Dewsnup, president of Allegiance Benefit Plan Management, noted that his employer groups don’t always have

NOVEMBER 2019

ENDEAVORS practices that match their summary plan description (SPD). “We’ll get situations, particularly with leaves of absence, where some of the issues that come back and forth can create gaps in coverage,” he said.

His recommendation is to have as much of that information available during the marketing and renewal phases so that the employer, TPA, stop-loss carrier and broker have “a similar, or ideally, the exact same understanding of how all these things work together.”

One best practice is having both the employee handbook and plan document available at either underwriting or implementation to spot any discrepancies, according to Jerry Castelloe, a principal with Castelloe Partners, LLC. “The TPA, in my opinion, should be responsible for making sure all the documents and all the provisions are in sync,” he observed.

There also may be disagreement with a stop-loss partner on the definition of usual, reasonable and customary charges, Castelloe noted. He said the time to iron out whether claims are in or out of network or provider billing practices are outrageous

“not when you’ve got a claim that you’ve already written the check for your client’s money, and they’re expecting something back.”

is early on and

Another recommendation was to ensure that pharmacy benefit management (PBM) is in sync with the SPD, Dewsnup noted. “We have seen some issues arise over the course of the past few years with regard to higher cost medication being used off label, and then being questioned not at the PBM part, but when the claim is filed with the stop-loss carrier,” he said, “because that’s the first time it’s been looked at and the TPA has been kind of out of that whole equation.”

Kurt Haag, SVP of Optum, noted that since brokers are not only marketing more stop-loss contracts, but also PBM coverage, it’s imperative to spell out in the implementation meeting when and how Rx claims will be submitted.

“Sell me on it at the time of the RFP,” he suggested. “If we can learn more about that and be different on our pricing, then we can be different in terms of the administration as we work with you from a claims and clinical standpoint.”

Bruce Shutan is a Portland, Oregon-based freelance writer who has closely covered the employee benefits industry for more than 30 years.

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IRS Offer to 831 (b) Captives

FEATURE

Industry Reacts to

IRS Offer to 831(b) Captives

Written by Karrie Hyatt

ollowing three successful court cases against captives choosing the 831(b) tax option, the Internal Revenue Service (IRS) is offering a settlement to some captives currently under audit.

For the last seven years the IRS has been investigating small and medium-sized captives taking the 831(b) tax option. Referring to them as “micro captives,” the IRS suspects some of the companies of using the 831(b) designation as a tax dodge for estate planning and wealth transfer purposes. For the last five years the IRS has named these types of captives to their “Dirty Dozen” list—a list the department releases each year warning taxpayers of potential tax scams.

Small to medium-sized captives, also known as Enterprise Risk Captives (ERCs), have been the largest segment of growth in the captive space for the last decade. Their growth was spurred by several factors. By the late 2000s, most large companies had already formed captives, so the market began to look to medium and small companies. New captive structures, including cell and series captives, along with the increase in U.S. domiciles made it more affordable for smaller companies to form their own captive.

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IRS Offer to 831 (b) Captives

With the rapid expansion of ERCs, criticism has stemmed from two key issues— misusing the captive structure as a tax shelters or as a wealth transfer mechanism. Additionally, captives misusing the 831(b) tax designation are often set-up by promoters who may not have a background in insurance. Small captives opting for the 831(b) designation gain a hefty tax advantage which gives critics fodder for questioning their validity. The IRS being the biggest critic of them all.

It is estimated that the IRS is currently auditing or in the appeals process with about 500 captives choosing the 831(b) designation. Since late 2017, the Tax Appeals Court has decided in favor of the IRS in three key cases involving “micro captives.” Following hard on these successes, the IRS has now issued a settlement offer to some captives currently under audit.

The offer was issued by letter and was sent to up to 200 captives currently under audit, according to the IRS’s press release on September 16, 2019. The offer may be expanded to other captives at a later date. The captives who receive and accept the offer will be required to pay penalties and concede a substantial portion of the tax benefits that were previously claimed. It is a one-time offer—if a “micro captive” declines the offer, they won’t be eligible for any other offers that may become available in the future.

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In the press release from the IRS, Commissioner Chuck Rettig said, “The IRS is taking this step in the interests of sound tax administration. We encourage taxpayers under exam and their advisors to take a realistic look at their matter and carefully review the settlement offer, which we believe is the best option for them given recent court cases. We will continue to vigorously pursue these and other similar abusive transactions going forward.”

The reasoning behind this offer at this time is likely that, with a few key court wins behind them, the IRS feels they are emboldened in their pursuit of “micro captives.” When their audit decisions are appealed in court, their wins come at a steep price. In making the settlement offer, and those captives accepting it, the IRS will be able to reduce their audit burden and free up some of their limited resources.

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IRS Offer to 831 (b) Captives According to Dave Provost, the deputy commissioner of Vermont's Captive Insurance Division, “It seems like a practical approach to take care of a large number of cases at minimal cost. I think it’s appropriate for the IRS to try to minimize their collection expenses. I assume that the bulk of the companies that will receive a letter are close enough in facts and circumstances to recent IRS wins that the recipients will very likely opt to settle and cut their exposure to larger losses, and continued time and expense.”

precedents that they established, the the IRS might expand its sights beyond 831(b) captives to the larger insurance industry.

“We have known for quite some time that the IRS has a large number of audits out on 831(b) captives,” said Ryan Work, vice president of government relations for SIIA. “That, along with recent court wins, has provided the Service with leverage to issue various settlements in the hope of decreasing the number of outstanding audits. However, the current audit settlement continues to demonstrate that the Service still has not yet developed any appropriate guidelines to objectively distinguish between good and bad actors in the space.”

For Jerry D. Messick, CEO of Elevate Captives, “The problem I see is when the Service casts such a broad net, they will include owners that have absolutely every reason to have a well-structured captive to support their risk management needs. That said, if the captive in question doesn’t have the normal attributes of an insurance company, I would think the offer to settle would be positive for those owners.”

According to Harry Tipper, a long-time insurance professional who has been working with SIIA since the 1980s, “If this settlement strategy succeeds in shaking out the bad actors, the ones who used captives taking an 831(b) election as the centerpiece of an abusive tax shelter, then the settlement strategy will be a good thing.” He continued to say that if it is emboldened by its successes and, more importantly, the legal

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Jeffrey Kenneson, president of Quest Captive Management LLC, believes the IRS is trying to cast a wide net over 831(b)s. “I think the IRS is trying to lessen its burden to go after the questionable entities while ensnaring many entities that might be in the gray area and will settle to avoid the hassle and potential penalties for not settling.”

“Generally, I don’t like settlement offers because it’s a ‘catch all’ for the IRS,” Kenneson added. “[It] adds fear to the calculation due to the uncertainty on the taxpayers part, however, I think it might be a quicker and cleaner way to clean up this area in captives that have somewhat abused the tax election.”

IRS Offer to 831 (b) Captives followed the fact pattern of the cases that have been adjudicated unfavorable to date, I would settle.” According to Joseph Holahan, of counsel with Morris, Manning & Martin, LLP, “Each captive owner will need to evaluate its position based on its own facts and circumstances, but my sense is that many of the captive owners who have been offered the settlement will conclude it is in their best interest to accept it and move on.”

For the nearly 200 ERCs who received the letter from the IRS, the question is, should they settle?

“Each captive under audit who has received a settlement letter will have to decide the most appropriate approach for them,” said Work. “In talking to various recipients of these settlement letters, there are captives that have received such settlement offers that believe they are operating above and beyond standards, some of which see no reason to accept the terms, particularly shutting down their appropriate captive structure.” Kenneson has a similar take on the question. “I think the captives that were formed properly with risk management concepts in mind and adhere to the requirements that were put in place a few years ago regarding policy spread and ownership structures should hold their ground. For others that are questionable or in the gray area, I would strongly suggest obtaining some legal advice on the matter. For those that have

“I’m neither a tax expert nor advisor, but if it I were to get an offer like that, I’d jump on it,” said Provost.

Captive insiders see the settlement offer as a way to eliminate many of the captives that were formed as tax shelters. Many of those captives were formed at the beginning of the small captive boom a decade ago before the industry had yet to develop guidelines for good governance of ERCs, when it became apparent to shady promoters that the 831(b) tax option could be used to create tax shelters.

“It’s clear some 831(b) arrangements were not sufficiently mindful of the principles governing economic substance and business purpose,” said Holahan. “I see the settlement offer as part of the process of recalibration and movement away from the more aggressive approaches in this area.”

NOVEMBER 2019

IRS Offer to 831 (b) Captives “Again, I hope the 831(b) captives that were formed properly will hold their ground and defend their position if called upon,” said Kenneson. “If the highly questionable 831(b)s are removed and the proper 831(b)s remain in existence, I see little to no effect to the captive industry as a whole. I can’t say the same for the 831(b) promoters that have colored outside the lines.”

According to Provost, “I don’t see much long-term impact on large publicly-traded captive owners—they’ve been through the process already. There will be some adverse press and other pain in the short term, but over the long haul the effect will be minimal. I think this will clear out some questionable practices and practitioners.”

“Everyone in the captive industry is aware that there are bad actors out there,” said Tipper. “That is why SIIA’s Captive Committee developed the Code of Conduct as a way to differentiate between those who would push the limits beyond recognition and those who try to conduct their business and to form captives for their clients in a responsible manner.” SIIA’s Captive Manager Code of Conduct was released in January of this year. The Code is meant to guide captive managers to a high standard of ethical conduct and to help strengthen the reputation of the captive industry. SIIA created the Code to take a proactive approach to answer any lingering questions about the validity and effectiveness of captives.

To shore up the captive industry’s reputation, particularly with the IRS, “SIIA is coalescing members on strengthening industry practices though its Captive Manger Code of Conduct, which it hopes to readdress in the near future, along with additional discussions and recommendations to regulators on principles to better ascertain appropriate captive structures and activities,” said Work.

“The audit settlement announcement demonstrates that the Service continues a careful watch over 831(b) captives,” continued Work. “At the same time, the industry should also continue to carefully address issues, strengthen practices and continue to move forward.”

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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OUTSIDE THE BELTWAY

outSIDE the Beltway

Written By Joanne Wojcik

magine you fell off a ladder and sprained your ankle while cleaning out your gutters. Your wife drives you to the emergency room at the nearest hospital, which you checked to make sure was in your health plan’s provider network. The ER doctors examine you, take a bunch of X-rays, wrap your ankle with an ACE bandage and send you on your way with a prescription for painkillers. Then, a couple of weeks after your sprain has healed, you receive an astronomical bill in the mail from the radiologist who read your X-ray. It turns out he was not in network, so you’re on the hook for paying the bill. Depending on which state you live in, you may not be responsible since several states have enacted “hold harmless” laws protecting patients from balance billing. But what if you are a member of a self-insured benefit plan?

Although states are barred from regulating self-insured health plans under the Employee Retirement Income Security Act, ERISA plan members may be able to take advantage of laws in some states that shield patients from provider balance billing— as long as they apply directly to providers and not just to insurers.

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STEVE KINION, DIRECTOR Bureau of Captive & Financial Products Department of Insurance

Trinidad Navarro

Insurance Commissioner

BUREAU OF CAPTIVE & FINANCIAL INSURANCE PRODUCTS Delaware Department of Insurance 1007 Orange Street, Suite 1010 Wilmington, DE 19801 302-577-5280 | captive.delaware.gov Trinidad Navarro, Insurance Commissioner

OUTSIDE THE BELTWAY The term “surprise medical bill” describes fees charged when a patient receives care from non-network providers or services not covered by their health benefits. Surprise medical bills occur in 18% of emergency room visits and 15% of in-network hospital stays, according to an analysis of 2017 claims data from large employer plans conducted by the Kaiser Family Foundation. Three national studies—one using data from a large, national commercial insurer and two using a large data sample from self-insured employer plans—all found that more than half of all ambulance cases involved an out-of-network ambulance company.

When they occur, surprise medical bills are often substantial, averaging 800% of what Medicare pays for the same service, while in-network rates average about 300% of Medicare reimbursement rates. Particularly egregious are out-of-network bills from helicopter emergency medical services, or HEMS. Since air ambulance services are governed by the federal Airline Deregulation Act, which pre-empts states from regulating any part of the air industry, air ambulances have been free to charge what the market will bear, sometimes over $100,000 per flight. But Wyoming officials are seeking to change all that by channeling all medical air transportation through its Medicaid program (see related story).

As of September 2019, 29 states have enacted laws offering some form of balancebilling protection to their residents, according to research by the Commonwealth Fund and Zelis Healthcare, a Bedminster, N.J.-based firm that manages out-ofnetwork claims for both insured and self-insured plans (see map).

Because state laws do not pertain to ERISA plans, which cover approximately 100 million Americans, members of Congress also have introduced legislation to counteract surprise medical billing. Two of these measures, currently wending their way through the House and Senate with bipartisan support are:

• In July, the Senate Health, Education, Labor & Pensions Committee also passed the “Lower Health Care Costs” Act introduced in June by HELP Committee Chairman Sen. Lamar Alexander (R-TN) and Ranking Member Sen. Patty Murray (D-WA), that sets a reimbursement benchmark based on in-network median rates. This measure also addresses prescription drug costs and price transparency.

But even if state balance billing statutes cannot legally apply to self-funded ERISA plans, they may work to the benefit of self-funded plans and their members if they target providers, rather than insurers, according to Christen Linke Young, a Fellow with the Schaeffer Initiative at the Brookings Institution, and co-author of a February 2019 white paper on “State Approaches to Mitigating Surprise Out-of-Network Billing”. “States could regulate providers when dealing with members of all types of plans, though that is not what most state laws enacted to date have done.”

• Before leaving for the Labor Day recess, the House Energy & Commerce Committee passed the “No Surprises Act”, a proposal introduced by Chairman Frank Pallone (D-NJ) and Ranking Member Greg Walden (R-OR) that would have prohibited out-of-network providers from sending surprise medical bills to patients and require them to accept in-network median rates based on geography for both emergency and non-emergency care that is provided in network facilities. However, under pressure from physician lobbyists, coupled with Republican concerns about setting a government benchmark, the committee amended the legislation to require that bills over $1,250 be subject to arbitration.

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Of the 29 states that have enacted balance billing legislation, 19 include some type of provider prohibition (see map). For example, laws in Colorado, Florida and Oregon prohibit out-ofnetwork providers from billing enrollees in HMO and PPOs for any amount beyond in-network level of cost sharing for both emergency and nonemergency care that is administered at in-network facilities, whereas in Texas,

OUTSIDE THE BELTWAY the prohibition on providers from balance billing applies to HMO, PPO and EPO enrollees. By contrast, California’s balance-billing protections only apply to providers in those plans regulated by the California Department of Managed Care, which includes HMOs and most PPOs.

Regardless of whether a statute pertains to insurers or providers, in most cases “a provider doesn’t know when they’re seeing a self-insured plan member or an insured plan member,” suggested Matthew Albright, Chief Legislative Affairs Officer at Zelis Healthcare.

“Most providers just assume that out-of-network prohibitions on balance billing are applicable to all of their patients, regardless of the type of plan they are covered by,” he said. Moreover, all providers typically see is their patient’s insurance card, which usually identifies an insurance company, and that insurer could be the administrator of a self-insured health benefit plan.

Some states have set reimbursement levels for out-of-network services that can be useful to self-funded plans when negotiating payments to providers. “If you have TPAs that have both insured and self-insured ASO business, it may be the case that as state laws reshape the negotiating landscape between the insured segment of the market and providers, that those benefits are going to spill over to the ASO contracts,” observed Young.

Notification requirements also can benefit self-insured plan members, noted Albright. At least eight states now require providers to provide notices to patients about possible out-of-network charges for nonemergency services. If the provider doesn’t know whether a patient is enrolled in a self-insured plan or one that is state-regulated, it is very possible that such notices will go to some ERISA plan members, he said.

In some states, such as New York, members of all plans— including self-funded ERISA plans—have access to a dispute resolution process for settling payment of surprise bills for both emergency and non-emergency care. In New Jersey, self-insured employers have the option to access the dispute resolution process over egregious bills from out-of-network providers.

Until federal legislation prohibiting surprise medical billing is enacted, self-insured

NOVEMBER 2019

OUTSIDE THE BELTWAY plans should keep tabs on balance billing statutes in the states where they operate to determine if they can use them as leverage to protect their plan members, both Young and Albright recommend.

“Another potential role for payers is educating consumers about the potential for surprise billing,” Young said. “If consumers are aware that there is some risk of out-of-network billing, it will put some pressure on providers and hospitals.”

With the cost of emergency airlifts soaring, the state of Wyoming is seeking federal approval to make air ambulance services more affordable by channeling all medical air transportation in the state through its Medicaid program. The cost of air ambulance services, which sometimes top $100,000 per flight, also is being targeted in proposed federal legislation addressing surprise medical billing. Air ambulances charged private payers between about 4 and 9.5 times more than what Medicare actually paid for those services in 2016, according to a Health Affairs study by researchers at Johns Hopkins School of Medicine and Johns Hopkins Carey Business School. The Alexander-Murray bill would levy a $10,000 fine on air ambulance service providers each time they charge more than the median in-network rate for a particular geographic region set by HHS. Because all air travel in this country is regulated by the Airline Deregulation Act, states are preempted from regulating any part of the air industry. So Wyoming officials are asking the Centers for Medicare & Medicaid Services for a waiver that would enable it to expand Wyoming Medicaid to all state residents for the specific purpose of air ambulance transportation. According to a website the state created seeking public comment, waiver goals include: the elimination of surprise billing of patients; reduction of the cost of ambulance flights while ensuring a set level of access and quality; and increasing price transparency for patients and employer groups. Under the plan, the Wyoming Department of Health would competitively bid for a selected network of air ambulance providers, make periodic flat payments similar to a gym membership to the contracted providers, and then recoup the revenue needed to fund the system from the insurers and individuals already paying for transports. In public comments mostly supporting the proposal posted on the WDH’s website, Wyoming residents described their experiences with the use of air ambulances, in some cases noting that because of their isolated and remote locations it was the only form of transportation available to get them to a hospital in time of emergency. Nationally, the average helicopter emergency medical service (HEMS) bill has more than doubled since 2010 to $40,000, according to a 2019 report from the federal Government Accountability Office. A 2017 industry report estimates air ambulance operating costs at approximately $11,000 per flight. In Wyoming, Medicare pays an average of $6,000 per flight, and Medicaid pays even less, so air ambulance companies have been shifting these uncompensated costs to private payers. Meanwhile, the air ambulance industry has grown steadily from about 1,100 aircraft in 2007 to more than 2014 in 2018, and two-thirds of them are owned by private equity firms, according to the GAO. “The presence of private equity in the air ambulance industry indicates that investors see profit opportunities in the industry,” the report stated. --Joanne Wojcik

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OUTSIDE THE BELTWAY

STATES WITH BALANCE BILLING PROTECTIONS:

ARIZONA, CALIFORNIA, COLORADO, CONNECTICUT, DELAWARE, FLORIDA, ILLINOIS, INDIANA, IOWA, MAINE, MARYLAND, MASSACHUSETTS, MINNESOTA, MISSISSIPPI, MISSOURI, NEVADA, NEW HAMPSHIRE, NEW JERSEY, NEW MEXICO, NEW YORK, NORTH CAROLINA, OREGON, PENNSYLVANIA, RHODE ISLAND, TENNESSEE, TEXAS, VERMONT, WASHINGTON, WEST VIRGINIA

STATES WITH PROVIDER PROHIBITIONS: CALIFORNIA, COLORADO, CONNECTICUT, DELAWARE, FLORIDA, ILLINOIS, INDIANA, MAINE, MARYLAND, MISSISSIPPI, MISSOURI, NEVADA, NEW HAMPSHIRE, NEW JERSEY, NEW MEXICO, NEW YORK, OREGON, TEXAS, WASHINGTON

Sources: The Commonwealth Fund, Zelis Healthcare

NOVEMBER 2019

A QQ& A

ACA, HIPAA AND FEDERAL HEALTH BENEFIT MANDATES:

Practical

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 Womenâ&#x20AC;&#x2122;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 questionerâ&#x20AC;&#x2122;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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IRS EXPANDS SCOPE OF PREVENTIVE CARE FOR HSA PURPOSES FOR INDIVIDUALS WITH CHRONIC

The IRS has previously addressed the scope of preventive services that can be provided under an HDHP in several different rulings and notices. This prior guidance has not included much detail on permitted preventive care for many common chronic conditions.

CONDITIONS EXPANDING THE SCOPE OF PREVENTIVE SERVICES On July 17, 2019, the IRS issued new guidance that makes health savings accounts (HSAs) more user-friendly by allowing a high deductible health plan (HDHP) to cover certain treatments for chronic conditions before the plan’s deductible is satisfied.

The IRS had been considering issues relating to preventive care for HSA purposes for some time. IRS Notice 2019-45 was released less than 30 days after the President signed an Executive Order directing the Treasury and IRS to issue guidance on the issue. Notice 2019-45 provides some welcome clarification.

WHY DOES THE DEFINITION OF PREVENTIVE CARE MATTER?

An HDHP generally cannot pay any benefits before the deductible is met; the individual is responsible for 100% of covered medical expenses before the deductible is reached. The one exception to this rule is for certain preventive care. A broader definition of preventive care makes an HDHP more attractive to employees and provides an incentive for individuals to seek needed preventive care if it is covered by their plan.

Notice 2019-45 lists 14 specific treatments for certain chronic conditions that are considered “preventive care” for HDHP/HSA purposes. Preventive Care for Specified Conditions

For Individuals Diagnosed with

Angiotensin Converting Enzyme (ACE) inhibitors

Congestive heart failure, diabetes, and/ or coronary artery disease

Anti-resorptive therapy

Osteoporosis and/or osteopenia

Beta-blockers

Congestive heart failure and/ or coronary artery disease

Blood pressure monitor

Hypertension

Inhaled corticosteroids

Asthma

Insulin and other glucose lowering agents

Diabetes

Retinopathy screening

Diabetes

Peak flow meter

Asthma

Glucometer

Diabetes

Hemoglobin A1c testing

Diabetes

International Normalized Ratio (INR) testing

Liver disease and/or bleeding disorders

Low-density Lipoprotein (LDL) testing

Heart disease

Selective Serotonin Reuptake Inhibitors (SSRIs)

Depression

Statins

Heart disease and/or diabetes

The new guidance is effective immediately, meaning that employers can rely on the Notice now in covering the services listed in the Notice. The IRS intends to review this list of items and services approximately every 5 to 10 years. Hopefully, review and updates will occur more frequently; medical developments may quickly make such a list behind the times.

CONSIDERATIONS FOR EMPLOYERS

There are a number of issues for employers to keep in mind as they review their HDHP coverage or consider offering an HSA-compliant HDHP:

NOVEMBER 2019

 Any services or items that are considered preventive care under prior IRS guidance continue to be treated as preventive care for HDHP/HSA purposes.

 Notice 2019-45 does not require a plan to cover the listed services or items or restrict whether cost-sharing may be imposed with respect to covered services.

o Non-grandfathered

health plans are required under the Affordable Care Act (ACA) to cover certain preventive services without cost-sharing. The list of required preventive services is addressed in other rules and is not impacted by Notice 2019-45.

 The IRS has not provided an exhaustive list of what is considered preventive care, and some HDHPs may already treat some of the items and services listed in Notice 2019-45 as preventive care. Plan sponsors should review their HDHP in light of the new guidance and consult with their own advisers regarding any issues. In some cases, if the current preventive care list is overly broad, or the procedure for identifying specific diagnoses (as required by the

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IRS Notice) is not in place, the new guidance may actually narrow some employers’ lists of allowable preventive care.

 Remember that employees may have certain limited types of coverage in addition to the HDHP and still qualify for an HSA. HDHPs are intended to make individuals more aware of and involved in their health care decisions by ensuring that the individual has “skin in the game” for medical expenses before the deductible is met. Thus, in general, individuals may not have health coverage in addition to an HDHP and also qualify for an HSA. A limited exception applies, however, for certain types of permitted insurance and permitted coverage. Under this exception, individuals can have certain types of coverage and still be eligible to contribute to an HSA. Permitted insurance and coverage includes:

• Accident and disability coverage • Insurance coverage for a specified disease (e.g., cancer) or illness (sometimes called “critical illness” coverage)

• Hospital indemnity insurance coverage that pays a fixed amount per day (or other period) of hospitalization

• Dental and vision care • Long-term care

CONCLUSION

The new guidance provides some helpful clarification as to the scope of preventive services that may be provided under an HDHP for persons with chronic conditions. Employers who offer HDHPs/HSAs or are considering doing so should review their plans with the new guidance in mind and consult their advisors as to any design changes.

In some cases, if the current preventive care list is overly broad, or the procedure for identifying specific diagnoses (as required by the IRS Notice) is not in place, the new guidance may actually narrow some employersâ&#x20AC;&#x2122; lists of allowable preventive care.

As for possible future guidance, hopefully the IRS will continue to look at these issues and provide updates more frequently than the 5 to 10-year timeframe mentioned in the Notice. The need to appropriately define the scope of permitted preventive care services remains an on-going issue, as HSAs expand, more individuals need to manage chronic illnesses, and there are continued improvements in medical care.

NOVEMBER 2019

BROKER/ADVISOR PERSPECTIVES

INSIGHTS FOR AND ABOUT BROKERS/ADVISORS ACTIVE IN THE SELF-INSURANCE MARKETPLACE

HAS THE SALES PROCESS BECOME A DRIVERLESS CAR?

Written by Kevin Trokey

e are all well aware of the huge shift of power in the sales process. Gone are the days when the salesperson was in control. Now the buyer reigns supreme. Sure, there are many factors that have influenced the shift, but there is definitely one primary factor: access to information. In todayâ&#x20AC;&#x2122;s online world, buyers no longer have to wait for a salesperson to educate them on potential solutions to their problems; they are going online and researching themselves. Because of the ease to self-educate, buyers are now waiting until MUCH later in the process until they meet with a salesperson.

38 THE SELF-INSURER

In fact, some reports have shown that a typical buyer is somewhere between 60% and 90% of their way to a buying decision before agreeing to meet with a salesperson.

BUT WHAT DOES THAT REALLY MEAN? This shift has some obvious and some not-so-obvious implications, for both buyer and seller. For the buyer, the most obvious implication is that they now have the flexibility to research and learn on their own terms. The not-so-obvious is that we are seeing their buying process grow significantly longer. And with increasing frequency, they are abandoning their search altogether and not making any purchase decision (other than to NOT purchase), often to their detriment. The reason? An overwhelming amount of information and no clear path or timeline to their decision. For the salesperson, the most obvious implication is that it is now harder to get in front of a prospect and, once there, harder to bring value to the conversation. The not-so-obvious is that salespeople need a marketing team more than ever.

WHO IS DOING WHAT AROUND HERE? In “The Challenger Sale,” the authors (Dixon & Adamson) helped identify that an effective salesperson is effective because of his/her ability to: •

control the sales conversation/ decision;

•

establish the standard to earn the business (i.e. the basis on which the buyer will make a final decision);

•

and follow a process (asking/answering the right questions) to keep the buyer moving toward that final decision.

However, with so much of that buying process now in the hands of the buyer, the opportunity for the salesperson to establish the standard and keep the process moving forward happens way too late in the process or has been taken away altogether. Sales teams need to find a way to intervene earlier, both for their benefit and that of the buyer.

YES, MARKETING IS DEFINITELY A PART OF THE SALES TEAM The key to earlier intervention lies with your marketing strategy and team. In order to give salespeople a chance to enter the buying decision earlier in the process, the marketing department must make sure prospects see your organization as an educational resource from the very beginning of their search. Rarely, if ever, does a buyer go out searching for a new broker. WAY more often they go out searching for answers to problems with which they’re struggling. When you’re marketing strategy creates a presence with ideas and content that speaks to those problems you will be able to guide that buyer down a path that leads to a conversation with your sales team.

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NOVEMBER 2019

THE PROBLEM IS MORE COMPLEX THAN WE REALIZE While the educational research the buyers are conducting is typically spearheaded by one individual or department, they are doing so on behalf of a broader group of interests. And this gets directly to the reason for the longer buying process and the increased abandonment rates. In complex buying decisions, there are almost always multiple decision-makers and influencers. The average number has increased over the years, and we’re seeing reports as high as 6.8 people participating in complex B2B solutions purchases, according to Harvard Business Review. Because each influencer has a different role within the organization, they each have different parts of the organization they are charged with protecting. Which means they all come into a buying process with different concerns and agendas. You can start to see how difficult it is for whomever is doing the research on behalf of the group to gather the all of the information necessary to satisfy everyone’s individual interests. Therefore, it should be no surprise that buyers are having trouble coming to consensus within their own groups in order to make a buying decision. Indecision and abandoned searches usually aren’t because the buyer couldn’t find the right solution, it's because the buyer couldn’t come to an internal consensus as to what, if any, problem needs to be addressed. Or, more accurately, their inability to effectively address the complexities of said problem.

THE SELF-INSURER

MARKETING WILL BE YOUR DIFFERENCE-MAKER You know who the influencers/decision-makers are with your buyers (CEO/Owner, CFO, HR), and you know how to answer their unique concerns. As a salesperson, you can’t do that if you’re not in the room. BUT the efforts of your marketing activities can be out there to speak on your behalf. However, you'll likely need to shift the intent of your marketing message – at least initially – because most marketing messages are designed to solve a selling problem by connecting the potential buyer with the seller’s value proposition. But this method of marketing and messaging does not resonate with today’s buyers! Stop using marketing to try and solve your selling problem and start using it to solve the prospects buying problem. The real struggle for the various stakeholders of the buyer isn’t in connecting to the seller’s value proposition; it’s connecting with one another internally to find agreement around their problem. Use this challenge to your marketing advantage. You can anticipate the concerns, questions, and likely issues where the buyer’s stakeholders will be looking to satisfy their own self interests. You know the areas where they will potentially disagree with one another. Anticipate these potential bottlenecks, provide the answers, and build the bridges into your early-stage marketing content. Make it easy for them to find their respective answers, connect with one another, become comfortable moving forward, and rally around a sense of urgency to make that final buying decision.

BOTTOM LINE Marketing is not some optional activity for insurance agencies or any other provider in the employer/healthcare eco-system. It is a critical daily function of running any successful sales organization. It is THE difference-maker for you as you strive for predictable growth. Use educational marketing content to help your prospects coalesce around their challenge, and you will be the obvious partner for them as they coalesce around an answer. Kevin Trokey is the Founding Partner of Q4intelligence, a marketing and sales enablement firm committed to the preservation and transformation of the independent agency system. He writes prolifically regarding the many challenges being faced by today’s agencies, providing guidance to overcome those challenges. He is a frequent industry speaker and was recognized by the National Association of Health Underwriters as their speaker of the year in 2016.

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For current ﬁnancial ratings of underwriting companies by independent rating agencies, visit our corporate website at www.sunlife.com. For more information about Sun Life products, visit www.sunlife.com/us. Stop-Loss policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) in all states except New York, under Policy Form Series 07-SL REV 7-12. In New York, Stop-Loss policies are underwritten by Sun Life and Health Insurance Company (U.S.) (Lansing, MI) under Policy Form Series 07-NYSL REV 7-12. Product offerings may not be available in all states and may vary depending on state laws and regulations. © 2019 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. Sun Life Financial and the globe symbol are registered trademarks of Sun Life Assurance Company of Canada. Visit us at www.sunlife.com/us. BRAD-6503k SLPC 29427 02/19 (exp. 02/21)

Written by Corrie Cripps

ACA ROUND-UP FOR 2020: ITEMS AFFECTING EMPLOYER-SPONSORED GROUP HEALTH PLANS

D D

uring this open enrollment season, plan sponsors of group health plans should be aware of any Affordable Care Act (ACA) changes that may affect the design and administration of their plans.

The case Texas v. United States1 is the ongoing litigation challenging the constitutionality of the ACA. A decision on this case is expected at any time from the Fifth Circuit Court of Appeals (“Fifth Circuit”). Any decision appears likely to be appealed to the Supreme Court. Whether or not the Supreme Court will take the case depends on how the Fifth Circuit rules. If the Supreme Court does not take the case, the Fifth Circuit’s decision will remain the law; however, the agencies will most likely need to issue regulatory guidance on how they interpret the decision.

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As of the date of this article, the Trump administration is continuing to enforce the ACA. As such, plans will need to ensure they are maintaining compliance with the ACA provisions. The following is a summary of the recent regulatory actions that will affect self-insured plans in 2020.

ACA CONTRACEPTIVE MANDATE Update on the Obama-Era Rules

On June 5, 2019, U.S. District Judge Reed O’Conner of the Northern District of Texas issued a nationwide injunction2 against the Affordable Care Act’s (ACA’s) contraceptive mandate and its accommodation process, stating the mandate can no longer be enforced against employers who object to contraceptive coverage as it violates the Religious Freedom Restoration Act (RFRA). The injunction applies to all employers and individuals who object to contraceptive coverage based on sincerely held religious beliefs. The case, DeOtte v. Azar3, was filed in October 2018 on the grounds that the plaintiffs (two Christian couples and one business whose owner is a Christian [Braidwood Management Inc.]) are forced to choose between purchasing health insurance that includes contraceptive coverage or not having insurance.

The basis of the claim is having to choose between covering contraceptives under its group health plan, complying with the accommodation process of the contraceptive mandate, or paying a penalty for noncompliance.

The court ruled that requiring employers with religious objections to use the contraceptive mandate’s accommodation violates RFRA, as does requiring individuals to obtain coverage with contraceptives. This decision will apply to all employers that object to the contraceptive mandate, based on sincerely held religious beliefs, regardless of size or status as a nonprofit or for-profit entity. Since these employers are now exempt from the accommodation process, employees under these employer group health plans will no longer have coverage for some or all contraceptive services. As for individuals, this decision allows individuals who object to some or all contraceptive services based on sincerely held religious beliefs to “…purchase or

obtain health insurance that excludes coverage or payments for some or all contraceptive services from a health insurance issuer, or from a plan sponsor of a group plan, who is willing to offer a separate benefit package option, or a separate policy, certificate, or contract of insurance that excludes coverage or payments for some or all contraceptive services.”

Based on this injunction, it is not clear if self-funded plans will need to offer a separate plan that does not include contraceptive coverage for employees who are religious objectors. There is a safe harbor for officials who enforce the contraceptive mandate. Under the safe harbor, the federal government can ask whether an employer or individual that fails to comply with the contraceptive mandate is a sincere religious objector and file notice in court “…if the defendants reasonably and in good faith doubt the sincerity of that employer or individual’s asserted religious objections”. Federal regulators can also enforce the mandate against those who are found by a court to not be sincere religious objectors.

Update on the Trump Administration Rules

There are at least three lawsuits— brought in California, Massachusetts, and Pennsylvania—challenging the Trump administration’s final rules on religious and moral objections to the contraceptive mandate.4,5

NOVEMBER 2019

Those rules were set to go into effect in January 2019 until they were enjoined by federal district court judges in Pennsylvania and California.

OUT-OF-POCKET LIMITS FOR NON-GRANDFATHERED PLANS

The rulings in Pennsylvania and California do not permanently block the new rules on the contraceptive coverage exemptions; however, the rulings stop the rules from going into effect while legal challenges are pursued.

For non-HDHPs:

Those employers who are potentially eligible for the expanded exemptions of the Trump administration’s final rules and wish to utilize an exemption in the future will need to closely monitor the latest developments.

2020 Out-of-Pocket Maximums

The Health and Human Services Department issued a Final Rule on its Notice of Benefit and Payment Parameters for 2020 (2020 NBPP Final Rule).6 The ACA 2020 maximum annual limitation on cost-sharing is $8,150 for individual coverage and $16,300 cumulative for family coverage. (Note that the ACA’s embedded selfonly limitation is $8,150 for family plans).

For HSA-compatible HDHPs: In Revenue Procedure 2019-25, the Internal Revenue Service (IRS) provided the inflation-adjusted Health Savings Account (HSA) contribution limits effective for calendar year 2020, along with minimum deductible and maximum out-of-pocket expenses for the high-deductible health plans (HDHPs) that HSAs are coupled with.7

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For HDHP self-only coverage, the minimum deductible amount cannot be less than $1,400. The 2020 maximum out-of-pocket expense amount for self-only coverage is $6,900. For 2020 family coverage, the minimum deductible amount is $2,800 and the out-of-expense maximum is $13,800. (Note that the ACA’s embedded self-only limitation is $8,150 for family plans).

Drug Manufacturer Coupons Per the 2020 NBPP Final Rule, health plans are not required to count drug manufacturer coupons toward the annual limit on cost-sharing when a medically appropriate generic equivalent is available.

drugs (considering the discount) until the deductible is met.9 This Q&A requires the HDHP to disregard the drug assistance when determining whether the minimum deductible for an HDHP had been satisfied by only allowing amounts actually paid by the individual to be taken into account for that purposes. The 2020 NBPP Final Rule, layered with the existing IRS Q&A, creates conflicting policy. As a result, the Departments, as stated in this August 2019 FAQ, realize this “ambiguity” and intend to undertake future rulemaking for 2021. In addition, until 2021, the Departments will not initiate an enforcement action if a group excludes the value of drug assistance from the annual limitation on cost sharing, including in circumstances in which there is no medically appropriate generic available. Plans, however, when implementing or utilizing such a provision should be cognizant that this does not conflict with the existing Q&A for HDHPs. Prior to adopting such a provision, the plan, employer, and all related entities should ensure they understand the impact for the participants and the plan.

On August 26, 2019, the Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury (collectively, “the Departments”) issued a joint FAQ regarding limitations on costsharing under the ACA.8 Specifically, the FAQ addresses whether nongrandfathered group health plans must count drug manufacturers’ coupons toward the annual cost-sharing/out-ofpocket limits under the ACA. Per this new FAQ, it came to the attention of the Departments that the drug manufacturer coupon provision of the 2020 NBPP Final Rule could create a conflict with the IRS regulations pertaining to HDHPs. Specifically, Q&A 9 of IRS Notice 2004-50 provides that the provision of drug discounts will not disqualify an individual from being eligible (for the HDHP) if the individual is responsible for paying the costs of the

NOVEMBER 2019

NEW (OR MODIFIED) PREVENTIVE CARE RECOMMENDATIONS FOR NON-GRANDFATHERED HEALTH PLANS

2. Recommendations of the Advisory Committee on Immunization Practices adopted by the Director of the Centers for Disease Control and Prevention (CDC).

3. Comprehensive guidelines for infants, children, and adolescents supported by the Health Resources and Services Administration (HRSA).

4. Comprehensive guidelines for women supported by the Health Resources The Affordable Care Actâ&#x20AC;&#x2122;s (ACA) preventive services mandate for nongrandfathered plans requires certain preventive services be covered innetwork without cost-sharing for plan participants. The ACA uses the following when determining the preventive services that must be covered:

and Services Administration (HRSA).

The final preventive services regulations, issued in July 2015, contain guidelines for when plans must incorporate any modified recommendations.10Â

The following are new or modified preventive care recommendations that become effective in 2020:

1. Evidence-based items or services rated A or B in the United States Preventive Services Task Force (USPSTF) recommendations.

1. Skin Cancer Prevention (Date Issued: March 2018; Best practice is to incorporate by the first day of the plan year on or after January 1, 2020)

The USPSTF updated its 2012 recommendation on skin cancer prevention. In this updated recommendation, the USPSTF expanded the age range for behavioral counseling interventions to include persons aged 6 months to 24 years with fair skin types (the previous recommendation applied to persons aged 10 to 24 years, based on the evidence available at that time).11

2. Screening for Osteoporosis to Prevent Fractures (Date Issued: June 2018; Best practice is to incorporate by the first day of the plan year on or after January 1, 2020)

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The USPSTF recommends osteoporosis screening for postmenopausal women younger than 65 years at increased risk of osteoporosis (created from prior osteoporosis screening mandates, this requirement clarifies the population for screening, introduces reference to menopause, and references clinical risk assessment for determining increased risk).12

3. Spinal muscular atrophy screening for newborns (Date Issued: July 2018; Best practice is to incorporate by the first day of the plan year on or after January 1, 2020)

The Uniform Panel of the Discretionary Advisory Committee on Heritable Disorders in Newborns and Children (an HRSA task force) added newborn screening for certain kinds of spinal muscular atrophy.13

4. Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults (Date Issued: September 2018; Best practice is to incorporate by the first day of the plan year on or after January 1, 2020)

The USPSTF updated its previous 2012 recommendation statement on screening for obesity in adults. While it is still a “B” recommendation, the USPSTF expanded the description of behavioral counseling interventions. As with the 2012 recommendation, the 2018 recommendation is that clinicians offer or refer adults with a body mass index (BMI) of 30 or higher (calculated as weight in kilograms divided by height in meters squared) to intensive, multicomponent behavioral interventions.14 The only update to the recommendation is the expansion of the type of behavioral counseling interventions.

ACA REPORTING

Both the Employer Shared Responsibility Mandate (“Employer Mandate”) and the Individual Shared Responsibility Mandate (“Individual Mandate”) of the ACA continue to apply. As such, Applicable Large Employers (ALEs) will need to ensure they file the applicable forms for Internal Revenue Code (IRC) §§ 6055 and 6056 reporting in early 2020.

CONCLUSION

For plans and TPAs, being well-informed on regulatory developments is always of the upmost importance. Plan sponsors should review their plan documents as well as their plan administration procedures to ensure they are compliant.

Corrie Cripps is a plan drafter/compliance consultant with The Phia Group. She specializes in plan document drafting and review, as well as a myriad of compliance matters, notably including those related to the Affordable Care Act.

5. Screening for Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults (Date Issued: October 2018; Best practice is to incorporate by the first day of the plan year on or after January 1, 2020)

This USPSTF recommendation incorporates new evidence since 2013 and provides additional information about the types of ongoing support services that appear to be associated with positive outcomes.15

NOVEMBER 2019

References 1 Texas v. United States, Partial Summary Judgment, https://www.documentcloud.org/documents/5629711-Texas-v-US-Partial-Summary-Judgment.html, (Last visited October 1, 2019). 2 DeOtte v. Azar, Summary Judgment Order, https://affordablecareactlitigation.files.wordpress.com/2019/06/deotte-summary-judgment-order.pdf, (Last visited October 1, 2019). 3 DeOtte v. Azar, Plaintiffsâ&#x20AC;&#x2122; Class-Action Complaint, https://affordablecareactlitigation.files.wordpress.com/2019/05/deotte-complaint.pdf, (Last visited October 1, 2019). 4 Religious Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act, 26 CFR Part 54, 29 CFR Part 2590, 45 CFR Part 147, October 13, 2017, https://www.gpo.gov/fdsys/pkg/FR-2017-10-13/pdf/2017-21851.pdf, (last visited October 1, 2019). 5 Moral Exemptions and Accommodations for Coverage of Certain Preventive Services Under the Affordable Care Act, 26 CFR Part 54, 29 CFR Part 2590, 45 CFR Part 147, October 13, 2017, https://www.gpo.gov/fdsys/pkg/FR-2017-10-13/pdf/2017-21852.pdf, (last visited October 1, 2019). 6 Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2020, 45 CFR Parts 146, 147, 148, 153, 155, and 156, April 25, 2019, https://www.govinfo.gov/content/pkg/FR-2019-04-25/pdf/2019-08017.pdf, (last visited October 1, 2019). 7 Internal Revenue Bulletin: 2019-22, Rev. Proc. 2019-25, May 28, 2019, https://www.irs.gov/irb/2019-22_IRB#REV-PROC-2019-25, (Last visited October 1, 2019). 8 Employee Benefits Security Administration, Frequently Asked Questions (FAQs) about Affordable Care Act (ACA) Implementation Part 40, August 26, 2019, https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-40, (Last visited October 1, 2019). 9 2019).

Internal Revenue Bulletin No. 2004-33, August 16, 2004, https://www.irs.gov/pub/irs-irbs/irb04-33.pdf, (Last visited October 1,

10 Coverage of Certain Preventive Services Under the Affordable Care Act, 26 CFR Part 54, 29 CFR Parts 2510 and 2590, 45 CFR Part 147, July 14, 2015, https://www.govinfo.gov/content/pkg/FR-2015-07-14/pdf/2015-17076.pdf, (Last visited October 1, 2019). 11 U.S. Preventive Services Task Force, Skin Cancer Prevention: Behavioral Counseling, March 2018, https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/skin-cancer-counseling2, (Last visited October 1, 2019). 12 U.S. Preventive Services Task Force, Osteoporosis to Prevent Fractures: Screening, June 2018, https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/osteoporosis-screening1?ds=1&s=osteoporosis, (Last visited October 1, 2019). 13 Health Resources & Services Administration, Recommendations to HHS Secretary with Responses: Spinal Muscular Atrophy (SMA), https://www.hrsa.gov/advisory-committees/heritable-disorders/recommendations-reports/index.html, (Last visited October 1, 2019). 14 U.S. Preventive Services Task Force, Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Behavioral Interventions, September 2018, https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/obesity-in-adults-interventions1, (Last visited October 1, 2019). 15 U.S. Preventive Services Task Force, Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Screening, October 2018, https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening1?ds=1&s=violence, (Last visited October 1, 2019).

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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 SIIAâ&#x20AC;&#x2122;s premium memberships, please contact Jennifer Ivy at jivy@siia.org.

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NEWS DIAMOND MEMBERS THE PHIA GROUP OPENS NEW OFFICE IN LOUISVILLE Louisville, KY - The Phia Group, LLC is pleased to announce the opening of a new office in Louisville, KY. Under the leadership of the newly appointed Vice President of Operations and Total Quality Management, Scott Byerley, Esq., this new location strengthens The Phia Group's presence in the central United States - just as it did in the west with its Boise, ID, office - continuing to allow The Phia Group to identify, recruit, and hire the most talented professionals, nationwide. With a focus on subrogation and claims recovery, as well as other cost containment activities, the Louisville team shares the same passion as the entirety of the "Phia Family," to deliver robust yet affordable health benefits to as many hard working

" We're very excited to bring The Phia Group to Louisville. This is a continuation of year after year growth for The Phia Group," remarked Mr. Byerley. "The Phia Family made this happen with their dedication and passion for everything cost containment and reducing the costs of healthcare." Americans as possible.

"These days, it seems like everyone wants to meet virtually... but at The Phia Group, we feel being there still matters. By continuously expanding our physical presence, we are not only able to draw from an ever-expanding talent-pool, but we can also proudly say that our partners are also our neighbors," said Adam V. Russo, CEO of The Phia Group.

For more information regarding The Phia Group's Louisville Office, or to learn more about any of The Phia Group's other locations and services, please contact Tim Callender by email at tcallender@ phiagroup.com or by phone at 781-5355631. About The Phia Group The Phia Group, LLC, headquartered in Braintree, Massachusetts, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets. By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans. Visit www. PhiaGroup.com.

ARLENE CAYETANO AND JIM MCENTEE JOIN ELMC RISK SOLUTIONS’ IOA RE DIVISION, EXPANDING THEIR LABOR AND PUBLIC SECTOR FOCUS East Norriton, PA -- IOA Re, LLC (“IOA”), a subsidiary of ELMC Risk Solutions, LLC, (“ELMC”) is pleased to announce that Arlene Cayetano and Jim McEntee have joined IOA effective September 1, 2019 and will head a new division of IOA under the brand, CM Risk Management. The addition of Cayetano and McEntee as the leaders of the CM Risk Management team enhances IOA’s reputation as a national leader in providing managing general underwriting services and strengthens ELMC’s

NOVEMBER 2019

NEWS growing portfolio of stop loss, reinsurance, and consulting services offered through IOA Re, RxReins, Sequoia Reinsurance, Rockport Benefits, AST Risk, and ELMC Rx Solutions. Both Ms. Cayetano, who will be General Manager and Executive Vice President of the CM Risk Management Division, and Mr. McEntee, who will serve as Senior Vice President of Sales, are well known industry veterans with extensive experience in working with Taft-Harley Health Plans popular in the labor and public sector markets. CM Risk Management’s team will be based primarily out of Indianapolis, Indiana. Ms. Cayetano has more than 30 years of employee benefits underwriting and management experience. Prior to joining IOA Re, she served as the President and CEO of Greymatter. Prior to that she was with AIG Benefit Solutions as the Vice President of Underwriting. Mr. McEntee has more than 30 years of experience in sales and business development within the public sector and labor markets. Prior to serving as Executive VP of Sales at Greymatter, he was the Vice President of Taft Hartley Sales for AIG, VP of Taft Harley Sales for HCC Life and also held leadership positions with Pacific Mutual Group, Safeco and Stop Loss International.

Richard J. Fleder, CEO of ELMC, stated “Arlene and Jim’s knowledge of the Labor and Public Sector stop loss marketplace will allow us to serve these clients from the start with the highest standards of integrity, quality, professionalism, and performance.” John O. Parker, President of IOA is enthusiastic about bringing the CM team aboard, “We have great respect for Arlene and Jim, and believe their skills are an asset to and complement IOA’s strengths. Their knowledge of the labor and public sector markets and sales and underwriting expertise combined with our superior back office and operations platform will broaden our appeal to the market.”

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NEWS

Joining the IOA team will bring numerous benefits to clients, brokers and TPAs. IOA’s resources will allow us to focus on delivering best in class stop loss solutions to the marketplace. We have been impressed with IOA’s client-focused approach to its business and partners and believe this approach will bring the best of both worlds to clients and producers.” Arlene Cayetano agrees with Parker’s sentiment, “

About ELMC ELMC owns, manages and seeks to acquire premier MGUs across the nation that specialize in underwriting stop loss insurance for self-funded health plans as well as reinsurance for providers and managed care companies. ELMC provides a best-in-class platform for delivering solutions to brokers, carriers and clients. Visit www.elmcgroup.com. About IOA IOA Re has operated in the insurance/reinsurance marketplace for more than 40 years and provided Medical Stop Loss services for more than 35 years. IOA Re is recognized as leader in the Medical Stop Loss industry for its creative, innovative, and profitable underwriting and the caliber of the services provided to clients. Visit www.ioare.com.

SYMETRA APPOINTS MIGLENA ROGAN VICE PRESIDENT OF UNDERWRITING FOR STOP LOSS BELLEVUE, WA -- Symetra Life Insurance Company, a leading medical stop loss carrier for more than 40 years, announced that Miglena Rogan has joined the company as vice president, stop loss underwriting. Ms. Rogan brings 14 years of strategic experience in medical stop loss and group benefits to her new role. Most recently, she led the Stop Loss Collaborative at Willis Towers Watson in St. Louis, where she also served as a director in their Health & Benefits division. She previously held senior actuarial roles at Ascension Health and Towers Watson in St. Louis. “Symetra’s stop loss unit is a cornerstone of our Benefits Division business line and a critical component of the solutions-driven product suite we offer employers looking to effectively manage their healthcare costs. Miglena’s broad group benefits industry expertise spans strategic planning, risk management, plan design and

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implementation. We are pleased to have her lead Symetra’s stop loss underwriting team as we further expand and strengthen our position in the market,” said Jeremy Freestone, senior vice president, Stop Loss. Ms. Rogan reports to Mr. Freestone and is based out of Symetra’s Enfield, Connecticut office. Ms. Rogan is a Fellow of the Society of Actuaries, a member of the American Academy of Actuaries, and a Chartered Enterprise Risk Analyst. She earned bachelor’s degrees in mathematics and in business administration with a concentration in finance from Truman State University in Kirksville, Missouri. About Symetra Symetra Life Insurance Company is a subsidiary of Symetra Financial Corporation, a diversified financial services company based in Bellevue, Washington. In business since 1957, Symetra provides employee benefits, annuities and life insurance through a national network of benefit consultants, financial institutions, and independent agents and advisors. Contact Diana McSweeney at (425) 256-6167, diana. mcsweeney@symetra.com and visit www.symetra.com.

AMWINS GROUP, INC. TO ACQUIRE SPECIALTY GENERAL AGENT STEALTH PARTNER GROUP CHARLOTTE, NC -- AmWINS Group, Inc., a global distributor of specialty insurance products and services,

NEWS announced that it has signed a definitive agreement to acquire Stealth Partner Group (“Stealth”), an Arizona-based, independent full-service general agent (GA) specializing in medical stop-loss insurance. In early 2020, Stealth will combine with Stop Loss Insurance Services (“SLIS”), an AmWINS Group company, to form the premier stop-loss general agency in the United States. Operating under the Stealth brand and led by Patricia Berridge and Harley Barnes, the combined firm will be part of AmWINS’ Group Benefits division. Berridge and Barnes will be highly focused on combining the best of both firms in order to provide exceptional products and service to retailers and their self-funded clients. “We’re excited to partner with Patty, Harley, and the entire team at Stealth,” said Scott M. Purviance, Chief Executive Officer of AmWINS. “As the number of self-funded employer groups continues to increase, the addition of Stealth significantly expands our ability to empower brokers to provide stop-loss and cost containment solutions to their self-funded clients.” Based in Scottsdale, Ariz., Stealth has seven regional sales offices throughout the country. The incredible growth of the firm since its creation in 2009 demonstrates

how Stealth’s comprehensive approach has resonated in the specialty GA space. “We are looking forward to joining the AmWINS family and expanding our offering through this partnership,” said Patty Berridge, co-founder of Stealth. “We know our employees and clients will benefit from the merger of two highly specialized firms, rooted deeply in the stop-loss space.” “The partnership between Stealth and SLIS will generate incredible value and opportunity for group benefits brokers and their clients,” said Harley Barnes, co-founder of Stealth. “We look forward to working with Rebecca Bocek, Gerry Gates and the entire team at SLIS. Together, our two firms will provide us with unique access to all of the leading

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NEWS and handles premium placements in excess of $16 billion dollars annually. Visit www.amwins.com. About Stealth Partner Group Stealth Partner Group was founded in 2009 and has grown to be one of the largest specialized general agencies in the country. The firm partners with brokers, consultants, and third-party administrators (TPAs) to

stop-loss markets and enable us to build a wide range of other value-added capabilities that support our carrier partners, retail brokers, and their selffunded clients.” The transaction is expected to close in the fourth quarter of 2019, pending regulatory approval and customary closing conditions. Dowling Hales served as financial advisor to Stealth. Terms of the transaction were not disclosed. 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 brokers 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

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negotiate, implement, and assist in managing medical stop loss and ancillary benefits with the nation's top-tier carriers. With offices in Phoenix, Atlanta, Dallas, San Francisco, Denver, Detroit and Charleston, Stealth offers its clients more than 125 years of collective experience in the stop loss and ancillary insurance marketplace. Visit www. stealthpartnergroup.com. About Stop Loss Insurance Services, Inc. Stop Loss Insurance Services, Inc. is the result of AmWINS Group’s acquisition and concurrent merger of three of the leading medical stop loss insurance wholesalers in the industry in 2009: American Stop Loss, Health Benefits Solutions, and MedEx. Stop Loss Insurance Services, Inc. is one of the largest wholesale distributors of medical stop-loss insurance in the United States, representing over $190 Million in annualized stop-loss premium. With over 30 years of experience, the company is able to leverage its collective expertise and relationships to provide clients with high-quality services and innovative solutions. Visit stoploss.amwins.com.

HM INSURANCE GROUP ANNOUNCES ROBERT MELILLO AS MANAGED CARE REINSURANCE VICE PRESIDENT PITTSBURGH – Robert Melillo has joined HM Insurance Group (HM) in the role of vice president, sales and account management, for the company’s managed care reinsurance line of business. In this role, he will be responsible for product distribution and new business development, along with the expansion of HM’s market presence in the managed care reinsurance space.

NEWS “I’ve known Rob for years, and his understanding of reinsurance is exceptional,” Tom Doran, president, HM Insurance Group, said. “He uses his high-level market knowledge to bring a consultative approach when working with partners and clients, and that aligns well with how we do business at HM.” Melillo has more than 20 years of insurance experience in underwriting, sales and product/business development across a variety of group benefit products, including managed care services. Most recently, he served as a principal consultant for RJM Consulting where he provided subject matter expertise to the self-funded health care marketplace. Prior to that, he served as the second vice president and head of stop loss at Guardian Life and national vice president, Risk Financing Solutions, at USI. Additionally, Melillo has worked at several other top insurance companies, including Sun Life Financial and GE Insurance Solutions (ERC), as well as in the Lloyd’s of London market. HM’s managed care reinsurance product line includes health plan reinsurance and provider excess insurance. These products are designed to cover excess risk and work to reflect the changing dynamics of the health care market, aligning well with the company’s employer stop loss products and solutions. About HM Insurance Group HM Insurance Group (HM) works to protect businesses from the potential financial risk associated with catastrophic health care costs. The company provides reinsurance solutions that address risk situations confronting employers, providers and payers. A recognized leader in employer stop loss, HM also offers managed

care reinsurance nationally. Through its insurance companies, HM Insurance Group holds insurance licenses in 50 states and the District of Columbia and maintains sales offices across the country. Visit hmig.com.

GOLD MEMBERS WINDSOR STRATEGY PARTNERS APPOINTS PAUL FALLISI AS PRESIDENT, FOUNDER DAVID WILSON WILL CONTINUE AS CHIEF EXECUTIVE OFFICER PRINCETON, NJ -- Windsor Strategy Partners Inc., a leading health care actuarial firm, announced that Paul Fallisi, FSA, MAAA has been appointed president. Fallisi succeeds David Wilson, FSA, FCIA, MAAA, founder of the company, who will remain in the role of Chief Executive Officer. His appointment is effective immediately.

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NEWS Fallisi has more than 30 years of health care actuarial and reinsurance experience. Prior to joining Windsor Strategy Partners in 2017, Fallisi served as president and CEO of Munich Re Stop Loss. He was also a co-founder of Cairnstone Re, which was later purchased by Munich Re, and held actuarial and senior leadership positions at John Alden Life Insurance Company. Fallisi attained a FSA designation from the Society of Actuaries and is a Member of the American Academy of Actuaries (MAAA). He earned a bachelor’s degree in Actuarial Science from Temple University. “As Windsor Strategy Partners prepares for its next phase of growth, we wanted a leader with direct experience in helping companies achieve their goals,” said Wilson. “I’ve worked with Paul in various capacities over the past 30 years and have always been impressed with his leadership, innovation and commitment to excellence. We believe Paul is an outstanding choice to serve as our company’s next president and we look forward to his many contributions.” “I am very excited to accept the role of president,” said Fallisi. “Since joining Windsor Strategy Partners, I have seen first-hand the organization’s commitment and dedication to finding solutions to health care issues our clients are facing. I am very excited about serving in this important position and to build upon the organization that Dave and his amazing team have created and strengthen our position as a leading actuarial firm in the health care industry.”

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NEWS “I am thrilled to have Paul become part of our executive management team,” said Jim Tillett, Windsor Strategy Partners’ chief operating officer and chairman of the board of directors. “This is an exciting time for our company and the health care insurance industry. Paul has the experience, skills, passion and innovation to help take us to the next level.” About Windsor Strategy Partners Windsor Strategy Partners is a leading healthcare actuarial firm specializing in pricing, program evaluation, product development, and portfolio risk management. Based in Princeton, NJ and founded in 2004, the firm provides actuarial services to a wide range of health care industry stakeholders including insurance companies, managed care organizations, investment groups, plan sponsors and health care entrepreneurs. Visit www.wspactuaries.com.

BERKSHIRE HATHAWAY SPECIALTY INSURANCE ADDS MIKE GASTINEAU TO MEDICAL STOP LOSS TEAM Stop Loss Actuary, Michael “Mike” Gastineau has joined the Berkshire Hathaway Specialty Insurance Medical Stop Loss team. Mike comes to BHSI from Tokyo Marine HCC and will provide his expertise in stop loss pricing to his new team. It will be a smooth transition as he has worked with several BHSI team members at previous companies. His contribution has always been of the highest value, and the BHSI stop loss team is excited to have him on board. Contact Mike at Michael.Gastineau@bhspecialty.com. About Berkshire Hathaway Specialty Insurance Medical Stop Loss We make choosing your Medical Stop Loss insurer simple. As part of Berkshire Hathaway Specialty Insurance, we come to the table with a name you know and trust. People with industry track records that span decades. And the financial strength to tailor your coverage, pay covered claims quickly…and keep pace with your evolving needs, year after year. Visit www.bhspecialty.com.

AMPS ENHANCES ITS STRATEGIC CONSULTING SERVICES WITH THE ACQUISITION OF INVENTAVIS ATLANTA, GA -- Advanced Medical Pricing Solutions (AMPS), the pioneer in cost containment for the self-insurance industry, announced the acquisition of Inventavis, LLC, a leading strategic consulting firm founded by Lawrence Thompson and Steve Manzelli.

Inventavis services a wide range of customers through innovative, expert strategic guidance on a variety of business elements including new customer markets, programs, services and products for the Health plan vertical. Customer segments include health systems, insurance carriers, technology vendors, Third Party Administrators, employer groups, Taft Hartley organizations, associations, healthcare investors and select brokers/consultants. “The acquisition of Inventavis strengthens our ability to form partnerships with health systems, Association Groups, TPAs and other strategic channels to deliver cost containment solutions to the health care market,” explained Kirk Fallbacher, AMPS CEO and President. With the acquisition of Inventavis, Lawrence Thompson is joining AMPS as Chief Strategy Officer. Larry brings 40 years of success in the benefit industry and will lead AMPS strategic initiatives with health systems, association plans, TPAs and other strategic channel segments. His knowledge of administration, technology, compliance, plan design, reinsurance and the market will make him a critical resource for AMPS strategic partnerships and clients. Larry has worked for major insurance carriers, the Blues, TPAs and technology companies. He is a nationally recognized speaker on healthcare, has served on several association Boards and frequently works on State & Federal healthcare regulation.

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NEWS Kirk continued, “We are pleased to have Larry join our team as Chief Strategy Officer. The rapid changes in the health care market require all companies to be strategic and nimble. We look forward to Larry helping position AMPS for continued growth.

“I am pleased to be joining the AMPS leadership team as I feel that the cost of US healthcare is the most significant problem our system has, and AMPS provides tools to address this issue. I look forward to guiding AMPS as we innovate and work with both health systems and self-funded employers in managing the cost of care based on value.”

innovative dashboards and analytics to provide clients with insights based on Plan performance. Visit www. advancedpricing.com.

Mr. Thompson said,

About AMPS Advanced Medical Pricing Solutions (AMPS) provides market leading healthcare cost containment services for self-funded employers, public entities, brokers, TPAs, and reinsurers. AMPS mission is to help clients attain their goals of reducing healthcare costs while keeping members satisfied with quality healthcare benefits. AMPS leverages 15 years of experience in auditing and pricing medical claims to deliver "fair for all" pricing both pre-care and post-care. AMPS offers

PARTNERRE NAMES NICOLAS BURNET AS CFO TO SUCCEED RETIRING MARIO BONACCORSO PartnerRe Ltd. has named Nicolas Burnet to succeed Mario Bonaccorso, executive vice president and chief financial officer, who will retire from the company on March 31. Mr. Burnet will join PartnerRe on Feb. 3. He joins the reinsurer from the Zurich Insurance Group, where he was most recently chief risk officer and chief financial officer. Mr. Bonaccorso, who is leaving to pursue an entrepreneurial venture with financial support from PartnerRe owner and Turin, Italy-based Exor S.p.A, will be invited to join the PartnerRe board of directors as a non-voting observer, the statement said. “Nick brings deep experience in risk, capital, and finance functions in both the Life and Non-Life businesses that will benefit us as we continue to grow as a composite reinsurance company,” PartnerRe President and CEO Emmanuel Clarke said in the statement. Additionally, Andrew Gibbs was named to the newly created role of executive vice president and chief operations officer, effective Oct. 14, with responsibility for the company’s end-to-end underwriting processes, including underwriting support, reinsurance accounting, claims, payments and collections, as well as its

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NEWS Craig Maloney most recently served as president of Aon Voluntary Benefits and Enrollments Solutions Division, where he spent 20 years of his career. Prior to Aon, he spent nearly ten years at Marsh Inc., a global leader in insurance and risk management. Bringing his rich experience in employee health and benefits, Maloney is prepared to further Maestro Health’s mission and lead the company to its next phase of growth.

legal, compliance and internal audit services, the statement said. He joins from Maiden Reinsurance Ltd., where he most recently was executive chairman. Mr. Burnet and Mr. Gibbs will be based at the company’s Bermuda headquarters.

“I’ve observed Maestro Health from afar since its founding and have a great deal of respect for the company’s history, vision, unmistakable culture and progress under Rob’s leadership,” said Maloney. “I

“The past five years at Maestro Health have been filled with major accomplishments, including the company’s acquisition by AXA,” said Butler.

am excited to join the company for many reasons, not the least of which is the mission to make employee health and benefits people-friendly again. My experience in the employee benefits space paired with Maestro Health’s commitment to improving the healthcare experience for all will enable us to accelerate the execution of the company’s key initiatives. I look forward to building upon the momentum I’ve seen thus far, together with a very talented team.”

“Together, we’ve enhanced our product and service offerings and gained operational efficiencies, and both AXA and I believe unwaveringly in our company’s future success. Given the strength of our partnership and headway we’ve made in the market, I’ve decided that now is the right time to exit. I am grateful to the Board of Directors for supporting me in this decision to pursue new challenges. With AXA and our Maestro Health employees, let me be the first to welcome Craig to the Maestronite family.”

Maestro Health was created to simplify and personalize how people shop, enroll and live with their healthcare benefits. Upon its acquisition in 2018 by AXA, the worldwide leader in insurance and asset management, Maestro Health has expedited the shared mission to lower

SILVER MEMBERS MAESTRO HEALTH ANNOUNCES DEPARTURE OF FOUNDER ROB BUTLER; APPOINTS CRAIG MALONEY AS NEW CHIEF EXECUTIVE OFFICER CHICAGO -- Maestro Health, a leading all-in employee health and benefits company, announced its Board of Directors has accepted the resignation of Founder Rob Butler from the position of Chief Executive Officer and has appointed Craig Maloney as its next CEO, effective Oct. 7, 2019.

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NEWS healthcare costs, reduce complexity and empower consumers. Fully committed to helping transform the U.S. healthcare market, AXA has continued to invest in Maestro Health to help the company scale and industrialize their solutions.

pursuing its efforts to bring new solutions and services to the U.S. healthcare market under Craig’s leadership.”

“Rob Butler has been instrumental in maintaining Maestro Health’s continued success,” said Guillaume Borie, Chief Innovation Officer, AXA. “On behalf of the Board, we thank Rob for his passion and commitment to Maestro Health, its customers and employees, and wish him the best in his future endeavors. I am very happy to welcome Craig and have great confidence that he will further position Maestro Health for success. AXA is looking forward to accelerating the development of Maestro Health and

With nearly 400 employees, including more than 80 hires since the start of 2019, it has also been recognized with some of the industry’s most prestigious awards and accolades, including Fortune’s “Coolest Companies to Work For,” Chicago Tribune’s “Top Workplaces,” and ChicagoInno’s “Coolest Companies.” Maestro Health has also been recognized by the American Business Awards in the “Most Innovative Company of the Year” and “Tech Startup of the Year” categories.

Maestro Health works with leading employers of all sizes and its customer base continues to grow rapidly, currently serving over 700 groups on its maestroEDGE™ platform.

“I’ve become familiar with the business and its culture, and I’m confident in Maestro Health’s strategy to improve health outcomes for consumers while lowering costs for employer and employee alike,” continued Maloney. “I look forward to working in close coordination with the Board and the rest of the talented Maestro Health team to serve customers while acting as a disruptor in the space.”

From operating rooms to board rooms,

QBE is there.

No matter where you do business, you can trust QBE to deliver flexible solutions for self-funded and alternative risk structures. As an integrated specialist insurer, QBE applies deep technical expertise to deliver future-ready products, customized underwriting solutions and superior service — all backed by a strong balance sheet and well-diversified portfolio. Turn to QBE for the certainty you need to manage your business across the globe and discover what’s possible, wherever you are.

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NEWS About Maestro Health™ Maestro Health makes employee health & benefits people-friendly again by delivering an all-in platform that works together to improve the health of employees while lowering costs and administrative burdens for employers. Maestro Health owns and operates the three most strategic components of an effective employee health & benefits program: (me) SELF-FUNDED BENEFITS™, (me) BENEFITS ADMIN 2.0™ and (me) BENEFIT ACCOUNTS™. The flexible solutions are designed and unified on a tech-meets-service platform, maestroEDGE™, so customers can customize their own HR suite based on what works best for their unique needs—all to optimize and simplify the way employees and employers shop, enroll and live with their benefits. Contact Lauren Metsig at 312.517.3521, lmetsig@maestrohealth. com and visit www.maestrohealth.com.

ACS BENEFIT SERVICES ANNOUNCES NEW CFO, LANA DAVIDSON Winston-Salem, NC – Following a national candidate search, ACS Benefit Services has announced the addition of Lana Davidson, CPA, as the company’s new Chief Financial Officer. As a key member of ACS’ executive team, Davidson will report directly to ACS CEO Kari Niblack and be responsible for directing the fiscal function of the company, including managing all financial activities and ensuring that day-today operations proceed efficiently and

effectively. She will also support Niblack in ensuring that resource allocation and utilization reflects and facilitates the achievement of ACS’ goals and strategic vision. Davidson comes to ACS from Wake Forest Baptist Health/High Point Regional Health, where she has served for the past seven years as Controller and Director of Accounting. While there, she directed the accounting, consolidated reporting, and oversaw budgets, payroll, accounts payable, and audits. Prior to working with the hospital systems, Davidson was the VP of Finance and Administration at United Way of Greater Greensboro for ten years, where she directed all financial operations and Human Resource functions. Before that, she worked as an auditor and tax manager. “Lana brings an incredible breadth of knowledge and experience to the table,” said Niblack. “Her stellar financial background and proven track record as a leader will be invaluable as we continue to maximize results for our clients, deliver profitable growth and drive business value across our product lines. We couldn’t be more thrilled to welcome her to the ACS family!” About ACS Benefit Services Founded in 1982, ACS Benefit Services was formed on the realization that there needed to be better benefit solutions and health plans available in the marketplace. Since then, ACS has grown to be a leading third-party administrator by focusing on the future of the industry, creating long-term solutions, and predicting the benefit administration needs of our employer groups. Contact Kari L. Niblack, JD, SPHR, Chief Executive Officer, at KNiblack@ACSbenefitservices.com and visit ACSbenefitservices.com.

GILSBAR, LLC NAMES DERREK BARFIELD STRATEGIC SALES DIRECTOR COVINGTON, LA -- Gilsbar is proud to announce a title and role change expansion for Derrek Barfield from Senior National Sales Executive to Strategic Sales Director. With this role expansion, Mr. Barfield will continue to grow Gilsbar in the Carrier Outsourcing marketplace with a focus on building relationships and creating partnerships. Working with carrier and affinity partners has been a central part of Gilsbar's 60-year history, and this expansion is a commitment to investing in the capabilities to make those partnerships an even larger part of Gilsbar's organization. With almost 20 years of experience, Mr. Barfield has successfully executed the role of Employee Benefits Department Manager, overseeing the reinsurance and account

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NEWS management functions for self-funded employer business. In addition, he has managed several national life, medical and ancillary programs for carriers, and executed outside sales responsibilities for Gilsbar's fully-insured agency business.

"Gilsbar has been fortunate to partner with various insurance carriers and affinity/association groups across the country, especially in the past several years," shared Mr. Barfield. "As an independent administrator with a national footprint, we believe we are well positioned today and are eager to invest in additional capabilities to expand those carrier and affinity partnerships tomorrow." Ryan Haun, Gilsbar Vice President, stated, "Gilsbar remains committed to investment and growth of this component of our business. Having industry leaders such as Derrek on our team will ensure success, and he has earned the recognition of his talent and efforts."

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About Gilsbar, LLC Established in 1959, Gilsbar, LLCÂŽ is one of the largest privately-held insurance services organizations in the country. Recognized as a catalyst for creating healthy businesses, Gilsbar, LLCÂŽ offers self-funded and fully-insured benefit plan management services, along with Wellness, Advocacy, and overall Population Health Management. Gilsbar, LLC's integrated delivery model improves the health and well-being of its members, resulting in significant health plan savings for its clients. Gilsbar, LLCÂŽ has been honored by Inc. magazine for its sustained growth, Modern Healthcare and Business Insurance magazines as a Best Place to Work, and WELCOA and the American Heart Association for its proven wellness methodology. Visit www.Gilsbar.com.

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, WORKERSâ&#x20AC;&#x2122; COMP COMMITTEE Mike Zucco Business Development ATA Comp Fund Montgomery, AL

Les Boughner Director Alex Giordano Director

NOVEMBER 2019

SIIA new members novemBER 2019

REGULAR CORPORATE MEMBERS Jason Jurgill ABD San Mateo, CA

Stan Smith Gradient A.I. Cambridge, MA

Bri Koopmans VP Business Administration analytic.li LLC Indianapolis, IN

Brian Johnson President & Consulting Actuary Risk International Actuarial Consulting Charleston, SC

Denny Weinberg CEO Strategic Advisor BMEB Santa Rosa Valley, CA Kerry Drake President, Employee Benefits BXS Insurance Baton Rouge, LA John Duldner CEO Connect & Care, LLC Columbia Station, OH David Kwasny CRO Drexi Chandler, AZ David Vizzini CEO EquitasDx Portland, OR

Deborah Masse UnityRe Gloucester, MA Mitchell Ma CEO Zhibao Technology Shanghai limited Shanghai, China

SILVER CORPORATE MEMBER

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

Rajesh Rao CEO IndusHealth Raleigh, NC

EMPLOYER CORPORATE MEMBER Michelle Pryse Director of HR PESI, Inc. Eau Claire, WI

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

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