The Self-Insurer 2024 August Issue

ONSITE, NEAR-SITE CLINICS

What’s Working for Employers

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By Anthony Murrello

By Laura Carabello

By Caroline McDonald

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By Bruce Shutan

HIPAA PRIVACY PROTECTIONS FOR REPRODUCTIVE HEALTHCARE: WHAT IT MEANS FOR REGULATED ENTITIES THE AFFORDABLE CARE ACT (ACA), THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) AND OTHER FEDERAL HEALTH BENEFIT MANDATES

ONSITE, NEAR-SITE CLINICS

What’s Working for Employers

Written By Laura Carabello

AAtop-of-mind concern among voters in the upcoming 2024 presidential election is healthcare affordability. Along the campaign trail, candidates will be debating the best solutions for controlling runaway expenditures as the cost of providing healthcare services continues to accelerate due to advances in medical technologies, the rising cost of prescription drugs, system inefficiencies and mounting labor shortages.

Voters nationwide say it is difficult to afford healthcare costs, as the Kaiser Family Foundation reports that about half of U.S. adults say they can’t manage to pay for needed services and one in four say they or a family member in their household had problems paying for healthcare in the past 12 months.

“An onsite medical center is the best way to provide affordable healthcare and, at the same time, inspire employees and families to achieve optimal well-being and health,” says Ernie Clevenger, president of My Health Guide. “When quality care is delivered with compassion, enthusiasm and innovation, patients’ health outcomes improve, and healthcare cost trends decline. Over 80 percent of employers with onsite care find total healthcare costs trends decline compared to the traditional market.”

When physicians, patients and payers can work in concert to achieve the highest and best outcomes, Clevenger says, “it’s a win-win-win.”

One crucial aspect to onsite clinics that Zahoor Elahi, COO, Health at Scale often sees overlooked is this: “The “what next”? Employees visiting the clinic will frequently need specialist care not offered,

which is a rare opportunity for employers to support them with navigation to specialists who are well-suited to their needs, and more likely to help them achieve superior health outcomes.”

CHOOSE THE BEST MODEL FOR YOUR BUSINESS: ONSITE OR NEAR-SITE CLINIC

When managed effectively, both approaches are documented to improve access to care and lower costs. Selecting the right model for your workforce will drive utilization, ensure employee adoption and satisfaction and ultimately fuel cost savings.

 An onsite clinic allows employers to offer medical and wellness services delivered by primary care physicians and other licensed practitioners in settings that are located directly at their companies.

A wide range of services can be offered to all or a portion of eligible employees, including general first aid or treating minor illnesses to primary care appointments and ongoing management of chronic diseases. The Business Group on Health reports that in 2023, 53% of large employers offered this option, and a Mercer study found that nearly a third of all organizations with at least 5,000 employees offer a primary care clinic to their employees, rising to 38% for employers with 20,000 or more employees.

 A near-site or multi-employer, shared clinic model is a healthcare facility primarily managed by a third-party provider that is usually located near an employer and can be used by multiple employers in a specific area. The vendor takes charge of day-to-day operations, collaborates with employers on goals, staffing, and engagement and can offer a variety of services, including primary care, occupational health, and urgent care.

They can also be used to supplement onsite clinics by allowing employees’ families to use them. This model is a good option for mid-size and small employers or workforces with employees spread out among multiple locations within the same geographic area, allowing them to reap the benefits of better healthcare, regardless of size.

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David Voorhees,

SHRM-SCP, CEO, True Captive,

explains,

“Our organization works with customers who are interested in sponsoring onsite and near-site clinics, primarily because they offer enhanced quality of care, convenience for their employees, and effective control over healthcare costs. We outsource the management of the clinics to various partners based upon geographic region and their shared focus, which aligns with the business for which we are installing the solution.”

He says that this practice has significantly impacted their member experience, offering more comprehensive health coverage and resulting in betterquality healthcare outcomes that focus on the employee/patient experience.

“Our member employees have expressed high satisfaction with the convenience and quality of care provided, which has, in turn, led to improved overall productivity and financial success for both the employee/member and the sponsoring organization,” he adds.

Making the decision to manage a clinic with in-house resources and employ or contract for staff directly vs. outsourcing administration to a third-party management company depends upon a company’s capabilities, although the vast majority of employers now choose to outsource as they expand

the range of services offered in their worksite clinic. Outsourced management increases the scope of resources for staff management, risk avoidance, clinical oversight and access to electronic medical records, analytics and reporting.

Employers also wrestle with issues related to employee cost or copays for onsite clinic services. An increasing number of employers offer them as part of their benefits plans—not only to improve employee health but also as a way to reduce healthcare costs for their businesses. It is important to remember that steep charges are likely to make employees less likely to engage and the employer less likely to achieve a significant ROI. Offering employees financial incentives can encourage them to use onsite care, with some of the most popular incentives including:

• Eliminating employees’ co-payments

• Reducing the dollar amount of co-payments.

• Decreasing employees’ premium contributions.

• Offering the clinic as a plan option.

• Contributing to employees’ HSA accounts.

• Providing cash or gift cards.

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SOURCE: KFF Employer Health Benefits Survey 2023

PILLARS OF SUCCESS

ACCESS

Nearly all respondents to the Mercer-sponsored study indicated that providing their employees with access to quality care was a key consideration in the decision to open and maintain a clinic. Employers increasingly see worksite clinics as a way to provide convenient, quality, and cost-effective primary care, not just to employees but to their family members as well.

Just 40% of sponsors with 5,000 or more employees limit the use of the clinic to employees only, while the majority permit family members to use the clinic: 59% allow spouses and domestic partners, and 49% allow children. The study also documented clinic utilization rates, with the percentage of eligible individuals accessing clinic services at least once during the year averaging 52% for employees.

Access to behavioral health services is another key clinic offering, as Dani Kimlinger, Ph.D., CEO, Mines & Associates, points out, “Our organization provides therapists in the self-insured space to onsite

and near-site clinics. We contract with both clinics and client organizations directly, depending on their needs and structure.”

She says the onsite, near-site clinic model is an attractive option for employers in terms of quality care, convenience and cost control, adding, “Having a therapist onsite or near-site allows for easy access to mental health services, which are an integral part of overall healthcare. Many still see a separation between “mental health” and “physical health,” but this relationship cannot be separated.”

For example, a patient managing diabetes who is also experiencing depression may struggle to comply with daily blood tests and make healthy food choices.

“By addressing their depression, they can better manage their diabetes,” she continues. “Additionally, an integrated intake process between the clinic and behavioral health partner can help identify underlying mental health issues contributing to physical symptoms, like lack of sleep and headaches. It is crucial for all partners associated with the clinic to work together to integrate all services and provide comprehensive care.”

The experience of having onsite or near-site clinics and integrating mental health services has shown positive impacts on benefits and overall healthcare quality. Kimlinger states that by

providing easy access to mental health services, employers can support their employees’ wellbeing and address underlying issues that may impact physical health.

“This comprehensive approach to healthcare can lead to better outcomes, improved employee satisfaction and cost savings in the long run,” she says. “In most all our clinic contracts, there is no co-pay for the therapy sessions to allow for a low barrier to entry, and the client organization is always welcome to participate in the hiring process to allow for the best possible fit for the organizational culture is selected.”

Employers have the option to outsource directly for behavioral health services with organizations such as MINES which provide clinical supervision and oversight, acting as the employer for the therapists.

“This arrangement allows us to have a direct role in managing the therapists and ensuring quality care,” says Kimlinger. “However, we also understand that some organizations may choose to outsource the overall management of the clinic to a vendor, and we collaborate with the clinic management if that is the case.”

COST SAVINGS

In addition to ensuring convenience and ready access to quality healthcare services

for employees, saving on healthcare costs is a driver for companies deciding to offer this option. Measuring the return on investment (ROI) and value on investment (VOI) of a clinic can be extremely complex. Many attribute savings generated by preventive care, a strategy that decreases healthcare expenditures by:

o Increasing diagnostic screening, early detection: mammography, colonoscopy

o Implementing vaccinations, such as influenza.

o Managing chronic conditions: medication compliance, blood pressure checks, laboratory tests for lipid or glucose management.

Seattle Children’s attributes employee engagement as the key to savings. Over the course of five years, the organization reaped nearly $16 million as a result of their onsite clinic:

• 10% drop in prescriptions

• 80% drop in hospital stays

• 20% drop in PMPM ambulatory expense

• 3.5 million net savings in 24 months

One provider of services, OnSite Health, reports that on average, employers save $1,200 per employee per year through an onsite healthcare program, attributed to reduced absenteeism, improved productivity and lower healthcare costs resulting from early detection and management of chronic diseases.

Further confirmation of savings comes from Bobbie Jo Aue, Director, Product Development, The Alliance, “Some employer-members of The Alliance utilize onsite or near-site clinics which increase access to care by providing services at or close by the employees’ place of work. These clinics are also a cost reduction strategy as services performed at these clinics are often significantly less expensive than services performed at traditional doctors’ offices or health systems.”

She says that the use of these clinics and/or Direct Primary Care (DPC) clinics can help employers lower their total cost of care by 15-30%, with cost savings typically beginning 12-18 months from inception.

“By using these models, employers can offer care at low or even no cost to their employees and covered family members and still save money,” she continues. “Offering access to high-quality, low-cost care also fosters trust with employees and encourages them to prioritize their health and utilize preventative care, which results in lower healthcare costs in the future.”

STUDIES VALIDATE SAVINGS

The cost of onsite clinic care as a percent of total health plan spending varies widely, with the majority of Mercer survey respondents reporting that it accounts for between 2% and 10% of spending. Only 14% say the clinic accounts for less than 2% of total spending on healthcare, while 25% of respondents did not know the cost of clinic operations relative to total spending.

Another interesting aspect of the survey is that a majority of clinics (63%) are part of the employer health plan, and about one quarter (27%) submit zero-dollar claims to the health plan to ensure clinic services are part of total health data on population. Nearly a fifth (17%) collect fees through the clinic and submit them to the health

plan for accumulation towards deductible and out-of-pocket maximums. Another 13% are part of the health plan but do not submit claims.

Another study reported in the Journal of Nursing showed the cost of a visit to an onsite clinic is less expensive than the same visit to an off-site clinic, often due to lower operational costs at a worksite clinic than at a community clinic.

Additionally, employees can seek prompt treatment for health concerns for which they would typically see a primary care provider, thereby receiving

costs associated with unscheduled absences from work, the burden of which is high for companies. The cost of absences can add up in direct payroll cost and indirect costs, such as overtime to co-workers covering work of absent employees or payment for temporary workers to cover the absence and further increasing healthcare costs for the company.

A more recent cohort study (JAMA; 4.30.2020) of 23,518 commercially insured employees assessed the utilization and cost of a comprehensive primary care model that incorporates employersponsored onsite, near-site, and virtual primary care. A subset of the population with most primary care visits through employer-sponsored onsite, near-site, or virtual care clinics was matched to a subset not having most such visits through the employer-sponsored clinics using propensity score matching.

Findings document that the employer-sponsored services cost a mean standard deviation of $87 ($32) per member per month after accounting for infrastructure and service costs. Members used the model clinics for most of their primary care, having higher primary care costs but lower total healthcare costs in a matched cohort analysis controlling for demographics, diagnoses and risk.

These findings suggest that lower total healthcare costs per person and higher primary care costs may be associated with preferential use by lower-risk persons and/or with the use of comprehensive primary care.

CONVENIENCE

Employers that desire to increase convenience for employees are implementing onsite/near-site clinics to provide physical and mental healthcare. This option provides not only easy access for workers but also ensures that they are prioritizing regular, preventive care.

In addition, clinics added virtual care options, as National Association of Worksite Centers reports the use of clinic-based telehealth is expanding significantly, rising to 78% in 2021 from just 21% in 2018. Clinics providing telehealth have moved quickly to offer a range of virtual advanced primary care services including disease management and coaching, behavioral health and physical therapy.

“The importance of convenient access to healthcare for employees cannot be overstated,” states Jonathan Wiesen, MD, cofounder and Chief Medical Officer, MediOrbis. “It is a vital benefit, improves wellness and productivity, prevents absenteeism and lowers overall total healthcare costs. With the emergence of telemedicine as an

important adjunct to traditional care, the value of virtual employee clinics is self-evident.”

In addition to the added convenience that it provides, employees can now receive care wherever they are located and at whatever time they are available.

“The cost savings and ROI for both general telemedicine as well as virtual primary care have been well described,” he continues. “Many telehealth services provide holistic virtual patient care to ensure that employees have all of the clinical programs and services that they need to function at a high level, and at their healthiest capabilities, in the workspace.”

Dr. Wiesen shares this personal anecdote demonstrating his own experience with an onsite clinic at the hospital where he was working:

“A few years back, I was iceskating with my daughter, who stumbled and fell backward. I quickly realized that I had to keep her upright by grabbing her hands, but in doing so, I lost my own support. Without my hands to brace myself, I fell directly on my knee. It was among the most painful experiences of my life.

Being in the midst of a busy rotation, I didn’t have time to go to a physician. I hobbled around the hospital for a few days in exquisite pain. Eventually, I found an onsite clinic for employees in an adjacent building. After being seen and evaluated with imaging

and pain control, my treatment plan was underway.”

Scott Shreeve, founder and CEO, Crossover Health, states, “Healthcare is broken, and savvy employers are looking for change. One solution that we see savvy employers turning to is advanced primary care that can be delivered through onsite, near-site or virtual care channels. Furthermore, these offerings typically involve new benefit designs and value-based payment models that align the interest of employees, employers and directly contracted providers.”

He says that companies are reevaluating the value of their multiple-point solutions and making decisions to consolidate with vendors that integrate multidisciplinary capabilities.

Shreeve observes several acquisitions and mergers in the industry as more capital is being infused into the industry to create more comprehensive, more accountable and better performing companies.

“All of this has created new opportunities for providers that differentiate their services in terms of the ability to deliver primary care in person, online, and anytime,” says Shreeve. “To appeal to both mid-size and large employers, Crossover has now modularized its offering for custom implementations, added new services like Occupational Health to address new market segments and further enhanced

our account management function to be even more responsive to the evolving needs of our clients.”

He foresees these trends accelerating in the months and years ahead as employers must adapt to an evolving workforce and increasing cost pressures. He projects that an investment in advanced primary care will pay dividends decades into the future.

PRODUCTIVITY

Onsite clinics are particularly beneficial for decreasing the number of off-site, health-related, patient care visits. Industry observers advise that treating acute conditions at workplace clinics can eliminate trips to off-site clinics and/or emergency departments that can take hours or even the entire day.

Analysts also report the importance of advancing “presenteeism.” When workers report for duty and are seemingly impaired by illnesses, such as colds, influenza, minor injuries or chronic conditions, such as migraines and arthritis pain, they are less likely to be fully productive. Having clinicians onsite can help address these health conditions that affect productivity by addressing illnesses in a timely manner.

According to one of the most expansive studies in the onsite and nearsite healthcare sector, conducted by Premise Health and Cedar Gate Technologies, the study validated that these models not only improve morale, productivity and job satisfaction but also play a pivotal role in shaping the workplace environment. Key findings include:

Improved employee morale: Knowing that their employer provides easy access to healthcare can enhance employees’ sense of being valued and cared for. This boosts their morale, making them more positive and enthusiastic about their work.

Increased productivity: Healthier employees are often more productive. When employees have easy access to healthcare, they can address and manage health issues promptly, leading to fewer sick days and reduced absenteeism.

Enhanced job satisfaction: Access to convenient healthcare can be seen as a perk or benefit, making employees feel that their well-being is a priority for the organization. When employees feel that their needs are acknowledged and met, it increases their satisfaction with their job and the company.

Onsite clinic manager Medcor points to the role of these centers in preventing needless claims and OSHA recordables. When workers are injured on the job, they need immediate care to evaluate the severity

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of their injuries and receive treatment. With an onsite medical clinic, they can receive this and avoid traveling to a hospital or urgent care center. For those injuries that can be managed by the worksite clinic, companies avoid potential workers’ compensation claims and OSHA recordables that result from workers receiving off-site care when it isn’t necessary.

IMPORTANT CAVEATS

While onsite clinics offer multiple advantages, there are challenges and limitations to consider.

Initial investment, space requirements and ongoing costs: Setting up an onsite or near-site center often requires significant space allocations and a hefty initial capital investment, including costs related to construction, infrastructure, equipment, personnel and technology. Once established, these centers require continuous funding for maintenance, equipment upgrades and staff salaries.

Sadhna Paralkar, national medical director at Segal, an HR and benefits consulting firm, agrees that the biggest challenge employers face when considering an onsite clinic is the expense.

“The largest cost is staffing, as a typical model assumes about 4,000 visits per physician or nurse practitioner per year,” Paralkar said. “Keep in mind that vendors that provide onsite clinic services typically charge on a cost-plus basis, so management fees could increase costs as much as 30 percent over direct medical costs.”

She says that on average, first-year startup costs for a dedicated clinic can be about $300,000, with annual operating costs of $800,000 to $1 million annually, based on membership size. The upside is that “a well-run clinic can yield an ROI of $1.50 on every $1 spent after three to five years.”

Compliance: Employers providing access to an onsite medical clinic for their employees have several potential compliance issues to consider, as McGriff Insurance Services points to ERISA, COBRA, HIPAA, the ACA, and the nondiscrimination provisions of the Internal Revenue Code. They say it is important for employers considering these programs to understand that the design of the program and the benefits offered under it will impact their compliance obligations as plan sponsors. As a general rule, the greater the services provided at the clinic, the greater the compliance concerns.

Privacy Concerns: The proximity of healthcare services to the workplace can raise concerns about privacy and confidentiality and some employees may feel uncomfortable accessing care – especially for a sensitive health issue -- through an onsite clinic. They might question whether their health data is fully confidential, which makes it critical for employers to create a robust data privacy policy. Additionally, employers must navigate a complex web of legal and regulatory requirements to ensure compliance and protect employee health information.

McGriff advises that onsite clinics are considered “excepted benefits” under HIPAA and are generally exempt from HIPAA’s portability, special enrollment, and nondiscrimination rules based on health status. Lawyers contend that this status likely exempts the clinic from the ACA insurance group market reforms and certain other ACA requirements.

However, the law firm Crowell & Moring provides this guidance:

“Where a company has an onsite health clinic, the clinic can fall under the broad HIPAA definition of “healthcare provider.” If an onsite clinic “furnishes, bills, or is paid for healthcare in the normal course of business,” it likely meets the HIPAA definition.”

They caution even if the onsite clinic meets the definition of “healthcare provider,” it is not considered a “covered entity” under HIPAA unless it engages in certain electronic transactions for which HHS has adopted uniform standards (e.g., electronic filing of healthcare claims with a health insurer).

Furthermore, if an onsite health clinic that is a healthcare provider engages in one or more of the designated HIPAA electronic transactions, HIPAA applies, and the company must implement the compliance measures designed to account for the above-described requirements or face potential civil monetary penalties.

To be on the safe side, employers should maintain confidentiality of data records. General perceptions of privacy in the context of medical information link directly to the trust that employees have in their healthcare delivery systems and the issues of health data sharing across the enterprise and in secondary use.

ENHANCING WORKFORCE WELLNESS

As access to healthcare becomes increasingly scarce in many parts of the U.S., onsite clinics can help to address some of this burden while offering ease of access and convenience to employees. Health and wellness benefits provided where employees report each day for work help people to manage

their health while lowering total cost of care more easily.

As defined in the book Corporate Wellness Programs: Linking Employee and Organizational Health, workplace wellness programs enable employers to improve employee productivity and reduce the cost of healthcare. Onsite clinics have expanded their scope of services to treat a wide variety of conditions, and many employers refer to them as “health and wellness centers.” With onsite wellness care, employers can promote a culture of proactive health management that is designed to support employees -- and often their families -- as they adopt and sustain behaviors that reduce health risks, improve quality of life, enhance productivity and benefit an organization’s bottom line.

Unlike traditional healthcare settings, onsite wellness centers are warm, inviting, and customized to reflect the organization’s unique culture and wellness goals. They are designed to enhance the member experience and engage individuals in their wellness journeys.

Onsite clinic manager Proactive MD says onsite Health & Wellness Centers may operate more like primary care offices, establishing longterm relationships of care with patients and offering a comprehensive range of services. More robust options may also include services outside the clinic walls, such as Patient Advocacy, second opinion networks for costly and complicated diagnoses and virtual care or telemedicine.

Now, there’s growing recognition of “Food is Medicine,” with increased federal investment and action to support approaches across many communities and health settings aimed at reducing the prevalence of chronic disease in the United States by 2030. Onsite clinics that focus on integrating consistent access to diet- and nutrition- related resources are a critical component to achieve this goal.

Dr. Will Clower, a behavioral neuroscientist and CEO, Mediterranean Wellness (MedWell), a company based upon the principles of the Mediterranean approach to nutrition, diet, stress, is partnering with clinics to bring the value of the Mediterranean diet to employees.

“These clinics are ideal settings for communicating the benefits of the Mediterranean Diet (MD), a rich tapestry of plant-based foods, supplemented by olive oil, fish, and poultry,” he explains. “This dietary pattern not only facilitates weight loss but also reduces the risk of chronic diseases and promotes longevity. By embracing portion control and regular exercise, individuals can reap the full benefits of this time-tested lifestyle.”

Power of the Pen

He attributes the effectiveness of a Mediterranean lifestyle to not only a diet but a culture and way of life that is focused on balanced and healthful living. PREDIMED research confirms the effectiveness of the MD diet in achieving sustainable weight loss and improving overall health outcomes:

Sources: https://www.bmj.com/content/361/bmj.k2396; https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC5625964/; https://www.ijmrhs.com/medical-research/mediterranean-dietin-prevention-of-chronic-diseases.pdf

He also cites a large prospective cohort study that followed 25,315 women in the U.S. for up to 25 years, providing robust evidence that closer adherence to a Mediterranean dietary pattern is associated with significantly improved longevity and reduced mortality (all causes) in women. The longer lives most likely reflect the favorable effects on metabolism, inflammation, lipids, insulin resistance, and body weight regulation.

“The goal of aligning with employer onsite and near-site clinics is to help employees reach their wellness goals and achieve lasting results without the perpetual reliance on expensive medications or short-term fixes,” says Dr. Clower. “Wellness platforms and a comprehensive wellness portal offer tailored programs that incorporate the principles of the MD and lifestyle, along with stress management techniques and personalized activity plans.”

Onsite and near-site centers also serve public employers. For example, Optimal Health Initiatives (OHI) was created 20 years ago to maximize employee benefit dollars by partnering with peers, effectively leveraging purchasing power to stabilize the cost of healthcare benefits. Public employers may participate on a stand-alone basis or join a shared-risk arrangement. An administration team embraces each of the multi-state markets for local, specialized support.

An effective resource in the OHI toolbox was created eight years ago with the development of on/ near-site Health and Wellness Centers. The results have been to reinforce access to local healthcare and save dollars that would have otherwise been spent on more costly fee-for-service market options.

Elaine Shafley, OHI chief administrator and Shafley Plan Management Service principal, says, “OHI’s goal is to focus on the benefits to both the employers and members/employees and dependents to drive improved member health outcomes, lower overall healthcare expenses through preventive care and manage chronic conditions. These, in turn, reduce claims such as emergency room visits and hospitalization.”

Shafley references their 13 Ohio and Indiana on/near-site locations, which provide FREE quality medical services to

over 34,000 eligible members. Services include primary care, laboratory services, generic prescriptions, wellness programs and behavioral health services.

“This, along with the ability to maximize employee benefit dollars by partnering with peer groups, resulted in many members experiencing less than a 2% average increase in plan premiums over the past five years,” she continues. “Operations have expanded to utilize three clinic management models, and we emphasize worklife balance for the health plans we service.”

She also points to the ease and convenience of virtual care as

particularly valuable when employees are in the midst of their busy day yet in need of medical advice.

ALL SIGNS POINT TO ARTIFICIAL INTELLIGENCE (AI)

AI integration with onsite clinic operations emerges as a transformative force and represents a paradigm shift in how medical care is delivered and managed. It impacts clinical decision-making, medical diagnostics, patient care and predicting clinical outcomes.

The advancement of machine learning algorithms and the exponential increase in computational power and data availability position AI applications to play an even greater role in these employer-sponsored settings. In these environments, where there is greater reliance upon remote monitoring, telemedicine, virtual care and other digital support that is changing patient-doctor interactions, AI integration impacts ethical considerations such as privacy, bias and data security.

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Jeremy VanderKnyff, PhD, PMP, chief integration and informatics officer, Proactive MD, says, “AI is an exciting new frontier in healthcare, and while the opportunities for its application seem limitless, we are approaching it cautiously. Instead of looking to AI to replace the human side of healthcare relationships, we are now hpiTPA.com

seeing many startups seeking to leverage large language models to create virtual doctors and nurses. Our current goal is to test AI tools that could improve the efficiency of administrative tasks, like coding or searching recent journals for evidence-based medicine and freeing our care teams to spend more time face-to-face with patients, not less.”

He reports that even in just the past two years, employer interest in onsite and near-site health clinics has grown. Employers have already realized the value and are looking to vendors like Proactive MD to provide improved reporting, better client service, and deeper integration with their health plans and benefits.

“Even the opportunities themselves have shifted,” says VanderKnyff. “Whereas several years ago, we spent much of our time educating self-funded employers on the potential of bringing primary care to their employee populations, now much of the growth is from transitions from other vendors or from companies who have previously run their own onsite health centers.”

He forecasts sustained growth in the onsite and near-site primary care market and points to key drivers:

“First, the continued rise in the cost of healthcare that’s leaving employers with no choice but to step outside the traditional corporate healthcare system to find cost-containment solutions,” he says. “Second, the rapid consolidation of the advanced primary care industry through mergers and acquisitions has left many employers looking for nimble and innovative groups to enhance their current service offerings.”

Finally, the Patient Advocacy model, in which social workers that are embedded within each care team to drive health center engagement,

coordinates resources for patients facing socioeconomic barriers to accessing care and guides patients through the maze-like healthcare system.

“We’ve found that the addition of Patient Advocates to a health center can increase engagement among rising and high-risk patients by 10 percent or more, with an average savings of $2000 per chronically ill member per year,” he concludes. “These endpoints are achieved through intentional care navigation, better outcomes and a strong provider-patient relationship with continued follow-up.”

Laura Carabello holds a degree in Journalism from the Newhouse School of Communications at Syracuse University, is a recognized expert in medical travel and is a widely published writer on healthcare issues. She is a Principal at CPR Strategic Marketing Communications. www.cpronline.com

Benchmarking

HEALTHCARE FINANCIAL ASSISTANCE HIDDEN IN PLAIN SIGHT?

Most Americans are eligible for 501(r) financial assistance at nonprofit hospitals, but experts say the charity care program has been flying under the radar.

Written By Bruce Shutan

IIn the face of rising healthcare costs, a federal charity care program that has been largely eluding group health plans holds tremendous promise for helping self-insured employers avoid expensive hospital claims and balance billing.

Look no further than Section 501(r) of the Internal Revenue Service Code, which requires 501(c)(3) hospital organizations to limit amounts charged for emergency or other medically necessary care to patients who are eligible for substantially discounted or free care.

Eligibility for this program, established as part of the Affordable Care Act (ACA) in 2010 and in effect since 2015 after a public comment period, is pegged at up to 400% of the federal poverty level, though some hospitals actually raise that threshold to 500%. The same rule applies to subsidies for enrollment in ACA Marketplace plans. Facilities that fail to meet this requirement run the risk of losing their tax-exempt status. Of 6,120 hospitals in the U.S., 5,129 are community hospitals – 58% of which are not-for-profit facilities.

“The headline is not as many people know about this program as should know about it,” observes Patrick Haig, co-founder and CEO of Goodbill, which actively promotes 501(r) through third-party administrators (TPAs) and benefit brokers. “It’s heavily underutilized.”

Advocacy is needed to “relieve consumers of the pressure from hardto-understand, opaque and extremely expensive hospital bills,” he explains. After initially targeting the direct-to-consumer market and building a product that automates bill negotiation, his company learned to apply other levers to reduce consumer burdens – one of those being 501(r).

Nearly 38 million Americans, or 11.5% of the population, live in poverty, according to the latest U.S. Census Bureau statistics from 2022. But even middle-class households are feeling squeezed when it comes to healthcare. That means a family of four earning a low-six income would qualify for financial assistance under the 501(r) program. Most polls show that as many as two-thirds of working Americans say they live paycheck to paycheck.

Moreover, medical debt is now the leading cause of personal bankruptcy filings in the U.S., and it is nearly double for Americans who’ve been hospitalized vs. those who have not, notes Stacy Morris, president and CEO of Employer Driven Insurance Services (EDIS), a TPA.

BILLBOARDS VS. FINE PRINT

The goal of 501(r) is to prevent any missed opportunities to eliminate out-of-pocket expenses for eligible populations and hold nonprofit hospitals accountable for discounting care as they’re required to do under the law, explains Justin Leader, president and CEO of BenefitsDNA, an employee benefits advisory firm. Nonprofit hospitals are supposed to proactively offer 501(r) financial assistance, according to Morris. “You should see it on billboards out there, and you don’t,” she says. Although taxexempt hospitals are required by law to make reasonable efforts to make the public aware of 501(r) assistance, Haig says many do not make it easy. For example, the information may be buried on a website, billing statement or waiting room, while few facilities make a digital application available as a PDF. Most require that it be snail-mailed or even faxed, which can result in piles of paper. More than 90% of policies require additional documentation

Justin Leader

Patrick Haig

Stacy Morris

that includes proof of income and assets in the form of pay stubs or bank statements.

Haig believes that members shouldn’t have to pull this type of valuable information out of their health plans. After all, he says the plan knows when a claim comes in, whether it’s from a nonprofit facility and which members might be eligible for financial assistance. As such, the employer can easily inform and instruct members on how they can apply for vastly reduced rates.

“It’s all about push vs. pull,” he says. “Catching people at a moment where they know they’re going to get a bill and you’re there to say, ‘no, let’s actually

make sure that bill doesn’t show up,’ I don’t know what stronger value prop you could possibly give them.”

Hospitals write of the balances of patients who qualify based on their income. How they calculate that dollar amount, he adds, is to divide the amount of money due from all claims within a 12-month period from any public or private payer by what was billed and apply that ratio to the claim. Hospitals must limit amounts charged, regardless of insurance coverage. Calculations are based on either the Medicare or Medicaid fee, or allowed amounts are divided over their billed amounts for both public and private payers from a 12-month lookback period.

Asked why 501(r) has flown under the radar as long as it has, Leader says, “Where there’s a mystery, there’s margin, and in turn, where there’s no effective oversight and consequences, there’s no incentive for change.”

While believing the threat of nonprofit hospitals losing their taxexempt status is real, he notes that no one has really forced the issue. But as it bubbles to the surface, he says, “There’s nothing that makes a hospital change their mind faster when you remind them of their obligation to the populations that they are meant to serve where

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they’re not paying city, state, local, federal or property taxes.”

Leader launched a business about four years ago with others that acknowledged the need for better health plan member education, including how to secure charity care. “We have a dedicated team member who is working with folks like Goodbill to evaluate eligibility at the countless not-for-profit hospitals that aren’t administering these programs,” he explains. The importance of advocacy, hand-holding, walking people through that process and making it as easy as possible for the member is critically important to securing 501(r) assistance, Leader adds.

A MATTER OF CAA COMPLIANCE

Given the increasing importance of complying with the Consolidated Appropriations Act (CAA), Haig says 501(r) fits the fiduciary duty conversation around what plan sponsors are doing to mitigate member costs.

The income graphic shows the typical federal poverty level thresholds

that hospitals use for 501(r) — each hospital may vary somewhat (using 2x instead of 2.5x FPL, for example), but these are the typical thresholds we see.

“If you have a population that would be highly eligible for this type of program, and you’re not doing anything about it, how can you credibly say you’re protecting their dollars?” he asks. “You should at least make it easy for them to avail themselves of it and save their own money.” He also urges TPAs to get it into their stack, noting that very knowable dollars will be left on the floor on behalf of clients and members if 501(r) isn’t part of their cost-containment measures.

“It’s all about saving dollars for the member and benefiting them transparently in an understandable way,” Haig says. “We think there’s a lot of value there for the plan, too, because the member is your secret weapon to contain costs.”

The “4 in 10” claim graphic is the average share of claims that Goodbill finds eligible for 501(r) discounts during our reviews.

Unlike the 401(k) and pension space that includes registered investment advisers, cofiduciaries and 3(21) investment advisers who are managing money like it’s their own, Leader laments that the health and welfare benefits side “has been built upon the extraction of dollars without the delivery of value… The sooner we get in line with 408(b)(2)(B) disclosure rules within the CAA that state plan sponsors have to understand direct, indirect and non-monetary compensation of covered service providers, the better it will be for all of us.”

HEARTSTRINGS AND HAPPY ENDINGS

The charity care topic hits close

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

to home for Leader, a child adopted into a blue-collar family who grew up covered under the federal Children’s Health Insurance Program in Bedford, Pa. His aunt, who lived nearby and worked for an hourly wage at Denny’s, avoided going to the doctor because she couldn’t afford the out-of-pocket costs tied to her high-deductible health plan. After years of neglecting her health, she was diagnosed with stage-four cervical cancer, and while her care was covered at 100%, she ended up passing away.

“Think about the impact to just one person, multiply that by the hundreds of thousands of patients who are eligible, and we can really start to change the perspective of healthcare in our country and understand the intent of systems to serve the community,” he says. The map graphic shows every hospital in the

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A member Goodbill serviced last year who had lost her job qualified for 100% off on her $4,800 claim. The hospital then retroactively applied her 501(r) application to previous unpaid bills, as well as an upcoming cataract surgery. Having long avoided her mailbox for fear that another hospital bill would arrive in the mail, she finally had peace of mind knowing more than $40,000 in charges were going to be waived.

“We’re not here to always paint the hospital in a bad light,” Haig explains. “It was the hospital saying, ‘Hey, we’re going to stretch that approval to cover the backdate,’ which, by law, they are required to do. If there was any kind of member out of pocket and they’re approved [for financial assistance], then they have to refund any dollars paid.”

In the span of just a few months, EDIS saw more than a dozen hospital bills written off across its client base. The savings have been so significant that the TPA initially rolled it out to one block of levelfunded stop-loss plans for larger employers and has since reached 830 different employer groups throughout the nation.

“We have members who, once they have saved thousands of dollars in what they otherwise would have been paying to the hospital, shout it from the rooftops, but they are just reaching the ears of their co-workers, friends and family,” Morris reports. “So, I feel like it’s a program that’s going to spread through word of mouth more than most other avenues.”

TALENT-MANAGEMENT TOOL

In a tight labor market, 501(r) also can be seen as a recruitment and retention tool that generates employee goodwill. Four members of EDIS’s own staff have had hospital bills completely written off from this program. Since the corporate office is located in a rural area between Fresno and Bakersfield, Calif., almost everyone at the TPA is eligible for financial assistance.

One such employee is a single mother with a heart condition who supports her children and grandchildren. A bill that was discounted to $138,000 was erased under 501(r), prompting tears of joy. “You’re talking about somebody living check to check,” Morris says. “Her checks aren’t even covering her bills because she has so many other responsibilities outside of herself. And so, this was a lifesaver. Not only did the hospital write off her claim, but they also agreed to apply the 501(r) discounts for the remainder of the year, so she doesn’t have to go through the process over and over again.”

often based on incorrect charges because most hospital bills are wrong, Morris cautions. “It’s humans throwing codes in there that that make the most sense to them, and it’s not them that has to pay the bill,” she explains. “So, the audits aren’t the strongest, but whenever you tie in 501(r) with a simultaneous 100% hospital bill audit, you’re guaranteeing the employer, the member, the TPA partner and everybody who has an investment in this program that you’re doing the best thing for the plan.”

Bruce Shutan is a Portland, Oregon-based freelance writer who has closely covered the employee benefits industry for more than 35 years.

SELF-INSURANCE INDUSTRY RAISES ITS VOICE DURING 2024 ELECTION CYCLE

Written By Anthony Murrello

IIn this pivotal election year, the Self-Insurance Political Action Committee (SIPAC) has strategically increased its campaign contributions to federal candidates who are positioned to support policy positions favorable to the self-insurance industry. This approach facilitates direct engagement between the Self-Insurance Institute of America (SIIA) representatives and key policymakers via fundraising events and private meetings.

SIPAC’s operations are fueled entirely by personal contributions from SIIA members, garnered through direct donations or participation in SIPAC-hosted fundraising events throughout the year. To optimize the impact of these contributions, SIPAC employs a rigorous review process to identify Congressional candidates best positioned to foster a thriving self-insurance marketplace. This vetting process involves selecting candidates who have demonstrated leadership on key issues pertinent to SIIA, either within their party or on relevant congressional committees. Additionally, SIPAC considers the candidate’s strength, the political climate, and the representation of SIIA member operations or employees.

To fulfill its mission, SIPAC identifies and supports capable candidates on a bipartisan basis across both chambers of Congress. By cultivating relationships with leaders from both parties, SIPAC ensures that the self-insurance industry’s interests are safeguarded regardless of electoral outcomes. Through SIPAC’s contributions, SIIA representatives have established and/or strengthened connections with a bipartisan group of candidates expected to win their elections and continue shaping the legislative agenda.

For example, SIIA representatives have had monthly lunches with Senator John Barrasso (R-WY), who has served as Wyoming’s Senator since 2007 and is currently the third-highest-ranking

Republican in the Senate. He also sits on the Senate Finance Committee, which oversees healthcare policy, making it a key committee for SIIA.

Should Republicans regain control of the Senate, Senator Barrasso’s influence on the legislative agenda will be significant. On the Democratic side, SIIA has routinely met with Sen. Cantwell (D-WA), who is a formidable member of the Senate Finance Committee and continued the longstanding relationship with Delaware Rep. Lisa Blunt Rochester. Rep. Lisa Blunt Rochester has supported a number of selfinsured policy goals during her time in the House and is looking forward to doing so as she is the

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overwhelming favorite to replace retiring Sen. Carper (D-DE) in the Senate.

In the House, SIPAC has supported long-time ally Representative Virginia Foxx (R-NC), chair of the Education & the Workforce Committee. Congresswoman Foxx has advocated for policies that benefit the self-insurance industry, such as strengthening ERISA and the Lower Costs More Transparency Act. SIPAC has also backed Congressman Richard Neal (DMA), allowing SIIA to engage with him regularly throughout the spring. Representing Massachusetts’s 1st district since 1989, Neal served as Ranking

Member of the Ways & Means Committee this past term. Should Democrats regain control of the House, Neal would likely chair this committee.

The support of SIIA members has been instrumental in fostering these relationships and contributing to additional candidates this cycle. More than 100 individual SIIA members have supported SIPAC by attending various events, and several companies have sponsored events ranging from fine dining experiences in Boston to retro arcade games, future leaders exclusive axe-throwing events, beer tastings, and an upcoming “tailgate” event.

For more information about SIPAC, please contact Anthony M. Murrello at  amurrello@siia.org.

Anthony Murrello serves as government relations manager for SIIA.

CHANGING ALTERNATIVE ENERGY MARKET RELYING ON CAPTIVES

Written By Caroline McDonald

AAresurgence of interest in alternative energy sources has led to increased formations of captives. One significant project involves using alternative energy sources –sustainable aviation fuel, or SAF – as fuel for aircraft.

“Captive insurance is a game-changer for alternative energy companies,” said Randy Sadler, Principal at CIC Services LLC. “These companies often use new technologies and face high operational risks, making it challenging for traditional insurers to accurately price coverage.”

In addition, “Frequent regulatory changes, market volatility, and natural hazards add to the complexity,” he said. “Captive insurance, however, offers a solution with cost savings through controlled premiums and customized coverage tailored to these unique risks.”

Captive insurance, he added, also leads to financial stability, better cash flow, and improved risk management, “all while letting companies keep underwriting profits and access reinsurance markets.”

SHIFTS IN THE ALTERNATIVE ENERGY INDUSTRY

Kevin Kaminski, executive vice president, underwriting at eMaxx, which provides insurance-backed captive solutions to cover product and performance shortfalls, notes that he is also seeing steady growth in the alternative energy industry, although the markets have changed.

For example, he said, “12 years ago, solar energy had a significant need for performance warranty insurance. That need is pretty much gone now.”

The reason, he said, is that solar and wind energy “have become so mainstream and accepted.” Emerging opportunities now, he said, are predominantly in waste energy operations, “where they are taking some waste stream, whether it be municipal solvent waste or some type of agricultural waste, or it could be plastics.”

Conversion of waste to energy through incineration has been going on for 100 years, Kaminski explained, “but the idea of doing it in a cleaner fashion, where you can produce some kind of synthetic gas that can be converted into energy in a significantly cleaner way is a big opportunity.” This is the case, he said, “because our country and the world are plagued with the waste that’s generated. Much of it has significant energy content that can be used.”

Alongside that, he added, is agricultural waste, “which is also an opportunity and is effectively clean energy. There is a lot of opportunity in those marketplaces. Just disposing of waste has become very expensive,” Kaminski said.

ATTRACTIVENESS OF CAPTIVES

More and more, captives are sought out, not as much because of terms or pricing rates, but capacity, said Michael Leonard, chief economist and data scientist at the Insurance Information Institute. “What happens is that traditional energy underwriters find it challenging to understand the risk profile, often from a lack of data specific to alternative energy projects,” he said. “For example,

they may find it challenging to understand the revenue model. A lot of those projects also have different ways of financing. The ratios are different.”

Some of the challenges, “certainly on the data side, are receding,” Leonard added. And as there are “more and more alternative energy products, capacity on standard or favorable terms becomes the issue.”

In the past, “a lot of the questions being asked didn’t yet have a benchmark reference,” Leonard said.

When insuring assets, he said, because the regulatory risks for alternative energy projects often fluctuate, “you may want to look at political risk insurance and government breach of contract, especially if you have a project in another country and you are concerned the government may change the rules.”

This can also be the case with offshore wind in the U.S., “where a state may ban the presence of offshore windmills,” Leonard said. “The wind turbines are gigantic, and they make noise and destroy birds.” This can create uncertainty, he said, “and the insurance industry is not comfortable with uncertainty.”

FILLING THE GAPS

Sadler noted that commercial insurance provides alternative energy companies with essential policies like general liability, errors & omissions, directors & officers, business interruption, product liability, and workers’ compensation.

“These coverages are crucial but can come with higher premiums due to the industry’s unique risks,” he noted. “Insurers often set higher deductibles and lower coverage limits to manage their own risk, impacting overall insurance costs.”

Captives step in where traditional policies fall short, Sadler said. “They cover risks linked to research & development activities, often excluded, and handle compliance costs for environmental and safety regulations.”

Unlike traditional insurance, “captives don’t leave alternative energy firms hanging during extended downtimes or unique operational issues—they’re tailored for these interruptions,” he noted.

Captives also address supply chain risks specific to energy projects “and can cushion revenue shortfalls from production dips or market fluctuations,” Sadler said. “They offer specialized coverage that meets the industry’s digital demands. Plus, they’re there for the long haul, covering post-project liabilities and safeguarding reputations from public relations nightmares.”

Creating a captive insurance company lets alternative energy companies secure tailored coverage, he said, “ensuring robust protection and financial stability in a fast-evolving sector.”

WHO IS FORMING CAPTIVES?

Sadler observed that alternative energy companies are increasingly turning to captive insurance as a strategic tool for managing risks specific to their sectors. For instance, solar energy firms are using captives to safeguard against equipment failures and weather-related disruptions in solar farms.

“Wind energy companies find captives beneficial for mitigating risks during turbine installation and maintenance, as well as fluctuations in wind patterns,” Sadler said. “Bioenergy and biomass firms use captives to navigate supply chain challenges and regulatory uncertainties affecting feedstock availability.”

Similarly, he said that hydropower companies rely on captives to manage operational risks associated with dam operations and environmental impacts. “Captive insurance also supports companies in emerging sectors like energy storage and battery technology, where risks include technological advancements and supply chain disruptions,” Sadler said.

Whether it’s in electric vehicle infrastructure, carbon capture technologies, or renewable energy project development, “captives offer tailored solutions for mitigating risks across various stages of operations, from construction to long-term environmental liabilities,” Sadler said. “By forming captives, these companies gain greater control over their insurance costs and enhance their ability to innovate and grow in a dynamic industry landscape.”

Leonard concluded, “it really takes an ecosystem for this to happen. You’ll have captive capacity that will come from traditional investors and from traditional carriers,” he said. “It could be cash bonds – the brokers often have expertise in managing those. And the willingness of all the individuals.”

It also comes down to “faith on the part of everyone to be willing to sit down and understand the uniqueness of these risks so that they become more common,” Leonard said.

WHAT IS SAF?

Sustainable aviation fuel, or SAF, is a biofuel used to power aircraft, which has properties similar to conventional jet fuel but with a smaller carbon footprint. Depending on the feedstock and technologies used to produce it, SAF can reduce life cycle GHG emissions dramatically compared to conventional jet fuel. Some emerging SAF pathways even have a net-negative greenhouse gas, or GHG, footprint.

According to the Office of Energy Efficiency & Renewable Energy, an office of the U.S. Department of Energy:

SAF, made from renewable biomass and waste resources, has the potential to deliver the performance of petroleum-based jet fuel but with a fraction of its carbon footprint, giving airlines solid footing for decoupling greenhouse gas emissions from flight.

A report from the Bioenergy Technologies Office states that the U.S. Department of Energy is working with the U.S. Department of Transportation, the U.S. Department of Agriculture, and other federal government agencies to develop a comprehensive strategy for scaling up new technologies to produce SAF on a commercial scale.

An estimated 1 billion dry tons of biomass can be collected sustainably each year in the United States, enough to produce 50–60 billion gallons of low-carbon biofuels. These resources include:

• Corn grain

• Oil seeds

• Algae

• Other fats, oils, and greases

• Agricultural residues

• Forestry residues

• Wood mill waste

• Municipal solid waste streams

• Wet wastes (manures, wastewater treatment sludge)

• Dedicated energy crops.

Caroline McDonald is an award-winning journalist who has reported on a wide variety of insurance topics. Her beat includes in-depth coverage of risk management and captives.

MID-YEAR LEGISLATIVE, REGULATORY & LEGAL ROUND-UP

Written By Chris Condeluci

WithWthe U.S. Congress and state legislatures adjourned for the summer and important legal cases still pending, this is a good opportunity to provide a quick round-up of the latest developments and related SIIA engagement.

The Prospects of Legislation Regulating Artificial Intelligence (AI) Dim: SIIA has reported in our Government Relations Newsletters and Webinars that a bi-partisan group of Senators – led by Senate Majority Leader Chuck Schumer (D-NY) – are “all in”

on enacting some form of AI regulation. Specifically, this bi-partisan group released a report titled Driving U.S. Innovation in Artificial Intelligence in which these Senators called for legislation that would:

• Increase Funding for AI Innovation

• Develop Nationwide Standards for AI Safety and Fairness

• Strengthen National Security

• Address Potential Job Displacement Due to AI

• Tackle “Deepfakes” and Election Interference

When it comes to healthcare and AI, these Senators called for the continued deployment of AI in healthcare, but they stressed the need to implement appropriate guardrails and safety measures. This bipartisan group also wants Congress to consider policies to promote innovation of AI systems that meaningfully improve health outcomes and efficiencies in healthcare delivery, but they want to make sure that patients are informed when a medical recommendation or prescription is AI-generated or furnished by an actual medical provider.

Upon the release of the Report, Senate Majority Leader Schumer publicly stated that he wants Congress to pass AI-related legislation by the end of 2024, which begs the question: If AI legislation is bi-partisan (and it’s backed by Senate Democratic Leadership), will the Senate – followed by the House – pass some form of AI-related legislation this Congress? Our answer: While never a guarantee, AI-related legislation could be taken up and passed during the “Lame Duck” session after the November elections.

While the prospects of something happening in Lame Duck looked promising due in large part to Senate Majority Leader Schumer’s endorsement of getting something done by the end of 2024, those prospects have dimmed due to House Majority Leader Scalise’s comments. SIIA will continue to track the ups and downs of Congress’s efforts to regulate AI.

Unworkable Proposed Mental Health Parity Regulations Could Be Final

HOWEVER, recent comments from House Republican Majority Leader Steve Scalise (R-LA) have thrown cold water on the prospects of passing legislation regulating AI by the year’s end. Majority Leader Scalise recently explained that House Republicans do not support legislation that would create new government agencies, new licensing requirements, and funding and research that might favor one technology over another. Leader Scalise further explained that, ultimately, House Republicans want to make sure that “government” does not get in the way of the innovation that is already underway.

Soon: Back in July 2023, the Biden Administration released proposed regulations intended to increase access to mental health and substance use disorder (MH/SUD) benefits through increased compliance with the Mental Health Parity requirements. These proposed regulations focused exclusively on Non-Quantitative Treatment Limitations (NQTLs) (such as prior authorization, concurrent review, and other utilization management tools) that selfinsured plans impose on MH/SUD benefits, requiring plans to ensure that the NQTLs imposed on MH/ SUD benefits are comparable to the NQTLs imposed on medical and surgical (M/S) benefits. According to the proposed regulations, to remain compliant with the Mental Health Parity law, plans would be required to comply with a number of mathematical tests – and satisfy various definitions – used to determine whether an appropriate level of comparability is present.

The employer community – including SIIA – has told the Biden Administration in multiple comment letters submitted back in October 2023 that the above-stated proposed requirements are unworkable and that the proposed tests and definitions amount to benefit mandates. We also explained that the proposed tests are impossible for self-insured plans to operationalize and that these new requirements could force employer and union plan sponsors to remove nearly all utilization management tools that they currently use to ensure that employees and their dependents receive safe and appropriate care. We further stated that, in the end, the proposed regulations could lead to the unintended consequence of decreasing access to MH/ SUD benefits.

What’s the alternative? The employer community – including SIIA – has been busy telling the White House and Congressional staff that a better approach to increasing access to MH/SUD benefits includes:

• Prioritizing training and treatment integration for primary care physicians and the front-line healthcare workforce to better identify and treat mental health and substance use disorders before they worsen.

• Increasing access to telehealth to enable mental health professionals to treat patients no matter where they live. Telehealth enables employees and their families to obtain the care they need, when and where they need it, in an affordable and convenient manner.

• Establishing long-term programs to build out the mental health workforce, such as programs to incentivize more medical students to enter the mental health field and to increase the supply of qualified clinicians.

Despite our efforts to suggest workable alternatives to achieving the Biden Administration’s policy goal of increasing access to MH/SUD benefits, the Administration is inching toward finalizing these unworkable proposed requirements. We could see final regulations sometime this summer. SIIA will continue to monitor the Administration’s activities in this important area.

Fiduciary Issues Impacting Self-Insured Health Plans Take Center Stage, And SIIA Responds: With the advent of the employeeparticipant lawsuit against Johnson & Johnson claiming breach of their fiduciary duties for failing to prevent the self-insured health plan from overpaying for covered benefits – followed by another employeeparticipant lawsuit against the Mayo Clinic lawsuit alleging fiduciary breach for underpaying out-of-network providers which produced balance bills for the participant – plan sponsors and the need to adhere to their fiduciary duties are under a microscope.

Add in a lawsuit filed by the Department of Labor (DOL) against Blue Cross/Blue Shield of Minnesota (BCBS of MN) in which the DOL alleges that BCBS of MN wrongfully used “plan assets” to pay a provider tax imposed on providers in BCBS MN’s network; plan

sponsors have been put on notice that failure to examine and analyze health claims data and the failure to discover things like hidden fees and/or overpayments could expose the plan sponsor to fiduciary liability (actionable by plan participants, but also the DOL).

SIIA’s Price Transparency Committee has developed various fiduciary “must-dos” that (once released) SIIA members may share with their clients and internally with their workforce. These fiduciary “must-dos” speak to four key concepts that every plan sponsor must know. They include:

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By supporting people in the moments that matter, we can improve health outcomes and help employers manage costs.

For over 40 years, self-funded employers have trusted Sun Life to help them manage financial risk. But we know that behind every claim is a person facing a health challenge and we are ready to do more to help people navigate complicated healthcare decisions and achieve better health outcomes. Sun Life now offers care navigation and health advocacy services through Health Navigator, to help your employees and their families get the right care at the right time – and help you save money. Let us support you with innovative health and risk solutions for your business. It is time to rethink what you expect from your stop-loss partner.

Ask your Sun Life Stop-Loss Specialist about what is new at Sun Life.

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. Group stop-loss insurance 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 and 22-SL. In New York, Group stop-loss insurance policies are underwritten by Sun Life and Health Insurance Company (U.S.) (Lansing, MI) under Policy Form Series 07-NYSL REV 7-12 and 22-NYSL. Policy offerings may not be available in all states and may vary due to state laws and regulations. Not approved for use in New Mexico.

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• Prudent Decision-Making: A plan sponsor – as a fiduciary – must make ALL plan-related decisions “prudently.” Here, the plan sponsor’s decision-making must always take into account the best interests of employees and their family members participating in the plan. Such decisions must be made in a way that illustrates that the plan sponsor took the appropriate amount of time and due care to think about the outcomes of the decision.

• Process: Prudent decision-making can be illustrated through the development of a “process” that (1) justifies the decision-making and (2) creates a record that tangibly shows that the plan sponsor spent the time and effort to think through matters like:

o What benefits and services should the plan cover and not cover?

o The cost of covered benefits and whether those costs are reasonable.

o The fees paid to your broker, benefit consultant, and the plan’s service providers.

Importantly, the plan sponsor is NOT required to find the cheapest options for the plan and its participants. Rather, the plan sponsor must choose the best options that the plan sponsor reasonably believes provide the best value to the plan and its participants.

• Review: Upon the establishment of a self-insured health plan, the plan sponsors will enter into agreements with brokers, benefit consultants, and specified entities providing services to your plan such as (1) a Pharmacy Benefit Manager (PBM), (2) the owner of the medical and/or prescription drug networks that plan participants may access, and (3) a third party that will adjudicate, process, and pay health claims incurred by plan participants, and also, provide management services to the plan and its participants.

o In these cases, the plan sponsor – with the assistance of in-house counsel or an outside ERISA attorney – must review these agreements for accuracy, for indemnification of liability, and for purposes of determining whether the fees charged by these entities are reasonable. In addition, this review must ensure that (1) the plan sponsor has access to a complete and accurate set of health claims data, (2) there are no unreasonable limitations placed on plan sponsor’s ability to audit these entities to determine if, for example, claims are being properly paid, and (3) the plan’s service providers are keeping confidential any participant-related information and they remain subject to liability for any confidentiality breach of any kind.

• Monitoring: Plan sponsors must continually monitor ALL of the entities providing services to the plan. This includes the plan’s broker, benefit consultant, PBM, owners of the provider networks, and the claims adjudication and management services TPA. Such monitoring requires ongoing determinations that (1) the fees charged to the plan are reasonable, (2) health claims are being properly paid, and (3)

each entity is adequately performing the services they were hired to perform. This also includes receipt of a required compensation disclosure from brokers, benefit consultants, PBMs, and TPAs providing specified services to the plan (known as a “408(b)(2)(B) compensation disclosure”)

o Plan sponsors should also remain informed about (1) the fees charged and (2) the types of services performed by other plan service providers that the sponsor may consider contracting with, especially in cases where, upon monitoring existing service providers, the sponsor determines that these existing service providers are not adequately performing the services they were hired to perform.

The complete fiduciary guidance can be accessed through the Resources section of the SIIA website at www.siia.org.

Chris Condeluci is SIIA’s Washington Counsel

ACA, HIPAA AND FEDERAL HEALTH BENEFIT MANDATES:

PRACTICAL Q & A

TheQ & A

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

Attorneys John R. Hickman, Ashley Gillihan, Carolyn Smith, Ken Johnson, Amy Heppner, and Laurie Kirkwood 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, Carolyn, Ken, Amy, and Laurie are senior members in the Health Benefits Practice. Answers are provided as general guidance on the subjects covered in the question and are not provided as legal advice to the questioner’s situation. Any legal issues should be reviewed by your legal counsel to apply the law to the particular facts of your situation. Readers are encouraged to send questions by E-MAIL to Mr. Hickman at john.hickman@alston.com.

NEW HIPAA PRIVACY PROTECTIONS FOR REPRODUCTIVE HEALTHCARE: WHAT IT MEANS FOR REGULATED ENTITIES

By Alston & Bird Health Benefits Practice

The Department of Health and Human Services (“HHS”) published its final rule on HIPAA Privacy Rule and Reproductive Healthcare in the Federal Register on April 26, 2024 (“2024 Privacy Rule”). This 2024 Privacy Rule, which is part of HHS’s increased focus on reproductive healthcare for women, prohibits HIPAA-covered entities and their business associates (together referred to as regulated entities) from using or disclosing protected health information (“PHI”) related to reproductive healthcare for certain investigatory-type purposes if the healthcare itself is provided lawfully.

Plan sponsors will need to take several compliance measures, including updates to their Notice of Privacy Practices (“NPPs”), HIPAA policies and procedures, and business associate agreements, as well as training for employees responsible for handling requests for PHI. Both covered entities and business associates will need to obtain attestations before using or disclosing PHI potentially related to reproductive healthcare for certain permitted purposes.

The 2024 Privacy Rule is effective June 25, 2024; covered entities and business associates have until December 23, 2024 to comply. The compliance date for updating NPPs is February 16, 2026. This update to the NPPs also includes changes finalized in this rule for the 2024 Confidentiality of Substance Use Disorder (SUD) Patient Records Final Rule (‘‘Part 2 Rule’’).

2024 PRIVACY RULE BASICS

The 2024 Privacy Rule adds a new defined term—“reproductive healthcare”—and adds special rules that limit the use and disclosure of PHI containing information about lawfully provided reproductive healthcare. Reproductive healthcare is that which “affects the health

of an individual in all matters relating to the reproductive system and to its functions and processes.” Regulated entities cannot use or disclose reproductive healthcare PHI for the purposes of conducting a criminal, civil, or administrative investigation into, or to imposing criminal, civil, or administrative liability on:

Any person for “the mere act” of seeking, obtaining, providing, or facilitating reproductive healthcare. This includes but is not limited to, any of the following: expressing interest in, using, performing, furnishing, paying for, disseminating information about, arranging, insuring, administering, authorizing, providing coverage for, approving, counseling about, assisting, or otherwise taking action to engage in reproductive healthcare; or attempting any of the same.

The 2024 Privacy Rule also prohibits use or disclosure of such PHI for the purpose of identifying any person for the purpose of conducting such investigation or imposing such liability. The new definition for “public health” finalized in this rule likewise carves out these prohibited purposes from uses or disclosures for public health surveillance, public heal investigation, and public health intervention.

Practice pointer: HHS provided this non-exhaustive list in the preamble of reproductive

healthcare examples: contraception, including emergency contraception; preconception screening and counseling; management of pregnancy and pregnancyrelated conditions, including pregnancy screening, prenatal care, miscarriage management, treatment for preeclampsia, hypertension during pregnancy, gestational diabetes, molar or ectopic pregnancy, and pregnancy termination; fertility and infertility diagnosis and treatment, including assisted reproductive technology and its components (e.g., in vitro fertilization); diagnosis and treatment of conditions that affect the reproductive system (e.g., perimenopause, menopause, endometriosis, adenomyosis); and other types of care, services, and

supplies used for the diagnosis and treatment of conditions related to the reproductive system (e.g., mammography, pregnancy-related nutrition services, postpartum care products).

PRESUMPTION OF LAWFULNESS

The prohibition on using or disclosing reproductive healthcare PHI for the prohibited purposes is not absolute. The reproductive healthcare must be lawful for the prohibition to apply. If the plan sponsor or third-party administrator receiving the request for PHI did not actually provide the reproductive healthcare, then a presumption of lawfulness applies if the following can be “reasonably determined”:

The covered entity or business associate neither (i) has actual knowledge that the healthcare was not lawful under state or Federal law under the circumstance, nor (ii) has factual information from the person requesting the PHI “that demonstrates a substantial factual basis that the reproductive healthcare was not lawful under the specific circumstances in which it was provided.”

In making a reasonable determination of whether the presumption applies, HHS requires regulated entities to evaluate the facts and circumstances, such as the individual’s diagnosis and prognosis, the

time such healthcare was provided, the location where such healthcare was provided, and the particular healthcare provider who provided the healthcare.

What happens if the regulated entity reasonably determines that the presumption applies, but law enforcement or the person requesting the information disagrees? According to HHS, the “presumption” of lawfulness applies, and the PHI cannot be used or disclosed for the otherwise prohibited activities unless and until the person requesting the PHI can provide additional information to overcome the presumption.

Practice pointer: Even if the person requesting the PHI can overcome the presumption, or even if the regulated entity has actual knowledge that such care was not lawful, the regulated entity is not required to provide the PHI to the requester. The 2024 Privacy Rule only permits and does not require the regulated entity to use or disclose reproductive healthcare PHI if such care is unlawful.

Attestation Required for Certain Permitted Purposes

In addition to adding new prohibited purposes for uses and disclosures of PHI, the 2024 Privacy Rule adds an attestation requirement for certain permitted purposes for PHI that may be “potentially related” to reproductive healthcare. Both covered entities and business associates are subject to this requirement, which applies when the PHI is requested for:

• healthcare oversight,

• judicial and administrative proceedings,

• law enforcement purposes, and

• about decedents to coroners and medical examiners.

Upon receiving such a request, the regulated entity must first determine that the use or disclosure of any PHI “potentially related” to reproductive healthcare is not for one of the new prohibited purposes. If it is not for a prohibited purpose, the regulated entity must then obtain a valid attestation from the person

requesting the PHI verifying that the purpose is permissible.

How is a regulated entity supposed to know whether PHI is “potentially related” to reproductive healthcare? HHS clarifies that there is no requirement to make an affirmative determination before requiring an attestation. Once the regulated entity determines that reproductive healthcare PHI may be involved, the attestation itself must be properly completed and submitted.

The attestation standard is rather strict. All the elements from the 2024 Privacy Rule must be included in the attestation, and no more, or else the attestation is invalid (a number of other offenses will likewise invalidate the attestation). The attestation requires a statement that the use or disclosure is not for a prohibited purpose for reproductive healthcare and a statement that the requester may be subject to criminal penalties if he or she knowingly and in violation of HIPAA obtains the information or discloses it to another person.

Compound attestations are generally invalid with some exceptions, and no attestation can be valid if a “reasonable” covered entity or business associate would not believe the attestation is true (or has actual knowledge that it is not true). HHS issued a model attestation form, which can be accessed here.

Practice pointer: Although HHS does not require a regulated entity to investigate the veracity of the information provided in support of an attestation, a regulated entity in the process of using or disclosing PHI in reliance on a facially valid attestation must halt the process if it discovers information reasonably showing that any representation made in the attestation was materially false and would lead to a prohibited use or disclosure.

NOTICE OF PRIVACY PRACTICES

The 2024 Privacy Rule includes changes that covered entities must make to their Notice of Privacy Practices by February 16, 2026. Plan sponsors will need to update their NPPs to add the following:

• A description, including at least one example, of:

o the types of uses and disclosures of reproductive healthcare PHI that the 2024 Privacy Rule prohibits;

o the types of uses and disclosures for which an attestation is required.

• A statement explaining to individuals that PHI disclosed pursuant to the Privacy Rule may be subject to redisclosure and no longer protected by HIPAA’s privacy rule.

In addition to modifications related to the 2024 Privacy Rule, changes to the NPPs include modifications HHS first proposed in the 2022 Confidentiality of SUD Patient Records Notice of Proposed Rule Making. That rule regulates the use of certain substance use disorders and treatment information. Although most of that rule was finalized separately, HHS decided to delay finalizing the changes to the NPPs to avoid requiring covered entities to revise their NPPs twice in a short period of time. Changes related to Part 2 that were finalized in this rule include:

• Covered entities creating or maintaining records subject to Part 2 must provide NPPs to individuals who are the subject of those records (although the inmate exception remains in the rule).

• Covered entities cannot use or disclose SUD treatment records received from programs subject to Part 2 or testimony relaying the content of such records for purposes of civil, criminal, administrative, or legislative proceedings against the individual unless the individual has consented

in writing or unless the use or disclosure is pursuant to a court order (accompanied by a subpoena or other legal requirement compelling disclosure).

• Covered entities cannot use or disclose Part 2 records for their own fundraising without providing individuals a clear and conspicuous opportunity to opt out of receiving fundraising communications.

PERSONAL REPRESENTATIVE

The 2024 Privacy Rule would not allow a covered entity to refuse to treat a person as a personal representative of an individual on the basis of abuse, neglect or endangerment if the basis for the covered entity’s belief is that the person facilitated or provided reproductive healthcare to the individual.

COMPLIANCE TAKEAWAYS

• Update NPPs to explain and provide examples of the new restrictions on using or disclosing reproductive healthcare PHI and the attestation requirement.

• Review HIPAA policies and procedures:

o update for reviewing and responding to requests that include or potentially include reproductive healthcare PHI;

o incorporate the new definitions for “reproductive healthcare” and “public health”;

o incorporate the restrictions for refusing to treat a person as a personal representative;

o implement the attestation requirement (model form can be accessed here).

• Review business associate agreements and amend them to ensure compliance with the 2024 Privacy Rule (although note that both the attestation requirement and the restriction on uses and disclosures of reproductive healthcare PHI for prohibited purposes apply directly to covered entities and business associates alike).

• Train any personnel who handle requests for PHI on the 2024 Privacy Rule requirements.

The compliance date for updated NPPs is February 16, 2026; the compliance date for all other requirements is December 23, 2024.

About the authors

Attorneys John Hickman, Ashley Gillihan, Steven Mindy, Ken Johnson, Amy Heppner, and Laurie Kirkwood provide the answers in this column. John 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 and Steven are partners in the practice, and Ken, Amy, and Laurie are senior members in the Health Benefits Practice. Answers are provided as general guidance on the subjects covered in the question and are not provided as legal advice to the questioner’s situation. Any legal issues should be reviewed by your legal counsel to apply the law to the particular facts of your situation. Readers are encouraged to send questions by E-MAIL to John at john.hickman@alston.com.

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NEWS FROM SIIA MEMBERS

2024 AUGUST 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.

If you would like to learn more about the benefits of SIIA’s premium memberships, please contact Jennifer Ivy at jivy@siia.org.

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SIIA MEMBER NEWS

SIIA boasts a very active and dynamic membership. Here are some of the latest developments from the companies powering the self-insurance industry.

Physicians Mutual Expands Stop-Loss Market Reach with ATS Partnership

Physicians Insurance - A Mutual Company, long known for exceptional products and services, is expanding its footprint for Employer Stop-Loss (ESL) coverage through a new distribution model, geographic expansion, and an array of complementary online resources geared toward the healthcare community. Coverage is already available in Washington, Oregon, Idaho, Montana, Wyoming, Utah, Colorado, and Alaska, with service for dozens of new states coming soon.

“As an organization with more than 40 years of dedication to Physicians and their practices— and having offered ESL since 2002—we see Employer StopLoss as a natural product extension to protect the financial health of Member organizations at a time when external forces are impacting their viability,” says Jennifer Millar, Associate Vice President, Stop-Loss, at Physicians Insurance. “And as our entire purpose is to protect, defend, and support our

members, we are also opening up our vast array of online resources, developed specifically for the healthcare community, to our ESL clients at no extra cost.”

To help scale the offering of this key coverage, Physicians Insurance has partnered with  ATS Underwriting, an innovative, strategic underwriting firm that specializes in Employer Stop-Loss, with specific expertise in healthcare practices. Through this partnership, members have efficient access to top-quality stop-loss solutions and services, backed by the financial strength and healthcare industry commitment of Physicians Insurance. The timing and the choice of partner could not be better.

“Over the past decade, the Stop-Loss market has seen exponential growth,” observes Andrew Trupiano, CEO and Founder of ATS Underwriting. “More healthcare organizations and companies in all industries have been migrating from the fully insured medical plans model to self-funded plans to gain better control over their plans and reduce their costs. As they make the move, Stop-Loss insurance is essential to cap employee medical claim costs and protect employers’ balance sheets against the outlying volatility of severe and catastrophic medical claims.”

WLT Teams up with ChoiceScripts for Improved Benefits Solutions

WLT Software Enterprises, Inc., a developer of custom benefits and claims administration software solutions, has announced its partnership with ChoiceScripts, an innovative pharmacy consultant and benefit architect specializing in flexible and transparent solutions.

For more than four decades, WLT Software has been a leading provider of benefits administration, claims processing, workers’ compensation, and consumer-driven healthcare solutions. WLT’s core system, MediClaims, was developed with the understanding that every organization has its own unique needs and requirements. Through this partnership, WLT aims to strengthen its mission as a steadfast provider of adaptive claims and benefits solutions.

ChoiceScripts’ innovative pharmacy benefits management provides best-in-class drug pricing, cutting-edge data analytics, and a hightouch service model that delivers the best savings and value for the clients and members they manage. ChoiceScripts offers tailored plan designs, concierge service, and support that results in improved cost management, quality outcomes, and increased member satisfaction.

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WLT President & CEO Shelley Van Etten stated, “WLT is always proud to see its network grow. As we continue to adapt to this everchanging industry, we look forward to evolving alongside our partners in order to bring the best possible solutions to our clients.”

Joseph Yaklic, ChoiceScripts President, Co-founder & Chief Clinical Officer, stated, “Our partnership with WLT Software is a pivotal step in streamlining our solutions to make them more accessible for our partners and clients, creating a better experience that removes the heavy administrative burden of PBM implementation.

Captive Insurance Veteran Mike Madden Joins Berkley A&H

Berkley Accident and Health, a Berkley Company, has appointed Mike Madden as Senior Vice President of Growth Strategy for its Group Captive business. In this role, Mike will be responsible for expanding the company’s portfolio and offerings, as well as developing highimpact strategies that drive continued growth in the Employee Benefit Group Captive market.

Mike joins Berkley Accident and Health with 25+ years of industry experience and as a recognized leader in the Group Captive space. He is a past chair of the Self-Insurance Institute of America (SIIA) Captive Committee, which is committed

to education, political advocacy, networking, and best practices for captive owners, participants, and professionals. His deep industry knowledge and reputation make him an ideal fit for his new role.

“Mike brings a depth of knowledge and insight that will help us to better serve our Captive clients and brokers,” said Brad Nieland, President and CEO of Berkley Accident and Health. “Having Mike join our team deepens our bench strength and will contribute to our continued success. I am very excited to be adding more top talent to our Stop-Loss Group Captive team.”

Teladoc Health Names New CEO

Teladoc Health, Inc., the global leader in whole-person virtual care, announced that its Board of Directors has appointed Charles “Chuck” Divita, III, as Chief Executive Officer, effective immediately. Concurrent with his role as CEO, Mr. Divita has also joined Teladoc Health’s Board of Directors.

Mr. Divita joins Teladoc Health from GuideWell, a leading health solutions organization that includes Florida Blue, the market-leading health plan in Florida, where he served as Executive Vice President, Commercial Markets.

“In today’s healthcare landscape, Chuck is the perfect example of experience, respect, and competence among executives, and we are pleased to welcome him to Teladoc Health,” said David B. Snow, Jr., Chairman of the Teladoc Health Board of Directors. “We are confident we have selected an innovative and visionary leader capable of delivering growth at scale, value for our clients and positive relationships with all our partners and colleagues.”

“I’m honored and grateful to the Board for this opportunity,” said Divita. “Teladoc Health has been successful at securing a leading position in the marketplace, and I look forward to working closely with my new colleagues to build upon this foundation, advance key strategic priorities and ensure the company is positioned for longterm, sustainable success. This will provide new opportunities to positively impact healthcare and the health and wellbeing of the people we serve.”

Christine Lui Chen to Lead Marketing at ParetoHealth

ParetoHealth, the nation’s largest and fastest-growing employerowned health benefits solution, is pleased to announce the appointment of Christine Lui Chen as Chief Marketing Officer. In her new role, Christine will oversee the company’s marketing, communications, and brand experience.

“Pareto is committed to bringing the industry’s top talent to support our members and benefit consultants,” said Maeve O’Meara, President of ParetoHealth. “Christine joins us in challenging the status quo, and she will be a tremendous asset as we expand our membership and innovate to reduce costs while improving health benefits for the industry.”

“I’m excited to join the ParetoHealth team’s fight for the greater good,” said Christine. “With our unmatched scale and technology, we’re in a unique position to help millions of small and medium-sized businesses finally gain back control over spiraling healthcare costs.”

Previously, Christine served as Senior Vice President of Marketing and Communications at Hinge Health, a pioneering digital musculoskeletal company. Christine’s extensive background includes

building new healthcare categories through leadership roles at Johnson & Johnson, Independence Blue Cross, and IMS Health, along with multiple innovative healthcare startups. Christine holds an MBA from The Wharton School of the University of Pennsylvania, a master’s from Columbia University, and a BA in Neuroscience from Johns Hopkins University.

Virtue Health Expand Executive Sales Team

Virtue Health, a leading private group stop-loss purchasing consortium, is pleased to announce the appointment of Fabian Carrillo as the new Senior Vice President of Sales. Fabian brings over two decades of extensive experience in the healthcare and insurance sectors, strengthening Virtue Health›s mission to provide innovative, long-term insurance solutions for employers in the small to mid-size market.

Fabian Carrillo joins Virtue Health with a robust background in managing and optimizing health plans to reduce medical spend waste. Previously, Fabian served as the Regional Vice President at MORE Health Inc., where he was responsible for U.S. sales and spearheaded new group

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sales initiatives in the digital health sector. With expertise in self-funded medical and ancillary product lines, Carrillo’s strategic vision and leadership will be instrumental in expanding Virtue Health’s reach and enhancing its cost-containment strategies. His appointment reflects Virtue Health’s commitment to reducing volatility and providing stable, cost-effective health insurance solutions for employers.

John Sbrocco, CEO of Virtue Health: “We are excited to welcome Fabian Carrillo to our leadership team. His extensive experience and proven track record in the healthcare insurance industry make him a valuable addition to Virtue Health.

Fabian’s expertise will undoubtedly strengthen our efforts in providing innovative solutions that benefit both brokers and employers”.

Trinity Capital Backs Gravie with Major Investment

Trinity Capital, a leading provider of diversified financial solutions to growth-oriented companies, announced a commitment of $40 million debt facility to Gravie, one of the nation’s fastest growing health benefits innovators.

Gravie offers self-funded health plans called Comfort® for small and mid-size employers. Comfort provides comprehensive coverage with no deductibles or copays on the most common healthcare services, including virtual care. Gravie aims to simplify healthcare by offering straightforward plans and providing additional benefits like interestfree payment options.

“Gravie’s innovative approach to health benefits can help small and mid-sized businesses provide quality, affordable coverage to their employees,” said Ryan Thompson, Managing Director, Tech Lending at Trinity Capital. “We’re excited to partner with Gravie as they continue

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scaling their Comfort health plan model nationwide.”

“We are excited to partner with the Trinity team as we grow our business and seek to make health benefits plans work for everyone,” said Charles Marentette, Chief Financial Officer of Gravie.

Todd Burkart Joins TrueScripts TrueScripts Management Services, a leading prescription benefit management company based in Washington, IN, is thrilled to announce the appointment of Todd Burkart as the new Vice President of Operations & Member Experience. Todd, a seasoned veteran in the Pharmacy Benefit Management (PBM) industry, brings a wealth of experience from his leadership roles at Express Scripts, Prime Therapeutics, and, most recently, Liviniti (formerly Southern Scripts). His extensive background and expertise will be invaluable as we continue to

expand our operations and member services.

“We are delighted to welcome Todd to the TrueScripts team as our new Vice President of Operations & Member Experience,” said Nick Rasche, CFO/COO of TrueScripts Management Services. “Todd’s extensive experience and proven leadership in the PBM industry will be instrumental in driving our commitment to exceptional member service and operational excellence. His strategic vision and dedication to enhancing the member experience align perfectly with our organization, and we look forward to the tremendous impact he will make at TrueScripts.”

In his new role, Todd Burkart will oversee the day-to-day operations of our growing organization. He will also be instrumental in enhancing TrueScripts’ unmatched member services, ensuring we continue to deliver Amazing Care.

“Todd brings a wealth of PBM leadership experience to the organization,” said Dean Merder, President & CEO of Truescripts Management Services. “We are very excited to have Todd join our leadership team. His devotion to excellence will be instrumental as we expand our operations and deliver exceptional care to our members.”

Advocacy in Action

2024 SELF-INSURANCE INSTITUTE OF AMERICA

BOARD OF DIRECTORS

CHAIRMAN OF THE BOARD*

John Capasso

President & CEO

Captive Planning Associates, LLC

CHAIRMAN ELECT*

Matt Kirk

President

The Benecon Group

TREASURER AND CORPORATE SECRETARY*

Amy Gasbarro

DIRECTOR

Stacy Borans

Founder/Chief Medical Officer

Advanced Medical Strategies

DIRECTOR

Mark Combs

CEO/President

Self-Insured Reporting

DIRECTOR

Orlo “Spike” Dietrich Operating Partner

Ansley Capital Group

DIRECTOR

Deborah Hodges

President & CEO

Health Plans, Inc.

DIRECTOR

Mark Lawrence

President

HM Insurance Group

DIRECTOR

Adam Russo CEO

The Phia Group, LLC

DIRECTOR

Beth Turbitt

Managing Director

Aon Re, Inc.

VOLUNTEER COMMITTEE CHAIRS

Captive Insurance Committee

Jeffrey Fitzgerald

Managing Director, SRS Benefit Partners

Strategic Risk Solutions, Inc.

Future Leaders Committee

Erin Duffy

Director of Business Development

Imagine360

Price Transparency Committee

Christine Cooper CEO

aequum LLC

Cell and Gene Task Force

Shaun Peterson

VP Head of Worksite Solution

Pricing & Stop Loss Product

Voya Financial

* Also serves as Director

SIIA NEW MEMBERS

AUGUST 2024

CORPORATE MEMBERS

G. Blair Campbell VP National Sales Arcuity AI Lakeland, FL

David Tischler Co-Founder CureTrust Menlo Park, CA

Leann Bond Event Marketing Manager FitOn Health Tampa, FL

Kaushil Shah Partner

Global Access Pharma Markham, ON

Dan Cooper Vice President, Business Development Intellivo St. Louis, MO

James Deren Managing Member

J. M. Deren & Associates, LLC Wesley Chapel, FL

Lindsay Clarke Youngwerth Founder Keenly Boise, ID

Sue Shields Director

Napa River Insurance Services New York, NY

Anna Mathy Senior Director Healthcare Resource Solutions NTT Data Lake Tomahawk, WI

James Benham CEO Terra College Station, TX

Barbora Howell CEO TrueClaim San Francisco, CA

Ryan Mitchell

Global Accident & Health Leader and Reinsurance Deputy Partner Wisterm London

SILVER MEMBERS

Wesley Bryan Business Development

Baylor Scott and White Quality Alliance

Dallas, TX

Stephanie Kirtley Events Manager Cotiviti, Inc. South Jordan, UT

Nicolas Raga CEO

Mano Health New York, NY

EMPLOYER MEMBERS

Christopher Bandak Administrative Director Adventist Health Roseville, CA

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