F EB R UA RY 2 0 2 4
A S I P C P U B L I C AT I O N
Eyeing AI’s Opportunities and Pitfalls Forum Examines Technology’s Applications and Workflow Dynamics
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TABLE OF CONTENTS
FEBRUARY 2024 VOL 184
W W W. S I P C O N L I N E . N E T
F E AT U R E S 4
EYEING AI’S OPPORTUNITIES & PITFALLS
By Bruce Shutan
MORE GROWTH AND AWARENESS SEEN FOR CAPTIVES IN 2024
By Caroline McDonald
SIIA HEALTHCARE PRICE TRANSPARENCY FORUM PREVIEW
SIIA MEMBERS GET TO WORK AS PART OF ASSOCIATION
NEWS FROM SIIA MEMBERS
VOLUNTEER LEADERSHIP TEAMS
WHAT YOU NEED TO KNOW ABOUT MSP REPORTING REQUIREMENTS
The Self-Insurer (ISSN 10913815) is published monthly by Self-Insurers’ Publishing Corp. (SIPC). Postmaster: Send address changes to The Self-Insurer Editorial and Advertising Office, P.O. Box 1237, Simpsonville, SC 29681, (888) 394-5688 PUBLISHING DIRECTOR Bryan Irland, SENIOR WRITER Bruce Shutan, CONTRIBUTING EDITORS Mike Ferguson, Jennifer Ivy and Ryan Work, PRESIDENT/CEO Erica M. Massey, CFO Grace Chen
F E AT U R E
Eyeing AI’s Opportunities and Pitfalls Forum Examines Technology’s Applications and Workflow Dynamics
Written By Bruce Shutan
he rise of artificial intelligence has seen multiple applications deployed in the self-insurance market to handle anything from mundane to strategic tasks. It also is revolutionizing the way people work. This month, SIIA is hosting a forum in Charlotte, N.C., which will exclusively focus on AI solutions. Several presenters at the event who work in various roles across the industry recently shared their insights on both the hurdles and opportunities that will arise. “It’s a whole different way of working that I think changes pretty much every role of intellectual work that can be done,” observes Reid Harris, a senior client advisor for Lockton Dunning Benefits, who will be speaking on how AI is transforming workforce dynamics.
AI Opportunities & Pitfalls
Citing a McKinsey study suggesting this burgeoning technology will help marginally improve all worker outputs and level the playing field, his sense is that natural learners and curious individuals will be amplified more so than everyone else. In particular, he says those who ask language models thoughtful questions and receive good answers will reap rewards.
AI will shift from transactional to more complex tasks over time, Harris predicts. It can take over routine matters entirely and free up people to focus on more human interactions and relationships. “I would imagine improved predictive modeling and pattern finding is going to have the largest impact on the way the self-insurance industry operates,” he surmises. “What that means for the workforce and roles, and implications of how we staff and model or even how careers look, that’s to be determined.” A BOON TO SMALLER GROUPS
Another factor to consider will be how and where the technology is deployed. The AI revolution, for instance, isn’t expected to be as impactful for larger employers, in a sense, because they’re already using or deploying the technology with their own data, data warehousing, or work with consultants, opines David Shore, EVP for Borislow Insurance, who will be moderating a session on using AI to improve risk precision, pricing and performance for clients.
steps in is, without having any data, what typically will happen, is you’ll get a tech or AI company to perform a lexical analysis, which ultimately is taking a member-level census." "They tokenize it,” he continues, “bounce it up against a credible database, and in a lot of cases they were returned back based upon the different attributes, with some being behavioral or medical claims, prescription or otherwise, they basically risk score the group. And that risk score is used by the reinsurance carriers in a lot of different places to help them price the group and be able to understand which group we should issue coverage to or if you’re trying to price the risk correctly, what price should we issue for someone who has or presents suspect risk?” EASING “PAJAMA TIME”
He says the ones who are benefiting most appear to be smaller groups that are a bit less credible with their claims experience and have grown tired of being dependent on the fully insured machine. The thinking is that these organizations would be given information that they’ve never had before, as well as the ability to be more precise in understanding their risk and deciding what to do with it. “What I see with smaller employers is most of them are nervous because they don’t understand their own risks,” he observes. “So, they’re more apt to just transfer that potential exposure. Where AI
AI is also expected to mine operational efficiencies on the clinical side, freeing up physicians who are seriously fatigued by the time so-called “pajama time” rolls around, according to Erich S. Huang, M.D., Ph.D., head of clinical informatics at Verily, who will address the role of AI at the bedside. The term is used to explain how after a busy day of performing mundane tasks alongside seeing patients, there’s limited time to cook dinner or interact with family. As a result, many physicians end up opening their laptops in the evening to finish charting clinic notes. FEBRUARY 2024
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AI Opportunities & Pitfalls OVERCOMING OBSTACLES
But these significant efficiencies must be put into perspective. There’s no escaping the fact that AI will have upsides and downsides.
Huang is hopeful that AI will create opportunities that allow his peers to spend more time on patient care. He says AI and machine learning can easily take care of all the labor-intensive tasks that bog down Doctors so that they can spend more of their time thinking about patients.
“There definitely will be in the future people who are killed by AI in healthcare settings,” Huang cautions. “There also will be people whose lives are saved by AI in healthcare settings.” He says it’s no different than the early days of bone marrow and liver transplantation when some patients unfortunately died. “We have to use frameworks with which to integrate AI into healthcare delivery in a safe and responsible way just as we have with other technologies,” he adds. While AI excels at combing through reams of data, making exponential gains on a linear scale with almost unlimited capabilities, Harris notes that there are still several obstacles that must be overcome. “It’s not very good at this point in time at creating novel solutions,” he observes. “The other core limitation is going to be around the workforce itself.” With regard to the latter, his chief concern is atrophy of learning and critical thinking.
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AI Opportunities & Pitfalls Much the way people stopped memorizing facts when computers and the internet came along and simply looked up that information on search engines, Harris worries about this next paradigm shift. “So does that mean that we stop thinking?” he asks. “If we stop learning, stop contributing, stop creating new sources of data, it just becomes recursive in nature, and the quality of the outputs, especially if you feed outputs into inputs, then you have a nightmare scenario where these models no longer work.” EXPOSURE TO LIABILITY
Outsourcing too many tasks to AI could create problems in our litigious society. Ashley Gillihan, a partner with Alston & Bird who will address legal and compliance issues, believes AI may expose health plan administrators to liability where nuances and variations of claims can’t be picked up or analyzed. Initial iterations of medical necessity and experimental or investigative procedures sometimes require analysis that may or may not be automated, he explains. “I just don’t know how yet AI can actually do that,” he says, fearing exposure to litigation. Self-insured employers that decide to tap into AI should be transparent about it, Gillihan suggests. “You would definitely want to build into any health plan contracts the fact that you’re using AI and what you’re using it for,” he says, adding that plan sponsors also will want some sort of audit capability.
“A lot of the incentives become orthogonal to getting good outcomes for our patients in a world that’s still mostly feefor-service and volume-based,” Huang points out. “There’s still a little bit of an incentive to do more without necessarily benefiting the patient because it brings you more reimbursement. Value-based care aligns the motivations so that if you do well for your patient, then you actually get to keep more of your capitated funds that you have devoted to that patient. If more reimbursement gets aligned with getting beneficial outcomes for your patients, the more opportunity there will be for AI to actually align with getting the best outcomes for your patients as well.”
One of the prerequisites for AI and value-based care being truly effective at a national level is the need for data interoperability. Privacy is another area of concern, with the goal of ensuring that Huang notes that the 21st Century personal health information continues to be confidential. “We used to Cures Act includes interoperability not text people information about their claim or other aspects of health resources as the data standard plan information, but that’s become quite common,” he notes. for exchanging health information. In short, Gillihan explains the fiduciary duty that a claims administrator “There’s an ecosystem problem that has to be solved,” he might have with using AI would be to ensure that the terms of the explains. “You don’t just throw plan are enforced and administered. “I think AI is set up to do that,” an algorithm into some place and he says. “I wonder, though, if it’s possible to take into account all think it’s going to magically make the variations that might arise with any of the claims administration everything better. We want AI because facts differ, and scenarios differ.” to be useful on a national scale and uniformly for everyone. ALIGNING WITH VALUE-BASED CARE We need to think about how we can equalize people’s access While AI holds tremendous promise for helping improve clinical to all these potentially useful outcomes and reducing wasteful spending, there are larger systemic technologies.” problems that first must be addressed, and legislative solutions pursued in order to leverage this technology.
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AI Opportunities & Pitfalls EYEING PREDICTIVE MODELING
Growing interest in AI appears to involve the power of anticipating or forecasting claims experience. Most of the CFOs whom Shore encounters, for example, are much more interested in the predictive element of their insurance risks and what will happen in the future than in assessing what has already happened. “It’s a really engaging place for smaller businesses that are fed up with what I call the ‘less bad renewal’ in which eventually the client settles at an effective increase that is probably higher than what they should really accept,” he reports. “This is giving them another tool to be able to combat that.”
Bruce Shutan is a Portland, Oregon-based freelance writer who has closely covered the employee benefits industry for more than 35 years.
While Shore’s team mines much of the minutia behind the scenes as data scientists, harnessing AI from a consulting standpoint is about assessing whether it makes sense for the client to take on more risk or proceed with caution. That decision heavily depends on the organization’s size and what stop-loss insurance has been put in place, he adds. Whatever the case, he believes that embracing predictive AI-type tools presents an opportunity for consultants to differentiate themselves – continually being innovative and entrepreneurial while also putting clients first. AI gives finance and HR executives alike what Shore calls the “magic or tragic space” where clients are big enough to be held accountable for their claims before they’re looked at but don’t get to see them. “It gives them a data point that they’ve never had before,” he says.
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F E AT U R E
More Growth and Awareness Seen for Captives in 2024 Written By Caroline McDonald
hile an increase in the number of captives has been steady over the past few years, even as rates for coverages climb, experts in the industry expect captive growth to continue. Other drivers in captive growth include the ways captives are used, the size of companies forming them, and their usage for costly medical procedures. “Overall, activity is very robust,” said Victoria Fimea, chief captive analyst at the Arizona Department of Insurance and Financial Institutions. “We see that the commercial market is such that many businesses feel it is not supporting them in their pricing and coverage. As a result, we are having a lot of inquiries about captives, and that is one trend that will continue well into 2024.”
Growth for Captives in 2024 Secondly, there is an increasing awareness that captives are an alternative for risk management, she said. “And when you have that increased awareness, it generates a lot of activity and discussion amongst the service providers initially because they are the ones that will do the analysis for the business owners to determine if a captive is a feasible route.”
broader potential risk.”
Third, Fimea said, market fluctuations are steady, principally in the property area. “We are also seeing quite a bit with auto commercial transportation and medical stop-loss,” she added. The reason is that “everything is more expensive medically and therefore is driving up premiums for employers.” As they look at their medical stop-loss program, she said, they are “looking for a way to put that deductible in the captive and thus get better pricing in the commercial market. I think those three trends will continue well into 2024.”
A reinsurer he spoke to “said they have had a large uptick in cancer claims. We are not sure what is driving that, but we have also heard it from other sources,” he said.
ADDRESSING GENE & CELL THERAPY
Ward Humphreys, senior vice president at Risk Strategies Company, noted that “Gene therapy remains the elephant in the room, and there are a good number of captives that have been approved for $2.5 million and above for therapies.” Zurich said in its July 31, 2023, report, “Why Employee Benefits Captives are Adding Medical Stop Loss,” that high-cost medical claims have become a top concern for employers over the past decade and that since 2016, the number of health plan members with claims of $3 million or more has doubled. Concerns about therapies include pricing for them, Humphries said. “There is also concern about premature birth, which they see as having a higher frequency. So, until gene therapy starts hitting with more frequency, it will be looming out there.” Questions include “how active doctors will be in terms of prescribing, whether facilities will have the capacity for them, and how many of these therapies can they do in a month?” An example, Humphreys said, is gene therapy as treatment for extremely rare conditions. “Some of them are very complicated, like sickle cell therapy, which requires a 30-60 day stay to remove cells. That all remains to be seen,” he said. Another concern is the therapies that will be introduced. “Instead of it being for hemophilia, which is maybe 20,000 people, they are going to introduce them for broader conditions,” he said. “So, you’ll still have that $2 million price tag, but instead of it being for a population of 20,000, it will be for a population of one or two million and a much
The other big one, Humphreys said, is cell therapy, “which is more commonly directed towards cancers.”
The incidents of more intensive cancer are also higher, Humphreys noted. “It used to be that when most cancers were diagnosed, someone was at stage-one or two, and now it seems they are diagnosed at stage-three or four. So, much more aggressive and costly treatment is required.” A possible reason for this, he added, is that the cancers are not identified as early. Another is that “some types of cancer are more aggressive than what is typically seen.” Regarding captives for this, “that may be a broader theme that the market will continue to watch,” Humphreys said. GROWING INTEREST IN CAPTIVES
Jeffrey Fitzgerald, Managing Director, Strategic Risk Solutions Benefit Partners at Strategic Risk Solutions, and chair of SIIA’s Captive Insurance Committee, said that overall, “We’re seeing more focus on going downmarket in terms of group size,
Growth for Captives in 2024 popularity of self-funding of small groups also continues. “While the self-funded market for benefits has been $100,000 to $250,000 and For the most part, “you’re still above,” he said, “Now we are seeing a movement of groups below selling each group individually, $50,000 self-funding their employee benefits – not necessarily with using captives to get larger blocks a captive. There are infinitely more small groups than groups above of oftentimes smaller groups,” he $200,000, so it’s been a big market move.” said. Potentially, he said, these groups could start looking at captives. “The growth of heterogeneous Fitzgerald observed that decisions on where to locate captives “tend employee benefit major medical to be more geographic than anything. Brokers are the drivers of this group captives has been the growth, and most brokers are more specific to their geography than to largest success story over the last ten years in the captive world industries.” and the employee major medical benefits world,” Fitzgerald noted. Another thing, he noted, is that there are increasingly two different types of buyers. “There is the buyer that really wants to get involved “This is continuing, even though there are still huge pockets where in all the cost drivers of their program and is therefore very engaged in the choices they may have.” they are not used. Or there is a lack of education.” The other group relies on brokers, and the captive is “put together to more on a program basis.”
contain all of that for them. The captive industry must be aware of that and provide solutions for both,” Fitzgerald said.
Humphreys said that the
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Growth for Captives in 2024
FUELING INTEREST IN INSURANCE CAREERS
It’s predicted that the insurance industry will grow by about 9 percent annually, reaching $8.4 trillion by 2026, according to Statista. While the industry is growing, however, the employment rate remains stagnant, with only three million employed by the industry – about 3 percent more than in 2020, according to Marketplace. This illustrates the need for new interest and talent in the industry. Fimea, who also serves as an adjunct professor at Northern Arizona University in Flagstaff in their Risk Management and Insurance certificate program, is working to change this. “I teach the senior year Capstone course for the RMI Certificate,” she said. “We graduated our first students with their RMI certificate in May.” An important trend she is seeing is the industry working to “open the eyes of college students about the opportunities that exist in the RMI industry, specifically in captives.” She noted, “In my class, students are made aware of captive insurance companies. Indeed, it is a new topic for the students.” Her students, she said, “find it intriguing that a corporate insured can own its own insurance company.” The industry is also actively working to attract more students to careers in insurance. For example, several large captive and association conferences “have competitions for scholarships that are offered for college students, and that trend I see continuing in 2024,” Fimea added. This is “needed to ensure that people out there have interest in joining our industry, building a career in it, and contributing to the industry,” she said. As an adjunct professor, Fimea added, “I can tell you that when you work with college students on risk management and captive insurance, they get really interested. It’s tied to current events, such as a major storm and its impact on pricing. They hadn’t realized that insurance is right on the front lines.”
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.
SIIA HEALTHCARE PRICE TRANSPARENCY FORUM PREVIEW
Written By Laura Carabello
s self-insured health plans take the lead in bringing transparency to a rapidly evolving healthcare system, they draw upon the resources of SIIA to fulfill their mission for better decisionmaking and optimal clinical outcomes. As they envision healthcare to include more accountability and greater transparency, it is clear that evidence of efficacy facilitates the transition to safer healthcare with value for the resources that are invested. From the latest policy and compliance discussions to innovative ways of tackling the cost of care and prescription drugs, the upcoming SIIA 2024 Healthcare Price Transparency Forum brings together industry-leading experts and innovators who will provide expanded understanding and guidance to help navigate these complex issues. Attendees will learn the value of increasing transparency to improve care at a lower cost.
Ryan Work, SVP, Government Relations, Self-Insurance Institute of America, Inc. (SIIA), oversaw the design of the Forum and will be moderating several of the panels. He explains, “Price transparency has not only become an important policy and regulatory discussion before Congress and the Administration, but it is also a critical issue for the future of employer-sponsored healthcare generally and self-insured plans specifically.” He says SIIA is hosting this event since it recognizes that members need all the tools at their disposal to ensure plans are paying the right price for the correct patient care, in addition to doing all they can collectively to effectively manage the rising cost of healthcare. As a regulatory expert who pro-actively advocates on behalf of members, he asserts, ‘SIIA continues to actively engage with Congress and the Administration on price transparency, from the implementation of the No Surprises Act (NSA) to the ongoing debate on drug pricing and Gag Clause attestation. With ongoing litigation surrounding NSA, to congressional legislation on PBM and price transparency, our team is busy educating Federal agencies and policymakers on the Hill about what members are facing and the solutions we support.” Encouraging attendance and participation at this year’s Forum, he advises, “The 2024 event is broader than in years past as the debate on price transparency has also widened in scope. Stemming from the implementation of NSA, the 2024 Transparency Forum will also address drug pricing, the Gag Clause prohibition, and the challenge and opportunities being faced by self-insured health plans.” Most importantly, he says the panels of experts will address what is working, what needs to be fixed and what can be done to effectively bring transparency and lower costs to healthcare delivery. “The Forum’s goal is to be an interactive dialogue with industry leaders, including plan sponsors, brokers, third party administrators (TPA’s) and vendors, to talk about best practices, market viewpoints and what lies ahead in an ever-changing landscape.” ATTEND AND LEARN
Chris Condeluci, Esq., Washington counsel, SIIA, a co-architect of the event who will also be participating and moderating many of the sessions, says, “Until we can figure out how to reduce the unit cost of healthcare, costs will continue to rise. To manage these increased costs, employers continue to look to different strategies that can empower participants to be better consumers of healthcare.” Additionally, employers are looking at better ways to manage costs, and Condeluci advises that transparency is a means to these ends. “For example, the public disclosure of medical prices and greater access to cost-sharing liability information will help participants consume healthcare more efficiently,” he continues. “Also, access to FEBRUARY 2024
pricing information and health claims data will empower employers in their contract negotiations with third-party service providers and owners of provider networks and help employers develop cost-containment programs. This Forum will discuss in detail the various types of transparency tools that are available to employers and other organizations sponsoring a self-insured health plan, and expert panelists will explain how these tools are being deployed and whether and how savings are being realized.” Condeluci points to policymakers and other healthcare experts who have heralded the Transparency in Coverage and Hospital Transparency Regulations as being transformative. But he raises this question: “3.5 years after their release, are these regulations really having a transformative impact on the healthcare industry?”
He reports that some healthcare stakeholders would say, “No,” adding, “Many healthcare stakeholders would caution, “Give it time…increased access to pricing and health claims data will dramatically change the way health coverage is offered and consumed. The future and overall impact of increased transparency will be debated and explored in depth at SIIA’s Healthcare Transparency Forum. If you play any type of role in the healthcare industry, you won’t want to miss it.” Christine Cooper, CEO, aequum, and chair of the SIIA Transparency Committee, expects robust exploration of hospital price transparency requirements, explaining, “There is a lack of standardization in the requirements for what and how hospitals report transparency data. While the government has issued guidance relating to the requirements, the guidance is not enforceable, and we are still seeing significant non-compliance by hospitals sharing the required data.” Cooper says Machine Readable Files continue to be incomplete or missing entirely, and as of July 2023, PatientRightsAdvocate.org reported that only 36.0% of the 2000 surveyed hospitals were fully compliant: 69 providers had no usable information accessible. A new report is due out in February 2024. SIIA FORUM PANELISTS TACKLE KEY ISSUES
Transparency: Policy & Regulatory Update Tuesday, February 27, 2024, 8:45-9:30 AM Attendees will benefit from the guidance of SIIA’s Government Relations team, who will provide the latest insights and discussion on regulatory and legislative activities on PBMs, price transparency, and surprise medical billing, in addition to ongoing Hill debates. Condeluci observes, “Owners of provider networks, such as entities that “rent” a provider network to a self-insured health plan, are still refusing to share pricing and claims data with self-insured health plans and their plan sponsors -- both unions and single-employers. They are filing lawsuits and asking a court of law to compel owners of provider networks to share the data with the plan and plan sponsor.” These lawsuits are currently at the District Court level, and it remains unclear when and how the Courts will rule. However, the Transparency Forum will provide ideas of how the Courts may rule, whether there are more lawsuits on the horizon, and whether these lawsuits – in and of themselves – are changing bad behavior and having a positive impact on contract negotiations between plan sponsors and owners of provider networks. 18
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Panelists – including two lead attorneys in these data-sharing lawsuits – will take a deep dive into the ongoing struggles to access pricing and claims data and discuss what the future might hold. Gag Clauses & Data Sharing: What Should We Do & Where Do We Go From Here? Tuesday, February 27, 2024, 9:30-10:15 AM While the Gag Clause Prohibition has been effective for three years, this panel of thought leaders will tackle the issues still facing plan sponsors, such as how they are getting their data and how they – and their service providers – are handling the “attestations.” Presenters will also weigh in on what steps Congress and the Federal Departments or courts can take to help. Panelist Mark Combs, CEO, Self-Insured Reporting, expects to address the impact of the attestation filing deadline and the fact that the vast majority of plan sponsors “…really couldn’t tell you anything about the Consolidated Appropriations Act (CAA) or that a prohibition on gag clauses and a compliance attestation deadline even exists.” He says that there is a severe lack of understanding and information in the marketplace, which has led to silence on the matter in hopes that additional guidance, or even a delay in the requirement, will be forthcoming. “For fully insured groups, they typically do not even know that they should indeed have access to their data now,” continues Combs. “For self-insured groups, most have not given much thought to the requirement. Instead, they primarily rely upon their brokers’ word that they are in the clear. The broker also rarely knows much about this, and they are relying upon the word of the TPA – which sees this as a plan sponsor requirement and is trying to avoid getting involved at all. Bottom line – it is a mess.” Combs advises that before we even talk about getting data, plan sponsors first must (1) understand what this requirement is, (2) identify and remove all gag clauses, and then (3) have access to all claims data and provider quality data. 20
Furthermore, for those plan sponsors who are aware of the attestation deadline, many are relying on their service providers to attest on their behalf. However, the service providers are requiring a hold harmless before they are willing to file. “The fact of the matter is that the overwhelming majority of self-insured groups are NOT compliant,” shares Combs. “Filing a false attestation to the DOL just sounds like a bad idea.” Finally, he states that it is clear that Congress is seeking to use market influence as a tool to clean up the marketplace, adding, “In a perfect world, Congress would simply make gag clauses illegal at the TPA/PBM/Carrier level so that the plan sponsor would not have to deal with it directly – although that may not be realistic. At the end of the day, there is no getting around the marketplace having to learn what in the world this whole thing is about. Brokers need to up their game and guide their clients, as opposed to taking the TPAs’ word for it that things are all good.” Decided in Court: Lawsuits to Access Pricing and Claims Data Tuesday, February 27, 2024, 10:4511:30 AM Self-insured plan sponsors have filed numerous lawsuits to get access to the plans’ claims data, while other lawsuits have challenged and changed the course of the No Surprises Act.
While some cases have settled and others are still making their way through the courts, this discussion will provide attendees with current information, what these lawsuits mean for increased price and claims data transparency, and how to plan for the future. Panelist Herman Hofman, partner, Varnum Law Firm, expects to bring clarity to the issues of ownership of the claims data and whether plan sponsors or TPAs own the claims data; the role of TPAs as fiduciaries and how to determine if a plan’s TPA is a fiduciary to the plan – including the implications of fiduciary status to a plan sponsor’s ability to access and use their claims data. Hofman points to the barriers to accessing claims data, questioning, “What effect do contractual audit provisions and gag clauses have on a plan sponsor’s ability to access claims data, and how can you overcome barriers?” He states that barriers to using and interpreting claims data also raise questions, “Assuming a plan sponsor obtains some or all of their claims data, what other barriers often exist to using and interpreting the claims data? Furthermore, what should plan sponsors be on the lookout for in reviewing the claims data, and how can they overcome those barriers?”
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Expect some lively discussions as presenter Julie Selesnick, Esq., senior counsel, Berger Montague, declares, “We need MORE lawsuits filed against payers/insurance carriers that contract with employersponsored health plans to give them access to provider networks if transparency in pricing and full, unmasked claims data is ever going to become the norm. And it needs to become the norm if we are ever going to gain control of healthcare costs.” She says the current environment is completely opaque, and the masking of cost and quality information, in concert with other actions taken by the large payers/insurance carriers, has left us “…in an environment devoid of competition, where even the largest companies are forced to sign contracts of adhesion if they want access to one of the “BUCA” networks (Blue Cross, United, Cigna or Aetna).” While Selesnick acknowledges that there have been many advances over the past several years in the law (e.g., the gag clause prohibition in the Consolidated Appropriations Act of 2021, No Surprises Act), by executive order (Transparency in Coverage and Hospital Price Transparency), and in rulemaking and guidance by the DOL and other regulatory bodies, “There is still a major lack of cooperation from the payers/insurance carriers hired by self-funded plans or their independent TPAs to provide the plan participants with access to their established networks at their negotiated rates.” She cites that one of the major reasons for this lack of cooperation by insurance carriers is that it is critical for them to keep the terms of their agreements with providers and facilities a secret if the current business model is to continue. “Once those terms become public, there will likely be a huge backlash against some of the provisions in these contracts that most self-funded plans currently have no idea they are subject to,” she advises. “It appears that the only way we are going to make substantial progress towards this goal, however, is by self-funded plans, through the plan fiduciaries, suing these payers to establish their right to unfettered access to the data, as the law doesn’t seem to be enough to change some long-engrained anticompetitive behavior.” She cautions that, unfortunately, the majority of cases filed against the payers/carriers, to date, have settled prior to any court opinions being rendered on the topic and prior to the completion of discovery -which might make public the types of information that would motivate other plans to act. Hugh O’Toole, CEO, Innovu, views this discussion as an opportunity for employers to harness their data, yield significant financial benefits, and enhance healthcare outcomes for employers and their plan participants. “This is the first time in American history that Plan Sponsors in health insurance have the disclosure and data necessary to work in the best interest of their participants,” imparts O’Toole. “In response to this, the laggers will say that they’re waiting to see if the government is serious and what the consequences are. Just like what we saw with retirement, civil lawsuits are becoming more common.” He points to a plan participant’s lawsuit against Major League Baseball/Aetna over mental health and a lack of parity. “Not only are plan participants taking legal action but also is the government,” he continues. “We are seeing the DOL directly getting involved, such as suing UMR for not following the Plan document in adjudicating emergency claims on behalf of the plan.”
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He says the evidence is clear: “The government has intentionally put the Plan Sponsor in harm’s way. They know from experience that a Plan Sponsor in harm’s way will discipline the industry that puts them at risk.” O’Toole looks forward to expanding on several key concerns: Why governmental involvement mirrors that of the 401k Industry The economic value to the employer and employee of functioning as a fiduciary -- appreciating the
role and importance of data, deciphering the stories within the data, and differentiating between intriguing insights and straightforward findings.
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Hospital & Provider Price Transparency: Is It Making A Difference? Tuesday, February 27, 2024, 11:30 AM– 12:15 PM Compliance with the Hospital Transparency Rule is still woefully low despite the threat of increased penalties. However, there is an increase in the percentage of hospitals and providers that are making efforts to post pricing information on a public website. Attendees can expect to learn a great deal about the usability of pricing information among self-insured plan sponsors and participants – and what more can be done.
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Here’s a preview from panelist Cheryl Matochik, Managing Director, Third Horizon Strategies, “The charge on price transparency continues. It is not the destination but rather an essential step on the journey of upending historic black box pricing dynamics in healthcare to create a more transparent and accountable healthcare system.” She points out that lawmakers will continue to look to a variety of policy levers to provide relief to their constituents, as evidenced by these initiatives, which will be discussed more fully during the presentation:
Unusual broad-backed House passage of the Lower Costs, More Transparency Act which requires hospitals and insurers to spell out more clearly their costs to consumers and reduces Medicare payments to hospitals for some services that are provided in outpatient facilities and doctor’s offices.
Updates to the Hospital Transparency Rule: by 7/1/2024, hospitals and health systems must publish machine-readable files (MRFs) according to a standard format that includes more detailed data elements. CMS has coupled the required MRF format with additional measures designed to strengthen and automate enforcement efforts.
“Our organization is encouraged and interested to see how this update plays out in a few key areas,” says Matochik. “Each payer-negotiated rate must now be accompanied by a description of the contract provision used to calculate the rate (i.e., case rate, per diem, etc.). This needed context on contract payment methodology has been missing, making it difficult to create apples-to-apples comparisons. Additionally, the final rules also require providers to elaborate on how each rate was calculated throughout the process of creating the MRFs.” She suggests that these changes should bolster price transparency data quality by removing a lot of current guesswork required to add meaning to dollar values that exist without a defined methodology.
“It will be really interesting to see if in 2024 CMS requires these updates to the payer MRFs as well -- we expect they will,” she advises. Finally, Matochik cites State actions to control commercial healthcare costs, including:
States are enacting legislation to enforce federal price transparency rules for hospitals and insurance plans, as well as establish additional state-level requirements
States are floating proposals on capping hospital rates based on Medicare payments (ex. Indiana)
States are looking to address health facility fees
Panelist Patrick Haig, CEO and co-founder, GoodBill, offers this perspective: “Current pricing information is a good start, though it’s still not actionable for the average patient and average plan. But it’s useful if you’re armed with the right way to access the information and use it.” He maintains that software and data are the tools needed to ingest the data from the price transparency files and use it – but in no way is it easy for patients to use. “The files come in all formats and sizes that are hard to access, and not everyone’s computer is capable of opening or parsing a JSON file,” he asserts. “Then there’s the question of what the average patient can do once they have that data. The spirit of price transparency is well and good, but it’s only useful to patients if they can tie a line item on a bill to its published price and if they can get their hands on that information in a timely manner.” To do that, he argues that you need to get the underlying procedure codes to match line items one for one. “Those codes are on the claim or itemized bill, but I can’t tell you how many facilities still refuse to provide patients with a copy of their claim (such as a UB-04), even though it’s part of the designated record set that patients are entitled to under HIPAA Right of Access.” He contends that there is not enough awareness and that the average American doesn’t know if their hospital’s prices are published. A lot of times, he insists that even the workers in hospital billing departments don’t even know about the data. Haig calls for the inclusion of transparency around contracting terms, giving patients programmatic access to their claims and EOBs in one place and enabling third parties to connect the dots with medical record data. The call for hospital price transparency will get additional substantiation from panelist Ahmed Marmoush, CEO, Handl Health, who says, “Schemas are becoming standardized, and the growth in compliance and quality of data we’ve seen over the last 2.5 years is significant from the standpoint of data access, scalability and manipulation. The manpower involved in creating a national database, interrogating that data, and making apples-to-apples comparisons is substantial. Standardization will start to make a big difference for people and companies looking to meaningfully use this data.” He believes there have been lessons learned on the value of standardized schemas to support scalable analytics and interrogation of data to drive decision-making. “The unique component of the hospital price transparency data is that discounted cash rates are published,” he explains. “In a world where direct contracting and specialty carveouts are becoming more common, having data points around the relative differences between contract negotiated rates and cash FEBRUARY 2024
payments is material, and it also begs the question of why there are such differences in cost and inflation of the true cost of healthcare.” Marmoush cites the value of provider price transparency as it relates to real-time payments and cash payments, noting, “If there was a world whereby, in the same way we got hospital cash price transparency, we got provider cash discount prices, we would not only know that it costs, say, $467 for an MRI, but we could then start to understand the cash payment to see a physical therapist or your family medicine doctor or even to have a mole removed. This creates an entirely new world of direct contracting and carveouts for health plans that we see a little bit through direct primary care models.” Finally, he views one of the most exciting things about price transparency is the No Surprises Act and the Good Faith Estimate, predicting, “That’s where we see the future of healthcare going. A world whereby a consumer can understand exactly how much an appointment costs and even how much an elected surgical procedure costs. This could be approved by all the parties involved, such as the provider, the employer, the TPA, or the carrier, and can be transacted at the point of care delivery — or at least within a few hours after. The Good Faith Estimate provision and the Advanced Explanation of Benefits lays the groundwork for this world.” Surprise Billing Arbitration: The Future of Uncertainty Tuesday, February 27, 2024, 1:15-2:15 PM The last year has proven to be challenging for self-insured plans and their service providers, defending against disputes initiated by providers over out-of-network care. With fits and starts and changes to the Federal IDR process and the development of the QPA, this panel will explore what industry participants should know and where this is headed. Christine Cooper provides this update, with deeper discussion on the topic during the panel presentation: Batching of Claims: will not be implemented until the later of August 15, 2024 or 90 days after effective date of the final rules. Providers can submit multiple claims for a single adjudication so long as the services were rendered by the same provider, within the same 30 business days, were paid for by the same payer, and were related to the treatment of a similar condition. This is limited to 25 line items per dispute. • Open Negotiation (not implemented until the later of August 15, 2024 or 90 days after effective date of the final rules). Parties will be required to conduct activities through the online portal, which is currently only used for the arbitration process. The initiating party will be required to include additional information with its negotiation notices, including more details about the disputed items or services; the non-initiating party will be required to file a response within 15 business days of receiving the initiating party’s open negotiation notice. IDR Process: will not be implemented until the later of August 15, 2024 or 90 days after effective date of the final rules. Notice of IDR would have to include additional information identical to the ONN. o The non-initiating party will be required to furnish a written response regarding claim eligibility within three business days of receiving the Notice of IDR Initiation. o A preliminary three-business day selection window in which the parties could negotiate regarding IDRE selection, followed by a final selection window in which the IDRE would undergo conflicts screening 28
IDR Government Fee o As of 2024, increases to $150; payment due within 2 business days following selection; fee submitted to CMS directly IDR Registry: payers would register with the Departments and provide general information on the applicability of the Federal IDR process to items or services covered by the plan or coverage; payers would receive a registration number How Did We Get There: PBMs, Gene Therapy and Drug Pricing Tools Tuesday, February 27, 2024, 2:15-3:15 PM Policymakers and regulators are taking a serious look at PBM practices and drug pricing transparency. With ever-increasing drug costs and more and more states including self-insured plans in legislative activities, what does the future hold for PBM transparency and the cost of prescription drugs? What best practices are in place for self-insured plans? It’s likely going to be a robust discussion, given the recent announcement by CVS, an initiative that is part of a broader effort to stabilize its retail pharmacy business and address criticisms regarding the complexity and lack of transparency in drug pricing. Kristi Bohn, VP, Lead Actuary, RGA, looks forward to explaining the role of PBMs with an overview of the disruptor Mark Cuban effort and an update on plans and employer uptake of that effort. “In terms of gene therapy and how we get there, I will touch on several sub-topics such as the role of stop-loss/reinsurance, access, equity, network considerations including discounts, warranties, and other aspects,” says Bohn. “For the discussion of drug pricing tools, we will review particular tools being referenced or practices that entities each employ, as well as data mining practices and benchmark resources not related to a particular tool.”
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She points to facilities’ J-code upcharges as a major concern, as this is more commonly problematic than retail drugs. Will Price Transparency Lead to Lower Costs? Tuesday, February 27, 2024, 3:45-4:30 PM While great strides have been taken by the government and the private sector to increase price transparency, this panel confronts the remaining questions: does all of the new information and data that is now available really matter, and do the prospects for it actually lead to lower costs for self-insured plans and healthcare consumers? Panelist Francois de Brantes, senior partner, HVC Incentives Advisory Group, leads the discussion, reframing the title: Will Price Transparency Lead to Lower Costs Prices? “In the year 2000, the average annual cost for an employer to cover a family was about $6,400, and the annual per beneficiary costs for Medicare were $5,800,” he begins. “By 2023, the costs to cover a family had risen to $24,000 and per Medicare beneficiary costs had risen to $15,700. Therefore, while per Medicare beneficiary costs had multiplied by 2.7, family coverage had been multiplied by 3.7, reflecting a significantly higher rate of inflation.” He says we all know that Medicare beneficiaries are older and sicker than under 65 employed individuals, and what accounts for the more than doubling of costs comes from the expansion of Medicare to cover pharmacy, new treatments, and the yearly price increases that the government applies to Medicare rates. “However, by all accounts, families in the year 2023 aren’t sicker or older than in 2000,” he comments. “So, what accounts for the close to fourfold increase in total yearly costs? Certainly, new treatments, but mostly much, much higher prices. We knew this as early as 2003 when a group of academic researchers famously titled their study: ‘It’s the Prices, Stupid!’ And that has been confirmed many times since, including in 2019 with another study aptly entitled: ‘It’s Still the Prices, Stupid!’ “ Since July 1, 2022, when the first payer rate files were released, the evidence of the differences in prices paid by Medicare and the private sector has poured out and unambiguously confirmed what the researchers found. “There should be no doubt left for anyone that the single biggest contributor to price increases has been the lack of transparency,” he asserts. “Behind a carefully guarded veil of secrecy, carriers have allowed prices on employed populations to increase because they have directly benefited from those increases. With the passage of the Affordable Care Act, carriers have seen their total profit margin for insured plans capped at a fixed percent of total premiums. But if premiums increase, so do total profits. Further, with the increase in popularity of and enrollment in Medicare Advantage, carriers have bargained hard to get lower than Medicare rates from hospitals, mostly in exchange for ever-increasing prices on employers.” De Brantes says we now know one thing for sure, which is that the lack of transparency has led to higher prices. “But will transparency help lower prices?” he asks. “By itself, the release of the information is unlikely to lead to lower prices. However, there are several other factors that will inevitably lead to lower prices and greater competition amongst providers.” He cites these points: 1.
First, employers have to give their plan members estimates of cost-sharing for upcoming care, and FEBRUARY 2024
they have to show those estimates by provider. There is ample evidence of plan member pricesensitivity, dating all the way back to the famous RAND study in the 1980s, which was reaffirmed in the early 2000s. 2. Second, employers have new fiduciary responsibilities related to their health benefits plan that
compels them to attest to the prudent use of funds. And certainly, it’s not very prudent for an employer to spend two to three times more for a given service with a given provider than they otherwise would. That’s why benefits consultants are hard at work developing new tools that leverage all of the published rate files to construct much smarter ways to assess and build networks.
3. Third, the regulators have already corrected the deficiencies in the hospital rate files, which will
lead to even greater specificity, completeness, and accuracy of that information, and the same will happen with the payer rate files.
“The democratization of all the information contained in the price transparency files is happening and will likely accelerate as the demand from employers and their plan members for better ways to compare rates and control costs goes up,” he concludes. “And it will, because once you realize you’ve been fleeced for years, you rarely stand still waiting to be fleeced again.”
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
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SIIA MEMBERS GET TO WORK AS PART OF ASSOCIATION VOLUNTEER LEADERSHIP GROUPS
By Self-Insurer Editorial Staff
IIA received a massive response to its recent “request for volunteers” communication, which invited members to apply to serve on the association’s various committees and task forces that will be active in 2024. These groups have now been populated with individuals from more than 100 member companies (see participating company listing nearby) and will start to meet soon. They provide guidance and recommendations to SIIA’s board of directors and professional staff regarding membership services and related opportunities.
Below is a listing of these volunteer groups with a brief overview of their focus. Note that “committees” are permanent groups, while some “task forces” have been activated to determine how SIIA may want to proceed in certain areas. The task forces may complete their work and disband or transition into standing committees at a later date. Please watch for additional reporting on committee/task force activity later this year. Committee/task force appointments are rotated yearly, so there will be another opportunity to get involved in 2025 if you are not part of a volunteer team this year. CAPTIVE INSURANCE COMMITTEE
The Captive Insurance Committee promotes and protects the interests of middle market captive owners and participants, service providers, and insurance industry professionals in a domicile-neutral capacity through education, political advocacy, networking, and development of best practices. The committee has identified three specific focus areas: 1) Stop Loss Captive Programs, 2) Enterprise Risk Captives and 3) Property & Casualty Captives. As part of its work, committee members review and develop materials on upcoming and trending captive topics and educational materials to help the larger industry further understand captive insurance
possibilities. In addition, the committee is responsible for developing and disseminating the SIIA Captive Survey, an annual survey of both captive industry managers and participants and captive owners, and to help identify educational needs, trends, and emerging risks. PRICE TRANSPARENCY COMMITTEE
The Price Transparency Committee seeks to strengthen industry engagement, understanding, and education surrounding healthcare price transparency through regulatory and legislative advocacy, bestpractice development, and other related activities.
The committee is a critical component in developing the SIIA Healthcare Transparency Forum. It has taken an active role in providing feedback to Federal Agencies as they further implement the No Surprises Act (NSA) and Transparency in Coverage Rule. To that end, the committee seeks to develop industry-specific resources for recent transparency rules and legislation, including FAQs on the independent dispute resolution (IDR) process under the NSA and to collect IDR outcomes. With the TiC, the committee has also worked on identifying industry challenges in implementation and best practices for machine-readable file implementation. FUTURE LEADERS COMMITTEE
The Future Leaders Committee is tasked with developing membership services of particular interest to younger (under 40) self-insurance industry professionals. Previous and ongoing initiatives include 36
an annual Future Leaders Forum, virtual mentor connection events, session development for SIIA’s National Conference, and the creation of networking and educational opportunities specific to this age demographic. ARTIFICIAL INTELLIGENCE TASK FORCE
The growing interest in Artificial Intelligence (AI) promises to transform most segments of the U.S. economy, and the self-insurance marketplace will be no exception. To help its members prepare to operate more successfully with augmented AI capabilities, SIIA has formed a new AI Task Force to identify potential membership service opportunities, which could take various forms. This is an addition to the inaugural SIIA AI Forum scheduled for this month in Charlotte, NC. CELL & GENE THERAPY TASK FORCE
SIIA members consistently cite Cell & Gene Therapy (CGT) as one of the most critical issues affecting the self-insurance industry, with this importance only expected to increase in the years ahead. Responding to this feedback, SIIA has formed a new Cell & Gene Therapy Task Force to help identify opportunities for the association to help its members with clinical management, administrative, and financial responsibilities to adapt successfully to the evolving treatment environment. The task force’s work will be in addition to the SIIA Cell & Gere Therapy Stakeholder Forum. PROVIDER DIRECT CONTRACTING TASK FORCE
There has been increased interest among providers and self-insured payers in making direct contracting for healthcare services more commonplace. This group will explore potential strategies that could be initiated by SIIA, which could accelerate the growth of such arrangements.
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SELF-INSURANCE POLITICAL ACTION COMMITTEE (SIPAC)
The Self-Insurance Political Action Committee (SIPAC), under the leadership of a SIIA member-led PAC Board, seeks to advance the interests of the self-insurance and captive insurance industry by supporting and educating candidates for federal office. This mission is especially important heading into a crucial federal election in 2024. SIPAC is built on individual SIIA members’ support through several fundraising events.
In 2024, SIPAC is looking to: •
Double total contributions to candidates, taking advantage of an important election year.
Look towards industry leaders to take a more active role in promoting SIPAC.
These planned events for 2024 include ax throwing at the Future Leaders Forum, a retro arcade bar during the Price Transparency and • Challenge SIIA Future AI Forums, a unique dining experience during the Spring Forum, and a Leaders to get more tailgate beer-tasting event during the National Conference. In addition involved with SIPAC. to events taking place during SIIA conferences, SIPAC will also be hosting several other regional events throughout the year. If you are interested in learning more about SIPAC, please contact In 2023, nearly 100 different SIIA members attended various SIPAC Anthony Murrello at amurrello@ events, which in turn allowed the PAC to contribute over $40,000 siia.org to a bipartisan group of congressional candidates. These ongoing contributions allow SIPAC to talk directly to and educate candidates and their staff on several issues ranging from stop-loss and ERISA preemption to price transparency and captive insurance.
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SIIA 2024 Committees/Task Forces/ SIPAC Include Representatives from the Following Companies 4L Data Intelligence, Inc. 90 Degree Benefits Advanced Medical Strategies Advanced Risk Managers, LLC Advantage Insurance MGMT Aegle Health Partners aequum LLC Allegeant, LLC Alpha Isle Services, LLC American Trust Administrators, Inc. Amalgamated Life Amwins Anthem Armanino LLP Artex Risk Solutions, Inc. Auxiant Avant Specialty Benefits/Holmes Murphy Axis Communications BCS Financial Corporation Benefitfocus
Berkshire Hathaway Specialty Insurance BillingNav LLC Borislow Insurance Brown & Brown Cadence Insurance Captive Resources CERIS ClaimInformatics Claros Analytics ClearPoint Health Clearwater Benefits Administrators
Emerging Therapy Solutions® Employers Health Network Evolution Risk Partners First Stop Health Goodbill GPW and Associates, Inc. Gradient AI Granular Insurance Company Guy Carpenter & Company, Health Plans, Inc Healthcare Bluebook Healthcare Highways
Connect Healthcare Collaboration
Conner Strong and Buckelew
HM Insurance Group
Hub International Insurance Services
Crum & Forster Dentons Bingham Greenebaum LLP
Imagine360 Keenan & Associates
DSG Benefits Group, LLC
KeyState Captive Management
ELMCRx Solutions, LLC
Windsor Strategy Partners
Stealth Partner Group, LLC
Womble Bond Dickinson (US)
Sterling Seacrest Pritchard,
MSL Captive Solutions, Inc.
Strategic Risk Solutions, Inc.
Strategic Underwriting Solutions
OneDigital Health & Benefits
Swiss Re Corporate Solutions
Tatum Re Intermediary, LLC
The Phia Group, LLC
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PartnerRe America Insurance
Planned Administrators, Inc.
Underwriting Management Experts
Providence QBE North America Qualexa Healthcare
Verikai Voya Financial
Rejuvenate Kidney Transplant Solutions Renalogic Ringmaster Technologies, Inc. Risk Strategies Roundstone Management Self-Insured Reporting Serif Health Solv Independent Insurance Associates Specialty Care Management
WHAT YOU NEED TO KNOW ABOUT MSP REPORTING FAILURES
By Alston & Bird, LLP Health Benefits Practice
n October, the Centers for Medicare & Medicaid Services (“CMS”) issued its final rule for civil money penalties on Medicare Secondary Payer (“MSP”) reporting failures. Although penalty calculation rules might not seem to be of much interest to anyone who works hard to be compliant and never expects a penalty, third-party administrators and insurers should consider self-auditing current compliance due to the severity of the potential penalties. Under the rule, a single failure to report could result in a penalty of $1,000 per day (typically increased annually) up to a maximum of $365,000 (also typically increased annually) for each failure. The rule also announces that CMS will begin random MSP reporting audits. RECAP: MSP REPORTING REQUIREMENTS (MMSEA SECTION 111)
Beginning in 2009, Section 111 of the Medicare, Medicaid, and SCHIP Extension Action of 2007 required reporting by group health plans and non-group health plans (for example, liability insurance, no-fault insurance, and workers’ compensation). The intent of these reporting 42
requirements is to reduce the instances where Medicare mistakenly pays primary. Although the goal of reporting is similar, the requirements and liability for group health plans (“GHPs”) and non-group health plans (“non-GHPs”) are different as CMS’ final rule and separate detailed guidance make clear. CMS’ reporting guidance is voluminous (see https://www.cms.gov/medicare/coordination-benefits-recovery/ mandatory-insurer-reporting-group-health-plans), so only a very high-level overview of the reporting requirements is possible here. WHAT PLANS ARE GHPS?
MMSEA Section 111 borrows from an Internal Revenue Code (“Code”) definition of group health plan to define GHPs subject to mandatory reporting. However, it does not include that definition’s exception for plans sponsored by government employers, which are also subject to mandatory reporting. Generally, a GHP is: “a plan (including a self-insured plan) of, or contributed to by, an employer (including a selfemployed person) or employee organization to provide healthcare (directly or otherwise) to the employees, former employees, the employer, others associated or formerly associated with the employer in a business relationship, or their families.” 26 U.S.C. § 5000(b)(1). Although this definition is broad, CMS recognizes some exceptions to this definition and the reporting requirement, including:
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HSAs (if Medicare beneficiaries are not allowed to make current-year contributions or did not contribute to an HSA at any time they were a Medicare beneficiary)
Stand-Alone Dental, Vision, Behavioral, and Mental Health Coverage (including EAPs)
“Small-Dollar” HRAs – The definition of HRA for MSP mandatory reporting purposes is broader than the definition of HRA under the Code. It includes not only the alphabet soup of HRAs like ICHRAs, EBHRAs, and QSEHRAs, but also employer-funded medical reimbursement accounts that are not typically defined as HRAs because unused amounts are forfeited at the end of each year without any carryover (e.g., MERPs). Although the MSP definition of HRA is broader than the Code’s, CMS provides an exception to reporting for HRAs with an annual benefit of less than $5,000 at the beginning of the year. Amounts carried over from prior years must be included when determining if the current year benefit is less than $5,000. HRAs embedded with medical coverage must be reported separately and in addition to the medical coverage.
WHO IS RESPONSIBLE FOR REPORTING?
Responsible reporting entities (“RREs”) must report the GHP’s active covered individuals. The RRE is typically the insurer or third-party administrator. The employer is not the RRE except when it is the plan administrator or a fiduciary of a GHP that is both self-insured and self-administered, which is rare. In short, a TPA or insurer should generally assume it must fulfill the MSP reporting requirements for the GHPs they administer or insure, respectively, and likely cannot punt ultimate responsibility and liability back to the employer or plan. WHEN CAN CMS IMPOSE A CIVIL MONEY PENALTY ON A RRE FOR A GHP REPORTING FAILURE?
The civil money penalty applies when a GHP does not report a GHP’s coverage of a Medicare beneficiary within the later of 365 days from the Medicare beneficiary’s (a) GHP coverage effective date or (b) Medicare entitlement date. WHAT IS THE PENALTY AMOUNT?
For GHPs, the penalty is $1,000 for each day after the 365-day deadline above for reporting an individual, as adjusted annually by statute ($1,325 as of June 8, 2023). The penalty begins accruing after the 365day period to report coverage. The maximum penalty per individual is $365,000, as adjusted annually. Notably, CMS said for non-GHPs, it will assess “up to” $1,000 per day, which gives CMS discretion to negotiate the penalty amount. However, CMS decided that the statute does not give CMS the same discretion when assessing the penalty for violations by GHPs. HOW DOES CMS INTEND TO ENFORCE THESE REQUIREMENTS?
CMS will audit a randomized sample of new beneficiary records received each quarter. CMS says it will not undertake an automated review of all records submitted, as it initially proposed. HOW WILL CMS NOTIFY RRES OF PENALTIES?
CMS says it will communicate informally with RREs before issuing a formal notice assessing the penalty (the "pre-notice process"). CMS says that this pre-notice process will allow the RRE "to clarify, mitigate, or explain any errors that were the result of a technical issue or due to an error or system issue caused by CMS or its contractors." CMS declined to regulate or specify the mitigating information that RREs FEBRUARY 2024
can provide, as doing so "would be impractical and counter to the spirit of the informal notice process[.]" Instead, "any mitigating factors or circumstances are welcomed, and a dialogue is encouraged in an attempt to find solutions that are short of imposing a CMP." RREs that do not resolve penalties favorably during the pre-notice process must request a hearing before an administrative law judge if they wish to appeal an assessment. As a result, RREs should not ignore any notices for CMS, especially the initial informal notice, as the pre-notice process could prove to be one of the most effective and affordable methods of eliminating or reducing a penalty. As discussed above, the statute limits CMS' ability to negotiate the penalty amount for GHPs if assessed. Is it too late and are we doomed if we are an RRE that might have current or past reporting compliance failures? Not at all, but you’re in the 11th hour and you need to make reporting compliance a priority now. Although the rule is effective on December 11, 2023, it does not become applicable until October 10, 2024. Accordingly, CMS expects RREs to be compliant with the reporting requirements no later than October 10, 2024. Any RREs that are not compliant by then may be penalized. Attorneys John R. Hickman, Ashley Gillihan, Steven Mindy, Carolyn Smith, 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 email@example.com
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We appreciate the positive response our medical stop loss coverage has received coast to coast. We look forward to bringing our trusted brand name, stellar balance sheet, and decades of underwriting experience to the medical stop loss marketplace for years to come.
Thanks. Atlanta | Boston | Chicago | Columbia | Dallas | Houston | Indianapolis | Irvine Los Angeles | New York | Plymouth Meeting | San Francisco | San Ramon Seattle | Stevens Point | Adelaide | Auckland | Barcelona | Brisbane | Brussels Cologne | Dubai | Dublin | Frankfurt | Hong Kong | Kuala Lumpur | London Lyon | Macau | Madrid | Manchester | Melbourne | Munich | Paris Perth | Singapore | Sydney | Toronto | Zurich
NEWS FROM SIIA MEMBERS 2024 FEBRUARY MEMBER NEWS The SIIA membership is dynamic both in terms of companies and individual industry professionals. Provided below is some of the latest member news on our radar. If you represent a SIIA member company and would like us to consider your news in the next edition of The Self-Insurer, please send it to Siera Kinder at email@example.com.
NEWS Vālenz® Health Names Frederick Karutz as Executive Vice President, Strategic Solutions
the way toward optimizing cost, utilization and quality for all.”
PHOENIX, AZ — Vālenz® Health announces that Frederick Karutz has joined the executive leadership team as Executive Vice President, Strategic Solutions. In his new role, Karutz will drive transformative value for health plans, employers and members through a solution suite that delivers optimal care navigation and management, payment integrity and risk mitigation for exceptional customer experiences and savings.
Karutz has deep experience in leveraging advanced analytics to identify at-risk members and engage them with health plan programs, point solutions and providers, driving significant improvements in health outcomes, claims trend reductions and average savings. Karutz also directed growth, sales enablement and marketing efforts on behalf of the Advanced Analytics and Services division within Carelon. Before that, he led consumer-based programs, strategy, growth, marketing, and product development functions for companies including AIM Specialty Health, ConnectedHealth, Health Care Services Corporation, Silverlink and GoHealth.
Frederick Karutz Executive Vice President, Strategic Solutions Vālenz® Health An early innovator in consumer-driven healthcare, Karutz brings more than 25 years of expertise in analytics-supported care engagement and member-centered solutions, most notably for members with complex and emerging needs. He comes to Valenz after serving as President for Carelon Advocacy, where he worked with health plans to unlock personalized engagement for high-risk, emerging-risk and complex-care members. “Fred is a true champion of everything Valenz Health stands for in serving members: engaging early and often to ensure better outcomes at lower costs of care through a culture of innovation,” said Rob Gelb, Chief Executive Officer of Valenz. “His tremendous background and skills in leveraging data- driven, member-centric programs and solutions make him an outstanding fit for our company as we lead
“The Valenz continuum of solutions delivers significant and immediate cost savings for health plans, employers and other payers, as well as optimal care navigation and management for members. It’s a timely, winning combination for smarter, better, faster healthcare,” Karutz said. An active member of his community in Chicago, Karutz was a member of Greater Leadership of Chicago; served as Vice Chairman with Instituto del Progresso Latino, helping the organization establish the Instituto Health Sciences Career FEBRUARY 2024
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NEWS Academy; and has been a board member with AgeOptions for more than 14 years. He also has developed an innovative healthcare internship program for high school seniors sponsored over the years by HCSC, Anthem and Carelon.
Berkley Accident and Health Launches Cell and Gene Therapy Solution for Employer Stop-Loss Insurance New benefit designed to help customers address high cost of cell and gene therapies
Hamilton Square, NJ – Berkley Accident and Health, a Berkley Company, has added a new benefit to its Employer Stop-Loss protection in response to the rapidly growing cell and gene therapy Karutz earned a bachelor’s degree market. As more cell and gene therapies enter the market, employers in economics from Northwestern may be faced with the challenge of paying for these high-dollar University and a master’s degree treatments. Berkley Accident and Health is proud to provide its selfin business administration from funded customers with a tangible benefit that can reduce the financial the University of Chicago Booth impact of these therapies. School of Business. “Cell and gene therapies are groundbreaking treatments that have the About Vālenz® Health potential to reduce or cure life-threatening diseases. They can make a real difference to patients and their families,” said Brad Nieland, Valenz Health is the platform President and CEO. “However, they can also come with extraordinarily to simplify healthcare – the high costs. The latest gene therapies to enter the market have destination for employers, payers, estimated costs of $2 million to $4 million,” explained Nieland. providers and members to reduce “That’s why we’re excited to proactively help customers navigate the costs, improve quality, and elevate complexities of cell and gene therapies and lower the financial burden. the healthcare experience. The It’s part of our ongoing commitment to making self-funding more Valenz mindset and culture of accessible and predictable.” innovation combine to create a distinctly different approach to Berkley Accident and Health’s new Cell and Gene Therapy Stepan inefficient, uninspired health Down Deductible benefit is designed to help customers mitigate the system. With its fully integrated risk of these transformative treatments. It lowers the Specific Stopsolution, Valenz executes across Loss deductible for cell and gene therapy claims when an approved the entire patient journey – from Center of Excellence network is utilized. Berkley Accident and Health care navigation and management has recently approved the Emerging Therapy Solutions (ETS) Center to payment integrity, risk solutions of Excellence, which provides customer assistance with education, and provider validation. With a network and contract evaluation, and access to preferred pricing at 99% client retention rate, we leading facilities nationwide. elevate expectations to a new level of efficiency, effectiveness Benefit Highlights and transparency where smarter, better, faster healthcare is possible. The Cell and Gene Therapy Step-Down Deductible endorsement is: Visit www.valenzhealth.com. • Available at no additional cost to all Stop-Loss policyholders and members of Group Captive programs •
Automatically added to all new and renewal Stop-Loss policies with 1/1/24 effective dates or later FEBRUARY 2024
NEWS A top ten independent Stop-Loss provider, Berkley Accident and Health is committed to finding new ways to make self-funding less volatile and put it within reach of more companies. The Cell and Gene Therapy Step-Down Deductible reduces the policyholder’s Stop-Loss deductible for qualifying claims, provided certain provisions are included in the employer’s plan. For more details, please contact your Berkley Accident and Health representative. About Berkley Accident and Health Berkley Accident and Health is committed to protecting the financial well-being of people and organizations. We are an industry leader offering an innovative portfolio of accident and health solutions and the personal support that our clients need. Berkley Accident and Health is a member of W. R. Berkley Corporation, a Fortune 500 company, and provides Employer Stop-Loss, Group Captive, Specialty Accident, and Managed Care solutions nationwide. Stop-Loss and Managed Care coverage is underwritten by Berkley Life and Health Insurance Company, rated A+ (Superior) by A.M. Best. Specialty Accident coverage
is underwritten by Berkley Life and Health Insurance Company or StarNet Insurance Company. Visit www.BerkleyAH.com. Berkley Accident and Health assumes no responsibility or liability for any advice or resources provided by ETS. ETS makes no representation, warranty, or commitment of any kind regarding the outcome of any care provided or the coverage or payment for the same.
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NEWS HM Insurance Group Announces Evan Stratton as Director, Denver Regional Sales Office
existing clients. Prior to that, he worked as an employee benefits representative at Sun Life Financial and a health benefits consultant at Mercer.
Pittsburgh, PA – Evan Stratton joined HM Insurance Group (HM) as director, Denver Regional Sales. In this role, Evan will work to grow and maintain the HM Stop-Loss book of business in HM’s new Denver Regional Sales Office, serving Colorado, Utah, Idaho and New Mexico.
A Marine Veteran, Evan serves on the board of directors for Fight Oar Die, a nonprofit organization helping Veterans to grow, develop, excel and achieve. During his time in the United States Marine Corps, he completed four years of active-duty service and four years of reserveduty service; served two overseas deployments; and was awarded the Purple Heart Medal for Military merit. About HM Insurance Group HM Insurance Group (HM) works to protect businesses from the financial risk associated with healthcare costs. A recognized leader in Employer Stop-Loss, the company delivers protection for a range of group sizes. HM also offers reinsurance quota share and excess coverage through its HM Specialty product line. HM Life Insurance Company, HM Life Insurance Company of New York and Highmark Casualty Insurance Company are all rated “A” (Excellent) by AM Best Company. Through its insurance companies, HM Insurance Group holds insurance licenses in 50 states and the District of Columbia and maintains sales offices across the country. Visit www.hmig.com. iiSi and Spectrum to Combine Operations
Evan Stratton Director, Denver Regional Sales HM’s new Denver Regional Sales Office Adding the Denver location is a component to HM’s strategic initiative to deepen relationships with producers in the Mountain States. Evan most recently served as vice president, producer at Aon where he connected Aon’s suite of benefits consulting and health solutions to new and 54
iiSi and Spectrum, each a division of Companion Life Insurance Company, have announced they are combining operations in 2024. iiSi’s strength in the large-group and RBP space, combined with Spectrum’s strength in the small-group, level-funded and program management space perfectly complement each other, and the collective product offerings will be formidable for brokers, benefits consultants and TPAs seeking the absolute best stop-loss solutions available for employer groups and stop-loss captives. The transition to one organization will take place during the first half of 2024, and once completed, the combined divisions will operate under the iiSi brand, with select products, services, and programs offered under Spectrum Solutions. The Executive and Department leaders of the combined operations are: •
Jon Anderson, Chief Executive Officer & President
Kurt Ridder, Chief Revenue Officer
Jim Henry, Chief Marketing Officer
Paul Rovira, Chief Financial & IT Officer
Joe Martin, Chief Operating Officer
Eric Wunderly, Vice President of Underwriting
Tony Matthews, Vice President of Underwriting – Spectrum Solutions
Belinda Moss, Vice President of Medical Risk Management
Laurie Mollé, Vice President of Claims
Marla Thombleson, Vice President of Administration
Fatima Rodriguez, Vice President of Operations
Daniel Richards, Controller
Tina McElroy, Office Manager
Kurt Ridder, Spectrum’s President, commented, “In early 2023, through conversations with Jon Anderson and Jim Henry of iiSi, it struck me that we share a common vision of what a full-service
medical stop-loss MGU should be, and more importantly, what it can be. At that point, I began developing the idea that our combined operations would be even more impressive than they are separately and that the opportunity for growth, profitability, and enhanced products/services was off the charts. I pitched the idea to Jon and Jim, and they 100% agreed that this was a perfect path forward. From there, we developed a plan, presented it to Companion and now we’re off to the races!” Jon Anderson, iiSi’s President, commented, “Over the past several years, our organizations
Meritain Health is an independent subsidiary of Aetna and CVS, and one of the nation’s largest employee bene�ts administrators.1 We are uniquely positioned to enable our customers to combine our �exible plan administration, products and external point solutions with the right resources from parent companies Aetna and CVS. 1. Business Insurance; Largest Employee Bene�t TPAs (as ranked by 2019 bene�ts claims revenue); May 2020.
NEWS have increasingly collaborated on finding solutions to the challenges we face in the stoploss marketplace. Through this spirit of cooperation, we realized our companies share a common vision to provide excellent service and products to our policyholders and producers, generate profitable results for our risk-takers, and maintain a family-oriented and flexible work environment where our employees can thrive. Keeping these three objectives in mind will keep us grounded, balanced and successful. I’m excited to see what our combined teams can achieve.” Mark Smidt, Companion Life’s Vice President of Employer StopLoss, added, “From the outset, Companion Life has endorsed iiSi’s and Spectrum’s proposal to merge. Over decades, iiSi and Spectrum have become widely recognized as industry leaders in their respective employer stoploss market segments. Uniting the two teams under one banner will provide their respective customers with an enhanced product offering and an even more robust customer service experience. iiSi and Spectrum have each built reputable legacies of effective risk management solutions and have earned trust among policyholders, producer partners, and risk-takers. We are very excited to see what they’ll accomplish together.”
Core Acquires Stop-Loss Business Core Specialty Insurance Holdings, Inc. and its subsidiaries (“Core Specialty” or the “Company”) announced the completion of the acquisition of the MGU/Stop-Loss business of American National Group (“ANAT”), which was previously announced on June 12, 2023. The acquisition marks Core Specialty’s 14th Specialty Business Unit. Jim Stelling has joined the company as President of the new Medical Stop-Loss Division, which is maintaining its presence in League City, Texas. The business was acquired for cash through the acquisition of 100% of the stock of Standard Life and Accident Insurance Company (“SLAICO”) and certain reinsurance transactions. The transaction is expected to be accretive to Core Specialty’s earnings per share and return on equity in 2024. Together with the Fronted Casualty Division, Core Specialty would have over $750 million in gross premium income and over $40 million in fee income from these two business units based on full-year 2022 results. Jeff Consolino, Core Specialty’s Founder, President, and Chief Executive Officer, said, “Core Specialty’s vision is to become the leading specialty insurer, and finalizing this transaction is another step in the direction of that mission. The medical stop-loss market has grown at over a 12% annual rate since 2014, according to AM Best market data. Medical Stop-Loss is an attractive class of business to us due to its specialty nature, the fact that it does not correlate with our other specialty classes of business, the ability to generate appropriate underwriting profits, and the resultant attractive return on capital. We look forward to having Jim Stelling join Core Specialty and working with his team.” Ascella Health Announces New Strategic Partnership Ascella Health, a global healthcare and specialty pharmacy (SP) solutions company, is proud to announce a strategic partnership with 4Merit, a dedicated provider of exceptional outsourced services to the UK government. This collaboration marks the formation of 4Merit Solutions, a global joint venture aimed at delivering comprehensive services and solutions to governments and public organizations around the world. “This strategic collaboration brings together our collective strengths and expertise to establish a new enterprise that delivers innovative healthcare solutions aligned seamlessly with values-based government outsourcing,” says Dea Belazi, president and CEO,
NEWS AscellaHealth. “4Merit Solutions reflects our shared commitment to providing unparalleled services to governments and public entities worldwide. Leveraging our combined capabilities will have a positive impact on the communities we serve.” “4Merit Solutions aspires to establish exemplary standards in delivering efficient, secure and transparent solutions across various industries and public service sectors, such as justice, immigration, health, transport and defense,” says Colin Dobell, CEO, 4Merit. “Our alignment with AscellaHealth allows us to tap into deep bench healthcare and pharmaceutical experience across various functions to provide a wide range of healthcare services to governments and public entities.” Crum & Forster Announces Promotion of Tanya Crum & Forster’s (C&F) Accident & Health (A&H) Division announces the promotion of Tanya Arrowsmith to Senior Vice President. In this role, she will lead the Division’s successful Medical Business Unit (MBU) and its suite of products, including Employer Stop-Loss, HMO Reinsurance and Provider Excess of Loss, Medicare Supplement, and
Ancillary & Employee Benefits. Ms. Arrowsmith joined C&F in 2019 and served as Vice President of A&H, working on all aspects of medical underwriting and account management, with a primary focus on Managing General Underwriter programs.
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NEWS “I’m excited to have Tanya at the helm of our Medical Business Unit,” said Gary McGeddy, President of Crum & Forster Accident & Health. “Tanya has been an integral member of the team, successfully and profitably managing much of the A&H Division’s Employer Stop-Loss and Managed Care program business. As SVP, she will continue to manage these segments in addition to overseeing our close to $1 billion MBU across all programs and direct business, as well as taking on responsibility for other product lines. The MBU is a strategic growth area for A&H, and Tanya will lead its diverse products and distribution team.”
insurance entities, including captives, commercial reinsurers, and service companies. His experience includes managing the accounting and reporting requirements for group captive programs, underwriting both employee benefits and property and casualty risk.
Tanya has more than 25 years of Stop-Loss and Medical Reinsurance Underwriting experience at several ESL MGUs, as well as HM Insurance Group and Swiss Re. She is a graduate of the University of New Hampshire with a Bachelor of Science in Family Studies.
TrueScripts Becomes a Team Member Owned Company
“I am excited to be joining MSL at this stage of the company’s growth. I have been impressed by the company’s development to date, and the future opportunities as captives become a more established funding mechanism for medical stop-loss. Joining MSL allows me to focus my prior captive experience on this sector and develop best-in-class servicing processes to support our captive programs, said Sykes. Most recently, Sykes was managing director of Strategic Risk Solutions Bermuda (SRS), where he led the insurance management operations for SRS for over a decade before relocating to the US. “We are extremely pleased to be able to add the experience and expertise that David brings to MSL Captive Solutions,” said Phil Giles, Managing Director, MSL Captive Solutions.
TrueScripts Management Services, a pharmacist-founded Prescription Benefit Management (PBM) company, proudly announces they are now Team Member Owned. The company’s transition to a Team Member Owned plan (also known as an Employee Stock Ownership Plan, or ESOP) turns more than 150 Team Members across the United States into company owners.
“Becoming a Team Member Owned Company means that each and every member of our dedicated team now has an even greater stake David Sykes Named CFO at MSL in our success. We often say that “Amazing Care starts from within,” and we strongly believe that a shared ownership model fosters Captive Solutions collaboration, innovation, a sense of belonging, and a strong culture MSL Captive Solutions has within our talented organization,” said TrueScripts Founder Nathan appointed David Sykes as chief Gabhart. “From the beginning, it has been our unspoken goal that financial officer, assuming the everyone who works for TrueScripts leaves changed. This allows us role with immediate effect. to do that.” MSL is a managing general underwriter dedicated to captive TrueScripts’ Leadership and Executive Team will continue in its programs for medical stop-loss. current form, with the addition of an ESOP Committee that will facilitate large decisions and act in the exclusive interest of the team. In line with TrueScripts’ position in the marketplace as an “anything Mr. Sykes has more than 30 but ordinary” company, its leaders have chosen to do things a bit years of experience in financial differently in the ESOP arrangement as well: management for a range of 58
TrueScripts Team Members are not your average employees, and while “ESOP” remains the technical term for their new arrangement, TrueScripts will refer to themselves as a “Team Member Owned Company.”
The selling shareholders and Board wanted this past year to count towards vesting schedules, so all Team Members hired before Nov. 13, 2023, will receive contributions for the year.
TrueScripts currently offers a 6% company match to Team Members’ 401(k) contributions.
When an ESOP is introduced, it is common for the plan sponsor to decrease its 401(k) match in order to fund the ESOP. With TrueScripts, there will be no changes to the existing 401(k) Retirement Plan and 6% Company Match, except that the profitsharing contribution will be made to the ESOP starting in 2024. To assist in the transaction, TrueScripts hired Business Transition Advisors (BTA), a succession planning services provider that has helped more than 400 companies transition to ESOP. BTA’s Managing Director, Rick Jaye, explained that over his career in helping business
owners with exit planning, those who gravitate to ESOPs have common goals and objectives. Rick states, “In working with TrueScripts, the three owners and Executive Management Team had many of those same characteristics. They deeply care about the organization and the people who help make it successful. They feel an overriding commitment to the community and customers they support, and they want to see the legacy of what they have built continue and not be dismantled or broken apart through an alternative sale.” When reflecting on the transaction, Rick says, “The
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NEWS unique beliefs and actions of the TrueScripts team resonated with me and the BTA team in a very different way. These individuals hold themselves to a different standard, putting others they serve first.” He says, “I spent time thinking about what this transaction truly meant to me and my team, the owners of TrueScripts, the families of their Team Members, and to the thousands of customers who rely on the incredible guidance and work that TrueScripts provides. The lyrics to a wonderful song came to mind: “You raise me up to more than I can be.” I can think of no greater words to describe what this company and transaction mean to so many. All are better for what this does and how it will continue to support patients, families, businesses, and communities. I appreciate all the companies who entrust me to help guide them through this process, but I have to say that the TrueScripts transaction changed me for the better just having spent time with these individuals.” TrueScripts has received many significant purchase offers over the years, but the owners have remained adamant about not selling out to another corporate entity. Company CoFounder John Bell says, “We’ve been blessed many times over here at TrueScripts, and we (the Founders) want to make sure that this never – and I do mean never - goes away. The best way we 60
knew how to do that was to make TrueScripts a Team Member Owned Company.” In a message to the TrueScripts Team, Co-Founder Kevin Messmer adds, "We have always said, "We are blessed so that we can be a blessing to others." And now, it is our sheer joy to be a blessing to you. You are now the owners of TrueScripts!” To sum things up, in the words of TrueScripts President and CEO Dean Merder, “The best is yet to come!” About TrueScripts TrueScripts Management Services is a pharmacist-founded PBM based on truth and transparency. Our mission is to build lasting relationships by providing prescription benefit management expertise at a personal and customized level to ensure optimum value at the lowest possible cost. We are committed to lowering prescription drug spend, achieving clinically enriched outcomes, and always delivering Amazing Care. Visit www.truescripts.com.
CVS Plans to Overhaul How Much Drugs Cost CVS Health, the nation’s largest drugstore chain, will move away from the complex formulas used to set the prices of the prescription drugs it sells, shifting to a simpler model that could upend how American pharmacies are paid. Under the plan called CostVantage, CVS’s roughly 9,500 retail pharmacies will get reimbursed by pharmacy-benefit managers and other payers based on the amount that CVS paid for the drugs, in addition to a limited markup and a flat fee to cover the services involved in handling and dispensing the prescriptions. Today, pharmacies are generally paid using complex measures that aren’t directly based on what they spent to purchase specific drugs. CVS’s move is to be phased in starting in the first half of 2024. It will take the approach to a far greater scale, embedding it in a company that stands at the core of the American drug-supply chain. For consumers, employers and health insurers paying for prescriptions, the change will have mixed effects. Some drugs may cost less, while others might rise in price, CVS executives said. More should show declines than increases, they said.
NEWS CVS is making the move as it seeks to stabilize its retail pharmacy business, which has long struggled with stagnating margins on its core function of dispensing prescriptions. The company is also responding to criticism from lawmakers, employers and patients about the complexity and opacity around how drugs are bought and sold. Members of Congress and some employer groups have argued that the current setup is flawed and secretive. Caremark CVS will also introduce a new option for clients of its PBM, CVS Caremark, which will work in tandem with the new retail pharmacypayment scheme. The new PBM product, called TrueCost, will be based on the net cost of drugs with defined fee structures, the company said. Employers and other clients will have the choice whether to use it or not. However, employers may be reluctant to take one step that is part of the TrueCost setup, which involves applying rebates the PBM receives from drugmakers to individual prescriptions for those drugs. Currently, patients often pay out of pocket amounts based on the higher, prerebate price. Employers and insurers sometimes use those rebates to offset other healthcare costs. Medefy Health Lands $10M Series A to Help Employees Navigate Complex Health Benefits Matt Scovil, co-founder and CEO of Medefy Health, and his cousin Nathan Gilchrist launched Medefy Health for the self-funded community in 2018 motivated by a shared nagging desire to make accessing health benefits less complicated. The company developed a mobile-first healthcare benefits navigation platform that offers realtime guidance from actual people, not AI-based chatbots. The Tulsa, Oklahoma-based company has seen rapid growth and landed $10 million in series A funding to build out its tech platform, the executives shared with Fierce Healthcare in an exclusive interview. Medefy will also use the funds to expand its teams. “We will be pouring a lot into product development,” Scovil said. “We have such a low churn rate our employers are asking for more and more from the platform, more features, more tools, the market wants more features
and tools, and we are doing our best to keep pace and exceed that. That’s going to require more engineers, more product people, more sales and marketing. We’ll be pouring investment into continuing to scale aggressively into the market.” Medefy’s centralized platform helps employees identify the best quality care at a reasonable cost through personalized, proactive guidance. The platform connects members with a variety of digital tools as well as live, in-app benefits experts with an average response time of under 60 seconds, any time of day. “We don’t use chatbots. We don’t use 1-800 numbers. We don’t have hold lines,” said Gilchrist, who has an engineering background and came on board as chief operating officer. “We don’t have any of those traditional things that are front-facing. It is really in-the-moment guidance when that healthcare episode is actually happening to help them to make the best healthcare decision for themselves.” He added, “The care guide will walk them through that entire process and that might be something simple, like, ‘What’s my deductible?’ or maybe it’s something more complex, ‘I need to get an MRI or I need to get a knee replacement’.”
NEWS About Medefy Medefy currently serves over 1,500 employers and their members, offering solutions to self-insured employers, insurance brokers, benefits advisors, TPAs and enterprise groups. Visit www.medefy.com. Marpai Appoints Jennifer Calabrese and Robert Pons as Independent Directors NEW YORK -- Marpai, Inc, an independent national ThirdParty Administrator (TPA) transforming the $22 billion TPA market supporting self-funded employer health plans, announced the addition of two new
members to its Board of Directors as part of the Company’s ongoing transformation plan and commitment to strong corporate governance and shareholder value creation. Effective December 7, 2023, Jennifer Calabrese and Robert Pons joined Marpai’s Board as new independent directors. In addition, the Board will also implement a strategic plan designed to enhance the Company’s performance and drive shareholder value creation. The actions are targeted at accelerating Marpai’s transformation and positioning the Company for both near- and longterm success. “We are very excited and honored to welcome Ms. Calabrese and Mr. Pons, two accomplished and experienced business leaders, to our board of directors,” said Yaron Eitan, Chairman of the Board. “They each bring unique experience and perspective that will complement the skills and background of the current board of directors.” Ms. Calabrese has been the founder and Chief Executive Officer of Calabrese Consulting, LLC («CCL»). Founded in 2012, CCL is a woman-owned, full-service accounting and advisory firm with over
Markel is a global specialty insurance provider, with a truly people-first approach. At Markel, we believe that what we do really matters and are committed to building successful relationships. Accident medical products include: – Group outpatient prescription drugs – Medical GAP supplemental health – Employer medical stop loss coverage Markel is providing these offerings in collaboration with Nevaeh. To learn more, contact Nevaeh. Nevaeh Tom DeNoma, Chief Executive Officer, and President firstname.lastname@example.org | +1.614.561.9904
Coverage is provided by Markel Insurance Company, NAIC# 38970, Rosemont, IL. Nevaeh Insurance Solutions, LLC is the underwriting facility for accident medical products. Coverage and services availability may vary by state. Terms and conditions for rates and coverages varies. Nothing herein shall be construed as an offer to sell or a solicitation or offer to purchase any products or services. Markel® is a registered trademark of Markel Group Inc. © 2023 Markel Service, Incorporated. All rights reserved.
40 employees, serving more than 350 clients around the world. Ms. Calabrese is a Certified Public Accountant, a Chartered Global Management Accountant, and a member of both The American Institute of Certified Public Accountants and The New York State Society of Certified Public Accountants. Ms. Calabrese will serve on the Audit Committee of the Board. Mr. Pons has served on the board of directors of 15 publicly traded companies, utilizing his more than 40 years of hands-on operating experience as a Chief Executive Officer and in senior executive positions in high growth companies and companies in need of turnaround strategies. Mr. Pons has served as President and Chief Executive Officer of Spartan Advisors, Inc., a management consulting firm specializing in telecom and technology companies, since January 2017. Mr. Pons will serve on the Compensation Committee of the Board. About Marpai, Inc. Marpai, Inc. (Nasdaq: MRAI) is a leading, national TPA company bringing value-oriented health plan services to employers that directly pay for employee health benefits, primarily competing in the $22 billion TPA sector serving self-funded employer health plans representing over $1 trillion in annual claims. Marpai works to deliver the healthiest member population for the health plan budget. Operating nationwide, Marpai offers access to leading provider networks including Aetna and Cigna and all TPA services. Visit www.marpaihealth.com. H.H.C. Group Announces 2023 Client Survey Results H.H.C. Group announced the results of its annual client survey today. The survey is designed to assess the company’s performance and help
identify its clients’ greatest needs going into 2024. Survey respondents again said the quality of H.H.C. Group’s solutions, excellent savings, and exceptional service give them a real advantage in today’s highly competitive marketplace. •
Nearly 90% described that advantage as “vital” or “big.” All indicated they get a great bang for their buck.
Almost 90% rating the value they receive for the price they pay as “outstanding.”
Reflecting on their satisfaction, every respondent said they would recommend H.H.C. Group to a colleague or friend.
Clients again said H.H.C. Group provides exceptional service, promptly responding to questions and requests, meeting or FEBRUARY 2024
NEWS beating deadlines, and delivering innovative solutions. Notably, respondents indicate they value that H.H.C. Group’s people listen to them and genuinely care about their businesses. “We are very pleased that our savings and service continue to give our clients a real advantage while enabling them to do their jobs effectively and efficiently. We are especially pleased with the success of negotiating settlements for No Surprise Act claims,” said Bruce Roffé, H.H.C. Group’s President and CEO. “We look forward to continuing to support our clients in achieving their cost containment goals and to assisting them in implementing the No Surprise Act in the coming year.”
About H.H.C. Group HH.H.C. Group is a leading national health insurance consulting company providing a wide range of cost-containment solutions for Insurers, Third Party Administrators, Self-Insured Employee Health Plans, Health Maintenance Organizations (HMOs), ERISA, and Government Health Plans. H.H.C. Group utilizes a combination of highly skilled professionals and advanced information technology tools to consistently deliver targeted solutions, significant savings, and exceptional client service. H.H.C. Group’s services include Claim Negotiation, Claim Repricing, Medicare Based Pricing, DRG Validation, Medical Bill Review (Audit), Claims Editing, Medical Peer Reviews/Independent Reviews, Independent Medical Examinations (IME), Case Management, Utilization Review, Data Mining, Disease Management and Pharmacy Consulting— finally, H.H.C. Group services as 1 of 5 Independent Dispute Resolution Entities for New York State. For additional information about H.H.C. Group and our services, visit hhcgroup.comor contact Bob Serber at email@example.com or 240-813-6005 ext. 163.
2024 SELF-INSURANCE INSTITUTE OF AMERICA BOARD OF DIRECTORS CHAIRMAN OF THE BOARD* John Capasso President & CEO Captive Planning Associates, LLC
DIRECTOR Deborah Hodges President & CEO Health Plans, Inc.
CHAIRMAN ELECT* Matt Kirk President The Benecon Group
Mark Lawrence President HM Insurance Group
TREASURER AND CORPORATE
Adam Russo CEO The Phia Group, LLC
SECRETARY* Amy Gasbarro Chief Operating Officer Vālenz
DIRECTOR Stacy Borans Founder/Chief Medical Officer Advanced Medical Strategies
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
DIRECTOR Mark Combs CEO/President Self-Insured Reporting DIRECTOR Orlo “Spike” Dietrich Operating Partner Ansley Capital Group
* Also serves as Director
SIIA NEW MEMBERS FEBRUARY 2024 REGULAR CORPORATE MEMBERS
Efrat Marmur VP Marketing Air Doctor Beit Nekofa, Israel Kevin Doherty Partner Dickinson Wright Nashville, TN Neil Gordon CEO INTERVENT International Savannah, GA Catherine Dowie Senior Associate Matthiesen, Wickert & Lehrer, S.C. Hingham, MA Troy Corley SVP Employer Engagement Proactive MD Simpsonville, SC Cindy Baker Chief Executive Officer Quality Care Partners Zanesville, OH
Jason Nau Director of Business Development Rocky Mountain Review Worland, WY
Sue Finkam Marketing Director Rejuvenate Kidney Transplant Solutions Toledo, OH
Dominic Belmonte Marketing Manager Vida Health San Francisco, CA
Kara Johnson Director of Strategic Growth Initiatives Security Health Administrative Services Marshfield, WI
Zach Nye General Counsel Blackhawk Claims Services Irving, TX Mark Riendeau SVP of Sales Codoxo Duluth, GA Nina Stanley Head of Partnerships Healthee New York, NY Jourdan Miller Marketing Director PayMedix Milwaukee, WI
Jenny Simmons Equity Risk Management, Inc. Las Vegas, NV Tim O’Brien TIB Risk Management, Inc. Las Vegas, NV
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Life Is Not Without Risk.
Unforeseen complications could take a routine surgery from $25,000 to nearly $1 million in costs.*
John didn’t think his routine surgery would result in a life-threatening situation. Neither did his self-funded employer. Catastrophic claims can arise unexpectedly. If the plan has the right Stop Loss protection in place, focus can remain on achieving business goals and welcoming John back when it’s time. When you work with the experts at HM Insurance Group, you can have confidence that the claims will be paid. Find more on hmig.com.
SECURE FINANCIAL PROTECTION WITH OUR INSURANCE AND REINSURANCE OPTIONS: Employer Stop Loss: Traditional Protection • Small Group Solutions • Coverage Over Reference-Based Pricing Managed Care Reinsurance: Provider Excess Loss • Health Plan Reinsurance *
Cost estimate based on HM Insurance Group historical Stop Loss data and additional industry observations, August 2022.
In all states except New York, coverage may be underwritten by HM Life Insurance Company, Pittsburgh, PA, or Highmark Casualty Insurance Company, Pittsburgh, PA. In New York, coverage is underwritten by HM Life Insurance Company of New York, New York, NY. The coverage or service requested may not be available in all states and is subject to individual state approval. MX3200789 (R12/23)