The Self-Insurer November 2023 Digital Edition

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Wellness Program RESET: What Employers Should Expect from Vendors

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Wellness Program RESET:

What Employers Should Expect from Vendors Written By Laura Carabello


ps and downs with wellness vendors over the past few years may have left employers and plan sponsors pondering what their expectations should be in 2024 and beyond. One thing is for certain: employers increasingly see wellbeing as crucial to their workforce health, productivity, and benefits strategy. Despite any downturn in the current economic environment, it doesn’t appear that they will be reducing their investment in support of programs and services with more growth surrounding incentives. In fact, according to the 14th Annual Employer-Sponsored Health & Wellbeing Survey of 184 employers fielded by Fidelity Investments and Business Group on Health, 9 in 10 employers felt that a sagging



Wellness Program RESET economy would not lead to any reduction and 3 in 10 planned to actually increase their investment. The responses point to particular promise for those interested in increasing social cohesion: •

82% of employers plan to focus on social connectedness (70% in 2022)

79% plan to focus on community (67% in 2022)

This heightened attention to employee wellbeing undoubtedly resulted from the physical and mental toll of the pandemic along with increased emphasis on job satisfaction. Harvard Business School advises that at Amanda Rieger-Green a time when many workers are struggling with mental health issues, workplace wellness programs need to go beyond providing gym Amanda Rieger-Green, MPH, CEO discounts and start offering employees tailored solutions that improve and founder of Soul Pathology, their physical and emotional well-being. described as a transformative force in wellness, resilience They advise that many wellness programs are simply built on a and personal growth serving “set-it-and-forget-it” mentality, often making them undervalued employers, organizations and and inadequate in supporting employees’ needs, both on and off individuals, says, “Vendors the job. They contend that many companies are wasting precious provide solutions and financial resources on ineffective programs and as a result, suffer the accountability and should not rely costs of losing talent, replacing disengaged employees and watching upon the employers to create productivity take a nosedive. wellness solutions with metrics, data and statistics to document Harvard business experts still point a finger at COVID-19, highlighting performance.” the fact that workers expect employers to go beyond offering access to mental health apps and setting up fitness challenges. Traditionally, She recommends that employers workplace wellness programs have focused on ways to lower seek out vendors that can offer healthcare costs, but this is far from adequate to meet employee uniquely tailored solutions for needs. their population and organization, creating accountability, employee engagement and traction -- the Furthermore, when there’s a drain on employees’ physical, mental, calm that results in an ongoing and emotional energy, productivity is naturally affected. As a result, conversation that yields value. companies ultimately bear the cost of lost productivity through employee resignations, as well as the expense of replacing unhappy, “In the rapidly evolving landscape burned-out workers who depart. With the costs of replacing an of modern business, success employee cited at as much as three to four times a position’s salary, is no longer solely defined by attrition due to burnout is worth preventing. bottom-line profits and market share dominance,” she says. Given the benefits of introducing a robust wellness program, the “A new era has dawned, one question becomes, “What should employers expect from their wellness where organizational success is vendor?” intimately intertwined with the well-being of its most valuable asset: its employees. This NOVEMBER 2023


Wellness Program RESET paradigm shift has ushered in the age of enlightened employers who recognize that the path to sustained success is paved with a genuine commitment to employee well-being.” She emphasizes that organizational success is unequivocally linked with the well-being of its workforce. “Prioritizing employee well-being isn’t a transient trend -- it’s a strategic imperative that reshapes the destiny of organizations,” she says. “By nurturing an environment that honors employees’ physical, mental, and emotional health, organizations are sowing seeds of prosperity that ripple across every facet of their operations.”

She says there should be a clear line between claims cost drivers, employee demographics, and employee feedback to any wellness and mental health initiatives being undertaken. “This is a crowded marketplace when it comes to point solutions and tactics, and employers should avoid doing everything and instead take a more targeted approach,” she continues. “Answering the wellness and burnout question should go beyond perks or benefits offered to include the overall corporate culture and how things like time off, flexible work and career development opportunities are accounted for.” NEED FOR EMPLOYER SUPPORT

WELCOA, an organization with 4,000 corporate members and respected resource for building high-performing, healthy workplaces, says there’s a hard truth to this dissonance that many companies experience with wellness vendors. In many instances, it’s not the vendor, it’s the organization. They recommend some “tough love” before searching for another vendor partner: gain clarity around organizational needs, develop a deep awareness of how conducive the work environment is for wellness, and assess strengths and weaknesses. At UR Medwatch, providing care management solutions that address employee wellness at all stages of health, Sally-Ann Polson, President and CEO, advises, “Historically, traditional wellness programs have been ineffective because of lack of employer support and therefore member engagement. It is not enough to simply offer the benefit -- it has to be promoted and members rewarded for participating and truly working towards improved health."

Teri Weber

Teri Weber, Senior Vice President, Spring Consulting Group, an Alera Group Company, concurs, “While we expect continued innovation in this space, we believe it is not necessarily about needing more but about assessing the options available and understanding what an organization’s unique needs are related to wellness.”

She says the most effective wellness programs include some type of member incentive that is important to their specific population, “One size does not fit all, but often removing the cost barrier and decreasing or eliminating member co-pays and deductibles has proven to be enticing.” Polson advises employers not to expect to see a fast return on their investment: “Wellness is a long-term event, and the benefits of getting or staying healthy are almost impossible to measure, but the cost of doing nothing will soon become painfully evident through the increase in ongoing and high-cost medical events.” Jenny Wan, director, Sales & Marketing, Health Portal Solutions, shares, “I don’t think lack of options is the issue here. EAP-type programs have been around for years, and new mental health NOVEMBER 2023 7

Wellness Program RESET Although wellness can be defined similarly, some suggest that wellness is more active and process-oriented whereas health is more of a state of being. For example, the National Wellness Institute (NWI) defines wellness as, “an active process through which people become aware of, and make choices toward, a more successful existence.” Natural Jenny Wan She says an employer can have the approaches, self-healing and best program in the world, but if it’s preventive care provide a firm not promoted, program utilization and ROI will be low. Wise wellness foundation for wellness today. vendors will not only provide a solid program but also well-established NWI advises that by mindfully tools and strategies to equip employers in promoting it. focusing on wellness in our lives, people can build resilience and HEALTH VS. WELLNESS are able to thrive amidst life’s challenges. The terms “health” and “wellness” are often used interchangeably. The World Health Organization (WHO) defines health as, “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” programs and vendors are entering the market every day now. What employers need the most is support in promoting and driving employee utilization of these programs. This support could come in the form of giving employers training on communication strategies, privatelybranded materials to use, and even suggested promotion schedule.”

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Wan says, “Absolutely. The COVID-19 pandemic brought to the surface an issue that had been building below the surface for quite some time. The effects of isolation, loneliness, and stress have brought to light an incredible mental health need that is just as detrimental to employee presenteeism and productivity as many physical health issues.”

Source: National Wellness Institute. resources/six-dimensions-of-wellness/

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Because mental health issues are much less stigmatized than they used to be, she says the timing is right to add and promote mental health resources as part of employers’ larger wellness programs: “This will not only show an employer’s empathy toward employees, but also equip employees with resources to productively manage their mental health needs.” Weber adds that whether there are standalone wellness solutions pertaining to behavioral/mental health, or there are sufficient offerings within a health plan or EAP program, mental health is a critical component of overall wellbeing and should be addressed. “We advise clients to think about key barriers to mental health care including cost, access, and stigma as they strategize around the issue,” she notes.

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The Forbes Advisor adds yet another dimension: financial wellness. They point out that wellness as an overall concept has found its way into more and more corners of American life, bringing attention to the fact that by adopting healthy lifestyle changes, people can live a better life. These practices, they say, can also help people to improve their financial lives and achieve financial wellness. What is required is a change in one’s financial behaviors and incorporating more effective money habits to secure financial stability. Financial wellness is a topic that increasingly pops up on the agenda of employers and Human Resource Executive asserts that 69% of workers are stressed about their finances while 72% are worrying about their personal finances at work. As a result, a growing number of organizations are launching financial wellness programs for their employees to help them get their finances back on track. In fact, research from the Bank of America shows that

over half of employers (53%) in the US now offer financial wellness programs compared to only 24% in 2015. The Academy to Innovate HR (AHIR) explains that financial stress has a negative impact on both the personal and professional lives of employees and by extension, on the entire organization. According to the Society for Human Resource Management, financial stress results in a 34% increase in absenteeism and tardiness. Employees who worry about money also miss almost twice as many days per year compared to their unstressed colleagues.

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Wellness Program RESET

THE WELLNESS CONTINUUM According to the Global Wellness Institute, one way to understand wellness is to consider health as a continuum that extends from illness to a state of optimal wellbeing. On one end, patients with poor health engage the medical paradigm to treat illnesses, interacting in a reactive fashion and episodically with doctors and clinicians who provide care. On the opposite end are people who focus proactively on prevention and maximizing their vitality. They adopt attitudes and lifestyles that prevent disease, improve health and enhance their quality of life and sense of wellbeing.





“Diabetes has topped the charts for one of the largest disease states for economic impact,” she reports. “Compared to other countries, the U.S. has a higher disease burden among the younger and working‐ age population and the situation is expected to become worse. Over the next 20 years, the Institute for Health Metrics and Evaluation at the University of Washington forecasts that the overall U.S. disease burden will increase by about 20% percent as age and lifestyle‐related conditions, such as cardiovascular diseases, cancers, and neurological disorders rise.” Lynch advises that by deploying approaches to improve health and prevent and treat diseases, the U.S. can reduce its disease burden by as much as one-third by 2040.

Jakki Lynch

Jakki Lynch RN, CCM, CMAS CCFA, Director Cost Containment, Sequoia Reinsurance Services, shares a recent report published by McKinsey which estimates that poor health costs the US economy about $3.2 trillion annually from premature deaths and the lost productive potential associated with diseases.



“Plan sponsors can be instrumental in these prevention efforts by ensuring access to effective wellness programs for their employees with interventions that are preventive in nature, such as weight management -- the key to reversing metabolic syndrome.” she continues. Rieger-Green states, “Configurable and results-driven employee wellness programs with best-in-class reporting and measurable ROI result in amplified employee engagement and productivity. At the heart of a well-functioning organization lies an engaged and motivated workforce. Robust well-being initiatives, encompassing everything from fitness regimes to stress management workshops, fuel employees’ motivation and resilience. This translates into higher job satisfaction, diminished absenteeism and a significant boost in overall productivity.”

Wellness Program RESET


Source: International Foundation of Employee Benefit Plans Choosing-Wellness-Toolkit.pdf?_gl=1*mkiqmw*_ga*NDgyMjczNDkxLjE2OTM5MTk1NzQ.*_ga_ K25EMRG77W*MTY5MzkxOTU3NC4xLjEuMTY5MzkxOTY0OS42MC4wLjA. NOVEMBER 2023



When it comes to creating a culture of wellness, one of the most effective methods is to start from the top down. Chris McReynolds, CEO of Wellsource, says it’s all about the importance of building trust within your population, which then leads to an increased willingness to participate. “You cannot simply launch a wellness program and expect it to work,” he counsels. “Everyone needs to participate from the top down. By participating as a leader, you help to build trust, which can lead to increased willingness to participate in the wellness programs you’ve designed. This, as we know, can lead to a healthier, more engaged workforce among other benefits.” Rieger-Green concurs, “There should be a direct connect between the vendor, the CEO and other members of the leadership team, even the HR executives. The entire C-suite and organization need to be fully engaged and invested in any wellness initiative and provide a voice in its adoption and understanding. If the C-Suite is not wanting to participate in this themselves, it’s not worth the investment and the

program will fall flat. The goal is to create a sustainable, valuable solution.” A culture that places paramount importance on employee wellbeing fosters an atmosphere of collaboration. “When employees are supported and valued, they become more inclined to freely exchange ideas, communicate transparently, and pioneer innovative solutions,” she says. “The result is a resilient workforce that thrives not only individually but also collectively, cultivating an authentic and inclusive organizational culture that drives success from within.”

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Wellness Program RESET


Source: International Foundation of Employee Benefit Plans




Employers and HR professionals should consider shaping allencompassing holistic wellbeing initiatives that cover a spectrum of essential aspects, including personal growth. Well-being offerings can be elevated by incorporating a variety of resources that empower employees from every angle: from invigorating wellness retreats that provide a rejuvenating escape from routine to online synchronous and asynchronous programs designed to cater to diverse schedules and preferences. “A comprehensive approach ensures that well-being is not just a buzzword but an integral part of a company's DNA,



enriching its overall health, ability to attract and retain talent and ensure long-term viability,” says Rieger-Green. “A holistic approach drives organizational culture, enhances resilience, and ultimately shapes an organization's narrative of success. When employees adopt healthier behaviors, there is less likelihood that they will develop health risks.” She says that transforming organizational culture is an important step in building individual and corporate resilience that enables the workforce to effectively face challenges, adding, “In today's unpredictable business landscape, resilience is a prized attribute. Well-being programs arm employees with essential tools to navigate stress, achieve work-life harmony and bolster their resilience, ensuring they remain adaptable and agile in times of change.” Bravo Well affirms that a reduction in health risks across the population likely means a reduction in filed insurance claims for preventable conditions. The less claims that are filed, the lower the expected future claims costs will be, and the lower the benefit renewal costs for employers and in turn, employees. With higher employee engagement and a greater number of connected employees who are committed to the company’s vision and values, the higher the presenteeism and productivity throughout the organization.

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Wellness Program RESET

VENDOR WELLNESS PROGRAMS Employers should seek out vendors that offer multiple programs for wellness and preventive health services. Here’s a sample of some of the more outstanding wellness platforms and their service offerings: Wellable is a holistic wellness provider that empowers organizations of all sizes to create engaging employee well-being programs. Working with employers, health plans, and properties across the world, Wellable has active users in more than 35 different countries. Clients partner with Wellable to support the physical and mental health of employees, strengthen organizational culture, and improve key workplace productivity metrics. CoreHealth is a one-stop corporate wellness solution. Their solutions include biometric management, health assessments, challenges, incentives, coach facilitation, and more. Rather than working directly with employers, CoreHealth specializes in providing their technology to other wellness-related companies, insurers, employee assistance providers, and human resource consulting firms. Soul Pathology offers comprehensive options for self-insured companies as well as brokers, TPAs, Benefits Consultants, Captives, EAP providers and other organizations supporting the self-funded industry that are seeking to enhance employee well-being. • • • • •

Broker Breakfasts Lunch and Learn Sessions Executive Consulting Management Training Synchronous/Asynchronous Programs

• • • • • •

Newsletters Wellness Days Corporate Wellness Retreats Webinars Health Fairs Stress Management Programs

Kona is a worker wellness tool that uses real-time emotional health data to avoid and respond to burnout. You may use Kona to increase workplace teamwork by motivating team participation through conversation. An employer can utilize Kona to keep track of wellness-improvement initiatives that benefit their entire organization. Empathy and work-life balance aren't optional at Kona. They're an absolute must-have. LifeSpeak Inc. is mental, physical, and family wellbeing. The Company provides the only holistic wellbeing product suite built for business that leads with digital education and supports with human connection. Limeade tailors its wellness program model to each company. The platform utilizes surveys and other metrics to gauge key corporate wellness indicators like burnout and turnover, constituting a dashboard with actionable insights. Targeting the right team members at the right time with the right support means higher employee retention and long-term engagement.



Wellness Program RESET

Starling offers early intervention for stress, depression, and anxiety to enhance efficiency and lower absenteeism. It can help firms save money on health care by offering prompt support to employees in need. Starling also offers a Return-to-Health employee benefit to help employees who are on leave due to a physical or mental ailment return to work faster. TotalWellness offers on-site health screening and flu shot clinics to companies of all sizes. Small- to medium-sized companies will enjoy Beata, the TotalWellness all-in-one employee wellness program. This streamlined, online platform improves employee health while stripping away the clutter that accompanies other employee well-being programs. Welltok connects with people on a personal level, empowering employees to join a stress management program, refill a prescription, schedule a wellness visit, and more. Solutions include their Consumer Activation Platform, a partner ecosystem, enriched data, and top-notch professional services to help health plans, employers, and health systems achieve their goals. Sprout At Work is a leading workplace wellness platform. Driven by data science, cognitive behavioral science, game theory, and behavioral economics, it empowers your team to make lasting behavior change. Employees using Sprout at Work saw a reduced risk of developing Type II diabetes and cardiovascular disease and an increased rate of physical activity. IncentFit specializes in small- and medium-sized businesses and health insurance providers. IncentFit has spent over 10 years helping hundreds of businesses develop wellness programs that meet their needs. IncentFit programs are geared toward rewarding employees for healthy behavior year-round.




With an increased number of companies adopting employee wellness programs, the debate about their return on investment (ROI) grows. • In a study done on the ROI of employee wellness programs, Harvard researchers conclude that, on average, for every dollar spent on employee wellness, medical costs fall $3.27 and absenteeism drops $2.73. This is a 6-to-1 return on investment. • A report by the International Foundation of Employee Benefit Plans determined that most North American employers saved $1 to $3 in their overall health care costs for every dollar spent on an employee wellness program. These savings come from direct costs, like workers’ compensation claims, and indirect costs, like improved retention and increased productivity. • According to the Rand Wellness Programs Study, the disease management component to the studied wellness program was responsible for 86 percent of the hard health care cost savings, generating $136 in savings per member, per month, and a 30 percent reduction in hospital admissions. • A Harvard Business Review article confirmed how ROI can be attained through employee wellness programs, specifically looking at high health risk employees. Of those classified as high risk (with body fat, blood pressure, anxiety level and other measures) when the study started:

• 57 percent were converted to low-risk status by the end of the • •

six-month program Medical claim costs declined by $1,421 per participant, compared to the previous year Every dollar invested in the employee wellness program yielded $6 in health care savings

ROI is not always as ‘cut and dried’ as we would like it to be, but thoughtful programs do pay off. Weber counsels, “The more targeted you can get, such as addressing smoking cessation or diabetes management, the more likely a program will prove its value. When we talk about ROI, the primary focus is on dollars, but we should not discount more qualitative components like engagement, attraction, and retention, and employees feeling like they have support in achieving personal wellness goals.” At Spring Consulting Group, they typically recommend that wellness programs should not require out-of- pocket expenses in order to increase participation, with Weber adding, “In fact, programs with 22


the best participation often have prizes or incentives built in to encourage team members to engage.” Wan says ROI for wellness programs is largely dependent on how much the program is promoted. She continues, “The saying “If you build it, they will come” does not apply when it comes to wellness programs. The best wellness program ROI comes when the program is promoted regularly by the employer.” Promotion of wellness programs doesn’t have to be labor intensive or expensive. “It can be as simple as sending employees the materials provided by the wellness vendor, making the program accessible from the benefits portal and reminding employees about the programs during company events. The goal is to keep wellness programs at the top of employees’ minds, so that when they’re ready to participate, they know how to get started.” When it comes to out-of-pocket expenses, Wan expresses that from her experience, the lower the cost to the employees, the more likely the program will be adopted and used. “However, because every program has limitations, it’s also reasonable for employees to pay out-of-pocket for additional services that may be required. As long as all of this is communicated and explained

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Wellness Program RESET to the employees, employers shouldn’t be afraid of talking about the costs. If employers emphasize how the program will benefit the employees, the employees will see that any outof-pocket expenses are worth the cost.” PRACTICAL STEPS ON THE ROAD TO WELLNESS

She advises that providing access for employees to receive education, resources, and support can positively impact their overall wellness, which in turn can provide both immediate and long-term savings related to healthcare for the member and the benefit plan. “With the dramatic uptick in behavioral health issues, well-structured programs in behavioral health are more important than ever,” says Polson. “They should include a comprehensive behavioral health support component that provides assistance to members who are dealing with situations stemming from work/family life stresses to more complex mental health and substance dependency challenges, and should encompass mental, physical, emotional, and economic factors. When left unaddressed, these issues quickly compound in severity and overall cost.” Metabolic disease is one of the most problematic and potentially costly challenges that can be addressed through effective wellness programs. The National Institutes of Health defines metabolic syndrome as “a group of conditions that together raise your risk of coronary heart disease, diabetes, stroke, and other serious health problems.” Metabolic syndrome is also called insulin resistance syndrome.

Sally-Ann Polson

“Navigating our healthcare system is challenging enough for healthy individuals and for those diagnosed with an acute or chronic health condition, even more so,” says Sally-Ann Polson, noting that MedWatch provides Concierge Services for complex health plans and RBP, clinical resources to achieve and maintain optimal health with a serious illness to a chronic disease, a maternity program and an EAP. “Wellness attributes and psychological assessment exist in all of these, and having access to quality care management services is an important part of an effective wellness program.”



“More than 30% of adults in the United States meet the diagnostic criteria for metabolic syndrome,” says Jakki Lynch. “High blood pressure, elevated blood sugar, increased body fat and abnormal cholesterol are select conditions of Metabolic Syndrome. These conditions lead to diseases such as Type II Diabetes, cardiovascular disease, and stroke.” The NIH reports that making a commitment to choose the right foods to eat and adopting an intermittent fasting program can prevent metabolic syndrome or may improve the patient’s condition if already diagnosed. “Intermittent fasting is one of the best ways to impact your health,” Lyn advises. “There is an ease and flexibility to this discipline that is unlike any other lifestyle change and is easier than counting calories. The benefits of intermittent fasting can help people lose weight, lower their blood glucose levels, reduce inflammation and improve their overall health through a process called autophagy-cellular recycling.” She explains that the main premise of the method is to only eat during a reduced number of hours during the day, adding, “This includes not eating late at night or during the earlier morning hours. The most common method is to eat for an 8-hour period during the day (e.g., 11am to 7pm). This period could be reduced to 6 or even 4 hours.”

Wellness Program RESET According to a recent study published in Cell Metabolism, 137 firefighters who worked 24-hour shifts showed that reducing the window of time for eating improved multiple markers of health in just 12 weeks. The study concluded that time restricted eating/intermittent fasting may serve as a novel intervention to treat and potentially prevent cardiometabolic disease. Lynch cites another recent study from the University of Illinois Chicago, which has studied intermittent fasting for the past two decades. Researchers found that intermittent fasting can help people lose weight and keep it off over the course of a year, with effects similar to tracking calories. The results of the clinical trial results of the clinical trial were published in the Annals of Internal Medicine. Lastly, in the Dec. 26, 2022 issue of The New England Journal of Medicine, neuroscientist Dr. Mark Mattson — who has studied intermittent fasting for 25 years — stated evidence which supports that it can be a “part of a healthy lifestyle.” Lynch concludes, “The study found that participants had a decreased resting heart rate, lower blood pressure, and reduced blood lipid levels after intermittent fasting. The top US academic medical centers along with the American Hospital Association recognize the potential benefits and they provide cost effective programs for intermittent fasting.”

These programs are a great example for payers and providers to expand existing collaboration to innovate care delivery through targeted wellness programs. The prevention strategies are simple and novel and the positive impacts on patient health and clinical outcomes warrant a strategic approach for plan sponsors to consider wellness benefits. WELLNESS: A MULTI-


William F. Ziebell, CEO, Gallagher’s Benefits & HR Consulting Division, advises that today’s workforces consist of multiple generations and people from a variety



Wellness Program RESET of backgrounds, requiring employers to analyze whether their benefit offerings are addressing a wide range of employee needs. The new Gallagher 2023 Physical and Emotional Wellbeing Report says 90% of employers have increased support for one or more core employee wellbeing dimensions. “As organizations continue to focus on recruiting and retention as top operational and HR priorities, it’s clear that they’re paying closer attention to important issues, such as



flexibility, burnout and inclusive medical coverage,” he says in the report. Other findings in the survey showed that: • Employers are investing in employee morale: Providing mental health training for managers, leaders or HR increased by 5 points to 22% and roughly 7 in 10 employers (71%) offer clinical care such as virtual or telephonic mental health counseling. • Offering more downtime to avoid burnout: 25% of employers are allowing time off for mental health and burnout (up from 3 points in 2022). • Updated paid leave policies are on the rise, but unlimited time off is slow to catch on: Access to new child or parent bonding paid leave has increased 5 points from 2022 to 41%, but only 5% of employers offer unlimited PTO. • Employers still unsure of specialty drug coverage: Challenges remain in managing specialty drugs (e.g., weight loss, gene therapies, biosimilars), and 48% of employers don’t know or don’t use tactics to manage their use and costs.

Wellness Program RESET The road to wellness is paved with a different set of bricks for each employer group. The key is deciding which pathway holds the most promise for each workforce. Weber concludes, “Using a broad definition of wellness, just about every employer already offers some type of wellness benefit through their health plan, employee assistance program or a separate wellness vendor. Most of these benefits are voluntary in that employees are not required to participate but do not require any additional cost sharing for participation.” She says it’s likely that wellness will continue to evolve and encompass even more programs under the wellness banner. “For example,” she explains, “as prescriptions for weight loss medications increase in usage, employers are making decisions around coverage and prior authorizations and considering how their wellness providers, including programs that may focus on weight management and diabetes management, might be able to support decision making for employees and employers in this area.” 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. SOURCES on,to%2D1%20return%20on%20investment. How Workplace Wellness Programs Can Give Employees the Energy Boost They Need - HBS Working Knowledge

https://www. article/the-power-of-resiliencein-employee-wellbeing resources/six-dimensions-ofwellness/ research_reports/RR254.html opinion/articles/2023-06-23/ companies-must-treat-employeewell-being-as-a-businessimperative advisor/investing/financialwellness/#:~:text=Financial%20 wellness%20is%20a%20 relative%20measure%20of%20 how,aim%20of%20improving%20 your%20overall%20quality%20 of%20life. blog/employee-financialwellness/#:~:text=With%20 69%25%20of%20workers%20 being,their%20finances%20 back%20on%20track. employers-are-doubling-downon-financial-wellness-is-ithelping/ resourcesandtools/hr-topics/ benefits/pages/employeesfinancial-issues-affect-their-jobperformance.aspx The Surprising Reasons Your Wellness Vendor Relationships Aren’t Working - WELCOA






Written By Bruce Shutan



very year, there’s a hot topic that dominates the conversation not only in keynotes and workshops at industry events, but also exhibit hall booths and during networking discussions. Artificial intelligence was a clear winner at SIIA’s National Conference at the JW Marriott Desert Ridge in Phoenix, AZ. In describing AI as the basis of a radically different society, futurist Mike Walsh told a record-breaking 2,000-plus attendees in the opening keynote address that organizations will increasingly compete on their capacity to deliver compelling algorithmic experiences for customers. He noted a marked shift to building technology platforms from simply developing products and services.



ENDEAVORS “What are the unique data points that can transform your business?” asked Walsh, a dynamic speaker and leading authority on digital disruption who heads up the global consultancy Tomorrow. It was his third appearance as a SIIA keynoter since 2018. He suggested that companies identify pain points that AI can ease, which will help them compete. The challenge for the next 18 months will be considering how AI can automate mundane workflow and instead focus on areas that require more meaningful human judgment, according to Walsh.

That means using AI to elevate rather than eliminate employees. His suggestion was to teach AI, machine learning and other technology to employees. “Talk to the tech team to see if there’s a solution that doesn’t require human work,” he said. And as it becomes easier to create computer codes, he believes that a growing number of workers will learn to be coders.



ENDEAVORS The key to scaling AI will be to think beyond incremental productivity improvement in the algorithmic age, he observed. Noting how the AI revolution kicked off in 2012, he said ChatGPT’s introduction 10 years later became a game-changer and added that the previous 10 months have seen technology advance at a pace quicker than the previous decade. For example, ChatGPT Coe Interpreter, which was launched in May, has the capability of doing 30% of all work, according to Walsh. He noted that it examines trends and produces elaborate PowerPoint presentations in just seconds. But by October, ChatGPT had the capability of actually seeing, hearing and speaking. “This is the beginning of civilization,” he quipped in his trademark dry British humor.

He noted that Snack, a dating app for GenZ, allows users to create and train AI avatars to recognize their interests. But at some point, he predicted that kids will be talking primarily with AI, not their parents or friends.

“Do not underestimate the pace of change,” Walsh implored the audience, noting that the next 10

years will seem like a century worth of change. He predicted that 2033 will be much more profoundly transformed than we can imagine with the question being, what will be possible then that’s now possible now? Explaining that AI is not a trend or fad, he said people need to embrace its uncertainty and not fear the unknown. The future actually will be easier with the help of AI, he predicted.

“Be curious,

not judgmental,” he suggested in screening a scene from

the popular TV show “Ted Lasso.” His view is that humans are going to need a new set of skills – a software update, if you will – and, of course, a fresh mindset in thinking about impending changes.

“This is truly going to be an AI-powered society where the digital and real will be intertwined,” he concluded. “The future is now!”

A shift from customer transactions to experiences can be seen in anything from Spotify’s CHRONIC CARE DRIVING ENORMOUS STOP-LOSS MARKET monthly music subscription service, which he noted now GROWTH features AI-generated playlists, Since the Affordable Care Act passed in 2010, the stop-loss market to ordering Uber ridesharing and Starbucks coffee. Mobile apps are has grown from about $10 billion to more than $31 billion largely in renewal increases in small and midsize groups and in the captive driving these purchases. space, noted Phil Gardham, President of Accident and Health for U.S. Walsh believes the biggest trend Berkshire Hathaway Specialty Insurance. While consolidation has in the next 10 years will be slowed in recent years, he said new carriers and MGUs are entering personalized AI that can help the space – allowing self-insured employers extremely competitive humans have more meaningful rates. relationships than ever before. But that’s not to say everyone will Chronic illnesses are certainly a driving force behind this growth. fall into lockstep with that vision. Jennifer Collier, President of Health Risk Solutions for Sun Life, referenced that as many as 16 of 18 high-cost claims involve patients with co-morbidity factors. This has given rise to carveout products and exclusions in the costly cell and gene therapy space. 30


ENDEAVORS Michael Meloch, CEO of TPAC Underwriters, referenced an IV infusion company in Minneapolis that dispatches technicians to patient home. His hope is that the stop-loss community helps carriers figure out how they can move more care to this setting. There will be a continued movement toward outpatient and in-home care to help reduce costs, added John Fries, Head of Accident and Health for Swiss Re Corporate Solutions. Other highly effective methods he suggested include underwriting claims as a pool, personalized medicine, cell and gene therapy, and population health management. Fries also sees a tremendous opportunity to automate more routine tasks so that stop-loss carrier can spend more time focusing on underwriting risks. He’s optimistic that cell and gene therapies that reduce, say, the number of hemophiliacs with curative care will also help manage stop-loss expenses over time.



One other key trend that is affecting claims involves the movement toward home-based care. The pandemic fueled virtual care, which Collier believes will continue to move treatment from hospitals to homes with more technology helping strengthen that connection and tether them to triage care centers.



Ernie Clevenger is a Baby Boomer who likes the energy, curiosity and heart that younger generations possess. But here’s the rub: the President of CareHere, a Premise Health Company, and publisher of the MyHealthGuide said those

ENDEAVORS younger than 30 will change jobs seven times. He told a panel discussion on generational differences in the workplace that younger talent believes it needs to move around to earn more money and climb the corporate ladder. Les Boughner, Chairman of Advantage Insurance Management LLC, has noticed that younger generations aren’t afraid to challenge conventional thinking and hatch solutions on the spot. There’s much more hierarchy among his fellow Boomers, he added, while Milennials and GenZ members are just the opposite. Corporate involvement in outside

missions or charities can be an important retention tool, according to Clevenger. His employees, for example, suggested a giving campaign for soldiers who were deployed in Operation Desert Storm in Iraq. Another strategy is creating a purpose-driven culture. GenXer Kevin Seelman, Executive Vice President and Special Practices Leader for Lockton Dunning Benefits, noted that his marketing team helps employees understand how the work they’re doing touches lives in a very personal way and what it means to those families. At the end of the day, it’s less about tenure and more about contribution as far as the retention equation is concerned, observed GenXer Amy Gasbarro, COO of Vālenz®Health. Boughner said would much rather promote based on potential than someone who is overqualified. “You want someone who is going to be very inquisitive and willing to try new things,” she added. DIRECT CONTRACTING PLEASES BOTH PAYERS AND PROVIDERS

As if the shortage of doctors, nurses and other workers in the health care ecosystem weren’t already a huge headache, the problem is being exacerbated by other developments.



ENDEAVORS Brian Felty, Vice President of Business Development and Valuebased Care for Baylor Scott & White Health, cautioned that by purchasing high volumes of provider practices, the BUCAHs and private-equity companies could trigger an even greater exodus among those professionals. If hospital systems attempted to do the same, he believes they would be subject to a much higher level of scrutiny by federal regulators. “We’ve all been misaligned on who the customer is, which is the patient,” he observed, noting that his firm has incorporated incentives for employees to visit their primary care physician (PCP) for earlier detection of health issues and to drive lasting change. Physician assistants can certainly help fill care gaps and better manage patient loads, while direct contracting will keep dollars in the community, according to Brad Byars, Executive Director of Providence St. Joseph Health. He also is a big believer in narrow networks, value-based care and benefit designs built around highquality care as ways to drive down costs.


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“We need to find a way to meet employers where they are,” said Philip Eaves, President and CEO of Ascension Seton Accountable Care Organization, noting the need to pave multiple avenues for direct contracting. He described the beauty of this arrangement as offering a solid discount that makes it attractive to employers, while physicians are happy about being reimbursed without having to claw back money from

“Providers like living in that world,” Eaves reported. BUCAH plans.

Success for his ACO is keeping people out of a hospital’s four walls unless they absolutely need to be there. Physicians want to focus on prevention, which he said is the benefit of working with a clinically integrated network.

“We’re at an inflection point for hospital systems, which are not going to compete at the top of that funnel for lives,” he explained.

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“They’ll turn into a high acuity tertiary facility, or they’re going to show more innovation in their DNA like Intermountain Health” or similar systems. CLAIMS DATA SHAPES GAG CLAUSES, FIDUCIARY RESPONSIBILITIES

Under the Consolidated Appropriations Act (CAA), self-insured plan sponsors should have more access than ever to data from their downstream vendors and provider networks under the gag clause prohibition included in the 2020 legislation. This provision prohibits gag clause provision, both direct and indirect, in any agreement between a plan and a network or TPA for data related to pricing and quality information, or claims data from those parties, explained Chris Condeluci, SIIA’s Washington, D.C. counsel, who moderated this lively panel discussion. “Having claims data empowers plan sponsors to shop for a better deal,” he said. “That’s what we hope transparent pricing rules will help secure.” However, with an upcoming December 31 deadline for plan sponsors to attest to the federal agencies that there are no gag clauses in their contracts, many plan sponsors are finding increasing obstacles as they seek to do so. It may be necessary for both Congress and the U.S. Department of Labor will need to add further clarifications and enforcement measures, he said. While it’s unlikely that all the needed clarifications will be settled before the upcoming attestation deadline, there remains open a possibility of an extension for granting relief to plan sponsors until these further clarifications happen. Still, he said there’s an effort afoot to impose penalties on TPAs or provider network owners that are unreasonably restricting access to plan sponsor data.



ENDEAVORS Plan sponsors don’t necessarily own their data, which payers say becomes proprietary once it’s integrated into their system, noted Julie Selesnick, Senior Counsel for Berger Montague. She said the provisions in those agreements affecting the payment amounts is what plan sponsors need to make sense of. This will make them a better steward of the dollars that are paid out. There are also some cracks in the system to loosen plan data, explained Selesnick, who said parties that are holding onto information will face increasing pressure to settle current pending litigation between plan sponsors and some network carriers refusing to provide that data. . Her advice to plan sponsors is that they must include language that says gag clauses from contracts with TPAs, PBMs and provider networks are null and void. The onus is on plan sponsors to have ironclad contracts, and they cannot accept at face value any written statements from vendors on this topic, she advised, adding that confidentiality agreements must be negotiated at the same time as service agreements.

“The CAA has been a blessing for those of us out there who have been trying to do the right thing,” opined Dawn Cornelis, Chief

Transparency Officer for ClaimInformatics. She said there are gold nuggets in each of the lawsuits over gag orders that can help selfinsured employers ensure that they have complete access to their health plan data.

Contracts between hospitals and managed care companies are complex and nearly impossible to understand, according to Denny Weinberg, director and former CEO of Granular Insurance Company. “Our selffunded employers are not aware of how they’re being used as a consequence of this information,” he said. “We want to be an advocate and hold our partners accountable. They should be equipped on how to deploy the right employer solutions.”


Cancer has now surpassed musculoskeletal conditions in terms of driving health care claims in large companies, explained moderator Laura Carabello, a principal with CPR Strategic Marketing



ENDEAVORS Communications in setting the stage for this session. With cancer diagnoses becoming so common, it’s not a question of if but when employees and their dependents will be told they have the disease, observed Anthony Masotto, General Manager and Executive Vice President of Drexi, an AMPS Company. All the boxes need to be checked in plan documents to ensure that lifesaving cancer drugs are available and covered.

stop-loss carrier or MGU to understand options for members if certain coverage isn’t stipulated in the plan document, according to Rasnick. How drugs are defined in the plan document she said will become crucial as more costly and curative cell and gene therapies are brought to market. But it’s also important to recognize that non-clinical interaction with patients is vital because it can account for about 80% of the claim, according to Parker, whose company specializes in this area. He described hand-holding as a gigantic part of the cancer journey and whole-person health, which can help alleviate fear, anxiety and confusion among patients and their families.


Given the enormous financial and clinical implications, the panelists agreed that early detection, preventive screenings and treatment saves both money and said Michael Gorton, founder lives. Masotto urged employers to incentivize participation in cancer of Recuro Health who also started Teladoc. screenings to avoid problems down the road.

“Talking to a patient in their home was considered criminal 20 years ago, but we’ve come a long way,”

A stage-one cancer diagnosis that costs more than $60,000 can double if it reaches the next stage, noted Craig Parker, CEO of Guideway Care, Inc. Getting nurses involved right away from the initial diagnosis before the claim even starts will help engage patients, added Caryn Rasnick, Vice President of Client Success for MedWatch, LLC. There’s more than $200,000 difference when patients are engaged, she said. It also will improve outcomes, Parker added. All TPAs should have a good communication path with their



ENDEAVORS His own experience wasn’t too far off from that observation. He recalled DEA agents abruptly walking into Teladoc’s office in 2005 with their badges and guns visible, concerned that prescriptions were being written for controlled substances. Fast forward to today’s opioid crisis, and Gorton noted that if there’s a street value to any script, the industry must be aware of the risks and steer clear of this area.

Despite economies of scale, the growing shortage of health care professionals has proven to be a challenge for EZaccessMD President Lois Irwin whose firm can always use more radiologists and ultrasound stenographers.

Virtual care long ago fixed the problem of access, then pivoted to catch ailments early with tools that make it easy for patients to seek treatment, according to Gorton. He said the technology has evolved to a point where behavioral health issues can be diagnosed just by using a smartphone.

“Our population will need more of them, especially as we age,” she explained.

But it’s much more encompassing. The Journal of the American Medical Association estimates that as much as 70% of care can be delivered virtually, according to Vibin Roy, M.D., Senior Medical Director of Virtual Primary Care for Included Health. He also said virtual health enables patients to leverage access to resources in other states and level the playing field.

The fact is that virtual care allows doctors to earn more and charge patients less because of the inherent operational efficiencies of this model, Gorton noted.




That has created a much higher comfort level among Americans, 65% of whom he said did not trust telemedicine pre-pandemic, whereas now 87% of them now prefer it. Irwin said care is moving to the home because it’s convenient and removes cost barriers. Making a benefit available for free, which EZaccessMD does through its employer contracts, is the ultimate incentive to

“You have to make an impression,” she said, “and the pandemic has been a change agent in terms of patient behavior.” drive utilization.

Roy is not a fan of fee-forservice medicine, noting how the per-employee-per-month model allows for resources to be invested more creatively. Clinicians need the latitude to provide patients with more time and follow up, which he said is difficult to achieve under the traditional model. But he added that being able to do those things for patients in the comfort of their own home makes it easier to be more thoughtful about patient care.



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



Written By Caroline McDonald


he 2023 survey of captive owners and service providers by the Self-Insurance Institute of America, Inc., released in October, found that they were overwhelmingly positive about the direction of the industry. More than 30 individual captive companies, service providers, and owners provided feedback on a number of topics important to captives. This year’s survey was divided into three sections focusing on general industry issues, service providers, and captive owners. “Overall, the 2023 captive survey underlines what many in our industry see; that the captive market is growing, particularly in the employee benefit and medical stop-loss side,” said Ryan Work, Senior Vice President, Government Relations at SIIA.



Most respondents (77%) selected Employee Benefits/Medical Stop Loss as the area in which they have seen the most growth this past year. In addition, Work said, the emerging trends identified by the survey, “really capture the other hot topics of the day.” They include cyber, medical stop loss; and larger healthcare trends, “such as the cost of new cell and gene therapies – some drugs which can cost upwards of $25 million or more.” Because of those trends, he added, “We are seeing increased cost of risk, in addition to much higher costs to obtain coverage in the commercial market, if any coverage exists at all.” Work also concluded that inflation “is a much newer driver this year, that cascades to larger economic issues that may very well be pushing business owners to look at captive coverage for not only benefits, but other risks in the P&C space.” Simon Kilpatrick, President at Advantage Insurance Management (USA) LLC noted, “I wasn’t surprised that the industry outlook was very bullish. Responses to other survey questions are that captives are growing. Most managers are forming captives at four times the rate that they were closing captives last year.” He noted, “I expected to see that the industry is growing, because now is the time for the captive market.” Kilpatrick added that there were also a few negative responses regarding the outlook. “I can only assume they have very specific reasons,” he said. “They may have a type of captive that is challenged, such as § 841(b) captives.” In this case, “The question is what will happen with all these regulations being challenged by the IRS with small captives. I can see that if you are focused on small captives, you might have a less positive outlook than the rest of the industry.” GENERAL INDUSTRY OBSERVATIONS

SIIA stated: “The positive data and industry growth trends reported in the survey include increases in staff hiring, captive formations, and total captive premium amounts. This is especially true in the employee benefits and medical stop-loss areas, where 77 percent of respondents reported strong growth in the past year.”



Jeff Simpson, Partner at Womble Bond Dickinson (US) LLP, said that the first thing that stuck him about the survey results was that “It’s a small sample, but it shows me massive numbers of captives and really large premium amounts.” This, he said, suggests that “there is much more uptake of captive insurance than people appreciate.” Simpson observed that trade press counts of captives usually come in at about 6,000 worldwide. “Our survey, however, accounts for 6,000 participating captives.” He added that with other statistics, “The number of cells or the number of group captives and participants are not being counted.” What’s more, group captive formations, he said, are moving to the forefront. “This year in our practice, we’ve seen more group captives being formed than any year previously. What I’m seeing reported on the survey is consistent—a lot of group captives are being formed for a lot of reasons,” Simpson said. More traditional groups—”your classic property-casualty and workers’ comp general liability being formed,” he said. “The conclusion is that we’re seeing so much more because more people are learning about it.” Another underlying factor, Simpson said, is inflation, which is pushing more people into captives. “Inflation is

everywhere, including insurance premiums, and when premiums go up, people start looking for alternatives,” Simpson said. Kilpatrick said that what was not surprising is stop-loss purposes. “That response was consistent from the service providers and also the captive owners and prospective captive owners,” he said. The reason for these formations, he added, is the increasing costs in the industry, “and captives can be a way to maintain control, but also to find capacity that may not exist in the commercial market. You can use a captive to fill gaps that you can’t fill commercially.”


Service providers, instructed to count individual cell structures for the survey, noted that the total of reported clients currently served is 5,377. The estimated average premium per captive is $6,734,722 and the highest estimate of average premium per captive is $65 million. MULTIPLE CAPTIVE FINDINGS

The average reported percentage of customers with multiple captives is 14% Median reported percentage of customers with multiple captives: 13% Types of captives formed: Group captives—43.2 % Single parent—35.1 % Cell—18.9 % Risk retention group—2.7 %



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Most captive owners (43 percent) reported first hearing about captives from working in the insurance industry and 29 % of respondents reported that they heard about captives from their brokers. “Owners are moving to captives for specific reasons, including the increased costs of risk – from health to P&C, to cover risks when coverage is unavailable in the commercial market, and to take advantage of economies of scale in the self-insured market,” Work said. Captive owners, he added, are looking at other risks that they may be able to insure in a captive structure, “whether that is on the medical side, or whether it’s an emerging risk like cyber or an economic risk.”

The reality now, he added, is that “Everyone’s credit card information has leaked and is potentially out there.” An onerous risk for businesses now is “being hacked with ransomware and being held hostage,” Kilpatrick said. “They have to negotiate a settlement with the ransomer or retool and repurchase equipment and try to rebuild their backup with servers.”

Risks have changed, “and coverage of commercial carriers has evolved over time as well,” he said. “But the carriers are so large that it takes them a couple This is important because cyber risk has changed so rapidly, Kilpatrick of years to get new policy rates and forms approved and to observed. “A couple of years ago a cyber claim was related to a data decide at the board level what to breach and the cost of the claim was the cost of notifying all of your do.” customers that their card number was leaked and putting them on a credit watch for a year.” Captive managers, on the other As for trends, Kilpatrick said, “Not surprising was that the risk people were considering most was cyber insurance. That’s been a trend for years and I believe the reason is that captives are able to adapt very quickly to changes in the outlook.”

hand, “can come in and change a manuscript policy very quickly and get it approved in a matter of days by their regulator. Captives are always able to react to big changes in the industry.”

Similarly, another relevant topic is the versatility of captives “and how they can be used in areas in which commercial insurers are exiting markets, as is happening with storm, fire and other property-casualty risks in Florida and California,” Work said. “Business owners are acutely aware of both cost and risk, and they see the upside of covering them through captive insurance structures.”




Survey respondents rated the future of the captive industry as a 9 on a scale of 1-10. This is a nearly identical result from last year, when close to 90% of respondents reported having a bullish outlook on the future of the captive industry.

Nearly 75% of respondents reported that they have added staff in the past year, with a significant number of these additions being management staff, underwriting, and accounting. This is an increase from last year’s survey, where 66.7% of respondents reported staff growth.

For the third year in a row, captive formations have significantly outpaced closures. Survey respondents reported an average of 4 new captive formations for every 1 captive closure per respondent. That is nearly double last year’s reported rate, in which there were an average of 2.5 formations for every 1 closure.

43% of respondents reported group captives as the captive structure most formed, with singleparent captives coming in a close second at 35%, compared to last year’s survey, in which single parent was the most selected, followed by group captives.

The average respondent reported 206 captive clients being served by their organization, an increase from last year, which reported an average of 137 clients served. The total number of captive clients served by ALL respondents in this year’s survey was 5,377 – nearly double last year’s reported total of 2,884.

The average estimated premium per captive was $6,734,722.

Employee benefit and medical stop-loss growth – A majority of respondents (77%) reported seeing the most growth in employee benefits and medical stop-loss captives. This was the third year in a row demonstrating this trend.

Price inflation is up – 34% of respondents listed price inflation as the biggest yearly trend, with staffing shortages coming in second at 19%. They were also listed as the top two trends in last year’s survey.

Captive Domiciling Moving Onshore – Onshore domiciles reported included Vermont and North Carolina, while Bermuda was a top offshore response.

Captive Owners Setting Up Multiple Captives – Captive owners reported an average of 1.6 captives per business, an increase from last year.

Captive Owners Benefit from Captives – The majority of captive owners (71.4%) reported that they have not considered closing or leaving their captives. At the same time, 57% of respondents reported that they were able to find similar coverage in the commercial market, an increase from last year’s 42%.

Caroline McDonald is an award-winning journalist who has reported on a wide variety of insurance topics. Her beat has included in-depth coverage of risk management and captives. NOVEMBER 2023


Q A Q & A &



he Affordable Care Act (ACA), the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other federal health benefit mandates (e.g., the Mental Health Parity Act, the Newborns and Mothers Health Protection Act, and the Women’s Health and Cancer Rights Act) dramatically impact the administration of self-insured health plans. This monthly column provides practical answers to administration questions and current guidance on ACA, HIPAA and other federal benefit mandates. Attorneys John R. Hickman, Ashley Gillihan, Carolyn Smith, Ken Johnson, Amy Heppner, and Laurie Kirkwood provide the answers in this column. Mr. Hickman is partner in charge of the Health Benefits Practice with Alston & Bird, LLP, an Atlanta, New York, Los Angeles, Charlotte, Dallas and Washington, D.C. law firm. Ashley, Carolyn, Ken, Amy, and Laurie are senior members in the Health Benefits Practice. Answers are provided as general guidance on the subjects covered in the question and are not provided as legal advice to the questioner’s situation. Any legal issues should be reviewed by your legal counsel to apply the law to the particular facts of your situation. Readers are encouraged to send questions by E-MAIL to Mr. Hickman at



AGENCIES ISSUE EXTENSIVE MHPAEA GUIDANCE: PLAN AND TPA ACTION REQUIRED On July 25 the Departments of Labor, Treasury, and Health and Human Services issued a proposed rule on requirements related to the Mental Health Parity and Addiction Equity Act (MHPAEA). The Proposed Rule, if finalized in its current form, will impose significant new compliance obligations on group health plans and health insurance issuers and would be effective for plan years beginning on or after January 1, 2025. The focus on the Proposed Rule is on nonquantitative treatment limitations (NQTLs) under MHPAEA. Along with the Proposed Rule, the departments issued a technical release (TR) related to the Proposed Rule’s data collection requirements, a report to Congress, an enforcement fact sheet, and an MHPAEA guidance compendium. EXECUTIVE SUMMARY

This Article contains background regarding MHPAEA, a detailed analysis of the Proposed Rule, the TR, and the Report to Congress as well as Practice Pointers but the following is a summary of the key provisions. We will refer to just “group health plans” or “plans” in this Article with the understanding that the MHPAEA requirements are also applicable to health insurance issuers. This article is part 2, with part 1 in the October issue of The Self-Insurer. THE DESIGN AND APPLICATION REQUIREMENT

The Proposed Rule contains a design and application requirement that applies the factors, processes, strategies, and evidentiary standards requirements that plans have been laboring over for the past two and one-half years in documenting an NQTL comparative analysis.

been added in the Proposed Rule. The preamble notes that this provision is intended to codify the departments’ “consistent interpretation” on the current requirements for NQTLs and to bring it in harmony with the CAA 2021 statutory requirements. The Proposed Rule adds a provision that a plan cannot rely on a factor or evidentiary standard if the basis of the factor or evidentiary standard “discriminates against mental health or substance use disorder benefits as compared to medical/surgical benefits.” Impartially applied independent professional medical or clinical standards or standards to detect or prevent fraud, waste, and abuse are specifically listed as nondiscriminatory.


This requirement states that an NQTL cannot be imposed “under the terms of the plan as written and in operation” unless “any processes, strategies, evidentiary standards, or other factors used in designing and applying the nonquantitative treatment limitation to mental health or substance use disorder benefits in the classification are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in designing and applying the limitation with respect to medical/surgical benefits in the classification.”

NQTLs other than network composition

This language is almost identical to the 2013 final rule, but that rule was limited to “applying” the NQTL, and the word “designing” has

The manner and form of that data request (except for network

In designing and applying an NQTL, the Proposed Rule would require plans to “collect and evaluate relevant data” to assess the impact an NQTL has on MH/ SUD benefits compared to Med/ Surg benefits.



composition) is left open to further guidance from the departments, but specifically mentioned are claims denials and data required by state law or private accreditation standards. Practice Pointer: This requirement would codify what the departments are already doing with MHPAEA examinations in practice. In their April 2021 FAQs, the departments noted that a plan should be prepared to provide, as part of an examination, “internal testing” performed as well as “samples of covered and denied MH/ SUD and medical/surgical benefit claims.” The DOL, in its investigations, insists that data analysis is part of the required stringency testing. The 2023 report emphasized that the DOL currently requests this sort of data in any examination. In fact, the DOL noted that “Data showing the effect of an NQTL’s application were particularly important and sometimes operated as a ‘green flag’ signaling that an NQTL in question did not appear to apply more stringently to MH/SUD benefits relative to medical/surgical benefits.” If the analysis of the outcomes data reveals “material differences” in access to MH/ SUD benefits compared to Med/Surg benefits, then the Proposed Rule states that this is a “strong indicator” that the 48


NQTL violates MHPAEA. The Proposed Rule then requires the plan to take “reasonable action” to address the material differences and then document the action taken to mitigate those material differences. Neither the Proposed Rule nor the TR defines “material differences,” but the departments have requested comments on how to define the term. The preamble to the Proposed Rule states that, except for network composition, material differences alone would not be dispositive of a violation but reasonable action would need to be taken. The preamble further provides:

Whether any particular action would be considered reasonable in response to any given material differences in access resulting from an evaluation of outcomes data would be determined based on the relevant facts and circumstances, including the NQTL itself, the relevant data, the extent of the material differences in access to mental health and substance use disorder benefits as compared to medical/surgical benefits, and the impact of the material differences in access on participants and beneficiaries.

A discussion of that reasonable action would then be a required element of the plan’s NQTL comparative analysis. The preamble notes that this inclusion in the comparative analysis would allow plans “to explain why material differences in access demonstrated by the outcomes data should not result in a violation of the rules for NQTLs.” Required data collection for the network composition NQTL and the TR The Proposed Rule emphasizes the importance of the network composition NQTL in providing access to MH/SUD benefits. This NQTL is different from other NQTLs in two ways. First, material differences would not just be a strong indicator of an NQTL violation—they would actually be an NQTL violation. Second, the Proposed Rule states data collection requirements for this NQTL that are in addition to those required for all NQTLs. This additional data collection includes in-network and out-ofnetwork utilization rates (including data related to provider claim submissions), network adequacy metrics (including time and distance data, and data on providers accepting new patients), and

provider reimbursement rates (including compared to billed charges).

Outpatient office visits.

The TR provides further clarification on the departments’ thinking on the data collection for this NQTL and seeks comments. Under the TR there would be four data collection requirements.

Other outpatient items and services.

The first requirement would be out-of-network utilization. Data collection and evaluation would be required on the percentage of covered and submitted out-of-network claims for MH/SUD benefits compared to Med/Surg benefits. The TR proposes that the data collection and evaluation would be on the following out-of-network services:

Inpatient, hospital-based services.

Inpatient, non-hospital-based services (one focus here is comparing Med/Surg services for rehabilitation facilities and skilled nursing facilities with residential treatment facilities for MH/SUD services).

Outpatient facility-based items and services (intensive outpatient and partial hospitalization are among those particularly noted here).

The second requirement would be the percentage of in-network providers actively submitting claims. Here, the departments believe that plans have provider network directories that include providers not actually providing services and term this a “ghost network.” Plans would be required to collect and evaluate the percentage of in-network providers who submitted no in-network claims and the percentage of in-network providers who submitted claims for fewer than five unique participants and beneficiaries



during a specified period. The TR designates the types of providers that the departments are considering requiring for this data collection. The third requirement would be time and distance standards for participants and beneficiaries to obtain MH/SUD services compared to Med/Surg services. Time and distance standards are already required for Medicare Advantage plans. The data collection and analysis would include data on the percentage of participants and beneficiaries who can access, within a specified time and distance by county-type designation, at least one in-network MH/SUD provider and at least one in-network MH/SUD provider. The TR specifies certain types of MH/SUD and Med/Surg providers the departments are considering for this data collection. For MH/SUD providers, the TR specifically mentions, among others, child and adolescent providers, geriatric providers, eating disorder providers, and autism spectrum disorder providers. The departments envision using the same county-type designations used for Medicare Advantage Plans. The fourth requirement would be reimbursement rates of in-network MH/SUD providers compared to Med/Surg providers. Plans would be required to collect data on reimbursement rates for yet-to-be-specified types of MH/SUD providers and yet-to-be-specified types of Med/Surg providers. That data collection would be for specified CPT codes (the TR mentions four). The analysis would then determine any material differences between in-network payments (compared to billed charges) for MH/SUD benefits and Med/Surg benefits. There would also be a comparison of allowed amounts and a comparison against a Medicare benchmark. Practice Pointer: The Proposed Rule’s data collection requirement and the substantially all/predominant test would dramatically change the way NQTLs are analyzed. While factors, processes, strategies, and evidentiary standards would still be a part of validating NQTLs, these inherently contain some subjectivity and provide plans some leeway in designing NQTLs. Previously, the departments stated that comparable application of these criteria was the “test” and that outcomes were not determinative. Now, at least for the substantially all/predominant test and for the network composition NQTL, outcomes will be determinative.



The TR has approximately 75 issues that the departments have asked for specific comments (many with subparts). So it is likely that the data collection requirement for NQTLs will be further refined when the Proposed Rule is finalized. The TR suggests that this data collection and analysis be performed by a third-party administrator (TPA) or other service provider in the aggregate for all plans that use the same network of providers or reimbursement rate. If there is a material difference based on any of these four data collections, then the Proposed Rule would find that the plan’s network composition NQTL is not valid. That does not mean automatic enforcement of the violation by the departments. The preamble to the Proposed Rule states that the departments will not cite a plan for a violation if there is a shortage of MH/ SUD providers in a geographic area and where, despite proper action, and through no fault of the plan itself, that shortage persists—provided that the plan is otherwise compliant with MHPAEA. The preamble goes on to state that plans should document the actions they have taken to resolve the disparity and demonstrate why any disparities are attributable to provider shortages in the geographic area and are due to factors other than NQTLs related to network composition. The departments


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request comments on this provision, including on whether and how to allow plans to account for external circumstances that impact material differences in access. A possible safe harbor for the network composition NQTL The TR raises the possibility of a future safe harbor for the network composition NQTL. If plans meet or exceed future specified standards on the four data elements, they would not be subject to an enforcement action by the departments for the network composition NQTL for a period that would be specified in future guidance. That safe harbor would include a “variety of metrics” on the four data elements. The safe harbor would cover all the following for network composition: standards for provider and facility admission to participate in a network



or for continued network participation, methods for determining reimbursement rates, credentialing standards, and procedures for ensuring the network includes an adequate number of each category of provider and facility to provide covered services under the plan or coverage. The departments are proposing that the safe harbor will last two calendar years beginning with the time the comparative analysis is requested. To be able to rely on the proposed safe harbor, however, no changes could be made that would affect the network composition NQTL, and certain other NQTL modifications would be prohibited as well. The departments expect that the safe harbor would set a “high bar” but are considering a phased-in approach in which plans can demonstrate progress toward meeting or exceeding the standards over the course of multiple plan years. EXCEPTIONS FOR INDEPENDENT PROFESSIONAL MEDICAL OR


All three of the NQTL requirements have exceptions or provisions for independent professional medical or clinical standards or standards to detect fraud, waste, and abuse. For the application and design requirement, this comes in the way of stating that these standards are nondiscriminatory. For the other two NQTL requirements, it is a specific exception.

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The Proposed Rule itself is terse on these important exceptions. To fall within the independent professional medical or clinical standards exception, a plan must “impartially apply generally recognized independent professional medical or clinical standards (consistent with generally accepted standards of care) to medical/surgical benefits and mental health or substance use disorder benefits, and may not deviate from those standards in any way, such as by imposing additional or different requirements.” To qualify for the fraud, waste, and abuse exception, an NQTL “must be reasonably designed to detect or prevent and prove fraud, waste, and abuse, based on indicia of fraud, waste, and abuse that have been reliably established through objective and unbiased data, and also be narrowly designed to minimize the negative impact on access to appropriate mental health and substance use disorder benefits.” The preamble provides slightly more explanation and emphasizes that these exceptions are not intended as a “loophole” and are “narrowly tailored.” The departments do recognize that these exceptions improve health care and outcomes. But the departments warn that if they become aware of the creation of new standards for the purpose of imposing NQTLs that are more restrictive for MH/SUD benefits, they may provide additional guidance consistent with MHPAEA’s fundamental purpose. Recognizing that these exceptions could be subject to various interpretations, the departments are soliciting comments on ways to better or more fully frame these exceptions. Practice Pointer: When an NQTL cannot satisfy the substantially all/predominant test or when an analysis of the data collection reveals “material differences,” the exceptions or provisions for independent professional medical or clinical standards or standards to detect fraud, waste, and abuse will be critically important if the plan wants to maintain the NQTL. THE MEANINGFUL BENEFIT REQUIREMENT

The final rule provided that if a plan provides MH/SUD benefits in one of the MHPAEA classifications it must provide benefits in all the classifications. The Proposed Rule expands this requirement to provide “meaningful benefits” when compared to Med/Surg benefits in that classification. Two examples in the Proposed Rule demonstrate this requirement. In one, a plan covers outpatient, out-of-network developmental evaluations for autism spectrum disorder (ASD) but excludes all other ASD services in that classification, including applied behavior



analysis (ABA). For Med/Surg, the plan provides a “full range” of outpatient treatments for services in this classification. The departments conclude that since the plan only covers one type of benefit for ASD in the classification but provides a full range of Med/Surg benefits in the same classification, it has not met the meaningful benefit requirement. In another example, a plan covers diagnosis and treatment for outpatient, in-network eating disorders but does not provide nutritional counseling for that disorder. The plan generally provides Med/Surg benefits for primary treatments in that classification.

The departments conclude that since nutritional counseling is one of the primary treatments for eating disorders, the plan does not provide meaningful benefits for eating disorders compared to the services provided for Med/Surg benefits in that classification. CONTENT REQUIREMENTS


The Proposed Rule would reshape the content of the NQTL comparative analysis by incorporating the data collection requirements and the substantially all/predominant test. Other organizational and substantive changes are made as well.

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There are six separate requirements with multiple subparts under each requirement. Under the Proposed Rule, including subparts, there would be approximately 40 requirements for a comparative analysis (some that might not apply to all plans).

apply the NQTL and the evidentiary standards supporting those factors. •

Description of how the factors are used in the design and application of the NQTL: This requirement (with 10 different subparts) codifies much of the prior 2021 FAQs on the content of an NQTL comparative analysis.

Determination of comparability and stringency as written: There are 10 different subparts for this requirement.

The six broad requirements are:


Description of the NQTLs: There are four subparts here, including the results of the substantially all/ predominant NQTL testing and how the plan identified the variations of the NQTL for the predominant aspect of that testing.

Determination of comparability and stringency in operation: The “as written” and “in operation” stringency requirements are similar in that they both require discussion of the results of the data collection and analysis. Stringency in operation is more detailed, requiring identification of the data collected, an evaluation of the outcomes of the data, a detailed description of any material differences found that are not attributable to differences in the comparability or stringency of the NQTL, and measures taken to mitigate any material differences.

Identification and definition of the factors used to design or apply the NQTL: Here, with five different subparts, the plan will identify and give a detailed description of the factors relied on to design and

Findings and conclusions: There are five different subparts for this requirement.


Practice Pointer: If the Proposed Rule is finalized, every NQTL comparative analysis will need to be updated and expanded.


The Proposed Rule would provide further clarity on the NQTL comparative analysis process. When a department requests an NQTL comparative analysis from an employer, it typically provides a very short timeframe for response. The departments emphasize that under the CAA 2021 that comparative analysis should have been prepared by February 10, 2021. Similarly, the departments typically provide short timeframes for employers to respond to follow-up requests. Under the Proposed Rule, each of those time periods would be codified as 10 business days.

actions between March 25, 2022 to June 6, 2022, although both departments give statistics from the 2022 report going back to February 2021. Both departments found the same deficiencies stated in the 2022 report. The DOL has six current NQTL enforcement priorities. Four were previously announced and two are new:

If there is a final finding of noncompliance with the comparative analysis, the CAA 2021 required that the plan notify all participants and beneficiaries of that noncompliance within seven calendar days.

The Proposed Rule now contains eight content requirements for that notice, including a statement “prominently displayed” and in no less than 14-point type that the applicable department “has determined that [the group health plan] is not in compliance with the Mental Health Parity and Addiction Equity Act.”

Prior authorization requirements for innetwork and out-ofnetwork inpatient services.

Concurrent care review for in-network and outof-network inpatient and outpatient services.

Standards for provider admission to participate in a network, including reimbursement rates.

Out-of-network reimbursement rates (methods for determining usual, customary, and reasonable charges).

New: Impermissible exclusions of key treatments for mental health conditions and substance use disorders.

New: Adequacy standards for MH/SUD provider networks.

The Proposed Rule specifies the delivery method for the notice and allows an internet posting if the participant or beneficiary is notified in paper form (such as a postcard) that the notice is posted on the internet. Also, if there is a final determination that a group health plan is noncompliant with the comparative analysis requirement, the departments can direct the plan not to apply any NQTL where that analysis was noncompliant until the plan comes into compliance. For ERISA-covered plans, the Proposed Rule would codify the DOL’s position previously expressed in FAQs that the NQTL comparative analysis is an instrument under which the plan is established or operated for purposes of Section 104 of ERISA. Under the Proposed Rule, plan administrators must provide the comparative analysis to participants and beneficiaries within 30 days following a written request or potentially face a $110 per day penalty. Also, for ERISA-covered plans there must be a certification by one or more named fiduciaries that they have reviewed the comparative analysis and found it to be in compliance with the Proposed Rule’s content requirements. THE 2023 REPORT TO CONGRESS

The 2023 report covered DOL actions between November 1, 2021 to July 31, 2022 and Centers for Medicare & Medicaid Services (CMS)

The DOL has placed an increased enforcement emphasis on network composition and participation standards, which also includes how plans set their



reimbursement rates. The DOL reports that it is pursuing over 20 network admission standards investigations. The DOL notes that it is currently devoting 25% of the Employee Benefits Security Administration enforcement program to focus on NQTLs. This is a dramatic shift from years ago when DOL investigations almost always centered on retirement plans and investigations of health and welfare plans were a relative rarity. Also, the DOL states that during the reporting period that it “continued to expand staffing dedicated to MHPAEA enforcement, including an increase of over 30 investigators and technical experts.”



The DOL is prioritizing potential violations stemming from actions of service providers since those potential violations may affect hundreds or thousands of plans. During the reporting period, the DOL indicates that it worked with 20 service providers to obtain corrections.

During the reporting period, the DOL took the following actions:

25 initial letters requesting comparative analyses for 69 NQTLs. o Prior authorization, exclusion of ABA and other therapies, network admission (including reimbursement rates), and concurrent care review were the top four NQTLs for which a comparative analysis was requested.

52 insufficiency letters covering over 100 NQTLs.

22 initial determination letters finding that plans and issuers had violated MHPAEA’s requirements for 26 NQTLs.

3 final determination letters finding MHPAEA violations for 3 NQTLs.

The DOL notes that the majority of corrections it obtained were without the need to issue notices of noncompliance.

While all NQTLs should be in the analysis, focus on the six NQTLs that the DOL has identified as enforcement priorities.

Of those six NQTLs, note that network composition including network provider reimbursement rates is an area of increasing scrutiny. Appendix II of the MHPAEA SelfCompliance Tool, “Provider Rate Reimbursement Rate Warning Signs,” provides a data framework for analyzing reimbursement rates. We do, however, expect a new version of the MHPAEA SelfCompliance Tool sometime this year.

In addition to the Appendix II framework, together with your TPAs/ASOs, perform additional data stringency analyses on various NQTLs. For example, a comparison of denial/ approval rates on requests for preauthorization for Med/Surg and MH/SUD claims in each MHPAEA classification.

Begin working with your TPA/ASO on how they will comply with the data collection and analyses requirements contained in the Proposed Rule and the TR even though exact parameters of those requirements are not known.

During the reporting period, the DOL found that none of the comparative analyses initially submitted were sufficient to demonstrate compliance. The DOL also mentions a lack of data to support the comparative analyses that were ultimately submitted. Also, because of NQTL operational compliance issues identified by the DOL, it is “increasingly conducting full investigations” into MHPAEA compliance. Practice Pointer: An insufficient NQTL comparative analysis can lead to a full DOL MHPAEA investigation, which can often span several years and involve numerous data requests, subpoenas, interviews, and depositions.

CMS’s reporting was largely similar to the DOL’s but was limited to 21 comparative analyses for six state and local governmental plans and five health insurers. CMS’s focus was on preauthorization and concurrent review NQTLs.


There is no set timetable for the Proposed Rule to be finalized. Comments on the Proposed Rule and the TR must be submitted to the departments by October 2, 2023, and it is unknown what, if any, aspects of the Proposed Rule may be modified. In the interim employers should:

Work with their TPAs/ASOs to make sure there is a compliant NQTL comparative analysis under the CAA 2021 and existing guidance. The 2022 and 2023 Reports to Congress, April 2021 FAQs, and the existing MHPAEA Self-Compliance Tool provide guidance on completing that NQTL comparative analysis.

Document that a plan fiduciary has actually reviewed the NQTL comparative analysis with the TPA/ASO or other service provider.




As part of the NQTL comparative analysis, isolate “variations” of any NQTL in anticipation of performing the substantially all/ predominant testing.

Confirm with your TPA/ ASO that they will revise (or work with you in revising) any NQTL comparative analysis to conform with the Proposed Rule once finalized.

Review any service provider agreement with the TPA/ASO to have clear provisions on the


TPA/ASO’s responsibility to provide the comparative analysis or information to complete that analysis if another service provider is going to perform this function. Specify any additional fees for this service and indemnification/remedies for failure to comply.


NEWS FROM SIIA MEMBERS 2023 NOVEMBER MEMBER NEWS SIIA Diamond, Gold, and Silver member companies are leaders in the self-insurance/captive insurance marketplace. Provided below are news highlights from these upgraded members. News items should be submitted to All submissions are subject to editing for brevity. Information about upgraded memberships can be accessed online at If you would like to learn more about the benefits of SIIA’s premium memberships, please contact Jennifer Ivy at NOVEMBER 2023



This will give our broker and TPA partners the ability to implement unique solutions, delivering immediate results to their clients,” continued Fleder.


In 2013, Fleder created ELMC through acquisitions and a partnership SOLUTIONS with investment firm J.C. Flowers & Co. He has been active in insurance and healthcare for more than 40 years and has successfully Wayne, PA — ELMC Rx Solutions, developed and exited multiple companies. LLC (“ELMCRx”) is pleased to announce its independent In 1995, Fleder created broker consulting firm Thesco Benefits, LLC launch. This follows its purchase (“Thesco”), one of the top 10 largest specialists in the country, which by Principal Owner and CEO, he merged into the T&H Group in 2006 before its ultimate sale to Richard Fleder, from its former Blackstone. parent, ELMC Risk Solutions, LLC Prior to that, Fleder co-founded Comprehensive Benefits (CBSC) in (“ELMC”). 1978, which he built into the largest third-party administrator in the Fleder and Mary Ann Carlisle, Northeast. CBSC was then acquired by EBP Healthplans before their ELMCRx’s CRO and COO, will combined sale to First Health, a division of First Data Corporation. continue to lead ELMCRx in its Carlisle brings senior experience from a variety of industries to mission to provide quality cost ELMCRx. In addition to her eight years of executive leadership at containment and clinical PBM ELMC, she has more than a dozen years of TPA and brokerage services through a growing portfolio of organically developed leaadership. Since 2018, she has led ELMC’s prescription drug companies and managed the acquisition and rebuild of Tesser, a digital programs, acquired companies, health platform. Before joining ELMC, Carlisle was an executive at and select partnered services. Thesco Benefits, Fleder’s brokerage firm. Fleder is committed to ELMCRx’s About ELMCRx Solutions mission to “maximize the value of pharmacy benefit plans and ELMCRx Solutions, “ELMCRx”, is a PBM services company with a to expand cost containment and technology-based focus on clinical management and prescription drug management offerings, with cost containment. The company was founded and purchased by Richard enhanced specialty and nonFleder and Mary Ann Carlisle, who together bring many years of specialty solutions.” industry experience. Visit By targeting skyrocketing prices and inefficiency in the specialty drugs market, ELMCRx’s model centralizes expert clinicians and technology for the benefit of plan sponsors, carriers, TPAs, brokers, consultants, and members.


PHOENIX, AZ — Vālenz® Health announces that Christina Morrison will join the company October 24 as Chief Financial Officer (CFO). Morrison’s appointment comes as Larry Eisel, who has served as Valenz CFO since 2019, has shared his plans to retire at the end of the year.

“Through our strategic acquisitions and partnerships, we’re building a portfolio of service solutions that can be In addition to overseeing the financial operations of Valenz, Morrison accessed through one entry point. will play a key role in strategic planning and establishing company NOVEMBER 2023


NEWS goals for sustainable growth. Most recently, she served as CFO with PE GI Solutions, acquired last year by SCA Health. Previously, Morrison was Senior Vice President of Finance at Aramark, where she led financial planning and analysis, mergers and acquisitions, treasury, and global shared services. She was among the leaders of Aramark’s initial public offering in 2013. Prior executive roles also include Senior Vice President of Business and Financial Planning at Merck & Co., Inc., and Senior Vice President/CFO of Wyeth Pharmaceuticals. She began her career in investment banking and became Managing Director at Alex. Brown & Sons, now Deutsche Bank. “As the top financial executive for a wide range of organizations, Christina brings tremendous business acumen in financial analyses and mergers and acquisitions,” said Rob Gelb, Chief Executive Officer of Valenz. “With a successful track record leading three different company-wide transformation projects, she will set a very high bar for achieving the profound organizational change that accompanies rapid growth.” Beyond the traditional roles of controller, treasurer and financial risk manager, Morrison will also be responsible for ensuring agreement and alignment on future mergers and acquisitions.

“I’m thrilled for the opportunity to address the ongoing challenges in health insurance that Valenz has dedicated itself to solving -- changing the way the industry works with selfinsured employers, improving simplification across the board, and driving a member-friendly experience that still manages costs,” Morrison said. “This is a terrific team that truly has a vision to help its customers and their members thrive.” Based in the Philadelphia area, Morrison has a Bachelor of Science degree in Economics from The Wharton School at the University of Pennsylvania, and she received her MBA from the Tuck School of Business at Dartmouth College. She is also



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Pittsburgh, PA – Brent Shelly has joined HM Insurance Group (HM) in the role of account manager, Tampa Regional Sales. In his new role, Brent will be responsible for managing HM’s existing accounts and working with producers to

support the growth of HM’s Stop Loss business in Florida. Brent comes to HM from Bouchard Insurance/Marsh McLennan Agency where he served as an employee health and benefits marketing manager since 2018. With nearly 30 years of experience in insurance, Brent has held team leadership, sales and account management roles at USI, Ameritas, United Concordia and other industry leaders. He has a Bachelor of Arts degree in Communications from the University of Louisville. About HM Insurance Group HM Insurance Group (HM) works to protect businesses from the financial risk associated with health care costs. A recognized leader in Employer Stop Loss, the company delivers protection for a range of group sizes. HM also offers Managed Care Reinsurance, including Provider Excess Loss and Health Plan Reinsurance, as well as accident and health specialty reinsurance. Visit www. and follow on LinkedIn.


Nashville, TN - Alliance Captive Management, a groundbreaking insurance services firm, is set to revolutionize the insurance landscape with its innovative approach to the formation and management of captive insurance companies. Headquartered in the heart of Tennessee, Alliance Captive Management is set to commence its operations over the Labor Day weekend in 2023. Captive insurance has long been a strategic financial tool for businesses seeking to manage risk and enhance control over the insurance programs. Alliance Captive Management steps into this domain as a trailblazer, offering expert guidance and services tailored to middle market businesses. With a leadership team that boasts over 50 years of combined experience and insight to its clients. “We’re thrilled to introduce Alliance Captive Management to the world” said Tim Luby CMO and Co-Founder of Alliance Captive Management. “Our mission is to empower middle market businesses with the financial flexibility and control they need to navigate the complex insurance landscape.”



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NEWS Key Highlights of Alliance Captive Management: • Expert Leadership: The leadership team at Alliance Captive Management brings together a wealth of knowledge and experience from diverse sectors within the captive insurance industry. Their strategic insights and deep understanding of market dynamics will be pivotal in delivering effective solutions. • Middle Market Focus: Recognizing the unique challenges faced by middle market businesses, Alliance Captive Management is dedicated to offering tailored solutions that fit the precise requirements of this segment. Their services will encompass every aspect of captive insurance, from formation to ongoing management. • Innovation: Alliance Captive Management is committed to staying at the forefront of industry trends and technological advancements. By leveraging cutting-edge tools and data analytics, they aim to provide clients with insightful and datadriven solutions. • Client-Centric Approach: Collaboration and open communication are at the core of Alliance Captive Management’s philosophy. They will work closely with clients to understand their risk profiles, business goals, and unique challenges, ensuring that the strategies implemented are aligned with their long-term vision.

The grand launch of Alliance Captive Management is scheduled for the upcoming Labor Day weekend in 2023. The company is excited to begin its journey towards transforming the way middle market businesses approach their insurance strategies. For more information about Alliance Captive Management and its services, please visit or contact Tim Luby at T.luby@ or direct at 386-527-8200.


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NEWS Innovations Lifestyle Benefits can help employers expand their company culture and promote employees’ mental and physical well-being.

contribution from their employer (42%), employees cite more benefits and resources to help with their financial well-being (33%) and more options and benefits to choose from (33%) as the most valuable improvements to their current benefits package, according to the 2022 EBRI and Greenwald Research Workplace Wellness Survey.

Lifestyle benefits, also sometimes called Lifestyle Spending Accounts (LSAs), are provided in addition to a traditional health plan, allowing employees the option to spend funds on eligible products and services to best meet their needs. Employers can choose the products, services, and activities they want to cover.

“Lifestyle benefits help employees invest in their physical and mental health,” said Jerame DellaPenta, Nova’s director of service delivery and engagement. “For employers, it’s a new way to engage employees, promote healthy workplaces and support unique employee circumstances. Well-rounded benefits packages can be deciding factors for employees searching for a new role or questioning whether to stay with their current company. These extra perks can have a positive impact on recruitment and retention.”

Adding a benefit to help defray the cost of health and wellness expenses is an investment in employee time outside of work. Outside of greater financial

Employers can determine their level of contribution, style of plan build, and which expenses are covered. This includes our “off the shelf” or customized network options. Nova’s Lifestyle Benefits network uses predefined merchant categories so employers can choose to customize their plan based on their employees’ needs and interests – examples range from gyms and recreation centers to hobby shops or car washes.



Depend on Sun Life to help you manage risk and help your employees live healthier lives By supporting people in the moments that matter, we can improve health outcomes and help employers manage costs. For over 40 years, self-funded employers have trusted Sun Life to help them manage financial risk. But we know that behind every claim is a person facing a health challenge and we are ready to do more to help people navigate complicated healthcare decisions and achieve better health outcomes. Sun Life now offers care navigation and health advocacy services through Health Navigator, to help your employees and their families get the right care at the right time – and help you save money. Let us support you with innovative health and risk solutions for your business. It is time to rethink what you expect from your stop-loss partner. Ask your Sun Life Stop-Loss Specialist about what is new at Sun Life. The content on this page is not approved for use in New Mexico. For current financial ratings of underwriting companies by independent rating agencies, visit our corporate website at For more information about Sun Life products, visit Stop-Loss policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) in all states except New York, under Policy Form Series 07-SL REV 7-12. In New York, Stop-Loss policies are underwritten by Sun Life and Health Insurance Company (U.S.) (Lansing, MI) under Policy Form Series 07-NYSL REV 7-12. Product offerings may not be available in all states and may vary depending on state laws and regulations. © 2023 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. Sun Life and the globe symbol are trademarks of Sun Life Assurance Company of Canada. Visit us at BRAD-6503-y SLPC 29427 01/22 (exp. 01/24)

NEWS Through employer contributions, employees receive a debit card to use toward a variety of recreation, fitness, health and wellness goods and services. Employers determine the unique benefit structure that fits their population. To simplify your plan, an FSA, HRA or HSA can all be offered through one debit card, along with a Lifestyle Benefit. To learn more about this flexible benefit, visit www.novahealthcare. com/novainnovations or contact About Nova Founded in 1982 and headquartered in Buffalo, NY, Nova is one of the largest third-party administrators of self-funded employee benefit programs in the nation, providing the health care solutions our clients need in the way they need them. Nova provides a comprehensive array of services, including medical, dental, vision, COBRA, reimbursement account administration, and private-labeled solutions. Nova also offers award-winning, in-house, integrated medical management programs. We are the stewards of our clients’ benefit plans, offering best-in-class partnerships, customized solutions, and personalized service. To learn more, visit

representatives to fortify its nationwide presence. This strategic recruitment bolsters HealthEZ’s commitment to advancing growth, enhancing service, and expanding capabilities across the United States. The recent appointments underscore HealthEZ’s dedication to providing businesses with dynamic alternatives to the costly and underperforming models of major insurance carriers. Meet the new sales executives: John Gaudette, Regional Vice President, based in CA Jamy Parker, Regional Vice President, based in TX


Mike Rotolo, Regional Vice President, based in IL

Bloomington, MN -- HealthEZ, a pioneering force in healthcare benefits administration, proudly welcomes four accomplished sales

Jake Gothard, Sales Development Executive, based in IA



You want unparalleled customer service. Employers need the right stop loss coverage. At Swiss Re Corporate Solutions, we deliver both. We combine cutting-edge risk knowledge with tech-driven solutions and a commitment to put our customers first. We make it easy to do business with us and relentlessly go above and beyond to make stop loss simpler, smarter, faster and better. We’re addressing industry inefficiencies and customer pain points, moving the industry forward – rethinking employer stop loss coverage with you in mind.

Employer Stop Loss: Limit Health Care Exposure. Advancing Self-funding Together. Insurance products underwritten by Swiss Re Corporate Solutions America Insurance Corporation. © Swiss Re 2022. All rights reserved.

NEWS These seasoned professionals bring a wealth of experience and a proven track record in the healthcare benefits industry. Their collective expertise aligns seamlessly with HealthEZ’s mission to deliver unparalleled self-funding and level funded solutions.

clients across various industries. Through innovative partnerships, superior cost containment models and a commitment to service, HealthEZ empowers employers and brokers to take a strategic approach to employee benefits.

“As we continue to see increasing demand for innovative benefits solutions, we are delighted to welcome these talented people to the HealthEZ team,” said Jim Wachtel, Chief Revenue Officer at HealthEZ. “Their extensive knowledge and dedication to client satisfaction will undoubtedly play a pivotal role in our mission to revolutionize the benefits landscape.”

About HealthEZ

“We are committed to offering businesses a superior alternative to the high-cost, low-service models often associated with major insurance carriers,” added Jim Wachtel. “This investment in our expanded sales team is poised to drive this vision forward.”

HealthEZ is a trailblazing, independent third-party administrator of self-funded and level funded medical plans, leveraging technology to simplify the complexities of benefits management. With a clientcentric approach and a relentless commitment to innovation, service and cost containment, HealthEZ empowers employers and brokers to navigate the evolving landscape of healthcare benefits. Headquartered in Bloomington, MN, HealthEZ operates nationwide. Contact John Blackburn, Chief Marketing Officer, at and visit www.

HealthEZ operates coast-tocoast, providing tailored benefits solutions to a diverse array of



HCC Life Insurance Company operating as Tokio Marine HCC - Stop Loss Group

We Know ... Risk We study it, research it, speak on it, share insights on it and pioneer new ways to manage it. With underwriters who have many years of experience as well as deep specialty and technical expertise, we’re proud to be known as experts in understanding risk. We continually search for fresh approaches, respond proactively to market changes, and bring new flexibility to our products. Our clients have been benefiting from our expertise for over 45 years. To be prepared for what tomorrow brings, contact us for all your medical stop loss and organ transplant needs.

Tokio Marine HCC - Stop Loss Group A member of the Tokio Marine HCC Group of Companies TMHCC1196- 11/2023

Visit us online at

2023 SELF-INSURANCE INSTITUTE OF AMERICA BOARD OF DIRECTORS CHAIRWOMAN OF THE BOARD* Elizabeth Midtlien Vice President, Emerging Markets AmeriHealth Administrators, Inc. Bloomington, MN

DIRECTOR Adam Russo CEO The Phia Group, LLC Canton, MA


DIRECTOR Deborah Hodges President & CEO Health Plans, Inc. Westborough, MA

CORPORATE SECRETARY * John Capasso President & CEO Captive Planning Associates, LLC Marlton, NJ

DIRECTOR Stacy Borans Founder/Chief Medical Officer Advanced Medical Strategies Lynnfield, MA DIRECTOR Matt Kirk President The Benecon Group Lititz, PA

COMMITTEE CHAIRS Captive Insurance Committee Jeffrey Fitzgerald Vice President Innovative Captive Strategies Waukee, IA Future Leaders Committee Erin Duffy Director of Business Development Imagine360 Wayne, PA

DIRECTOR Mark Combs CEO/President Self-Insured Reporting Greenville, SC

Price Transparency Committee Christine Cooper CEO aequum, LLC Cleveland, OH

DIRECTOR Shaun L. Peterson VP, Stop Loss Voya Financial Minneapolis, MN

Workers’ Compensation

DIRECTOR Amy Gasbarro Chief Operating Officer Vālenz® Phoenix, AZ


Nigel Wallbank President Leadenhall, LLC Ocala, FL PRESIDENT Daniél C. Kimlinger, Ph.D. CEO MINES and Associates Littleton, CO DIRECTORS Freda Bacon Administrator AL Self-Insured Workers' Comp Fund Birmingham, AL Les Boughner Chairman Advantage Insurance Management (USA) LLC Charleston, SC Alex Giordano Chief Executive Officer Hudson Atlantic Benefits Bellmore, NY Virginia Johnson Strategic Account Director Verisk/ISO Claims Partners Charlotte, NC

Committee Shelly Brotzge Regional Underwriter, Group Self Insurance Midwest Employers Casualty Chesterfield, MO

* Also serves as Director




Arielle Carter Director, Operations Hawaii Mainland Administrators, LLC Tempe, AZ Tenna Hartman President Health West Bountiful, UT Tae Kim Executive Director, Global A&H Howden Tiger New York, PA Dr. Sid Karabel Chairman Near Shore Medical Specialist Coral Springs, FL

Xixue Zhang President PhotranIT Inc. Sugar Land, TX

Sumanth Reddy Chairman Quantify Holdings Irvine, CA Joseph Lovelidge Vice President of Sales Regional Care, Inc. Scottsbluff, NE Alan Cantor Co-Managing Member Risk Analysis Services LLC Santa Monica, CA Heather Dorsey, MS, LCGC Genetic Counselor Synergistic Genomics, LLC Portland, OR

Carey Gruenbaum The Big Plan Cedarhurst, NY Jon-Michael Kerns Partner Transparent Risk Strategies, LLC Dayton, OH

David Balinski CEO Wire Health Glenmoore, PA Shawn Gillon Partner Withum East Brunswick, NJ Thomas Boyd VP Sales & Marketing Zealic Health Raleigh, NC

SILVER MEMBERS Gerardo Zampaglione Founder Aegle Health Partners Minneapolis, MN John Sbrocco Principal Virtue Health Henderson, NV

EVENTS Healthcare Price Transparency Forum February 26-27, 2024 JW Marriott Charlotte Charlotte, NC

Artificial Intelligence Forum February 27-28, 2024 JW Marriott Charlotte Charlotte, NC

Spring Forum March 25-27, 2024 JW Marriott Hill Country Resort & Spa San Antonio, TX

Future Leaders Forum April 9-10, 2024 Kansas City Marriott Downtown Kansas City, MO

Corporate Growth Forum May 6-8, 2024 Westin Poinsett Greenville, SC

Cell & Gene Therapy Stakeholders Forum May 29-30, 2024 JW Marriott Mall of America Minneapolis, MN

International Conference July 22-24, 2024 Westin Dublin Dublin, Ireland

National Conference September 22-24, 2024 JW Marriott Desert Ridge Phoenix, AZ



Save your clients money while improving their member experience? Doesn’t sound possible. But Zelis is delivering. We’ve saved over $27B in network and claim costs while helping healthcare carriers, TPAs, and self-insured employers modernize the healthcare financial experience. Zelis is your trusted partner to optimize financial performance and manage risk while delivering a great experience.

Connect with Zelis today at 888.311.3505 or visit to get started.

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

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. MTG-3449 (8/22)

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