The Self-Insurer - August Issue 2022

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AU G U S T 2 0 2 2




Accident & Health Insurance

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your business Get the help you need to self-fund your healthcare and grow your business.

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QBE and the links logo are registered service marks of QBE Insurance Group Limited. ©2021 QBE Holdings, Inc. This literature is descriptive only. Actual coverage is subject to the terms, conditions, limitations and exclusions of the policy as issued.


AUGUST 2022 VOL 166

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



By Laura Carabello



By Bruce Shutan









The Self-Insurer (ISSN 10913815) is published monthly by Self-Insurers’ Publishing Corp. (SIPC). Postmaster: Send address changes to The Self-Insurer Editorial and Advertising Office, P.O. Box 1237, Simpsonville, SC 29681,(888) 394-5688 PUBLISHING DIRECTOR Erica Massey, SENIOR EDITOR Gretchen Grote, CONTRIBUTING EDITOR Mike Ferguson, DIRECTOR OF ADVERTISING Shane Byars, EDITORIAL ADVISOR Bruce Shutan, 2022 Self-Insurers’ Publishing Corp. Officers James A. Kinder, CEO/Chairman, Erica M. Massey, President, Lynne Bolduc, Esq. Secretary

AUGUST 2022 3





Written By Laura Carabello


hen the US Centers for Disease Control and Prevention lifted its requirement for travelers to test negative for COVID-19 before entering the US, the medical travel industry received another boost for program adoption. A post-COVID surge in the volume of patients accessing care outside of their local healthcare delivery system is re-Invigorating opportunities for self-insured employers and plan sponsors. The thirst for high quality care at lower costs is fueling this trend which is directly tied to several factors:



Health care spending in America grew 9.7 percent in 2020, reaching $4.1 trillion or $12,530 per person. As a share of the nation's Gross Domestic Product, health spending accounted for 19.7 percent.

Full Speed Ahead for Medical Travel

• •

Health coverage costs will jump around 5.2 percent in 2022 – as the healthcare benefit accounts for 12% of an employee’s pay -- representing $1,500 - $2,000 per GM automobile Data shows that the vast majority of U.S. employers (94%) say managing healthcare benefit costs will be their top priority over the next two years. A highly competitive employee recruitment market amid worker shortages makes it even more critical for employers to offer a robust health benefit package with affordable options on co-pays and deductibles. Swelling ranks of uninsured with no employee benefits: in 2021, 30.0 million people of all ages were uninsured in the United States


Here’s a capsule summary of the volume of medical travelers:

• •

Self-insured employers are more than ready for innovative cost containment solutions based upon patient-centered quality care while maintaining budget-conscious, bundled pricing. Mike Lanza, vice president, Claims, USBenefits Insurance Services, LLC, advises, “Medical travel provides greater options for employees challenged by cost, treatment access, or perceived care quality, but it is not without heightened travel-related risks.”

Mike Lanza

He says that from a financial perspective, the plan document should specifically outline which medical costs are covered – this includes unforeseen expenses.

“For instance, does your plan have a contract with an air ambulance firm in case the employee has to air transported back to the US or are you at the firm’s mercy? Unexpected charges like this could mean the difference between a successful medical procedure and being hit with hundreds of thousands of dollars in medical debt,” continues Lanza.

2020: estimated 290,000 Americans went abroad for dental and medical procedures 2019: estimated 780,000 sought outbound services 2021: about 650,000 Americans traveled outside the US Medical travel has largely rebounded to pre-pandemic levels while healthcare spending has increased 20% to 50% Americans are traveling abroad to save anywhere from 50% to 80% on medical and dental procedures Medical departures account for about 15% of total U.S. outbound business -- 100,000 or more Americans travel each year to Mexico alone.

Laurie Mollé, vice president of Claims, Spectrum (a division of Companion Life Insurance Company), provides solid guidance: “For a medical tourism claim to be eligible under the stop loss policy, the plan document must include the program and allow for travel as it relates to the program. The same will be required for any incentives that are expected to be included in the stop loss.



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Full Speed Ahead for Medical Travel She says the claim review process will be much smoother if the appropriate documentation is provided with the

to 19 million. Employers that don’t drop coverage will be under pressure to move their employees to Health Savings Accounts.

“This includes an itemized bill from the provider for services rendered, billing for the concierge services (airfare, hotel, meals, etc.) and program fees. There could be significant cost savings to the plan, provided plan participants are willing to use the program.”

Finally, there are escalating provider shortages, as the US faces a critical shortage of physicians and nurses. This is creating issues with access to care, as expanding coverage to 35 million more Americans creates even more access problems. Further complicating this problem are projected reductions in payments to medical professionals by Medicare and Medicaid and lack of tort reform also magnify shortage problems.

submission, adding,

The result of these issues is that more patients are willing to travel rather than wait for services. The most likely medical tourists are Americans who have an HSA: they are willing to travel, are internet savvy and don’t mind shopping abroad for value because they are spending “their own money.” With new transparency provisions in place, Americans are more aware of costs, especially the newly uninsured who are looking for less expensive places to access care. Furthermore, wealthy seniors are retiring overseas to avoid higher taxes on investments and will access care in their new “home” country. The introduction of new technology and treatments not yet available in the U.S. has always been a deciding factor in medical travel and continues to be a driver.

TIMING IS RIGHT There are many factors impacting the adoption of medical travel. U.S. Health Reforms that affect self insured employers appear to be ongoing. Among these reforms, fines will be imposed if companies don’t purchase appropriate coverage. Higher premiums, higher taxes, and longer waiting times are in play even if an employer does purchase appropriate coverage. Finally, there are potential limits on access to new technology and treatments. With continued budgetary constraints, employers are under pressure to drop or limit coverage, shift full-time workers to part-time or cease operations. Employerbased coverage is dropping: estimates of Americans who will lose their employer-based insurance range from 8



Full Speed Ahead for Medical Travel

Now, US employers and insurance carriers are looking to send employees overseas for procedures to lower their cost of benefits and avoid excise tax. It is also an opportunity for insurance companies to build relationships with foreign doctors and hospitals as they look for opportunities to sell insurance products in emerging markets. This option is not simply for large companies, as medium-sized and smaller employers are now taking advantage of this opportunity to reduce healthcare costs with a travel surgery program. Some industry reports show that 140,000 employers with fewer than 5,000 lives are using medical travel programs -nine times bigger than the total of large companies.




• • • • • • • •

Dental Cardiovascular Orthopedics (Shoulders, Hips, Knees) Bariatric surgery Fertility treatment Eye surgery Rx travel and general treatment Children’s Medical Care

DESTINATIONS Latin America • Mexico • Brazil • Costa Rica • Caymans • Panama • Colombia Europe • Germany • Spain • Poland • Turkey Asia • South Korea • India • China • Thailand

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1599500 11-21

Full Speed Ahead for Medical Travel SPOTLIGHT ON MEXICO

The savings are substantial: between 50% - 80% of the cost in the U.S. This

Over one million people traveled to Mexico last year for affordable or alternative medical procedures. Mexico's medical tourism generates over 3 billion dollars a year. Expansion of new clinics and health facilities are currently under construction

can fluctuate based upon exchange rates, inclusions or exclusions. As an example, a hip replacement performed at a local hospital could be $40,000…100 miles away it may cost $30,000…and if performed abroad, it might run as low as $20,000.

Given its close proximity to the US, it’s not surprising that most of these medical tourists traveled from the United States, where healthcare costs keep rising. Many Americans seek unconventional cancer treatments, which are either too expensive or not approved. There are a few caveats: medical professionals caution patients to be careful in choosing their medical facility since there is wide variation in quality. Safety is also a big concern given the tumultuous political situation in Mexico.


But pricing should never be the sole concern. The best advice is to NEVER choose surgeon or hospital solely based on cost. Safety, quality and service are primary considerations, with a goal is to find the best VALUE not price. Using a qualified facilitator is the best way to ensure value.

Other countries can charge less for several reasons: 1) lower pay to physicians and other health care workers 2) much less overhead because patients pay cash 3) subtract the substantial cost of malpractice insurance.

Accreditation is critically important: More than 1,000 health care organizations have achieved The Gold Seal of Approval® as Joint Commission International-Accredited organizations. JCI identifies, measures, and shares best practices in quality and patient safety with the world. Click Here or Visit https://www. Find JCI-accredited organizations https://www. about-jci/accredited-organizations/



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Full Speed Ahead for Medical Travel

US DOMESTIC MEDICAL TRAVEL Centers of Excellence throughout the country are competing for patient volume that emanated from outside the local service area. Here again, they are focused on cost, quality and patient outcomes. Hospitals are being forced to this new level of competition since excess capacity requires filling beds at reduced rates. In this new environment, cost and efficiency equal survival. A few of the high-profile hospitals that are in the medical travel business include Mayo Clinic, Johns Hopkins, Cleveland Clinic, Geisinger and others. Many companies are utilizing this approach and are regarded as industry pioneers. This includes some well-known businesses such as Lowes and Pepsico and 15% of Fortune 50 companies now offer a domestic medical travel program. While savings are not the only issue, some report savings of 20-30%. For employees, the option to travel is highly attractive since more employers incent adoption by eliminating any deductible, providing travel expenses for the patient and a companion, and often paying a cash bonus.

Wright Dickinson, AMWINS, says, “We consider domestic medical tourism to be built around the COE (centers of excellence) concept where facilities with statistically superior outcomes for complex procedures offer them at a very competitive rate, often in a bundled payment scenario. It’s an easy win-win for the plan and the member/ patient, if the logistics of travel and support are a fit.” He explains that transplant COEs have been around for decades, but today there are a much wider array of procedures offered in the COE model including complex items like cancer and gene therapy with additional options for more routine procedures like hip or knee replacements.

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Full Speed Ahead for Medical Travel

“Facilities with specific treatment focus, expertise and higher patient volumes are able to reach scale and really dial in the cost/ benefit while offering an outstanding product and service experience,” he continues. The risk/reward tradeoff moves further out on the spectrum when considering traveling outside the U.S. for service. Wright says that those treatments may come with impressive savings, noting, “But the same system controls or recourse options may not exist if something goes wrong. That doesn’t mean there aren’t many quality providers abroad, there are just more variables at play so there is a heightened need to research and weigh them carefully." He cautions that this option may extend outside the comfort zone of some employers. “For others, they may make a program available for members to decide for themselves.” Wright advises that a lot may depend on what procedure is involved. Is it a dental surgery? Administration of a specialty drug? Or something more complex? “There are many more options available today that offer excellent quality of care and material cost savings,” he concludes.

“Consumers just need to do a little research to determine the right fit for their situation.”

ROLE OF DIRECT CONTRACTING Medical travel arrangements typically fall under the umbrella of direct arrangements with a hospital or provider organization: typically a large health system or provider network, accountable care organization or clinically integrated network. Employers take advantage of a unique opportunity to gain control over the quality and escalating cost of health care benefits. They can contract for an entire spectrum of health care services or tailor the contract to a specific subset of services: joint replacement surgeries, cardiac catheterization procedures, transplants or other highvolume, high-cost procedures. Many of these arrangements require travel for treatment if the employer has a workforce that is geographically diverse but wants employees to access care at a hospital under a direct contract. Under these arrangements, companies design the benefit offerings, custom-tailored to meet specific needs of its employee population. This includes key negotiated terms on which the provider will provide and manage the provision of care to the employer’s employees and dependents.

AUGUST 2022 13

Full Speed Ahead for Medical Travel Among the many benefits of direct contracting, self-insured employers point to these two advantages:

Rather than pay premiums to a commercial payer/third party traditional health insurer and accept unknown carrier network pricing, employers designate these select providers to be their preferred points of service for employees’ healthcare needs. Contracts ranging from fee-for-service, risk-based (using capitation or other global payment methods), service level agreements and in some cases, medical tourism programs to access care outside of local or regional delivery system.

“PHARMACY MEDICAL TRAVEL” The newest and possibly most attractive option is an International Rx provision that many employers are finding as a great addition to any benefit plan, fully-insured or self-funded. As an example, you are allowed to bring prescription medications approved by the Food and Drug Administration (FDA) from Mexico into the United States for your personal use. But there is a limit. In general, you may bring up to 50 dosage units into the U.S. without a prescription.

Bob Repke, president, IC West Insurance Services LLC and a long-time member of the SIIA community who has served on the international committee and

“Just as medical inflation continues unabated, the same is true for pharmacy costs. In fact, with the introduction of new high end prescription treatments, the costs exceed budgeted medical inflation. Self-funded employers now have the option of including an International Rx benefit alongside their existing PBM.” other SIIA groups, says,

He points out that for the past five years, the State of Utah thru its health plan, PEHP, has included an International Rx benefit for its members. ProvideRx Pharma, the company coordinating this program for employers, offers a customized pharmacy program with high-cost prescriptions available from both Mexico and Canada. Patients can obtain up to a 90-day supply of their prescription while getting their copay and deductible waived. “This includes brand name drugs like Stelara, Cosentyx and Humira and has been legally vetted as part of their health benefit,” says Repke. “ProvideRx Pharma has a formulary of close to 10k name brand drugs at discounts averaging 50%



Full Speed Ahead for Medical Travel available to customize an international Rx plan for self-funded employers. Members have the option of continuing local service, traveling to either Canada, Mexico or having their prescription delivered directly to their home. Savings are significant and this is worth exploring.” In addition to handling surgical travel programs for employers for many years, Raj Rao, CEO, Indus Health, has also introduced Rx medical travel programs. Raj says that these programs can be introduced any time of year and that employers are saving incredible sums on many specialty drugs – the highest cost Rx expense. Here’s a sampling of the specific drugs: Therapeutic Class

Specialty Rx


Annualized Savings ($K)

Annualized Savings (%)

Chronic Inflammatory Disease

Humira Pen


17 - 27

27% - 44%

Chronic Inflammatory Disease

Humira Pen (High-Dose)


53 - 64

42% - 51%

Chronic Inflammatory Disease



21 - 33

24% - 38%

Chronic Inflammatory Disease

Stelara (Low-Dose)


34 - 40

39% - 46%

Chronic Inflammatory Disease

Stelara (High-Dose)


137 - 146

52% - 56%

Chronic Inflammatory Disease

Enbrel Sureclick


21 - 26

34% - 44%

Chronic Inflammatory Disease

Orencia Clickjet


11 - 17

21% - 33%

Chronic Inflammatory Disease

Cosentyx Sensoready Pen


24 - 30

37% - 46%

Rheumatoid Arthritis



21 - 31

29% - 44%

HIV-Multiclass Combo

Genvoya 150mg


5 - 11

13% - 28%




7 - 12

19% - 33%

Autoimmune Disease



7 - 18

11% - 27%

Hepatitis C



7 – 10

24% - 35%

Hepatitis C



24 - 27

32% - 36%

Hepatitis C

Viekira Pak


23 - 26

27% - 30%

Multiple Sclerosis



9 - 15

14% - 23%

AUGUST 2022 15

Full Speed Ahead for Medical Travel BOTTOM-LINE: WHAT

Here are some caveats from VeryWell Health: Is it legal to import prescription drugs from Mexico? In most cases, it is illegal to import drugs from Mexico. However, the FDA does not object to the importation of drugs unavailable in the United States that are intended for personal use to treat a serious medical condition. When is it legal to import drugs from Mexico? According to the FDA, you can do so if you have a serious medical condition; there are no effective treatments available in the United States; and the drug does not pose any unreasonable risks. You are only allowed a three-month supply and must state in writing that the drugs are for personal use. What do I need to legally buy drugs from Mexico? Customs officials will want a letter stating that the drug is intended for personal use to treat a serious medical condition and is not available in the U.S. You will also need to provide information about the doctor treating you or proof that you are continuing treatment started in another country. What are the dangers of buying prescription drugs from Mexico? Drug purity, safety, and effectiveness are the main concerns as these cannot be monitored or guaranteed. This is especially true with drugs that are available only by prescription in the United States but sold over the counter in Mexico.


Medical travel programs can suit the needs of any size employer and can be customized to meet specific requirements. Amy Argeros, managing director of Rockport Benefits, owned by ELMC Risk Solutions, shares, “From the stop-loss perspective, COVID did not help this concept to prosper, but we have had a few groups inquire over the years and maybe a vendor discussion or two. While nothing had ever come to fruition, we do feel it could have its merits, depending upon what the procedure and certainly the country. As with anything, if determined parameters are in place

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Full Speed Ahead for Medical Travel based upon facility credentials and diagnosis/procedure, it may certainly have its place despite some issues.”

References: Willis Towers Watson

Self-insured companies are looking for medical travel-for-treatment programs that deliver:

• • • • • • • • • • News/2022/04/employers-to-tackle-employee-healthcare-affordability-amid-ris-

Value and Quality High Performance Networks & Providers Improved Outcomes Bundled Pricing Safety Cost Containment Transparency Pricing "0" Infections Lower Re-admissions Reporting & Benchmarking

ing-costsWillis Towers Watson's 2021 Best Practices in Health Care Survey; https:// benefits/pages/health-plan-cost-increasesreturn-to-pre-pandemic-levels.aspx Centers for Medicare and Medicaid Services (CMS)

Despite the upbeat forecasts for medical travel among employers, there is lackluster interest from the stop loss community. Mark Lawrence, President, HM Insurance Group, says, “We’ve seen very few requests for domestic or international medical travel. Decisions about where care is provided is between the employee, plan sponsor and Administrator.

NationalHealthExpendData/NationalHealthAccountsHistorical#:~:text=U.S.%20 health%20care%20spending%20grew,For%20additional%20information%2C%20 see%20below. Forbes

Stop loss carriers don’t direct care, as Lawrence explains, “HM’s Stop Loss contract follows the benefits provided under the plan document, so we would look to see if it’s covered under the Plan when we receive a claim. I’m interested to see where this market goes, but in the near term, I don’t see medical travel making a large impact on our business.” Mark Lawrence

ing-to-other-countries-for-medical-procedures/?sh=65180ab57ba3 VeryWell Health U.S. Food & Drug Administration. 1) CFR—code of federal regulations Title 21.

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.

2) U.S. Food & Drug Administration. Personal importation. 3) U.S. Customs and Border Protection. Prohibited and restricted items. 4) Food and Drug Administration. Is it legal for me to personally import drugs? 5) Food and Drug Administration. Imported drugs raise concerns.








here’s finally cause for celebration on the state of organ donation and transplantation, which is a top-of-mind issue for self-insured health plans. Annual volume records have been set for kidney, liver and heart transplants, the most commonly transplanted organs. Rather surprisingly, this has occurred two years into the worst pandemic in more than a century. Consider, for instance, how 2021 marked the eleventh consecutive recordbreaking year for organ donation from deceased donors and the ninth in a row for deceased donor transplants, according to the United Network for Organ Sharing (UNOS), which serves as the Organ Procurement and Transplantation Network under federal contract.

Written By Bruce Shutan



Organ transplants performed in the U.S. increased 5.9% from 2020 to 2021, which as UNOS noted, surpassed the 40,000 milestone for the first time. Of the most common transplants done last year, UNOS reports that 24,669 were kidney transplants; 9,236 were liver transplants, which set annual records for the past nine years; and 3,817 were heart transplants, which set a new record in each of the past 10 years.

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The Gift that Keeps on Giving But this encouraging news doesn’t trickle down to most people who are in need of organ transplantation. Scores of potential recipients are still waiting for life-saving treatment. UNOS reports that more than 106,000 people are waiting for organs, nearly 90,000 of them on the list for a kidney transplant. And more than 60,000 people are added to the waiting list every year.

“Our vision is a world in which there is no wait for a transplant,” says UNOS spokeswoman Anne Paschke, who would like to see more people register to be

“Although many lives are saved by transplantation, there still aren’t enough organs to go around.”

an organ, eye and tissue donor.

Anne Paschke

That’s due in part to only about 2% of the population dying under the right conditions to be a deceased organ donor, which involves being connected to a hospital ventilator. This phenomenon, however, doesn’t extend to issue and cornea donations. Many people who die in motor vehicle accidents become organ donors, depending on the type of injury they sustain. There are many reasons why the number of donors and transplants have increased, according to Paschke. One is a lot more advocacy by organ procurement organizations and tissue banks, as well as community leaders working getting the word out and media coverage. Other factors include innovation and improvement in the field or organ donation and transplantation.

With bills as high as seven figures for many different types of transplants and paid-out charges in the $400,000 to $600,000 range, he says more attention is being paid to a fully-insured organ transplant carveout product. Coverage for most of them would involve the transplant itself and full episode of care that include follow-up visits. Using the kidney as an example because it’s relatively inexpensive relative to other transplants, Kerr says coverage would extend to treatment throughout a patient’s chronic kidney disease, endstage renal failure, dialysis and ultimately the transplant. The prevalence of this condition, which is caused by high blood pressure and diabetes and often called a “silent epidemic,” helps explain why it flickers so bright on the radar of self-insured health plans. “But then you get up into the space where you’re doing an allogeneic bone marrow, heart transplant or heart/lung that’s very expensive,” he explains. “Now you’re talking paid out costs potentially getting up there; just on the transplant alone $750,000 higher in that space.”

CARVING OUT COVERAGE Whatever the case may be, employers have a lot to take in when it comes to deciding on cost-containment strategies, as well as steering health plan members to quality providers and facilities. Robby Kerr, an SVP with Tokio Marine HCC - Stop Loss Group (TMHCC), has seen increased awareness of the organ-transplantation line from the self-funded industry over the past five years. The key driver, of course, is that health care continues to get more expensive. Robby Kerr



The Gift that Keeps on Giving If it’s a known condition, he says the stop-loss carrier will look to laser out the claim, which simply shifts the burden to the policyholder. Bottom line: Kerr says a fully-insured organ transplant carveout is the best solution, but it must be purchased at the right time. Namely: when the plan doesn’t have those claimants. “No one’s looking to sell you insurance when your house is on fire,” he quips, “so the same thing applies in the organ transplant space.” Just like property and casualty insurance, he says premiums are reasonable and a separate policy is a no-brainer for the right size group. “It’s definitely designed for the small to midsize employer because those are the ones that are scared about a big price change on their stop-loss,” he explains. “If you can give them something that is cost relative and manageable, and they can pay that over time and get rid of that exposure, it’s a really solid move.”

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Transplants represent an excellent example of good known risk that could be underwritten from a self-funded, stoploss side of a potential laser because of the wait times for organs, Kerr explains. “People are beginning to finally say it might not be a bad idea to align this little niche product with our self-funded plan to carve out that risk and put it in a different policy,” he says.

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The Gift that Keeps on Giving THE PANDEMIC’S IMPACT Prior to the pandemic, Kerr noticed an uptick in living livers that was becoming somewhat of a new cultural phenomenon. An elective-surgery shutdown during the early days of COVID-19 erased that progress, along with living kidney and bone marrow donations, which he says led to “a reasonable catchup toward the end of 2020 and beginning of 2021.” The first six weeks of the pandemic, the number of deceased donor transplants were down 40% to 50%, Paschke reports. Living donor transplants dropped much further, and there were few of those being done at all. Some transplant programs temporarily curtailed living donor transplants in areas hit hardest by large COVID-19 outbreaks. But then the transplant community found ways to solve logistical problems, which included testing donors for COVID-19. One morbid pattern that Kerr saw emerge was that there weren’t as many deceased organs available earlier in the pandemic because people didn’t vacation as much and, therefore, fewer traveling fatalities occurred. There also were concerns about the quality of lungs inside the body of people who died from the virus. Given the need for respirators to combat breathing problems linked to the virus, there was a greater need for lung transplants, especially double-lung vs. singlelung procedures, which Kerr says was a trend that was already in motion just by coincidence. He attributes the increase in living liver donation to technology enhancements. Noting how the liver will easily regenerate, he says transplanting just a portion of this organ

will enable both the donor and recipient to thrive and benefit. On the flip side, he says more people turned to alcohol to cope with pandemic isolation and depression during the pandemic, which obviously is detrimental to the liver.

“The alcohol itself is a qualifier that kicks people out,” Kerr says, tracing the rising number in liver transplants to the pandemic. Technology plays a significant role in other ways. For example, it was customary to put an organ on ice in an Igloo cooler. But organs that are approved for transplantation can be preserved for much longer periods of time, which Kerr says means that patients can travel further distances to their recipients. Technologies involving machines that perfuse organs instead of shipping them on ice allow them to be maintained in a warm environment, Paschke explains. That can extend how long they can be out of the body, as well as in some cases, even improve the organs themselves. Another manifestation of incredible medical breakthroughs means that someone who has hepatitis C or HIV can donate their organs, whereas that wasn’t possible before.



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The Gift that Keeps on Giving Kerr says the most interesting area right now involves cell and gene therapies to replace or augment bone marrow transplant as the treatment of choice. While a Chimeric Antigen Receptor (CAR) T-cell is closely connected with transplantation, he says it’s not identical and is just a tangent of those procedures. “If you can turn a large percentage of your bone marrow into a CAR T-cell, and a CAR T-cell is less expensive than a bone marrow transplant, then it would make sense to try to do that,” he says. “That’s just yet to be proven to be the pathway.” While the Food and Drug Administration has delayed many approvals in the gene therapy space, Kerr reports that they have been approving products in the cell therapy space.

Another way employers can help is by supporting living donation. More than 6,000 transplants last year came from living donors. As such, she encourages employers to provide time off to employees who become a living donor. "There’s actually a recognition program with the American Society for Transplantation for employers who provide that benefit,” she says.

“To some degree,” he adds, “it has increased confusion of what is covered in one of the Preserving one’s health following a fully-insured organ transplant carveout policies.” transplant may be an ongoing battle for some. After people receive a kidney Bone marrow accounts for about 40% of all transplants on an annual basis with kidneys next in line, according to Kerr. He says the lowest number of transplant types transplant, for example, Paschke says powerful drugs are required to suppress involve intestines, pancreas and a combination of kidney and pancreas (fewer than the immune system for the rest of their 1,000 of those). lives so that you don’t lose the organ. Until recently, she notes that Medicare For bone marrow procedures, Kerr says it can take anywhere from 90 to 100 days only covered three years’ worth of between diagnosis and transplant, while kidney and liver recipients who bring in an immunosuppressive drugs. organ for donation go to the front of the line and skip lengthy waits. In the kidney space, he says wait times are long and there’s a need for many pretransplant medical procedures. A debate, in fact, is brewing about whether it’s better for patients to go straight to a kidney transplant vs. having 30 months of dialysis. “It’s certainly less costly to have a transplant, and it’s probably a lot better of a body from a toxicity standpoint than what’s being done to you by going through dialysis,” Kerr observes.

“If people weren’t able to continue paying for those drugs and they stopped taking them, chances were they would reject the kidney, need another and have to go back on dialysis,” she explains.

Meanwhile, signing up to be an organ donor has never been easier. “You don’t HELPING PROMOTE PREVENTION have to wait until you go to the DMV,” Paschke says. “You can simply go to your What group health plans can do to reduce the need for organ transplants in the first state registry or and fill place is promote disease prevention, Paschke notes. “We have a lot of perks with our out the form. And that’s all it takes, just a health plan that incentivizes us to live a healthy lifestyle,” she says. couple of minutes. If you have an iPhone, you even can sign up in the iPhone A related strategy involves communicating the need for employees to take vacations so that they can be both physically and mentally fit. “Our CEO held a monthly town hall health app.” during the pandemic where he talked about how just because you’re at home and you can’t go on vacation doesn’t mean you don’t need to take your time off,” she recalls. Bruce Shutan is a Portland, Oregon-based freelance writer “The benefit is there for a reason, and people need to use it. It’s part of that work-life who has closely covered the employee benefits industry balance.” for more than 30 years.



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



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MEDICARE SECONDARY PAYER ACT AND END STAGE RENAL DISEASE On June 21, 2022 the United States Supreme Court issued its decision in Marietta Memorial Hospital Employee Health Benefit Plan et al. v. DaVita Inc. et al., reversing the decision by the United States Court of Appels for the Sixth Circuit which found that a plan design singling out dialysis treatment for lower reimbursement violated the Medicare Secondary Payer Act (MSPA). The MSPA makes Medicare a “secondary” payer to an individual’s existing group health plan coverage for certain medical services, including dialysis, when that plan already covers the same services. In 1972, Congress extended Medicare coverage for individuals with end-stage renal disease (ESRD), regardless of age or disability, after three months of dialysis. The Supreme Court ruled that since the plan provisions applied to all dialysis services, including individuals who did not have ESRD, the plan did not violate the MSPA. In the Sixth Circuit, DaVita successfully argued that the MSPA provides for liability when a group health plan’s inferior coverage of dialysis services, as compared to other services, disparately impacts those with ESRD even if it also applies to those without ESRD. DaVita asserted that the plan’s provisions had this “disparate impact” because 99.5% of outpatient dialysis patients have or will develop ESRD. And, since those with

ESRD are eligible for Medicare, the plan’s provisions were discriminatory under the MSPA. The Supreme Court rejected this “disparate impact” analysis/standard in a 7-2 decision finding no basis to employ such an analysis under the MSPA. The Court went on to note that such a standard would be a “prescription for judicial and administrative chaos” because it would be impossible to provide a benchmark on when dialysis treatment would be considered inadequate. More details with regard to the plan design, Medicare coordination of benefits for ESRD, the MSPA provisions, the Supreme Court’s decision and other considerations are below.

THE PLAN The plan design challenged by DaVita had three tiers of coverage with outof-network providers being in the bottom tier. All dialysis providers were considered out-of-network under this plan design; however, they were paid at the in-network tier 2 level. DaVita alleged that there were further limitations on reimbursement for dialysis providers. Other out of network providers were compensated at “reasonable and customary” rates. For dialysis services, however, DaVita alleged that reimbursements were capped at 87.5% of the Medicare rate, and that this was lower than the industry wide definition of what was reasonable and customary



fee for dialysis services. (Marietta Hospital explained that the plan bases its 70% co-insurance for tier 2 on 125% of the Medicare allowable fee for dialysis providers, resulting in actual reimbursement of 87.5%.) Based on these provisions DaVita argued that it was reimbursed at a relatively lower rate under the plan both compared to in-network providers and to other out-ofnetwork providers creating the alleged discrimination.


As mentioned above, Medicare covers individuals diagnosed with ESRD after three months of dialysis regardless of age. But there is a special coordination of benefits provision with regard to ESRD. For those with ESRD, Medicare will pay secondary to a group health plan for dialysis for a 30-month coordination period. Unlike other Medicare coordination provisions, the group health plan will be primary (and Medicare secondary) even for plan coverage not based on active employee status. So this coordination exists for those on COBRA as well as those on retiree coverage. This coverage can, of course, be very expensive for a self-funded group health plans. If, however, an individual makes a truly voluntary decision to drop group health plan coverage during the 30-month coordination period, Medicare then becomes the primary (and only coverage).


DaVita alleged two violations of the MSPA. First, the MSPA prohibits a group health plan from differentiating in benefits between individuals with and without ESRD. DaVita argued that since dialysis services are used overwhelmingly by those with ESRD, limiting coverage for those services has a disparate impact on those with ESRD thereby creating the differentiation prohibited by the MSPA. As a variation to this argument DaVita offered a “proxy theory” that singling out dialysis is simply a proxy for singling out individuals with ESRD and that, again, results in a differentiation of benefits. Second, the MSPA prohibits a plan from “taking into account” Medicare/ESRD and DaVita argued, based on the same reasoning above, that a plan “takes into account” Medicare when it imposes a benefit limitation that overwhelmingly affects Medicare enrollees.



THE DECISION In a brief seven page majority opinion, Justice Kavanagh rejected all of DaVita’s arguments. The Court noted that the MSPA “simply coordinates payments between group health plans and Medicare” and “does not dictate any particular level of dialysis coverage by a group health plan.” The Court stated that the MSPA is not a traditional anti-discrimination statute. Since the plan’s dialysis reimbursement provisions applied, on their face, to both those with ESRD and those without, the Court ruled that the plan’s provisions were neither making any benefit differentiation based on ESRD nor taking Medicare into account.

OTHER CONSIDERATIONS MSPA is not the only issue that might arise in designing a plan’s coverage for dialysis services. There are also potential concerns under the Americans with Disabilities Act (ADA) as well. While beyond the scope of this article, there would need to be a demonstration, based on certain actuarial calculations or experience, that would justify the change. Under EEOC guidance, the required demonstration, likely going to the solvency of the plan, can take several forms. Also, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) nondiscrimination provisions generally prohibit discrimination based on a health factor but careful plan design and timing of any amendment can likely limit those concerns.

BOTTOM LINE Based on MSPA concerns, many plan sponsors have hesitated to make changes with regard to coverage of dialysis services. The Supreme Court’s decision removes those concerns for certain plan designs as long as the plan design focuses on all participants and beneficiaries receiving dialysis services and not just with ESRD. But the ADA and HIPAA issues remain and should be addressed. Very similar ADA and HIPAA issues arise in a number of contexts such as excluding certain specialty drugs from a formulary or whether to exclude coverage for certain conditions such a hemophilia. Of course, many employers may view more robust coverage of dialysis services as an important part of their plan design and will not impose further restrictions even when legally permissible.



Do you aspire to be a published author? We would like to invite you to share your insight and submit an article to The Self-Insurer! SIIA’s official magazine is distributed in a digital and print format to reach 10,000 readers all over the world. The Self-Insurer has been delivering information to top-level executives in the self-insurance industry since 1984. Articles or guideline inquires can be submitted to Editor Gretchen Grote at ggrote@ The Self-Insurer also has advertising opportunties available. Please contact Shane Byars at sbyars@ for advertising information.

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he self-funded industry, and the insurance industry in general, has always been subject to constant change and 2022 is not proving to be any different. From the Consolidated Appropriations Act of 2021 (CAA) (which includes the NQTL Comparative Analysis requirement, the No Surprises Act (NSA), and the Transparency Rules, there are a lot of regulations to keep our eyes on. And of course, we cannot forget about the ongoing implications COVID-19 have on group health plans, and those implications continue to compound. There has been no shortage of government regulations and mandates in terms of this virus; to do it all justice, it makes sense to start with a quick summary of the many rules and regulations that are still in existence.



From a review of the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Justice (DOJ) long COVID guidance, to the United States Equal Opportunity Commission (EEOC) guidance that many have overlooked, it is worth reviewing ongoing requirements.

ongoing. President Biden last extended the National Emergency in February 2022 this year.


This rule defines an “Outbreak Period” from March 1, 2020 until 60 days after the end of the declared state of the National Emergency, and states that this Outbreak Period must be disregarded for the calculation of any applicable deadlines, including:


These periods are often conflated, but the distinction is an important one, since some health plan requirements hinge on the PHE, while others hinge on the National Emergency. The PHE (declared by the HHS Secretary) was extended in April 2022 and set to expire in mid-July 2022; however, the Biden administration noted there will be 60 days advance notice before the PHE will expire.

TOLLING OF DEADLINES UNDER COVID-19 RELIEF Due to the COVID-19 pandemic, the DOL and IRS issued a Joint Rule extending certain deadlines for most group health plans, disability and other employee welfare benefit plans, and employee pension benefit plans.1

1. With respect to plan participants, beneficiaries, qualified beneficiaries, and claimants: • the 30- or 60-day period to request Health Insurance Portability and Accountability Act special enrollment; • the 60-day election period for Consolidated Omnibus Budget Reconciliation Act (COBRA) continuation coverage; • the date by which COBRA premium payments must be made; • the date by which individuals must notify the plan of a COBRA qualifying event or determination of disability; • the date by which individuals may file a benefit claim or appeal under the plan’s claims and appeals procedures; and • the date by which individuals may file a request for an external review or file information to perfect an incomplete request for external review.

No such notice has been given as of the date of this article was written, thus the PHE is likely ongoing, potentially for at least 60 more days. The coverage mandates related to COVID-19 testing and the vaccine are tied to the status of the PHE. The “Extensions of Certain Timeframes” – often referred to as the “tolling of deadlines” – such as HIPAA special enrollment rights, COBRA election periods, and, most daunting of all for many, claims and appeals submission timeframes – hinge on the National Emergency and especially the so-called Outbreak Period. The Outbreak Period ends 60 days after the announced end of the National Emergency, which to date is also still



2. With respect to group health plans and their sponsors and administrators, the date by which a COBRA election notice must be provided. On February 26, 2021, the Agencies released EBSA Disaster Relief Notice 2021-01, which clarified that there is a one-year limitation on the “Outbreak Period” tolling relief outlined above. To summarize the notice, there are three key points:

The DOL interprets this one-year limit to apply to each individual event tolled, not the relief as a whole or the Outbreak Period. The period disregarded under the Final Rule above will end after one year, or at the end of the Outbreak Period as originally outlined, whichever comes first. This relief notice does not end the Outbreak Period.

The crucial takeaway for Notice 2021-01 is that in no case will the disregarded period with respect to any of the events outlined above exceed one calendar year. To illustrate an example of that guidance, a claim that ordinarily must be submitted on or before March 1, 2020 would now still be considered timely filed until March 1, 2021. Obviously, this causes self-funded plans and their claims administrators a great deal of grief; from the administrative headache to potential stop-loss denials (since stoploss carriers are not bound to this same requirement!), the ongoing tolling period has proven problematic for many. To summarize the above, the extension of timeframes to submit special enrollment information, appeals, and COBRA elections are all ongoing, as well as the requirement for group health plans to cover COVID-19 testing and the vaccine. Now that we have been living with COVID-19 for over two years, there is more developing guidance on those who suffer from longer term effects of COVID-19, so let’s switch gears.

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In July 2021, HHS and the DOJ issued guidance on “long COVID” as a disability.2 The Centers for Disease Control and Prevention (CDC) defines long COVID as a condition where an individual who has been infected with the COVID-19 virus experiences long-term effects from the infection. Long COVID symptoms can occur for months after the initial infection and can include new or recurring symptoms at a later point in time. One might think that long COVID automatically qualifies as a disability, but the guidance indicates otherwise. An individual’s condition and any of the symptoms must substantially limit a major life activity in order to rise to the level of a disability. When assessing the individual’s situation, the impact to a major life activity must be reviewed without the benefit of medications, treatments, and other measures used to reduce or compensate for symptoms. This guidance is not earth-shattering; it simply draws attention to those who suffer from long COVID and gives a high-level summary of the symptoms and impairments an individual with long COVID may experience. It also stresses the importance of determining whether these symptoms rise to the level of a disability on a case-by-case basis, which is also referenced by the EEOC.

EEOC COVID-19 TECHNICAL ASSISTANCE The EEOC has updated its guidance on COVID-19 and employment considerations approximately 20 times since March of 2020. In December 2021, the EEOC updated its COVID-19 technical assistance (again) to clarify when COVID-19 may be considered a disability under the Americans with Disabilities Act (ADA) and the Rehabilitation Act. Both Acts address employment discrimination and assist employers with balancing their rights and responsibilities with respect to individuals who have been diagnosed with a disability. This technical assistance intentionally broadly addresses COVID-19 related to employment, while the DOJ/HHS guidance focuses on long COVID specifically. Each plays an important part in the regulatory oversight, and generally there is no meaningful overlap between the two. The addition to the technical assistance added a new set questions and answers to assist employers with the application of the rules to individuals with COVID-19 or a post-COVID-19 condition that is classified as a disability. In general, individuals diagnosed with a disability are protected from employment discrimination, and these individuals may also be eligible for reasonable accommodations; with COVID-19 being so pervasive, this creates issues that are novel for many employers, or at least that occur on a larger scale than many employers are used to.



The December 2021 technical assistance included a few key pieces of information which can be summarized as follows:

1. 2. 3. 4. 5.

Even if COVID-19 does not constitute a disability, an individual may have impairments that arose from COVID-19 that will constitute a disability. An individual who had COVID-19 that resulted in only mild symptoms, resolved in a few weeks, and had no other issues, will likely not be considered to have ADA disability and thus will not be eligible for reasonable accommodations. The ADA is a floor for employers – meaning employers can always offer greater benefits than the ADA requires. Individuals are only entitled to a reasonable accommodation if their disability requires it and that accommodation is not an undue hardship for the employer. Employers are cautioned to rely on medical professionals and guidance related to determining when an employee can return to work (i.e., the person is medically able and does not pose a threat of exposing other workers to COVID-19). Employers should be careful to distinguish fact from assumptions and/or fear.

The ADA, like most regulating authority, requires that the definition of “disability” is broadly construed in favor of the more expansive coverage. In other words, the rules are generally construed in favor of the individual with the disability; however, even with COVID-19, an individual must meet one of the three definitions of “Disability” under the ADA:




“Actual” Disability: The person has a physical or mental impairment that substantially limits a major life activity (such as walking, talking, seeing, hearing, or learning, or operation of a major bodily function); “Record of” a Disability: The person has a history or “record of” an actual disability (such as cancer that is in remission); or “Regarded as” an Individual with a Disability: The person is subject to an adverse action because of an individual’s impairment or an impairment the employer believes the individual has, whether or not the impairment limits or is perceived to limit a major life activity, unless the impairment is objectively both transitory (lasting or expected to last six months or less) and minor.3

To determine whether an individual meets any of the three definitions of “disability,” ultimately the ADA requires the dreaded case-by-case analysis based on the facts and circumstances surrounding the individual person.

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Those tend to be some of the most difficult analyses to make, given the complexities involved in any given case. However, since COVID-19 has only been around for two years (despite seeming like a lifetime), the application and guidance will likely continue to evolve as medical professionals gather more data and information and continue to assess those with long-lasting COVID-19 effects, and the case-by-case analysis may get easier.

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Self-funded health plans have been on high alert for quite some time with all the aforementioned rules and regulations that have gone or will be going into effect in the near future. Employers should regularly review their summary plan descriptions and plan documents (SPD/ PDs) to ensure that current regulatory requirements are accurately reflected.

effects will be permanent? Will the permanent side effects need continuing care? It is a sure bet that the regulators will continue to modify and evolve their guidance and the number of COVID-19 cases found to be a disability will increase over time. Aside from potential claims costs and the timeline extensions, employers need to be aware of their leave of absence and continuation of coverage provisions. Questions for employers include: How long should these ill individuals stay on the health plan? Does plan language support the continuation of coverage? Is stop-loss on the same page? These and other related questions need to be addressed based on the mindset of a particular employer.


Additionally, employers may choose to address continuations of coverage related Despite the various rules, pieces of guidance, and bits of technical assistance, there to short-term and long-term disabilities as will always be more unknowns. the prevalence of COVID long-haulers will In fact, year-old HHS and DOJ guidance provides that “The CDC and health experts increase over time. are working to better understand long COVID.”4 Unfortunately, COVID-19 long-haulers raise a lot of additional unknowns. How long will they need treatment? What side



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As the experts’ understanding evolves, so will the rules and regulations applicable to self-funded plans and the employers that sponsor them. Employers will need to keep a watchful eye on these as the Public Health Emergency and Public Health Emergency Periods continues to be in effect. Above all else, a best practice is that when in doubt, ask for help from your trusted self-funded health plan compliance gurus.

References: 1

View the Joint Rule here:

ments/2020/05/04/2020-09399/extension-of-certain-timeframes-for-employee-benefit-plans-participants-and-beneficiaries-affected 2



See N.1. at

and-ada-rehabilitation-act-and-other-eeo-laws?utm_content=&utm_medium=email&utm_ name=&utm_source=govdelivery&utm_term=#N 4

See page 4, Section 3 at


Kelly E. Dempsey is an attorney with The Phia Group, LLC. As the Vice President of Phia Group Consulting, Kelly’s specialization is an interesting mix of compliance matters impacting self-funded plans (such as issues relating to ERISA, ACA, COBRA, FMLA, MHPAEA, and MSP) and “outside-the-box thinking,” finding creative and innovative ways to help plans, brokers, and TPAs achieve their various self-funding goals. Kelly is admitted to the Bar of the State of Ohio and the United States District Court, Northern District of Ohio.

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IIA’s 42nd National Educational Conference & EXPO will be October 9-11th at the JW Marriott Desert Ridge Resort & Spa in Phoenix, AZ.

This year’s SIIA conference will provide more ways to engage with colleagues and friends. The Exhibit Hall has more than 100 companies showcasing products/services for self-insured health plans and captive insurance companies.




The Blue Eagle Lounge is back! The Lounge is a comfortable and stylish lounge area that will be open for the duration of the conference. Just like old times, the famous SIIA cocktail receptions are back in person…see and be seen!

Networking opportunities kick off Sunday, October 9th with the Self Insurance Educational Foundation (SIEF) Golf Tournament Fundraiser.

Don’t miss this exclusive opportunity to better your handicap, refine your putting skills and support the foundation dedicated to ensuring the development of tomorrow’s leaders in the selfinsurance/ART industry.

The SIEF Golf Tournament Fundraiser at the Wildfire Golf Club is open to all conference registrants and promises to be an excellent opportunity to network with executive-level industry colleagues and peers.

Please note that registration for the SIIA Conference is required to participate in the golf tournament, and the tournament is not included in conference registration fees.

SCHEDULE & FEES Sunday, October 9th Registration & Breakfast 7:00 a.m. - 8:00 a.m. Shot-Gun Start 8:00 a.m. Tournament Play 8:00 a.m. - 12:30 p.m.

FEES Single Player $500.00 Foursome $2,000.00 Golf Club Rental $65.00 (per set)

Also taking place on Sunday from 3pm to 6pm is a reception benefiting the SelfInsurance Political Action Committee (SIPAC) at Dave and Busters. Attendees will be provided Food, Drinks & Game passes.

SIPAC suggested minimum contribution of $200 to attend (personal contributions only*) and limited to SIIA members. For more information, please contact Anthony M. Murrello at or (732) 853-5825. RSVPs are requested at least 10 days prior to the event.

Future Leaders will set aside their knowledge of self-insurance for a night to focus on competing in SIIA’s Inaugural Future Leaders Cornhole Tournament. The competition will be center stage during the opening night reception on Sage Court located outside the lobby bar from 8pm to 10pm. Teams of two will square off for trophies and bragging rights as SIIA 22 Cornhole Champions!

Make sure to stay Tuesday night for the legendary SIIA National Conference party. This year's National Conference Party is going to be a HULLABALOO!



ENDEAVORS Immerse yourself in a funky, relaxed Bohemian atmosphere (think Coachella), dance to a killer band with a great vibe, or just chill around a huge fire pit. There might even be a few surprises along the way. We'll serve up light snacks and a cash bar so come ready to engage with SIIA members. It’s not a party…it’s a HULLABALOO!! For more information, including registration, please visit

* Contributions to SIPAC are used for political purposes and are not tax deductible for federal income tax purposes. All contributions to SIPAC are voluntary and must be made with personal funds. Federal law prohibits contributions from corporations. You

may refuse to contribute without reprisal. SIPAC will not favor or disadvantage anyone by reason of the amount contributed or the decision not to contribute. SIPAC participants must be US citizens or permanent resident aliens.

SCHEDULE-AT-A-GLANCE: Sunday, October 9, 2022 8:00 a.m. - 12:30 p.m.

SIEF Golf Tournament

3:00 p.m. - 5:00 p.m.

SIPAC Reception & Networking

4:00 p.m. - 7:00 p.m.

On-site Conference Registration

5:00 p.m. - 7:00 p.m.

Welcome Reception in Exhibit Hall

8:00 p.m. - 10:00 p.m.

SIIA Future Leaders Networking Event

*All times are listed in Mountain Time.

Restoring Rationality to Healthcare Pricing We offer the best in defensible claim repricing, Reference Based Pricing, ACA/NSA/TIC-compliant transparency solutions, and a high-touch Member Advocacy and Care Coordination experience. Contact us today to learn more!



About us Payer Compass is the innovator in cost control. We tackle healthcare's most challenging problems - rising costs and a lack of price transparency.


Corporate Solutions 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 Westport Insurance Corporations and North American Specialty Insurance Company. © Swiss Re 2020. All rights reserved.

ENDEAVORS Monday, October 10, 2022

Tuesday, October 11, 2022

7:30 a.m. - 6:30 p.m.

On-site Conference Registration

7:30 a.m. - 5:00 p.m.

On-site Conference Registration

7:30 a.m. - 8:30 a.m.

Networking Continental Breakfast

7:00 a.m. - 8:00 a.m.

Networking Continental Breakfast

8:30 a.m. - 10:00 a.m. Address

Welcome Remarks & Keynote

8:30 a.m. - 10:00 a.m.

Keynote Address

10:15 a.m. – 11:30 a.m.

Breakout Sessions

10:15 a.m. – 11:30 a.m.

Breakout Sessions

11:30 a.m. – 1:30 p.m.

Luncheon & Exhibit Viewing

11:30 a.m. – 1:30 p.m.

Luncheon & Exhibit Viewing

1:30 p.m. - 2:45 p.m.

Breakout Sessions

1:30 p.m. - 2:45 p.m.

Breakout Sessions

3:15 p.m. - 4:30 p.m.

Breakout Sessions

3:15 p.m. - 4:30 p.m.

Breakout Sessions

7:30 p.m. - 10:00 p.m.

SIIA National Conference Party

4:30 p.m. – 6:30 p.m.

Reception in Exhibit Hall

*All times are listed in Mountain Time.

**All times are listed in Mountain Time.

sCL specialty pharmacy: Alternative funding integration




flexible specialty copay program


AUTOMATED Dispensing Pharmacy

HIGH-SPEED Drug Authorization Program

FIND OUT HOW WE COULD CUT YOUR SPECIALTY PROGRAM COSTS TODAY! Script Care’s Specialty Pharmacy Program offers a solution to effectively reduce specialty costs through automated processing and review technology; adaptable, advanced integration capabilities with alternative funding providers; and highly-trained clinical professionals dedicated to improving patient care.

(800) 880-9988 // WWW.SCRIPTCARE.COM





Introducing the myMarpai SMART App

The myMarpai SMART App puts the power of good health in the palm of your hand. With just a click, show your health ID card, see health benefits, track spending and deductibles, find a healthcare provider, review claims, manage family care, access telehealth and more. Good health never felt better.

What will be.

©2022 Marpai, Inc.


NEWS FROM SIIA MEMBERS 2022 AUGUST MEMBER NEWS SIIA Diamond, Gold, and Silver member companies are leaders in the self-insurance/ captive insurance marketplace. Provided below are news highlights from these upgraded members. News items should be submitted to 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 and



Depend on Sun Life to help you manage risk and help your members live healthier lives Behind every claim is a person facing a health challenge. By supporting members in the moments that matter, we can improve health outcomes and help employers manage costs. For nearly 40 years, self-funded employers have trusted Sun Life to quickly reimburse their stop-loss claims and be their second set of eyes, looking for savings opportunities. But we are ready to do more to help members in the moments that matter. We now offer care navigation and health advocacy services to help your employees and their families get the right care at the right time – and achieve better health outcomes. Let us support you with innovative health and risk solutions that benefit you and your medical plan members. 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 or click here to learn more! STOP-LOSS











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. © 2022 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-u SLPC 29427 01/22 (exp. 01/24)




PHOENIX, AZ — Valenz®, a tech-enabled healthcare ecosystem optimization platform for the self-insured industry, recently partnered with GenRocket, a synthetic test data automation company, to leverage synthetic test data in its quality assurance process for the company’s next-generation claims processing platform. According to Garth Rose, CEO and Co-founder of GenRocket, software testing requirements for healthcare industry applications are particularly complex, with strict data privacy regulations along with complex data sets to manage. “Valenz, like most companies, realized using real data posed unacceptable privacy and security risks, and the option to manually create the necessary test data posed undesirable time constraints,” explained Rose. GenRocket’s synthetic test data automation platform replicated the data model from the Valenz claims application to generate realistic and accurate synthetic data without the use of any PHI during testing and development. “Using GenRocket’s synthetic test data automation platform, we were able to produce 300,000 claim records approximately 50 times faster than a manual method of scrubbing data to produce the required test data for building and testing the next generation of our platform,” said Edward Zwicker, Chief Information Officer for Valenz.

“With GenRocket, we accelerated our time to market significantly, allowing Valenz to re-direct staff to other time-sensitive tasks required for us to deliver a more automated and scalable claims processing platform to better support our customer needs,” added Zwicker. For more details, read the case study: private-secure-healthcare-test-dataproduced-50x-faster-with-genrocket/

About Valenz Valenz® simplifies the complexities of self-insurance by offering an end-to-end Healthcare Ecosystem Optimization Platform that manages the cost and quality of care for employers and their members. To balance the relationship between healthcare quality, advocacy and cost, the Valenz enterprise-level solution suite aligns the member, provider and payer. Supported by a dynamic, innovation-first culture and a steadfast commitment to data transparency and decision enablement, Valenz leverages its technology infrastructure and enterprise data warehouse to drive value across clinical and member advocacy, network development and the validation,






integrity and accuracy (VIA) of claims. Learn more about how Valenz engages early and often for smarter, better, faster healthcare. Valenz is backed by Great Point Partners.



About GenRocket


GenRocket is the leader in real-time synthetic Test Data Automation (TDA), high-performance technology for provisioning test data for Agile and DevOps environments. GenRocket’s patented, groundbreaking platform accelerates test data provisioning by more than 1,000% as it improves data quality and test coverage while reducing cost and ensuring data privacy. Headquartered in Ojai, California, GenRocket operates in global markets through a network of systems integration partners and has customers in more than 14 vertical markets including financial services, insurance, and healthcare. Visit

Indianapolis, IN – Spectrum is pleased to announce the addition of two Regional Sales Directors, Broker Markets. Adam Hall joins the company as Regional Sales Director for the territory of AR, IL, IA, KS, LA, MN, MO, NE, ND, OK, SD, TX & WI and will service brokers and benefits advisors from his office in Bennington, NE (near Omaha).

Amalgamated Life Insurance Company Medical Stop Loss Insurance — The Essential, Excess Insurance As a direct writer of Stop Loss Insurance, we have the Expertise, Resources and Contract Flexibility to meet your Organization’s Stop Loss needs. Amalgamated Life offers:

• Specialty Rx Savings Programs and Discounts

• Excellent Claims Management Performance

• “A” (Excellent) Rating from A.M. Best Company for 46 Consecutive Years

• Specific and Aggregate Stop Loss Options

• Licensed in all 50 States and the District of Columbia

• Participating, Rate Cap and NNL Contract Terms Available

• Flexible Contract Terms


• Accident

• AD&D

• Critical Illness

• Dental

• Disability

• Hearing

• ID Theft

• Legal

• Portable Term Life

Amalgamated Life Insurance Company 333 Westchester Avenue, White Plains, NY 10604 914.367.5000 • 866.975.4089

• Whole Life Insurance

For product information, contact: Financial Strength Rating

Policy Form ALSLP-2020*

Group • Stop Loss • Voluntary


BES S ST T A Excellent

*Features & form numbers may vary by state.

Amalgamated Family of Companies Amalgamated Life ▲ Amalgamated Employee Benefits Administrators ▲ Amalgamated Medical Care Management ▲ Amalgamated Agency ▲ AliGraphics



NEWS He brings over 15 years of employee benefits and insurance sales experience, having worked for both large insurers and quality brokerage shops. Adam has a B.A. Degree in Business Administration and Economics from Hastings College. He can be reached via email at a.hall@ Marc Smith also joins as Regional Sales Director for the territory of CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI & VT and will service brokers and benefits advisors from his office in Westminster, MA (near Boston). He brings over 21 years of TPA, stop loss and EAP experience, having worked for both large insurers and third party administrators. Marc has a B.S. Degree in Marketing from the University of Massachusetts and an MBA from Assumption College. He can be reached via email at

aggregate accommodation, terminal liability, and no-laser renewal options, as well as its innovative Integrated Stop Loss, a bridge product designed to ease an employer’s transition from fully-insured coverage to true self-funding. Spectrum is headquartered in Indianapolis, IN. Visit

About Companion Life Headquartered in Columbia, Companion Life ( has specialized in employee benefits since 1971. The company markets life, dental, disability, accident, specialty health — including medical stop-loss, limited benefit health plans and group supplemental retiree prescription drug plans — as well as other insurance programs, through a network of independent agents and brokers, general agents and managing general underwriters. Companion Life is licensed in 49 states and the District of Columbia. It holds an AM Best Rating of A+ (Superior).

Kurt Ridder, Spectrum’s President, commented, “We’re excited to add Adam and Marc to our Sales Team — they’re well-rounded and bring meaningful street-level sales experience to Spectrum. We know that to make waves in the broker and benefits advisor space, we need sales professionals that can not only talk the talk, but that have actually walked the walk – that’s these guys in a nutshell.” About Spectrum Spectrum, founded in 1990 and acquired by Companion in 2016, is an industry-leading provider of medical stop loss insurance for employers as small as 15 employees. Spectrum’s broad product portfolio includes specific and aggregate stop loss with specific advance,




LEADERSHIP CONFERENCE IN SELF-INSURED HEALTHCARE NEW YORK -- Marpai, Inc., an artificial intelligence (AI)-technology company transforming the $22B Third-Party Administrator (TPA) market supporting selffunded employer health plans, featured Dr. Marty Makary as a keynote speaker at its second annual Broker Retreat held at the Four Seasons hotel in Ft. Lauderdale, FL. The annual event brings the nation's top brokers and consultants in self-insured healthcare together from across the country to explore the use of big data and AI to improve health outcomes and savings. In his keynote address, Dr. Makary talked about using quality metrics to transform the healthcare system, especially in the self-insured sector. "I'm glad to have the opportunity to speak with the country's top brokers and consultants as they can create real change across the industry. We all share an aspiration to lower costs and improve outcomes. By focusing on quality metrics related to the appropriateness of care, we can better address avoidable care and

reduce the medicalization of ordinary life," said Dr. Makary. Lutz Finger, Marpai's President, Product and Development, praised Dr. Makary's accomplishments during his introduction. "Dr. Makary's groundbreaking work shows where we need to go. It aligns with our Marpai Cares member-centric approach to the market which leverages quality data to protect members and guide them to the best health solutions," said Lutz. "It is how we create the healthiest member population for the health plan dollar and get to a valuebased care model in the self-insured sector."

Shared Values Customer Service, Cost Controls, Quality Performance We deliver value other TPAs can’t match. Our three-year medical trend is beating the industry at 2.6%, our claims reviews are finding an extra 15% in savings before network discounts, and our Excellent NPS Score tells us we’re

Scan the QR code with your smart phone to learn more

keeping our clients very happy. Our people deliver incredible value for our customers. They can do it for you too.

400 Field Drive • Lake Forest, IL 60045 | 800.832.3332 • ©2022 Trustmark Health Benefits®




Increase Your Top Line! It’s Simple! Step Into the Ring!

Ringmaster Technologies will help you get there by utilizing our transformative technology built exclusively for Stop-Loss. Ringmaster Technologies is a cloud-based, healthcare software provider. We build our products exclusively to simplify, enhance and drastically reduce the complexity and time necessary for Stop-Loss quoting, contracting, and policy administration.

Our cloud-based Stop-Loss software products include:





Connect with us today to learn how our suite of products will increase your top line. 330.648.3700 • •

Built exclusively for Stop-Loss

NEWS Dr. Marty Makary is a New York Times bestselling author, surgeon and public health researcher who leads efforts to improve the health of populations and re-design health care. He is a member of the National Academy of Medicine and has served as a visiting professor at over 25 medical schools. He has published over 250 peer-reviewed scientific articles with a focus on public policy, vulnerable populations, and new models of health care. His recent book, "The Price We Pay, What Broke American Health Care and How to Fix It," is cited as "A must-read for every American" by Steve Forbes, editor-in-chief, Forbes.

About Marpai, Inc. Marpai, Inc. (Nasdaq: MRAI) is a technology company bringing AI-powered health plan services to employers that directly pay for employee health benefits. Primarily competing in the $22B TPA (Third Party Administrator) sector serving self-funded employer health plans representing over $1T in annual claims, Marpai maximizes the value of the health plan as measured in health outcomes. Marpai takes a member-centric approach that uses AI and big data to connect members to health solutions predicted to have a high probability of positive outcomes and aims to bring value-based care to the self-insured market. With effective early intervention, disease management, claims processing and proactive member outreach, Marpai works to deliver the healthiest member population for the health plan budget. Operating nationwide, Marpai offers access to provider networks including Aetna and Cigna and all TPA services. Visit





On July 1, H.H.C. Group celebrates its 27th anniversary of providing cost containment services to ERISA plans, TPAs, self-insured and government entities nationwide. Founded in1995, by Dr. Bruce Roffe’, its president and CEO, the company’s mission from day one has been to assist payors in minimizing their liability for the medical services provided to their enrollees/members. H.H.C. Group offers an ever-growing suite of targeted solutions to meet payers’ evolving needs. It utilizes a combination of industry expertise, technical innovation, highly trained staff, and dedication to superior customer service to meet its clients’ needs and exceed their expectations. Importantly, it continues to add services to meet emerging marketplace challenges.

“From day one we have worked to help our clients achieve their cost-containment goals. We have dedicated to meeting their existing and future needs in the ever-changing healthcare insurance environment,” said Dr. Roffe.

Scalable Solutions for Self-Funded Employers We’re a leading third party administrator for self-funded employers of all sizes, in all industries. Driven by the unique needs of our employers and brokers, our proprietary technology systems enable us to administer cost-effective plan designs that match the needs of your organization. Full Suite of Solutions

In addition to claims and benefits administration, we offer pharmacy benefit management, health management and wellness programs, stop-loss insurance, and print and payment solutions. Seamless Integration

We offer a broader range of services compared with other TPAs and administer solutions that seamlessly integrate with your vendors. See What Pinnacle Can Do For You



“We started by just negotiating claims. Over the years, we have added, and continue to add, more services to meet emerging marketplace needs. Our clients come for the savings and stay because we deliver on our promises, offer sound advice, and provide exceptional, personalized customer service.” In addition to its cost containment services, H.H.C. Group is URAC accredited Independent Review Organization (Internal & External), 5.1. The company received its initial URAC accreditation in 2004. It is licensed or certified to provide reviews by 32 states.

For additional information about H.H.C. Group and our services, visit www. or contact Bob Serber at or 301-963-0762 ext. 163#.

About H.H.C. Group H.H.C. Group's services include Claim Negotiation, Claim Repricing, Medicare Based Pricing, DRG Validation, Medical Bill Review (Audit), Claims Editing, Medical Peer Review/Independent Review, Independent Medical Examinations (IME), Case Management Utilization Review, Data Mining, and Pharmacy Consulting. Visit


Limiting Self-Funded Employer Risk, One Policy at a Time Founded on the principles of stability and integrity, Litchfield Underwriters’ proprietary underwriting methodologies deliver superior self-funded reinsurance solutions to both commercial clients and Welfare Funds alike.

Specific & Aggregate Coverage


Custom Solutions

is proud to partner with




Underwriting Flexibility

A B O U T@ L I T C H F I E L D M G U . C O M




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

Laura Hirsch Co-CEO Aither Health Carrollton, TX


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

Elizabeth Midtlien Vice President, Emerging Markets AmeriHealth Administrators, Inc. Bloomington, MN


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


Lisa Moody Board of Directors Chair Renalogic Phoenix, AZ Shaun L. Peterson VP, Stop Loss Voya Financial Minneapolis, MN

SIEF BOARD OF DIRECTORS CHAIRMAN Nigel Wallbank Preisdent 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

Thomas R. Belding President Professional Reinsurance Mktg. Svcs. Edmond, OK

Les Boughner Chairman Advantage Insurance Management (USA) LLC Charleston, SC

Amy Gasbarro Chief Operating Officer Vālenz Phoenix, AZ

Alex Giordano Chief Executive Officer Hudson Atlantic Benefits Bellmore, NY

* Also serves as Director

Virginia Johnson Strategic Account Director Verisk/ISO Claims Partners Charlotte, NC

Best in class Claims Administration System powered by state of the art technology. Serving Third Party Administrators, Insurance Carriers, Insurtech Health Plans, Provider Sponsored Plans, Medicare Advantage Plans Customization capabilities well beyond other systems Industry leading features and functionality with optimal performance Real time modification Ease of configuration Secure cloud based software - no upfront hardware costs





Robert Kachelries President Ally Partners Allentown, PA

Aaron Browder Staff Vice President Meridian Resource Company Indianapolis, IN

Loraine Daugherty CEO Ascellus St. Petersburg, FL

Antoinette Bryant Operations/Compliance SBMA San Diego, CA

Crystal Dorsey Founder, Managing Director Dragonfly Actuarial Eatonville, WA

Sandy Nixon Senior Vice President Business Development The Rawlings Company La Grange, KY

Patrick Van Pelt Managing Advisor Insgroup Houston, TX

Robert Cowan Principal Katz/Pierz Cherry Hill, NJ



Lauren Byers VP - Marketing Woodmere, OH

Nick Welle Partner Foley & Lardner Milwaukee, WI

Bailey Smith COO/Founding Partner Reliant Health Partner's LLC Collierville, TN


The Payment Harmonization Index 2022 The Business Case for Harmonizing the Healthcare Payment Experience. We all know the healthcare financial experience is complex and often slow, confusing and even frustrating. Ever wonder what can be done to make it more seamless and simple? This groundbreaking research from the Aite-Novarica Group establishes the current state of healthcare payment modalities and identifies practical and prescriptive ways to align your business around the optimal healthcare financial experience for all. Get your copy of the report to gain insights like these:

Why payment integrity requires workflow automation How maintaining up-to-date provider directories improves relationships Why electronic remittances are important for provider satisfaction What the industry views as important to a personalized member experience Download the report at or call 888.311.3505 to find out how Zelis can help harmonize healthcare payments. © 2022 Zelis.

Pay for care, with care.

Life Is Not Without Risk.

An infant with a 60-day NICU stay could exceed $1 million in costs.*

Amy didn’t think she’d spend her maternity leave with her baby in the NICU. Neither did her 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 Amy 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, May 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-3438 (5/22)