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By Scott Bennett
By Laura Carabello Written By Bruce Shutan
Written By Andrew Berry
NAVIGATING THE NEW FRONTIER IN REFERENCE-BASED PRICING
NSA IMPACTS, DATA OVERLOAD, AND THE AI REVOLUTION
Written By Scott Bennett
Ifyou’re reading this, it’s because you’re already familiar with Reference-Based Pricing (RBP) in the self-funded employer landscape. You know the basics and have followed the major developments shaping the industry. What demands your attention now are the latest challenges and opportunities that have emerged as RBP continues to evolve from a relatively simple cost-containment method to a strategic component of self-funded health plans. As you delve deeper, consider the No Surprises Act (NSA), the overwhelming flood of healthcare pricing data, and the increasingly critical
role of artificial intelligence in reshaping RBP strategies. This article identifies some trends and issues in modern RBP strategies and makes a few recommendations along the way.
THE EVOLUTION OF REFERENCE-BASED PRICING: FROM SIMPLICITY TO STRATEGIC COMPLEXITY
In its infancy, Reference-Based Pricing was refreshingly straightforward: anchoring healthcare payments to multiple Medicare rates and focusing on reducing costs. However, today’s RBP programs bear little resemblance to their predecessors. No longer a surprise to weary hospitals and doctors who used to assume all employers were part of some network, traditional RBP plans face rejection at the front desk, accompanied by a demand to pay billed charges or go elsewhere. As a result, modern RBP strategies have become layered and nuanced, integrating a suite of sophisticated components focused on access and navigation. Where RBP once stood alone, it now operates within a rich ecosystem of interconnected tactics that aim to minimize costs while maximizing member satisfaction and provider relations and acceptance.
At the core of this evolution is the shift from a transactional approach to a comprehensive strategy that prioritizes Access and Navigation, Direct Contracting, and Care Coordination. Member Care Navigation, for instance, is no longer an afterthought but a crucial element of RBP programs. It involves personalized assistance for members, including education about benefits, scheduling of services, and advocacy throughout the healthcare journey.
Direct Contracting has also become indispensable as employers and third-party administrators (TPAs) work to forge direct agreements with high-quality providers. These agreements not only control costs but also secure better outcomes for plan members. Add to that components like Pre-Medical Service Single Case Agreements and Legal Services to protect members from surprise bills, balance bills and legal disputes, and you see just how complex today’s RBP strategies have become.
Perhaps the most significant change is that the referencebased pricing component is now often viewed as a last resort, implemented only when all other cost-control methods—such as negotiated contracts and patient redirection—have been exhausted or an emergency occurs, where access cannot be denied. This transformation highlights the increasing complexity of RBP as it transitions into an integrated, flexible framework. However, the emergency services just mentioned are no longer protected by a self-
funded plan’s Reference-Based Price. In the past, this employerdefined cap was one of the most powerful components of an RBP plan, forcing the hospital to resort to balance billing (surprise billing) to attempt leverage for a higher payment because the plan’s payment was set and ReferenceBased Pricing vendors were at the ready to defend those patients and achieve a reasonable result.
Now, those emergent services balance bill disputes, often deterred/settled by the cost and ambiguity of a civil court case, have been shifted into a new forum: the No Surprises Act (NSA) Independent Dispute Resolution (IDR) process, which has removed the ability to bill the patient, but created its own set of issues in an infant agency process delegated to random and inconsistent private arbitrators, struggling to properly handle these complex issues. The next section highlights some major issues presently faced by RBP plans in the NSA IDR process.
THE NO SURPRISES ACT: HEIGHTENING RBP COMPLEXITY AND RISK
The No Surprises Act (NSA), designed to shield patients from unexpected out-of-network bills, has complicated ReferenceBased Pricing (RBP) strategies. The act’s Independent Dispute Resolution (IDR) process introduces new challenges, with RBP programs often facing
increased financial risks and drawn-out negotiations when their cost-containment tactics clash with providers’ payment expectations, and those providers can, and do, yank these employers into the process with a simple flick of a letter (an Open Negotiations Request). In contrast to a balance bill, an Open Negotiations Request is straightforward, efficient, and effectively, in the opinion of this author, transforms this new formal procedure into a collection mechanism for knowledgeable medical providers. Many of these providers are already acquainted with similar advantageous billing dispute processes under Workers’ Compensation and Personal Injury State arbitration laws and agencies.
Several key IDR issues have emerged that RBP plans must address proactively:
1. Uneven Burden of Proof: Despite guidance that neither party should bear the burden of proof, IDR Entities (IDREs) frequently favor provider offers unless payers present overwhelming evidence. To counter this, RBP plans should provide comprehensive and highly specific data, including geographic relevance and detailed breakdowns of allowed amounts, to support their offers. Presenting this data in a clear, logical manner tied directly to the reimbursement rate can help reduce the risk of an unfavorable outcome.
2. Inconsistent Evidentiary Standards: The rejection of evidence from credible sources like The Fair Health Allowed database (incorrectly mixed in with the prohibited factor Fair Health UCR database) has created unpredictability. RBP plans should explicitly address potential biases in their submissions, explaining the reliability of their data sources and the difference between Fair Health Allowed data and Fair Health UCR data. They should also include supporting documentation that details the source of the data used to bolster their case. Unfortunately, Fair Health’s branding has worked so well that IDR Entities regularly issue determinations misidentifying one dataset as the other, possibly rendering the decision and reasoning arbitrary. It is not helpful that Initiating Party Providers regularly characterize the Fair Health UCR database as only Fair Health to support their offers and in open negotiations.
3. Excessive Payment Determinations: Some IDR outcomes have exceeded both standard commercial reimbursement rates and even providers’ billed charges, contradicting the NSA’s intent. To combat this, RBP plans should ensure their submissions highlight the disparities between the requested rates and typical market standards. Demonstrating the irrationality of inflated charges and emphasizing the regulatory aim to prevent such outcomes can be beneficial. Further, these determinations, when there is clearly no basis to award an amount well beyond any reasonable market benchmark, imply the application of an impermissible burden on the non-initiating party to “prove the discount” or pay whatever number the initiating party places in their offer.
By employing detailed, well-substantiated evidence and preemptively addressing potential gaps or questions in their submissions, RBP plans can better navigate the complexities of the NSA and protect their cost-containment strategies. This is often best accomplished with data, which is now readily available but difficult to distill and present to an IDR Entity.
DATA OVERLOAD: THE DOUBLE-EDGED SWORD OF HEALTHCARE TRANSPARENCY
The rise of transparency laws has opened the floodgates of healthcare pricing data, leading to both groundbreaking opportunities and overwhelming challenges. Hospitals, insurers, and providers are now required to disclose previously hidden prices and payment agreements, making it possible for employers
and TPAs to analyze the cost landscape like never before. On the surface, this transparency empowers RBP (Reference-Based Pricing) programs, providing a wealth of information that can be leveraged to negotiate better deals and optimize cost strategies.
Yet, with great data comes great responsibility—and complexity. The sheer volume of information available today can be paralyzing. Decision-makers must sift through mountains of data to derive meaningful insights and avoid analysis paralysis. More data does not necessarily equate to better outcomes; without the right tools and strategies to interpret this information, it can
create confusion and inefficiency. The challenge lies in developing robust data governance practices and utilizing advanced analytics to extract actionable intelligence from the sea of numbers.
EXAMPLES OF CREDIBLE DATA SOURCES
While numerous sources are available and worth considering, two viable sources of healthcare pricing and quality data stand out as reference points in negotiation: RAND’s publicly available commercial payment data study and billing/payment/cost information from the Centers for Medicare & Medicaid Services (CMS). RAND provides a well-respected, comprehensive study of commercial payments based on all-payer claims databases (one of the noted variables in the NSA itself), offering insights into how commercial prices compare using Medicare multiples to express those rates/ratios. Meanwhile, CMS publishes detailed data on Medicare payments and hospital billing, giving a transparent set of guideposts for evaluating and deriving healthcare market payments and costs.
MAKING DATA ACTIONABLE: A SPECIFIC EXAMPLE
Consider a recent analysis of hospitals within the Harrisburg-Carlisle, York-Hanover, and Lebanon metropolitan statistical areas using a combination of these sources. The data revealed that the average historical billing rates for these hospitals range from 3 to 5 times the Medicare rates, with an average billing multiple of 4. RAND’s commercial data shows that standard commercial payments typically fall within the 2-3 times Medicare rate range. The use of Medicare in this instance is not to assert Medicare itself but a median commercial rate expressed as a multiple of Medicare. This information highlights potential areas for negotiation and cost savings.
For instance, UPMC Carlisle and UPMC Pinnacle Hospitals showed billing ratios at or below Medicare rates for general historical costs, making them more reasonable pricing targets. On the other hand, Milton S. Hershey Medical Center and UPMC Pinnacle demonstrated higher case acuity, as evidenced by elevated DRG case acuity and case mix indexes, suggesting that higher rates could be justified for complex cases. By using this data, employers and TPAs can craft strategic negotiations that reflect both cost and clinical complexity, ensuring
fair payments that align with the quality and acuity of care provided.
This data, gathered into this descriptive format, allows a negotiator to place it into an artificial intelligence environment and prompt, “You are a seasoned negotiator with an understanding of the No Surprises Act, negotiating on behalf of a self-funded employer against a hospital asking for 5 times the Medicare rate as payment: please draft an open negotiations response making reasoned good faith arguments why an offer of 2 times the Medicare rate is a good reflection of the median commercial rate and the
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best resolution for a claim. Also, add in that a self-funded employer does not have the market share of a carrier, and therefore deserves deference where a large insurance carrier may not.” Here is the response to this prompt and the data provided (not perfect, but editable and useable in a negotiation): [ChatGPT 4o Response to the Aforementioned Prompt and Data]
Subject: Good Faith Negotiation Response
Dear [Hospital Representative],
I hope this message finds you well. I am writing to engage in a good faith negotiation on behalf of [Self-Funded Employer] regarding the payment terms for services provided by [Hospital Name]. We appreciate the critical care you deliver to our members and recognize the importance of ensuring fair and sustainable payment arrangements that reflect the quality and complexity of services rendered. However, after a thorough review of current market trends and data, we respectfully propose a payment rate of 2 times the Medicare rate for the claim in question.
Justification
for the Proposed Rate
1. Alignment with Median Commercial Rates
2. Based on our analysis and supported by independent studies such as RAND’s commercial data, the median commercial reimbursement typically ranges between 2 and 3 times the Medicare rate. These findings provide a reliable benchmark for reasonable payment terms across the commercial market. By proposing a rate of 2 times the Medicare rate, we are not only adhering to market norms but also ensuring that payment remains fair and reflective of broader commercial reimbursement practices.
3. Reasonableness and Historical Billing Multiples
4. Data from the Harrisburg-Carlisle, York-Hanover, and Lebanon metropolitan statistical areas indicate that historical billing rates often range from 3 to 5 times Medicare rates. However, billing rates alone do not account for negotiated payment trends, which generally settle in the 2 to 3 times Medicare range. By offering 2 times the Medicare rate, we are presenting a good faith proposal that sits well within reasonable market norms, ensuring that [Hospital Name] receives a fair and consistent payment while mitigating the financial burden on the self-funded employer.
5. Consideration of Self-Funded Employers
6. It is important to acknowledge that self-funded employers operate differently from large insurance carriers and do not possess the same market share or leverage. Self-funded employers often lack the bargaining power that insurance giants wield, making them more vulnerable to higher payment demands. Recognizing this, the No Surprises Act emphasizes the need for reasonable and balanced negotiations. Therefore, deference to the position of a self-funded employer is justified, especially when our offer is firmly supported by median commercial benchmarks.
7. Case Acuity Considerations
8. We are aware that case acuity and complexity, as indicated by DRG case mix indexes, can justify higher rates for complex cases. However, for the claim in question, the proposed rate of 2 times Medicare remains a reasonable and defensible payment, ensuring the hospital is fairly compensated while aligning with payment standards for comparable services. Should there be specific, documented clinical complexities that would warrant a higher payment, we are open to reviewing and adjusting our offer accordingly, in good faith.
We trust that this offer of 2 times the Medicare rate reflects a fair and balanced resolution. We remain committed to reaching an amicable agreement that supports the sustainability of healthcare delivery while also ensuring prudent financial management for our self-funded plan.
Thank you for your consideration, and we look forward to further dialogue.
Best Regards,
[Your Name]
[Title, Company]
ARTIFICIAL INTELLIGENCE: TRANSFORMING RBP STRATEGY WITH ADVANCED CAPABILITIES
As Reference-Based Pricing (RBP) strategies evolve, artificial intelligence (AI) presents a powerful opportunity to enhance efficiency and drive better outcomes, especially in the areas of negotiations and dispute resolution for self-funded plans.
I had a situation with one of my bills and was going back and forth for hours. It wasn’t until I was able to work with your customer service rep that my issues were straightened out and resolved. She probably saved me another two hours of frustration and went above and beyond to help me by calling the provider directly to work on the billing issue.”
AI integration into office productivity tools, such as Copilot within Microsoft Office, can significantly augment communication and analysis efforts related to payment disputes and claims. By leveraging AI, RBP professionals can insert verified data and enhance the persuasiveness and precision of their written communication. Copilot can quickly draft well-reasoned arguments, suggest datadriven insights, and perform complex analyses of historical claim data, enabling teams to build more compelling cases for reimbursement rates. The example earlier in this article demonstrates this capability, and it will only become more automated as the technology advances.
Additionally, Copilot (or OpenAI’s similar offerings) can automate repetitive tasks like summarizing long documents, extracting relevant data points, or generating financial comparisons, allowing teams to focus on strategic decision-making. While security is an important concern in this instance, many enterpriselevel AI solutions now have strict security measures in place and can execute Business Associates agreements with healthcare data entities. That said, many tasks (like the one above) do not require sensitive information or PHI and can be derived and are valuable entirely using public data.
Looking ahead, AI holds the potential to revolutionize the entire claims negotiation process. In a future state (or nearly present state for some advanced companies in this space), AI assistants could automatically analyze claims by cross-referencing them with extensive databases of prior settlements, industry benchmarks, and regulatory guidelines. These systems could then draft communication tailored to each negotiation, outlining evidence-based justifications for proposed payment amounts. Further, AI could initiate and even complete negotiations autonomously, drafting detailed settlement agreements for human review and final approval. This level of automation would not only expedite the resolution process but also enhance accuracy and consistency, enabling RBP strategies to be more efficient while maintaining compliance and safeguarding plan interests.
The landscape of Reference-Based Pricing (RBP) has dramatically evolved from a basic cost-containment strategy into a complex, multifaceted approach that integrates a myriad of tools and considerations to achieve optimal outcomes. The implementation of the No Surprises Act has introduced new challenges and opportunities, requiring RBP programs to become more proactive and data-driven in navigating dispute resolutions and defending their cost strategies. The explosion of healthcare pricing data brings both opportunities and challenges, making effective data management and analytics crucial for deriving actionable insights. Furthermore, the incorporation of artificial intelligence is poised to revolutionize the RBP space, enhancing negotiation precision, automating processes, and unlocking unprecedented efficiencies. As RBP strategies continue to adapt, the key to success lies in harnessing these advancements thoughtfully to maximize cost control while prioritizing member satisfaction and compliance.
Scott Bennett is senior vice president of provider relations at the Phia Group.
EMPLOYERS RESPOND TO
FINAL RULE ON MENTAL HEALTH PARITY
Written By Laura Carabello
PPushbacks and mixed responses from the self-insured community and other payers to the final rule of the Mental Health Parity and Addiction Equity Act (MHPAEA) are resonating throughout the industry. Conversely, praise from other healthcare stakeholders expresses that this regulation is long overdue.
Although federal law does not mandate insurers and employers to provide mental health coverage, under the new final rule, those that do will have to upgrade their benefits. The rule also requires non-federal governmental health plans to comply with mental health parity, which was not the case when the regulation was first enacted. Some aspects of the final rule will take effect in 2025, while others will be implemented in 2026.
Essentially, MHPAEA requires plans that cover mental health and substance use disorders (MH/SUD) to treat these benefits the same or better than medical/surgical benefits, specifically regarding:
• Quantitative Treatment Limitations (QTLs), such as plan copays, deductibles or visit limitations.
• Non-quantitative Treatment Limitations (NQTLs), such as prior authorization requirements, network adequacy, provider reimbursement rates or medical necessity determinations.
Health plans must assess their mental health networks, payment rates and prior authorization (PA) policies to ensure they are not more restrictive than for medical care. As health plans evaluate their provider networks, they must determine how much they pay outof-network providers and how often they utilize PAs. Careful study of these issues will help health plans make changes to their mental health coverage when needed.
MENTAL HEALTH RELEVANT STATS
• The Integrated Benefits Institute analyzed data to identify the prevalence, lost productivity, and compounded effects of comorbidities in the US workforce. The average annual cost per employee due to mental health issues is about $1,488, including lost time ($445), job turnover ($533) and healthcare ($510).
• According to government reports, patients enrolled in private health plans paid an average of $1,500 per year in out-ofpocket costs for mental health care, largely because they seek coverage from out-of-network providers.
• Studies show that members with coverage are about four times as likely to go out-of-network for mental healthcare compared to physical healthcare. Analysts say this could create a spike in out-of-network balance billing and Independent Dispute Resolution (IDR), the process for determining the appropriate out-of-network (OON) payment rate for certain services and items.
Christine Cooper, CEO, aequum, explains, “For non-emergency mental health services, the likelihood of balance billing is significant and could only worsen the person’s mental health,” says Cooper. “Medical
debt can be a major stressor in a patient’s life. Compounding that with a mental health crisis, this fragile population needs an advocate to help reduce their medical bills while allowing them to continue with their care.”
Cooper advises that if patients cannot find a mental health provider, “We may see an uptick in patients coming through the emergency room. This will lead to an increase in the usage of the Independent Dispute Resolution (IDR) process in mental health cases.”
IDR is a way to resolve payment disputes between health plans or issuers and providers, facilities or air ambulance services. The process is established by the No Surprises Act (NSA) and is used when open negotiations are unsuccessful.
Christine Cooper, CEO
EXECUTIVE SUMMARY OF THE FINAL RULE
1. Formalizes, clarifies, and expands on requirements regarding a plan’s Comparative Analysis of non-quantitative treatment limitations or requirements (NQTLs) applicable to mental health and/or substance use disorder benefits.
2. Requires group health plans and health insurance carriers (issuers) to conduct a two-part analysis to determine parity compliance with regard to NQTLs. This effectively raises the bar as to what employers must do to show that any NQTL meets parity requirements. Plans must proactively review relevant plan data to demonstrate operational compliance and ensure the design and application of any NQTL passes MHPAEA muster.
3. Plans and issuers to provide “meaningful benefits” to treat covered mental health and substance use disorders in each benefit classification in which medical/surgical benefits are provided. “Meaningful benefits” in this context means covering at least one “core treatment” (if one exists).
4. Directs plans to rely on independent medical standards in treatment decisions, which must be based on unbiased, current medical literature.
5. The final rule is generally effective for plan years beginning on or after January 1, 2025. However, and importantly, the final rule delays the effective date for some of the more complex changes, including the application of the design and application analysis and relevant data analysis, to plan years beginning on or after January 1, 2026.
6. Employer plan sponsors must adhere to current MHPAEA rules, which are still in effect, and plans should already be taking steps to ensure compliance with those rules. Plans must have a current Comparative Analysis on hand and confirm that they have reviewed the conclusions reached on NQTL compliance therein. If a Comparative Analysis has not been conducted since the enactment of the Consolidated Appropriations Act of 2021 (CAA), it’s well past time to take that action.
7. Requires an ERISA plan fiduciary to certify they have engaged in a prudent process to select at least one qualified service provider to complete the plan’s Comparative Analysis.
Scott Haas, CLU, RHU, Partner, Senior Vice President, USI Insurance Services, attests to the prevailing lack of awareness among plan sponsors: “Most plan sponsors are not aware of the final regs because their advisors are not talking about it. Nor are the advisors talking about the Consolidated Appropriations Act (CAA) and the compliance risk to the plans. “
In his opinion, the agencies in which the advisors reside are waiting for the legal and regulatory process to dictate the minimum compliance requirements and at what point in time to be serious.
“Because these agencies are being paid overrides by the BUPAs and PBMs, they are trying to figure out a glide path to other fee-based strategies that will support the services they provide to their clients,” continues Haas. “The overrides contribute greatly to any agency’s overall ability to provide a broad-based scope of service. Furthermore, each agency’s fiscal model is unique to them. This means inclusive and a la carte services within a fee basis are dependent upon the advisor/agency the plan sponsor retains and varies from A to Z.”
Haas is advising its clients to wait and see what the appeals to the
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final rule produce in clarity and reduction in the complexity of compliance. Quantifiable compliance is one thing. Nonquantifiability is another issue that requires service providers to disclose policies, processes, methodologies, etc. Most are not forthcoming about their fully insured books of business let alone to the self-insured clients they serve. I believe the bigger threat to plan sponsors is from class action activity more than the DOL. There are not enough DOL agents in the world to police mental health parity, let alone the CAA. “
But Nick Soman, CEO, Decent is well aware of the final mental health parity rule and says
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his Company has proactively exceeded its requirements.
“We offer unlimited mental health care to all members, not due to regulations, but because we believe it’s fundamental to comprehensive healthcare,” offers Soman. “Our plans are built around a Direct Primary
Care model to facilitate easy access to mental health services, with $0 expenses for in-network care.”
He says that by eliminating barriers to treatment, they have seen a significant portion of our members accessing these vital services without financial strain.
“This approach ensures compliance with parity regulations while aligning with our mission to provide truly decent healthcare that prioritizes both physical and mental wellbeing,” he says.
PROVIDER RESPONSE
The American Medical Association, an advocacy organization for physicians, came out in support of the final rule.
A statement from Bruce A. Scott, MD, president of the AMA, expressed support: “While the AMA continues to evaluate the final rule, the AMA strongly supports multiple provisions that will help increase transparency, oversight and enforcement of MHPAEA in areas such as prior authorization and network adequacy. Health plans have violated MHPAEA for more than 15 years, and this final rule is a step in the right direction to protect patients and hold health plans accountable for those failures.”
Nick Soman, CEO
The American Psychological Association (APA) believes the rule targets the issue of network adequacy and recognizes that low pay for mental health providers is a major cause of network inadequacy.
Dr. Jared Skillings, chief of professional practice at the APA, provides this perspective: “While some insurance companies may claim network inadequacy is primarily due to a workforce shortage. We disagree.”
He says the final rule is aimed at closing the gaps by requiring health insurers to evaluate which mental health providers’ services are covered by their plans, how much those providers are paid, and how often they require or deny prior authorizations for coverage. Such requirements may push health plans to add mental health providers to networks,
HEALTH INSURERS RESPOND
In a joint statement, America’s Health Insurance Plans (AHIP), the Blue Cross Blue Shield Association, the ERISA Industry Committee, representing large employers, and the Association of Behavioral Health and Wellness, including several insurers, said the rule will have “severe unintended consequences” -- increasing costs without improving access. They contend that with nearly 50 million Americans experiencing a mental illness, there’s no question that addressing the shortage of mental health providers must be a top priority.
But they also argue that there are proven solutions to increase access to mental health and substance use disorder care, including more effectively connecting patients to available providers, expanding telehealth resources and improving a for primary care providers. They decry that the final rule falls short of promoting these solutions and, instead, complicates compliance to the extent that it will be virtually impossible to operationalize, resulting in worse patient outcomes. The ERISA Industry Committee is considering all possibilities, including litigation, to challenge the regulation.
Litigation may likely ensue in light of the recent Supreme Court decision to overturn Chevron deference, which required federal courts to defer to agencies’ interpretations of ambiguous federal laws. The mental health parity rule could be more vulnerable to a legal challenge.
PRIMARY CARE INTERVENTION MIGHT REDUCE SUICIDE ATTEMPTS
When employers weigh the value of mental health vs. physical health benefits, the issue of suicide prevention becomes critically important. Industry observers recommend the presence of integrated mental health specialists on primary care teams.
Some health systems already screen for depression in primary care, but the findings of a study -originally funded to examine the integration of alcohol-related care in primary care -- suggest that going a step further to address suicidality in clinical practice could be potentially life-saving. Following the launch of an integrated suicide prevention program across Washington state, researchers observed a 25% drop in the rate of attempted suicides once a suicide screening and safety planning program was introduced to 19 primary care practices in the state.
A spokesperson for the study reported that some primary care teams expressed concerns about having the time and resources to address suicide during routine visits, but the team-based element of the program kicked in with having integrated mental health specialists available. A patient may have visited the doctor for a non-mental health-related issue, but thoughts of suicide in the last month could be noted during screening. Suicide then becomes the primary issue, one for which patients are ideally connected to mental health specialists the same day,
Source: Annals of Internal Medicine https://www.acpjournals.org/doi/10.7326/M24-0024
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As today’s employers recognize the importance of offering fertility benefits, they are taking a vital step toward creating a healthier, happier and more productive workforce. Think of all the medical/surgical services such as in vitro fertilization (IVF), intrauterine insemination (IUI), egg freezing, and reproductive surgery (to name a few), along with one area that often goes overlooked: the emotional toll of infertility.
“Infertility is not just a physical health issue; it has profound emotional and psychological
effects,” says David Adamson, MD, Founder and CEO, ARC Fertility. “The process of trying to conceive, often without success, can lead to feelings of grief, loss, frustration and depression. The emotional strain of infertility is often compounded by financial stress, particularly when employees have to bear the high costs of fertility treatments like IVF out-of-pocket expenses.
Dr. Adamson points to one national study of employer-provided healthcare plans, where nearly half of the respondents reported employees missing additional work time (beyond time missed for treatment or diagnosis) because of psychological stress, depression, or other conditions associated with their infertility. Respondents without coverage for infertility treatment were 2.354 times more likely than those with insurance to report missing time from work due to psychological stress, depression, or other conditions related to their infertility.
David Adamson, MD
“For many individuals and couples, the journey to parenthood can be fraught with emotional distress, financial strain and feelings of isolation,” he continues. “To help ease the mental anguish of infertility, it is important to also provide a high-touch experience throughout the fertility journey, beginning with easy access to personalized ‘human’ care as well as digital resources. Emotional support, guidance and counseling to address mental health hurdles go hand-in-hand with the medical-surgical fertility services. The final rule indicates that these must be provided .”
SIIA ADVOCACY IN ACTION
SIIA has been actively monitoring the implications of this regulatory change on behalf of the self-insured community to gauge the impact of changes to increase access to mental health and substance use disorder (MH/SUD) benefits through increased compliance with the Mental Health Parity requirements.
The proposed regulations had focused exclusively on Non-Quantitative Treatment Limitations (NQTLs), such as prior authorization, concurrent review, and other utilization management tools that selfinsured plans impose on MH/SUD benefits, requiring plans to ensure
Advocacy in Action
that the NQTLs imposed on MH/ SUD benefits are comparable to the NQTLs imposed on medical and surgical (M/S) benefits.
The proposed regulations required plans to remain compliant with the Mental Health Parity law and comply with a number of mathematical tests –and satisfy various definitions – to determine whether an appropriate level of comparability was present.
Chris Condeluci, Washington General Counsel, SIIA, affirms, “When the final regulations were released in September 2024, SIIA was pleased that its voice was heard: the Biden Administration opted against finalizing one of the mathematical tests called the “substantially all” test. SIIA, along with employer and labor groups, explained to the Administration how burdensome and unworkable this requirement was in its proposed form.
“However, there are other tests and definitions that the
Chris Condeluci
Administration ultimately finalized that SIIA, along with its employer and labor friends, believe are near impossible to operationalize,” says Condeluci. “There are questions that the Federal Departments exceeded their statutory authority with many of the finalized requirements, which could invite a lawsuit, especially now that courts cannot defer to the Federal Departments’ interpretation of the law when developing regulations.”
For access to the final regulations and a fact sheet of the regs, visit: https://www.dol.gov/agencies/ ebsa/about-ebsa/our-activities/ resource-center/fact-sheets/ final-rules-under-the-mentalhealth-parity-and-addictionequity-act-mhpaea.
THE PATH FORWARD
The time is now for plan sponsors to seek help from legal counsel, advisors, carriers and/or third-party administrator (TPA) partners to identify and address any problematic challenges to compliance with MHPAEA. The goal is to help employees get the mental help they need since many polls and surveys indicate that this is simply not the case.
The recent KFF Survey of Consumer Experiences with Health Insurance found that 17% of insured adults indicated that even with health coverage, they did not get the mental health care that they thought they needed in the past year. Of these individuals, more than 4 in 10 (44%) indicated that one of the reasons they did not get needed mental health care was that they could not afford the cost. Additionally, about a third of insured adults who did not get needed mental health services in the past year say their insurance not covering the services was a reason they did not get the care.
Despite these reports, many stakeholders in the self-insured community are still not certain that the new regulations are a solution.
Jeff Walter, CSFS®, President, Professional Benefit Administrators,
Inc., says, “We appreciate the intentions of the MHPAEA as it helps break down significant barriers for people desperately in need of mental health services. Unfortunately, the final rule burdens our self-funded health plans with another layer of bureaucracy that continues to drive up the already excessive cost of sponsoring a health plan.”
Walter believes there are more effective ways to prove compliance when an audit is required, adding,
“As our industry becomes more complex, agencies should focus on how to simplify regulations to make care available. It is apparent that these rules no longer create parity with other covered illnesses, conditions or services. Mental health is now elevated above all other covered services.”
While the MHPAEA Final Rule provides more detail related to the NQTL requirements, there are still many unanswered questions. Lisa Campbell, Principal, Groom Law Group, Chartered, says it provides a delayed effective date for some of the more onerous requirements to plan years beginning on or after January 1, 2026, but still leaves many new provisions effective for plan years beginning on or after January 1, 2025.
“This puts plans in a real bind, given that January 2025 is only a few short months away,” she explains. “Many self-insured plans are working to get as much of what they need in place for the 2025 effective date, but there will most definitely be a lag in compliance given everything that needs to be completed.”
Campbell’s advice is that self-insured plans should not wait to develop an NQTL comparative analysis but instead do the best they can to develop and maintain an analysis for 2025, which includes the new fiduciary certification.
“This new requirement, effective in 2025, requires the named fiduciary of the plan to engage in a prudent process to hire a qualified
expert to perform and document the NQTL comparative analyses and provide oversight of the expert by reviewing the NQTL comparative analysis and asking questions.”
Laura Carabello holds a degree in Journalism from the Newhouse School of Communications at Syracuse University, is a recognized expert in medical travel and is a widely published writer on healthcare issues. She is a Principal at CPR Strategic Marketing Communications. www. cpronline.com
Jeff Walter, CSFS
Lisa Campbell, Principal
ICHRA s RISING
Early adopters and fans of these consumer-directed accounts tout the power of choice, a competitive individual market, offloading risk and achieving bipartisan healthcare reform.
Written By Bruce Shutan
AAmong all the acronyms involving employee health savings and reimbursement accounts, one represents a radical departure in that it replaces group health insurance with individual-market options. While the individual coverage health reimbursement arrangement (ICHRA) cash-forcoverage option created in 2019 has generated rave reviews, a resistance to substantive change and misperceptions have resulted in snail-paced adoption.
ICHRAs allow employees to purchase a health plan of their choice on exchanges set up under the Affordable Care Act (ACA), through which more than 20 million Americans have bought health insurance. Employers earmark those dollars as part of a defined contribution approach to healthcare benefits whose fixed costs are predictable.
ICHRA membership has grown about 350% since its 2020 inception, four years after the passage of a similar scheme known as the qualified small employer health reimbursement arrangement, which was part of the 21st Century Cures Act. Anywhere from 200,000 to 500,000 working Americans are estimated to have enrolled in these accounts. In just the past year, ICHRA adoption has risen 29%, according to the HRA Council.
But a wide – and wild – range of predictions have been made about their potential market penetration. The Centers for Medicare & Medicaid Services, for example, surmised that as many as 11 million working Americans could be enrolled in ICHRAs by next year – an amount that one bullish supporter thinks could triple by 2032 when the Congressional Budget Office estimated that only about two million would enroll.
SHOPPING FOR COMPARABLE COVERAGE
Employers that roll the dice on an ICHRA are able to find coverage for their employees that’s comparable to or less expensive than group health offerings, says Matthew Kim, CEO of SureCo, which transitioned from TPA to early adopter of ICHRAs.
While an intriguing option, they’re still very complicated and not designed for the self-insurance market, cautions Keith McNeil, a partner with Arrow Benefits Group, a division of Patriot Growth Insurance Services. To some extent, he says they can break the employer-employee relationship as far as how that health benefit plan is perceived. Another issue is COBRA. “What if you are 55 years old, and you’re leaving [your employer]?” he asks. “Depending on the size of the group, you may have a level rate. If you’re in the exchange, you pay whatever rate it is.
“So how does COBRA work?” he continues. “You’re already within an individual policy. COBRA is just stay where you are – but now without a subsidy. Maybe that’s good or bad, depending on the situation, but it’s another issue to consider because, in a level rate, you have the same
rate for everybody, whether you’re older, younger or hurt. None of these are good or bad issues. They’re just issues to be resolved.”
The ideal ICHRA customer is a midsize self-funded employer whose premium rates are too volatile to manage. “They are no longer able to find something that’s actually fair and equitable, and a lot of these companies are coming from healthcare, education, manufacturing and real estate,” notes Kim, whose company offers an individual health insurance enrollment platform.
He cites a case study involving a large international consulting firm in Pennsylvania with the same carrier, plan, and deductible in the individual market, which is about 18% cheaper overall than their group health plan.
“That’s just a better value, so it’s just a no-brainer,” he says. “A lot of employers make the assumption that they know exactly what’s the right plan, but the reality is once they go through open enrollment, one-third of
Joe Markland, CEO
Keith McNeil
Matthew Kim, CEO
the population sticks to the comparable plan, one-third buys down, and one-third buys up.”
An ICHRA is ideal for employers that can’t find a group health plan that’s better than what employees can get on their own in the individual market, especially in states where product offerings are competitive, observes Joe Markland, CEO of a benefits and human capital management firm called Nfor1, Inc. as well as cofounder and president of Enrichly HR, Inc.
One of the biggest obstacles to ICHRA growth is brokers who aren’t familiar with these accounts, accustomed to doing things a certain way, not open to change or assume employees don’t know how to choose their health insurance coverage, he
says. However, just the opposite may be true. For example, a TIAACREF survey found that as many as 80% of employers don’t know how to choose the right coverage for their employees.
When employees get to choose, he says, they become the benefactor of those choices and have an incentive to become more knowledgeable and empowered to make better decisions. “We’re finding that when the brokers present it the right way, and after the employers adopt it, very few have buyer’s remorse,” reports Markland, who provides the technology for brokers to deliver ICHRAs in a more cost-effective way. “They’re surprised how happy employees are when they move to an ICHRA.”
Where Kim believes ICHRAs can play a huge role is that they involve far fewer and smaller rate increases and overall cost savings for employers and employees alike. The employer also no longer owns the risk of its group health plan and is able to avoid blame for any problems that arise. Finally, employees benefit from having the power of choice to decide what’s best for them and their families.
REIMAGINING HEALTH PLAN NAVIGATION
While offering an ICHRA may send a message that an employer has decided to bail out of the group health game, there are still tactical and strategic missions to implement, according to Jerame DellaPenta,
director of service delivery and engagement at Nova Healthcare Administrators, which offers HSA, FSA and HRA products.
They include determining the availability of plans where their employees live and work, how much money they’re willing to shell out, complying with notification time frames and, ultimately, helping those who are used to the traditional group health plan transition to a new and uncertain approach. With regard to that last point, he says employees need instructions on how to enroll in an ICHRA and who will field their questions.
Most employers, however, are not inclined to do an analysis of the different plans that are available for those who are in an ICHRA or generate a plan booklet that details the difference in coverage, McNeil believes, noting that the employee education effort is harder under these circumstances.
ICHRAs appeal to a younger and healthier demographic that doesn’t see a doctor too often and is tech-savvy, DellaPenta notes. Those who enroll in these accounts are not encountering utilization management, pharmacy benefit managers, stop-loss carriers or other such entities, which he says makes it much simpler to deal with a certain amount of money and then have tax professionals help with some of the background information.
The prospect of cherry-picking a higher-risk population that is prone to comorbidity factors “has definitely been an ask out of the gate from employers, especially where you see a dichotomy between headquarters, the warehouse and franchise businesses,” Kim reports. However, his company isn’t working with too many employers that are just trying to offload their risk into the individual market, which can create a misalignment of values across the organization.
“When employers that test pilot ICHRAs see their power and what it could mean for their entire staff, they end up deciding to extend this to everyone because it’s so much of a better deal,” he says. Some employees are actually receiving richer coverage because their federally required ERISA plans didn’t have all the essential health benefits in comparison to the individual market.
Employers can carve out a segment of their population to have an ICHRA option or group health plan, Kim explains, but they cannot offer both options to the same group of employees. With the exception
of one or two customers that have carved out an ICHRA for segments of their employee population, he says clients are rolling it out to all covered lives.
Other enrollments are just the opposite. “No one has really been all in for everyone, at least in our experience,” DellaPenta reports. “So far, what we’re getting is those locations that are either a small office in a different area, something that’s outside of our area.”
Some early adopters are seeing dramatic results. SureCo clients with noteworthy success include the Robert F. Kennedy (RFK) Community Alliance, Ansafone and Volta Oil. ICHRAs can be used as a recruiting tool when employees learn that these vehicles cost significantly less and provide more choice, according to Kim.
While RFK saved 29% on premiums, as many as 93% of its employees were able to reduce their healthcare costs – prompting several of them to question whether they were actually given a raise without their knowledge. Facing a 20% increase in premiums driven by high-cost claims, Anuvu switched to an ICHRA and saved $1 million. Those savings were reinvested in the form of a 25% increase in 401(k) contributions for the company’s employees.
MORE PAYER ENGAGEMENT
Kim is seeing much more payer engagement and proactive claims
Jerame DellaPenta
utilization management in the individual market, whereas TPAs aren’t always incentivized to do this with self-insured employers. “The way they are judged is ultimately on the quality and the accuracy in which they adjudicate claims,” he explains, “but no one ever holds their feet to the fire to actually manage the validity and amount of those claims or determine if they were necessary.”
Kim is hearing from the employers that they just want a better deal without taking on all the risk and jumping through administrative hoops. That’s key to the product and technology innovation his firm is focused on, which is to create a holistic group-like enrollment and management experience for the employee and employer. It includes building comfort about logging into their employer portal, picking health, dental and vision coverage, and being able to feed this information back to HR so they understand who’s enrolled in the plan.
Administration of an ICHRA is as easy or easier than the average group health plan because new entrants into this marketplace have simplified processes, according to Markland. When ICHRAs first came out, he said an employee who incurred an expense would have to file for reimbursement, which was a problem if the bill was, say, $2,000 and there wasn’t enough money in the bank to cover that amount.
Nowadays, an employer simply funds a virtual debit card to solve this banking issue. “They’re taking money out of people’s pay – no different than a group plan – and the payments are automatically happening,” he explains. “So, there’s no need for employees to front the money and file for reimbursement, and no entity has to reimburse the employee.”
Nova’s ICHRA enrollees usually send in a receipt based on their insurance premium for which they are reimbursed, while additional dollars in the account can be put onto a debit card to help offset some of the member liability cost.
As people become more comfortable with this new concept, DellaPenta thinks an expanded commitment is possible, likening it to fully insured employers testing level funding before fully embracing self-insurance. The common denominator is that there’s a fixed cost to employee healthcare.
STRIKING THE RIGHT BALANCE
The beauty of ICHRAs is that they strike a balance between strengthening the individual health insurance market, which leftleaning politicians want, and appealing to conservatives who want to reduce pressure on small businesses to offer group plans and allow them to manage risk and cost in an affordable way, according to Kim.
While many Democrats would like to see a single-payer solution or public option, whereas Republicans prefer a consumer-driven market, Markland says an ICHRA is somewhere in the middle and one of the few Trump administration initiatives that President Joe Biden did not overturn. Both political parties also consider the individual marketplace reliable.
“There is interest because of the subsidies on the exchanges to make sure the individual markets are competitive,” he explains. “If you’re subsidizing something that’s going up at double inflation, your government is going to go broke, so they need to be able to make sure that the individual markets are competitive.”
Irrespective of who’s in power in 2025, there’s bipartisan support to eliminate a substantial obstacle to ICHRA adoption, which is that an individual cannot purchase an individual health policy with pretax dollars unless their employer chooses to adopt an ICHRA. The Personalized Care Act, sponsored by Ted Cruz (R-Texas), would make the purchase of an individual health insurance policy a pretax expense under a health savings account (HSA). That means an HSA, unlike an ICHRA, would no longer require an employer’s “permission” for an individual to purchase a health insurance policy pretax, Markland notes.
corporatesolutions.swissre.com/esl
Likening the 401(k) to pensions, Kim says, “This is what the ICHRA is to the self-funded group health plans. That’s where we see the future of benefits moving because it disconnects in a good way the employee’s decision for healthcare from the employer and empowers that choice… At the end of the day, the employee wants a better product, and we believe ICHRA is a gateway to actually drive a better product.”
Bruce Shutan is a Portland, Oregon-based freelance writer who has closely covered the employee benefits industry for more than 35 years.
ADVERSE RISK SELECTION: NO NEW LASERS, RATE CAPS AND CAPTIVES
Written By Andrew Berry
LEditor’s Note: The author offers an opinion on a timely industry issue. The Self-Insurer welcomes additional opinions should they be suggested.
Lasers are commonly used in the medical stop-loss industry to manage the cost of known high-cost conditions. Participants on the plan with known high-cost conditions have increased specific deductibles applied against them equal to the anticipated cost of treatment. This removes those known high costs from the medical stop-loss program and leaves them with the employer and its self-funded plan. The argument is that insurance is not an effective mechanism for paying for known events. The equivalent of buying homeowners insurance when your house is on fire.
While insurance may not be an effective mechanism for insuring known high-cost conditions, employers are concerned that they will buy stop-loss only for the costs from
high-cost claimants to be transferred back to them through lasers in future years. This has led to a market practice of employers and their brokers seeking a no new laser (NNL) provision in stop-loss policies. This is usually matched with a rate cap provision, so the additional cost of not being able to laser a high-cost claimant is not just passed on to the employer through higher premiums, or the ability to do so is limited. Rate caps can be anywhere from 30-50%+. The requests for no new lasers and rate caps have become very common and a standard request in many RFPs, without much thought as to whether this is a good strategy in every situation.
THE CASE AGAINST NNLS AND RATE CAPS
Why wouldn’t you want to avoid having a laser imposed in a future year and limit any premium increase? Doesn’t this transfer the risk of a future high-cost condition to the stop-loss insurer from the employer and the very situation in which you buy insurance? Even within traditional stop-loss policies, this strategy is flawed for a number of reasons.
• No guaranteed renewal: the major problem with trying to transfer the risk of a future high-cost claimant to the stop-loss insurer through the NNL and rate cap provision is that the insurance contract is not a multi-year contract. It is typically a 12-month contract, and unless there is a guarantee to renew, the insurer is not committed to the NNL and rate cap provision. Put another way, the NNL and rate cap are the parameters for renewal, i.e., we will only renew if you don’t have a new high-cost condition, or your experience doesn’t warrant more than the rate cap increase. If an employer does experience those events and stop-loss is a volatile line of coverage, being nonrenewed is not going to be helpful in providing stability to its stop-loss program.
• Other policy provisions: a laser is not the only way for an insurer to protect against the cost of a known or potential high-cost claimant. The use of an aggregating specific deductible or exclusions could be applied without breaching the NNL provision.
• Increased premiums and overall cost: an NNL provision is paid for through premium. It will typically cost an additional 10-15% of premium just to include the provision. That is without knowing whether you will ever benefit from it. Should you have a high-cost claimant that would normally warrant a laser, the additional cost will be passed on through further premium increases. Paying for known costs through insurance increases the cost of care as insurance premiums include administrative expenses and insurer profit. Claims are only likely to account for 70-80 cents of every premium dollar, so paying for care through premiums will increase those costs by at least 25%. The rate cap is intended to limit the impact of this, but someone has to pay. The cost of the known high-cost claimant is socialized across all policyholders, increasing everyone’s premiums. The amount of the rate cap becomes the buffer across all policyholders that is needed to absorb the costs that can’t be passed on with lasers. The rate cap may be exactly what you should expect for a rate increase for the following year. The impact of this socialization of the lasers in a captive situation is discussed in more detail later in this article.
• Continued upward spiral in premiums: a second impact of absorbing no new lasers in increased premiums is that premiums rarely, if ever, come down. The laser should be a temporary policy condition to address a specific condition and claimant. Once the condition is treated or the claimant is no longer on the plan, the laser will go away. Reducing premiums may not be as responsive, resulting in a continued elevated cost of care.
HOW THIS IMPACTS CAPTIVES
The NNL and rate cap provision is particularly challenging for captives. The captive is a risk-sharing pool where there needs to be a high level of trust in how the shared risk is managed among members. Risk sharing is necessary for the captive to qualify as an insurance company for tax purposes, but there is some flexibility in how the captive is operated, particularly around who gets distributions and when.
A major advantage of a captive is the ability to get returns of premiums through distributions. It is a particularly effective financial tool to recapture investments in cost containment that may not be fully incorporated into premium rates. When employers join a captive, they go from insurance buyers to owners, and with that change, there is a change in focus to limiting claims made against the captive. A second benefit is one of stability. The volatility that is naturally seen in stop-loss can be spread across a pool of employers to smooth this out from year to year. Group captives must establish a balance between the stabilizing effect of the group and rewarding the members of the group that have favorable claims experience.
Including NNLs and rate cap provisions into a captive creates two main problems:
1. Uneven contributions to the risk in the pool. The employer with the high-cost claimant is protected, and the cost of the high-cost condition is socialized by the other members of the captive through increased premiums. This is similar to ordering the Wagyu steak while everyone else in your party is eating burgers and expecting to split the bill evenly. This doesn’t do much to keep the group together, even if everyone is promised that the group will pick up the cost of their Wagyu steak at some point in the future.
2. Impact on distributions: Some captive programs are managed to break even rather than for distributions. It is argued that this creates a more tax-efficient structure as premiums can be deducted, but distributions will likely be taxed. These captives also offer NNLs and rate caps. The profit in these programs from the cost containment efforts and good performance of most members is being used to pay for the cost of the NNL and rate cap provision. This creates a doublewhammy where the good-performing members are not receiving distributions, and they are also seeing rate increases to absorb NNLs. While all captives differ in how they are structured and run, it is quite common for distributions to only be made to the members with surplus (premiums paid to the captive less claims). Those with deficits do not receive distributions. In that way, the good-performing members are rewarded, and the poor-performing members are not. By using surplus to fund high-cost claimants and limit rate increases, the poor-performing members are being rewarded at the expense of the good. This creates a situation of adverse risk selection. Over time, the good-performing members will leave, and the experience in the captive will increasingly deteriorate.
Unfortunately, the people who benefit most from that approach are the providers and even the stop-loss insurers and reinsurers. Absorbing known high-cost claimants into premium sees an increase in demand and pricing for the stop-loss insurance product. Providers who are usually paid in relation to volume of premium or employees benefit.
This can quite easily move to a situation where the captive is run for the benefit of the providers or sponsors and not for the benefit of the members. This becomes a critical governance issue to ensure the members are actively engaged and have some control over the actions of the providers on the program.
There are many examples of group captives (P&C and benefits) that have failed due to abuse or misaligned interests from the sponsors or providers to the program.
WHAT TO LOOK FOR IN A CAPTIVE PROGRAM
Treat captives offering NNLs and rate caps with caution. As a buyer, this may seem like a good benefit, and it has become a fairly standard ask from the brokers, but as an owner of the captive, accepting NNLs on another member’s program may be less appealing. Ask how the captive is going to finance the cost from those provisions.
Understand the captive’s distribution philosophy. Is it trying to generate a profit and recapture premium, or is it trying to underwrite to break even? If it is underwriting to break even, how are funds generated from improved cost containment used if they are not returned to the members?
How are distributions calculated, and who is eligible to receive them? When are distributions made? As well as setting expectations on what distributions might be available, it will impact the amount of collateral that is needed. For example, if underwriting years are not closed out for 12 months after the end of the treaty year, there will be a stacking of collateral over two years.
MANAGING HIGH-COST CLAIMANTS AND CONDITIONS
No New Lasers and rate caps are insurance jargon to address employees with serious medical conditions. Employers have taken on a responsibility to provide care to these employees through their self-funded health plan. Instead of trying to transfer responsibility to pay for the employer’s obligations, shouldn’t we be focused on what is being done to ensure that the affected employees or beneficiaries receive the care they need at an appropriate price? With good case management, many of these cases can be managed with the right care at a lower cost than projected.
Lasers can also play a role in cost containment and reducing the total cost of care. Keeping the cost out of premiums provides a more efficient way of paying for care. There is also some uncertainty around how cases will develop. Imposing a conditional laser rather than including the projected cost, plus expenses, into premium provides a structure where maximum costs are known, but actual costs could be significantly lower.
The TPA might find a lower cost and higher efficacy solution or treatment. The member might leave the plan, take another job, etc. In the event of specialty rx, the drug could be sourced internationally, or they are approved under a patient assistance program. Lasers, especially conditional lasers, encourage the group and TPA to find lower-cost alternatives, as the liability is entirely with the employer. This reduces the employer’s cost of care and, in a captive situation, provides protection to the other members of the captive.
Andrew Berry is President of SRS Employee Benefits, part of Strategic Risk Solutions. Andrew oversees SRS’s activities related to the insurance of employee benefits within captives, both single parent and group captive programs. This includes program management activities, underwriting services and claims administration services within this sector. In this role, he also serves as President of MSL Captive Solutions, the industry’s only MGU dedicated to underwriting captive programs for medical stop-loss insurance.
WHEN DISASTER STRIKES: ISSUES AND RELIEF FOR HEALTH BENEFIT PLANS
Written By Alston & Bird Health Benefits Practice
InIthe period following natural disasters such as Hurricanes Helene and Milton, employer plan sponsors will be faced with any number of hardship-related employee benefit plan administration issues. Many of these involve critical questions for employees and employers, such as whether and/or how health coverage continues if an employer is closed or employees are otherwise unable to come to work, and meeting required plan-related deadlines.
While many issues need to be considered on a case-by-case basis depending on the employer’s plan and the situation, guidance provided for past disasters by the IRS and other regulatory agencies in some areas, including issues relating to health plans, tax filings, and leave donation programs, may be helpful.1 The availability of relief depends on a number of factors, including whether the business or individual (as relevant) is located within a designated disaster area.
This article provides a brief discussion of common issues and a high-level overview of the types of relief that may be available. Due to the fact-specific inquiries applicable to these issues, plan sponsors should consult with benefits counsel to address disaster-related situations.
HEALTH PLAN COVERAGE ISSUES
Ensuring continued healthcare coverage is a critical issue for many employees (and their spouses and dependents) impacted by disaster in the face of business closures and absences from work. In 2017, in the aftermath of hurricanes Harvey and Irma, the Department of Labor (DOL) published FAQs for plan participants that provide general information regarding health coverage issues that may arise. The DOL also published guidance that encouraged health plan fiduciaries to make reasonable accommodations to prevent the loss of coverage following a disaster and to minimize the possibility of individuals losing benefits because of a failure to comply with pre-established timeframes. 2
Although some of this guidance may be out of date with respect to qualified retirement plans, the information for group health plan sponsors provides “a guiding principle” for plans to “act reasonably, prudently and in the interest of the workers and their families who rely on their health plans for their physical and economic well-being.” The DOL has acknowledged that there may be instances when full and timely compliance by group health plans and issuers may not be possible and that their approach to enforcement will be marked by an emphasis on compliance assistance and include grace periods and other relief where appropriate, including when physical disruption to a plan or service provider’s principal place of business makes compliance with pre-established timeframes for certain claims decisions or disclosures impossible.
In addressing many health plan issues, the health insurer or TPA will be heavily involved. In other cases, employers/plan sponsors will need to make judgment calls on a case-by-case basis. Issues such as the following will arise:
• If the business is temporarily closed and payroll is delayed, how long can/should coverage continue?
• If specific employees cannot return to work, can coverage continue during an unpaid leave, and if so, for how long?
• Can substantiation requirements for health and FSA claims be relaxed, and to what extent?3
• Can enrollment or qualified election change periods be extended or waived?4
• Can COBRA election periods be extended?5
In every case, the employer/plan administrator should carefully review its insurance and contract documentation and work carefully with impacted plan administrators and carriers (including stop-loss carriers) and confer with legal counsel when necessary.
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TAX FILING DEADLINES (INCLUDING MANY EMPLOYEE BENEFIT PLAN-RELATED DEADLINES)
The IRS has an established procedure (Rev Proc 2007-56) for waiving certain tax filing and payment deadlines for taxpayers affected by Presidentially declared disasters. The deadlines that are waived through this process include a number of employee benefit plan-related deadlines, including the deadline for filing Forms 5500. The availability of the relief is triggered by the IRS through a press release or other announcement relating to a specific event.
The IRS announces when this relief is available and posts the information on its website. This relief allows affected taxpayers (including businesses and individuals) an extension to file certain returns and pay certain taxes that were originally due on or after the date of the disaster. This relief also applies to certain individual and business taxpayers with valid filing extensions that run out on Oct. 16 (for individuals) and Sept. 15 (for businesses). Note, though, that these extensions generally do not apply for paying taxes that were due prior to the date of the declared disaster. Deadlines vary depending on the disaster and locality (usually by county). More information on recent disaster relief for presidentially declared disasters is available on the IRS’s website around the nation. Click on the states below for details on which counties have been affected by recent disasters:
• Taxpayers in all or parts of Connecticut, Florida, Illinois, Kentucky, Louisiana, Minnesota, Missouri, New York, Pennsylvania, Puerto Rico, South Dakota, Texas, Vermont, Virgin Islands and Washington state have until Feb. 3, 2025, to file their 2023 tax year returns.
• Taxpayers affected by Helene in all or parts of Alabama, Florida, Georgia, North Carolina, South Carolina, Tennessee and Virginia will have until May 1, 2025, to file their 2023 tax year returns.
LEAVE DONATION PROGRAMS
Employers may assist their employees in helping others cope with disasters through a leave donation program. As a general rule, employees would be taxed on the full value of any leave they donate under long-standing tax concepts. If certain requirements are met, the taxation may shift to the recipient of the donated leave, as discussed herein. There are three different options available:
1. Leave donation programs that allow employees to transfer leave to employees who are absent from work as a result of a Presidentially declared major disaster. These programs are also referred to as “leave-sharing” programs.
2. Leave donation programs through which the employer makes contributions to a charitable organization. In these programs, the donating employee gives up some or all of their unused leave, and the cash value is donated by the employer as a charitable contribution.
3. Leave donation programs that allow employees to transfer leave to employees who are absent from work as a result of a medical emergency. These programs are also “leave-sharing” programs but have different rules that apply.
LEAVE DONATION TO EMPLOYEES ADVERSELY AFFECTED BY A PRESIDENTIALLY DECLARED MAJOR DISASTER
After providing guidance on leave donation programs in response to various disasters, the IRS provided permanent guidance on such programs in Notice 2006-59 in the case of major disasters as declared by the President that warrant individual assistance or individual and public assistance from the federal government. The FEMA website provides information on which disasters and which locations have
received such designations. A disaster-related leave program of this nature allows employees to deposit leave for transfer to employees who are adversely affected by a major disaster. An employee is considered to be adversely affected by a major disaster if the disaster has caused severe hardship for the employee or a family member of the employee that requires the employee to be absent from work.
If IRS requirements are satisfied, the employee donating the leave is not taxed on the value of the leave (and also is not entitled to a charitable or loss deduction for the leave). Instead, the leave is treated as compensation to the recipient, including for payroll tax (FICA and FUTA) and income tax purposes. The employer is entitled to a deduction for the payment of wages to the leave recipient (just as it would have been if the donating employee had taken the leave) and is responsible for payroll taxes and wage withholding on such amounts. In most cases, an unfunded leave-sharing program will not be subject to ERISA.
Among the requirements for such a program are the following:
• It must be in writing.
• Donors cannot deposit leave for transfer to a specific recipient. Rather, the donated leave must be redistributed based on the provisions of the bona fide plan.
• The amount of donated leave must be limited to the maximum amount of leave the donor accrues during a single year (i.e., there cannot be donations of multiple years of accrued leave).
• The recipient must exhaust all paid leave available before using the leave bank.
• The recipient must request paid leave in writing, and the employer must approve the leave. Thus, a
request and claims review process must be established and administered.
• The recipient must receive the paid leave at his or her normal rate of compensation (and not at the donor’s rate).
• The leave must be used for purposes related to the major disaster.
• There must be a reasonable limit on the period of time after the event in which the leave can be deposited into the bank and used by recipients. For major disasters, leave deposited for one major disaster may only be used for that disaster. (An exception applies, however, for small amounts that make accounting unreasonable or administratively impracticable.) Any leave not used after the time limit must be returned to the donors (who still are employees) on a prorated basis (amount donated in proportion to the total amount of leave donated on account of the disaster).
• There cannot be a cash-out feature with regard to the donated leave, but: (1) recipients may use leave to eliminate a negative balance that arose from leave that was advanced to the recipient, and (2) recipients may substitute leave received under the plan for leave without pay used because of the major disaster or medical emergency.
• The amount of leave available under the plan to individual recipients must be reasonable and based on need.
Programs in which employees can donate unused leave in the form of charitable contributions will, as a rule, be taxable to the employee donating the leave. For previous disasters such as Hurricanes Harvey and Irma in 2017 (Notice 2017-52) and the COVID pandemic in 2020 (Notice 2020-46), the IRS has provided temporary exceptions from taxation for leave programs under which employees elect to forgo vacation, sick or personal leave in exchange for cash payments that the employer makes to charitable organizations for the relief of victims of a particular disaster. This exception applies so long as the qualifying leave donations are made by the deadline set by the IRS for a particular disaster. Such payments are not includible in the income or wages of the donating employees; employees may not claim a charitable contribution for such payments, and the employer may deduct the payments as a business expense rather than a charitable contribution. The IRS has not yet issued any such exceptions or guidance for these programs in the aftermath of Hurricanes Helene and Milton.
LEAVE DONATION TO EMPLOYEES WITH A MEDICAL EMERGENCY
IRS guidance on leave donation programs that allow employees to transfer leave to employees experiencing a medical emergency dates back to the 1990s and requires no special announcement from a government agency to implement. Many employers may have already adopted such programs; the medical emergency need not relate to a disaster. A “medical emergency” is a medical condition of the employee or a family member of the employee that will cause prolonged absence from work. The requirements for such a program and the tax consequences are generally similar to those relating to programs that allow employees to transfer leave to other employees adversely impacted by a disaster, although there are some differences.
WEBSITES TO CHECK FOR UPDATES
• IRS: Around the nation
• FEMA website
• DOL/EBSA: Disaster Relief Information for Employers and Advisers
• DOL/EBSA: Disaster Relief Information for Workers and Families
“You have become a key partner in our company’s attempt to fix what’s broken in our healthcare system.”
- CFO, Commercial Construction Company
“Our clients have grown accustomed to Berkley’s high level of customer service.”
- Broker
“The most significant advancement regarding true cost containment we’ve seen in years.”
- President, Group Captive Member Company
“EmCap has allowed us to take far more control of our health insurance costs than can be done in the fully insured market.”
- President, Group Captive Member Company
“With EmCap, our company has been able to control pricing volatility that we would have faced with traditional Stop Loss.”
- HR Executive, Group Captive Member Company
People are talking about Medical Stop Loss Group Captive solutions from Berkley Accident and Health.
Our innovative EmCap® program can help employers with self-funded employee health plans to enjoy greater transparency, control, and stability.
Let’s discuss how we can help your clients reach their goals.
This example is illustrative only and not indicative of actual past or future results. Stop Loss is underwritten by Berkley Life and Health Insurance Company, a member company of W. R. Berkley Corporation and rated A+ (Superior) by A.M. Best, and involves the formation of a group captive insurance program that involves other employers and requires other legal entities. Berkley and its affiliates do not provide tax, legal, or regulatory advice concerning EmCap. You should seek appropriate tax, legal, regulatory, or other counsel regarding the EmCap program, including, but not limited to, counsel in the areas of ERISA, multiple employer welfare arrangements (MEWAs), taxation, and captives. EmCap is not available to all employers or in all states.
CONCLUSION
Employers will continue to face many employee benefit-related issues during the aftermath and rebuilding process following Hurricanes. Federal regulatory agencies have provided relief that may be applicable in a variety of circumstances. Determining what is needed and what relief may be available will nevertheless often require a case-by-case analysis.
About the Authors
Attorneys John Hickman, Ashley Gillihan, Steven Mindy, Ken Johnson, Amy Heppner, and Laurie Kirkwood provide the answers in this column. John is partner in charge of the Health Benefits Practice with Alston & Bird, LLP, an Atlanta, New York, Los Angeles, Charlotte, Dallas and Washington, D.C. law firm. Ashley and Steven are partners in the practice, and Ken, Amy, and Laurie are senior members in the Health Benefits Practice. Answers are provided as general guidance on the subjects covered in the question and are not provided as legal advice to the questioner’s situation. Any legal issues should be reviewed by your legal counsel to apply the law to the particular facts of your situation. Readers are encouraged to send questions by E-MAIL to John at john.hickman@alston.com.
References
1 Although outside the scope of this article, it should be noted that similar relief is often provided for retirement plan arrangements.
2 Available at Compliance Guidance for Employee Benefit Plans Impacted by Hurricane Harvey and Compliance Guidance for Employee Benefit Plans Impacted by Hurricane Irma
3 Note: In the Office of Chief Counsel Memorandum from April 2023, the IRS rejects certain common substation practices. There is no mention of whether any allowance would be permissible for disasters or hardships.
4 Note: Recall that when the COVID outbreak period was winding down and plan sponsors were no longer required to allow extended timeframes for filing claims, electing COBRA, or requesting special enrollment (as well as other deadlines and timeframes), group health plans were reminded that “nothing in the Code or ERISA prevents a group health plan from allowing for longer timeframes for employees, participants, or beneficiaries to complete these actions, and group health plans are encouraged to do so.” See FAQ 5 of the FAQs Part 58.
5 See fn4.
NEWS FROM SIIA MEMBERS
2024 DECEMBER MEMBER NEWS
Provided below are news highlights from these upgraded members. News items should be submitted to membernews@siia.org.
All submissions are subject to editing for brevity. Information about upgraded memberships can be accessed online at www.siia.org.
If you would like to learn more about the benefits of SIIA’s premium memberships, please contact Jennifer Ivy at jivy@siia.org.
Strong relationships. More solutions.
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As a leader in Medical Stop Loss coverage for 20 years, and in the health business for more than 80 years, you can trust Nationwide to take care of you and your clients.
To learn why top Medical Stop Loss producers and underwriters choose Nationwide, email stoploss@nationwide.com or visit nationwidefinancial.com/stoploss.
ranking from AM Best received 10/17/02, affirmed 12/7/23, and A+ ranking from Standard & Poor’s received 12/22/08, affirmed 5/16/23.
SIIA boasts a very active and dynamic membership. Here are some of the latest developments from the companies powering the self-insurance industry.
KARI NIBLACK RETURNS TO TPA SECTOR AS PRESIDENT OF BOON-CHAPMAN
Boon-Chapman, a leading claims administration, cost containment and care navigation company, announced the appointment of Kari L. Niblack, Esq., as President. Niblack brings twentyfive years of expertise in leading and transforming multiple corporations in the self-insurance ecosystem and has a proven track record of driving hyper-growth and innovation.
Niblack’s distinguished career leading third-party administrators and as an ERISA and employee benefits attorney makes her the ideal choice to drive BoonChapman’s continued innovation, growth and operational excellence. Her diverse executive experience across all stakeholder perspectives in healthcare ranges from claims administration and alternative risk solutions to physician practice management and revenue cycle models for insurers and providers. Most recently, Niblack served as founder and President of Blackwell Captive Solutions.
As the former Chairwoman of the Board of Directors at the SelfInsurance Institute of America and a former two-term Chairwoman of the national Health Care Committee, Niblack is an industry pioneer and a frequent national speaker on innovative risk stratification, cost containment, legal and human resource strategies.
“Kari brings a wealth of knowledge and accomplishments to Boon-Chapman,” said Sanjiv Anand, CEO of Boon-Chapman. “Her background in enhancing health and wellbeing-solutions, proven expertise in driving TPA growth and client satisfaction, and experience leading a growing ecosystem of world-class cost containment solutions will be an asset as Boon-Chapman continues to build on its strong reputation for innovative solutions and operational excellence.”
“People are at the heart of every single thing we do, and it’s an honor to join Boon-Chapman, an institution I have long admired and respected,” said Niblack. “We will continue honoring the legacy of our founders with exceptional client service, all while driving greater optimization and expansion of our value chain. In short, Boon-Chapman’s stellar ability to totally customize the healthcare experience will reward our clients and partners by making our partnership innovative, seamless and affordable.”
NOVA PROMOTES CHARLENE ZIELINSKI
Nova Healthcare Administrators, Inc. has announced the hiring of Charlene Zielinski as its Chief Client Services Officer.
Charlene
Zielinski,
Chief Client Services Office
Zielinski has played a pivotal part in Nova’s success, most recently serving as Director of Client Services. With nearly two decades of experience in the health insurance industry, including more than 10 years at Nova, Zielinski brings a depth of knowledge to her new role.
“Her wealth of knowledge and deep expertise make her the ideal candidate to lead Nova’s client services strategy, and we are confident in her ability to drive continued client satisfaction, retention, and growth,” said Jim Walleshauser, President, Nova.
As Chief Client Services Officer, Zielinski will oversee relationship management with Nova’s key clients and guide strategic direction within the self-funded market. She will also assume responsibility for regulatory and compliance functions. Her top priority is ensuring she and her team are delivering elevated service to every Nova client.
“I love having the opportunity to develop strong, lasting relationships with clients while collaborating with them on creative strategies to meet their plan goals and achieve member satisfaction,” said Zielinski.
MARSH ANNOUNCES LEADERSHIP UPDATE FOR ITS CAPTIVE BUSINESS
Will Thomas-Ferrand, international practice leader at Marsh Captive Solutions, will assume leadership of the intermediary’s captive insurance business on 1 January 2025. He will take on the new role as Ellen Charnley, President of Marsh Captive Solutions, retires at the end of 2024.
In his new position, UK-based Thomas-Ferrand will report to Pat Donnelly, President, Marsh Specialty and Global Placement.
“Will’s knowledge and experience in the captive sector across various geographies, in addition to his unwavering dedication in supporting our captive insurance clients, makes him the ideal person to lead Marsh’s captive business going forward,” said Donnelly.
“I want to personally thank Ellen for her tremendous leadership over the last seven years and wish her well in her retirement. “Ellen, Will and our leadership team will be working closely together over the next few months to ensure a smooth and seamless transition.”
During his 20 years as a broker, Thomas-Ferrand has held various roles of responsibility within Marsh’s captive business.
Kevin O’Donnell, MPA
VĀLENZ® PROMOTES KEVIN O’DONNELL
Vālenz® Health announced the promotion of Kevin O’Donnell to Executive Vice President, Solution Strategy & Expansion. O’Donnell leads the expansion and integration of Vālenz® Health platform solutions for brokers, providers and payers, leveraging more than a decade of expertise in operations, change management, payment integrity and claims quality. A member of the senior leadership team since joining Vālenz® Health in 2022, O’Donnell has an extensive background with healthcarerelated organizations, providing advisory and strategy services, project management and implementation support.
“Kevin is a tremendous leader who consistently delivers on our brand promise: engage early and often for smarter, better, faster healthcare,” said Nathan Nelson,
claim-doc.com
Carmie Johnson Coding Auditor
Chief Revenue Officer. “He brings a self-motivated, entrepreneurial approach with an ability to quickly identify opportunities and develop recommendations to resolve issues and manage risks. In his new role, Kevin further leverages his vision and creative mindset to simplify healthcare.”
BERKLEY A&H ANNOUNCES STARNET AS NEW CARRIER SOLUTION
Berkley Accident and Health, a Berkley Company, announced that StarNet Insurance Company, a subsidiary of W. R. Berkley Corporation, has been added as a carrier solution for its Employer Stop-Loss insurance business. StarNet joins Berkley Life and Health Insurance Company, expanding Berkley Accident and Health’s ability to meet the demands of its distribution partners for both Stop-Loss and its rapidly growing Group Captive programs.
“The strategic addition of StarNet Insurance Company provides us with greater flexibility to meet the needs of our clients,” said Brad Nieland, President and CEO, Berkley Accident and Health. “It enables us to stay at the forefront of an ever-changing marketplace and distribution landscape.”
Berkley Accident and Health is a leader in protection for selffunded health plans, offering Stop-Loss insurance and Group Captive programs that enable small and midsize employers to
self-fund with greater scale and stability.
WELLRITHMS RECOGNIZED AS A RISING STAR IN THE HEALTH BENEFITS INDUSTRY
WellRithms, a leading payment integrity firm, has been named to BenefitsPRO Liminaries Class of 2024 in the Rising Star category, one of only two recipients. This recognition celebrates top professionals and organizations within the benefits industry that strive to transform and humanize the field and set a bright example within the business.
The 2024 honorees were selected by a panel of industry experts based on how well they stated and achieved goals with regard to the nomination category, how impactful their work has been, how dedicated the nominee has been to furthering modernization and humanization in the insurance business; and the nominee’s commitment to the highest ethical standards, as well as dedication to service and excellence.
“Our 2024 honorees are leading examples of the progress our industry continues to make toward creating more equitable, affordable benefits and transparent, high-quality healthcare for millions of Americans,” says BenefitsPRO Editor-in-Chief Paul Wilson. “BenefitsPRO is proud to once again shine a spotlight on thought leaders and innovators in our industry who are doing things the right way.”
CHARM PRATT NAMED NEW COO FOR INTELLIVO
Intellivo, a solution that locates payment sources for accident-related medical claims, announced the appointment of Charm Pratt as its new Chief Operating Officer. Pratt joins Intellivo as a strategic addition to the company’s leadership team. Pratt will play a central role in driving Intellivo’s continued growth and strengthening its position as a leading innovator in the healthcare payments sector.
As COO, Pratt will lead the strategy and operations for all Intellivo product lines. Her focus will be on fostering operational collaboration, driving strategic initiatives, and building partnerships. She also will focus on enhancing and shaping Intellivo’s solution portfolio.
“Charm complements her strong financial and operational acumen with her deep understanding of business strategy, culture-building, and leadership development,” said Laura Hescock, CEO of Intellivo. “Her ability to navigate business challenges, cultivate high-performing teams and establish a vision for organizational excellence will be invaluable to us.”
Pratt brings more than two decades of experience in driving significant business outcomes across complex and high-growth enterprises. Her expertise spans product and pricing innovation, data analytics, governance, risk management, and process optimization. Pratt’s impressive background includes managing a $22 billion P&L, overseeing mergers and acquisitions, and spearheading revenue cycle management.
BILL MOURELATOS NAMED TO KEY BUSINESS DEVELOPMENT POSITION AT GPW & ASSOCIATES
GPW & Associates, Inc. (“GPW”), a leading captive manager and Beyond Risk company, announced the appointment of Bill Mourelatos as Senior Vice President of Business Development and Head of its new Specialty Captives Division.
Mr. Mourelatos joins GPW from Aon’s Captive & Insurance Management team, where he served as Managing Director for over a decade. His leadership contributed to significant growth and the successful execution of key insurance optimization strategies for Fortune 500 clients. Mr. Mourelatos’ expertise in developing highperforming teams and driving operational efficiency will be invaluable as he establishes the new division at GPW.
“Bill’s strategic vision and deep understanding of the captive insurance landscape make him an excellent addition to our leadership team,” said George Belokas, President of GPW. “His track record in delivering innovative client solutions and fostering strong relationships aligns perfectly with our commitment to excellence in the specialty captives
space.”
ARTEX EXPANDS CAPTIVE OPERATIONS INTO THE UAE
Artex has launched alternative risk and captive management solutions in the Abu Dhabi Global Market (ADGM) in partnership with Gallagher. This new development and range of solutions allows Artex and Gallagher to expand their services further to support clients in the Middle East & Africa (MEA) region.
The Middle East has experienced significant economic growth and diversification across various sectors in recent years, with industries including energy, construction, finance and healthcare all growing at pace.
Paul Eaton, CEO of Artex EMEA, said: “We are excited to expand our global Artex footprint by offering alternative risk and captive management services in ADGM. As companies expand their operations and face more complex risks, captives and other alternative risk transfer strategies are an increasingly important solution for the largest firms. Partnering with Gallagher’s existing team of professionals in the region provides a strong foundation for this new offering.”
HEALTH COST IQ EXISTS TO HELP SELF-INSURED ENTITIES SAVE MONEY WITHIN THEIR HEALTH PLANS
Leveraging its proprietary HealthAnalytIQ software platform, HCIQ can:
Identify problematic utilization patterns and risk trends
Forecast future healthcare costs
Predict potentially high-use, high-cost members
Identify medical claims payment irregularities and pharmacy utilization inefficiencies Schedule
Armed with these insights, customers are empowered to make strategic changes in their health plan spending and realize significant savings. Customers reclaim an average of 20-30% annually, resulting in hundreds of thousands of dollars for midsize entities and tens of millions of dollars for larger enterprises in reduced health plan spend.
2024 SELF-INSURANCE INSTITUTE OF AMERICA
BOARD OF DIRECTORS
CHAIRMAN OF THE BOARD*
John Capasso President & CEO
Captive Planning Associates, LLC
CHAIRMAN ELECT*
Matt Kirk President
The Benecon Group
TREASURER AND CORPORATE
SECRETARY*
Amy Gasbarro President
ELMCRx Solutions
DIRECTOR
Mark Combs
CEO/President
Self-Insured Reporting
DIRECTOR
Orlo “Spike” Dietrich Operating Partner
Ansley Capital Group
DIRECTOR
Deborah Hodges
President & CEO
Health Plans, Inc.
DIRECTOR
Mark Lawrence President
HM Insurance Group
DIRECTOR
Adam Russo CEO
The Phia Group, LLC
DIRECTOR
Beth Turbitt
Managing Director
Aon Re, Inc.
VOLUNTEER COMMITTEE
CHAIRS
Captive Insurance Committee
Jeffrey Fitzgerald Managing Director, SRS
Benefit Partners
Strategic Risk Solutions, Inc.
Future Leaders Committee
Erin Duffy Director of Business Development
Imagine360
* Also serves as Director
Price Transparency Committee
Christine Cooper CEO
aequum LLC
Cell and Gene Task Force
Shaun Peterson
VP Head of Worksite Solution
Pricing & Stop Loss Product
Voya Financial
2024 BOARD OF DIRECTORS
SIEF CHAIRMAN
Nigel Wallbank President New Horizons Insurance Solutions 2601 Sheltingham Drive Wellington, FL 33414
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José faced more setbacks after receiving his new liver. Stop Loss helps protect his self-funded employer.
Catastrophic claims can arise unexpectedly. Medical claims could reach $1.5 million if a liver transplant is complicated by sepsis and renal failure.* When the self-funded employer has the right Stop Loss protection in place, focus can remain on achieving business goals and supporting José through his recovery.
When you work with the experts at HM Insurance Group, you can be confident that claims will be paid. We process 99% of Stop Loss claims within six business days, with more than 99% technical and financial accuracy. Find more at hmig.com.
