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May 2017


The World’s Leading Alternative Risk Transfer Journal Since 1984


Enemy Within

Texas Association of School Boards offers cautionary tale for workers’ comp risk pooling standards and practices following dramatic discovery of massive fraud by trusted employee

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The World’s Leading Alternative Risk Transfer Journal Since 1984

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The Self-Insurer (ISSN 10913815) is published monthly by Self-Insurers’ Publishing Corp. (SIPC) Postmaster: Send address changes to The Self-Insurer P.O. Box 1237 Simpsonville, SC 29681




Enemy Within


By Bruce Shutan

EDITORIAL ADVISORS Bruce Shutan Karrie Hyatt


Volume 103


Inside the Beltway House Overwhelmingly Passes SIIA-Backed Self-Insurance Bill – Seeking Similar Senate Result


Outside the Beltway New Minnesota Stop-Loss Law Expands Self-Insurance Options

24 ACA, HIPAA and Federal Health Benefit Mandates The Affordable Care Act (ACA), the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other federal health benefit mandates

Editorial and Advertising Office P.O. 1237, Simpsonville, SC 29681 (888) 394-5688

2017 Self-Insurers’ Publishing Corp. Officers


James A. Kinder, CEO/Chairman Erica M. Massey, President Lynne Bolduc, Esq. Secretary


Continues to Investigate Captives Choosing the 831(b) Tax Option


Don’t Let Your LOAs Leave You DOA


SIIA Endeavors


News from SIIA Members

By Karrie Hyatt

May 2017 | The Self-Insurer



Enemy Within

Texas Association of School Boards offers cautionary tale for workers’ comp risk pooling standards and practices following dramatic discovery of massive fraud by trusted employee

I By Bruce Shutan

t was right out of a movie or riveting crime novel. Dubravka Romano was in London for meetings with reinsurance underwriters in March 2013 when the phone rang. “Are you sitting down?” a caller asked the associate executive director for risk management services with the Texas Association of School Boards.

Whenever such a foreboding rhetorical question is posed, it’s almost always followed by terrible or shocking news. In this case, a red flag waved wildly back in the Lone Star State. Roughly $200,000 worth of self-funded workers’ compensation payments made to a medical provider were curiously traced to one of TASB’s most trusted, respected and affable employees – in a supervisory role, no less.


Hmm, she thought. There must be much more to the story than meets the eye. Indeed, there was. Suspicious activities led investigators to uncover a series of brazen crimes committed intermittently over a decade using three separate theft schemes and two fictitious vendors. The culprit was none other than Herman G. Wilks, director or TASB’s workers’ comp claims administration who later pled guilty to charges of embezzling more than $1 million from the fund’s workers’ comp and employee benefit programs. It was a fox-guarding-the-henhouse moment that shattered trust and stirred emotion right alongside the terrible toll it took on time, financial matters and morale.

Romano was dumbfounded. When she first confronted Wilks, there was a long and uncomfortable silence – confirming her fear that serious wrongdoing had been committed.

“Fraud really can and does happen,” she recalls one of TASB’s board members, a retired IRS agent, saying prior to this revelation. “It

was such a shock to our organizational consciousness because we see ourselves as a bunch of dogooders in the world.”

Fraud-prevention strategies What makes this story even harder to comprehend is that massive fraud took place at TASB in spite of rigorous annual audits, regular external reviews by reinsurance partners, an active internal audit function and regularly scheduled policy reviews that adhered to industry standards. Could a similar scenario occur within other self-insured entities? Apparently so, according to Romano. Upon hearing the details of her account, several people have sheepishly admitted to uncovering fraudulent activity in their own organization, though on a smaller scale.

May 2017 | The Self-Insurer



She has given about 10 presentations on the topic (aptly entitled “The Enemy Within”) in hopes that it helps prevent a reoccurrence of the TASB debacle. Each talk deepens the level of catharsis that helped power her organization through this crisis. Romano suggests that employers pay particularly close attention to reviewing their vendormanagement process, as well as verify the legitimacy of all service providers and remove those with whom they no longer do business. Another tip is to verify system security, which TASB now does on a quarterly basis. In addition, she says there must be an audit trail with detailed records, which can be bolstered by a response plan and crisis communications strategy. Her dramatic account of this story, which Romano gave at SIIA’s national conference last fall and a recent webinar, was “incredibly heartbreaking” to Freda Bacon, who administers the Alabama Self-Insured Worker’s Compensation Fund and is on SIIA’s Workers’ Compensation Committee. “To have that type of fraud occur right under your nose, it’s an eye-opener,” she says. This is especially true for fellow public entities that she believes are expected to go the extra mile from a fiduciary standpoint. “You have to have very firm guidelines that you can


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present to your board of trustees or the public that you’re doing everything you can to detect and prevent fraud,” Bacon explains. After nearly 40 years in business, Bacon has never heard of anything quite like TASB’s tale occurring among peers. Fraudulent or criminal behavior in this sector is exceedingly rare, reports Ann Gergen, executive director for the Association of Government Risk Pools. The group’s mission is to provide public entity risk pool education and networking, as well as operational and best practices support, to more than 200 members in the U.S. There are 78 AGRiP recognition standards that are based upon a self-audit process for these pools to follow and continually improve over time.


“An audit is designed to identify process improvements,” Gergen says. “We see pools actively engaging in conversation to share how they’re improving their own operations. Our pool members are highly collegial and very collaborative. They view themselves as extensions of the public entities that they serve, and by and large, they’re people who are passionate about providing local government public entity service.”

Peeling back the onion When TASB investigated Wilks’ wrongdoing, Romano and her crew wondered how he went undetected for so long. Eventually they learned that he had requested a report on large hospital bills to identify actual workers’ comp claimants who received medical implants.

In addition, two separate internal control audits by a Big 4 accounting firm were done to determine how the theft occurred before a U.S. attorney began prosecution. TASB soon discovered that Wilks was able to circumvent a four-step claims adjudication process because of his intimate knowledge of the system. But he obviously tripped himself up along the way. The dead giveaway was having an employee with his own LLC, surmises Stu Thompson, CEO of The Builders Group, a construction self-insured group started in 1997, and member of SIIA’s Workers’ Compensation Committee. “I was amazed at how much he was able to get away with, especially over a long period of time,” he says of Wilks. A key takeaway from Romano’s presentation is to know who’s being paid, whether they’re staffers or contractors, according to Thompson, and ensure that all necessary forms that must be filed are accurate, including name, address, federal ID number, etc.

“We have Positive Pay,” he explains, “so if there’s any type of questionable payment from our bank, they alert us, and then we can say yes or no.”

The information was then used to create fictitious medical bills with codes for implantables into the claims system with a slightly altered date of service to circumvent system controls that were in place to detect duplicate payments. Payments were surreptitiously entered, adjudicated and released after work hours. Wilks also changed the address for a claimant’s explanation-of-benefits form in the system to his own so that it would not go to the employee, then changed back the address after the check was issued to himself. The crime triggered a comprehensive probe by a former FBI agent whom Romano describes as “straight out of Central Casting with a crew cut, blue suit, white shirt and dark tie.” Since TASB is a public entity with dismayed taxpayers to consider, this theft necessitated the involvement of additional law enforcement officials.

May 2017 | The Self-Insurer



The TASB crimes made him reevaluate his own operation, which pays more than $20 million in claims each year. He believes that having a TPA to adjust and pay claims adds another layer of protection. When Thompson returned home from the SIIA conference he made sure he had an updated certificate of insurance from his TPA so he knew what their fidelity limit was in the unfortunate event of a crime occurring. TASB has since taken corrective steps to prevent this type of fraud from ever happening again. They included changes to the vendor set up and maintenance process, IT system security and set up, and segregation of duties. Other actions involved greater focus on fraud awareness, as well as TASB ethics and values. Wilks pled guilty to 10 counts of mail fraud in January 2014 and was sentenced to 63 months in federal prison just two months later when he also was ordered to pay full restitution for his crimes. He also wrote a letter of apology to his supervisor and will be eligible for release in November of this year. One of the painful lessons TASB staffers learned was that internal controls are everyone’s responsibility, not just the finance department, which reviewed its internal-control recommendations from purely a financial and not also operational lens. While compliance can be burdensome, it’s also seen as necessary. But beyond that, Romano says collateral damage actually can be much worse than financial losses. She cites a long list of unfortunate consequences that included a profound sense of shock and disbelief, loss of trust and confidence, resentment and extra work to review processes. She also mentions that Wilks’ actions triggered serious betrayal, shame and embarrassment, particular among his fellow African-American employees for whom feelings of disappointment perhaps ran deepest among all TASB staffers. In short, she says many of them were at once mortified and apologetic. Romano recalls how Wilks was genuinely remorseful, but that did not change the fact that unraveling his crimes proved to be time-consuming for her staff as well as emotionally draining on a personal level. Her sage advice to others: “Be

prepared with a response plan, be prepared with a crisis communication plan, which we did not have, and be prepared for a recovery plan.”

Bruce Shutan is a Los Angeles freelance writer who has closely covered the employee benefits industry for nearly 30 years.


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the Beltway written by Dave Kirby

House Overwhelmingly Passes SIIABacked Self-Insurance Bill – Seeking Similar Senate Result When the U.S. House of Representatives approved H.R. 1304 The Self-Insurance Protection Act (SIPA) by a landslide vote of 400-16, SIIA and the self-insurance industry were halfway toward gaining strengthened protection against the government being able to define stoploss insurance as health insurance with all the resulting taxation and regulatory challenges.

“This issue has been like the sword of Damocles hanging over our heads for decades,”

It remains for the U.S. Senate to pass comparable legislation for the industry to breathe a great sigh of relief.

Government Relations Committee and

said Larry Thompson, chairman of SIIA’s regional president of Pomco Administrators, Inc. of Fresno, California, who has nearly 30 years of involvement with the organization including a term as chairman.


The Self-Insurer | www.sipconline.net

SIPA was sponsored in the House by Dr. Phil Roe (R-TN). It would clarify existing law to ensure that federal regulators would not be able to re-define stop-loss insurance as traditional “health insurance” under the ERISA law or the Internal Revenue Service tax code. SIIA stated that the law would result in small- and mid-size private sector employers as well as smaller Taft-Hartley plans and public sector employers being secure in continuing to provide high-quality health benefits to their workers and members through self-insured group health plans. Now SIIA is campaigning for a SIPA mirror bill in the Senate according to Ryan Work, vice president of government relations. Sponsors were being lined up and bill language was written in the wake of the House vote. “With a 400 to 16 vote in the

House, our hope is to continue with bipartisan and broad support in the Senate,” Work said. The victory in the House had its own challenges. SIPA was first introduced during the prior administration and never reached the floor for a vote. SIIA government relations staff and members were determined to leave no margin of error for the bill’s success during the current session. Work estimates that more than 100 meetings were held by SIIA members and staff with pivotal members of the House. Bob Clemente, SIIA chairman-elect, was a leading advocate of SIPA during visits to House members and staff. Founding chairman of Specialty Care Management of Lahaska, Pennsylvania, Clemente made six trips to Washington, each time visiting several House offices with Ryan Work. He was encouraged by the bipartisan reception of the SIPA message which resulted in the strong 400-16 acceptance of the bill. “We were apparently able to separate SIPA from other health care issues in the minds of legislators,” he said. “Both Democratic and Republican Congressmen each have many thousands of constituents whose health coverage is provided by self-funded plans, and stoploss insurance is an integral element of that. Now our job is to take this same message to members of the Senate.”

May 2017 | The Self-Insurer


A pivotal point in SIPA’s progress in the House was the hearing by the House Education and Workforce Committee titled “Legislative Proposals to Improve Health Care Coverage and Provide Lower Costs for Families” on March 1, 2017. Health care, of course, had been the hot topic in Washington as the administration and House leaders attempted to repeal and replace the Affordable Care Act (ACA). Even as that attempt was suspended, observers note that the appetite for health care coverage improvements had been stimulated. Jay Ritchie, SIIA chairman and executive vice president of Tokio Marine HCC Stop-Loss Group, testified that morning, delivering a ringing endorsement for SIPA based on the coverage provided for an estimated 100 million Americans by self-insured employers and Taft Hartley plans. Much of his testimony dealt with the importance of stop-loss insurance to plans that are not large enough to self-fund the largest claims.


“Stop-loss is what makes self-insurance work,” he said. “If regulators are permitted to redefine stop-loss coverage as health insurance, the availability and access to stop-loss will be significantly reduced. This would eliminate the most valuable aspects of self-insurance and restrict plans to a limited amount of health insurers. This would also lead to self-insurance being available for the largest organizations and we would see its benefits and advantages eliminated for the small- and medium-sized organizations that need access to it the most.” Ritchie told committee members that SIPA simply seeks to amend the definition of “health insurance coverage” under the Public Health Services Act (PHSA) and parallel sections of ERISA and the Tax Code to clarify that stop-loss insurance is not health insurance. The legislation does not amend the ACA and – a popular point with legislators – it carries no cost. Now SIIA’s campaign continues in the Senate to protect the ability of self-insurance to be the most efficient and effective form of U.S. health care.

SIIA member inquiries about this or other federal government relations issues are welcome to contact Ryan Work at rwork@siia.org or (202) 595-0642.

The Self-Insurer | www.sipconline.net

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the Beltway written by Dave Kirby

The new regulation changed a stop-loss policy aggregate attachment point to 110 percent of expected claims for groups of 51 or fewer – leveling the playing field between large and small employers related to the level of stop-loss insurance they can access in the marketplace. Previously the aggregate attachment point for small employers was set at the greater of $4,000 per group member or l20 percent of expected claims. The specific attachment point for claims incurred per individual remained unchanged at $20,000. “It was apparent that the $4,000 per group member attachment point presented significant financial challenges to smaller businesses,” Brackemyre noted.

New Minnesota Stop-Loss Law Expands Self-Insurance Options


New Minnesota stop-loss insurance regulations enacted by the legislature are expected to make self-insurance of employee benefit plans less costly and more convenient for the state’s small businesses. “The new law allows employers more options and possibly lowers their costs,” reports SIIA Vice President of State Government Relations Adam Brackemyre, who led SIIA’s advocacy of the new law that was pursued for eight years by state business organizations.

“The lessons for future government relations projects is to be persistent, set realistic goals and be ready to compromise,” Brackemyre said of the campaign initiated in 2009 by the Minnesota Association of Health Underwriters (MAHU). The resulting regulations could comprise a goal model for future regulations in other states, he said.

14 The Self-Insurer | www.sipconline.net

The other significant element of the law was to change stop-loss contract terms from 12-24 to 12-15, meaning the “run-out period” of claims submission and payment was reduced from 12 months following a12-month period of claims incurrence to three months following a 12-month period. “This should also help reduce costs for plan sponsors,” Brackemyre said, explaining that plan sponsors would now be less vulnerable to claims they didn’t expect.

These significant changes in the rules governing Minnesota stop-loss insurance have been a continuing effort initiated by Dave Wiest, Legislative Chairman of MAHU, who is president and CEO of EMEX Benefit Systems, Inc. of Medina, Minnesota.

“In working with my clients I found the state stop-loss regulations to be unfairly restrictive and I brought that to the attention of MAHU leaders in 2009,” Wiest recalls. “Gradually, other members became interested in the issue and we began to push for corrective legislation.”

Wiest said that MAHU faced a long uphill educational campaign among the evolving membership of the legislature and the governor’s office. “Lawmakers were not quick to understand the elements of selffunding or stop-loss insurance and how these serve to benefit a large portion of the state’s business community,” he said. “Some years we were just breaking through to a level of understanding of our issue as the legislative session ended.”

self-insurance would ruin the small group market. “But when the Chamber got involved it changed everything,” Wiest said of the welcome participation on the issue by the Minnesota Chamber of Commerce along with the National Federation of Independent Business (NFIB). Wiest noted that the Chamber’s and NFIB’s vast membership of state employers weighed heavily with legislators.

Wiest said that MAHU went into successive legislative seasons in St. Paul with experienced lobbyist Tim Wilken but was seemingly outgunned by the legislative clout of the traditional insurance industry: “They never let up on the assertion that

May 2017 | The Self-Insurer


Bentley Graves, director of health care and transportation policy for the Minnesota Chamber, said, “We

got involved in this issue because it’s important to us that smaller employers in Minnesota have a level playing field and the coverage options they need. We viewed this legislation as a way to accomplish that. Our data for two years prior to 2016 showed that about one-third or 8,000 small employers left the fully-insured benefits market.”

“Even with our united effort and some Democratic support, we still lost out for seven years as bills failed to pass both houses or were vetoed by the governor,” Wiest said. He described this year’s compromise breakthrough when Gov. Mark Dayton (D) allowed the legislation to go forward with a stipulation that provides rebates for state health care exchange policyholders ineligible for advance premium tax credits (APTC). The revised stop-loss regulations have sparked new interest among stop-loss insurance carriers in entering the Minnesota market, and should bring increased interest by employers to sponsor self-insured health plans, according to Wiest. “Now our mission is to educate our industry here in Minnesota and through them, the employers,” he said. SIIA Chairman Jay Ritchie has communicated his encouragement of SIIA members in Minnesota to participate in educational events with MAHU. “Joining in state advocacy efforts strengthens self-insurance in the eyes of each state’s government and business communities,” he said. MAHU held its Tech Expo last month with industry exhibits and presentations on the new stop-loss law, and will begin offering sponsorships next month for its annual fall convention. Information is available at the organization’s website www.emahu.org.


The Self-Insurer | www.sipconline.net

SIIA members who wish to join the state government relations advocacy team are invited to contact Adam Brackemyre at the Washington, DC, office, (202) 463-8161 or abrackemyre@siia.org.

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Continues to Investigate Captives Choosing the 831(b) Tax Option


fter five years of investigating small captives that choose the 831(b) tax option, the Internal Revenue Service has stepped up its investigations by releasing Notice 2016-66 last November and again listing captives to their annual “Dirty Dozen” list of potential tax scams.

By Karrie Hyatt

831(b) captives are generally small to mediumsized companies that elect to take advantage of the Internal Revenue Service 831(b) tax code. Small captives are referred to by several different names—micro captives and Enterprise Risk Captives (ERCs) are two of them—but not all small captives take the 831(b) tax designation. Just like any other alternative risk transfer vehicle, these small captives must qualify as actual insurance companies. Opting for the 831(b) designation can give captives a tax advantage. What seems to be provoking the IRS’s suspicions of 831(b)s are their use for mitigating certain risks—especially regarding estate planning and wealth transfer—that may not qualify them as proper insurance companies.


Smaller captives choosing the 831(b) designation are probably the fastest growing segment of the captive industry. There are a growing number of state domiciles that specialize in their formation. With their expansion in the last decade, these smaller captives have gained more criticism stemming from three main issues: some may seek to use them for tax shelter purposes; there have been a number of “promoters” engaging in setting up captives who may not have a background in insurance; and some have been used for wealth transfer planning. In the wake of a difficult insurance market throughout the 1970’s and early 1980’s, Congress enacted 831(b) as part of the 1986 tax reform legislation in an effort to make it easier for rural mutual insurance companies, as well as small and medium sized business, to access insurance not readily available or too expensive in the general insurance marketplace. Captives using the designation have expanded since this time to include additional types of risks and are in wide-spread use throughout the country. “From the IRS standpoint,” said Kevin Doherty, a lawyer with the law firm Dickinson Wright, “The current way the 831(b) designation is used was not the intention of Congress. The fact of it is that it is the law and it’s permitted.”

IRS’s Micro Captives For the third year in a row, the IRS has named captives operating under the 831(b) tax designation to their “Dirty Dozen” list—a list the department releases each year warning tax payers of potential tax dodges and scams. This list, released at the beginning of tax season, highlights tax schemes that target consumers. Called “micro captives” in the IRS press releases, it says that some captives using the 831(b) designation are using it for wealth transfer rather than insuring genuine risk.

May 2017 | The Self-Insurer



The captive industry has been swift and steady in the IRS’s general and broad condemnation. According to Doherty, “It makes no sense to sweep captives up under the same category. [The industry has pushed back], but the IRS is going to have to be convinced that there are very few bad actors. It’s sort of like saying that if you’re in the dry cleaning business and there are maybe 15 dry cleaners across the country who have cheated on their taxes, that obviously means dry cleaning is a really bad business. That’s the logic the IRS is using and we’d like to see that changed.”

Les Boughner, chairman of Advantage Insurance Management, said “The

IRS has always been critical of captives and has a history of challenging captive structures. They also have a history of losing their legal challenges…. Labeling them a transaction of interest is intended to identify questionable structures and it would be more appropriate to list ‘abusive captive structures’ rather than ‘captives’ on the ‘Dirty Dozen’ list.”

Notice 2016-66 Last November, the IRS issued Notice 2016-66 which named 831(b) captives as “transactions of interest” and sought to require additional financial disclosures. According to the IRS website, “Transaction of Interest” (TOI) is defined as a transaction that the IRS and the Treasury Department believe is a transaction that has the potential for tax avoidance or evasion, but lack sufficient information to determine whether the transaction should be identified specifically as a tax avoidance transaction.” With Notice 2016-66, the IRS requested specified entities to file additional financial disclosures by January 30, 2017—90 days after the Notice was issued.

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Once the IRS and Treasury Department have collected enough information to make a decision, Notice 2016-66 states that one or more of three actions will happen: “Removing the transaction from the transactions of interest category in published guidance, designating the transaction as a listed transaction, or providing a new category of reportable transaction.” According to Doherty, Notice 2016-66 is “an attempt by the IRS to get as much information as possible about these small captives. I think the effect of it, whether intended or not, is to create a burden on small captives, adding an extra cost. One way to look at it is the increase cost makes it more difficult for the smaller companies to justify using a captive or a cell in a captive. It effectively favors large companies and hurts the smaller companies.”

The captive industry has been very vocal in its disapproval. SIIA led the campaign to modify and withdraw Notice 2016-66, along with dozens of trade associations, captive managers, and regulators joining in, including a letter from Kevin Doherty on behalf of the Tennessee Captive Insurance Association. SIIA was one of the only industry groups to meet with the IRS to discuss their concerns regarding the notice. Their meeting had a direct impact on the IRS extending the reporting deadline by 90 days. Criticism was initially pointed towards the fact that there was no comment period before the deadline was set and that only 90 days was an unreasonable amount of time to put together the disclosures required. At the end of December, the IRS extended the deadline to May 1, 2017. Other points of complaint from the industry were the potential for duplicate financial filings and the broad requirements in Notice 2016-66 that sweeps up nearly all 831(b) captives. CIC Services, a Tennessee-based captive manager, has filed a lawsuit against the IRS and Treasury Department arguing that Notice 2016-66 was unlawfully issued and did not meet the authority or “reasoned analysis” requirements of the Administrative Procedure Act. The original lawsuit was filed last December and a second suit was filed at the end of March with Ryan, LLC, a Texas-based tax firm, named as co-plaintiff.

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A Premature Action Another criticism leveled at the IRS and the Treasury Department is that Notice 2016-66 was issued prematurely. The Protecting Americans from Tax Hikes Act of 2015 (PATH Act) went into effect on January 1st of this year. The law creates tax relief benefits for business and families, and for the captive insurance industry the PATH Act increases the limit of net annual written premiums to 2.2 million dollars for 831(b) captives. The Act also changes the qualifications regarding ownership diversity for those captives. It will require any captive electing for the 831(b) designation to meet a “Diversification Requirement” in ownership. The PATH Act is now in effect and should help stem many of the abuses the IRS believes to be taking place, while also allowing these smaller captives to grow. Additionally, the captive industry is looking to Congress to clarify some of the parameters of the Act, which should help to strengthen captives’ standing. SIIA requested these clarifications by Congress and they were introduced at the end of last year. According to Ryan Work, vice president of Government Relations with SIIA, “Understanding that the IRS would not provide needed clarification surrounding the PATH Act, as directed by Congress, prior to its implementation, SIIA spearheaded a letter with 15 state captive associations formally requesting that the IRS do so. To this date, the IRS has yet to respond or issue this guidance. This is one of the sticking points with the Notice—if they don’t have the willingness or time to issue guidance on the PATH Act, which has already gone into effect, and don’t understand its implications, how can they spend time and issue the Notice without comment?”

“Here is the contradiction,” said Boughner. “Unless Treasury and the IRS operate in a complete vacuum the IRS had to be aware of Treasury liberalizing the 831(b) election in the PATH act by increasing the threshold to $ 2,200,000. The PATH act also imposes ownership restrictions which limits a captives ability for family wealth transfer, another IRS concern. These changes highlight that a captive should be used for fundamental corporate risk management purposes. My interpretation is that they worked in tandem and that, while the IRS is concerned about abuses, they support the proper application of a captive structure for risk management purposes.”

Even with the deployment of the PATH Act and the upcoming decision in the Avrahami case, the IRS and the Treasury Department chose to list 831(b) captives as a TOI and continued listing them to the “Dirty Dozen” list. This has put the industry on edge. As Doherty said, “Legitimate domiciles, and most of us in the industry, are working very hard to make sure there are no abuses. Certainly there are people on the fringe who float in from time to time, captive managers that are a little bit questionable, but the regulators work hard to make sure guys like that don’t get licensed.” This year will be a proving ground for 831(b) captives. With the additional disclosures the IRS is seeking, the PATH Act requirements, and a Tax Court decision, 831(b) captives might finally see themselves clear of their controversy. The captive industry will be there to back them up. As Doherty said, “This is our business, we’re not going to be deterred.” Karrie Hyatt is a freelance writer who has been involved in the captive industry for more than ten years. More information about her work can be found at: www.karriehyatt.com.

A U.S. Tax Court decision in the case of “Avrahami v. Commissioner” should be decided during the next few months. In this case, a Phoenix-based jewelry company is suing the IRS in response to a multi-million dollar notice of deficiency. The captive is suspected by the IRS of misusing the 831(b) tax designation as a tax-avoidance scheme. However the case is decided, case law will be established which will help define the tax designation.

May 2017 | The Self-Insurer




Q& A T

he Affordable Care Act (ACA), the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other federal health benefit mandates (e.g., the Mental Health Parity Act, the Newborns and Mothers Health Protection Act, and the Women’s Health and Cancer Rights Act) dramatically impact the administration of self-insured health plans. This monthly column provides practical answers to administration questions and current guidance on ACA, HIPAA and other federal benefit mandates. Attorneys John R. Hickman, Ashley Gillihan, Carolyn Smith, and Dan Taylor provide the answers in this column. Mr. Hickman is partner in charge of the Health Benefits Practice with Alston & Bird, LLP, an Atlanta, New York, Los Angeles, Charlotte and Washington, D.C. law firm. Ashley Gillihan, Carolyn Smith and Dan Taylor are members of the Health Benefits Practice. Answers are provided as general guidance on the subjects covered in the question and are not provided as legal advice to the questioner’s situation. Any legal issues should be reviewed by your legal counsel to apply the law to the particular facts of your situation. Readers are encouraged to send questions by E-MAIL to Mr. Hickman at john.hickman@alston.com. 24

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THE MENTAL HEALTH PARITY COMPLIANCE: REVAMPED FOR 2017 As noted in our October Self Insurer column1, comprehensive regulations have been issued under the Paul Wellstone and Pete Dominici Mental Health Parity and Addiction Equity Act of 2008 (“MHPAEA”), and we have seen an uptick in Department of Labor (“DOL”) investigation and enforcement activity with respect to the MHPAEA. We suggested in that column that employers focus on MHPAEA compliance. This article updates activity in this area since the election and the passage of the 21st Century Cures Act in December.

Legislative Background The MHPAEA amended Section 712 of ERISA, Section 2705 of the Public Health Services Act and Section 9812 of the Internal Revenue Code, and is designed to require true benefit parity between medical benefits for physical conditions and mental health and substance abuse benefits. The MHPAEA applies to mental health and substance abuse benefits offered in connection with group health plans. If a plan provides medical/surgical benefits and mental health or substance abuse benefits, the plan must provide parity with respect to (i) financial requirements (e.g., deductibles, copayments, coinsurance and out-of-pocket maximums), (ii) quantitative treatment limitations (e.g., number of visits or treatments or days of coverage) and (iii) nonquantitative treatment limitations (“NQTLs”)(e.g., medical management standards). MHPAEA generally became effective for plan years beginning on or after October 3, 2009 (January 1, 2010 for calendar year plans). For years prior to 2010, the Mental Health Parity Act (MHPA), the precursor to MHPAEA, applied. MHPA’s more limited equality provisions only required parity between annual and lifetime dollar limits applicable to medical benefits and mental health benefits.

The 21st Century Cures Act Further supporting the notion that the MHPAEA will not be affected by postelection changes, the 21st Century Cures Act (the “Cures Act”), which includes provisions relating to MHPAEA, was signed into law on December 13, 2016. The Cures Act has a broad ranging effect on mental health issues. Of note to sponsors of employee benefit plans, the Cures Act includes a directive to the Secretaries of Labor, Treasury and Health and Human Services (HHS) to develop and issue a compliance program guidance document (the “Guidance Document”) to help improve compliance with the MHPAEA, as incorporated in Section 712 of the Employee Retirement Income Security Act of 1974 (ERISA), Section 9812 of the Internal Revenue Code and Section 2726 of the Public Health Services Act (PHSA). This is intended to supplement information previously provided by the enforcement agencies. The Guidance Document under the Cures Act would be required to include illustrative examples of previous findings of compliance and non-compliance, including:

We note that the MHPAEA pre-dates the Affordable Care Act (ACA). Accordingly, even if Congress undertakes to repeal and replace the ACA in 2017, a rollback of MHPAEA requirements is unlikely.

May 2017 | The Self-Insurer


Examples illustrating requirements for information disclosures and nonquantitative treatment limitations; and Descriptions of violations uncovered during the course of investigations.

The examples will include sufficient detail to fully explain the findings, including a full description of the criteria involved for approving medical and surgical benefits and the criteria involved for approving mental health and substance use disorder benefits. This additional information in the Guidance Document should provide valuable assistance to employers seeking to confirm compliance with the MHPAEA. This can be very important given the potential for significant liability associated with noncompliance.


Penalties Potential enforcement actions should be cause for concern for employers and insurers, as significant penalties can result under the Code. MHPAEA violations can give rise to a $100/ day/employee excise tax under Code § 4980D. Certain limitations and exceptions apply for employer sponsors of small fully insured plans as set forth in Code § 4980D.2 In addition to the IRS taxes, participant claims may be asserted and DOL might choose to sue employers for breach of fiduciary duty based on their failure to comply with MHPAEA.

Summary Given the potential for significant penalties, employers should focus (or re-focus) their attention on compliance with the MHPAEA. Employers should watch for issuance of the Guidance Document and use that guidance to ensure their health plans comply with the MHPAEA. This will likely require coordination with insurers and claims administrators. References: 1 http://www.alston.com/advisories/mental-health-parity/pdf 2 Code § 4980D(d) provides an exemption from the excise tax for employers with between 2 and 50 employees.

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Don’t Let Your LOAs Leave You DOA Written by Kelly E. Dempsey


magine a scenario where an employer has a long-time reliable employee that suddenly has a stroke of bad luck and is diagnosed with stage four cancer after being relatively asymptomatic and having never been diagnosed with cancer previously. The employee works with a team of medical professionals to come up with a game plan for beating this terrible disease. The employee quickly begins what will hopefully be life-saving treatment as soon as a game plan is mapped out. The claims start rolling in and the treatment starts taking its toll. The employee starts missing an hour here and there for appointments – and then a few hours for appointments and sickness –and then full days of work during treatment. When the employee is at work, the employee struggles to perform normal job functions and the employee is now unable to work because the rigorous chemotherapy regiment.


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The employee decides it’s time to take a leave of absence to focus on treatment. To the dismay of the employee, though, the employee doesn’t have any additional leave available under The Family and Medical Leave Act (FMLA), since the full allotment of FMLA leave was recently exhausted while the employee and the employee’s spouse were finally bringing home their new adopted baby that they had waited so long for. Is this pulling at your heart strings yet? The employer recalls that sometime in 2016, the U.S. Equal Employment Opportunity Commission issued guidance on a leave associated with The Americans

with Disabilities Act (ADA)1. Ah ha! The employer tells the employee they have just the solution – take a leave under ADA and the employment and leave situation can be reevaluated in a few months. The employer tells the employee not to worry about anything except becoming cancerfree; the health plan coverage will continue as long as the employee needs it, even though the last of the employee’s paid time off is exhausted and no additional FMLA is available. In other words, the employer, via its health plan, is taking care of its employee, as so many employers try so hard to do. The employee is then signed up for the short-term disability policy which will help replace some income during the leave, and the employee is all set – there is continuing health plan coverage and some income replacement to boot. All is well. Fast forward in time. Three months have passed, and the employee is making miraculous recovery. The employee is not ready to come back to work yet, but things are looking up and the employee is respected to return to work at some point in the near future. With the end of the health plan year approaching, the employer is attempting to get its ducks in a row for renewal season, which includes a stop-loss policy renewal. The cancer treatment

May 2017 | The Self-Insurer


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claims are continuing to roll in and, as expected, the dollars keep adding up – but unfortunately, as anticipated, stop-loss is going to become a factor before renewal (ugh). Claims are filed with the stop-loss carrier and all the typical supporting documents are provided. During the stop-loss carrier’s review, the carrier starts scratching its head. This individual has been on a non-FMLA leave of absence for over three months. The health plan document discusses FMLA and COBRA, but no other types of leave. Why was this employee still on the plan? Why was COBRA not offered when plan


coverage seems to have terminated? The stop-loss carrier questions the employer and requests additional documentation to support eligibility; the carrier even generously says the employee handbook is acceptable. As everyone knows, the stop-loss policy is underwritten based on the plan document alone; anything contained within the employee handbook is entirely separate from the plan document and the stop-loss underwriting generally won’t take into account anything within the employee handbook. The employer thinks “boy, am I lucky!” *queue the suspenseful music*

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The employer pulls out the employee handbook and skips to page 42 – Employer Leave Policies. The employer starts reading, “In addition to FMLA, employees that have exhausted paid time off and FMLA may be eligible for an additional extended leave of absence; referred to as non-FMLA leave. This non-FMLA leave is created to comply with the ADA’s requirement to provide a leave of absence as a reasonable accommodation and will be offered in addition to FMLA.

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Thus the non-FMLA leave will not run concurrently with FMLA. Additional information regarding how to request this leave and the additional requirements associated with this leave is further detailed herein:” The employer’s wheels start turning: okay, this ADA leave doesn’t run concurrently with FMLA – great, that helps, but where’s the part about continuing health plan coverage? That must be in this handbook somewhere. The employer starts frantically turning pages looking for those magical words “employees are entitled the health plan benefits during a non-FM LA leave of absence.” But alas, no such wording is contained within the 163-page employee handbook. The employer’s internal dialogue starts racing. “How can this be? We never meant for our employees to be out sick and not have health coverage. Doesn’t the ADA say we have to provide coverage to employees while they’re out on leave?” So you ask, “What now?” The bottom line is that there is no stop-loss reimbursement for the cancer claims, and quotes for renewal just added a few extra zeros. No need to review the gory details in depth – but one can imagine what happened during the plan and stop-loss renewal. The employer’s bank account is looking bleak, as are the proposed stop-loss renewal rates. The employer starts shopping other options despite having been with the same stop-loss carrier for years.


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All the while, the employer just thinks

“How did I end up here? All I wanted was to take care of my employees and give them the best benefits possible. Where did I go wrong?” It’s intuitive to think that a leave of absence from employment is coupled with a continuation of health plan coverage, especially if the leave is illness related; to the dismay of many, however, a continuation of coverage (other than COBRA) isn’t always coupled with a leave of absence. As shown in the scenario above, many employers struggle to align their health plan documents with their employee handbooks (and other internal policies) which subsequently increases the potential for a gap to arise between all the relevant documents.

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While most federal and state laws do not require a continuation of coverage, employers can choose to provide the benefit of continued coverage – but if the employer wants to ensure stop-loss reimbursement, the terms of continuation of coverage need to be clearly spelled out not only in the employee handbook, but also in the health plan document. The health plan document is key to showing proof of continued coverage, especially in a situation where stop-loss is relevant. Many employers don’t even realize they have gaps between their policies and the health plan documents until it’s too late. All it takes is one large medical event - a cancer claim, an ESRD diagnosis, premature twins, a transplant – to discover that the documents the employers has aren’t airtight, and may not even align with the employer’s intent. In summary, most employers need to do some homework. Go back to the office and take a look at the health plan document and the employee handbook. Do the two documents reference the same types of leave? Do the documents clearly indicate when coverage under the health plan is maintained during a leave? Do the terms of these documents meet the intent of the employer? What does the stop-loss policy say about eligibility determinations? Can the handbook be used to document eligibility in the health plan? What (if any) changes need to be made to minimize or eliminate gaps, to the extent possible? Don’t let large unexpected claims leave you dead on arrival. Do the leg work now, and figure out what needs to be done to avoid being caught by surprise. Kelly E. Dempsey is an attorney with The Phia Group. She is one of The Phia Group’s consulting attorneys, specializing in plan document drafting and review, as well as a myriad of compliance matters, notably including those related to the Affordable Care Act. Kelly is admitted to the Bar of the State of Ohio and the United States District Court, Northern District of Ohio.


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References: 1 https://www.eeoc.gov/eeoc/publications/ada-leave.cfm


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SIIA held its annual Self-Insured Health Plan Executive Forum (formerly known as the TPA/ MGU Excess Insurer Executive Forum) March 28-29, 2017 at JW Marriott Tucson Starr Pass Resort & Spa, in Tucson, Arizona.

JW Marriott Tucson Starr Pass Resort & Spa, in Tucson, Arizona 36

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The Board of Directors of the Self-Insurance Education Foundation (SIEF) would like to thank the participants in their always popular golf tournament, and congratulate the winners:

First Place Team Vance Sible Sam Sletager Zach Walker David West

Second Place Team Charley Erwin Matthew Herrera

The First Place Team

Greg Rudisill Russ Krueger

Third Place Team Fred Toncone Jonathen Socko Joghn Foley

Hole Contests Longest Drive

Zach Walker

Closest to the pin

Zach Walker R6

Closest to the pin

Abby Zipoy R8

Closest to the pin

Charley Erwin RR1

Closest to the pin

Fred Troncone RR3


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The 2nd Place Team

May 2017 | The Self-Insurer


Conference attendees participated in a variety of networking events and educational sessions. Highlights of the educational program included:

Legislative/Regulatory & Political Advocacy Update Ryan Work, Vice President, Federal Government Relations for SIIA and Adam Brackemyre, Vice President, State Government Relations for SIIA provided detailed updates of important legislative/ regulatory developments and the association’s political advocacy strategy at both the state and federal levels. Regulatory Compliance “Hot Spots” for SelfInsured Health Plans Chris Condeluci, Esq., Washington Counsel for SIIA, discussed current regulatory developments affecting self-insured employers with specific compliance guidance useful to employers and their business partners.

How Self-Insurers Can Help Restore the American Dream by Curbing the Healthcare Heist In this TED-style talk, Dave Chase, Executive Producer of The Big Heist, connected the dots on how healthcare’s status quo represents a significant David Chase threat to the American Dream and how employers who sponsor self-insured health plans are playing an increasingly important role in providing real solutions that bring hope to a dysfunctional health care system.

Winning Technology Strategies for the Self-Insurance Marketplace

Joe Hodges, President, Inetico, moderated a discussion of senior executives of companies operating within the self-insurance marketplace guidance on how to view and evaluate technology strategies in a way that will help them grow their business and strengthen their corporate brands.

Networking reception in the Exhibit area


The Self-Insurer | www.sipconline.net

Networking reception in the Exhibit area

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May 2017 | The Self-Insurer



from SIIA



SIIA Diamond, Gold & Silver Member News SIIA Diamond, Gold, and Silver member companies are leaders in the selfinsurance/captive insurance marketplace. Provided below are news highlights from these upgraded members. News items should be submitted to Wrenne Bartlett at wbartlett@siia.org. All submissions are subject to editing for brevity. Information about upgraded memberships can be accessed online at www.siia.org. For immediate assistance, please contact Jennifer Ivy at jivy@siia.org. If you would like to learn more about the benefits of SIIA’s premium memberships, please contact Jennifer Ivy and jivy@siia.org.

Diamond Members Zelis™ Healthcare Announces Acquisition of Strenuus® Zelis Healthcare, a market-leading healthcare information technology company, is pleased to announce the purchase of Strenuus. Overland Park, Kansas-based Strenuus is a healthcare information technology company and provider of healthcare provider network analytics. Strenuus is the largest collector of managed health care data in the U.S., delivering actionable network insights to health plans, data analytics and healthcare provider data companies, healthcare exchange platforms and employee benefits consultants.


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This isn’t our first



Being in the medical self-insurance stop loss

market isn’t new to Houston International Insurance Group (HIIG). The experts and seasoned employees that founded the Company have decades of experience in this industry. In fact, HIIG was built using strategy, sound judgment, and business savvy from some of the same leaders who made this industry great from the very beginning. Don’t get thrown for a loss. Make HIIG Accident & Health your partner in stop loss.

Learn more at hiigah.com or call us at 800.796.9165. 2

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The Strenuus acquisition further enhances Zelis’ healthcare data analytics product portfolio supporting payer clients. Strenuus is now a part of the Zelis Network Solutions business unit led by Tina Ellex, President. “The combination of Zelis and Strenuus further expands our Zelis integrated cost management and payments platform and enables Zelis to provide our payer clients with enhanced support of network access, quality and cost optimization efforts. This is particularly important as many payers seek to deliver high performing, cost effective, narrower networks that meet the changing needs of employers and members,” said Doug Klinger, CEO of Zelis Healthcare.

“We welcome the Strenuus team to Zelis. They have technology and provider data coupled with their deep experience and background in provider analytics that have positioned them as the premier company in our industry. I look forward to offering their solutions to our healthcare payer clients in an evolving marketplace,” said Tina Ellex, President of Network Solutions for Zelis Healthcare. “We are thrilled to join Zelis. We look forward to providing greater impact for the healthcare community with our continued focus on product enhancements and new product development,” said Matthew Mellor, CEO of Strenuus.

About Zelis Healthcare Zelis Healthcare is a healthcare information technology company and market-leading provider of end-to-end healthcare claims cost management and payments solutions. Zelis Healthcare focuses on network solutions, claims integrity and electronic payments for healthcare payers, providers and consumers in the medical, dental and workers’ compensation markets nationwide. Zelis Healthcare is backed by Parthenon Capital Partners. About Strenuus Strenuus is the leader in healthcare provider network analysis and data management. Their flagship platform, Network360®, delivers actionable network intelligence services to payer clients nationwide. Strenuus also powers consumer-facing solutions for leading benefit consultant and healthcare IT companies with the only unified provider search in the marketplace and manages the industry’s largest network dataset, sourcing from thousands of commercial medical, dental, Medicare, Medicaid and specialty business lines.




The Self-Insurer | www.sipconline.net

QBE Announces

Jon Tolzin has been named Regional Vice President in the Northwest, heading our Minneapolis Regional Office. His responsibilities include, managing underwriting, marketing and risk management services for QBE›s Medical Stop Loss products. His regional office serves brokers and TPA partners throughout 14 states. With 23 years of insurance experience, Tolzin moved to increasing levels of responsibility in underwriting at both ASO and standalone stop loss carriers. He holds a Bachelor of Arts degree in Economics from the University of Minnesota.

Ed Wadhams has been appointed Vice President, A&H National Partnerships. In this role, Wadhams will be responsible for positioning our business priorities with top producers in the U.S. In conjunction with our global strategy, Ed will work collaboratively with our Field Operations team to focus on increased visibility and profitable growth with select national partners. In addition, Wadhams will further collaborate and execute the strategy with our regional vice presidents, regional underwriters and business development staff. He holds a Bachelor of Science  degree in Communications from the University of Tennessee.

Appointments: Jon Tolzin, Regional Vice President, Northwest Region and Ed Wadhams, Vice President, A&H National Partnerships As an integrated specialist insurer and one of the largest insurance companies in the world, QBE applies deep technical expertise to deliver future-ready products, customized underwriting solutions and superior claims service. Working through preferred and limited distribution partners, they mobilize and synchronize market-facing functions to write multiple lines of coverage for our customers. They write over $14 billion in gross written premium and trade in all major insurance markets. Backed by the strength of their strong balance sheet and a welldiversified global portfolio, QBE provides customers the certainty they need to manage their business at home, and around the world. A key to their success as a business is our people, and they remain committed to recruiting, retaining and developing the best talent in the industry. At the heart of their culture is a commitment to our employees, their professional development, and providing them with career opportunities by promoting from within. QBE North America’s Accident & Health division is proud to announce the following appointments:

May 2017 | The Self-Insurer


Primary responsibilities

“These appointments demonstrate the importance we place on underwriting excellence, industry expertise and customer service,” said Steve Gransbury, President -- Accident & Health, QBE North America. “By identifying employees with unique skills and experience, while providing them with opportunities for impact in key leadership positions, we further invest in our development culture and our organization’s greatest asset, our people,” he added.

Serve as the primary trainer and resource for UW, new hire, and general product training.

Work with SL leadership team to assess baseline and prospective learning and development needs.

Evaluate data from Employee Engagement Survey, Brighter Way Initiatives, and varying VoC collection activities to identify key areas of focus.

Collaborate with leaders to assess specific needs by functional area and identify expected resource commitment required to develop and deliver training content.

Develop and implement learning strategy aligned with overarching Stop Loss strategic plan and identified learning and development needs.

Drive plan for comprehensive learning and organizational development initiatives across Stop Loss.

About QBE QBE North America is part of QBE Insurance Group Limited, one of the largest insurers and reinsurers worldwide. QBE NA reported Gross Written Premiums in 2016 of $4.6 billion. QBE Insurance Group’s 2016 results can be found at www.qbena.com. Headquartered in Sydney, Australia, QBE operates out of 37 countries around the globe, with a presence in every key insurance market. The North America division, headquartered in New York, conducts business through its property and casualty insurance subsidiaries. QBE insurance companies are rated “A” (Excellent) by A.M. Best and “A+” by Standard & Poor’s. Contact Amy Sandusky, AVP, Marketing Business Partner, Marketing & Communications, at amy.sandusky@us.qbe.com and visit www.qbena.com.

Sun Life Seeks Associate Director, Stop-Loss Training and Learning Development Role Summary The Associate Director, Stop-Loss Training and Learning Development will drive the business unit’s training and learning development strategy with the goal of increasing the expertise and talent across the collective organization. The Associate Director will work closely with stop-loss business leaders to assess learning and talent development needs across the business, and then develop and execute on a robust multi-year strategy to meet the identified needs aligned to our key business goals, imperatives, and initiatives. Initially, a key focus will be on underwriting training.

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May 2017 | The Self-Insurer


Coordinate, design, and implement training across all facets of the stop loss business. Design and develop new hire training curriculum. Research and model best practices in learning in order to ensure innovative, best-in-class training and performance support for Stop Loss organization. Partner with various subject matter experts to facilitate and deliver specific topic / expertise level training sessions Schedule, coordinate, and ensure successful execution of planned training sessions

Create metrics and reports to evaluate and present findings related to training impact and effectiveness.

Establish a framework for continuously measuring success of learning initiatives.


Bachelor’s degree

7+ years of experience working with Stop-Loss product in UW, Claims, Product Pricing, Quality, or Stop-Loss Operations

Ability to define strategy, overall direction, and effectively communicate vision to key stakeholders

Experience in collaborating with business leaders, supporting evolving business strategies, and driving to a collective identified goal

Ability to create and build learning and training programs that are innovative, comprehensive, and repeatable

Demonstrated expertise in leading through influence / can manage without authority

Direct experience with training or coaching -- has developed learning and knowledge solutions for a variety of roles

Proficient facilitation skills

Experience in partnering with SME’s to help facilitate or deliver training content

Can manage complexity -- distributed learners, centralized teams, and multi-site locations

Demonstrated ability to manage change throughout all levels of the organization

Interested candidates should email resume to Margaret Peterson at  Margaret.Peterson@ sunlife.com. About Sun Life Sun Life offers a variety of stop-loss insurance products and services that provide a great source of financial protection -- allowing companies to limit their liability for claims and maintain the budget. You can depend on their excellent sales, underwriting, and claims service. Plus, they deliver opportunities for companies to save money through cost-containment resources that can help lower health care costs even before a stop-loss claim occurs.  Visit www.sunlife.com/us/.

Silver Members

Qualifications •

The Self-Insurer | www.sipconline.net

HHC Group Launces New Website HHC Group announces the launch of its new, updated website – www.hhcgroup. com. This site is designed to give insurers and those who manage their cost-containment efforts an introduction to the company and its suite of highly-effective, cost-containment services. The site is also designed for use by HHC Group’s clients. It enables them to effectively and efficiently manage their claims-related, cost-containment efforts. Using the website, they can now securely submit claims, track claim status. They can download processed claims files, review their claim history, create reports and more, 24 hours a day seven days a week.

About HHC Group HHC Group is a leading national health insurance consulting company providing a wide range of cost containment solutions for Insurers, Third Party Administrators, Self-Insured Employee Health Plans, Health Maintenance Organizations (HMOs), ERISA and Government Health Plans. HHC Group utilizes a combination of highly skilled professionals and advanced information technology tools to consistently deliver targeted solutions, significant savings and exceptional client service.

For additional information about HHC Group, its new website and our services, email info@ hhcgorup.com or contact Bob Serber at rserber@hhcgroup.com, 301-963-0762 ext. 163, and visit www.hhcgroup.com.

HHC Group’s services include Claim Negotiation, Claim Repricing, Medicare Based Pricing, DRG Validation, Medical Bill Review (Audit), Claims Editing, Medical Peer Reviews/ Independent Reviews, Independent Medical Examinations (IME), Case Management Utilization Review, Data Mining, Disease Management and Pharmacy Consulting.

INNOVATIVE STOP LOSS AND ANCILLARY SOLUTIONS At BenefitMall, we know that employer groups benefit most from treating their health plan as an investment rather than an expense. Our team of self funded consultants can help you succeed by offering: U 1˜Lˆ>Ăƒi`ĂŠ Ă?ÂŤiĂ€ĂŒÂˆĂƒiĂŠ>˜`ĂŠ,iĂ›ÂˆiĂœ U ĂŠÂ˜ÂˆĂŒÂˆ>Â?ĂŠ*Â?>Vi“iÂ˜ĂŒ]ĂŠ“Â?i“iÂ˜ĂŒ>ĂŒÂˆÂœÂ˜ĂŠ>˜` ,i˜iĂœ>Â?ĂŠÂœvĂŠ ÂœĂ›iĂ€>}i U ĂŠ Â?>ÂˆÂ“ĂƒĂŠĂ•`ÂˆĂŒ]ĂŠ-Ă•LÂ“ÂˆĂƒĂƒÂˆÂœÂ˜]ĂŠ/Ă€>VŽˆ˜}] >˜`ĂŠ,iĂƒÂœÂ?Ă•ĂŒÂˆÂœÂ˜ĂŠ-iĂ€Ă›ÂˆViĂƒ U ĂŠ,iÂŤÂœĂ€ĂŒÂˆÂ˜}]ĂŠ ÂœÂ“ÂŤÂ?ˆ>˜ViĂŠ-iĂ€Ă›ÂˆViĂƒĂŠ>˜` *Â?>Â˜ĂŠ ÂœVՓiÂ˜ĂŒĂŠ,iĂ›ÂˆiĂœ U ˆÂ?Â?ˆ˜}ĂŠ>˜`ĂŠ*Ă€iÂ“ÂˆĂ•Â“ĂŠ ÂœÂ?Â?iVĂŒÂˆÂœÂ˜ U ˜VˆÂ?Â?>ÀÞÊ*Ă€Âœ`Ă•VĂŒĂƒĂŠ>˜`ĂŠ-iĂ€Ă›ÂˆViĂƒ



May 2017 | The Self-Insurer


We appreciate the positive response our medical stop loss coverage has received coast to coast. We look forward to bringing our iconic brand name, stellar balance sheet, and decades of underwriting experience to the medical stop loss marketplace for years to come.

Thanks. Asheville | Atlanta | Boston | Chicago | Houston | Irvine | Indianapolis Los Angeles | New York | San Francisco | San Ramon | Seattle | Stevens Point Auckland | Brisbane | DĂźsseldorf | Hong Kong | Kuala Lumpur London | Macau | Melbourne | Singapore | Sydney | Toronto


HIIG A&H has an opening for a Director of Clinical Risk Management to oversee CRM operations supporting our Medical Stop Loss product. Key Job Functions •

Serve as the lead resource for Medical Underwriting & Clinical Claims Management within the A&H division.

Identify potential high dollar medical claims, and project the expected claim costs for both prospective new business and in-force accounts.

Build strong relationships with internal and external clients to communicate risk factors, projected cost of claims, and facilitate communication with all parties to achieve cost savings on potential high dollar claims.

Manage, mentor and develop the HIIG A&H CRM staff.

Requirements •

Bachelor’s Degree with RN license required.

Ten years of relevant experience in medical underwriting, claims or cost containment, preferably with a stop loss carrier.

Prior clinical experience preferred.

May 2017 | The Self-Insurer



About HIIG

Any of the following regional offices:

Malvern, PA, Indianapolis, IN, Wakefield, MA, Atlanta, GA, Dallas, TX, Scottsdale, AZ.

HIIG A&H offers

1. A competitive base salary with performance based commissions

2. Leadership development through individualized support and mentoring

3. Medical benefits, STD/LTD, Life, Dental, Vision, 401k, PTO

4. Background check including drug screen

HIIG is a Houston based, fast expanding insurance group that provides creative solutions for our clients’ specialized needs. HIIG writes business throughout the USA and Internationally through its underwriting divisions that include Accident & Health, Construction, Energy, Professional, Transactional Property, and other Specialty business.  Visit www.hiig.com and www.hiigah.com.

Gold Members Berkshire Hathaway Specialty Insurance Seeks Stop-Loss Medical Risk Consultant Medical Risk Consultant Berkshire Hathaway Specialty Insurance is seeking a medical risk consultant to join their medical stop loss team. The ideal candidate will utilize professional and clinical knowledge to assess risk. These activities will provide BHSI medical stop loss underwriters, claim auditors and external clients with appropriate clinical assessment of the anticipated care needs and potential costs of identified claimants.

Interested candidates should email their resume to HR@hiig.


The Self-Insurer | www.sipconline.net

Look no further. Everyone claims to keep sight of the customer. But do they really? We do. At Companion Life, you can count on teamwork with individual attention. That’s a real advantage. We anticipate trends, identify opportunities, but, most importantly – we listen to you. We brainstorm with our partners. Together, we create products and solutions or carve out new distribution channels to get an early foothold in the market. Looking to the future is a large part of our vision. We focus on relationships and listening. Together, we’ll go places. Call us. We’ll take the time to listen.

stop loss limited benefit health plans short-term medical medicare supplement Rated A+ by A.M. Best Company. Rating as of Dec. 21, 2016. For the latest rating, visit ambest.com.

800-753-0404 Companion Life’s Specialty Markets

Essential Job Functions


Effectively explain complex clinical conditions to internal and external clients.

Build strong relationships with internal (UW’s, Claims) and external clients (TPA’s, external CM’s) to communicate risk factors and projected cost of claims.

Evaluate and assess both new business and renewal large claims/disclosure, clinical and claims data to identify known and potential risks and make potential cost recommendations to the stop loss underwriting team.

Serve as the lead resource for underwriting in identifying potential large claims, and to project the expected cost of the potential claim.

Quickly, thoroughly, and correctly assess a potential/actual claim situation to successfully influence risk decision makers, resulting in meaningful clinical and/or financial outcomes.

Document and effectively communicate claim projections and rationale to stop loss underwriters.

Develop a tracking system of claim cost projections and their effectiveness in reducing stop loss claims costs.

Bachelor’s Degree or equivalent combination of education and work experience.

RN license required.

Five years of relevant experience, preferably with stop loss carrier.

Prior clinical experience preferred.

Working knowledge of stop loss insurance policy and contract language.

Verified knowledge of ESL Office, particularly the Underwriting, Claims and Policy Administration modules.

Working knowledge of Microsoft Excel.

A Long Tradition of Insurance Solutions for Companies that Self-Fund Their Medical Plan Helping to better manage the risks associated with catastrophic claims

Manage the risks of self-funding.

AIG’s Group Benefits business has decades of experience in helping companies manage the risks of self-funding through stop loss, specified disease organ transplant, group captive, and Taft-Hartley solutions. Learn about all the ways AIG’s Group Benefits business is here for you. Talk to one of our representatives or visit us online at aig.com/us/benefits.

The underwriting risks, financial and contractual obligations, and support functions associated with products issued by National Union Fire Insurance Company of Pittsburgh, Pa., are its responsibility. National Union Fire Insurance Company of Pittsburgh, Pa., maintains its principal place of business in New York, NY, and is authorized to conduct insurance business in all states and the District of Columbia. NAIC No. 19445. Coverages may not be available in all states. © 2016. All rights reserved. AIGB100939 R03/16


May 2017 | The Self-Insurer


Excellent oral, written, and interpersonal communication skills to achieve positive outcomes.

Detail oriented.

Interested candidates should email their resumes to Ruth Weaver at Ruth.Weaver@bhspecialty.com. About Berkshire Hathaway Specialty Insurance Berkshire Hathaway Specialty Insurance provides medical stop loss, commercial property, casualty, healthcare professional liability, executive and professional lines, surety, travel, programs, and homeowners insurance.  Visit www. bhspecialty.com.

Do you aspire to be a published author? Do you have any stories or opinions on the self-insurance and alternati ve risk transfer industry that you would like to share with your peers? We would like to in vite you to share your insight and submit an article to The Self-Insurer ! distributed in a digital and print format to reach over 10,000 readers around the world. The Self-Insurer has been delivering information to the self-insurance /alternative risk transfer community since 1984 to self-funded employ ers, TPAs, MGUs, reinsurers, stoploss carriers, PBM s and other service providers.

Articles or guideline to Editor Gretchen Grote at ggrote@sipconline.net also has advertising opportunities available. Please contact Shane

Byars at sbyars@sipconline.net for advertising information.


The Self-Insurer | www.sipconline.net

It’s Your Health Plan Data —

TAKE CONTROL Lucent Health continues to innovate compelling and proprietary technology solutions that enable Employers to have more visibility into their healthcare spend and to control it.



The Self-Insurer | www.sipconline.net

SIIA would like to Recognize our Leadership and Welcome New Members 2016 Board of Directors CHAIRMAN* Jay Ritchie Executive Vice President Tokio Marine HCC – Stop Loss Group Kennesaw, GA PRESIDENT/CEO Mike Ferguson SIIA, Simpsonville, SC TREASURER & CORPORATE SECRETARY* Duke Niedringhaus Senior Vice President, J.W. Terrill, Inc. Chesterfield, MO CHAIRMAN-ELECT* Robert A. Clemente CEO Specialty Care Management LLC Lahaska, PAKennesaw, GA

Directors Adam Russo Chief Executive Officer The Phia Group, LLC Braintree, MA Joseph Antonell CEO/Principal A&M International Health Plans Miami, FL Kevin Seelman Senior Vice President Lockton Dunning Benefit Company Dallas, TX Andrew Cavenagh President Pareto Captive Services, LLC Philadelphia, PA Mark L. Stadler CEO BridgeHealth Denver, CO

Mary Catherine Person President HealthSCOPE Benefits, Inc. Little Rock, AR David Wilson President Windsor Strategy Partners, LLC Princeton Junction, NJ

Committee Chairs CAPTIVE INSURANCE COMMITTEE Michael P. Madden Senior Vice President Artex Risk Solutions, Inc. San Francisco, CA

HEALTH CARE COMMITTEE Kari L. Niblack Executive Vice President of Client Engagement & Services Apex Benefits Indianapolis, IN INTERNATIONAL COMMITTEE Robert Repke President Global Medical Conexions, Inc. Novato, CA WORKERS’ COMP COMMITTEE Stu Thompson CEO The Builders Group Eagan, MN

GOVERNMENT RELATIONS COMMITTEE Lawrence Thompson Senior Vice President, Sales & Client Services POMCO Group Syracuse, NY

May 2017 | The Self-Insurer


SIIA New Members Regular Corporate Members Paul Lavin President & CEO American Health Holding New Albany, OH Lena Andrews Vice President/COO Benefit Support, Inc. Gainesville, GA Elizabeth Turbitt Senior Vice President Cevian Intermediaries Berwyn, PA Roberta Wachtelhausen SVP & Chief Sales & Marketing Officer ConnectiCare, Inc. Farmington, CT

Maureen Pfeiffenberger Vice President, Client Consulting Murray Securus Lancaster, PA Rafael Carrillo CEO My Spine Treatment Center San Diego, CA Mary DeWitt Redirect Health Scottsdale, AZ Albert Ertel President/CEO Secure Health Plans of Georgia Macon, GA

Rick Burd President Contribution Health, Inc. Lancaster, PA

James Pennington President & CEO The Health Plan St. Clairsville, OH

Dino Sciulli President DS Benefits Group Medina, OH

Libby Henry Risk Consultant Thomas McGee, L.C. Kansas City, MO

Jeffrey Zavada President Exceedent LLC Menomonee Falls, WI

Chuck Bryan Senior VP of Sales & Marketing XeoHealth Corporation Frederick, MD

Christopher Moyer Vice President HealthNow Administrative Services Blue Bell, PA William Pace Producer Lockton Companies Memphis, TN


Tom Fabris President MedCost Solutions Canton, OH

The Self-Insurer | www.sipconline.net

Silver Member Charles Lavelle Partner Bingham Greenebaum Doll LLP Louisville, KY Alex Giordano President & CEO Monumental Risk Strategies Irving, TX Tom McGraw President & CEO Noridian Healthcare Solutions Fargo, ND Francesca Hartop CEO Zebu Compliance Solutions Portsmouth, OH

Employer Member Tracy Foss Director of Operations Kairos Health Arizona, Inc. Phoenix, AZ Marilyn Bartlett Administrator State of Montana Helena, MT

Better Service. Better Performance.

Experience Zelis Healthcare.

Network Solutions

Claims Integrity


Provides Discounts and Access to Networks

Ensures Appropriate Reimbursement for Care

Efficient and Timely Payment and Data

Zelis Healthcare is a healthcare information technology company that provides solutions which address pre-payment to payment needs across the claims life cycle.

Find out what Fully Integrated Healthcare Cost Management can do for you! Visit us at Zelis.com Copyright 2016 Zelis Healthcare. All rights reserved.

Another $500,000 claim? We can help. EthiCare saves claim payors money. Period.

888.838.4422 Savings@EthiCareAdvisors.com


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Self Insurer May 2017  

Self Insurer May 2017