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September 2017

The World’s Leading Alternative Risk Transfer Journal Since 1984

Staying Safe: A Tale of Two Captives Differing programs that help manage high-risk construction for work comp and other lines lay groundwork for safety culture

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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



Volume 107

Staying Safe:


Differing programs that help manage high-risk construction for work comp and other lines lay groundwork for safety culture

22 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

A Tale of Two Captives



By Bruce Shutan


EDITORIAL ADVISORS Bruce Shutan Karrie Hyatt

Outside the Beltway SIIA delegation ready to appear on Proposed Nevada stop-loss regulations

Mobile Medicine Offers Quicker Treatment, Better Outcomes

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

Regulating Insurers’

Cybersecurity By Karrie Hyatt


Paying Attention to Cancer Pays Off for Your Employees


Aid-in-dying laws and the Implications for Self-Funded Plans


SIIA Endeavors


News from SIIA Members

September 2017 | The Self-Insurer


Staying Safe: A Tale of Two Captives

Differing programs that help manage highrisk construction for work comp and other lines lay groundwork for safety culture


n the hardscrabble construction space, building a safety culture with the help of a group or single-parent individual captive insurance program is critical to managing self-insured workers’ compensation or even bolstering the bottom line.

It also can tug at the heartstrings of burly workers in hard hats when explained in the simplest terms, while residual effects can include improved job satisfaction, morale, loyalty, performance, recruitment and retention. These results offer a competitive leg up in an industry that often struggles to find safety minded talent with staying power.

By Bruce Shutan

Most construction workers who live paycheck to paycheck fear they’ll be homeless in the event of a serious accident on the job, says Charles H. Weiss, president of Scaffold Resource LLC. His firm is one of 39 high-risk or heavy construction members of a homogenous group captive program that underwrites the work comp, general liability and auto risks of more than 3,000 lives. Asked to close their eyes and imagine how loved ones would react to news about their father being seriously hurt or dying at work, he reports that “I get grown men tearing up.”


A similar story unfolds at Nibbi Bros. Associates Inc., which took a different approach in forming a single-parent individual captive in 2011 featuring nearly a dozen coverage lines with a focus on workers’ compensation and domiciled in Delaware. “We do a lot of training on safety,” reports Rick Fedick, the company’s CFO, who also notes its importance relative to an employee’s career path. “If you’re going to be promoted or think you’d like to be promoted from a lead man to a foreman or a foreman to assistant superintendent, you have to have these courses already under your belt before you do that. “Every employee for Nibbi has OSHA 10 already,” he continues. “Anybody in a supervisory role has OSHA 30. I have OSHA 30, and our president has OSHA 30, so we’re very safety-conscious. It saves you a lot of money in the long run.”

competitors cannot believe. Hand injuries can be significant considering that “our guys are touching 300 pieces of metal every day,” he reports, noting the potential for pinches and splinters that can undermine performance and raise claim costs. Of about 13 scaffold companies in the Washington, D.C. area, Weiss says his is the only one with at least one full-time person exclusively assigned to safety (they actually have two). Many Scaffold Resource employees encounter safety professionals on their job at least twice a week in addition to attending a morning hazard awareness meeting at the beginning of every shift that addresses specific job concerns and monthly safety roundtables. They learn the proper way to lift to avoid painful and costly lower-back or soft-tissue injuries, as well as stretches to stay limber. Every employee of Scaffold Resource carries a safety pledge card, which reads: “Safety

is the most important part of my job! Production is never more important than safety! It is my job to make sure every worker on the jobsite returns home to his family every day, without injury or harm. I make this pledge to my family and co-workers.”

An unflinching commitment to safety has paid off for the San Francisco-based general contractor, which builds anything from piers and parking lots to the city’s airport and low-income housing. It received the 2016 Excellence in Safety Award from the Construction Employers Association.

Showing leadership Both Nibbi and Scaffold Resource take a top-down approach to safety that trickles from executives and managers to the rank and file. “The guys have to know that the owner cares,” Weiss says. One way certainly is an eye-popping investment his firm has made in equipment, which includes $30 gloves and $150 helmets with a chin strap that

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The lines of communication are always open at Nibbi, which sends out a four-page monthly newsletter that features a safety section alongside company announcements. Company barbecues also are periodically held for various milestones being reached, as well as every quarter for the cleanest job. This allows employees and managers an opportunity to bond, as well as briefly address the importance of safety. In addition, there’s a program requiring new hires to wear a yellow hardhat for at least 60 days during which their commitment to safety, or any bad habits they had developed, is assessed. One or more superintendents will grade their performance and issue a white hardhat when they pass muster and feature their “graduation” photos in the employee newsletter.

Different methods Since there are numerous types of captive arrangements, one size clearly does not fit all self-insured employers. Scaffold Resource, for example, saw strength in numbers. About 150 covered lives from the company are part of a group captive that was assembled specifically around scaffolding and bridge painters, erectors, underground construction workers, truck drivers and others. It took Weiss about a decade to finally find this solution. Each member underwent an extensive vetting process that closely examined their previous risk and losses before being admitted to the group. The captive has approximately $250 million total payroll and about $18 million in premium. “Our insurer was only paying out 15% of our premium” before joining the captive, he says. “With this system, we get back that which we individually don’t pay out and that which the collective group does not pay out. So we take risk up to $100,000, and everything between $100,000 and $350,000, we risk-share.”

One major safety hazard on Nibbi’s proverbial radar is silica dust produced by cutting concrete or drywall, which can be very harmful to people and is addressed in changing regulations. “It’s the new asbestos,” Fedick explains, noting about two dozen different applications that could create this hazard. Nibbi construction workers – whose number fluctuates from about 150 to 200, depending on seasonal demand – are trained to use the right personal-protection equipment and tools for the right job. They’re encouraged to immediately stop a job at any level if they see something and they’re not sure about it if encountering a life-threatening situation. “If you’re running a forklift,” Fedick adds, “you have to be certified.” Certification requirements or renewals are tracked through the HR department. September 2017 | The Self-Insurer


STAYING SAFE | FEATURE Although Weiss believes a group captive can be difficult at first to understand among small-business owners, he’s grateful for taking a leap of faith and knowing his broker wasn’t going to risk $1 million-plus worth of premium putting his firm in the program.

“We have safety seminars and workshops, and share best practices with each other,” he says. “It gives us the collaborative efforts of a huge group of people with 39 safe companies.” Weiss hopes to “keep getting better people in the captive through our collaborative efforts. We’re all partners, so we have to have transparent dialogue on what our best practices are and learning from people in the captive group.” All 39 construction vendors meet offshore twice a year to share best practices with a basic philosophy in mind. “I’ve got to make sure I stay safe so I retain a competitive advantage,” he says. “If I get a little bit sloppy, I may not be in this group anymore.” While it’s tempting to share helpful safety benchmarks with like-minded employers, in some cases there are advantages to focusing all efforts internally. It made sense for Nibbi to pursue a single parent vs. group captive approach, according to T.J. Scherer, an account executive with Artex Risk Solutions, Inc., the captive manager for Nibbi, and a member of SIIA’s Captive Insurance Committee. “Nibbi had a couple large losses on work comp, but overall runs very low losses on all three lines of AL, GL and work comp and the market is responding to that by getting better rates,” he reports.

Fedick was more interested in focusing on the company’s own risk and decisions. Nibbi also was unsure if it had high enough main lines (auto and general liability, as well as work comp) premium to qualify for a group captive. “Being in a single captive works pretty well for us,” he says. “We pool some risk, but for the most part, we’re looking after ourselves.” Fostering a safety culture, of course, extends beyond work comp and involves other exposures. “Safety is all-encompassing on a job site or in the office,” Fedick notes. “But it’s just not thinking about the workers or crane operator who’s lifting stuff out over roadways; you’ve also got to think about pedestrians and tenants in buildings that we’re doing some renovation work for, and safety is everywhere, on all directions.”

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At Scaffold Resource, the same thinking spills from construction sites to the road below. Truck drivers, for example, are given a morning safety checklist required by law. They also attend the same safety classes and monthly meetings alongside workers in the field.

Gauging results A strong safety culture is credited for 1.4 million man hours having been logged by Scaffold Resource employees without a lost time recordable injury in the past five years, which the company describes in a promotional video as almost unheard of in the scaffolding industry.

in an enviable position among the group captive’s top 20% performers. Weiss describes the middle 60% as “the ones they break even on, and the lower 20% are the ones that we fund.” After the overhead burden, Weiss says his firm individually and collectively shares in the group’s success. If money is available, he points to a 4% or 5% rate of return on premium. “We’ve paid out about 10% of our premium, so that puts significant money and equity in my pocket from taking advantage of risk savings,” he explains, noting how the accumulating interest income reduces risk costs substantially, now and in the future. “We’re not funding a commercial insurance company; we’re funding our businesses.” Fedick explains that Nibbi “used to carry on our balance sheet an accrual to cover any insurance deductibles.” The company’s captive absorbs deductibles and shields Nibbi Bros. Associates from any deductible denting its financial statements.

There also has been a significant reduction in premium at the company, which finds itself

September 2017 | The Self-Insurer



A safer employment contract

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 also has advertising opportunities available. Please contact Shane

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There are larger strategic business considerations that are tied to deciding on a captive program. Many employers are struggling to lure and keep safety conscious employees across a number of industries, according to Duke Niedringhaus, SVP at J.W. Terrill, a Marsh & McLennan Agency LLC company who serves on SIIA’s Board of Directors. As such, he sees movement toward “a holistic management of casualty exposures” driven by work comp that allows companies with a best-in-class safety culture to maximize their program results. Nibbi adopts a three-legged stool approach to hiring, whose job requirements include experience and education, a desire to do the work and fitting the company’s culture. New hires are also assigned a mentor with whom they discuss safety, while jobsite safety reviews are done every month. Nibbi’s mission statement starts with safety in the first paragraph. Multiple breaches of safety protocols can lead to an employee’s dismissal, though Fedick says all the intensive training of the past three years has largely prevented that from happening with Nibbi employees. The safety effort at Scaffold Resource includes a pre-employment and post-accident drug screenings.

“Most of our people are from referrals, so they know that we have a safety culture,” Weiss reports, noting that they’re also paid at or above market wages to drawn top talent. “By showing them how safe you act, they know people care.” He says the significant amount of money Scaffold Resource spends to ensure its workforce stays safe is a good business practice that customers appreciate. “It’s a sales tool and revenue generator because people want safe teams on their sites,” Weiss adds. Bruce Shutan is a Los Angeles freelance writer who has closely covered the employee benefits industry for 28 years.

Regulating Insurers’



n the wake of increasingly high-profile cyber security attacks, regulatory bodies are looking to inact compulsory comprehensive cybersecurity risk management programs to emphasize data security and streamline what happens after a cyber attack. Earlier this year, the New York Department of Financial Security (NYDFS) began requiring cybersecurity programs for financial companies, including banks and insurers. The National Association of Insurance Commissioners’ (NAIC) Cybersecurity (EX) Working Group is currently working on a model law to help state insurance departments regulate this growing concern.

By Karrie Hyatt

So far, 2017 has seen a number of high-profile cyber security events. Experts agree that cyber crime is only going to get worse as people and companies become even more technology dependent. While many of the best-known events in the first half of 2017 were ransomware attacks—an attack where malware is used to take over another computer system or network and then hold its


data hostage—any type of cybercrime can have the potential to expose nonpublic information. By their very nature, insurance companies maintain a vast amount of private information for the individuals and companies they insure which makes them a significant target for a cyber security event. Concerned for the potential cyber exposures insurers face, state regulators and those in the industry are looking for ways to prevent and counteract any attacks. Appeals have even been made to the federal government to create uniform regulation for insurers and other financial institutions. In late July, the U.S. House Committee on Small Business met with business owners and insurance representatives about the lack of uptake of cyber liability insurance by smallto medium-sized companies.

NYDFS 23 NYCRR 500 In February of this year, NYDFS posted to the New York state register new requirements regarding cybersecurity for all NYDFS-regulated entities—including banks, insurance companies, and other financial institutions. The requirements went into effect on March 1 and affected companies need to file a Certification of Compliance with NYDFS’ Cybersecurity Regulations office on an annual basis starting next February. Exempted are companies with fewer than ten employees, have less than $5 million in gross revenue, or less than $10 million in year-end total assets. Regulation 23 NYCRR 500 emphasizes data security ahead of post-attack and reporting procedures and is quite broad in its scope. The new regulations focus on:

Insurance representatives took the opportunity to speak about standardizing cyber security regulation nationwide. While nearly every state has its own version of how data breaches are to be reported, this is burdensome to the industry. If regulatory processes were uniform it would help reduce insurance costs so small businesses could take better of the products available on the market.


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• Cybersecurity Program and Policy • Risk Assessment, Penetration Testing and Vulnerability Assessments, and Audit trail • Chief Information Security Officer, Personnel, Accesses, and Training • Encryption of Nonpublic Information, Multi-Factor Authentication, and Limitations on Data Retention

• Third Party Service Provider Security Policy • Incident Response Plan and Notices to Superintendent


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As required, each entity must have a specially designed cybersecurity program and cybersecurity policy that includes written policies that will protect “confidentiality, integrity, and availability” of the entity’s information systems. Entities must conduct periodic risk assessments of the company’s information systems to inform cybersecurity programs and policies as well as monitoring and testing of the cybersecurity program and maintaining an audit trail of at least five years. Financial entities will need to appoint a qualified Chief Information Security Officer to enforce cybersecurity policies and hire appropriate cybersecurity personnel. Companies must also limit accesses to nonpublic information and provide cybersecurity awareness training. Firms need to have controls to protect nonpublic information including encryption and multi-factor or risk-based authentication and must have policies and procedures for the secure disposal of certain nonpublic information. Companies need to have written policies and procedures in place that identify risks involving third party services providers, including cybersecurity practices that those providers must meet, as well as due diligence processes and periodic assessments in place.


Finally, firms must have a written incident response plan that will allow them to promptly address any cybersecurity event both internally and externally as well as immediately notifying the NYDFS. The NYDFS was very clear that risk retention groups (RRGs) would not be subject to this regulation. RRGs, while operating across state jurisdictions, are by law only to be regulated by their state of domicile. While many RRGs operate in the state of New York, there are no RRGs domiciled there.

September 2017 | The Self-Insurer



NAIC Insurance Data Security Law In 2015, the NAIC formed Cybersecurity (EX) Working Group as a subgroup to the Executive (EX) Committee to monitor developments in the area of cybersecurity and insurance companies. Since that time the subcommittee has been working to create a model law to help guide state insurance regulators with cybersecurity concerns. The first draft of the Insurance Data Security Law was released in early 2016 and has been undergoing a drafting process since then. During the drafting process, in its sixth iteration at the beginning of August, parties outside NAIC members that have been active in commenting range from the American Bankers Association to Blue Cross Blue Shield Association to the National Association of Professional Insurance Agents.


The prevailing endorsement among the commenters has been the Working Group’s efforts to streamline and standardized the regulation of this complex and changing issue. The draft model law is heavily based on the NYDFS’s regulation, but is more narrowly focused to just insurance companies. The primary differences from NYDFS’s regulation 23 NYCRR 500 and the proposed model law are few but important. The NAIC clearly recognizes that the Board of Directors of an insurance company is primarily responsible for its cybersecurity program. The model law is more explicit regarding security breaches involving reinsurers. The NAIC’s version also require more extensive information be given to the insurance commissioner in the event of an attack, but provides for confidentiality protections to keep private information from being made public. In the drafted model law, RRGs are subject to the law, but only in the state in which they are domiciled—not in those states in which they are registered. The Liability Risk Retention Act stipulates that RRGs are only to be regulated by their domicile state, regardless of how many other states they operate in. Captives, as the draft law stands in version 6, are not explicitly excluded from the model law. Richard Smith, president of the Vermont Captive Insurance Association (VCIA)—the largest association of its kind—wrote in a statement regarding version 5 of the model law, “VCIA recognizes that the NAIC might, in the future, seek to incorporate an Insurance Data Security Model Law as part of its accreditation standards. We note that the accreditation standards do not apply to single-parent or association captive insurance companies, or any other insurance company that does business in a single jurisdiction.”

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One of the most contentious points in the NAIC’s version is the language concerning “Oversight of Third-Party Service Provider Arrangements.” There has been much debate about the language describing third-party providers and their role in an insurer’s cybersecurity program.

As cybersecurity threats continue to loom large uniform regulation of cybersecurity programs has become imperative—both to regulators and to the industry.

Smith, in his comment letter on draft version 5, voiced concern over the third-party service provider section in regards the exemption for small businesses with ten or fewer employees—including independent contractors, “Small insurers often have fewer than ten employees but may retain a manager that is a large organization with thousands of employees, such as Marsh or Aon. We do not think it is the NAIC’s intent, nor do we think it would make any sense to count all of the manager’s employees for purposes of determining whether a small licensee qualifies for the exemption under Section 9.” He asked for further clarification on that point.

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:

The Insurance Data Security Law was approved by the Cybersecurity (EX) Working Group at the NAIC’s Summer Meeting in August. Now it will go before the Innovation and Technology (EX) Task Force for approval before being brought to the NAIC Executive (EX) Committee. Once approved by the Executive Committee it will need to be voted on by all NAIC members. From there it will go to the states for individual adoption, so nationwide uniform regulation is still several years away.

September 2017 | The Self-Insurer



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the Beltway written by Dave Kirby

SIIA delegation ready to appear on Proposed Nevada stop-loss regulations

NEVADA SIIA political action volunteers prepared to appear at the Nevada Department of Insurance (DOI) in Carson City to contribute to the state’s proposed stop-loss insurance regulations whose first draft provided significant potential challenges to self-insuring employers. When SIIA requested a meeting to present its comments, it was invited to join the DOI’s informal working group comprised of members of the Nevada insurance industry, then expanded to include interested parties from beyond the Silver State. SIIA’s participation in the working group had not been scheduled by the time this issue was prepared.

“Our experience is that it’s always better for members to appear in person on issues that affect the self-insurance industry in any state,” said Adam Brackemyre, Vice President of State Government Relations. SIIA’s representatives include SIIA Chairman Jay Ritchie, Government Relations Chairman Larry Thompson and Government Relations Committee member Catherine Bresler. The Nevada DOI’s examination of stop-loss regulations began earlier this year with the drafting of revised stop-loss regulations by the original working group comprised of members of the Nevada Insurance Commissioner’s Advisory Committee on Health Care and Insurance. The draft included these elements;

• Increasing the minimum individual attachment point from $10K to $20K. • Dropping the per-person aggregate. • Requiring standard financial information to be disclosed in a small group stop-loss contract.

• Prohibiting lasering in small group contracts. • Prohibiting stop-loss contracts to groups with 15 or fewer eligible employees.

“Obviously, we are pressing to make sure that SIIA’s positions are considered, and that these regulations provide the best options for Nevada employers of all sizes,” Brackemyre said. Government Relations Committee Chairman Thompson has a long history with such issues on both national and state levels. “We’re most effective when we provide an educational experience in a cooperative and consultative manner,” he said. “So we’ll be conciliatory in Nevada’s process and look for ways to serve their mission of protecting the state’s insurance consumers.

September 2017 | The Self-Insurer


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“There are elements of the proposed regulations that we could live with and also some that provide considerable concern on our part,” Thompson said. “First, we don’t believe it’s a good idea to ban the benefits of stop-loss insurance for groups of 15 or fewer employees. In many instances, very small groups are well-served by stop-loss. Rather than the government arbitrarily setting a limit, they could let the economics of a group’s needs be in control. “Second, the matter of disclosure in this context is troubling because it seems to indicate that Nevada would be confusing stop-loss insurance with health insurance,” Thompson said. He points out that the U.S. House of Representatives has drawn the line between the two by passing the SIIA-backed Self-Insurance Protection Act (SIPA) that specifically sets stop-loss apart as it covers losses by a self-insurance plan but does not pay specific health care claims to any individuals. SIIA continues to seek introduction of a companion bill in the U.S. Senate.

question is, who is best positioned to provide that? The Department’s initial draft regulation demonstrates a lack of understanding about how self-funding with stop-loss truly benefits employers of all sizes. “That’s why it’s important for us to stay involved, especially for the educational benefit we can provide. The more light we can shine on the subject, the clearer the benefits of stop-loss insurance to Nevada employers will be,” she added. As SIIA’s delegation waits for the green light to visit the Nevada DOI in Carson City, they continue to expand their intelligence on the state’s stop-loss market.

“It will strengthen our position to receive comments about stop-loss cases from SIIA members in Nevada as well as selfinsuring employers,” Brackemyre said. SIIA members who wish to comment on these points or join the state government relations advocacy team are invited to contact Adam Brackemyre at the Washington, DC, office, (202) 463-8161 or

Asking stop-loss carriers to provide broad financial disclosure appears to SIIA to require the levels of communication or coordination among carriers and administrators that are provided by traditional fullyinsured health carriers, but are unavailable to stop-loss carriers. “Stop-loss carriers should not be compelled to disclose information they do not reasonably have,” Thompson said. Government Relations Committee member Bresler said, “We can all agree that clients need plenty of information in order to make their best decisions but the

September 2017 | The Self-Insurer


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Loss Reserving

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Communication is Key to Successful Collateral Negotiations Collateral negotiations can often be contentious, and opinions on how much is required can significantly differ. An objective discussion between each party’s actuaries can lead to valuable middle ground.

Derek W. Freihaut FCAS, MAAA Why Parties Disagree A self-insured and an insurance carrier may disagree on a program’s required collateral amounts. Each side has its own motives and viewpoints. The self-insured wants to minimize its program costs, while the carrier has a solvency focus and needs sufficient capital to mitigate credit risk and meet regulatory requirements. Beyond motive, the two parties’ views of the program’s risk often vastly differ. A self-insured tends to trust the results of its business plan and claims process. Any unfavorable experience may be explained away, or changes may be made to correct problems and improve experience going forward. The carrier relies upon its own, much larger body of data to project the self-insured’s ultimate claims experience and develops the loss data based on its aggregate industry experience. While recognizing the self-insured’s business plan and claims process, the carrier is aware of similar self-insureds with adverse loss development. Carriers also have a greater appreciation of claims incurred but not reported (IBNR) and the potential for future development due to their size and longevity. Coming to an Agreement – Getting the Actuaries Together The negotiation’s starting point is usually estimates of unpaid claims liabilities developed by the actuaries for both the self-insured and the carrier. Understanding why these estimates can differ is invaluable and requires that both parties speak the same language -which is often Actuarial. While the self-insured is more likely to provide actuarial support in making its case, the carrier often does not share its actuarial study. And although a significant portion of the negotiation is based on these studies, the actuaries are not always involved in the conversation. The two sides rely on separate

actuarial studies with differing results. While the parties involved may understand the basics, they may not recognize some key differences in assumptions or where one actuarial study may be stronger than the other. Dialogue between actuaries can be the quickest, most efficient way to highlight the differences between collateral estimates. Sharing exhibits supporting the self-insured actuary’s analysis and diagnostics, as well as discussion of methodologies, differences in data, key assumptions and operations can be invaluable. Conclusion Due to its impact on a self-insured’s profitability and borrowing capacity, the amount of collateral required can lead to tough negotiations. At Pinnacle, we work with our clients, regulators and auditors to ensure our reports are clear and well supported. The selfinsured’s actuary must provide enough information to enable the carrier to best understand IBNR potential. Though no one usually “wins” a collateral negotiation, a self-insured can make a much stronger case to the carrier with the right amount of involvement from its own actuary. Derek Freihaut is a Principal and Consulting Actuary with Pinnacle Actuarial Resources, Inc. in the Bloomington, Illinois office. He has over 10 years of actuarial experience in the property/casualty insurance industry, with considerable experience in assignments involving loss reserving, funding studies, loss cost projections, captive feasibility studies, risk transfer analyses and personal and commercial lines ratemaking.

Commitment Beyond Numbers



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


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Avoiding Common Practices That Violate The Mental Health Parity And Addiction Equity Act 1 The Paul Wellstone and Pete Dominici Mental Health Parity and Addiction Equity Act of 2008 (“MHPAEA”)2 is designed to require true benefit parity between medical benefits for physical conditions and mental health and substance abuse benefits. 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).

Before diving into the prohibited terms and practices, let’s take a minute to review what aspects of a plan’s design and/or administration constitute NQTLs. The regulations provide the following non-exhaustive illustrative list of NQTLs that should be analyzed.

• Medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative;

• Formulary design for prescription drugs; • For plans with multiple network tiers (such as preferred providers and participating providers), network tier design;

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

• Plan methods for determining usual, customary, and reasonable charges;

• Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective (also known as fail-first policies or step therapy protocols);

• Exclusions based on failure to complete a course of treatment; • Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage;

• Limitations on inpatient services in situations where the participant is a threat to self or others;

• Court-ordered or involuntary treatment; and Our focus will be on NQTLs, and in particular those practices that have been identified in recent regulations or subregulatory guidance as violating the MHPAEA. These practices include plan terms that violate the MHPAEA on their face, as well as administrative and procedural practices that are impermissible. In this regard, the Department of Labor (DOL) maintains a website to help plans comply with the MHPAEA.3 Among other things, the

• Services provided by clinical social workers.

Now that we know what to look at, let’s see what we should look for. Here is a list of plan terms and operations/procedural practices that have been identified by DOL as being impermissible NQTLs. Of course, this is not an exhaustive list.

DOL has a posted a list of “warning signs” that require further consideration under the MHPAEA and a self-compliance tool that includes MHPAEA provisions.4

September 2017 | The Self-Insurer






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Issues with Plan Terms • A plan applies the same prior approval requirement and evidentiary criteria to medical/ surgical (“Med/Surg”) benefits and mental health/substance use disorder (“MH/SUD”) benefits, but the penalty for not obtaining prior approval differs. For MH/SUD claims without prior approval, no benefits are paid. For Med/Surg claims there is a 25% reduction in the benefits the plan would otherwise pay. Since the penalties for failing to obtain prior approval are greater for MH/SUD benefits than they are for Med/Surg benefits, the plan violates MHPAEA.

• An employee must exhaust his/her EAP counselling sessions before accessing MH/SUD benefits, while there is no similar requirement for Med/Surg benefits. Since the EAP exhaustion requirements only apply MH/SUD benefits, the provision violates MHPAEA.

• The plan automatically excludes coverage for inpatient substance use disorder treatment in any setting outside of a hospital (such as a freestanding or residential treatment center). For inpatient treatment outside of a hospital for other conditions, including Med/Surg benefits and MH/SUD benefits other than substance use disorder, the plan will provide coverage if the prescribing physician obtains authorization from the plan that the inpatient treatment is medically appropriate for the individual, based on clinically appropriate standards of care. The plan violates MHPAEA because of the differing treatment of substance use disorders as to residential treatment centers.

• A plan excludes coverage for inpatient, out-of-network treatment of chemical dependency when obtained outside of the State where the policy is written. There is no similar exclusion for inpatient/out-of-network Med/Surg coverage. The plan violates MHPAEA because of the geographic limitations on treatment for chemical dependency but not on other benefits.

• A plan requires prior authorization for all outpatient MH/SUD services after the ninth visit and will only approve up to five additional visits per authorization. With respect to outpatient Med/ Surg benefits, the plan allows an initial visit without prior authorization. After the initial visit, the plan pre-approves benefits based on the individual treatment plan recommended by the attending provider based on that individual’s specific medical condition. There is no explicit, predetermined cap on the amount of additional visits approved per authorization. While the plan is more generous with respect to the number of visits initially provided without preauthorization, the plan still violates MHPAEA because of the cap of five additional visits for MH/SUD benefits with no cap on Med/Surg benefits.

• A plan excludes treatment of chronic behavior disorders (any condition lasting more than six months) but does not impose any limits on chronic Med/Surg benefits.

September 2017 | The Self-Insurer


• A plan requires participants to obtain prior authorization for substance use disorder treatment and non-emergency admissions to MH/SUD treatment facilities while not requiring pre-authorization for Med/Surg benefits.

• A plan excludes coverage for residential level of treatment for substance use disorders in a substance use disorder treatment center but provides benefits for extended care expenses for Med/Surg benefits in similar settings such as a skilled nursing facility and hospice through home health care services.

• A plan imposes the following requirements for MH/SUD benefits with no comparable requirement for Med/Surg benefits: (1) a written treatment plan prescribed and supervised by a behavioral health provider, (2) follow-up treatment, and (3) a restriction that the written plan be for a condition that can favorably be changed (presumably with treatment).

Operational or Procedural Issues • A plan has identical preauthorization requirements for both Med/Surg and MH/SUD benefits. In practice, however, Med/Surg benefits are routinely approved for seven days after which a treatment plan must be submitted by the patient’s attending provider and approved by the plan while for MH/SUD benefits routine approval is given only for one day, after which a treatment plan must be submitted by the patient’s attending provider and approved by the plan. Although the plan’s terms are identical with respect to MH/SUD benefits and Med/Surg benefits, the differing application of the Plan’s


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preauthorization requirement violates MHPAEA.

• A plan will not cover “black box” warning drugs (i.e., certain prescriptions drugs labelled regarding serious or life-threatening reactions) for antidepressants but will cover black box warning drugs for other MH/ SUD conditions as well as Med/Surg conditions if the prescribing physician obtains authorization from the plan that the drug is medically appropriate for the individual, based on clinically appropriate standards of care. Even though black box warning drugs are provided for other MH/SUD conditions, the singling out of antidepressants for exclusion while black box warning drugs are available for all Med/Surg benefits violates MHPAEA.

Conclusion Employers may be responsible for penalties under the MHPAEA, whether they sponsor self-funded or fully-insured plans. Accordingly, a careful review of plan terms and administrative practices should be undertaken to insure compliance. The examples in this article should provide a good starting point for that review, but these are only illustrative of the types of provisions that can be problematic. Employers will likely need to engage legal counsel and the plan’s insurer/claims administrator to get a more thorough evaluation.

References: 1 Steven Mindy, a senior associate in Alston & Bird’s Washington DC office assisted with this article. 2 The MHPAEA amended Section 712 of ERISA, Section 2705 of the Public Health Services Act and Section 9812 of the Internal Revenue Code. 3 (last visited August 4, 2017). 4 warning-signs-plan-or-policy-nqtls-that-require-additional-analysis-to-determine-mhpaea-compliance.pdf; (last visited August 4, 2017).

September 2017 | The Self-Insurer


Mobile Medicine Offers Quicker Treatment, Better Outcomes


edical delivery options are evolving as fast as technology and innovation will allow, reaching people who typically have had trouble accessing medical care. Through telemedicine, telehealth and on-demand medical services, the workers’ compensation industry is finding ways to deliver medical care faster and more efficiently. The result is earlier interventions, better patient outcomes and lower costs for payers. “Access to care, speed of delivery, and starting the treatment sooner is something that can really expedite the return to work process and the whole outcome because [the injured worker] has had a positive experience,” said Dr. Teresa Bartlett, Senior Vice President of Medical Quality, at Sedgwick. “It results in high patient satisfaction, faster returns-to-work — all of those things that also lead to lower costs for employers.” In addition to providing access to medical care for injured workers in rural areas, these newer medical delivery options can also overcome language barriers and transportation issues. It additionally allows for multiple providers to be involved in a single session, something that can be especially helpful for providing biopsychosocial care.


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“When a patient is getting physical therapy our psychologist can join in via telemedicine so both see the patient face to face,� said Michael Coupland, CEO and Network Medical Director for Integrated Medical

Rather than having such a session in an open clinic, the physical therapist in this case goes to the injured worker’s home. In addition to overcoming privacy concerns, it also allows for more focused treatment. “The biggest benefit is the one-on-one care,� said Daniel Sanchez, VP of Operations for Onsite Physio. “You want to make sure it is not just basic care, but is one-on-one, hands on and functional rather than geriatric care.� Sanchez, Coupland and Bartlett will explore mobile medical services — the benefits,

“The patient is challenges and outcomes, during the SIIA National Conference & Expo, Oct. 8 – 10 at the being treated by both the JW Marriott Desert Ridge Resort & Spa in Phoenix. psychologist and the physical Telemedicine & Telehealth therapist in an intensive program where they are The idea of newer medical delivery options is to bring the best quality care to the patient as talking to each other and soon as possible, regardless of time or distance. In some cases that means using computer links to ‘bring’ the provider to the patient. In others, it literally means bringing the provider to the patient. It is like an the patient — at his home, workplace or other venue. And in still others, it can be a hybrid interdisciplinary program, but it’s done on a community of the two. ad hoc basis instead of an “We have a HIPAA compliant Web enabled video system, so the patient can use a computer, inpatient program outside tablet or smart phone and is able to talk and be seen by the provider,� Coupland said. “It of the injured worker’s home allows for face-to-face sessions, but not in person.� area.� Case Solutions.

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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.

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Coupland’s company, which works with injured workers in chronic pain, joined the telemedicine bandwagon last August.The idea is to provide early intervention and access to care for people who are still working, to prevent them from deteriorating into total disability. The system includes a ‘waiting room’ with reading materials and videos on cognitive behavioral therapy.The medical provider can see the patient has logged on and is in the waiting room, and clicks a button to begin the session. “We are using it mainly for psychiatry because it’s hard to get psychiatrists, especially good ones,” Coupland said. “The rule is the provider has to be licensed in the state where the patient is located.” There are challenges to overcome when having psychiatric sessions online.The company has turned to a hybrid approach on occasion. 32

“When [the psychiatrist] is trying to evaluate how well somebody is doing with their activities of daily living, a sense of smell is important to gauge their hygiene and grooming,” Coupland said. “To overcome that the patient, at least for the initial assessment, meets in person with a psychologist and the psychiatrist joins in via telemedicine. We have good coverage with psychologists, so the psychologist will establish a relationship with the patient, and the psychiatrist will join the session.” Bringing the physician to the patient for a face-to-face visit via computer is referred to as telemedicine. Telehealth, another form of mobile medical delivery involves such things as monitoring a patient’s heart rate or blood sugar levels. In that scenario, wifi and Bluetooth enable the information to be immediately uploaded to a physician’s office. Telehealth also includes coaching from medical providers. One such model is the ‘clinical consultation’ service Sedgwick unveiled nine years ago. “We provide a nurse right at the point of a potential injury,” Bartlett said. “We walk [the injured worker] through a whole triage of questions to put their minds at ease. Either they don’t require care and there is some self-care they can provide to prevent it from becoming an injury, or they do need care and we expedite the care either to a provider directly or through telemedicine, where we can link them directly with an occupational health physician.”

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A number of additional new medical care delivery models are emerging to get care to hard-to-reach patients as soon as possible. Telerehab, for example, allows medical providers to monitor their patients’ exercise regimens. “They may have physical therapy three times a week,” Bartlett explained. “Telerehab enables the therapist to check in on them to make sure they are independent and understanding what they are doing at home to advance their healing process.” For injured workers, these home physician visits, or ‘house calls’ let the patient know from the start that the employer cares about their well-being, which can result in lower costs. “When a worker doesn’t feel the system is easy to access or easily understood, statistics show they are more prone to litigation,” Bartlett said. “By finding different models of care you improve the injured worker’s experience.”

On-demand One of the best reasons to provide care as soon as possible is to prevent so-called creeping catastrophic claims; those seemingly simple injuries that continue endlessly and render the patient unable to function, let alone work again. Treating the patient soon after an injury occurs means getting them on the road to healing without them having to wait around for various medical appointments. Bringing the provider directly to the patient for oneon-one treatment can further accelerate the process. “It decreases their ‘sick role’ mentality,” Sanchez explained. “They are thinking more along the lines of recovery and getting better vs. being stuck in the rut of an injured person.”


Sanchez’ company uses an ‘on-demand’ model, where the physical therapist treats the patient at his workplace or home. Keeping injured workers at the job site reduces time spent going to and from PT clinics; but it also aids in the injured worker’s healing process.

“They have more of an active role in their recovery,” Sanchez explained. “Keeping them at work helps them assume it is workrelated and the goal is to get them back to work.” Where possible, the physical therapy is done at work even for patients who are not yet able to perform their jobs at all. It’s an alternative to sending the injured worker to a clinic. “It maintains that routine of them going to work and avoiding the loss of work identity, which is really important” Sanchez said. “Just because they are not working doesn’t mean they can’t do PT at work. It maintains their camaraderie with their coworkers.” Having the physical therapist visit the patient’s work site helps ensure the therapy is focused on the actual tasks the person does at work, which helps prevent reinjuries. It also aids return-to-work efforts. “We tend to see recoveries happen quicker because they are on an accelerated program,” Sanchez said. “Where the clinic-based model for PT focuses first on range of motion and strength before work-related goals, we can incorporate that into their therapy starting on day one.”

The Future Employers using mobile medical delivery models are often finding a cost advantage. “We work with clients to develop a rate that is comparable to providing therapy at a clinic,” Sanchez said. “It typically does not go above the fee schedule.” The time and convenience factors make telemedicine and telehealth financially more viable for some companies. “It’s often cheaper for telemedicine,” Coupland said. “That’s one of the things about telemedicine, you can bring it to a larger population and at decreased cost.” Those delivering medical care see a wide open future in terms of new models evolving. One idea, for example, would allow patients to connect with their providers online for follow up visits, rather than having to go to an office and wait. “I anticipate a lot of use for those rechecks to take the frustration factor out,” Bartlett said. “Imagine if you could just connect through telemedicine how much more satisfied you would be with the experience.” Bartlett also envisions the use of fitbit-type tracking devices among injured workers so a nurse monitoring the patient could determine if the patient was complying with medical treatment goals. Another possibility is to use wearable technology to make sure workers are using proper physical force and avoiding injuries. “The sky’s the limit in terms of what we would be able to have early notice of and alerts to prevent injuries,” Bartlett said.

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Paying Attention to Cancer Pays Off for Your Employees Learn how to manage your greatest health care expenditure - a case study from Johns Hopkins By Lillie D. Shockney


ere’s the good news about cancer, according to 2017 statistics from the American Cancer Society: nearly 15.5 million people diagnosed with cancer are surviving their illness, and about 53 percent of them are under the age of 70. As an employer, that means you will likely be paying the cancer-related health care costs for many more years than employers in the past, when the employee population tended to retire at age 62 or 65 rather than 67 or 70, or beyond.

Employers need to pay attention to these costs. Consider this: for every 100 employees in the workforce, 5 percent will have a history of cancer and 27.1 percent of those employees will be in treatment for cancer. A 2015 initiative of the Northeast Business Group on Health (NEBGH) notes that “employers report a level of complexity in managing employees’ cancer-related needs beyond that associated with any other type of disease or condition” due, in large part, to the related costs. Cancer treatment alone accounts for 12 percent of employers’ total medical costs in the United States, with $125 billion spent on direct medical costs.


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And keep in mind that another $139 billion are associated with diminished productivity and lost work time, either for cancer treatment or for caring for someone with cancer. Employees who are also caregivers account for nearly 75 percent of early departures and late arrivals at the workplace, often engaged in long telephone calls at work to handle caregiving issues. And caregivers often suffer stress-related illnesses, further reducing their productivity.

And employers are generally best served by having their experienced employees remain on the job and be as productive as they possibly can for as long as they possibly can. Again, from the 2015 NEBGH report: “Employers are concerned that programs and services to assist employees through the cancer journey appear to be limited and/or uncoordinated…[they] are searching for the best way to engage employees beyond traditional health plan programs, because as one employer noted: “I know my employees won’t even pick up the phone if they see their health plan on their [c]aller ID.”

Employers need to pay

The Johns Hopkins experience

attention to these employees.

We asked the same question at Johns Hopkins in February 2012. I and my colleague at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Terry Langbaum, informed our leadership that while we were among the nation’s most highly regarded cancer centers for diagnosis and treatment, we were not doing a particularly good job of supporting our own employees who had cancer or who were providing care for a loved one with cancer and still wanted to work. And we identified a gap in supporting supervisors who needed to understand the often complex issues related to managing these employees and their colleagues.

The incidence of cancer is going up. As of 2017, 1 in 2 men and 1 in 3 women will be diagnosed with a life-threatening form of cancer in their lifetime. And although cancer deaths have risen to more than 600,000 annually, by 2024, it is expected there will be more than 20 million cancer survivors.

So, here’s the question: What can you do to support your employees, both before and after a cancer diagnosis, keep your company running efficiently, and manage the related health care costs?

An overwhelming majority of employees who have received a cancer diagnosis— particularly those with breast cancer—either want to or need to keep working through treatment. Many people strongly identify with the work they do and the company they do it for. Among the roughly 40 percent of cancer survivors who are age 25 to 64, there’s often a feeling of loss of that identity as well a loss of a satisfaction with life and connectivity with friends who are work colleagues. These and other concerns can and do impact a cancer patient’s productivity and very ability to work.

September 2017 | The Self-Insurer


• We learned that most employees are not fully aware of their company’s policy on

We began a 4-month initiative to better understand what sort of engagement would best support both employees and managers. Here’s what we learned from employees:

sick leave, telecommuting, and flex time schedules;

• We learned that many employees do not know which websites and other resources provide credible information about risk factors, symptoms of specific cancers, and treatment options. So they end up wasting a lot of precious time trying to make sense of their condition and their options from often misinformed providers.

• We learned that most employees receiving cancer treatment are actually able to work throughout most of their treatments; this is because treatments have improved over the years and many have fewer side effects and, therefore, have less of an impact on a person’s quality of life. Employees didn’t always think to let managers know that for various reasons cancer treatment and how one feels after it may be better or worse than expected from one treatment to the next, so they might be able to work, or not, regardless of their plan;

Here’s what we learned from managers:

• They (and co-workers) want to support a colleague when told he or she has been diagnosed with cancer, but not everyone has the ability—the skill, really—to provide that support. Supervisors and co-workers can be at a loss for words, or worse, say and do the entirely the wrong thing. They may not be fully versed on their employees’ rights. We learned that managers need immediate access to this information when they learn they have an employee dealing with cancer. And that information must be continuously updated to include changes to internal policies and state and federal laws;

• We learned that managers who provide reasonable work flexibility for their employees in treatment or caregiving are commonly able to keep their employees on the job. Keeping your employee team intact has a positive effect on morale and productivity, for both the employee with cancer and her/his co-workers, who are likely to be part of their support system;

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The program is now called Managing Cancer at Work. Collaborating with our health literacy and patient education colleagues, we developed a comprehensive web-based platform with resources for employees at risk, newly diagnosed, surviving after treatment, and serving as a caregiver to a loved one. Employers also can choose to provide their workforce with a specially trained Johns Hopkins certified oncology nurse navigator, who is a patient advocate and resource, providing employees and managers with 24/7 telephonic, email, text support.

• We learned that managers are not as familiar as they need to be with the American with Disabilities Act (ADA), so they don’t inadvertently (or intentionally) fail to accommodate an employee with cancer. There have been situations across the country where employees have won high-dollar law suits because a supervisor eliminated the employee’s job or even fired the employee for not performing up to par while undergoing cancer treatment. Lack of managerial training can be an expensive incident for the company to have to bear, not to mention the company’s reputation.

Managing Cancer at WorkTM With this information, we wanted to build an employee benefit program that addressed what we’d learned, would be totally separate from an employer’s HR office, and was not a referral mechanism to drive patients to Johns Hopkins.

There are two important philosophies ingrained in Managing Cancer at Work. The first is to enable an employee to work while receiving their cancer treatment, if they so choose. This approach is based on one of my long-held mantras: Only give cancer the time it needs to get rid of it. Don’t allow it to steal away any more of a your time, your family time, your social time, your personal time, or even your work time. It doesn’t deserve it. Working provides a sense of normalcy, and maintain normalcy during any crisis reduces stress. The second philosophical grounding is this: Survivorship must begin at the time of diagnosis. This means keeping the patient’s life goals preserved rather than forfeited to this disease and its treatment. The Johns Hopkins nurse navigator gives priority to working with the patient as her/his advocate so that these life goals are known to the treatment team. The treatment team in turn can then incorporate these life goals into the treatment planning process.

So, how are we doing? We identified a technology partner, which gave us the ability in October 2014 to pilot the web-based platform and oncology nurse navigator with Pitney Bowes’ 10,000 employees. In January 2015, we launched the program for the approximately 31,000 employees across The Johns Hopkins University and Health System. And we’ve received positive feedback from employees with cancer, those who are caring for someone with cancer, and managers:

• Employee’s satisfaction with the program on a scale of 1-5, 5 being excellent ranges from 4.5 to 4.8;

• 94 percent of employees who became cancer patients found the nurse navigator to be very helpful;

• Prior to communicating with the nurse navigator;

September 2017 | The Self-Insurer


o 33 percent lacked information about their treatment plan; o 50 percent didn’t really understand their insurance coverage; o 37 percent lacked knowledge of support organizations and other available free resources;

• The most common sections of the website content visited has been o Screening/ prevention/risk assessment tool; o What if I am diagnosed; o Working during treatment. And as we hoped, the most frequent statement from managers and supervisors using the program—“I wish this program had been implemented sooner.”

Lillie Shockney is a University Distinguished Service Professor of Breast Cancer and a professor of surgery and oncology, at the Johns Hopkins University School of Medicine. She is the co-founder of the Johns Hopkins Medicine’s Managing Cancer at Work program.

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M when you consider more than 85% of most groups’ claims are for amounts less than $5,000.

ost cost-containment companies won’t pursue claims lower than $5,000, but we will. That adds up, especially

At HHC Group, we pursue the maximum available savings – with bulldog tenacity – for Great Dane sized claims down to claims as low as one dollar. In fact, our pursuit of small-dollar claims produces an average of 25% more savings for our clients than they would save otherwise.


“Key Facts About Small-Dollar Claims,” at


Claims Negotiation & Repricing DRG Validation



Claims Editing


Medical Bill Review (Audit)

Utilization Reviews and Independent Reviews



Reference-Based Pricing

Independent Medical Examinations

Aid-in-dying laws and the Implications for Self-Funded Plans By Maribel E. McLaughlin, Esq.


wo years ago, a woman close to my mother was diagnosed with an aggressive form of brain cancer. Along with her two daughters, she went through the various treatment options presented to her and determined that she was going to try all of them. She wanted to put her best foot forward for her daughters and her granddaughter, and she found the strength to fight the cancer with every cell in her body. After sixteen months of treatment, losing her hair, the inability to eat properly, and her body being riddled with the toxins that were used to fight the cancer, she decided that she wanted to end her life; her way, on her own terms. She had a lengthy discussion with her daughters about her choice, and as sad as they were that they would soon be losing their mother, they understood that their mother wanted to live every moment to its fullest, but, when she was ready, she would make the decision to die on her own terms. One particularly difficult night, she pushed herself to take one last walk through the Newport Cliff Walk with her daughters and granddaughter, enjoyed her last Del’s lemonade, savored the final clam chowder she was going to have, and decided that this was her chance to end her life on a high note. That night, she took a higher dose of the medicine that she had been taking for the last sixteen months, and never woke up. She purposely overdosed; or, as many would call it, she committed suicide. 42

The Self-Insurer |

D.C.’s New Death with Dignity Act The Death with Dignity Act went into effect on February 18, 2017 in Washington D.C., and last month, doctors were able to begin the process of prescribing life-ending drugs to terminally ill patients; adding the District to six states that currently authorize that practice. The D.C. Health Department launched a website where physicians can register to participate in the “Death with Dignity” program, where doctors, pharmacists, and patients can learn about the law’s requirements and patients and doctors can download required forms. Patients must be older than eighteen with a prognosis of less than six months to live in order to be eligible.

California’s Election of Death of Dignity Law In California, one of the six states, the law does not make it easy for a patient to elect death with dignity; the patient must be terminally ill to request a doctor’s prescription for medications intended to end their lives peacefully.3 The End of Life Option Act creates a long list of administrative obstacles that both patients and doctors must overcome. At the time of the law’s enactment, it became the fifth state to implement an aid-in-dying law, and it is currently also the most stringent. Patients must get a prescription from a participating physician. This is not as easy as it may seem. A coordinator may connect the patient with a physician that participates; but, if the patient is a U.S. military veteran that receives healthcare from the U.S. Department of Veterans Affairs, that patient will not be able to utilize this state law since federal law prohibits the use of federal funds for this purpose. Additionally, the forty-eight Catholic and Catholic-affiliated hospitals located in California will not provide patients with the option to end their lives.4

In addition, they must have made two requests at least fifteen days apart for lifeending medications. They must ingest the drugs themselves, and two witnesses must attest that the patient is making the decision voluntarily.1

Affordable Care Act & Physician-Assisted Suicide According to Section 1553 of the Affordable Care Act (“ACA”)2, a health plan may not discriminate against an individual or institutional healthcare entity because the entity does not provide any healthcare item or service that causes, or assists in causing, the death of any individual, such as by assisted suicide, euthanasia, or mercy killing. Put another way, if terminally ill patient requests that his doctor help him end his life, and the doctor refuses for moral or other reasons, that doctor is protected against discrimination by federal law. This protects the doctor that may be targeted by insurance companies because of their refusal to help patients end their lives. September 2017 | The Self-Insurer


Cost of Death vs. Cost of Healthcare Another obstacle that patients may come across is the cost of the drugs involved with the assisted suicide practice. The patient’s health plan may not cover them - and the states that have allowed the practice of assisted suicide do not require health insurers to cover the medications.5 Under The Employee Retirement Income Security Act of 1974 (ERISA), there are minimum standards for voluntarily established health plans in private industry to provide protection for individuals in these plans; plans must provide participants with information about plan features and funding, and furnish information regularly and free of charge.6

Nothing about the Acts requires that a self-funded plan under ERISA, cover the cost of the death-with-dignity practice. Luckily under ERISA, a Plan still has the liberty to create their own health benefits. A health plan, when drafting their Plan Document, can choose to either allow this practice, or not. The ACA prohibits the discrimination of a provider that does not provide assisted suicide services. The Act does not require health plans to allow the practice. The option is left to the Plan. Healthcare costs in the United States have risen astronomically over the past decade and many people fear that insurance companies may look to assisted suicide as a way for a health plan to save money on expensive medical care.7 One report concluded that it would save approximately $627 million dollars in 1995.8 Some, who oppose assisted suicide, argue that insurance companies may begin to limit expensive procedures for patients who are suffering from terminal illnesses such as cancer, AIDS, and multiple sclerosis. Others argue that even though the aggregate savings is small, the impact on an individual company or an individual family would be a powerful enough financial incentive to encourage the practice even where it was not intended.9

At AmWINS Group Benefits our team of specialists wakes up every morning committed to bringing your team innovative solutions to the opportunities and challenges you and your self-funded clients face. That’s the competitive advantage you get with AmWINS Group Benefits.


The Self-Insurer |

Many fear that patients would be more likely to consider physician-assisted suicide as a better alternative with the added bonus of saving their family money and the burden of prolonged, expensive care. Insurance companies may try to exclude life-saving or life-extending drugs and pressure people into thinking about the practice of physician assisted suicide.

Collins and the Suicide Exclusion Health plans are permitted to include a suicide exclusion that would enable the plan administrator to deny claims associated with the suicide. In Collins v. Unum Life Insurance Co., 185 F. Supp.3d 860 (2016),10 the Supreme Court held that “Unum reasonably interpreted the suicide exclusion to encompass insane suicide, [and that] Mr. Collins’ sanity at death has no bearing on the outcome.”11 The issue in this case involved a state law which stated that a suicide exclusion would be only be valid if liability was limited to an insured “who, whether sane or insane, dies by his own act.”12 Former Navy SEAL David M. Collins served this country for seventeen years, during

situations, many of which exposed him to enemy gunfire and blasts from mortar fire.13 Despite seeking treatment, Mr. Collins was found dead in the driver’s seat of his car with a gunshot wound to his head on March 12, 2014. The death was ruled a suicide.14 Prior to his death, Mr. Collins had been working for Blackbird Technologies, where he participated in an employee benefit plan that provided basic and supplemental life insurance through group policies funded and administered by Unum Life Insurance Company of America.15

which he was deployed to Iraq, Afghanistan, and Kuwait. He served in dangerous and stressful

September 2017 | The Self-Insurer


When Mr. Collins died, his widow, Jennifer Mullen Collins, applied for benefits under both policies. Unum granted benefits under the basic policy, but denied benefits under the supplemental policy’s suicide exclusion.16 In addition, the Court held that it found “substantial evidence in the administrative record to support Unum’s conclusion that the suicide exclusion applied.”17 As such, a health plan may be able to exclude the practice and not be held accountable for claims under the physician assisted suicide.

Option to Elect or Exclude Suicide Plan administrators can take the position of either excluding assisted-suicide claims or paying them. They can allow the practice, and give the power to the patient to make the decision for themselves, and ultimately save the Plan money for care that the patient would have ultimately not wanted; or, they can exclude the practice and have the peace of mind that everything that should have been covered was covered. Whether you’re a broker, a health plan sponsor, third-party administrator, or reinsurer, this is something that should not only spike an interest, but also should make you uneasy if you have health plans in the six states that currently allow physician assisted suicide practices. Specialists in plan document drafting can provide assistance in reviewing your plan document and ensuring that the plan document addresses this issue directly to meet the needs of the group. References: 1 HHS Office of the Secretary & Office for Civil Rights (OCR), Section 1553 - Refusal to provide assisted suicide services (2015), (last visited Aug 9, 2017). 2

42 U.S. Code § 18113 (2010)

3 AB-15 End of life.(2015-2016), Bill Text - ABX2-15 End of life. (2015), faces/billTextClient.xhtml?bill_id=201520162AB15 (last visited Aug 9, 2017). 4


5 Emily Bazar, Aid-In-Dying: Not So Easy Kaiser Health News (2017), (last visited Aug 9, 2017). 6

29 U.S.C. 18 § 1001

7 Physician Assisted Suicide and Health Care Costs, Low Fat Diet Plan, (last visited Aug 9, 2017). 8





Collins v. Unum Life Insurance Co., 185 F. Supp.3d 860 (2016)


Id. at 882


Id. at 871


Id. at 863


Id. at 864


Id. at 863


Id. at 865


Id. at 880


The Self-Insurer |

Maribel E. McLaughlin joined The Phia Group as a subrogation attorney in 2016. Previously, she was a plaintiff’s attorney, representing clients in medical malpractice and personal injury lawsuits. She is licensed to practice in the Commonwealth of Massachusetts and in the United State District Court for the District of Massachusetts



Self-Insurance Institute of America’s (SIIA) upcoming National Conference & Expo is scheduled for October 8th-10th at the JW Marriott Desert Ridge Resort in Phoenix, AZ. This is the world’s largest event focused exclusively on the self-insurance/ alternative risk transfer marketplace and typically attracts more than 1,700 attendees from around the United States, and from a growing number of countries around the world. The National Conference & Expo will feature more than 40 educational sessions focusing on self-insured group health plans, captive insurance, self-insured workers’ compensation programs and international self-insurance/ART trends.

Captive Insurance sessions include: Introduction to Captive Insurance for Mid-Market Employers with Robert J. Walling III, Principal and Consulting Actuary, Pinnacle Actuarial Resources, Inc. moderating and Adam Forstot, Vice President, USA Risk Group presenting Creative Captives for Mid-Market Employers – Five Stories to Tell with John Capasso, President & CEO, Captive Planning Associates, LLC, moderating the panel participants Debbie Gaglioti, Senior Vice President & COO, Captive Planning Associates, LLC and David Neufeld, JD, LL.M, Principal, Law Office of David Neufeld Stop-Loss Captive Programs – Opportunities for Self-Insurance Industry Service Providers with Jeff Fitzgerald, Vice President - Employee Benefits, Innovative Captive Strategies moderating panel participants Stephanie Mills, Vice President, Sales, American Health Holding Inc., Dean Thompson, Vice President Marketing and Sales, HCMS Group and Austin Wilcox, Vice President Business & Product Development, ACAP Health Advanced Health Plan Cost Management Strategies for Stop-Loss Captive Programs with Donald Lee, Director, Underwriting, Strategy & Partnerships, IMA, Inc. moderating panel participants Scott Byrne, Vice President, Captive Business Development, Berkley Accident & Health, LLC, Justin Moser, Director of Stop Loss Operations, Employee Benefit Management Services, Inc. and Phillip C. Giles, CEBS, Vice President - Sales & Marketing, Accident & Health, QBE North America Property & Casualty Group Captive Market Trends with Sandra L. Fenters, Managing Director – Principal Capterra Risk Solutions, LLC moderating and panel participants Carol Frey, Vice President, Great American Insurance Group, J. Brady Young, President & CEO, Strategic Risk Solutions, Inc. and John Shea, Executive Vice President/Chief Underwriting Officer, Tangram Insurance Services

September 2017 | The Self-Insurer


YOUR BEST PARTNER EARNS YOUR TRUST EVERY DAY Employers of all sizes experience high-cost medical claims. As an independent stop-loss provider with strong financial ratings, we’re here for you. Listening to you. Helping you design a stop-loss plan that meets your needs with specialized options. Delivering hassle-free claims reimbursements. Want a partner that earns your trust every day? Go with Sun Life. Ask your Sun Life Stop-Loss specialist how we can put our expertise to work for you.

STOP-LOSS | DISABILITY | DENTAL/VISION | VOLUNTARY | LIFE For current financial ratings of underwriting companies by independent rating agencies, visit our corporate website at For more information about Sun Life products, visit Group insurance policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) in all states except New York, under Policy Form Series 07-SL REV 7-12. In New York, group insurance policies are underwritten by Sun Life and Health Insurance Company (U.S.) (Lansing, MI) under Policy Form Series 07-NYSL REV 7-12. Product offerings may not be available in all states and may vary depending on state laws and regulations. Š 2017 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. Sun Life Financial and the globe symbol are registered trademarks of Sun Life Assurance Company of Canada. BRAD-6503f SLPC 28097 02/17 (exp. 02/19)

When Your Stop-Loss Captive Program Grows Up with Manjusha Sheobaran, Sales Director, Greymatter Risk Management, LLC moderating panel participants Andrew Kuykendall, Alternative Funding Specialist, Woodruff-Sawyer & Company, Tracey G. May, MHSA, Area Vice President, Gallagher Benefit Services, Arthur J. Gallagher & Co. and Donald McCully, President, Medical Captive Underwriters A Two Part Captive Regulator Panel Discussion, featuring W. Jay Branum, Director of Captives, South Carolina Department of Insurance, Michael A. Corbett, Director, Captive Insurance Section, Tennessee Department of Commerce & Insurance, Steve W. Kinion, Director of Bureau of Captive and Financial Insurance Products, Delaware Insurance Department, Steve Matthews, Captive Insurance Coordinator, Office of the Montana Commissioner of Securities & Insurance, David F. Provost, CFE, Deputy Commissioner, Vermont’s Captive Insurance Division, Ruben Gely Rodriquez, Director for Captives, Puerto Rico, Travis Wegkamp, Director, Captive Insurance, Utah Insurance Department and Debra Walker, Deputy Commissioner, Captive Insurance Companies Division, North Carolina Department of Insurance

Health Care sessions include: Introduction to Self-Insured Group Health Plans with Kari Niblack, Executive Vice President, Client Engagement, Apex Benefits Genetic Information and Self-Insured Group Health Plans – How to Leverage Personalized Genetic Intel in the Age of GINA with Brody Holohan, PhD, CEO, Genteract Level Funded Plans – Good or Bad for the Self-Insurance Industry? with Larry Thompson, Regional President, POMCO Group moderating panelists Todd Archer, Vice President, Boon-Chapman Benefit Administrators, Inc., Rob Melillo, Second Vice President – Head of Stop-Loss, Guardian Life Insurance Company of America, Michael Meloch, President, TPAC Underwriters, Inc. and Ashley Gillihan, Esq., Attorney, Alston & Bird LLP

When it comes to reducing healthcare cost and plan management, you may need some help. Is what you are doing effective? What are you doing that’s different? Are your employees engaged and willing to help? Are your employees “educated consumers” Are your employees and management satisfied?

The thinking that got us to this point is not the thinking that will lead us out. Pequot Health Care is a Common $ense Partner that works for YOU. Contact Sales and Marketing at 800-219-1226 or Providing access to cost effective provider networks Native Owned & Operated

September 2017 | The Self-Insurer


Strengthening Your PBM Partnerships with Doug Forrester, CEO, Integrity Health, John Marshall, Principal, Windsor Strategy Partners, Inc. and Steve Berna, Pharmacy Actuary, Remedy Analytics Cyber Risk, Security and Compliance for Self-Insured Group Health Plans with Noah Dermer, Security Officer, InstaMed and Andrew Hicks, Managing Principal, Coalfire Health Care Data Analytics 2.0 with Glenn McLellan, President, McLellan Consulting Services, LLC

Lowering Health Plan Costs by Identifying Behavioral Health Opportunities with Dani Kimlinger, Chief Executive Officer, Mines & Associates moderating panelists Ernie Clevenger, President, CareHere LLC, Scott Haas, Senior Vice President, Wells Fargo Insurance Services USA, Inc. and Robert Mines, Chairman & Psychologist, MINES and Associates Building and Maintaining a Successful MEWA with William Megna, Principal Attorney, Megna Law Firm, David Wilson, President, Windsor Strategy Partners, Inc. and John J. McSorley, President & CEO, RiskEval Resources LLC

Wall Street’s Perspective on the TPA

Referenced Based Pricing Reflections with Jason Davis, Business & Product Development Consultant, The Phia Group moderating speakers Brian Wroblewski, EVP Sales & Marketing, Clear Health Strategies and Rob Jackson, EVP, Cost Management Solutions, Zelis Healthcare Through the Looking-Glass – a Non-Vendor Take on Referenced Based Pricing with Jason Davis, Business & Product Development Consultant, The Phia Group moderating panelists Tim Culliton, CFO, Pacific Steel & Recycling, Stacey Lamy, Human Resources

Industry with Vincent Esposito, Chief Operating Officer, Endeavor Plus, Inc.

Director, Pacific Steel & Recycling, Holli Titus, CEO, Employee Benefit Logistics and Cori Cook, Founder, CMC Consulting, LLC

ACA Regulatory Compliance Update – Now What Do We Do? with Ashley Gillihan, Esq., Attorney, Alston & Bird LLP

Focusing Payment Integrity Controls on Waste and Abuse with Michael Taylor, M.D., President, Medical Audit & Review Solutions and Christopher Dorn, Vice President, Payment Integrity, MultiPlan, Inc.

Dialing it In – How Telemedicine is Connecting With Self-Insured Health Plans with Brian Connelly, Director of Product Development, Gilsbar, LLC and Steve Suter, President & CEO, Healthcare Management Administrators, Inc.

Workers’ Compensation sessions include:

Corporate Financial Transactions For Insurance Entities Operating SelfInsurance Marketplace with Richard Fleder, President & CEO, ELMC Holdings, LLC moderating panelists Phil Gardham, President, Companion Life Insurance Company, Anthony Plampton, Managing Director, Re-Solutions, Tom Arcieri, Director, Sica/Fletcher and Eric Rahe, Managing Director, J.C. Flowers & Co., LLC Leveraging Health Care Consumerism for More Effective Self-Insured Health Plans with Mark Gaunya, CEO, Captivated Health


The Self-Insurer |

Marijuana Implications to the Workforce, the Workplace, and to Work Comp with Mark Pew, Senior Vice President, PRIUM and Mark Walls, Vice President Communications & Strategic Analysis, Safety National Mental Health and Wellbeing – Total Employee Wellness with Kevin Lombardo, CEO, DORN Companies and Mark Pew, Senior Vice President, PRIUM Urine Drug Testing: Adding Value to a Medical Management Program with Maria Chianta, Director, Clinical Affairs, Managed Markets, Millennium Health and Tron Emptage, Chief Clinical Officer WC Division, Optum Intersection of ADAAA, FMLA & Workers’ Compensation with Mark Walls, Vice President Communication & Strategic Analysis, Safety National, Bryon Bass, Sr. VP, Disability and Absence Practice & Compliance, Sedgwick Claims Management Services, Inc. and Adrienne Paler, Director, Integrated Disability and Absence Management, Sutter Health OSHA Under the Trump Administration with Amanda Czepiel, J.D., Senior Managing Editor, Business and Legal Resources and Don Enke, ARM, Assistant Vice President Risk Control Services, Safety National

Medical Services On Demand: A Look at New Delivery Models with Daniel Sanchez, VP, Operations, Onsite Physio, Dr. Teresa Bartlett, Senior Vice President, Medical Quality, Sedgwick Claims Management Services, Inc. and Michael Coupland, CEO, Network Medical Director, Integrated Medical Case Solutions

International Sessions Include: What Are The Hottest ‘Value Added’ Services and Applications That Help Enable Successful Self-Insurance Solutions in the International Arena Greg Arms of WorldCare and MSH will moderate panelists Tom Shjerven, Chestnut Global Partners, Tina Karas, WorldCare International and Chris Burns, Vida Health SIIA International Conferences Update with Bob Repke, Passport For Health, other speakers to be announced.

Many senior industry executives representing TPAs, employers, stop-loss carriers, captive managers, brokers and other key players in the self-insurance marketplace have already registered, making this a truly must-attend event. Detailed conference information, including registration and sponsorship opportunity forms, can be accessed on-line at www.siia. org/national, or by calling 800/851-7789. We look forward to seeing you in Phoenix in October!

As a reminder, the always popular end of conference party will be held on the evening of October 10th, and will be a great way to cap off your conference experience and fit in one last round of networking, so you are encouraged to make your travel plans accordingly!

We can’t stop the unexpected. We can stop loss. • More than 35 years of stop loss experience • Ranked number 4 among third party stop loss carriers1 in the nation • Consultative approach and flexible contracts that match your unique needs Contact your local Voya Employee Benefits sales representative or call 866-566-2316 1

Ranking of top stop loss providers in the United States based on yearly premium as of 03/16/2017 by MyHealthGuide Newsletter: News for the Self-Funded Community, and does not include managed health care providers.

Stop Loss Insurance is underwritten by ReliaStar Life Insurance Company (Home and Administration Office: Minneapolis, MN) and ReliaStar Life Insurance Company of New York (Home Office: Woodbury, NY; Administration Office: Minneapolis, MN). Within the State of New York, only ReliaStar Life Insurance Company of New York is admitted, and its products issued. Both are members of the Voya® family of companies. Voya Employee Benefits is a division of both companies. Product availability and specific provisions may vary by state. ©2017 Voya Services Company. All rights reserved. CN0615-35247-0618 175487 08/01/2017

September 2017 | The Self-Insurer



from SIIA



SIIA Diamond, Gold & Silver Member News

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

Diamond Members SIIA Announces HealthSCOPE Benefits as Newest Diamond Member

The Self-Insurance Institute of America, Inc. (SIIA) announced that HealthSCOPE Benefits has upgraded to Diamond member status. Diamond membership signifies the highest level of support for SIIA and demonstrates a company’s leadership position within the self-insurance/captive insurance marketplace. “At HealthSCOPE Benefits, we pride ourselves in designing individualized strategic vision on a client-by-client basis,” said Mary Catherine Person, president of HealthSCOPE Benefits. “As such, we recognize that each employer’s situation is unique, and they rely on us to help guide them through the challenges of cost and management of their health plan. SIIA’s central focus of growth and development of the self-insurance marketplace is a natural fit September 2017 | The Self-Insurer


for HealthSCOPE Benefits. We continue to see first-hand how SIIA’s ongoing industry protection and promotion work provides real value for TPAs, so upgrading to Diamond membership makes sense.” This continued growth in the number of SIIA Diamond members reflects recognition by leading-industry companies of the importance to provide robust support to the trade association that is best positioned to protect and promote their business interests. This support has enabled SIIA to further expand its government relations staffing, media outreach efforts and legal defense capabilities, as well to fund various other industry promotion initiatives.

About HealthSCOPE Benefits HealthSCOPE Benefits is a full service claims administration and health management firm providing administrative and other support services to self-funded employers. As the fourth largest Third Party Administrator (TPA) in the country (and the largest independent TPA operating without ownership of an insurance carrier), HealthSCOPE Benefits goes beyond the offerings of a traditional administrator. Headquartered in Little Rock, AR, HealthSCOPE Benefits administers benefits in all 50 states for more than 300 clients and more than 500,000 members. The company’s 600 employees support clients in the management of greater than 1.6 billion in annual healthcare expenditures. Visit

HealthSmart Appoints Peter D. Beerman as Vice President of Sales

HealthSmart, the largest independent benefits administrator in the country, is pleased to announce the appointment of Peter D. Beerman as Vice President of Sales. Beerman has a proven track record of significantly increasing revenues, retaining clients and successfully launching products.

Approachable · Knowledgeable · Dependable.


We are well-versed in customized offerings and rooted in strategic thinking. Our dedicated team provides a consultative approach to achieve the best risk solution for you. Visit today to learn more.


The Self-Insurer |

Beerman will report to Tom Mafale, HealthSmart’s Chief Sales Officer. Beerman will be responsible for developing new business opportunities and creating customized solutions to meet client needs. He has more than 30 years of experience in plan-sponsored self-insurance, network leasing and change management. Beerman served as Vice President Sales, Labor and Trust, UnitedHealthcare, where he established UnitedHealthcare as a new vendor in the labor and trust market. While there, he also introduced new products for select third party administrators and self-insured plans. Beerman received the Top Sales Achievement Award in 2014 and the Altus Award in 2014 and 2015. About HealthSmart HealthSmart’s integrated approach makes a positive impact on your bottom line by supporting and empowering members to attain optimal health. We work closely with our clients and business partners to achieve better treatment outcomes at the lowest possible cost. Our URAC-accredited care management portfolio serves the entire member population: healthy individuals who need to stay that way, those at risk who need to improve their health, and those who need assistance managing chronic conditions. Our innovative strategies bring balance back to healthcare plans.  Visit www.

Silver Members Pareto Captive Has Opportunities for Sales Professionals

Pareto Captive Services, LLC (“Pareto Captive”) continues to grow and is seeking to add to its team of sales professionals. If you’re a competitive self-starter that is looking for a “no-cap” compensation plan, you excel at developing strategic relationships, thrive in a fast paced, results oriented work environment with minimal administrative responsibilities, please keep reading. Job Title Regional Vice President of Sales Summary Pareto Captive’s sales team is responsible for calling on consultants, explaining our product and its value proposition, analyzing submissions, and presenting quotes to consultants and employers. The position requires extensive out of town travel, including proposal presentations, seminars, and board meetings. Location Pareto Captive is located in Philadelphia and has business spread throughout the country. While we have a slight preference to locate new team members in Philadelphia, we are open to other locations too, as the individual may be able to work out of his/her house. Outside of Philadelphia, areas of particular interest to us include (but are not limited to) Seattle, Denver, Phoenix, Chicago, Texas, California, Florida and the Carolinas. 

September 2017 | The Self-Insurer


No matter your industry, Delaware’s award-winning Captive Insurance Bureau can help your business gain the upper hand...

Call us today to begin a conversation about your goals and our solutions.

BUREAU OF CAPTIVE & FINANCIAL INSURANCE PRODUCTS The Nemours Building | 1007 Orange Street, Suite 1010 | Wilmington, DE 19801

Phone: 302.577.5280 | Fax: 302.577.3057 Web:

Insurance Commissioner Trinidad Navarro Delaware Department of Insurance

Compensation Pareto Captive pays a base salary plus commissions. We pay 100% of premiums for health insurance and contribute to an HSA, contribute to employees’ 401k, and offer many additional benefits. Skills/Competencies Requirements

• • • • • • • • • • • •

Bachelor’s degree At least 3 to 5 years of experience in self-insured benefits business development Significant experience supporting the development of proposals to consultants Strong sales skills and performance driven Excellent written and verbal communication skills Comfortable presenting to large groups Organizational, planning, and prioritization skills Demonstrates effective negotiation and closing techniques Knowledge of cost containment products and vendors Strong customer orientation Commitment to company values Willingness and ability to travel frequently

Interested individuals should submit a cover letter and resume (or a cover letter and a link to a LinkedIn page) to All communication will be confidential.

About Pareto Captive Pareto Captive is the nation’s largest manager of member-owned benefit captives. Nearly 400 employers with approximately 45,000 enrolled employees use five different Pareto captive programs to reduce both the cost and volatility of employee benefits. Visit www.paretocaptive. com.

Gold Members ELMC Risk Solutions Announces Staci O’Toole as President of ELMC Underwriters, Western Region ELMC Risk Solutions, LLC, a manager of premier, full-service managing general underwriters specializing in underwriting medical stop-loss insurance is pleased to announce that industry veteran, Staci O’Toole, has joined ELMC as President of ELMC Underwriters (ELMCU), Western Region. In her new role, Staci will lead ELMCU’s sales efforts in the Western region expanding the company’s national presence.

Ms. O’Toole brings 25 years of experience in sales leadership, marketing, and underwriting, particularly in the West Coast market. She has a consistent record of creating profitable business in the self-funded market. In her previous engagement, she managed four regional sales offices accounting for more $90 million dollars in annual premium. Richard Fleder, ELMC’s founder and CEO said “We are quite fortunate and enthusiastic about bringing someone with Staci’s expertise and record of success in the medical stop loss market into the company.” This appointment is consistent with ELMC’s recent expansion efforts which have brought together Midwest Risk Underwriters, IOA Re, RxReins and Adler Rx Consulting, under the ELMC Risk Solutions banner.

September 2017 | The Self-Insurer


About Staci O’Toole Staci O’Toole is the President, Western Region of ELMC Underwriters. She brings more than 25 years of experience in the Self Insurance industry with a focus in sales, marketing, underwriting and management to this role. Prior to joining ELMC Underwriters, Staci served as Vice President of Sales for Houston International Insurance Group (HIIG). Staci joined HIIG as part of the Elite Underwriting Services (Elite) acquisition. While at Elite, she was a leader in driving the company’s growth. Prior to her tenure at HIIG, Staci was a member of the R.E. Moulton team where she was responsible for developing the Western Region, which grew to become the company’s largest block of profitable stop loss business. At Moulton she managed four sales offices generating more than $90 Million in annual premium and developed their Preferred Carrier Status with National Producers. Prior to joining R.E. Moulton, Staci was Regional Manager for the Hartford’s Stop Loss division where she created a new distribution channel that focused on TPAs in the Western United States. Staci started her stop loss career with SAFECO as the Regional Manager for the Pacific Southwest Region. She led the sales and field underwriting offices for Group Life, LTD and Excess Loss. Before moving to California, Staci was a broker for a regional P&C firm in Boston. She holds a Bachelor’s of Science in Education-Math & Science from Ohio State. About ELMC ELMC owns, manages and seeks to acquire premier MGUs across the nation that specialize in underwriting medical stop-loss insurance for self-funded health plans. ELMC provides a best-inclass platform for delivering medical stop-loss solutions to brokers, carriers and clients. Contact Mary Ann Carlisle at, 484-433-1412, and visit


The Self-Insurer |

Indigo Seeks National StopLoss Sales Executive

Job Title: Indigo National stop-loss Sales Executive Summary As an Indigo stop-loss Sales Executive, you’ll have the support of one of the nation’s leading insurance companies and the flexibility and growth potential of running your own business.You’ll solve clients’ needs through consultative and solution based selling, by building relationships with contacts in your territory to identify, develop and close sales opportunities. Responsibilities • Sell Indigo Insurance Services Medical stop-loss product through insurance brokers, third party administrators and consultants. • Build and establish relationships with key sources to market our product to some of the nation’s leading employers. • Construct and maintain a business plan for your designated territory based on sales and strategic initiatives. • Call on existing and potential customers to not only prospect new customers but also to develop a book of business. • Meet annual targets and individual sales goals.

Develop internal relationships with underwriters and internal support partners who will assist you in creating specialized plans to meet your clients’ needs. Qualifications • Bachelor’s Degree from a four-year college or university preferred. • Previous experience selling the stoploss product required. • Commitment to attaining state required Life and Health agent license. • Proven relationships with underwriting and technical product expertise. • Strong organizational skills. • Strong networking and relationship management skills.

• •

A passion to succeed and challenge yourself while building a book of business A winning attitude and interested in a career that offers independence, professional growth, and high income potential.

The successful candidate is driven, selfmotivated, consultative and a great problem solver. Interested candidates should send resume to Kim Grace at

About Indigo Indigo is a full-service insurance agency that offers an extensive suite of specialty insurance products including stop-loss, life, disability, vision, travel, accident, critical illness, workers’ compensation, and more. We partner with market-leading insurance carriers that offer outstanding customer service, fast claim payments, and flexible benefits that set them apart from their competition. We only partner with A-rated carriers, and we’re a wholly-owned subsidiary of the largest commercial health insurer in Massachusetts--so we’ll be there when we’re needed the most. Visit

Excellent listening, presentation, negotiating and communication skills

September 2017 | The Self-Insurer


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


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

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


WHEN EVALUATING STOP LOSS CARRIERS, JUST LOOK AT THE NUMBERS. Looking for assurance that Guardian Stop Loss Insurance will protect you against catastrophic claims and higher-than-expected medical plan usage? Our numbers speak for themselves: 155 years of financial stability, so you know we’ll be there when you need us

98 (out of 100) score from Comdex, making us one of the most highly rated insurers1

Average turnaround time of just 5 days on claims, whether $10K or $10M2

VISIT WWW.GUARDIANANYTIME.COM/STOPLOSS The Guardian Life Insurance Company of America®, 7 Hanover Square, New York, NY 10004. 1. As of 1/2017 and subject to change. Source: Vital Signs. Comdex is a composite of all ratings that a company has received from the major rating agencies (A.M. Best, Standard & Poor’s, Moody’s, and Fitch). 2. Upon receipt of complete information from the payer. Guardian’s Stop Loss Insurance is underwritten and issued by The Guardian Life Insurance Company of America, New York, NY. Policy limitations and exclusions apply. Optional riders and/or features may incur additional costs. Plan documents are the final arbiter of coverage. Financial information concerning The Guardian Life Insurance Company of America as of December 31, 2016, on a statutory basis: Admitted Assets = $51.9 Billion; Liabilities = $45.7 Billion (including $39.4 Billion of Reserves); and Surplus = $6.2 Billion. Policy Form #GP-1-SL-13. 2017-43335 (07/19)

SIIA New Members Regular Corporate Members Cheryl Kellond Apostrophe Denver, CO

Donald McCully President Medical Captive Underwriters Chicago, IL Gary Honey VP of Sales Oncology Analytics Plantation, FL

Steven Gass CEO Core Choice, Inc. Boca Raton, FL

Paul Griego President Polaris Insurance Company, Ltd. Albuquerque, NM

Seth Denson Principal GDP Advisors McKinney, TX

Cassie Anderson Reseco Insurance Advisors Phoenix , AZ

Ronald Friedman Owner Medgotiate LLC Scottsdale, AZ

Don’t let risk take your Health Plan out. Find out how Renalogic’s CKD Management program can significantly reduce medical spend and halt members’ progression to dialysis. For those members in dialysis, Renalogic can save up to 78% off of full-billed dialysis charges, inclusive of fees. Stop by Booth #700 at SIIA's 37th Annual National Educational Conference & Expo!

One-Time & Monthly Data Analysis

Chronic Kidney Disease Management & Education

Dialysis Cost Containment

For a FREE Health Plan risk assessment, e-mail or call (866) 265-1719.


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Employer Member Mike Hoffman President Arizona Benefit Plans, Inc. Phoenix , AZ

Better Service. Better Performance.

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

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