A P R IL 2 0 2 1
A S I P C P U B L I C AT I O N
SIIA FUTURE LEADERS SHARE THEIR FAVORITE PODCASTS, SOCIAL MEDIA, BOOKS, ONLINE TOOLS AND OTHER HELPFUL RESOURCES
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TABLE OF CONTENTS
APRIL 2021 VOL 150
W W W. S I P C O N L I N E . N E T
FEATURES 4 STAYING INFORMED SIIA FUTURE LEADERS SHARE THEIR FAVORITE PODCASTS, SOCIAL MEDIA, BOOKS, ONLINE TOOLS AND OTHER HELPFUL RESOURCES
By Bruce Shutan
SPOTLIGHT INTERVIEW: SHOMARI SCOTT, CHIEF BUSINESS OFFICER, HEALTH CITY CAYMAN ISLANDS
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
CAPTIVE DEVELOPMENTS IN 2020 REFLECTS A CHANGING MARKETPLACE
ARE YOUR ICS REALLY EES? A LOOK AT WHO’S WHO ON AN EMPLOYEE BENEFIT PL AN … THE SAGA CONTINUES
NEWS FROM SIIA MEMBERS
The Self-Insurer (ISSN 10913815) is published monthly by Self-Insurers’ Publishing Corp. (SIPC). Postmaster: Send address changes to The Self-Insurer Editorial and Advertising Office, P.O. Box 1237, Simpsonville, SC 29681,(888) 394-5688
Self-Insurer’s Publishing Corp.
PUBLISHING DIRECTOR Erica Massey, SENIOR EDITOR Gretchen Grote, CONTRIBUTING EDITOR Mike Ferguson, DIRECTOR OF OPERATIONS Justin Miller, DIRECTOR OF ADVERTISING Shane Byars, EDITORIAL ADVISORS Bruce Shutan and Karrie Hyatt, 2018 Self-Insurers’ Publishing Corp. Officers James A. Kinder, CEO/Chairman, Erica M. Massey, President, Lynne Bolduc, Esq. Secretary
APRIL 2021 3
F E AT U R E
SIIA FUTURE LEADERS SHARE THEIR FAVORITE PODCASTS, SOCIAL MEDIA, BOOKS, ONLINE TOOLS AND OTHER HELPFUL RESOURCES
rom podcasts and social media to business books and blogs, the next generation of movers and shakers in self-insurance are pursuing multiple avenues for tracking industry developments. A discussion thread in SIIA’s virtual national conference lounge featured some fruitful suggestions when Cassandra Van Dyke, director of sales for INTERLINK COE Networks & Programs, asked fellow members of the Future Leaders group how they best learn more about what’s happening across the industry.
Written By Bruce Shutan
Members of the group, who will be logging in for a virtual event this month, regularly tap scores of helpful resources that they’re more than happy to share with their peers. Apart from SIIA gatherings, Canoe and this magazine, there’s a seemingly endless stream of source material. “I don’t have any friends or colleagues that I’m aware of that watch the nightly news per se, but we’re all pretty informed,” observes Dani Kimlinger, Ph.D., CEO of MINES & Associates. The key to millennials tracking the latest news and trends is a multipronged approach that includes a targeted mix of news outlets, terrestrial radio, podcasts and social media.
Staying Informed Her own preferences include Up First, a podcast of 10 minutes or less that she likes to listen to in the morning, or any of the National Public Radio (NPR) stations – both of which deliver content quickly. Kimlinger also taps Twitter and various outlets for news about health care and other topics. “I can just tell by the title if it’s something I’m interested in, and then look into it further,” she explains. Few people age 40 or younger are as resourceful as Elliot Meena, VP of Ansley Capital Group, for whom there’s a bevy of material to stay plugged into industry developments and the business world in general. He stays in tune with the Health Care Administrators Association and subscribes to Ernie Clevenger’s weekly newsletter, MyHealthGuide, describing it as “a summary or snapshot of what’s been going on at a high level.” Dani Kimlinger
In the past year, Meena started listening to more podcasts, as well as NPR, The New York Times and its podcast known as The Daily, which he said does a good job on health care legislation. Another favorite of his is FiveThirtyEight, a website that focuses on opinion poll analysis, politics, economics and sports blogging.
“Those all give you some sort of relative quick turnaround on a topic, depending on the subject you want,” he notes. “Those are Elliot Meena the kind of voices I would like to go listen to if I thought maybe there was something to be said about what happened yesterday or this past week’s events.” AGGREGATING NEWS TO USE Tools that aggregate news that young industry practitioners can use also have proven to be extremely palatable. Google Alerts narrows relevant information for Raena Chatwin, operational systems manager and provider relations supervisor for MINES &
Associates, who says it helps give her “a little head start without having to do too much research and remember to check in on new ideas that are coming up.” At first, she began searching for content that was related to her company or clients before expanding the fields of information to include key words such as EAP, telehealth, behavioral health, telepsychiatry and work comp that would potentially have an impact on her slice of the self-insurance industry. Then Chatwin was able to dig deeper into her firm’s area of expertise by discovering very helpful news she could actually use. One such scenario involved new guidelines from the American Psychological Association allowing state lines to be crossed based on state licensure when providing services in
“That wasn’t even something I had really looked into or thought about how you might utilize that in this world of today where everything is telehealth,” she says. “It wasn’t until I saw a Google Alerts article that really kind of made me go, ‘let me look into this more.’” certain instances.
It was through this handy tool that Chatwin discovered a new national tele-behavioral health company that she approached about helping her firm provide services. Google Alerts also familiarized her with new rules and
Staying Informed guidelines around behavioral health treatment approved in the work comp arena that could be used to forge partnerships to improve tele-behavioral health network offerings or needs around treatment for claimants.
Craig R. Clemente, chief operating officer for Specialty Care Management, is also a big fan of the ShiftShapers podcast, which featured him as a guest. “I was excited to be asked to be on it because I was already a subscriber,” he reports. “David brings a unique perspective in that he’s a former TPA guy, and because of his interaction with the marketplace on a weekly basis, he gets to understand the trends and pulse of what is important to speak about in the moment.” The host’s strong suit is interviewing, as well as providing a great breadth of subject matter and different components of the self-insurance marketplace, according to Clemente. That includes a fairly technical and granular discussion, as well as keen insight, into some market segments that his peers don’t interact with on a daily basis. The result is authentic answers to off-the-cuff questions compacted into about 20 minutes, which he says fits nicely into the lives of busy professionals. Another favorite podcast for Kemper is Trendbreakers by Steve Watson, whose guests impart in-the-trenches wisdom on benefits, human resources and finance topics. An underlining theme, he explains, is to help employers “understand the power of moving to self-insured” from thought leaders with “various perspectives on different angles of the market.”
POPULAR PODCASTS Another increasingly popular source of information and entertainment is the podcast, which fuses part of the word broadcast with one of Apple’s products, the iPod. Jeremy Kemper, former director of sales for Verikai, recommends three standout podcasts. One is ShiftShapers, a weekly show with David Saltzman, which as the name suggests, showcases transformative shifts in the employee benefits industry that are then shaped into new business models, products and best practices. “I like his approach. He just cuts right in,” he says, noting Saltzman’s years of experience in the field. Although the podcast hasn’t been focused on health insurance as of late, Kemper notes that “there are good guests on there, and he does a great job with the types of questions he asks.”
A third show he likes is called A Healthy Dose of Dialogue by Don Antonucci. Although there are fewer episodes than other podcasts, Kemper says there are “some interesting guests on there with fresh perspectives” who “engage in healthy
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Staying Informed dialogue about transformative marketplace trends and industry insights... It’s more about the macro view of the market. That’s what I listen to it for.” LinkedIn is another favorite spot for Kimlinger to track good content that people in her network don’t necessarily produce but share. Her colleague, Chatwin, is part of a self-insured roundtable group on LinkedIn and recalls how it recently resolved a dilemma. “Someone was Raena Chatwin asking about a solution for providing telehealth services when telehealth wasn’t covered by most work comp,” she says. The suggestion was to have the client go into their doctor’s office and have a psychiatrist or psychologist call during the in-person appointment so that the service could be delivered virtually.
THE BEST BOOKS
tactic from a hostage situation into a negotiating tactic to a business situation.” An equally compelling book that helps explain the nation’s health care system, “An American Sickness” by Elisabeth Rosenthal, made a meaningful impression on Tyler Benware, an account executive at Verikai. The author’s background in medicine, research and journalism offers a unique perspective. “If we’re ever going to fix healthcare, we have to know the history of why it’s broken and the forces that are really perpetuating some of this brokenness,” he opines. “I think Rosenthal does a really good job of that, and then points out some really practical areas of improvement.”
One popular book that resonates with Meena is “Never Split the Difference” by Chris Voss and Tahl Raz, which he consumed in an audiobook format. “That I think is how many people get their resources nowadays,” he says. It was co-written by a former hostage negotiator who applies his tactics to business, teeming with examples that he notes “walk over the line, so to speak, of what it is like to transfer a negotiating
COLLEAGUES AND MENTORS Apart from tapping a steady flow of material, Benware believes one of the best industry-specific resources is talking to underwriters, actuaries and brokers. Many of these conversations moved online because of the pandemic, and he learned quite a bit from “understanding what everyone’s doing, the challenges that they’re facing day-to-day and some
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of the things they’re looking forward to this year, 2022 and beyond.” Clemente thinks his peers have adjusted well to a good deal of the light interaction on some Zoom or other video calls over the past year in working from home, though he laments an inability to “feel like you have your finger on the pulse of what’s happening on a daily basis.” Even in spite of these challenges, he has met with more people during nearly a year of pandemic lockdowns than at any time in his 15-year career. Chief among them: many brokers and TPAs. “You really do get a feel for what’s going on out there in the world,” he reports, “and then just in our normal, everyday interactions, we get a pretty good feel for what’s making the market tick, where are those pain points and positives are, just from all the constant interaction that we are having.” Indeed, there’s no substituting for the human touch in gaining a better understanding of the industry as a whole. “I’m not the TPA or MGU, but I can work with all of them, so learning the lingo for six different company types is a lot easier to pick up and make sense of it,” Van Dyke notes. “For us kinesthetic learners out there, we like to be hands-on in the conversation vs. reading it.” She also encourages millennial colleagues to absorb the institutional memory of mentors, and in the process, lessen or shave steep learning curves. She noticed at a recent SIIA event how someone estimated the self-insurance industry’s average age to be 58 or 59 years old.
“That’s why we keep asking for different kind of educational resources, so that when we do go up to the Carol Berrys, the Steve Resnicks, the Julie Wohlsteins, we’re not just asking from scratch,” she says. “We are able to listen to podcasts and tap other sources, and feel like we can contribute to the conversation.”
Bruce Shutan is a Portland, Oregon-based freelance writer who has closely covered the employee benefits industry for more than 30 years.
The focus on providing more resources for younger SIIA members will be showcased as part of the association’s Future Leaders Summit, a Connect from Anywhere (CFA) event, scheduled for April 2022, 2021. Details can be accessed at www.siia.org
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F E AT U R E
SPOTLIGHT INTERVIEW: SHOMARI SCOTT, CHIEF BUSINESS OFFICER, HEALTH CITY CAYMAN ISL ANDS
his interview was conducted by SIIA’s partner in the Connect from Anywhere (CFA) live Medical Travel seminars, and was originally released as a special issue of their digital newsletter, prior to the Health City Cayman Islands live seminar. A recording of the seminar is available to SIIA members at www. siiacanoe.org.
MEDICAL TRAVEL & DIGITAL HEALTH NEWS (MTDHN): TELL US
ABOUT YOUR INVOLVEMENT IN THE PROGRAM, ARE YOU CAYMAN NATIVE?
Shomari Scott (SS): Yes, I am a Caymanian and currently serve as Chief Business Officer for Health City Cayman Islands following several years as the Director of Marketing and Director of Business Development. Prior to this, I was the Director of Tourism for the Cayman Islands after being with the Department of Tourism for about a decade – I actually worked as an intern there while I was in college.
Shomari Scott Tourism is one of the two pillars that make up the Cayman Islands economy, the other being financial services. I first heard the vision of Dr. Devi Shetty, founder and CEO of Health City, at a time when tourism was on a significant upward trend in the Cayman Islands. Dr. Shetty, a surgeon, often says, "Life shouldn't be determined by a price," and he tells stories about his role. "What do you think my job is?" he might say. The answer is, "Well, obviously to operate and save lives." But he would counter: "No, my job is this pen." Dr. Shetty
MTDHN: IS HE REALIZING THIS VISION AT HEALTH
CITY CAYMAN ISLANDS OR
ELSEWHERE IN THE WORLD? SS: Most definitely. He was able to get a CABG (Coronary artery bypass grafting that improves blood flow to the heart) in India down from approximately US$10,000 to just US$1,400. He wants to do the same in regards to significant cost reduction here, on this side of the world.
"This pen?" is the typical reaction, at which he writes with the pen and he says,
"My job is to actually put a price on life. Now that's the most difficult thing, because when somebody comes in front of you and you actually have to tell them how much it costs for them to save their young child, because they need a highly technical cardiac surgery, that's the most difficult thing." Dr. Shetty says that his duty in life is to ensure healthcare is so accessible and so affordable that we reduce the job of putting a price on life. His goal is to enable anybody to be able to afford, for instance, cardiac surgery. He says, "One hundred years after the first cardiac transplant, 80% of the world -- if they need to actually have one of the tertiary types of cardiac procedures – would not have access or they can't afford it. That's wrong." He might even look up at you, put up his iPhone and say, "Does this iPhone cost the same as it did five years ago? It costs less. So why is it that healthcare is the only industry in the world with the benefit of time and technology that has prices going up, instead of down?” The point is that some people think they would die without an iPhone, but they won’t. But if people don't get access to healthcare, they will die.
"It's my vision to be able to change that," Dr Shetty declares.
He wants to prove that this price reduction wasn't just because they were operating in India. He is intent on showing that they're able to control price and that they're able to actually perform the highest quality of surgery in an environment akin to the top US health systems in accordance with US quality metrics. The Cayman Islands was the perfect place for him to come and prove it, especially based on the fact that our cost of living is equivalent to New York City, and the cost of doing business is parallel. If we can actually have the price of a cardiac surgery in the Cayman Islands dwarf a price in New York -- apples to apples -- why can't you do it elsewhere so more people can gain access to quality healthcare? Health City Cayman Islands really was a test case. Coming from my tourism background, I was never able to save a life. But thinking that I could be involved in an actual industry that had the potential to become the third pillar of the Cayman Islands economy as well as save lives, is an honor.
APRIL 2021 13
Shomari Scott Islands and in the US. We were starting with a blank canvas. In healthcare you need to build trust and I was able to understand why somebody like myself was needed to lead the team and develop the marketing and brand awareness. We are building the image and the brand story so individuals will recognize and trust Health City and then be willing to access and use us.
Health City Cayman Islands
HEALTH CITY IS KNOWN FOR
I spoke about the first two pillars, Tourism and Financial Services, and now, Destination Healthcare as we call it, or Medical Tourism is becoming the third pillar of the Cayman Islands. This is such an exciting industry and vision and I am delight to be a part of this project.
ITS CARDIOLOGY SERVICES.
You'll never get a chance like this in a lifetime. In the Cayman Islands, we're a success story, punching above our weight in many different areas -- tourism and financial services included.
ONLY CONSUMERS, BUT
It’s opportunities like this that create something people will speak about in the future -- for decades in time or maybe even hundreds of years from now – that don’t come along every day. These are serious lifesaving surgeries we are performing and I am proud to be a part of it.
MTDHN: IS YOUR EXPERIENCE IN COMMUNICATIONS, MARKETING AND ADVERTISING USEFUL IN THIS ROLE?
SS: Obviously, these skills were important for tourism and our team made the Cayman Islands successful. Health City wanted me to bring this skillset to support Health City. Even as great as Dr. Devi Shetty is, and being a former physician for Mother Teresa, his brand awareness and that of NH the parent organization was minimal both in the Cayman
TELL US ABOUT ITS OTHER
CAPABILITIES THAT WOULD BE OF INTEREST TO, NOT
TO BUSINESSES WHO ARE
EXPORTING THEIR PATIENTS
TRAVELING TO THE CAYMAN ISLANDS.
SS: We have a full suite of the top tertiary types of services that you would want, from neurology and neurosurgery to cardiology and cardiothoracic care. We treat patients from all over the world. In 2016, we treated patients from 60 different countries. We also have a sizable number of patients that travel from the US and Canada, and they
Shomari Scott mostly access orthopedic and spine surgery, as well as bariatric surgery. In Canada, they have socialized medicine – it’s not really free since the people obviously pay for healthcare with their taxes. For the most part, when you walk into a Canadian hospital, you don't pay out of pocket and there's no insurance mechanism. So why would Canadians come to Health City Cayman Islands for orthopedic surgery? The answer is they have such long wait times. If you're feeling hip pain, it may take you six months to have an MRI. From the time you start from the inception of pain or until you actually have the surgery, it can be 24 months. Conversely, they can purchase a plane ticket to the Cayman Islands, have their surgery, have two weeks of physiotherapy -- all inclusive, all bundled --and return home and be back to work within a month or two. Here’s an actual patient example: we treated one individual who owns a boutique art gallery and is the most important employee from a strategic perspective and she also contributes with man power by hanging paintings on the wall. Not being able
to use her shoulder was a big business disadvantage. So it made sense for her to spend US$16,000 to come to the Cayman Islands and have her shoulder taken care of. Two months later, she was back to work, 100% operational versus suffering for two years.
MTDHN: WHAT DOES THIS
MEAN TO SELF-FUNDED US EMPLOYERS?
SS: In the US there are quite a few self-insured companies that actually use Health City. What we've found is the companies that do it the best have been doing it for a long time.
Shomari Scott They have case managers on their team that are usually former nurse practitioners. They organize the travel and avail themselves of our services. For knees, shoulders or hips, the employee stays with us for two weeks and returns home. Our physicians are in constant contact with the patient, supported by a full international patient care team here at Health City that is assigned to specific companies or individuals.
The great thing is that the government then made this concierge approach an actual service that others – such as hotels -- can pay for to receive that type of service.
This team puts the Health City doctor in contact with either the nurse practitioner or the doctor on the patient side -- in the US or elsewhere. We have all the medical records uploaded to a HIPAA compliant portal. Our physicians see and review the medical records and decide on whether or not surgery is needed. One of our patient care representatives actually sets up all of the travel.
One of the unique things about Health City is that we have an offshoot of one of the Four Diamond Restaurants in town. The Blue Cilantro restaurant is one of the restaurants that has earned The Cayman Islands the distinction of being called the culinary capital of the Caribbean! We were able to convince its owner to be the third party provider for our kitchen here at Health City. The food patients receive is actually Four Diamond rated food.
The patients arrive and we have arranged with the government to meet them at the plane. To rewind a little bit, Dr. Shetty said he needed 14 things from the Cayman Islands government prior to agreeing to actually making the investment in the Cayman Islands. One of those things was the ability to greet our patients at the plane and carry them directly through customs and immigration to our vehicle that would be waiting for them outside the airport. So coming from tourism, many marquee hotel properties gave me grief in jest since we weren't able to offer this to their guests prior to Health City. Then all of a sudden, I am working at the hospital and we can meet patients at the foot of the plane.
But our patients receive this service free of cost to them, which eliminates a lot of anxiety for patients who are traveling to a destination they are unfamiliar with. We try and strip out all that anxiety, providing a friendly face that meets you at the foot of the plane and carries you through to the driver’s smiling face. From point to point, you're taken care of. You arrive at the hospital and are admitted if you are going directly in for treatment. We also have single as well as two- or threebedroom condo units right here on campus, which are like mini apartments with a refrigerator, balcony and a pool to accommodate families of every size.
Patients are amazed with this unique aspect. When we first started having testimonials, it was surprising that patients reported, “Great care, great doctors and nurses. Pam was a great Patient Care Representative. But the food, oh my goodness, you can't believe the food!" We offer international cuisine, but even to the point where we get tourists staying over on Seven Mile Beach, our visitor hub, coming to Health City just to dine in our
"Are you all here for surgery?" – to which they respond, "No, no, we're just here to get food. Yes! Our concierge told us that for the best curry on Island – and it sounds a little bit strange -- but there's a hospital with a cafeteria that has incredible food.”
cafeteria. Our staff reacts,
MTDHN: THE PATIENT EXPERIENCE SOUNDS GREAT. SS: It is. The overall experience at Health City is personalized and exceptional. Each patient has one representative assigned to take care of them and their family members while they’re in surgery. This care continues throughout the process and the representative is in constant communication with case managers from the patient’s home country, including their physicians. When you're discharged, finished with your physical therapy and it's time
Shomari Scott to leave, we organize all the details. We return you right back to the airport, straight through immigration, customs and departure. Then we keep track of our patients, anywhere from three months to six months to a year, until they fully complete the healing process. This end-to-end process is very successful.
MTDHN: LET’S TALK ABOUT Dr. Binoy
QUALITY – THE
QUALITY OF CARE, THE DOCTORS
AS WELL AS THE PATIENT OUTCOMES. IF THERE IS A LESS THAN
OPTIMAL OUTCOME, IS THERE A WARRANTY OR GUARANTEE ON PRICING FOR A RE-DO?
SS: The great news about Health City is that we're a Joint Commission International accredited facility. We received our JCI accreditation within one year of opening our doors. This is somewhat of a record because usually JCI would wait two years or so for the hospital to be ready. But we have the benefit of the Narayana Health group (NH), which has over 30 hospitals and embedded units across India, and many of the main facilities are JCI accredited.
everybody held their breath. He continued, "This is an excellent report. In my 20 years of doing this, I have never seen a facility that had only a few partial non-compliance areas. I've never seen this. So the only way you guys have to go from here is perfection. I don't know how you're going to beat it." That being said, we also track all of our quality measures. For instance, our unplanned return rate to the surgical theater within 48 hours is 0.88% and the benchmark for top-notch facilities is 4.6%. Other examples:
Our anesthesia-related complication rate is 0% and the benchmark is 4.8%.
Readmission rate to ICU within 48 hours, we are at 0.4% and the benchmarks 2%.
For patient falls, which people are used to hearing about, the benchmark is anywhere between three to 5%. We're at 0.31%.
So we already had a Quality Manager that came from the parent group that had previously been one of the strategic quality drivers getting facilities in India and even Dubai JCI-accredited. We knew that we were more than ready for JCI, and we've been accredited twice because accreditation occurs every two years. We're coming up to our third JCI accreditation in April and we've always passed JCI with flying colors. The last time we had a JCI inspection, the inspector told us and everyone else at the conclusion meeting, "I want to let you know that this is not a good report." And
regards to your quality," he said. What it really boils down to, is looking at where healthcare cost becomes exorbitant -and obviously there are many different areas. But when you look at complication rates or infection rates, that's where the cost increases. When a health policy contributor to Forbes visited the facility, he wrote an article about his experience and the quality of outcomes.
"You know what? In the US if we mess up, we pray you don't sue us. Then we fix it, and then we charge you for both."
For readmission rate after a total joint procedure the benchmark is 5.61% and we’re at 1.89%. We have a full list of the different quality indicators across every different specialty and anybody who asks, we're willing to share it with them. Back when the borders were more freely open, people would come here and we would participate in audits.
MTDHN: THIS IS IMPRESSIVE. IS THERE MORE?
SS: The great thing is that when we first opened, we had half of the Board of Directors from Ascension Health in the US. One of the board members actually was also a board member of JCAHO in the US and he was blown away by our quality. "I see the top of the tops in the US and your hospital is not only on par, you're exceeding some of the best facilities in
He pointed to our low infection rates and acknowledged that’s where the majority of the cost is in the US. With such low rates here, we are able to offer an affordable bundled price because we are actually very confident about surgical procedures and quality of outcomes.
MTDHN: TELL US ABOUT YOUR BUNDLED, ALL INCLUSIVE RATES. ARE THEY COMPETITIVE? SS: Extremely competitive. For instance, a knee, hip or shoulder replacement is approximately US$16,000. We don't have any differentiating pricing. We know that in the US, for example, a knee replacement -- which tends to be less than a hip or a shoulder -- can cost anywhere from $25,000 to 40,000 to 60,000 USD – or more! With our bundled pricing, that's the entire cost. You're not going to pay anything else. If there's any complication due to the actual procedure, that's on us. We won't charge you anything more.
Shomari Scott So we're that confident in what we do and that how we price our surgeries. That's the other thing that Dr. Shetty wants for healthcare: for it to become commoditized in the same way you go to a car dealership and you know exactly what that car costs. Why should you not know when you're coming for a cardiac surgery, exactly what that cardiac surgery is going to cost? Here’s another example: a CABG bypass surgery will cost about US$25,000-$35,000 at Health City, depending upon the type of procedure. But a recent article in Time Magazine talking about prices in the US says,
"What I learned from my $190,000 open heart surgery." We know open hearts can cost you on the lower side anywhere from US$80,000, all the way up to US$250,000- $300,000. We're able to charge less than $35,000, all inclusive for a cardiac bypass surgery. That’s a big price differential, with quality outcomes that are as high, if not better than, the top facilities in the US for those specialties.
MTDHN: TELL US ABOUT YOUR EXPERIENCE WITH COVID. DO
YOU NEED TO HAVE A VACCINE OR PROOF OF TESTING TO ENTER THE ISLAND?
SS: We are possibly the safest country in the world, because as the COVID pandemic started to unfold in March, we closed our borders to both cruise ships as well as to airlines.
We were in a serious lockdown for about three months until we understood that there was no community transmission on Island. We had constant, rapid testing and we slowly opened up locally. Since then, we've slowly opened up to certain categories of travelers coming into the Cayman Islands. But anybody traveling in has to have a negative PCR, 48 hours prior to travel. They then have a PCR test at the airport in Cayman upon arrival. To this date, anybody traveling into the Cayman islands has to quarantine for 14 days. We haven't had any masks for months. We're dining in restaurants and attending sporting events. Obviously, tourism has been hurt. But due to the power of our Financial Services Industry, as well as development, we have stayed in a good position. The government is also taking care of our tourism workers that aren't working. While this puts a strain on medical tourism, the good thing for our hospital is that in the Cayman Islands, albeit a first world country, tertiary care was non-existent until we arrived. We have filled major healthcare gaps and in doing so have a good local population base of patients.
MTDHN: DO THE LOCAL RESIDENTS USE THE HOSPITAL? SS: We've filled a lot of gaps in healthcare as previously mentioned. The drop in medical tourism has been offset with the local population that might have otherwise been going overseas. They are no longer traveling away from Cayman for care due to the COVID situation to previous healthcare centers in the US for instance. This has given us an opportunity to provide services to the 15 to 20% of local residents that may still have been going overseas. The good news is, even with our borders being more or less closed, we were able to treat all variety of illnesses and emergencies allowing the government to keep the virus contained and not being pressured to open due to medical necessity. The minimal medical tourism has been emergencies coming into the Cayman Islands. We were able to get special approvals -- and we've saved lives. With PPE, we go in and we do the surgery. Then the patient quarantines for the 14 days, and then with a negative PCR, they are released on the 15th day. We have vaccinated over 80% of persons over 60 years of age living in Cayman. The government has stated that when we achieve 90% of the persons over 60, who are the most vulnerable to the severe impacts of COVID, they will look to reopening general tourism. I think that by the Summer -- May, June, July -- we should be able to get more medical tourism back in the Cayman Islands.
Medical Stop Loss from Berkshire Hathaway Specialty Insurance comes with a professional claims team committed to doing the right thing for our customers – and doing it fast. Our customers know they will be reimbursed rapidly and accurately – with the certainty you would expect from our formidable balance sheet and trusted brand. That’s a policy you can rely on.
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MTDHN: ONE LAST QUESTION ABOUT THE AVAILABILITY
OF PRESCRIPTION MEDICAL
We do offer pharma, but we also treat the patient and work closely with the physicians overseas as well. You can't come here without seeing our physician and having a reason to get meds.
TRAVEL. IS IT AVAILABLE?
SS: At times there is a negative connotation associated with being a Rx hub if just the selling of medication occurs. We never wanted to be associated with this. Health City has always wanted to deal with serious ailments and be known as a world class medical center, first and foremost.
So we are not like some other destinations where you can fly in, and even in the airport, get pharmaceuticals. We want to be known in the world of medical tourism as one of the best facilities for surgical care and interventions for cardiac, orthopedics, neurosciences, oncology and other specialties etc.
Anybody traveling to Health City can get meds and pharmaceuticals. However, it has to be for a specific disease profile that we deal with. You can't just come and buy meds off the shelf.
Health City Cayman Islands
A QQ& A
ACA, HIPAA AND FEDERAL HEALTH BENEFIT MANDATES:
he Affordable Care Act (ACA), the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other federal health benefit mandates (e.g., the Mental Health Parity Act, the Newborns and Mothers Health Protection Act, and the Women’s Health and Cancer Rights Act) dramatically impact the administration of self-insured health plans. This monthly column provides practical answers to administration questions and current guidance on ACA, HIPAA and other federal benefit mandates. Attorneys John R. Hickman, Ashley Gillihan, Carolyn Smith, Ken Johnson, Amy Heppner, and Earl Porter provide the answers in this column. Mr. Hickman is partner in charge of the Health Benefits Practice with Alston & Bird, LLP, an Atlanta, New York, Los Angeles, Charlotte, Dallas and Washington, D.C. law firm. Ashley, Carolyn, Ken and Amy are senior 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 email@example.com.
HOW IS COBRA AFFECTED BY THE COVID-19 OUTBREAK PERIOD? On February 26, the Department of Labor (DOL) released EBSA Disaster Notice 2021-01, which clarifies the application of the one-year limit in ERISA Section 518 (and IRC Section 7508A) to the “Outbreak Period” established by the DOL and IRS in a 2020 Joint Notice. The Outbreak Period is the period beginning March 1, 2020 and ending 60 days after the announced end of the COVID-19 National Emergency that plans must disregard when determining the due dates of certain actions by plan participants and other individuals.
BACKGROUND Back in early May 2020, the DOL and the Department of Treasury (the “agencies”) issued the 2020 Notice. The 2020 Notice provided relief for the following actions and deadlines for plan participants and other individuals due to the COVID-19 pandemic:
· The 60-day period to elect COBRA. · The 45-day grace period to make initial COBRA premium payments and the 30-day grace period to make subsequent payments.
· The date for individuals to notify the plan of certain COBRA qualifying events or a determination of disability.
· The 30-day period (or 60-day period, if applicable) for HIPAA special enrollment rights.
· The date for filing benefit claims and appeals for welfare and retirement plans subject to ERISA.
· External review requests for non-grandfathered health plans subject to the Affordable Care Act. In determining the due dates for any of these actions, employee benefit plans were required to disregard the Outbreak Period when determining the due dates for these actions. In essence, plans have been required to stop counting such time during the Outbreak Period. When the Outbreak Period ends, plans can resume counting.
THE ONE-YEAR LIMITATION Although the National Emergency continues, questions were raised in February 2021 regarding the end of the Outbreak Period. This is because the 2020 Notice was a product of ERISA Section 518 and IRC Section 7508A, which allow the agencies to prescribe a period “of up to one year that may be disregarded in determining the date by which any action is required or permitted to be completed.” The 2020 Notice acknowledged the applicability of the one-year limitation, but it did not clarify how that one-year limit would be applied.
Since the Outbreak Period started on March 1, 2020, many believed that the Outbreak Period would end February 28, 2021 even though the President has not yet declared an end to the National Emergency. And, if it ended February 28, 2021, plans could resume counting on March 1, 2021 to determine the due dates of any of the actions affected by the Outbreak Period.
2021 NOTICE On February 26, 2021, the DOL issued the 2021 Notice to clarify how the oneyear limitation is applied to the Outbreak Period. Much to the dismay of many plan sponsors and administrators, the agencies did not apply the one-year limitation to the Outbreak Period itself. Instead, the DOL indicated that the one-year limitation is applied to individual periods affected by the Outbreak Period. More specifically, the 2021 Notice provides that the period for disregarding days in an individual’s affected period ends the earlier of one year from the date that an individual was “first eligible for relief” or 60 days after the announced end of the National Emergency (i.e., the end of the Outbreak Period). Thus, the 2021 Notice creates Outbreak Periods for each affected action. The 2021 Notice further states that once the Outbreak Period ends for a particular action, plans may resume counting when determining the due date for that action. Here are a few examples of how this will work: Example #1: Bob’s COBRA election period began February 15, 2020, and the due date for electing COBRA would have been April 15, 2020; however, the Outbreak Period began 14 days into his 60-day election period.
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The Outbreak Period related to Bob’s COBRA election period will end on the earlier of one year from March 1, 2020, the date that Bob first became eligible for relief for his COBRA election period, or 60 days after the end of the National Emergency. In this example, the Outbreak Period for Bob’s COBRA election period ends February 28, 2021, and Bob’s plan can start counting his COBRA election period again on March 1, 2021. Since Bob had 46 days remaining in his 60-day election period when the Outbreak Period began, Bob’s plan can require Bob to make his COBRA election by April 15, 2021. Example #2: Joe’s COBRA election period began May 1, 2020 and would have ended June 29, 2020; however, all 60 days of Joe’s election period fell during the Outbreak Period. Assume that the National Emergency is still ongoing in June 2021. Joe’s Outbreak Period for his COBRA election period will end April 30, 2021—one year after Joe first became eligible for relief. This means Joe’s plan can start counting the 60-day period on May 1, 2021. Joe’s plan can require him to elect COBRA by June 29, 2021.
PRACTICE POINTER: The
DOL provides two COBRA election examples that appear to provide a shortcut for applying the one-year limitation that would apply to all affected events. Instead of measuring the oneyear period from the date the individual first became eligible for relief and then adding the days that were disregarded during the Outbreak Period to determine the new due date, plans can identify the new due date simply by adding one year to the otherwise applicable due date. For example, you can also determine Joe’s new due date under the one-year limitation by measuring the one-year period from June 29, 2020. As it was above, the new due date for electing COBRA is June 29, 2021. If the Outbreak Period ends in its entirety before the one-year limitation is reached, then plans would add the disregarded days to the end of the Outbreak Period. Example #3: Rhonda was on COBRA when the Outbreak Period began on March 1, 2020. As of that date, Rhonda stopped paying her COBRA premiums. The Outbreak Period for the March 2020 premium ends on the earlier of one year from March 1, 2020 or the 60 days after the National Emergency ends. Since the National Emergency is ongoing, the Outbreak Period for the March 2020 premium ended February 28, 2021. This means that the plan can require Rhonda to pay her March 2020 premium by March 31, 2021. However, if Rhonda has not been notified about the end of her individual Outbreak Period, the plan may want to make an accommodation and provide Rhonda a reasonable period of time after she receives notice to make a payment.
PRACTICE POINTER: Does
the plan have to give Rhonda until April 30, 2021 to pay her April 2020 premium (if she wants April 2020 coverage) or can the plan require her to pay April 2020 and any other coverage months in 2020 that she wants by March 31, 2021? While there is little doubt that the plan can require Rhonda to pay her March 2020 premium by March 31, 2021, it is unclear how the one-year limitation is applied to other months because it is not clear when Rhonda first became eligible for relief for the other months that were not paid. Conservative sponsors will measure the oneyear period separately for each monthly premium that was not paid. It is interesting to note that the DOL provides an example in the 2020 Notice indicating that when the Outbreak Period ends, a qualified beneficiary must pay by the end of the first month after the Outbreak Period ends all premiums for all months that he or she desires that were not paid during the Outbreak Period. Example #4: ABC’s run-out period for the 2019 plan year would have ended March 31, 2020; however, 31 days of that run-out period—March 1, 2020 through March 31, 2020—were disregarded since it fell during the Outbreak Period.
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DENTAL / VISION
For current financial ratings of underwriting companies by independent rating agencies, visit our corporate website at www.sunlife.com. For more information about Sun Life products, visit www.sunlife.com/us. Stop-Loss policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) in all states except New York, under Policy Form Series 07-SL REV 7-12. In New York, Stop-Loss policies are underwritten by Sun Life and Health Insurance Company (U.S.) (Lansing, MI) under Policy Form Series 07-NYSL REV 7-12. Product offerings may not be available in all states and may vary depending on state laws and regulations. © 2021 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. Sun Life and the globe symbol are trademarks of Sun Life Assurance Company of Canada. Visit us at www.sunlife.com/us. BRAD-6503-n
SLPC 29427 02/21 (exp. 02/23)
The Outbreak Period for the run-out period for the 2019 plan year will end February 28, 2021, which means ABC can start counting again on March 1, 2021. Thus, ABC can require participants to submit claims incurred in 2019 by March 31, 2021.
PRACTICE POINTER: Unlike
COBRA elections or premiums, the run-out period for health FSAs is not connected to a participant-specific date. In our example, all claims incurred during 2019 would have otherwise been required to be filed by no later than March 31, 2020, irrespective of when in 2019 the claims were incurred. PRUDENT FIDUCIARY ACTIONS UNDER THE 2021 NOTICE The 2021 Notice states that plan fiduciaries: should take reasonable steps to minimize the possibility of individuals losing benefits because of a failure to comply with preestablished time frames. For example, where the plan administrator or other responsible plan fiduciary knows, or should reasonably know, that the end of the relief period for an individual action is exposing a participant or beneficiary to a risk of losing protections, benefits, or rights under the plan, the administrator or other fiduciary should consider affirmatively sending a notice regarding the end of the relief period. The DOL goes on to note that plans should make reasonable accommodations to prevent the loss of benefits and that plan disclosures may need to be revised if they “failed to provide accurate information regarding the time in which participants and beneficiaries were required to take action”—specifically mentioning COBRA election notices and claims procedure notices. Also, the DOL indicates that fiduciaries should “consider ways to ensure that participants and beneficiaries who are losing coverage under their group health plans are made aware of other coverage options that may be available to them, including the opportunity to obtain coverage through the Health Insurance Marketplace in their state.” In light of the fiduciary considerations posed by the DOL, employers, plans, and third-party administrators (TPAs) should consider the following action plan:
· Revise current COBRA materials and adverse benefit determination notices to reflect the one-year limitation.
· Coordinate with COBRA administrators, TPAs, and insurers to see how they anticipate addressing the 2021 Notice and any individualized disclosures.
· Likely, at a minimum, a communication should be sent to all individuals who had a COBRA qualifying event from January 1, 2020 (60 days before the beginning of the Outbreak Period) explaining how the one-year limitation period is applied.
PRACTICE POINTER: If
the one-year limitation for an individual expired before the notification was sent (or shortly thereafter) and an individual wishes to make an otherwise untimely COBRA election or delinquent COBRA premium payment, then an accommodation should likely be made assuming the applicable insurer or stop-loss carrier agrees.
· Similarly, at a minimum, a communication should go out to all affected current and former participants informing them of the calculation of applicable periods for claims and appeals, external review requests, and HIPAA special enrollment rights in addition to the COBRA deadlines.
· All applicable websites (employer, COBRA administrator, and TPA) should be updated with this new guidance.
· For COBRA, thought should be given on how this notice might be coordinated with notification concerning COBRA subsidies that are part of the recently enacted American Rescue Plan Act of 2021.
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ARE YOUR ICS REALLY EES? A LOOK AT WHO’S WHO ON AN EMPLOYEE BENEFIT PL AN … THE SAGA CONTINUES
Written By Philip Qualo and Kelly E. Dempsey
ast time we addressed the issue of classifying workers in the March 2020 issue of The Self-Insurer, the world was a totally different place. Face masks were only worn by doctors during surgery, quarantine was a term almost exclusively used in sci-fi and horror movies, and the blurry rules applicable to classifying workers had remained relatively unchanged for decades. What a difference a year can make! Facemasks have become the hottest new accessory, “Zoom fatigue” is a real thing, a new administration, and an entirely new framework for classifying employees and independent contractors is on the horizon. For most laymen, the question of whether a worker is an employee or an independent contractor is simple…an independent contractor is compensated by Form-1099, and an employee is compensated by Form W-2 as well as subject to federal and state tax withholding.
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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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Changes to state law and the impending federal rules make this a good time for employers to start reviewing their own internal processes for classifying workers (that is if employers did not heed Ms. Dempsey’s prior article - see The Self-Insurer March 2020 edition).
Many are surprised to find out that the analysis is far more complicated than which tax form is provided annually. For employers, this is a far more complex undertaking (whether they realize it or not). Employee status triggers employer obligations under various federal and state laws that do not apply to independent contractors, and the responsibility for classifying a worker correctly falls squarely on the employer. The implications are even larger for employers that sponsor self-insured health plans - correctly classifying workers is an extremely important undertaking as offering coverage to independent contractors can create significant compliance issues for their health plans as well as issues with stop-loss reimbursement. No bright-line test exists to determine when a worker should be classified as an employee rather than as an independent contractor. In September 2020, the U.S. Department of Labor (DOL) issued proposed rules aimed at simplifying classification of workers. Final rules were published on January 7, 2021 with a March 8, 2021 effective date; however, actions taken by the Biden administration delayed the effective date of the final rule to May 7, 2021. To further complicate matters, on March 11, 2021, proposed rules to withdraw the final rules published on January 7 were issued. While it is likely these rules will be withdrawn without much objection, it is important to understand what was being proposed as it is possible future rules may arise as the concept of employee vs. independent contractor is a very hot topic, especially in California. Prior to the DOL issuing final rules, California had previously placed California Proposition 22 on the November 2020 ballot. California Proposition 22 established more stringent classification standards for certain workers and it is likely the lobbying entities will seek similar legislation in other states.
Before we dive into the final rules that are now pending withdrawal, it is important to emphasize why this classification matters. Employers are required to withhold income taxes based on information employees provide on IRS Form W-4. If an employer fails to withhold income taxes on behalf of a worker improperly classified as an independent contractor, and the individual has failed to pay the taxes, the employer may be liable for federal or state taxes that were required to be withheld but were not. Furthermore, independent contractors are not eligible to receive tax-free benefits from an employer - such as an offer of coverage to participate in a self-insured health plan. If an employer chooses to offer health care benefits to an independent contractor, the contractor must pay income taxes on the value of the benefit. Additionally, if the company includes an independent contractor in its defined benefit pension plan, it risks losing the tax-exempt status of the plan. Employers offering self-insured health coverage to independent contractors are especially vulnerable to compliance risks for the plan, including inadvertently creating a Multiple Employer Welfare Arrangement (MEWA) plan subject to state law and no longer protected by ERISA preemption mandates.
Historically, the DOL, Internal Revenue Services (IRS), and federal courts have interpreted the Fair Labor Standards Act (FLSA) to consist of a broad general rule that a worker was an independent contractor, and not a bona fide employee, if the employer had the right to control or direct only the result of the work of an individual, as opposed to what will be done and how it will be done. To determine how to properly classify workers and assess the degree of control and independence in the employer/worker relationship, the agencies and the courts have focused on three broad categories, which consist of a total of 20 factors for employers to consider when determining whether a worker was a bona fide employee of the employer, or an independent contractor. The 20 factor list is fairly exhaustive and can be overwhelming, however, the categories are seemingly straightforward.
The first category is behavioral control - a worker is an employee when the business has the right to direct and control the work performed by the worker, even if that right is not exercised. The second category focuses on financial control - whether the business has a right to direct or control the financial and business aspects of the worker's job. The third category focuses on the relationship between the parties. Essentially, an expectation that the relationship will continue indefinitely, rather than for a specific project or period, is generally seen as evidence that the intent was to create an employer-employee relationship. Ultimately, whether a worker was an independent contractor or employee depended on the facts in each situation. Towards the end of 2020, however, the DOL published a proposed rule revising its interpretation of the FLSA's classification provisions to determine whether a worker is an employee or independent contractor. Subsequently the rules were finalized very early in 2021 but are now subject to withdrawal. With that said, it is important to understand what these rules would have changed. Under the “economic reality test”, the DOL would consider whether a worker is in business for themselves and thus is an independent contractor, or if the worker is economically dependent on an entity for work and is an employee. In making this determination, the DOL would identify two core factors: (1) the nature and degree of the worker's control over the work (2) the worker's opportunity for profit or loss based on initiative or investment. It also will identify three other factors
that may serve as additional guides in the analysis. These factors include the amount of skill required for the work, the degree of permanence of the working relationship between the worker and the potential employer, and whether the work is part of an integrated unit of production. The DOL noted that the first two core factors are entitled to greater weight than the other factors. The first factor would suggest that an individual is an independent contractor to the extent that he or she exercises substantial control over key aspects of the performance of the work. Examples of an individual's substantial control include setting his or her own work schedule, choosing assignments, working with little or no supervision, and being able to work for others, including a potential employer's competitors.
As for the skill factor, the DOL proposed focusing on the amount of skill required. Because the worker's ability to work for others is already analyzed as part of the control factor, the final rule articulates the permanence factor without reference to the exclusivity of the relationship between the worker and potential employer. The permanence factor would weigh in favor of an individual's being classified as an independent contractor when the working relationship is definite in duration or sporadic. By contrast, the factor would suggest someone is an employee if the working relationship is indefinite in duration or continuous.
In contrast, the control factor would weigh in favor of classification as an employee to the extent that a potential employer, rather than the worker, exercises substantial control over key aspects of the work, such as imposing requirements that the individual work for the employer exclusively during the working relationship.
The "integrated unit" factor would focus on whether an individual works in circumstances similar to a production line. This factor weighs in favor of employee status where a worker is a component of a potential employer's integrated production process, whether for goods or services.
The second factor would suggest that an individual is an independent contractor if he or she has an opportunity for profit or loss on either the exercise of personal initiative, including managerial skill or business acumen or the management of investments in or capital expenditure on (for example, helpers, equipment, or materials).
According to the DOL, if the first two core factors—control and opportunity for profit or loss—point toward the same classification, their combined weight is substantially likely to outweigh the other factors.
The overall production process must be an integrated process that requires the coordinated function of interdependent subparts working toward a specific unified purpose. This may happen when the worker depends on the overall process to perform work duties.
This differs from the original test supported by the agencies as the actual practice of the parties involved will be considered more relevant than what may be contractually or theoretically possible.
Stop Loss Solutions for Level-Funded Programs As a leading national Stop Loss company, HM Insurance Group (HM) works to deliver the right financial protection for the client at hand – whether it’s an employer of 1,000 or a group of a much smaller size.
Not only does HM write Stop Loss policies for traditional self-funded groups, the company also works with partners offering level-funded solutions to small groups interested in balancing the customization and autonomy of self-funding with the consistency and financial security associated with a fully insured plan. Since smaller, less well-capitalized groups may have cash flow challenges or concerns about having too small of a risk pool for a traditional self-funded arrangement, level funding offers a coverage alternative. A plan is designed with a set payment structure to fund it. Stop Loss insurance is embedded, helping to mitigate the financial risk of catastrophic claims. That’s where HM comes in, helping to guard the financial health of the employers selecting level-funded benefits programs.
HM’s Level Funding Arrangements • Partners with ASO carriers and TPAs, delivering Stop Loss protection for their small group programs • Holds 1/3 ownership of AST Risk, a leading MGU for small group level funding programs that are managed through TPAs
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The proposed withdrawal of the final rules outlines various reasons the rule should not become effective. In short, based on over 1,500 comments received, the DOL now believes the final rules create more confusion and potential inconsistency in application as opposed to providing clarity and certainty as intended. While these rules now face even greater uncertainty than just delayed application, one state has already implemented their own set of stringent rules for worker classifications that have been making headlines since the November elections.
CALIFORNIA’S PROPOSITION 22
As mentioned above, California’s Proposition 22 was on the ballot in November 2020 and passed with a relatively narrow majority at 58%. Several key requirements now apply to “gig companies” – sometimes referred to as “on-demand companies” and better known by their names including Uber, Lyft, DoorDash, and Instacart. These on-demand companies must provide (1) an hourly wage equal to 120% of local or state minimum wage requirements for time spend on rides; (2) a stipend for health insurance for individuals working 15 hours or more per week; and (3) access to accident insurance. The catch-22 (pun intended) is that Proposition 22 also solidifies an exemption under state law for these same on-demand ride-hail and delivery companies to treat workers as independent contractors. This means these workers are not protected by California’s generous employee protections, including paid sick leave laws.
Many following these developments in California have observed that California has essentially created a third category of workers. Aside from the general controversy surrounding the new requirements and permanent independent contractor status, the success in California means the door to additional states having similar laws has been kicked open.
NEW JERSEY CLASSIFICATION PENALTIES
Faithful readers may recall the March 2020 discussion of New Jersey’s modifications to worker classification laws. Some rules took effect in late 2019 and additional requirements began in April 2020. As a quick refresher, one very notable change was the addition of monetary penalties for misclassification of employees and independent contractor. Penalties include an administrative penalty for misclassifying an employee beginning at $250 per misclassified employee and increasing for subsequent violations to a maximum of $1,000 per misclassified employee.
The second penalty is a monetary amount that is to be no more than 5% of the worker’s gross earnings over the past 12 months. The limitation applies to the earnings from the employer that actually misclassified the individual – meaning a new employer that has contracted to work with the independent contractor cannot be held accountable for the prior employer’s mistake. Given the radical turn 2020 took with the pandemic, it is likely to be some time before information on violations make their way to the surface.
FINAL CONSIDERATIONS FOR SELF-INSURED PLANS
Those familiar with self-funding will know that private self-insured employers are generally used to enjoying ERISA preemption of state law; however, as classification of workers is a rule directed to employers, the lines begin to blur and as discussed, these rules can have an impact on how an employer is offering a self-insured benefit plan. Classification of workers is certainly an area of regulation that will continue to develop at a state and federal level. In addition to the various federal laws that include testing requirements (such as the Mental Health Parity Addiction Equity Act, Code Section 125, and Code Section 105(h)), employers will need to remain acutely aware of how they are classifying workers regardless of whether or not the final rules take effect. While the future always carries a fair amount of uncertainty, being proactive and assessing the status of their current workforce is something that employers should not ignore.
Philip Qualo, J.D. is Compliance and Regulatory Affairs Consultant, Philip provides consulting services to employers, third-party administrators, brokers, and vendors on an array of topics focused human resource and employee health benefit plan compliance. He proactively monitors the legal and regulatory environment to identify legal, regulatory and compliance-related gaps and advises internal and external stakeholders on areas of risks. Philip is also the founder and Chairperson of The Phia Group’s Diversity Inclusion Committee. He earned his J.D. from Villanova University School of Law. Philip’s professional experience has ranged from practicing employment law specializing in disability litigation, to managing federal grants and advocating for underserved communities.
Kelly E. Dempsey is an attorney with The Phia Group, LLC. As the Vice President of Phia Group Consulting, Kelly’s specialization is an interesting mix of compliance matters impacting self-insured plans (such as issues relating to ERISA, ACA, COBRA, FMLA, MHPAEA, and MSP) and “outside-the-box thinking,” finding creative and innovative ways to help plans, brokers, and TPAs achieve their various self-insured goals. Kelly earned her Juris Doctorate from ClevelandMarshall College of Law and is admitted to the Bar of the State of Ohio and the United States District Court, Northern District of Ohio. Kelly is a board member for Project: LEARN of Medina County (Ohio) and the Chi Alpha Nu Alumnae Board.
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CAPTIVE DEVELOPMENTS IN 2020 REFLECTS A CHANGING MARKETPLACE Written By Karrie Hyatt
espite indications that captives would see a banner year in growth in 2020, the reported number of formations was only slightly higher than 2019. The reason there weren’t larger gains was likely due to businesses being shut down for several months and the resulting slowed economy.
However, captive managers and regulators have indicated that interest in captives is very high which suggests that captive formations this year will be much higher.
There was very little activity in captive legislation among U.S. domiciles. Only two states managed to pass legislation to update their captive laws. Other domiciles were thwarted from making planned updates by the pandemic shutdown.
BY THE NUMBERS
The number of captive formations in 2020 was higher than 2019, but not excessively so. While many U.S. domiciles saw increased numbers of formations last year, other domiciles saw fewer captives formed.
Larger number of formations played out for Hawaii, North Carolina, and Vermont, but other states only saw a slight uptick in formations. States, such as South Carolina and Montana, had lower formations than the previous year.
North Carolina had the most formations in 2020 with 47 captives and 126 cell or series captives licensed. Utah and Vermont tied for second with 38 captives each. Utah’s numbers also include any cells licensed.
Montana and Nevada tied for third with 23 new captives. Montana’s number was down from the domicile’s 2019 40 formations. Following close in fourth place is Hawaii with 21 formations, which showed a 50% increase over 2019’s 11 formations.
Of the other domiciles that have reported formation numbers for 2020 are as follows; District of Columbia (18); Tennessee (18 and 41 cells); Texas (14); Arizona (12); South Carolina (9); Connecticut (6); and Missouri (2).
The outlier is Delaware with a reported 70 formations in 2020. While this ostensibly would put the domicile in first place for formations, far outpacing its competitors, 67 of those licenses were provisional. Six-month provisional licenses are unique to Delaware.
Added to the state’s captive law in late 2018, provisional licenses allow captive applicants to begin operations while their application is being processed by regulators. As captives operating under a provisional license are not fully licensed captives, it is not appropriate to compare them with other domiciles.
The two largest risk-regulating domiciles in the United States are North Carolina and Tennessee with 795 and 720 captive entities. However, for both domiciles, the bulk of their risk-bearing entities are cell or series captives.
North Carolina reports 545 cells/series and Tennessee reports 460. Looking beyond those two domiciles, Vermont is still the leading captive domicile with 589 operating captives. Delaware reports more than 500 captives. Utah (396), Nevada (296), Montana (270), and Hawaii (242) make up the list of U.S. domiciles with more than 200 captives.
Across the board, captive managers have reported an increase in interest in captives due to market conditions and coverage gaps highlighted by the pandemic which should make 2021 a dynamic year in captive formations.
reflect the regulation of standalone captives; and changes to align with NAIC accreditation standards. At this time, Vermont hasn’t announced any changes to their captive law for 2021.
BY THE LEGISLATION
After the rapid additions and changes to captive law in dozens of states during the 2010s, captive law revisions seem to have slowed down considerably. There hasn’t been a state passing new captive law since North Carolina in 2013 and Ohio in 2014.
Many years in the last decade saw five or more domiciles revise their captive law. Last year, there were only two states that pushed through new legislation. Several other states had the intention of passing new captive insurance legislation but were impeded by the pandemic.
One of the two domiciles that revised their law last year was Oklahoma. The revision was signed into law in May 2020. It changes how premium taxes collected from captive insurers are distributed within the state which offers transparency in how taxes collected from captives are used.
As it does nearly every year, Vermont tweaked its captive law again in 2020. In June, the governor signed the latest series of changes into law. Some of the many changes include new policies for protected cells; changes to capital requirements for dormant captives and for sponsored cell captives; changes to regulation of cell captives to
Last year, prior to the state legislature closing due to the pandemic, the Alabama House of Representatives unanimously passed a law to update the state’s captive law. The bill did not have a chance to be voted on in the senate, so languished for the rest of 2020. However, that update has again been presented, along with further updates, to the state legislature.
Last year’s changes included revising requirements for branch captives that would more closely match those of pure captives, removing the requirement that coastal homeowner captives have fronting carriers, clarifying how domestic captives can insure risks in foreign jurisdictions, and codifying a formal dormancy statute. The additions this year to the bill will create a new redomestication process, allow for
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risk retention groups, reduce minimum capital requirements, and offer three new alternative risk transfer entities.
In February, Delaware State Senate passed HB 36 that will update the domicile’s captive law. Similar to Vermont, the new amendments are meant to help clarify the existing law while making small, but important, improvements.
The new law makes some technical corrections to align better with Delaware law standards; it defines “policy” and “premium” and revises the definition of a pure captive; it expands the licensing authority for series captives to be licensed as an agency, branch, or reciprocal captive insurance company; and includes other small changes.
The conditions last year that made forming a captive appealing in 2020 will continue through 2021. The insurance marketplace will remain hard, which historically has seen a rise in captive formations. Additionally, gaps in commercial coverage that, for many businesses, was brought to the forefront during the COVID-19 shutdown will have businesses looking for alternative ways to finance that risk. 2021 should be a banner year for the captive industry.
However, there are several challenges on the horizon. The IRS increased its hostility towards enterprise risk captives (ERCs) in 2020 and that is not likely to change for the better in 2021. Especially, since the Service recently garnered its fourth tax court win against what it calls “microcaptives,” small captives that take the 831(b) tax deduction. In a decision handed down on March 10, the judge found in the case of Caylor Land & Development v. Commissioner that the “microcaptive” was not an insurance company because it didn’t have proper risk distribution.
This summer, the U.S. Supreme Court is due to hand down a decision in CIC Services v. IRS. This will be the first time that the highest court in the U.S. will decide a case involving captives. In 2016, when the IRS issued Notice 2016-66, CIC Services, a Tennessee-based captive manager, filed a lawsuit against the IRS and Treasury Department arguing that notice was unlawfully issued and did not meet the authority or “reasoned analysis” requirements of the Administrative Procedure Act. The decision, whether in favor of CIC Services or not, will have far reaching implications for all types of captives and how the IRS approaches their taxation.
Do you aspire to be a published author? We would like to invite you to share your insight and submit an article to The Self-Insurer! SIIA’s official magazine is distributed in a digital and print format to reach 10,000 readers all over the world. The Self-Insurer has been delivering information to top-level executives in the self-insurance industry since 1984. Articles or guideline inquires can be submitted to Editor Gretchen Grote at ggrote@ sipconline.net The Self-Insurer also has advertising opportunties available. Please contact Shane Byars at sbyars@ sipconline.net for advertising information.
Karrie Hyatt is a freelance writer who has been involved in the captive industry for more than ten years. More information about her work can be found at: www.karriehyatt.com.
APRIL CONNECT FROM ANYWHERE (CFA) EVENTS SIIA Advocacy in Action - Government Relations Webinar Update Series - April 13th at 2:00 pm EDT
With a new Administration and new Congress in Washington, DC, 2021 promises to be a very active year with regard to legislative/regulatory developments affecting the companies involved in the self-insurance/captive insurance marketplace. To keep members informed about what they need to know, SIIA’s government relations team will be holding a monthly webinar series from January through June.
This live event will offer engagement opportunities as part of each session, as well exclusive connection opportunities with other younger SIIA members as part of an entertaining and interactive networking session.
Bonus Networking Opportunity Escape Room
SIIA Medical Travel Webinar - Cleveland Clinic - April 15th from 1:00 – 5:00 pm EDT
SIIA has partnered with Medical Travel & Digital Health News to develop a CFA seminar series to specifically highlight medical travel destinations – both domestic and international – that provide low-cost/high quality health care treatment services for self-insured employers. We recognize that it may take a while for travel to return to normal, but when it does, this potential cost management solutions will receive increased attention. The April edition will focus on The Cleveland Clinic. SIIA CFA Future Leaders Summit - April 20-22nd
The self-insurance industry has started to witness a significant generational change, with an increasing number of its established leaders transitioning into retirement. Coming up the ranks behind them are many talented younger members who will lead our industry in the years and decades ahead.
SIIA is encouraging this transition through its SIIA Future Leaders (SFL) initiative. The highlight of this initiative in 2021 will be a SIIA Future Leaders CFA Summit that is being designed to help prepare these younger members (under 40) for the challenges and opportunities ahead of them.
Experience an escape room from wherever you are. This “add on” event to your SIIA Future Leader Forum will be a fun, interactive event that will test your “outside the box” thinking. Game Masters will serve as your personal in-game avatar! Sign up for this is done through the forum registration process but you will want to sign up early as there are only 30 spots available in the escape room.
More information, including session details, sponsorship opportunities and registration can be found at www.siia.org.
Hot Topic Webinar Series - NonNetwork Payment Experience in a Pandemic – April 28th from 2:00-3:00 pm EDT, sponsored by QBE
Non-Network Payment Experience in the Second (and Third) Waves of COVID-19 Just when the self-insurance industry started to get a handle on how to apply Reference Based Pricing and related non-network payment arrangements to COVID-related claims, some important variables have changed.
The infection rate has surged in many parts of the country, new treatments have been introduced and vaccines are now being made available for certain segments of the populations. These moving parts have scrambled the playing field again for those self-insured payers who regularly by-pass traditional network arrangements. This session will feature a panel of leading industry experts who will share their observations and analysis on how non-network payment arrangements need to adapt given the latest COVID-19 developments and we can expect in the coming months. SIIA CFA Members Only Networking Happy Hour – April 29th from 5:00-6:30 pm EDT
While we wait for improving public health conditions to allow for in-person networking events, the association is pleased to announce the launch of a monthly “Connect from Anywhere” (CFA) networking event produced via the Zoom video platform. The next event is scheduled for Thursday, March 25 from 5:00 p.m. to 6:30 p.m. EDT. The event will continue to be held monthly on the last Thursday of each month through June.
The casual “happy hour” format will start with an interactive trivia contest and then will prompt participants to rotate among small group video chat rooms to maximize connection opportunities. Following the conclusion of each event, an attendee list with complete contact information will be provided to all participants to facilitate easy follow-ups for anyone you connect with live.
For more information including webinar details and registration on all CFA events please visit www.siia.org.
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NEWS FROM SIIA MEMBERS
2021 APRIL MEMBER NEWS 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 firstname.lastname@example.org. All submissions are subject to editing for brevity. Information about upgraded memberships can be accessed online at www.siia.org. If you would like to learn more about the benefits of SIIA’s premium memberships, please contact Jennifer Ivy and email@example.com.
NEWS DIAMOND MEMBERS JOHN CHRISTIANSEN
JOINS RENALOGIC, BRINGS
AS THE INDUSTRY UNDERGOES
TRANSFORMATIONAL CHANGE Phoenix, AZ — Renalogic, Inc., the industry leader in dialysis risk management and cost containment, announced that John R. Christiansen has joined the company as Executive Vice President of Legal Risk and Strategy. The announcement comes on the heels of their recently announced partnership with Carrick Capital Partners, which will build on Renalogic’s market leading position.
Christiansen began providing legal counsel to the company nearly 20 years ago, when it was founded with one mission- to reduce the risk associated with catastrophic dialysis claims. Today, Renalogic has grown to offer the industry’s most comprehensive approach to reducing massive risks associated with Chronic Kidney Disease (CKD) and dialysis. “We are thrilled to officially welcome John to the in-house team,” Lisa Moody, Renalogic CEO said. “He’s been a trusted advisor for so long, it’s difficult to overstate John’s contributions to the industry regarding ERISA, self-funded plans, and risk management. His leadership in creating the most defensible repricing methodology for Renalogic makes John an excellent addition to our team.” “Renalogic has been able to achieve what others cannot. We are a missiondriven organization, determined to reduce risk for plans and their members,” John Christiansen said. “The next five years of industry transformation will determine the next 50 years for health plans facing catastrophic dialysis claims. I am excited to come fully on board, as Renalogic is a leader in the good fight to protect health plans and their members.”
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Christiansen, who began his law career in 1985, has a combined emphasis on selfinsured health plans and health information technology issues. After practicing in large, national law firm and consulting firm environments for many years, John formed Christiansen IT Law in 2005 to practice more flexibly and serve his clients more directly and personally. Recent Circuit Court rulings are changing the rules for dialysis benefits. The Amy’s Kitchen ruling from the 9th Circuit Court effectively established Renalogic’s dialysis claims repricing methodology as a safe harbor against Medicare Secondary Payor lawsuits. This is especially important given other rulings which put plans at new financial risk using other dialysis claims repricing methodologies. About Renalogic, Inc Renalogic has been the industry leader in dialysis cost containment for nearly 20 years and continues to innovate through the impact of the Kidney Dialysis Avoidance Program. We continue to revolutionize the industry by delivering predictive analytics to identify the progression of the disease, simplifying the costs and clinical complexities of chronic kidney disease to make a positive impact and reduce the dialysis incidence rate in every population we touch. Every chronic condition leading to End Stage Renal Disease is manageable and even preventable when identified early. Visit renalogic.com.
CARRICK CAPITAL PARTNERS ANNOUNCES GROWTH RECAPITALIZATION OF RENALOGIC
Leader in dialysis risk management and cost containment poised for accelerated growth and service offering expansion PHOENIX, AZ & SAN FRANCISCO, CA – Carrick Capital Partners (Carrick), a growth-oriented investment firm focused on software and softwareenabled businesses with more than $1B in assets under management has made a significant investment in Renalogic, the industry leader in dialysis risk management and cost containment. Renalogic has grown rapidly in recent years as rising healthcare costs
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associated with chronic kidney disease (“CKD”) have become increasingly painful for employers. Renalogic takes a holistic approach to reducing risk associated with CKD, offering proven intervention for plans’ highest risk population, member education, patient advocacy, and dialysis cost containment. Renalogic recently launched an innovative predictive modeling and artificial intelligence platform, CareINSIGHTS.ai that enhances their high-touch, personalized intervention. Their ability to proactively address previously hidden CKD risk is a welcomed change to an industry that has struggled to reduce massive claims costs. Renalogic delivers better health outcomes and significant savings for dialysis costs with substantially less risk than traditional multiple-of-Medicare reference-based pricing. The deal represents a major new investment in the category of health solution providers to the self-funded market and reflects Carrick’s thesis that self-funded employers, particularly in the mid-market, will increasingly explore innovative approaches to cost containment and risk management to combat rising PPO costs. Carrick’s interest in Renalogic and CKD cost containment builds upon its prior healthcare investments in Accolade, InstaMed, and Discovery Healthcare Partners. “Renalogic has demonstrated the ability to maximize employer savings while minimizing employee abrasion for managing CKD, which is among the most relevant and contentious disease states for cost containment in healthcare,” explained Managing Director Chris Wenner.
“We look forward to working with the talented team at Renalogic to build on their market leading position in dialysis by expanding their service offerings to help selffunded employers and stop-loss carriers manage catastrophic risk,” continued Wenner. Renalogic CEO Lisa Moody added “Renalogic has experienced unprecedented growth over the last three years by helping health plans and their members reduce risk associated with Chronic Kidney Disease,” Moody said. “Carrick’s expertise in the healthcare space combined with their focus on, software, tech-enabled businesses make them uniquely qualified to help broaden our mission-driven business. With this partnership, we can scale our business to provide support to our growing number of clients.” As part of the transaction, Managing Directors Steve Unterberger and Chris Wenner of Carrick Capital Partners will join Lisa Moody on the Renalogic Board of Directors.
NEWS Covington, LLC served as exclusive financial advisor to Renalogic in this transaction. About Renalogic Renalogic has been the industry leader in dialysis cost containment for nearly 20 years and continues to innovate through the impact of the Kidney Dialysis Avoidance Program. We are revolutionizing the industry by delivering predictive analytics to identify the progression of the disease, simplifying the costs and clinical complexities of chronic kidney disease to make a positive impact and reduce the dialysis incidence rate in every population we touch. Every chronic condition leading to End Stage Renal Disease is manageable and even preventable when identified early. For more information, please visit https:// renalogic.com/. About Carrick Capital Partners Headquartered in San Francisco and Newport Beach, Carrick Capital Partners is a growth-oriented investment firm that utilizes ABV (Approach to Building Value) to operationally scale fast-growing, technology-enabled businesses. Carrick adds value by taking a concentrated approach and dedicating significant resources post-investment. Leveraging decades of experience, Carrick helps scale great companies that deliver excellent returns for investors, stimulating economic growth and positively impacting the industry landscape. Working directly with CEOs and entrepreneurs, Carrick fulfills a vital need for investment capital and growth expertise. For more information, please visit http://www.carrickcapitalpartners.com/.
Andy is based in BHSI’s New York office and can be reached at andrew.barberis@ bhspecialty.com or 917-830-2336. About Berkshire Hathaway Specialty Insurance Berkshire Hathaway Specialty Insurance provides medical stop loss, commercial property, casualty, healthcare professional liability, executive and professional lines, transactional liability, surety, marine, travel, programs, accident and health, homeowners, and multinational insurance. It underwrites on the paper of Berkshire Hathaway's National Indemnity group of insurance companies, which hold financial strength ratings of A++ from AM Best and AA+ from Standard & Poor's. Visit www. bhspecialty.com.
GENERAL UNDERWRITERS ANNOUNCES STEPHANIE
GOLD MEMBERS BERKSHIRE HATHAWAY SPECIALTY INSURANCE APPOINTS ANDY BARBERIS SENIOR VICE PRESIDENT, CLAIMS
BOSTON--Berkshire Hathaway Specialty Insurance (BHSI) announced that Andy Barberis has joined the company as Senior Vice President, Claims. Andy will be working with the BHSI claims leadership team across the globe on the most catastrophic and complex casualty and healthcare claims. “With BHSI’s steady expansion around the globe, we are pleased to expand the depth of the leadership team delivering our on fundamental commitment – Claims Is Our Product – worldwide,” said Dave Crowe, Chief Global Claims Officer, BHSI. “Andy is a well-known and well-respected industry veteran and his exceptional technical expertise will be of great benefit to our customers.” Andy comes to BHSI with 35 years of commercial claims experience, including the last 23 at AIG where he held the position of Global Claim Officer. He holds a law degree from St. John’s University School of Law.
NAMPEL’S PROMOTION TO VP RISK MANAGEMENT
Phoenix, AZ -- Partners Managing General Underwriters (Partners) is pleased to announce Stephanie Nampel’s promotion to VP Risk Management. Stephanie has served as a VP Underwriting for the past 5 years where she created and delivered our internal Underwriting Curriculum. Risk Management is a new department at Partners and includes Medical Underwriting, Claims Adjudication and Clinical Risk/Cost Containment. Pulling these units together under a single leader is the best way to facilitate the seamless flow of information across each of the functional teams within Partners.
NEWS With 25 years of underwriting behind her and just freshly coming from the enormously successful project of developing and implementing our Underwriting Development Program, Stephanie is the perfect choice to lead this new department. Her industry experience and vast exposure allow her to “speak all of the languages” of stop loss. This new structure will, undoubtedly, take our customer service levels to new heights.
About Partners Partners Managing General Underwriters is an entrepreneurial and full service MGU, underwriting medical Stop Loss for the self-insured marketplace. Licensed in all 50 states, our team is comprised of seasoned professionals with a long history in employee benefits. We started Partners in 2016 and have already grown to one of the largest independently owned MGUs in the country. We do this by providing superior service and offering a unique value building opportunity unlike anything in the marketplace today. Visit partnersmgu.com.
SILVER MEMBERS 6 DEGREES HEALTH WELCOMES JEFF DIEKEMA AS VICE
PRESIDENT OF BUSINESS DEVELOPMENT
Hillsboro, OR- 6 Degrees Health is pleased to announce that Jeff Diekema has joined the company as VP of Business Development. Jeff has been in the benefits industry for 30 years, in roles ranging from sales and sales/marketing management to Third Party Administration operations and product development. Prior to his role at 6 Degrees Health, Jeff held positions at a national Third Party Administrator as VP, Underwriting & Sales Support as well as VP, Sales. He has extensive senior
We a re Ad voc a tes for Hea lthier Living As Ad voc a tes for Hea lthier Living , w e’ re im p roving c linic a l outc om es w hile red uc ing the Tota l Cost of Ca re. It’ s the found a tion of the servic e w e p rovid e our c lients, m em b ers a nd b usiness p a rtners. We Cha ng e Lives. We c rea te p ositive c ha ng e in every intera c tion w e ha ve. By listening a nd und ersta nd ing our c lients’ need s, w e offer flexib le, c ost-effec tive a nd ea sy-to-use hea lth c a re solutions. We a re d ed ic a ted to p rovid ing c om p a ssiona te sup p ort a nd g uid a nc e to help our m em b ers b e a c tive p a rtic ip a nts in their hea lth c a re.
For m ore inform a tion, visit www.m erita in.c om .
NEWS management experience with several Health Plans, Third Party Administrators, and consulting firms. Jeff’s experience is in self-funded and alternative funding arrangements with an emphasis on transparency and innovative payment and savings initiatives while utilizing current technology to maximize the cost impact of well-designed and integrated plan designs. Jeff received his Bachelor’s degree from Central Michigan University with majors in Psychology and Physical Education and a Master’s in Sport Psychology, also from CMU. He also maintains his Certified Employee Benefits Specialist (CEBS) designation for the International Foundation of Employee Benefit Plans (IFEBP) and the Wharton School. Jeff can be reached at email@example.com. “We couldn’t be happier to welcome Jeff to the 6 Degrees Team. His depth of knowledge and experience in the self-funded healthcare arena will be a huge asset to our TPA and Broker partners. Understanding the dynamics of the space is essential in working with all parties to successfully implement the appropriate RBP and Cost Containment solutions.” -Heath Potter, Chief Growth Officer
About 6 Degrees Health 6 Degrees Health is built to bring equity and fairness back into the healthcare reimbursement equation. Industryleading MediVI technology supports our cost containment solutions with objective, transparent, and defensible data. 6 Degrees Health’s solutions include everything from provider market analyses, reasonable value claim reports, ad hoc claim negotiations, evergreening provider contracts, and referenced-based pricing. Our veteran cost containment team partners with health plans and their channel partners to deliver unparalleled cost containment results. Visit www.6degreeshealth.com.
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PLAN DOCUMENTS PERFECTED
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www.phiagroup.com | 781-535-5600 | firstname.lastname@example.org 54
NEWS CLAIMLOGIQ CO-FOUNDER JANENE HILL RECOGNIZED AMONG FORBES' FIRST-EVER NEXT 1000 CLASS
CHARLESTON, SC -- ClaimLogiq co-founder and Executive Vice President Janene Hill has been named to Forbes' first-ever Next 1000 class. Hill joins the first 250 notable entrepreneurs from around the country and across industries in the original announcement of the 1000 list. “Her talent, drive, and commitment to our vision and our team are a direct influence on the payment integrity software innovations that we're pioneering in a cluttered healthcare marketplace. Her spirit and resolve have helped to build ClaimLogiq into the industry force that it is today.” "I'm honored to be recognized by Forbes as an honoree of the Next 1000 List," said Janene. "I'm humbled to be listed amongst so many driven and passionate entrepreneurs. It’s exciting to see people defiantly carving paths forward, overcoming challenges and roadblocks, and pursuing their dreams. To have that level of dedication is inspiring, and to have it recognized in this way is incredible." The inaugural Next 1000 class, presented by Square, was announced Feb. 16, 2021. The year-round initiative is designed to "showcase ambitious sole proprietors, selffunded shops … who are redefining what it means to build and run a business amid unprecedented uncertainty" from around the country. "(Those) featured on the Next 1000 reflect individuals from diverse communities who are redefining the American Dream," said Maneet Ahuja, senior editor for Forbes. Hill was selected by Forbes editors, plus a panel of successful entrepreneurs and thought leaders in business. This recognition joins a rapidly growing list of achievements that ClaimLogiq and members of its team have realized in recent months, most notably being named a Great Place to Work™ and becoming Microsoft® Gold Partner certified. "We're very proud that Janene has been recognized with this honor," said Todd Hill, co-founder and CEO. "Her talent, drive, and commitment to our vision and our team are a direct influence on the payment integrity software innovations that we're pioneering in a cluttered healthcare marketplace. Her spirit and resolve have helped to build ClaimLogiq into the industry force that it is today." Founded in 2013 by Todd and Janene Hill, ClaimLogiq has been in the business of challenging the norm and disrupting the healthcare space for almost a decade. The company believes the "Black Box" model for payment integrity — sending claims out for audit and waiting on the results to be delivered, without control or insight into the process — is no longer acceptable. The solution is ClaimLogiq's HITRUST CSF® certified TrueCost™ platform that can be adopted as either a SaaS or full-services business model. The payer-facing claimanalyzing software provides real-time transparency into the status of each and every review and empowers payers to adopt a proactive approach to payment integrity. Through complete client-driven control and customizability, audits conducted via the
platform are marked by unparalleled accuracy and consistency, lowering provider abrasion and maximizing cost avoidance, resulting in industry-leading ROI. "The ingenuity, compassion, and tireless dedication that Janene brings to the table daily has helped build ClaimLogiq into an industry disruptor, competitively poised to revolutionize healthcare payment," said Josh Burrus, the company's Chief Operating Officer. "Our co-founder's recognition by a major outlet like Forbes is well-deserved."
About ClaimLogiq ClaimLogiq is a healthcare software and technology company that delivers a proactive approach to payment integrity through a powerful, simplified solution. The unique payer-facing, claim-analyzing solution is HITRUST CSF® certified and makes claim reviews accessible to all size healthcare payers for in-depth insight and real-time access into the status of every claim at every stage of the audit lifecycle for controlled, consistent, accurate, and defensible outcomes, second to none. ClaimLogiq's innovative software stands out from the crowd by allowing payers client-driven control, customizability, and total transparency over the entire claim process and can be applied as a SaaS model, full services, or as a hybrid to suit the specific needs of every payer and provider agreement. ClaimLogiq's groundbreaking technology produces more cost savings and all-but-removed provider abrasion, impacting millions of lives annually in the pursuit of a higher quality of healthcare for all. Visit www.claimlogiq. com.
APRIL 2021 55
SELF INSURANCE INSTITUTE OF AMERICA, INC. 2021 BOARD OF DIRECTORS
CHAIRMAN OF THE BOARD* Robert Tierney President StarLine Osterville, MA
Mike Ferguson SIIA Simpsonville, SC
DIRECTORS Thomas R. Belding President Professional Reinsurance Mktg. Svcs. Edmond, OK John Capasso President & CEO Captive Planning Associates, LLC Marlton, NJ
Kari L. Niblack, JD, SPHR CEO ACS Benefit Services Winston Salem, NC
Laura Hirsch Co-CEO Aither Health Carrollton, TX
TREASURER AND CORPORATE SECRETARY*
Elizabeth Midtlien Vice President, Emerging Markets AmeriHealth Administrators, Inc. Bloomington, MN
Peter Robinson Managing Principal EPIC Reinsurance San Francisco, CA
Lisa Moody President & CEO Renalogic Phoenix, AZ Shaun L. Peterson VP, Stop Loss Voya Financial Minneapolis, MN
*Also serves as Director
SIEF BOARD OF DIRECTORS Nigel Wallbank, SIEF Chairman
Directors Freda H. Bacon Les Boughner Alex Giordano Virginia Johnson Dani Kimlinger, PhD, MHA, SPHR, SHRM-SCP
Accident & Health Insurance
We’ll focus on risk, so you can take care of
Get the help you need to self-fund your healthcare and grow your business. Self-insuring your healthcare benefits can be a big step for your company – and a complicated one. But with a medical stop loss solution from QBE, our experts will help you determine the level of risk protection to meet your financial needs. Discover a range of products to help you protect your assets: • Medical Stop Loss • Medical Stop Loss Captive • Special Risk Accident • Organ Transplant Together, we’ll create a solution that fits your needs – so no matter what the future holds, you can be sure that QBE is with you.
Premiums4Good When you choose QBE, you choose to give back – with a portion of all customer premiums committed to investments with social and environmental objectives.
For more information, visit us at qbe.com/us
Specialty & Commercial
QBE and the links logo are registered service marks of QBE Insurance Group Limited. ©2021 QBE Holdings, Inc. This literature is descriptive only. Actual coverage is subject to the terms, conditions, limitations and exclusions of the policy as issued.
SIIA NEW MEMBERS FEBRUARY 2021 REGULAR CORPORATE MEMBERS
Edward Dukehart President Allegeant, LLC Timonium, MD Kevin Klein Chief Marketing & Sales Officer Bento Dental Boston, MA
Stephen Carrabba President ClaimInformatics Bloomfield, CT Charlotte Dutcher Business Development Specialist Telligen
EMPLOYER CORPORATE MEMBERS
Michael Lamont Chief Operating Officer WCA Group Health Trust Madison, WI
West Des Moines, IA
Mind over risk. That’s how we properly assess risk – enabling our clients to focus on their business. We provide innovative stop loss solutions to protect self-funded employers from potentially catastrophic losses. We offer flexible captive solutions to help control the severity risk of your self-insured program. We have developed medical stop loss solutions specifically dedicated to meeting the unique needs of Taft-Hartley union plans. Our Organ & Tissue Transplant policy is a fullyinsured option to protect your self-funded plan from losses due to transplant exposures. Our clients have been benefiting from our expertise for over 45 years. To be prepared for what tomorrow brings, contact us for all your medical stop loss and organ transplant insurance needs.
Tokio Marine HCC - Stop Loss Group HCC Life Insurance Company operating as Tokio Marine HCC - Stop Loss Group A member of the Tokio Marine HCC group of companies tmhcc.com TMHCC1129 - 12/20
IS 1 TRILLION DOLLARS
in healthcare waste & errors too much?
YES. At Zelis, we listen to what payers and providers want and bring technology, people, expertise, and entrepreneurial energy together to create smart solutions and a better way for the industry. Integrated solutions to price, pay, and explain healthcare on a claim by claim basis, all offered by one trusted company.
Maximized Claim Savings. Optimized Payments. Transparent Explanations. Contact Zelis today at 888.311.3505 or visit zelis.com to find out how our pre-payment solutions are helping control the rising cost of healthcare.
Better Service. Better Performance.
zelis.com Copyright 2019 Zelis. All rights reserved.
Stability for those balancing risk and reward.
Those who self-fund a health plan seek autonomy and control over their benefits program and costs. It can be rewarding, but it does come with risk. Stop Loss protection from HM Insurance Group works to mitigate that risk for self-funded employers should high-dollar claims arise – delivering steadiness to the performance and confidence in the outcome. Find more on hmig.com.
CONNECT WITH ONE OF OUR EXPERTS ON OUR INSURANCE AND REINSURANCE OPTIONS: Employer Stop Loss: Traditional Protection • Small Group Solutions • Coverage Over Reference Based Pricing Managed Care Reinsurance: Provider Excess Loss • Health Plan Reinsurance
In all states except New York, coverage may be underwritten by HM Life Insurance Company, Pittsburgh, PA, or Highmark Casualty Insurance Company, Pittsburgh, PA. In New York, coverage is underwritten by HM Life Insurance Company of New York, New York, NY. The coverage or service requested may not be available in all states and is subject to individual state approval. MTG-3355 (R3/21)