A P R IL 2 0 2 2
A S I P C P U B L I C AT I O N
Essential Ingredients for
Direct Contracting Success
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TABLE OF CONTENTS
APRIL 2022 VOL 162
W W W. S I P C O N L I N E . N E T
SEVEN ESSENTIAL INGREDIENTS FOR DIRECT CONTRACTING SUCCESS
By Laura Carabello
UNCERTAINTY ARISES OVER FEDERAL SURPRISE BILLING IMPLEMENTATION
By Karrie Hyatt
CHECKING ALL THE RX BOXES SIIA’S DRUG PRICING TASK FORCE FINALIZES COST-CONTAINMENT ROADMAP 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
U.S. DOMICILED CAPTIVES HAVE STRONG SHOWING IN 2021
ONGOING LITIGATION OF INTEREST TO EMPLOYER GROUP HEALTH PLANS
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 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 2022 3
F E AT U R E
Essential Ingredients for
Direct Contracting Success Written By Laura Carabello
s forward-thinking self-insured employers and Plan Sponsors face yet another year of growing pressures to further reduce healthcare expenditures, they now recognize that direct contracting relationships with the provider community offer an optimal solution.
These arrangements present a unique opportunity to gain control over both the quality and the escalating cost of health care benefits, enabling companies to design benefit offerings that are custom-tailored to meet the specific needs of its employee population. This process may be a familiar practice for many benefits decision-makers that already negotiate contracts for products and services: direct arrangements with a provider organization — typically a large health system or provider network (accountable care organization or clinically integrated network)—include key negotiated terms on which the provider will provide and manage the provision of care to the employer’s employees and dependents.
Direct Contracting Success These contracts may apply to the entire spectrum of health care services for which health care benefits are provided, or they may be tailored to a specific subset of services, such as joint replacement surgeries, cardiac catheterization procedures, transplants or other high-volume, high-cost procedures.
Rather than pay premiums to a commercial payer/third party traditional health insurer and accept unknown carrier network pricing, employers designate these select providers to be their preferred points of service for employees’ healthcare needs, with contracts ranging from fee-for-service, risk-based (using capitation or other global payment methods), service level agreements and in some cases, medical tourism programs to access care outside of local or regional delivery system. Doug Healtherington
Employers are discovering that by “Going Direct” they are able to lower overall costs, improve pricing transparency and eliminate “middle-men” entities. Additionally, they also discover opportunities to leverage the medical expertise and resources that may already exist in the provider community.
Many providers have significant experience in dealing with issues related to the pandemic and have extensive knowledge about solutions -- including what works and what doesn’t work to ensure workplace safety. They are also learning that this approach differentiates the Company amid worker shortages and in an evolving and ever more competitive marketplace.
John Farnsley, EVP, 90 Degree Benefits, observes, “Direct contracting has become a core component of many self-funded group health plans. As the cost of healthcare continues to skyrocket, direct provider agreements have proven to be one of the most effective mechanisms to lower medical claim expense. Over the past 10 years, TPA’s, Consultants, and employers have all moved rapidly into the employer/provider contracting arena as a core cost containment tactic.”
He says the proper strategies surrounding direct contracting, and the subsequent operational setup and management of the agreement, will ultimately drive success or failure for all parties.
Doug Heatherington, CEO, founder and program architect, H2B asserts that in the current predominant PPO Insurance System, the carrier incentives drive shareholder value for Wall Street investors, rather than stakeholder value for the healthcare purchasers (employers and employees) and the providers of the services.
“Direct contracting removes the misaligned third-party insurer to create a direct relationship between employers and providers, which then realigns incentives to drive stakeholder value,” he says. “The incentive alignment affirms the fact that healthcare is local. Direct contracts re-localize health by forming the building blocks of CommunityOwned Health Plans, which return choice to the consumer. Of the four types of Direct Contracts (Closed, Open with Constraints, Open, and Open – Full Pay), Open and Open – Full Pay are the types of contracts we need to look to establish, as these provide true value and are the future.”
The right solution Self-funded health plan administration The speed of change in the health care industry is expanding the definition of health care and redefining roles for traditional players. New and emerging technologies led by single point solution vendors, rising health care costs, regulation, and non-traditional market entrants have many payers and health systems evaluating their options.
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Direct Contracting Success PROVIDERS WEIGH IN From the health system perspective, Nick Stefanizzi Chief Executive Officer, Northwell Direct, asserts that direct contracting has the potential to fundamentally transform the ability of employers to care for their workforce.
Once you receive buy-in and approval to proceed, Stefanizzi advises that providers and employers must establish a multidisciplinary team to ensure a seamless implementation and ongoing support. “The team must be aligned on key deliverables and outcomes,” he continues. “A collaborative and transparent process must be developed to maintain alignment and address “resistors” to the model. Prioritizing these critical elements will help to ensure the success of direct contracting relationships.”
Alongside the employers, provider organizations and health systems are paying attention.
Of special note, on their 2021 Q2 earnings calls, the four largest carriers indicated their two areas of focus – Medicare/Medicaid and PBM growth. Employer sponsored plans were not even mentioned, despite employers covering significantly more lives for healthcare than government: 49.6% versus 35.4%. And healthcare is now over 19% of the GDP. Nicholas Stefanizz
“In order for it to be successful, it must be built on a foundation of buyin and alignment from all key decision-makers and stakeholders, who need to clearly understand and believe in the value of direct contracting,” says Stefanizzi. “To be illustrative, these stakeholders include the CEO, CFO, and physician leadership (for provider/health systems), the CEO, CFO, CHRO and Human Capital team (for employers), and brokers, consultants, and TPAs.“
“What does this mean?” asks Ruth Coleman, strategic advisor, Contigo. “How do employers facing unsustainable costs and often unsatisfactory employee outcomes realize best value for their health plan?”
She maintains that direct contracting offers an increasingly viable way to a) gain buyer/consumer/seller alignment on priorities, incentives, and engagement; b) understand and therefore better control healthcare spend; and c) create a dialogue educating providers on the needs of their largest market, long masked by their carrier relationships.
Coleman points to the March 2019 “Harvard Business Review Big Ideas” series, “How Employers are Transforming Healthcare” which outlines Walmart’s success using Direct Contracting as a tool to gain value on behalf of their associates and healthcare spend.
Direct Contracting Success But direct contracting no longer requires being the largest US employer,” says Coleman. “It is now a tool deployed by self-funded employers of all sizes, increasingly allowing them to gain better alignment on outcomes and costs with the one entity that can bring control at the point of sale - providers.”
The movement towards direct contracting has gone from an emerging concept to a significant trend in the self insurance industry. Peter Robinson, managing principal, Epic Reinsurance, reiterates this point, saying, “The trend captures middle market employers willing to participate in the trend as they try to impact their employee benefit costs.”
SEVEN COMPONENTS OF SUCCESS While there are many nuances to direct contracting, the following provide a good starting point for employers as well as providers. 1.
Understand the Basics and the Value Proposition
provider shares a portion of “savings” generated against a baseline for spending—savings the provider aims to achieve through its care coordination and care management efforts.
In more sophisticated direct contracting arrangements, the provider may also be responsible for sharing a portion of the downside financial risk created when its efforts to control costs or to improve quality or patient satisfaction fail.
Alignment of incentives can be finetuned by measuring and encouraging both performance relative to cost measures and performance relative to agreed-upon quality and/or employee/ patient satisfaction metrics.
To optimize success, the company is self-insured and its employer size, footprint and location(s) empower the leadership team with enough clout and influence in provider negotiations. There should be existing and sufficient provider competition within a given market and the arrangement has to work for both parties: employers and providers are willing to participate, understanding that providers may be reticent to direct contract if they don’t perceive value of accessing an increased patient population.
Regardless of scope, at the heart of direct contract arrangements is a commitment by the provider to proactively and effectively coordinate and manage the provision of health care services to employees, with the goal of controlling the employer’s costs while improving quality of care and increasing employee satisfaction. In a direct contracting arrangement, the employer and the provider usually seek to align their respective business interests by aligning their respective economic interests.
For example, the employer may pay the provider a bonus for achieving certain agreed-upon quality and/or patient satisfaction metrics, such as hospital readmission rates, immunization rates, and infection rates.
The parties may also agree upon a “shared savings” arrangement whereby the
It’s important to also gauge the impact of a changing regulatory environment, such as the introduction of the ‘No Surprises Act’ (NSA). Christine Cooper, CEO, Aequum Health, says, “NSA has altered the significance of direct contracts and amplifies the notion that these contracts can be a blessing or a curse. For plans and administrators that strategically contracted with providers for reasonable
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Direct Contracting Success reimbursement amounts based on a rate outside of provider control, such as Medicare rates, direct contracting will likely be a blessing.”
But for plans and administrators that entered into direct contracts based on a reduction of the chargemaster rates, Cooper says direct contracting will be
“The contracted rates are the primary factor for determining the appropriate out-of-network reimbursement rates under the NSA. The direct contract now affects the reimbursement rates to other providers that are not parties to the direct contract." a curse:
2. Establishing a Pay-for-Value Model Direct Contracts should be designed to drive simplicity, accountability and collaboration, allowing the employer to directly impact benefits, quality and price of the services delivered. It is an efficient, cost effective approach that provides great outcomes based upon the value derived.
The direct provider relationships significantly reduce the complexity for members while navigating their health care system. Employers win because the health system will provide the best cost position because they have 100% of the employer’s patient volume.
It is important to ensure that network adequacy and capacity is sufficient to provide employees with convenient, reasonably timely access to care.
For example, a provider might agree to specific services designed to enhance employee satisfaction, such as basic primary care services at a convenient, on-site health or nearby urgent care center, as well as “concierge” style member services specifically designed to assist employees and their dependents with questions regarding benefits and to help them find the right provider for a given medical condition.
Similarly, the parties might choose to address areas of specific concern to the employer and its workforce by requiring adherence to measurable quality and
patient satisfaction metrics. To address the paramount issue of cost, the employer and provider might negotiate reimbursement rates to be paid to the provider that account for the historical or (in the case of primary/preventative care) desired utilization of services by the employer’s covered population.
Through direct involvement with the provider and regular monitoring and reporting on its performance, employers gain a level of transparency into costs and quality that is uncommon in typical arrangements. With this additional information, employers can use their resources to secure the best combination of value and service for their specific workforce. 3. Building the Right Team & Choosing the Right Partners Building the right team for ongoing management and performance of the program is directly aligned with ensuring that the key leaders are engaged in the success.
Blake Allison, CEO, Employers Health Network, advises, “Issues are guaranteed, so building the right team to be able to work collaboratively to overcome them can be achieved through a focus on three elements.
First, develop a shared governance model structured to engage the right decision makers across the complete stakeholder environment. Then, empower the leaders to make decisions quickly to resolve issues that will certainly arise.
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Direct Contracting Success Limiting the need to engage external leaders will increase the speed to resolution and create less risk for the program.”
He says by agreeing to a ‘no fault’ environment where each leader understands there will be challenges vs. engaging in determining fault will result in spending productive time working towards solutions. “Each party will have their share of success and failures, so highlighting them at best slows resolution and at the worse, erodes trust.”
Parties may also need to engage a qualified actuary, not only to assist with the development of the financial arrangement but also to provide support when claims and other data must be collected and analyzed to assess the provider’s performance.
4. Optimizing Set Up The right team is an inter-disciplinary team,
“The team includes actuarial, network, administrative, claims, clinical and IT. The sheer selection process is a big undertaking and the team needs to work together Peter Robinson and be held accountable as inevitable issues and problems arise.” advises Peter Robinson:
Engaging the right outsourced partners when needed remains a strategic imperative for negotiating contracts. All aspects of the arrangement must make financial sense for the parties and employers must be flexible and prepared to coordinate all of the moving pieces.
Implementing a direct contract requires well-orchestrated population management capabilities, physician integration partnerships and value-based financial models.
These arrangements call for navigating and coordinating relationships between and among the employer, the provider, and the TPA. The provider may assume responsibilities and provide services typically provided by insurers and TPAs. The provider in a direct contracting arrangement will often assume responsibility for various TPA functions, such as complex case management or even member services. However, rarely does a provider take on all TPA functions.
Look for a partner(s) with: •
Demonstrated expertise in direct contracting, negotiation and implementation experience
Data analytics that determine and prioritize which treatments, surgeries or procedures should be negotiated
Ability to compare direct contracting opportunities to current market options
Capabilities to integrate direct contract claims into medical plan reporting
Reliable stop-loss vendor for potential reimbursement
Transparent payment and fee structures: ongoing percentage of claims, PEPM fees or a one-time fee
Therefore, while a direct contracting relationship may reduce the employer’s need for the full spectrum of services offered by a TPA, the employer will normally continue to engage a TPA to handle certain functions, such as claims administration, that require specific infrastructure and skill sets.
Direct Contracting Success An employer will want to be satisfied that the provider has the administrative capacity and expertise necessary to provide such services.
In addition, the provider’s responsibilities and functions may need to be carefully coordinated with those of an employer’s TPA, in order to eliminate the chance of unintended “gaps” in responsibilities.
Establishing meaningful yet realistic cost and budget targets often requires a level of actuarial acumen that neither the employer nor the provider has available.
decisions quickly to resolve issues that will certainly arise. 3) Limiting the need to engage external leaders will increase the speed to resolution and create less risk for the program.”
Allison recommends agreeing to a ‘no fault’ environment where each leader understands there will be challenges vs. engaging in determining fault, “Spending productive time working towards
“Each party will have their share of success and failures, so highlighting them at best slows resolution and at the worse, erodes trust.”
solutions,” he continues. Many who see the value of connecting providers and employers via direct contracts work tirelessly to put a contract in place yet fail to realize that once the ink is dry, the contract is now in force, and the real work of administering the contract begins.
Doug Heatherington shares this expertise, “Too frequently, direct contracts have been bundled with another vendor - TPA, RBP vendor, Stop Loss Carrier or other - that require the employer to use their services to gain access to the direct contracts. The first step in direct contract administration is unbundling access to direct contracts from any other vendor so that employers of all sizes, independent of vendor stack can access the Direct Contracts.”
He says direct contract administration includes claims processing, compliance and maintenance, adding, “Provider directories, upholding the integrity of the contract and scaling contracts are not core competencies of Benefit Advisors or TPAs, RBP vendors, or Stop Loss carriers. This glaring gap in the direct contracting marketplace became apparent to me upon launching my Company.in 2019.”
Blake Allison says, “The ongoing management and performance of the program is directly aligned with ensuring that the key leaders are engaged in the success. Issues are guaranteed, so building the right team to be able to work collaboratively to overcome them can be achieved through a focus on these three elements: 1) Developing a shared governance model structured to engage the right decision makers across the complete stakeholder environment. 2) Empowering the leaders to make
5. Consider Plan Design Issues
Typically, employers have relied on their TPA for a self-insured plan design (often based on one of the TPA’s own insured products). This allows the employer to draft plan documents and participant communications based upon policies, evidence of coverage, summaries of benefits and coverage and other documents furnished by the TPA.
With direct contracting relationships, it will be up to the employer to decide whether the benefit plan design for any narrow network it negotiates will have a standard or custom design and will need to draft plan documents and participant
APRIL 2022 13
Direct Contracting Success communications that are in alignment. While custom documentation can be more costly, the benefits achieved through a custom designed plan may well outweigh the added administrative expense.
Both employers and providers need to gain a detailed understanding of the payer, administrator and provider functions. Employers will benefit from a thorough understanding of how care is actually delivered and a detailed picture of the health needs of the employee population.
assessment and management where each partner understands and agrees to the tasks associated for promotion execution, communications and implementation.
Success hinges upon the cooperation of all team members to collaborate, with ongoing scheduling of team meetings to review and monitor performance in near or realtime.
Providers must comprehend the employer’s benefit structure and the incentives it creates for employees in need of care – from primary and acute to post-acute. They need to be realistic in assessing their own capabilities to serve a defined population. . If the parties are not familiar with population health analytics, they need to learn the basics along with the metrics that are available for assessing the quality of health care delivered and any savings achieved.
6. Executing a Successful Launch
This is where all the planning finally pays off. Here are some core elements of a failsafe launch:
One final word about legal considerations of direct contracting: make certain all issues have been addressed, including compliance with regulations. Some legal issues may be new to the parties, including sharing in the financial gains/losses generated by the arrangement or the implications of state insurance laws, which vary from state to state.
Clearly defined clinical integration strategy. 7.
A tightly aligned network and clinical integration with a capitated or per member per month trend guarantee with shared risk. The employer must be large enough to assume risk.
Stop Loss Carrier in Place: many stop loss carriers offer some TPA services, but employers should know what is needed from each resource and communicate appropriately.
Fully defined program parameters must be articulated, including roles and responsibilities of all parties – as well as their agreement to all program components, timelines, expectations and metrics. This includes program
Now to the bottom line: the core elements of success should be measured for the overall PMPM o the population, specifically a reduction in the total cost of care that is being managed in the fully integrated direct to employer strategy.
Employers should expect to have some reduction of trend over an extended period of time based upon a combination of the following:
Direct Contracting Success
Strategic pricing from the integrated delivery system Effective provider-based ambulatory care coordination and management Benefit design to ensure alignment of the members to the high performing network. Blake Allison advises, “When a relationship between the provider and the employer is initiated, the overall measure of success is the delivery of high value healthcare. This is defined as high quality and efficient care which can be measured through two separate angles: 1) Quality Measurement – a focus on the HEDIS and other nationally recognized metrics can help validate quality has remained within the program. Additionally, through a partnership with providers, clinical outcome measures can be folded into the measurement process. 2) Financial Measurement – tracking the core cost and utilization elements of admissions, emergency room visits and high-cost imaging are effective in ensuring the program is performing. The ‘true north’ metric is quite simply the per member per month (PMPM) cost over time. For the program to demonstrate its success, it must bend the overall cost curve of the beneficiaries within the program.“
Peter Robinson echoes these sentiments, adding, “The direct contract needs to be formally measured on its impact and overall performance in the market. This measurement is critical during the launch but no less critical over time. If the success isn’t developing, what can be done? The interdisciplinary team described earlier can address and solve problems as they arise.”
Doug Heatherington wraps up this concept, explaining, “The key measure of success in direct contracting is the number of employers a given direct contract can serve. If the direct contract does not allow additional employers to join into it or different vendor stacks to be used, even if the financial and clinical outcomes are great, the overall impact at a community level will be small.”
He emphasizes that it is important to move the direct contracting space to open and independently administered direct contracts that allow as many employers as would like to join in.
“The goal is to impact not just 3 or 9 employer groups, but entire communities,” he concludes.
Laura Carabello holds a degree in Journalism from the Newhouse School of Communications at Syracuse University, is a recognized expert in medical travel, and is a widely published writer on healthcare issues. She is a Principal at CPR Strategic Marketing Communications. www.cpronline.com
Sources Jones Day, 2018 https://www.wtwco.com/en-US/Insights/2018/12/best-practices-in-healthcare-2018chapter-4-health-care-delivery Milliman, 2019 https://www.milliman.com/en/insight/is-direct-to-provider-contracting-a-potentialsilver-bullet-for-achieving-value-based-care Kaiser Family Foundation, 2021 https://www.kff.org/report-section/ehbs-2019-summary-of-findings/
APRIL 2022 15
F E AT U R E
Uncertainty Arises Over
Federal Surprise Billing Implementation Written By Karrie Hyatt
he implementation of the No Surprises Act (NSA) is causing a lot of uncertainty among self-insured health plans. Confusing matters even more is a recent Federal District Court decision that vacated part of the Interim Final Rules (IFR) that muddies the arbitration process between provider and insurer.
The No Surprises Act was passed by Congress in December 2020 as part of the Consolidated Appropriations Act of 2021 and went into effect on January 1, 2022. The law addresses the growing disconnect in patients receiving surprise balance bills in out-of-network situations, including emergency events or with out-ofnetwork ancillary providers in in-network settings. The No Surprises Act is meant to protect patient consumers while prohibiting providers from surprise billing in situations where patients do not have the ability to choose an in-network provider. Last July, the first IFR was released and was concerned primarily with qualifying payment amounts (QPA) and Employee Retirement Income Security Act (ERISA) preemption of state surprise billings laws.
Federal Surprise Billing Implementation In September, the federal departments released a notice of proposed rulemaking, titled “Reporting Requirements Regarding Air Ambulance Services, Agent and Broker Disclosures, and Provider Enforcement.” This release set-up data collection for these subjects for further research and clarification. Protecting patients against surprise, and high cost, air ambulance charges is one of the key components of the No Surprises Act.
Also in September, the second IFR (Phase II) was released and primarily pertained to the independent dispute resolution (IDR) and arbitration process for the No Surprises Act. It describes in detail the dispute resolution process between provider and insurer. It also issued guidance for individuals that do not have an insurance plan or prefer not to be billed through their insurance plan.
The NSA went into effect on January 1 and self-insurance plans, among other participants, have been struggling to make good faith efforts in meeting its requirements.
In addition, the Transparency in Coverage (TiC) rule, that requires health plans to make available publicly detailed information on the costs of covered items and procedures, is being implemented in roll-out phases over the next two years. Some of the TiC and NSA requirements overlap, and federal agencies have also been active in coordinating and aligning implementation mandates between now and 2024. While this is good news, the complexity and burden of various federal regulatory regimes will continue.
SURPRISE BILLING IMPLEMENTATION
Even with several rulemaking releases from the federal departments, implementing the NSA is proving burdensome to self-insurance health plans and participants. According to Mike Orth, principal, LaunchPad Health, “The new federal requirements are bringing about a significant transformation in how self-insured plans operate with the impact felt by everyone, including employers, TPAs, and vendors. Plans must now identify surprise billing claims and calculate a QPA.”
“With the NSA administrators/payors, on their own and behalf of their clients, have to change systems and processes—in most cases relying on third party vendors to get it right the first time,” said Bill Green, chief executive officer, Homestead Smart Health
Plans. “We have been working on this since before the IFRs came out and it will be a challenge for most teams to get this right out-of-the-box. We will act in good faith and iterate for another twelve months is my guess. Our mission is to make sure our clients, the plans, have all they need from us to be successful and stay out of regulatory issues.”
For Lance Lankford, vice president,
“If [selfinsured health plans] are fully aware of their obligations, I think they are overwhelmed given the extent of what they have to provide. There will be a lot of reliance on consultants to assist these groups, particularly as the rules are implemented and then defined and enforced.” Lockton Companies,
“While much of the industry talks about the NSA, there are also requirements plans must meet under the Transparency in Coverage rules and the broader Consolidation Appropriations Act,” said Orth. “These include a price transparency tool, which requires detailed cost estimates provided to members in realtime, and goes beyond the capability most plans have in place today.”
Federal Surprise Billing Implementation conference was timely in that our industry was able to come together at this critical time for implementation and exchange thoughts on best practices.”
A huge concern for self-insured plans is that the IDR portal is not yet active, even though the time period for the first claims to go to arbitration is fast approaching. The IDR portal will be an internet access point where insurers or providers can request arbitration and be assign IDR entity.
According to Orth, “Implementing these requirements have been especially difficult for self-insured plans in part due to the innovative network approaches we see in the self-insured space. For example, some of my clients have a network that is a combination of multiple networks managed by different vendors, such as direct contracts, a rental network, reference-based pricing, out-of-area wrap, and gap-fill. Calculating a single QPA based on contract data from these various vendors, and then defending the plan’s payment in IDR is proving to be an extremely complex and resource intensive implementation.”
In an effort to help members implement these new policies, SIIA held the Price Transparency Forum on March 1 in Dallas, Texas. This Forum was an opportunity for those involved in self-insurance to get a better understanding of the rules and to network with peers about implementation strategies. According to Green, “Attendees and SIIAs members are all taking this seriously and we all feel under the gun.” “Very few health plans are fully prepared for these new regulations,” said Orth. “This
While the NSA was passed as an overwhelmingly bipartisan bill by Congress and has the support of both patients and health insurance plans, the QPA section of the IFR has seen major pushback from health providers, provider networks, and their trade associations. At least six lawsuits have been filed on behalf of providers with one decision having already been handed down.
The U.S. District Court for the Eastern District of Texas decision handed down in late February regarded a suit brought by the Texas Medical Association (TMA) against the U.S. Department of Health and Human Services. The issue at stake is a rule regarding the independent dispute resolution (IDR) process and the rebuttable presumption factor within the QPA, TMA arguing that the rule is inconsistent with the legislative intent of the NSA. The judge agreed with the plaintiff and vacated the related provisions.
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Federal Surprise Billing Implementation While the whole of the IDR process can continue as planned to resolve payment disputes, the court’s decision vacated the rule that gave guidance to IDR entities related to calculating payments. If the arbiter can’t use the QPA as a primary factor for determining arbitration outcomes, providers could use the process to argue for higher out-of-network payments, defeating the purpose of the NSA. This could cause higher reimbursement rates and inflationary pressures on the cost of healthcare.
“This adds yet another wrinkle on top of an already difficult implementation,” said Orth, “Not to mention the short turnaround time plans have had to prepare for the IDR process. Self-Insured plans feel very strongly that the QPA will almost always reflect fair-market reimbursement rates, so it’s concerning that arbiters will no longer be tied to this value. Plans are particularly concerned about an increase in the volume of IDR cases, which would inevitably lead to higher costs for consumers.
According to Lankford, “[This decision] will create more uncertainty. Prior to the decision, there was at least a belief that to move away from the QPA (however determined) would require some significant justification and reasoning. I still feel the QPA will be a significant factor in the final determination of the IDR but the initial
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certainty around that aspect of the process will be missing until that issue is resolved, most likely by the higher courts.”
Four of the other lawsuits—filed in Washington, D.C., Illinois, and Georgia— make arguments similar to what the TMA claimed. Briefings have been held in the two cases located in Washington, D.C. with hearings to be scheduled soon. An additional lawsuit, filed in New York, makes some of the same arguments as the other lawsuits, but takes the claim further arguing that important sections of the NSA are unconstitutional and that Congress does not have the authority to legislate protection of patients from surprise balance billing.
SIMPLE. SAFE. SMART.
Federal Surprise Billing Implementation PRICE TRANSPARENCY COMMITTEE
While SIIA has been working on price transparency concerns for a number of years, the association recently converted its Price Transparency Task Force into a formal committee. The members of the Price Transparency Committee (PTC) bring to the table years of expertise in self-insured health plans. As federal agencies work to finalize the rules for the NSA and deal with other price transparency rulings, the members on the PTC will be able to offer their shared experience.
“There will be a significant need for targeted knowledge and expertise to work with our legislators in implementing the NSA and other related legislation. The Committee can serve as a funnel for all of the issues, expertise and knowledge available from the members of SIIA to try and ensure the legislation addresses the needs of employer groups and other constituents and also works from a practical perspective once implemented,” said Lankford.
“Our committee is closely monitoring the rulemaking process and communicating developments back to the rest of our industry,” offered Orth. “Facilitating communication between industry and regulators is essential given that these laws have a signification impact on all of us.”
For Green, the committee will offer an on-the-ground perspective. “It will assist members and regulators in understanding what is actually happening. Also, it will be able to suggest comments on new rules and proposed regulations when they come out, in part based on our shared experience. The committee can also help shape policy through SIIA’s government relations team.”
All three persons interviewed for this article were involved with the task force and are now members on the PTC. While they all support the focus of the committee, they are also hoping to bring more to the table. For Orth, “My focus is on helping SIIA members understand these rules while also listening to their questions and concerns and finding impactful ways to share this information with regulators.”
Green would like, “To see us develop a set of best practices we can share with members. Perhaps develop a training or certification program member firms may point to when dealing with regulators and IDR entities.”
“I hope that the committee is used by SIIA members as a sounding board and a resource to get concerns, questions and issues addressed so that we can pass this on to legislators and others involved in the creation and development of these various rules,” said Lankford. “Ultimately, we can work together to ensure the clients and their members that we work with to save money and find the best care.”
THE FUTURE OF PRICE TRANSPARENCY
The road to making price transparency an effective tool for consumers and insurers will bumpy. In the long run, price transparency legislation should work as intended, but for now the changes are burdensome for an already burdened industry.
As court decisions come in and rulemaking becomes finalized, self-insured health plans will better be able to adapt to the new rules.
For Lankford, “The more information available to plans and their members as to the costs and quality of care, the better. That being said, the information will only work to that end if it is used and applied effectively. The users of the information need to have ready access to it and be able to decipher it and use it in the way it is intended, or price transparency will not do what it is intended.”
Federal Surprise Billing Implementation
Orth sees both short-term and long-term changes for the positive. “Some effects will take more time than others. For example, consumer protections will be felt more immediately, like banning surprise balance billing and ensuring consumers have access to accurate provider data,” said Orth. “Requirements intended to drive costs down will take more time. For example, plans will be required to reveal in-network contract data starting in July, which will hopefully drive down costs as price variation becomes more evident. However, it’s going to take time for data aggregation services to pull this information together and present it in a useful manner.”
Green has a more jaundiced view of the outcome of these price transparency rules. “I think there will be some change in the short term, but providers will learn to game the new system. The law of unintended consequences is the law. For example, since the third party databases that can provide a QPA are based on billed charges claims data all providers will need to do is keep increasing the chargemaster over time to increase the amount they receive in arbitration. I don’t think that is what the legislation intended. I don’t think we will see the use of that data changing consumer choice in the near or medium term.”
“These laws are ultimately a positive development for our industry, because they provide members with the basic tools they need to make more informed decisions about their care,” said Orth. “[These laws have] the potential to drive down costs for plans. However, data itself will not drive consumerism in healthcare. We need to go beyond transparency and find ways to incentivize consumers to shop for the highest quality care at the lowest price. Transparency tools and incentives are key to driving costs down. This is just the first step.”
Bill Green, Mike Orth, and Lance Lankford will be panelists on this topic at SIIA’s Spring Forum in Orlando, Florida, where SIIA members can learn more.
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.
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SIIA’s Drug Pricing Task Force Finalizes Cost-Containment Roadmap
Written By Bruce Shutan
ver the past two years, SIIA’s Drug Pricing Task Force has been working to develop a targeted list of recommendations on how self-insurance industry stakeholders can better control the rising cost of pharmacy spend, including highcost specialty drugs. Much has happened during that time. An 18-member group of industry experts including clinicians, brokers, stop-loss carriers and TPAs to claims and pharmaceutical management firms were divided into subgroups to address three key areas: plan documents, roles and responsibilities, and finances. Their mission to produce a handy resource will be formally unveiled at a Spring Forum session in Orlando, Fla. The task force was created to help tackle a stark reality. “Pharmaceuticals now represent pretty much the largest spend when it comes to claims from a health perspective,” observes Doug Bloomquist, a task force member and SVP with StarLine Group whose focus is on plan documents. “When we look at claims, you can easily forecast what the overall spend is going to be for a member or a patient just based on the drugs that they utilize.”
Dealing with a complicated, fractured and nontransparent drug procurement and distribution process proved to be an uphill battle, according to Steve Kelly, another task force member as well as chairman and co-founder of ELAP Services whose focus is on the finance area. He says another challenge was the lack of standardization in how plan documents are worded for prior authorization and different methods used for cost containment. His hope is that the task force’s work will rectify these issues moving forward.
INTERDEPENDENCY AND THE NEED FOR COLLABORATION
about the process. “If people aren’t doing what they need to do in the process, you’re not going to get there,” Peterson notes. Additionally, the pursuit of high-quality care and outcomes must be built into the financing component. When all three areas are addressed, he says employers will be able to effectively execute their objectives. With specialty drugs representing an increasingly complex segment of the health
“What we wanted to build was a very simple roadmap that could be utilized by anyone who’s a SIIA member, be it a self-funded group, broker, TPA, stop-loss carrier, etc.,” explains task force member care industry, the task force let simplicity serve as its guide.
Marien Diaz, VP of excess loss claims at Symetra Life Insurance Company whose focus is on roles and responsibilities. Each of the work groups merged their recommendations into a single document that she calls a “condensed checklist” with all the essential components required for managing a self-insured employer’s pharmaceutical challenge. In its most practical form, she says the document can be printed and taken to a meeting or used as a tool by service providers for a conference call with customers or prospects. For the part she worked on, Diaz and her subgroup colleagues focused on issues such as how to schedule and approach communication between all the necessary parties to make sure they’re on the same page.
Interdependency among the three subgroups cannot be overstated, says SIIA Drug Task Force Chair Shaun Peterson, VP of stop loss for Voya Financial who’s also on SIIA’s board of directors. “It’s the old adage: a chain is only as strong as its weakest link,” he says, noting that each pillar needs to be set up in a way such that they’re holding their own. For example, the plan document needs to define clear actions that need to be performed around managing high-cost drugs, but also stipulate the roles and responsibilities of key stakeholders, which he believes is the hardest part
That included suggesting the frequency and content of those meetings, mindful that it’s not easy to adequately address everyone’s concerns when there are so many moving parts. She says every meaningful dialogue must start with crystal-clear expectations, noting that the task force’s final document will help align stakeholder objectives moving forward. “By enhancing communication,” Diaz says, “we are hoping to actually translate all that good dialogue into contractual provisions in the agreement that facilitate the management of these solutions.”
For Bloomquist, the biggest takeaway from his work on the task force was a recognition about the necessity of having strict guidance on how high-cost drugs are handled. “You need to be able to provide clear definitions around terms, and they need to be concise in order to be able to make the plan document itself an effective central mechanism of controlling costs,” he explains.
It’s also paramount given the complexity of these costly drugs that self-insured health plan sponsors assemble a team that he says includes an employer point person, legal representative, broker, TPA, PBM and others who meet on an annual or semi-annual basis to discuss Rx treatment trends.
Indeed, concern is mounting over new high-impact specialty pharmaceuticals moving out of the R&D pipeline and into the marketplace. With at least five such scripts receiving FDA approval last year, some featuring price tags of more than $1 million for a single dose or treatment of rare conditions, pharmacy benefits management will become increasingly difficult.
STICKER SHOCK Kelly has found that the price discrepancies and randomness by which specialty drugs are reimbursed to be rather startling and a wakeup call for substantive change. At its worst, he says the arrangement smacks of predatory pricing. “It’s very difficult for us to have any say in how these prices are generated if we only get involved at the very end of the process,” he cautions.
“These drugs have a set price tag from the moment that the FDA approves them,” Diaz notes. “Obviously, there’s the patent law that protects the manufacturer to keep that price for a number of years. So, somehow we have to figure out a way how to make this sustainable for employers, but also the stop-loss carriers that are taking on the lion’s share of that risk.”
The emotionalism surrounding treatment of serious conditions that often involve a life-or-death matter makes it difficult to negotiate prices, Kelly notes. In trying to do the right thing for families, he laments that it means “paying a price that’s completely unreasonable and unsustainable for the future.”
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As these costly drugs get approved, Diaz says one huge challenge will be ensuring that their high price tags are actually generating the intended results. That effort will involve communicating and partnering with drug manufacturers to help mitigate risks and including language in an employer’s plan document regarding expectations on drug efficacy. One area of pharmacy innovation that’s exploding is the oncology category. Diaz questions whether or not physicians and specialists are using those drugs as intended with regard to step therapy. “Sometimes,” she says, “if you just go to the most expensive and newest drug, it may not be the ideal solution for that particular patient from a clinical perspective… With the continued advances in oncology specialty pharmacy, there needs to be clinical validation, along with the costcontainment approach.” Bloomquist is highly concerned about rising Rx costs, citing reports that nearly 40 new high-cost genomics could flood the market within the next four to five years. Some of the other areas that are catching his attention include CAR (chimeric antigen receptor) T-cell therapy, as well as oncology scripts and so-called orphan drugs that treat extremely rare conditions. With regard to the latter category, he describes it as problematic for reining in, say, a drug costing $5 million that may be prescribed for only 20 people. What concerns Peterson is a lack of competition associated with the way drug manufacturers are able to lock out the production of similar scripts during a window of exclusivity. Alternative therapies cannot reach the free market until a particular
“Your hands are kind of tied a bit,”
he drug comes off patent. explains, though hopeful that costs will fall over time as more competition moves into the space. An area that has raised eyebrows involves cell and gene therapies which, while not technically drugs, are billed as pharmaceuticals. He predicts a continuation of significant inflation and no shortage of new specialty pharmaceuticals being brought to market. While manufacturer assistance programs help patients afford new treatments and close coverage gaps, Peterson cautions that they may or may not help the actual plan sponsor who’s paying the bill. Instead, he says their best hope is protections associated with stop-loss policies and emergence of vendors that are providing solutions to manage costly cell and gene therapies.
MINDFUL OF MIRACLES When weighing the high cost of certain pharmaceuticals relative to the overall medical spend, Peterson says it’s easy to often lose sight of the fact that these new therapies offer miracle-like treatments or cures and with “every one of these claims, there’s a person behind it.”
Five years ago, he observes, children with spinal muscular atrophy would die within the first two years of their life, whereas today they have a few options. “One of them is certainly durable, if not curative,” he adds, excited about what sort of medical care his children and grandchildren will receive based on the emergence of promising therapies. The caveat, however, is limited evidence of efficacy. Most studies of these drugs, for example, were only about three or four years. “We need plenty of history behind us to say they’re actually curative, and we just don’t have it yet,” according to Petersen. Describing the best-practices document as a critical first step to establish a foundation upon which the task force can build out meaningful discussions, Kelly would like to see the group continue to explore collaborative and holistic solution. Bruce Shutan is a Portland, Oregon-based freelance writer who has closely covered the employee benefits industry for more than 30 years.
CHECKLIST AT A GLANCE
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FDA Biologic Information
SIIA Member Resources
FDA Approved Drugs FDA Novel Drug Approvals FDA Approved Drug Information & Resources
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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 Laurie Kirkwood provide the answers in this column. Mr. Hickman is partner in charge of the Health Benefits Practice with Alston & Bird, LLP, an Atlanta, New York, Los Angeles, Charlotte, Dallas and Washington, D.C. law firm. Ashley, Carolyn, Ken, Amy, and Laurie are senior members in the Health Benefits Practice. Answers are provided as general guidance on the subjects covered in the question and are not provided as legal advice to the questioner’s situation. Any legal issues should be reviewed by your legal counsel to apply the law to the particular facts of your situation. Readers are encouraged to send questions by E-MAIL to Mr. Hickman at john.hickman@ alston.com.
TCPA COMPLIANCE AND HEALTH PLANS: IT’S YOUR CALL As health plans and wellness and disease management programs continue to innovate in order to better educate participants about tools and services that may improve health outcomes and curb costs, plan sponsors and service providers need to be mindful of compliance issues from an unexpected source. The Telephone Consumer Protection Act of 1991 (TCPA) generally restricts certain unauthorized calls and texts to residential and cellular phones, including some restrictions potentially applicable to health care messages. A recent federal district court opinion serves as an important reminder that even if a plan is in compliance with all other applicable laws, including the privacy requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the plan, absent express consent, may still be in violation of the TCPA when reaching out to plan participants via texts and pre-recorded messages. In today’s world of robust wellness and disease management activity all aspects of participant engagement must be carefully reviewed to ensure compliance. In Fiorarancio v. Wellcare Health Plans, Inc.,1 a health plan allegedly violated the TCPA by contacting the plaintiff’s cell phone twenty times over an eleven-month period, leaving eighteen voicemails and sending two text messages. While this case was merely allowed to proceed by surviving a preliminary motion to dismiss, it still serves as a clear warning concerning TCPA compliance issues. The nature of the communications may be familiar to some plans that offer wellness or navigation programs: a free healthy living program; an educational health program; a free preventative care program; an in-home health assessment visit; and an additional service that was described as part of the plan’s membership. Other calls referenced “important information” and one of the calls invited the plaintiff to make an appointment for a dental check-up, referencing his coverage under the dental plan. The two text messages reminded the plaintiff to schedule a flu shot. Four calls allegedly used a prerecorded message. Emails were not part of this case and are not covered under the TCPA, even though emails can be received on a smartphone. [Note: communicating sensitive health information by email has its own compliance concerns under HIPAA]. The health plan allegedly violated the TCPA in two ways: (1) by calling the plaintiff more than once in a twelve-month period after he placed his name on the National Do Not Call Registry2 and (2) calling him using a prerecorded voice and without his express consent.3 With regard to the first allegation, the regulations implementing the TCPA prohibit initiating a telephone solicitation to anyone who has registered his or her telephone number on the national-do-not-call registry.4
A “telephone solicitation” is a call or message for the purpose of encouraging the purchase or rental of, or investment in, property, goods, or services.5 The health plan’s position was that none of the calls mentioned or encouraged buying, renting, or investing in anything but rather sought to provide information, either about health care or about benefits, under the plan. Free services or programs are not in the TCPA definition of “telephone solicitations,” but the court noted that free offers often come with other requirements. For example, each of the messages the health plan left for the plaintiff required that he call back to obtain more information about, or take advantage of, the offer for free services. So, while the health plan’s messages may have been informational on their face, the court found that, because of the regularity and frequency of the communications—twenty in eleven months--it was possible for the messages to be part of a larger marketing scheme or other profit-making venture that could fall within the TCPA’s prohibition. The court stated that more information about the calls would need to be gathered before it could be determined whether the communications were purely informational, or whether they were a pretext. With regard to the plaintiff’s second allegation about the prerecorded messages, the TCPA prohibits the use of an artificial or recorded voice to call any telephone number assigned to a cellular telephone service without the prior express consent of the called party.6
The TCPA rules are complex, and the simplest way to understand them is to trace their evolution and purpose. First, the FCC prohibited all prerecorded phone calls unless they were made for emergency purposes or with the called party’s consent.7
2022 WL 111062 (D.N.J. 2022)
This first part was later changed and a carve-out was added for a heightened written consent for “any telephone call that includes or introduces an advertisement or constitutes telemarketing.”8 This heightened written consent applies to all calls that are advertising or telemarketing, unless the call delivers a health care message made by a covered entity or the business associate of a covered entity.
47 C.F.R. § 64.1200(c)(2)
47 U.S.C. § 227(b)(1)(A)
47 C.F.R. § 64.1200(c)(2)
47 U.S.C. § 227(a)(4); see also 47 C.F.R. 64.1200(f)(15)
47 C.F.R. § 64.1200(a)(1)
47 C.F.R. 64.1200(a)(1)
47 C.F.R. 64.1200(a)(2). There is an exception for non-profits, which require only express consent rather than written consent.
This exemption from written consent under the TCPA applies only when the communication is both advertising/telemarketing and a health care message. If the communication is not advertising/telemarketing, then the express written consent requirement still applies. The court granted the health plan’s motion to dismiss with respect to the two text message flu shot reminders, but denied the motion for all the other communications the plan made to the plaintiff. Health plans need to be mindful of how their third-party administrators are communicating with plan participants. Even though the nature of the communication may be related to participant education or the availability of plan services and benefits, plans should review which mode of communication is being used (pre-recorded phone calls, texts, fax, email), the frequency of those communications (weekly, monthly, quarterly, annually, etc.), the content of the messages (targeted, personal health information or generic plan information), consent/authorization for use of contact information (opt-in and optout features), and whether any commercial transaction could ever result from the communications. HIPAA is always a concern when sharing participant contact information with business associates who may initiate contact with participants, and service agreements may attempt to place the burden to obtain the proper consent and authorizations on the plan or plan sponsor. Although the TCPA does not apply to email, it does apply to phone calls, voicemails, text messages, and faxes. Legal counsel should be consulted to review service agreements with business associates and other health plan vendors to ensure that the health plan is properly using participant information and complying with all aspects of applicable law, including the TCPA.
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U.S. DOMICILED CAPTIVES HAVE STRONG SHOWING IN 2021 Written By Karrie Hyatt
here was robust captive growth across the board in 2021 for U.S. based domestic captives. In 2020, the hardening market and pandemic-related losses indicated that the captive sector would grow in 2021. That predication held true with large numbers of new captive formations last year. There was also slightly more captive legislation activity last year, definitely an uptick from 2020. States updating their captive legislation largely made small tweaks to keep up with industry changes.
CAPTIVE NUMBERS BREAKDOWN
Captive formations were high in 2021, with a total of 337 new captives in the eleven domiciles that have released numbers for last year. Leading the way was Delaware with 70 new captives, followed by Utah with 52 captive formations. Rounding out the top five domiciles were Vermont (45), North Carolina (31), and Montana (29).
In both 2020 and 2021, Delaware licensed 70 new captives. This was up from 56 in 2019. The domicile reports that the total number of captives in the state is 759, which would put Delaware ahead of every other domicile in terms of numbers. However, this total includes series and cell captives which most domiciles don’t include in their total number of captives.
Utah may have had the second largest number of formations last year, but their overall number of captives went down slightly from 396 in 2020 to 384 at the end of last year. In fact, this was the second year of decline in the state’s total captive numbers after reaching a high of 441 in 2019. In the first few months of 2022, however, Utah has already reported licensing a large number of new captives.
Vermont had a strong year, which also saw the domicile celebrating its 40th anniversary as a captive domicile. Their 45 new captives go on record as the fourth highest year of growth. After two years of static total number of captives— both 2019 and 2020 finished with a total of 589 captives— Vermont’s total number of captives rose to 620.
While no longer a new captive domicile, yet still one of the most recent, North Carolina continues their dynamic growth with 31 new captive formations in 2021, taking the number of captives from 250 in 2020 to 257 in 2021. The domicile is looking forward to a strong 2022 with several new captives licensed and new applications already being processed. Debbie Walker, who has been the captive regulator in the state since it passed captive law, has retired from the position. She oversaw the creation of captive regulation and its rapid growth to a large, wellregarded domicile. Her replacement, Lori Gorman, is a long-time financial analyst in the state, and will likely carry on Walker’s successful policies.
Montana continues to license a large number of captives each year, with 29 last year. However, since their 2019 high of 288 total captives the domicile’s total numbers have been in decline. In 2020, the domicile finished the year with 270. The number of total captives also went down again in 2021, with the domicile finishing with 261.
With 27 new captive formations in 2021, their highest number of formations yet, Arizona had a banner year. Last year’s growth was more than double 2020’s 12 formations. The domicile’s numbers continue to grow, going from 121 in 2019 to 149 in 2021.
Washington, D.C. came in just behind Arizona with 26 formations, giving the domicile 175 total captives, up from 159 in 2020.
Hawaii, one of the oldest captive domiciles, continues to be a be a quiet force in captive sector with 17 new captives in 2021. This brings the total number of captives to 251, up from 242 in 2020.
Connecticut added 13 new captives last year, more than twice the number the year before, for a total of 35 captives. Missouri added six new captives for a total of 80.
Notably missing from this list is Tennessee. This domicile usually has a strong showing in both formations and total number of captives, but the state had not yet released data for 2021 at the time of publication. The state’s captive insurance department has seen some rapid turnover in the leadership department since the end of 2019. Its most recent director, Belinda Foreman, left the position last summer. The interim director, Jonathan Habart, was appointed permanently to to position in November.
DOMICILE LEGISLATIVE UPDATES
In 2021, Delaware updated its captive law to allow for three key issues. The first part of the updated legislation allows for captive structures to be classified as “registered series,” which will allow for greater transparency. The update also clarifies provisions regarding the insuring of a parent company’s risks. The third provision changes the period of dormancy for captives that elect to take it from one calendar year of inactivity, to twelve consecutive months of inactivity. This change will allow captive
owners to enter into dormancy sooner and is meant to encourage owners to consider dormancy first rather than dissolution. Not a change to captive legislation, but a change to existing law that will affect captives, in January of this year the Delaware state legislature passed a bill that allows corporations to use captive insurance companies to insure directors and officers liability insurance.
In May 2021, Governor Phil Scott signed into law Vermont’s updated captive legislation. Vermont updates its captive law nearly every year with minor changes and adjustments to keep it the most attractive captive domicile in the U.S. Last year’s update allowed for protected cell captives to more easily convert to a standalone captive or to a different type of cell captive. It also simplified the processes pertaining to redomestication, captive mergers, and organizational document filings prior to a captive being licensed.
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Tennessee amended its captive insurance law in June 2021. The primary change was to reduce the statutory capital that a protected cell captive needs in order to commence operations from $250,000 to $100,000. The update also authorizes captives to insure parametric insurance coverage.
Alabama began the process of updating their captive law at the beginning of 2020. Due to the COVID-19 shut down, the legislature wasn’t able to proceed with the changes. Instead, in early 2021, the legislature went forward with passing the amendments suggested in 2020 and included several more changes. The updated legislation expanded the definition of branch captives, which will allow for easier creation and use of this type of captive. It authorized agency captives, reinsurance captives, and special purpose financial captives to domicile in the state. The law lowered the minimum capital requirements for pure and protected cell captives. It added to the existing law a formalized process for captive redomestication and now allows for captives to be capitalized with a surplus note as long as there is a written agreement between creditor and captive.
The outlook for captives sees the market continue to expand. The current hard market in most lines of insurance is expected to last through this year—with some lines easing capacity and others remaining tight, particularly for emerging risks and hard to insure risks. This places the captive sector in the optimal spot to help businesses insure their risks. The number of captives in the U.S. will likely have another year of solid growth in 2022.
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.
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VIA – Payer Claim Accuracy Billing Integrity Payment Audit & Recovery Networks Transparency
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VIA – Provider Credentialing License Monitoring Payment Validation
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Simplify the complexities of self-insurance. When you partner with Vālenz®, you have unparalleled transparency into our fully integrated and interactive ecosystem solutions. Our solutions intuitively build upon and learn from one another to uncover information that converts to proactive and real-time action, allowing us to engage early and often to lower your costs and improve quality across the member journey. Transparency is foundational to everything we do and how Valenz simplifies the complexities of selfinsurance for you and your members. With deep roots in member advocacy, and decades-long expertise in ensuring the validation, integrity and accuracy of claims, we have become the recognized leader for delivering smarter, better, faster healthcare. To make your business strong, vigorous and healthy today, visit valenzhealth.com or call (866) 762-4455.
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ONGOING LITIGATION OF INTEREST TO EMPLOYER GROUP HEALTH PLANS
Written By Corrie Cripps
ith COVID-19 temporary coverage mandates, transparency in coverage rules, and implementation of the No Surprises Act (NSA) provisions, the first quarter of 2022 has been a busy one for group health plan sponsors and third party administrators (TPAs). As policy changes and compliance issues continue to evolve this year, there is also a wide variety of court cases to watch, as they will have implications for employer-sponsored health plans.
COVID-19 TESTING PAYMENT
The Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) require group health plans to cover the cost of COVID-19 diagnostic testing and related services, but the CARES Act doesn’t specify a reimbursement amount for out-of-network providers. Instead, the law states these items are paid at the negotiated rate, if one exists. If no negotiated rate exists, the plan will pay the cash price publicly posted on the provider’s website, or such other amount as may be negotiated by the provider and plan.
As a result, there are lawsuits involving both payers and providers. For example, a Texas medical lab (Diagnostic Affiliates of Northeast Houston) is suing United Healthcare Services, Inc. in federal court alleging that the insurer failed to properly reimburse for COVID-19 testing services (Diagnostic Affiliates of Northeast Houston v. United Healthcare Servs., No. 21-cv-0131 (N.D. TX Jan. 18, 2022)).
are identified by the US Preventive Services Task Force, the Health Resources and Services Administration, and the Advisory Committee on Immunization Practices.
From a payer perspective, Premera Blue Cross is suing a COVID testing company (GS Labs), in Western Washington District Court, alleging that the lab attempted to exploit the pandemic through price gouging for its services (Premera Blue Cross v. GS Labs, No. 2:21-cv-01399 (W.D. WA filed Oct. 14, 2021)).
They further argue that some of the recommendations—to cover contraceptives and pre-exposure prophylaxis (PrEP) to prevent HIV—also violate the Religious Freedom Restoration Act (RFRA).
The entire preventive care mandate is being litigated in a case called Kelley v. Becerra (Kelley v. Becerra, No. 20-cv-00283 (N.D. TX filed July 20, 2020)). The plaintiffs in Kelley argue that Section 2713 is unconstitutional and unenforceable because it violates the “nondelegation doctrine,” the Appointments Clause, and the Vesting Clause. The plaintiffs are asking the court to declare that all preventive service mandates under Section 2713 are no longer required to be covered.
A decision is expected this year and could significantly impact the coverage of preventive services in group health plans.
Plan sponsors should monitor these cases and review how payment is processed for out-of-network COVID test claims with their TPAs.
ACA’S PREVENTIVE CARE MANDATE
The Affordable Care Act’s (ACA’s) preventive care mandate (under Section 2713 of the Public Health Service Act) requires non-grandfathered group health plans to cover, without costsharing, in-network, certain preventive care services. These services
ACA SECTION 1557 The US Department of Health & Human Services (HHS) is expected to issue a revised ACA Section 1557 rule this year, which will be the third version of this rule.1 ACA Section 1557 is the law’s nondiscrimination provision that prohibits health programs or facilities that receive federal funds from discriminating based on race, color, national origin, age, disability, or sex.
There are ongoing legal challenges to the two previous iterations of the rule (from the Obama administration and from the Trump administration). The district court orders for these cases will stay in place unless overturned.
Cummings sued, alleging that the refusal is a form of disability discrimination, and is asking for damages for the emotional distress caused by her experience. The court is deciding whether damages for emotional distress can be awarded under Section 504 of the Rehabilitation Act of 1973 and Section 1557. This will be an important case to watch, as it involves discrimination claims brought under Section 1557 by individuals.
FEDERAL IDR PROCESS OF THE A decision from the US Supreme Court is expected soon in Cummings v. Premier Rehab Keller (Cummings v. Premier Rehab Keller, No. 20-219 (US filed Aug. 21, 2021)). In this case, a physical therapy provider refused to provide Jane Cummings (who is deaf and legally blind) with an ASL interpreter to help treat her chronic back pain.
The No Surprises Act (NSA) of the Consolidated Appropriations Act, 2021 (CAA) contains extensive provisions intended to protect consumers from surprise medical bills for services provided by nonparticipating providers or facilities.
As Advocates for Healthier Living, we’re improving clinical outcomes while reducing the Total Cost of Care. It’s the foundation of the service we provide our clients, members and business partners. We Change Lives. We create positive change in every interaction we have. By listening and understanding our clients’ needs, we offer flexible, cost-effective and easy-to-use health care solutions. We are dedicated to providing compassionate support and guidance to help our members be active participants in their health care.
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Many medical providers and facilities take issue with the presumption in the federal independent dispute resolution (IDR) interim final rule (IFR) that the qualifying payment amount (QPA) is the correct reimbursement amount for out-of-network services. Provider groups argue that the law lists many factors that an arbitrator may consider, such as the out-of-network provider’s experience and training, and does not give presumptive weight to the QPA.
On February 23, 2022, a federal judge in Texas struck down a narrow piece of the NSA IFR dealing with the IDR process (Texas Med. Ass’n v. HHS, No. 21-0425 (E.D. Tex. Feb. 23, 2022)). The lawsuit was led by the Texas Medical Association (TMA), which argued that parts of the IDR rule are inconsistent with the NSA and should be invalidated. The judge agreed and vacated these provisions on a nationwide basis. An appeal is expected.
policy that allegedly causes UBH to deny coverage for certain services merely because they are provided in a residential treatment setting, even though UBH accepts that the services themselves are medically necessary.
The TMA lawsuit is one of six NSA-related lawsuits filed by health care providers. Plan sponsors should monitor these provider lawsuits, since they could impact the amount health plans must pay out-of-network providers for protected services under the NSA.
The federal agencies have indicated they will issue a final IDR rule by May 2022.
MENTAL HEALTH PARITY The CAA further enhanced federal mental health parity protections, with an emphasis on compliance regarding non-quantitative treatment limitations (NQTLs) on mental health and substance use disorder (MH/SUD) benefits.
As federal enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA) for employer-sponsored health plans continues to increase, plans should be aware of several class action lawsuits related to plan coverage of MH/SUD benefits.
In a class action lawsuit against UMR, Inc., the plaintiffs, who were denied coverage for residential treatment of mental health or substance abuse issues, ask for a declaratory judgment that clinical criteria used by UMR to deny coverage are overly restrictive and breach generally accepted medical care standards (Berceanu v. UMR Inc., No. 3:19-cv-00568 (W.D. WI Dec. 15, 2021)). Further, they seek a determination that the administrator acted in an arbitrary and capricious manner by adopting these guidelines.
In a class action lawsuit against United Behavioral Health (UBH), six plaintiffs allege UBH unlawfully denied coverage for medically necessary mental health and substance use disorder treatment (Beach v. United Behavioral Health, No. 3:21-cv-08612 (N.D. CA filed Nov. 4, 2021)). The lawsuit is challenging a UBH coverage
The complaint filed in Deighton v. Aetna Life Insurance by a proposed class of health plan participants allege that Aetna applies disparate limits to residential mental health/ substance abuse facilities and rehabilitation amenities, in violation of MHPAEA. (Deighton v. Aetna Life Ins. Co., No. 2:21cv-07558 (C.D. CA filed Sept. 21, 2021)).
The Department of Labor’s (DOL’s) published enforcement reports suggest that the DOL is continuing to investigate compliance with MHPAEA. To ensure compliance, self-insured health plans should consider conducting periodic claims audits and reviews, and can use the DOL’s self-compliance tools to assist with this.2
Corrie Cripps is a plan drafter/compliance consultant with The Phia Group. She specializes in plan document drafting and review, as well as a myriad of compliance matters, notably including those related to the Affordable Care Act.
Marietta Memorial Hospital Employee Health Benefit Plan v. DaVita, Inc. is a case scheduled for argument before the Supreme Court of the United States on March 1, 2022 (Marietta Mem’l Hosp. Emp. Health Benefit Plan v. DaVita, Inc. (No. 20-1641 (US filed May 21, 2021)).
The case concerns the Medicare Secondary Payer Act (MSPA), which prohibits group health plans from considering a plan participant’s eligibility when the individual has end-stage renal disease (ESRD) and from providing different benefits to these individuals than from other covered participants. The case also involves how much plans must reimburse their members for dialysis treatment costs.
The outcome of this case could have a significant impact on dialysis benefits in employer-sponsored group health plans.
For plans and TPAs, being well-informed on regulatory developments is always of the upmost importance. Due to rapid changes in the regulatory landscape, plan sponsors should review their plan documents as well as their plan administration procedures to ensure they are compliant.
References 1 Department of Health and Human Services, Statement of Regulatory Priorities for Fiscal Year 2022, October 2021, https://www.reginfo.gov/public/jsp/eAgenda/StaticContent/202110/Statement_0900_HHS.pdf, (last visited February 28, 2022). 2 Self-Compliance Tool for the Mental Health Parity and Addiction Equity Act (MHPAEA), October 23, 2020, https://www.dol.gov/sites/dolgov/files/EBSA/ laws-and-regulations/laws/mental-health-parity/self-compliance-tool.pdf, (last visited February 28, 2022).
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IIA CORPORATE GROWTH FORUM
This new SIIA event May 16-18 at the Westin Poinsett Hotel in Greenville, SC has been designed to help companies active in the self-insurance/captive insurance marketplace better understand growth strategies made possible by corporate financial transactions (mergers, acquisitions, capitalizations, etc.).
In addition to targeted educational content, attendees will have the opportunity to connect with representatives of private equity firms and related advisors, as well as network and share experiences with owners/senior executives of other companies with similar interests.
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ENDEAVORS Whether your growth objectives are immediate, or sometime in the future, this event promises to help your company to be better positioned for success.
PROGRAM HIGHLIGHTS INCLUDE:
for outside capitalization and how you can position your company for the best possible deal. Finding Your Worth -- The Art & Science of Valuation
Let Us Introduce Ourselves… Attendees will have the opportunity to introduce their companies to the event growth partner sponsors via private 10-minute presentations (one company/attendee at a time presenting to the full group of growth partner sponsors). Advance sign-ups will be required. Given the limited time available, requests will be accommodated on a first come basis. Details will be provided to attendees upon registration. Partnering With Private Equity…What to Really Expect A panel of SIIA members who have partnered with private equity firms for a variety of financial transactions share their experiences and offer candid advice for companies considering new private equity relationships. Becoming an Investable Company Just because you offer a great product or service doesn’t necessarily mean that your company is ready for first or second round investors. Learn what private equity firms and other investors look for when considering whether a company is viable
So what’s your company worth? This is an essential calculation for the majority of every corporate financial transaction but getting to that number can be tricky. This session will provide an overview of valuation approaches, with specific reference to factors specific to the selfinsurance marketplace. Selecting the Right Growth Partners There are many high-quality growth partners to choose from but how do you find them and then determine which ones are the best fit your company? Give us 60 minutes and you will have the guidance you need.
Specializing in serving the risk management needs of over 2,300 clients. GPW offers a unique combination of captive and reinsurance management, accounting, tax compliance, and actuarial services all under one roof, providing clients with efficient and comprehensive service. GPW’s team of experts includes credentialed Actuaries, Certified Public Accountants, and Associates of Captive Insurance. GPW and Associates, Inc. 3101 North Central Ave., Suite 400 Phoenix, Arizona 85012 Ph 602.200.6900 Fx 602.200.6901
HCC Life Insurance Company operating as Tokio Marine HCC - Stop Loss Group
We Know... Risk We study it, research it, speak on it, share insights on it and pioneer new ways to measure it. With underwriters who have many years of experience as well as deep specialty and technical expertise, we’re proud to be acknowledged as experts in understanding risk. We continually search for fresh approaches, respond proactively to market changes, and bring new flexibility to our products. 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, captive, Taft-Hartley and organ transplant needs.
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Tokio Marine HCC - Stop Loss Group A member of the Tokio Marine HCC Group of Companies TMHCC1171 - 04/2022
ENDEAVORS Acquisition Best Practices – Getting Ready for the Hunt
ABRY Partners, LLC
The time is right for your company to attempt to grow by acquisition…now what? This session will provide practical advice on how to effectively prepare your company to go hunting.
Abry is one of the most experienced media, communications, software, healthcare services and information services focused private equity investment firms. Since our founding in 1989, we have completed over $60 billion of leveraged transactions and other private equity or preferred equity placements, representing investments in over 500 properties. Currently, we manage over $5.2 billion of capital in our active funds, and our funds have consistently generated topquartile investment returns. As such, our investor base is highly stable, and consists of well-regarded institutions representing Fortune 100 pension funds, major insurance companies, prominent investment funds and foundations.
Transaction Structures — Pulling the Deal Together There are normally multiple components to consider as part of structuring and financial transaction. This session will highlight the various moving parts that you can expect to be “deal points” as part of typical capitalizations, mergers, acquisitions and sales. Ask the Experts – Open Discussion This is your opportunity to ask questions of the expert presenters that may have not been answered previously in the program. We’ll keep this informal to facilitate an open dialogue. SIIA is pleased to confirm the participation and sponsorship support of the following private equity firms and related advisors who have the expertise and industry knowledge to be valuable “growth partners” for SIIA member companies. These growth partners will help deliver the educational content, as well as be available to meet privately with event attendees to discuss their corporate growth objectives.
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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.
©2022 Berkley Accident and Health, Hamilton Square, NJ 08690. All rights reserved.
BAH AD2017-09 2/22
Specialty Accident www.BerkleyAH.com
ENDEAVORS Ansley Capital Group
Grant Avenue Capital
Ansley Capital provides investment banking and consulting services to small and middle-market healthcare services and information technology companies. We furnish clients with keen insights, practical advice and extensive industry contacts from our operating and transactional experience.
Grant Avenue Capital is a healthcare focused private equity firm investing alongside forward-thinking management teams that seek an experienced and innovative investor with operational insight and flexible capital for growth.
Website: ansleycapital.com Carrick Capital Partners Carrick Capital Partners is a middle-market private equity firm that targets minority and majority growth investments of $35 million to $120 million in software and techenabled services companies. Carrick’s partners are a collection of investors, business operators, and ex founders that work with management teams to identify and improve critical areas of their business that will deliver the highest strategic impact. Website: carrickcapitalpartners.com Council Capital Council Capital is a leading healthcare-focused private equity firm based in Nashville, Tennessee. We invest in lower middle market healthcare companies ($10-100M enterprise value) on the ‘right side’ of change in the healthcare industry – where growth will accelerate as cost pressure and quality demands increase. Our unique model helps support management teams in growing their businesses by drawing upon the relationships and resources of our CEO Council, Strategic Healthcare Investors, and Value Creation Team. The Council network, anchored by its CEO Council of 34 senior private and public sector executives who have personally invested over $140M in our funds, has direct relationships with payers, providers, and employers who represent more than two thirds of the country’s managed care lives, numerous provider organizations, and millions of self-insured lives. Website: councilcapital.com
Website: grantave.com LLR Partners LLR Partners is a lower middle market private equity firm investing in technology and healthcare businesses. We collaborate with our portfolio companies to define high-impact growth initiatives, turn them into action and create longterm value. Founded in 1999 and with more than $5 billion raised across six funds, LLR is a flexible provider of equity capital for growth, recapitalizations and buyouts. Website: llrpartners.com TAG Financial Institutions Group, LLC TAG Financial Institutions Group offers specialized investment and merchant banking services with a focus on middle market companies in the financial services sector. With a core competency in the Insurance Industry, TAG Financial has completed over 250 merger and acquisition and capital raising transactions including capital solutions involving alternative risk transfer concepts. Website: tagfingroup.com Water Street Healthcare Partners Our team has made more than 100 investments and strategic acquisitions to build 30 market-leading healthcare companies that contribute to a stronger
ENDEAVORS healthcare system through improved patient care, increased efficiencies and lower costs. Working closely with founders and management teams, we align our expertise and resources to support their growth objectives. Water Street companies lead in markets with strong customer relationships and proprietary, high-demand products and services. We specialize in growing middle-market companies in three healthcare segments where we have deep experience and a strong network of relationships: Healthcare Services (including services to self-funded employers), Medical Products and Diagnostics, and Pharmaceutical and Life Sciences. Website: waterstreet.com For more information including registration, please visit www.siia.org. Non-Member Participation Note: While non-members generally may attend the event subject to the applicable rate, private equity, venture capital and other related financial advisory firms are precluded from attending. New membership for such firms will not be processed until June 1, 2022.
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NEWS FROM SIIA MEMBERS 2022 APRIL 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 email@example.com. 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 firstname.lastname@example.org. 54
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NEWS DIAMOND MEMBERS VĀLENZ® PROMOTES JORDAN HERSH, MBA, TO SENIOR VICE PRESIDENT, CHANNEL DISTRIBUTION
PHOENIX, AZ — In response to continued expansion of the Vālenz® ecosystem and rapidly increasing demand for its solutions, Valenz leaders have announced a new position on their executive tram: Jordan Hersh, MBA, has been appointed to Senior Vice President, Channel Distribution. This appointment marks a promotion for Hersh, who initially joined Valenz in 2007 and has served as Vice President, Business Development since early 2019. Hersh is known as an excellent cross-functional leader, bringing the organization together to meet business goals through client-focused solutions and services. “Since joining Valenz at the very beginning of our ecosystem journey, Jordan has been a catalyst for ensuring our vision, organizational strategies and new product development are delivered to the market,” said Nathan Nelson, Chief Revenue Officer. “His passion for success, combined with his proven track record of delivering results, make him the ideal fit to head up channel distribution for our company.”
Hersh’s career spans 15 years at the intersection of healthcare and technology, focused on solving client and member challenges in the employersponsored healthcare domain. He has an MBA from the University of San Francisco School of Management and extensive experience in business development, strategic partnerships, product marketing, account management and sales strategy. “I believe deeply in the Valenz mission, vision and promise, and I’m excited to take on this new opportunity,” said Hersh. “I have a lot of ideas and an incredible team here to further enhance our distribution strategy for the benefit of our clients and their members, as well as our own company and ecosystem partners.”
Better manage your specialty drug spend, through powerful clinical management combined with real-time oversight. Every organization struggles to manage its Specialty Drug spend. ELMCRx Solutions understands the complexity of specialty drug management. By combining powerful clinical management with real-time oversight to control costs and prevent unnecessary payments, our unbiased program helps deliver the best outcome for the plan sponsor and the member. We partner with employers, health care coalitions, health plans, insurance captives, TPAs and Taft-Hartley Trusts. Cost Containment Solutions and superior clinical outcomes are achievable. ELMCRx Solutions is the partner to help you achieve them.
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NEWS VĀLENZ® HIRES JEFF SMITH AS DIRECTOR OF PROJECT MANAGEMENT
PHOENIX, AZ — Vālenz® announced that Jeff Smith has joined the team as Director, Project Management. Smith, a 33-year industry veteran, will lead all project management initiatives, including but not limited to IT projects, new client implementations, and projects involving mergers and acquisitions. As a senior-level managed care leader with extensive experience in operations management, product development and sales, Smith has conducted more than 100 implementation projects involving complex products and services. This experience has made him an expert in project planning, process and systems integration, product development, data transfer, and implementation. “I’ve known Jeff for many years, and several of us at Valenz have worked with him the past. There is no doubt Jeff will be an outstanding catalyst for growth and expansion, and successful delivery of solutions for our clients,” said Rob Gelb, Chief Executive Officer. “His expertise and exceptional project management skills will accelerate success for all stakeholders, and we are thrilled to have him on board.”
Smith’s career spans three decades in the managed care and payer domains, including 10 years as Senior Project Manager at Coventry Health Care, where he led client implementation projects. “When you have an in-depth understanding of the needs, objectives and environment at the core of every project, then you can ensure implementation will be successful and results will be optimal,” said Smith. “Results-driven project management is a collaborative process that engages early and often, just like all things Valenz. I’m honored to be on the team and feel this is a perfect fit.”
NEWS JANET KOCH, VĀLENZ® VICE PRESIDENT OF CARE, ANNOUNCES
assure a seamless transition before Koch’s retirement begins on June 1.
PHOENIX, AZ — After more than 10 years in care management leadership roles with Vālenz®, Janet Koch, RN, BSN, CCM, has announced her retirement beginning June 1.
Most recently, Chesek was Director of Clinical Operations, Healthcare Management for Trustmark Health Benefits. She also served as Clinical
JUNE 1 RETIREMENT
Janet became Vice President of Care in 2017 after joining Valenz in 2011. Her many accomplishments include transforming the business through clinical platform migrations, leading multiple URAC accreditation certifications for the three core clinical businesses, designing and deploying quality incentive programs for team members, and building the company brand through consistent quality and outcomes for Valenz customers and their members.
“Janet has made such a tremendous impact on Valenz, the Care team and our customers,” said Rob Gelb, Chief Executive Officer of Valenz. “She has been the bedrock of our Care business for 10 years and left her mark on every aspect of our care management operations and team.” “Although her announcement is bittersweet, we are thrilled for her and her family to embark on the next chapter of her life journey, and we wish her the greatest happiness in the future,” added Amy Gasbarro, Chief Operating Officer of Valenz. Before joining Valenz, Janet’s career in nursing spanned over 25 years after she served as an air traffic controller in the U.S. Navy for 17 years. “I have absolutely loved every single day of working side by side with such a talented Care team and the entire extended Valenz family,” Janet said. “I have especially valued my time working with our customers and their members. I’m very grateful to our leadership and my team for the once-in-a-lifetime opportunity I’ve had to make a difference in the lives of so many.” Janet will continue to work closely with the Valenz team to support a smooth transition.
VĀLENZ® HIRES SUZANN CHESEK AS VICE PRESIDENT OF CARE PHOENIX, AZ — Vālenz® announced that Suzann Chesek, BSN, RN, MBA, CCM, joined the team as Vice President of Care on February 21. Chesek, who has more than 20 years’ experience with managed care and healthcare organizations, will lead care management operations for Valenz following the retirement of Janet Koch. Over the next three months, Chesek and Koch will work closely to
Operations Manager with Holy Spirit Health System and as Hospital Administrator and Clinical Manager Employee Health & Safety with Wellspan Health. Chesek’s background in clinical operations for managed care is fortified by her strong foundation as an ICU nurse, including roles such as ICU Bedside & Charge Nurse, House Supervisor & ICU Flex Nurse, and PRN ICU RN. With a bachelor’s degree in Nursing from Eastern Mennonite University and an MBA in Healthcare Management from Western Governors University, Suzann is working toward a second master’s degree in Management & Leadership from WGU. “By leveraging a rich blend of leadership skills and technical expertise throughout her impressive career, Suzann has established herself as a proven leader who thrives in a fastpaced, complex environment,” said Rob Gelb, Chief Executive Officer of Valenz. “She welcomes a challenge and is highly recognized for her superior planning, decision-making and change management capabilities.” Chesek pointed to her experience in managed care organizations as well as her studies in healthcare management and leadership as great preparation for her new role with Valenz. “The teamwork, collaboration and leadership model at Valenz clearly align with my vision for the continuous growth
and innovation of care management operations,” Chesek said. “As a strong believer in asking “why” to discover what is best for patients, clients and the company, I look forward to further enhancing our culture of partnership and accelerating our ability to deliver smarter, better, faster healthcare for the people we serve.”
HM INSURANCE GROUP
ANNOUNCES KIMBERLY MORSE AS NEW SALES DIRECTOR FOR PHOENIX AND SOUTHERN CALIFORNIA MARKETS
About Valenz Vālenz® simplifies the complexities of self-insurance for employers through a steadfast commitment to data transparency and decision enablement. To balance the relationship between healthcare quality, advocacy and cost, the Valenz approach aligns the patient, payer and provider. We deliver this synergy through a strong foundation with deep roots in clinical and member advocacy, alongside decades-long expertise in claim reimbursement and payment validity, integrity and accuracy. By establishing ‘true transparency’ and offering data-driven solutions that improve cost, quality and outcomes for you and your members, Valenz engages early and often for smarter, better, faster healthcare. Visit valenzhealth.com. Valenz is backed by Great Point Partners.
Full service plan administration
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Deep cost savings; up to 30%
PITTSBURGH – Kimberly Morse joined HM Insurance Group (HM) as director, Phoenix and Southern California Regional Sales. In this role, she will work to grow and maintain the HM Stop Loss book of business in the company’s Phoenix Regional Sales territory, which serves Arizona, Colorado, New Mexico, Utah and Nevada, as well as the company’s Southern California Regional Sales territory, which serves the Los Angeles and San Diego markets and other Southern California counties.
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Morse most recently served as regional vice president of stop loss sales for Western Skies MGU’s Western division. Prior to that, she worked as a senior sales executive at Sun Life Financial for almost 11 years, marketing stop loss products since 2014. Additionally, Morse gained significant sales and relationship management experience at Aetna, Aon and other industry leaders. With more than 25 years of experience in insurance sales, Morse brings a great deal of knowledge to HM, particularly her familiarity with the California and West Coast markets. She has a Bachelor of Arts degree in Psychology from California State University, Fullerton.
states and the District of Columbia and maintains sales offices across the country. Visit hmig.com.
SILVER MEMBERS GOOGLE EXECUTIVE LUTZ
FINGER JOINS MARPAI HEALTH AS PRESIDENT, PRODUCT AND
About HM Insurance Group
HM Insurance Group (HM) provides insurance and reinsurance coverage to protect businesses from the financial risk associated with catastrophic health care costs. A recognized leader in Employer Stop Loss, the company delivers protection for a range of group sizes. HM also offers managed care solutions, including Provider Excess Loss insurance and Health Plan Reinsurance. HM Life Insurance Company, HM Life Insurance Company of New York and Highmark Casualty Insurance Company are all rated “A” (Excellent) by AM Best Company. Through its insurance companies, HM Insurance Group holds insurance licenses in 50
NEW YORK -- Marpai, Inc.,. an AItechnology company transforming the $22B Third-Party Administrator market supporting self-funded employer health plans, announced Google Group Product Manager of healthcare analytics Lutz Finger is joining the company as President, Product and Development.
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Lutz is an esteemed technologist with a diverse background in building innovative technology platforms for companies including Google, LinkedIn and SNAP. In this role, he will create and lead a formal product management function. He will direct all product development including internal systems aimed at making Marpai the most efficient payer in the market and AI-driven products that predict costly events and help members live healthier lives.
"Lutz is a visionary leader in our industry, an expert in data science with rich expertise in creating innovative products at the intersection of AI and healthcare," said Edmundo Gonzalez, co-founder and CEO of Marpai.
"Lutz knows how to turn AI into usable healthcare products with a real value proposition," said Dr. Eli David, Marpai co-founder and Chief Science Advisor. "The high level of AI and healthcare analytics expertise that he brings will help us deliver innovative new products that can reduce costs, enable healthier lives and might even end up on your smartphone." "In order to help people to live better lives we need to provide a road to better health," said Finger, who starts in his new role at Marpai on February 28th. "I look forward to working alongside some of the most talented AI and deep learning data scientists in the world to create an AI driven approach to proactive healthcare that draws on extensive data analytics and predictive algorithms. AI is needed to augment and improve healthcare services and Marpai is leading the way in changing the company health plan by driving costs down and improving member health." At Google, Lutz led the health products group where he used AI to create products to improve consumer health and reduce healthcare costs. "There's a real revolution going on in how we consume healthcare services, pay for them and leverage historical data to deliver new value," says Marpai co-founder and Chairman Yaron Eitan. "This process requires a lot of creativity, data and data science. Lutz not only brings the right experience and skills, he also brings a unique vantage point from which to envision the future." Residing in the San Francisco Bay Area, Mr. Finger brings over 20 years of diversified experience in data science and product management, most recently at Google as a Group Product Manager in health products where he spearheaded life-changing products using AI and healthcare data.
"We have a shared vision for the evolution of healthcare, and we are delighted that he has agreed to join us on this journey of transforming health plans so we drive costs down and health outcomes up." APRIL 2022
Lutz has served on the faculty at Cornell University's S.C. Johnson School of Business, and is a regular contributor to Forbes Magazine, where he writes about AI and deep learning. His book "Ask Measure Learn," was published in 2014 and serves as a non-technical guide on how to extract significant business value from big data. He serves as an advisor and board member at several data-centric corporations in Europe and the US, including Deutsche Bank. He has an MBA from INSEAD as well as an MS in quantum physics from TU Berlin. About Marpai, Inc.
premiums, and elevating care quality for plan members. Marpai's proprietary deep learning algorithms predict potential near-term health events for members to prevent costly claims and improve health outcomes. Operating nationwide, Marpai offers access to provider networks including Aetna and Cigna, and partners with brokers and consultants. Visit marpaihealth.com.
Marpai, Inc. (Nasdaq: MRAI) is a technology company bringing AI-powered health plan services to employers providing health benefits to employees. Primarily competing within the $22B TPA (Third Party Administrator) sector serving selffunded health plans and representing over $1T in annual health care claims, Marpai's SMART services focus on reducing claims costs, lowering reinsurance
From day one, StarLine’s differentiator has always been its people. Now, decades later, we are at a position of strength because of our people. Our team goes above and beyond to create and sustain solutions to match today’s constantly evolving needs. There is no part of our process that is not underscored by a dedicated, collaborative, and approachable group — powered to propel you forward to achieve your goals. starlinegroup.com | (508) 809-3179
STOP LOSS | C A P TIVE | PAYOR | PROVIDER | GROUP ACCIDENT
Depend on Sun Life to help you manage risk and help your members live healthier lives Behind every claim is a person facing a health challenge. By supporting members in the moments that matter, we can improve health outcomes and help employers manage costs. For nearly 40 years, self-funded employers have trusted Sun Life to quickly reimburse their stop-loss claims and be their second set of eyes, looking for savings opportunities. But we are ready to do more to help members in the moments that matter. We now offer care navigation and health advocacy services to help your employees and their families get the right care at the right time – and achieve better health outcomes. Let us support you with innovative health and risk solutions that benefit you and your medical plan members. It is time to rethink what you expect from your stop-loss partner. Ask your Sun Life Stop-Loss Specialist about what is new at Sun Life or click here to learn more! STOP-LOSS
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The content on this page is not approved for use in New Mexico. For current financial ratings of underwriting companies by independent rating agencies, visit our corporate website at 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. © 2022 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. Sun Life and the globe symbol are trademarks of Sun Life Assurance Company of Canada. Visit us at www.sunlife.com/us. BRAD-6503-u SLPC 29427 01/22 (exp. 01/24)
SELF INSURANCE INSTITUTE OF AMERICA, INC. 2022 BOARD OF DIRECTORS
CHAIRWOMAN OF THE BOARD*
Kari L. Niblack, JD, SPHR CEO ACS Benefit Services Winston Salem, NC
Laura Hirsch Co-CEO Aither Health Carrollton, TX
Deborah Hodges President & CEO Health Plans, Inc. Westborough, MA
Elizabeth Midtlien Vice President, Emerging Markets AmeriHealth Administrators, Inc. Bloomington, MN
TREASURER AND CORPORATE SECRETARY*
John Capasso President & CEO Captive Planning Associates, LLC Marlton, NJ
DIRECTORS Thomas R. Belding President Professional Reinsurance Mktg. Svcs. Edmond, OK Amy Gasbarro Chief Operating Officer Vālenz Phoenix, AZ
* Also serves as Director
Lisa Moody Board of Directors Chair Renalogic Phoenix, AZ Shaun L. Peterson VP, Stop Loss Voya Financial Minneapolis, MN
SIEF BOARD OF DIRECTORS Nigel Wallbank SIEF Chairman Dani Kimlinger, PhD, MHA, SPHR, SHRM-SCP, SIEF President
DIRECTORS Freda H. Bacon Les Boughner Alex Giordano Virginia Johnson
SIIA NEW MEMBERS APRIL 2022
REGULAR CORPORATE MEMBERS
John Howard Service Manager CANARX Windsor, ON Jeffrey Erickson Chief Executive Officer Crescent Health Solutions Asheville, NC Carol Adams Chief Risk Officer EB Employee Solutions/ The Difference Card White Plains, NY Jeremy Berk Performance Firefly Health Watertown, MA Nick Severino VP, Marketing First Stop Health Chicago, IL Christine Marx Divisional Senior Vice President Great American Insurance Group Cincinnati, OH Jennifer Ramella Director of Marketing gWell, Inc. Lexington, MA
Keith Somers Co-founder, CRO HealthCorum Boston, MA Lizbeth Sanchez Marketing Coordinator, Senior IngenioRx Morristown, NJ Jessica Palvino Attorney Mitchell Williams Austin, TX Joe Bush Chief Strategy Officer NavMD Overland Park, KS Amber Herron Marketing Project & Event Manager Papa, Inc. Miami, FL David Voorhees CEO True Captive Insurance Overland Park, KS
SILVER CORPORATE MEMBERS Ron Houghton Sales Director, Data Insights Benefitfocus Charleston, SC Phillip Berry CEO Northwind Pharmaceuticals Indianapolis, IN Laurent Laor CEO Viveka Health New York, NY
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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)