The Self Insurer August

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AU G U S T 2 0 2 1


Post-Pandemic Preparation


Industry insiders anticipate impact of claims on actuaries, brokers, stop-loss carriers, TPAs, MGUs and captives

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AUGUST 2021 VOL 154

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The Self-Insurer (ISSN 10913815) is published monthly by Self-Insurers’ Publishing Corp. (SIPC). Postmaster: Send address changes to The Self-Insurer Editorial and Advertising Office, P.O. Box 1237, Simpsonville, SC 29681,(888) 394-5688

Self-Insurer’s Publishing Corp.

PUBLISHING DIRECTOR Erica Massey, SENIOR EDITOR Gretchen Grote, CONTRIBUTING EDITOR Mike Ferguson, DIRECTOR OF OPERATIONS Justin Miller, DIRECTOR OF ADVERTISING Shane Byars, EDITORIAL ADVISORS Bruce Shutan and Karrie Hyatt, 2018 Self-Insurers’ Publishing Corp. Officers James A. Kinder, CEO/Chairman, Erica M. Massey, President, Lynne Bolduc, Esq. Secretary

AUGUST 2021 3


Written By Bruce Shutan

Post-Pandemic Preparation

Industry insiders anticipate impact of claims on actuaries, brokers, stop-loss carriers, TPAs, MGUs and captives


mployers are bracing for a possible surge in medical claims as long-delayed elective and routine procedures are scheduled amid loosening Covid-19 restrictions. While it’s anyone’s guess what will actually happen, several executives across a broad spectrum of the self-insured community expressed both caution and optimism over post-pandemic work and life. They also sprang into action to ensure that their customers stay on track and lives were protected. “Our clinical team really worked throughout the pandemic to monitor risk increases from delays in care,” reports Pamela Coffey, executive vice president and chief clinical officer of HealthSmart, a TPA with internal care management solutions and clinics. On the frontline of those efforts was an intensive oncology case management program to guide cancer patients who were immunosuppressed and, therefore, extremely vulnerable in terms of where, when and how they received their chemotherapy and radiation therapy during the pandemic. That meant scouting alternate sites of care with so many hospitals at capacity or serving as breeding grounds for Covid-19. With lives hanging in the balance, it was clearly a top priority. She describes those actions as an opportunity to “minimize some of that backlog or bottleneck of procedures post-pandemic by addressing those needs in real time.”



Post Pandemic Preparation Overall, HealthSmart coordinated conservative care involving additional therapy, home-based services, pain control and other issues to avoid complications or exacerbated problems stemming from delays in surgery. In addition, members involved in cases where surgeries opened back up were given assistance in getting evaluated and rescheduled. The need for prudence repeatedly came up during conversations with industry insiders. Bret Bret Brummit Brummitt, founder of the Generous Benefits insurance brokerage, believes that self-insured health plans are cushioning some of the stop-loss or general premium numbers to buffer the unexpected.

“they’re going to be severely off on the attachment points.”

costs, he says

A lull in medical procedures led many self-insured health plans to hoard cash. The best possible practice was overreserving insurance risk during the pandemic when most medical services were down, didn’t return or shifted to lower-cost telemedicine, banking any difference between projected and actual costs, according to Khoja.

As such, he doesn’t expect a long-term spike of service or claims, “at least not in regions like Texas, or maybe others that have been a little bit more relaxed on the settings, just because there has been access for elective services at some level. I live and work predominantly in a market where there’s just not a lot of empty capacity or people waiting around. I could see it being much different in either a less thriving economic region or a less populous region.”

“My sense is most of those plans are holding onto those dollars, and what wasn’t spent on health care in 2020 is being reallocated to 2021,” he says. “We fully expect the large and jumbo employers to operate in that way. But as you go down market, it’s just hard to know.”


There was a recognition early on that some data variations or abnormalities would appear at the group level where many of the elective procedures “would normally come into the aggregate side of our business,” reports Dan Boisvert, president and CEO of AccuRisk Solutions, LLC, an MGU. “So those implications were more about what the frequency around the claims activity was going to be, not necessarily the severity.”

Forecasting claims for a post-pandemic world will not be easy. One leading stop-loss provider has found it rather challenging to calculate attachment points for self-insured health plans after a year of experience unlike any other on record. Mehb Khoja

“The biggest mistake you could do right now is looking at 2020 data and say, ‘well, take that data and project it forward by 8% because that’s what we expect in 2021, and another 8%, and that’s what we expect for 2022,’” cautions Mehb Khoja, president of Medical Risk Managers, a wholly-owned stop-loss subsidiary of BCS Financial for whom he also serves as chief actuary. Unless stop-loss carriers are more thoughtful about making the right type of adjustments before projecting

He has seen a dramatic decrease in diabetes maintenance costs from February 2020 through February 2021 that’s going to have some implications on exposure to higher-level chronic condition claims around diabetes-type comorbidities.



Post Pandemic Preparation But that’s just the tip of an iceberg. “I’m sure diabetes isn’t the only thing,” he says, surmising that a number of other diagnoses are likely going to follow that same pattern. “There’s a lot of things that people have put off that could exacerbate their severity of claim going forward. People have avoided going in for just a normal kind of check-up on chronic conditions.” The main concern is exactly when, and how much, will there be a resurgence of medical trend, as well as both inpatient and outpatient services that were deferred or avoided during the pandemic, observes Sue Taranto, a principal and consulting actuary with Milliman, Inc.

Sue Taranto

“There are already backups for elective-type surgeries in many markets in the country,” she says,

adding that a return to higher utilization will be driven to some extent by demographics and geography. Data, however, can be mined to understand just how bad the Covid-19 infection rate was and sick people were, she says, as well as longer-term impacts, and whether risk scores and morbidity will increase. Another bright spot is that encountering significantly fewer medical procedures during the pandemic has borne fruit for employers with captive insurance. Mike Schroeder, president of Roundstone, reports that the $4.2 million pro rata cash distribution to roughly 150 employers in his July captive was 17.5% of stop-loss premium, which is about twice what it normally is runs. Moving forward will be tricky.

“Our underwriters understand that we’ve got to fund this to the right level,” he says. “The claims are going to be different than they were over the last 12 months.” Mike Schroeder Since Roundstone serves midsize employers, he explains that the stop loss features “a pretty low attachment point.”

Pamela Coffey

BACK TO THE FUTURE? While no one has a crystal ball, predictive

“an excellent tool to identify multiple types of risk,” Coffey notes. Key modeling can be

areas include determining whether patients are receiving adequate provider oversight and care in both inpatient and outpatient settings, as well as spotting redundant medications or the need to refills scripts. Moreover, many individuals who were on maintenance drugs were able to use mail-order, which improved

“and we could monitor that compliance through our predictive modeling,” she adds.


A telling metric for predictive modeling would be if more imaging claims emerge from an employee population, which Brummitt says could be a precursor of surgical claims to follow. “But you don’t have a lot of leading indicators on that because those are typically done in 30to 90-day windows,” he explains.



Post Pandemic Preparation The bottom line is that data gathering needs to be done in real time in order “to put through the algorithms that will be successful in predicting impact,” Taranto suggests. Complicating matters is that “services have been suppressed and the data gathering hasn’t happened to the same extent it might otherwise,” she notes.

Dan Boisvert

But the endgame is to use data mining to effectively communicate with potential high-risk patients so they can change their behavior, which she says will eliminate the need for emergency room visits.

One fear is that deferred care has the potential to drive health plan costs higher for years to come. The Partnership to Fight Chronic Disease projects that the number of people with three or more chronic diseases will swell to 83.4 million by 2030 from $30.8 million in 2015 – a prediction that was made even prior to Covid-19. Another concern is the deadly toll it may take. For example, the National Cancer Institute has warned that there will be an additional 10,000 deaths over the next decade from breast and colorectal cancer alone due to Covid-19.


But there are also silver linings in the dark cloud that has hung over everyone for more than a year. One such positive development is growing acceptance of telehealth to treat both physical and mental ailments, which is helping broaden the scope of digital solutions. While telehealth has its limitations, it’s convenient for members and was a lifeline during the pandemic, according to

that alone drives improvement in compliance.”

Coffey who says “

Virtual care not only helped reduce ER and urgent-care visits, but also managed an increase in behavioral health needs stemming from pervading isolation and despair. In addition, it helped remove the stigma of showing up at a psychiatrist’s office and makes it much easier and affordable to support members, she notes. Her hope is that self-insured health plans strike a reasonable balance between telehealth and brick-and-mortar provider visits. Placing too much stock in virtual care is risky business. The danger of misdiagnosing someone during a telehealth call, for example, could lead to additional absenteeism because the severity of that condition is worsened, Boisvert warns. Supplementing in-person care with telehealth and finding synergistic partnerships obviously will be a major strategic objective in the months and years ahead. “One of the things we’re watching closely,” Schroeder reports, “is the merger of primary care and



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Post Pandemic Preparation telehealth, and how much of these capitated direct primary healthcare products can be delivered in tandem with a really good telehealth strategy. We think there’s some real opportunity there. There seems to be a pretty strong traction as it relates to mental health.” Apart from national telehealth providers like Teladoc, Schroeder notices that more virtual care is being delivered by provider systems, “so the local hospitals all have telehealth services.” It’s now increasingly common for in-person primary care visits to end with a telehealth visit being scheduled for six months later, he says. The result is a better experience for the patient. Covid-19 appears to have bolstered the use of digital health tools at a time when some people double-downed on exercise to break their isolation, while others

“Every time you turn around, there’s something that tells you how many steps you’ve took,” Schroeder says. “Google has this thing called Heart Points, based on your movement. Clearly, folks are starting to subscribe to these things, whether it’s a watch or it’s on your phone, where you’re being told you’re moving and living in a healthy way from an activity point of view.” fell into sedentary lifestyles.

Patients will likely gravitate toward a telehealth-first model post-pandemic with local touchpoints pre-built into those arrangements, Brummitt notes, adding that “something like a Crossover Health fits the future model that got ushered in a lot faster than the standalone service.” He also sees more embedding of virtual care for mental health. “Having that access, whether it is a true phone call with a provider or an artificial-intelligence app, is going to be very helpful,” he says.

INCENTIVIZING WELLNESS The upshot of this pandemic is that self-insured employers and their vendor partners will need to keep a closer watch on their health plan participants moving forward. “We’re going to have to up our game a little bit to get members back into the routine of improving their health,” according to Boisvert. For those with chronic conditions, he says it’s often a matter of making sure medication is being taken as prescribed and renewing prescriptions. The best hope for motivating health plan members, he says, is offering financial incentives for healthy behaviors in the form of lower copays, coinsurance or deductibles.



Boisvert is hopeful that people will be much more responsible about their health post-pandemic, especially given how so many Americans became sedentary or depressed during their isolation from others. “Mental health is a really big part of that,” he adds, noting a tendency to ignore or underestimate its impact. As such, he says it’s important to find incentives to pull people out of the “behavioral malaise” that set in during the pandemic. Coffey’s favorite method is reward money for pursuing healthy behaviors and limiting care gaps that can be placed into a flexible spending account or health savings account “so it actually has to be spent on health care expenses.”

Bruce Shutan is a Portland, Oregon-based freelance writer who has closely covered the employee benefits industry for more than 30 years.


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ate last year, Congress passed the No Surprises Act (NSA) to address the growing disconnect in patients receiving surprise balance bills in out-of-network situations, including emergency events or with out-of-network ancillary providers in in-network settings.

On July 1st, federal departments—including Health and Human Services (HHS), Labor, and Treasury—released an interim final rule (IFR) that is the first step in issuing important guidance on this new law. This IFR, and subsequent rules expected throughout the next year, will have far-reaching effects on self-insurance plans.



No Suprise Act THE NO SURPRISES ACT The NSA was passed by Congress last December as part of the Consolidated Appropriations Act of 2021 and goes into effect on January 1, 2022. The law is meant to protect consumers from the most pervasive types of surprise “balance” billing in certain out-of-network situations by limiting the amount of the bill to the cost-sharing they would have paid if the care had been from an in-network providers.

This legislation was one of the largest pieces of healthcare legislation since the passage of the Affordable Care Act, and it was passed quickly with endorsements from both sides of the aisle.

According to Barbara Lambert, internal service consultant with HUB International, “Surprise billing is a serious problem that is having a negative impact on patients. The charges from surprise medical bills can lead to a family’s financial ruin. Imagine your child is ill or injured and must be airlifted to a hospital only for you to later receive a bill for more than $100,000 for the air ambulance charges. These families who have already gone through a personal trauma and are coping with any repercussions of the medical emergency are now having to deal with potential litigation or credit issues.”

“Surprise billing is one of the most prevalent consumer issues in the healthcare industry,” said Brian Wroblewski, executive vice president of sales and marketing with ClearHealth Strategies, LLC. “A [health plan] member may end up in an emergent site of care and whether out-of-network and having services performed by out-of-network providers, or in a network but still having out of network providers treat the member at the in-network location, the issue arises that the member had no choice of the out-of-network provider and no ability to contain costs. A provider treating this member might charge, for example, $5,000 or more for a service that ordinarily costs $250 and without the legislation, the member would be liable for all of the portion not paid by the health plan.”

Surprise medical bills can cost a family thousands of dollars, even in non-emergency events. The NSA is a much-needed piece of legislation 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.

as they can no longer be billed by the medical provider for any amount beyond the cost sharing associated with a rate that is based on network pricing,” said Wroblewski. “This is very positive for the plan member as it goes to protect a main vulnerability of the healthcare system.”

SIIA ADVOCACY AND THE IFR Well before the NSA made it to the floor of Congress, SIIA was asked to engage on the surprise billing issue by the White House. For nearly two years, SIIA has been advocating on behalf of self-insured health plans on the topic, even encouraging Congress to consider the intricacies of self-insured plans. Immediately after the CAA was passed, the association put together the SIIA Price Transparency Working Group to better formulate industry comments, recommendations, and implementation. SIIA has also led discussions with staff from the various federal departments involved in developing the IFR.

In May, SIIA submitted an initial comment letter to the federal agencies providing recommendations and clarification on the first phase of the surprise billing rulemaking process, specifically focusing on the Employee Retirement Income Security Act (ERISA) preemption of state surprise billings laws, in addition to recommendations on certain terms and definitions set forth under the statute. These comments were driven by SIIA’s Price Transparency Working Group which is comprised of TPAs, brokers, service providers, and stop-loss carriers.

“The legislation overall has significant positive impact on healthcare consumers

AUGUST 2021 13

No Suprise Act When the first IFR was released on July 1st, the self-insurance sector was pleased to find that the guidance issued took into account much of what was addressed in SIIA’s comment letter. Going so far as to follow the association’s advice on ERISA preemption.

The main point of SIIA’s advice was that ERISA must always preempt conflicting state law when applied to self-insurance plans. An additional point was made that self-insurance plans could opt-in to state law. The IFR agrees with SIIA’s main point allowing ERISA to supersede state law as well as with the option for self-insured plans to voluntarily opt-in to state law. The IFR also concurred with SIIA’s suggestion that, as ERISA preempts state surprise billing law and any state all-payer model agreement, the only “recognized amount” to be paid to an out-of-network provider must be equal to or lesser than the qualifying payment amount (QPA).

A QPA is defined as the median of the in-network (i.e., contracted) rate in a geographic area, and serves as the focal point for a number of other implementation pieces of the surprise billing statute, including the base-line primary factor that an

arbiter must consider when making a final payment determination under the federally developed arbitration/ independent dispute resolution process. The IFR added that cost-sharing must be the same as that for in-network services and if a patient had not yet met their deductible, the patient is responsible for paying the entire QPA.

The NSA did not define the term “initial payment” and SIIA asked that the term remain undefined, or if it must be, then it should be defined by the ERISA plan document. The IFR did not require any specific minimum initial payment but suggests that a minimum payment rate could be developed. The ruling offered the advice that the initial payment should

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No Suprise Act be an amount that the plan or issuer intends to be a full payment based on the circumstances and as required by the terms of the plan.

Under the law, when a self-insured plan and out-of-network provider cannot agree on a rate, then the rate will be determined through an independent dispute resolution (IDR) process.

One of the most important aspects of SIIA’s recommendations and the IFR’s guidance was the establishment of a median contracted rate as the QPA. SIIA offered that a median in-network rate for a self-insured plan should be identified through the various plans provided by the self-insurer.

The IFR agreed, and took it further, that a median contracted rate should be determined by taking into account every group health plan offered by the sponsor of a self-insured plan.

In addition, for TPAs, SIIA suggested that median in-network rates could be simplified by looking at all of the in-network rates charged by all of the TPA’s selfinsurance plans. The IFR, in an effort to reduce the administrative burden imposed on sponsors of self-insured plans, will permit TPA’s to determine the QPA for the sponsor by calculating the median contract rate based on all of the plans it administers.

Regarding median contracted rates for rental networks, SIIA wanted the federal departments to develop a series of categories for type of self-insured plan or provider network in order to identify a median rate for each category.

The IFR recognized the issue and decided that the contracted rates between providers and the manager of the provider network for the insurance plan would be treated as the self-insurer’s contracted rates for purposes of calculating the QPA.

The geographic regions used to determine median contracted rates will follow the metropolitan statistical areas (MSA) used by both Medicare and the U.S. Census. The IFR closely followed SIIA’s recommendation on this point. The IFR included the “rule of three” expansion, meaning that if a plan cannot identify three rates to



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No Suprise Act determine a median rate within a MSA then the plan is permitted to increase the size of the MSA to include the state as a single region.

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QPA determination will rely on information sharing between plan and provider. SIIA centered several comments on ensuring data sharing and accessibility between plan sponsors and service providers.

The association believes that self-insured plan sponsors and their service providers must be able to access the required pricing and health claims data so they can comply not only with the surprise medical billing requirements, but also to better comply with the “transparency in coverage” regulations.

The IFR issued clear guidelines in the steps to be taken by each in order to determine the correct rate. Much of determining QPA will be based on using databases. SIIA strongly advised that any database applying for federal approval be able to prove that they have no conflict of interest. The IFR agreed stating that the organization maintaining the database cannot be affiliated with, controlled by, or owned by any health insurance issuer, provider, or healthcare facility.

At the end of SIIA’s comment letter, the association requested a good faith compliance safe harbor for implementation of the act, as there will be a number of administrative

No Suprise Act changes that self-insurance plans will need to execute in a short amount of time. The IFR didn’t formally create a safe harbor but agreed to take good faith efforts into consideration.

REACTIONS TO THE IFR “A number of provisions within the IFR closely aligned with a number of specific SIIA recommendations from the clarity on ERISA-preemption, to the QPA methodology in looking across similar self-insured plans by administration,” said Ryan Work, vice president of government relations for SIIA.

According to Troy Sisum, senior vice president and chief counsel with ELAP Services, LLC, “While the IFR still leaves much unaddressed, on the items it did address, it is far more protective of self-funded plan interests than we anticipated. From that point of view, it was a win for self-insured plans. The regulators understood that rules couldn’t be fashioned solely on the commercial insurance markets, because of the differences with the self-funded markets are material.”

“It is fantastic to see how closely SIIA’s comments were followed, or evaluated,” said Wroblewski. “I don’t believe there was a point that was forgotten, but rather, the ruling for the qualified payment amount being based on contract rates in place of historical claims data was the item that seemed to not be consistent with industry norms.”

Wroblewski continued, “The IFR is in line with what was expected and matched the key points that were previously addressed through the Act. And, the ability to have a review and commentary period really suggests that the goal is to ‘get it right.’ There are a couple confusing aspects to the IFR which have the opportunity to get addressed following the 60-day review and commentary period. The only real missed opportunity based on the IFR was the stipulation of using contract rates rather than claims history in order to calculate the network median due to the dynamics and nuances of each one as a basis for analysis.”

Overall, the self-insurance sector is pleased with this initial ruling. However, from an administrative perspective there is a lot to manage. Plan administrators and contractors will bear the burden of implementing the legislative changes and updating their processes when new rulings come down.

“There are a lot of administrative requirements on plans and service providers as a result of the CAA, and the interim rules didn’t address many items. There will be ongoing rulemaking throughout 2021,” said Sisum.

THE NEXT FEW MONTHS While the IFR will likely not be altered drastically by the federal departments working on it, it does allow for a 60-day comment period. SIIA’s Price Transparency Working Group is already in discussion on the IFR and will be submitting comments addressing the outstanding issues and questions. In addition, SIIA expects a second rulemaking out of the federal departments surrounding the arbitration/ independent dispute resolution (IDR) process sometime around September 1.

“The mechanics of the arbitration process is critical and needs to be concise,” said Lambert. “Specifications on the criteria for the selection of arbitrators, along with clear guidance for settling any disputes is necessary to avoid inflated costs.”

In addition to more information regarding arbitration in the future rulings, Sisum is looking for clarification on other sections of CAA including advanced explanation of benefits, provider directories, machine readable files, and more. There is also some anticipation that the final rulings will provide exceptions for health plans with unique designs that don’t squarely fit withing the rules.



No Suprise Act

We are hoping to hear more clarification on the administration of the QPA and how to reconcile administration of that amount knowing that contracted rates are hard to obtain and have many dynamics to them, including percent-off, outlier, per diem, and stop loss, to name a few. We’re hoping for the QPA to be calculated using prior claims history which can then be managed across the appropriate population of claims.”

For Wroblewski, “



A third IFR is expected in October to address emergency air ambulance charges and broker compensation.






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



IRS PROVIDES 86 ANSWERS TO 86 QUESTIONS ABOUT THE COBRA SUBSIDY (PART TWO) On May 18, 2021 the Internal Revenue Service (IRS) issued Notice 2021-31, providing 86 Q&As on the COBRA premium assistance subsidy under the American Rescue Plan Act of 2021 (ARPA). This guidance comes less than two weeks before the May 31 deadline to send the ARPA-required COBRA subsidy extended election notices. Notice 2021-31 is largely consistent with the guidance issued back in 2009 for the COBRA subsidy under the American Recovery and Reinvestment Act of 2009 (ARRA) but with a few differences.


1. Beginning of COBRA Premium Assistance Period (Q&As 43–46)

Q&A 44 clarifies that even though an AEI might be eligible for the subsidy as of April 1, 2021, that AEI can elect subsidized COBRA coverage at a later date during the subsidy period (this Q&A was designed to facilitate moving off of individual coverage in a Marketplace plan and the way the ACA premium subsidies operate for Marketplace plans).


assistance eligible individuals (AEIs) was May 31. Steps should be taken to ensure that notices are sent as required to minimize potential agency penalties and claims exposure. Any late or missed notices (especially in light of the evolving IRS guidance) should be sent out as soon as feasible.

2. End of COBRA Premium Assistance Period (Q&As 47–50)

THE ARPA COBRA SUBSIDY The ARPA COBRA subsidy applies to certain individuals (referred to as “assistance eligible individuals” or AEIs) whose COBRA qualifying event was an involuntary termination of employment or a reduction in hours of employment. This 100% COBRA subsidy is provided for the period April 1, 2021 to September 30, 2021. To be eligible for the COBRA subsidy, an AEI cannot be eligible for other group health plan coverage or Medicare. AEIs also include qualified beneficiaries who are the spouse or dependent child of the AEI employee who also lost coverage because of the AEI employee’s involuntary termination of employment or reduction in hours. Generally, an employer advances the subsidy and then recoups that advance through tax credits against the employer’s Medicare tax obligations.

Q&A SUMMARY The IRS divided its 86 Q&As into the following sections: (1) Eligibility for COBRA Premium Assistance; (2) Reduction in Hours; (3) Involuntary Termination of Employment; (4) Coverage Eligible for COBRA Premium Assistance; (5) Beginning of COBRA Premium Assistance Period; (6) End of COBRA Premium Assistance Period; (7) Extended Election Period; (8) Extensions Under the Emergency Relief Notices; (9) Payments to Insurers Under Federal COBRA; (10) Comparable State Continuation Coverage; (11) Calculation of COBRA Premium Assistance Credit; and (12) Claiming the COBRA Premium Assistance Credit. Q&As in categories 5-12 are covered in this Part Two of our article. Part One addressed Q&As in the first 5 categories above.

Q&A 50 confirms that the death of an AEI does not affect the entitlement of any spouse or dependent children who are also AEI qualified beneficiaries (and in fact may be a second qualifying event extending eligibility for that spouse and dependent children for the COBRA subsidy).

3. Extended Election Period (Q&As 51–55)

Q&A 51 is similar to prior DOL guidance providing that if an AEI had family coverage at the time of the involuntary termination of employment or reduction in hours but elects self-only COBRA, the other family members are eligible for the “second bite” at COBRA for subsidized coverage. Similarly, Q&A 55 provides that if an AEI at the time of involuntary termination of employment elected only some of the benefit options available but not others, then that AEI has a second



bite for those other benefit options for subsidized coverage. For example, if an AEI had vision, dental, and medical coverage at the time of the involuntary termination of employment or reduction in hours but elected only medical coverage for COBRA, that AEI can now also election vision and dental for purposes of the subsidy in addition to medical. These contingencies should be addressed in any ARPA election forms. Q&A 52 mirrors the DOL model notices and FAQs providing that the second bite at COBRA (extended election period) is not available under state mini-COBRA laws unless the state law provides for a similar extended election period.

4. Extensions Under the Emergency Relief Notices (Q&As 56–59)

In these Q&As, the IRS provided important guidance on the interaction of the 60day extended election / second bite period under the ARPA COBRA subsidy and elections under the Outbreak Period. First, Q&A 57 is similar to prior DOL guidance stating that that the Outbreak Period extensions do not apply to the 60-day period to elect subsidized COBRA coverage under the second bite opportunity.

Q&As 56, 58, and 59 confirm that an AEI can elect just subsidized COBRA coverage or elect subsidized COBRA coverage and unsubsidized coverage for prior periods pursuant to the Outbreak Period guidance. However, if within the 60-day ARPA extended election period for subsidized coverage the AEI elects the subsidy but does not elect retroactive coverage, the AEI will forfeit the right to retroactive coverage. This is true even if the election would not have otherwise been required under the prior Outbreak Period guidance.



Once retroactive coverage is elected, however, payment for that retroactive coverage will be subject to the Outbreak Period guidance. Premium payments for retroactive coverage will not be due until the Outbreak Period ends (or one year after payment would ordinarily have been due if earlier). If the AEI then fails to pay those premiums, the employer can retroactively cancel COBRA coverage for periods for which the premiums are not paid (but, of course, not the subsidized period). Also under the Outbreak Period guidance, coverage can be suspended for the retroactive period until COBRA premiums are actually made. Practice Pointer: This one aspect of the Notice caught most by surprise and appears contrary to the prior Outbreak Period guidance. Indeed, it seems contrary to a sentence in the DOL model notices which states: “The election period for COBRA continuation coverage with premium assistance does not cut off an individual’s preexisting right to elect COBRA continuation coverage, including under the

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extended timeframes provided by the Joint Notice and EBSA Disaster Relief Notice 2021-01.” It is likely this has not been communicated since most extended election notices were formalized or actually mailed before the IRS provided this guidance. On the other hand, if this guidance is ignored and COBRA elections are allowed pursuant to prior understandings of the Outbreak Period guidance, then there could be issues with stop-loss carriers for self-funded plans or carriers for fully insured plans.

5. Comparable State Continuation Coverage (Q&As 61–62)

Under state mini-COBRAs, even if an employer pays the subsidized premium directly to the insurer, the employer still cannot take the Medicare tax credit. This is one of the limited instances where the carrier takes the tax credit. (Q&A 62)

6. Calculation of the COBRA Premium Assistance (Medicare Tax) Credit (Q&As 63–70)

Q&As 64–67 provide guidance on how the ARPA COBRA subsidy interacts with employers that are already providing a COBRA subsidy, and Q&A 64 provides four different examples of this interaction. Consistent with ARRA guidance, if an employer provides a “true” subsidy (in other words, not the ARPA subsidy), then the amount of the Medicare tax credit is only the amount the AEI would be charged without the ARPA subsidy. For example, if an employer otherwise charges COBRA beneficiaries 50% of the $600 maximum COBRA premium, the AEI would only be charged $300 and the employer could only take a $300 tax credit. Continuing with this example, if the employer subsidy ends and a COBRA beneficiary is otherwise required to pay $600, then an employer’s Medicare tax credit for an AEI would be $600. In Q&A 66, the IRS provides an example where the maximum COBRA premium is $1,000, but COBRA beneficiaries are only charged $400. The employer increases the COBRA premium obligation to $1,000 but provides AEIs with a $600 taxable severance payment. The $600 is not treated as an employer-provided COBRA subsidy, and the employer can take the full $1,000 Medicare tax credit.

Practice Pointer. Employers will want to carefully examine any existing “true” employer-provided COBRA subsidy to see whether that subsidy can be ended to take full advantage of the ARPA COBRA subsidy. It appears that employers can offer taxable incentives for an AEI to forgo any subsidy provided in a severance agreement or severance plan in order to take advantage of the ARPA COBRA subsidy.



The Notice also makes clear that (other than a newborn or adopted children) AEIs only include individuals who were covered by a plan at the time of the involuntary termination of employment or reduction in hours. For example, if an AEI had self-only coverage at the time of the involuntary termination of employment or reduction in hours but subsequently added a spouse or dependent children during a plan’s open enrollment, neither that spouse nor dependent child would be AEIs (Q&A 68, Example 3). While no additional family members can be added at open enrollment for purposes of the subsidy, new benefits can be elected and they will count for the subsidy. As another example, if an AEI had only vision coverage immediately before an involuntary termination of employment or reduction in hours, that AEI could only elect vision coverage for COBRA. But if there is an intervening open enrollment when the AEI elects group medical and dental as well, then that group medical and dental coverage (in addition to vision) will be eligible for the subsidy. (Q&A 69)

7. Claiming the COBRA Premium Assistance (Medicare Tax) Credit (Q&As 71–86)

In Q&A 75, the IRS provides the methods of taking the Medicare tax credit either on the quarterly Form 941 employment tax return or an advance of the credit using Form 7200. IRS Notice 2021-24 provides more detail. If an individual is treated as an AEI eligible for the subsidy but that individual

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Practice Pointer: The rules regarding third-party payers can be complex. Q&A 81 contains even more guidance on the methods that third-party payers should use to claim the credit on behalf of their clients. The exception in Q&A 82 is narrow, but we believe that some multiple employer welfare arrangements, including association health plans, may be able to use the Q&A 82 exception in certain instances.


· The deadline for issuing ARPA No Guarantee of Results – Outcomes depend upon many factors and no attorney can guarantee a particular outcome or similar positive result in any particular case.

fails to inform the plan of other disqualifying coverage, then the employer will not have to refund any Medicare tax credit it has taken for that individual. (Q&A 78) In Q&A 79, the IRS repeats the ARPA statutory rule that the Medicare tax credit is generally included in the gross income of the employer. Placing timing issues aside, this inclusion of income should not have any adverse tax effects on an employer because it should be able to deduct the payments that the credit is intended to reimburse (for example, the premium payments to the insurer in the case of a fully insured plan or the actual payment of benefits to the AEI in the case of a self-funded plan).

For a plan covered by federal COBRA (other than a collectively bargained multiemployer plan), the employer is the entity that takes the Medicare tax credit. Q&A 81 clarifies that this is the general rule even if an employer uses a “third-party payer” such as a reporting agent, payroll service provider, professional employer organization, certified professional employer organization, or § 3504 agent to report and pay its federal employment taxes. Q&A 82 contains an exception to this rule if the third-party payer meets the following three conditions: (1) it maintains the group health plan; (2) it is considered the sponsor of the group health plan and is subject to the applicable DOL COBRA guidance, including providing the COBRA election notices to qualified beneficiaries; and (3) it would have received the COBRA premium payments directly from AEIs if not for the COBRA subsidy. In that limited instance, the third-party payer will be entitled to the Medicare tax credit.



COBRA subsidy notices to AEIs was May 31. Steps should be taken to ensure that Notices are sent as required.

· Ensure that a process is in place to collect (and retain) AEI election (and certification) forms to support claimed Medicare tax credits.

· Use the Q&As to help you identify when there has been an involuntary termination of employment or a reduction in hours (whether voluntary or involuntary).

· It is important to analyze whether a dependent or spouse is eligible for the subsidy on a case-by-case basis.

· A spouse or dependent who was covered under a plan at the time of an involuntary termination of employment or reduction in hours is going to be an AEI even if the employee elected self-only COBRA coverage.

o On the other hand, a spouse or dependent who was not covered at the time of the involuntary termination of employment or reduction in hours but is added during open enrollment will not be an AEI eligible for the subsidy.

· A spouse or dependent whose initial qualifying event was a death, divorce, or dependent aging out will not be an AEI.

o On the other hand, if the initial qualifying event was an involuntary

termination of employment or reduction in hours and the second qualifying event was a death, divorce, or dependent aging out, then the spouse or dependent may be an AEI.

· Review any employer severance plan or severance agreements where a “true” employer subsidy is being offered to AEIs and see if that severance plan or severance agreement can be modified to take full advantage of the ARPA COBRA subsidy. Modifications could include taxable payments to AEIs to incentivize them into waiving any previous contractual promise for the employer subsidy.

· Understand how the Outbreak Period interacts with the 60-day extended election period (second bite) and make sure that AEIs know that if they make a subsidy election without making a retroactive election under the Outbreak Period for unsubsidized COBRA coverage, they will lose the right to unsubsidized coverage.

· Review the process for claiming the Medicare tax credit on Form 941 or 7200 and make sure document retention systems are in place to justify the credit in the case of audit. Use of an AEI attestation form is a best practice. It will be difficult if not impossible to prove that an AEI was not eligible for other disqualifying coverage without it.





he industry is buzzing. Congress and the Department of Labor are shaking things up with the Consolidated Appropriations Act – including, of course, the No Surprises Act and new requirements for compliance with the Mental Health Parity and Addiction Equity Act.

Even though the fiduciary liability standards we have all come to understand have been relatively static for a long time, a recent Mental Health Parity-related federal court decision has sent a shockwave across the self-funded industry, potentially changing the way TPAs and other entities will need to view fiduciary liability.

The decision in question is in response to a motion in Jane Doe v. United Behavioral Health, in the U.S. District Court for the Northern District of California (Case No. 4:19-cv-07316-YGR), decided March 5, 2021. The dispute in this case centered around the health plan’s blanket exclusion of Applied Behavioral Analysis and Intensive Behavioral Therapy – two of the primary treatments for Autism Spectrum Disorders.






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The facts of the case demonstrate that the SPD excluded these two services, and the claims administrator – United Behavioral Health, or UBH – administered the exclusion that was written in the SPD, and denied a medical claim pursuant to that SPD language as written. UBH moved to dismiss the suit under the theory that even assuming the truth of all facts alleged, applicable law would not classify UBH as a fiduciary.

The relevant case law generally indicates that if the Plan makes the rules via the Plan Document, and if the TPA is just following the literal written terms without exercising discretion, the TPA has not rendered itself a fiduciary.

Based on case law and regulatory guidance, that’s the prevailing sense of the fiduciary rules. The court’s decision started out very much as we tend to expect from cases like this: the court recited the facts of the case, iterated the general rules of fiduciary duties, and cited to lots of cases that have indicated that rule, apparently using those cases to guide its decision.

Then, though, the court’s decision changed course, and things got a little strange.


Department of Labor (DOL) guidance has made it clear that the intended interpretation of ERISA’s fiduciary duty designation is fairly broad, but still wellestablished through an explicit set of exceptions to the “general” rule that an entity that makes decisions for a health plan is a fiduciary.

According to the DOL, there is an eleven-item list of actions that explicitly do not render an individual or company a TPA, including applying established rules (as opposed to making the rules), processing claims pursuant to established rules (as opposed to adjudicating claims), and calculating benefits (as opposed to determining benefits).

With respect to this list, the DOL has stated that “a person who performs purely ministerial functions such as [these] for an employee benefit plan within a framework of policies, interpretations, rules, practices and procedures made by other persons is not a fiduciary.” (Emphasis added).

The distinctions may seem small, but the regulators and courts have been clear that if an entity performs only those broad functions listed in the exceptions, that entity is not a fiduciary. Of course, a TPA or other entity can become a fiduciary if it performs any of these eleven items in addition to other actions – but limiting its actions to solely these eleven items does not cause the TPA to assume a fiduciary designation.



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The court appeared to agree, making the point multiple times: a purely ministerial act does not in itself rise to the level of a fiduciary act. This court did not show any evidence of a desire to change that well-established law; in fact, its language tends to indicate that the court agreed and embraced these principles.


According to UBH, when acting as the TPA, they did exactly what the SPD said, and they didn’t exercise discretion in doing it. The Plan Document excluded ABA and IBT services, and the TPA read the SPD and applied it as written.

To an onlooker, UBH’s conduct seems like a textbook definition of a purely ministerial decision; denial of the ABA or IBT claim is indisputable. All indications are that UBH performed “purely ministerial functions…for an employee benefit plan within a framework of policies, interpretations, rules, practices and procedures made by other persons…” and therefore “is not a fiduciary.”

Interestingly enough, the court apparently didn’t disagree with that premise, but still concluded nonetheless that UBH did act as a fiduciary. The logic employed is unexpected, given all the precedent cited: the court reasoned that even though UBH did exactly what the Plan Document provided, UBH still made a decision, and the simple act of making a coverage decision is enough to render UBH a fiduciary.

Recall, however, that the eleven explicit exceptions to the general fiduciary rule include applying established rules and processing claims pursuant to those established rules; the facts suggest that UBH meets those exceptions and is therefore not a fiduciary. For a reason the court did not quite explain, however, it disagreed.

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In reaching its conclusion, the court placed a great deal of reliance on the United States Supreme Court’s decision in Aetna Health Inc. v. Davila. According to the Supreme Court, “A benefit determination under ERISA . . . is generally a fiduciary act”. Aetna Health Inc. v. Davila, 542 U.S. 200, 218-19 (2004) (Emphasis added; internal quotations omitted). Despite all the iterations of the “purely ministerial” standard that the court cited in reviewing UBH’s conduct, the court nonetheless relied on the Supreme Court’s quotation above, and concluded that the TPA was necessarily a fiduciary, since all benefit determinations are fiduciary in nature.

Hang on a minute, though: are all benefit determinations fiduciary in nature? Is that really what the Supreme Court wrote? A plain reading of the quote casts some doubt on this court’s interpretation.

Despite quoting the Supreme Court’s general rule, including the very telling word “generally”, this court interpreted the Supreme Court’s rule as an absolute one. The difference is that a general rule is subject to exceptions (recall that case precedent and regulatory guidance suggests that UBH is subject to an exception) while, to contrast, an absolute rule has no exceptions (and this is what the court ultimately concluded).

The Supreme Court’s rule can be read as: benefit determinations are generally fiduciary acts, unless they are purely ministerial in nature and the decisionmaker exercised no discretion in making the determination. Instead, the court in Doe v. UBH read the Supreme Court’s rule as benefit determinations are fiduciary acts, period. That doesn’t seem right, though – especially based on everything else the court in Doe v. UBH wrote.

In other words, the text of this decision shows that the court added 2 and 2 and got 5.

Sometimes a court will reimagine or reinterpret existing law, but this court showed no evidence of doing that. Instead, the court went through all the premises, but then disregarded those premises and reached a different conclusion entirely.

An analogy would be to say that if oranges are generally round, then all oranges must be round.


On the topic of general versus absolute rules, the fiduciary duty within ERISA to strictly abide by the terms of the SPD is a general rule, an important exception to which being if the terms of the SPD do not comply with applicable law.



It is therefore possible to violate a fiduciary duty by choosing to enforce noncompliant plan language over contradictory law, but in order to violate a fiduciary duty, the entity must first be determined to be a fiduciary.

As it happens, the court did go on to determine that the plan language in this case did violate federal law and was therefore unenforceable – but again, the question isn’t whether UBH violated a fiduciary duty, but whether UBH owed one in the first place. An act performed by a non-fiduciary wouldn’t give rise to fiduciary liability, after all.

In any event, the court performed this ancillary one-paragraph analysis of whether UBH violated a fiduciary duty only because it had already decided that the TPA is a fiduciary; in other words, this single paragraph discussing how UBH can’t “hide behind plan terms” already assumes that the TPA is a fiduciary, which means that this discussion can’t be relevant to the analysis of whether the TPA is a fiduciary to begin with.


At one point, after it had already analyzed the expected premises and reached the unexpected conclusion, the court iterated the fiduciary duty to apply plan terms as written except to the extent inconsistent with ERISA.

The court wrote that UBH “cannot hide behind plan terms” since applicable law conflicts with those terms, which is unquestionably accurate – but this statement or the single paragraph explaining, which appears to be an afterthought, it still does not explain why UBH should be deemed a fiduciary to begin with.

It’s possible that the court’s intended logic was that UBH exercised discretion by choosing to follow the SPD over the conflicting law, thereby rendering it a fiduciary on that basis. The court did not iterate that connection, but giving the court the benefit of the doubt, perhaps that was the intended meaning.

In a logical fallacy known as “begging the question”, the court used its conclusion (that UBH is a fiduciary) to form one of its premises (that UBH’s conduct violated a fiduciary duty) – the only premise that even comes close to explaining why UBH might be a fiduciary (which, again, is the conclusion).

Put more simply, the court apparently used its conclusion to justify its conclusion. From a logic perspective, this doesn’t track.

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At one point in this decision, the court indicated that UBH was a fiduciary because UBH did not sufficiently prove it was not a fiduciary. Interestingly, the old adage “innocent until proven guilty” does not always apply in the civil court setting.

Without getting too far down the rabbit hole on this particular point, it is worth noting that any allegation that a TPA has acted as a fiduciary could prompt the need for the TPA to defend itself – and as a good portion of the self-funded industry has experienced first-hand, plan participants and their attorneys often opt for a “kitchen sink” approach, suing everyone possible, sometimes resulting in an apparently baseless suit against a TPA, broker, consultant, or other entity.

As this case makes clear, though, court is sometimes like the wild west, where anything can happen.

As discussed, the court’s logic is not quite clear, and hopefully an appeals court will shed some light on this so we can at least get some closure one way or the other – but one thing is for sure: if this case doesn’t get reversed, or even if other courts start to rely on this case prior to appeal, TPAs across the country may be in for a paradigm shift when it comes to their ability to strictly follow the clear, literal terms of an SPD without fear of reprisal.

Strengthening plan language is always a good idea, but health plans (and their TPAs!) need to ensure that strong language isn’t stronger than the law permits, since there could be liability landmines even where we least expect them.

Formerly Director of The Phia Group’s Provider Relations department, Jon Jablon currently serves as Director of Consulting Services, as well as assisting with in-house legal needs. In his eight years with The Phia Group, Jon has helped numerous entities in the self-funded industry navigate and overcome issues related to claims negotiation, balance-billing, compliance, cost-containment, and more. Jon and the rest of The Phia Group’s legal team stay up-todate on the issues that most effect our client base, in order to help health plans and their TPAs prepare for the future.





eputational risk, considered an emerging risk over the last decade, has suddenly entered the spotlight as one of the most important risks a company can manage. While there are box-standard insurance products for this risk, the fluid nature of reputational risk makes insuring it through a captive a much better prospect.

In January 2020, well before the COVID-19 pandemic wreaked havoc on the world’s economy, the RepTrak 2020 Global Trends study found that 70 percent of risk managers believed that managing reputation for their company was more important than it had ever been before.




Reputation is one of several intangible assets that have become as important as, and in some cases more important than, what are traditionally considered assets, such as cash and property. Other intangible assets that are also becoming increasingly important relate to cyber risk and business interruption risk, and all three can occur from similar events.

To define it, reputational risk is when a company’s established character or good standing is threatened by the actions of the company, through the actions of an employee or employees, or through a connection with a third party. Or, as Jerry D. Messick, CEO of Elevate Risk Solutions, puts it, “An event that causes a decrease or reduction in a company’s value based on public perception.”

As use of the internet has grown, particularly social media, companies insuring their reputation has increased substantially. When news breaks, whether substantiated or not, and its dissemination is amplified, a company’s reputation can be undone in a few days. Reputations that took years, or even decades, to build can be demolished by an ill-timed Tweet and takes far longer to make a recovery.

In April, the Howden Group released a report, titled “Insuring the Invisible,” that expressed how a company’s intangible assets have become so important. “In recent years, as economic value has shifted from tangible to intangible assets. The proliferation of data, technology, and automation has revolutionized the way people live, interact, work, and travel. It has also transformed the composition of companies’ assets: today, most corporations value IP, brand and reputation ahead of property, plants and equipment. Even organizations that manufacture physical goods now typically offer complementary data and advisory services.”

According to Messick, “I think the ‘always on, 24-hour-a-day’ nature of (social) media is impacting recognition. When a company’s sales can be impacted so dramatically by negative comments on social media, they must focus on mitigation and have a way to fund those efforts.”

As reputation becomes more vulnerable, customers and clients are increasingly ready to call to account companies when expectations are not being met. Risk managers have to be constantly on top of potential threats, and many reputational risk plans have a component that monitors media and other potential issues.

For executives and boards, managing reputational risk is about using data and intelligence to identify threats and to protect loss. Well-developed risk plans now include reputational risk insurance coverage.



For many types of risks, claims can take months or years to realize. When a reputational risk event occurs, companies will feel the financial effects immediately—through bringing on a crisis management team, including public relations professionals, to handle the fallout and through the loss of sales, partners, or investors.

The pandemic demonstrated to many businesses just how important a company’s reputation is. “With COVID much has been learned,” said Michael A. Corbett, senior vice president with Pinnacle Financial Partners. “Protecting the reputation of a firm includes getting the message out to customers via broad based communications including media (both free and paid), internal communications, networking, operations, industry partnerships and, of course, social media.”

For Messick, “I believe the pandemic helped focus the need to have plans in place to address a ‘public perception’ event, especially in the healthcare industry. Hopefully, if we learned anything from the pandemic, we learned that having a plan in place is vitally important because we simply don’t know what’s going to happen at any given time.”



Reputational risk can be hard to define as it has many components that come into play. Every type of business and each individual company will have different factors that expose them to reputational risk. Yet, it can be quantified which is why it can be insured. Insurance policies for reputation usually covers short-term profit loss and addresses costs for crisis management and reputation mitigation. Policies can also cover sales forecasts providing companies assurance that their business plans see less interruption.


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Reimbursement done right. The information contained herein is for general informational purposes only and does not constitute an offer to sell or a solicitation of an offer to buy any product or service. Any description set forth herein does not include all policy terms, conditions and exclusions. Please refer to the actual policy for complete details of coverage and exclusions.

Before reputational risk emerged as a singular risk, a form of it could be found in defamation policies, then as part of cyber-related coverage and product recall coverage. During the last few years, reputational risk insurance policies have come out as a stand-alone policy.

Many traditional insurance companies offer reputational risk products, but off the shelf policies can’t attend to the nuances of each company leaving gaps in coverage. According to Messick, “The traditional market addresses a broad array of risk and typically doesn’t provide focused strategies within the coverage form. As an example, in the event of an alleged physical abuse situation, does the coverage form provide for immediate attorney and public relations expense when the police and press show up at the front door?”

Quick response and flexibility are necessary to mitigate any long-lasting effects of an event threatening a company’s reputation. While an event that triggers a reputational risk policy is going to be rare, it is for that reason that putting this risk into a captive is the best option. Low frequency, high payout risks are what captives can excel at.

“Companies are as different as snowflakes,” said Corbett. “Off the shelf coverages by traditional carriers may not be tailored enough to suit the needs of every client. Captives provide the flexibility to tailor policies and how claims are paid that fit a particular company.”

Corbett continued, “Captives have covered reputational risk in the past; however, given the effects of COVID (i.e. a crisis), previous policies proved deficient in providing protection. It is perhaps best illustrated by counting the number of companies that were able to file claims for business interruption. Industry has indicated that it could be done on one hand! This is a problem in need of a solution, hence captives offer a solid solution.”

Jerry Messick offered a real-life example of how reputational risk can be successfully insured through a captive, “We had a case in a long-term care facility captive where the police and press did show up. The [facility’s] policy in the captive allowed them to immediately respond with an attorney that drove there within one hour. In addition, they engaged the public relations expert that was on retainer by the captive to respond to exactly this type of event.”

As a method for dealing with a crisis, reputational risk insurance is irreplaceable. As many companies found out during the pandemic, insuring crisis, especially through a captive, can be an effective way to stay in business. Corbett said, “With COVID, com-



panies have learned some very valuable lessons: Be prepared before a crisis arrives; decisions during a crisis risks damage to a reputation and shareholder value; responses need to be quick and decisive; it is possible to emerge from a crisis stronger; and the major lesson... when you think the crisis is over, it probably is not!”

As more and more companies are facing critical risk to their reputation, and therefore livelihood, insuring that risk is imperative. With the flexibility of insuring risk through a captive, companies will be able to bridge coverage gaps to keep business running smoothly, even when crisis strikes.

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.

Being Powerful. Being Human. Being PharmPix.

Partnership is within your grasp.

Discover why PharmPix has been revolutionizing PBM since 2009. Schedule a personalized demo at or call 404-566-2000.





IIA’s 41st Annual National Educational Conference & EXPO will be October 3 - 5, 2021 and will be in-person & virtual at the JW Marriott in Austin, TX.

The world’s largest self-insurance event is back with an entirely fresh approach to conferencing. So what’s The Way Forward….in person or virtual?

SIIA will deliver the best of both formats, with a “blended” National Conference that will allow everyone to participate in whatever way works best for them and their organizations. Join us and be a part of what promises to be a groundbreaking industry event.



ENDEAVORS SCHEDULE AT A GLANCE While the schedule offers three days of educational content and activity, we know most people do not want to sit at their desks for the duration, so you will see there are plenty of breaks incorporated for each day. Closer to the date, attendees will be able to customize their schedule, further enhancing their ability to experience this event in a way that works the best for them.

Sunday, October 3, 2021 All session times are Central Standard Time 4:00 pm - 7:00 p.m. On-Site Registration Open 4:00 p.m. - 7:00 p.m. Blue Eagle Lounge

Monday, October 4, 2021 All session times are Central Standard Time 7:30 a.m. - 6:30 p.m. On-site Registration Open 7:30 a.m. - 5:00 p.m. Blue Eagle Lounge & Virtual Hall 8:00 a.m. - 9:00 a.m. Networking Continental Breakfast 9:00 a.m. - 10:30 a.m. Welcome Remarks & Keynote Address 11:00 a.m. - 12:15 p.m. Educational Sessions 12:15 p.m. - 1:30 p.m. Virtual Luncheon 1:30 p.m. - 2:45 p.m. Educational Sessions 3:15 p.m. - 4:30 p.m. Educational Sessions 4:30 p.m. - 6:30 p.m. Blue Eagle Lounge Networking Reception

Tuesday, October 5, 2021 All session times are Central Standard Time 7:30 am - 6:30 pm On-Site Registration 7:30 a.m. - 5:00 p.m. Blue Eagle Lounge & Virtual Exhibit Hall 8:00 am - 9:00 a.m. Networking Continental Breakfast 9:00 a.m. - 10:30 a.m. General Session 11:00 a.m. - 12:15 p.m. Educational Sessions 12:15 p.m. - 1:30 p.m. Virtual Luncheon 1:30 p.m. - 2:45 p.m. Educational Sessions 3:15 p.m. - 4:30 p.m. Educational Sessions 4:30 p.m. - 6:30 p.m. Blue Eagle Lounge Networking Reception

For more information visit




NEWS FROM SIIA MEMBERS 2021 AUGUST MEMBER NEWS SIIA Diamond, Gold & Silver Member News SIIA Diamond, Gold, and Silver member companies are leaders in the self-insurance/captive insurance marketplace. Provided below are news highlights from these upgraded members. News items should be submitted to All submissions are subject to editing for brevity. Information about upgraded memberships can be accessed online at If you would like to learn more about the benefits of SIIA’s premium memberships, please contact Jennifer Ivy and 46



HOUSTON -- Tokio Marine HCC (TMHCC) announced that, effective April 30, 2021, Daniel Strusz retired as Chairman of Tokio Marine HCC – Stop Loss Group, and Jay Ritchie, currently serving as President of the same group, has been named Chief Executive Officer, effective June 1, 2021. Mr. Strusz will continue to serve the Stop Loss Group as a consultant until October 31, 2021. “We want to thank Dan for nearly 20 years of service at Tokio Marine HCC, while acknowledging his many contributions and achievements. Possessing significant industry experience and knowledge, he has been an invaluable leader who has helped us grow our Stop Loss Group to become one of the leading providers of stop loss insurance. We congratulate Dan and wish him the best in retirement,” said Susan Rivera, Tokio Marine HCC Chief Executive Officer. Today, Tokio Marine HCC – Stop Loss Group covers over 3,000 self-funded employers and union plans for medical stop loss and another 1,000 groups with organ transplant insurance. By listening to the demands of the market, the group

has developed exceptional products, unparalleled resources and value-added services that set it apart in the industry. “Dan is completing an outstanding career in the insurance industry, and it has been a pleasure working with him over the last two decades. I applaud him for all of his success and hope he finds retirement as fruitful as his time at Tokio Marine HCC,” added Mr. Ritchie. Ms. Rivera continued, “We are pleased to name Jay as Chief Executive Officer of the Stop Loss Group. For 25 years, his vision and expertise have helped shape our stop loss business, including the stop loss captive business and Taft-Hartley self-funded plans, as well as the industry as a whole through his participation in the Self-Insurance Institute of America (SIIA). We look to Jay to continue

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.


John Adler | 262 707.1076 Mary Ann Carlisle | 484 433.1412

An ELMC Risk Solutions Company



NEWS the evolution of our stop loss and organ transplant businesses by delivering new solutions and greater value to employer groups in the self-funded industry.” About Tokio Marine HCC Tokio Marine HCC is a member of the Tokio Marine Group, a premier global company founded in 1879 with a market capitalization of $33 billion as of March 31, 2021. Headquartered in Houston, Texas, Tokio Marine HCC is a leading specialty insurance group with offices in the United States, Mexico, the United Kingdom and Continental Europe. Tokio Marine HCC’s major domestic insurance companies have financial strength ratings of “A+ (Strong)” from S&P Global Ratings, “A++ (Superior)” from A.M. Best, and “AA- (Very Strong)” from Fitch Ratings; its major international insurance companies have financial strength ratings of “A+ (Strong)” from S&P Global Ratings. Tokio Marine HCC is the marketing name used to describe the affiliated companies under the common ownership of HCC Insurance Holdings, Inc., a Delaware-incorporated insurance holding company. Visit www.tokiomarinehcc. com.

detail that Kylie brings to her territory.” Kylie joins Berkley Accident and Health with eight years of experience in selffunded account management and consulting. She has experience in both TPA and BUCA environments, and most recently served as an account executive for a TPA. Kylie holds a BS and MS in Finance from the University of Wyoming and resides in Denver, CO. About Berkley Accident and Health

The Company has financial strength ratings of “A+ (Strong)” from S&P Global Ratings, “A++ (Superior)” from A.M. Best, and “AA- (Very Strong)” from Fitch Ratings. HCC Life is backed by the financial strength of its parent company, HCC Insurance Holdings, Inc. Visit

Berkley Accident and Health is a member company of W. R. Berkley Corporation, a Fortune 500® company. Berkley Accident and Health provides an innovative portfolio of accident and health insurance products. It offers four categories of products: Employer Stop Loss, Group Captives, Managed Care (including HMO Reinsurance and Provider Excess), and Specialty Accident. The company underwrites Stop Loss coverage through Berkley Life and Health Insurance Company, rated A+ (Superior) by A.M. Best. Visit or connect with us at



Tokio Marine HCC – Stop Loss Group is the marketing name used to describe the medical stop loss and organ transplant-related insurance operations of Tokio Marine HCC through its wholly owned subsidiary HCC Life Insurance Company (HCC Life). HCC Life is a leading provider of medical stop loss insurance through brokers, consultants and third-party administrators.


Hamilton Square, New Jersey – Berkley Accident and Health, a Berkley Company, has appointed Kylie Hunter a as Regional Sales Manager for its EmCap® Group Captive segment.


In her new role, Kylie will be responsible for contributing to the company’s growth initiatives as well as developing group captive program business in Colorado, Utah, Wyoming, Idaho, Montana, North Dakota and South Dakota.

PHOENIX, AZ — Vālenz® has announced a strategic partnership with Beecher Carlson, an insurance brokerage firm that leverages advanced analytics for optimal risk management.

“We’re delighted to continue the expansion of our EmCap business. Kylie’s strong grasp of the health care marketplace, the associated funding arrangements and financial concepts make her an excellent addition to our team,” said Brad Nieland, President and CEO of Berkley Accident and Health. “Brokers and prospective clients in the Rocky Mountain region will appreciate the level of service and attention to

Through this partnership, Valenz and Beecher Carlson collaboratively offer the industry’s most in-depth Risk Bearing Provider Organization (RBPO) Assessment for thorough, data-driven



NEWS analysis of whether an organization is positioned successfully for two-sided risk contracts in a value-based payment model. Value-based payment models offer significant opportunities to reduce costs, enhance quality and improve outcomes. However, the pay-for-performance reimbursement structure might not be right for every health system or provider group. This RBPO Assessment identifies areas that need assistance and offers solutions to address potential deficiencies. It also helps determine if the program goals and incentives are aligned with the organization’s expected results and endorsed by all stakeholders.

About Valenz

“While there is a high level of interest and enthusiasm for value-based care, the clinical and financial risks need to be carefully considered – and in a two-sided contract, cultural and operational requirements must be in place to ensure success,” said Rob Gelb, Chief Executive Officer of Valenz. “Through this partnership with Beecher Carlson, we are excited to provide actionable insights and proven solutions to guide our clients’ approach to value-based care.” As noted by Brad Lawson, Senior Vice President-Provider Risk Solutions of Beecher Carlson, the RBPO Assessment financial models assess risk-reward ratios, quantifying maximum probable gains as well as the maximum probable losses.

Focused on Clients.

Dedicated to Results.

“The 360-degree data and trend analyses account for real-world conditions, allowing organizations to stay nimble, proactively manage risk, and prepare for developing situations – such as an influx of more serious cases following the COVID-19 pandemic as a result of delayed care,” he said.

Valenz enables self-insured employers to make better decisions that control costs across the life of a claim while empowering their members to lead strong, vigorous and healthy lives. Valenz offers transparency through data to pinpoint members at highest risk, address gaps in network designs, ensure appropriate and accurate charges, and expertly navigate

Our Complex Claim Consulting Practice is committed to making your business better. We have a team of Clinicians and risk managers working to simplify your most complex claims

Complex Claims Medical Benefits

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employees to optimal care solutions for substantial cost savings and improved health outcomes. Visit Valenz is backed by Great Point Partners.


About Beecher Carlson


Beecher Carlson is a large account risk management broker that values depth of industry and product knowledge. Operating as a single profit center organized by specialization, we align our service teams to be structured based on what is best for clients’ business rather than geographic convenience. We go beyond one off transactions and utilize advanced analytics on every program. By quantifying the effects each decision will have on a company’s risk profile, we take the mystery out of buying insurance. Execution on analytical findings is our true differentiator in mitigating losses and affecting process changes. Our collective success is earned by creating the ideal risk management solution for our clients. Visit


BOSTON – Dennis Cook has been appointed President, IronHealth, Global Risk Solutions North America. In his role, Dennis will drive the continued profitability and growth of an organization that provides specialty healthcare liability and medical stop loss solutions that meet the complex risk management needs of hospitals, healthcare providers, managed care organizations, life science companies, senior care facilities, and self-insured employer health plans. Liberty Mutual works with brokers to

THEY’RE COUNTING ON YOU. YOU CAN COUNT ON US. When you need to protect your plan and its members against risk associated with chronic kidney disease and dialysis turn to the industry leader that has already saved self-insured plans nearly $1 billion while improving members’ health and vitality.

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seamlessly provide a full range of primary and specialty solutions for healthcare companies across the US and Canada. “Dennis has demonstrated success growing a profitable healthcare insurance business of scale,” said North America Specialty President Mathew Dolan. “He has the perfect blend of healthcare underwriting, product management and leadership skills to continue IronHealth’s growth as a leading provider of specialty solutions.” Cook joined Liberty Mutual four years ago. Most recently, he served as IronHealth’s Chief Liability Officer, where he successfully led an operation with $220 million in gross written premiums. Prior to joining Liberty Mutual, Cook was at AIG. In addition to Cook, Liberty Mutual has appointed Robert Hatcher as Chief Underwriting Officer, Stop Loss. Hatcher will report to Cook and lead Liberty Mutual’s medical stop loss offering. About Liberty Mutual Insurance At Liberty Mutual, we believe progress happens when people feel secure. By providing protection for the unexpected and delivering it with care, we help people embrace today and confidently pursue tomorrow. In business since 1912, and headquartered in Boston, today we are the sixth largest global property and casualty insurer based on 2020 gross written premium. We also rank 71 on the Fortune 100 list of largest corporations in the U.S. based on 2020 revenue. As of December 31, 2020, we had $43.8 billion in annual consolidated revenue. We employ over 45,000 people in 29 countries and economies around the world. We offer a wide range of insurance products and services, including personal automobile, homeowners, specialty lines, reinsurance, commercial multiple-peril, workers compensation, commercial automobile, general liability, surety, and commercial property. Visit


ATLANTA – Advanced Medical Pricing Solutions (AMPS), a pioneer in healthcare cost containment, is pleased to announce the expansion of its fiduciary duties to include Drexi, its pharmacy benefits manager (PBM) solution. Drexi was acquired by AMPS in January 2021 and offers price transparency and pass-thru on prescription medications at more than 65,000 pharmacies. The expansion makes it one of the first PBM fiduciaries in the U.S. Under the expanded fiduciary model, employer clients will have the ability to give Drexi the fiduciary authority to determine prescription drug benefit claims for benefits

under their Plans, as well as the authority to act as the appropriate fiduciary to determine appeals of any adverse benefit determinations under the Plan. Drexi will also administer complaints, appeals, and requests for independent review according to the Plan’s appeals policy, and any applicable law or regulation, unless otherwise provided in the Plan. “Traditional PBM contracts are often confusing and lack clarity around drug pricing and reimbursement to purposefully drive costs that increase the overall margin or “spread” for the PBM,” said Kirk Fallbacher, AMPS president and CEO. “Adding Drexi to our existing fiduciary duties means we are able to deliver even better financial outcomes for employers, their enrollees, and patients by limiting conflicts of interest and additional fees or margins otherwise gained from favorable tier-placement on high-cost drugs.” AMPS has protected health plans since its inception in 2005. With the launch of its Reference Based Pricing Program, it expanded that protection as a formal fiduciary for medical costs, now expanded to include Drexi as a fiduciary for pharmacy costs. About Advanced Medical Pricing Solutions (AMPS) Advanced Medical Pricing Solutions (AMPS) provides market leading healthcare cost management services for self-funded employers, brokers, TPAs, health systems, health plans, and reinsurers. AMPS mission is to help clients attain their goals of reducing healthcare costs while keeping members satisfied with quality



NEWS healthcare benefits. AMPS leverages 16 years of experience in auditing and pricing medical claims to deliver "fair for all" pricing both pre-care and post-care. AMPS offers innovative dashboards and analytics to provide clients with insights based on Plan performance. Visit


For over a decade, ClaimLogiq has been empowering analysts with its leading claim review platform, TrueCost, reducing review times of large, complex claims from days or weeks to just hours. This 15-minute audit solution is the latest demonstration of ClaimLogiq’s innovations that simplify complex payment integrity processes.

Advancement of In-House Proprietary Technology Reduces End-to-End Complex Hospital Bill Reviews Down to Mere Minutes

A key component in delivering a 15-minute audit is the advancement of the ClaimLogiq’s Rapid Optical Character Recognition tool, ROCR (pronounced

CHARLESTON, S.C. – ClaimLogiq, a leading independently owned healthcare payment integrity company is announcing breakthrough technology that enables a complete end-to-end hospital itemized bill review in under 15 minutes. With this latest advancement, the company continues moving ever closer to facilitating near real-time payments of facility bills.

rocker) which converts itemized bills from PDF to electronic format in minutes. The two technologies together, ROCR and TrueCost, are the ingredients that enable the 15-minute audit solution.

We can build a new normal

together The world is returning to normal, but that doesn’t mean healthcare has to. For 30 years, TPAC has developed thoughtful stop loss solutions that go outside the normal way of doing business. Now, we invite you to join us and not let how things are go back to the way things were. Help us change the way healthcare is financed, disclosed and delivered.

Let’s build a better normal




WE ARE HERE FOR YOU Now, more than ever, it is important to do business with partners you can depend on. For more than 35 years, self-funded employers have trusted Sun Life to deliver flexible stop-loss options and seamless claim reimbursement. Helping you make the best decisions for your business is our business. Our team of dedicated experts is ready to support you with innovative solutions, tools, and resources to help you manage your self-funded plan every step of the way. Ask your Sun Life Stop-Loss Specialist about what is new at Sun Life or click here to learn more!












For current financial ratings of underwriting companies by independent rating agencies, visit our corporate website at For more information about Sun Life products, visit Stop-Loss policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) in all states except New York, under Policy Form Series 07-SL REV 7-12. In New York, Stop-Loss policies are underwritten by Sun Life and Health Insurance Company (U.S.) (Lansing, MI) under Policy Form Series 07-NYSL REV 7-12. Product offerings may not be available in all states and may vary depending on state laws and regulations. © 2021 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. Sun Life and the globe symbol are trademarks of Sun Life Assurance Company of Canada. Visit us at BRAD-6503-n

SLPC 29427 02/21 (exp. 02/23)

NEWS Todd Hill, ClaimLogiq's CEO stated: "Our 15-minute IBill audit is another example of our commitment to staying ahead of the curve. Removing complexity and reducing turnaround time on large claim reviews is a top priority for healthcare organizations. We believe this technology will be a game-changer for many payers and will have a very positive ripple effect throughout our industry.”

About ClaimLogiq

And because ClaimLogiq has not compromised its baseline framework or architecture in implementing its 15-minute audit, reviews are still completed with the same standard of quality, accuracy and consistency that TrueCost users have come to expect.

ClaimLogiq is a healthcare software and technology company that delivers a proactive approach to payment integrity through a powerful, simplified solution. The unique payer-facing, claim-analyzing solution is HITRUST CSF® certified and makes claim reviews accessible to all size healthcare payers for in-depth insight and real-time access into the status of every claim at every stage of the audit lifecycle for controlled, consistent, accurate, and

About the ClaimLogiq Pre-pay Review Process

defensible outcomes, second to none.

According to Mr. Hill, what is especially meaningful with this announcement is that even though the benchmark is now set at 15-minutes, teams are already completing finalized reviews in far less time in certain cases.

The 15-minute lifecycle of a claim begins with ClaimLogiq's Operational Routing and Rules Engine (CORRE), which runs claim data through an intelligent, logic-based and payer/provider-customized rules library for a pay or pend-for-review result in under 250 milliseconds. The speed of CORRE ensures no interruption to the adjudication throughput. Claims pended for review are then paired with an itemized bill to be prepped for review. ROCR converts the PDF to data which is then normalized and imported into TrueCost. This process takes only a few minutes regardless of the size or file types. From here, TrueCost's framework applies automation and payer-specific rules and edits to produce results in minutes. ClaimLogiq’s IBill review process maintains an industry-leading standard of a less than five percent appeal rate and a less than one percent overturn rate. TrueCost is uniquely available as SaaS for payers who choose to manage their payment integrity programs in-house, as full services for those who prefer to outsource the process, or even as a hybrid model where responsibilities are shared between ClaimLogiq and its clients in real-time. "It can’t be overstated what this technology means: our 15-minute IBill review will enable payers to move to a pre-pay review model - when they previously may not have had the ability to do so. This alone will eliminate millions of dollars in waste by simply not having to pay and chase," says ClaimLogiq COO, Josh Burrus. For more information, case studies, and articles detailing ClaimLogiq's 15-minute IBill review, visit



ClaimLogiq's innovative software stands out from the crowd by allowing payers client-driven control, customizability, and total transparency over the entire claim process and can be applied as a SaaS model, full services, or as a hybrid to suit the specific needs of every payer and provider agreement. ClaimLogiq's groundbreaking technology produces more cost savings and all-but-removed provider abrasion, impacting millions of lives annually in the pursuit of a higher quality of healthcare for all. For more information, visit or follow ClaimLogiq on LinkedIn.





Winston-Salem, NC – Kari L. Niblack, Esq., CEO of ACS Benefit Services, has been named “Most Admired CEO” by the Triad Business Journal. Part of the Journal’s 2021 C-Suite Awards,

NEWS recognizing outstanding CEOs and CFOs in the Triad area, this award highlights Kari’s tremendous contributions to both ACS and the greater Triad community. The 22 honorees this year were chosen by a panel of local judges based on evidence of exemplary leadership, performance, and innovation in their respective roles, along with their civic and philanthropic engagement—locally and beyond. C-Suite Award nominees must work in the Piedmont Triad region of North Carolina, which includes the counties of Alamance, Caswell, Davidson, Davie, Forsyth, Guilford, Montgomery, Randolph, Rockingham, Stokes, Surry, and Yadkin. “I am thrilled and honored to be among such an esteemed group of 2021 C-Suite honorees,” Niblack said in a statement. “Leading ACS Benefit Services fuels my passion for our industry, and I am so incredibly grateful to every member of our phenomenal team for never shying away from pushing the boundaries of innovation and exceptional customer service. Our success is because of YOU, along with the unwavering support of our amazing community over the past four decades. Thank you to the team that supports me personally and professionally.”

About ACS Benefit Services At ACS Benefit Services, our sole focus is providing the most innovative products and services available in the health benefits marketplace—all backed with the highest level of customer support. Over the past four decades, we are proud to have grown into a leading third-party administrator (TPA) by continuously focusing on the future of the industry and creating long-term health plan solutions for our employer groups that consistently deliver improved outcomes. Visit

The 2021 C-Suite Award winners will be recognized by the Triad Business Journal in a special publication out July 30th. See the full list of winners.

Stop Loss that does more than stop loss Looking for an insurance carrier that does more than identify trends? At Voya Employee Benefits, we take the next step, providing in-depth insights into what’s driving costs. Our proprietary data and analytics tools reveal the solutions that help your self-funded clients manage risk better—and protect assets over time.

For Stop Loss insurance that does more, contact your local Voya Employee Benefits sales representative or to download our latest proprietary insights visit

Stop Loss Insurance is underwritten by ReliaStar Life Insurance Company (Minneapolis, MN) and ReliaStar Life Insurance Company of New York (Woodbury, NY). Within the State of New York, only ReliaStar Life Insurance Company of New York is admitted, and its products issued. Both are members of the Voya® family of companies. Voya Employee Benefits is a division of both companies. Product availability and specific provisions may vary by state. ©2020 Voya Services Company. All rights reserved. 1151065 205914 - 05012020




cost containment results. Visit

Hillsboro, OR- 6 Degrees Health is pleased to announce that Shannon Miller has joined the company as an Account Manager.



Shannon hails from Washington State but took up roots in Arizona in 2013. She has been in the insurance industry for over 20 years in various aspects of products and enjoys the relationships she has built along the way. Shannon is married and has 5 children, 3 of which are the furry 4-legged kind, and 2 are her incredible sons. Her family enjoys the outdoors and activities that go along with that. She is very excited to be a part of the 6 Degrees Health family and has been welcomed warmly by all within this organization. Shannon can be reached at "We’re excited to welcome Shannon to the 6 Degrees Health team. Her experience and depth of knowledge in the self-funded healthcare arena will be a tremendous asset to our partners and Business Development Team.” -Heath Potter, Chief Growth Officer About 6 Degrees Health 6 Degrees Health is built to bring equity and fairness back into the healthcare reimbursement equation. Industry-leading MediVI technology supports our cost containment solutions with objective, transparent, and defensible data. 6 Degrees Health’s solutions include everything from provider market analyses, reasonable value claim reports, ad hoc claim negotiations, evergreening provider contracts, and referenced-based pricing. Our veteran cost containment team partners with health plans and their channel partners to deliver unparalleled




PLANO, TX -- Payer Compass, a leading provider of healthcare reimbursement technology and price transparency solutions, together with Spectrum Equity, a growth equity firm focused on the information economy, and Health Enterprise Partners (HEP), a healthcarefocused investment firm, announced the appointment of Doug Williams as an independent member of its Board of Directors. Williams, who has more than 25 years of experience in healthcare IT, joins Jeff Haywood, Steve LeSieur and Michael Radonich from Spectrum Equity, as well as David Tamburri from HEP, on Payer Compass' Board of Directors. He is currently the Executive Vice President and Chief Operating Officer of HMS, a Gainwell Technologies Company providing cost containment solutions to healthcare payers, where he is responsible for leading the company's business development and product strategy. Prior to HMS, Williams served as Chief Information


Officer of Aveta, now part of Optum, Inc. "We're delighted to welcome Doug to our board of directors," said Greg Everett, President and CEO of Payer Compass. "His experience leading healthcare technology companies that are focused on regaining control of the spiraling costs of healthcare aligns with our core mission." Payer Compass solves one of the most difficult problems in healthcare: rising costs and a lack of price transparency. Its purpose-built healthcare pricing engine and contract management system addresses the complexities of Medicare, Medicaid and Commercial claims pricing, enabling employer groups and health plans to make smarter decisions about the way they pay for care. "I admire Payer Compass' mission to drive transparency in healthcare pricing," said Williams. "I'm looking forward to helping the team execute on their ambitious growth plans and deliver innovative products to the market." "Doug's experience in driving innovation and growth will be a terrific asset to Payer Compass as we accelerate our efforts as the leading provider of reimbursement and price transparency solutions," said board member David Tamburri, Managing Partner of Health Enterprise Partners. Payer Compass has been growth equity-backed by Spectrum Equity and Health Enterprise Partners since December 2018.

Representative investments include Ancestry, Definitive Healthcare, Everlywell, GoodRx, Grubhub, Headspace, Kajabi, Lucid, Lynda. com, Net Health, The Knot Worldwide, SurveyMonkey and Verafin. Visit

About Health Enterprise Partners Health Enterprise Partners provides expansion capital to the most innovative healthcare services and healthcare information technology companies. Central to HEP's strategy is its unique and extensive hospital system and health plan network, 36 members of which are investors in HEP's funds. HEP seeks to invest in companies that improve the quality of the patient experience, expand access, and reduce the cost of healthcare. Visit

About Payer Compass Payer Compass is dedicated to restoring rationality to the cost of care. We focus squarely on tackling the most complex problems in today's healthcare landscape: spiraling costs and associated lack of price transparency. For health plans, we are minimizing overall spend on claims pricing, administration, and processing. And, for self-funded organizations, our innovations and services are driving down the costs of healthcare claims reimbursement. By combining our next-gen technology — Visium™, a multi-faceted pricing platform — with an emphasis on client success, Payer Compass is helping organizations control the cost of care. Visit About Spectrum Equity Spectrum Equity is a leading growth equity firm providing capital and strategic support to innovative companies in the information economy. For over 25 years, the firm has partnered with exceptional entrepreneurs and management teams to build long-term value in market-leading internet-enabled software and information services companies.






TAMPA, FL -- Marpai Health, a SMART health plan services company providing AI-powered third-party administration to self-insured employers, announced the appointment of Pamela Burns as Vice President of Enterprise Sales. Ms. Burns will be focused on building Marpai’s brand with national Brokers and Consultants, Unions, Associations, Tribal, Public Sector, and School Districts. Her appointment is effective July 1, 2021.

NEWS Ms. Burns brings over 30 years of industry experience in the self-funded healthcare space. Prior to joining Marpai, Ms. Burns, Vice President of Business Development at Valenz, focused on growing Valenz’s presence in the self-funded market. With a background in PPOs, cost containment and TPAs, Ms. Burns’ prior experience in developing distribution channels will support the growth of Marpai Health’s portfolio of services to support self-funded employers on a national basis. “We are excited to welcome Pamela to Marpai Health’s leadership team,” stated Edmundo Gonzalez, CEO of Marpai Health. “Pamela’s experience in the self-insured industry and the relationships she has in this market will enable her to strengthen our brand with key audiences and establish a leading presence for Marpai Health and the SMART Health Plan Services System.” About Marpai Health

With deep learning, Marpai helps patients get ahead of future health risks, avoid costly procedures and access top quality care; employers reduce healthcare, reinsurance and administration costs; and providers meet changing patient demands with less administration. Marpai uses deep learning capabilities to conquer the complex challenges standing in the way of better outcomes and lower costs, and to fuel the new consumer-driven healthcare world. Visit

Marpai Health is a leader in deep learning, the most advanced artificial intelligence, and brings the first SMART Health Plan Services System to selfinsured companies and their employees to improve health outcomes and reduce healthcare costs. Marpai delivers a member-centric health plan administration experience powered by deep learning and SMART automation that makes it easy for members, employers and providers to improve outcomes and save money in new ways.




Our Actuaries Have Seen It All ... WSPACTUARIES.COM | 777 ALEXANDER ROAD, SUITE 201 | PRINCETON NJ 08540



HCC Life Insurance Company operating as Tokio Marine HCC - Stop Loss Group

Mind over risk. That’s how we properly assess risk - enabling our clients to focus on their businesses. We provide innovative stop loss solutions to protect self-funded employers from potentially catastrophic losses. We offer flexible captive solutions to help control the severity risk of your self-insured program. We have developed medical stop loss solutions specifically dedicated to meeting the unique needs of Taft-Hartley union plans. Our Organ & Tissue Transplant policy is a fully-insured option to protect your self-funded plan from losses due to transplant exposures. Our clients have been benefiting from our expertise for over 45 years. To be prepared for what tomorrow brings, contact us for all your medical stop loss and organ transplant insurance needs.

Visit us online at

Tokio Marine HCC - Stop Loss Group A member of the Tokio Marine HCC Group of Companies TMHCC1151- 06/2021


CHAIRMAN OF THE BOARD* Robert Tierney President StarLine Osterville, MA


Mike Ferguson SIIA Simpsonville, SC


DIRECTORS Thomas R. Belding President Professional Reinsurance Mktg. Svcs. Edmond, OK John Capasso President & CEO Captive Planning Associates, LLC Marlton, NJ

Kari L. Niblack, JD, SPHR CEO ACS Benefit Services Winston Salem, NC

Laura Hirsch Co-CEO Aither Health Carrollton, TX


Elizabeth Midtlien Vice President, Emerging Markets AmeriHealth Administrators, Inc. Bloomington, MN

Peter Robinson Managing Principal EPIC Reinsurance San Francisco, CA


Directors Freda H. Bacon Les Boughner Alex Giordano Virginia Johnson Dani Kimlinger, PhD, MHA, SPHR, SHRM-SCP

Lisa Moody President & CEO Renalogic Phoenix, AZ Shaun L. Peterson VP, Stop Loss Voya Financial Minneapolis, MN

*Also serves as Director



SIIA NEW MEMBERS AUGUST 2021 REGULAR CORPORATE MEMBERS Adeyanju Ademiluyi CEO Alaffia Health New York, NY Mitch Ronnei Head of Health Plan Partnerships Carrot Fertility Lakeville, MN David Carney Chief Risk Officer FCE Benefit Administrators, Inc. San Antonio, TX Nate Reznicek Head of US Distribution International Re London, England Nicholas Morse Chief Marketing Officer Nadora Health Johnstown, CO Richard Henriksen CEO/Founder Nokomis Health Minneapolis, MN Sanjay Srinivasan Director of Partnerships and Business Development Paytient Columbia, MO



Todd Bryant President of GA Branch Relation Insurance Johns Creek, GA John Owens Chief Underwriting Officer Stonewater Underwriters, Inc. San Antonio, TX Scott Haas Senior Vice President Translucent Healthcare Consulting Meridan, ID

SILVER MEMBERS Richard Hardin President Edison Health Solutions, LLC Jenks, OK

EMPLOYER CORPORATE MEMBERS Kristof Wild Director Modern Business Council, Inc. Washington, DC



in healthcare waste & errors too much?

YES. At Zelis, we listen to what payers and providers want and bring technology, people, expertise, and entrepreneurial energy together to create smart solutions and a better way for the industry. Integrated solutions to price, pay, and explain healthcare on a claim by claim basis, all offered by one trusted company.

Maximized Claim Savings. Optimized Payments. Transparent Explanations. Contact Zelis today at 888.311.3505 or visit to find out how our pre-payment solutions are helping control the rising cost of healthcare.

Better Service. Better Performance. Copyright 2021 Zelis. All rights reserved.

Stability for those balancing risk and reward.

Those who self-fund a health plan seek autonomy and control over their benefits program and costs. It can be rewarding, but it does come with risk. Stop Loss protection from HM Insurance Group works to mitigate that risk for self-funded employers should high-dollar claims arise – delivering steadiness to the performance and confidence in the outcome. Find more on

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)

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