The Self Insurer January 2021

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JANUARY 2021 VOL 147

W W W. S I P C O N L I N E . N E T





By Karrie Hyatt









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

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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

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Written By Bruce Shutan


ust prior to the pandemic, Alecia Nash was looking for office space to better accommodate her growing InsurTech/stop-loss consultancy, which brought on two new employees in August. But the founder of HippaWare, LLC decided to maintain her telecommuting model when COVID-19 hit hard. She ended up using her own proprietary software and Trello, a web-based list-making application that helps organize and prioritize projects, to not only survive but thrive. For Todd Martin, COVID lockdowns weren’t exactly a shock to the system. “Being in Buffalo, we have always prepared for a 100% remote work environment” because of frequent snowstorms, says the chief sales officer for Nova Healthcare Administrators. “So we were ready to flip the switch in early March.” Although located 373 miles from New York City, which was the nation’s coronavirus epicenter early on, the TPA’s operation has been subject to statewide restrictions on both business and personal activities. “When we went to a 100% remote environment, we also put a lockdown on travel,” Martin reports. “In the beginning, it was stressful being one of the first areas locked down. Many of our competitors were in fact traveling.”



COVID Connections FROM AUDIO TO VISUAL COVID triggered a massive shift from audio to video communication when in-person contact became rare or impossible. As such, virtual meetings were the norm for maintaining business relationships in 2020 and are expected to continue across many workplaces post-pandemic. “There’s almost the expectation that we don’t do conference calls anymore,” observes Lorraine Byrnes, assistant vice president of captive program services for Berkley Accident and Health, a member company of W. R. Berkley Corporation whose riskmanagement services include stop loss, managed care, accident and group captive programs. Her group captive business typically involves one or two face-to-face member meetings a year as well as several conference calls. But given travel restrictions, every touchpoint occurred in a video call. “It’s so easy to turn on your webcam, so why not talk to the person and engage them?” Byrnes suggests. “You gain a lot from seeing the facial expressions and seeing where people are at… I actually have had more face time with our customers this year than I have ever had. It’s been an interesting outcome of the pandemic.” Paul Fallisi, president of Windsor Strategy Partners, Inc., says nearly every communication he has had during the pandemic is on Zoom or Teams – video conferencing platforms that he finds much more efficient than when he traveled one or two days a week. As a result, he expects about 80% of all client work to stay in the virtual realm with face-to-face visits reserved for more special occasions. While working Americans have cottoned to videoconferencing, he insists “there are some items that you just can’t replace getting in front of somebody and hashing things out. The one thing I miss is going out to dinner, having a nice glass of wine with a client.” Still, adjustments have been made. For example, some clients that have later afternoon video calls scheduled will share a glass of wine virtually. “We call them ‘wine-downs,” Fallisi says. In many respects, COVID has humanized business communication to a point where the self-insured community has grown closer than before. He says it’s not unusual for young children to interrupt parents or seeing pets dart around in the background, noting how his business associates have grown accustomed to seeing his 80-yearold mother. “I think people are just oblivious to that now,” he quips. “They’re comfortable. It’s no big deal. This is the new norm.” While lauding Zoom meetings as a great tool for maintaining face-to-face contact, Martin says there’s still no substitute for in-personal human interaction when it comes to landing new business.

Concern mounted when it became clear that several industry conferences, including SIIA’s 40th annual national event, would be virtual summits in 2020. “We thought it was going to be a major setback,” he recalls. “A lot of times, that’s where we meet new vendors and have the ability to continually educate ourselves.”

KEEPING PEOPLE ENGAGED The challenge of virtual meetings is a need to find new strategies to maintain engagement when there are important topics to discuss. Methods have included conducting surveys and using the handraising icon to illicit the same level of input and engagement, according to Byrnes. Another approach involves tighter agendas. It’s difficult enough to hold people’s attention and stay focused when everyone is gathered in the same room and there’s three hours of content to cover. “So we’ve had to recognize up front that longer meetings need to be broken up in shorter sessions,” she explains. “This has been effective with the brokers we work with, and we have even applied this strategy to our annual member meetings for our group captives.” Keeping in touch during the pandemic has been predicated upon understanding that customer needs have changed. For example, Byrnes says some are tethered more to their computers and expect more frequent communication. Others are harder to reach because they’re experiencing more disruption to their business and end up putting out fires, she adds.



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COVID Connections In one particular case, Byrnes had a hunch something wasn’t right when a manufacturing client who always responded promptly to her emails didn’t get back to her. After sending a followup email and finally connecting by phone, the client lamented an inability to read emails because they were too busy ensuring that all production-line processes complied with COVID safety protocols. From that point on, she decided to call and leave a voicemail vs. using email. Byrnes has discovered that more attention is required on presentations, noting how virtual meetings aren’t as effective without important visual cues. While she might distribute handouts at a face-to-face meeting, virtual gatherings require “creative condensing” into slides and visual aids to keep participants engaged. In response to COVID, Nova has recorded its open enrollment meetings, which can be distributed in an email format for people to watch at their convenience. Also, to help build relationships, the TPA has participated in many webinars wherein the discussion transcended products to include different types of patterns or strategies that are working well for the groups it serves. Adapting to the new normal appears to be paying dividends. “We actually won a lot of opportunities doing remote presentations,” Martin notes. “We’ve been very productive and efficient, and I think that it goes to show that there sometimes can be a lot of wasted conversation or time within the office.”

HUMAN TOUCHES COVID-19’s enormous impact is being felt across the self-insured marketplace. New stoploss cases have plummeted with a reluctance to make significant health plan changes, resulting in many passive renewals, according to Nash.

“I’ve had groups where it’s like, Alecia Nash ‘here’s $200,000 in savings,’ and I get a decline,” she says. “I have nicknamed this the “COVID decision” staying with the incumbent and taking an increase, even when not necessary. This year everyone is off the mark for new sales, so we have had to be creative and use technology in new ways to overcome the fear in the market by increasing transparency and communication between the stop-loss market and the customer.” At BRM Specialty Markets, client-relation touchpoints involve little gifts and outreach that ensure key contacts “we still care and we’re available,” reports Carrie Urbanelli, the MGU’s chief underwriting officer. She checks in regularly by phone, and in some cases, local TPA friends were open to having lunch outside. “I’d offer, even if they were like three hours away, just to get out of the house,” she says. Knowing that many TPA clients have struggled to write new business during this time, Urbanelli notes how the initial fear of furloughs morphed into concern about losing coverage or being rerated. But the fact is that many of the traditional underwriting approaches and procedures had to be abandoned and replaced by creativity. For example, if there was a change in the risk or even a potential new group that they were trying to write that didn’t neatly fit inside the box, she Carrie Urbanelli says some enrollment fluctuation contingencies could be waived. Another tack could be to “get as aggressive on the rating as we can just because people don’t really have a lot of money right now. And so, it’s a balancing act.”



COVID Connections The pandemic has taught Urbanelli to continue finding new ways to do things and be flexible. “It can’t always be about what you’re selling or doing that particular day,” she explains. “It has to be about what’s good for the long term and really forging those relationships and making sure that you have everyone’s best interests at heart.” Nash says she has been “nose to the grindstone” since signing a national contract with S&S Healthcare Strategies, a technology platform and back office TPA service provider, to market her online platform and services, which help insurance agencies and TPAs manage a higher volume of work more quickly and accurately, as well as specialty quoting. “We haven’t missed a beat, and the reinsurers love it because we only send the complete submission that they can work with,” explains Nash, whose software-as-aservice tames the inherent complexity of self-funding that many fellow brokers find a resource drain and source of frustration. “It was really revealing for me to learn from several MGUs and carriers that they are in some cases sending back 50% to even 90% of submissions from some TPAs and brokerage firms as ‘incomplete’ submissions, meaning an underwriter will not even lay eyes on it until it gets fixed.”

Mindful of 2020’s personal and professional challenges, Nash routinely stays in contact with her foot soldiers to gauge their stress levels and ask if they need any assistance. “I have always been a huge proponent of checking in and mental health, but I ratcheted it up,” she reports. “That’s a core value, frankly… We wanted an environment where people were happy and healthy.”

LONG-TERM EFFICIENCIES Working through the pandemic has made Martin much more of a morning person, knowing that rising earlier helps him avoid household challenges. “Even when you are isolated, there still is that bit of distraction when you’re working at home

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COVID Connections and you have other people around,” he says. Moreover, his laptop is now open 24 hours a day. He has white-knuckled his way through

Some days, I look at my schedule, and it’s literally nonstop,” he confides, “and I’m working from home. I’m Todd Martin struggling to find time go to the bathroom or make a sandwich. If one Zoom meeting runs two minutes over, you’re already two minutes late for the next one.” much of 2020. “

One silver lining has been the February 22 birth of his nine-month-old son who his mother has been able to watch upstairs since his wife returned to her job as a registered nurse in their local hospital. “He came a month early, which got us in and out of the hospital before this huge uptick in COVID,” Martin notes, breathing a sigh of relief. “I’m in the middle of remodeling my basement because it just needs to be more comfortable. I don’t know when we’re going back… I think there’s a lot of people that would like to go to the office because they can focus better and don’t have distractions with children.” There’s little doubt that some practices over the past year will likely stick around post-pandemic. “I don’t think I’ll ever go back to traveling the way that I was,” enthuses Martin, who used to spend four nights in a hotel each week. “As long as I have my laptop, cell phone and Internet I can do my job from anywhere in the world now.”



Going virtual has enabled Byrnes and her team to be nimble in maintaining business relationships. As a result, they will likely carry these new strategies and unexpected benefits into the firm’s post-

They say when life gives you lemons, you’ve got to make lemonade,” she says. “I believe that we’ve made our fair share of lemonade.” pandemic toolbox. “

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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Reaching Out to Find New Captive Talent


he talent gap the insurance industry is facing is still a looming challenge and has been for at least a decade since baby boomers started turning 65 in 2010.

For captives, the issue is even more precarious as many of today’s leaders in the captive sector have grown with the industry since the 1980s and 1990s and have specific expertise in that arena that is essential to keep building the sector.

Written By Karrie Hyatt

The Risk Institute at the Ohio State University, Fisher College of Business in their fifth annual survey on integrated risk management published at the end of 2019, found that, “Almost all of the surveyed firms will be somewhat impacted by baby boomers retiring, with this fraction reaching to 64 percent for public firms.”

In 2016, the Bureau of Labor Statistics estimated that 400,000 insurance professionals would be retiring by 2020. While it is yet to be seen if that estimate bears out, what that statistic doesn’t show is that the insurance industry is also growing, opening up even more opportunities for the younger generations. Captives are seeing massive growth this year with the combination hard market and COVID-19 pandemic. That means even more career opportunities will be opening up in the sector in the coming years.



New Captive Talent Yet, when young professionals and college students are considering careers, insurance rates low on the excitement scale. As one of the oldest financial professions, young people are not aware of the vibrant possibilities that exist, especially in captive insurance.

Captives fulfill many of the things that the younger generations want out of a career. Job seekers under 35 are looking for long-term creative and entrepreneurial positions with growth opportunities. They want to use their skills in technology and problemsolving to tackle real issues and find creative solutions that benefit the greater good. Captives, and other types of self-insurance, offer the flexible, dynamic, and leadership potential that they want.

them to be tomorrow’s trailblazers.

In 2018 and 2019, SIIA’s National Conference & Expo offered a discounted price to young professionals, considered to be those younger than 40, and geared educational tracks towards entry and mid-level insurance professionals.

The problem is conveying this message to those under-35 jobseekers. Of the more than 4,000 universities in the United States, fewer than 100 offer degree programs in insurance. Many of these programs offer an introductory course in captive insurance, but on the whole there is little awareness or education about captives in the university system.

There were also networking opportunities at the events aimed towards encouraging SFLs to interact with seasoned alternative risk transfer professionals. Similar programs were offered for the 2020 conference, but as it was held virtually, the networking opportunities were limited.

However, one university is working to bring captive insurance knowledge to their students. In 2017, the Davey Risk Management and Insurance Program at Butler University’s Lacy School of Business launched MJ Student-Run Insurance Company Ltd., a Bermuda-domiciled captive that insures various risks on campus, from the University’s fine art collection to student run enterprises. The captive even insures the University’s service animals, its bulldog mascot and its bomb-sniffing dog. While the program is proving to be a success, no other universities are following in Butler’s footsteps at this time.

SIIA’s mentoring program, which was formerly announced in 2019, was curtailed during most of 2020 due the pandemic. However, SIIA developed a new format to connect its host of alternative risk transfer veterans with young professionals interested in nontraditional insurance.

The lack of available education early on means that the captive industry has to promote itself among risk management students and young professionals. Several captive associations are taking the initiative to seek out potential talent through a variety of programs.

In November, SIIA hosted the virtual Mentor Connection Forum. Over the course of two days, the interactive event started with a virtual networking reception that included access to several distinguished industry executives.

In April of 2018, SIIA launched its SIIA Future Leaders (SFL) initiative to reach out to young insurance professionals, to encourage young talent to become involved in the self-insurance industry, and to become members of SIIA. A committee was formed to take the lead in identifying engagement ideas to reach out to young insurance professionals and those just entering the workforce. The goal of the committee is to help foster a community of young professionals involved in self-insurance and alternative risk insurance sectors, and to help prepare

The main event was a new take on the “speed dating” idea - “SpeedMentoring.” Attendees were given access to experienced mentors who offered

JANUARY 2021 13

New Captive Talent practical career advancement advice and answered questions to foster greater interest in captives and self-insurance. While the event was limited to 100 attendees, SIIA has plans for more virtual mentoring events in the coming year.

Several regional captive associations are also actively seeking new talent. The South Carolina Captive Insurance Association (SCCIA) works with the University of South Carolina’s insurance degree program to bring students to the association’s conference each year. For the last ten years, SCCIA Scholars attend the Captive 101 session and other sessions at the conference and are offered networking opportunities. While the conference was suspended in 2020 due to the pandemic, in 2019 SCCIA worked with Strategic Risk Solutions who sponsored the attendance of several students.

In a program launched a year ago, the Alabama Captive Insurance Association (ACIA) offers an internship program dubbed “Risky Business” to encourage students to consider careers in captive insurance and alternative risk management. The 18-week internship offers participants a chance to gain experience in both risk management and insurance environments and allows participants to build relationships with industry professionals as well as industry regulators. While the program has not been in effect for



long, so far it has generated a 100% employment rate for interns that complete the program.

The Tennessee Captive Insurance Association (TCIA) has been working with Middle Tennessee State University’s insurance program to bring students to the association’s annual conference for free as well as including students in networking and educational events. Several TCIA board members have volunteered their time to guest teach a class in the university’s insurance program. While the outreach has been curtailed during the pandemic, the association’s intention is to find other means to encourage and to educate young insurance professionals and college students.

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:


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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



HEALTH CARE BENEFITS YEAR IN REVIEW: HINDSIGHT 2020 2020 has been a year like no other. Congress and regulatory agencies entered a high gear of sorts to respond to the COVID-19 pandemic. To date, congressional and agency efforts have provided some welcome relief, as well as several new requirements for health plans and a variety of non-pandemic related developments.

COVID-19 DEVELOPMENTS Congress and the agencies reacted quickly in 2020 to adopt legislation, regulations and other guidance to address a number of COVID-19 related issues, including the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security (CARES) Act. COVID-19 provisions generally have an uncertain end date tied to the end of the COVID-19 public health emergency (PHE) or the national emergency. The COVID-19 PHE is determined by the HHS Secretary under the Public Health Service Act and is currently set to expire on Jan. 20, 2021 but is expected to be extended. The national emergency was established pursuant to a declaration by the President under the National Emergencies Act. Required coverage of COVID-19 vaccines: Under the Affordable Care Act (ACA), non-grandfathered group health plans (GHPs) are required to cover certain preventive care services without cost-sharing. The general deadline for implementation of new preventive recommendations and guidelines is the plan year beginning one year after the new recommendation or guideline is issued. Prior ACA regulations provide for coverage only for vaccines listed for “routine use” and generally allowed plans to apply cost-sharing if the preventive service is delivered by an out-of-network (OON) provider. The CARES Act accelerates the time by which a COVID-19 vaccine is a required to be offered as a no-cost preventive service to 15 business days after a recommendation for a COVID-19 vaccine is made. Unlike many aspects of COVID-19 relief, this CARES Act provision does not sunset (end) at a future date. On October 28, 2020 the “Tri-Agencies” (the Departments of Treasury, Labor and Health and Human Services) issued an Interim Final Regulation (IFR) under the

CARES Act that also requires, for the duration of the COVID-19 PHE, that a COVID-19 vaccine be covered as a preventive service even if not listed for “routine use” and also that costsharing cannot be imposed regardless of whether the vaccine is provided in- or out-of-network. Plans are required to pay an OON provider a “reasonable” amount (e.g., the amount Medicare would pay). Note that the cost of the administration of the vaccine is subject to the mandate even if the cost of the vaccine itself is paid for by a third party (e.g., by the federal or a state government). This mandate does not apply to plans that are not subject to the ACA preventive care coverage mandate. Thus, this mandate does not apply to retireeonly plans, plans providing only “excepted benefits” (e.g. hospital indemnity and other fixed indemnity plans, cancer or specific disease only policies, standalone dental and vision plans, certain employee assistance programs and health flexible spending accounts) or grandfathered plans. Required coverage of COVID-19 testing: Generally effective Mar. 18, 2020 through the COVID-19 PHE, the FFCRA, as amended by the CARES Act, requires most GHPs to cover COVID-19 testing, including certain related items and services, without cost-sharing and prior authorization or the use of medical management techniques. This mandate generally does not apply to plans that are not subject to the ACA health coverage mandates, such as retiree-only plans and plans providing only excepted benefits. The mandate does, however, apply to grandfathered plans.



If testing is performed by an OON provider, plans are required to pay the provider’s posted cash rate, unless another rate is agreed upon. Federal regulators issued two sets of FAQs providing more detail on the testing coverage requirement, which may be found here and here.

EAPs permitted to cover COVID-19 testing and diagnosis: Qualifying employee assistance programs (EAPs) that do not provide significant benefits in the form of medical care and meet certain other requirements are “excepted benefits” and therefore exempt from ACA health coverage requirements. The Tri-Agencies issued guidance providing that, for the duration of the COVID-19 PHE or national emergency, diagnosis and testing for COVID-19 will not be treated as significant benefits in the form of medical care and therefore may be provided through an EAP. See Q&A 11 in these agency FAQs.

Reimbursement of over-the-counter (OTC) medicines and drugs: The ACA prohibited health Flexible Spending Arrangements (health FSAs), Health Reimbursement Arrangements (HRAs), and Health Savings Accounts (HSAs) from reimbursing expenses for medicines and drugs (other than insulin) without a prescription. Effective for expenses incurred on or after Jan. 1, 2020, the CARES Act eliminated that ACA restriction and also provides that menstrual care products qualify as a reimbursable expense. Prospective plan amendments will likely be required to take advantage of these permissive changes for health FSAs and HRAs.

Telehealth and other HSA/HDHP flexibility: The CARES Act permits telehealth and other remote care services (including services unrelated to COVID-19) to be provided below the minimum required deductible for a high deductible health plan (HDHP) without adversely impacting HSA eligibility. The provision is effective for services provided on or after January 1, 2020 and for plan years beginning before Dec. 31, 2021. See IRS Notice 2020-29. In other words, this provision only applies to services during the 2020 and 2021 plan years for a calendar year plan. There is some hope that this provision may subsequently be extended. Additionally, IRS Notice 2020-15 provides that HDHPs may provide benefits for testing and treatment of COVID-19 below the HDHP deductible without adversely impacting HSA eligibility. As noted above, the CARES Act now requires first dollar coverage of COVID-19 testing. The flexibility under Notice 2020-15 also does not sunset. Nothing in the CARES Act or FFCRA required coverage for COVID-19 treatments without cost sharing. Some states did have mandates for first dollar coverage of treatment applicable to fully insured plans.

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Also, some insurers extended this coverage even without a state mandate while giving their self-funded clients an option to provide treatment without cost sharing. For many plans and insurers any voluntary coverage of COVID-19 treatment without cost sharing was of a limited duration which varies by insurer and plan. Extension of certain COBRA and ERISA deadlines: The DOL and the IRS issued a notice extending certain timeframes for participants, beneficiaries and plan administrators. When applying these time frames, the period between March 1, 2020 through a date that is 60 days after the end of the national emergency (Outbreak Period) is disregarded.

It is unclear when the national emergency (and therefore the Outbreak Period) will end. The extension of these timeframes, statutorily, can be no more than one year (ending at the latest on February 28, 2020). The following time frames were extended:

 The 30/60 day HIPAA special enrollment periods,  The 60-day COBRA election period for COBRA qualified beneficiaries,  The 45-(initial) and 30-day (subsequent) COBRA premium payment deadlines,

 The 60-day period in which COBRA qualified beneficiaries must notify the plan administrator, of certain qualifying events, second qualifying events or determination of disability

 A plan administrator’s 14-day period for sending COBRA election notices (or the 44-day period if the employer is the plan administrator),

 The time period for filing claims and appeals under an ERISA-covered plan,  The time period to request external review of an adverse benefit determination under the ACA.


Legislative developments: ACA taxes and fees Calendar year 2020 is the last year that the ACA health insurance tax (HIT) applies. The HIT has an on againoff again history and legislation was enacted at the end of 2019 that finally repealed the tax starting 2021. HIT is, however, applicable for 2020. The same legislation also repealed the so-called “Cadillac tax” which would have gone into effect starting in 2022. The Patient-Centered Outcomes Research Institute (PCORI) fee proved resilient through its unexpected extension—so that it now applies for the next decade—to plan years ending before Oct. 1, 2029. The PCORI fee is imposed on most self-funded and fully insured plans. Excepted benefit plans aren’t subject to this fee. For policy and plan years ending after Sept. 30, 2019, and before Oct. 1, 2020, the applicable dollar amount was $2.54. For policy and plan years ending after Sept. 30, 2020, and before Oct. 1, 2021, the applicable dollar amount is $2.66. Additional information is on the IRS PCORI Fee website.

REGULATORY DEVELOPMENTS Additional flexibility for cafeteria plans and FSAs: IRS Notice 2020-29 provides employers flexibility to allow additional mid-year cafeteria plan elections for group health plans, health FSAs and dependent care assistance plans (DCAPs) during calendar year 2020 This Notice also provides increased flexibility with respect to the grace periods that apply unused amounts in health FSAs to medical expenses incurred through Dec. 31, 2020 and to similarly apply unused amounts in DCAPs incurred through Dec. 31, 2020.

Two new types of HRAs for 2020: Regulations that were finalized in 2019 created two new types of HRAs for plan years beginning on or after Jan. 1, 2020: Individual coverage HRAs (ICHRAs) and Excepted Benefit HRAs (EBHRAs). The details of the rules for each new type of HRA are detailed and complex. ICHRAs allow employers to help pay premiums for qualifying individual market major medical coverage and out-of-



pocket expenses not reimbursed by insurance. Among other requirements, ICHRAs cannot be offered to employees who are eligible for a traditional group health plan offered by the employer. There are intricate rules if an employer only wants to offer an ICHRA to a certain subset of employees. Applicable large employers (ALEs) offering ICHRAs need to consider how the ACA employer pay-or-play penalties apply and in particular when and ICHRA will be considered “affordable” under the ACA. Form 1095-C was revised to accommodate the mandatory ACA reporting of ICHRAs for ALEs. EBHRAs are designed to reimburse certain medical expenses for employees who are eligible to participate in a traditional group health plan offered by the employer (even if they are not enrolled in the traditional group health plan). The maximum annual contribution to an EBHRA is currently set at $1,800. The IRS issued final ICHRA and EBHRA regulations in June of 2019, and has issued proposed rules on ICHRAs with regard to ACA affordability and penalty issues, as well as nondiscrimination requirements. As of this writing, these rules have not been finalized. DOL allows expanded use of electronic disclosure: The DOL finalized a revamped electronic disclosure rule under ERISA. Although not applicable to health and welfare plans (including health FSAs and HRAs), the new rule forwards the broader electronic communication initiative for retirement plans by adding two new safe harbor methods: a “notice and access” method and e-mail delivery.

The notice and access method allow electronic delivery by posting information on-line. The e-mail delivery method allows delivery directly by means of email. While only applicable to retirement plans currently, it is possible that similar changes will be made in the future for health plans. For now, DOL indicates that additional time is necessary for coordination between the Tri-Agencies who all have jurisdiction over some aspects of GHPs. New SBC template: Federal agencies introduced a new Summary of Benefits and Coverage (SBC) template to be used for plan years starting on or after Jan. 1, 2021. The template eliminates the reference to the ACA individual mandate, makes changes to the coverage examples and provides no further relief for HRAs subject to SBCs. More information is on the DOL SBC webpage. 2021 Notice of Benefit and Payment Parameters (drug coupons and the ACA out of pocket limit): This annual HHS Notice clarified that, to the extent consistent with state law, insurers and plans will be permitted, but not required, to count toward the ACA maximum out of pocket limits any form of direct support offered to participants and beneficiaries by drug manufacturers (e.g. coupons). For fully insured plans, state law may require that coupons be counted for the OOP limit which could make an HDHP non-conforming with respect to the ability of individuals to contribute to an HSA. This annual Notice also set the 2021 ACA maximum out of pocket at $8,550 (self only)/$17,000 (family) and allowed midyear special enrollment for Qualified Small-Employer HRAs (QSEHRAs).



Transparency rules for group health plans: The Tri-Agencies finalized sweeping transparency regulations creating two significant price and coverage disclosure requirements that require non-grandfathered GHPs and insurers of nongrandfathered health insurance coverage in the group and individual markets to:

 individually disclose cost-sharing information to plan participants; and  publicly disclose negotiated rates for in-network providers and allowed amounts for OON providers. The public disclosure requirements are effective for plan years beginning on or after January 1, 2022 with the individual disclosure requirements following a year later (plan years beginning on or after January 1, 2023). The rule will impose significant disclosure requirements on employer plan sponsors and health plan insurers. The rule doesn’t apply to excepted benefit plans and the rule contains several enforcement safe harbors which are only available if the plan is exercising good faith and reasonable diligence. Further, beginning with the 2020 medical loss ratio (MLR) reporting year, the rule allows insurers a credit for “shared savings” in calculating their MLR when a

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consumer selects a lower-cost provider. Promptly planning ahead and taking prudent action can help ensure that new transparency rule responsibilities are upheld. A deeper-dive summary of the rule can be found in our article next month. Proposed Rule on Direct Primary Care and Health Care Sharing Ministries: An IRS proposed rule provides that certain direct primary care arrangements and health care sharing ministries are “medical care” for federal tax purposes as either payment for medical care or medical insurance. As a consequence, fees, premiums or contributions for participation in such arrangements qualify for the individual itemized deduction for medical expenses. Further, such payments and fees may be

reimbursed by HRAs. The proposed rule also notes that Health FSAs may not reimburse “premiums” for the these arrangements and that participating in either of these arrangements may, depending on the specifics of the arrangement, disqualify an individual from contributing to an HSA. While the proposed rule would provide favorable federal tax treatment, there are a host of other issues under the ACA, ERISA, and COBRA if an employer desires to sponsor one of these arrangements for its employees. Revised Rule on Grandfathered Plans: Another IRS proposed rule would amend the grandfather plan rules to provide relief for HDHPs that lose grandfather status merely due to the technical increase of IRS deductible amounts. The proposed rule would also provide an alternative means to determine whether increases to fixed-amount cost-sharing trigger a loss of grandfather status. On December 11, as we were going to press with this article this proposed rule was finalized without substantial changes.

BENEFIT PLAN INFLATION ADJUSTED AMOUNTS FOR 2021 FOR POPULAR BENEFITS The following table provides a summary of key dollar limits for health and certain other employee benefits for 2020 and as adjusted for inflation for 2021. BENEFIT 2020 2021 HSA contribution max (including employ- $3,550 ($7,100 family) $3,600 ($7,200 family) ee and employer contributions) 2019 contribution deadline extend- (Rev. Proc. 2020-32) ed to 7/15/2020 HSA additional catch-up contributions $1,000 (this is not indexed) Same HDHP annual deductible minimum $1,400 ($2,800 family) Same (Rev. Proc. 2020-32) Limit on HDHP OOP expenses $6,900 ($13,800 family) $7,000 ($14,000 family) (Rev. Proc. 2020-32) ACA limit on OOP expenses $8,150 ($16,300 family) $8,550 ($17,100 family) Health FSA salary reduction max $2,750 Same Health FSA carryover max $500 $550 Limit on amounts newly available under $1,800 Same an Excepted Benefit HRA QSEHRA max reimbursement $5,250 ($10,600 family) $5,300 ($10,700 family) Transit and parking benefits $270 (monthly) Same 401(k) employee elective deferral max $19,500 (Catch-up contributions Same $6,500) Highly compensated employee $130,000 (applies for 2021 plan $130,000 (applies for 2022 plan year under look-back rule) year under look-back rule) Key employee $185,000 Same

CONCLUSION As this article goes to press, the year isn’t quite done. Federal agencies and Congress are still at work. Also, 2021 looks to once again be an exciting year. Issues related to COVID-19 will likely dominate the beginning of 2021 and we will have a new administration with new Secretaries of the Tri-Agencies. We are also awaiting important Supreme Court decisions that will come in the late Spring or early Summer of 2021. Key among these is the pending case challenging the constitutionality of the ACA. We are still awaiting an appellate court ruling on the fate of the association health plan regulations. While not yet public, the EEOC has submitted proposed regulations to the Office of Management and Budget on wellness programs under the Americans with Disabilities Act and the Genetic Information Nondiscrimination Act. There are sure to be many other developments in 2021 and we will continue to keep you informed.





Written By Brady Bizarro, Esq.


he United States Supreme Court has experienced a whirlwind of a year. Early on, the threat of COVID-19 forced the Court to take the unprecedented step of hearing oral argument via telephone conference call.

Other notable headlines throughout the year included the Court deciding important cases on abortion, religion, and immigration, hearing a crucial case on the Affordable Care Act, rejecting an urgent case on the 2020 presidential election, mourning the loss of an esteemed colleague, and welcoming a new justice to the bench.

You would be forgiven, then, if you missed the case of Rutledge v. Pharmaceutical Care Management Association, decided on December 10, 2020. For employersponsored health plans and the healthcare industry as a whole, this 8-0 decision may prove to be the most important of its kind in the last several years because of what it foreshadows – more state regulation of PBMs and the possible regulation of other third-party vendors involved in ERISA plan administration.



At its core, Rutledge involved an attempt by a state to regulate its own healthcare market in the face of federal preemption under the Employee Retirement Income Security Act of 1974 (“ERISA”). To properly understand the context of the state law at issue, a brief overview of drug pricing and the process by which many Americans get their prescription drugs is required.

Most Americans are covered by private health insurance (specifically, employersponsored health plans) and they purchase prescription drugs from retail pharmacies. Hardly any health plans contract directly with pharmacies. Instead, they contract with pharmacy benefit managers (“PBMs”). PBMs are an integral part of this process, serving as intermediaries between health plans and the pharmacies that plan members use.

When a plan member fills a prescription at a pharmacy, the pharmacy checks with the contracted PBM to confirm insurance coverage and determine any cost sharing requirements. After the plan member’s transaction is complete, the PBM reimburses the pharmacy for the prescription (less any cost sharing). Finally, the health plan reimburses the PBM.

The amount at which a PBM reimburses a pharmacy for a drug is set by a contract between the PBM and the pharmacy. In that contract, rates are set according to a list specifying the maximum allowable cost (“MAC”). Similarly, the amount at which a health plan reimburses a PBM is set by contract. These contractual arrangements are often crucial to the success of each entity because each relies on access and steerage to some degree.

Consider the following scenario: a pharmacy pays a drug manufacturer $250 to obtain a drug. The PBM has set a MAC of $200 for the drug. If a plan member pays a $15 copay for the drug, the PBM would reimburse the pharmacy $185.

Under its contract with the PBM, the health plan reimburses the PBM $300, which includes a spread price or fee for the drug (in some cases a manufacturer rebate is involved). In this example, the pharmacy lost money because the MAC was less than the price the pharmacy paid the manufacturer to obtain the drug in the first place. How or why this occurs is disputed by pharmacies and PBMs alike; however, this situation has caused many independent and rural pharmacies to lose money and close over the past few decades.



In 2015, the Arkansas state legislature took action to protect its independent pharmacies (which are common in rural Arkansas) from this fate. It passed Act 900, which regulates the price at which PBMs reimburse pharmacies for the cost of drugs covered by health plans.

Specifically, the bill requires that PBMs reimburse pharmacies at or above their acquisition costs, and it included three key enforcement mechanisms. First, the law requires PBMs to tether reimbursement rates to pharmacies’ acquisition costs by timely updating their MAC lists when drug wholesale prices increase.

Second, PBMs must provide administrative appeal procedures for pharmacies to challenge MAC reimbursement prices that are below the pharmacies’ acquisition costs. Finally, the law permits a pharmacy to decline to sell a drug to a beneficiary if the PBM at issue will reimburse the pharmacy at less than its acquisition cost. Ark. Code Ann. § 17-92-507(c)-(e).

Soon after the law passed, the Pharmaceutical Care Management Association (“PCMA”), representing the eleven largest PBMs in the country, filed suit against the state, alleging that Act 900 was pre-empted by ERISA. Under 29 U.S.C. § 1144(a), ERISA pre-empts “any and all [s]tate laws insofar as they may now or hereafter relate to any employee benefit plan.” Courts have broadened the scope of pre-emption over time to include state laws that have a “connection with” or “reference to” an ERISA plan; though the Supreme Court’s jurisprudence in this area has arguably been conflicting.

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The lower courts, including the Eighth Circuit Court of Appeals, sided with the PCMA, ruling that the Arkansas law had an impermissible “connection with” ERISA plans by interfering with central plan functions and nationally uniform plan administration, as well as an impermissible “reference to” ERISA plans by regulating PBMs that administered benefits for those plans. Arkansas appealed this decision to the U.S. Supreme Court.

To resolve this case, the Court considered whether the Arkansas law had an impermissible “connection with” or “reference to” an ERISA plan. In its brief to the Court, PCMA argued that Act 900 impermissibly affected plan design by mandating a particular pricing methodology for pharmacy benefits.

Sotomayor first outlined the Court’s ERISA pre-emption scheme. Then, she dealt with the two issue in turn.

First, she noted that “not every state law that affects an ERISA plan or causes some disuniformity in plan administration has an impermissible connection with an ERISA plan . . . especially so if a law merely affects costs.” Rutledge, 2020 U.S. LEXIS 5988, at 10. For support, she cited to New York State Conference of Blue Cross & Blue Shield Plans v. Travelers Ins. Co., 514 U.S. 645 (1995).

In that case, New York state imposed a surcharge of up to 13% on hospital billing rates for patients covered by insurers other than Blue Cross and Blue Shield (“BCBS”). The Court presumed that the surcharges would be passed on to ERISA plan members, which in turn would incentivize ERISA plans to steer their plan members to BCBS networks. Still, the Court found that the “indirect economic influence” did not create an impermissible connection between the state law and ERISA plans because it did not “bind plan administrators to any particular choice.” Travelers, at 659.

Then, it argued that the law’s appeal procedure interfered with central matters of plan administration. Further, PCMA asserted that the enforcement mechanisms interfered with nationally uniform plan administration by creating “operational inefficiencies.”

Finally, PCMA contended that by allowing pharmacies to decline to dispense prescriptions in certain cases, the law effectively denied plan members their benefits.

Writing for a unanimous Court (Justice Amy Cony Barret took no part in the consideration or decision of the case), Justice Sonia



Justice Sotomayor reasoned that the Arkansas law in this case was merely a form of cost regulation, much like the New York law which had been upheld by the Supreme Court in Travelers. She rejected all of PCMA’s arguments, finding that Act 900, as a form of cost regulation, and despite its enforcement mechanisms, did not require plan administrators to structure their benefit plans in any particular manner and did not lead to anything more than potential operational inefficiencies, which by themselves are insufficient to trigger ERISA pre-emption.

Having dealt with the first issue, Justice Sotomayor then easily dispatched the second issue; whether Act 900 impermissibly referenced an ERISA plan. She argued that the law does not act immediately and exclusively upon ERISA plans because it applies to PBMs whether or not they manage an ERISA plan. It affects ERISA plans only insofar as PBMs pay pass along higher pharmacy rates to plans with which they contract. Rutledge, at 12.

It is possible, as the Court noted, that one consequence of this decision will be higher drug prices for employer-sponsored health plans and their plan members as PBMs look to recoup losses in revenue. It is far more likely, however, that more states will pass laws modeled on Arkansas’s Act 900, without fear of them being pre-empted by ERISA (though additional litigation is likely to ensue).

Having announced a distinction between cost regulations and dictating plan choices, the Court has also opened up the possibility that states may try to regulate other third-party vendors involved in ERISA plan administration; from third party administrators to provider networks to audit firms.

As we in the self-funded space have been saying for years, on issues where the federal government and the relevant industry players have failed to provide relief; prescription drug pricing, balance billing, and price transparency (just to name a few), states will step in to fill the void.

Now, with a unanimous Supreme Court restricting the scope of ERISA pre-emption, those state have new latitude to enact laws which may ultimately prove unpopular or even counterproductive for all involved in the fight to contain healthcare costs.

After the Court’s decision, the PCMA released a statement expressing disappointment and noting, “As states across the country consider this outcome, we would encourage they proceed with caution and avoid any regulations around prescription drug benefits that will result in higher healthcare costs for consumers and employers.”



Brady joined The Phia Group as a healthcare attorney in early 2016. As the Director of Legal Compliance & Regulatory Affairs for The Phia Group, he specializes in regulatory, transactional, and compliance matters related to healthcare and employee benefits law. He provides general consulting services to clients, including employers, third-party administrators, brokers, and vendors associated with health benefit plans on matters related to the health insurance industry, including ERISA, ACA, and HIPAA compliance.

He also performs contract review and due diligence on healthcare transactions and assists with dispute resolution efforts between the various players in the healthcare industry in an effort to protect plan members and plan sponsors. Brady has previously spoken at numerous industry conferences, including those held by the Self-Insurance Institute of America (“SIIA”) and the Health Care Administrator’s Association (“HCAA”). He currently serves as a member of SIIA’s Future Leaders Committee and is a regular contributor to The Self-Insurer, the world’s leading alternative risk transfer journal.

Attorney Bizarro earned his law degree from Boston University School of Law, concentrating in health law. During law school, Brady served as an editor for BU Law’s International Law Journal, participated in the Edward C. Stone Moot Court Competition, completed a legal internship in the U.S. House of Representatives, and wrote for the National Security Law Brief. He also worked as a summer associate at Greene LLP, a complex civil litigation firm in Boston that specializes in healthcare fraud cases, and as a Rule 3:03 attorney with BU Law’s Civil Litigation Clinic, where he represented indigent defendants in employment and discrimination cases in state court. Prior to law school, he worked as a mediator for a local consumer advocacy arm of the Massachusetts Attorney General’s Office. Brady graduated magna cum laude in 2010 from Boston University, where he was the recipient of the Herbert and Mary Greig Scholarship in American History.

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What are clients saying about our EmCap® program? “You have become a key partner in our company’s attempt to fix what’s broken in our healthcare system.” - CFO, Commercial Construction Company

“Our clients have grown accustomed to Berkley’s high level of customer service.” - Broker

“The most significant advancement regarding true cost containment we’ve seen in years.” - President, Group Captive Member Company

“EmCap has allowed us to take far more control of our health insurance costs than can be done in the fully insured market.” - President, Group Captive Member Company

“With EmCap, our company has been able to control pricing volatility that we would have faced with traditional Stop Loss.” - HR Executive, Group Captive Member Company

People are talking about Medical Stop Loss Group Captive solutions from Berkley Accident and Health. Our innovative EmCap® program can help employers with self-funded employee health plans to enjoy greater transparency, control, and stability. Let’s discuss how we can help your clients reach their goals. This example is illustrative only and not indicative of actual past or future results. Stop Loss is underwritten by Berkley Life and Health Insurance Company, a member company of W. R. Berkley Corporation and rated A+ (Superior) by A.M. Best, and involves the formation of a group captive insurance program that involves other employers and requires other legal entities. Berkley and its affiliates do not provide tax, legal, or regulatory advice concerning EmCap. You should seek appropriate tax, legal, regulatory, or other counsel regarding the EmCap program, including, but not limited to, counsel in the areas of ERISA, multiple employer welfare arrangements (MEWAs), taxation, and captives. EmCap is not available to all employers or in all states.

Stop Loss | Group Captives | Managed Care | Specialty Accident ©2017 Berkley Accident and Health, Hamilton Square, NJ 08690. All rights reserved. BAH AD2017-09 7/17


SIIA ENDEAVORS POPULAR MENTORING EVENT ALLOWED PARTICIPANTS TO CONNECT FROM ANYWHERE The Self-Insurance Institute of America, Inc. (SIIA) further demonstrated its ability to effectively connect members in new ways by conducting its popular Mentor Connection Forum last month entirely via Zoom.

Designed to connect younger SIIA members (under 40) with senior level industry executives in a rotating small group mentoring format, the Forum has been previously produced as an in-person event.

The new “Connect from Anywhere” approach proved to be a great success based on the overwhelming positive feedback received from both mentors and mentees. Here’s what some of the participants had to say:



ENDEAVORS EVENT FEEDBACK…. “Having just started my career in stop loss insurance, something that really resonated with me during the forum was the importance of lateral movement over vertical movement in your career. It’s the idea that sometimes the best move for you is to become more of a generalist, rather than climbing the corporate ladder as fast as possible. Overall, it was a great experience, and I was pleasantly surprised by how well the virtual platform was carried out. I felt just as connected to my peers and colleagues as I would have if it had been in-person. I am very happy this great event was able to be conducted during Covid-19.” Ben Hopton, Underwriting Assistant, Tokio Marine HCC – Stop-Loss Group

“I wasn’t sure how well the program was going to work given that we could not have in-person contact with the younger member participants, but I was very pleasantly surprised. It was equally as rewarding for me to be able to share my experiences and relate to them in a more relaxed setting with no distractions. Not as much pressure than face-to-face for all.”

"This was my first SIIA event and I really enjoyed it from start to finish. I gained some pretty valuable advice which I can take back and use as I continue to grow my career within the industry. I'll definitely be attending future events." Bryan Dunton, Health Benefit Plan Consultant, The Phia Group

"In a year where so many are struggling due to COVID’'s impact on their business, it was so refreshing to hear from these industry veterans that the most important things are: you're happy, you're passionate about something, and your life is more than your job." Lisa Elder, Sales Director, Maestro Health

Liz Midtlien, Vice President, Emerging Markets, AmeriHealth Administrators "I was REALLY impressed by how invested the mentors all seemed to be. I got the sense that they genuinely wanted to be there and cared about helping the participants grow." Tony Birdsong, Data Analytics, TPAC Underwriters, Inc.

"I thoroughly enjoyed being a mentor, learning from the attendees about their concerns; hearing about their goals and giving advice to help them grow and learn about how to be their personal best. It was so rewarding, especially once I got the timing down!" Lisa Moody, CEO, Renalogic



ENDEAVORS “I enjoyed engaging with attendees and sharing ways to pave the path to great leadership. I believe gaining broad exposure to a wide range of experiences accelerates career development. This ‘lattice approach’ provides the opportunity to learn from mistakes while building the confidence necessary to determine the best actions to take as a leader. Hopefully, my contributions empowered others to see what’s possible for the future.” Rob Gelb, CEO, Vãlenz

SIIA thanks S&S Health Care Strategies and Guy Carpenter for their generous financial sponsorship of this unique industry event.

The next Connect from Anywhere (CFA) Mentor Connection Forum has been scheduled for June 17-18, 2021. Watch for event details closer to the date. In the meantime, please contact Justin Miller at should your company be interested in supporting this Forum – and the broader SIIA Future Leaders initiative – by becoming an event sponsor.



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NEWS FROM SIIA MEMBERS 2021 JANUARY 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




Hamilton Square, NJ – Berkley Accident and Health, a Berkley Company, has appointed Eliane Olson as Regional Sales Manager for its EmCap® Group Captive division. In this role, Eliane will be responsible for developing business and maintaining relationships in the western U.S. to support our growing captive business. Eliane will serve the territories of California, Nevada, Arizona, New Mexico, Oregon, and Washington.

“Eliane has an established track record of market expansion and business growth in the western U.S. Her extensive professional network of broker and TPA relationships will be an asset to our organization” said Brad Nieland, President and CEO of Berkley Accident and Health. “I am excited to have her on our team.”

Eliane comes to the Berkley Accident and Health team with over 20 years of experience in medical stop loss underwriting and sales, on both the direct carrier and MGU sides of the business. Eliane holds a Bachelor of Arts degree in Political Science from UCLA, in Los Angeles, CA and resides in San Diego, CA.





Hamilton Square, NJ– Berkley Accident and Health, a Berkley Company, is pleased to introduce Oak Harbor Reinsurance Company (Oak Harbor Re), an onshore captive insurance company offering protected cell programs. Domiciled in North Carolina, Oak Harbor Re focuses on group captive programs that enable employers to self-fund their employee health plans with greater scale and stability. “The creation of Oak Harbor Re provides a new onshore option for our clients and expands our suite of capabilities in a growing segment of the market,” commented Brad N. Nieland, president of Berkley Accident and Health. “Employers will



NEWS benefit from Berkley Accident and Health’s management, expertise, and account support, while experiencing the many advantages of participating in a captive.” Berkley Accident and Health is a market leader in group captive solutions. Captive management services for Oak Harbor Re are provided by Strategic Risk Solutions, one of the nation’s largest independent captive managers. For additional information about programs offered by Oak Harbor Re, please visit www.OakHarborRe. com or contact David Littlehale at

About Berkley Accident and Health 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. For more information, please visit


PHOENIX, AZ — Vālenz™ is pleased to announce the appointments of Randy Dorshorst and Patty Onion to the leadership team. Dorshorst joins the company as Vice President, Ecosystem Success, while Onion will serve as Vice President, Claim Operations.



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NEWS Dorshorst will lead and advance the innovation behind the Valenz health administrative ecosystem, combining health data analytics with care service delivery to reduce health costs for the self-insured industry and promote quality care.

“We are thrilled to welcome Randy to our senior leadership team to oversee the continuing success of our product, data and client program solutions,” said Rob Gelb, Chief Executive Officer of Vālenz.

“Randy offers 30 years of expertise in driving growth, technology and value through custom solutions, which makes him an outstanding fit to lead Valenz in the purposeful expansion of our ecosystem.” Most recently, Dorshorst served as Vice President for AViDEL Medical Management in Irving, Texas. With his comprehensive leadership and management skills, he directed the successful launch of AViDEL as a sister company to Service Lloyds Insurance Company, where he was Vice President for Medical Management Service. Dorshorst also has held executive positions at HealthSmart Casualty Claims

Solutions, Web TPA and CorVel Corporation. Onion will draw from more than 30 years’ experience in managed care, workers’ compensation and third-party administration to lead Claim Operations. “Patty’s proven success in setting strategic direction and implementing managed-care platforms and services makes her uniquely well-positioned for this role,” said Amy Gasbarro, Chief Operating Officer of Valenz. “She brings tremendous expertise in claim operations and process improvements that will help us go even farther to drive results for our clients and offer the highest possible level of service.” Onion most recently served as principal for Milana Health Systems in Kansas City, Mo., specializing in workers’ compensation managed-care consulting. She was CEO of Berkley Medical Management Solutions and has held executive roles with numerous health-related companies including Coventry Health Care, Premera Blue Cross and Mercy Health Plan. “I have been fortunate to know Patty and Randy for years, and most recently we have benefited from their guidance and counsel as consultants to Valenz,” Gelb said. “Today, I couldn’t be happier to have them on board full time, as they both bring outstanding leadership and deep expertise that will empower us to further deliver on our promise of smarter, better, faster healthcare.” About Vālenz Through a complete health administrative ecosystem, Valenz connects cost and quality data on a single-source, end-to-end analytics platform for smarter, better, faster healthcare. Vālenz solutions integrate data from comprehensive care management services (Vālenz Care), high-value provider networks (Vālenz Access), claim flow management (Vālenz Claim), and solutions for payment integrity, revenue cycle management and eligibility compliance (Vālenz Assurance) into the ecosystem. Visit Valenz is backed by Great Point Partners. About Great Point Partners Great Point Partners (“GPP”), founded in 2003 and based in Greenwich, CT, is a leading healthcare investment firm, currently with approximately $1.8 billion of equity capital under management and 28 professionals, investing in the United States, Canada and Western Europe. Visit



Cost containment alone is no longer the gold standard for managing risks associated with Chronic Kidney Disease (CKD). It's better to avoid catastrophic dialysis, and

JANUARY 2021 41

NEWS CKD claims costs altogether. Now, enables Renalogic to manage cohort risks by predicting health states and future costs. Renalogic, the leader in comprehensive kidney care and dialysis risk management, announced is the first of its kind clinical intervention program powered by AI-based predictive modeling and is proven to help bend the catastrophic claims cost curve. is the industry's most advanced kidney care management program combining intelligence with tailored intervention to reduce the associated risk.

"We're putting an end to surprise dialysis claims and changing the prognosis while reducing the hidden risk associated with CKD," Mark Masson, President at Renaolgic, said. "The shift to identifying previously hidden risk results in a new, higher standard of chronic condition management. Today, we are identifying future CKD risk earlier than anyone else. can accurately predict when individuals will progress to higher acuity stages of chronic kidney disease and when they will progress to dialysis without proper intervention. This enables us to control future risks and provide the right care at the right time. We are helping to avoid growing claims costs associated with CKD and dialysis." arrives at a time when CKD continues to be the third-highest medical claims cost category. In 2020, estimated claims cost associated with CKD, which is often referred to as "the silent epidemic," will total over $100 billion for commercial health plans. With new predictive modeling and AI, using hundreds of data dimensions, can accurately predict each plan member's propensity to advance to the next CKD stage, including dialysis within the next 12 months. That's every member, even those without a CKD diagnosis. This makes it possible to avoid the risk associated with CKD and dialysis by delivering personalized intervention based on much more than the member's CKD stage, including their trajectory and expected progression toward dialysis.



For more than a decade, Renalogic has been using data to mitigate CKD and dialysis risk. Now, is the next evolution of predictive modeling powered by AI. reports with 90% accuracy in identifying where and when CKD and dialysis claims will appear in the future. Over time, predictive modeling will improve as it continues to think and learn as a "doctor." gives health plan administrators a look into future healthcare claims costs and utilization. "When we know what's coming, we have time to avoid an emergent start to dialysis," Masson said. Renalogic, a pioneer in dialysis cost containment, is again leading the industry by adopting a modern, AI-driven approach. "By taking the guesswork out of hidden risk, we're giving health plan fiduciaries an extraordinary advantage compared to other dialysis cost containment options. layers claim cost containment and cost avoidance. What's more, the proprietary predictive intelligence indicates plan needs and could present additional savings for plans year over year." The Renalogic Kidney Dialysis Avoidance Program (KDAP) successfully slows, stops, and even reverses CKD progression. Nearly 80% of active KDAP members who have participated for six months or more have maintained or improved their CKD disease state. identifies additional risk earlier, identifies gaps in care, and is the leading indicator for each member's dialysis trajectory. This makes personalized intervention as unique as

Medical stop loss insurance from Berkshire Hathaway Specialty Insurance comes with a most trusted name and the stability of an exceptionally strong balance sheet. Our executive team has 30 years of experience and a commitment to tailoring solutions and paying claims quickly. All of which is key to ensuring your program’s success for years to come. With so many choices, you can make this one with certainty.

Atlanta | Boston | Chicago | Houston | Indianapolis | Irvine | Los Angeles New York | San Francisco | San Ramon | Seattle | Stevens Point | Adelaide Auckland | Brisbane | Cologne | Dubai | Dublin | Hong Kong Kuala Lumpur | London | Madrid | Macau | Melbourne | Munich Paris | Perth | Singapore | Sydney | Toronto

NEWS each member's fingerprint a reality for Renalogic clients. About Renalogic For nearly two decades, we continue to be proud, forward-thinking leaders in a niche industry that is in crisis. We are an ambitious disruptor driving positive change to contain the catastrophic costs of dialysis. We are changing the way plan administrators think about dialysis. Chronic Kidney Disease (CKD) costs are an epidemic issue that will not resolve on its own. The logical approach is to get ahead of the curve. We are one company, one cause, leading the industry by empowering our clients to avoid dialysis altogether with solutions and technology for kidney disease management. No one does what we do. We exist to open minds, achieve sustainable results for our clients, and advocate for kidney disease management, dialysis cost containment, and prevention. Contact Renalogic at and visit


Canton, MA – It is with great honor and humility that The Phia Group announces it has been named by The Boston Globe as one of the Top Places to Work in Massachusetts. In its 13th annual employee-based survey, The Boston Globe – having assessed anonymous employee feedback, and details about the company – determined that The Phia Group provides one of the most rewarding, meaningful employment



experiences in the Commonwealth of Massachusetts. Each year, The Boston Globe publishes in its “Top Places to Work” issue, a list of employers it recognizes as being the most admired workplaces in the state, voted on by the people who know them best – their employees. The survey measures employee opinions about their company’s direction, execution, connection, management, work, pay and benefits, and engagement. When the results were tallied and analysis was completed, The Phia Group was ranked #27 of the top 55 medium sized companies. “This was a particularly challenging year to be a great place to work, and the companies that made our list went above and beyond to keep their employees safe, engaged, and cared for,” said Katie Johnston, the Globe’s Top Places to Work editor. “From offering help with childcare to making the workplace more equitable, to holding virtual events, these employers showed that the best get better in crisis.” The rankings are based on confidential survey information collected by Energage (formerly Workplace Dynamics), an independent company specializing in employee engagement and retention, from more than 80,000 individuals at hundreds of Massachusetts organizations.

Delaware’s Captive Bureau is business at the next level

In Delaware, our captive regulators are dedicated exclusively to our captive insurance clients’ needs, and work under the direction of our Captive Bureau leadership, directed by Steve Kinion.

There are 34 people working on Delaware’s Captive team. Of this total 15 are financial analysts. Under Delaware’s regulatory organization, the financial analyst is the first-line regulator who communicates with the captive manager or owner. As a result, all inquiries, business plan changes, dividend requests, and other related matters are first addressed by the analyst. The experience level of these analysts is unmatched. STEVE KINION, DIRECTOR

Call us today to speak with a team member

Bureau of Captive & Financial Products Department of Insurance


Our team has 15 analysts 12 hold the Associate in Captive Insurance (ACI) designation 12 hold the Accredited Financial Examiner (AFE) designation 9 hold the Certified Financial Examiner (CFE) designation 2 are Certified Public Accountants (CPA)

BUREAU OF CAPTIVE & FINANCIAL INSURANCE PRODUCTS 1007 Orange Street, Suite 1010 Wilmington, DE 19801 302-577-5280 

NEWS The winners share a few key traits, including offering progressive benefits, giving their employees a voice, and encouraging them to have some fun while they’re at it.

“This is one of the proudest days of my life.” The Phia Group’s CEO, Adam Russo, remarked. “I say this team is like family; but we don’t usually get to choose who is a part of our family. Our employees choose to be part of this family. “Ensuring that people have access to the best health care at the lowest cost possible is our purpose. It’s what we provide to our clients, and it’s what we provide to our own staff.” Adam continued. “When your people are happy, your clients are happy. It’s not always the easiest or quickest path to success, but it is a lot more permanent.” About The Phia Group The Phia Group, LLC, headquartered in Canton, Massachusetts, and with offices in Hartford, Boise, and Louisville, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets. By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, The Phia Group is truly Empowering Plans. Contact Garrick Hunt at, 781-535-5644 and visit www. About Boston Globe Media Partners LLC Boston Globe Media Partners, LLC provides news and information, entertainment, opinion and analysis through its multimedia properties. BGMP includes The Boston Globe,,, STAT and Globe Direct. Visit www.



WELLESLEY, Mass.-- For the third year in a row, Sun Life U.S., a national provider of medical stop-loss and other lines, has been named a Top Place to Work in Massachusetts by The Boston Globe, making the top ten for the state's largest employers. Top Places to Work recognizes the most admired workplaces in the state, voted on by the people who know them best—their employees. The survey measures employee opinions about their company's direction, execution, connection, management, work, pay and benefits, and engagement. This year, Sun Life engaged employees in new and unique ways to offer family support and a healthy work/life balance during the pandemic with everyone working from home.



"This year has brought many new challenges, and with them a new sense of commitment and camaraderie," said Dan Fishbein, M.D., president of Sun Life U.S. "Even while working virtually our employee engagement has never been higher, and we are extremely fortunate to be able to support our employees while maintaining strong levels of productivity and service for our clients, who we know are also facing challenges during this difficult time." Since March 16, Sun Life has had nearly all employees working from home. Over the summer, Sun Life partnered with the Boston Children's Museum to create a virtual summer camp program for employees' children, providing families with fun and educational activities to do at home. Sun Life leaders also took flexibility to a new level with a Flexibility Pledge that encouraged employees to take time to spend with children during the day, get groceries, check on loved ones, or simply step away and take a walk. Continuing that initiative into the fall, Sun Life implemented Flexibility 2.0, an arrangement allowing employees to flex up to 12 hours per week without manager approval in order to accommodate homeschooling or other caregiving commitments. As part of Sun Life's focus and commitment to supporting racial equality and equity, the company partnered with the NAACP Legal Defense and Education Fund and the Smithsonian National Museum of African American History & Culture to support voting and educational initiatives.

AccuRisk A VALUED PARTNER FOR 2021 AND BEYOND AccuRisk’s goal from day one has been to be a real partner. We listen to and collaborate with our partners to ensure they are able to offer the best, most customized products to their clients. We are leaders in benefit and service solutions, and product development with a staff that has diverse skills and broad expertise. As we embark on the New Year, we continue to lead the way with dynamic solutions to fit our ever-evolving world with the launch of our Ancillary and Captive Products. Challenge us to earn your business, and we’ll prove there is an AccuRisk Difference. (312) 857-9100

NEWS Additionally, Sun Life's Team Up Against Diabetes grant program is supporting community organizations around the country who are fighting diabetes and health disparities in communities of color.

"We believe in an inclusive workplace that recognizes the value of diversity in our business and our culture," said Tammi Wortham, vice president of human resources at Sun Life U.S. "We also recognized the urgency of acknowledging and addressing racial inequity and inequality in our communities and the country. We have assembled a cross-functional team of employees called Allies Acting for Change, to ensure that we are supporting all aspects of equality within our workforce and our industry." About Sun Life Sun Life is a leading international financial services organization providing insurance, wealth and asset management solutions to individual and corporate Clients. Sun Life has operations in a number of markets worldwide, including Canada, the United States, the United Kingdom, Ireland, Hong Kong, the Philippines, Japan, Indonesia, India, China, Australia, Singapore, Vietnam, Malaysia and Bermuda. As of September 30, 2020, Sun Life had total assets under management of C$1,186 billion. Visit In the United States, Sun Life is one of the largest group benefits providers, serving more than 60,000 employers in small, medium and large workplaces across the country. Sun Life's broad portfolio of insurance products and services in the U.S. includes disability, absence management, life, dental, vision, voluntary and medical stop-loss. Sun Life and its affiliates in asset management businesses in the U.S. employ approximately 5,500 people. Group insurance policies are issued by Sun Life Assurance Company of Canada (Wellesley Hills, Mass.), except in New York, where policies are issued by Sun Life and Health Insurance Company (U.S.) (Lansing, Mich.). Visit



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




BOSTON -- Berkshire Hathaway Specialty Insurance (BHSI) announced that Lauren Finnis has been named Vice President, Customer & Broker Engagement, for the Central Region, based in Chicago. She was previously Vice President of Customer & Broker Engagement for the Eastern Region. “Since joining BHSI in 2014, Lauren has played an integral role in BHSI’s success in building our customer and broker intelligence platforms. Most recently she has been responsible for working with our underwriting team to strengthen customer and broker relationships throughout the Eastern U.S. region. We are excited about the impact Lauren will continue to have on our business, spearheading our growth strategies and deepening our customer and broker relationships in the Central region,” said Lori Spoon, Head of Customer & Broker Engagement, BHSI. Lauren has more than a decade of industry experience. Before joining BHSI, she held various roles focused on broker relationship management and global property underwriting.

Lauren holds a master’s degree in Accountancy from Vanderbilt University and a bachelors degree in Business Administration from the University of North Carolina at Chapel Hill. She holds Associate in Risk Management and Chartered Property Casualty Underwriter (CPCU) certifications. About BHSI Berkshire Hathaway Specialty Insurance provides commercial property, casualty, healthcare professional liability, executive and professional lines, transactional liability, surety, marine, travel, programs, accident and health, medical stop loss, homeowners, and multinational insurance. It underwrites on the paper of Berkshire Hathaway's National

Does managing specialty costs feel like a balancing act?

Script Care’s Flexible Specialty Copay Program (FSCP) offers the best of both worlds. Specialty costs are tricky: Lean too hard on copays and members can no longer afford their medications – leading to expensive medical complications. But if copays are set too low, the plan is left shouldering additional costs for these expensive medications.

Script Care’s FSCP helps navigate this troublesome cost dilemma: Our team of specialists secures every available penny of copay assistance for members and, at the same time, the program reduces the plan’s overall specialty costs by as much as 22%!

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Corporate Solutions You want unparalleled customer service. Employers need the right stop loss coverage. At Swiss Re Corporate Solutions, we deliver both. We combine cutting-edge risk knowledge with tech-driven solutions and a commitment to put our customers first. We make it easy to do business with us and relentlessly go above and beyond to make stop loss simpler, smarter, faster and better. We’re addressing industry inefficiencies and customer pain points, moving the industry forward – rethinking employer stop loss coverage with you in mind.

Employer Stop Loss: Limit Health Care Exposure. Advancing Self-funding Together.

Insurance products underwritten by Westport Insurance Corporations and North American Specialty Insurance Company. Š Swiss Re 2020. All rights reserved.

NEWS Indemnity group of insurance companies, which hold financial strength ratings of A++ from AM Best and AA+ from Standard & Poor's. Based in Boston, Berkshire Hathaway Specialty Insurance has offices in Atlanta, Boston, Chicago, Houston, Indianapolis, Irvine, Los Angeles, New York, San Francisco, San Ramon, Seattle, Stevens Point, Adelaide, Auckland, Brisbane, Cologne, Dubai, Dublin, Hong Kong, Kuala Lumpur, London, Macau, Madrid, Manchester, Melbourne, Munich, Paris, Perth, Singapore, Sydney and Toronto. Visit


Deerwalk’s announces latest release of Plan Analytics, the flagship population health analytics and reporting application that incorporates several new and enhanced features in version 10.6. Plan Analytics is fully integrated with the clinical workflow platform, Care Manager.

• Include/Exclude High Cost Members • Dynamic Benchmarks - “BYOB” Reporting • New! Out-Of-Pocket Distribution Report • Enhanced User Management Configurable Phi/Fi Rules • Include/Exclude High cost Members We’ve added new functionality that makes it easy for users to omit or include high cost members when reporting on or analyzing a population. Either from the Default Settings menu or from the report generation menu, users can elect to exclude high cost members (which is




LEGAL EXPERTISE SECURED | 781-535-5600 | 52


NEWS user defined) from reports or only report on high cost members. This allows users to quickly determine the impact high cost members have on various metrics, such as trend - making for more informed decision making. Dynamic Benchmarks - “BYOB” Reporting Like other analytics vendors, Deerwalk's benchmarking has been based on a static benchmark dataset - meaning that the benchmark results are pulled from a table of pre-calculated values. The Deerwalk commercial benchmark dataset, that is incorporated into our standard reports, consists of over 1,100 benchmark values that contain data from a pre-set 24-month period. Most other benchmark data sources are based on a 12 month period - which is less reliable than a 24 month period. With the launch of dynamic benchmarking, which essentially allows users to build their own benchmark (BYOB) reporting from within the custom reporting Create Module. In other words, users can access unique benchmark values, beyond our standard benchmark values, that can be generated on the fly by pulling data from either the Deerwalk book of business (BOB) or their own BOB data set (if applicable). For example, if you’re building a non-trended Chart report and you select certain value field operators (Average, PMPM, PMPY, PEPM, PEPY, Per 1000, or % of Total), you will be given the option to add benchmark values to the resulting chart. Example reports show the averages for Actual Paid Amount, Prior Period Paid Amount, and Benchmark Average Paid Amount by Relationship Class. Another example could be the ability to quickly determine the average cost of a high cost drug. New! Out-Of-Pocket Distribution Report Users can now access an Out-of-Pocket Distribution Report that allows users to answer questions such as How many members have met their deductible? How many members have met their OOP max? This report can be run on a Subscriber or Member basis for either total Out-of-Pocket expenses or Deductibles. The top half of the report displays population distribution tables and pie charts that show the number of Individual Subscribers and Family Subscribers that (1) hit, (2) exceeded, or (3) spent less than the OOP maximum/deductible that users entered in the option fields. The bottom half of the report displays expense distribution tables and spline charts that reflect average OOP/deductible expenses for subscribers/members with expenses that fell within any of the predefined expense ranges shown in the tables.

Enhanced User Management Configurable Phi/Fi Rules Prior to this release, Administrative users could set up other users with either blinded or unblinded PHI access. There was an ability to define the PHI parameters which Deerwalk could configure behind the scenes. With this release, we’ve put the configuration control in the hands of our clients and expanded these settings to allow Administrative users to choose from Deerwalk curated default PHI and FI (Financial Information) settings or the ability to create multiple custom PHI and FI parameters - and apply at the individual user level. Other configuration options within the User Rights Module include: creating user roles; creating default user permissions; copying existing permissions; granting access to specific groups, functionality, and reports. About Deerwalk, Inc. Deerwalk is an innovative population health management, data management, and healthcare analytics software company based in Lexington, Massachusetts. Founded in 2010, Deerwalk is privately held with over 300 employees worldwide, including a technology campus in Kathmandu, Nepal. Deerwalk Partners with industry leaders responsible for making decisions for the health of a population to optimize costs and improve the quality of care. Deerwalk offers a complete population health management suite built on a foundation of data integrity that delivers reliable data insights and actionable

JANUARY 2021 53

NEWS intelligence. Contact Leslie Ricci, MBA, BSN, RN, Director of Sales, Care Management, at and visit


The company structural changes combine its 50% female-owned status with a 50% female-led organization. ClaimLogiq, a healthcare payment integrity software and technology company, today announced the addition of Jenn Voss as Vice President of Operations and Krystal Vargha as Director of Human Resources and Compliance. These changes to the leadership team make the company a 50% female-led organization and are a result of the accelerated growth experienced by ClaimLogiq in 2020. ClaimLogiq continues to make strategic moves to scale the company and operations amid a heightened demand for their end-to-end payment integrity solutions uniquely offered to the healthcare payer market as SaaS, Services or Hybrid models.

Despite 2020 presenting challenges to many, ClaimLogiq has experienced no disruption in business and is thus maintaining yearend projections for triple-digit revenue growth alongside a record-setting year for software developments. This has paved the way for Mr. Burrus to strategically restructure the company talent landscape for continued explosive growth and tactical scalability. He comments, “We are at an exciting juncture in our company growth and I am honored to be in a position to bring immense talent to the team.” He continues, “The addition of subject matter experts such as Jenn Voss and the movement of already acquired talent such as Krystal Vargha to key positions within the company, adds the best possible quality to our internal infrastructure that will resonate in strength with our products and excellence in service we provide for our clients.”

Mr. Burrus is working to strengthen ClaimLogiq’s mission to deliver a proactive approach to payment integrity for all size healthcare payers and brings with him two decades of BPO experience with a focus on payment integrity in the healthcare space.

As Vice President of Operations, Mrs. Voss will oversee the day-to-day workflows of processes and people and align that directly with company strategic goals to over-deliver on client expectations and meet objectives at above industry-standards.

Mr. Burrus’ career in the healthcare industry is well-suited to the trajectory of ClaimLogiq’s products and services as he is known for his expertise at building successful teams and programs ready for scalability.

Her 17-year experience in the payment integrity field includes claim auditing at Connolly (now, Cotiviti) and following

Mrs. Voss and Mrs. Vargha, amongst others, join a leadership team under newly-hired Chief Operating Officer, Josh Burrus.



NEWS that, Optum - before joining ClaimLogiq. Voss has specific roots in data mining and over payment recoveries spanning both pre- and post-payment modalities and will leverage this focus to grow those product lines within ClaimLogiq. Her previous roles in operations with service-specific focus at the Director level, has the breadth and depth of experience to take on the fast-paced growth of operations at ClaimLogiq at the VP level. “I am beyond thrilled to be joining the team at ClaimLogiq and readily embrace their much-needed fresh perspective on disrupting the payment integrity space, that is already bringing next-generation solutions to their clients.” She continues, “I am excited to be hands-on in a leadership role with a department that is vital to the beating heart of any organization and at ClaimLogiq, a key component to our success with clients. I believe we are poised with strength, experience and fortitude in our values and that these are evident in the products and innovative solutions that we bring to the market empowering our clients to have the best possible outcomes, improving the healthcare industry as a whole.” Joining the leadership team as newly appointed Director of Human Resources and Compliance is Krystal Vargha. She has spent her career in talent recruitment and development and is credited with building the future structure of human talent acquisition and retention at ClaimLogiq. Mrs. Vargha’s new role with the inclusion of compliance is “A perfect fit for her talents and attention to core values that drive ClaimLogiq’s people and product foundation. As we focus our attention to hire the best and the brightest in the payment integrity space, the privacy and compliance standards we uphold for our clients must be the same for those that are charged with delivering these day in and day out,” states Josh Burrus, ClaimLogiq COO.

“It makes great sense to combine our people values and with our product values and more closely intertwine them as they really are, one and the same.” Mrs. Vargha adds by commenting, “I am excited to be in a transformative position within ClaimLogiq where I am empowered to simultaneously grow the number of people who are passionate about making claims logical and share our values of trust and transparency to reflect those in our technology offerings.” She continues “The addition of compliance to my role enhances our ability at ClaimLogiq to service our clients with quality as our first focus when it comes to upholding the strictest of compliance and privacy standards and retaining the right people who are charged with delivering those high standards.”

Voss and Vargha join Burrus, Chief Operations Officer, Justin Hudd, Chief Information Officer, Todd Hill, CEO, Janene Hill, Executive Vice President, Scott Strent, Senior Vice President of Sales and, Rebecca L. Price, Director of Marketing as the newly formed leadership team at ClaimLogiq, making the company 50% female-led. “I am enjoying this exciting growth period at ClaimLogiq and can clearly see the bright future ahead for our company and our clients under this extremely driven and passionate group of people.” states Todd Hill, ClaimLogiq CEO. “I know that the vision we have for our part in transforming the healthcare industry is in good hands as our bench is stacked with subject matter experts and leaders in their fields who are ready to execute our mission to deliver proactive payment integrity and a higher quality of healthcare for all.” Founded by Todd and Janene Hill, ClaimLogiq has been in the business of challenging the norm and disrupting the healthcare space for nearly two decades. ClaimLogiq believes the "black box" model for payment integrity is no longer acceptable – sending claims out for audit and waiting on the results to be delivered after an unknown period of time, without control or insight into the process. As an industry disruptor, ClaimLogiq can offer software and technology with unparalleled accuracy and consistency, agile enough to adapt to each requirement of specific payer and provider agreements. The payer-facing claim-analyzing software provides real-time transparency into the status of each and every claim

JANUARY 2021 55

NEWS and empowers payers to adapt to a proactive approach to payment integrity through complete customizability and client-driven control over the software.

for controlled, consistent, accurate and defensible outcomes, second to none.

The platform can be implemented as a SaaS, full-services or hybrid model giving clients the power to choose how their payment integrity goals are managed.

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 applied as a SaaS model, full services, or as a hybrid, to suit the specific needs of every payer and provider agreement.

ClaimLogiq’s HITRUST CSF® certified solution leverages automation, machine learning and collaboration to support payers' payment integrity programs including Hospital DRG and Itemized Bill reviews, Facility and Professional claims, pre-pay or post-pay recovery programs and data mining. The software performs its extensive battery of claim selection rules and edits without interruption to payers’ adjudication throughput regardless of claim type or volumes. Moreover, TrueCost delivers its audit results with repeatable, predictable results, all of which is managed within a single platform providing industry-leading ROI, bar none. About ClaimLogiq ClaimLogiq is a healthcare software and technology company that delivers a proactive approach to payment integrity through a powerful, simplified solution. The unique payer-facing, claim-analyzing solution is HITRUST CSF® certified and makes claims 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



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.


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

SIEF BOARD OF DIRECTORS Nigel Wallbank Chairman Heidi Leenay President Freda Bacon Director Les Boughner Director Alex Giordano Director

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

*Also serves as Director Please forward any changes to your contact information to Amy Troiano at

JANUARY 2021 57


REGULAR CORPORATE MEMBERS Nicholas Stefanizzi Chief Executive Officer Northwell Direct New Hyde Park, NY





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 2019 Zelis. All rights reserved.

Stability for those balancing risk and reward.

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

CONNECT WITH ONE OF OUR EXPERTS ON OUR 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 (12/20)

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