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MARCH 2019



A Turning Tide Long accustomed to simply helping employers choose among health insurance carriers and earning commissions, benefit brokers and advisers have increasingly embraced self-insured solutions and flat-rate compensation

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Table of contents

MARCH 2019 VOL 125

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


4 The turning tide Long accustomed to simply helping employers choose among health insurance carriers and earning commissions, benefit brokers and advisers have increasingly embraced self-insured solutions and flat-rate compensation By Bruce Shutan

12 Captive Boards and Investing: What You Need to Know

By Karrie Hyatt

ARTICLES 18 ACA, HIPAA and Federal Health Benefit Mandates The Affordable Care Act (ACA), the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other federal health benefit mandates



News from siia members

22 The Self-Funded Case – Back to Basics 32 Pre-Emptive and Analytics-Based Early Action Can Delay Kidney Dialysis, Reduce Plan Costs and Improve Quality of LifE

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

Self-Insurer’s Publishing Corp.

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

MARCH 2019



A Turning Tide

Long accustomed to simply helping employers choose among health insurance carriers and earning commissions, benefit brokers and advisers have increasingly embraced self-insured solutions and flat-rate compensation


he Affordable Care Act has safely secured its place in history as both a lightning rod for discontent and beacon of hope, but the ACA also led the employee benefits brokerage and advisory community to a critical tipping point. Scores of industry consultants have grown tired of seeing fully insured employer clients face soaring premium rate hikes at renewal that they have no control over, observes Doug Layman, president of health and life at Gilsbar, LLC. He says there’s also a realization that highly effective wellness programs, care management and engagement in disease management are game changers in a self-funded environment for reducing presenteeism, improving health and increasing productivity. And it’s trickling down market as never before. As a third-party administrator (TPA) whose average size group is 800 lives, this means Layman is now encountering “brokers and consultants that we’ve never had conversations with before.”




A Turning Tide Jonathan Socko, SVP for East Coast Underwriters, has seen a significant growth of knowledge and expertise in recent years from the brokerage community where self-insurance is concerned. He says industry producers have been able to leverage blocks of business with stop-loss carriers and managing general underwriters (MGUs) to negotiate better deals on behalf of employer clients. In the process, many have transitioned from the role of traditional sales-oriented broker to strategic adviser driven by marketplace innovation. With more movement to self-insurance, One Digital Health has evolved from a traditional benefit broker with commoditized services to “a trusted adviser and business partner” with commission transparency, says George Papagelis, the brokerage’s SVP of specialty health sales. There’s now more emphasis on leveraging client and market insights, as well as data analytics, alongside developing a long-term strategy for value-based plan designs, alternative network options, employee engagement and wellbeing, and other cost-containment programs. “We can clearly articulate the value we bring to the table to meet our clients’ goals and the compensation that we make doing so,” he explains.    Mark Kunkle

Begrudging acceptance

But it wasn’t always that way. Many brokers have begrudgingly accepted selfinsurance to avoid losing clients instead of proactively using it as a tool to help manage their health care spend, opines Mark Kunkle, president of Power Kunkle

“most of us who are fully engaged in analyzing and reviewing self-funded are of the opinion that over time, you will outperform the fully-insured market,” he

Benefits Consulting. However,

says. His firm has been tracking those differences since 2014. For Kunkle’s self-funded level premium consortium block of business, for example, the average annual increase for employer groups with 50 to 99 lives is 10.86%, but if a client applies surplus dollars to offset this cost then the net renewal increase is just 3.9%. A 10% average annual increase for employer groups with 100-plus lives is a mere 1% net renewal if surplus dollars are applied. In comparison, fully insured employers experienced annual increases of 21.19% and 15.34%, respectively, for groups with 50 to 99 and 100-plus lives. What’s drawing more brokers to self-insurance is the demand for transparency and value, as well as a deeper understanding of cost drivers, which may involve unbundling various components of a health plan, according to Robert Relph Jr.,

Robert Relph Jr. president of Relph Benefit Advisors, an Alera Group company. One key part of that equation involves prescription drug costs. He sees growth in the stop-loss captive area where groups with 100 to 500 lives that previously might have been reticent about self-funding can purchase stoploss coverage at a lower attachment point. Kunkle placed a fair amount of selffunded business in the late 1990s and into the early 2000s when stop-loss coverage tightened and self-insured opportunities dried up a bit, forcing many clients back to fully-insured plans. A lot of chatter about the merits of this approach resumed about 2010 with passage of the ACA whose medical loss ratio rules do not apply to selffunded plans and removal of the lifetime maximum spiked claims. Since the 2014 rollout, self-insurance has become increasingly palatable to small and midsize employers amid the creation of level-funded products and captives in the workers’ comp space. A key difference between those timetables is that “we’re astute on how we can build in protections so that somebody doesn’t get chased out of the stop-loss market again,” Kunkle says,

MARCH 2019


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A Turning Tide Health insurance carriers then tweaked their override programs with membership targets. All the major agencies have significant overrides known as “stay bonuses” to ensure that that business doesn’t move, which the source describes as creating “a huge conflict of interest when you’re supposed to be independently representing your customer.”

Arleigh Kennedy

But volume bonuses and overrides paid to brokers from fully-insured health plans have been eclipsed by flat fees and even performance-based compensation involving self-insurance, according to Socko. While the latter arrangement is obviously risky relative to the days of easy commissions, it’s a bold commitment to wresting control over soaring employer-provided health benefit costs.

warning that the pattern could resurface. “There are some things out there that you can do to protect yourself.”

“Ultimately, it’s promoting transparency, which is something that we’re trying to do in the medical and insurance world to begin with, and I think a lot of that has trickled down,” he says.

Brokers have long embraced fully insured arrangements with easy

At least 90% or more of his new clients in the past 18 months are brokers and advisers who have become more educated about their client options and savvy at negotiating stop-loss terms. This has actually enhanced, rather than diminished, relationships with TPAs.

“because it was the path of least resistance,”


notes Arleigh Kennedy, SVP for Evolution Risk Partners. Some continue clinging to this vision. When previously working for a Blues plan, she recalls how a broker requested a 35% commission for moving an employer client from a fully-insured

“He wanted to get the same commissions,”

“I have discussions almost every week with advisers who want to know who our preferred TPAs and cost-containment vendors are,” Socko reports. “There can be challenges to working with TPAs or vendors that we do not have an existing relationship with, so our input is sought after quite often.” In many instances, the result is a more collaborative approach wherein he has helped advisers convert employer groups out of fully-insured plans and explored common ground on the best possible pairings.

to self-funded plan.

she quips. Every time fully-insured plan premiums increase, broker commissions also balloon. This phenomenon essentially means their pay is commensurate with the pain points of those employer clients, observes the head of a TPA who asked not to be identified. “Brokers who had the fully-insured business lost it to somebody else, and they realized that the market dynamics shifted and they would have to change their ways,” he says, noting the rise of flat fees and payments on multiple platforms.

MARCH 2019


A Turning Tide

“The former broker who was getting that money no longer has it,” he explains, “and so 33% of a fixed number vs. 66% of a number that no longer exists, I’ll take it all day, every day.”

Jonathan Logan

“If you’re in stop loss and want to work with more advisers, I think you need to have some of that upfront discussion about what’s going to happen to any given case,” he suggests. “There is definitely a greater comfort level if I know that they want to pair a piece of business with an administrator or a subset of costcontainment vendors that we already have a relationship with or have vetted.”

Value in flat fees A growing realization that large health insurance carriers struggle to control costs has eroded that comfort level, according to Kennedy. They’re increasingly seeing greater value in charging a flat consultative fee and working harder to earn a client’s trust. Large brokerage houses that were once reluctant to work with MGUs now believe they’re more creative and in tune with claims management and Rx programs than some of the big direct-writer carriers, she observes. Jonathan Logan, president of Logan & Associates, accepted a 66% pay cut moving a BUCA group to a self-insured deal with a TPA because it was the right thing to do for that client.



As someone who has long been comfortable charging employer clients a flat-rate consulting fee or generating revenue on a per-employee-per-month basis, Kunkle values the importance of fee transparency and fair compensation. “When you’re getting a 32% increase in your fully-insured premiums, does that warrant a 32% increase in your fees? Probably not,” he says. Relph prefers to strip out all his compensation relative to stop-loss, Rx and other sources in favor of a direct fee based on the specific Doug Layman services and resources delivered to each client. This enables him to better “add straight value” to clients and is in more line with his approach to business. Interestingly enough, his firm was also moving in that direction for insured clients in his home base of New York, but the state’s Department of Financial Services prohibited brokers from doing so. “Carriers had to pay according to their filed commission structure,” he adds. Indeed, regulatory restrictions at the state level obviously will shape an adviser’s business. Stop-loss coverage cannot be written for groups of 100 or fewer lives in New York. As such, most of his self-funded clients have tended to be in the 1,000plus lives range.

Keep it simple One caveat for industry producers is that they avoid unnecessary layers of complexity aimed at complementing a self-funded plan, which can create confusion.

“There’s so much of that stuff out there that it becomes difficult for the employer and their employees to understand it,” Layman cautions. Examples include specialty network carve-outs, cash-pay strategies, level-funded plans and reference-based pricing, all of which he supports in certain situations depending on the employer’s needs. Layman says each of these solutions must be delivered and designed appropriately with three goals in mind: keep in simple, lower costs and improve health outcomes.

A Turning Tide Noting that self-funding isn’t a silver bullet or necessarily the best solution for all small employers, Layman believes it’s the right strategy in many cases. But ultimately he says “it’s about each employer and their situation.” Kennedy’s former sales colleagues at the Blues plan she worked at often would crow about improving the member experience, but never would cite specific examples in terms of better cost control

“The days of just sitting back and letting the BUCA carriers handle things have long gone,” she says. “We’re seeing a turn back to the TPA marketplace where people really want to control the cost of their health care.” than self-insurance.

Producers are gradually realizing the possibilities are virtually endless with self-insurance. Kunkle’s firm, which offers self-insurance to clients with as few as five employees, has its own wellness division that conducts biometrics in conjunction with various program initiatives. He describes patient responsibility as missing from the health plan management equation, along with a need to better educate patients about their disease or condition so they can ask better questions and ultimately enjoy a higher quality of life.



Since many TPAs and insurance companies continue to use the broker and consultant sales channel, the anonymous TPA source from earlier suggests a need for “more accountability and direct relationships with HR and benefit directors at companies.” His prediction is that more CFOs will need to be dialed into the mix to help rein in health insurance costs as a rising business expenses. Given that as many as 60% of companies with 50 or more employees nationwide self-insure, Logan says it behooves fellow brokers and advisers to consider these solutions. “We’re talking about something that is as common as breathing, and more and more employers are embracing it for just a whole lot of reasons,” he notes.

Bruce Shutan is a Los Angeles freelance writer who has closely covered the employee benefits industry for more than 30 years.

SIIA panel to weigh deeper broker role

Growing broker and adviser activity in the self-insurance marketplace will be a hot topic of discussion during a SIIA conference panel March 18-20 in Charlotte. N.C. The session, “Beyond Disruptors and Rock Stars – Let’s Talk Execution,” will examine how effective execution and coordination can make all the difference when transitioning employers into self-insurance or making substantive changes to a plan. This panel will share success stories and address areas where there’s room for improvement on how brokers and advisers, TPAs and stop-loss carriers can team up to serve the best interests of plan sponsors. Speakers include Mark Gaunya, co-owner and chief innovation officer of Borsilow Insurance; Kevin Trokey, founder of Q4intelligence; Jim Rinere, president of CWI Benefits, LLC; and Arlene Cayetano, managing member, president and CEO of Greymatter Risk Management, LLC.


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We’ve got your back. Four words that anyone seeking to self-fund healthcare benefits needs to believe, particularly when contemplating the financial risks associated with catastrophic medical events. That’s why we’re firm believers at Swiss Re Corporate Solutions in building strong relationships, understanding exactly what our partners expect of us, and creating innovative ways of fulfilling those expectations. By working closely together, we combine our expertise and capabilities with our brokers, payers and advisors to provide enhanced value for your clients – not to mention extra peace of mind. When it comes to employer stop loss solutions, now, more than ever, we’ve got your back. We’re smarter together. Insurance products underwritten by Westport Insurance Corporations and American Specialty Insurance Company. © Swiss Re 2018. All rights reserved.


Captive Boards and Investing: What You Need to Know


he Directors of captive Boards have fiduciary duty to effectively handle the claims made against the company, but they also have a fiduciary duty to make the best possible decisions in the management of the companies’ assets. Captive Board Directors don’t often have any expertise, or a lot of interest, in insurance asset management. This leads many Directors to concentrate on the liability side of the captive, putting little or no time into the company’s investments.

That is a mistake. A captive Board needs to be active in the development of an investment policy, be well-informed about hiring an investment manager, must look deep into asset allocation, and above all be on top of getting the most out of the captive’s investments each year.




Captive Boards and Investing Building an Investment Policy

No captive should be without an investment policy. An investment policy helps define a captive’s investment goals by clearly stating long-term objectives and the investment structure needed to meet those objectives. A well-developed investment plan will also help the investment manager to meet to the needs and interests of the captive. It’s important to have an investment policy in place before hiring an investment manager, otherwise that person is likely to bring in their own biases, which may not necessarily align with what the captive is looking for. Another important part of creating an investment policy is to approach it from an enterprise risk management (ERM) viewpoint. So often an investment plan is created separately from the rest of the business. “Investment decisions are usually done in a silo rather than by correlating them to activities on the liability side of the balance sheet,” said Carl Terzer, principal of CapVisor Associates, LLC. “Often we see captives that don’t properly define their investment objectives and risk tolerances. They don’t correlate their investment risk with their liability risk as proper use of ERM and Asset Liability Management (ALM) techniques would require.”

When building an investment policy, a generic, boilerplate plan won’t serve. The most basic objective, ‘to earn as much money as we can with as little risk as possible’, is near-sighted. It doesn’t take into account the different types of assets being invested nor does it pertain to the different risks associated.

The captive’s Directors, “Should articulate their objectives and their risk tolerance in their investment policy statement by portfolio segment,” continued Terzer. “The liquidity component of their portfolio is used to play current claims and their operating expenses. That segment has a unique investment objective: that of preservation of principal. You can’t afford a loss there because it basically has to be cash or cash equivalents. Then you have the reserve component. It’s actuarially determined how much you need to “reserve” to be able to pay your claims. That reserve is usually invested in investment grade, or very high-quality bonds. Whatever is in excess of the liquidity and reserve components, that is your surplus which typically receives most of your risk budget allocation and can be invested in a variety of risk assets.”

The captive’s investment policy needs to be built around the three parts of the portfolio—liquidity, reserve, and surplus. Each of these parts needs to be given a different investment objective because each one has a different risk tolerance.

While one investment policy might seem hard to put together, three can be daunting to a Director with little experience in finance or insurance. But with the advent of computer modeling, the creation of a highly specialized investment plans is easier than ever. With the help of an investment consultant, the captive can have access to hundreds of investment strategies that can be modeled to find what mix of risk tolerance best fits the captive’s needs.

Selection of the Asset Manager

While a captive is an insurance company, and risk and claims are the bread and butter of an insurance company, successful asset management is what keeps the company moving forward. With a specialized investment plan in place, the captive Directors need to work with an investment manager who has a deep understanding of investing for the needs of an insurance company.

Not all asset managers are alike. There are those that specialize in wealth management or pension management. There are those that best understand investing for individuals and those who specialize in company assets. To haphazardly choose an asset manager based on the recommendation of a colleague or choosing one that other captives use, is not the most diligent way to choose a manager. Captives usually form because standard insurance doesn’t work for the owners, so why use a standard asset manager?

MARCH 2019


Captive Boards and Investing Captive Directors need to make sure they understand the difference between wealth management and insurance asset management. They need to consider how involved they want to be—whether they are going to be monitoring their investments quarterly or if they are more interested in where they will end up in three to five years. An investment manager that is unfamiliar with insurance assets, specifically those of captives, will not be able to help determine the best way to allocate available assets. Directors need to select their manager based on what their needs are and how, specifically, the manager can meet those needs. There are more than 3,000 investment managers in the U.S. with, according to Terzer, 20,000 investment strategies to choose from. To find the best manager for the captive, there are several national databases, such as OSN and ENVestNet, that can compare investment managers based on a selection of criteria.

In addition to an investment manager, hiring an investment consultant or advisor can help bypass any conflicts of interest that may come up if the investment manager is also the captive’s investment advisor. Working only with a manager presents several potential problems.



The first is that the investment manager will set their own benchmarks, which is not helpful to Directors trying to understand the success, or set-back, of their investments. Another issue is that a manager won’t recommend an investment product that could send their business elsewhere, but as a client the captive Board will never know that without an additional advisor.

Without a third-party advisor or an investment-wise Directors, one thing that a Board can do is ask the right questions. A good way to do this is to pick five key metrics, that are understandable to the members of the Board or related directly to the captive’s investment policy. These can help the Director’s ask the right questions to determine the adequacy of

STEVE KINION, DIRECTOR Bureau of Captive & Financial Products Delaware Department of Insurance

Delaware Licenses 46 Captive Insurers in 2018

Conditional Licensing System Very Successful Captive insurance formations faced a number of challenges in 2018, due to recent changes in tax law. Despite the headwinds, Delaware’s having knowledgeable captive regulators continues to attract quality applicants. Delaware is the fifth largest captive domicile in the world, and 3rd largest in the U.S. It is only one of four captive insurance domiciles that is ICCIE (International Center for Captive Insurance Education) trained. Its captive insurers generate more than $12.5 billion of annual captive insurance premium. We are committed to licensing captive insurers with sound business plans formed by reputable individuals. I thank my captive team for its hard work to make Delaware a leading captive domicile. I attribute 2018’s success to the newly enacted conditional licensing legislation. Delaware is the first state in the nation allowing electronic filing of a conditional license. It permits the issuance of a conditional license to a captive insurance applicant on the same day as the application submission. Of the 46 licenses issued in Delaware, 30 were conditional licenses. It allows speed to market for issuing a license, while at the same time maintaining regulatory integrity and safety. It is only available to certain captive managers who satisfy specific standards set by the Department of Insurance. If an approved captive manager needs a captive insurance license by a certain date, then they are encouraged to seek a conditional license.

Trinidad Navarro Insurance Commissioner


Delaware Department of Insurance 1007 Orange Street, Suite 1010 Wilmington, DE 19801 302-577-5280 Trinidad Navarro, Insurance Commissioner

Captive Boards and Investing an investment manager. It will take some research but can help determine how good a manager will be for the captive.

In choosing an asset manager, it comes down to understanding that captives are a unique niche—both in insurance and in investments—and will have specialized needs. A captive needs to hire advisors and investment managers that have a deep understanding of the insurance landscape and know how maximize investment yields while minimizing the risk.

Strategically Allocating Assets

Deciding on how a captive’s assets are apportioned amongst various asset classes is, by far, “The most important decision a board will make. It accounts for more than 90% of the portfolio’s long-term returns,” according to Terzer. Captive Directors need to be knowledgeable about the different types of investments available and what the risk appetite of a captive should be.

A captive’s investment strategy needs to ensure that cash flow will adequately cover any claims while yielding the best possible returns. Captive Boards must take forward action to determine the best mix of investments and not take the most obvious, and easiest, investment route. Many times, captive Boards go with fixed assets and bonds as the most responsible way of investing the



captive’s assets. However, this narrow view will only get so-so results. They may earn a solid 5% a year, but there are lots of other types of investments that are not as conservative that will have a higher yield. A multi-asset approach to investing will spread the risk and allow for better returns. Investments in equities, alternative credit, and property are solid ways to spread the investment risk.

Terzer believes that a “Board should not make an asset allocation decision without some kind of analytic foundation for making that decision.” There are several approaches to doing this type of analysis, but one of the most useful is a Dynamic Financial Analysis (DFA).

Recommended by the Casualty Actuarial Society, a DFA is a computer simulation that looks at an insurance company’s risk on an enterprise-wide scale rather than the traditional way conducted by actuaries that analyzes each risk individually. A DFA can be expensive, so might only be reasonable for a large captive. However, there are simpler systems that can aid small to medium-sized captives properly allocate their assets.

Leaving No Money On the Table

What an investment policy, the right investment manager, and strategic asset management together lead to is a Board that is proactive on the investment side of their captive. When a Board goes with a boilerplate plan, an investment manager that isn’t a good fit, and develops their asset allocation on the back of a napkin, those Directors could be missing important opportunities—they could be leaving money on the table because investments have become an afterthought.

Captive Boards and Investing “[Directors] are never held accountable because no one knows how much money they’ve lost, or not earned by maintaining an inefficient asset allocation,” said Terzer.

Investment management isn’t just a one-time duty. Investments should be reviewed quarterly and the investment policy should be revisited once each year. The financial market can undergo a lot of changes in a year, as can a captive’s liquidity and claims outlook, so the program needs to change with both internal and external conditions. A bad claims year with a loss carried forward means that it might be time to take some of the risk out of the captive’s portfolio. After a few years, the surplus might be built up, so the investments could take on more risk.

What it comes down to is that investment risk is as important as liability risk and should be given equal consideration by a captive’s Board. Unfortunately, there is no way to measure how much better a captive’s investments could be doing if the Board were paying closer attention.

Karrie Hyatt is a freelance writer who has been involved in the captive industry for more than ten years. More information about her work can be found at: www.

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MARCH 2019


Q A Q & A &




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



A Texas Court Says the ACA is Unconstitutional! What Does It Mean?

the ACA individual mandate was unconstitutional. The case went to the Supreme Court, which found that the mandate was constitutional because Congress has the authority to impose taxes. The 5-4 decision also found that the provision was not a tax for certain statutory provisions;

Perhaps Back to the Future, but Nothing for Now.

A federal district court judge in Texas made headline news in December 2018 by ruling that the Affordable Care Act (ACA) is unconstitutional and therefore invalid. The decision has already been appealed and will likely eventually be decided by the Supreme Court.

A final decision in the case – which could either uphold the ACA or find some or all of it unconstitutional – will take some time with a final resolution likely in 2020 or beyond. The ACA remains in effect while the court case works its way through the appeals process.

Thus, employers and insurers must continue to comply with the ACA. This article provides a high level overview of the court case and potential long-term implications.

How did we get here? The law suit centers around Congress’ recent repeal of the ACA individual mandate, which imposed a tax penalty on individuals that don’t have qualifying coverage. A little bit of history helps to explain the law suit:

In 2012, the National Federation of Independent Businesses (NFIB) and 26 states brought a law suit arguing that

In 2017, the Republican controlled Congress considered a number of different bills that would have repealed and replaced the ACA, but was not able to pass any overall repeal legislation in the Senate.

At the end of 2017, Congress passed the Tax Cuts and Jobs Act (TCJA), and the President signed it into law. The TCJA reduced the tax penalty for failure to have qualifying coverage to zero starting in 2019, while keeping the “mandate” to have coverage in the law. As a practical matter, for individuals, reducing the penalty to zero and eliminating the “mandate” are the same; however, the fact that the “mandate” remains in the law has become a core issue in the current lawsuit.

After enactment of the TCJA, Texas and 19 other states sued the federal government, arguing that the TCJA change reducing the penalty to zero means that the individual “mandate” is no longer a tax and is therefore unconstitutional. Further, because the rest of the ACA is so intertwined with the mandate, all of the ACA is unconstitutional. The lower court federal judge in the case agreed, but has “stayed” the decision, meaning that it is on hold until the case goes through the appeals process. The case will likely end up in the Supreme Court.

What do employers need to do now? The short answer – nothing. Because the district court decision has been stayed pending appeal of the case, the ACA remains in effect. It is expected to take some time for the case to work through the appeals process; a final decision is not expected until 2020, and could be later. As the lawsuit works through the appeals process, employers and insurers need to continue to comply with the ACA, including the following requirements:  Employer penalties for applicable large employers that fail to offer affordable, minimum value coverage to full-time employees and dependents

 Dependent coverage to age 26

 Coverage of essential health benefits (small group)

 Pre-existing condition protections

 Required 100% coverage for certain preventive care

 Metal tier levels/minimum value

 Out-of-pocket limits

 No annual or lifetime dollar limits

 ACA employer reporting requirements under IRC 6055 and 6056

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Regardless of how the law suit turns out, starting in January 2019, there is no penalty for individuals who do not have qualifying health coverage.

other aspects of plan coverage (e.g., imposing dollar limits on certain benefits). ERISA does not preempt State laws that apply to insurance, so that health insurance issuers providing coverage under group health plans are required to comply with State-law mandates. Many States have adopted legislation to implement the provisions of the ACA.

What happens if the ACA is ultimately held to be unconstitutional? We can’t really know the answer to this question unless and until such a decision is reached, which will most likely be by the Supreme Court. However, it is possible that a final decision could potentially hold all of the ACA unconstitutional or just certain parts.

If some or all of the ACA health coverage mandates are held unconstitutional, then employers will have new plan decisions to make. For example, some employers may decide to keep in place certain provisions that have become very popular, such as coverage of certain preventive care services without cost sharing and coverage of dependent children to age 26, while re-adjusting


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Thus, even if all of the ACA is struck down by the Supreme Court, State laws implementing the ACA may still be in place. Depending on the specifics of the State legislation, action of the State legislature may be required to undo the ACA implementing legislation.

Plans that are not subject to ERISA, such as self-funded church plans and governmental plans, also need to consider State law. In the case of fully insured plans, policy and contract terms will need to be taken into account when an employer is considering plan design changes if the ACA is struck down

Tax Provisions In addition to the coverage mandates addressed above, repeal of the ACA would also undo many of the ACA tax provisions including the following.

Employer Mandate to Provide Affordable Minimum Value Coverage and ACA Reporting: If the ACA is repealed, the employer responsibility requirement to provide affordable minimum value coverage and excise taxes (under IRC 4980H) would be

repealed as well as the associated ACA reporting requirements under IRC 6055 and 6056.

Prohibition on reimbursement of over-the-counter (OTC) medicines: Under the ACA, OTC medicines and drugs could not be reimbursed tax free without a prescription. If the ACA is repealed, tax-free OTC reimbursement from group health plans, health FSAs, HRAs and HSAs would again be permitted.

Conclusion The federal district court ruling has sparked a lot of media attention, but for now, the ACA is in effect. It will take some time for the case to wind its way through the appeals process, and a final decision is not expected before 2020. Employers may want to start considering what sort of plan decision changes they would make if some or all of the ACA is eventually held invalid, but for now employers and insurers must continue to comply with the ACA.

$2,500 cap on salary reduction contributions to health FSAs: A decision striking down all of ACA would repeal this cap.

W-2 reporting: The ACA requires that the value of health coverage be reported on employees’ Forms W-2. This is a reporting requirement only; it does not affect employees’ tax liability. This requirement should no longer apply if all of the ACA is struck down.

Cadillac plan tax: Although the Cadillac plan tax is not effective until 2022, many employers have already been reviewing their plans to determine if the tax would apply. If all of the ACA is struck down, the tax will not go into effect.

MARCH 2019


The Self-Funded Case – Back to Basics


Written By Tim Callender, Esq., Vice President, Sales & Marketing, The Phia Group


elf-Funding – So Many Toys in the Sandbox

Not to criticize our industry, in the least, but if we are being honest, we should all agree that it takes thousands of “parts” to make this “car” run, so to speak. This fact has its positives. An industry chock full of numerous stakeholders does lead to incredible innovation, teamwork, healthy competition, creative solutions, and the general strength that comes with an industry steeped in camaraderie. Likewise, this reality of many stakeholders can also create confusion and distraction unless we are paying close attention and working to block out the noise. The typical self-funded case will likely have a list of stakeholders that include (in no particular order & I am sure to leave something / someone out):



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• The broker / consultant • The employer, plan sponsor • A benefits committee and/or benefits decisionmakers within the plan sponsor

• A third-party administrator or a carrier ASO platform • A plan document solution provider • A pharmacy benefits manager • A specialty Rx cost containment solution provider • A case management / utilization management solution provider • A concierge and/or centers of excellence solution • A stop-loss carrier / managing general underwriter • Internal legal counsel • External legal counsel • Legal counsel for all the solution providers • A dialysis cost-containment solution provider • A claim re-pricing solution provider • A network • A wrap network or wrap network alternative • A claim negotiation solution and/or patient advocacy solution provider • A data analytics platform • A claims auditing solution provider • A number of independent review organizations • A subrogation and recovery solution provider • And many, many, more…. (I felt the bullet points were becoming excessive – time to stop)

In short – there are many, many toys in this sandbox of self-funding.



So…. How About, Back to Basics? As discussed, there are an incredible number of stakeholders in the selffunding sandbox. To reiterate, this is not necessarily a bad thing, but it can steer us away from the fundamental basics and core needs of our industry, which can lead us astray from the root goal. What is that goal? In short, most self-funded plan sponsors are going to tell you that they entered into the self-funded space for two reasons: (1) to bring the costs associated with their health plan down; and (2) to have the creative control needed to deliver topnotch health benefits to their employees and their families. Not to take away from the importance of the newest healthcare-related iPhone app, or the newest, innovative methodology behind case management, but sometimes it is important to step back and focus on the basics of this complex, self-funded system. Whether from the outside looking in, or deeply involved in the self-funded industry, all viewers should agree that this industry – this system – is definitely a complex one, as noted by the copious bullet points listed above. To wade through the complex and try to identify the key roots of a successful self-funded case is not only a noble pursuit but should be a point of pride for all in this space. With the roots in place, all of the other, more complex solutions can fall into place and will do so with a much higher likelihood of success. While like minds might rightly differ on the key elements that lead us toward the goals discussed above, I would list out the five most important roots that push the goals of driving down costs while delivering great benefits as follows:

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(1) A well-written and understandable plan document.

(2) A vested “benefits committee” or other decision-making body housed within the employer Plan Sponsor.

(3) An educated and empowered consultant.

take advantage of the beneficial medical tourism program? Not only does the plan sponsor run the risk of implementing benefit structures that may cause legal problems, since they are not outlined in the plan document, but the plan sponsor will most surely lose out on gaining the benefit of these innovative solutions. Not to mention paying claims outside the terms of the plan’s stop-loss policy. Without a well-written and understandable plan document, the it is pointless to pursue more complex solutions and the goals of cost containment and rich benefits will surely never be met.

(4) A partner-focused third-party administrator.

(5) A well-oiled subrogation and recovery platform.

The All Powerful and Governing Document Without a plan document, what is a self-funded plan, truly? It is a nebulous financial instrument, or bizarre oral contract slightly memorialized by HR emails and broker notes that exists without clear guidance or application. Yet this plan is still subject to incredible responsibility and liability. Needless to say, not only is having a plan document a good idea (if not required, depending on how you read the law) but it is an even better idea to have a well-written and understandable plan document. As discussed above, many plan sponsors become enamored with new and innovative solutions, ranging from specialty Rx cost control to a medical tourism program filled with plan member incentives. These are wonderful solutions that may yield outstanding results – but what if the plan document does not properly support and outline the specialty Rx program? What if the plan document fails to provide clear instruction to the plan member on how he/she can



The Heart & The Brain Every employer plan sponsor should have a benefits committee in place, whether the committee is made up of 3 people or 15 people. Too many employers rely solely on the expertise of their consultant and “pass the buck,” so to speak, when it comes to truly understanding the ins and outs of their self-funded plan. Not to say that relying on a consultant is a bad thing – that’s why they exist! However, as any expert will tell you, the expert’s job is always easier when he/she is advising an educated consumer. An educated plan sponsor, backed by a benefits committee full of diverse knowledge and expertise, and advised by an industry expert consultant, is already leaps and bounds ahead of the rest when it comes to the ability to choose and implement solutions that will lead to cost savings and rich benefits. Not to mention, the committee can share the labor burdens associated with running a self-funded health plan. Like, working together to finalize that plan document!

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The Partner A sophisticated plan sponsor, governed by a benefits committee and advised by an expert consultant, should next seek a true partner in its third-party administrator. Plan sponsors can sometimes fall victim to regionalism or sticker attraction (seeking out the lowest administrative fee), which may not always lead to the best payor partner for that particular plan.

Additionally, a benefits committee increases the chances of a plan successfully implementing a complex solution. Let’s use an out-of-network, referencebased pricing solution as a singular example. Such an innovative and disruptive program does not stand a chance if there is not employee / member buy in and understanding. There will likely be balance billing and “scary” situations which will lead plan members to bring the noise, so to speak, directly to HR. This noise can quickly cause enough pain that the plan sponsor will choose to abandon an otherwise legitimate and beneficial program. But. What if a savvy, vested, and educated benefits committee existed, at the employer, plan sponsor level? Imagine the education and communication opportunities that could exist – imagine the opportunities to work with the plan members, ask critical questions of the vendor, and course correct when needed. A benefits committee, whether small or large, will move a plan closer to its goals of containing costs and delivering rich benefits, every time. Likewise, it takes the industry expert consultant to advise this bought in committee and bring them the solutions and ideas that they may not be aware of, that they can then interpret and execute, on their own terms. To repeat: the vested benefits committee plus the expert consultant = reduced plan costs and the implementation of solutions to drive rich benefit delivery.



Instead, plan sponsors and their consultants should begin by clearly understanding and defining their own needs and their own goals. They must do this first before trying to find the right payor partner. Is the plan focused on a strong network? An in-house dialysis solution? Is a domestic call center presence important? What about reporting capabilities? What does the account management model look like and how involved will they be with enrollment meetings and finalizing the plan document? Will the payor listen to the plan’s recommendations and needs regarding stop-loss? The list goes on. Needless to say, combining a thoughtful benefits committee, with an expert consultant, and a true partner-oriented payor, will allow for a plan to truly innovate and successfully put solutions in place that will meet the plan’s goals.

The Money at The End of The Chain In thinking on the goals of driving costs down while delivering great benefits, there is one area that provides a clear “win.” Subrogation and recovery efforts. Why is this the case? In efforts to contain costs, many plans go straight to the overly advertised, upfront, disruptive solutions that may drive costs down before costs are incurred. Many of these solutions have merit and bear fruit! But plan sponsors should not lose sight of the big recovery win that is available through a robust subrogation and recovery platform. Especially now, where copious opportunities exist to seek the recovery of plan dollars on so many fronts.

Traditionally, most plans would focus their recovery efforts on the routine motor vehicle accident – the benchmark example of third-party liability. Anymore though, alongside these benchmark MVAs, plans should be considering other sources of third-party liability, such as torts, product recalls, and class actions. The list, and opportunities, go on. Additionally, whether governed by ERISA or state law, or a combination of both, all self-funded plans are bound by some level of fiduciary duty. Instead of quoting federal or state law, the gist is this: plan fiduciaries must behave prudently with plan assets, which includes how the fiduciaries spend plan assets, don’t spend plan assets, or get plan assets back! To this end, it is easy for a plan sponsor to focus on asset expenditure and upfront plan savings, while forgetting about recovering dollars from a third party. This is understandable! Upfront expenses and upfront plan savings are exactly that, “upfront!” But, the concept of chasing around a third party, sometimes for years, in an effort to return plan funds back to the plan – well, it is easy to see how this concept can fall by the wayside and become easily forgotten.

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Yet, maximizing recovery efforts should be just as important to a plan fiduciary as the more routine, upfront savings and expenses that usually take priority. Seeking to assure that subrogation and recovery efforts are maximized is an important obligation of every plan fiduciary. Not to mention, returning plan assets into the plan’s coffers means costs can be kept down and the plan can reinvest those dollars in other areas that might lead to that richer, more robust health plan.

Tim serves as the Vice President of Sales and Marketing for The Phia Group, LLC. Prior to his current role, Tim served as a health care lawyer, staff attorney and lead PACE counsel for The Phia Group. Before joining The Phia Group, Tim spent years functioning as in-house legal counsel for a third party administrator. Tim is well-versed in complex appeals, plan document interpretation, stop-loss conflict resolution; keeping abreast of regulatory demands, vendor contract disputes, provider negotiations, and many other issues unique to the self-funded industry. Tim has spoken on a variety of industry topics at respected venues such as the Self-Insurance Institute of America (“SIIA”), the Society of Professional Benefit Administrators (“SPBA”), the Health Care Administrator’s Association (“HCAA”), and the National Association of Health Underwriters (“NAHU”). Tim currently sits on the Board of Directors for HCAA as well. Prior to his time as a TPA’s in-house counsel, Tim spent many years in private practice, successfully litigating many cases through full adjudication or to resolution through mediation or arbitration. Tim received his Bachelor’s Degree from The College of Idaho, prior to obtaining his Law Degree from The University of San Diego School of Law. Tim operates out of The Phia Group’s western office in Boise, Idaho.

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Pre-Emptive and Analytics-Based Early Action Can Delay Kidney Dialysis, Reduce Plan Costs and Improve Quality of LifE Written by Barbara Rutkowski, EdD, MSN, CCM - Vice President, Clinical Operations, Advanced Plan for Health & Joy McGee-Cory - Senior Vice President, Advanced Plan for Health


t is time to disrupt the business-as-usual paradigm of waiting until a member “triggers” for medical management intervention because they use the emergency department excessively, take high cost medications, have a hospital admission or have high dollar claims. Early intervention is the key to slowing or stopping chronic kidney disease (CKD), improving the quality of lives for those at risk and containing health plan costs. Avoiding dialysis for just one member represents a health plan savings of $350,000 to $700,00 per year, which more than pays for the CKD program by itself. A well-reasoned, proactive kidney disease management program is a necessity, not a luxury.



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Once dialysis starts, the self-insured employer will pay these costs for 33 months after outpatient dialysis is initiated because when health plan members have private insurance, this payer is always primary for medical care, even during the coordination period where dialysis patients are waiting for Medicare benefits. After that time period, Medicare takes over if the individual member has made a timely application. When a member does become primary on the Medicare dialysis program, the employer is no longer the primary payer of the dialysis patient. Caveat: The failure to monitor a dialysis patient to be sure they have enrolled successfully and timely in Medicare means that the employer keeps paying for dialysis instead of Medicare becoming the primary payor. Medicare will not send a reminder, and Medicare will not reimburse these extra health plan payments for the member on dialysis. Who should be tested for possible CKD? According to a video produced by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)1, those with diabetes, hypertension, family history of kidney disease or heart disease are at higher risk of developing CKD. Obesity is also a contributing factor, but blood pressure control is one of the most critical factors in controlling kidney damage. The risk for CKD is also magnified for those of African American, Hispanic or Indian descent. Finding at-risk individuals early is critical, since CKD does not have any discernible symptoms until kidney disease is advanced. By the time, symptoms appear, there is often permanent and severe kidney damage.

Early Detection and Aggressive Management is Vital The American Kidney Fund published an overview2 of which tests show that kidneys are not working properly. A simple urine test is done to check for protein or blood, which indicates that there is an acute or lasting problem with your renal system. Providers will also draw blood to check creatinine levels, to show how kidneys are filtering waste from the blood.

Blood pressure will also be tested to see how hard the heart is working to pump blood throughout the body and through the organs. High blood pressure can be caused by kidney disease and likewise kidney disease can cause high blood pressure. Blood sugar will also be evaluated, since diabetes control helps kidney function. Once these test results are in, a good consumer-facing reference tool on interpreting test results is available from the National Kidney Disease Education Program (an initiative of the National Institutes of Health (NIH)). Their very simple handout for use in helping individuals understand the tests for kidney disease is called: “How Well are Your Kidneys Working: Explaining Your Kidney Test Results�3.

Spotting the Symptoms and Finding the Individuals with CKD More than 30 million people in the USA are living with chronic kidney disease4 – which is defined as lasting kidney damage that worsens and ultimately may end in kidney failure. When the kidney failure is permanent, the individual must be on dialysis or have a kidney transplant to live. When kidney damage is severe, there may be symptoms because of the waste and extra fluid building up in the body. These symptoms include: Itching; Muscle cramps; Nausea and Vomiting; Swollen feet or ankles; Sleeping difficulty; Loss of appetite; Excessive or diminished urine output and Trouble breathing. Did you know that damaged kidneys can also cause anemia, poor bone health, heart disease and fluid accumulation5 causing a whole host of other health



problems that create human misery, loss of productivity and high health plan costs? Advanced and predictive analytics systems that combine medical and pharmacy claims as well as labs, biometrics and more for current state and predictive visibility can greatly assist employer clinical resource professionals such as Nurse Navigators and chronic condition managers in finding persons with metabolic syndrome, diabetes, heart disease and kidney disease so they may address predicted risks and close care gaps to improve financial and clinical outcomes. Some individuals can reverse their kidney disease, whereas others will be able to delay the progression of kidney failure. When employers deploy resources to intervene early to help their employees and members to control blood sugar, weight and blood pressure, and encourage a healthy lifestyle and compliance with the physician’s treatment plan – individuals will be able to stabilize and improve health and quality of life which can help to avoid progression of kidney disease.

The Art and Science of Nurse Navigation and Coaching Intervention The NIDDK has published a five-part series on chronic disease nutrition and management training6 for Nurse Navigators and Nurse Health Coaches working with the at-risk population to avoid or slow the progression of end stage renal disease (ESRD). This series is highly recommended as a basis for understanding CKD, helping at-risk individuals, and having useful tools and tables that apply to all stages of the disease.



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The key is controlling risk factors, modifying the lifestyle and nutritional patterns, and closely monitoring disease progression so that targeted intervention is possible. Other helpful tools include the consumer handout called “Eating Right for Kidney Health: Tips for People with Chronic Kidney Disease CKD”7, which is a simple, effective tool from the National Kidney Disease Education program for individuals trying to address their CKD.

Proactive Intervention to Minimize Risk and Cost Since End Stage Renal Disease (ESRD) and dialysis can be so expensive ($350,000 - $700,000 annually per individual on average), and the health plan is the primary payor for 33 months after outpatient dialysis is initiated8, we believe it’s possible to delay ESRD and increase quality of life by catching those in the early stages of chronic kidney disease and getting them on a renal diet and closely monitoring blood pressure and diabetes.

What a difference delaying dialysis for just one person makes to both the individual and the employer! Dr. Barbara Rutkowski, EdD, MSN, CCM is vice president, clinical operations at Advanced Plan for Health. She brings more than 20 years of experience in operations, integrated medical management for health plans and self-insured employers, as well as care quality for hospitals and managed care organizations. She works hand-in-hand with clients to ensure members who need support are not slipping through the cracks of in-place medical and clinical programs. Joy McGee-Cory is a senior vice president at Advanced Plan for Health. She advises self-insured employers, health systems, managed care organizations, integrated delivery systems, and physician groups on managed care operations, provider compensation and contracting, regulatory compliance, and accreditation issues.

Get started by seeing if there is a nephrologist and dietician who would be willing to help the Nurse Navigator start a comprehensive CKD program. Having support from endocrinology and cardiology would also be a good idea. The good news is that we have seen Nurse Navigation intervention and support reduce heart disease, improve diabetic control and optimize the health of participants. This proactive intervention impacts financial outcomes related to lower acute care stays, as well as other resource utilization rates. After all, health plan costs are a result of resource utilization multiplied by the times a particular resource is utilized. Consider also the value of having employees regain their health and vitality so that they can be contributing, productive team members.

References 1. watch?v=XFHPGxWyy1s 2. chronic-kidney-disease-ckd/#symptoms 3. professionals/clinical-tools-patient-educationoutreach/explain-kidney-test-results

Steps in getting started are just a matter of:

• Getting prepared • Obtaining administrative support • Having an easy-to-use intelligent system to measure care gaps, health patterns and access predictive analytics to find at-risk individuals, and then help participants bend the trend by reversing or slowing the risk drivers that placed them in the high predictive risk category

• Measuring the program baseline, outcomes and individual compliance • Providing personalized, individualized clinical support that encourages people to become motivated in making critical life changes vital to their well-being and that of the health plan



4. chronic-kidney-disease-ckd/#symptoms 5. chronic-kidney-disease-ckd/complications/ 6. communication-programs/nkdep/identifymanage-patients/professional-education/chronickidney-disease-nutrition/management-trainingprogram 7. UpdatedPatientEd/Kidney_Health_For_CKD.pdf 8. news-events/blog/part-3-the-cost-of-dialysis-andtpa-and-medical-management-best-practices/


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IIA recently announced the launching of their new online educational platform, Canoe. Created in response to the growing educational needs of SIIA members, Canoe is an online content resource with an expansive assortment of useful information including self-insurance industry updates, educational videos, interviews, commentary, conference recordings, and much more. And all of it is available anytime and from anywhere on-demand! Please check back to Canoe often as new content will be added regularly.

Canoe will also be the home of SIIA News & Views - a new monthly video program created to report on important news of interest to those involved in the selfinsurance/captive insurance marketplace. Each show will also include an interview segment where a prominent industry leader shares their views on various important topics.



ENDEAVORS The following article pairs with the video “The conundrum of an impaired workforce for Workers’ Compensation self-insurers” with Mark Pew that can be found on the Studio section of Canoe.

Both come down to the productivity of an employee for an employer. In other words, can they do the job. That is often either a subjective assessment or a pragmatic decision. Especially for a self-insured employer whose bottom line is directly impacted by productivity (or lack thereof).

Here’s some interesting statistics from the State Accident Insurance Fund of Oregon (also known as SAIF)2: An increasingly impaired workforce creates significant issues for employers. But it’s even more problematic for selfinsured employers and their workers’ compensation program as they attempt to return their employees to work while encountering potentially unrelated obstacles. Often, addressing impairment is part of the process, even if it’s not fully related to the original work injury.

• Impaired workers are 25-30% less productive • 7.1% of workers reported drinking alcohol during the work day • Being awake for more than 20 hours can be equal to having a blood-alcohol concentration of .08 (the legal limit for intoxication in Oregon)

According to a July 4, 2018 blogpost published on verywell-mind3:

• “The loss to companies in the United States due to alcohol and drug-related abuse by employees totals $100 billion a year.” So what is impairment? There are two potential definitions of being “impaired” according to Merriam-Webster1:

1. “unable to function normally or safely (as when operating a motor vehicle) because of intoxication by alcohol or drugs”

2. “diminished in function or ability”

Definition number 1 specifically mentions alcohol or drugs. That is obviously a concern with the ever-evolving opioid epidemic and legalization of medicinal and recreational marijuana.

• Not only are they less productive, but alcohol and drug users … o Use three times as many sick days o Are more likely to injure themselves or someone else o Are five times more likely to file workers’ compensation claims

The first item – sick days – obviously has a direct impact on the employer’s ability to get the job done. But the next two items – where injuries and work comp claims are more likely – has a broader impact on the costs of the business. Employees that are hurt more often and hurt more seriously increases the number of people not at work and potentially the duration of disability. Both, along with more total work comp claims, can impact administrative costs and the MOD (experience modification) rate, therefore impacting the bottom line.

In August 2018 the CDC estimated there were 72,000 drug overdoses in 20174. Definition number 2 is more broad and inclusive and may not actually have anything to with substance abuse.

If the trend continues from past years, approximately two-thirds of those will be from opioids. While Rx opioids are still a culprit, the primary opioid killer now is illicit fentanyl. According to NPR, for every fatal overdose there are roughly 30 non-fatal overdoses5.

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ENDEAVORS Of course, that doesn’t count patients taking Rx opioids per the doctor’s advice, along with other Rx drugs for side effects (like benzodiazepines, muscle relaxants, antidepressants, stool softeners, sleeping aids) that are impaired at home, at work and on the road. Before the November 2018 elections, only Idaho & South Dakota & Nebraska & Kansas have not legalized medical if not recreational marijuana. Chances are good that some of the 17 with limited medical cannabis programs will expand them soon and more than the current nine states (plus DC) will have legalized recreational use.



So, what does that all mean? That our homes, streets and workplaces are filled with impaired people – from alcohol, Rx painkillers, marijuana, and a host of other intoxicants. What does that mean to an employer? Hold that thought …

Definition #2 deals with a broader form of impairment. That can come from fatigue, or short-term or long-term stress (on the job or at home) or preparing for an external event such as an exam or wedding, or relationship issues (on the job or at home), or mental illness, or side effects from medical treatment (like chemotherapy), or traumatic shock6.

One can also be impaired by reduced cognitive abilities that come from aging or disease. With the number of Americans over the age of 65 increasing from 40.2 million in 2010 to 88.5 million in 20507, managing an aging workforce will provide increasing challenges. Important institutional knowledge combined with a lack of retirement savings can create a need for that employee to stay on the job past their prime. Those issues can create not just absenteeism but also presenteeism (where they are physically but not emotionally present and their lack of focus reduces productivity and motivation).


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ENDEAVORS This all means an employer needs to identify impairment and the type.

For definition #1, that may mean a drug policy that encourages or mandates a drug-free workplace. Of course, that is complicated now by marijuana where presence doesn’t necessarily mean impairment. For employers that accept federal dollars (state legalization is misleading –marijuana is still illegal at the federal level) or have drivers with a CDL (governed by the Department of Transportation), a zero-tolerance policy is required – meaning that presence is all that’s needed.

business open are increasingly deciding to forego pre-employment and/or postaccident drug testing or removing THC (the primary psychoactive component of marijuana) from the drug panel. Those employers may be inviting impairment into their workplace.

There is an employer in northern California that requires pre-employment drug testing for forklift drivers but not for customer service agents. They have decided the risk for a stoned or drunk customer service agent is less important than actually having a customer service agent available to answer a call. For them, it’s about the pragmatism of getting the job done. So there is a paradoxical relationship between increasing societal impairment and decreasing expectation – by policy – of a drugfree workplace.

For definition #2, one solution is an Employee Assistance Program (EAP) or a wellness program that focuses on the whole-person. An August 2018 article published by Risk & Insurance entitled “5 Ways to Help Injured Workers Avoid Opioid Misuse”8 offers some useful advice:

Employers not under those constraints and are having difficulty finding “clean” candidates for jobs needed to keep the

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ENDEAVORS The body’s natural healing abilities can be greatly enhanced by a person’s overall health and wellness. Employers can be proactive by cultivating a robust wellness culture. Fit and healthy workers are better able to avoid prolonged pain after an injury.

Habits such as smoking and inactivity and comorbidities such as obesity can have a dramatic effect on pain severity and duration. As pain drags on, people lose patience with feeling pain and may turn to opioids to make it finally stop.

A healthy diet, good muscle tone, well managed blood pressure and good stress-management skills are all goals that employers can help their people work toward, said Pew. “From a wellness standpoint, you can set the standards,” said Pew. That might mean swapping out soda for vitamin water or candy for protein bars in the vending machines. It might mean providing standing desks, or advocating for walking meetings, or reminding workers to get up and walk around every hour. It might mean bringing a nutritionist in to teach people how to cook with less oil and less sodium.

“You can convey this attitude and let it permeate [through the organization],” said Pew. “It sends a subtle message that the best way to deal with life’s curveballs is to develop some resiliency. “We need to focus on the whole person so when the injury occurs, they’re more fit psychologically, emotionally and physically, so that the injury isn’t catastrophic, and they’re not out of work as long.”


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ENDEAVORS For either definition, part of the solution is more education for management staff on how to recognize impairment – the inability to do the job – and use coaching techniques (i.e. “management”) to help that person achieve their potential. The focus is always on their behavior that is non-judgmental and objective.

Then with a paper trail of assistance, finding them a different job – or different employer – is an easier transition. Building the process of managing impairment into Human Resources requires thinking through what impairment is and how to deal with it. The Canadian Human Rights Commission uses the following characteristics to describe potential signs of impairment:

• personality changes or erratic behavior (e.g. increased interpersonal conflicts, overreaction to criticism);

• appearance of impairment at work (e.g. odor of alcohol or drugs, glassy or red eyes, unsteady gait, slurring, poor coordination);

• working in an unsafe manner or involvement in an accident/ incident;

• failing a drug or alcohol test; • consistent lateness, absenteeism, or reduced productivity or quality of work9.

(for the individual and with their peers) to gauge performance. Without knowing what “meeting expectations” means in relation to their job duties then it’s nearly impossible to judge whether they can perform their job.

It’s unfortunate that often determining that is subjective (“it doesn’t look like you’re into it today … again”) rather than objective (“you’ve been showing up late for work and not turning in your assignments by their deadline”). To be fair to both the employer and employee, having detailed written expectations and consequences is a key.

Creating an impairment-free workplace seems to get more difficult and complex with each passing day. Ultimately it comes down to promoting not just a productive but safe workplace. At its most basic, managing impairment is about whether the employee can do the job they were hired to perform.

So the conundrum is not whether impairment occurs in a workplace. It’s how to manage the impairment that is present already. As with all aspects of business it comes down to an informed and proactive risk management strategy that fits the unique business model. For a self-insured employer that means a strategy developed in-house and customized specifically for that organization. In this case, a “cookie cutter” approach absolutely will not work. But pretending it doesn’t exist won’t work either. Creating a methodical approach to identifying and mitigating impairment will separate the thriving from dying employers.

References 1. 2. 3. 4. 5. 6. 7. 8.

Another aspect, regardless of definition, is a detailed job description of body and brain expectations along with a baseline


MARCH 2019


Celebrating 10 years of Employee Benefit Group Captives We’ve been innovating for a very long time. Ten years ago, Berkley Accident and Health was an industry pioneer with EmCap®, our employee benefit group captive program. Today, we are a market leader with an impressive track record of building and managing successful captives. For group captives, it’s a clear choice. Choose the team with a decade of experience and success. These statements are 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

© 2018 Berkley Accident and Health, Hamilton Square, NJ 08690. All rights reserved. BAH 2018-14


Specialty Accident


NEWS FROM SIIA MEMBERS 2019 MARCH 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 For immediate assistance, please contact Jennifer Ivy at If you would like to learn more about the benefits of SIIA’s premium memberships, please contact Jennifer Ivy at MARCH 2019 47

NEWS Diamond Members

We’ve got a novel solution to improving health care benefits: Build plans that actually benefit the employers and employees who use them. At Homestead, we believe that’s the right way to go. Which means building plans with no network restrictions. No referrals. No hoops to jump through. Just plans built around the needs of our self-funded employer clients and their employees. Plus, on average, a Homestead Smart Health Plan saves as much as 30% on the total cost of healthcare without cost shifting to employees. All of which we think makes benefits…well, beneficial. Our proprietary, platform-agnostic Claim Watcher system is a powerful reference-based pricing tool for auditing and repricing that can either stand alone or work as part of a comprehensive benefits plan. And our Stop Loss services protect companies against catastrophic claims. Whether you are a TPA or a broker, a Homestead Smart Health Plan gives you a strong alternative to present to your clients that puts them at the center of the benefits equation. And that’s a real

Symetra Life Insurance Company Launches New Value-Add Program For Stop Loss Policyholders Symetra Compliance Solutions, provided by Enquiron®, is now available for Symetra stop loss policyholders. This convenient, online resource can help employers navigate the continuously changing landscape of ERISA, HIPAA and related laws. “Our vision is to help self-funded employers better understand and control their health care costs,” said Jeremy Freestone, senior vice president of stop loss at Symetra. “Teaming up with Enquiron will allow us to offer additional solutions for employers at a time when they need them most.” Clients can log in to connect with ERISA attorneys for advice and answers to specific regulatory and compliance questions related to their self-funded medical plans. They can also access educational webinars, resources and tools, and even complete a compliance assessment to identify areas of risk followed by a discussion facilitated by an ERISA attorney.

solution to improving health care benefits. Homestead Smart Health Plans. Better Health For All…together.

This new offering pairs well with Symetra’s best-in-class stop loss policy and supports our goal to help provide clarity in a complex industry. About Symetra | 844 -307-3788



As one of the nation’s first stop loss carriers, we bring a level of expertise and plan design flexibility most carriers can’t match. We are committed to helping groups across




o two groups are exactly alike and no one Reference Based Pricing program design is right for them all. That’s why HHC Group starts by learning each group’s objectives and constraints. Then we help design and implement the right Reference Based Pricing program for them. Some want pre-cert and concierge services. Others want just claims repricing or repricing, provider appeal support and patient advocacy. Some want customized models and some provider contracting. We have the experience and expertise to help the group design and deliver the RBP program that’s just right for you.

163 CONTACT US 301.963.0762 EXT. Claims Negotiation & Repricing | Claims Editing | Medical Bill Review (Audit) | Reference-Based Pricing DRG Validation | Utilization Reviews and Independent Reviews | Independent Medical Examinations



Point6 delivers Financial Savings, Risk Reduction, Growth, Innovation, Value and Efficiency to entities Managing Large Complex Medical claims and Stop Loss Insurance for employers.

POINT6HEALTHCARE.COM the country manage health care costs while providing valuable benefits to employees and their families. We earn the trust of our distribution partners and clients by following through on our promises and supporting every plan with professional, informative and responsive service. To learn more, visit www.symetra. com or contact Jeremy Freestone at 425-256-8480 or jeremy.freestone@ Symetra Compliance Solutions is provided by Enquiron® through Symetra and may not be available in all states. Symetra assumes no responsibility or liability for any resources or content provided by Enquiron®. Enquiron® is not affiliated with Symetra Life Insurance Company or its affiliates. © 2018 Enquiron. All rights reserved.



HCC Life’s Ratings Affirmed by A.M. Best A.M. Best Company, Inc. has affirmed the “A++” (Superior) financial strength ratings (FSR) and “aa+” long term issuer credit ratings (ICR) of HCC Life Insurance Company and the property/casualty companies of Houston Casualty Group. The outlook for these ratings is stable. Contact your regional marketing representative or underwriter to find out how high ratings for financial strength benefit you and your clients. About Tokio Marine HCC A member of the Tokio Marine HCC group of companies. Tokio Marine HCC is the marketing name used to describe the affiliated companies under the common ownership of HCC Insurance Holdings, Inc. Tokio Marine HCC’s products are underwritten by American Contractors Indemnity Company, HCC International Insurance Company PLC, HCC Life Insurance Company, HCC Specialty Insurance Company, Houston Casualty Company, Lloyd’s Syndicate 4141, United States Surety Company and U.S. Specialty Insurance Company. Visit

NEWS Voya Financial Launches Suite of Voya Health Savings and Spending Accounts Voya Financial, Inc. (NYSE: VOYA), announced the launch of its new suite of Voya Health Savings and Spending Account solutions1 as optional benefits for employers to offer their employees at the workplace. The suite of solutions will initially include the following tax-advantaged2 accounts: a Health Savings Account (HSA) to be used in combination with high deductible health plans (HDHPs); a Health Flexible Spending Account (Health FSA); a Limited Purpose FSA; a Dependent Care FSA; and a Commuter Benefit Account. “Our new suite of savings and spending accounts will give employees even more tools to help them realize their financial goals, offering options for handling unexpected health care costs without dipping into their retirement savings,” said Rob Grubka, president, Voya Employee Benefits. “And we are giving employers the flexibility to choose what best fits their benefits portfolios and the ability to meet the needs of their employees.” Voya’s research has found approximately one-third of retirement plan hardship withdrawals are due to an unexpected medical expense3. Voya’s solutions will include several key features:

• Easy access to accounts: Employees can access and manage all of their Voya Health Savings and Spending Accounts — when, where and how they need to — through one user-friendly web portal or mobile app.

• One debit card to manage all accounts: Account holders only need one debit card to access funds from any of their Voya Health Savings and Spending Accounts to pay qualified expenses.

• Employer flexibility: Access one administration portal to review reports and activity on all of their Voya Health Savings and Spending Accounts.

Each of Voya’s businesses — Employee Benefits, Investment Management and Retirement — plays a role in delivering these valuable solutions to help customers in all of its markets achieve holistic financial wellness to and through retirement. An industry leader and advocate for helping Americans achieve financial wellness to and through retirement, Voya Financial is committed to delivering on its vision to be America’s Retirement Company®, and its mission to make a secure financial future possible — one person, one family, one institution at a time. References 1. Health Savings Accounts (HSAs), Health Flexible Spending Accounts (Health FSAs), Limited Purpose FSAs, Dependent Care FSAs, and Commuter Benefit Accounts are individual accounts offered by Voya Benefits Company, LLC (in New York, doing business as Voya BC, LLC) and administered by WEX Health, Inc. 2. The amount saved in taxes will vary depending on the amount set aside in the accounts, annual earnings, whether or not Social Security taxes are paid, the number

In addition to the savings and spending features of all of the Voya Health Savings and Spending Accounts, HSA account holders with $2,000 or more in their HSA may choose to actively manage their account and select their investment options within their HSA. For the Voya HSA, Voya Investment Management is providing manager selection and oversight and has constructed the HSA investment menu that includes a mix of funds managed by Voya Investment Management as well as other wellregarded managers4. “We are pleased to provide this valuable savings tool,” said Grubka. “We put a lot of thought into helping people easily access and manage the funds in their accounts, so they can focus more quickly on the medical or family needs at hand.”

of exemptions and deductions claimed on tax returns, tax bracket, and state and local tax regulations. Account holders should check with a tax advisor for information on how participation will affect their tax savings. 3. Based on aggregated Voya retirement account data for full-year 2017. 4. Investments are not FDIC Insured, are not guaranteed by Voya Benefits Company, LLC (in New York, doing business as Voya

MARCH 2019


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 | Irvine | Indianapolis | Los Angeles New York | San Francisco | San Ramon | Seattle | Stevens Point Auckland | Brisbane | Dubai | Dublin | DĂźsseldorf | Hong Kong | Kuala Lumpur London | Macau | Melbourne | Munich | Perth | Singapore | Sydney | Toronto

NEWS BC, LLC), and may lose value. All investing involves risks of fluctuating prices and the uncertainties of return and yield inherent in investing. All security transactions involve substantial risk of loss.

About Voya Financial® Voya Financial, Inc. (NYSE: VOYA), helps Americans plan, invest and protect their savings — to get ready to retire better. Serving the financial needs of approximately 14.3 million individual and institutional customers in the United States, Voya is a Fortune 500 company that had $8.6 billion in revenue in 2017. The company had $543 billion in total assets under management and administration as of September 30, 2018. With a clear mission to make a secure financial future possible — one

person, one family, one institution at a time — Voya’s vision is to be America’s Retirement Company®. Certified as a “Great Place to Work” by the Great Place to Work® Institute, Voya is equally committed to conducting business in a way that is socially, environmentally, economically and ethically responsible. Voya has been recognized as one of the 2018 World’s Most Ethical Companies® by the Ethisphere Institute; one of the 2018 World’s Most Admired Companies by Fortune magazine; as a member of the Bloomberg Gender Equality Index; and as a “Best Place to Work for Disability Inclusion” on the Disability Equality Index by Disability:IN. For more information, visit Follow Voya Financial on Facebook, LinkedIn and Twitter @Voya.

Silver Members H.H.C. Group Promotes Stella Chung to Executive Vice President of Sales H.H.C. Group is proud to announce the promotion of Stella Chung to Executive Vice President of Sales, with overall responsibility for the Sales Department. A six-year H.H.C. Group employee, Stella was most recently Vice President of Sales with responsibility for the Eastern United States. Prior to joining H.H.C. Group, Stella was an award-winning District Manager for a Sprint Preferred Retailer. She attended the University of Maryland Baltimore County where she studied international affairs and psychology.

You can insure your risk and make a difference at the same time. At QBE, we’re committed to aligning our values with yours to help communities develop, grow and thrive. Our innovative, global Premiums4Good initiative is one way we’re doing just that. Through Premiums4Good, we commit to investing $100 million of policyholder premiums in programs that have an added social or environmental objective, including social impact and green bonds. So far, we’ve invested over $440 million to help make the planet healthier and our communities happier, all without raising premiums one cent.

To learn more about

Premiums4Good, please visit

QBE and the links logo are registered service marks of QBE Insurance Group Limited. Coverages underwritten by member companies of QBE. © 2019 QBE Holdings, Inc. 141871-AD (1-19)

MARCH 2019


NEWS “Stella brings a rare combination of industry knowledge, sales acumen, client service expertise and leadership skills that will enable her to successfully lead our sales team for many years to come”, said Dr. Bruce Roffé, H.H.C. Group’s President and CEO. About H.H.C. Group H.H.C. Group is a leading national health insurance consulting company providing a wide range of cost containment solutions for Insurers, Third Party Administrators, SelfInsured Employee Health Plans, Health Maintenance Organizations (HMOs), ERISA and Government Health Plans. H.H.C. Group utilizes a combination of highly skilled professionals and

advanced information technology tools to consistently deliver targeted solutions, significant savings and exceptional client service. H.H.C. Group’s services include Claim Negotiation, Claim Repricing, Medicare Based Pricing, DRG Validation, Medical Bill Review (Audit), Claims Editing, Medical Peer Reviews/Independent Reviews, Independent Medical Examinations (IME), Case Management Utilization Review, Data Mining, Disease Management and Pharmacy Consulting. For additional information about H.H.C. Group and our services, visit www. or contact Bob Serber at or 301-963-0762 ext. 163.

ACS Benefit Services Names Connie Griffith Vice President, Client Relations Winston-Salem, NC -- ACS Benefit Services, LLC, is pleased to announce the addition of Connie Griffith as Vice President, Client Relations, reporting to Kari L. Niblack, Chief Executive Officer. ACS takes a customer-first approach to doing business, and with the growth of ACS’ mid-market and enterprise customer base, ACS has increased its

Artex provides a full range of alternative risk management solutions, customized for our clients’ individual challenges and opportunities. Powered by independent thought and an innovative approach, we empower our clients and partners to make educated risk management decisions with confidence.

Operating in over 30 domiciles and in more than 15 offices internationally, we have the proven capacity to supply any alternative risk need. For more information, please contact us at:

 Stop-Loss Captives

 Single-Parent Captives

 Enterprise Risk Captives

 Rent-a-Captive and Program Solutions

E: T: 630.694.5050 W:

 Group and Association Captives

 Bermuda Market Access





NEWS investments in Client Relations to ensure customers have the best experience from point of sale through the entire customer lifecycle.

the-art product portfolio to positively affect our clients’ bottom line. Contact Kari Niblack, JD, SPHR, Chief Executive Officer ACS Benefit Services, LLC at (336) 759.2013, and visit

Griffith brings over twenty-five years of client consulting and operations experience to ACS where she will be responsible for creating meaningful, personalized customer experiences and client retention. Her uncompromising commitment to product innovation, anticipating trends and understanding her clients’ industry and organizational goals are shared values of ACS.

Marketing Director

“I am thrilled to join the ACS Client Relations team, working with like-minded individuals. ACS is both innovative and client-centric, and I’ll be able to offer the high level of services, resources and support my clients expect,” said Griffith. Prior to joining ACS, Griffith worked at Meritain Health for six years, where she served as an Account Executive in the Midwest and Great Lakes Regions. “Our core commitment to client service will be bolstered by Connie’s creativity, energy and in-depth product knowledge. She excels at talking with business leaders about their vision for their organizations, reinforcing our personal commitment to their success,” says Kari L. Niblack, CEO, ACS Benefit Services, LLC.

Sextant Self Funding Names Mark Chapman Regional

Syracuse, NY -- Mark Chapman has joined Sextant Self Funding, LLC as Regional Marketing Director responsible for stop loss marketing throughout the country. He is based out of the Kansas City area. Bill Lutz, Managing Director at Sextant states that Mark has worked with this team of underwriters and principals in the past and he successfully built a profitable block of business. At Sextant, it is not like Mark is starting over, he is picking up where he left off. Mark was most recently working as a National Stop Loss Sales Executive at Indigo Insurance Services. His 18 year background in medical stop loss marketing and field underwriting includes roles with both national carriers and MGU’s. He received his Bachelor of Business Administration from Pittsburg State University in Pittsburg, Kansas. About Sextant Self Funding, LLC Sextant Self Funding, LLC., a full service Managing General Underwriter (MGU). Sextant was established to provide modern day guidance through the realm of Stop Loss and Program Management. We underwrite on behalf of Greenwich Insurance Company, an A.M. Best “A+” rated carrier. As an MGU, you can expect us to be responsive, creative and nimble. Due to our relationship with Greenwich Insurance Company, we carry the same financial strength and backing of a direct writer, thus giving you and your clients the best of both worlds! Contact Mark Chapman at and Bill Lutz at and visit

About ACS ACS Benefit Services, founded in 1982, is a full service, customercentered third party administrator dedicated to creating value and delivering results. ACS emphasizes “high-touch” innovation with a state-of-

MARCH 2019


We watch the trends.

We share our knowledge.

We deliver solutions you can trust.

There’s no simple way to overcome the rising claims trend in today’s market. But we know that incorporating smart practices into our business model is helping us to gain more control of the situation. We’re making informed decisions based on data analytics and industry knowledge; using the insight of in-house experts to create thoughtful solutions; and choosing our cost-containment partners wisely as we work to protect our clients’ financial wellbeing. Learn more about our efforts to help manage the unpredictable at


MTG-3173 (1/19)


Products are underwritten by HM Life Insurance Company, Pittsburgh, PA, or HM Life Insurance Company of New York, New York, NY.

SIIA 2019 BOARD of directors & committee chair ROSTER

Chairman of the Board*


Committee Chairs

Adam Russo Chief Executive Officer The Phia Group, LLC Braintree, MA

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


Mary Catherine Person President HealthSCOPE Benefits, Inc. Little Rock, AR

CAPTIVE INSURANCE COMMITTEE John R. Capasso, CPA, CGMA, PFS President & CEO Captive Planning Associates, LLC Medford, NJ

Chairman Elect*

Kevin Seelman Senior Vice President Lockton Dunning Benefit CompanyDallas, TX

Mike Ferguson SIIA Simpsonville, SC

David Wilson President Windsor Strategy Partners, LLC Princeton, NJ

Treasurer and Corporate Secretary* Gerald Gates President Stop Loss Insurance Services AmWins Worcester, MA *Also serves as Director

SIEF Board of Directors Nigel Wallbank Chairman Heidi Leenay President Freda Bacon Director Les Boughner Director Alex Giordano Director



Jeffrey K. Simpson Attorney Gordon, Fournaris & Mammarella, PA Wilmington, DE Robert Tierney President StarLine East Falmouth, MA Peter Robinson Managing Principal Integro Re San Francisco, CA

GOVERNMENT RELATIONS COMMITTEE Steven B. Suter President & CEO Healthcare Management Admtrs., Inc. Bellevue, WA Chair, International Committee Liz D. Mariner Ford Senior Vice President Re-Solutions, a Risk Strategies Company Minneapolis, MN Chair, SIIA Future Leaders Committee Craig Clemente Chief Operating Officer Specialty Care Management Lahaska, PA Chair, TPA Best Practices Task Force Ron Dewsnup President Allegiance Benefit Plan ManagementMissoula, MT Chair, Workers’ Comp Committee Mike Zucco Business Development ATA Comp Fund Montgomery, AL

SIIA new members MARCH 2019 Regular Corporate Members Tim Moses Executive Director of National Business Aliera Healthcare, Inc. Atlanta, GA

Employer Corporate Members James Knutson Risk Manager Aircraft Gear Corporation Loves Park, IL

Matt Nesbett CFO Synergy Risk Group Greenville, SC

Gabrielle Charette, Esq. Legal Consultant MEWA Association of America Somerset, NJ

Kimberly Andrews Executive Assistant BASELoad, Inc. Rock Hill, SC Julianne Lillie VP, Implementation & Marketing CerpassRx The Colony, TX


Anne Vallette Benefit Advisor CGI Business Solutions Hooksett, NH


Gary King President Healthcare Horizons Consulting Group, Inc. Knoxville, TN Roland Lamy, Jr. Vice President, Payer Relations Hemophilia Alliance Clearwater, FL Cara Rhyner, GBA Broker, Consultant Poms & Associates Roseville, CA



Defends out-ofnetwork and balance bills in all 50 states

Utilizes a proprietary and fully relational database to manage claims and provide customizable reports

Has a record of savings of up to 97.5% of disputed charges


Through our integrated PREPAYMENT REVOLUTION Zelis is the market leader in integrating network solutions, payment integrity and electronic payments to deliver insights that drive even greater savings before a claim is paid. Working in a prepayment environment, we price the claim correctly before you pay, avoiding unnecessary costs, time and reducing member and provider abrasion. In fact, 85% of the time we find claim savings that other vendors don’t. We do this by focusing on every step of the pre-payment claim cycle and delivering value-driven solutions from payment to reconciliation.

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 2018 Zelis Healthcare. All rights reserved Copyright 2017 Zelis Healthcare. All rights reserved.



SPECIALIZED. SEAMLESS. STRATEGIC. We are raising the expectation of efficient delivery and fair costs for employers and consumers of healthcare. Dovetailed with the work of the UCS service model, we bring to market a fully integrated approach to care, medical access, claim cost reductions and claim accuracy and efficiency through our commitment to technology. We have impactful capabilities you won’t find from the competition.


Profile for SIPC

The Self Insurer March 2019  

The Self Insurer March 2019  

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