The Self Insurer - March

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MARCH 2021




The End is Near?


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MARCH 2021 VOL 149

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

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

MARCH 2021 3


COVID-19: The End is Near?



cross the self-insurance community, rapt attention is being devoted to digging out of the worst pandemic in a century. In a year like no other defined by lockdowns, sheltering in place, a hybrid of remote and office work arrangements, social distancing, masking up and incessant handwashing, working Americans are finally being vaccinated against the scourge of COVID-19. But those efforts, which eventually will spark a return to normalcy, are plodding and ponderous.

Written By Bruce Shutan

Employers are essentially faced with three options: mandate, motivate or educate, according to Carrie B. Cherveny, chief compliance officer, employment law and employee benefits, South region, for HUB International. Much of the vaccination discussion has been “aspirational, theoretical and strategic,” observes her colleague, Cory Jorbin, chief compliance officer, employee benefits, West region for HUB International. One of his clients in New York City has expressed serious interest in mandating the vaccine and terminating employees who refuse to be inoculated unless they’re exempt under the law. But most will stick with motivating and educating their workforces.



The End is Near? In fact, only 3% of roughly 1,100 people who attended one of HUB’s recent webinars on COVID-19 vaccination indicated that they were going to mandate the vaccine. The secondhighest response was no plan is in place yet.

Cory Jorbin

He says many employers are seeking guidance from their brokers and consultants on the compliance component and practicality of pursuing some type of COVID-19 vaccination program, as well as designing a program that actually works for their employee population.

‘WHAT’S OLD IS NEW’ A mandatory vaccination program is about as complex as any initiative from an employment law standpoint, Cherveny says. But the fact is that “health care facilities and hospitals have been doing this for the past 10 or 15 years when it comes to the flu and the hep B vaccines,” she notes. “I find myself saying to HR people really frequently, what’s old is new.” Private employers can mandate that their employees get vaccinated as long as there’s a reasonable basis for doing so, explains Adam Russo, Esq., CEO of the Phia Group, LLC, citing healthcare and commercial aviation as two examples. “In certain industries, it might be harder to establish a reasonableness standard,” he adds. Russo hasn’t seen any private employers require COVID-19 vaccinations. “A big part of that is a liability concern,” he says, noting the possibility of some workers suffering a serious adverse reaction or the vaccine being administered incorrectly at an onsite clinic. Experts are advising them to simply encourage employees to get vaccinated. Most companies are offering remote work arrangements, virus-monitoring programs, temperature checks and self-certification logs, as well as helping employees find testing sites, he observes. While the federal government hasn’t made vaccinations mandatory, Russo says states have the authority to do so in certain industries involving, say, critical infrastructure or health care jobs. But once again, he hasn’t seen any such action at the state level.

are safety concerns about the vaccine’s impact on pregnant women because of limited data. However, having the EEOC declare COVID-19 a direct threat to the health and safety of others serves as a compelling vote of confidence for the vaccination effort, Cherveny observes.

HIGH ANXIETY Trepidation about returning to workplaces has been mounting for months. More than 70% of working Americans consider their offices unsafe and nearly 30% say they’d search for a new job before returning to work, according to a Honeywell poll. Roughly half of more than 1,000 respondents to a PwC survey felt forced to sacrifice their personal safety to stay employed. Fear and anxiety could linger in a post-pandemic workplace. Glassdoor found that 70% of employees would prefer continuing to work from home at least part time once COVID-19 is under control. It’s such a hot-button issue that several SIIA members declined to be interviewed or did not respond to a request for comment about inoculating their own employees or any advice they’ve given to employer clients.

Under vaccination guidance issued by the Equal Opportunity Employment Commission (EEOC), reasonable work accommodations must be given to people with disabilities or those with a religious objection to being vaccinated, bringing into play both the Americans with Disabilities Act and Title VII of the Civil Rights Act.

The first wave of vaccinations involving health care workers went smoother than it did for older Americans, especially those who don’t have caregivers and aren’t proficient on a computer.

The point is that there cannot be any discrimination against people on the basis of an underlying health condition or their religious beliefs. It’s also worth noting that there

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MARCH 2021



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The End is Near? “glitchy websites, jammed phone lines and long lines outside clinics,” according to one published account. Of course, it’s anyone’s guess how the four-phase approach to vaccination will unfold in the coming months with fewer than 8% of the U.S. population having been vaccinated against COVID-19 as this issue went to press. About 40% to 50% of Americans seem to want the vaccine, according to Paul S. Bradley, M.D., chief medical officer of Scripta Insights and principal investigator for Meridian Clinical Research for whom he is leading the Moderna, Pfizer and Novavax COVID-19 vaccine clinical trials. A rush to market under Operation Warp Speed and politization of this issue obviously has raised concerns, but “from everything we’ve seen, it’s very safe,” he said during a recent webinar on the topic of COVID-19 vaccination. Other recent polls have suggested that as many as 60% of the U.S. population is willing to be vaccinated.

injection is being considered to help guard against new and more highly contagious strains. More than 450,000 Americans – and counting – had died from COVID-19 complications amid more than 26 million infections nationwide as the U.S. edged toward the first-year anniversary of pandemic restrictions. “Until we can get large numbers of people vaccinated, it’s the only way we’re going to quiet it down,” Bradley said. Federal authorities expect vaccines could be available to the general public by the second quarter of 2021, though timetables will vary from one state to the next. One gray area would be someone who identifies as an anti-vaxxer. While Russo says such individuals wouldn’t be afforded those same protections, it could complicate the job of a frontline or essential worker who is philosophically opposed to being vaccinated. Those objections always could be addressed in a bargaining agreement, but in non-union workplaces he says their fate may be uncertain. If reasonable accommodations cannot be made, he says it’s possible that these individuals could lose their job.

“there’s still a good percentage of the population in this country that is afraid to be vaccinated,” Russo believes Americans

Realizing that

All of the usual bureaucratic roadblocks to approving a COVID-19 vaccine were removed, while government financial support was pledged in terms of prefunding the effort, Bradley noted. This is why clinical trials were done so quickly, resulting in a safe and efficacious vaccine. Indeed, he said there were no serious adverse reactions to the vaccinations during clinical trials, while any allergic reactions were easily treated.

Adam Russo will likely wait and see how the early vaccination rounds go and possible side effects before warming up to the idea. As more people

Arm tenderness and swelling are side effects associated with the first injection, while flu-like symptoms and extreme fatigue have been reported as a side effect after the second injection. A third


“expect some kind of return to normalcy in the fourth quarter... I’m seeing that just based on our actual clients and their expectations as to when claim volume returns.”

are vaccinated, his sense is that people

While some employees may be reluctant to be vaccinated, cost will not be a concern. “From a benefits perspective, the vaccine does need to be covered without cost sharing by essentially all group health plans,” Jorbin explains. “The federal

MARCH 2021


The End is Near? government, at least initially, is going to be picking up the cost of the vaccine itself,” he reports. “That being said, we expect those that are providing the vaccine to charge administrative fees, which they are allowed to do. Plans outside of grandfathered health plans are required to pick up that administrative fee.” For companies that hire a third-party vendor to administer vaccinations onsite, Cherveny says they serve as a contracted agent of the Carrie Cherveny organization, “and your liability is an obligation to avoid prohibited medical inquiries under the ADA, conducting private conversations with the employee where other people can’t hear, securing the medical information that you receive.” Pre-vaccine medical questionnaires are confidential, and the information must be confined to only those who need to know it. The easiest way to comply is sending employees to a third party of their choosing and ask them to provide proof of vaccination within a certain timeframe, she explains.



Cherveny advises clients to separate the vaccination effort from their health and wellness program, which will make it less complicated. Participating in a fun run, quitting smoking or agreeing to a biometric screening “is irrelevant to whether or not I get the vaccine, and we can establish an even safer workplace for our employees than we’ve already established over the course of the last 10 months,” she says. Best practices based on other types of vaccination programs have used a company-wide campaign to promote the effort in which senior leadership actively promote the campaign as well as get vaccinated themselves, Gigi AcevedoParker, clinical risk management practice leader for HUB International, noted in a recent webinar on the topic.

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The End is Near?

They need to lead by example so that workers know they’re all in on the vaccination,” she said, adding that “just like high school, peer pressure sometimes works to convince employees to have that vaccine.” “

For employees who decline vaccination, Acevedo-Parker suggested they sign a form stating the reason for their decision, which would help employers track the acceptance rate of their COVID-19 vaccination program. Russo, the father of four young children who have been showing up to school in person, was recently tested for COVID-19 three days after texting his direct primary care doctor under his company’s health care plan. For the sake of his family, he has been working from home along with 197 others.

“We’ve got maybe five people at the actual office,” he says, “and the reason is every week we just see another employee with a positive test, knows someone with a positive test or lives with someone who’s very sick with COVID.” Looking ahead, Cherveny believes employers will impose more rigorous standards to keep their workplaces clean and disinfected. Even with vaccinations, she says “we will all be observing safety protocols, including masks, through the end of the year.”

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

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Written By Nick Bonds, Esq.


ne of the brightest spots in the headlines over the past few months has been the success of several vaccine candidates to inoculate the world against the scourge of the coronavirus pandemic. These vaccines have been developed at an unprecedented pace in the face of an unprecedented public need. They are truly a marvel of modern medical technology, and likely our most direct path back to some semblance of normalcy.

Even so, the promised miracle of these vaccines cannot be fulfilled until the doses find their way into the arms of the public. As dramatic efforts are being undertaken to ensure adequate supplies of vaccines, the rollout of a mass vaccination campaign is impeded by logistics.



Pharmacy Deserts For some in these low-access areas, even a pharmacy more than two miles away could be completely inaccessible in an urban setting where individuals lack readily available personal vehicles or efficient public transportation.

For rural pharmacy deserts the distances may be even greater, with the nearest pharmacy upwards of ten miles away. Simply being unable to physically reach a pharmacy could make it impossible to complete a course of pharmaceutical treatment. Individuals otherwise eligible to receive the vaccine struggle to schedule appointments, are discouraged by long lines at administration sites, or they struggle to make their way to one such site to begin with. These are all problems at least partially amplified by a dilemma that has been quietly festering within the healthcare industry for years: the pharmacy desert.

The “pharmacy desert” is a companion of the “food desert” – a concept utilized by the U.S. Department of Agriculture to denote a geographic area with insufficient access to fresh, healthful food. Residents living in these food deserts experience a number of negative impacts from this phenomenon, including significantly higher food expenses, and substantially inadequate nutrition, as well as a myriad of related detrimental health and developmental complications. These food deserts disproportionately impact low-income and minority communities, in both urban and rural settings.

In 2014 article, Dr. Dima M. Qato and her co-authors expanded on this concept, coining the term “pharmacy desert” to describe a parallel anomaly in the health care space.1 Through their research, they identified a trend in areas around Chicago where whole communities were losing access to pharmacies.

Residents of these pharmacy deserts found themselves with little or no avenue to obtain not just prescription drugs, but also the other myriad services for which had come to depend upon their local pharmacy: over-the-counter products, diagnostic services, even a level of preventive and urgent care services.

While the 2014 article focused on Chicago, the trend they detailed were troubling. About 32% of the census tracts, they observed were located within a pharmacy desert, translating to roughly a million Chicagoans with little to no ability to easily fill their prescriptions at a pharmacy.2 Development of these pharmacy desserts is driven by a number of factors. Lower income and minority neighborhoods tended to have lower rates of insurance coverage and pharmacy providers in those areas experienced lower rates of reimbursement for prescription drug claims.

Smaller pharmacy operating on relatively thin margins struggle to stay afloat, with many selling out to larger chains or closing entirely. Areas with higher reliance on Medicare and Medicaid

MARCH 2021 13

Pharmacy Deserts also tended to have lower rates of reimbursement for prescription drugs, and saw their local pharmacies going dark.

While the hardships faced by smaller pharmacies led to increased consolidation by the massive chain stores like CVS, Duane Reade, and Walgreens, these pharmaceutical behemoths were not immune to the negative economic forces. These chains have resorted to closing substantial numbers of their locations in areas where they are less profitable, thus expanding the radius of the pharmacy deserts.

On top of relatively mundane market forces, the companies administering state Medicaid plans have made changes that effectively cut off access for individuals relying on Medicaid for prescription drug coverage.

As detailed by the Chicago Tribune, near the end of last year, Aetna drooped Walgreens from its pharmacy network, meaning about 400,000 Medicaid members could no longer fill their prescriptions at a Walgreens location. These new holes in prescription drug available effectively riddled Illinois with a new swath of pharmacy deserts just as the economic impacts of the coronavirus pandemic drove more and more pharmacies to shutter their doors, spurring the cycle of contributing factors faster still.

For self-funded plans, these developments are especially troubling.



Prescription drug spending is a huge expense for many plans, particularly those with older employee populations – the same populations that are at elevated risk of infection by the coronavirus.

The expansion of pharmacy deserts serves to drive up prescription drug prices. Additionally, many plans are already struggling to contend with the cost of coronavirus testing, a service frequently performed at local pharmacies. For populations in a pharmacy desert, the associated cost of this testing – which selffunded plans are mandated to cover – will also continue to be pushed ever higher. Perhaps most importantly, the efforts to vaccinate the public are also being exacerbated by pharmacy deserts, blunting the impact of one of our key weapons to address this public health struggle. Pharmacies like CVS and Walgreens are two of the biggest vectors through with many are likely to seek their coronavirus vaccine.

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Pharmacy Deserts For individuals living in a pharmacy desert, this avenue may be prohibitively difficult, thus delaying distribution of the vaccine to some of our most vulnerable populations. The virus has already hit lower income communities the hardest, and areas caught in a pharmacy desert will struggle to share equitably in the most effective solution. Urban communities tend to be hot spots of viral transmission. Where these hot spots overlap with a pharmacy desert, not only are efforts at testing and treating that community greatly hindered, on top of the effort to vaccinate that community being hamstrung as well.

In other words, a pharmacy desert becomes a vaccine desert, and these communities are hit doubly as hard. This perpetuates a vicious cycle of ever-burgeoning risk alongside the intractability of the underlying problem: the economic havoc wrought by the pandemic squeezes out small, local pharmacies.

This quandary will inevitably begin having an impact on self-funded plans covering individuals in these urban pharmacy deserts similar to the struggles faced by plans whose participants are in more remote rural areas.

As participants find themselves with ever more limited access to pharmacies, the plan’s spending on prescription drugs will begin creeping higher. Furthermore, as the pandemic rolls on and plans find themselves covering more and more coronavirus testing, treatment, and vaccinations, the ultimate costs of those services will be driven higher as well.

The reduced pharmacy access expands the radius of pharmacy deserts. And the diminishing access to pharmacies and all the services they offer (e.g., vaccinations) intensifies the health and financial impacts of the pandemic, ad infinitum.

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Pharmacy Deserts Where an individual lives should not determine their access to prescription drugs, let alone the coronavirus vaccine. Ultimately, the only solution is to break this particular wheel.

References 1 See hlthaff.2013.1397 2 See id.

In the near term, that means overcoming the coronavirus, which necessarily requires a significant push in testing, tracing and vaccinating – all of which appear to be priorities of the Biden administrations pandemic response.

Beyond that, addressing the expansion of pharmacy deserts will require a broad policy push, including funding to expand pharmacy access in underserved communities, expansion of telemedicine and direct shipment of prescription drugs, adjustment to Medicaid and Medicare requirements on when and where prescriptions can be filled, and continued efforts to rein in the total cost of prescription drugs.

Nicholas Bonds, Esq. joined The Phia Group, LLC as an attorney in the winter of 2018. He is a member of Phia Group Consulting’s Independent Consultation & Evaluation (ICE) team, working on consultation, plan document review, and regulatory compliance with state and federal laws including ERISA, ACA, HIPAA, COBRA, FMLA and more. Nicholas attended McMurry University in Abilene, Texas, graduating cum laude with his B.A. in History. He earned his Juris Doctor at New England Law where he was a member of the Intellectual Property Law Association and the International Law Society and graduated with an intellectual property concentration. He is licensed to practice in the Commonwealth of Massachusetts.

MARCH 2021


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, Ken Johnson, Amy Heppner, and Earl Porter provide the answers in this column. Mr. Hickman is partner in charge of the Health Benefits Practice with Alston & Bird, LLP, an Atlanta, New York, Los Angeles, Charlotte, Dallas and Washington, D.C. law firm. Ashley, Carolyn, Ken and Amy are senior members of the Health Benefits Practice. Answers are provided as general guidance on the subjects covered in the question and are not provided as legal advice to the questioner’s situation. Any legal issues should be reviewed by your legal counsel to apply the law to the particular facts of your situation. Readers are encouraged to send questions by E-MAIL to Mr. Hickman at



GROUP HEALTH PLAN PROVISIONS OF THE CONSOLIDATED APPROPRIATIONS ACT: A DEEPER DIVE On December 27, 2020, the Consolidated Appropriations Act, 2021 (CAA) was signed into law. In addition to funding the government and further COVID-19 relief, the CAA included significant provisions impacting health benefit coverage. Over the next several articles we will discuss four of the provisions relevant for group health plans: (1) expanded relief for health and dependent care flexible spending arrangements; (2) new expanded compliance requirements under the Mental Health Parity and Addiction Equity Act (MHPAEA); (3) new reporting requirements for commission and similar compensation; and (4) new requirements to limit surprise billing.


In 2020, the Department of the Treasury and Internal Revenue Service issued Notice 2020-29 that provided an extended grace period for unused funds in health flexible spending arrangements (FSAs) and dependent care FSAs (DCAPs), as well as additional opportunities to change elections for health coverage and FSA benefits. The IRS also released Notice 2020-33, which increased the amount of the carryover permitted for health FSAs to $550 due to inflation indexing. A portion of the CAA, the Taxpayer Certainty and Disaster Tax Relief Act, expands on the prior IRS relief. As was the case with the IRS relief, employers may choose whether to adopt any of the options provided in the Relief Act. If an employer adopts any of these options, a plan amendment (potentially retroactive) needs to be made by the end of the calendar year following the plan year the change relates to.

Extension of carryover amounts for health FSAs and DCAPs The CAA allows employers to adopt a carryover for health FSAs or DCAPs (or both) for plan years ending in 2020 or 2021. Thus, for a calendar year plan, health FSA and DCAP balances that are unused at the end of the 2020 plan year may be carried over into the 2021 plan year, and unused balances at the end of the 2021 plan year may be carried over into the 2022 plan year.

For a fiscal year plan (e.g., 7/1-6/30), funds remaining at the end of the FY ending in 2020 (e.g., 6/30/20) can be carried over into the FY ending in 2021 (7/1/20-6/30/21 PY) and funds remaining at the end of the FY ending in 2021 (e.g., 6/30/21) can be carried over into the next PY (7/1/21-6/30/22 PY). There is no limit on the amount of permitted carryover. The prior IRS guidance allowed a more limited carryover only for health FSAs (not DCAPs). There are special issues to consider for employers that have high deductible health plans (HDHPs) and want to provide a health FSA carryover. Employers that offer an HDHP should consider steps to protect ongoing health savings account (HSA) eligibility for employees (e.g., by restricting carryover funds in a health FSA for those who elect an HDHP to limited purpose vision/dental coverage). DCAP benefits are subject to Form W-2 and participant reporting requirements that must be considered in connection with a carryover or grace period. More specifically, employers are required to report DCAP benefits on employee Forms W-2 each year. The IRS has previously provided guidance allowing employers to report DCAP benefits based on the amount of salary reductions and has confirmed that this treatment still applies when a plan has a grace period. Presumably, the same rules apply to an extended 12-month grace period and a DCAP carryover. Similarly, potential issues can arise if a carryover or grace period causes the amount of DCAP benefits received in a year to exceed the $5,000 maximum exclusion allowed for a DCAP. DCAP participants are required to report their

MARCH 2021


excludable DCAP benefits on Form 2441 filed in conjunction with their annual Form 1040.

months immediately following the end of each plan year (e.g., up to March 15 for a calendar-year plan year). Any used amounts remaining at the end of the plan year may be used to pay expenses incurred for the same benefits during the grace period.

IRS Form 2441 notes that DCAP amounts are to be reported in the year they are used and that any amounts used in a year exceeding the annual $5,000 limit should be reported as taxable compensation on Forms 2441 and 1040. Presumably the same rules would apply to an extended 12-month grace period and a DCAP carryover.

The Relief Act permits a grace period for unused benefits in health FSAs and DCAPs to be extended to 12 months for plan years ending in 2020 or 2021. [Note that the Relief Act references an “extension” of the grace period; query whether such language could also apply to the extension of a grace period for the first time. We think it should, but formal confirmation would be welcome.]

Extension of grace periods for health FSAs and DCAPs Normally, health FSAs and DCAPs may provide a grace period of up to 2-1/2



The Relief Act does not address whether the extended grace period can be limited by plan design in amount or in duration. Under the pre-COVID-19 grace period guidance, plan sponsors could limit carryovers to specified amounts (e.g., no more than $2,000). Also, it would seem that a plan sponsor should be able to choose to restrict the extended grace period to less than 12 months. Presumably, agency guidance will confirm that plan sponsors have similar leeway with the extended grace period under the Relief Act.

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As with the carryover, ongoing grace period coverage in a general-purpose health FSA would make an individual ineligible for an HSA for the entire period of coverage. Employers that offer an HDHP and are considering the grace period extension for a health FSA should also consider steps to protect ongoing HSA eligibility (e.g., by limiting the grace period duration or by restricting the use of unused funds for all participants to limited purpose vision/dental coverage).

Practice Pointer: Which is better, a 12-month grace period or a carryover? In many respects, for plan years ending in 2020 and 2021, both the extended grace period and the carryover accomplish the same thing – a carryover of unused funds. In some cases, the carryover may be advantageous because it would allow funds to move forward from 2020 to 2021 and 2021 to 2022. The grace period may only allow associated funds to move forward a single year before forfeiture, and if required, this feature may also be problematic for some third-party administrators (TPAs). Otherwise, it may come down to a matter of which approach employees are most familiar with and which arrangement might be continued after 2021. In addition, it is worth noting that employers that also sponsor an HDHP may be more comfortable with the carryover



since the guidance relating to restricting existing balances for individual participants to a limited purpose vision/dental FSA based on a prospective HDHP election is clearer with the carryover. Temporary expansion of eligible dependent to age 13 for 2020; also for 2021 for unused DCAP grace period or carryover funds Normally, DCAP benefits may be provided for eligible dependents through age 12 (i.e., dependents who have not turned age 13). The Relief Act permits employers to reimburse DCAP expenses for eligible dependents through age 13 (i.e., dependents who have not attained age 14) for the 2020 plan year.

In order for this relief to apply, the plan’s regular annual enrollment period must have ended on or before January 31, 2020. The same relief also applies for the next plan year, but only for unused grace period amounts from the 2020 plan year or other amounts carried over into the 2021 plan year. Plan sponsors seeking to avail themselves of this change should ensure that their administrators can differentiate between carryover and non-carryover funds in processing claims for age 13 dependents. Prospective election changes during 2021 for health FSAs and DCAPs

The FSA relief may make sense in such cases. In other situations, forfeitures may be small and there may not be a need for the expanded FSA carryover or grace period relief. Fortunately, employers may have a little time to consider which approach may be best for them since Relief Act FSA amendments can be adopted retroactively.

Prospective changes in health FSA and DCAP elections may be made for plan years ending in 2021 without a corresponding change-in-status event. This is a one-year extension of the relief provided in IRS Notice 2020-29 except that the extended relief applies only to FSAs. Again, while the Relief Act is somewhat ambiguous, the relief likely applies to employees making new FSA elections since these employees had previously made an election not to participate. Employers considering such a provision may want to impose reasonable restrictions on the number of such changes and to possibly restrict prospective FSA reductions to be no lower than the amount of benefits already paid. Post-termination spend down for health FSA funds Plans may permit health FSA participants who terminate participation in the plan during the 2020 or 2021 plan year to spend down their unused balances for expenses incurred through the end of the plan year in which the termination occurred, including any grace period extension. This approach is similar to what is and has always been permitted for DCAPs. Under such an approach, FSA reimbursements are limited to the amount of unused FSA contributions. The Relief Act does not address whether the health FSA spend down can be limited by plan design in amount or in duration. It would seem that a plan sponsor should be able to choose to restrict the period for a spend-down provision (e.g., until 90 days following termination). Also, steps should be taken to coordinate the spend down with any COBRA coverage required for the health FSA. Presumably, the spend down would be offered as a mutually exclusive alternative to COBRA coverage. As with the grace period extension and carryover provisions, ongoing coverage in a general-purpose FSA will adversely impact HSA eligibility for the entire period of coverage. Plan sponsor considerations

The FSA relief under the Relief Act is temporary (applicable only for plan years ending in 2020 or 2021) and discretionary. Plan sponsors should evaluate their individual circumstances and decide whether changes are appropriate for their plans. In some cases, the COVID-19 pandemic may have caused a large amount of potential forfeitures (e.g., because daycare centers and/or health care providers were closed).

MARCH 2021




Written By Karrie Hyatt


ust like any business, a captive insurance company needs to undergo routine maintenance. Once a captive is up and running smoothly, owners may think that they can relax, but keeping a captive running optimally is a continual process. Especially during the past year, as the market has gone through rapid changes, many captive owners have had to scramble to keep their captives up-to-date.

Routine maintenance for a captive means taking the time out every year to reevaluate not only how it is operating, but many of its fundamental structures.

According to Anne Marie Towle, Global Captive Solutions Leader with Hylant, said, “Thinking about routine maintenance should be a requirement/best practice for all captive owners. Regular checkups and reviews of policies and procedures for the operations of the captive, including reviewing the business plan on file with your domicile, is very important. Routine maintenance should include a review of all your service providers (including RFPs), your overall strategy, and the domicile.



Your strategy should include evaluating lines of coverage and leveraging surplus to align with the goals and objectives of owners.”

From a regulatory perspective, Sandy Bigglestone, director of Captive Insurance for the Vermont Department of Financial Regulation, said that “Routine maintenance should include a review of the captive’s business plan to maximize its benefits. Captives play an important role in the overall risk management strategy of their owners and are likely to evolve over time, which may result in amendments to the business plan, for example, to add new lines of business, adjust existing coverage, and add or eliminate reinsurance coverage.”

Periodic operational and strategic reviews should also be conducted with

A whole laundry list of items, such as governance practices and structure, use of service providers, claims data/trends, loss control strategies/ educational needs, reserve and pricing adequacy, investment strategy, use of reinsurance, financial performance, capital needs, financial projections/ comparison to actual results, accounting policies and internal controls, industry benchmarking, industry developments, technology developments, and current the regulatory environment,” added Bigglestone.

some frequency. Including, “


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With so many aspects of the captive to reevaluate, the process can seem daunting. In many ways, it is similar to the work put into starting a captive. Karin Landry, managing partner for Spring Consulting Group, suggests taking the process in steps, such as these:

Bigglestone agrees that basic maintenance should be done annually. “Other issues may be addressed less frequently, as needed, as part of board committee work or special reporting by a service provider or consultant.”

· Ensure that corporate and captive goals still align with the organization’s risk profile

· After identifying changes, evaluate how any changes will impact other parts of the organization

· Build a roadmap for implementation of changes · Evaluate the captive structure to make sure it meets the needs of new changes

· Consider any regulatory or legislative updates, including the results of court cases affecting captives

Conducting a new feasibility study is a secondary way to make sure that a captive is operating optimally. According to Landry, “We recommend that captive owners reassess, or conduct a ‘refeasibility’ study every few years. Just like you care for your car, regular checkups are provided for optimal performance and, in this case, compliance.”

· Create a way to measure success for the next evaluation of the captive

Basic routine maintenance should be conducted at least annually to make sure the business plan is accurate and up-to-date with domicile regulators. According to Towle, “It is important to ensure a timely audit and actuarial opinion is completed in addition to review and acceptance of financials.”



The study should check to make sure the captive is operating with the appropriate surplus and has underwriting criteria and lines of coverage which meet the goals and objective of the captive owner.

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Additionally, a feasibility study is recommended when the owner wants to expand coverage in the captive. According to Bigglestone, “When a captive is considering a change in plan of operation to expand or add new lines of coverage, a loss and funding analysis to support the change is often a best practice if not a requirement.”

For Landry, “Typically we recommend every three to five years, but market changes and events like COVID-19 should generate reviews in addition to that timeline. Policy changes or emerging risks might also cause you to speed up your review cadence.”


The past year has shown how important routine maintenance for captives can be with many companies facing risks that were not adequately covered when the U.S. went into lockdown in March 2020. “The last year has proven that even the best run captives can be thrown for a loop. We had clients who learned about gaps in coverage too late, and need to now revisit policy language and limits. This goes to show that as part of your maintenance–whether as a proactive or reactive measure– you need to be clear on your coverage and policy intricacies,” said Landry.

witnessed many organizations with captives evaluate the captive utilization and how improvements to their overall risk strategy can make the captive core and central to all their risk buying decisions. Captive owners are improving the policies and procedures and ensuring the captive will be able to respond particularly with the hard market conditions of late.”

“I think companies and their consultants have kept an eye on the commercial marketplace for a long time,” said Bigglestone, “And the past year or so has spurred a lot of interest in captives… Existing captive owners are positioned to maximize the benefits, adding a level of certainty in a chaotic environment. New captive owners are also realizing the benefits captives have in the negotiation process with commercial insurers during the hard market renewals.”

For many captive owners, the pandemic made maintenance for their captive less routine and more imperative as it revealed gaps in coverage. Towle said, “I have Many captives are scurrying to add new lines to their captive since the start of the pandemic. The hard market and coverage gaps that have been seen in the traditional marketplace are steering owners to put more risk into captives.

According to Landry, “This year, we have seen an uptick in including business interruption and medical stop-loss within the captive, for example. [Owners will] need to understand how surplus will be used going forward, which will involve a review of the average cost of capital, retention levels, reinsurance use and taxes, and other factors that an actuary can assist with.”



When asked about what advice she had for captive owners regarding captive upkeep during the COVID-19 crisis, Landry said, “I would say to keep an open mind about the lines that can benefit from being written into your captive. Traditional lines like benefits and P&C remain a good match for a captive, but the pandemic highlighted issues with cyber risk and catastrophic claims, to name a couple, and a captive can be used to address these. Rising costs are causing more employers to engage in voluntary benefits, which can also work well in a captive. I would also say that a captive program should be reasonably nimble in that it's feasible to make relatively quick changes. Overall, the depths of how your captive can perform is likely bigger than you thought.”

For Bigglestone, right now it’s reasonable to put aside extra or non-routine maintenance in order to prioritize the captive’s resources until the current economic difficulties have passed. “The pandemic has caused extreme uncertainty for many companies, operationally and financially. As a regulator, I like to see that a captive owner has taken the time to assess the current and prospective impacts the pandemic has had on its business and how they may impact the captive’s results. A captive owner should leverage its service providers and other resources for any upkeep needs. A secondary benefit of doing so will help a captive owner assess it service providers’ value.”

“I would encourage captive owners to review their captive strategy and how it aligns with the parent company’s strategy,” said Towle. “Alignment and implementing appropriate measures can have an incredible impact to both the short and long-term utilization of the captive. Double checking the business plan on file, ensuring the captive is in compliance, and regularly updating the captive manager and domicile is instrumental for the long-term success of a captive program.”

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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Written By Ryan Work and Joanne Wojcik


s part of its advocacy and engagement activities series, the Self-Insurance Institute of America, Inc. (SIIA), is launching a targeted Self-insured Employer Narrative Campaign designed to identify self-insured employers and their employees. These narratives will be used to illustrate the value of the self-insurance industry to state policymakers, Members of Congress and others. Once SIIA members identify self-insured employers willing to share their stories, SIIA will help draft professional narratives, interview the employers, and use the narratives to reach out to policymakers and influencers on the local, state and national level. These narratives can include innovative and effective benefit designs, employer health stories and how employers and employees both benefit from a self-insured health plan. While advancing self-insurance generally, these employer stories can also impact policy consideration. More than ever, voices from the self-insured industry are needed as we collectively advocate and engage with policymakers on the state and federal levels to show the value of the self-insurance industry and its ongoing success.



Connect in New Ways through HCAA As an association leader in transforming the self-funding industry, and one that focuses heavily on The Value of Connection, HCAA education, advocacy and networking has not stopped. We’ve just found new and creative ways to connect, engage and educate during this time. The HCAA Experience is unlike any other, and we challenge you to discover the value it brings to your self-funding career. Learn more about the many benefits HCAA membership offers to the self-funding industry at

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Provided below is an example of an employer narrative story from SIIA member Aircraft Gear Corporation to demonstrate just one example of the impact that self-insured employers can have on policy and industry discussions.

AIRCRAFT GEAR CORPORATION Loves Park, Ill.-based Aircraft Gear Corp.’s foray into self-funding started out as a cost-saving initiative that has morphed into a holistic healthcare strategy that is enabling this small Midwestern employer to offer high-quality medical care to its 125 employees and their dependents with very little cost-sharing. It all began about 30 years ago when Aircraft Gear Corp. downsized from 600 employees to about 250. The company manufactures aircraft parts, and at the time, a significant portion of its business was derived from defense contracts. As the defense contractors consolidated, AGC retreated from that industry and refocused on private contracts. While AGC was self-insured when it had 600 employees, it didn’t seem feasible for it to continue to self-insure with just 250 employees because having one or two large claims could be financially disastrous for the newly downsized company.

So we stayed fully insured, but in the first year, our Chicago division had a 30% rate increase at renewal. That was big for us,” recounted Jim Knutson, Risk and Benefits Manager. “I asked our broker and carrier why such a big increase, and they said it was because we had bad experience.” “

“But the next year, we happened to have a good year, so I was looking forward to my renewal but instead got a 35% increase,” Knutson said. “When I asked why, they said we were too small to be statistically credible” so the company was being charged based on the overall experience of insurer’s book of business, which was worse than AGC’s.

“They essentially were saying that our experience was good enough to count in the bad year, but in the good year, I had to pay for somebody else’s bad year,” Knutson said. While that may be the nature of insurance—to spread the risk—Knutson decided to explore self-insurance so that AGC could get more control over its benefit costs. AGC hired a third-party administrator (TPA) to help develop plan documents and process claims. The company also bought Medical Stop-loss Insurance, a type of excess insurance policy that pays claims that exceed a predetermined amount. In AGC’s case, its medical stoploss policy paid claims for individuals that exceeded $40,000. If the total sum of the company’s claims for all its plan members exceeded 120% of the amount actuaries projected the company would likely pay in a given year, the medical stop-loss coverage also would pay claims above that predetermined threshold.



Being self-insured also enabled AGC to address other healthcare-related issues affecting employees such as access. Because of the ongoing consolidation of healthcare delivery systems throughout the United States, it’s become harder for AGC to obtain discounts from providers since it doesn’t provide the volume of business these larger systems need. As a result, AGC contracted directly with a handful of independently operating primary care physicians—the ones that weren’t bought by healthcare systems. AGC also changed how it compensated providers to address underuse and overuse of care. Working with a neurosurgeon who shared a similar philosophy toward healthcare, Knutson focused on the primary care piece first. The underuse problem had shown up when plan members had difficulty getting appointments for primary care needs. Next, attention turned to specialists and hospital contracts. Knutson and his colleagues consulted publicly available provider quality data to create physician and hospital profiles. After identifying the high-quality providers in its market, and using additional data derived from a RAND Corp. benchmarking study, AGC negotiated its own discounted fee schedule for paying providers under direct contracts.


In 2021

The company also was able to improve benefits by self-insuring. Currently, employees have no deductible and only pay 30% of the cost of care up to a maximum $500 out of pocket per plan member. Employees also are not required to make a premium contribution for their own or their dependents’ coverage. By contrast, when the company was fully insured, it was forced to increase plan deductibles and annual out of pocket caps to offset yearly premium hikes. Even though AGC is still shrinking—it’s now down to 125 employees—it is still self-insured and is continuing to finetune its benefit plan. Six years ago, AGC began working with another SIIA member, East Coast Underwriters, a Greenville, S.C.-based

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MARCH 2021


managing general underwriter (MGU) to form its own cell captive with six other Illinois-based companies ranging in size from 75 to 200 employees, none of which is large enough to form their own single-parent captive. As a result of spreading its healthcare risks with other captive members, “a lot of the cost spikes have been removed. There’s still variation from year to year, but we’re not seeing those 35% bumps,” Knutson said. The captive also helps on large claims that overlap the renewal of stop-loss contracts, which are usually for a one-year period, Knutson said. If there is a large claim still developing at renewal time, the stop-loss carrier will try to limit its exposure by capping the amount it will pay on that claim, or even removing the individual who filed that claim from the stop-loss coverage altogether, a practice known as “lasering.” AGC’s story is just one example of the benefits of self-insurance for midsize employers. Such anecdotes are an effective way to influence policy on the local, state and federal levels. Every day, self-insured employers are making decisions and designing benefit plans that help American workers and their families. Similarly, ongoing policy and regulatory actions have real-life impacts on the ability of employers to operate these self-insured health plans. SIIA members interested in contributing to the Employer Narrative Campaign by contributing a successful self-insurance story should contact Dakota Jackson at

Ryan Work currently serves as the vice president of government relations for the Self-Insurance Institute of America, Inc. (SIIA) where he heads up the association’s federal advocacy and political activities related to captive insurance and other alternative insurance issues. In this role, Ryan is responsible for developing and managing strategic outreach and policy development before Congress, the Administration and various federal regulatory agencies. Prior to joining SIIA, Ryan directed government affairs activities for S&P Global (previously McGraw Hill Financial), where he represented brands including Standard & Poor’s, Platts and J.D. Power. Ryan has served in a number of senior staff positions within the U.S. House of Representatives, most recently as Legislative Director for Rep. Cathy McMorris-Rodgers (WA). He previously served as Chief of Staff to Rep. Katherine Harris (FL) and in various staff roles with the Committee on Ways and Means and the Office of the Speaker of the House. Joanne Wojcik is an accomplished journalist and communications professional with more than 30 years of experience covering the commercial insurance industry. Over the course of her career, she has researched, reported and authored thousands of news articles, commentaries and White Papers on topical issues affecting the commercial insurance, risk management, workers compensation and employee benefits industries. She currently is a freelance writer and conference programmer, generating content for all types of media platforms and SIIA’s National annual conference. Previously, Joanne served as the Director of Conference Programming for Business Insurance magazine, producing educational conferences and webinars targeting risk management professionals and its annual Women to Watch Awards and Leadership Conference.



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

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SIIA MEDICAL TRAVEL SEMINAR SERIES Your Best Opportunity to Secure High Quality, Low-Cost Health Care Services May be Somewhere You Never Considered


The Self-Insurance Institute of America, Inc. (SIIA) announced that it has partnered with Medical Travel & Digital Health News to produce a series of Connect from Anywhere (CFA) live Medical Travel seminars. In anticipation of travel patterns further normalizing in the coming months and years, SIIA will showcase leading medical centers – both domestic and international – that partner with self-insured group health plans to provide high quality health care often at significantly discounted cost as part of “Medical Travel” arrangements. The seminar series schedule is as follows: Seminar Schedule (all event times – 1:00 p.m. to 5:00 p.m. Eastern Time) March 11, 2021 – Health City Cayman Islands March 24, 2021 – Costa Rica April 15, 2021 – The Cleveland Clinic May 5, 2021 – Colombia



are the largest hospital in the Caribbean to be accredited by JCI, and our patient services reflect those high standards of care.

COSTA RICA This informative and engaging seminar is designed to showcase what it takes to offer a functional medical travel benefit, how it benefits employers and employees, and what makes our network of providers and services in Costa Rica a popular and valued medical travel option for members and sponsors of self-insured employer health plans.

This is a unique opportunity to learn more about these options without having to leaving your home or office, with specific content to be of interest to employers, broker/advisors, TPAs, stop-loss carriers and other key service providers. While each seminar will have its own location focus, common content elements for all seminars are expected to include:

• • • • • • • • •

Stories from real members of self-insured health plans who received medical treatment in that location Key Medical Staff Profiles and Experience in Providing Medical Travel Services Actual Self-Insured Employer Experience Offering Medical Travel Options Quality Metrics and Safety Information Assistance Service with Travel Logistics/Other Member Support Services Qualifying Criteria and Follow-Up Care Considerations for Participants Financial Incentives and Benefits for Stakeholders How to Incorporate Medical Travel Options into Self-insured Health Plans Live Q&A to Answer Your Questions in Real Time

HEALTH CITY CAYMAN ISLANDS Health City Cayman Islands is a medically advanced tertiary hospital located near High Rock in the district of East End in Grand Cayman. We are a unique model of healthcare, built with a focus on the patient and rooted in innovative business models that allow the delivery of high quality, affordable care. As an internationally accredited center of global excellence, we attract patients from the Cayman Islands, the Caribbean, the U.S, and Latin America. In April 2015, just over a year after we opened, our facility earned the prestigious Gold Seal of Approval from Joint Commission International (JCI), the worldwide leader in accrediting the quality of healthcare. We



The event sponsors have worked together for over a decade to help members of self-insured health plans – many with little or no prior travel experience – who choose to obtain qualified surgical treatment in Costa Rica with outstanding results. The program details and schedule for this “Connect from Anywhere” (CFA) event are being finalized, but below is a preview list of topics expected to be covered with opportunities for moderated, interactive Q&A. We welcome members and nonmembers to this free event, but advance registration is required, so please do so now if you plan to attend. Updated program information will be sent all event registrants.

ABOUT CIMA ( Located in San Jose’s modern suburb of Escazu, CIMA is a full-service, tertiary care hospital bringing accessible and affordable healthcare to the global market with top tier-talent and providing medical services to both local

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and international patients. CIMA has been accredited by Joint Commission International (JCI) since 2008 and, in 2021, completed its 5th consecutive certification, receiving JCI’s Gold Seal of Approval® for the highest standards in patient safety and medical care. CIMA offers medical services from more than 800 credentialed physicians representing more than 65 medical specialties and sub-specialties, a complete imaging department, including open magnetic resonance imaging (MRI), computed tomography (CT), x-ray, ultrasound, and endoscopy, a fullservice laboratory, and a 24-hour onsite pharmacy. Medical specialties include cardiology, orthopedics, oncology, neurology, urology, cosmetic and reconstructive surgery, maternity care, neonatal care, laparoscopic surgery, ophthalmology and otolaryngology (ear, nose, and throat) and more.


INDUSHEALTH (www.indushealth. com) Established in 2005, IndusHealth is the leading corporate global medical travel administrator in the U.S., providing self-insured employers a compelling solution to reduce expenditure on elective surgeries and certain specialty Rx treatments. IndusHealth’s Global Healthcare Option program offers eligible plan



members the choice of pursuing a wide range of qualifying medical treatments at top-notch international and domestic facilities with Joint Commission (JCI/JCAHO) accreditation. IndusHealth’s unique turnkey solution includes a complete set of administrative and concierge services including personalized nurse case management, patient advocacy, safety compliance, risk management, travel coordination, billing administration and reporting. IndusHealth has extensive experience in serving self-insured employer groups ranging from 500 to over 40,000 members in size.


( Medical Tours Costa Rica is a medical travel “one-stop-shop” and concierge center that coordinates the entire continuum of care in Costa Rica with our network of hospitals, hotels, tourism and transportation providers, and more. Our goal is to not only support patients during the diagnostic and quotation process but to eliminate any possible barriers. Our team of experienced industry professionals will connect the dots interfacing with each certified provider to assure a seamless medical travel experience. Medical Tours Costa Rica is the leading medical tourism facilitation service in the region, having provided offshore, managed health care services for more than 3500 patients from the United States, Canada, England and other nations worldwide.

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

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

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

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

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

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

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Cleveland Clinic

CLEVELAND CLINIC Cleveland Clinic is a nonprofit multispecialty academic medical center that integrates clinical and hospital care with research and education. Located in Cleveland, Ohio, it was founded in 1921 by four renowned physicians with a vision of providing outstanding patient care based upon the principles of cooperation, compassion and innovation. Cleveland Clinic has pioneered many medical breakthroughs, including coronary artery bypass surgery and the first face transplant in the United States. U.S. News & World Report has named Cleveland Clinic as the nation’s number one heart and heart surgery provider for 26 consecutive years. In addition, they consistently name Cleveland Clinic as one of the nation's best hospitals in its annual "America's Best Hospitals" survey.

ProColombia is the entity in charge of promoting international tourism, foreign direct investment, non-traditional exports and the Country Brand of Colombia. It is committed with the promotion of Colombia as a MEDICAL DESTINATION. The Country has been placed as the 1st country in Latin America and 10th place in the ranking of the MEDICAL TOURISM, 2nd Place with LOWER COSTS associated with medical tourism (India#1), and 24 Colombian clinics and hospitals are included among the 58th BEST IN LATIN AMERICA, It is also ranked as the 22nd best HEALTH SYSTEM in the world according to the World Health Organization (WHO).

Among Cleveland Clinic's 67,554 employees worldwide are more than 4,520 salaried physicians and researchers, and 17,000 registered nurses and advanced practice providers, representing 140 medical specialties and subspecialties. Cleveland Clinic is a 6,026-bed health system that includes a 165-acre main campus near downtown Cleveland, 19 hospitals, more than 220 outpatient facilities, and locations in southeast Florida; Las Vegas, Nevada; Toronto, Canada; Abu Dhabi, UAE; and London, England. In 2019, there were 9.8 million total outpatient visits, 309,000 hospital admissions and observations, and 255,000 surgical cases throughout Cleveland Clinic's health system. Patients came for treatment from every state and 185 countries.

Last year Colombia marked 16 years of uninterrupted work in the development of Colombia's unique health accreditation system that the Colombian Institute of Technical Standards (Icontec) has been responsible for implementing in the country's Health Care System. In its continuous search for excellence, the Joint Commission International has already recognized five Colombian institutions for their maximum quality in the services provided. Colombian medical institutions have also obtained other international accreditations like CARF - Commission on Accreditation for Rehabilitation Facilities, New Palex, Temos International, PlaneTree, among others.

Cleveland Clinic’s Employer Solutions offer proven ways to manage costs and provide quality healthcare. The Employer Solutions programs make it possible to offer employees and plan members access to specific Cleveland Clinic services, in areas where our experts treat the most complex cases with the best outcomes. To learn more, visit:

The 5 clinics accredited by the (JCI), recognized for their top quality services in medical specialties such as oncology, cardiology, fertility, bariatric surgery, ophthalmic surgeries, and comprehensive



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medical examinations are committed to working with international insurance companies assuring high quality standards, technology and infrastructure, knowledge, warm services and innovation, thus giving patients a wellrounded option to treat different types of procedures and obtain satisfactory results. Centro Médico Imbanaco, located in Cali; Fundación Cardioinfantil, in Bogotá; Hospital Pablo Tobón Uribe, in Medellin; Hospital Universitario Fundación Santa Fé de Bogotá; and FCV institutions-Hospital International de Colombia and Instituto Cardiovascular, are committed to providing the best care to international patients. Colombia today is the perfect and emerging medical destination that offers integral care for many of the complex medical procedures supported by service quality, state-of-the-art technology, flight connectivity and competitive prices. With a population close to 50 million people, Colombia has a welldeveloped health care system with experienced professionals capable of performing highly complex medical procedures, with an exceptional care for every patient focusing on the quality of life. Current times have called for major adjustments, thus making sure we make all effort to best handle the pandemic with the use of technologies at the pointof-care, creating a mobile app (CoronApp) that uses artificial intelligence to actively search for contacts with positive cases, early detection in affected areas and providing alerts about nearby people with a positive diagnosis for COVID-19. With this and many other initiatives, Colombia has managed to be the first country in the world



to adopt the Tourist Biosafety Seal, Certified Check-in, created by the Ministry of Trade, Industry, and Tourism and endorsed by the World Tourism Organization, which makes Colombia a medical destination ready to receive visitors following strict safety measures.

REGISTRATION INFORMATION These will be free events for both members and non-members, but advance registration will be required. Watch for additional details about each specific seminar coming soon, but you can access preliminary information now and reserve your spot through the following link

CONTENT DISCLAIMER This Connect from Anywhere (CFA) event has been designed to allow for the sponsor(s) to showcase product/service solutions to those involved with the management of self-insured health plans, captive insurance companies, and/or self-insured workers’ compensation programs. The sponsor had paid a fee to SIIA for production and promotional services and is entirely responsible for its content. Registrant information will be shared with event sponsor(s). SIIA does not endorse any company, product or service. For information regarding similar sponsorship opportunities, please contact Justin Miller at


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Nearly 100 SIIA members from across the country networked with each other last week as part of SIIA’s first ever Connect from Anywhere (CFA) Networking Happy Hour, sponsored by Hi-Tech Health.

Conducted entirely via the Zoom video platform, members were randomly shuffled among small group chat rooms for a series of lively conversations. Here’s what several of them had to say about their experience:



Benefits are an endlessly evolving landscape. Stop-loss. Skyrocketing prices. Administrative challenges. Shock claims. Amwins is your group benefits lifeline—whether you need help navigating the chaos, solving for the unique or simply looking for additional options. Our purpose is simple: Find and deliver the specialty products you want coupled with the administrative solutions you need. Broker, consultant or carrier, let us make your life easier through custom programs and expanded capabilities. Amwins has the relationships and insights to tackle what comes next.

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"Is anyone else out there missing their usual face-to-face meetings and networking events? I am, but the SIIA networking happy hour event I attended was fun. I saw familiar faces, made some new connections, and we shared some Lori Sartori laughs. Even if the people I met weren't directly involved with what I do, which is stop loss, I still enjoyed talking with everyone. I look forward to the next one." - Lori Sartori, Regional Sales Manager, Stop Loss, American Fidelity “The SIIA Happy Hour event was a great platform to network with other professionals and keep connected. The ‘break-out’ rooms were especially valuable as they allowed the dialogue to happen in a more personal setting. I will be attending future events and look forward to connecting with others Chris Ewing to learn about their role and companies and how they fit into the self-insurance landscape.” - Chris Ewing, Assistant Vice President, Lockton Dunning Benefits, Lockton Companies



Christine Vago

“In the current environment of travel bans and stay at home orders, we are all eager to ‘connect’ with our industry friends and peers. Thank you, SIIA, for doing a knockout job hosting the recent trivia and speed networking event and I’ll be back for the next one. This was yet another SIIA membership perk! Thanks for organizing.” - Christine Vago, Senior Vice President of Specialty Health Sales, Intact Insurance Accident & Health


“I attended the first SIIA ‘Happy Hour’ zoom meeting and was excited with the format and the transition from room to room. It was great to see old friends and to meet new ones! I have not been able to travel at all during Tom Belding this pandemic (just like most people) so it felt good to almost become normal in meeting people and learning what they are doing and hearing about new trends in the market. I believe this is a great resource for our members and an opportunity to network with new sources to enhance all of our business opportunities. Thank you SIIA for putting this together!” – Tom Belding, President, Professional Reinsurance Mktg.

Greg Arms

“The SIIA CFA Happy Hour event on January 28th was awesome! Really appreciated re-connecting all at once with so many SIIA members - and then breaking into smaller groups to chat about Svcs. COVID, enjoying life, and even a few new business opportuni“I want to commend SIIA for developing the Virtual Happy Hour ties. Have already heard from sessions. As much as I appreciated the Virtual conference three folks that were on the CFA held last year under a very trying pandemic environment, what Zoom call. And for the next CFA was lacking was a really good way to interact with my friends, Happy hour on Feb 25th, my colleagues and also meet new industry leaders. This event is CareClix colleague Augusteen the perfect solution as I was able to not only reconnect with Cowan will join the conversation ‘old’ industry friends but also meet ‘younger’ industry leaders. with me. All good!” - Greg Arms, I even met a fellow Puerto Rican involved in our industry! I am CareClix, Senior Advisor events will be held the last already connected via linked in with a new group of contacts. These Thursday of each month through June and are free for SIIA members, Thanks, SIIA! I look forward to the next ‘Happy Hour!’” – Armando Baez, President, Baez Insurance Services, Inc.



so please plan to join the fun next time. SIIA membership information can be accessed at, or for immediate assistance, contact Jennifer Ivy at




Bring balance to your health plan Improve Quality, Manage Utilization, Reduce Cost

The long-term financial security of your medical benefit plan depends on managing much more than the cost of care. Let Vālenz® lead you to the perfect balance between quality, utilization and cost. By gathering and analyzing millions of data points within the Valenz ecosystem, we enable you to make better decisions that control costs while empowering members to lead strong, vigorous and healthy lives. We help you manage the full continuum — from pre-claim losses through postclaim resolution — offering transparent, data-driven collaboration with members, providers and payers to keep you on the path to smarter, better, faster healthcare. Visit or call (866) 762-4455 to bring balance to your medical benefit plan.

23048 N 15th Ave., Phoenix, AZ 85027 • (866) 762-4455 • Proud to be a Diamond Member



2021 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 If you would like to learn more about the benefits of SIIA’s premium memberships, please contact Jennifer Ivy and




PHOENIX, AZ – Vālenz™ is pleased to announce the appointment of Ed Zwicker, MBA, as Chief Information Officer. Zwicker joined Valenz in April 2020, bringing 35 years of experience in the design, development, and implementation of highly robust data systems and business intelligence applications. He carries out innovative IT initiatives that add value to the company’s primary business, creating and executing data strategies that align with business goals. “Ed is an integral member of the senior leadership team, he provides the vision for our technology teams and fosters partnerships between IT and business,” said Rob Gelb, Chief Executive Officer of Valenz, a leading innovator for datadriven solutions that reduce medical claim costs and promote quality healthcare. A mentor and trusted leader who proactively drives projects and programs, he held IT leadership roles at Integress, Inc., Philadelphia Insurance Companies, Cigna and Penn Mutual before joining Valenz.

risk-reduction advantages and cost-effectiveness of combining employer plans in a medical stop loss (MSL) group captive program, Vālenz® has launched CaptiV to solve the challenges market volatility can pose for small to medium-sized employers. Valenz CaptiV goes beyond risk sharing to provide a fully integrated, data-driven model for cost and risk reduction. By bringing together employers that are committed to managing their medical costs while improving health outcomes – and equipping them to engage early and often via its end-to-end analytics platform – Valenz CaptiV represents the next generation of MSL group captives. “We operate at the center of the MSL group captive, actively engaging the group of employers and their employees in our proprietary ecosystem of data and service solutions,” said Rob Gelb, Chief Executive Officer of Valenz. “Our analytic and predictive capabilities uncover new strategies to drive savings of 20-30 percent by targeting the high-dollar claims that drive the majority of health plan spending. We continually integrate those learnings among Valenz CaptiV members to reduce the potential for catastrophic claims and create value for everyone.”

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YOUR HEALTH PLAN SPEND No Guarantee of Results – Outcomes depend upon many factors and no attorney

PHOENIX, Ariz. — As health care costs rise exponentially, self-insured employers are facing greater risks of high-dollar claims. Recognizing the significant

can guarantee a particular outcome or similar positive result in any particular case.

MARCH 2021 55

NEWS For self-insured employers with fewer than 1,000 employees, Valenz CaptiV leverages a larger and more diverse population to reduce plan level and catastrophic risk, while delivering exceptional cost-reduction strategies, increased underwriting credibility, and long-term rate stability.

“For captive members, our ecosystem offers unparalleled data-driven collaboration. from pre- claim loss to postclaim resolution,” said Gelb, explaining, “Valenz solutions build on one another, providing actionable information at each step in the life cycle of a claim.” To accelerate its captive offerings, Valenz partnered with MSL Captive Solutions, the industry’s only platform dedicated to the development and delivery of comprehensive services exclusively for MSL captives. MSL Captive Solutions works with top insurance carriers and claims administrators to deliver market-leading results for Valenz CaptiV members.

“Properly structured group captives have proved to reduce costs and increase plan stability by effectively managing, diversifying and broadly diffusing risk,” said Phil Giles, Managing Director of MSL Captive Solutions. “By taking a discerning approach to membership and enabling more active, data-driven risk management, Valenz CaptiV promises superior performance.” Together, the firms offer more strategic, proactive risk control and cost-reduction decision- making. And, as costs are contained, Valenz CaptiV members share in the profitability of the program. For more information on Valenz CaptiV, call (866) 762-4455.

Better manage your specialty drug spend, through powerful clinical management combined with real-time oversight. Every organization struggles to manage its Specialty Drug spend. ELMCRx Solutions understands the complexity of specialty drug management. By combining powerful clinical management with real-time oversight to control costs and prevent unnecessary payments, our unbiased program helps deliver the best outcome for the plan sponsor and the member. We partner with employers, health care coalitions, health plans, insurance captives, TPAs and Taft-Hartley Trusts. Cost Containment Solutions and superior clinical outcomes are achievable. ELMCRx Solutions is the partner to help you achieve them.


John Adler | 262 707.1076 Mary Ann Carlisle | 484 433.1412



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About Valenz Through a complete health administrative ecosystem, Valenz connects cost and quality data on a single-source, end-to-end analytics platform for smarter, better, faster healthcare. Valenz solutions integrate data from comprehensive care management services (Valenz Care), high-value provider networks (Valenz Access), claim flow management (Valenz Claim) and solutions for payment integrity, revenue cycle management and eligibility compliance (Valenz Assurance) into the ecosystem. More information is available at Valenz is backed by Great Point Partners. About Great Point Partners Great Point Partners (“GPP”), founded in 2003 and based in Greenwich, CT, is a leading healthcare investment firm, currently with approximately $1.8 billion of equity capital under management and 28 professionals, investing in the United States, Canada and Western Europe. Learn more at About MSL Captive Solutions, Inc. MSL Captive Solutions is the industry’s only platform devoted exclusively to the development of comprehensive (re)insurance solutions for group and singleparent medical stop loss captives. MSL Captive Solutions provides consultative underwriting support to some of the industry’s leading stop loss carriers and operates independently to work with all qualified brokers, consultants, and captive managers. For more information visit


Hamilton Square, NJ – Berkley Accident and Health, a Berkley Company, has appointed Bob Hosler as Regional Sales Manager for its EmCap® Group Captive division. In this role, Bob will be developing captive business in key parts of our eastern region as well as supporting programs opportunities in various markets across the country based on his established relationships.

“Bob strengthens our growing team of EmCap Sales professionals,” said Brad Nieland, President and CEO of

“His industry knowledge and deep expertise in stop loss and group captives will be an asset to our clients.” Berkley Accident and Health.

INNOVATIVE STOP LOSS AND ANCILLARY SOLUTIONS At BenefitMall, we know that employer groups benefit most from treating their health plan as an investment rather than an expense. Our team of self funded consultants can help you succeed by offering: • Reporting, Compliance Services and Plan Document Review • Billing and Premium Collection • Ancillary Products and Services

• Unbiased Expertise and Review • Initial Placement, Implementation and Renewal of Coverage • Claims Audit, Submission, Tracking, and Resolution Services

©2020 BenefitMall. All rights reserved. 58



Being Powerful. Being Human. Being PharmPix.

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


NEWS Bob joins Berkley Accident and Health as an industry veteran with over 30 years of experience in the Stop Loss industry. Bob earned a B.S. in Business Administration from the Ohio State University and resides in Granville, Ohio. About Berkley Accident and Health Berkley Accident and Health is a member company of W. R. Berkley Corporation, a Fortune 500® company. Berkley Accident and Health provides an innovative portfolio of accident and health insurance products. It offers four categories of products: Employer Stop Loss, Group Captives, Managed Care (including HMO Reinsurance and Provider Excess), and Specialty Accident. The company underwrites Stop Loss coverage through Berkley Life and Health Insurance Company, rated A+ (Superior) by A.M. Best. Visit or connect with us at


Canton, MA – The Phia Group announced that it has earned a 2021 Top Workplaces USA award, issued by Energage. Energage, an organization that develops solutions to build and brand a vast array of companies, leveraged their 14-year history of surveying

more than 20 million employees across 54 markets, to award this prize during what is the prestigious honor’s inaugural year. Earning this accolade was no small task. Several thousand organizations from across the country were invited to participate, and winners of the Top Workplaces USA were chosen based solely on employee feedback gathered through an employee engagement survey, issued by Energage. These results were then calculated by comparing the survey’s researchbased statements, including 15 Culture Drivers that are proven to predict high performance against industry benchmarks.

Why pay more than you should? Overinflated pricing for healthcare is not unusual. But with referencebased pricing, members pay what’s fair and reasonable. Trustmark Health Benefits® offers flexible RBP solutions, allowing employers to choose what’s right for them.

Expect more. Benefit more.

Learn about reference-based pricing at Self-funded plans are administered by Trustmark Health Benefits, Inc.. ©2021 Trustmark Health Benefits® R45021-01





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“The Phia Group’s mission is to reduce medical costs and improve the quality of health care. That mission starts and ends with our people. Our job is to help other employers secure the best benefits for their employees and families; it behooves us to do the same for our own team,” The Phia Group’s CEO, Adam Russo, remarked. “This award is proof that our focus on benefits, opportunities, and general employee satisfaction is not misguided. While employee satisfaction is valuable in and of itself, it is equally important as a crucial element of improving our company’s overall value. If our team doesn’t share our passion or buy into our principles, that reflects in the work product. Employer success is therefore built upon a foundation of employee success. By emphasizing an atmosphere of employee satisfaction, we generate better outcomes, satisfied clients and success for all.” About The Phia Group The Phia Group, LLC, headquartered in Canton, Massachusetts, is an experienced provider of health care cost containment techniques offering comprehensive claims recovery, plan document and consulting services designed to control health care costs and protect plan assets. By providing industry leading consultation, plan drafting, subrogation and other cost containment solutions, Contact Garrick Hunt at, 781-535-5644 and visit

Staci moved into the PBM space in 2013, where she served as Director of Clinical Management/Health Services for RxBenefits, and Regional Director of Sales for Southern Scripts. She has served on various committees, including Pharmacy & Therapeutics and Quality Assurance. In addition to many successful years as a sales executive, Staci has held leadership roles in Operations and Health Services. Staci can be reached at “We are very excited to welcome Staci to the 6 Degrees Team. Her background brings multiple perspectives and clinical understanding to the healthcare landscape. This experience will be a significant value to her channel partners and clients as they seek to implement Reference Based and Cost Containment solutions.” -Heath Potter, Chief Growth Officer About 6 Degrees Health


Hillsboro, OR -- 6 Degrees Health is pleased to announce that Staci Branham has joined the company as VP of Business Development. Staci is a healthcare veteran with 27+ years of experience. She has served in many roles throughout her healthcare career including, 10 years as Director of Health Services at a large Medicare, Medicaid, HMO and Alabama-based TPA. In her tenure, Staci was instrumental in growing new business, designing a case management system, launching the Medicare Part D drug program, and creating programs and processes to streamline business practices and improve the overall health of the company.



6 Degrees Health is built to bring equity and fairness back into the healthcare reimbursement equation. Industryleading MediVI technology supports our cost containment solutions with objective, transparent, and defensible data. 6 Degrees Health’s solutions include everything from provider market analyses, reasonable value claim reports, ad hoc claim negotiations, evergreening provider contracts, and referenced-based pricing. Our veteran cost containment team partners with health plans and their channel partners to deliver unparalleled cost containment results. Visit


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


Mike Ferguson SIIA Simpsonville, SC


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

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

Laura Hirsch Co-CEO Aither Health Carrollton, TX


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

Peter Robinson Managing Principal EPIC Reinsurance San Francisco, CA


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

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

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

MARCH 2021 63


Jeremy Doak Vice President, Sales & Marketing Abacus Health Solutions Cranston, RI

Dinesh Tulsiani EVP, Head of Strategy and Corporate Development Alight Solutions Evanston, IL

Alan Wiederhold Executive Vice President Evolution Healthcare Baltimore, MD

Melissa Taylor COO Health Rosetta Group Seattle, WA

Brad Byars COO Providence Irvine, CA

Michael Fackler Director - Captive Safety Services Trinity Safety Group Indianapolis, IN


Davis Smith Partner Bradley Arant Boult Cummings LLP Montgomery, AL

Robert Malone National Sales Director Genomic Life San Diego, CA

Jim Barsness CFO Medefy Health Tulsa, OK




in healthcare waste & errors too much?

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

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

Better Service. Better Performance. Copyright 2019 Zelis. All rights reserved.

Stability for those balancing risk and reward.

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

CONNECT WITH ONE OF OUR EXPERTS ON OUR REINSURANCE OPTIONS: Employer Stop Loss: Traditional Protection • Small Group Solutions • Coverage Over Reference Based Pricing Managed Care Reinsurance: Provider Excess Loss • Health Plan Reinsurance

In all states except New York, coverage may be underwritten by HM Life Insurance Company, Pittsburgh, PA, or Highmark Casualty Insurance Company, Pittsburgh, PA. In New York, coverage is underwritten by HM Life Insurance Company of New York, New York, NY. The coverage or service requested may not be available in all states and is subject to individual state approval. MTG-3355 (12/20)

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