The Self Insurer October

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National Conference & EXPO Oc tober 3-5, 2021 Austin, TX

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OCTOBER 2021 VOL 156

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







By Bruce Shutan









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

OCTOBER 2021 3



ENDEAVORS SIIA Endeavors: On the Record with SIIA President & CEO Mike Ferguson SIIA President & CEO Mike Ferguson


he Self-Insurer Editor Gretchen Grote sat down with SIIA President & CEO Mike Ferguson for a wide-ranging interview to talk about how the association continues to evolve and play an increasingly important role in helping its members be successful in the self-insurance marketplace.

Gretchen Grote: Let’s jump in and talk about how SIIA has positioned itself in the ongoing COVID environment. Mike Ferguson: Yes, I guess ongoing is the best description to use as you and I are talking today. Shortly after last year’s virtual National Conference we assessed that in-person events were not going to be viable for at least the first half of 2021 so we concluded that it was going to be critical to pivot on how we delivered educational content and networking opportunities.

Of course, this meant developing a comprehensive virtual strategy, which is exactly what we did. But before figuring out all of the details, we addressed a messaging issue, which was the perception that most people were getting tired of the term “virtual.” This prompted us to launch our “Connect from Anywhere” or “CFA” brand.



ENDEAVORS Through this CFA format, we produced a packed schedule of educational content ranging from one-hour webinars to three-day conferences. This was supplemented by monthly networking events that proved to be very popular as a solution to keep members connected.

So while we would of course have liked to have been able to produce in-person events earlier in the year, we received great feedback from many CFA event participants, which validated our strategy.

For those who want to catch some of the educational content while in Austin, they will also have control over that as well. They can join with other SIIA members in designated viewing areas, or view sessions privately via their laptop/ electronic device from wherever they are.

We view our National Conference as a transition point where an in-person component is being blended back in alongside the CFA format, allowing people options on how they would like to participate considering the current COVID environment.

Not only do we think this new format will improve attendee experience generally, this approach also takes COVID transmission risk into consideration by allowing for attendees to participate and engage on their own terms.

GG: Let’s talk more about that. Can you provide more detail about how SIIA is taking a unique approach to producing a large industry event given complicated COVID considerations?

GG: Switching gears just a bit, can you update our readers about Canoe, SIIA’s on-line educational platform?

MF: As we monitored developments earlier in the year, it became clear that two distinct membership populations were taking shape – those who are not likely to attend in-person conferences in the near-term regardless of vaccination developments, and others who are very much ready to get back to such events.

MF: Canoe’s value continues to increase as now SIIA members easy access to nearly 200 pieces of unique content, including recordings of all our CFA events from this year. I like to call it the “Netflix for Self-Insurance” and all employees of SIIA member companies can access it for free. For those members who have not already checked it out, I encourage them to do so at It's really a great benefit that can be utilized by all employees of SIIA member companies.

Based on this observation, we made the decision to create a hybrid event that will allow those from both populations to participate in whatever way they deem best and that are consistent with company policies. While most organizations have decided to go one way or the other, our bet is that we can deliver the best of both formats.

Obviously additional planning needed to be done to ensure that we can mitigate COVID transmission as much as possible and multiple safety protocols will be incorporated as part of the in-person event. But we saw an opportunity to create a safer environment by changing the format in a way that provides more flexibility for in-person attendees.

First and foremost, we are setting things up to facilitate networking and business meetings. This will include a dedicated networking lounge/exhibit area supplemented by tables/chairs spread out over two large floors of the hotel. Given the extensive amount of space available, this will help attendees control how much or how little interaction they have with other attendees.

GG: It’s been a few years since the launch of the SIIA Future Leaders Initiative. How have things been going and what we can expect going forward? MF: Let me first say that this remains one of the association’s most important strategic initiatives as the generational



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ENDEAVORS The obvious reason, of course, is that it is much easier to make and keep friends on Capitol Hill if you provide financial support for their campaigns. This does not mean that if you contribute to a specific member of Congress that they are certain to vote a specific way, but it’s certainly easier to get a meeting with the member and/or their senior staff to explain your issues.

shift continues to accelerate in our industry. Like other association initiatives, we have been a little challenged by ongoing COVID developments, but still offered multiple engagement opportunities specific for our younger members.

These included two CFA events – a first ever Future Leader Forum, along with another Mentor Connection Forum. Both events were very well received based on attendee feedback.

The SFL committee will be meeting before the end of the year to plan initiatives for 2022 and I expect some exciting news to announce soon.

GG: You have commented publicly on several occasions about how important it is for SIIA to become more of a major player in terms of political contributions. Can you elaborate a bit on why this should be such a priority and give any progress that has been made to move in this direction? MF: I have actually been saying this for the past several years and this objective has continued to move up the list of association priorities. There are two primary reasons for this emphasis, with the one reason being fairly obvious for most members, and the second reason less obvious for those who are not creatures of the DC lobbying world.

Not so obvious to those outside the beltway is that when an organization establishes itself as a political financial player, it raises your “street cred,” so to speak, with other important organizations in town that we may need to partner with on various lobbying efforts.

Our progress has been somewhat slow but steady since we established the SelfInsurance Political Action Committee (SIPAC) about eight years ago as a vehicle for SIIA members to channel political contributions to key members of Congress. Things have accelerated over the past few years thanks to this more dedicated focus, combined with increased staffing resources, and you are now starting to see SIIA really establishing itself as a money player in DC. Obviously, we are not the biggest player by any means, but it’s solid progress that has already directly complimented advocacy efforts and we expect even more positive results after the upcoming election.



ENDEAVORS GG: I have seen that SIIA has been involved in some litigation efforts this year. Can you bring our readers up to speed on this? MF: For those who may not be aware, SIIA has a long history of either leading or supporting litigation efforts to support the interests of our members when legislative/ regulatory advocacy opportunities are not viable. These efforts are financed though the association’s Legal Defense Fund (LDF), which in turn is funded by voluntary contributions from the members.

This year, at the specific request of various members, SIIA’s LDF has funded the filing of two separate Amicus Briefs at the federal and state level. One case was focused on protecting health plan sponsors and participants from nefarious hospital billing practices with the other involving the ability of plan sponsors that take advantage of specialty cost containment opportunities. We expect rulings for both cases in the coming months.

Another litigation effort we supported last year proved successful earlier this year when the U.S. Supreme Court issued a unanimous ruling declaring that the IRS improperly imposed a reporting requirement rule that adversely affected many captive insurance company owners and their advisors.

GG: So on that last note, how do you view SIIA’s role in the captive insurance space, as this membership constituency continues to grow? MF: My view is that SIIA is playing a very unique and useful role in the captive insurance space by integrating its stakeholders into the much broader selfinsurance world.

This is important because mid-market employers are becoming increasingly sophisticated in how they manage risk, understanding that they can integrate multiple self-insurance strategies that may include the formation of a captive insurance company. SIIA brings this all together, giving captive insurance professionals more educational, networking and advocacy resources.

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ENDEAVORS I am particularly pleased to see how much progress SIIA has made over the past year with political advocacy in Washington, DC in order to better position the captive insurance market segment with key policymakers.

Unfortunately, many of those who influence the legislative and regulatory process affecting captives, have minimal or no understanding of why an increasing number of employers rely on them to deal with risk management strategies. We are making real progress and look forward to even more positive results in 2022.

GG: Tell us about the CrowdSource Forum coming up in December MF: We are taking one last opportunity to get members together before the end of the year to talk about the hottest issues affecting our industry. The format will be a series of moderated roundtable sessions with each focused on a single topic including: price transparency, cell & gene therapy, specialty drug cost, technology, and workforce development.

We’ll be back at the Charleston Place Hotel in Charleston, SC so it will also be a great opportunity for holiday dinners and year-end client entertainment opportunities. For those who are not able to join us in person, a livestream connection option will be available so everyone can be part of the conversation.

GG: What is SIIA’s 2022 event calendar going to look like? MF: Broadly speaking, members can expect to see a combination of in-person and connect from anywhere (virtual) events. And for some of the in-person events, there will be a livestream connection option. This approach this will continue to allow for members to access SIIA in whatever way that makes sense for them.

More specifically, the event schedule will include at least three entirely new events that will appeal to different membership constituencies. We expect to announce the event calendar next month so watch for details then.



GG: There certainly sounds like a lot of exciting things going on at SIIA. What advice would you give industry executives who want to become more active in the organization? MF: Well of course, become a member if you are not already. Showing up at association events – as they are available-- is a big deal because SIIA is a very interactive and social organization and there is no substitute for being there. We also recruit members to serve on our various volunteer committees and participate in periodic grassroots lobbying campaigns, which are great involvement opportunities. I like to say we are happy to put our members to work, so be on the lookout for announcements.

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Specialist Care



he decades-long pursuit of high-value, low-cost medical treatment delivered through self-insured health plans is elevated when it comes to specialist care. An analysis by the Institute for Health Metrics & Evaluation at the University of Washington suggests that it accounts for as much as 72% of the nation’s total health care spending across the entire population. A closer look at various trends help explain why this is the case. For example, hip and knee replacements have become increasingly routine with wild price variations complicating care decisions. Another area of consideration involves musculoskeletal disorders, whose total cost government research shows can be as high as $45 billion to $54 billion.

Written By Bruce Shutan

But that’s only part of the story. An estimated 60% of U.S. adults have a chronic illness and 40% have two or more such conditions, according to the Centers for Disease Control and Prevention. Among the leading drivers, which the CDC says costs an eye-popping $3.8 trillion a year, are heart disease, cancer, chronic lung disease, stroke, Alzheimer’s disease, diabetes and chronic kidney disease. Few would argue with the notion that the U.S. has become an unhealthy nation.



Rethinking Specialist Care

The key to managing these costly conditions and improving clinical outcomes is a partnership approach that combines data mining, episodic care with bundled prices, technology tools and innovative stop-loss products, industry experts say.



“The biggest challenge is a lack of transparency in the system,” observes Brian York, VP of value-based care at

“How do you know who provides quality care? How do you understand the differences between physicians or healthcare systems? It’s not an easy task. It’s very opaque to the consumer.”


provide quality service. The price for the episode of care is spelled out as a fixed bundle payment to the provider, who he says is on the hook for the excess cost of care.

SHARING RISKS AND REWARDS What makes an episode-of-care program so valuable is that it involves more sharing of information and risk, collaboration and much clearer expectations for what the process should look like, according to Dave Terry, founder and CEO of Archway

In securing the best possible care for patients at a reasonable cost, he says there needs to be an alignment between the insured, employer and physician, which will improve loss ratios and stabilize monthly premiums. With such great variability in quality and cost of care, he strongly believes health care consumers “deserve insight into that to help them make wiser choices.” One promising solution involves a bundled set of services to treat various conditions. Orthopedic surgeons have traditionally focused on filling up their OR schedule, perpetuating the practice of higher volume translating into higher profits. But in an episodic payment model, York says they’re given a target price from preop to postop and everything in between with financial incentives tied to outcomes. “If they do one knee surgery well, they get their surgeon’s fee but also reap the upside of the overall savings for that episode,” he explains. “They are actually managing the rehab and anesthesia costs.” Instead of just handing off patients, York says physicians will want to choose their downstream providers more wisely and stay connected throughout their episode of care in hopes of reaping greater cost efficiencies. That means choosing a rehab center with the lowest infection rate and a shorter stay, avoiding facilities that will bill for extraneous days just to rack up additional fee-for-service charges. “An orthopedic surgeon that does knee surgery well can make more money doing fewer surgeries, as long as they are quality surgeries that have a quality outcome,” he notes. By managing that continuum of the episode, the physician is incentivized to

Dave Terry Health. He says it also features a single entity or individual who’s responsible for managing cost and quality, as well as patient experiences along the continuum of care. This improves the chance of a good outcome. His firm has profiled every specialist in the U.S. and examined the total cost of care over an episode of treatment to both the employer and employee to match up the quality with the value.

“We have a tremendous amount of data that we use to evaluate this,” he reports. OCTOBER 2021 13

Rethinking Specialist Care

One of the first things his firm looks for is expertise, whether it’s knee replacement surgery, valve replacement or a stent, breast or lung cancer treatment, etc., as well as experience performing these procedures.

giving away web services to health care providers and hospital systems in exchange for data.

“Volume is not necessarily an indicator of quality, but it’s necessary,” Terry believes.

“It will be interesting to see what they bring to market because they are not traditional providers or payers of health care,” he notes. “They’re going to use that quality and cost variation as an arbitrage tool.”

Other critical factors that must be considered include overall health outcomes, complication and readmission rates, hospitalization rates in certain case, end-of-life care – in short, a variety of different quality metrics that vary by type of condition or procedure. What’s important is that self-insured employers find ways to engage employees in this process and help them make wiser, more informed choices, according to Terry. “Some of that can be direct engagement through benefit design and the HR team,” he says, noting how technology tools are facilitating that process. Another avenue is that primary care organizations increasingly are partnering with employers to ensure they’re working with high-value, high-quality specialists, he adds. York describes technology as the Holy Grail and future of health care, noting how scores of scrappy startups are disrupting the industry alongside established players such as Google and Amazon. In the stop-loss space, he says Amazon is actually



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Rethinking Specialist Care


An impediment to managing specialty care has been lack of innovation in the insurance space. Stop-loss products, for instance, have generally been the same over the past 15 or 20 years, York notes. However, he’s encouraged by more tech-driven products that analyze care patterns within a given network without regard to contractual relationship that a payer would have in order to find highquality specialists. Bundling standard insurance products will not only protect self-funded employers from runaway costs, he believes, but also arm them with the intelligence to make proper health care choices. “You have to link the two together to mutually benefit,” he adds. “Self-funded employers are uniquely suited to do this and drive patient care to the best physician.” Archway Health has developed an aggregate product that Terry says creates an opportunity for employers and their employees to pay closer attention to the first dollar and manage the total cost of care below a total-cost deductible. It also arms patients with enough information to make wiser choices from the very beginning. “It’s really important to think about how every employee makes choices for any type of specialty care that they need because it’s all building up toward the ag and attachment point,” he explains. “When that happens, there’s just a lot more engagement across the enterprise with people in the C-suite at the company, HR, and then coming in with creative ways to engage the employees and help them make wise choices.”



Early engagement is the key. Terry says developing an understanding of market variability with respect to quality and total cost along the way to making better choices can help improve the whole process, including outcomes and patient experiences. “But you want to get engaged with everyone sooner,” he points out. “In a spec product, it sort of pushes that decision out, but in an ag product, it really kind of gets everyone on the same page faster and folks working together and using information in new ways.”

RESHAPING REFERRALS AND CARE DELIVERY Citing a recent article in The Wall Street Journal that revealed C-section pricing at a Northern California hospital ranging from $6,000 to $66,000, Terry describes the massive variation as unbelievable and indicative of a deeply flawed marketplace. Perhaps even worse is when patients choose costly facilities that under deliver. “We’ll see examples where very high-priced organizations will have poor outcomes for certain procedures or conditions,” Terry observes.

“There are very few multi-trillion industries left where the decision making, information and underlying contracts are so opaque,” he laments. Still, he’s sanguine about what lies ahead: “I think we’re at the precipice of that changing pretty significantly over the next several years, and information flow is the key to changing the way health care is delivered and referrals are managed in our industry.” Bruce Shutan is a Portland, Oregon-based freelance writer who hasclosely covered the employee benefits industry for more than 30 years.

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Rethinking Specialist Care

BENEFITS CONSULTANT PRACTICES WHAT HE PREACHES As both a benefits consultant and employer with 95 associates who he cares deeply about, CGI Business Solutions President Dan Cronin says the quality of measurable data ranking specialists for the firm’s nearly four-year-old self-insured health plan is critically important. “We’ve experienced a very high degree of satisfaction with a program like this,” he told attendees of a panel discussion about specialist care strategies at SIIA’s 2020 virtual national conference. He referenced lessons learned from some cases involving low-level orthopedic care, lamenting a hit to the plan’s reinsurance from complications associated with a roughly $75,000 knee-replacement surgery. Cronin’s company introduced financial incentives to steer health plan participants to the most affordable, high-quality care. Lowcost ambulatory surgical centers are built into a standard PPO-style plan with a $1,000 annual deductible for individuals and $3,000 for families, as well as a plan featuring a Dan Cronin health savings account (HSA). The challenge was incorporating this concierge service to drive it even further. Those who elected the PPO option and called a toll-free number that connected them to a nurse who would guide them to a lower-cost, high-quality provider received a $750 credit off their health reimbursement arrangement toward their deductible. That meant the net-member responsibility was only $250. In taking it a step further, his company would waive the deductible on lab tests for those who used the service. As for the HSA plan, a $1,000 reimbursement was applied on the back end of deductibles for employees who engaged a health care advocate so that they wouldn’t lose their qualification to contribute to the HSA. And with a $125 monthly employer contribution to those accounts, the net out-of-pocket cost was just $500 for individual coverage.

“This type of arrangement is prevalent with all our selffunded groups,” Cronin reported, noting the power of practicing what is preached. On a personal note, he was thrilled with the results of steering his mother to a top eye surgeon in the Boston area to repair a detached retina in her right eye and remove a cataract in her left eye with the help of this program. – Bruce Shutan



Do you aspire to be a published author? We would like to invite you to share your insight and submit an article to The Self-Insurer! SIIA’s official magazine is distributed in a digital and print format to reach 10,000 readers all over the world. The Self-Insurer has been delivering information to top-level executives in the self-insurance industry since 1984. Articles or guideline inquires can be submitted to Editor Gretchen Grote at ggrote@ The Self-Insurer also has advertising opportunties available. Please contact Shane Byars at sbyars@ for advertising information.

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arlier this year, SIIA conducted a first of its kind survey among its captive insurance members in order to collect key information about the state of the industry. The survey comes after several years of growing advocacy activities by SIIA and its Captive Insurance Committee. The goal of the survey is to continue to facilitate coordination among captive professionals with information and data sharing across the industry.

Written By Karrie Hyatt

The survey results were formally released in early-July, followed by a webinar to discuss the results in-depth. This initial survey was the first in what SIIA hopes will be an annual survey that will be an ongoing information resource for its members.

“The survey results were very informative, specifically in the time of COVID,” said Jeff Fitzgerald, vice president of Employee Benefits at Innovative Captive Solutions. “All of us get involved in running our own captives, it’s good to have the opportunity to find out what is going on with the rest of the industry, to see where everyone else is.”



For Jerry Messick, CEO of Elevate Risk Solutions and current chair of SIIA’s Captive

“The results echo how important captives continue to be in protecting the assets of not only larger organizations, but the small to medium sized business market. The survey will hopefully serve as a foundation to build upon in the future as I believe it’s critically important to demonstrate the pulse of this growing industry.” Insurance Committee,

COVID-19 Impacts COVID-19 is changing the risk landscape for all of these sectors. Responding survey participants said that interest remains high for small businesses to form captives, but those businesses are finding funding unavailable due to capital contraction as a result of the pandemic. Businesses are also more interested in business interruption coverage, pandemic coverage, and risk sharing with fronting carriers post-COVID.

RESULTS OF THE SURVEY During the pandemic, many businesses The survey focused on three areas: the current state of the captive market, the impact of COVID-19, and the IRS’s continued activities surrounding captive insurance companies.

State of the Captive Market

The survey of the captive market found that of the captive managers surveyed, the median number of captives managed is 50, with a range from 18 captives per manager to over 3,000. The top three domestic domiciles utilized by survey participants are Delaware, Tennessee, and North Carolina. In 2020, captive managers saw more captive formations than closures, with an average of 28 new captives formed during the year, and an average of 20.8 captives closed.

“I personally know two companies that closed due to the effects of the pandemic,” said Messick,” “So that naturally had a dramatic effect. On the other hand, you saw the true benefits of captives that paid millions in claims to their insureds. I would also say that many of these claims would have been denied by the commercial market. The fact that you saw an increase is a testament to progressive companies understanding that well-structured captives provide incredible protection.”

being insured by the traditional market were caught off guard by claims denied by their insurers.

According to Messick, “I was astounded at the number of business interruption claims denied by the commercial market. I think that just demonstrates how little most company executives understand about their own policies. While not talked about much, captives are excellent drivers of education in understanding the coverages being purchased. I think you’ll see the trend to captive continue because of this and the market conditions.”

The pandemic has been a game changer in the insurance marketplace leading to more interest in captives and the more flexible coverage they can provide.

“Captives are always found where people are frustrated with traditional insurance.” As Fitzgerald said,

New trends identified in the captive insurance space are the hard market’s influence on traditional insurance rates which is spurring new captive formations, as well as changes to risks in the in the property and casualty sector, in medical stop-loss, and in self-insurance spaces. IRS activities are still an ongoing concern.



“Captives helped during the pandemic, in many ways, but especially from the supply chain and business interruption coverage perspectives,” said Messick. “While COVID was a major influence on these risks, the repercussions of inflation, reduced manufacturing capabilities, and especially the disruption in the shifting labor market will have profound effects on business. I was on a captive board call recently where the insured said he relied on the captive as a backstop to the more aggressive management decisions they were having to make due to dramatic labor shortages.” The survey found that the average number of COVID-related claims in 2020 was 75, with one captive manager reporting 300 claims. Going into the pandemic, it was expected that most small business claims would be healthcare related.

However, most claims from captives were related to business interruption. “We just did not see that the economic repercussions of COVID being that the interruption of day-to-day operations would be more expensive than medical claims. The average COVID case was not that expensive, even for those cases that involved a hospital visit, versus the loss of operating revenue,” said Fitzgerald.

At the time of the survey, in the spring of this year, 80.5% of COVID-related claims were paid and approximately six claims on average were still open. The average amount paid on COVID-related claims was $650,000, with the highest claim being $2 million.

Captives were instrumental in helping their owners and parent companies stay solvent during the pandemic. According to Fitzgerald, “For us, with our focus on employee benefits, it was the stability of captives that helped through COVID, as well as having the opportunity to define how coverage could be provided. When everyone was locked down and not going to the doctor, employee benefits captives could recognize those savings and put that money by for later use.”



IRS Activities

The survey’s section on IRS activity focused on four issues: appeals, global settlement, audits, and court cases. In both the appeals and court case section the vast majority of respondents did not have any direct experience—not appealing any IRS decisions nor taking them to court.

In relation to audits, 35% of survey respondents said they have at least one captive currently under audit. With roughly a third of captives under audit, captive managers believed they were not treated consistently under the Taxpayer Bill of Rights. Respondents reported that the average cost of defending a captive in an audit is $150,000. The lowest cost reported was $30,000 and the highest cost estimated

at $250,000. Captive managers stated that the overall costs of defending their captives during an audit have exceeded $3 million per manager.

The IRS’s global settlement offers have created a lot of tension in the industry, with captives receiving the offers vacillating on whether or not to accept. Respondents to the survey said that, of the captives they manage that received an offer to settle, a majority of their clients chose not to settle. One captive manager reported that 95% of their clients chose not to settle, while several others reported that there was a mixed number of captives that chose to settle—either a 40/60 split or 50/50 split.

Regarding those that accepted the settlement offer, 55% did so even though they believed the merits of their case were inconsistent with the offer. They did so because the cost of litigation outweighed the cost of settlement.

SIIA’s Advocacy

Committee has been advancing its charter by taking on policy and regulatory issues, including developing and releasing the Captive Manager Code of Conduct.

The more recently formed Captive Advocacy Team has been instrumental in getting captive owners involved in legislative and regulatory issues. According to Ryan Work, SIIA’s vice president of government relations, “This year alone, we have working groups updating the Code and looking at regulatory guidance, conducted the captive survey, in addition to ongoing advocacy on captive policy and regulatory issues.”

The inaugural captive survey is part of SIIA’s dynamic captive strategies for the coming months and years. Over the last five years, SIIA’s Captive Insurance

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SIIA’s increased focus on captive issues is meaningful in many ways for their captive membership, not least of which is being a vocal supporter of captives. According to Messick, “SIIA’s work means responsible captive managers finally have a voice. It means we can try and make our industry stronger as witnessed in the first version of the SIIA Captive Code of Conduct. I’ve been blessed to be in this business for over 37 years. It’s my profession and I’m extremely proud of the work we do. Quite frankly, SIIA’s support and involvement means everything to me.”

For Fitzgerald, SIIA’s engagement with captives and advocacy is key to his involvement with the organization. “I think that it is invaluable. There is more than one captive organization. Most of them are focused on their own jurisdiction. SIIA’s mandate is the protection of self-insurance and captives are a great example of self-insurance done well. Being able to look at captives in context with the larger self-funded world is important to understand our place in it. To be a part of that and realize we have the same problems. It’s huge to know that, to be a part of it.”

SIIA’s first annual captive survey will be influential in helping to set the course for its captive engagement in future years. Messick said, “SIIA has once again demonstrated their commitment to the captive management industry by performing a first-of-itskind survey.”

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

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Employee benefit plans are insured by Symetra Life Insurance Company, 777 108th Avenue NE, Suite 1200, Bellevue, WA 98004, and are not available in all U.S. states or any U.S. territory. Our New York subsidiary issues our products for New York residents. Symetra® is a registered service mark of Symetra Life Insurance Company. SLM-6245







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




coverage, other than an exclusion or coordination of benefits or a permitted affiliation or waiting period. •

Ancillary services provided by an OON provider at an in-network facility. Ancillary services include items and services related to emergency medicine, anesthesiology, pathology, radiology, and neonatology (whether or not provided by a physician or non-physician practitioner); items and services provided by assistant surgeons, hospitalists, and intensivists; and diagnostic services (including radiology and laboratory services). In addition, items and services provided by an OON provider are considered ancillary if there is no in-network provider that can furnish the service at the facility. Regulations may add additional items and services that are ancillary and may also provide a list of advanced diagnostic laboratory tests that are not ancillary services.

Non-emergency services performed by an OON provider at an in-network facility, unless the provider has complied with notice requirements and the individual consents to using the OON provider. The exception for complying with notice and consent requirements does not apply to ancillary services or to any item or service that is furnished as a result of unforeseen, urgent medical needs that arise at the time a covered item or service is furnished.

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. In prior articles we discussed the impact of CAA on FSA administration; the forthcoming broker/consultant fee disclosure rules; and the new comparative analysis disclosure requirement under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). This article provides an introduction to the so-called No Surprises Act (NSA) billing provisions of the CAA. These provisions dramatically change the way that certain emergency and additional (e.g., ancillary) health benefits are administered and requires changes beginning with plan years on and after January 1, 2022 that are applicable to all plan sponsors and TPAs. In subsequent articles we will drill down on the interim final regulations providing how the claims and dispute resolution (IDR) processes will work.


Under the NSA, the financial obligation of plan participants and beneficiaries is limited to in-network cost-sharing (deductibles, co-payments, and co-insurance) for the following services performed by an out of network (OON) provider:

Emergency services provided in an emergency department of a hospital (including a hospital outpatient department) and in a freestanding emergency department. Rules similar to the ACA requirements for emergency services also apply. Thus, if a plan covers any benefits for services in an emergency department of a hospital (including a hospital outpatient department) or emergency services in a freestanding emergency department: (1) plans cannot impose prior authorization requirements on emergency services (whether in-network or OON); (2) plans must cover emergency services even if the provider or facility is OON; (3) if the services are provided by an OON provider or facility, the plan cannot impose any requirement for prior authorization or any limitation on coverage that is more restrictive than the requirements that apply to in-network emergency services; and (4) plans must cover emergency services without regard to any other term of condition of




Plans must count participant cost-sharing for these OON services in the same manner as in-network cost-sharing (e.g., counting the cost-sharing against any innetwork deductible or out-of-pocket amount). In applying the plan’s in-network costsharing provisions to these OON services, the “recognized amount” is treated as the amount that would have been charged by an in-network provider.

For example, if a plan’s cost-sharing rate for an in-network service is 20%, then if the service is performed by an OON provider, the cost-sharing amount would be 20% multiplied by the recognized amount.

In general, the recognized amount is one of the following three amounts: (1) the amount determined by an applicable state law (e.g., for a fully insured plan); (2) if there is no applicable state law (e.g., in the case of a self-funded plan subject to ERISA), the qualifying payment amount (or QPA) which is based on median contracted rates recognized by the plan; or (3) in the case of a state that has an all-payer model agreement in effect with the Centers for Medicare and Medicaid Services (CMS) pursuant to Section 1115A of the Social Security Act, the amount the state approves for the item or service.



Providers are prohibited from balance billing plan participants for any amount exceeding the in-network cost-sharing for these OON services. Group health plans are required to make an initial payment to the OON provider or a notice of denial of payment within 30 calendar days after receiving a bill from the provider.

The NSA specifically provides that the provisions relating to surprise medical bills do not adversely impact HSA eligibility. In other words, the requirement to pay an additional amount pursuant to the dispute resolution provisions before the HDHP deductible is satisfied will not cause an individual to be ineligible to contribute to an HSA.


A number of states already have laws that protect participants from surprise medical bills under fully insured plans. Where applicable, the NSA defers to payment amounts for surprise medical bills as determined under applicable state law where such laws provide equal or greater protection (specified state laws). If such a state law does not apply (e.g., in the case self-funded plans subject to ERISA or a law that is not a specified state law), bills will be resolved under the NSA IDR arbitration process.

Following the decision, the party that initiated arbitration cannot request arbitration for similar claims for a “lockout” period of 90 days. This waiting period is intended to provide some incentive for the parties to negotiate similar claims. Claims relating to the lockout period may, however, be submitted after the lock-out period ends.

AIR AMBULANCE SERVICES Under the IDR process, plans and providers may negotiate during a 30-day coolingoff period, which starts on the date the provider receives the initial payment or notice of denial. If a settlement is not reached during this period, either party may initiate the IDR process within four days of the end of the cooling-off period. Providers may bundle payments to be considered in the IDR process.

There is no dollar threshold for claims to be submitted to arbitration, so claims of any amount may be submitted. The IDR process is “baseball style” arbitration, meaning that each party provides a payment offer and the arbitrator must choose one of the offers. The losing party pays the cost of arbitration. If the provider and plan agree to a payment amount before the IDR entity makes its decision, costs are split between the parties.

In general, the IDR arbitrator can consider any factors submitted by either party in making its decision. There are, however, certain factors the arbitrator can and cannot consider. For example, the arbitrator is to consider the qualified payment amount as well as information relating to the level of training, experience, and quality of outcomes of the provider, the market share held by the provider, the acuity of the individual receiving the service, and the teaching status, case mix, and scope of services of the OON facility where the services were performed.

Rules similar to the surprise billing provisions also apply to air ambulance services. There are some differences; for example, the factors the IDR reviewer are to consider are somewhat different in the case of air ambulance services.

Ground ambulance services are not subject to the surprise billing provisions. Instead, the CAA directs the Secretaries of Labor, Treasury, and HHS to establish an advisory committee on ground ambulance services and patient billing. The committee is to submit its report and recommendations to Congress within 180 days after the committee’s first meeting.


INCLUDING TRANSPARENCY REQUIREMENTS Importantly, the IDR arbitrator cannot consider the provider’s billed charges or reimbursement rates from public payors, including Medicare and Medicaid. Access to external review process for surprise medical bills The IDR arbitrator has 30 days to make a decision. The decision is binding on the parities (except in the case of fraud or misrepresentation of facts). The decision also is not subject to judicial review, except in limited circumstances such as fraud, partiality, or corruption on the part of the arbitrator, misconduct on the part of the arbitrator, or if the arbitrator exceeded its powers.

The ACA external review process is extended to cover issues relating to surprise medical bills, including whether



a particular item or service is subject to new surprise billing rules. Note that the external review process does not apply to grandfathered plans, so that such plans should not be subject to this new requirement.

- the contractual relationship between the plan and provider or facility is terminated;

Continuity of care


When a provider leaves a plan’s network, individuals in certain circumstances must be provided 90 days of continuing care as if the provider were still in-network. This applies if an individual is undergoing a course of treatment for a serious and complex condition; undergoing a course of institutional or inpatient care; scheduled to undergo nonelective surgery, including postoperative care; is pregnant and undergoing a course of treatment for the pregnancy; or was determined to be terminally ill.

benefits provided under the plan with respect to the provider or facility are terminated because of a change in the terms of the participation of such provider or facility in the plan; or


a contract between the plan and a health insurance issuer offering health insurance coverage in connection with the plan is terminated, resulting in a loss of benefits provided under the plan with respect to the provider or facility.

Specifically, if an individual is covered under a group health plan with respect to an in-network health care provider or facility and such individual is a "continuing care patient" with respect to such provider or facility, the plan must provide notice to the individual, and potentially provide transitional care for up to 90 days, if:

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Although applicable for plan years beginning on or after January 1, 2022, the agencies have indicated that they will not be issuing any regulations before then. Therefore, until such a time that there is further rulemaking, plans, providers, and facilities are expected to implement the continuity of care requirements using a good faith, reasonable interpretation of the CAA.

Disclosure and transparency rules included in the NSA

A number of new disclosure and transparency provisions are imposed on group health plans. Many of the effective dates for these requirements were addressed in Agency FAQs 49. These requirements include:

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Provide an advanced explanation of benefits before scheduled care, including information such as the estimates of cost-sharing and the amount the plan will pay for the service and whether the provider is in-network or OON (Original effective date of plan years on/after January 1. 2022 but the agencies will defer enforcement until regulations to fully implement the requirements are adopted and applicable).

Maintain price comparison tools available online and over the phone (Original effective date of plan years on/after January 1. 2022 delayed until plan years on/after July 1, 2022).

Maintain up-to-date provider directories (Original effective date of plan years on/after January 1. 2022 retained).

Include in-network and OON deductibles and out-of-pocket maximums on health plan member electronic or physical identification cards (Original effective date of plan years on/after January 1. 2022 retained pending future regulations, plans are expected to implement the ID card requirements using a good faith, reasonable interpretation of the law).

Providers are subject to disclosure requirements, including a requirement for OON providers to provide a “good faith estimated amount” for all services to be provided. (Original effective date of plan years on/after January 1. 2022 but the agencies will defer enforcement until regulations to fully implement the requirements are adopted and applicable)


The surprise billing and related provisions applicable to group health plans are added to the Code, PHSA, and ERISA and will be subject to the same general enforcement structure as the ACA coverage mandates. States retain primary enforcement authority over fully insured plans, subject to federal enforcement by HHS if a state fails to substantially enforce a provision. HHS also has jurisdiction over self-funded governmental plans.

The DOL has enforcement authority over plans subject to ERISA. Under the Code, a $100 per day excise tax may apply in the case of noncompliance by private sector plans and church plans. Provisions applicable to providers are added to the PHSA and are subject to primary enforcement at the state level and potential federal enforcement. The DOL is specifically authorized to coordinate with states and HHS regarding violations of provider requirements for group health plans and conduct investigations as appropriate.




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QBE finds stop loss large claim frequency increased during the pandemic

In QBE’s 2021 Accident & Health Market Report, QBE notes an increase in the frequency of $200,000+ claims, when comparing annual policies that started in the first quarter of 2019 against those that started in the first quarter of 2020. These two time periods serve as a proxy for claims coming in before and after the onset of the COVID-19 pandemic. The increase was driven by more claims for mental and respiratory illnesses, which were only partially offset by fewer claims for neoplasms and circulatory system diseases.

Frequency/10,000 employees

Data shows increases in claims for mental and respiratory illnesses outweighed declines in claims for neoplasms and circulatory diseases. All conditions 50.0 40.0 30.0 20.0 10.0 0.0 2017




Policy year * Data as of April 30, 2021.

Neoplasms continue to be a top consideration for stop loss claims. Although the frequency of $200,000+ claims for neoplasms declined during the pandemic, neoplasms remain a leading concern. They were by far the most common of such claims both before and during the pandemic. Meanwhile, the decline in claims frequency throughout the pandemic may be the result of missed and delayed cancer screenings, which could lead to an increase in treatment costs and complications in the future.

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Diseases of the respiratory system 2.0 1.5 1.0 0.5 0.0 2017




Frequency/10,000 employees

Frequency/10,000 employees

Claims frequency by primary diagnosis for members exceeding $200,000 in annual claims.

Policy year

1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 2016





Neoplasms 20 15 10 5 0.0 2017




Frequency/10,000 employees

Frequency/10,000 employees

Policy year

Diseases of the circulatory system 6.0 4.0 2.0 0.0

Policy year





Policy year

* Data as of April 30, 2021.

To learn more about QBE Accident & Health and access our full report, visit us at This literature is descriptive only and should not be construed as legal or professional advice. QBE makes no representation or warranty regarding the information contained herein or the suitability of this information for a particular purpose. Any reference to prior QBE claims is illustrative only, trends are based on QBE claims data and should not be perceived as a representation that such type or frequency of claims will continue. This document is not a policy document. Actual coverage is subject to the language of the policies as issued.QBE and the links logo are registered service marks of QBE Insurance Group Limited. © 2021 QBE Holdings, Inc.

“The claims frequency nearly doubled for respiratory illnesses, and it more than doubled for mental illnesses,” said Tara Krauss, Head of Accident & Health at QBE North America. “It demonstrates the broad impact of the pandemic and explains why we have seen employers seek more holistic solutions that connect mental and physical health.” For more key findings, read the full QBE 2021 Accident & Health Report.

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oint and back pain are the second and third most common reasons for patients to seek care from a physician, according to a Mayo Clinic study of more than 142,000 individuals. That first physician is typically a primary care doctor. Primary care, as popularly defined, is a family doctor, internal medicine doctor or doctor of osteopathy.

Written By Sherry McAllister, DC

For employers, however, particularly those in manufacturing, construction, distribution and other occupations that involve greater physical demands on their employees, a doctor of chiropractic (DC), should be the primary care doctor at the top of the list. After all, self-insured employers face enormous healthcare, disability and workers’ compensation costs for employee back and neck pain and other types of neuromusculoskeletal pain. DCs specialize in these conditions. Given these doctors' ability to deliver positive outcomes, patient satisfaction and overall lower costs and reduced safety risks compared to traditional pharmacologydriven primary care, DCs need to be included in the scope of primary care.




Workplace injuries, caused by a single accident or repeated movements over years, created $171 billion in costs in 2019, and not for employers alone. Rather, the figure includes wage and productivity losses of $53.9 billion, medical expenses of $35.5 billion and administrative expenses of $59.7 billion, according to the National Safety Council (NSC). The total also includes employers’ uninsured costs of $13.3 billion, which factors in the time lost in investigating and reporting any incidents. The NSC also studied the most common injuries that result in workers’ compensation claims. While traumatic injury from a motor vehicle, burn or other accident were the costliest, claims attributed to “strain” and “cumulative injury” were in the top 10 with strain costing nearly $34,000 per claim and cumulative injury averaging more than $31,000 per claim. Likewise, injury to the neck, arms, shoulders and back were among the top 10 body parts attributed to workers' compensation claims, which are the areas most treated by DCs. Another report showed that the top cause of these work-related injuries was “overexertion and bodily reaction,” defined as excessive physical effort and repetitive motion. Such injuries are common and can be devastating to employers and employees. For example,

27 out of every 10,000 workers suffer overexertion and bodily reaction injuries and lose 13 workdays a year on average. DCs are trained to identify these problems and treat the underlying causes instead of masking symptoms with a pharmaceutical drug. Chiropractic care is, and has always been, drug-free. Considering 75% of employers polled say opioids have negatively impacted their workplace, increasing access to drug-free care should be a priority. Furthermore, clinical guidelines from the American College of Physicians and the National Academy of Medicine recommend treating acute back pain first with nonpharmacologic methods and that opioids, in particular, should be avoided for chronic back pain. Whether the pain comes on suddenly or has been lingering for years, DCs can help employees manage nearly all neuro-musculoskeletal conditions, often at a lower cost. A large study in Texas found the average workers’ compensation claim for an employee with a low-back injury was $15,884. However, if a worker received at least 75% of their care from a DC, the total cost dropped by nearly one-quarter to $12,202. If the DC delivered at least 90% of the care, the average cost declined to $7,632.




Conversely, seeking neuro-musculoskeletal care from an allopathic or osteopathic primary care doctor may contribute to worse outcomes. Researchers examined the records of more than 5,000 patients with low back pain who had been treated at 77 medical primary care practices. Nearly half of the patients with low back pain that later became chronic received a treatment that was not recommended by medical consensus (also called a “nonconcordant” recommendation). Nonconcordant recommendations include a prescription for opioids (such as oxycodone or Vicodin) or benzodiazepines (such as Valium or Xanax). Orders for expensive imaging tests such as computerized tomography (CT) or magnetic resonance imaging (MRI) are also considered nonconcordant. Even after researchers examined other variables about the patients such as obesity or their initial level of disability, the non-recommended back pain management approaches increased their likelihood of developing chronic low back pain. In total, about one-third (32%) of patients developed chronic pain.

Although employees will never receive an opioid prescription from a DC, they may receive care for their pain from multiple doctors. In several studies, however, researchers have found that patients who seek care from a DC more often avoid opioids. A 2020 paper examined the records of more than 100,000 adults with spinal pain ages 18 to 84 who visited a DC and another primary care doctor and compared them to patients who did not visit a DC. Patients who did not receive chiropractic care for their spinal pain filled an opioid prescription up to twice as often as those who did visit a DC. Representatives from Optum, a subsidiary of UnitedHealth Group, have repeatedly stated how seeking nonpharmacologic care first for pain has reduced costs and opioid prescriptions.

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While DCs undergo rigorous education and training for musculoskeletal conditions, a survey from 2018 found only 27% of allopathic medical school students thought that their musculoskeletal education was adequate. Additionally, a survey found more than half of family/general medicine physicians refer their patients to another provider for spinal manipulative therapy, which is most often delivered by a DC. Achieving long-term pain

For example, during a 2018 National Academy of Medicine workshop, David Elton, DC, senior vice president for clinical programs at Optum, explained that conservative care for low back pain could save $230 million in annual medical expenditures for the insurer and reduce opioid prescribing by 26%. At the same time, DCs can reduce demand on family doctors and other types of primary care physicians. The U.S. could experience a shortage of up to 55,200 primary care physicians by 2033, so diverting more employees’ neuro-musculoskeletal problems to DCs first can improve primary care access for other employees with unrelated conditions.

THE ADVANTAGE OF CHIROPRACTIC CARE The focus of chiropractic care is on spinal health and helping patients suffering from musculoskeletal conditions, but the goal of chiropractic care is much larger. DCs take a holistic view of health and are trained and experienced in correcting the root causes of a health problem and correcting associated musculoskeletal imbalances. A majority of chiropractic patients also report the care improves their sense of wellbeing. Furthermore, DCs receive at least four years of post-graduate education, including a minimum of 4,200 hours of classroom, laboratory and clinical experience. To earn their license and practice, all U.S. states require a degree from an accredited chiropractic doctorate program and passing all four parts of the National Board of Chiropractic Examiners exam.



relief from a DC may also avoid the need for expensive prescriptions, CT or MRI scans, and surgery, which will significantly reduce employer and employee spending in the long run. Chiropractic visits after the first are typically quick, less than 15 minutes, which means employees will spend less time away from work or home. Chiropractic care also improves employee productivity by preventing/ eliminating disability and helping avoid surgery, which can extend the number of days away from work. That is one of the reasons more employers are adding DCs to onsite employee health clinics, which are common in larger companies. In these clinics, employees who received chiropractic care were absent from work only half as much as the national average, according to a study of one such clinic.

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More importantly, a DC can offer employees exercises they can do at home and advise them how to adjust the repetitive or exertive movements required for work to prevent a reinjury and improve their range of motion.

MAKING DRUG-FREE CARE ACCESSIBLE While the health and safety benefits of seeking chiropractic care first are clear, employers need to structure employee health benefits to encourage that such services are accessed first. Employees with low-back pain who had health plans with greater restrictions on provider choice were less likely to choose conservative, less-costly therapy compared to those covered under the least restrictive plan type. These restrictions could include lack of coverage, provider network limitations or higher out-of-pocket spending for employees. A 2018 study and associated commentary published in JAMA Network Open found that one commercial health plan required members to pay a $60 copay for chiropractic care while generic prescription opioids can often be obtained with no coverage for less than $10. To encourage access to safer, more effective care, UnitedHealthcare, in 2019, eliminated copays to DCs or physical therapists on some employer-sponsored health plans if employees sought care from these providers for their acute low-back pain.



All types of employees can develop back pain. In fact, office workers who sit at a desk for most of the day carry a significant risk of musculoskeletal injury due to inactivity, poor posture, or ergonomic factors. That is why even if the employer has just a few or many employees with physically demanding jobs, a doctor of chiropractic should be the primary care doctor of choice to help these employees find lasting pain relief and correct the cause of their pain, not just mask the symptoms.

Sherry McAllister, DC, is president of the Foundation for Chiropractic Progress (F4CP). A not-for-profit organization with nearly 29,000 members, the F4CP informs and educates the general public about the value of chiropractic care delivered by doctors of chiropractic (DC) and its role in drug-free pain management. Learn more or find a DC at


NEWS FROM SIIA MEMBERS 2021 OCTOBER 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 at 44



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Westborough, MA – As the company’s expansion continues to flourish across the country, HPI has tapped Matt Kennedy, self-funding and Reference-Based Pricing (RBP) expert, as their new national vice president of sales. Matt brings over 15 years of experience as a trusted resource in the industry and will hit the ground running as an impactful and purposeful leader on HPI’s national sales team. “I couldn’t be more excited to have Matt on board at HPI,” said Drew Rozmiarek,

“Matt’s the type of person you want in your corner; everything he does is with intention. He’s a respected, trusted source in the industry and an RBP expert eager to add knowledge to his repertoire. Matt’s never-ending quest to pursue more is exactly what we are always looking for at HPI—someone who will embrace our mission to keep innovating and evolving healthcare. He’s a great fit for us, and I can’t wait to finally get to work together on the same team.” senior vice president of national sales and emerging markets.

Matt most recently served as senior vice president of growth at HST, where he was a leading driver of company expansion and client retention and was regarded as the top salesperson for the successful RBP start-up for four years. Previously, he served as a sales consultant for Intuitive Surgical. “Having worked with HPI as a partner for five years, I have been able to experience first-hand the success this organization has achieved helping employers drive down cost while always putting the member first,” said Matt Kennedy. “HPI’s ability to offer many solutions that can be customized to meet each client’s needs as well as how they continually look at ways to improve healthcare were major reasons why I wanted to join this team. I am thrilled to be with HPI working alongside a group of great people and eager to help future clients and their members.” About HPI HPI redefines what is possible with self-funded health plans. As a leading national third-party administrator, they partner with health plan brokers and employers to provide innovative self-funding strategies and customized plans tailored to each client’s needs and population. HPI’s solutions give employers greater cost transparency and control, while elevating the member experience. It is their flexible



approach, entrepreneurial spirit and commitment to quality, technology, and service that enable them to deliver premium value to their customers. Contact Su Doyle, VP of Strategic Marketing, at sdoyle@healthplansinc. com and visit



PHOENIX, AZ — Vālenz®, the innovators behind the industry’s most transparent, data-driven ecosystem for self-funded employers and their health plan partners, recently announced that Brian Campbell has been promoted to Vice President, Client Services. Campbell joined the firm in January 2019 as a senior client services executive. In his new role under the leadership of Nathan Nelson, Senior Vice President, Growth, Campbell now oversees the client services team. “Since joining us nearly three years ago, Brian has exemplified the character, culture and vision of our company – he lives our values and promotes the strong, vigorous, healthy mindset at the core of the Valenz brand,” said Rob Gelb, Chief Executive Officer. “His ability to collaborate and lead will serve him, our team, our clients and our company well as we move forward and further our ecosystem vision for all stakeholders of the self-insurance community.” Brian’s career spans two decades of proven success in client-focused relationships in the healthcare and financial services industry.

Accident & Health Insurance

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QBE and the links logo are registered service marks of QBE Insurance Group Limited. ©2021 QBE Holdings, Inc. This literature is descriptive only. Actual coverage is subject to the terms, conditions, limitations and exclusions of the policy as issued.

NEWS Prior to joining Valenz, his career highlights included leading national accounts in commercial insurance, workers’ compensation, reinsurance and more. Brian also has a degree in Marketing/International Business from Kansas State University. “I am extremely energized to take this next step at Valenz,” said Campbell. “My account management approach has always been to put clients first and create genuine partnerships, and it’s an honor to do so as part of this extraordinary leadership team. I believe in limitless potential for our clients as we partner with them to engage early and often for smarter, better, faster healthcare.” About Vālenz Valenz enables self-insured employers to make better decisions that control costs across the life of a claim while empowering their members to lead strong, vigorous and healthy lives. Valenz offers transparency through data to pinpoint members at highest risk, address gaps in network designs, ensure appropriate and accurate charges, and expertly navigate employees to optimal care solutions for substantial cost savings and improved health outcomes. More information is available at Valenz is backed by Great Point Partners.



PHOENIX, AZ and CHICAGO, IL– Renalogic, the leading company helping employers and health plans fight the human and financial costs of chronic kidney disease, announced today the addition of three new executives. Scott Vold has joined the team as Chief Commercial Officer, Forrest Barnes III as Vice President of Data and Technology, and Kyle Bersnak as Vice President of Finance.

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

RENALOGIC.COM 888.808.9380



NEWS Renalogic simultaneously helps clients reduce risk and manage costs by supporting better health outcomes and providing significant savings related to dialysis care. Renalogic’s predictive analytics identify potential risks associated with CKD while the clinically proven Kidney Dialysis Avoidance Program delivers tailored intervention that slows, stops, and in some cases, reverses the trajectory toward dialysis. For those on dialysis, the company’s proprietary claims repricing methodology provides net savings of up to 85%, which can translate to as much as $1 million per individual.

“Today we have an opportunity to build on our marketleading position and to help more health plans reduce the human and financial costs associated with chronic kidney disease and dialysis claims,” Kevin Weinstein, Renalogic CEO said. “There’s never been a greater need for organizations to bring innovative solutions to help their employees battle chronic diseases and save on healthcare. Scott, Kyle and Forrest have the leadership experience and skills we need to help more people and plans.” Scott Vold joins Renalogic as the company’s new Chief Commercial Officer. Prior to Renalogic, Vold drove an industry-wide effort to redefine the physician referral management process as Founder and CEO of Fibroblast, Inc., a company he led from concept to successful acquisition by Cerner Corporation in October 2020. Vold began his career as an attorney representing Fortune 1000 companies and financial services firms in complex commercial litigation. •

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

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

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

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

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

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

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

NEWS Dialysis Avoidance Program. We are revolutionizing the industry by delivering predictive analytics to identify the progression of the disease, simplifying the costs and clinical complexities of chronic kidney disease to make a positive impact and reduce the dialysis incidence rate in every population we touch. Every chronic condition leading to End Stage Renal Disease is manageable and even preventable when identified early. For more information, please visit https://


CONNECTICUT OFFICE TO DOWNTOWN HARTFORD Forrest Barnes III joined Renalogic as the company’s new Vice President of Data and Technology. Barnes is an Information Technology leader with nearly 20 years’ experience in healthcare, Financial Services, and Insurance sectors. Prior to joining Renalogic, Barnes Served as Director of Information Technologies for Evolution Health, Director of Operations for Blue Cross Blue Shield Insurance and as a Customer Engagement Executive for GuideIt, where he built an enterprise-class background in compliance, security, network architecture, and innovative technology solutions. Kyle Bersnak was appointed the company’s Vice President of Finance, leveraging more than 15 years of executive finance roles, most recently at one of the largest independent third-party administrators (TPAs) in the United States. Kyle’s proven history of implementing process improvements and optimizing financial results will benefit all Renalogic clients and partners. Earlier this summer, Kevin Weinstein was appointed to lead Renalogic as its new Chief Executive Officer. These executive appointments, geared toward better serving clients and growing the company, follow the growth recapitalization with Carrick Capital Partners which was announced in March 2021. About Renalogic Renalogic has been the industry leader in dialysis cost containment for nearly 20 years and continues to innovate through the impact of the Kidney



WINDSOR, CT -- Sun Life U.S. announced plans to move its Connecticut office to One Financial Plaza, also known as "The Gold Building," at the corner of Main and Pearl Streets in downtown Hartford. Sun Life will occupy 47,000 square feet of space in one of the largest, most prominent office towers in Hartford. The building offers modern amenities, including a fitness center, onsite café, and an attached parking garage with state-of-the-art equipment. The location is within walking distance to a number of excellent restaurants, theater venues, museums and other activities. "Hartford is one of the strongest markets in the world for insurance and related technology professionals, and bringing our Connecticut team to Hartford is an important step in making us an even stronger home for top talent in the area,"


"We look forward to developing a strong presence in and relationship with the city of Hartford." said Dan Fishbein, M.D., president of Sun Life U.S.

"Our office-work dynamic has shifted to a more flexible model and we intend to design our new space with advanced concepts for the future of work, including features that support how employees choose to work, leading technology, and amenities such as complimentary parking," added Fishbein. At full capacity, the new office will accommodate up to 450 employees. Currently there are approximately 300 Sun Life employees based in Connecticut, a mixture of underwriting, actuarial, technology, operations, clinical, sales, and product professionals in Sun Life's Stop-Loss & Health and Group Benefits businesses, as well as legal, HR and finance team members. "This new office will be a hub for Sun Life and give us the opportunity to operate with modern, more efficient capacity for our employees and clients," said Jen Collier, R.N., senior vice president, Stop-Loss & Health, at Sun Life U.S. "Our new, flexibilityinspired space will support our teams' optimal work styles, help us drive better health

We are Advocates for Healthier Living As Advocates for Healthier Living, we’re improving clinical outcomes while reducing the Total Cost of Care. It’s the foundation of the service we provide our clients, members and business partners. We Change Lives. We create positive change in every interaction we have. By listening and understanding our clients’ needs, we offer flexible, cost-effective and easy-to-use health care solutions. We are dedicated to providing compassionate support and guidance to help our members be active participants in their health care.

For more information, visit



outcomes for our members and support our employer clients." About Sun Life Sun Life is a leading international financial services organization providing insurance, wealth and asset management solutions to individual and corporate Clients. Sun Life has operations in a number of markets worldwide, including Canada, the United States, the United Kingdom, Ireland, Hong Kong, the Philippines, Japan, Indonesia, India, China, Australia, Singapore, Vietnam, Malaysia and Bermuda. As of June 30, 2021, Sun Life had total assets under management of $1.36 trillion. Visit

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SAN FRANCISCO -- Grand Rounds Health announced that it is partnering with Trustmark Health Benefits to support Trustmark Health Benefits' self-funded clients and their members as they navigate complexities within the healthcare system. Trustmark Health Benefits, a national employee health benefits administrator, can now offer additional personalized healthcare support to optimize health outcomes, network discounts and services, costs, and member experience

via The Trustmark Navigation and Advocacy service powered by Grand Rounds Health. "Our collaboration takes the complexity out of healthcare by providing personalized, high-quality, and cost-effective support for Trustmark Health Benefits clients and their members throughout their healthcare journeys in one simple, integrated offering," said Robin Glass, President of Grand Rounds Health and Doctor On Demand. Without proper guidance, a complex care journey can quickly escalate to unnecessary procedures, high healthcare costs, confusion, and uncertainty for patients. Trustmark Health Benefits can now offer to its clients and their members the ability to leverage Grand Rounds Health's wraparound clinical navigation and advocacy capabilities across a full spectrum of healthcare needs. Through the Trustmark Navigation and Advocacy service powered by Grand Rounds Health, Trustmark Health Benefits clients and their members can access a complete suite of claims and member services support, along with healthcare navigation offerings all in one place, including treatment decision support, personalized matching to top-quality in-network healthcare providers, expert opinions from worldclass experts, cost transparency, and intelligent routing to other benefits in the healthcare ecosystem.




LEGAL EXPERTISE SECURED | 781-535-5600 | 56




NEWS "We have worked with Grand Rounds Health for years and have experienced exceptional results after adopting their expert medical opinion service as a benefit for our own employees," said Nancy Eckrich, President of Trustmark Health Benefits. "We are excited to expand our relationship by offering the expert medical opinion service, along with Grand Rounds Health's complete healthcare navigation capabilities, to our clients and their members to simplify personal care plans and help improve people's overall health." After offering Grand Rounds Health's expert medical opinion service for several years, Trustmark experienced a positive return on investment; 75% of its expert medical opinion cases resulted in a change of diagnosis or treatment, typically leading to a more cost-effective, medically appropriate or less-invasive treatment path. Now, Trustmark Health Benefits will offer that expert medical opinion solution to its clients and their members through The Trustmark Navigation and Advocacy service powered by Grand Rounds Health in addition to the full healthcare navigation offering.

About Grand Rounds Health and Doctor On Demand Headquartered in San Francisco, the combined company of Grand Rounds Health and Doctor On Demand has been recognized several times in the past year—including Best Workplaces by Inc. magazine, Best Workplaces in Healthcare and Biopharma™ by Great Place to Work and Fortune, Best Overall Digital Health Company by MedTech Breakthrough Awards, and Best Employer Wellness Company by UCSF Digital Health Awards. Learn more at and

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

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

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



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NEWS About Trustmark Trustmark Mutual Holding Company, through its operating divisions and subsidiaries, including Trustmark Health Benefits, offers specialized expertise in voluntary benefits, self-funded health plan design and administration, and the delivery of fitness, recreation, and injury prevention and treatment programs. Trustmark offers all sizes of employers access to benefit options usually reserved for large companies, combined with the personal service you would expect from a small firm. Our commitment to building long-term, trusted relationships helps people and businesses thrive. Trustmark: benefits beyond benefits. Visit us at

GOLD MEMBERS HCAA LAUNCHES THE B2B MARKETPLACE ST. LOUIS, MO The Health Care Administrators Association (HCAA), a leader in education, networking, resources and advocacy for the self-funding industry, launched the HCAA B2B Marketplace, a complimentary online listing of service vendors for the self-funded sector.

The B2B Marketplace is a unique and interactive experience that connects buyers and sellers from across the selffunded sector in branded ‘store fronts' offering information on the seller and its products, and services. “The self-funding industry is built on collaboration, and we are thrilled to offer this important resource beyond HCAA events,” said HCAA CEO Carol Berry. “The B2B Marketplace was previously only offered during our Executive Forums and TPA Summits for only our Sponsor Partners, but now we are opening participation to all HCAA Members. Each participant will get their own 'store front' which we will assist them in populating with their information and their products and services. We believe the Marketplace




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NEWS will provide an invaluable opportunity for our members to engage not only with one another but also with the public. It will also allow them all another very needed opportunity to showcase themselves, improve their customer interactions, boost referrals, and achieve their business goals.”


The marketplace is in its early stages and continues to build in new TPAs and related service vendors to the dozens currently listed there. Those interested in becoming a part of the marketplace and taking advantage of this great member benefit should contact Sara Ayers at

SAN FRANCISCO, CA – Verikai announced that co-founder and Chief Executive Officer, Hari Sundram, will transition the role of CEO to current President & Chief Revenue Officer, Jeffrey Chen, who will also be joining the board of directors. As CEO, Jeff will oversee all company operations.

Access HCAA's B2B Marketplace at hcaab2b/marketplace . About HCAA The HCAA is the premier nonprofit trade association elevating third-party administrators (TPAs) and other stakeholders from across the self-funding industry. Throughout our 40-year history, we've remained committed to improving the quality, sustainability, and value of this essential sector on behalf of our members, while forging a path for tomorrow's health care benefit administrators. Visit www.


“This shift is something we’ve planned for a long time, and the time is now,” said Hari Sundram.

30Years of Creative

Stop Loss Problem Solving

At TPAC, we have always brought creative solutions to the challenges facing our industry. Whether it’s the nation’s first aggregate only level-funded stop loss product or developing a program that addresses balance billing concerns, we are not afraid to take on a challenge.

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Jeff joined Verikai a long time ago and built out all the company’s major functions we needed to make it successful. It’s one thing to start a company, but a whole different beast to scale it. Jeff has been the architect of our operational strategy, creating the processes we needed then honing them so we could expand at the rate the market demanded.” “

“When I started Verikai, the goal was always for me to expand on the thesis that the use of alternative data coupled with machine learning could greatly improve risk prediction. Now that we have proved this thesis true with our market traction, it’s time for Verikai to scale. Having Jeff’s background as a former management consultant along with his insurance software experience makes him the perfect person to lead Verikai into the next phase,” said Sundram. “I couldn’t be more confident in Verikai’s future with Jeff leading the charge.”



Hari is best described as a serial entrepreneur – a visionary and builder who pushes the envelope of ideas; always looking for what he can develop, which will make the biggest impact. This transition has always been part of the plan for Verikai, and with the company’s immense success over the last year, the timing was right for a transition from Hari to Jeff. “I’m honored to be appointed the CEO of Verikai at such an exciting time in our company history,” said Jeff Chen. “In the last year alone, we have seen tremendous improvement of our risk models as well as the launch of our game-changing Marketplace. Our market momentum is palpable and with so much upside, the opportunities feel endless.”

NEWS “I’d like to thank Hari for his guidance and leadership, and for entrusting me with the opportunity to lead the great organization that he built,” said Chen. “I have been lucky to work side-by-side and learn from one of the best entrepreneurs I know. Using his unique vision and market knowledge, he has laid out a plan for Verikai to achieve great things for many years to come.” About Jeffrey Chen Jeffrey Chen has 20+ years of experience as a management consultant and enterprise software leader. Prior to Verikai, he spent six years at Guidewire Software leading their value sales organization. Prior to his move into software, he worked at multiple consulting firms, advising fortune 500 companies for over a decade on customer strategy and operations. Jeff holds a BS from Penn State University, MS from George Washington University, and an MBA from Georgetown University. About Verikai Founded in 2018, Verikai is an insurance technology company leveraging alternative data and machine learning to change the way the industry views risk. Our well-established database of more than 1.3 trillion data points includes over 5,000 behavior attributes for 250+ million people in the United States and provides deep insight to these individuals’ true health risks. With this data, Verikai generates risk reports in real-time with only a census. This greater insight helps insurance companies increase new business, reduce losses and improve efficiency in the underwriting process – and ultimately, provide consumers and businesses with greater access to a broader range of insurance products. Contact Ellie Newby, Marketing Manager, at and visit



Capture the power of the Vālenz® ecosystem Transparent data engagement and integrated solutions for smarter, better, faster healthcare Where others provide visibility into data, only Vālenz® delivers the clarity you need to see your path to lower costs, better health outcomes and enhanced member lives. As the industry’s first fully transparent, end-to-end ecosystem, Valenz integrates a comprehensive suite of solutions with deep and continuous data analysis across the life of every claim. From network design to care delivery, expert bill reviews, claim management, payment integrity and more, our ecosystem enriches your data and decision-making at every step. The result: transparent data engagement and integrated services that pave your way to smarter, better, faster healthcare. To capture the power of the Valenz ecosystem, visit us at SIIA or call (866) 762-4455 today.

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


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





Bobby Handley Vice President CareFactor Dublin, OH

Monica Raj Rudrapatna Collective Health Pacifica, CA

Jeffrey Fausey Director Stop Loss Program Florida Blue Jacksonville, FL

Hy Byrd COO Golden Triangle Arrington, TN

Cristin Dickerson CEO Green Imaging, LLC Houston, TX



James Coale President Litchfield Underwriters Darien, CT

Steve Fehr Founder Musketeer Group, Inc. Ballwin, MN

Jennifer Stuart Employee Benefits Practice Leader Risk Services - Leavitt Houston, TX

Kirk Behrens Chief Operating & Technology Officer, Ryan Specialty Benefits Ryan Specialty Group Chicago, IL

SILVER CORPORATE MEMBERS Pierre Paquette Chief Development Officer MediResource Inc. Toronto, ON

Stability for those balancing risk and reward.

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

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

In all states except New York, coverage may be underwritten by HM Life Insurance Company, Pittsburgh, PA, or Highmark Casualty Insurance Company, Pittsburgh, PA. In New York, coverage is underwritten by HM Life Insurance Company of New York, New York, NY. The coverage or service requested may not be available in all states and is subject to individual state approval. MTG-3355 (R3/21)

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