S EP T EMB E R 2 0 2 1
A S I P C P U B L I C AT I O N
Evaluating Market Dynamics HOW INVESTORS, HEALTH PL ANS AND PROVIDER SYSTEMS ARE CL AMORING FOR PIECES OF THE SELF-INSURANCE PIE AND WHAT IT MEANS TO YOU
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TABLE OF CONTENTS
SEPTEMBER 2021 VOL 155
W W W. S I P C O N L I N E . N E T
EVALUATING MARKET DYNAMICS
HOW INVESTORS, HEALTH PLANS AND PROVIDER SYSTEMS ARE CLAMORING FOR PIECES OF THE SELF-INSURANCE PIE AND WHAT IT MEANS TO YOU
By Bruce Shutan
CAPTIVE BOARD ASSESSMENTS FOR THE BETTER By Karrie Hyatt
ARTICLES 20 26
ACA, HIPAA AND FEDERAL HEALTH BENEFIT MANDATES THE AFFORDABLE CARE ACT (ACA), THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) AND OTHER FEDERAL HEALTH BENEFIT MANDATES WHO IS ON FIRST? OPERATIONAL HURDLES AND HOLES FOUND IN PORTIONS OF THE NSA
WHAT EMPLOYERS NEED TO KNOW ABOUT BEHAVIORAL HEALTH AND TELEHEALTH SERVICES
NEWS FROM SIIA MEMBERS
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
SEPTEMBER 2021 3
F E AT U R E
Evaluating Market Dynamics
HOW INVESTORS, HEALTH PL ANS AND PROVIDER SYSTEMS ARE CL AMORING FOR PIECES OF THE SELFINSURANCE PIE AND WHAT IT MEANS TO YOU
convergence of market developments is re-shaping the self-insurance landscape with game-changing implications for improving results, insiders suggest. One noteworthy trend is that the investor community recognizes the unique and rising value of companies that serve self-funded employers and influence their decisionmaking process. But that’s just the tip of a larger iceberg. Two other active players are part of that mix. They include national and regional health plans that are aggressively acquiring many of these vendors to pump up their presence with administrative-services-only offerings. Their need to move beyond fully insured arrangements, of course, took on some urgency since the Affordable Care Act’s passage.
Written By Bruce Shutan
Large provider systems also are dotting the horizon, leveraging massive infrastructure they built to handle Medicare and Medicaid markets for direct-contracting arrangements. Experts say many of the most efficient systems were forced into learning how to control costs and quality by the Centers for Medicare & Medicaid Services. Whatever will become of these market dynamics, the consensus is that more investment in primary care will be increasingly vital in the years ahead alongside aligned incentives, integrated and value-based care that’s fully transparent, and white-glove service.
Market Dynamics GROWING NEED FOR TRANSPARENCY
Sometimes both of these forces muscle their way to the top. Joe Cunningham, M.D., founding managing director of Sante Ventures, sees regional battles between the BUCAHs and provider health systems jockeying for reputational market leverage and ownership of independent primary care practices. The upshot is that entities with no shortage of capital are Joe Cunningham able to jack up prices. Any academic center that is also involved in teaching and research, he adds, will have higher fixed costs and, therefore, tend to be more expensive. They also generally have market leverage to command higher prices. Since insurance carriers and medical providers alike have a financial stake in rising prices just like any for-profit industry, it’s easy to understand why health care costs continuously outpace inflation, observes Matt Dale, CEO of Point Health. But as the C-suite becomes more involved in health plan management, he says corporate executives are going to demand transparency at both the carrier and provider level.
there needs to be a tool that allows people to shop for medical care in a similar way that they’re used to shopping for everything else that they buy.”
Before this approach is able to gain meaningful traction, Dale says “
He recalls a recent case that epitomizes the need for transparent shopping. One of his clients, a health insurer, instructed someone who needed rotator cuff surgery to shop the routine procedure at a local hospital, which quoted him $68,000. Under his defined benefit, the insurance would have paid just $3,000, while he would have been responsible for $65,000 out of pocket. When Point Health approached the hospital about their cash price, the quote was cut in half. Upon further investigation, a surgery center 30 minutes away agreed to do it for less than $10,000.
“That example is happening hundreds of thousands of times a month on all types of procedures,”
Dale laments. However, as patients make more prudent choices built around value, he’s hopeful that a tipping point will be reached where hospitals will offer more competitive pricing for fear of losing business.
FOCUSING ON FLEXIBILITY One avenue to greater cost savings may be more flexible products and services. Health plans are looking to acquire pieces of the delivery system that can be folded into smaller TPA operations, which are easier to accommodate add-on services, notes Michael Taylor, a principal with MT Healthcare Consulting. In the case of UnitedHealthcare, he says the UMR TPA operates alongside Equian, which was added under the health plan’s Optum unit, to expedite payments more efficiently for employers that decline a full-service offering. Noting a continuation of health care industry consolidation, Taylor points to the January 2021 merger of Tufts Health Plan and Harvard Pilgrim Health Care in his home state of Massachusetts. “That’s going to give them more leverage with the provider systems” that he says are reaching out more directly to employer customers in hopes that to some degree they can “diminish the impact that carriers have both around the price they negotiate, as well as the services they need to provide.” Similarly, some of the larger consolidated provider systems such as Priority Health, Geisinger, and Baylor Scott & White have acquired health plans of their own. But since their margins are typically tight, Taylor believes many will “sort of stay on
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the sidelines for a bit” until the pricing of niche vendors stabilizes and health systems figure out how to fund these acquisitions.
WHITE-GLOVE ADVANTAGE While scale breeds comprehensive offerings, it doesn’t necessarily result in higher customer satisfaction. Smaller players that aren’t part of the BUCAHs or large health plans will have some advantage because of the white-glove service they offer, observes Steve Cosler, an operating partner with Water Street Healthcare Partners, a strategic investment firm focused exclusively on the health care industry. “Health Steve Cosler care is a very important benefit, and they’re going to want absolutely the best service that they can provide to their own employees,” he says, noting the implications for retention, especially in a tightening labor market. One example involves the pharmacy benefits management field. He says Pharmaceutical Strategies Group bifurcated responses to an annual survey between
PBMs to represent more than and fewer than 20 million members. While size matters when it comes to negotiations with manufacturers for rebates and purchasing massive blocks of generic drugs for network rates, he highlights a surprising result. The survey found that PBMs with 20 million or fewer members beat the larger group on satisfaction, even though they can’t compete on scale. “They’re competing and winning on service and innovation,” Cosler says. He sees a real opportunity for innovative TPAs and others that serve self-funded employers to be a part of that mix with large provider groups and boast a strong regional presence. “Somebody’s going to have to process claims, administer the plan, do repricing, send out EOBs – all the things that go into running a health plan,” Cosler explains.
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Such attention to detail can be a huge difference-maker. In order to prevent wasteful spending, Cunningham explains that the key to building credible care is aligning incentives so that patients aren’t over-treated and wind up in the ER. Put another way, it’s a matter of receiving the right care at the right time in places where the fewest ancillaries that don’t really affect the outcomes to care can be needlessly ordered. “It’s about engaging the patient with a primary care provider that’s going to navigate and advocate, and basically win their trust that the guideline treatment plan that they’re putting forth is in their best interest,” he says.
Market Dynamics The marketplace recognizes this reality. For example, more of the BUCAHs and behemoth retail or e-commerce outlets have developed guideline or evidence-based primary care with aligned incentives, according to Cunningham. Driven by payers, he sees these arrangements in place at Optum, Cigna, Aetna, CVS, Walgreens, Amazon and Walmart – all of which are aggregating primary care and absorbing risk for patients. Self-insured employers have the best chance for success when there’s a direct relationship with medical providers across a fully transparent, integrated infrastructure that produces a product that’s acceptable to their employees and dependents. So says Orlo “Spike” Dietrich, founder and CEO of Employers Health Network and operating partner of the Ansley Capital Group.
Orlo Spike Dietrich
“The only thing that’s ever worked for me is sitting across the table with the provider leadership within my community and trying to figure out what’s going right, what’s going wrong and solving the problem together,” observes Dietrich,
who moderated a panel discussion on market dynamics at SIIA’s virtual national conference.
Elite provider systems not only embrace value-based contracting along the road to greater accountability, Dietrich explains, but they’re also willing to take on both upside and downside risk. When a hospital system reaches out to the employer community, he says it must be done around a product that transcends a network or TPA sale. That means offering a host of services that manage adjudication, pharmacy and specialty drugs, data and analytics, care management, etc. – not simply a network with discount pricing. Amazon Care’s virtual-first version of 24-hour primary care has worked well in the Northwest, according to Dietrich. “We’ve looked at it, and quite frankly, are very impressed,” he says. Although the company hires its own primary physicians, he notes a great willingness to work with local provider systems. Another firm that has had great success tying together primary and urgent care, as well as telemedicine, is Whole Foods, which is owned by Amazon. Their onsite clinics support and encourage primary
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Market Dynamics care access, Dietrich explains, noting the “superb” job of staying involved with care beyond the primary care clinic through the chief medical officer and his staff.
CREATING VALUE With so much perversity in the U.S. health care system, corporate and medical executives have been forced into closer collaboration. There’s a growing realization among providers about significant value in the self-insured marketplace. “Just name a large health system, and they have an initiative for direct employer contracting,” Cunningham notes. Providence St. Joseph is leading the charge, he says, along with Massachusetts General Brigham, the Cleveland Clinic, Mayo Clinic and Sentara Health. Others include Baylor Scott & White in Dallas, whose quality alliance for companies like American Airlines is doing leading-edge work, and Orlando Health in Orlando, which contracts with Disney. When Cunningham was involved with primary care, caring for patients was a 24/7 responsibility. But many primary care offices now simply activate their voicemail at 4:30 and suggest patients go to the ER if they’re having a medical emergency. “You’re never going to win if that’s the approach, and yet, that’s way too common, currently with the independent groups,” he warns, noting that organization and technology can help solve that problem as long as primary care physicians have support and call coverage. Another issue to consider is that primary care is a low-margin business, he explains, even if it features a multitude of payers and maximizes efficiencies. And while some employers establish onsite medical clinics to widen access to primary care and create value, Cunningham says there are better ways to accomplish that objective such as telemedicine or direct primary care (DPC). While believing DPC “is a great idea,” Dietrich notes the importance of structuring the right incentives and support for physicians in those subscription-based practices beyond their office. What’s necessary is to have an integrated and coordinated with the specialty community and inpatient environment, he adds. The emergence of guideline-driven, evidence-based medicine delivery will slowly replace PBMs and other managed care-based utilization management, “which have become something of a shell game of volume discounts and rebates,” Cunningham predicts. A growing number of large provider systems have come to the realization that pursuing direct contracting arrangements with employers is a mutually beneficial arrangement, according to Cosler. Both parties, of course, are able to cut out insurance middlemen, but he also sees a wider path to innovative plan design
and customization from an employer standpoint. For example, there could be a shared-risk arrangement and value-based care that ties a provider’s compensation to outcomes. But achieving these objectives takes time. “The movement to more valuebased, risk-based contracts is glacially slow, and it really is disappointing,” notes Taylor, who’s a huge believer in realigning payment methodologies among providers. He’d like to see alternative payment mechanisms gain traction, but realizes they’re much more complicated to administer than traditional fee-forservice and act as a barrier for employerto-provider direct contracting. There’s also concern about health equity. “I worry that if you’re not careful, some of these DPC models will be unaffordable to a large percentage of the population,” he says.
Bruce Shutan is a Portland, Oregon-based freelance writer who has closely covered the employee benefits industry for more than 30 years.
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F E AT U R E
Captive Board Written By Karrie Hyatt
Assessments for the Better
ust like any other part of a business, a company’s board of directors must have regular evaluations to understand if it is doing the job it’s supposed to. While it doesn’t necessarily have to be conducted every year, a board assessment should be conducted every three to five years, and, most importantly, it must be acted on.
According to PwC’s 2020 Annual Corporate Directors Survey, in 2014 only 50 percent of directors said their board made changes as a result of their assessment process, but that figure had risen to 72 percent by 2020.
In the past, joining a board was something with which to polish a resume, now joining a board means more responsibility and being held responsible, for issues from fiduciary decisions to company reputation.
The PwC survey found that 72 percent of responders felt that a reputational crisis for a company reflected negatively on the board of directors and more than three quarters felt that it reflected negatively on their personal reputation.
Captive Board Assesments According to John Foehl, an independent director with more than 30 years’ experience in the captive industry, “Especially in the captive space, board members need to understand the personal liability they assume when they sit on a board. Lack of understanding will come home to roost when the captive board finds itself in trouble and the finger pointing starts.”
This is why regular board assessments become important. With boards holding more responsibility and liability for mistakes made, understanding where a board is not living up to its commission is key.
Whether the assessment is evaluating the full board, its committees, individual directors, or conducting peer assessment, it has to be as comprehensive as possible and it has to result in changes. It’s a feedback tool that an effective board will review and act on.
For captives, assessments should focus on board culture, board composition, best practices, and planning for board succession and can be conducted through questionnaires and surveys, individual interviews, and facilitated discussions.
Captive board assessments can be done either entirely in-house or with an outside proctor. For Foehl, “My preferred methodology for doing an evaluation would be using a third-party facilitator. I think that when an individual comes in with no prejudices, with no axes to grind, and their sole responsibility is to conduct an assessment, they can draw forth all of the potential issues that are circulating among board members.”
“Board assessments should be done in two parts,” he continued. “The first is the self-assessment by individual directors and is shared only with the chairman or with an independent consultant. What you’re hoping for is that the board member who is doing it is being as honest as they can be of their own assessment of their performance. The second part is the overall assessment of the board.”
Peer review is becoming a more popular and much needed form of assessment. In the PwC survey, 49 percent of directors felt that a least one fellow board member should be replaced. This is likely reflected in captive boards as well, and of actionable assessment results, it’s one of the hardest to implement.
“There are really good board members and some that are not so good. Given the fact of the heightened responsibility of boards, including a fiduciary duty to the captive owners or parent, each director must pull their weight,” said Foehl. “Board assessments, if done properly, can home in on issues with individual board members.” SEPTEMBER 2021 13
Captive Board Assesments
While Foehl believes a third-party facilitator is key to getting good results from a board assessment, many captive boards are reluctant to spend the money. However, bringing in an outsider to help conduct the evaluation can help diffuse any brewing personality conflicts, while providing a more objective analysis of the assessment’s results.
An outside facilitator is better positioned to identify where a board may be experiencing a gap in knowledge. For pure captives, their boards usually consist of individuals who are already involved with the parent company—either working directly for the parent or as a consultant.
For group captives, board members are often made up entirely of captive owners. As there is often not an experienced insurance professional on the captive board (besides the captive manager), assessments evaluating the board becomes even more important in understanding where knowledge gaps may be occurring.
“The problem for group captives is, in many instances, is that every policyholder, every member wants to have a seat at the board and then the board becomes unwieldy. The are 35 to 40 people on the board and you don’t get to any decisions because, in essence, it becomes a huge debating society,” said Foehl.
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Captive Board Assesments “Additionally, group captive boards run into what I would call a ‘group think’ problem. When they all come from the same background, they are likely to think the same way.”
Using a board assessment to identify gaps in knowledge—whether it be IT, legal, specialty insurance, or something else—can help boards solve the issue in two ways: by appointing an independent director and by providing educational opportunities.
From experience, Foehl strongly advocates for having an independent director on a captive board, particularly in group captives. “Too often the fallback position is that the captive manager knows the answers. I think that is a weak position because in many instances, captive managers don’t have all the answers,” he said.
The most common reason that captive boards don’t bring on an independent director is that this type of director should be compensated, whereas most directors on group captive boards are volunteers and only reimbursed for costs related to traveling for meetings.
“It’s a tough sell,” said Foehl, “But I think that the money spent on an independent director is well spent. Both captives that I was involved with used an independent director solely as an outside sounding board. They provide the perspective that, potentially, is not represented in a group captive given it’s set up.” Board assessments can also help determine what educational components would be useful for members. Whether it’s dedicating at least one meeting a year to education or bringing directors to captive conferences, insurance education is a key component to building a knowledgeable board.
Foehl suggested, “Given the fact that captive boards tend to be noninsurance professionals, one thing that should occur in an on-going basis is an educational session at least once a year on insurance topics to help make the directors more attuned to the business they are running.”
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Captive Board Assesments
“Too often, members come from whatever industry the group captive serves and don’t understand insurance,” continued Foehl. “In many instances, the board members rely solely on the captive manager for that expertise, which can be problematic simply because the captive managers are interested in making sure the relationship with the captive continues and are not necessarily always willing or potentially able to bring up topics that might be difficult to have discussions around.”
Captive conferences are an excellent education tool for board members because they offer not only educational sessions for directors, but also the opportunity to meet other captive board members.
Foehl found that early in his career, creating a personal network of directors from other captives was essential in understanding the business. “Being able to talk to peers about issues is a great way to learn about what’s going on and to get different viewpoints on how to handle problems you may be faced with. The more that board members are able to interact with peers and hear stories about what’s going on with other similar organizations the better they will be as board members.”
A board assessment is not an easy undertaking—especially as it can point to both personal and collective weaknesses. Yet, to make sure your captive board is performing optimally and meeting its stated goals, board assessments are a necessity.
Good corporate governance, continued education, and strong board oversight are the results when an effective board assessment is conducted, and its recommendations implemented.
Karrie Hyatt is a freelance writer who has been involved in the captive industry for more than ten years. More information about her work can be found at: www.karriehyatt.com.
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@ sipconline.net The Self-Insurer also has advertising opportunties available. Please contact Shane Byars at sbyars@ sipconline.net for advertising information.
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A QQ& A
ACA, HIPAA AND FEDERAL HEALTH BENEFIT MANDATES:
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 firstname.lastname@example.org.
GROUP HEALTH PLAN PROVISIONS OF THE CONSOLIDATED APPROPRIATIONS ACT: A DEEPER DIVE On December 27, 2020, the Consolidated Appropriations Act, 2021 (CAA) was signed into law. In addition to funding the government and further COVID-19 relief, the CAA included significant provisions impacting health benefit coverage. Over the next several articles we will discuss four of the provisions relevant for group health plans: (1) expanded relief for health and dependent care flexible spending arrangements; (2) new expanded compliance requirements under the Mental Health Parity and Addiction Equity Act (MHPAEA); (3) new reporting requirements for commission and similar compensation; and (4) new requirements to limit surprise billing.
MHPAEA compliance has been a primary focus in DOL audits of group health plans over the last several years. In a 2018 Report to Congress DOL acknowledged that “a MHPAEA investigation can take a year or more, depending on a variety of factors”. In our experience MHPAEA audits can stretch over several years.
B. NQTLS The following is a non-exclusive list of NQTLs •
Medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative;
Prior authorization or ongoing authorization requirements;
Concurrent review standards;
Formulary design for prescription drugs;
For plans with multiple network tiers (such as preferred providers and participating providers), network tier design;
Standards for provider admission to participate in a network, including reimbursement rates;
Plan or issuer methods for determining usual, customary, and reasonable charges;
Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective (also known as “failfirst” policies or “step therapy” protocols);
In prior articles we discussed the impact of CAA on FSA administration and the forthcoming broker/consultant fee disclosure rules. This article provides background on new comparative analysis disclosure requirement under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). The CAA specifically mandates that group health plans and insurers perform and document a MHPAEA comparative analysis of a plan’s or policy’s nonquantitative treatment limitations (NQTLs) and provide such documentation to the auditing agencies (and participants) upon request.
A. BACKGROUND MHPAEA is designed to require benefit parity between medical and surgical (Med/ Surg) benefits and mental health and substance use disorder (MH/SUD) benefits. If a plan provides Med/Surg benefits and MH/SUD benefits the plan must provide parity with respect to (1) financial requirements (e.g., deductibles, copayments, coinsurance and out-of-pocket maximums); (2) quantitative treatment limitations (e.g., number of visits or treatments or days of coverage); and (3) NQTLs, discussed below. The CAA’s amendment to MHPAEA’s provisions in ERISA, the Internal Revenue Code (Code) and the Public Health Services Act (PHSA) focus on NQTLs. Since MHPAEA’s provisions fall under three distinct statutes, enforcement falls under three federal agencies: the IRS, the Department of Health and Human Services (HHS) and the Department of Labor (DOL) (collectively the Tri-Agencies). Also, state departments of insurance have jurisdiction over insured plans. MHPAEA applies not only to ERISA-covered plans but also, with limited exceptions, to local state and governmental plans and church plans.
Exclusions of specific treatments for certain conditions;
Restrictions on applicable provider billing codes;
Standards for providing access to out-of-network providers;
Exclusions based on failure to complete a course of treatment; and
Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage.
DOL has put out several useful tools with regard to NQTLs including a SelfCompliance Tool and a listing of MHPAEA NQTL Warning Signs. Under MHPAEA, benefits are broken down into six different classifications: inpatient, in-network; inpatient, out-of-network; outpatient, in-network; outpatient, out-ofnetwork; emergency care; and prescription drugs. MHPAEA regulations prohibit a group health plan from imposing NQTLs on MH/ SUD in a classification unless, under the terms of the plan as written and in operation, any processes, strategies, evidentiary standards, or other factors used in applying the NQTL to MH/SUD benefits are comparable to, and are applied no more stringently than, those used in applying the limitation with respect to Med/Surg benefits in the same classification. The parity analysis requires not only identifying the NQTLs as written and in operation but also examining the factors considered in the design of the NQTLs. Examples of factors include:
o Excessive utilization;
o State and federal requirements;
o National accreditation standards;
o Internal market and
o Medicare physician fee schedules; and
o Evidentiary standards,
including any published standards as well as internal plan or issuer standards, relied upon to define the factors triggering the application of an NQTL to benefits
Group health plans must then demonstrate that any factor used, evidentiary standard or source relied upon, and process employed, in developing and applying the NQTL are comparable and applied no more stringently to MH/SUD services as compared to Med/Surg services.
o Recent medical cost escalation; o Provider discretion in determining diagnosis; o Lack of clinical efficiency of treatment or service; o High variability in cost per episode of care; o High levels of variation in length of stay; o Lack of adherence to quality standards; o Claim types with high percentage of fraud; and o Current and projected demand for service Then the sources for the factors must be examined. Examples of sources include:
o Internal claims analysis; o Medical expert reviews; 22
Needless to so say this is a huge and difficult undertaking. In our experience many self-insured group health plans have not undertaken the exercise of documenting a NQTL analysis and compliance.
This is not a service normally performed by a third party administrator (TPA) or pursuant to an administrative services only (ASO) agreement with an insurer.
Most often a firm with specialized MHPAEA expertise and/or actuarial capabilities must be engaged for the analysis. As frequently noted by the
agencies, the Self-Service Tool linked above is a useful start and framework for such an analysis.
C. CAA’S AMENDMENT TO MHPAEA Although MHPAEA compliance has been required for well over a decade, there has never been a specific statutory requirement to have a documented NQTL analysis; although DOL frequently requests such an analysis when it performs a group health plan audit. The CAA now mandates that group health plans and insurers shall perform and document comparative analyses of the design and application of NQTLs. The CAA requirements are specific as to the analysis as described above and must: identify the NQTLs; identify the factors used to determine the NQTLs; identify the evidentiary standards and sources used to develop the factors; perform a comparative analysis; and contain specific findings and conclusions. Beginning 45 days after the enactment of the CAA (February 10, 2021), that comparative analysis of the NQTLs must be provided, upon request, to state regulators (e.g. a state department of insurance for an insured plan) or to any one of the Tri-Agencies. Each of the Tri-Agencies is required to request at least 20 NQTL analyses per year. The request from each Tri-Agency will be triggered by complaints, identification of potential violations of MHPAEA, or any “in any other instances that the [Tri-Agency] determines appropriate”. The Tri-Agency will then review the NQTL analysis and if it finds it noncompliant the Agency will provide the plan/insurer 45 days to provide an analysis showing NQTL compliance.
If a plan/insurer fails to demonstrate compliance in that 45 day period then, within 7 days of the determination of noncompliance, the Tri-agency will notify all individuals enrolled in the plan or policy of the non-compliance. Although recent years have seen increased guidance from the TriAgencies on MHPAEA, there remain many uncertainties on when a NQTL might violate MHPAEA. The CAA has provisions similar to the 2016 21st Century Cures Act, which required the Tri-Agencies to take certain steps to promote understanding and compliance with MHPAEA. The CAA requires the Tri-Agencies to develop a “compliance program guidance document” which will provide deidentified examples of NQTL compliance and non-compliance and other recommendations to advance NQTL compliance. That document will also provide information on how plans and insurers may disclose information in compliance with MHPAEA. The deadline for issuing this guidance is eighteen months after enactment (late June 2022).
The guidance will also provide further information on the process and timelines for participants and beneficiaries to file complaints with respect to alleged MHPAEA violations. The compliance program guidance document will be updated once every two years. While specific regulatory guidance is still in the works, the agencies have provided guidance as to what they expect in the Comparative Analysis in the form of FAQ guidance. (ACA FAQs 45). Specifically, with regard to the format of the Comparative Analysis, the agencies have stated that:
Comparative analysis for each NQTL must be sufficiently detailed and reasoned
Conclusory or generalized statements without specific supporting evidence and detailed explanations are insufficient
Include supporting information (e.g., claim processing policies, samples of claims)
Follow guidance in the MHPAEA Self-Compliance Tool
D. SUMMARY AND ACTION ITEMS For self-insured plans now is the time to perform a MHPAEA NQTL comparative analysis if one has not already been performed. Even where an NQTL comparative analysis has been performed, it needs to be reviewed under the requirements provided in the CAA’s amendments to MHPAEA. As noted above, the Tri-Agencies could be asking for such an analysis as early as February 10, 2021. And for the last several years DOL has requested the analysis as part of its group health plan audit protocol. The Tri-Agencies goal, however, appears to be one of better overall compliance. That said, DOL will take action if it discovers noncompliance. Violations of MHPAEA under ERISA are limited to what is known as “equitable relief.”
That can include requiring a plan to reprocess claims if they were improperly denied or not fully reimbursed because of a noncompliant NQTL. Depending on the volume of claims involved, reprocessing can be a burdensome and expensive proposition.
There is, however, no civil monetary penalty for MHPAEA violations under ERISA. DOL also has limited jurisdiction over insured plans although when it discovers a violation it will work with insurers and state departments of insurance to bring policies into compliance.
Under the Code there can be an excise tax for MHPAEA violations of $100 per day for each individual to whom a failure relates.
There has also been a significant uptick in MHPAEA litigation by private parties under ERISA. These cases often involve NQTLs and having a NQTL analysis establishing compliance could go a long way in preventing those claims or defending them if they are brought.
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WHO IS ON FIRST? OPERATIONAL HURDLES AND HOLES FOUND IN PORTIONS OF THE NSA
he Consolidated Appropriations Act (“CAA”) did many things and has created obligations, questions, and confusion for many stakeholders in the healthcare space.
Written By Tim Callender
This article could cover COBRA topics, mental health parity topics, surprise billing, or any other number of pandora’s boxes opened by the CAA, but no one wants to read a 1M word article filled with legal jargon and uncertain statements on how a pending rule or vague regulation should be interpreted. Instead, this piece aims to spend some brief time focused on some specific obligations that have been handed down in the CAA and throw a few questions against the wall, so to speak, in the interest of starting a dialogue toward understanding how our industry might meet the obligations of the CAA. We will not be looking at all of the obligations within the CAA but will pick out a few of my favorites as examples of the things we need to be considering as the CAA rolls out.
The CAA requirements discussed below are in no particular order and, again, have randomly been picked by me as some that seemed to have a few issues glaring right at the top. I tend to be very guilty of finding glee in identifying logistical problems, so, the requirements I decide to write about all have this in common – they will create some headaches – let’s figure out how to get past those headaches. Please note – as annoying as it might be, I may not offer big solutions to the logistical questions posed herein. But, by raising the questions, hopefully this will get us all thinking and working together to make sure our industry is poised to handle these new duties and we can find opportunity therein.
REQUIREMENT 1 – THE ADVANCED EOB REQUIREMENT OF THE NO SURPRISES ACT
The No Surprises Act is everyone’s favorite portion of the CAA. That is, unless you are really excited by COBRA, then there are other portions of the CAA that might tickle your fancy a little more. But most of us in this increasingly complicated healthcare space find balance billing, surprise billing, and pricing transparency to be pretty juicy – hence our interest in the No Surprises Act. Contained within the NSA is a provision that requires a health plan to provide an advanced EOB any time the plan receives notice from a provider of a scheduled procedure and/or a request from a plan participant seeking an explanation of benefits regarding an upcoming procedure.
The advanced EOB is required to contain quite a swath of information, including, whether the provider is in-network or out-of-network; information on how to seek out an in-network provider, if needed; contracted rates for the relevant in-network provider; good faith cost estimates as furnished by the provider; a good faith estimate of the plan’s obligation (what the plan will pay); a good faith estimate of the plan participant’s cost share; deductible and out-of-pocket information related to the participant; medical management information if relevant; and a statement that the numbers provided are merely estimates. In terms of timelines, the plan is obligated to provide this advanced EOB in 1 business day when the plan receives notice of a proposed procedure, from a provider, and 3 business days when the plan receives a notice/request from a plan participant. This is clearly going to be an obligation that falls to the plan sponsor’s contracted, third-party payer. Of course. Payers already handle the EOB work for their plan clients, typically, so it is a fair assumption this new obligation will be handled at that level as well. Knowing this obligation will fall to the third-party payer, some questions arise: • Will payers have to increase their administrative fees to account for this new operational lift? • What about 3rd party EOB production vendors & their relationship with the payer community – will these stakeholders be able to handle these tight turnarounds?
What processes will a payer put in place to account for the intake of these requests whether from a provider or a member? How will plans and/ or payers alert plan members to the availability of this information & that participants have a right to request this information?
What if the contracted rates for the in-network provider are not known by the payer (I understand this should be known, but I also understand that network contracts are a bit like narwhals – we know they exist but only a few people have ever seen one).
How will the payer go about getting a good faith cost estimate from the provider, especially with such a tight turnaround time to provide the info!
REQUIREMENT 2 – PLANS MUST PROVIDE BALANCE BILLING
INFORMATION ON THEIR WEBSITES ALONG WITH A WEB-BASED, PRICE COMPARISON TOOL
This requirement will be live as of January 1, 2022, unless the regulators decide otherwise. Additionally, it should be noted that this requirement applies to both grandfathered and non-grandfathered plans alike. No getting out of this one!
Interestingly, it is not clear who will actually handle the logistics in fulfilling this requirement. Clearly the regulatory obligation falls onto a “plan,” but does a plan even have the ability to comply with this requirement? It is hard to imagine that a self-funded, plan sponsor, is going to literally place balance billing support information and/or balance billing education tools on its website. Trying to picture a random employer who makes widgets, in a factory, coordinating its HR department with its IT department to make sure that their company’s website contains balance billing information and a web-based price comparison tool for health plan participants is laughable at best.
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On its face, this requirement makes a great deal of sense. Patients should not be financially punished because their favorite doctor chooses to leave a network. However, how can we guarantee that the plan does not become the bearer of that punishment – have we simply shifted the financial burden of paying for an out-of-network provider from the plan member to the plan?
Will the insurance broker / consultant advise the plan sponsor to do this? Likely not. Where will this obligation end up then? Does it fall to the payer (TPA / ASO) to put this information on their website? How would the payer go about accomplishing this task on behalf of a plan it administers? It seems that the contracted payers’ contractual duties will be getting thicker and thicker come 2022.
REQUIREMENT 3 – CONTINUITY OF CARE This requirement is a truly interesting one in that it states that plans are now obligated to provide in-network coverage to participants who access care from a provider that is no longer a part of the network. Said another way, when an in-network provider leaves a network, a plan participant who was seeing that provider can continue to see that provider and the plan is obligated to provide the benefit as though the provider were still in-network, for 90 days. The plan is also obligated to provide notice to the plan member when the plan learns of this provider network change. Now, there are obviously many more details than I’ve outlined here – for example, the patient must be seeking serious and complex care – the care cannot be a routine physical. But for this discussion, we will just focus on the concept of in-network versus out-of-network, for whatever reason.
To be more specific, what happens when the provider leaves Network A and does not contract with any network so the provider can bill at a higher rate? Suppose the provider does exactly that & begins billing at a higher rate on a number of patients seeing the provider within the 90-day continuity of care timeline. The claims are submitted to the payer, as before, only now the third-party payer, on behalf of the health plan, must adjudicate the claims and apply the old, Network A, payment structure to the claims. But this will leave a balance, correct? And this will cause the provider to seek reimbursement on that balance, correct? From whom? It is clear from the intent of the CAA that this balance cannot fall onto the plan member, which means the plan itself, and/or the plan’s third-party administrator, will be forced to invent mechanisms that will capture these balances – perhaps direct provider negotiations with plan funds at risk?
REQUIREMENT 4 (MY FAVORITE) – REMOVAL OF GAG PROVISIONS
The gag provision requirement prohibits plans from entering into service contracts with an entity where the contract restricts the plan from providing provider specific cost information, among other details, through a transparency tool or through other means, to plan members or those eligible to enroll in the plan. The provision goes on to also state that a plan cannot enter into service contracts where certain detailed claim information is restricted from disclosure to the plan. This requirement seems incredibly logical – clearly, it is set up to promote transparency and assure that cost information is readily available to plan members and the plan alike. Of course, this is a great thing! But once you start thinking of the unintended, collateral impacts, the sense behind the way this requirement was put together becomes questionable. You will note that it is the PLAN who is prohibited, by this requirement, from entering into these restricted contracts. The provision does not require networks, providers, or other third parties to remove these gag provisions from their contracts. Instead, it has shifted the burden of fighting these gag provisions onto actual health plans by outlawing a plan’s ability to agree to a gag provision. This seems to put a plan in a bit of a weird situation in that the plan is now the government’s policeman and will be forced to try and negotiate gag provisions out of service contracts.
What if a network, or a provider, or other third-party refuses to remove a gag provision? There is no remedy readily available to the plan other than to say, “well, ummmm… I guess we can’t sign that contract then. Ok. See ya later.” Although the third party might be motivated to remove gag provisions in the interest of gaining business, there is not guarantee this will happen. Unless there is a critical mass of business being lost, third parties who value their gag provisions will likely stand firm and let some business go by in favor of protecting the information that they do not wish to share. Or will the various, contracting parties find a way to sneak around this requirement and ruin the intended spirit? Could a TPA enter into a network contract full of gag provisions and then
sell the network access to a plan, via their administrative services agreement, so long as the administrative services agreement does not incorporate the terms of the network contract, thus circumventing the gag provision requirement entirely? Someone should ask a lawyer. In closing, it is important to note that the CAA and, more specifically, the NSA, work toward some great goals that I think we all believe in. There is much more to the CAA than discussed in this brief article and it really does deserve a more detailed treatment whenever possible. Today’s goal was to raise a few questions about a very few provisions of the CAA in the hope that we will all look through the CAA, in its entirety, with questioning eyes. Not for the sake of poking holes
necessarily, but for the sake of asking questions so that we can find opportunity and solutions, together, and continue to move our industry forward.
Tim Callender serves as the Vice President of the Client Solutions Group for The Phia Group, LLC. Prior to his current role, Tim served as a health care lawyer, staff attorney and lead PACE counsel for The Phia Group. Before joining The Phia Group, Tim spent years functioning as in-house legal counsel for a third party administrator. Tim is well-versed in complex appeals, direct provider negotiations, plan document interpretation, stop-loss conflict resolution; keeping abreast of regulatory demands, vendor contract disputes, and many other issues unique to the self-funded industry. Tim has spoken on a variety of industry topics at respected venues such as the Self-Insurance Institute of America (“SIIA”), the Society of Professional Benefit Administrators (“SPBA”), the Health Care Administrator’s Association (“HCAA”), and the National Association of Health Underwriters (“NAHU”). Tim currently sits on the Board of Directors for HCAA as well. Prior to his time as a TPA’s in-house counsel, Tim spent many years in private practice, successfully litigating many cases through full adjudication or to resolution through mediation or arbitration. Tim holds a leadership role with The Phia Group’s executive leadership team while continuing to assist on many general consulting and industry projects. Tim also employs his experience to focus on the development of new services and the enrichment of The Phia Group’s existing services. Tim received his Bachelor’s Degree from The College of Idaho, prior to obtaining his Law Degree from The University of San Diego School of Law. Tim operates out of The Phia Group’s office in Boise, Idaho.
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WHAT EMPLOYERS NEED TO KNOW ABOUT BEHAVIORAL HEALTH AND TELEHEALTH SERVICES
Written By Julie Mueller
mployees are more stressed than ever, but technology is making it easier for them (and their employers) to do something about it. Addressing employee mental health issues has been a focus of concern for some time, but the lingering psychological effects of COVID-19 pandemic fatigue are raising the stakes for employers to do more. Workers continue to report high rates of burnout, stress, substance abuse problems, financial concerns and uncertainty. In fact, more than 40% of American adults said they struggled with mental health issues stemming from the pandemic, according to a CDC survey. In the same survey, anxiety disorders were found to be three times higher than before the pandemic started, while depressive disorders multiplied by a factor of four.
Aside from the very real problems posed to the individual, untreated behavioral health issues can be a drain on an organization’s bottom line, according to the National Alliance on Mental Illness. The good news is that many companies understand that to get the best from their employees, they need to create an environment that not only normalizes the need to seek out help, but encourages them to do so. One way to achieve this is by increasing access to Behavioral Telehealth Care services.
HOW BEHAVIORAL TELEHEALTH
CARE IS MAKING A DIFFERENCE Increased use of telehealth services – using a phone, computer or mobile device to hold an office visit – gave individuals the freedom and flexibility to meet with their doctors from the comforts of home during the pandemic.
BENEFITS OF BEHAVIORAL TELEHEALTH SERVICES Easier to Schedule – Many therapists in telehealth networks are available outside of the traditional 9a.m.-5p.m. office hours, giving patients more leeway to balance health needs with other commitments. With commutes removed, it’s easier to work in a telehealth visit than an office visit. Plus, many online services for behavioral health make it simple to research practitioners so you can find one with a background or specialty best suited to your needs. Shorter Wait Times – Finding a mental health professional in your area who is available to meet in-person within a matter of minutes (let alone days or weeks) is a tall order in normal times, but even more so today. Telehealth services offer added flexibility and access to a much larger network of certified counselors, therapists and psychiatrists, making it easier to find the help you need faster. Privacy and Confidentiality – Being able to attend sessions on your terms and in an environment that makes you the most comfortable, like your home, can help you collect your thoughts and feelings. You can speak and interact directly with your practitioner instead of having to call and schedule an appointment with the receptionist and then be surrounded by strangers in a waiting room. Less Expensive – Because there’s no need to take time off of work or drive to and park at the counseling office, your employees save more money. In fact, there are many plans available that provide behavioral health services that are completely free for employees. As an employer, you also save money because telehealth services are less expensive than office visits.
The rise in use of telehealth services for behavioral health in particular has been staggering, with many patients seeking behavioral health care for the first time. According to a report from health insurer Cigna, 97% of people who accessed services during the initial stay-at-home order did not have a behavioral telehealth claim prior to lockdown. Further, more than half of Americans say they are comfortable with virtual consultations replacing in-person visits. Among the reasons cited was the fact that telehealth services provide several benefits over traditional in-person visits that make them more convenient, affordable and accessible.
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• Psychiatrist visits: average savings of $215 per visit • Therapist visits: average savings of $181 per visit • Plus additional $62 average in direct absence costs • Source: Teladoc Health
Many people may recognize that there is a correlation between mental health and overall health and wellness. They may also recognize the benefits of counseling and offer support for those who pursue it.
Treatment Success – Research shows that remote sessions with a behavioral specialist work. According to Call a Doctor Plus, more than 75% of members with depression or anxiety reported a clinically meaningful improvement after their third and fourth virtual care visits. How to Increase Behavioral Health Care Utilization Rates (Promotion & Engagement with Your Employees is Key)
However, the perception – that there is something wrong with you when you decide to seek help – still persists. In fact, 8 out of 10 workers say shame and stigma prevent them from seeking mental health care.
A lot of heavy lifting goes into designing strategic benefits plans, but if the services aren’t used, it won’t help boost the potential of your employees or help your organization save money. So what can you do to encourage more employees to avail themselves of telehealth programs?
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This is where business leaders and human resource professionals can help. Making mental health a regular part of the discussion and periodically reviewing employee benefits can help to keep things top of mind and lessen the stigma around it. The important thing is to let employees know they have an outlet – and the resources – to express how they feel that maintains their privacy and confidentiality. Encourage Statistically Vulnerable Populations to Seek Care Taking a closer look at your employee demographics (while maintaining confidentiality) can help you pinpoint where you may need to focus some of your outreach efforts. Employees who are older, lack internet access or computer skills need to be considered, as they may need additional assistance or alternatives to telehealth services. Mothers, parents and unpaid caregivers were particularly stressed during the pandemic, with many experiencing adverse mental health symptoms. In addition, certain positions within your company and others who have worked continuously throughout the pandemic may also be struggling with similar issues.
Show Employees How to Access Telehealth Services Don’t simply leave it up to your employees to discover the option for telehealth services on their own. When the time comes to review benefits, make sure to discuss the option and provide a tutorial that explains exactly what they need to do to search for care should they need it. Ensure Confidentiality Some employees may fear or erroneously believe that if they seek counseling to discuss a work-related problem or substance abuse issue that it will come back to haunt them. Dispelling this myth can help inspire confidence that employees won’t be at-risk of losing their job or become the subject of office gossip if they decide to pursue counseling.
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Keep the Conversation Going Don’t limit the conversation about behavioral health benefits and telehealth options to open enrollment. Aim to find ways throughout the year to provide helpful reminders in team meetings, emails and other forms of communication when it makes sense to do so. The goal here is to intentionally create an environment where talking about emotional and behavioral health is OK.
Julie D. Mueller is President & CEO of Custom Design Benefits. Serving in the healthcare field throughout her career she joined Custom Design Benefits in 2003, after 20 years as senior executive for a national TPA. As President and CEO, Julie leads a dynamic serviceoriented organization, ready to administer your custom, self-funded benefits plans and consumer driven accounts.
CONCLUSION Providing access to behavioral telehealth services doesn’t just help to improve the overall health of your employees. It’s crucial to the health and financial wellbeing of your entire organization as well. While the pandemic exposed an immense need for remote behavioral health, the popularity of those services isn’t expected to recede any time soon. At this point, with the demand and cost benefits so apparent, taking steps to make behavioral telehealth a reality is a no-brainer for anyone involved with the health benefits selection process.
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A Third Party Administrator can show you how self-funded plans with telehealth service benefits can yield cost-savings year after year. Get started by asking your broker today about the options that may be best suited for your company.
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IIA’s 41st Annual National Educational Conference & EXPO will be October 3 - 5, 2021 and will be in-person & virtual at the JW Marriott in Austin, TX. The world’s largest self-insurance event is back with an entirely fresh approach to conferencing. So what’s The Way Forward….in person or virtual? SIIA will deliver the best of both formats, with a “blended” National Conference that will allow everyone to participate in whatever way works best for them and their organizations. Join us and be a part of what promises to be a groundbreaking industry event. This year’s SIIA conference will provide more ways to connect than ever before.
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The Blue Eagle Lounge SIIA will be transforming 50,000 square feet of hotel ballroom space into a comfortable and stylish lounge area that will be open for the duration of the conference. This will be the perfect forum to connect and re-connect in person with everyone you want to see. Nightly Receptions Just like old times, the famous SIIA cocktail receptions are back in person… see and be seen! Virtual Networking Luncheons For the lunch hours on Monday and Tuesday, all registrants will be invited to participate in a virtual networking event where industry professionals will be able to connect with each other from around the country. Virtual Exhibit Hall SIIA’s virtual exhibit hall conference will provide perfect shopping opportunity for products/services specific to the selfinsurance/captive insurance industry. Open throughout the conference, it is easily accessible for all conference attendees.
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Chat Rooms Engage with other conference registrants both in Austin and elsewhere by participating in multiple conference chat rooms with various hot topics presented for real time discussion and debate. For more information visit www.siia.org. Member FDIC
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Stability Two-year total maximum cost guarantee and fixed monthly contributions
Security Complete fee transparency eliminates undisclosed fee sharing and rebates
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NEWS FROM SIIA MEMBERS 2021 SEPTEMBER 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 firstname.lastname@example.org. All submissions are subject to editing for brevity. Information about upgraded memberships can be accessed online at www.siia.org. If you would like to learn more about the benefits of SIIA’s premium memberships, please contact Jennifer Ivy and email@example.com. 46
NEWS DIAMOND MEMBERS BERKLEY LIFE AND
HEALTH HELPS HUB INTERNATIONAL LAUNCH NEW
CANNABIS GROUP CAPTIVE
Hub International Ltd. has launched an employee benefits group captive for cannabis organizations. The captive is designed for cannabis clients and prospects seeking an alternative to traditional employee benefit programs, Chicago-based Hub said in a statement Wednesday. Built in collaboration with Hamilton Square, New Jersey-based Berkley Life and Health Insurance Co., a member company of W.R. Berkley Corp., the captive is for cannabis employers with more than 50 insured employees with stable claims experience and a predictable cash flow, Hub said. Employee benefit group captives allow members to share the risks of costly claims and back claims into their cash reserves and medical stop loss insurance, Hub said.
“It’s ideal for the cannabis industry whose demographic is viewed more favorably by carrier underwriters than the risks associated with many
other leading industries,” the statement said. About Berkley Accident and Health Berkley Accident and Health is a risk management leader that specializes in accident and health products in the U.S. We help employers, membership groups, and healthcare organizations to better understand and manage their risk. We offer a full range of Stop Loss, Managed Care, Accident, and Group Captive programs through brokers, agents, consultants, and third party administrators. Founded in 2005, Berkley Accident and Health was created by longtime industry experts with a vision to create a nimble, entrepreneurial company that can quickly understand, analyze, and design a plan that addresses each client’s unique risk challenges. Visit BerkleyAH.com. About Hub International Headquartered in Chicago, IL, Hub International Limited is a leading global insurance brokerage that provides property and casualty, life and health, employee benefits, investment and risk management products and services from offices located throughout North America. Visit hubinternational.com.
NEWS QBE’S STEVE GRANSBURY
For the medical stop loss industry, the quality of our overall response through a period of unforeseen adversity is emblematic of the important role we play in business.
QBE’s Steve Gransbury is featured in Leader’s Edge, EBLF edition: EmployerFunded Health Insurance is More Than a Competitive Rate.
As employers reflect on this period of extraordinary economic disruption and change, now is an appropriate time to pause and review carrier relationships beyond just rates and terms on a renewal spreadsheet.
FEATURED IN LEADER’S EDGE
For many employers that self-fund health insurance benefits for their employees, the COVID-19 pandemic exposed the imprudence of basing a medical stop loss insurance purchasing decision primarily on rates over coverage terms. While there is nothing inherently wrong with squeezing out a few percentage points of premium savings when buying medical stop loss, the COVID-19induced service interruptions show how purchasing insurance based on lowest price alone can backfire.
About QBE QBE North America is a global insurance leader focused on helping customers solve unique risks, so they can focus on what matters most. Part of QBE Insurance Group Limited, QBE North America reported Gross Written Premiums in 2020 of $4.775 billion. QBE Insurance Group's 2020 results can be found at www.qbe.com. Headquartered in Sydney, Australia, QBE operates out of 27 countries around the globe, with a presence in every key insurance market. The North America division, headquartered in New York, conducts business through its property and casualty insurance subsidiaries. The actual terms and coverage for all lines of business are subject to the language of the policies as issued. QBE insurance companies are rated "A" (Excellent) by A.M. Best and "A+" by Standard & Poor's. Visit www.qbe. com/us or follow QBE North America on LinkedIn and Twitter.
From day one, StarLine’s differentiator has always been its people. Of course, we have decades of experience, but we are also genuine, capable, and collaborative. Our team always goes above and beyond to create and sustain solutions to match today’s constantly evolving needs. There is no part of our process that is not underscored by a dedicated group powered to propel you forward. Call us today at (508) 809-3179 or visit starlinegroup.com and linkedin.com/company/star-line-group Stay safe and stay well.
STOP LOSS | CAPTIVE | PAYOR | PROVIDER | ACO | GROUP ACCIDENT
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 GOLD MEMBERS AMPS ADDS INDUSTRY EXPERTS TO BOLSTER SELF-FUNDED MARKETING PRESENCE NATIONWIDE
Atlanta, GA - Advanced Medical Pricing Solutions (AMPS), a pioneer in healthcare cost containment, has expanded its self-funded market sales division with three new business development professionals – Shawn Hanlon, Tim Thomas, and John Gaudette. All three professionals are experienced benefits veterans who understand how to help self-funded employers reduce their medical and pharmacy costs.
TOKIO MARINE HCC - STOP LOSS GROUP NAMED WARD'S 50 TOP PERFORMING INSURANCE COMPANIES
For the sixth consecutive year, Tokio Marine HCC has been awarded the coveted Ward’s 50® group of top performing companies in the property-casualty and lifehealth insurance categories. This acknowledgement demonstrates Tokio Marine HCC’s standing for outstanding financial results in safety, consistency, and performance over a five-year period. Click here to learn more about Tokio Marine HCC and Ward’s 50® group for 2021. Or visit our website to learn more about Tokio Marine HCC – Stop Loss Group’s innovative medical stop loss, captive, Taft-Hartley, and organ transplant solutions.
About Tokio Marine HCC Tokio Marine HCC - Stop Loss Group (TMHCC) has been helping protect selffunded plan sponsors from catastrophic claim events for over 45 years. Rated A++ (Superior) by A.M. Best Company, A+ (Strong) by Standard & Poor’s, and AA(Very Strong) by Fitch Ratings, TMHCC is a leading provider of medical stop loss coverage provided through brokers, consultants, and third-party administrators. By listening to the demands of the market, we have developed exceptional products, unparalleled resources and value-added services that set us apart in the industry. Visit our website to learn more about our innovative stop loss, Taft-Hartley, captive and organ transplant solutions.
“AMPS is adding the necessary talent and experience it takes to deliver AMPS’ flexible, unmatched options to more self-funded employers in the marketplace,” notes Lawrence Thompson, chief revenue and strategy officer of AMPS. “As employers continue to take on more financial risks than ever before, it’s important they have access to transparent pricing with the ability to lower their costs. We’re ensuring they’re getting the help they need by adding professionals like John, Shawn, and Tim to our team.” Shawn Hanlon will serve as vice president of business development in the Southeast region of the U.S. He brings nearly two decades of strategic employee benefits and risk management experience to AMPS, previously holding senior leadership and consulting roles with BlueCross BlueShield of WNY, Brown & Brown of Florida, Willis Towers Watson, and Thomas Financial.
Accident & Health Insurance
We’ll focus on risk, so you can take care of
your business Get the help you need to self-fund your healthcare and grow your business.
Self-insuring your healthcare benefits can be a big step for your company — and a complicated one. But with a medical stop loss solution from QBE, our experts will help you determine the level of risk protection to meet your financial needs. Discover a range of products to help you protect your assets: • Medical Stop Loss • Captive Medical Stop Loss • Special Risk Accident • Organ Transplant Together, we’ll create a solution that fits your needs — so no matter what the future holds, you can be sure that QBE is with you.
QBE Accident & Health Market Report 2021 Explore industry trends, insights and product details that can help you better manage the risks of a self-funded healthcare plan.
To learn more and read the full report, visit us at qbe.com/us/ah
Specialty & Commercial
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 Tim Thomas, CIC, CLU, CSFS will serve as vice president of business development in the Southwest region of the U.S. Tim has more than three decades of benefits risk management and financial experience. Prior to AMPS, he held strategic sales leadership positions with Securance Corporation Agency, Alliant Insurance Services, and Gallagher Benefit Services. Tim also holds multiple insurance licensures, including a Group 1 Life and Health License, Property & Casualty License, and Risk Manager License. John Gaudette, MBA, PHR will serve as vice president of business development in the Pacific region of the U.S. He is an award-winning sales professional who brings a decade of experience in business development for benefits management and human resources administration. John previously held various sales roles and leadership positions with Delta Health Systems, Aetna, Ultimate Software, and Ceridian Corporation.
“I’m excited to add these three new business development professionals, who will help us educate employers about cost containment that goes above and beyond traditional Reference Based Pricing (RBP) solutions,” he says.
According to AMPS President and CEO, Kirk Fallbacher, today’s self-funded employers need to understand what options are available to manage the complexities around their increasing healthcare costs.
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 voyastoploss.com.
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
“With AMPS, employers not only have access to RBP backed by 15+ years of data, but also medical bill review, pharmacy benefit management, and stop loss – a multifaceted approach that minimizes their risk while ensuring financial flexibility.”
deep into diverse, impactful topics and perspectives surrounding the selffunding industry.
About Advanced Medical Pricing Solutions (AMPS)
Be sure to tune in to the site to hear the first four episodes which offer unparalleled perspectives on the following topics:
Advanced Medical Pricing Solutions (AMPS) provides market leading healthcare cost containment solutions serving self-funded employers, brokers, TPAs, health systems, health plans, and reinsurers. AMPS mission is to help clients attain their goals of reducing medical and pharmacy costs while keeping members satisfied with quality healthcare benefits. AMPS leverages its 15+ years of experience and data in auditing and pricing medical claims to deliver "fair for all" pricing. AMPS offers detailed analytics and transparency to provide clients with insights based on plan performance. Visit amps.com.
HCAA LAUNCHES 4 NEW SELF-FUNDING PODCASTS The Health Care Administrators Association (HCAA) announced the launch of its podcast, Voices of Self Funding. Tune in to hear host Ramesh Kumar, CEO and Co-Founder of zakipoint Health, as he interviews key self-funding experts and dives
Episode #1: Virtual Primary Care in 2021 Episode #2: Honest Discussions on Reference Based Pricing Episode #3: What are Direct Provider Contracts? Episode #4: Putting Together HighPerformance Networks & Programs For more information, please visit https://www.hcaa.org/page/voices-ofself-funding.
NEWS The platform leverages insurance verification and precertification data to get ahead of costly healthcare decisions and guide members to alternatives. HealthJoy's virtual AI assistant, JOY, is at the center of the experience to educate and engage with clients year-round. "Our healthcare system has become increasingly complex, and more than ever, employees need support and tools to guide decisions about their health," said Dave Mallen, Executive Vice President, TPA+ National Practice Leader at HealthJoy.
About HCAA The Health Care Administrators Association is the nation’s most prominent nonprofit membership trade association supporting the education, networking, resource and advocacy needs of benefit administrators (TPAs), stop loss insurance carriers, managing general underwriters, audit firms, medical managers, technology organizations, pharmacy benefit managers, brokers/agents, human resource managers, plan sponsors and health care consultants. For over 40 years, HCAA has taken a leadership role in transforming the self-funding industry, and increasing the importance of self-funding as an important alternative in the health care delivery systems of our country. Visit HCAA.org.
SILVER MEMBERS NOVA HEALTHCARE ADMINISTRATORS ANNOUNCES PARTNERSHIP WITH HEALTHJOY
CHICAGO -- Nova Healthcare Administrators, Inc. (Nova) announced its latest partnership with HealthJoy, the on-demand personalized healthcare navigation platform, to bring HealthJoy TPA+ to current clients and new business prospects. HealthJoy TPA+ proactively connects members with a variety of services, including telemedicine, healthcare concierges, price transparency assistance, and more, to help them choose high-quality, lower-cost healthcare.
"We're proud to bring that guidance to Nova's members by linking their innovative and holistic approach to plan management with HealthJoy's connected navigation platform and personalized support." Through HealthJoy TPA+, Nova's clients can also expect to see time savings for HR teams across all industries, along with an increase in employee benefits satisfaction. "Controlling healthcare costs begins with consumer education and engagement," said Todd Martin, Chief Sales Officer, Nova Healthcare Administrators. "HealthJoy's connected healthcare platform provides an incredible consumer experience through navigation tools and proactive support. Our clients will have more control over their healthcare spend, their employees will have better healthcare outcomes, and ultimately, we'll begin to shift the way people experience healthcare."
NEWS About Nova Founded in 1982, the Buffalo, N.Y.-based Nova Healthcare Administrators, Inc. is a wholly-owned affiliate of Independent Health and third-party administrator of selffunded employee health benefits. Nova provides a unique, comprehensive array of services, including medical, dental, vision, COBRA, reimbursement account administration, and private-labeled solutions. Nova also offers award-winning, inhouse, integrated medical management programs. Visit novahealthcare.com.
About HealthJoy HealthJoy is a mobile application that maximizes the value of employers' benefits packages, reclaims HR's time to focus on strategy over administrative tasks, and helps employees achieve better healthcare outcomes. With a mission to guide members to affordable, high-quality healthcare, the company offers telemedicine, EAP, behavioral health, and 24/7 concierge support that removes the complexity of being healthy and well. Contact Rick Ramos, at firstname.lastname@example.org and visit healthjoy.com.
MAESTRO HEALTH ANNOUNCES BRANDON WOOD AS NEW CEO FOR NEXT PHASE OF COMPANY GROWTH
CHICAGO -- After nearly two years at the helm, Craig Maloney, current CEO of Maestro Health, has decided to pursue a new opportunity. Under his leadership, Maestro Health successfully navigated a transformation of the organization, building new management teams, and overall, pushing healthcare innovation. We are grateful for all his contributions and wish him well. Brandon Wood has been appointed to this position and will move into the role of CEO, effective August 3rd, 2021. Brandon has more than 25 years of experience in the healthcare and benefits industries, has a passion for solving complex problems, developing high performing teams and making healthcare understandable and affordable for employers and their employees. "My focus will be continuing to build on our strong foundation and positive momentum in bringing solutions to market. We will continue to demonstrate our deep passion as careful stewards of our clients' healthcare spend and the health and wellbeing of their valued employees." – Brandon Wood Brandon joined Maestro Health in 2015 and has led Maestro Health's clinical, selffunded administration, cost containment and ancillary businesses, serving as COO for six years.
In his role, Brandon used his background in product management and operations leadership as a driving force in delivering solutions that result in cost savings and improved health outcomes; he has also been responsible for the creation of numerous new product offerings and savings programs. Prior to joining Maestro Health, Brandon served as President and Chief Operating Officer of a large benefits company. Brandon holds a degree from East Carolina University and is a frequent podcast guest & speaker on a variety of healthcare topics.
About Maestro Health Maestro Health works with employers and their trusted advisers to administer self-funded health plans. By blending technology, analytics, care management and administrative services, Maestro Health helps employers optimize their health plans, drive better health outcomes and lower costs. When partnering with Maestro Health, employers can save money on employee healthcare and focus on what really matters—their people. Contact Mary Margaret Williford at email@example.com and visit maestrohealth.com.
SELF INSURANCE INSTITUTE OF AMERICA, INC. 2021 BOARD OF DIRECTORS
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
TREASURER AND CORPORATE SECRETARY*
Elizabeth Midtlien Vice President, Emerging Markets AmeriHealth Administrators, Inc. Bloomington, MN
Peter Robinson Managing Principal EPIC Reinsurance San Francisco, CA
Lisa Moody President & CEO Renalogic Phoenix, AZ Shaun L. Peterson VP, Stop Loss Voya Financial Minneapolis, MN
*Also serves as Director
SIEF BOARD OF DIRECTORS Nigel Wallbank, SIEF Chairman
Directors Freda H. Bacon Les Boughner Alex Giordano Virginia Johnson Dani Kimlinger, PhD, MHA, SPHR, SHRM-SCP
SIIA NEW MEMBERS
Ali Alhimiri, MD Founder, CEO Modus Allen Park, MI
Michael Rominiecki Vice President Prognos Health New York, NY
Daniel Smith President Western Skies MGU Las Vegas, NV
Benjamin Rozum Co-Founder Coterie Advisory Group, Inc. Phoenix , AZ Lane Morris VP of Commercial Services Crown Administrators Austin, TX
Chris Lewis Sales Operations Enrollment123, Inc. Laguna Hills, CA Elizabeth Chasse Vice President, Strategic Marketing Goodroot, Inc. Canton, CT Monique Eubanks Employee Benefits Manager INSURICA Bakersfield, CA
EMPLOYER CORPORATE MEMBERS
Orlando Lynch President Atlanta Peach Movers Peachtree Corners, GA
Client onboarding in less time Sometimes, things just need to be done quicker. With the expedited client onboarding model from Trustmark Health Benefits®, we can get health plans up and running in 30 days or less, instead of the standard 45-60 days.
Learn more about our expedited onboarding model at trustmarkbenefits.com/SIIA Self-funded plans are administered by Trustmark Health Benefits, Inc.. ©2021 Trustmark Health Benefits® R45021-02
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 hmig.com.
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)