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General & Company News

People News

Market Trends, Studies, Books & Opinions

Legislative & Regulatory News

Medical News

Recurring Resources

Upcoming Conferences

Editorial Notes, Disclaimers & Disclosures

General & Company News

Integro Re Survey Detects Softening Provider Excess Insurance Market
MyHealthGuide Source: Integro Re, 11/16/2015,

New York, NY -- The growth in the Provider Excess insurance market has stalled in 2015, according to Integro Re's annual survey released today. Total premium in 2015 is expected to be $167M, which would represent a 3% drop from a total of $172M in 2014.

Provider Excess is an insurance product for health care providers who take on risk via capitation, shared savings plans or a bundled/episodic payment plan. Although payers typically offer protection from large claims in their risk contracts with providers, the provider excess market typically provides claims mitigation services and competitive pricing.

The survey included the participation of 15 of the top insurance and reinsurance companies in the provider excess space. The companies were asked for their premium volumes in 2014 and projections for 2015 and 2016, as well as their current and anticipated level of participation in emerging population health coverages. The survey was conducted by the Integro Re analytics team.

Ironically, premium volume is dropping as population health risk is growing rapidly. Why? Integro Re identified several underlying reasons total premium may be stagnating:

  • Rate adequacy is a key driver: Integro Re's analysis indicates that rate levels have dropped 5% since 2013;
  • Many buyers are accepting the large claim protection offered by payers in their provider risk contracts, effectively closing out the provider excess market from their services;
  • Higher retentions and the use of captives has also led to more risk being retained by providers rather than being ceded to the insurance market.

"Risk takers need to be educated on the stop-loss coverage embedded in their provider risk contracts," says Peter Robinson, Accident & Health practice leader of Integro Re, a division of Integro USA Inc. "The provider excess market will beat the payers on price and service nine times out of ten."

Survey participants were decidedly optimistic about next year, anticipating strong growth. Their premium projections for 2016 are $190M, which would represent a 14% increase over the estimated 2015 total.

Much of the growth in 2016 is expected to come from new sources of risk in the provider market. For instance, many Medicare ACOs will take on significant risk in 2016, whether through Track 3 of the Medicare Shared Savings Plan or as a Next Generation ACO. Although CMS includes truncation clauses in those contracts that limit large per-claim risk, there is a need for aggregate protection against an extremely costly outcome. On the commercial side, rising pharmaceutical costs has fueled demand for protection against a huge hit to a risk taker's bottom line.

"Provider excess isn't just a per-claim excess-of-loss coverage anymore," notes Patrick Gallagher, chief actuary at Integro Re. "Whether it be specialty drug costs, pandemics or surge risk, there is a growing need for aggregate protection for risk takers across the health care spectrum."

Other survey findings include:

  • While a number of underwriters indicated a willingness to write aggregate provider excess coverage, fewer than 25% of the respondents currently have aggregate coverage on their books.
  • There is growing comfort with the use of captives; approximately half of the respondents are currently participating in conjunction with a provider owned captive.
  • Provider Excess for bundled or episodic payment risk has not taken off; fewer than 10% of respondents reported having policies in force for bundled payments.
  • There have not been many "mega claims" in the provider excess space to date. While there have been a number of paid claims in excess of $5M in the HMO Re space, there has not yet been a $5M paid provider excess claim.

About Integro Re

Integro Re, a division of Integro USA Inc., is a full service reinsurance broker with particular expertise in healthcare, developing and implementing reinsurance strategies for a client base that includes insurance companies; alternative risk entities such as captives and risk retention groups; managing general agencies and third party administrators. Integro Re has locations in New York, San Francisco, Chicago, Denver, Boston and London. 

About Integro

Integro is an insurance brokerage and risk management firm. Clients credit Integro's superior technical abilities and creative, collaborative work style for securing superior program results and pricing. The firm's acknowledged capabilities in brokerage, risk analytics and claims are rewriting industry standards for service and quality. Launched in 2005, Integro and its family of specialty insurance and reinsurance companies, some having served clients for more than 150 years, operate from offices in the United States, Canada, Bermuda and the United Kingdom. Its U.S. headquarters is located at 1 State Street Plaza, 9th Floor, New York, NY 10004.  Call 877.688.8701 and visit


Health Catalyst Ranked 136th Fastest Growing Company in North America on Deloitte's 2015 Technology Fast 500

MyHealthGuide Source: Health Catalyst, 11/16/2015,

SALT LAKE CITY  -- Health Catalyst, a leader in healthcare data warehousing, analytics and outcomes improvement, announced it ranked No. 136 on Deloitte's Technology Fast 500™, a ranking of the 500 fastest growing technology, media, telecommunications, life sciences and energy tech companies in North America.

Technology Fast 500 award winners are selected based on percentage fiscal year revenue growth from 2011 to 2014. Health Catalyst revenue grew 629 percent during this period.

Health Catalyst CEO Dan Burton attributes the company's growth to the increasing demand for technologies and processes that improve clinical and financial outcomes and enable healthcare organizations to thrive under the fast evolving system of value-based reimbursement. Burton said: "We are honored to be named among the nation's fastest growing companies. This recognition is a reflection of our customers' success in using Health Catalyst's analytics platform to systemically improve clinical and financial outcomes."

Health Catalyst's Late-Binding™ Data Warehouse and Analytics platform forms the information foundation for value-based performance at some of the nation's largest health systems, serving more than 50 million patients overall. The platform can be implemented in a matter of weeks, providing health systems a single source of truth by combining clinical, financial and operational data from electronic health records (EHR) and many other enterprise applications while enabling flexible and fast visualization of the data across all clinical and process domains. Equipped with near real-time data and self-service analytics, health systems can quickly adapt to changing market conditions and identify opportunities for key process improvements.

"Amid a fierce business climate, there seems to be no shortage of new and established companies that are unlocking a seemingly unlimited potential for growth and advancement through technology's continued disruption and proliferation across industries," said Sandra Shirai, principal, Deloitte Consulting LLP and U.S. technology, media and telecommunications leader. "It is inspiring to witness the innovative ways that companies are incorporating emerging technologies for business gains. We congratulate all those ranked on this year's Fast 500 and look forward to seeing their continued growth into 2016."

About Deloitte's 2015 Technology Fast 500™

Deloitte's Technology Fast 500 provides a ranking of the fastest growing technology, media, telecommunications, life sciences and energy tech companies - both public and private - in North America. To be eligible for Technology Fast 500 recognition, companies must own proprietary intellectual property or technology that is sold to customers in products that contribute to a majority of the company's operating revenues. Companies must have base-year operating revenues of at least $50,000 USD or CD, and current-year operating revenues of at least $5 million USD or CD. Additionally, companies must be in business for a minimum of four years and be headquartered within North America.

About Health Catalyst

Health Catalyst is a mission-driven data warehousing, analytics and outcomes-improvement company that helps healthcare organizations of all sizes perform the clinical, financial, and operational reporting and analysis needed for population health and accountable care. Our proven enterprise data warehouse (EDW) and analytics platform helps improve quality, add efficiency and lower costs in support of more than 50 million patients for organizations ranging from the largest US health system to forward-thinking physician practices. Visit


Wellcentive Named Among Fastest Growing Companies in North America on Deloitte's Technology Fast 500

MyHealthGuide Source: Wellcentive, 11/16/2015,

ATLANTA -- Wellcentive, the leader in population health management and value-based care solutions for healthcare organizations, announced that it has been named to the 2015 Deloitte's Technology Fast 500™, an exclusive annual ranking of the 500 fastest growing technology, media, telecommunications, life science and energy tech companies in North America.

Ranked No. 172 overall, the Alpharetta, Georgia-based company reported a three-year revenue growth of 465 percent from 2011 to 2014, while more than doubling its staff of clinical, technology, service, sales and market experts. This substantial growth placed Wellcentive No. 6 among healthcare information technology companies and No. 2 for the state of Georgia.

Tom Zajac, Wellcentive's CEO, credits the company's growth to his team's passion to support its customers. "Nothing is more important to us than partnering with our customers to help them drive revenue and improve the value of the care they deliver," said Zajac. "Since 2005, we have been dedicated to our mission of providing the technology, solutions, services and insight to help our customers manage the complexities of the healthcare environment, and drive improved financial, clinical, and human outcomes. We are honored to be recognized in the Deloitte Fast 500, which is a tribute to our customers, our outstanding team, and our commitment to improving healthcare."

Wellcentive enables healthcare organizations - health systems, physicians, accountable care organizations, employers and payers - to drive quality, revenue and support the transformation to value-based care. The company's solutions aggregate data for patients across all points of care, apply analytics to identify and stratify patient health, trends and risk, and deliver action-based workflows that proactively manage patient health and aggressively forecast outcomes and costs for populations.

"Amid a fierce business climate, there seems to be no shortage of new and established companies that are unlocking a seemingly unlimited potential for growth and advancement through technology's continued disruption and proliferation across industries," said Sandra Shirai, principal, Deloitte Consulting LLP and U.S. technology, media and telecommunications leader. "It is inspiring to witness the innovative ways that companies are incorporating emerging technologies for business gains, be it cognitive computing, or the Internet of Things. We congratulate all those ranked on this year's Fast 500 and look forward to seeing their continued growth into 2016."

"Through the efforts and utilization of new and emerging technologies from these companies, we are witnessing greater business demands from across almost all industries," added Jim Atwell, national managing partner of the emerging company practice, Deloitte & Touche LLP. "We look forward to the opportunity to serve these companies as they strive to grow to the next level - be it towards introducing new solutions or entering new markets - and with it make important and long lasting impressions on the technology market as a whole."

About Deloitte's 2015 Technology Fast 500™

Deloitte's Technology Fast 500 provides a ranking of the fastest growing technology, media, telecommunications, life sciences and energy tech companies - both public and private - in North America. Technology Fast 500 award winners are selected based on percentage fiscal year revenue growth from 2011 to 2014.

In order to be eligible for Technology Fast 500 recognition, companies must own proprietary intellectual property or technology that is sold to customers in products that contribute to a majority of the company's operating revenues. Companies must have base-year operating revenues of at least $50,000 USD or CD, and current-year operating revenues of at least $5 million USD or CD. Additionally, companies must be in business for a minimum of four years and be headquartered within North America.

About Wellcentive

Since 2005, Wellcentive has driven quality improvement, revenue growth, and business transformation for providers, health systems, employers, and payers transitioning to value-based care. Recognized as an industry leader for delivering immediate and tangible results, Wellcentive's analytics simplify complex data from all points of care, advancing comprehensive care management and payer collaboration. Customers achieve more than $500 million annually in value-based revenue, improving outcomes for more than 30 million patients. Call 877-213-8456 and visit


EmployerDirect to Showcase SurgeryPlus at Benefits Design Forum and Vendor Fair

MyHealthGuide Source: EmployerDirect, 11/18/2015,

AUSTIN, TX -- EmployerDirect Healthcare, a leader in value-based healthcare for large employers with self-funded medical plans, announced that it will showcase its SurgeryPlus at the Dallas Fort Worth

Business Group on Health's 11th Annual Benefits Design Forum and Vendor Fair. SurgeryPlus is a supplemental healthcare benefit for employers that directs planned medical procedures to high-quality providers. The event will be held on Thursday December 3 at the Westin Galleria in Dallas. The Forum provides valuable opportunities to learn about evidence-based solutions that can help employers purchase high value healthcare, improve employees' overall health and well-being, reduce their health risks and manage chronic conditions more effectively, while controlling healthcare costs.

"This conference is a great opportunity to meet health and wellness executives from large employers in our home state of Texas who are interested in increasing access to quality and  reducing costs," said Clint Hampton, CEO of EmployerDirect. "We encourage conference attendees to stop by our booth to learn more about SurgeryPlus, which provides self-funded employers with cost savings and transparency, and contributes to increased employee productivity."

SurgeryPlus offers bundled case rates for planned medical procedures by pre-negotiating and consolidating all costs before surgery, including surgeon, assistant surgeon, anesthesia fees, facility costs, inpatient diagnostics, therapy, and pharmacy. The covered procedures are mostly elective and include orthopedic, spine, cardiovascular, bariatric, general surgery and carpel tunnel surgeries, along with minor outpatient procedures such as colonoscopy, endoscopy, arthroscopy. Each procedure is implemented by a care coordinator, who acts as a personal assistant for each member. Care coordinators help select a SurgeryPlus provider, schedule appointments, aid in transferring medical records, and manage travel logistics for patients when necessary.

Over 400 business and healthcare executives are expected to attend the Dallas Fort Worth Business Group on Health's 11th Annual Benefits Design Forum and Vendor Fair. This includes corporate benefits and wellness executives from large and mid-size Texas employers, health and benefits service providers and healthcare professionals. More information is available at

About EmployerDirect Healthcare and SurgeryPlus

EmployerDirect's supplemental benefit, SurgeryPlus, transforms the way self-insured employers provide and pay for planned medical procedures for their employees, saving 30-50 percent per procedure. With a nationwide network of board certified surgeons and high quality facilities, SurgeryPlus covers over 100 procedures with pre-negotiated bundled rates consolidating all costs for each episode of care. Dedicated Care Coordinators personally assist covered members with scheduling procedures by selecting a provider, transferring medical records, coordinating any travel logistics and guiding the member through the entire continuum of care. SurgeryPlus members do not pay an additional premium for the benefit and members do not receive medical bills for procedures. Call (888)241-8537 and visit


Symetra Financial Corporation and its Subsidiaries Ratings Affirmed by A.M. Best

MyHealthGuide Source: AM Best, 11/19/2015, 

OLDWICK -- A.M. Best has affirmed the financial strength rating of A (Excellent) and the issuer credit ratings (ICR) of "a+" of Symetra Life Insurance Company and its subsidiary, First Symetra National Life Insurance Company of New York (New York, NY).

The ratings reflect Symetra's trend of favorable operating earnings in its business segments, and solid liquidity and risk-adjusted capitalization. Symetra reported good operating results through the first three quarters of 2015, although slightly lower than the prior year due in part to volatile mortality experience and the macroeconomic environment. Results were bolstered by year-over-year sales growth in all core product segments, and pre-tax operating income was favorable to prior year in the company's deferred annuities business within the Retirement Division. The annuity business benefited from a favorable unlocking adjustment in the third quarter of 2015.

Stop Loss

The company's Benefits Division, which is primarily medical stop-loss business, reported a loss ratio that was favorable to the company's target range.

A.M. Best notes that while Symetra continues to be a leading medical stop-loss carrier, the company has grown its Retirement Division, and specifically its annuity business, materially in the past few years.

While business diversification is viewed favorably, A.M. Best remains concerned regarding the sustainability of earnings across key product lines given the continued low interest rate environment and evidence of lower net investment yields throughout the industry. The organization continues to focus on growth within the competitive individual life segment, through distribution growth and focus on value-added product offerings. Symetra's solid capital position and strong balance sheet, including its well-managed, diversified, investment portfolio, partially offset potential concerns regarding pressured operating performance in the somewhat volatile interest rate environment.

About A.M. Best

A.M. Best Company is the world's oldest and most authoritative insurance rating and information source.  Visit


People News

Berkley Accident and Health Appoints Matt Smith as Regional Sales Manager

MyHealthGuide Source: Berkley Accident and Health, 11/16/2015,

Hamilton Square, NJ -- Berkley Accident and Health, a W. R. Berkley Company®, has appointed Matt Smith as Regional Sales Manager for its rapidly growing Group Captive product, EmCapSM. In his new role, Matt will develop new EmCap programs for employers in Texas, Oklahoma, Arkansas, and Louisiana.

"We are very excited to add Matt's experience and ability to our expanding EmCap distribution efforts," said Christopher Brown, President and CEO of Berkley Accident and Health. "Matt has an impressive background, as well as strong consultative experience that will be invaluable to our brokers and clients." In his new role, Matt will help clients, brokers, and consultants understand how Group Captives can fit into a long-term employee benefit risk strategy.

Matt has more than 15 years of industry experience in employee benefits consulting, business development, large group health underwriting, onsite clinics, and human resources. He brings with him a variety of experiences in the group health market space, including time with large national insurers and brokerages.

Prior to joining Berkley Accident and Health, Matt held a sales executive role for a large health insurer and has worked with a wide spectrum of clients, ranging from small, fully insured groups to large, multi-site national accounts with 50,000+ employees.

Matt earned an MBA from the University of Connecticut and an undergraduate degree from James Madison University and holds Professional of Human Resources and SHRM-CP designations. Matt is based out of the company's Kansas City office.

EmCap is Berkley Accident and Health's innovative approach that helps employers manage their health care costs through alternative risk sharing. EmCap provides midsize employers with all the benefits of self-funding and the stability of a group captive program. The EmCap program has experienced extraordinary growth in the past five years and is poised for continued growth, as more and more employers seek effective ways to control health costs.

About Berkley Accident and Health

Berkley Accident and Health is a member company of W. R. Berkley Corporation, a Fortune 500 company. Berkley Accident and Health provides an innovative portfolio of accident and health insurance products. It offers four categories of products: Employer Stop Loss, Group Captive, Managed Care (including HMO Reinsurance and Provider Excess), and Specialty Accident.  The company underwrites stop loss coverage through Berkley Life and Health Insurance Company, which is rated A+ (Superior) by A.M. Best Company.  Contact Linda King, Marketing Manager, (609) 584-6990, and visit and


Sun Life Seeks Senior Stop Loss Underwriter

MyHealthGuide Source: Sun Life, 11/2015,

The Sun Life Stop Loss Underwriting Team is growing! As a member of the Stop Loss Underwriting team.  The position is Senior Stop Loss Underwriter-UND01192.


  • Evaluate, price and propose rate and strategy on Stop-Loss prospects, including specific and aggregate benefits
  • Manage assigned workload to meet productivity and time service standards
  • Manage field office relationships in regards to industry information, prospects and regional medical trends
  • Formulate a successful strategy with regional sales team to sell cases within general underwriting guidelines
  • Independent decision making on case work utilizing general underwriting guidelines
  • Act as a resource for other underwriters and the field sales team
  • Analyzes information on medical industry, demographics, plan document design, medical network and other standard criteria
  • Determines level of risk based on well established underwriting guidelines
  • Quotes appropriate rates based on risk properties of prospect to field sales team
  • Supports the identification and development of best practices work flows and procedures


  • Minimum 5 years of Stop-Loss product underwriting experience
  • BA/BS degree preferred
  • Strong math, communication, negotiation and analytical skills required
  • Demonstrates multi-tasking ability
  • Must be detail oriented, well organized and have the ability to manage a high volume workload with competing demands
  • Requires strong Microsoft Excel and Word knowledge

Join our talented, diverse workforce and launch a rewarding career.

Visit us at to learn more.

About Sun Life Financial

Celebrating 150 years in 2015, Sun Life Financial is a leading international financial services organization providing a diverse range of protection and wealth products and services to individuals and corporate customers. Life Financial is a leading provider of group insurance benefits in the U.S., helping people protect what they love about their lives. More than just a name, Sun Life symbolizes our brand promise of making life brighter -- for our customers, partners, and communities. Visit


Market Trends, Studies, Books & Opinions

High Copayments and Coinsurance Cause Employees to Delay Needed Health Care

MyHealthGuide Source: Commonwealth Fund Health Care Affordability Tracking Survey, July-August 2015, Commonweath Fund Report

Copayments and coinsurance create disincentives for many people--especially those with low incomes--to get needed health care services.

How Do Deductibles and Copayments Affect People's Health Care Decisions?

Employers and insurers have made the argument that deductibles and copayments in health plans create disincentives for consumers to overuse health care or use services that might be of limited value. The survey finds evidence that cost-sharing also creates disincentives for people to get necessary care, like going to the doctor when they are sick or filling prescriptions for their medications. 

We asked adults whether their deductibles had affected their decisions to get needed health care over the past year. Adults whose deductibles were high relative to their income were significantly more likely to report delaying or avoiding needed health care than those with lower deductibles.

Effects of Copayments and Coinsurance on Health Care Decisions

Copayments and coinsurance also created disincentives for many people--especially those with low incomes--to get needed health care services.

  • 40% of adults with deductibles that amounted to 5 percent or more of income reported that because of their deductible: they had
    • not gone to the doctor when sick,
    • did not get a preventive care test,
    • skipped a recommended follow-up test, or
    • did not get needed specialist care.
  • Adults with lower deductibles relative to their income were less likely to avoid needed care, but 21% said they did not get needed care because of their deductible.
  • 39% of adults with incomes under 200 percent of poverty ($23,340 for an individual or $47,700 for a family of four) said that because of their copayments or coinsurance, they had either...
    •  not filled a prescription,
    • not gone to the doctor when they were sick,
    • skipped a medical test or follow-up visit recommended by a doctor, or
    • not seen a specialist when they or their doctor thought they needed one.
  • 19% adults with relatively higher incomes also reported that their copayments were barriers to filling prescriptions or getting needed medical care.
"In the past 12 months, was there any time when you delayed or did not get any of the following because of the amount you would have to pay toward your deductible?"
Commonweath Fund Chart

This issue brief draws from the second installment of the Commonwealth Fund Health Care Affordability Tracking Survey to measure the extent to which U.S. adults have high health care cost burdens. We created what we call the Commonwealth Fund Health Care Affordability Index, a composite measure that assesses the share of U.S. adults who have high premium costs, high deductibles, and/or high out-of-pocket health care costs relative to their incomes (see graphic below). In addition, we asked adults about how they perceive the affordability of their premiums, deductibles, and copayments or coinsurance. Adults also told us how their deductibles and copayments affected their health care decisions in the past year.

The data reflect the health insurance and health care expenditures reported by adults who were insured continuously all year with private insurance through an employer, the Affordable Care Act's marketplaces, or the individual market.

The majority of the survey sample has employer coverage (90%), but the sample also includes people in marketplace plans (6%) and with individual coverage (5%). In the survey, 61 percent of U.S. adults had been insured continuously with private coverage for the prior 12 months, up from 56 percent one year earlier (data not shown).

About The Commonwealth Fund

The Commonwealth Fund is a private foundation that aims to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.

The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries. Visit


Legislative & Regulatory News

Connecticut DOI Issues New Rules for Stop-Loss Policies

MyHealthGuide Source: Connecticut Insurance Department, 11/12/2015, Connecticut Insurance Department Bulletin HC-108 & PC-80

The Connecticut Insurance Department issued joint Bulletin HC-108 & PC-80, setting new rules for stop-loss policies. This bulletin supplements, but does not replace, joint Bulletin HC-95 and PC-75 (issued March 2014), establishing basic standards and updated attachment points for stop-loss coverage.  Applies to stop-loss policies issued or renewed on or after January 1, 2016, the new bulletin:

  • Lists 15 types of stop-loss policy provisions that will no longer be approved by the Department.
  • New rules for "lasering", the practice of "assigning a different attachment point or deductible or denying coverage altogether for an individual employee or dependent that has a pre-existing, high cost medical condition or other identified risk".
  • Include limits on attachment points, limits and prohibitions on lasering after the effective date of a policy, and disclosure requirements for the use of lasers.
November 12,2015




This bulletin rescinds and replaces Bulletins HC-103 & PC-79 issued on July 8, 2015. This bulletin should be read in conjunction with Connecticut Insurance Department joint Bulletin HC- 95 and PC-75 dated March 17, 2014.

A stop loss insurance policy insures the employer or its group health plan not the enrollees covered by the plan. The policy may be issued by either a property and casualty insurer or an accident and health insurer and is not regulated as group health insurance. Recent stop loss insurance policy filings have included provisions that are common in health insurance policies, but inappropriate for stop loss policies. A key issue is that stop loss carriers are making individual claims determinations that may be different than those made in the underlying group health policy. A self-funded employer remains legally responsible to pay the claims under the group health plan, but may be financially unable to fulfill its fiduciary obligations due to the limitations found in the stop loss policy.

Stop loss policies will not be approved if they contain provisions relating to the following:

  • Claims denials that the employer is legally obligated to pay under the health plan
  • Medical necessity determinations
  • Usual or customary determinations
  • Experimental/investigational determinations
  • Case management requirements
  • Annual dollar limitations in specific coverages or for specific enrollees
  • Mandated provider networks/benefit incentives for enrollees
  • Requirements that enrollees be actively at work
  • Right to examine enrollees
  • Rescission for reasons other than fraud or intentional misrepresentation
  • Early termination at the discretion of the carrier other than in accordance with cancellation and nonrenewal laws applicable to these policies
  • Terms or conditions that are misleading, deceptive or contrary to the public interest
  • Mid-term rate increases at the discretion of carrier
  • Provisions that conflict with state law
  • Other provisions that are deemed to be health insurance and inappropriate for an excess loss policy

Lasering is the practice of assigning a different attachment point or deductible or denying coverage altogether for an individual employee or dependent that has a pre-existing, high cost medical condition or other identified risk. Insurers may use lasers when underwriting stop loss plans, but no attachment point for an enrollee shall exceed three times the attachment point chosen for the policy. Lasers cannot be added or changed after the effective date of the policy.  Insurers and producers shall fully disclose the increased risk when a laser is used along with any available options to the policyholder. If any lasers are used, the application shall include a statement that the financial risk was fully explained to the policyholder and that the policyholder understands such risk. The signatures of both the policyholder and producer shall be required below such statement if any lasers are used.

Insurers shall not use previously approved forms containing prohibited provisions for policies issued or renewed on or after January 1, 2016. All policy form filings should be made through the System for Electronic Rate and Form Filings. For changes to currently approved forms in compliance with this bulletin, carriers may simply file amendatory language. The filing should indicate the state tracking number of all policies to which the amendment is being made and the date such filings were previously approved. A red-lined version should be included in the filing.


Please contact the Insurance Department Life and Health Division at with any questions.

Katharine L. Wade
Insurance Commissioner


ERISA: Medical Providers Lack Standing For Reimbursement -- Anti-Assignment Provisions Enforceable

MyHealthGuide Source: Mike Reilly, 11/16/2015, Lane Powell Boom ERISA Blog

Case: University of Wisconsin Hospitals v. Aetna Health & Life Ins. Co., 2015 WL 6736983 (W. D. Wis., November 3, 2015)  Court's Document

You know that patients typically assign rights under a health insurance plan to the provider of medical services. This is accomplished by signing an assignment form upon intake/admission. Then, the healthcare provider sends the claim directly to, and receives reimbursement directly from, the patient's health insurance company for services rendered to the patient.

But what happens when the ERISA-governed health insurance plan has an anti-assignment provision?

Anti-assignment provisions are enforceable. As a result, health care providers lack standing to bring a claim for reimbursement.

The recent University of Wisconsin case above highlights the point.


Chandra Aschenbrener, an insured under an ERISA-governed Aetna health insurance policy, incurred $16,893 in hospital expenses. The plan specified that benefits may not be assigned to another party, including the right to bring legal action. The University of Wisconsin Hospital sued Aetna, seeking reimbursement for medical expenses.

Court Held: Anti-Assignment Provisions Enforceable.

  1. "Courts are to strictly enforce the terms of ERISA plans where possible." Op. at 5.
  2. "[I]n order for a beneficiary to collect a plan's benefits, the assignment by a participant to the beneficiary must comport with the insurance plan." Op. at 5.
  3. "[C]ircuits have overwhelmingly held that anti-assignment clauses in ERISA employee welfare benefit plans are enforceable, and therefore medical provider plaintiffs lack standing to pursue payment as ‘beneficiaries.'" Op. at 8.
  4. "In order for [the hospital] to become a beneficiary, Aschenbrener must designate it as such. The plan, however, specifies unambiguously that the benefit rights may not be assigned….The plan also expressly states that a direction to pay a provider, directly or otherwise, is not an assignment of any right and that a direction to pay does not extend to a provider any legal right to initiate court proceedings." Op. at 8 (emphasis in original).

Key Take Away

Anti-assignment clauses in ERISA employee welfare benefit plans are enforceable. As a result, medical providers lack standing to pursue payment as "beneficiaries." See, e.g., Physicians Multispecialty Grp. v. Health Care Plan of Horton Homes, Inc., 371 F.3d 1291, 1295 (11th Cir. 2004) ("an assignment is ineffectual if the plan contains an unambiguous anti-assignment") (citing cases from the First, Ninth and Tenth Circuits); Letourneau Lifelike Orthotics & Prosthetics, Inc. v. Wal–Mart Stores, Inc., 298 F.3d 348, 353 (5th Cir. 2002) (plaintiff lacked standing under ERISA because anti assignment clause was enforceable).


Health Plans Should Learn New Rules to Prevent Balance Billing

MyHealthGuide Source: Todd Leeuwenburgh, 11/20/2015, Thompson Blog 

Thanks to cost pressures exacerbated by the Affordable Care Act, narrow-network plans have increased in popularity because of their lower premiums, but plans using such networks need to think about associated potential problems with poor provider access, balance billing and provider directory information.

Detailed information about the latest regulatory and legislative measures to prevent balance billing of patients were discussed by attorneys from the law firm Epstein Becker & Green in a Nov. 16 webinar.

‘Surprise' Billing of the Patient

Surprise bills can arise in the surgical context when patients are treated by a care team but not all members of that team are part of the same provider network. Non-participating providers may want adequate compensation and may refuse to participate on the plans' stated terms. The patient's health plan either underpays or doesn't pay the non-participating provider and the provider sends the bill to the patient.

  • Example: A patient gets scheduled care at an in-network hospital, and the surgeon is in-network … but the anesthesiologists and pathologists are out-of-network. The patient expects the whole amount will be covered because he or she is in an in-network facility. Instead, the two ancillary providers send the patient a surprise bill to cover amounts the plan would not pay.

Regulators are especially concerned when balance billing occurs in connection with emergency services, because then patients are not in control of which providers are treating them and can't necessarily stay in-network, according to EB&G attorney Helaine Fingold. Because of concerns with consumer protection, regulatory authorities at the federal and state level have responded with preventive rules.

NAIC Act on Network Sufficiency

The National Association of Insurance Commissioners will finalize its model act on network sufficiency on Nov. 22. It is non-binding, and will only be adopted if states agree to it in whole or in part. For example, if a state wants to allow or prohibit balance billing, it may do that. Elements of the model act include:

  • Written notice within 10 days of scheduling non-emergency services and at admission, that services may be provide by an OON provider.
  • OON emergency services must include a notice that the patient only has to pay the in-network cost-sharing amount.

Under the model act, insurers also must state that some services may be provided by OON providers; and must set up a mediation process for a provider that objects to rates set by the insurer's OON billing process.

Federal Protections

Under the Affordable Care Act, if a plan or policy includes emergency services benefits, then it must cover them by both in and out of network providers; OON ER benefits must not have more restrictive administrative requirements or benefit limits than in-network ERs do. And OON ER services must be reimbursed at a "reasonable" level. "Reasonable" is defined as the greatest of:

  1. the in-network amount;
  2. the amount the plan generally uses to pay for other OON services (for example, the "usual/customary/reasonable" amount); or
  3. what Medicare would pay for the emergency service.

This applies to all group plans -- large, small, insured and self-funded. The ACA allows balance billing, if allowed under state law.

The ACA says OON costs don't apply to out-of-pocket limits; plans are not required to count such costs. If a plan doesn't have a network, then all emergency services providers would be considered in-network for applying the out-of-pocket maximum.

Hospitals must post on their websites a list of their standard charges for services, even for bundled diagnosis-related groups. Also under state rules, they must post a notice that physician services provided in the hospital may not be included in charges; and that such physicians may not participate in the same health plans as the hospital. Therefore the patient should check with referring physicians to see the extent of coverage by all members of the care team.


Medical News

'Cash for Lower Cholesterol' Program Works With Doctor-Patient Teams

MyHealthGuide Source: Dr. David Asch, MD, et al, 11/10/2015, Journal of American Medical Association

A study offering cash rewards to both patient and doctor helped people lower their cholesterol levels according to a study published in the Journal of American Medical Association.

The study determined whether physician financial incentives, patient incentives, or shared physician and patient incentives are more effective than control in reducing levels of low-density lipoprotein cholesterol (LDL-C) among patients with high cardiovascular risk.

The study involved four-group, multicenter, cluster randomized clinical trial with a 12-month intervention conducted from 2011 to 2014 in 3 primary care practices in the northeastern United States. Three hundred forty eligible primary care physicians (PCPs) were enrolled from a pool of 421. Of 25,627 potentially eligible patients of those PCPs, 1,503 enrolled. Patients aged 18 to 80 years were eligible if they had a 10-year Framingham Risk Score (FRS) of 20% or greater, had coronary artery disease equivalents with LDL-C levels of 120 mg/dL or greater, or had an FRS of 10% to 20% with LDL-C levels of 140 mg/dL or greater. Investigators were blinded to study group, but participants were not.

Primary care physicians were randomly assigned to control, physician incentives, patient incentives, or shared physician-patient incentives. Physicians in the physician incentives group were eligible to receive up to $1024 per enrolled patient meeting LDL-C goals. Patients in the patient incentives group were eligible for the same amount, distributed through daily lotteries tied to medication adherence. Physicians and patients in the shared incentives group shared these incentives. Physicians and patients in the control group received no incentives tied to outcomes, but all patient participants received up to $355 each for trial participation. 

Main Outcomes and Measures Change in LDL-C level at 12 months.

Study findings

  • Patients in the shared physician-patient incentives group achieved a mean reduction in LDL-C of 33.6 mg/dL.
  • Patients in the physician only incentives group achieved a mean reduction of 27.9 mg/dL
  • Patient-only incentive group achieved a mean reduction of 25.1 mg/dL
  • Only patients in the shared physician-patient incentives group achieved reductions in LDL-C levels statistically different from those in the control group.

Researchers conclude that shared financial incentives for physicians and patients, but not incentives to physicians or patients alone, resulted in a statistically significant difference in reduction of LDL-C levels at 12 months. This reduction was modest, however, and further information is needed to understand whether this approach represents good value.


Recurring Resource

Medical Stop-Loss Providers Ranked by Annual Premium Survey (last updated 11/9/2015)

Source: MyHealthGuide

Editor's Note: The following is a recurring article. This Newsletter is often asked by readers for a list of medical stop-loss providers and their respective premiums. Below the first of a recurring article that attempts to lists stop-loss providers and annual premiums. Sources includes press releases, AM Best reports, conference presentations and more.

Stop-loss Premium Ranking
Compiled by MyHealthGuide Newsletter

Reader response and correction is encouraged.
Sources will be cited. Please send updates / changes to

  Stop-loss Provider Years Providing Stop Loss Associated Carriers / MGUs Annual stop-loss Premium
Capital /Equity
1. CIGNA     $2,318
  CIGNA Financial Supplement 2014, P.5 12/31/2014
2. Sun Life Financial     $1,034.2
  Sun Life 2/12/2015 Management Discussion of "13% stop loss growth over 2013" of 2013 premium of $915.2M provided by Scott Beliveau, Sun Financial 4/28/2014
3. HCC Life Insurance Company >35 Years HCC Life
(A.M. Best Rated: A+)
Perico Life
(A.M. Best Rated: A+)
$3,903 HCC Insurance Holdings, Inc. Form 10-K
4. HM Insurance Group >30 Years HM Insurance Group
(A.M. Best Rated: A-)
Matt Rhenish, President & COO, 2/16/2015
5. Symetra >36 Years Symetra Life Insurance Company
(A.M. Best Rated: A)
(Block - $495M
MRM - $233M)
Symetra 4Q 2014 Financial Supplement;
Tom Doran, President, Medical Risk Managers, Inc.
6. Voya Employee Benefits > 35 Years ReliaStar Life
(A.M. Best Rated: A)
Joe Keller, Lead Financial Analyst, Voya Employee Benefits,
7. Companion Life > 20 Years   $440
  Philip Gardham, Vice President, Specialty Markets,
8. Independence Holding Company   Standard Security Life Insurance Company of New York,
Madison National Life, Independence American Insurance Company
  Independence Holding Company
9. National Union Fire Insurance Company of Pittsburgh >35 Years AIG Benefit Solutions $215
  Jeff Gavlick, VP, Stop Loss Products, AIG Benefit Solutions
10. Zurich North America     $150   Joseph Byers, Zurich North America.
11. Munich Re Stop Loss, Inc.   American Alternative Insurance Company (AAIC),
  Travis Micucci, the Chief Executive Officer of Munich Re Stop Loss, Inc., 11/09/2015
12. The Union Labor Life Insurance Company  (ULLICO) >25 Years ULLICO
(A.M. Best Rated: B++)
  Victor Moran, Second Vice President, Actuarial Operations.  3/6/2015
Markel Insurance Company <5 Years Markel Insurance Company
(A.M. Best Rated: A-)
$3 $3,388
Mark Nichols, Managing Director.

Other stop-loss leaders include the following list. However, we await reader response providing stop-loss premium volume (and additional carriers) so that each could be added to the table above. 

  • ACE America
  • Aetna
  • Amalgamated Life
  • American Fidelity Assurance Company 
  • American National Life Insurance Company of Texas
  • Berkley Accident and Health
  • BEST Re 
  • Blue CrossBlue Cross Blue Shield (various regions)
  • Gerber Life Insurance Company
  • International Insurance Agency Services, LLC
  • Lloyd's of London
  • Nationwide Life Insurance Company
  • Pan American Life
  • QBE Insurance Company
  • Trustmark Insurance Company
  • UnitedHealthcare

Stop-loss Premium Volume is not the Whole Story

Industry executives question the purpose of a chart reporting only stop-loss premium without additional information such as:

  • Ratings from Best, S&P, Moodys and others (data collection began 6/2012)
  • Capital size of the insurance company (data collection began 6/2012)
  • Reinsurance purchased and from whom
  • Length in the business (data collection began 6/2012)
  • Number of open litigation claims
  • Is stop-loss a core business or ancillary business?
  • % age of risk retained vs. ceded
  • Average stop-loss claim processing turn-around time
  • % age of claims denied
Should reader interest indicate such measures are important, this Newsletter will attempt to collect and report.  

Reader response and correction is encouraged. Sources will be cited. Please send updates / changes to  


The Value of Self-Funding

MyHealthGuide Source: The Self-Insurance Educational Foundation, Inc. (SIEF), 2014, The Self-Insurance Educational Foundation, Inc. (SIEF has published The Value of Self-Funding.

Self-funding is an important contributor to the financial and physical health of America's wellness future. Self-funding is more than processing claims and receiving premiums, it provides quality coverage and proactive healthcare management for employers of all sizes and industries.

About the SIEF

The Self-Insurance Educational Foundation, Inc. (SIEF) is a 501(c)(3) non-profit organization affiliated with the Self-Insurance Institute of America, Inc. (SIIA). The foundation's mission is to raise the awareness and understanding of self-insurance among the business community, policy-makers, consumers, the media and other interested parties. Visit


ICD-10 Readiness Tools

MyHealthGuide Source: Industry Study Group (ISG), 9/19/2015

In the early 2000s a group of industry professionals collectively known as the Industry Study Group ("ISG") created a Standard Disclosure Notification form and a standardized list of ICD-9 diagnosis codes, known as the Trigger list.

On October 1, 2015, our industry transitions to the new ICD-10 coding system. The ISG has once again undertaken the development of a new Trigger list based on the ICD-10 diagnosis codes. Please find links to the ISG White Paper on the process and to the new ICD-10-CM Trigger list.

  • The new ICD-10-CM Trigger list is endorsed by SIIA and HCAA and supported by SPBA.  

Below are useful links for members of the self-funded community including TPAs, stop-loss carriers, MGUs, and others.


Upcoming Conferences

November 30, 2015 - Webinar 3:00 PM (EST) to 4:00 PM
A Changing Industry: Keeping PACE With the Trends presented by The Phia Group.  The self-funding industry is experiencing great opportunity and growth. In the past two years, millions of lives have transitioned away from the fully-insured health plan model in favor of the self-insured model - and despite the rise of exchanges, many employers are steering away from them for various reasons. These encouraging facts are tempered by the increased burdens facing both new and existing employer sponsors, third party administrators, industry brokers, and even stop-loss carriers and MGUs.  Fiduciary responsibilities have grown, liability shifting is now a common theme in a standard RFI, and lawsuits over claims and appeals decisions are becoming more prevalent.  Register

December 3, 2015 - 9:00 am PT/11:00 pm CT/12:00 pm ET Webinar
HCAA Webinar: Dealing with Key Issues Relating to Information Security, Revenue Optimization and Business Process Outsourcing presented by Health Care Administrators Association. Presenters:

Health plans push for their members to get check ups; it improves the patient-provider relationship, health outcomes, and reduces overall medical spend. Like its members, health plans also need to have check ups since they're increasingly exposed vulnerabilities in the areas of information security; revenue optimization (such as fraud, waste, & abuse, and utilization management; and the inability to handle staffing needs during open enrollment and peak customer times. This webinar will help attendees to learn how to specifically deal with key issues in each of these areas.

If you are a current HCAA member, be sure to log into your HCAA account first to receive the HCAA member rate for this webinar. Log into your account by navigating to the "Sign In" area located on the right hand side bar of the HCAA website or click the button below.

If you have any questions regarding your HCAA member login information, please feel free to contact HCAA at (888) 637-1605 and visit Information and registration:

February 9-11, 2016
Executive Forum 2016 presented by Health Care Administrators Association (HCAA). Senator Tom Daschle is opening keynote presenting "An Insider's View on President Obama's Public Policy and Its Implications for the Election of 2016" on Wednesday 2/10/16 from 9:00am - 10:30am.  Caesars Palace, Las Vegas, NV. Room rates: $220 / night plus tax (through 1/15/16).  Call 866-227-5944 and reference Health Care Administrators Association or SCHCA6.  Information and registration: 

March 7-9, 2016
The Sixteenth Population Health Colloquium presented by HC Conference. Philadelphia, PA and WEBCAST.  Featuring Special Medical Home Track.  Presenters include: Troyen Brennan, MD, MPH, Executive Vice President and Chief Medical Officer, CVS Health, Former Chief Medical Officer, Aetna Inc., Woonsocket, RI.  Bill Copeland, MBA Vice Chairman and US Life Sciences & Health Care Industry Leader, Deloitte LLP, Philadelphia, PA.  Peter R. Orszag, Vice Chairman, Citigroup, Former Director, OMB (Obama), Former Senior Economist, Council of Economic Advisers (Clinton), New York, NY Information and Phone: (800) 503-7439, and 

March 21-23, 2016
Self-Insured Health Plan Executive Forum presented by Self-Insurance Institute of America. 
The program's keynote speaker will be Dr. Martin Makary, professor of surgery at John Hopkins University School of Medicine and author of the widely-acclaimed book Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care.  Breakout session highlights include:

  • Karen van Caulil, chairwoman of the National Business Coalition on Health describes how health care coalitions are starting to break the grip of health insurance monopolies in certain regions around the country.
  • Heather Lavallee, president of employee benefits distribution for Voya Financial will team up with Matt Rhennish, president & COO of HM Insurance Group, for an interactive discussion exploring what "Big Data" means for stop-loss underwriting.
  • The potential opportunity for TPAs to partner with provider sponsored health plans will be addressed by Karin Landry, managing partner of Spring Consulting Group, LLC.
  • Rick Raup, president & CEO of Business Administrators & Consultants, will lead a panel discussion focused on how TPAs, stop-loss carriers and other key industry players are adapting to the ICD-10 transition.
  • We'll preview the expected evolution of TeleHealth solutions for self-insured health plans with a presentation by Dr. Jeffrey Kesler, president & COO of Salus.
  • For the closing general session, the SIIA government relations team will provide a detailed report on important legislative and regulatory developments affecting companies involved on in the self-insurance marketplace.

For those companies interested in promoting their corporate brands at this event, a limited number of exhibiting and sponsorship opportunities are now available. We should note that exhibit space and sponsorships sell-out well in advance of the event each year, so it is suggested that you act fast to secure your preferred promotional opportunity. Contact Justin Miller at for immediate assistance. New Orleans, LA.  Registration and information: 

March 30-April 1, 2016
SPBA Spring Meeting (members only). Washington, DC. Society of Professional Benefit Administrators (SPBA).

April 5-7, 2016
SIIA International Conference presented by Self-Insurance Institute of America. San Jose, Costa Rica.

May 4-6, 2016
15th Annual Health Literacy Conference
presented by The Institute for Healthcare Advancement's (IHA).  Anaheim, CA. One-day and Two-day conferences presents practical and effective solutions to health literacy challenges, ranging from how to write and design effective communication, to tools for addressing low health insurance literacy skills.  Emphasis on ACA-related programming. The conference will attract health educators, health insurance agents, physicians and nurses, hospital representative, academics, writers, researchers and public health workers among others interested in the health literacy field. The conference also offers up to 20 continuing education credits to attendees.

May 18-19, 2016
Self-Insured Taft-Hartley Plan Executive Forum  presented by Self-Insurance Institute of America. Chicago, IL.

May 24-26, 2016
Self-Insured Workers' Compensation Executive Forum presented by Self-Insurance Institute of America. Scottsdale, AZ. 

July 13-15, 2016
TPA University 2016 presented by  Health Care Administrators Association (HCAA). Renaissance Dallas, Dallas, TX.

September 25-27, 2016
36th Annual National Educational Conference & Expo presented by Self-Insurance Institute of America. Austin, TX. 

October 17-19, 2016
SPBA Fall Meeting (members only). Minneapolis, MN. Society of Professional Benefit Administrators (SPBA).


February 8-10, 2017
Executive Forum 2017
presented by Health Care Administrators Association (HCAA). Bellagio, Las Vegas, NC.  

March 15-17, 2017
SPBA Spring Meeting (members only). Washington, DC. Society of Professional Benefit Administrators (SPBA).

September 13-15, 2017
SPBA Fall Meeting (members only). Cincinnati, OH. Society of Professional Benefit Administrators (SPBA).


Editorial Notes, Disclaimers & Disclosures

  • Articles are edited for length and clarity.
  • Articles are selected based on relevance and diversity.
  • No content in this Newsletter should be construed as legal advice. All legal questions should be directed to your own personal or corporate legal resource.
  • Internet links are tested at the time of publication.  However, links change or expire often.
  • Articles do not necessarily reflect views held by the Publisher.
  • Disclosure: Owner of MyHealthGuide also has ownership interest in CareHere, LLC® and LabInsight®
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Clevenger Ernie Clevenger
President & Publisher
MyHealthGuide, LLC