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News for the Self-Funded Community

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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

New Stop Loss MGU, Greymatter Risk Management, LLC, Formed

MyHealthGuide Source: Greymatter Risk Management, 4/10/2015

The Managing Members are pleased to announce the formation and introduction of a new stop loss Managing General Underwriter, Greymatter Risk Management, LLC effective April 1, 2015.

Greymatter Risk will be led by long time insurance and stop loss executive, Arlene Cayetano, President/CEO, located in Indianapolis, IN. Arlene is joined by a management team of seasoned and qualified professionals with an average experience of 30+ years in the stop loss industry.

The new MGU will specialize in providing stop loss insurance to Taft-Hartley health plans and public sector employers. Greymatter Risk has established a relationship with Transamerica Premier Life Insurance Company which carries the following financial strength ratings* as of most recent report: A.M. Best A+ (2nd of 16 categories); Fitch AA- (4th of 19 categories); Moody's A1 (5th of 21 categories); Standard & Poor's AA- (4th of 21 categories).

Sales is headed by Jim McEntee, Executive Vice President of Sales, and brings with him 30+ years of experience specifically dedicated to the Taft-Hartley, public and labor sectors on a national scale. For products and sales inquiries, Jim may be contacted at telephone number 770-280-5270 or email

Brokers, consultants and TPAs interested in submitting Requests for Proposal should forward their RFPs to


Bravo Wellness Applauses EEOC's Proposal for Wellness Programs

MyHealthGuide Source: Bravo Wellness, 4/17/2015,

Cleveland, OH -- The U.S. Equal Employment Opportunity Commission (EEOC) issued a highly-anticipated preliminary rule on workplace wellness programs and their impact on the Americans with Disabilities Act (ADA) on Thursday.

Bravo Wellness applauds the EEOC's proposed rule for reflecting a fair balance of equipping employers with meaningful tools to mitigate rising healthcare costs and promote better health in the workplace, while protecting the privacy rights of their employees. Although a few questions and inconsistencies with the Affordable Care Act (ACA) and Health Insurance Portability and Accountability Act (HIPAA) regulations remain, this is a clear sign to employers that the EEOC supports their efforts to control costs and improve the lives of workers and their families.

"There is a growing body of evidence that proves meaningful incentives will frequently cause those who typically decline participation in wellness programs to get engaged, stay engaged and to reduce their chronic risk factors," said Jim Pshock, Bravo Wellness Founder and CEO. "The EEOC guidance removes the final compliance barrier many employers feared, and will result in greater adoption of these win/win program designs."

The proposed rule, which the EEOC announced on Thursday, April 16, 2015, would provide "much needed guidance" to both employees and employers about wellness programs offered as part of the employer's group health plan which comply with the ADA and HIPAA.

"We feel very much prepared and ahead of the curve on this," said Tony Bodak, Bravo's Vice President of Operations. "We've always required explicit privacy notices, made sure there is ample time and notice of alternatives given to employees and emphasized that the goal of these programs is health promotion and improvement. Our plan documentation and security standards equal or exceed what is required elsewhere in the health insurance industry and what is proposed in these regulations. It's great to see these things become industry standards."

The proposed rules do not prohibit the use of incentives or penalties to encourage participation in employee health programs, but rather put limitations on how employers can treat employees who do not elect to participate.

The EEOC's proposed rule makes clear that wellness programs - along with incentives - are here to stay. Until now, there were some lingering questions about the impact an EEOC decision could have on the longevity of workplace wellness programs. While the proposed rule may not reflect what appears in the final version, it does strongly indicate the EEOC's priority is to prevent employers from discriminating against those who do not participate in the program by terminating employment, refusing to offer coverage for non-participants, or offering penalties so exorbitant the program can no longer be considered voluntary.

The EEOC suggests in its proposal that employers can offer incentives - as a reward or penalty -amounting to no more than 30% of the total cost of an employee-only health plan to participate in their wellness plans. They acknowledge that up to 50% could be used for tobacco use as long as the amount above 30% doesn't require an individual to submit to a medical exam. The EEOC's proposal contends this should apply to participation-based programs, as well as health-contingent wellness programs, where incentives are tied to physical activity or achievement of specific health outcomes.

The proposed rule will be published in the Federal Register for a 60-day public notice and comment period. Based on the variances seen between the proposed and final ACA wellness regulations, Bravo believes it is important not to draw final conclusions from the EEOC's proposed rule just yet, and encourage others to submit thoughtful comments as requested by the EEOC.

Bravo also believes that their clients are effectively positioned to align their wellness programs with the EEOC and ADA. With Bravo's enhanced capabilities to provide health coaching, activity programs, team challenges, tobacco cessation, and more, their clients are better positioned than ever to have the tools needed to offer programs that are reasonably designed to improve the health and well-being of their employees.

Bravo will use this opportunity to provide guidance to their clients as to where their wellness programs fit the spirit of the proposed rule and strengthen Bravo's position as compliance partners in the wellness incentives industry.

It will be interesting to see what if any impact this has on the Preserving Employee Wellness Programs Act (S.620) now circulating through Congress, as well as the outstanding EEOC lawsuits against employers who crossed a previously unknown line. Bravo is actively engaged in monitoring this legislation and how the proposed regulations align with it.

Webinar: Proposed Rules and Impact to Wellness Programs

  • Bravo Wellness will unpack these proposed rules and what they may mean to wellness programs in their next webinar on Thursday, April 23 at 11:00 a.m. EST.  Employers and brokers won't want to miss it.
  • To sign up for Bravo's upcoming webinar, click the link here: Sign up soon as space is limited.

Bravo Wellness is giving employers a free compliance consultation on their wellness plan. Click on the link to register:

About Bravo Wellness

Bravo Wellness has been a disruptive force in the wellness industry since its inception in 2008. Bravo pioneered the outcomes-based wellness incentive space and carefully designs compliant incentives that result in unprecedented engagement levels. Bravo's case studies prove and demonstrate sustained health improvement and reduced claims spending-all while equipping individuals to make better choices and providing thoughtful alternatives to those for whom special exceptions are warranted. With roots in data management, compliance and technology, Bravo recognizes that it's rarely the lack of activities that makes a program unsuccessful, it's often the lack of motivation and engagement -- a problem that can be solved. Visit


America's Choice Provider Network (ACPN) and JMS & Associates (JMS) Joint Venture to Expand ACPN's National Provider Network

MyHealthGuide Source: JMS & Associates (JMS), 4/13/2015, and

America's Choice Provider Network (ACPN) and JMS & Associates (JMS) enter into a joint venture to expand ACPN's National Provider Network.  The results of this venture will provide ACPN with a winning formula by blending ACPN's unique contracting style with the back-office strength derived through JMS resources and technology based solutions that will dramatically accelerate the development of ACPN's provider network.

The newly opened call center facility in Farmington Hills, Michigan uses state-of-the-art technologies that will be used to support network development and other payor related customer service inquiries.

"The ACPN team and product were a great fit for JMS, our clients, and partners, and will also provide additional opportunities for the health care community as a whole to reduce claim payment and claim processing costs without risk or investment " stated by Frank Gigliotti, CEO JMS and Associates, Inc.

"With over 120,000 provider locations and growing fast, Providers, Payors, and Patients will all benefit through ACPN's future growth by further reducing the payment cycle, eliminating balance billing issues, and reducing customer service inquiries. Having JMS as a partner will enable ACPN with cutting-edge technology, higher service levels, and enhanced provider contracting to the healthcare industry," says Seth Breeden, General Manager, ACPN.

About JMS

JMS is a Michigan based corporation with over 30 years of experience providing human resource and technology outsourcing solutions. For its health care insurance partners, JMS supports front-end and back-office claim processing services that improve most aspects of the claim payment cycle. The JMS value proposition is derived through our focus on performance and productivity that results in lower operating costs, quick turn-around, and higher quality. Contact Shana Boley at, 877-489-8881 x207 and visit

About ACPN

ACPN is an independent, multi-specialty national provider network that has developed its own proprietary network and technology for the purpose of achieving consistency in healthcare transactions, simplifying claims adjudication processes, creating reasonable reimbursement arrangements and establishing reliable healthcare access for all parties; providers, payers and patients. Visit


The Actuarial Society of Greater New York Announces its Spring Conference

MyHealthGuide Source: The Actuarial Society of Greater New York, 4/15/2015,

The Actuarial Society of Greater New York is pleased to announce an exciting educational program at this year's ASNY Spring Meeting. The meeting will commence with a general professionalism session followed by breakout sessions.

At the breakout sessions an accomplished group of industry leaders will present on a broad range of topics of interest including actuarial and IT partnerships, actuarial governance, and evolving regulations. At the conclusion of the meeting, we will have an evening networking reception where you can connect with actuaries and other insurance professionals and executives.

Conference Highlights

  • Current Professionalism Topics at the Academy - Darryl Wagner, FSA, MAAA. Principal, ARA Life, Deloitte Consulting
  • Actuarial Convergence with IT - Matt Clark, FSA, CERA, MAAA. Principal, ARA Life, Deloitte Consulting
  • Combo Products Update - Sheila Matheson,  VP CI Marketing, Optimum Re
  • Solvency II and Analytics - Howard Zail, FSA, FFA, MAAA. Partner, Elucidor, LLC
    Nefissa Sator, Fellow of the French Institute of Actuaries, CERA, MAAA. Senior Vice President USA, Forsides Actuary
  • Evolving Regulations and the Impact on Modeling - Marshall Lin, FSA, MAAA. Manager, Insurance and Actuarial Services, EY
  • Impact of Analytics in Health Insurance - Gerry Smedinghoff, ASA, MAAA. Manager, Health Actuarial, KPMG, Ryan Wilson, VP of Managed Care, HealthSouth Corporation

Education Credits

Total expected Continuing Education credits: 4.2 credits.  As an approved provider of the American Academy of Actuaries, ASNY certifies that it believes in good faith that the above sessions meet the requirements under the U.S. Qualification Standards. The Continuing Education credits for each session and the applicable actuarial practice areas will be provided with a more detailed agenda.

About The Actuarial Society of Greater New York

Founded on September 1, 1932, the Actuarial Society of Greater New York (ASNY) is a non-profit actuarial organization committed to four major objectives: further the development of actuarial science and knowledge, provide grants to fund these efforts, assist in the ongoing education of ASNY members and offer continuing education.  Visit


People News

MCM Welcomes Connie J. Wolf as Vice President of Sales

MyHealthGuide Source: MCM Solutions for Better Health, 4/16/2015,

CHICAGO, IL - MCM Solutions for Better Health, a national leader in providing population health management services, is pleased to announce the addition of Connie J. Wolf as Vice President of Sales.

Connie J. Wolf brings with her over 35 years of industry experience in life and health insurance with a focus on self-funding. An attendee of both the University of New Mexico and Wright State University in Ohio, Connie comes to us with tremendous passion and knowledge in Medical Self-Funding, Stop Loss, Third Party Administration (TPA), Cost Containment, and Benefit Consulting.

Connie formed and owned Managed Health Resources, a TPA in Oklahoma, and was co-owner of Employer's Resource Group, a Professional Employer's Organization. Prior to joining MCM, Connie was the Self Funding Specialist for Frates Benefit Administrators. Connie is a member of the Society of Professional Benefit Administrators.

Mike O'Connor, President, stated, "The addition of Connie to our executive leadership team reflects MCM's commitment to being the market leader in offering innovative and cost effective Solutions for Better Health. Her experience in self-funding and employee benefits for both the small and large group market provides the perfect skill set needed for our Vice President of Sales position. Our team is thrilled to have her on board."

About MCM

Medical Cost Management Corporation, dba MCM Solutions for Better Health, was founded by Michael O'Connor in 1986. They are a leading provider of population health management programs that cover the entire continuum of care. MCM is a physician directed company that is URAC accredited and licensed in all states with requirements. MCM and its subsidiary Med-Care provide services to over 550 plans representing over 600,000 members on a nationwide basis. Visit


Rockport Benefits Announces Addition of Susan Herzog

MyHealthGuide Source: Rockport Benefits, LLC, 4/13/2015,

Beverly, MA -- Rockport Benefits, LLC is delighted to announce its latest addition, R.N., Susan Herzog.

"Sue has worked alongside me for many years. She is a very well respected nurse consultant and will be an invaluable asset. We are proud and fortunate to have her on board," states Managing Director, Amy Argeros.

Sue's responsibilities will include conducting medical reviews, acting as a cost containment liaison and providing consultative services both internally and externally. Rockport Benefit's business partners will be afforded the opportunity to prosper from Sue's knowledge, expertise and genuine willingness to help.

About Rockport Benefits

Rockport Benefits, LLC has been formed with the hope of providing a refreshing alternative to the Medical Stop Loss market, offering the same reliability and consistency to which you are accustomed, fused with a true optimism and excitement toward our future capabilities.  Contact Amy K. Argeros, Managing Director, at 978-969-0658, and visit


Bravo Wellness Adds to Its Team

MyHealthGuide Source: Bravo Wellness, 4/13/2015, and

Cleveland, OH -- As industry experts in the compliance and administration of outcomes-based wellness incentive programs, Bravo Wellness continues to bring solutions to organizations desiring to impact employee health and productivity. Bravo Wellness can help business leaders committed to improving the health of their workforce, and bring programs that meet organizations' needs and fit their culture. Bravo is pleased to announce it has hired additional sales team members to champion the message of workplace wellness programs that work and produce real results.

Serving in the following states:

  • Gregg Tokar, Vice President of Business Development - Alabama, Georgia, and Florida.
  • Kevin Martin, Regional Sales Director - Connecticut, New Jersey, and New York.
  • John Patrick, Regional Sales Director - Illinois, Wisconsin, and Iowa.
  • Andrea Brody, Regional Sales Director - Arizona, Southern California, and Nevada.

In addition to the growing business development team, Bravo Wellness has also added a consulting Medical Director. Dr. Joseph Berley has spent 20 years helping companies achieve success through corporate wellness programs. He will guide Bravo and their wellness provider partners to examine and enhance the clinical efficacy of their customer solutions.

Bravo is also excited to announce the internal promotion of Tony Bodak to Vice President of Operations. Formerly Bravo's Director of Data & Analytics, Bodak led the effort to reshape and enhance client aggregate reporting to help Bravo stand out in the industry. His scientific approach to planning will be leveraged to further advance Bravo's cycle-based offering and will act to better service clients. Bodak's appointment will allow Bravo to strengthen areas that entail heavy transactional work, management of sensitive data, and strict timelines for turnaround, with fulfillment and opportunities for operational efficiencies and process improvements.

"As Bravo continues to meet the growing needs of employers, brokers, captives, MEWAs, and private exchanges, not only will these individuals bring another layer of expertise to our organization, but they will also act as a reminder that outcomes-based wellness incentive plans are growing," stated Jim Pshock, Bravo Wellness founder and CEO. "We are excited for what  the future holds in employee benefits and wellness and couldn't be happier to have each of these individuals on our team."

About Bravo Wellness

Bravo Wellness has been a disruptive force in the wellness industry since its inception in 2008. Bravo pioneered the outcomes-based wellness incentive space and carefully designs compliant incentives that result in unprecedented engagement levels. Bravo's case studies prove and demonstrate sustained health improvement and reduced claims spending-all while equipping individuals to make better choices and providing thoughtful alternatives to those for whom special exceptions are warranted. With roots in data management, compliance and technology, Bravo recognizes that it's rarely the lack of activities that makes a program unsuccessful, it's often the lack of motivation and engagement-a problem that can be solved. Visit to learn more.  Contact Heather Bowers, Senior Marketing Specialist, at 877.662.7286 ext. 572, and visit and


Cypress Benefit Administrators' Tom Doney Named CEO/Executive of the Year

MyHealthGuide Source: Cypress Benefit Administrators, 4/13/2015,

APPLETON, WI -- Tom Doney, president and CEO of Cypress Benefit Administrators, has been named CEO/Executive of the Year by Post-Crescent Media, a part of Gannett Co., Inc., the national media corporation headquartered in Virginia. Post-Crescent Media serves the Fox River Valley region of Eastern Wisconsin.

Doney, who co-founded Cypress in 2000 with Marsha Phillips, received the honor as part of the newspaper's recently published 60th Annual Report.

Cypress is a leading third party health benefit administrator (TPA) headquartered in Appleton, Wis., with clients in all 50 states. Once a two-person operation, the company now has additional locations in Portland and Salem, Ore., Omaha, Neb. and Denver, Col., and employs more than 100 people.

In January, Doney was named chairman of the Society for Professional Benefit Administrators (SPBA), the national association that represents the self-funding industry. Cypress was also one of 14 firms nationally to win a Gold Well Workplace Award through the Wellness Council of America and its Wellness Council of Wisconsin affiliate in 2013.

About Cypress Benefit Administrators

A privately held company headquartered in Appleton, Wis., Cypress Benefit Administrators has been pioneering the way toward cost containment in self-funded health benefits since 2000. The third party administrator (TPA) is the country's first to bring claims administration, consumer driven health plans and proven cost control measures together into one package for companies ranging from 50 employees to thousands of employees. It serves employer-clients across the U.S. with additional locations in Portland and Salem, Ore., Omaha, Neb. and Denver, Col. Visit


HCC Life Insurance Company Has Immediate Opening for Regional Marketing Representative in Plano, TX Office

MyHealthGuide Source: HCC Life Insurance Company, 4/10/2015,

As a Regional Marketing Representative for the Southwest Region, you will maintain and develop relationship with clients to help achieve production, premium growth and persistency. The geographic territory of the region includes Arizona, California, Nevada, New Mexico, Oklahoma, Texas and Utah.

Key Responsibilities

Relying on limited experience and knowledge, the Marketing Representative is responsible for accomplishing the following assignments. These assignments are varied in nature.

  • Responsible for new business through outside sales and marketing to Third Party Administrators (TPA's/Broker's) within assigned territory.
  • Fosters additional business opportunities through writing of correspondence and attending trade shows.
  • Conducts sales calls to cultivate and maintain long-term client relationships.
  • Manage and increase existing blocks of business. This requires developing a strong relationship with TPA/Broker through on-site visits and resolving client issues in a timely fashion.
  • Develop and maintain database of current and prospective producers.
  • Monitor competitor pricing and industry trends to identify marketplace characteristics.
  • Gather information from utilization review and managed care organizations to develop medical stop loss, group life, and disability pricing.
  • Monitor producer quote ratio, close ratio, renewal persistency and loss ratio. Adapt marketing strategy as needed.
  • Serve as liaison between Claims Department and new TPA producers during the approval process.
  • Develop and implement specific marketing strategies and materials.
  • Ensures sound working relationships with clients and other company departments by acting as the point of contact.
  • Various projects and duties as assigned by supervisor.
  • Requires 50% travel


  • Follow work plans, established timelines, and pre-defined goals for assigned work.
  • Meet commitments on deadlines.


  • Communicate activities, results, and observations with employees and management as appropriate.

Cost Management

  •  Identify areas for improvement in existing business practices.
  •  Perform work thoroughly in a cost efficient manner and at a high productivity level.

Business Controls and Policies

  •  Comply with all corporate policies and procedures.
  •  Report any breakdowns in controls to management.
  •  Conduct all activities in a safe manner.

Position Knowledge, Skills, and Requirements


  • Bachelor's degree in Business Administration or a related field or the equivalent education and/or experience


  • Minimum of two years of relevant marketing/sales experience

Interested candidates should email their resume to

About HCC Life Insurance

HCC Life Insurance Company (HCC Life) is an Indiana-domiciled life insurance company with an extensive product portfolio including medical stop loss, group term and short term medical insurance. HCC Life has consistently held an A+ (Superior) rating for financial strength by A.M. Best Company as well as AA (Very Strong) ratings by Standard & Poor's and Fitch Ratings.

HCC Life has more than 30 years of experience and is a leading provider of medical stop loss insurance through brokers, consultants and third party administrators. Guided by an 11-person executive management team whose members have an average of more than 20 years of insurance experience, the entire HCC Life staff works together with third-party administrators and brokers to find the best solution to managing risk for our mutual clients. Our commitment to medical stop loss enables HCC Life to remain a stable partner for producers in a constantly changing marketplace. Unlike many providers of medical stop loss, HCC Life assumes 100 percent of the risk, and is therefore responsible for all underwriting, claims and administrative decisions.  Visit


Market Trends, Studies, Books & Opinions

Three's a Crowd: Challenges in Adding the Broker/TPA in a Third Party Action

MyHealthGuide Source: Thomas A. Croft, Esq., Self-Insurer's From the Bench, May 2015

The Group is peeved that the stop loss reimbursement claim has not been paid, even though their TPA paid the underlying claim under the Plan. What can happen under such circumstances? As we all know, lots.

I infer that the group, either through counsel or directly, asked the TPA why the TPA paid the claim if the stop loss carrier has refused to pay it, on whatever basis (exclusion under the Plan, under the stop loss policy, lack of eligibility, or a host of other possible reasons). The TPA will respond that the stop loss carrier is wrong, being unreasonable, etc.

What will the group do next to get the stop loss claim paid? 

Scenarios include:

One option is for the group to sue (or initiate arbitration against, if the stop loss contract so provides) the stop loss carrier, on the theory that the claim denial was improper, add a claim for "bad faith" under one or more of several theories, and see how that plays out, leaving the TPA out of the equation.

Another, more aggressive option, is to sue both the TPA and the stop loss carrier, arguing that the group did nothing wrong, and that either, in the alternative: 1) the stop loss carrier denied the claim improperly; or 2) the TPA breached its contract with the group and/or negligently paid the claim without adequate investigation. Alternative pleading is perfectly permissible, essentially allowing a claim that says either party #1 is liable or party #2 is liable-either way the group is entitled to a recovery-or so the pleading goes.

Another option for the group is to cut a deal with the TPA which says, essentially, that if we don't win our case against the stop loss carrier then the TPA agrees to make up the difference.

Yet another option I have seen recently is for BOTH the TPA and the group to sue the stop loss carrier for improperly denying the claim, for bad faith, etc. This is a defective choice in my view, as the TPA has no cause of action against the stop loss carrier whatsoever. There is no contract between the TPA and the stop loss carrier. Therefore, there cannot conceivably be a breach of contract action. The TPA is the agent of the group-NOT the stop loss carrier-and it has no rights against the stop loss carrier capable of enforcement in my view. So what explains such cases?

One possibility is that the TPA has agreed to indemnify the group for its losses, but wants to piggyback on the group's (now completely indemnified) claim against the carrier. If there was a valid assignment of the group's claim against the carrier in return for the TPA's promise of indemnity, then it is the TPA-and ONLY the TPA-that has any cause of action against the stop loss carrier as the "real party in interest," i.e., the only entity with a real economic stake in the controversy. The group no longer has any damages because it has been indemnified by its TPA.

Federal Rule of Civil Procedure 17(a)-and most state analogue rules-require that an action be prosecuted in the name of the "real party in interest." The typical remedy for an action not being prosecuted in the name of the party with the true economic interest in the transaction is, after a motion or objection by the defendant, that the "real party in interest be substituted "for the plaintiff who isn't. Often, such a motion cannot practically be brought until after some discovery takes place, and the agreement between the TPA and the group is disclosed. A grant of such a motion would eliminate the group from the case.

Tactically, I do not think this serves the group well, as leaving the TPA as the only plaintiff in the suit seems somehow less compelling than having the insured group as the sole plaintiff. (Rule 17(a)(3) speaks in terms of "ratification" by the real party in interest as an alternative to substitution, but in my experience, substitution is the more likely outcome.)

Adding TPA, Broker or Other in a Third Party Action

Under many of the scenarios described above, the defending party (be it the carrier or the TPA) will try to add the "missing party" to the case via what is known as a "third-party action." For example, a stop loss carrier might attempt to add the broker or the TPA to the case in a case where the broker/TPA participated in the disclosure process and there was a disclosure-based denial of a large claim. The theory of the carrier might be that the broker/TPA was negligent in gathering/providing the disclosure information, and should pay all or some of the judgment in the event the group prevails in the case.
(There may be many reasons the group chose to sue the stop loss carrier only-the group did not believe that the broker/TPA did anything wrong, a long-time business relationship with the broker/TPA, trial tactical reasons, etc., etc.). In any event, "adding" a party to a case via a third party action is not as simple as it might seem. In the hypothetical above, under Federal Rule of Civil Procedure 14(a)(1), one must get permission from the Court in most circumstances to add the additional party, and, whether or not permission is required, must ultimately show that the nonparty " is or may be liable to it for all or part of the [plaintiff's] claim against it." Otherwise, the third-party action is defective and subject to dismissal upon motion of the proffered third-party defendant, the plaintiff, or both.

Challenges in Adding the Broker/TPA as a Third Party

In the above hypothetical, the stop loss carrier is essentially trying to add the broker/TPA on the theory that the alleged disclosure problems were the fault of the broker/TPA, or at least partially so, such that the broker/TPA should share in the liability to the group, should there be any. This should not work under existing procedure in the federal-and most state-courts for the following reasons.

First and foremost, the broker/TPA could never be liable to the stop loss carrier defendant: the broker (or TPA) is the agent for the group in the self-funded context, and has liability, if any, to the group and only the group, and the group has not sued them. So, the stop loss carrier's claim cannot meet the threshold test for bringing in a third-party defendant-the broker/TPA cannot be liable to "it." (Actual fraud might be an exception, but is beyond the scope of the discussion here.).

One "end-run" attempted by the carrier in such a situation may be to attempt to rely on the "contribution" statutes of the State's law applicable to the controversy. Contribution is typically provided in one of many forms in the several states. Essentially, the concept is that where two parties combine to cause a single injury to an injured plaintiff, the liability is apportioned between them in the manner specified by the applicable contribution statute. In the above hypothetical, the carrier would argue that the broker/TPAs actions in allegedly providing defective disclosure and the actions of the carrier (in denying the claim) somehow "combined," such that an action for contribution lies between the carrier and the broker/TPA, thus providing the predicate for a Rule 14(a)(1) third-party action by the carrier against the broker/TPA. This may sometimes be a tactical move by the stop loss carrier to attempt to implicate the broker/TPA's E&O coverage and bring it to the table at a mediation and/or at trial.

The astute reader will see the flaw in this tactic. It is this: if the carrier improperly denied the stop loss claim, then nothing the broker/TPA did caused any damage to the group. Put differently, either there was no disclosure problem sufficient to deny the claim so the stop loss carrier wrongfully denied it, or there was negligent conduct by the broker/TPA sufficient to cause a disclosure problem justifying a denial, in which case the stop loss carrier is not liable for anything. It's one or the other; it can't be both. In neither event could the broker/TPA be liable to the stop loss carrier, and the prerequisites of Rule 14(a) are not present, such that the third-party action should be dismissed.

[There is a related problem-beyond the scope of this article-regarding the status of the broker/TPA and the stop loss carrier as "joint tortfeasors" under state law-typically a requirement for any valid contribution action to lie. I will spare the reader a discussion of that, but I don't think it alters the result.].


To summarize-there are a myriad of possibilities and angles when brokers, TPAs, groups and stop loss carriers become embroiled in multi-party litigation. These can be expensive to sort out. The existence of arbitration clauses in either the stop loss contract or broker agreement or TPA agreement can compound these exponentially. For example, can the broker/TPA be compelled to participate in an arbitration required by the stop loss contract for claims disputes? The law on these kinds of issues is unclear and evolving, and may be the subject of future articles.

In the meantime, the old saw about two being a "party" and three (or more) being an unmanageable "crowd" applies in my judgment. At the National Conference in October, I will be narrating a full-fledged "mock mediation" of a three-party dispute between a carrier, a TPA and a self-insured group, complete with counsel, party representatives, and an experienced mediator. Those with interest in these kinds of issues may want to attend.

About the Author

Thomas A Croft is a magna cum laude graduate of Duke University (1976) and an honors graduate of Duke University School of Law (1979), where he earned membership in the Order of the Coif, reserved for graduates in the top 10% of their class. He returned to Duke Law in 1980 as Lecturer and Assistant Dean (1980-1982) and as Senior Lecturer and Associate Dean for Administration (1982-1984). He also taught at the University of Arkansas-Little Rock law school, where he was an Associate Professor of Law (1990-91), earning teacher of the year honors.

Until 2004, when he specialized in medical stop loss litigation and consulting, Tom practiced general commercial litigation. He was a partner in the litigation section of a major Houston firm in the late 1980s, and moved to the Atlanta area in 1991. He has been honored as a Georgia "Super-Lawyer" by Atlanta Magazine for the last eight years running, and holds an AV® Preeminent rating from Martindale-Hubble®.

Tom currently consults extensively on medical stop loss claims and related issues, as well as with respect to HMO Excess Reinsurance, Medical Excess of Loss Reinsurance, and Provider Excess Loss Insurance. He maintains an extensive website analyzing more than one hundred cases and containing more than fifty articles published in the Self-Insurer Magazine over many years. See He regularly represents and negotiates on behalf of stop loss carriers, MGUs, Brokers, TPAs, and Employer Groups informally, as well as in litigated and arbitrated proceedings, and has mediated as an advocate in many stop-loss related mediations. Tom can be reached at 770-674-4292 and


EEOC Wellness Rule Eases Fears for Employers

MyHealthGuide Source: Andrea Davis, 4/16/2015, EBN Benefit News

The Equal Employment Opportunity Commission released a proposed rule this week on wellness programs, removing what at least one business group calls a "big cloud" that has been hovering over employers as they struggle to ensure their wellness incentive programs don't run afoul of the EEOC.

The EEOC has come under fire in recent months for what some say was a lack of clarity on wellness programs. Last October, the agency filed a lawsuit against Honeywell over its wellness program, claiming the program violated the Americans with Disabilities Act and the Genetic Information Nondiscrimination Act by imposing penalties on employees who refused to participate in the company's biometric screening program.

Thursday's proposed rule aims to clarify how Title I of the ADA applies to employer wellness programs that are part of group health plans.

The proposed rule removes confusion for employers who are complying with the Health Insurance Portability and Accountability Act and the Affordable Care Act rules with respect to their wellness incentives, says Steve Wojcik, vice president, public policy with the National Business Group on Health. "If you're complying with HIPAA and ACA rules you shouldn't have any problems with the ADA," he says.

The EEOC proposed rule coincides with an FAQ about wellness programs from the Departments of Labor, Health and Human Services and the Treasury, which aims to clarify what it means for a health-contingent wellness program to be "reasonably designed" and how compliance with DOL and HHS regulations on wellness programs affect compliance with other laws, such as HIPAA and the ADA.

"I think it's very good news, at the end of the day, for employers. It removes a big cloud that had hung over the wellness program since the legal action of the EEOC," says Wojcik.

The Senate and House of Representatives have introduced identical bills (S. 620 and H.R. 1189) to reaffirm laws already in existence that allow for employee wellness programs tied to a financial reward. How these bills will be affected by the EEOC proposed rule remains to be seen, says Tami Simon, managing director for Buck Consultants at Xerox.

"If the EEOC is pretty quick to turn around a final version [of the proposed rule] after the public comment period closes, we'll have to see what the final rule says, then the House and Senate will have to decide if a bill is still needed," she says.

The proposed rule is a step in the right direction, she says, and the EEOC "appears to understand the need for consistency among the different laws that apply many of the rules that come from HIPAA and the Affordable Care Act. … At the end of the day, though, the question is how is that application going to actually work itself out?"

The EEOC has also published a fact sheet for small businesses and a Q&A for the general public.


Legislative & Regulatory News

EEOC Issues Proposed Rule on Application of the ADA to Employer Wellness Programs

MyHealthGuide Source: The U.S. Equal Employment Opportunity Commission, 4/16/2015, EEOC Release

WASHINGTON -- The U.S. Equal Employment Opportunity Commission (EEOC) published a Notice of Proposed Rulemaking (NPRM) describing how Title I of the Americans with Disabilities Act (ADA) applies to employer wellness programs that are part of group health plans. The NPRM is available in the Public Inspection portion of the Federal Register, and will be officially published on Monday, April 20, 2015. Members of the public have 60 days from that date (or until Friday, June 19) to submit comments.

The EEOC's proposed rule would provide much needed guidance to both employers and employees about how wellness programs offered as part of an employer's group health plan can comply with the ADA consistent with provisions governing wellness programs in the Health Insurance Portability and Accountability Act (HIPAA), as amended by the Affordable Care Act. In addition, the EEOC is also publishing a Fact Sheet for Small Businesses and a Question and Answer document for the general public.

Many employers that provide health insurance also offer workplace wellness programs intended to encourage healthier lifestyles or prevent disease. These programs sometimes use health risk assessments and biometric screenings to determine an employee's health risk factors, such as body weight and cholesterol, blood glucose, and blood pressure levels. Some of these programs offer financial and other incentives for employees who participate or achieve certain health outcomes.

Although the ADA limits the circumstances in which employers may ask employees about their health or require them to undergo medical examinations, it allows such inquiries and exams if they are voluntary and part of an employee health program.

The NPRM further requires that if an employee health program seeks information about employee health or medical examinations, the program must be reasonably likely to promote health or prevent disease. Employees may not be required to participate in a wellness program, and they may not be denied health coverage or disciplined if they refuse to participate

The EEOC's proposed rule makes clear that wellness programs are permitted under the ADA, but that they may not be used to discriminate based on disability. The rule explains that under the ADA, companies may offer incentives of up to 30 percent of the total cost of employee-only coverage in connection with wellness programs. These programs can include medical examinations or questions about employees' health (such as questions on a health risk assessment).

This limit is generally consistent with limits that HIPAA imposes on wellness programs. The rule also makes clear however, that the ADA provides important safeguards to employees to protect against discrimination based on disability. Accordingly, medical information collected as a part of a wellness program may be disclosed to employers only in aggregate form that does not reveal the employee's identity, and must be kept confidential in accordance with ADA requirements.


Amendments to Regulations Under the Americans With Disabilities Act

MyHealthGuide Source: Federal Register, 4/20/2015, Federal Register Full Text Article


The Equal Employment Opportunity Commission (EEOC) is issuing a proposed rule that would amend the regulations and interpretive guidance implementing Title I of the Americans with Disabilities Act (ADA) as they relate to employer wellness programs. The proposed rule amends the ADA regulations to provide guidance on the extent to which employers may use incentives to encourage employees to participate in wellness programs that include disability-related inquiries and/or medical examinations.

This proposed rule provides guidance on the extent to which the ADA permits employers to offer incentives to employees to promote participation in wellness programs that are employee health programs.

A wellness program may be part of a group health plan or may be offered outside of a group health plan. The references in the proposed rule regarding the requirement to provide a notice and the use of incentives, and changes to the corresponding section of the interpretive guidance, apply only to wellness programs that are part of or provided by a group health plan or by a health insurance issuer offering group health insurance in connection with a group health plan.

The term "group health plan" includes both insured and self-insured group health plans and is used interchangeably with the term "health plan" throughout the preamble. All of the other proposed changes to the regulations apply to all "health programs," which include wellness programs whether or not they are offered as part of or outside of a group health plan or group health insurance coverage. The term "incentives" includes both financial and in-kind incentives, such as time-off awards, prizes, or other items of value.


Montana Governor Signs Captive Legislation

MyHealthGuide Source: Montana Captive Insurance Association, Inc., 4/13/2015,

Montana Governor Steve Bullock last week signed separate bills that will further improve the state's regulatory environment for captive insurance.

H.B. 536 authorizes public sector entities in the state to establish captive insurance companies, while H.B. 537 clarifies existing statutes to specify that captive insurance companies can be set up as limited liability companies (LLCs).

Working in conjunction with the office of Montana Commissioner of Securities and Insurance (CSI), the Montana Captive Insurance Association (MCIA) spearheaded an effective lobbying campaigned that secured passaged of both bills with minimal opposition. Since the founding of the association more than 10 years ago, MCIA has supported multiple legislative improvements to the captive statute and has never been turned away.

"We are once again pleased to report to our membership and the larger captive insurance industry that MCIA has been successful in making meaningful improvements to what is already one of the country's premier captive domiciles," said association President John Jones. "We certainly could not have done this without the support of our members and from our regulator partners at CSI."

Learn more about these legislative/regulatory developments and more at MCIA's upcoming annual conference, scheduled for July 21-23, 2015 in Whitefish, MT. Details can be accessed on-line at, or by calling 866/388-6242.

About Montana Captive Insurance Association, Inc.

Montana licensed its first captive insurance company in January 2002. Since then the number of active captive insurance companies has grown to 65. These captives insure rural hospitals, nursing homes, fuel stations, commercial trucking firms, an investment firm, a medical professional firm, a construction company and attorneys. Visit


Medical News

Bre.ast Cancer Treatment Cost and Outcomes Reported

MyHealthGuide Source: Aaron Feinstein, Yale University School of Medicine's Cancer Outcomes, Public Policy, and Effectiveness Research Center, et al, 4/6/2015, Health Affairs

Researchers compared care costs and survival rates among women ages 67-94 diagnosed with stage II or III bre.ast cancer during two time periods, 1994-96 and 2004-06.

Study findings

Researchers reported that over the course of a decade,

  • Median cancer-related costs increased from $12,335 to $17,396 among women with stage II disease;
  • Five-year survival rate for these women improved from 67.8 to 72.5 percent.
  • For women with stage III disease, costs increased from $18,107 to $32,598 with an accompanying five-year survival improvement from 38.5 to 51.9 percent.
  • The cost increase was largely attributable to a substantial increase in the cost of chemotherapy and radiation therapy.

The authors note that the price society is willing to pay for an additional year of life remains controversial in the United States and suggest that more research is needed to determine how to best contain costs while continuing to advance patient care.


Recurring Resource

Medical Stop-Loss Providers Ranked by Annual Premium Survey (last updated 4/4/2015)

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. National Union Fire Insurance Company of Pittsburgh >35 Years AIG Benefit Solutions $215
  Jeff Gavlick, VP, Stop Loss Products, AIG Benefit Solutions
9. Independence Holding Company   Standard Security Life Insurance Company of New York,
Madison National Life, Independence American Insurance Company
$200   Roy T.K. Thung, CEO, Letter to Stockholders
10. Zurich North America     $150   Joseph Byers, Zurich North America.
11. Munich Re Stop Loss, Inc.   AIC, TransAmerica $110
  Susan McGrath Bowman,
Chief Operating Officer, Munich Re Stop Loss, Inc.
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


Upcoming Conferences

April 23, 2015 - webinar 1:00 PM EST to 2:00 PM EST
"Survival of the Fittest" - Best Practices to Perfect a Modern TPA presented by The Phia Group.  Featuring best practices and new methodologies TPAs are considering, in their quest to remain relevant in a modern healthcare arena. Covered topics will include innovative services, products, and processes being used today, and developed for tomorrow. The Phia Group will identify both the issues and solutions that seem to be spreading, and how proactive administrators are addressing both.  Register:  If you do not receive a confirmation email shortly after registration with webinar log-in details, check your spam filter for emails from

April 23, 2015 - webinar 11:00 a.m. EST
npack Proposed Wellness Program Rules presented by Bravo Wellness.  Learn what the new proposed rules mean to wellness programs.  Information and registration: Bravo Wellness is also giving employers a free compliance consultation on their wellness plan. Click on the link to register:

April 29-30, 2015
Self-Insured Taft-Hartley Plan Executive Forum (NEW EVENT!) presented by Self-Insurance Institute of America. This one-day forum features a focused educational program designed to showcase self-insurance strategies and information that is sure help unions provide even more robust benefits while more effectively controlling costs. Register before February 27, 2015 and take advantage of discounted early bird fees. SIIA room block at the Marriott Metro Center will be released on April 7, 2015, so if you would like to stay at the host hotel, please register and make your room reservations at your earliest opportunity as we expect the hotel to be sold out. Marriott Metro Center, Washington, DC.  Information and registration: 

May 6-8, 2015
Northshore's 26th Annual Claims Conference.  Salem, Massachusetts. This is an invitation only event. If you are interested in attending or presenting at next year's conference, you may contact Steve Murphy at

May 11, 2015 - 1:00 PM - 7:00 PM
The Actuarial Society of Greater New York Announces its Spring Conference. At the breakout sessions an accomplished group of industry leaders will present on a broad range of topics of interest including actuarial and IT partnerships, actuarial governance, and evolving regulations. At the conclusion of the meeting, we will have an evening networking reception where you can connect with actuaries and other insurance professionals and executives. New York Marriott Downtown Hotel, 85 West Street (at Albany Street), New York, NY 10006.  Information and Registration:

May 12-14, 2015
Self-Insured Workers' Compensation Executive Forum presented by Self-Insurance Institute of America. Windsor Court Hotel, New Orleans, LA

June 3-5, 2015
Institute 2015 presented by America's Health Insurance Plans.  Be part of the nearly 4,000 health care professionals focused on making health care work as consumers are more in control of health care decisions, and data and technology are transforming our industry. You'll enjoy lively discussions about what's working and what's ahead, learn from leaders from other industries, see firsthand the newest products and services, and have plenty of time to network and forge new business relationships. Register: Contact: or 877.291.2247

June 15-17, 2015
Second annual Claims Symposium presented by Advanced Medical Strategies (AMS). Sheraton Colonial in Wakefield, Massachusetts.  Contact Adria L. Garneau, CEBS at, 781-224-9711, ext. 106, and visit

July 15-17, 2015
TPA University 2015 presented by Health Care Administrators Association (HCAA). Swissotel Chicago.  Information and registration:  

July 21-23, 2015
MCIA Annual Conference presented by The Montana Captive Insurance Association, Inc. (MCIA). Features key captive regulators, captive owners and leading service providers addressing a variety of timely educational topics. The conference also serves as the premier networking event for those doing captive insurance business (or would like to) in the growing Montana captive domicile. Lodge at Whitefish Lake in Whitefish, MT. Sponsors: Shane Byars at 866/388-6242, or via e-mail at Contact and visit

September 14-16, 2015
2015 MCRA Annual Conference presented by Managed Care Risk Association. Terranea Resort, Palos Verdes Peninsula, California-overlooks the Pacific Ocean and Catalina Island. Early bird conference fee is $650 through May 18, $750 afterwards. Hotel number is (866) 802-8000 and mention "Managed Care Risk Association". See The mission of the Managed Care Risk Association is to support the health care excess of loss reinsurance and provider excess markets by facilitating information exchange between reinsurers, underwriters, brokers, and cost containment providers.

September 28-30, 2015
SPBA Fall Meeting (members only). Scottsdale, AZ. Society of Professional Benefit Administrators (SPBA).

October 18-20, 2015
National Educational Conference & Expo presented by Self-Insurance Institute of America. Marriott Marquis, Washington, DC 


February 9-11, 2016
Executive Forum 2016 presented by Health Care Administrators Association (HCAA). Caesars Palace, Las Vegas, NV.

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

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