MyHealthGuide Newsletter
News for the Self-Funded Community
8/22/2016

Published weekly by MyHealthGuide, LLC (www.MyHealthGuide.com). This Newsletter is for personal, non-commercial use only.  This weekly newsletter is FREE OF CHARGE to subscribers.  Subscribe free. Send news, press releases and announcements to mailto:Info@MyHealthGuide.comClick here if Newsletter stops arriving.

TABLE OF CONTENTS

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



Companion Life Named to a National Top 50 List

MyHealthGuide Source: Companion Life, 8/3/2016, www.CompanionLife.com

Columbia, SC -- The business consulting firm Ward Group named Companion Life Insurance Company one of its top 50 performing life and health insurance companies for the sixth consecutive year.

Cincinnati-based Ward Group, a provider of benchmarking and best-practices services to the insurance industry, annually analyzes the financial performance of hundreds of life and health insurance companies in the United States to identify the top performers. It recognized Companion Life for achieving outstanding results in the areas of safety, consistency and performance.

"Companion Life strives for best practices in all our product areas. It's an honor to be recognized by an independent, external organization that knows our industry," said Scott Hinton, Companion Life president.

"In selecting the Ward's 50, we identify companies that pass financial stability requirements and measure their ability to grow while maintaining strong capital positions and underwriting results," said Jeff Rieder, president of Ward Group.

About Companion Life

Headquartered in Columbia, Companion Life has specialized in employee benefits since 1971. The company markets life, dental, disability, accident, specialty health, including medical stop loss, limited benefit health plans and group supplemental retiree prescription drug plans, as well as other insurance programs, through a network of independent agents and brokers, general agents and managing general underwriters. Companion Life is licensed in 49 states and the District of Columbia. It holds an A.M. Best Rating of A+ (Superior).  Contact Philip Gardham at Philip.Gardham@companiongroup.com and visit www.CompanionLife.com.

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Data Dimensions Named to Inc. Magazine's Annual 5000 List for 2016

MyHealthGuide Source: Data Dimensions, 8/17/2016, datadimensions.com

JANESVILLE, WI -- Data Dimensions, a leader in business process automation, has been honored for its innovation once again with a place on the exclusive Inc. 5000 list of the nation's fastest-growing private companies.

This is the fourth time Data Dimensions has made the prestigious Inc. 5000 list, ranking this year in the #1,869 spot. It has moved up more than 3,000 spots since its initial appearance in 2012, when it ranked #4,969.

For 35 years, Inc. Magazine has celebrated the fastest-growing private companies in America. In earning a spot on the list, Data Dimensions shares a pedigree with Microsoft, GoPro, Oracle, Timberland, Zappos and many other well-known names that gained early exposure as members of the Inc. 5000. On average, the companies on the Inc. 5000 list have grown almost five-fold over the past three years.

Jon Boumstein, Data Dimensions President and CEO, said receiving the Inc. 5000 award once again would serve as an inspiration to the company and its team members, "Data Dimensions has continued to experience strong growth in 2016. 

"Our company saw the addition of new clients and revenue sources. Our recognition as a leader in the industry by Inc. 5000 will encourage us to work even harder in achieving our goals.  I'd like to extend a special thanks to our loyal clients, who have been a major factor in our continued growth and success," Boumstein added.

For more information about the Data Dimension Inc. ranking, see the company profile page at http://www.inc.com/profile/data-dimensions.

About Data Dimensions

Since 1982, Data Dimensions has been helping clients better manage business processes and workflows by bridging the gap of automation, technology, and physical capabilities. As an innovative leader in the area of information management and business process automation, we provide a complete range of outsourcing and professional services including mailroom management; document conversion services; data capture with OCR/ICR technologies; physical records storage and electronic retrieval services through our state of the art Tier III data center. Contact Will Pfeifer, Marketing Coordinator, at wpfeifer@datadimensions.com, 800-782-2907 and visit datadimensions.com.

Data Dimensions is a portfolio company of HealthEdge Investment Partners, LLC. HealthEdge is an operating-oriented private equity fund founded in 2005. HealthEdge's investment team has over 100 years of combined operating experience as operators and investors. Visit www.healthedgepartners.com.

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EthiCare Advisors, Inc. Launches HIPAA Compliance Solutions on the 20th Anniversary of HIPAA Becoming Law

MyHealthGuide Source: EthiCare Advisors, Inc., 8/19/2016, www.EthiCareAdvisors.com

Budd Lake, NJ -- EthiCare Advisors, Inc. is pleased to announce a valuable new service for our clients, HIPAA Compliance Solutions. This new service is being launched on the 20th anniversary of HIPAA being signed into law by President Bill Clinton on August 21, 1996.

HIPAA Compliance Solutions was created to help our clients abide by the strict guidelines set out in the law regarding the privacy and security of protected health information. Having the proper measurers in place to meet the requirements of HIPAA will help our clients protect their businesses and to be prepared if they ever face a federal compliance audit.

Mark S. Hartmann, Jr., MS
, EthiCare's Managing Partner & CEO said, "Our clients were instrumental in the creation of this service, many stressed the need for assistance with HIPAA compliance. We think we have the solutions to help."

The major components to good HIPAA compliance include the performance of regular Security Risk Assessments, updated and customized Policies & Procedures and systematic Employee Training. EthiCare will offer these and other compliance related services such as IT Security, Software Compliance and Breach Investigation.

To learn more about our new offering please contact Mark S. Hartmann, Jr., MS, directly at 888-838-4422 extension 703 or visit our HIPAA Compliance webpage.

About EthiCare Advisors, Inc.

Founded in 2002, EthiCare Advisors, Inc. is an innovative medical claims settlement, cost containment and consulting services company that helps medical claim payers save money, by focusing on the claims that ruin loss ratios, namely, catastrophic claims over $100,000 and the ultra-expensive dialysis claims. EthiCare is an independent, owner-operated private corporation and is a three time honoree of the Inc. 500|5000 award as one of the fastest growing privately held companies in America. Contact Mark S. Hartmann, Jr., MS, Managing Partner & CEO, at Mark@EthiCareAdvisors.com, 888-838-4422 extension 703 and visit www.EthiCareAdvisors.com.

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EBSO Partners with Integrated Health Network of Wisconsin

MyHealthGuide Source: EBSO, 8/15/2016, www.ebsobenefits.com

Wisconsin -- EBSO is one of four Third Party Administrators (TPAs) recently chosen to offer the Integrated Health Network of Wisconsin (IHN) to self-funded employer groups and brokers throughout the state. The synergy created between IHN's comprehensive network and care model as well as the proven disease management capabilities of EBSO was cited as a key advantage of the partnership.

EBSO has over 35 years of TPA experience, founded in 1977. As a privately owned company and full service TPA, they have the ability to offer objective, independent solutions and innovative products and services to their employer groups and broker partners. They provide a range of self-funded and fully insured benefit plans in addition to Human Resource and Finance support, compliance and auditing services and retirement plan options. They also offer a Chronic Disease Management program that helps their clients improve the overall health of their workforce.

About IHN

IHN is a broad-choice value network of major Wisconsin health systems working together to deliver high quality, affordable health care. Founded in 2010, it includes eight Owner Member health systems, 53 hospitals, 8,400 providers, 1,180 clinical locations and more than 100 Associate Member resources. IHN's care model enables it to offer flexible health care solutions for employers, producers and insurance companies that result in excellent health care plus immediate and sustainable health plan savings.

About EBSO

EBSO strives to form relationships with trusted partners and the best networks whose business priorities align with theirs, which is why they were happy to partner with IHN. To learn more about EBSO and how they are prepared to work with every client, in every situation, every day contact: Bruce Flunker, President, at (800) 558-7798 and visit www.ebsobenefits.com.

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HHC Group Certified by Pennsylvania as Utilization Review Entity

MyHealthGuide Source: HHC Group, 8/18/2016, www.hhcgroup.com

The Pennsylvania Department of Health has certified H.H.C. Group as a Utilization Review Entity for Pennsylvania Managed Care Plans. The State has also certified HHC Group to conduct External Grievance Appeal Reviews received from consumers and providers of health service decisions by Managed Care Plans. The State has begun assigning HHC Group cases for review.

Utilization Review Entities or Independent Review Organizations (IRO) provide peer review services when insurers deny health insurance claims. The purpose of these reviews is to determine if a service is medically necessary, medically appropriate, experimental or investigational. The Affordable Care Act requires insurance companies to contract with at least three IROs that are nationally accredited.

HHC Group is a URAC accredited IRO. URAC (formerly the Utilization Review Accreditation Commission) is a nonprofit organization promoting healthcare quality by accrediting healthcare organizations. URAC's IRO standards "assure that organizations that perform this service are free from conflicts of interest, establish qualifications for physician reviewers, address medical necessity and experimental treatment issues, {and} have reasonable time periods for standard and expedited reviews, and appeals processes."

HHC Group provides Internal and External Independent Peer Reviews for insurance companies, health maintenance organizations, self-insured companies and ERISA plans. The team overseeing the review process utilizes its combined 125 years of healthcare experience to ensure that every review fully answers all questions being asked, cites the appropriate medical guidelines, and is clearly written and grammatically correct.

HHC Group serves a Utilization Review Agency, Licensed\Certified\External IRO, Private Review Agent or Licensed Medical Claims Review Agency in 25 states.

About HHC Group

HHC Group is a leading national health insurance consulting company providing a wide range of cost containment solutions for Insurers, Third Party Administrators, Self-Insured Employee Health Plans, Health Maintenance Organizations (HMOs), ERISA and Government Health Plans. HHC Group utilizes a combination of highly skilled professionals and advanced information technology tools to consistently deliver targeted solutions, significant savings and exceptional client service.

HHC Group's services include Claim Negotiation, Claim Repricing, Medicare Based Pricing, DRG Validation, Medical Bill Review (Audit), Claims Editing, Medical Peer Reviews/Independent Reviews, Independent Medical Examinations (IME), Case Management Utilization Review, Data Mining, Disease Management and Pharmacy Consulting. H.H.C. Group is one of 46 URAC accredited IROs. Contact Bob Serber at rserber@hhcgroup.com, (301) 963-0762 ext. 163, and visit www.hhcgroup.com.

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Blue Cross Blue Shield, Billings Clinic Announce Insurance Network for Self-Funded Employers

MyHealthGuide Source: Zach Benoit, 8/19/2016, Billings Gazette

Blue Cross Blue Shield of Montana and Billings Clinic have partnered to create a new insurance network for large employer-sponsored plans.

The network, called Blue Options, lets employers who self-fund employee health insurance plans and have 50 or more employees pay less for care if those employees receive it at Billings Clinic.

"It doesn't mean that large self-funded groups who purchase it can't go elsewhere," said John Doran, BCBSMT spokesman. "However, by steering their members to Billings Clinic they receive a cost-of-care savings."

The plan designates Billings Clinic as the only "tier one" facility in the Yellowstone County area. Employees of businesses signed up for it will receive lower fixed care costs, which have been determined through negotiations between the hospital and insurance provider.

Other health care providers within the BCBSMT coverage network will be designated, within the plan, as tier two, with a potentially higher cost. Out-of-network facilities are tier three.

Connie Prewitt, chief financial officer at Billings Clinic, said that in her experience, the approach is a fairly new one that is aimed in part at adapting to quickly changing health care and insurance industries, especially in light of the Affordable Care Act and Medicaid expansion, while lowering what patients pay.

"What I hear from businesses is they want to provide high-quality health insurance to their employees, and this is another option that offers high-quality care at a lower cost," she said.

Blue Cross Blue Shield of Montana recently announced a similar plan with Benefits Health System in Great Falls. Doran said that the tier one designations don't apply in other areas, so somebody signed up for the Yellowstone County program wouldn't get the same discount at Benefits.

"It's really a local product, rather than a statewide product," he said. "It steers members to the tier one facility in their area for better savings, but it does not limit them to that facility."

The insurance provider is working on similar plans in other communities across Montana.

The new plan with Billings Clinic will be offered beginning Jan. 1, 2017.

"We anticipate this will be a very popular product because it will help steer people to cost-effective care," Doran said.

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People News



Thomas A. Croft of Croft Law LLC Named Best Lawyers in America© for 'Law, Litigation-Insurance, and Commercial Litigation'

MyHealthGuide Source: Croft Law LLC, 8/18/2016, www.stoplosslaw.com

Thomas A. Croft of Croft Law LLC was recently selected by his peers for inclusion in the Best Lawyers in America© in the areas of Insurance Law, Litigation-Insurance, and Commercial Litigation.

Since it was first published in 1983, Best Lawyers® has become universally regarded as the definitive guide to legal excellence. Best Lawyers lists are compiled based on an exhaustive peer-review evaluation. Over 83,000 leading attorneys globally are eligible to vote, and we have received more than 13 million votes to date on the legal abilities of other lawyers based on their specific practice areas around the world. For the 2017 Edition of The Best Lawyers in America©, 7.3 million votes were analyzed, which resulted in almost 55,000 leading lawyers being included in the new edition. Lawyers are not required or allowed to pay a fee to be listed; therefore inclusion in Best Lawyers is considered a singular honor. Corporate Counsel magazine has called Best Lawyers "the most respected referral list of attorneys in practice.

About Tom Croft

Tom Croft, Esq. 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 www.stoplosslaw.com. 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 tac@xsloss.com.

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Advanced Medical Pricing Solutions (AMPS) Adds Stewart W. Karge as Chief Legal Counsel

MyHealthGuide Source: Advanced Medical Pricing Solutions (AMPS), 8/19/2016, www.advancedpricing.com

ATLANTA, GA -- Advanced Medical Pricing Solutions (AMPS), a Physician Led, Technology Driven cost management company continues to strengthen the organization by adding Stewart W. Karge as Chief Legal Counsel.

"For more than three decades Stew has blended the practice of law with executive business management and entrepreneurship. He led teams through complex high stakes litigation in multiple arenas, balanced business development with risk management, guided strategic growth for a diverse group of companies, and operated his own litigation support business, all of which makes him the perfect complement for us and our clients", concluded Mike Dendy, Vice Chairman and CEO.

A distinguished graduate of Northwestern Law School, Stewart was a Capital Partner and Practice Group Leader for 25 years at one of the largest law firms in the world, effectively representing clients across the U.S. in multi-billion-dollar construction, health care, and finance litigation. He earned significant public praise as an effective court appointed advocate on behalf of retirees in a highly publicized pension fund case. He was a principal on the successful team defending a century old company after the famous Chicago Flood disaster, ultimately decided by the United States Supreme Court in a landmark admiralty verdict. In 2000 he took all of his experience in house as the General Counsel for a multi-million-dollar transactional company, where he advised the executive team through a period of exponential growth and acquisition.

Karge has also been a generous volunteer as a founding member of a foundation providing educational scholarships and serving in leadership positions on multiple boards and charities, with an emphasis on those working for children and the arts.

About AMPS

Advanced Medical Pricing Solutions is a cutting edge healthcare cost management company providing unique solutions to dramatically reduce Health Plan medical spend and employee out-of-pocket costs. Focusing on aggressive alternatives to traditional PPOs, this Physician Led, Technology Driven company offers industry leading savings through Reference Based Reimbursement (RBR) solutions, Medical Bill Review services, Direct Provider Contracting, and flexible Out-of-Network Repricing options.

Contact AMPS if you are looking for:

  • A Partner that is invested in your success
  • Alternative solutions to drive Dramatic Health Plan savings
  • Flexible options to meet your unique needs

Contact John Powers, Executive VP, Sales, at 630-361-2525, jpowers@advancedpricing.com and visit www.advancedpricing.com.

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Integro Hires Reinsurance Expert Raj Gulati as Senior Vice President

MyHealthGuide Source: Integro Re, 8/15/2016, www.integrogroup.com

New York, NY -- International broker and risk management firm Integro Insurance Brokers announced that Raj Gulati joins reinsurance subsidiary Integro Re as senior vice president, based in New York.

At Integro Re Gulati will work with clients to attain optimal program structure, conditions and pricing.

"We are delighted that Raj is onboard to contribute his considerable market experience and significant technical skills to the benefit of our rapidly growing specialty reinsurance portfolio. His transactional depth perfectly complements our overall commitment of a true consultative and analytic based approach to the development of customized solutions to client challenges in this arena," said Managing Principal Peter Robinson.

Gulati brings more than 16 years of insurance and reinsurance industry experience to Integro Re. Most recently he served as vice president in JLT Re's Life, Accident and Health group, responsible for managing all aspects of client engagements.

Gulati is a graduate of Pennsylvania State University with a Bachelor of Science degree in management. He also earned the FLMI (Fellowship, Life Management Institute) and ARA (Associate, Reinsurance Administration) designations granted by LOMA (Life Office Management Association).

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, healthcare providers, alternative risk entities such as captives and risk retention groups, managing general agencies and third party administrators. Integro Re has locations in New York, London, San Francisco, Chicago, and Boston.

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. headquarter office is located at 1 State Street Plaza, 9th Floor, New York, NY 10004.
Contact Betsy Van Alstyne at 1-877-688-8701, betsy.vanalstyne@integrogroup.com and visit www.integrogroup.com.

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Stop Loss Insurance Services Names Cory Rodgers Vice President

MyHealthGuide Source: Stop Loss Insurance Services (SLIS), 8/17/2016, www.amwins.com

Charlotte, NC -- Stop Loss Insurance Services ("SLIS"), an AmWINS Group company, announced the appointment of Cory Rodgers as Vice President, Sales. Rodgers is a leading producer with more than 13 years in the stop loss, disability and life insurance industry. 

"Cory's experience in designing benefit solutions for self-funded clients fits nicely with our approach to delivering a competitive edge to clients while advocating on their behalf in complex situations," says Rebecca Bocek, President and National Sales Director of SLIS.

Prior to joining SLIS, Rodgers was responsible for the sales and management of stop loss, disability and life insurance products through HCC Life Insurance Company. He also has experience in employee health and voluntary benefits, giving him a unique perspective into what a client faces when it comes to structuring a stop loss plan that provides protection against catastrophic or unpredictable costs.
 
Rodgers will be based out of Atlanta, GA and will be focused on growing the SLIS footprint in the Southeast.

About Stop Loss Insurance Services
 
Stop Loss Insurance Services (SLIS) provides brokers, consultants and TPAs a competitive edge by serving as a time-saving resource that is singularly focused on self-funded benefits solutions. Benefits professionals become more productive and successful in their core business by putting SLIS to work in this highly specialized segment of their practice.
With more than 25 years of focused experience in self-funding, SLIS is known for deep expertise, strong market relationships and hands-on service, backed by the security of AmWINS Group, the largest insurance wholesaler in the U.S.  Contact Lisa Kuszmar, Vice President of Marketing at 704-749-2780, Lisa.Kuszmar@amwins.com and visit www.amwins.com.

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Market Trends, Studies, Books & Opinions



SIIA Member Employee Security Planning (ESP) Hosts Congresswoman Marsha Blackburn

MyHealthGuide Source: Self-Insurance Institute of America, 8/16/2016, www.SIIA.org

Self-Insurance Institute of America (SIIA) member Employee Security Planning (ESP) yesterday hosted Congresswoman Marsha Blackburn at their office located in Brentwood, TN.

Focusing on the self-insurance marketplace for small businesses located in Rep. Blackburn's district, the visit included and office tour as well as a question and answer session between the attendees and the Congresswoman. During the visit, there was a tour of the office as well as a question and answer between the attendees and Rep. Blackburn. Hosting the event were Bob Shupe, owner of ESP, as well as Jeremy Shupe with ESP, and Valerie Shupe, ESP's secretary and treasurer.

ESP
SIIA Member ESP Hosts Congresswoman Marsha Blackburn

Pictured from Left to Right: Bob Shupe, ESP; Valerie Shupe, ESP; Rep. Marsha Blackburn, Bob Hash, Airsystem Sales; Kerry Couch, Nashville Computer; Jeremy Shupe, ESP; Brittany Spradling, ESP; and Charles Henson, Nashville Computer

"Our meeting with Representative Blackburn showed the continued positive support of the Tennessee delegation in matters regarding self-insurance," said Bob Shupe. "Our representatives from Tennessee are the good guys and have been working to address issues in health insurance that are so important for Middle Tennesseans. We appreciate Rep. Blackburn's open mind and concern for issues in our industry."

Rep. Blackburn is a Republican from Tennessee's seventh district, serving as Vice Chairman of the House Committee on Energy and Commerce, as well as serving on the Subcommittee on Health.

About ESP

Founded in 1969, ESP is an employee benefits and property and casualty insurance consulting firm with experience working in both public and private markets. It provides management for insurance programs, working as a client partner. ESPinc is now on annual retainer for approximately thirty public entities in Tennessee. Contact Bob Shupe at bob@esptn.com and visit www.esptn.com.

About SIIA

The Self-Insurance Institute of America, Inc. (SIIA) is a dynamic, member-based association dedicated to protecting and promoting the business interests of companies involved in the self-insurance/alternative risk transfer (ART) industry, both domestically and internationally.  If you are interested in setting up a visit with your representative, please contact Wrenne Bartlett at wbartlett@siia.org, 800-851-7789 and visit www.SIIA.org.

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Legislative & Regulatory News


District Court Incorrectly Applies Discretionary Clause Ban To ERISA Self Funded Plan

MyHealthGuide Source: Roy F. Harmon III, 8/18/2016, Health Plan Law

Case: Thomas v. Aetna Life Ins. Co., No. 215-CV-01112-JAM-KJN, 2016 WL 4368110, at *7 (E.D. Cal. Aug. 15, 2016)

This opinion addresses two issues:

  • first, the adequacy of the plan document's delegation of discretionary authority to the claims administrator and,
  • second, whether state law prohibiting discretionary clauses may apply to a self funded ERISA plan.

In a poorly reasoned opinion, the district court reached the wrong conclusion on both issues. The mistake in the ERISA preemption analysis is the most troubling. In fact, this is at least the second time that a California district court has incorrectly applied a state law regulation to a self funded ERISA plan.

  • ...the Court concludes that section 10110.6 applies to self-funded plans in the same way it applies to insured plans and effectively bars the Court from applying the abuse of discretion standard of review. The Court will therefore review Aetna's decision on a de novo basis.

Delegation of Authority

The plaintiff (Thomas) argues that:

  • ...the abuse of discretion standard would be inappropriate here because Aetna was never unambiguously granted discretion by the Benefits Committee. Thomas concedes that the Benefits Committee was granted discretion for its determination of whether Thomas was disabled but contends that "there is no language in the Plan granting Aetna discretion and Defendants have not cited anything evidencing that the Benefits Committee expressly delegated its discretion to Aetna."

In short, while the plan grants the "Benefits Committee" discretionary authority, it does not grant that authority to the claims administrator (Aetna) -- and, significantly, the Benefits Committee never delegated its authority to Aetna. This argument should be viewed in context of the historical and prevailing ERISA jurisprudence that ERISA plan terms must be in writing and enforced accordingly.

Inexplicably, the Court rules against the plaintiff on the issue, finding that, "[r]ead as a whole, the Plan sufficiently delegates the Plan Administrator's discretionary authority to Aetna." (emphasis supplied).

ERISA Preemption

The Court then turned its attention to the ERISA preemption issue. The Court saw the issue as merely one of whether the state law ban conflicted with ERISA's administrative scheme.

  • ...the Ninth Circuit has concluded that state laws that bar discretionary clauses (such as section 10110.6) are not preempted by ERISA because they do not "authorize any form of relief in state courts nor serve as an alternative enforcement mechanism outside of ERISA's civil enforcement provisions." Standard Ins. Co., 584 F.3d at 846 [Standard Ins. Co. v. Morrison, 584 F.3d 837, 846 (9th Cir. 2009)] (rejecting claim that ERISA preempted a policy implemented by the Montana insurance commissioner of disapproving any insurance contract containing a discretionary clause).

On this view, state law bans on discretionary clauses "merely force ERISA suits to proceed with their default standard of review," which is de novo, and therefore do not "duplicate, supplement, or supplant the ERISA remedy."

The Problem With the Court's Reasoning

The problem with the Court's reasoning lies in its careless reading of Ninth Circuit authority, i.e., the Standard Ins. Co. v. Morrison opinion.

That opinion involved two arguments, each of which would have been fatal to the application of the discretionary clause ban. The Court ignored the first argument in Morrison which involved application of ERISA's savings clause and went straight to the second argument of whether the law conflicted with ERISA remedies.

Let's review the first argument as presented in Morrison. The Ninth Circuit opinion began by asking:

  • Is Commissioner Morrison's practice of denying approval to insurance forms with discretionary clauses preempted by ERISA? Here, no one disputes that Commissioner Morrison's practice "relate[s] to any [covered] employee benefit plan." 29 U.S.C. § 1144(a). It is thus preempted unless preserved by the savings clause.

Only after resolving this issue in favor of applying the savings clause did the Ninth Circuit reach the second argument. And the second argument was essentially advancing an exception to the savings clause -

  • We decline to create an additional exception from the savings clause here. Like the regulatory scheme in Rush Prudential, the Commissioner's practice "provides no new cause of action under state law and authorizes no new form of ultimate relief." Id. at 379, 122 S.Ct. 2151. The Rush Prudential court emphasized that the scheme in that case "does not enlarge the claim beyond the benefits available" and does not grant relief other than "what ERISA authorizes in a suit for benefits under § 1132(a)." Id. Neither does the Commissioner's practice. Standard Ins. Co. v. Morrison, 584 F.3d 837, 848 (9th Cir. 2009)

By failing to appreciate the significance of the self funded status of the plan, the Court reached the wrong result. Without benefit of the savings clause (which could not apply since it only extends to laws regulating the business of insurance), the state law discretionary ban is preempted since it relates to an ERISA plan.

Note

The Court appears to have relied in part on the decision by another district court which also reached the wrong conclusion on this issue:

  • During the hearing, however, Defendants conceded that the only court that has directly addressed the issue of whether the application of section 10110.6 to self-funded plans is preempted by ERISA concluded that there is no preemption. Williby v. AETNA Life Insurance Company, 2015 WL 5145499, *5 (C.D. Cal. Aug. 31, 2015).1 The defendant in Williby argued just as Defendants argue in this case "that the insurance code does not apply because (1) the STD benefits are self-funded … and (2) Aetna is granted discretion by the Plan, which is not an insurance policy, and thus, not regulated by the insurance code." Id. at *5. The Williby court rejected this argument. Thomas v. Aetna Life Ins. Co., No. 215CV01112JAMKJN, 2016 WL 4368110, at *6 (E.D. Cal. Aug. 15, 2016)

Deemer Clause

 Since the overarching issue here is the application of state insurance law to self funded ERISA plans, note that states may not treat self funded plans as "insurance" so as to avoid ERISA preemption:

  • We read the deemer clause to exempt self-funded ERISA plans from state laws that "regulat[e] insurance" within the meaning of the saving clause. By forbidding States to deem employee benefit plans "to be an insurance company or other insurer … or to be engaged in the business of insurance," the deemer clause relieves plans from state laws "purporting to regulate insurance." As a result, self-funded ERISA plans are exempt from state regulation insofar as that regulation "relate[s] to" the plans.  FMC Corp. v. Holliday, 498 U.S. 52, 61, 111 S. Ct. 403, 409, 112 L. Ed. 2d 356 (1990)

About Roy Harmon

Roy F. Harmon III is an ERISA lawyer with Harmon & Major, P.A. located in Greenville, South Carolina.  Visit www.HealthPlanLaw.com.

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Medical News


Hospitals with Higher ICU Use are More Likely to Perform Invasive Procedures and Cost More but Have No Improvement in Hospital Mortality

MyHealthGuide Source: Dong W. Chang, MD, MS and Martin F. Shapiro, MD, PhD, 8/8/2016, JAMA Internal Medicine Abstract

For medical conditions where ICU care is frequently provided, but may not always be necessary, institutions that utilize ICUs more frequently are more likely to perform invasive procedures and have higher costs but have no improvement in hospital mortality according to a study published in the JAMA Internal Medicine.

The study's objective was to examine whether hospitals had consistent patterns of ICU utilization across 4 common medical conditions and the association between higher use of the ICU and hospital costs, use of invasive procedures, and mortality.

Researchers conducted a retrospective cohort study of 156,842 hospitalizations in 94 acute-care nonfederal hospitals for diabetic ketoacidosis (DKA), pulmonary embolism (PE), upper gastrointestinal bleeding (UGIB), and congestive heart failure (CHF) in Washington state and Maryland from 2010 to 2012.

Hospitalizations for DKA, PE, UGIB, and CHF were identified from the presence of compatible International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Multilevel logistic regression models were used to determine the predicted hospital-level ICU utilization during hospitalizations for the 4 study conditions. For each condition, hospitals were ranked based on the predicted ICU utilization rate to examine the variability in ICU utilization across institutions.

The primary outcomes were associations between hospital-level ICU utilization rates and risk-adjusted hospital mortality, use of invasive procedures, and hospital costs. 

Study findings

  • The 94 hospitals and 156,842 hospitalizations included in the study represented 4.7% of total hospitalizations in this study. ICU admission rates ranged from
    • 16.3% to 81.2% for diabetic ketoacidosis (DKA),
    • 5.0% to 44.2% for pulmonary embolism (PE),
    • 11.5% to 51.2% for gastrointestinal bleeding (UGIB), and
    • 3.9% to 48.8% for congestive heart failure (CHF).
  • Spearman rank coefficients between DKA, PE, UGIB, and CHF showed significant correlations in ICU utilization for these 4 medical conditions among hospitals (ρ ≥ 0.90 for all comparisons; P < .01 for all).
  • For each condition, hospital-level ICU utilization rate was not associated with hospital mortality.
  • Use of invasive procedures and costs of hospitalization were greater in institutions with higher ICU utilization for all 4 conditions.

Researchers summarized that hospitals had similar ICU utilization patterns across the 4 medical conditions, suggesting that systematic institutional factors may influence decisions to potentially overutilize ICU care. Interventions that seek to improve the value of critical care services will need to address these factors that lead clinicians to admit patients to higher levels of care when equivalent care can be delivered elsewhere in the hospital. 

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Recurring Resources



Medical Stop-Loss Providers Ranked by Annual Premium Survey (last updated 8/8/2016)

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 update is encouraged.
Sources will be cited. Please send updates / changes to Info@MyHealthGuide.com
  Stop-loss Provider Years Providing Stop Loss Associated Carriers / MGUs Annual stop-loss Premium
(Millions)
Capital/Equity
(Millions)
1 CIGNA     $2,701
2015
 
  Source - CIGNA Financial Supplement 2015, P.5 12/31/2015
2 Sun Life Financial > 30 Years   $1,155
2015
 
  Source - Sun Life Financial, Financial Planning and Analysis department (8/8/2016)
3 Tokio Marine HCC
>35 Years Tokio Marine HCC Life
(A.M. Best Rated: A+)
$907
2015
$29,700 as part of Tokio Marine Group
  Source - Ketrice Williams, 5/6/2016
4 Voya Employee Benefits > 35 Years ReliaStar Life
(A.M. Best Rated: A)
$807
2015
$396
12/31/2015
  Source - Joe Keller, Lead Financial Analyst, Voya Employee Benefits, 3/28/2016
5 HM Insurance Group >30 Years HM Insurance Group
(A.M. Best Rated: A-)
$751.4
2015
$588
12/31/2015
  Source - Matt Rhenish, President & COO, 2/19/2016
6 Symetra >36 Years Symetra Life Insurance Company
(A.M. Best Rated: A)
(Block - $495M
MRM - $233M)
$728
2014
$3,360.6
12/31/2014
  Source - Symetra 4Q 2014 Financial Supplement;
Tom Doran, President, Medical Risk Managers, Inc., 2/9/2015
7 Companion Life > 20 Years   $440
10/8/2014
 
  Source - Philip Gardham, Vice President, Specialty Markets, 10/8/2014
8 Swiss Re Corporate Solutions >40 Years Standard Security life Insurance Company of New York, Westport Insurance Corporation and Independence American Insurance Company $324
3/31/2016
 
  Source - Swiss Re Corporate Solutions Accounting Department
9 National Union Fire Insurance Company of Pittsburgh >35 Years AIG Benefit Solutions $253
2/1/2016
 
  Source - Jeff Gavlick, FSA, FCA, VP, Stop Loss Products, AIG Benefit Solutions, 2/1/2016
10 Zurich North America     $150  
  Source - Joseph Byers, Zurich North America, 4/6/2015
11 Munich Re Stop Loss, Inc.   American Alternative Insurance Company (AAIC),
TransAmerica
$147
2015
 
  Source - Travis Micucci, the Chief Executive Officer of Munich Re Stop Loss, Inc., 11/09/2015
12 United States Fire Insurance Company 15   $120
2015
$1,200
  Source - Lauren Woods, VP Marketing Fairmont Specialty, 1/4/2016
13 The Union Labor Life Insurance Company  (ULLICO) >25 Years ULLICO
(A.M. Best Rated: B++)
$104
12/2014
 
  Source - Victor Moran, Second Vice President, Actuarial Operations.  3/6/2015
14 Gerber Life Insurance Company   Gerber Life Insurance Company $35
2016
$6,800
  Source - Gerber Life Insurance Company Stop Loss Director Job Description.  4/11/2016
15
Markel Insurance Company <5 Years Markel Insurance Company
(A.M. Best Rated: A-)
$3 $3,388
12/31/2011
  Source - Mark Nichols, Managing Director.  7/20/2012

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 Cross Blue Shield (various regions)
  • International Insurance Agency Services, LLC (IIS)
  • 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 Info@MyHealthGuide.com.  

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The Value of Self-Funding

MyHealthGuide Source:  The Self-Insurance Educational Foundation, Inc. (SIEF), 2014, www.SIEFOnline.org 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 www.SIEFOnline.org.

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Video Highlighting Captive Solutions for Mid-market Companies

MyHealthGuide Source: The Self-Insurance Educational Foundation (SIEF), 5/11/2016, www.siefonline.org

The Self-Insurance Educational Foundation (SIEF) announced that it has released a new video highlighting captive insurance solutions for mid-market companies, including stop-loss captive programs, enterprise risk captives, and property & casualty group captives. Please click here to access the video.

The video can be accessed through the Foundation's web site at www.siefonline.org or by clicking here.  The video includes a separate video focused on self-insured group health plans. Both videos can be private labeled by individual companies interested in using them for their own purposes. Contact Justin Miller at jmiller@siia.org or 800-851-7789 for more information about private labeling.

About 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). Its 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 www.siefonline.org.

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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. 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.

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Upcoming Conferences


August 23, 2016 - Webinar - 1:00 PM (EST) to 2:00 PM
Unwrapping Your Wraps presented by The Phia Group.  Wrap networks provide plans with discounts off billed charges for claims that don't fall within the plan's primary network. But do these wraps really add value? With skyrocketing provider charges and static discounts off of those charges, the modern-day wrap network doesn't seem to provide much help when it comes to claims costs.  Join The Phia Group's legal team as we analyze provisions of wrap network agreements, with a focus on what plans can or can't do to cut costs. We'll propose some innovative ways for your plans to save additional money above and beyond wrap networks, generating unprecedented value for your plans.  Registration: https://attendee.gotowebinar.com/register/5687996127885571587

September 12-13, 2016
11th Executive Forum on On-site and Near-Site Employee Health Clinics presented by World Congress.  The event convenes executives involved in on-site care and wellness to exchange ideas and gain the latest insight on building, maintaining, and innovating on-site clinics. Rosen Plaza Hotel, 9700 International Drive, Orlando, Florida 32819.  Information and Registration: http://www.worldcongress.com/events/HH16078/ 

September 19-20, 2016
Texas Association of Benefits Administrators' 2016 Fall Conference and Annual Membership.  Corpus Christi Omni Hotel, Corpus Christi, Texas.  Information and registration: Phyllis Campbell at pcampbell@tabatpa.org and visit www.tabatpa.org.

September 19-21, 2016
MCRA's 2016 Conference presented by Managed Care Risk Association.   Don't miss out on what this year's conference has to offer. We will hear speakers address the potential impacts on the ACA from this year's election; join in a discussion with industry underwriters to share lessons learned with underwriting Exchange business; receive information on today's concerns with specialty pharmacy, and much more. Agenda:

  • Monday
    • Cocktail Welcome Reception in Stratus Rooftop Lounge
  • Tuesday
    • Election Impact / ACO / Market Update: David Smith, Leavitt Partners
      Bringing New Talent to Your Door: Abbe Sodikoff, The Jacobson Group
      The State of ACA and Where We Are Headed: Robert Field, Drexel University
      Specialty Pharmacy: Susan Faust, Diplomat
  • Wednesday
    • Panel Discussion: Lessons Learned 2014 to 2016
      Making Sense of Clinical Trials: Melinda Baxter, ROSE® Program
      Transparency in Healthcare: Dir. Marty Makary, Johns Hopkins

The MCRA hotel room rate at Hotel Monaco is $249 which allows use of many hotel amenities without an additional resort fee. Reserve your room now by visiting our website for a link to the Hotel Monaco reservation site: www.mcraweb.org. Registration and Information: www.mcraweb.org

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

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

December 1-2, 2016 - A Hybrid Conference and Internet Event
Population Health Colloquium Special Edition: Pop Health Policy & Strategy Under the New Administration.  Speakers: Sheila Burke, MPA, RN, FAAN, Chair, Government Relations & Public Policy, Baker, Donelson, Bearman, Caldwell & Berkowitz, Faculty Research Fellow, Stephen K. Klasko, MD, MBA, President and Chief Executive Officer, Thomas Jefferson University and Jefferson Health, Donato J. Tramuto, President and Chief Executive Officer, Healthways, Founder, Health eVillages, Nashville, TN.  Hyatt Regency on Capitol Hill, Washington, DC.  Information and registration: www.populationhealthcolloquiumspecialedition.com/index.html 

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January 29-31, 2017
2017 AAPAN Annual Forum!.  This year's forum features session tracks tailored to group health, workers' compensation and specialty health markets. Keynoters will challenge attendees to think outside the box and offer insights into healthcare public policy under the new administration. And we've expanded the number of opportunities for quality networking.  Ritz-Carlton, Dove Mountain, Tucson, AZ at the  resort January 29 - 31, 2017. Early bird registration runs through September 30, 2016. Information and registration: http://aapan.org/AnnualForum.aspx

January 30-February 1, 2017
26th Annual National Health Benefits Conference & Expo.   Real-world education with numerous sessions focusing on case study evaluations and addressing many of today's hottest topics and issues from the latest ACA regulations to wellness program trends. To assist you in continuing your education, we are also pleased to provide CE credit for numerous designations including PHR/SPHR/GPHR, CIMA, CPA, CHES/MCHES, CEBS CPE and more! And because we understand that education goes beyond the classroom, this three-day program is designed to give attendees numerous opportunities to network with peers, speakers and exhibitors. ​Clearwater, FL.  Registration and information: https://www.hbce.com/Pages/Default.aspx  

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

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

March 27-29, 2017 -  A Hybrid Conference and Internet Event
17th Population Health Colloquium.  The Leading Forum on Innovations in Population Health & Care Coordination Academic Partner: Jefferson College of Population Health. Loews Philadelphia Hotel, Philadelphia, PA. Information and registration: www.populwww.populationhealthcolloquiumspecialedition.com/index.html

March 28-30, 2017
Self-Insured Health Plan Executive Forum presented by The Self-Insurance Institute of America. www.SIIA.org

April 18-19, 2017
SIIA 2017 International Conference presented by The Self-Insurance Institute of America, Inc. Focus on Latin America and self-insurance-related business opportunities emerging within the region. Condado Vanderbilt Hotel. San Juan, Puerto Rico.  Visit www.SIIA.org

May 16-18, 2017
Self-Insured Workers' Compensation Executive Forum presented by The Self-Insurance Institute of America. www.SIIA.org

October 8-10, 2017
37th Annual National Educational Conference & Expo presented by The Self-Insurance Institute of America. www.SIIA.org

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

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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.
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  • 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
Clevenger@MyHealthGuide.com