MyHealthGuide Newsletter
News for the Self-Funded Community
9/22/2014

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

Legal, Legislative & Regulatory News

Medical News

Recurring Resources

Upcoming Conferences

Editorial Notes, Disclaimers & Disclosures


General & Company News



PLAN DOC Builder Acquired by Zywave from Strategic Recovery Partnership

MyHealthGuide Source: Strategic Recovery Partnership, 9/17/2014, www.srpsubro.com and www.zywave.com

Milwaukee, WI -- Zywave, Inc., a leading provider of insurance software solutions, announced that it has completed the acquisition of PLAN DOC Builder, a division of Strategic Recovery Partnership, a law firm specializing in subrogation rights. Terms of the transaction were not disclosed.

PLAN DOC Builder is a software tool that automatically produces compliant Health Plan Documents and Summary Plan Descriptions (SPDs). All employers subject to ERISA are required to provide compliant, easy-to-understand Summary Plan Descriptions to employees. In a 2014 Zywave survey of over 3,000 employers, more than 90% of respondents said that it was important or very important that their insurance broker help prepare their SPDs to comply with the ACA and ERISA. PLAN DOC Builder simplifies this process for health insurance brokers and their clients.

Commenting on the acquisition, Dave O'Brien, Chief Executive Officer of Zywave said, "Producing compliant plan documents is a crucial need for employers as the DOL substantially increases the number of ERISA compliance audits it conducts, and PLAN DOC Builder allows brokers to efficiently step in to fulfill this need. In conjunction with the Zywave suite of solutions, PLAN DOC Builder creates a compelling story for our network of brokers to gain and retain business."

About Zywave

Zywave is the leading provider of software-as-a-service (SaaS) technology solutions for the employee benefits and P&C insurance distribution industry. The company's solutions include technology-enabled content and communication, agency automation, and business intelligence and analytics, designed to help insurance brokers of all sizes gain profitable market share. More than 2,700 clients, including 93 of the top 100 U.S. insurance firms, use Zywave's proven solutions to help them differentiate from the competition, enhance client services, improve efficiencies and achieve organic growth. Visit www.zywave.com.

About Strategic Recovery Partnership

Strategic Recovery Partnership (SRP) is a law firm specializing in healthcare subrogation recovery. Since 1993, SRP has focused on maximizing recoveries, generating client revenue, leveraging state of the art technology, and providing unlimited legal support. SRP partners with client claim processes to identify potential subrogation cases and recovery opportunities, consistently achieving a proven revenue stream for TPAs and health plans. SRP was among the early firms to assist health plans arguing for full reimbursement of their clients' interest that helped shape the healthcare subrogation industry. Contact Bob Marcino, Esq., Principal  at rmarcino@srpsubro.com, 215.784.1616 ext. 312 and visit www.srpsubro.com.

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Viverae Acquires OneHealth To Create A Full-Spectrum Wellness Platform

MyHealthGuide Source: Viverae, 9/17/2014, www.viverae.com and www.onehealth.com

DALLAS -- Viverae, a leader in wellness and health management, has acquired OneHealth, a company that provisions private online social communities designed to help people improve behavioral health outcomes.

Viverae is best known for its expertise in workplace wellness with approximately 300 clients in a variety of industries across the U.S. Its health-management programs are designed to improve the health of employee populations and manage healthcare costs.

OneHealth's platform complements Viverae's offerings by providing a robust technology platform that allows members to anonymously give and receive support for emotional and physical health.

"Viverae and OneHealth are well matched, because we share a passion for helping people get healthier," said Michael Nadeau, founder and CEO of Viverae. "We're emotionally invested in this business because we see the impact every day, and we know we're making a difference. Our combined resources will help individuals navigate through a maze of health concerns while increasing productivity and preventing or mitigating the risks associated with chronic disease."

More than 68 percent of adults with a clinically diagnosed mental disorder reported having at least one general medical disorder according to the National Comorbidity Survey Replication.

Learn more about the acquisition at www.Viverae.com/onehealth.

About Viverae

Founded in 2003, Viverae (viv-AIR-a) is a national leader in health management solutions based in Dallas. Viverae provides partners a wellness and health management platform to support businesses and their employees with the tools and resources needed to create a healthy lifestyle. Viverae's solutions are a unique combination of comprehensive health assessments, employee incentives, coaching and engagement strategies, and proprietary software to manage client programs from beginning to end. All of Viverae's health management programs adhere to the requirements set forth in the Affordable Care Act and other applicable law. Contact Jacy Cochran at 972-677-1675, jacy.cochran@viverae.com and visit www.viverae.com.

About OneHealth

OneHealth's award-winning, cloud-based service delivers dynamic content, tools and real-time structured peer support to engage members to achieve sustainable behavior change. The patent-pending Social Solutioning® platform integrates physical and mental health management into a mobile and web experience for health plan members, employees and patients. Visit www.onehealth.com.

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RxResults Announces $4 Million Financing

MyHealthGuide Source: RxResults, 9/3/2014, www.rxresults.com

LITTLE ROCK, AR  -- RxResults, LLC, a next-generation pharmacy risk management company, announced that it has closed on a $4 million capital raise led by Ansley Equity Partners and Ansley Securities. The proceeds of this capital raise are to further accelerate the company's growth and to expand service offerings.

Beginning with its keystone Evidence-Based Formulary Management program and extending into a range of solutions including Medication Therapy Management, Specialty Drug Management, and Prescriber Profiling, RxResults is positioned as the leading comprehensive pharmacy risk management company.

"This capital raise is a confirmation and endorsement that after nearly a decade of R&D, RxResults has successfully commercialized a suite of proprietary solutions offering clients an impressive return-on-investment while improving the health status of covered members." said Tery Baskin, CEO of RxResults.

About RxResults

RxResults is an evidence-based pharmacy risk management company. Led by an independent team of pharmacists, physicians and benefit industry experts, RxResults features an exclusive joint-collaborative with the UAMS College of Pharmacy and its Evidence-Based Medicine Center. RxResults provides comprehensive clinical and strategic expertise to identify and deliver significant and immediate savings in the areas of formulary management, medication therapy management, specialty drug management and prescriber profiling. Contact Tery Baskin, President/CEO, at501-367-8402, tbaskin@rxresults.com and visit www.rxresults.com.

About Ansley Equity Partners

Ansley Equity Partners ("AEP") is a private equity firm which invests in small to mid-sized healthcare information technology and technology-enabled healthcare service companies. AEP has over 15 years experience in the healthcare-focused investment banking field. In addition to decades of experience in finance, investment banking and business strategy, AEP's founders have extensive operating experience in healthcare and have helped build several highly successful companies. They have arranged over $1 billion in transactions for a wide variety of investors. Visit www.acgequitypartners.com.

About Ansley Securities

Ansley Securities, a wholly owned subsidiary of Ansley Capital Group, is a registered broker-dealer and a member of FINRA and SIPC. Together with Ansley Capital Group, Ansley Securities provides strategic consulting, financial advisory, and investment banking services exclusively to companies in the healthcare market, including technology-enabled healthcare services and health information technology companies providing care management, clinical decision support, medical informatics, revenue cycle management, and online health content and services. Contact Donald P. Carson, Member, at (828) 333-4200, doncarson@ansleycapital.com and visit www.ansleycapital.com.

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Integro Re Survey Sees Surge in Provider Excess Insurance

MyHealthGuide Source: Integro Re, 9/16/2014, www.integrogroup.com

New York, NY -- Provider Excess premiums are expected to approach $175M in 2014, representing a 30% increase over the size of the market just two years ago, according to an Integro Re survey of leading healthcare underwriters.

Provider Excess is an insurance product for health care providers who take on risk such as capitation, shared savings plans, or bundled payment plans. This is a departure from traditional fee-for-service arrangements, which remunerate hospitals and physicians based on the amount of care they provided. Although payers typically offer protection from large claims in their risk contracts with providers, the provider excess market provides claims mitigation services and competitive pricing.

"Hospitals and physician groups are gaining the expertise necessary to take on more types of risk than ever before," notes Peter Robinson, Accident & Health practice leader of Integro Re, a division of Integro USA. "And underwriters have demonstrated a willingness to share in that risk."

Much of the dramatic increase in alternative payment models has come from the Centers for Medicare & Medicaid Services (CMS), the survey found. The participation of Accountable Care Organizations (ACOs) in Medicare Shared Savings Programs has grown, as has the duals demonstration, a new program in several states for capitating losses on patients eligible for both Medicare and Medicaid.

"CMS has aggressively pursued risk-sharing deals, and providers are taking notice," says Patrick Gallagher, chief actuary at Integro Re. "The early adopters are gaining the advantage."

The survey included the participation of 15 of the top underwriters in the provider excess space.

Other findings of the survey include:

  • 2015 premium projections are just over $200M, representing a 15% growth from 2014.
  • The prevalence of aggregate provider excess is still very small, although a majority of respondents indicated a willingness to consider writing such risk.
  • There is a growing trend toward provider owned captives - nearly 10% of Provider Excess premium is excess of a captive insurance company.

About Integro Re

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

About Integro

Integro is an insurance brokerage and risk management. 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. Call 1-877-688-8701 and visit www.integrogroup.com.

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CieloStar Partners with Clearview Group for Expert Benefits Administration

MyHealthGuide Source: Maura Donley, CieloStar Partners, 9/15/2014, www.cielostar.com

Minneapolis, MN -- CieloStar, a leading nationwide healthcare benefit distribution, private health exchange and payment technology company, announced today that it has partnered with Clearview Group to begin offering employers expert solutions to help reduce costs and maximize the value of their employee benefits programs. Clearview Group brings innovative solutions for national and multinational companies using a unique blend of expert consultants, responsive service and cutting edge technology.

"With its emphasis on health and welfare, retirement and non-qualified benefits plans, Clearview Group is a welcome new partner for CieloStar," said William Mehus, Executive Chairman of CieloStar. "Our customers and clients will value their high level of personalized service as well as their understanding of the needs of small to mid-sized businesses."

Clearview Group is a specialty consultant firm offering an array of services designed to keep employers on top of the latest industry developments and navigate the ever changing and often confusing compliance and regulatory arenas. Their services and recommendations are based on sound data, reporting and customized strategies created for each individual business to ensure that the company goals and objectives are met while balancing the needs of the employees.

CieloStar's highly successful channel partner programs are giving employers nationwide a one-stop shop for benefits and ancillary products through their BenefitReady® enrollment, self-service system. CieloStar's BenefitReady® platform facilitates the collection, management, processing, and transfer of all the pertinent data that is typically involved with benefits administration.

"All of our partners have come to expect a level of technology and service that is unmatched in the industry," added Mehus. "Data integrity, affordability, and fully compliant technology are the cornerstone of our BenefitReady® platform. Combine these with the expertise, customer service and professionalism of Clearview Group and we've got a dynamic new service offering."

About CieloStar

CieloStar has been helping employers and employees across the country navigate the ever-changing world of benefits since 1988. The company's expanding suite of products and services includes high-tech, high-touch SaaS based solutions, sophisticated decision support technology, private exchanges, enrollment solutions, mobile and web-enabled technology, health and wellness tools, bill consolidation and provider payment solutions. CieloStar, headquartered in Minneapolis, MN is privately held, employee owned. Visit www.cielostar.com.

About Clearview Group

Founded in 1998, Clearview Group has been providing solutions to our clients for over 15 years. The Clearview Team consists of three founding partners and supporting associates located in New York and Atlanta, GA. Clearview partners have over 45 combined years in designing employee benefit and retirement plans. Clearview Group seeks to build a true partnership with our clients through personalized attention, high levels of customer service, and a dedicated team that understands all of the fine details of a company's plans and needs. The Clearview difference helps clients work faster and smarter while controlling benefit, retirement, and non-qualified plan costs. Visit www.clrviewgroup.com.

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SpendWell and PaySpan Partner to Enable an Innovative Health Care Consumer Experience that Strengthens Provider Reimbursement

MyHealthGuide Source: PaySpan, 9/18/2014, www.PaySpan.com and www.SpendWellHealth.com

PORTLAND, OR -- SpendWell Health™, an online marketplace for health care services, has partnered with PaySpan®, Inc., the leading provider of health care reimbursement and payment automation services. Through the partnership, the SpendWell consumer retail experience of shopping for routine health care services now reaches PaySpan's network of more than 700,000 health care providers. Together the partnership transforms how people shop for health care, provides financial benefits to providers and promotes a patient experience that is more affordable, administratively efficient and economically sustainable.

SpendWell is leveraging PaySpan's financial network to reach providers, payers and consumers to create a nationwide online marketplace to give consumers with high-deductible plans a way to shop for quality routine health care services at competitive and fair prices. PaySpan creates new opportunities for providers to expand their business by treating more cash-pay patients with no financial risk.

Through a competitive market search and solution evaluation process, SpendWell selected PaySpan to power its financial reimbursement infrastructure for consumers, health plan members, patients, providers and payers using PaySpan's Patient Centered Financial Home® commerce framework.

"Our new partnership with SpendWell's market-leading health care consumer retail experience extends and reinforces PaySpan's commitment of Empowering the Healthcare Economy through the integration of health care-enhanced financial services," Kevin Arner, Chief Executive Officer of PaySpan, said. "Our partnership with SpendWell brings to market a new era of health care economics to help people live well, through informed care purchases, utilization of their benefits and efficient management of their patient responsibility amounts."

As high-deductible health plan adoption continues, consumers bear more health care cost responsibility. As a result, employers are looking to SpendWell to help employees manage their health care spending and achieve greater value through quality care.

"PaySpan fosters a continuous financial dialogue between payer, provider and consumer to create an enhanced patient financial experience," notes Marcee Chmait, President of SpendWell. "Our platform, combining price transparency with an online marketplace for health care services, puts PaySpan's providers at the forefront of the market, enabling them to speed their revenue cycle, improve their patient collections and grow their business through additional patient access."

PaySpan providers can quickly and easily join the SpendWell marketplace directly by completing the SpendWell registration process and linking their existing PaySpan registration and account information to their new SpendWell user account and profile.

SpendWell's onboarding team helps providers curate their services and helps determine competitive market prices so practices can attract direct-pay patients.

Shopping with SpendWell is simple. Consumers search for health care providers and services, see reviews from other patients, determine their out-of-pocket costs for services and pay online for selected services prior to the appointment. After the patient's appointment, providers simply click to verify services and SpendWell releases the patient's payment.

Examples of health care services that will be available on SpendWell include provider office visits, laboratory tests, imaging, outpatient procedures and specialty services from chiropractors and acupuncturists, as well as speech, occupational and physical therapists.

SpendWell is offering the service to employer groups nationwide. The SpendWell service will launch at the end of 2014.

About PaySpan

With more than 25 years of payments expertise, PaySpan® is a trusted source of innovative health care reimbursement solutions that Empower the Healthcare Economy® for health plans, providers, members and banks. Our solutions enable stakeholders to interact across communities, conduct commerce, capture value, instill trust and use reimbursement currency strategically. PaySpan's customers comprise an elite array of industry leading payers, providers and solution partners spanning the health care reimbursement spectrum. Visit www.PaySpan.com.

About SpendWell

SpendWell™ is an online marketplace where employees with high-deductible health plans can shop and buy health care services directly from providers. With clear pricing on everything from routine wellness exams and preventive care to screenings and urgent care, employees will be able to maximize the health care dollars they have to spend. And caring for direct-pay patients will give providers more time to focus on people, not paperwork. SpendWell is a wholly owned subsidiary of Cambia Health Solutions, Inc. Learn more at www.CambiaHealth.com. Visit www.SpendWellHealth.com.

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Simplicity Health Plans® Offers Free White Paper Illustrating Health to Wealth Connection 

MyHealthGuide Source: Simplicity Health Plans®, 9/15/2014, www.simplicityhealthplans.com

CLEVELAND, Sept. 15, 2014 -- Simplicity Health Plans® free white paper supports the health to wealth connection and illustrates how using their patent pending online assessment tool can help individuals understand the link between improving physical health and their ability to accumulate personal wealth.

Employers who wish to realize their wellness business objectives should explore the implementation of the Health Index Calculator (HIC). This new and innovative approach offers a tangible solution to a growing market demand. The HIC is cost effective and offers an integrated approach to addressing both physical and financial wellness in the workplace. It is the new Health Risk Assessment that does double duty.

The Health Index Calculator uses personal economics to motivate behavior change. It shows the user how small, incremental changes in their health habits can be transformed into potential monthly cash savings! "This is a new concept to many organizations and employees. Finding the best way to connect with each of their respective interests is always a challenge.  Connecting changes in health risk behaviors to personal economics is truly a terrific concept." said Dr. Dee Edington, PhD.

The HIC integrates all of a company's current wellness tools and delivers self-directed Alert reminders that provide pertinent, just in time content to the users mobile device. Current usage data shows much greater participation than a Health Risk Assessment, multiple use throughout the year and that users get at least three Alerts per day. The HIC tracks the eight behaviors that contribute to 75% of all chronic disease and helps to mitigate that risk while driving incremental health behavior change and cash savings. It truly links physical health to financial wealth.
 
About Simplicity Health Plans

Simplicity Health Plans® of Cleveland, Ohio is a transaction integrator that creates SaaS technologies for comprehensive consumer healthcare solutions. Our technology portfolio includes; the Health Index Calculator™; The Med Negotiator, our Web Based medical bill price negotiator (to market in 2015); the StayFit Plan™ wellness platform; and the first of its kind and proven CDHP/HSA Point of Service Payment System for healthcare, which fuses unparalleled technology, point of service adjudication, real-time data, and anti-fraud controls. Contact Lisa Holland, Vice President at (216-367-3092), lisaholland@simplicityhealthplans.com and visit www.simplicityhealthplans.com.

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EthiCare Advisors, Inc. has Been Named to the Inc. 5000 for the Third Consecutive Year -- Among the Only Medical Claims Cost Containment Firms so Honored

MyHealthGuide Source: EthiCare Advisors, Inc., 9/16/2014, www.ethicareadvisors.com

Budd Lake, NJ -- EthiCare Advisors, Inc., a leading medical claims settlement and cost containment organization, has been named to the prestigious Inc. 5000 list of fastest growing privately-owned companies in America for 2014. This is the third consecutive year EthiCare has had the honor to be included on the list. EthiCare is one of a select few medical claims cost containment companies included on the list in 2014 and earned the overall position of 4552 and position 57 in the Insurance category.

"It's a tremendous honor to be recognized by Inc. Magazine for the third year in a row," remarked EthiCare's Managing Partner and CEO, Mark S. Hartmann, Jr., MS. "Some of the most innovative companies in the country are on this list; it's very exciting to be included with them. As always, I would like to thank our customers, strategic partners and team members for helping EthiCare achieve this honor."

Inc. Magazine ranks the fastest-growing, privately held companies in America. The 2014 Inc. 500|5000 rankings are based on revenue growth from 2010 to 2013. To qualify, companies must be based in the United States, privately-owned, independent (not a subsidiary or division of another company) and must have generated at least $100,000 in revenue in 2010 and $2 million in revenue in 2013.

All 5000 honoree companies are individually profiled on Inc.com. EthiCare's profile can be found here: www.inc.com/profile/ethicare-advisors

About EthiCare Advisors, Inc.

Founded in 2002, EthiCare Advisors, Inc. is an innovative medical claims settlement and cost containment company that helps payers handle high dollar and specialized claims without breaking the bank or the law. 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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SIIA Announces QBE North America and The Union Labor Life Insurance Company (Ullico)  Have Upgraded to Gold Member Status

MyHealthGuide Source: Self-Insurance Institute of America, Inc. (SIIA), 9/18/2014, www.SIIA.org

The Self-Insurance Institute of America, Inc. (SIIA) today announced that QBE North America and The Union Labor Life Insurance Company (Ullico) have upgraded to SIIA Gold member status.

This latest membership upgrade announcement is part of a strategic initiative to increase membership support of the association so that it is better positioned to protect and promote the business interests of organizations involved in the self-insurance/alternative risk transfer marketplace.

Upgraded members (Silver, Gold and Diamond) receive a variety of additional membership benefits. Details can be accessed on-line at www.siia.org and by contacting SIIA Membership Director Jenn Ivy at jivy@siia.org.

About QBE North America

QBE North America is part of QBE Insurance Group Limited, one of the top 20 insurers and reinsurers worldwide. QBE NA reported Gross Written Premiums in 2013 of $5.855 billion. Headquartered in Sydney, Australia, QBE operates out of 43 countries around the globe, with a presence in every key insurance market. The North America division, headquartered in New York, conducts business through its property and casualty insurance subsidiaries. QBE insurance companies are rated “A” (Excellent) by A.M. Best and “A+” by Standard & Poor’s.  Visit www.qbena.com.

About Ullico

Union Labor Life is a wholly owned subsidiary of Ullico Inc. The company has also been a leader in designing and offering group medical stop loss programs to self-funded multiemployer health care plans.  For more than 85 years, Ullico, the only labor-owned insurance and investment company, has been a proud partner of the labor movement, keeping union families safe and secure. From insurance products that protect union members, leaders and employers, to investments in building projects that have created thousands of union jobs, our customers continue to trust us with protecting their families, employees and investments. The Ullico Inc. family of companies includes The Union Labor Life Insurance Company; Ullico Casualty Group, Inc.; Ullico Investment Company, Inc.; and Ullico Investment Advisors, Inc. Visit www.ullico.com.

About SIIA

he 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.  Visit www.SIIA.org.

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Express Scripts Honored in Forbes' List of the World's Most Innovative Companies in 2014

MyHealthGuide Source: Forbes, 9/15/2014, www.forbes.com/innovative-companies/list/ and www.express-scripts.com

Express Scripts was honored to be included on Forbes' list of the World's Most Innovative Companies in 2014. Of the 100 companies listed, Express Scripts ranked 28th overall and 16th in North America. No other pharmacy benefit managers were included on the list.

Listing includes

  • #28 Innovative Companies (2014)
  • #158 Global 2000 (2014)
  • #51 in Sales
  • #369 in Profit
  • #449 in Assets
  • #157 in Market value

About Express Scripts

Express Scripts manages more than a billion prescriptions each year for tens of millions of patients. On behalf of our clients — employers, health plans, unions and government health programs — we make the use of prescription drugs safer and more affordable. Express Scripts uniquely combines three capabilities — behavioral sciences, clinical specialization and actionable data — to create Health Decision Science℠, our innovative approach to help individuals make the best drug choices, pharmacy choices and health choices. Better decisions mean healthier outcomes.  Contact Kathy Bonnell, Vice President of National Strategic Sales, Workers' Compensation, at 800.332.5455 ext. 34.4169, kbonnell@express-scripts.com and visit www.express-scripts.com.

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People News



Trustmark Companies Names Jim Coleman as Chief Enterprise Marketing Officer

MyHealthGuide Source: Trustmark Companies, 9/19/2014, www.trustmarkcompanies.com

LAKE FOREST, Ill -- Jim Coleman, 51, joined Trustmark Companies in the newly created position of Senior Vice President and Chief Enterprise Marketing Officer. He reports to Trustmark President and CEO Joe Pray.

"Jim is uniquely suited to this role," said Pray. "His background, experience and expertise will fit well here at Trustmark. Equally important, he's also a great cultural fit, with a passion for cross-functional collaboration and leadership."

Pray said this newly created strategic position will increase enterprise growth and value by leveraging market and distribution synergies between Trustmark's four main businesses – HealthFitness, CoreSource, Starmark and Trustmark Voluntary Benefit Solutions.

Coleman has more than 20 years of marketing leadership experience, most recently as Senior Vice President and Chief Marketing Officer at Combined Insurance Company, the $1.4 billion supplemental insurance subsidiary of ACE Limited.

Prior to Combined, Coleman was Chief Marketing Officer for Culligan International and Vice President, Marketing, at Northwestern Mutual Life. He holds a bachelor's degree in Management from Rutgers University.

About Trustmark Companies

More than 100 years of Trust. Founded in 1913, Trustmark provides access to a full spectrum of employee benefit solutions, including benefits administration, payroll-deducted voluntary products, group medical benefits, and population wellness, health and fitness management programs. Trustmark's success is based on building and maintaining trust through personal, responsive service and flexible benefit solutions. Contact Cindy Gallaher at cindy.gallaher@trustmarkins.com, 847-283-4065 and visit www.trustmarkcompanies.com.

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IHC Risk Solutions Announces Bradley Dumon as Regional Sales Executive in the Southeast Region

MyHealthGuide Source: IHC Risk Solutions, 9/19/2014, www.ihcrisksolutions.com

IHC Risk Solutions, a leading provider of Stop Loss Insurance, has announced the addition of Bradley Dumon as Regional Sales Executive in the Southeast Region.

Bradley has worked in the group insurance industry in the Georgia market for the last 25 years. Most recently, Brad served as a Senior Stop Loss specialist for Sun Life Financial. Prior to Sun Life, he spent 15 years as one of the top large group Account Executives for Blue Cross and Blue Shield of Georgia. He has extensive experience working with the broker community in Georgia and throughout the south east. Bradley graduated from the University of Georgia.

Ken Gumbiner, Executive Vice President of Sales commented, we are very pleased to have Brad representing IHC Risk Solutions in this region. Our expectation is that Brad's experience coupled with our product portfolio will allow us to further develop strategic relationships with both Third Party Administrators and Benefit Consultants.

About IHC Risk Solutions

IHC Risk Solutions (IHCRS) offers medical stop-loss, group stop-loss captives, and an Organ Transplant Solution program. IHCRS is a full service direct writer for self-insured employer groups in all 50 states and is a member of the IHC Group, an insurance organization composed of Independence Holding Company (NYSE:IHC) and its operating subsidiaries. Coverage is underwritten by Standard Security Life Insurance Company of New York, also a member of the IHC Group. The IHC Group is built on financial strength and stability of IHC which has over $1 billion in assets as of December 2013 and over 25 years in the stop-loss business. Contact Ken Gumbiner at 260.557.1667, kgumbinerr@ihcrisksolutions.com and visit www.ihcrisksolutions.com.

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Data Dimensions Welcomes Cindi Benson  as New Vice President of Finance

MyHealthGuide Source: Data Dimensions, 9/2014, www.datadimensions.com

JANESVILLE, W -- Data Dimensions has announced the addition of Cindi Benson to its executive leadership team as Vice President of Finance.

Benson is a Certified Public Accountant with extensive experience in the service arena, along with a strong public accounting background. She has been the Plant Controller at Simmons Manufacturing in Janesville since 2007, managing more than $160 million in annual revenue. Benson has a Master's Degree in Business Administration from the University of Wisconsin-Whitewater with an emphasis in Finance and Management.

Jon Boumstein, Data Dimensions President and CEO says, "I am excited to have Cindi join Data Dimensions and our executive leadership team. She is very goal-oriented, experienced at working in a fast-paced environment and a proven leader with great problem-solving skills."

The addition of Cindi Benson continues a period for strong growth for Data Dimensions. This summer, the company hired its 1,000th employee and announced plans to open a new facility in Mt. Sterling, KY. And in August, Data Dimensions earned a spot for the second time on Inc. Magazine's exclusive Inc. 5000 list of the nation's fastest growing private companies.

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.  Call 800-782-2907 and visit www.datadimensions.com.

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Market Trends, Studies, Books & Opinions



Minimum Value Calculator Issues -- Part 2

MyHealthGuide Source: Hobson D. Carroll, FSA, President, MedRisk Actuarial Services, Inc., 9/20/2014

Preface from Mr. Carroll: On 8/25/2014, this Newsletter published a paper I submitted entitled "A Dangerous Game -- Testing the Limits of the MV Calculator as Sole Determiner of Minimum Value." The article resulted in direct as well as indirect feedback relating to the content of that paper, some favorable, and some unfavorable for reasons that I believe derive from a possible misreading of what I said, or perhaps I simply did a poor job of communicating what I intended to say. As such, I should like to take this opportunity to provide an alternate statement that will strive to clarify what I said (or meant to say) and especially declaring what I did not say.

There are plenty of people who think that any plan of benefits that is short of the richest option available in the Federal Employee Health Benefit program is unfair, criminal, and a travesty of justice, and that entities (read, TPAs) who create, sell, and administer, or even contemplate, such plans should be considered outlaws.

I am not certainly not one of them, having been involved myself in designing such plans since the day after the ACA became law. What I did indicate is that there are such people and entities that disparage both lower level benefit plans, and those who create, sell, and administer them in a perceived abuse of the "spirit" of the law, and in a way that especially prejudices lower income employees and their families.

So, if I may borrow from a famous (or infamous) quote, please let me be perfectly clear about this: There is nothing wrong with designing a plan that achieves plan value of at least 60% without covering inpatient or emergency room hospital services, and it is both a fact of MVC determination, and general actuarial reality, that such excluded benefits, in the context of plan "value," do not account for more than 40% of an original 100%, "cover everything with no cost sharing" plan.

ACA Requirements

The law says that self-insured plans do not have to cover all Essential Health Benefits (EHB) to be ACA compliant. They must be MEC compliant, and if they cover an EHB, there are limits to how they may restrict or limit the benefit. If they can muster a plan benefit value ratio of at least 60% without covering one or several of the EHBs, then they can also be Minimum Value (MV). That is what the law says, so any suggestions that regulators can "legally" change the law by a regulation requiring an MV plan cover all forms of service provided in a hospital are far-fetched in my view (it would be excessive regulatory over-reach, to say the least). To attempt to control it by manipulating the MV calculator tables so that it would be impossible to get to 60% without such hospital benefits being included would essentially require abuse of the actuarial basis on which the calculator is built. In other words, they would have to change reality on the ground, or substantially modify the basis of how MV is determined, stretching beyond the breaking point of legitimate interpretation of the law.

The fact is that many "policy" people simply don't like the idea, philosophically, that a benefit plan labeled as "meets minimum value" doesn't actually have to cover inpatient hospital or emergency room services. They cannot or will not understand the actuarial mathematics that says that ambulatory specialist services are worth almost as much as inpatient hospital services, at least in terms of relative plan value, and based on the data underlying the MVC itself. And while many of us in the industry will not argue that removing such services eliminates a significant part of the true "insurance" aspect of such coverage, we also recognize that society has dictated through the ACA that things like primary care, physician services, diagnostic testing of various sorts, and basic Rx coverage are to be considered a major portion of what is deemed as "health insurance." As such, the MVC is a tool that has been provided to "value" different kinds of benefits in order to achieve the law's standard for "minimum" qualifying coverage, and the values of different combinations of the indicated categories fall where they may as a result.

MVC Authors Did Not Anticipate Hospital Benefit Exclusions
 
However, the MV calculator does have some significant issues, and they need to be addressed. I believe that anyone who suggests the authors of the MVC knew exactly what they were doing in anticipating how "skinny-fat" plans would designed have simply got it wrong. Because MVC categories could be "excluded," they implicitly knew it was possible, but it was not on their radar as to the extent of benefit manipulation that would take place, and it certainly wasn't something that they actually wanted to encourage somehow. At this point, CMS doesn't want to admit or deal with the possibility that they may need to refine some rules for qualifying the process for how the MVC should be used.

Clarification of choosing an EHB benchmark, and showing how the detailed list of such services fall (cross walk) into which MVC categories would go a long towards improving the use of the MVC, as I tried to suggest in my previous paper. I also believe there are some actuarially technical questions that might be put to the authors of the MVC surrounding bits and pieces that don't always appear to add up, which might allow for some picking and choosing to manipulate a calculation into coming in just over 60%. However, I am more concerned at the moment with the possibility that selective "word" interpretation of what might or might not be in which category is achieving the same goal, and so when in my paper I refer to the MVC being "gamed," that is my meaning.

Now, it is certainly possible to "game" a set of rules without doing anything illegitimate, let alone illegal. For example, tax mitigation/avoidance is a perfectly appropriate pastime, while tax evasion is not. I have simply suggested that playing games with the lack of clarity in the use of the MVC might not be the best in the longer run for either our employer clients, or their employees, when the full context is considered. Get to 60%, but be aware of any assumptions you had to make to get you there, even within the "hidden" meanings of the MVC categories.

It has been suggested that we (as an industry) should oppose any criticism of "skinny fat" plans, no matter how accurate or well intentioned such criticism might be, because it could, through some very large "guilt by association" blanket, imply that all legitimate efforts to use the opportunity provided by the MVC will be vilified as well, and that the powers that be will react accordingly. I believe we should not simply be saying "Don't question the Minimum Value Calculator!" (Because we have discovered how to use its deficiencies to our advantage, and so don't want any red flags raised?) Rather, we should not be afraid to vigorously, and proactively, defend legitimate, "creative" and affordable minimum value plans that can be great first steps for many of the "no prior coverage" employers to enter the stream of providing useful, practical, and affordable (all taken together, read "valuable") employee benefits to people who have not previously had much of a choice.

About The Author

Hobson D. Carroll, FSA, MAAA is President of MedRisk Actuarial Services, Inc..  Contact Hobson at 1 281 368 7878 XT 123 and hdc@medriskactuarial.com.

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Legal, Legislative & Regulatory News


SIIA Submits Comment Letter in Response to NAIC Whitepaper 'Stop Loss Insurance, Self Funding and the ACA'  

MyHealthGuide Source: The Self-Insurance Institute of America, Inc., 9/16/2014, www.SIIA.org

The Self-Insurance Institute of America, Inc. (SIIA) submitted a formal comment letter in response to a draft whitepaper entitled "Stop Loss Insurance, Self Funding and the ACA" released last month by the National Association of Insurance Commissioners (NAIC).

The full text of the letter is provided below. Should you have questions regarding the white paper drafting process, please contact SIIA State Government Relations Director Adam Brackemyre at abrackemyre@siia.org.

SIIA's engagement with the NAIC is part of a larger advocacy initiative to protect the self-insurance marketplace from harmful regulation. Other highlights of this initiative include:

  • Introduction of federal legislation to prevent HHS/DOL/Treasury Department from defining stop-loss insurance as health insurance;
  • SIIA's CEO testified at two congressional hearings explaining the importance of self-insurance;
  • Spearheaded lobbying effort in Connecticut that resulted in the defeat of two separate legislative proposals targeting self-insured employers;
  • Continue to spearhead lobbying efforts in New York and the District of Columbia related to stop-loss insurance regulation;
  • Continued to challenge the state of Michigan in Federal Court in response to legislation that raises ERISA preemption concerns;
  • SIIA's political action committee (PAC) has made financial contributions to numerous members of Congress who are positioned to be supportive of the self-insurance industry;
  • Numerous meetings have been arranged/coordinated for association members to meet with their elected representatives to discuss self-insurance issues.

Self-Insurance Institute of America, Inc.
September 16, 2014

Ms. Christina Goe
Chair, NAIC ERISA B Working Group
C/o Montana Office of the Commissioner of Securities and Insurance
840 Helena Ave
Helena, MT 59601

Dear Ms. Goe:

The Self-Insurance Institute of America (SIIA) respectfully submits this comment letter in response to the "Stop Loss Insurance, Self Funding and the ACA" draft whitepaper. As you may know, SIIA is a national trade association that represents companies involved in the self-insurance marketplace, including self-insured organizations, third party administrators, stop loss insurance carriers and other service providers. Because of this membership composition, our association is uniquely positioned to comment on the subject matter contained in the draft white paper.

While it is hoped that these limited comments are helpful to your drafting process, we would welcome the opportunity to discuss a broader range of issues addressed in the white paper to the extent you believe this would be useful.

PAGE 3: In response to these issues, some employers have sought out alternative arrangements. For example, an employer may hire a company to manage its health benefit program typically referred to as a third party administrator (TPA). TPAs (including insurers with ASO contracts) can provide a variety of services. They may assist the employer in designing the benefit package, estimating the costs associated with the entire program or in adding a particular benefit, as well as ensuring that the health plan complies with applicable federal law and notice requirements. TPAs may also provide cost management services, like access to provider networks and the ability to conduct sophisticated care management programs like large insurers. Finally, a TPA will have staff available to help the employer deal with enrollment issues and process medical claims. For all these services, employers will pay a fee and provide the "checkbook," i.e. the money necessary to pay the claims.

SIIA Comment: The white paper should more appropriately acknowledge the critical role state licensed and regulated insurance brokers, consultants and TPAs play in assisting plan sponsors with evaluating viable options for their health plan needs. Stop loss policies are written to address the needs of the plan sponsor, and are designed as a reimbursement mechanism where the plan sponsor is liable for funding all underlying first dollar medial claims. Plan sponsors work with their broker, consultant and/or TPA to evaluate and select coverage options based on the plan's characteristics, financial assets and tolerance for risk. For example, the determination of both specific and aggregate attachment points requires the analysis of multiple plan specific characteristics such as group size, risk tolerance, claims experience, care management, cost containment measures and provider network savings to name a few.

Further, stop loss insurance is regulated by each state's regulatory agencies governing insurance matters. Although the regulation of stop loss insurance may vary state-by-state, it is regulated in the same manner as other coverages filed by either a commercial life carrier or a property and casualty carrier. Like other forms of insurance, one of the principle reasons for regulating stop loss insurance is consumer protection. Stop loss policy forms, including riders, are subject to regulation and approval. Insurance laws relating advertising and fair trade practices also apply to stop loss insurance.

SIIA recognizes that health insurance and health plans are complex and confusing, which is why the state requires the individuals who sell and service insurance contracts and plans to be licensed and meet continuing education requirements. SIIA recommends that only licensed individuals and entities counsel plan sponsors on the many cost-cutting health plan options available, such as care management, provider networks savings and the advantages and disadvantages of incorporating them into the self-funded health plan, including purchasing stop loss insurance.

PAGE 4: An employer with 100 employees buys stop loss coverage with a $10,000 specific limit, and a $150,000 aggregate limit. After meeting the limits, coverage is at 100%.

SIIA Comment: SIIA appreciates the demonstration on how stop-loss insurers reimburse plan sponsors. We are concerned, however, that the demonstration is misleading. In reality, stop loss insurance is a type of liability coverage that reimburses the plan sponsor for losses exceeding a predetermined level, referred to as a specific individual and aggregate attachment points. Claim payments to the plan's beneficiaries (typically employees and their dependents) or their provider are the responsibility of the plan sponsor regardless of whether an attachment point has been reached. Note that stop loss insurers are not responsible for nor do they make claim payments to providers or individual employees. Therefore, the statement "after meeting the limits, coverage is at 100%" is misleading. A more appropriate statement is that after meeting the predetermined attachment point level, the plan sponsor is eligible for reimbursement subject to the terms of the stop loss policy.

Further, specific individual attachment points are generally set above $20,000. Aggregate attachment points are typically not set below 110% of expected claims for large groups and 120% of expected claims for small groups. A report issued by Milliman earlier this year on behalf of the Self-Insurance Educational Foundation (SIEF) found that fewer than 0.3% of all stop-loss policies have individual attachment points below $20,000. The median specific deductible found across all plans was $85,000. For groups with fewer than 50 employees, the median deductible was $30,000. For groups of 51-100 employees, the median was found to be $45,000. The most common annual aggregate attachment point was $125% of expected claims. The full report is attached/enclosed for your review.

PAGE 10: Some policies include policy provisions that mitigate the risk of high and low claims months by allowing claims accounts to include a temporary negative balance. This is essentially a loan from the TPA to the employer, and the contract should specify any repayment provisions including penalties and interest. Some stop loss insurance products marketed to small employers contain specific "advance funding" provisions, which may expose small employers to risk in the event they are unable to repay, especially if the repayment provisions are unduly punitive.

SIIA Comment: SIIA appreciates the white paper's discussion on policy provisions that mitigate the plan sponsor's risks, but the "advance funding" references include several misconceptions. SIIA is not aware that any of its members are engaged in the practice of offering "loans" or financial advancements resembling loans to plan sponsors. If this practice is occurring it is extremely limited in scope. SIIA is aware, however, of stop loss insurers offering riders that provide plan sponsors with cash flow management and protection against fluctuations in claim experience. A common risk mitigation rider is "advance funding," which provides for reimbursement of specific stop loss claims when certain conditions are met. The claim submitted for advance funding must have been fully processed by the TPA, be ready for the TPA's payment, and must be an expense for which the advanced funds are reimbursed within a limited number of days after receiving the advance (typically five days).

On the other hand, a monthly aggregate accommodation rider allows for claims reimbursements to be made monthly rather than waiting until the end of the policy year. Under this rider, the stop loss carrier reimburses the plan sponsor monthly for claims that exceed a predetermined monthly aggregate deductible throughout the contract period. These types of riders provide plan sponsors with more flexibility with regard to its financial assets, risk tolerance and plan design. Again, it is important to note that stop loss policy forms, including riders, are subject to State regulation and approval.

PAGE 11: All of the above factors increase the financial risk and uncertainty to the small employer. However, states generally do not regulate stop loss insurers in terms of the size of the employer policyholder, and some stop loss insurers, TPA's and brokers may market to employers with as few as 10, or even 5, employees.

SIIA comment: An employer's ability to self-fund depends upon a number of factors. A small business with very few employees may be an unlikely candidate for self-funding, but if it has a strong balance sheet, the cash flow to pay claims, the desire to actively manage a health plan and a stop loss policy, self-funding may be a viable option. SIIA members also report that some smaller employers choose between self-funding and not offering coverage, so regulating stop loss contract size (i.e., prohibiting stop loss in the 50 and under market) may lead to fewer people with access to employer-sponsored coverage.

PAGE 14: Some stop loss insurance policies do not include a standard benefit package, and some benefits such as prescription drugs, may not be covered unless the employer opts into the coverage. Small employers should be made aware of these types of exclusions before they purchase a stop loss policy
  • Other exclusions, though rare, included broad stop loss exclusions for certain types of mental illness. Employer health plans are required to follow ACA provisions and federal mental health parity laws and may be responsible for paying these claims even if the stop loss insurer excludes coverage.
  • Some stop loss policies have additional deductibles for transplants, or for individuals who have been identified as an "exceptional" risk.
SIIA Comment: Regarding the white paper's reference to stop loss insurance policies not including a standard benefit package SIIA would like to point out that the function of stop loss insurance is not to offer standard benefits, but to reinsure the plan the employer is providing.

During the stop loss policy underwriting process, the evaluation of the plan sponsor's benefit plan is assessed based on the plan sponsor's disclosures. This process includes a review of the characteristics of the underlying plan design, claims experience, provider discounts, managed care networks, the summary plan description, and the TPA administering the plan and any cost containment measures used by the TPA to determine the potential risk and coverage options suitable to the employer. At this time, the plan sponsor may determine it is more suitable to exclude certain claim losses from eligibility for stop loss reimbursement based on tolerance for risk and financial assets. These exclusions are generally intended to reduce the premium cost of the stop loss policy. Further, it may be more cost effective to fully insure certain benefits such as transplant or prescription drug coverage. The market is designed to meet the needs of the individual self-funded plan by being flexible and innovative in risk transference.

SIIA believes that any exclusion under a stop loss policy should be appropriately vetted during the disclosure and underwriting process and included in the contract. This is customary practice in the fully insured, self-funded and stop loss business. Self-funded health plans are frequently designed to meet an employer's specific needs and as such most stop loss policies align with the plan's summary plan description. It is important to note, stop loss policy forms, and riders, are subject to State regulation and approval.

PAGE 15: Some stop loss insurers will immediately terminate the coverage if the employer changes TPAs.

SIIA Comment: it is highly uncommon for an employer to change their TPA prior to the conclusion to a designated anniversary date. In fact, most TPA changes are done on anniversary and coincide with a new stop loss policy. That said, SIIA believes there are scenarios where the termination of stop loss policy is appropriate when they happen off anniversary or during the plan year. During the disclosure and underwriting process the evaluation of the plan sponsor's benefit plan is assessed to determine the underlying risk. This process includes, but is not limited to, a review of the underlying characteristics of the underlying plan design, claims experience, provider discounts, managed care networks, the summary plan description, and the TPA administering the plan and any cost containment measures used by the TPA to determine the potential risk and underlying coverage options suitable to the employer. Many stop loss carriers and managing general underwriters (MGUs) review TPAs to ensure they are properly licensed, bonded and insured.

It is common practice for stop loss policies to include a provision that requires notice of material changes to the underlying benefit plan, including a change in the entity (TPA) administering of the plan. If an employer makes a material change to the health care plan's benefits or administration during the stop loss contract period, then the premium initially charged may no longer reflect the risk assumed by a stop loss carrier. Further, material change provisions may include termination rights in addition to the right to increase premium. Such actions are only taken when the original premium no longer reflects the risk assumed by the stop loss insurer.

By way of example, a change in TPA administration may result in a loss of the health care plan's provider network and access to discounted payment schedules and other cost containment measures. Should a plan sponsor fail to notify the stop loss insurer material change or if the plan sponsor does not agree to the increased premium resulting from a material change, the stop loss insurer may either terminate the policy in accordance with the policy or increase the premium to reflect the revised risk. Again, it is important to note, stop loss policy forms, including material change and termination rights are subject to State regulation and approval. While the stop loss carrier reserves the right to approve the new TPA, it is rare that the change is not approved.

PAGE 18: No rate guarantees. Most stop loss insurance policies state that premiums can increase at any time or even retroactively during the policy year when additional, unforeseen risk occurs, making financial planning very difficult, especially for a small employer.
  • Some stop loss insurance policies charge a "provisional premium rate." The premium is then adjusted 6 months after the end of the policy period to reflect actual claims paid. The adjusted premium is a variable percentage of the claims paid by the stop loss insurer.
  • The concept of an "unforeseen risk" is problematic. The risk of plan participants developing medical problems during the year is precisely the risk the employer might reasonably believe it is insuring against when it buys a stop loss policy.
SIIA Comment: SIIA suggests that that the statement "most stop loss insurance policies state that premiums can increase at any time..." is misleading. The practice, known as "retro rating," is not common and not sought by knowledgeable brokers and consultants. In reality, most stop-loss contacts are issued with 12-month rate guarantees. However, there are instances in which a material change may trigger a premium rate increase. Most stop loss policies reserve the right to approve any material change and require that the plan sponsor or the TPA provide written notice prior to the effective date of material change. If necessary, premium adjustments may occur when the original premium no longer reflects the risk assumed by the stop loss insurer. Premium adjustments resulting in an increase are subject to the plan sponsor's acceptance of the adjustment to the premium.

The most common causes for premium increases are material changes resulting from benefit or enrollment changes. For example, should the employer eliminate jobs or increase health plan benefits, the underlying risk have changed and a premium adjustment may be appropriate. We believe this is an entirely reasonable business practice.

PAGE 20: Disclosure. A small employer is unlikely to have a human resources manager or other designated employee whose job it is to manage the health plan and understand commercial insurance products. Because stop loss insurance products are not generally required to conform to state or federal health insurance law, including the ACA, there may be exposure to additional risk in some stop-loss insurance products that is not immediately apparent. Small employers may benefit from education on or disclosure of the risk they are assuming in "self-funding" a health plan, as well as protections that they should be looking for when they shop for a stop loss insurance policy.

SIIA Comment: It is first important to clearly distinguish self-insured "plans" from the stop-loss insurance "policies." Self-insured groups health plans are extensively regulated under several federal laws and are subject to most ACA provisions. While stop loss is not currently regulated at the federal level, stop loss insurers are state regulated insurance companies and stop loss forms are subject to state regulation and approval. Stop loss insurance is a type of liability product that reimburses the plan sponsor for claim losses exceeding a predetermined level. It does not function like a health plan because stop loss policies do not pay claims to providers or plan participants. Instead reimbursement payments are made to plan sponsors after the plan sponsor has paid the underlying first dollar medical claim. Stop loss insurance provides plan sponsors with cash flow management and protection against fluctuations in claims experience when the plan experiences large or catastrophic claims. In this regard, SIIA believes it is misleading to imply that stop loss policies expose the plan sponsor to additional risk due to deficient federal or state regulation.

That said, SIIA fully supports proactive and meaningful disclosure practices among all entities involved with self-insured group health plans. It is our view, however, some approaches in the white paper suggests are unreasonable. For example requiring stop-loss carriers to provide an actuarial memorandum for each employer (Page 24) would be significantly burdensome without providing information valuable to that employer.

Finally, we believe that the burden of disclosure should be placed on the appropriate entities. For example, care management and other cost containment measures are more appropriately disclosed by the TPA administering the plan, even though they may be contained in the stop loss policy. Similarly, brokers should disclose commissions that he or she may receive for placing the business. Lastly, stop-loss insurers should and do provide disclosure of events or material changes that may trigger premium adjustments and or terminations in marketing materials, policy forms and through their appointed brokers.

Conclusion

Thank you for your consideration of these comments. Please contact SIIA State Government Relations Director Adam Brackemyre at abrackemyre@siia.org should there be an opportunity for SIIA to continue this dialogue with the working group prior to the draft white paper being finalized.

Sincerely,

Michael W. Ferguson
President & CEO

About SIIA

he 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.  Visit www.SIIA.org.

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Medical News


Optimizing Enrollment in Employer Health & Wellness Programs: A Comparison of Enrollment Strategies in the Diabetes Health Plan

MyHealthGuide Source: Lindsay B. Kimbro, MPP, et al, American Journal of Managed Care, 9/4/2014, AJMC Article

For employer-based health and wellness programs that struggle with low enrollment rates, especially among certain employee subgroups, an automatic enrollment strategy may not only increase the total number of enrollees but may also decrease some enrollment disparities.

Researchers analyzed enrollment rates resulting from 2 different strategies: voluntary and automatic enrollment. They used regression modeling to estimate the associations of patient characteristics with the probability of enrolling within each strategy. The subjects were 5,014 eligible employees from 11 self-insured employers who had purchased the Diabetes Health Plan (DHP), which offers free or discounted copayments for diabetes related medications, testing supplies, and physician visits. Six employers used voluntary enrollment while five used automatic enrollment. The main outcome of interest was enrollment into the DHP. Predictors were gender, age, race/ethnicity, dependent status, household income, education level, number of comorbidities, and employer group.

Study findings

  • Overall, the proportion of eligible members who were enrolled within the automatic enrollment strategy was 91%, compared with 35% for voluntary enrollment.
  • Income was a significant predictor for voluntary enrollment but not for automatic enrollment.
  • Within automatic enrollment, covered dependents, Hispanics, and persons with 1 nondiabetes comorbidity were more likely to enroll than other subgroups.
  • Employer group was also a significant correlate of enrollment. Notably, all demographic groups had higher DHP enrollment rates under automatic enrollment than under voluntary enrollment.

Despite extensive recruitment efforts by health plans, state and local governments, and other stakeholders, many eligible individuals do not voluntarily enroll in health promotion or insurance benefit programs designed to improve health outcomes. Employers are increasingly sponsoring wellness programs as a way to possibly decrease costs and increase productivity across a large component of the workforce.  However, despite the use of various approaches, enrollment in wellness programs often remains low.  Although many of these programs and benefits may improve access and outcomes among the subset of persons who are enrolled, with limited reach they are unlikely to improve the health of the overall targeted population.

Many employer health programs use a voluntary enrollment approach, which employees must actively join in order to be enrolled. However, voluntary program enrollees may have different demographic characteristics than the underlying population, in terms of gender, age, race/ethnicity, income, risk for chronic conditions or disability, and other factors. Voluntary program enrollees may also have different clinical characteristics than the underlying population, potentially representing either the "worried well" who may have less need for services or a sicker subgroup motivated to enroll because of the severity of their underlying condition. A recent review of enrollment into a variety of public benefit programs identified multiple barriers to voluntary enrollment and suggested automatic enrollment of all eligible participants as a preferential strategy. There is little current, "real-world" data on patient-level differences comparing "voluntary" and "automatic" enrollment approaches. Such information may be useful in the design of future health promotion or insurance benefit programs.

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Recurring Resources


Medical Stop-Loss Providers Ranked by Annual Premium Survey (last updated 6/30/2014)

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 Info@MyHealthGuide.com

  Stop-loss Provider Years Providing Stop Loss Associated Carriers / MGUs Annual stop-loss Premium
(Millions)
Capital /Equity
(Millions)
Source
1. CIGNA     $1,907
2013
  CIGNA 2013 10-K, page 46 2/27/2014
2. Sun Life Financial     $915.2
2013
  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+)
$818
2013
  HCC Insurance Holdings, Inc. Release,
2/11/2014
4. HM Insurance Group >30 Years HM Insurance Group
(A.M. Best Rated: A-)
$762.4
2013
$507
12/31/2013
Mike Sullivan, President & COO
2/4/2014
5. Symetra >36 Years Symetra Life Insurance Company
(A.M. Best Rated: A)
(Block - $475M
MRM - $255M)
$730
2012
$3,429
6/30/2014
Michael Fry, Executive Vice President, Symetra;
Mike McLean, Chairman Medical Risk Managers, Inc.
1/7/2014
6. ING Employee Benefits > 35 Years ReliaStar Life
(A.M. Best Rated: A)
$560
2013
$1,942
12/31/2013
Joe Keller, Lead Financial Analyst, ING Employee Benefits,
3/18/2014
7. Companion Life > 20 Years   $310
12/31/2013
  Philip Gardham, Vice President, Specialty Markets,
11/20/2013
8. National Union Fire Insurance Company of Pittsburgh >35 Years AIG Benefit Solutions $215
5/2014
  Jeff Gavlick, VP, Stop Loss Products, AIG Benefit Solutions
6/20/2014
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
3/31/2014
10. Zurich North America     $130   Tracey Brennan, Zurich North America.
7/22/2011
11. Munich Re Stop Loss, Inc.   AIC, TransAmerica $110
2012
  Susan McGrath Bowman,
Chief Operating Officer, Munich Re Stop Loss, Inc.
4/25/2013
12. The Union Labor Life Insurance Company  (ULLICO) >25 Years ULLICO
(A.M. Best Rated: B++)
$96
2/2014
  Victor Moran, Second Vice President, Actuarial Operations.  3/12/2014
13.
Markel Insurance Company <5 Years Markel Insurance Company
(A.M. Best Rated: A-)
$3 $$3,388
12/31/2011
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 CrossBlue Cross Blue Shield (various regions)
  • Gerber Life Insurance Company
  • 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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Upcoming Conferences


September 24, 2014 - Webinar 1:00 - 2:00 PM EST
Plans for the Future presented by The Phia Group, LLC, CEO, Adam V. Russo, Esq., Senior Vice President and General Counsel, Ron E. Peck, Esq., and Vice President of Consulting Jennifer McCormick, Esq. discuss the Phia Document Management system, innovative plan design, and why it is especially relevant in light of changes we predict all plan documents will be required to undergo in the coming years. As new products, procedures and methodologies are adopted by health benefit plans, each change in claims processing must be preceded by a change made to the applicable plan document. Nothing - from reference based pricing to MEC/Skinny Plans - can be implemented unless and until the plan document is adjusted accordingly. Information and registrationwwww.phiagroup.com

September 25, 2014 - Webinar - 10:00 am PT/12:00 pm CT/1:00 pm ET
"Pay or Play" Rules under 4980H: Planning for 2015 presented by Health Care Administrators Association (HCAA).  Speakers Ashley Gillihan and John Hickman, Alston & Bird LLP.  The ACA Employer Shared Responsibility (Pay or Play) final regulation includes complex rules for identifying full-time employees for purposes of determining which employees need to be offered coverage to avoid penalty taxes. HCAA Members: $25
Non-Members: $100.  Contact HCAA (888) 637-1605, hcaainfo@hcaa.org and visit www.HCAA.org.

September 25, 2014 - Webinar - 11:00 AM - 12:00 PM EDT
Medical Round Table: NCCN Clinical Practice Guidelines® and Derivatives presented by INTERLINK CancerCARE Program.  Presenter: Joan McClure, MS, Senior Vice President of Clinical Information and Publications for the National Comprehensive Cancer Network (NCCN). Covers: Rationale for evidence-based guideline use, Explanation of processes for guideline development and updates, Discussion of how guidelines are shared.  Reservations: www2.gotomeeting.com/register/406589490

October 5-7, 2014
National Educational Conference & Expo presented by Self-Insurance Institute of America (SIIA). The event typically attracts more than 1,700 attendees from throughout the United States and from a growing number of countries around the world.  The program features more than 40 educational sessions designed to help employers and their business partners identify and maximize the value of self-insurance solutions. Highlights:

  • Click here for speaker listing
  • Self-insured group health plans from every angle
  • Plan design and cost containment
  • Financial risk transfer
  • Broker involvement
  • ACA compliance
  • Stop-loss captive programs
  • 831(b) captives
  • Workers' Comp self-insured funds (SIGs)
  • Over 150 Exhibitors
  • SIG Roundtable Discussion
  • Sessions Provide Unique Learning and Industry Collaboration Opportunities
  • Featured speaker: Dr. Richard Pimentel, senior consultant with Milt Wright & Associates, Inc., His presentation focus will be Updating Yesterday's Disability Management Solutions to Address Today's Workers' Compensation Dilemmas.

J.W. Marriott Desert Ridge, Phoenix, AZ. contact Justin Miller at 800/851-7789, or jmiller@siia.org.  Information and Registration: www.www.siia.org/i4a/pages/index.cfm?pageid=6300

October 8-9, 2014
An In-Depth Look at the State of Worksite Health presented by World Congress.  James A. Levine is a Professor of Medicine at Mayo Clinic and a world-renowned leader in obesity research and child advocacy. He is also a tenured Professor in ASU's School of the Science of Health Care Delivery. Dr. Levine is an international expert on obesity. In the United States, he has been an invitee to the President's Panel and the State Department. Internationally, he has consulted with governments around the world.  Hyatt Regency McCormick Place. Chicago.  Registration: http://worldcongress.com/common/regsplit.cfm?confcode=HH14077

October 15, 2014
Health Insurance Exchanges Forum hosted by America's Health Insurance Plans. An ongoing series to provide the latest and most critical exchanges information on the business of the exchanges, including best practices and how business processes have changed. Hear from the leadership implementing exchanges at the state and federal levels. Enjoy early registration rates before September 5, 2014. Contact: 202-778-3200 or registrations@ahip.org . See www.ahip.org/Conferences/OctoberExchange2014/

October 15, 2014
Lloyd's Meet the Market in Chicago. Spend half a day (1:30pm -- 6:30pm) with Lloyd's underwriters and London brokers learning how our market's solutions remain viable 326 years after its humble beginnings in Edward Lloyd's coffee shop. Opening remarks from Inga Beale, Lloyd's CEO and Vincent Vandendael, Lloyd's International Markets Director. Information: Contact David Stirling, Director, Crispin Speers & Partners Ltd, at David.Stirling@CSPInsurance.com. University Club of Chicago, 76 East Monroe Street, Chicago, Illinois 60603. Registration.

October 15-17, 2014
SPBA Fall Meeting (members only). Nashville, TN. Society of Professional Benefit Administrators (SPBA). www.SPBATPA.org 

October 16-17, 2014
The State Health Issues Conference hosted by America's Health Insurance Plans. Brings together the leading authorities and thought leaders to discuss the state legislative and regulatory issues challenging health plans. Enjoy early registration rates before September 5, 2014. Contact: 202-778-3200 or registrations@ahip.org . See www.ahip.org/Conferences/StateIssues2014/

October 16, 2014
Clearwater HIPAA Compliance BootCamp™.  Designed for busy professionals, this event distills into one action-packed day, the critical information leaders need to know about the HIPAA Privacy and Security Final Rules and the HITECH Breach Notification Rule. The Clearwater HIPAA Compliance BootCamp™ has helped hundreds of professionals learn HIPAA-HITECH fundamentals in a highly interactive classroom setting. Los Angeles, CA.  Contact Clearwater Compliance at 800-704-3394 and info@clearwatercompliance.com.

October 16-18, 2014
Leading Business Change Through Analytics offered by Columbia Business School and the School of Continuing Education.  Combines the elements you need to transform business through analytics, including business models, technology, and strategy and innovation. This program will benefit professionals in the insurance industry including the healthcare market and understanding the impacts of data access and the decision making process.  Sample sessions:

• Analytics: The Big Picture
• Analytics Frameworks, Methods and Visualization
• Beyond Technology: Personal Skills Required to Drive Analytics

You'll visualize data, learn a specific model for business transformation, examine a case studies, and more. After completing the program, you'll earn a certificate of completion plus three days toward a Certificate in Business Excellence. Location: Midtown Executive Club, NYC.  Tuition: $5,850. The application deadline is Friday, October 10. Contact Sandra E. Will, President, sandra@renaissancemi.com, 212.960.3210.  Skype: sandra.e.will. Registration: https://columbiaexec.secure.force.com/cs/ProgramApplication2?id=a0G7000001vknc1

November 5-12-19, 2014 -- Web Event
Clearwater HIPAA Compliance Virtual BootCamp™.   Designed for busy professionals, this event is a series of three, 3-hour web sessions delivering an action-packed HIPAA-HITECH curriculum This virtual workshop series provides critical information leaders need to know about the HIPAA Privacy and Security Final Rules and the HITECH Breach Notification Rule. The Clearwater HIPAA Compliance Virtual BootCamp™ has helped hundreds of professionals learn HIPAA-HITECH fundamentals in a highly interactive, online classroom setting. Contact Clearwater Compliance 800-704-3394 and info@clearwatercompliance.com.

November 10-12, 2014
4th Annual IHC FORUM West presented by Institute for HealthCare Consumerism.  Join employers, brokers, health plans, TPA's, consultants and solution providers to LEARN, CONNECT and SHARE HealthCare Consumerism trends, challenges and solutions including:
Learn next steps and best practices in HealthCare Consumerism, Compliance issues with health care law in 2015 and beyond, Access latest health and benefit innovations and trends, Look into real time open enrollment statistics, Perspectives on election results, Analyze benefit models, including defined contribution and exchanges, Network with your peers and other industry stakeholders, Receive top quality education, more.  Red Rock Resort & Spa. Las Vegas, NV. Free registration for first 25 to register by September 15, 2014 using the registration code is MYHEALTHGUIDEVIP. Information and registration: www.theihccforum.com/2014west/

November 17-19, 2014
The Ops/Tech Forum, hosted by America's Health Insurance Plans, gathers industry experts to discuss critical issues such as: consumer engagement, exchange implementation, cost drivers, data analytics, and innovative technologies. Gain insights on the strategies, tools, and solutions you need to guide you into 2015 and beyond. Register today! Contact: 202-778-3200 or registrations@ahip.org .

December 4-5, 2014
IHC Forum West presented by the Institute for HealthCare Consumerism. Las Vegas, NV. Contact Joni Lipson at jlipson@theihcc.com and visit www.www.theihccforum.com/2014-ihc-forum-and-expo/

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January 18-20, 2015
The 2015 Taft-Hartley Benefits Summit presented by Financial Research Associates, LLC.
Caesars Palace in Las Vegas. Contact Jennifer Clemence at jjclemence@frallc.com.  Information and registration: www.frallc.com/register.aspx?ccode=B940 and visit
www.frallc.com

January 25-27, 2015
AAPAN 2015 Annual Forum presented by American Association of Payers Administration & Networks.  The theme for this year's forum is "Thinking Forward -- Rethink, Retool, Realign." This will be your opportunity to join industry leaders and an exciting lineup of speakers as we examine how best to position our businesses in this fundamentally changed healthcare environment. You will hear firsthand from experts and colleagues about challenges and opportunities at the state and federal level that are unique to TPAs, PPOs, and Workers' Comp professionals. Information: aseiler@aapan.org and (502) 403-1122.  Ritz-Carlton, Laguna Niguel in Dana Point, CA.

February 10-11, 2015
2015 Executive Forum presented by Heath Care Administrators Association (HCAA).  Encore at Wynn Las Vegas. Las Vegas, NV. www.HCAA.org.

March 4-6, 2015
Self-Insured Health Plan Executive Forum presented by Self-Insurance Institute of America.  J.W. Marriott Camelback, Scottsdale, AZ.  www.SIIA.org

March 18-20, 2015
SPBA Spring Meeting (members only). Washington, DC. Society of Professional Benefit Administrators (SPBA). www.SPBATPA.org


April 13-15, 2015
International Conference presented by Self-Insurance Institute of AmericaHilton Panama, Panama City, Panama. www.SIIA.org

April 29-30, 2015
Self-Insured Taft-Hartley Plan Executive Forum (NEW EVENT!) presented by Self-Insurance Institute of America. Marriott Metro Center, Washington, DC www.SIIA.org

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 smurphy@niis.com


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

July 21-23, 2015
MCIA Annual Conference presented by The Montana Captive Insurance Association, Inc. (MCIA) at the Lodge at Whitefish Lake in Whitefish, MT.  Contact mcia@mtcaptives.org and visit www.mtcaptives.org

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

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

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

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

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March 15-17, 2017
SPBA Spring Meeting (members only). Washington, DC. Society of Professional Benefit Administrators (SPBA). www.SPBATPA.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.
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Clevenger Ernie Clevenger
President & Publisher
MyHealthGuide, LLC
Clevenger@MyHealthGuide.com