MyHealthGuide Newsletter
News for the Self-Funded Community

Published weekly by MyHealthGuide, LLC ( 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.



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

Advanced Medical Strategies Innovates on Unprecedented Scale with PredictDx 2.0

MyHealthGuide Source: Advanced Medical Strategies, 9/25/2014,
It's been one year since PredictDx, our medical cost prediction database, launched and our subscribers couldn't be happier with the results. Since then, more than 40 carriers, reinsurers, MGUs, TPAs and brokers have implemented PredictDx. Today, PredictDx has more than 350 active daily users who turn to PredictDx for accurate, dependable cost-prediction data.

In the past year, the database has expanded from 135 high cost diagnoses to more than 160, thanks to the efforts of Dr. Stacy Borans and our clinicians. There is no question that PredictDx continues to be the most comprehensive and effective medical cost prediction tool available anywhere.

With the ongoing efforts of our expanding team, PredictDx will continue to provide users with the most important and up-to-date information available. Here are just some of the ways we have further enhanced PredictDx:

  • Knowledge of standard Medicare pricing provides massive advantages to healthcare payors. We have included Medicare payment data for every state for both urban and rural pricing to further empower the PredictDx user.
  • Easy searching just got easier. All diagnoses have an executive summary available from the SEARCH screen to allow users to rapidly acquaint themselves with the diagnosis.
  • Staying up-to-date is your number one priority, and ours. Push notifications are provided to keep our core users abreast of changes and inform them of updates, new diagnoses, and more. No more searching obscure websites.
  • CPT Module users will get expanded CPT codes as well as Medicare Billed by State by Procedure and Medicare Paid by State by Procedure derived from available CMS data.
  • Information about Network Discounts has been expanded and updated for PPO Module subscribers with a comprehensive set of PPO fee schedules, regular discount updates, and new networks being added on a regular basis.
  • All diagnoses in PredictDx received a full review in the summer of 2014 and continue to be updated on a weekly basis.

Our subscribers have been using the PredictDx software to underwrite policies, set lasers, streamline their processes, plan their reserves, and accurately predict the cost of catastrophic diagnoses that account for more than 80% of all healthcare claims. As costs continue to rise, we're confident that our users will continue to realize returns on PredictDx many times over.

Thank you to all of our subscribers for helping make PredictDx a success. We look forward to the continued enhancement of PredictDx and our continued commitment to our existing and new users.

View a video of PredictDx at
For more information, or to schedule a demo, please call Danae Lambeth, National Sales Director at Office: (781)-224-9711 x107 or email at

About Advanced Medical Strategies

Advanced Medical Strategies is a physician led organization that can bring some of the most innovative & proactive solutions in the Health Care Payor industry today. In addition to saving our clients time and money, we provide peace of mind when dealing with all facets of Medical Claims. Visit


IHC Risk Solutions Offers Experience Refund Feature on Qualified Stop-loss Policies

MyHealthGuide Source: IHC Risk Solutions (IHCRS), 9/23/2014,

In order to provide the best value to our business partners and clients, IHC Risk Solutions (IHCRS) has developed an Experience Refund Feature available on qualified stop-loss policies.

  • This option offers employer groups a greater comfort level with the cost of coverage, knowing that a percentage of profits will be returned to them if their specific stop-loss claims costs are below expected.
  • This option strives to reward those employers who put in place effective medical management tools and services to control claim costs.

To learn more about our new feature, contact your Regional Sales Executive today or visit our website at

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 January 2014 and over 25 years in the stop-loss business. Contact Teresa Bair at, 260.918.8021 and visit


Global Excel Management (GEM) Launces FairChex, a Hospital Value Ranking Tool

MyHealthGuide Source: Global Excel Management (GEM), 9/24/2014,

Sherbrooke, Quebec, Canada -- Global Excel Management (GEM) recently launched FairChex, a hospital value ranking tool to help plans save money and improve quality outcomes on their inpatient admissions. GEM anticipates this product could save thousands of dollars on each inpatient admission while increasing quality of care for patients.

FairChex is a unique tool that prompts the user to choose a clinical category or DRG, a geographic area and out-of-pocket member responsibilities. The results page ranks facilities by value -- a weighted blend of cost and quality. It highlights estimated costs for a procedure,  provider mark-ups, Medicare reimbursements and quality rankings specific to the procedure selected. In addition, the tool can be customized to each plan to show in-network hospitals and savings, allowing for the opportunity to optimize network access.

GEM partnered with CareChex®, a division of Comparion Medical Analytics, to provide access to the most comprehensive and accurate inpatient quality data available to consumers, providers and purchasers of U.S. medical care. Unlike other publicly available quality ratings, Comparion provides a composite evaluation of inpatient medical quality including process of care, outcomes of care, and patient experiences.

According to Benjamin Tabah, Product Development and Marketing Manager at GEM, "there are a lot of tools out there for shopping routine care but we wanted to focus on high value inpatient care and use the most objective data we could find. With more patients acting like consumers, the ability to influence behavior through incentives is ripe and the time for FairChex is now."

GEM anticipates clients could see savings of $10 000 or more each time an 'A' facility is selected over a 'C' one. For complex (more expensive) admissions, or in situations where network discounts might play a larger role, the savings could be significantly higher.

"The value to the clients on this new product is quite exciting," states David O'Connor, president of GEM. "This isn't limited to cost savings either - by using FairChex, administrators have access to a tool that can help them work with members to choose high quality facilities, improving outcomes of care."

To learn more about Fairchex, or to request a presentation, visit For additional information on how FairChex could impact your organization, please contact Benjamin:, 819-437-2277.

About GEM
Global Excel Management (GEM) is a worldwide leader in the field of medical cost containment services. Founded in 1996, the company has been offering cost-containment and cost-avoidance solutions for payers with exposure to US healthcare. Domestically, GEM is recognized as a leader in negotiations and high-dollar bill reviews. GEM has been promoting pre-service negotiations for years and, with FairChex, the company has laid the foundation necessary to promote this type of healthcare shopping. Visit

About Comparion

As one of the nation's largest privately held healthcare information services companies, Comparion is dedicated to providing an extensive array of products and services designed to measure, manage, and monitor the clinical, financial, and market performance of healthcare organizations.

Comparion's products and services include the CareChex Quality Rating System, CareTracks Provider Profiling System, CarePoints Episode Evaluation System, and associated consulting and training services. Each day, more than 1,000 healthcare professionals from leading academic medical centers, health systems, Fortune 500 companies, and payers rely on our medical analytics and software solutions to assess the cost and quality of medical services delivered across the continuum of care. Visit


Truveris Launches RxChoice, the Industry's First Pharmacy Benefit Marketplace

MyHealthGuide Source: Truveris, 9/23/2014,

NEW YORK -- Truveris, the leading pharmacy benefit pricing and analytics company, announced the first U.S. pharmacy benefit marketplace, RxChoice. Designed with pharmacy benefit brokers and health plan advisers in mind, RxChoice creates the ability to generate free pharmacy benefit quotes from the nation's top vendors and award contracts in minutes, providing unprecedented transparency, access and significant time savings.

As brokers look to finalize PBM contracts in time to award plans with a January 2015 start date, the RxChoice marketplace is an invaluable tool in meeting the tight deadlines. RxChoice provides access to pre-negotiated contracts and highly competitive pricing in just a few simple steps, automating the formerly laborious process of selecting a pharmacy benefit manager (PBM).

In a rapidly evolving healthcare market, RxChoice will continue to streamline the complex pharmacy benefit selection process in 2015 with the addition of plan design modeling. Starting in Q1 of next year, brokers and advisors will be able to use RxChoice to identify plan improvements and savings opportunities by calculating the financial impact of plan design changes, access stop loss insurance and have insight into drug-level inflation.

"RxChoice builds naturally on our foundation of providing state of the art pharmacy benefit plan tools designed to help employers keep their benefit costs in check," said Bryan Birch, CEO of Truveris. "We are very pleased with the traction RxChoice has seen out of the gate – running more than 150 quotes in the past 90 days, with extremely positive broker feedback."

About Truveris

Founded in 2009, Truveris is a leader in bringing unprecedented efficiency, transparency and cost containment to the pharmacy benefit process through cloud based, SaaS solutions for PBMs, health insurers, benefit consultants and self-insured companies. An early innovator in the pharmacy benefit landscape, Truveris currently analyzes nearly 10% of the prescriptions in the U.S., giving Truveris unique insights into the issues and challenges of the $300 billion prescription drug industry in the U.S. Based in New York City, Truveris is funded by Canaan Partners, New Leaf Venture Partners, Tribeca Venture Partners, New Atlantic Ventures and First Round Capital.  Visit


Data Dimensions Launches New Website

MyHealthGuide Source: Data Dimensions, 9/25/2014,

JANESVILLE, WI -- In order to better serve its customers and showcase information about its solutions and services, Data Dimensions, a leader in the field of business process automation, has launched a new website.

The site,, is a streamlined, easy-to-navigate portal for information. The home page features icons linking to pages that showcase the solutions Data Dimensions offers, including Centralized Mailroom, Medical Claims Processing, AP Processing and others. Those pages link to services specific to each solution, allowing customers to find information they need in three clicks or less.

The new site also has pages focusing on the company's history, affiliations and career opportunities, as well as a page devoted to Compliance, letting visitors know that Data Dimensions meets regulations related to HIPAA, PHI, GLBA, PCI, Sarbanes-Oxley, FISMA and other regulatory initiatives.

Jon Boumstein, Data Dimensions President and CEO, says: "As Data Dimensions continues to grow, it's important for our web presence to reflect that growth. The new site shows clients how Data Dimensions can offer solutions to their specific needs, allowing them to increase efficiency and focus on their core competencies."

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, 800-782-2907 and visit


SIIA Announces Global Excel and DialysisPPO Upgrade to Gold Member Status

MyHealthGuide Source:  The Self-Insurance Institute of America, Inc. (SIIA), 9/26/2014,

The Self-Insurance Institute of America, Inc. (SIIA) today announced that Global Excel and DialysisPPO have upgraded to SIIA Gold member status.

These latest membership upgrades 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.

About Global Excel

Global Excel is a worldwide premium medical cost containment company, providing services to a broad range of market segments. Our partners trust our expertise in controlling healthcare costs for the management of their claims dollars as well as our ability to provide a superior member experience.  Visit

About DialysisPPO

DialysisPPO helps group health plans and their partners manage the exceptionally high cost of dialysis cases for the treatment of End-Stage Renal Disease. Our patented program enables plans to capitalize on the unique Medicare reimbursement aspects of this costly disease, yielding average client savings of $590,000 per dialysis case annually. Contact Mike Jeffers, Director of Sales and Marketing, at 610-590-2203 or visit

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.  Contact Jenn Ivy, SIIA Membership Director, at and visit


People News

United Claim Solutions (UCS) Seeks Regional Sales Manager for the Southeast

MyHealthGuide Source: United Claim Solutions (UCS), 9/26/2014,

PHOENIX, AZ -- United Claim Solutions (UCS) continues to grow nationwide. We are seeking a high energy, results driven individual that is interested in a company that values its employees and rewards performance.

Candidates should have a minimum of 2 years sales success in the cost containment, PPO or health insurance markets selling to payers, employers, labor organizations or health plans.

For more information contact Corte Iarossi, VP, Sales & Marketing at 866-762-4455, Ext. 120, or at

About UCS

United Claim Solutions is an innovative Medical Cost Reduction and Claims Flow Management company providing cutting edge and customizable programs for payers, employers, unions, reinsurers, accountable care organizations and health plans. UCS offers end to end services including Bill Review, Out-of-Network Bill Repricing, Medicare Plus Repricing, PPO Administration, Medical Management, Clearinghouse Services, Data Warehousing, Scanning/OCR, and Plan Modeling. We provide solutions for Group Health, Workers' Compensation, and Auto Liability. Contact Corte Iarossi at 866-762-4455 Ext. 120, and visit


Market Trends, Studies, Books & Opinions

Fred Hunt Comments on 'Minimum Value Calculator Issues'

MyHealthGuide Source: Fred Hunt, Active Past President, Society of Professional Benefits Administrators, 9/22/2014,

Editor's Note: At recent SPBA meeting and in newsletters, Mr. Hunt comments on "Minimum Value Calculator Issues" An article written by Hobson D. Carroll, FSA is published again below for reference in this Newsletter issue.

The text of ACA was never intended to be a law. It was a hodge-podge political negotiating tool of the Senate Finance Committee, and about 80% was expected to be dropped or "traded off" during negotiations with the House. However, Teddy Kennedy died, was replaced by a Republican, and Democrats no longer had a slam dunk. So they passed the only thing that had passed.

The House was strong-armed to pass the Senate hodge-podge as-is (so Nancy Pelosi was accurate that the House members had never seen it before). So, the moral of the story is that the law is the disjointed hodge-podge negotiating document. So, trying to assume there is careful thought and deep logic is a lost cause.

Below are excerpts from Mr. Hunt's recent report to SPBA members about Minimum Value Calculator formation and opinions on the actuarial goal of the Calculator.

"Gone viral" is a description of plans to meet the Calculator, but not include hospitalization. The good news is that the reaction has been positive. My political heads-up senses there is a larger strategy to portray employers, the private benefits system, and professionals such as TPAs as conniving and evil (and thus the "need" for government single payer). So, I urged the benefits community not to get lured into an internal spitting match, and to look at the issue in its real-world impact, not knee-jerk emotion.

SPBA President Anne Lennan and Rhonda on the SPBA staff and SPBA TPAs are striving to guide Washington Post article writers and others who use words like "gaming", "substandard" and "glitches". The authors appreciates the insight and plans a second story on "perspectives that deserve to be heard". This is especially important, because the government agencies are being absolutely mum to everyone.

  • (1) This is not a political finger-pointing issue pro or con Obama, so don't get bogged down in election mania. SPBA members know from first-hand face-to-face experience that ACA was a hodge-podge political negotiating document never intended to be a law, so never try to make sense of it. In the case of the Calculator, the actuaries simply did actuarial science on value. They did not put a political spin on it to make it a goodie bag.
  • (2) Putting on my historian hat, politicians, publishers and public have the tunnel vision assumption that "access" and "coverage" are synonymous with womb-to-tomb price-is-no-object health care. Decades ago, when this myopia was taking shape, SPBA repeatedly tried to explain that we would reach a point where people had a coverage card…but that did not mean health care services. We now see a market where the number of doctors and choices is shrinking, and things like high co-pays and deductibles embraced by Exchanges act like a financial fence blocking low-cash-flow people from actually using that coverage card.
  • (3) Easy to understand Value examples: Which was more valuable to give a worker: A Ferrari for which the worker could not afford gas or insurance costs?  Or, an economy car to do the necessary daily activities? Of course, the economy car was of far more useful value.

About SPBA

SPBA is the national association of Third Party Administration (TPA) firms who provide comprehensive ongoing administrative services to client employee benefit plans. SPBA also has a Stop-Loss Service Partner category for carriers, MGUs, and re-insurers of self-funded health plans.  Visit


Minimum Value Calculator Issues -- Part 2
--Publish again for reference from last issue

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


Legal, Legislative & Regulatory News

SIIA Participates in Discussion of NAIC's Stop Loss White Paper Draft

MyHealthGuide Source: 9/23/2014,

The Self-Insurance Institute of America, Inc. (SIIA) participated on a National Association of Insurance Commissioners (NAIC) teleconference to discuss the organization's draft white paper entitled "Stop Loss Insurance, Self Funding and the ACA."

As reported last week, SIIA submitted a detailed comment letter in response to the draft white paper.

Today's call was convened by the NAIC's ERISA (B) Working Group chair, Christina Goe of Montana, and NAIC staff liaison, Jennifer Cook.

Call Highlights

  • The NAIC received eight comment letters from regulators, industry and consumer groups.
  • In general, the comments were focused on three general areas: aggregate annual funding, consumer disclosure and stop loss form review.
  • One regulator said he appreciated SIIA's detailed comments about advanced aggregate funding and making revisions to the language about TPAs "loaning" money to clients.
  • After revisions are made, staff will release the revised white paper before the mid-November NAIC meeting.
  • The NAIC will be taking additional testimony from interested parties at that the meeting.
    SIIA will keep you updated on the latest from the NAIC and advise you when the latest version of the NAIC stop loss paper is made available.

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.  Contact SIIA State Government Relations Director Adam Brackemyre at and visit


Tough to Appeal District Court's ERISA Remand Order

MyHealthGuide Source: Mike Reilly,, Lane Powell Attorneys & Counselors, 9/18/2014, Blog Entry

Case: Mead v. Reliastar Life Insurance Company, 2nd Cir. 9/16/2014. Court's Ruling

Case Background

Mead sought ERISA-governed long term disability benefits, which were denied by claims administrator Reliastar. After she filed suit, the district court remanded to Reliastar to calculate the amount of benefits owed. Reliastar appealed, but Mead argued the remand was not a "final decision" from which an appeal can be taken.

Whether an order remanding the claim to the ERISA administrator constitutes a "final decision" from which an appeal may be taken?

The 2nd Circuit held: NO. Appeal Dismissed--Remand decisions are not "immediately appealable."

  • "[S]ister circuits are split on the issue….[T]he First, Fourth, Sixth, Eighth and Eleventh circuits hold that because an ERISA remand order contemplates further proceedings before the plan administrator, it is not 'final' and therefore may not be immediately appealed except when the familiar collateral order doctrine applies." Op. at 7.
  • "[T]he Third, Ninth and Tenth [circuits]…permit immediate appeals in certain circumstances." "[T]he Seventh Circuit… also permits immediate appeals in certain situations." Op. at 8.
  • "Taking into consideration our prior case law and the various analytical approaches used by our sister circuits, we now hold that remands to ERISA plan administrators are not 'final' because in the ordinary case, they contemplate further proceedings by the plan administrator." Op. at 10.
  • "We decline, however, to adopt a hard and fast rule that such orders are never immediately appealable[.]" Op. at 10.
  • "[A]fter a determination by the plan administrator on remand, either party may seek to reopen the district court proceedings and obtain a final judgment." Op. at 11.


Misclassified Employees Not Barred from Recovering Damages Based on Value of ERISA Plan Benefits They Should Have Been Provided

MyHealthGuide Source:  Mark Thomas, Williams Mullen, 9/26/2014, News Article

Case: Gray v. FedEx, No. 4:06-CV-00422 (E.D. Mo. 9/5/2014).  Court's Ruling

Author Preface: This case reminds us that not every dispute referring to ERISA-regulated benefit plans will support the preemption defense. The Gray court's systematic analysis of the preemption defense provides useful instruction on how to apply it. It also offers a caution that the misclassification of workers as independent contractors can have broader consequences than just an impact on the calculation of wages and payroll taxes.

A federal court has held that plaintiffs who proved they had been misclassified as independent contractors, and should have been considered employees, could recover money damages under state law based on the value of the ERISA plan benefits that the defendant employer failed to provide them.

In the above Gray case, the court highlighted the limits of ERISA's powerful preemption clause and of its impact on state law claims.

Case Background

The Gray decision was the latest in a long-running case brought by plaintiffs who were full-time package delivery drivers for the defendant package delivery service, FedEx Ground Package System, Inc. Plaintiffs asserted, among other things, a claim under state law that FedEx had misclassified them as independent contractors when, in fact, they were employees entitled to benefits under FedEx plans for medical, dental, vision, disability, life, travel and accident insurance and under FedEx's Pension and 401(k) retirement plans. The plaintiffs also claimed that FedEx had wrongfully withheld information from them that prevented plaintiffs from determining whether they would be eligible for benefits under those plans.

FedEx denied that it had misclassified the plaintiffs' employment status, and contended also that the plaintiffs could only have pursued these claims for benefits in a federal multi-district case in Indiana. There the court had dismissed the claims without prejudice because that set of plaintiffs had not exhausted administrative remedies. FedEx also contended in Gray that plaintiffs' state law claims for money damages were barred by ERISA's preemption clause. On these two grounds, FedEx moved the court to grant summary judgment against the plaintiffs.
ERISA's section 514(a) generally provides that, except as limited in section 514(b), ERISA's provisions "shall supersede any and all State laws insofar as they may now or hereafter relate to any employee benefit plan" covered by ERISA.

The U. S. Supreme Court and lower federal courts have held that a state law, including a state's common law, "relates to" an ERISA plan if the state law

  • (1) expressly refers to the ERISA plan or
  • (2) has a connection with it. ERISA plan defendants typically invoke ERISA preemption to dismiss state law claims when possible,

because the remedies under ERISA are usually much more limited than those allowed under state law, for example, compensatory and punitive damages.

Court's Ruling

The Gray court acknowledged that FedEx had always maintained that the plaintiffs were independent contractors, not employees eligible for the disputed plan benefits, but the court concluded that, under state law, FedEx controlled the manner and means of the plaintiffs' work to such an extent that they were in fact FedEx employees.

Among other factors, FedEx controlled the drivers' work dispatches and routes, required that packages be dropped off and picked up at certain times, and determined what the drivers wore. However, until the court had resolved this question of employee status, the plaintiffs could not have asserted their claims in the federal case in Indiana, and the Gray court therefore rejected that defense.

Turning to FedEx's preemption defense, the court noted that plaintiffs' expert had opined that each plaintiff lost $6,000 annually for benefits that such plaintiff otherwise would have received under the FedEx welfare benefit plans, and $1,000 annually for estimated benefits, including matching 401(k) contributions, under the FedEx retirement plans.

FedEx did not assert that plaintiffs' state law misrepresentation claims explicitly "referred to" the FedEx plans, but contended that they were preempted because they had a "connection" to the plans.

Court Rejects FedEx's Preemption Argument

Considering several factors under cases in the U. S. Court of Appeals for the Eighth Circuit, in which the Gray court is located, the court rejected FedEx's preemption argument. The court held that the plaintiffs were not seeking to recover benefits due under the FedEx plans, enforce rights under the plans or clarify rights to future benefits, pursuant to ERISA's civil remedies section 502(a).

They sought instead to recover damages arising from their misclassification as independent contractors, and the damages would be paid by FedEx, not the plans. Thus, their state law claims "would not have any significant economic impact on FedEx's plans." In addition, the dispute was between FedEx and the plaintiffs as employees, not as ERISA participants, and thus would not affect relations among the ERISA entities (such as the plans and plan administrators), or impact the structure of the plans or plan administration. Although the plaintiffs' claims required some reference to the plan documents in order to calculate damages, this relationship was too tenuous to trigger ERISA preemption. FedEx's summary judgment motion was therefore denied.

Significant Lessons

The broad scope of ERISA preemption has been tested many times since the statute's enactment, and has often been applied to supersede and dismiss claims asserted under state law, but Gray reminds us that not every dispute referring to ERISA-regulated benefit plans will support the preemption defense. The Gray court's systematic analysis of the preemption defense provides useful instruction on how to apply it. Gray also offers a caution that the misclassification of workers as independent contractors can have broader consequences than just an impact on the calculation of wages and payroll taxes.


Medical News

Use of Decision-Support Guide by Pregnant Women Results in Less Prenatal Testing and Less Costs

MyHealthGuide Source: Miriam Kuppermann, Ph.D., M.P.H., et al. Journal of American Medical Association, 9/24/2014, JAMA Article

An intervention for pregnant women that included a computerized, interactive decision-support guide regarding prenatal genetic testing, and no cost for testing, resulted in less prenatal test use and more informed choices, according to a study in the September 24 issue of JAMA.

Since the introduction of amniocentesis, prenatal genetic testing guidelines have focused on identifying women at increased risk of giving birth to an infant with Down syndrome or other chromosomal abnormalities, for whom invasive diagnostic testing should be recommended. Prenatal genetic testing guidelines recommend providing patients with detailed information to allow informed, preference-based screening and diagnostic testing decisions. The effect of implementing these guidelines is not well understood, according to background information in the article.

Researchers randomly assigned 710 pregnant women to receive either a computerized, interactive decision-support guide and access to prenatal testing with no out-of-pocket expense (n = 357) or usual care as per current guidelines (n = 353). The trial was conducted from 2010-2013 at prenatal clinics and practices from throughout the San Francisco Bay area.

Study findings

  • Less than half of the women who were assigned to the intervention group underwent invasive diagnostic testing compared with women randomized to the control group (5.9 percent vs 12.3 percent).
  • The overall prenatal testing strategy used by the 2 groups also differed: women randomized to the intervention group were more likely to have no testing (25.6 percent vs 20.4 percent) or screening alone (68.5 percent vs 67.3 percent).
  • Women assigned to the intervention group had significantly higher genetic testing knowledge scores, were more likely to correctly report both the miscarriage risk of amniocentesis and their likelihood of carrying a fetus with the congenital disorder trisomy 21.

"This study's finding that women who were randomized to the intervention group were less likely to undergo testing than those who received usual care adds support to the contention that women may not be receiving adequate counseling about their options. This underscores the need for clinicians to be clear that prenatal testing is not appropriate for everyone, and to present forgoing testing as a reasonable choice," the authors write.

This study was funded by grants from the National Institutes of Health and the March of Dimes Foundation. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.


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

  Stop-loss Provider Years Providing Stop Loss Associated Carriers / MGUs Annual stop-loss Premium
Capital /Equity
1. CIGNA     $1,907
  CIGNA 2013 10-K, page 46 2/27/2014
2. Sun Life Financial     $915.2
  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+)
  HCC Insurance Holdings, Inc. Release,
4. HM Insurance Group >30 Years HM Insurance Group
(A.M. Best Rated: A-)
Mike Sullivan, President & COO
5. Symetra >36 Years Symetra Life Insurance Company
(A.M. Best Rated: A)
(Block - $475M
MRM - $255M)
Michael Fry, Executive Vice President, Symetra;
Mike McLean, Chairman Medical Risk Managers, Inc.
6. ING Employee Benefits > 35 Years ReliaStar Life
(A.M. Best Rated: A)
Joe Keller, Lead Financial Analyst, ING Employee Benefits,
7. Companion Life > 20 Years   $310
  Philip Gardham, Vice President, Specialty Markets,
8. National Union Fire Insurance Company of Pittsburgh >35 Years AIG Benefit Solutions $215
  Jeff Gavlick, VP, Stop Loss Products, AIG Benefit Solutions
9. Independence Holding Company   Standard Security Life Insurance Company of New York,
Madison National Life, Independence American Insurance Company
$200   Roy T.K. Thung, CEO, Letter to Stockholders
10. Zurich North America     $130   Tracey Brennan, Zurich North America.
11. Munich Re Stop Loss, Inc.   AIC, TransAmerica $110
  Susan McGrath Bowman,
Chief Operating Officer, Munich Re Stop Loss, Inc.
12. The Union Labor Life Insurance Company  (ULLICO) >25 Years ULLICO
(A.M. Best Rated: B++)
  Victor Moran, Second Vice President, Actuarial Operations.  3/12/2014
Markel Insurance Company <5 Years Markel Insurance Company
(A.M. Best Rated: A-)
$3 $$3,388
Mark Nichols, Managing Director.

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

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

Stop-loss Premium Volume is not the Whole Story

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

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

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


Upcoming Conferences

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  Information and Registration:

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:

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 . See

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 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). 

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 . See

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

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,, 212.960.3210.  Skype: sandra.e.will. Registration:

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

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:

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 .

December 4-5, 2014
IHC Forum West presented by the Institute for HealthCare Consumerism. Las Vegas, NV. Contact Joni Lipson at and visit


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  Information and registration: and visit

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: 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.

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

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

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

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

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

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

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 and visit

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

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


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

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


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

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


Editorial Notes, Disclaimers & Disclosures

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

    •  Is the Newsletter email in your junk or spam folder?
    •  Have your IT team "whitelist" sender (
    •  Provide another email address.
    •  Access the Newsletter online at

    Our email servers inactivate an account (email address) after three successive failed attempts to deliver the Newsletter. Failures to deliver occur when your email server "bounces" our Newsletter because your server views our email as spam because of anatomical terms often referenced in our "Medical News" section and for other reasons.


Clevenger Ernie Clevenger
President & Publisher
MyHealthGuide, LLC