MyHealthGuide Newsletter
News for the Self-Funded Community
1/16/2017 

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

TABLE OF CONTENTS

General & Company News

People News

Market Trends, Studies, Books & Opinions

Legislative & Regulatory News

Medical News

Recurring Resources

Upcoming Conferences

Editorial Notes, Disclaimers & Disclosures


General & Company News



Transamerica Plans to Exit the Stop Loss Insurance Market Mid-2018

MyHealthGuide Source: Julie Quinlan, 1/10/2017, www.Transamerica.com

Transamerica will exit the Stop Loss insurance market by mid-year 2018. "At Transamerica, we constantly evaluate our product portfolio to ensure that we provide value to our many customers and shareholders," said John Stanley, Vice President and Managing Director of Transamerica Employee Benefits.

"We have determined that Stop Loss insurance no longer fits within Transamerica's longer-term strategic priorities and consequently, we expect to conclude most new business by the end of 2017. We will be working diligently with our managing general underwriters and reinsurers to complete our exit over the next 18 months. In the meantime, we will honor our commitments to them and fully support our existing stop loss customers with the same high level of service they have come to expect."

Transamerica has notified key distribution partners and reinsurers regarding the plans to exit the Stop Loss insurance market.

About Transamerica

With a history that dates back more than 100 years, the Transamerica companies are recognized as leading providers of life insurance, savings, retirement and investment solutions, serving millions of customers throughout the United States. Transamerica works to Transform Tomorrow® for those who entrust its dedicated professionals with their financial needs, helping them take the necessary steps to achieve their long-term goals and aspirations. Transamerica's 10,000 employees serve nearly every customer segment, providing a broad range of quality life insurance and savings products, individual and group pension plans, as well as asset management services. In 2015, Transamerica fulfilled its promises to customers, paying more than $6.9 billion in insurance and annuity benefits, including return of annuity premiums paid by the customer. Transamerica's corporate headquarters is located in Baltimore, Maryland, with other major operations in Cedar Rapids, Iowa. Transamerica is part of the Aegon group of companies. Aegon is one of the world's largest providers of life insurance, pension solutions and asset management products, operating in more than 20 markets worldwide. For the full year of 2015, Aegon managed $768 billion in revenue generating investments. Visit www.transamerica.com.

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Advanced Medical Strategies Releases Top 5 Lists for Drugs and Diagnoses

MyHealthGuide Source: Advanced Medical Strategies (AMS), 1/17/2017, www.mdstrat.com

LYNNFIELD, Mass -- As catastrophic diagnoses and their associated costs continue to rise Advanced Medical Strategies (AMS) has released its 3rd annual lists of the most commonly researched diagnoses and specialty drugs of 2016. PredictDx and PredictRx are two key modules of the AMS Predict Suite of solutions, which provides predictive clinical and financial analytic tools that allows payers deep insight into catastrophic healthcare claims.

With hundreds of thousands of searches on the Dx and Rx directories, it's clear that payers have come to trust the clinical and financial data that they both provide. AMS has analyzed the diagnoses and drugs that have been trending highest for its subscribers over the past year and issued reports listing the top 5 in each category with associated facts & figures about each one.

The first report is entitled the PredictDx Top 5 Diagnoses of 2016. From the 200+ diagnoses within the PredictDx database AMS found that Breast Cancer was researched the most over the past year with 14,841 searches. ESRD was not far behind with 13,318, well above the next three.

PredictDx Top 5 Diagnoses of 2016

  1. Breast Cancer
  2. Chronic Renal Failure / End Stage Renal Disease (ESRD)
  3. Non-Hodgkin Lymphoma
  4. Prostate Cancer
  5. Multiple Myeloma

The full PredictDx Top 5 Diagnoses data sheet can be found here. The report includes cost trends, complications, average total billed claims and more about those popular medical diagnoses.

For the PredictRx Top 5 Researched Drugs of 2016, among the hundreds of the costliest pharmaceuticals prescribed today AMS pinpointed Remicade as the one its clients inquired about the most during the past 12 months. Industry professionals should be particularly mindful about this drug and the four others (see below) when addressing high dollar claims in 2017.

PredictRx Top 5 Drugs of 2016

  1. Remicade
  2. Opdivo
  3. Humira
  4. Rituxan
  5. Herceptin

More information about the PredictRx Top 5 Drugs can be accessed from the link. It is AMS' goal, through this list and within the PredictRx platform, to enable its clients to make informed decisions with regard to a drug's reasonable costs, especially since the price of specialty drugs continues to spiral out of control.

Peter Borans, president of AMS: "As always when presenting these lists, we're excited to inform and educate our subscribers about what drugs and diagnoses are impacting them the most. Our clients rely on the cutting-edge information. And, fittingly, with such an active subscriber community we are fortunate to have an on-going dialogue about enhancements, data elements and information that pushes us to repeatedly break ground on new ways to view clinical and financial information. As AMS continues on its path to provide increased transparency of pricing, predictive analytics and knowledge around the pharmaceuticals, implants and diagnoses that contribute to the ever-escalating spend, it's becoming increasing clear why the Predict Suite has become so widely adopted."

  • PredictDx: A web-based solution that combines medical data and financial analytics to address the challenges associated with managing, reimbursing, and underwriting catastrophic claims.
  • PredictRx: A comprehensive directory of specialty drugs that evaluates cost data, FDA approved indications, notable off-label usage, adult/pediatric dosing regimens, specialty drug coding, and critical physician commentary.

About AMS

Advanced Medical Strategies is a physician-led organization serving TPAs, Health Plans, HMOs, Worker's Compensation Payers, MGUs, Stop-Loss Carriers, Specialty Risk Insurers, Occupational Accident Insurers, A&H Insurers, and Self-Administered Group Health Plans. With thousands of hours saved in research, analysis and underwriting AMS has leveled the playing field between the Administrator and Carrier resulting in superior premiums and increased revenue streams for payers.  Contact Stephanie Belschner at stephanie@mdstrat.com, 781.224.9711 ext. 116 and visit www.mdstrat.com.

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Data Dimensions Earns SOC 2 Certification for Secure Data Practices

MyHealthGuide Source: Data Dimensions, 1/2017, datadimensions.com

JANESVILLE, WI -- Data Dimensions is proud to announce it has successfully completed the Security Organization Control (SOC) Type 2 audit, meeting the SOC 2 criteria and standards for security. The audit is conducted in accordance with American Institute of Certified Public Accountants (AICPA) Trust Services Principles, and the SOC 2 certification assures Data Dimensions' clients that, because of the methods the company utilizes, their data is secure.

"The SOC 2 acknowledges our strong focus on security," said Jon Boumstein, Data Dimensions President and CEO. "It serves as recognition of the fact that at Data Dimensions, our clients' sensitive data remains safe and protected. What's more, the SOC 2 certification shows that our applications, including Dimensions360, our Enterprise Content Management solution, are developed and utilized under the strictest standards of reliability and security."

Security Organization Controls (SOC) are a series of standards that measure how well a service organization controls its information. The SOC 2 is an audit report awarded to advanced service providers demonstrating a superior level of controls in the areas of security, availability, processing integrity, confidentiality and privacy. Applications and software developed by a SOC 2-certified organization, such as Data Dimensions, must follow audited processes and controls that ensure applications and code are developed, reviewed, tested, and released following the AICPA Trust Services Principles. The certification is crucial when trusting a company with highly sensitive information, including passwords, documents and secure images.

"Our clients can feel even more reassured that their information is safe with Data Dimensions," Boumstein said. "The SOC 2 certification confirms Data Dimensions' commitment to security, integrity and confidentiality."

About Data Dimensions

Since 1982, Data Dimensions has been helping clients better manage business processes and workflows by bridging the gap of automation, technology, and physical capabilities. As an innovative leader in the area of information management and business process automation, we provide a complete range of outsourcing and professional services including mailroom management; document conversion services; data capture with OCR/ICR technologies; physical records storage and electronic retrieval services through our state of the art Tier III data center.  Contact Will Pfeifer, Marketing Coordinator, at wpfeifer@datadimensions.com, 800.782.2907 and visit datadimensions.com.

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

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Brentwood Services Administrators Inc. Opens New Office in Conyers, Georgia

MyHealthGuide Source: Brentwood Services Administrators Inc., 1/12/2017, www.BWood.com

BRENTWOOD, TN -- Brentwood Services Administrators Inc. recently opened a new claims office in Conyers, Georgia, according to Jeff Pettus, president and chief executive officer of Brentwood Services Administrators Inc., a third-party administrator.

Overseeing the operations in the Conyers office is Cheryl Hill, claim supervisor. The office currently provides claims management and loss control services for a wide range of employers and employer associations in the state of Georgia, including those in local government, school systems, major health systems and manufacturing.

Pettus explains, "We've been handling claims in Georgia for over 20 years. The office was opened due to our company's business growth and increasing opportunity in the market. We felt having a physical office location in the state was a strategic move towards solidifying our presence in Georgia and one that reflects our commitment, stability and desire to grow." 

For information related to claims administration in the Georgia office, please contact Hill at Cheryl.Hill@bwood.com or 1-800-524-0604.

About Brentwood Services Inc.

Brentwood Services Inc. is an independent employee-owned company headquartered in Brentwood, Tenn., specializing over the past 26 years in structuring and managing alternative market solutions for employers and insurance providers. contact John Smitherman, senior vice president, sales, at John.Smitherman@bwood.com or Randy Chapman, vice president, sales, at Randy.Chapman@bwood.com. Both can be reached at by phone at (800) 524-0604 and visit www.BWood.com.

About Brentwood Services Administrators Inc.

Brentwood Services Administrators Inc. provides claims management and loss control services to employers and employer associations with self-insured and large deductible programs for workers' compensation and other casualty lines throughout the contiguous 48 states. BSA's aggressive coordinated approach to claims administration and loss control has a proven track record of reducing the cost of claims for its clients. BSA also provides underwriting, policy management and accounting services to association-sponsored pools and mutual insurance companies.

About Brentwood Reinsurance Intermediaries Inc.

Brentwood Reinsurance Intermediaries Inc. (BRII) provides insurance brokerage services encompassing self-insurance, guaranteed cost and deductible insurance with a focus on workers' compensation. Reinsurance intermediary services include workers' compensation, accident and health, general and automobile liability casualty and specialty coverages. Clients include corporations, governmental entities, insurance companies and captive insurance companies. Visit www.brentre.com.

About CompPoint Managed Care Inc.

CompPoint Managed Care Inc., a managed care provider and wholly owned subsidiary of BSI, offers medical case management, utilization review, medical bill review, pharmacy benefits management and other ancillary services designed to control claim costs. Visit www.comppointmc.com.

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Rx Savings Solutions Offers Self-funded Teachers Health Trust Implements Rx Savings Tool

MyHealthGuide Source: Rx Savings Solutions via PRNewswire, 1/9/2017, rxsavingssolutions.com

OVERLAND PARK, Kan. -- The Teachers Health Trust of Southern Nevada has teamed with Rx Savings Solutions to offer its 38,000 participants access to the innovative healthcare software. Founded by pharmacist Michael Rea, Rx Savings Solutions helps health insurers and self-funded employers drive consumerism and engagement for employees by focusing on the most predictable spend in healthcare--pharmacy.

"We are excited to partner with the Teachers Health Trust and help their participants navigate the complex world of prescription drugs. Our goal is to make their lives easier while spending less money by providing access to information not previously available," says Michael Rea, founder and CEO of Rx Savings Solutions. "We leverage technology in every part of our lives to be an educated consumer, except in healthcare, and we are changing that."

The state-of-the-art tool relies on patented algorithms to analyze thousands of recommendations to find the best clinical option while maximizing savings.

"As stewards of the overall health and productivity of our valued teachers in Southern Nevada, we recognize the immense value and importance of innovative technologies and systems aimed at not only controlling costs, but improving the overall health of our population and purchasing experience," says Gary Earl, CEO of Teachers Health Trust. "Rx Savings Solutions has emerged as our single most powerful new and inventive tool in our efforts to educate, engage and activate our participants in the essential elements of access, affordability, compliancy and improvement. We are bullish on our new provider partner and look forward to evolving our mission from one of success to one of significance."

Rx Savings Solutions serves organizations nationwide with marquee clients including Blue Cross and Blue Shield of Kansas City, the State of Kansas Employee Health Plan, Community Health Options Health Plan, West Virginia Public Employees Insurance Agency, BH Media Group--a Berkshire Hathaway company--and American Century Investments, among others.

Rx Savings Solutions' system is HIPAA security compliant. All interaction between the software platform and the employee is confidential. Rx Savings Solutions is without bias and delivers the most accurate, cost-effective data to subscribers based solely on the location and medication needs of each user.

About Rx Savings Solutions
 
Rx Savings Solutions offers an innovative, patented engagement software system empowering employers and employees to be educated consumers of healthcare. Founded and operated by a team of pharmacists and software engineers, Rx Savings Solutions supports a collaborative, cost-saving solution for purchasing prescription drugs. Using their clinical backgrounds, Rx Savings Solutions delivers proactive personalized recommendations on ways to optimize therapies to members, while achieving proven savings results for employers, employees and health plans. Located in Kansas City, Rx Savings Solutions serves self-insured businesses, employer groups, health plans and their members nationwide. Visit rxsavingssolutions.com and follow on LinkedIn and Twitter.

About Teachers Health Trust

Teachers Health Trust is a self-funded health trust, which provides medical, dental, and vision benefits to all licensed employees of the Clark County School District.

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People News



ELMC Group, LLC Appoints Industry Veteran John Gedney to the Role of Executive VP, Chief Growth Officer

MyHealthGuide Source: ELMC Group, LLC, ("ELMC"), 1/3/2017, elmcgroup.com

New York, NY -- ELMC Group, LLC, ("ELMC"), a manager of premier, full-service managing general underwriters ("MGUs") specializing in underwriting medical stop-loss insurance, announces the hiring of John Gedney into the role of Executive Vice President, Chief Growth Officer. Gedney is an employee benefits entrepreneur with more than 30 years of experience helping companies optimize their benefits plans and is considered an industry expert in the emerging Private Exchange market.

In his new role, Gedney will drive business development and new market opportunities that will further ELMC's accelerated rate of growth and profitability. Prior to joining ELMC, Gedney held the position of Vice President of National Partnerships at Liazon, a Willis Towers Watson company, where he was responsible for creating, developing and overseeing the national broker partner channel.

"John is known throughout the industry as a pioneer who has been on the leading edge of significant industry shifts including managed care and technology," said Richard Fleder, co-founder and CEO of ELMC. "His expertise and experience uniquely positions him to lead our business development efforts, and he will be a great addition to our senior leadership team," said Fleder.

Gedney's previous industry experience includes executive positions with Oxford Health Plans and EBP Healthplans, at the time the nation's leading mid-market, Third Party Administrator and MGU. Prior to joining EBP, John owned an employee benefits advisory firm, Securis, and was a founder of OnlineBenefits, the creator Benergy, the industry leading benefits communications portal.

Gedney holds a Bachelor's Degree in Business from Adelphi University. He is a former finalist in Ernst & Young's Entrepreneur of the Year award and has mentored entrepreneurs in formulating and growing their businesses.

About ELMC

ELMC owns, manages and seeks to acquire premier MGUs across the nation that specialize in underwriting medical stop-loss insurance for self-funded health plans. ELMC provides a best-in-class platform for delivering medical stop-loss solutions to brokers, carriers and clients. Contact Mary Ann Carlisle at mcarlisle@elmcgroup.com and visit elmcgroup.com.

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Brentwood Services Inc. Promotes Riley Brown Promoted to Staff Accountant

MyHealthGuide Source: Brentwood Services Inc., 1/9/2017, www.BWood.com

BRENTWOOD, TN -- Brentwood Services Inc. promoted Riley Brown to the position of staff accountant, according to Jeff Pettus, chief operating officer of Brentwood Services Inc.

As staff accountant reporting to Penny Morrow, accounting manager, Brown is responsible for compiling, analyzing and preparing financial information and reports to maintain the fiscal standards of the organization.

Prior to his promotion, Brown had been serving as a BSI accounting intern since joining the company in May 2015. Brown previously was employed as a customer service associate with Amazon.  A graduate from the University of Tennessee Martin, he holds a degree in accounting. He is a member of the UT Martin Accounting Society.

About Brentwood Services Inc.

Brentwood Services Inc. is an independent employee-owned company headquartered in Brentwood, Tenn., specializing over the past 26 years in structuring and managing alternative market solutions for employers and insurance providers. contact John Smitherman, senior vice president, sales, at John.Smitherman@bwood.com or Randy Chapman, vice president, sales, at Randy.Chapman@bwood.com. Both can be reached at by phone at (800) 524-0604 and visit www.BWood.com.

About Brentwood Services Administrators Inc.

Brentwood Services Administrators Inc. provides claims management and loss control services to employers and employer associations with self-insured and large deductible programs for workers' compensation and other casualty lines throughout the contiguous 48 states. BSA's aggressive coordinated approach to claims administration and loss control has a proven track record of reducing the cost of claims for its clients. BSA also provides underwriting, policy management and accounting services to association-sponsored pools and mutual insurance companies.

About Brentwood Reinsurance Intermediaries Inc.

Brentwood Reinsurance Intermediaries Inc. (BRII) provides insurance brokerage services encompassing self-insurance, guaranteed cost and deductible insurance with a focus on workers' compensation. Reinsurance intermediary services include workers' compensation, accident and health, general and automobile liability casualty and specialty coverages. Clients include corporations, governmental entities, insurance companies and captive insurance companies. Visit www.brentre.com.

About CompPoint Managed Care Inc.

CompPoint Managed Care Inc., a managed care provider and wholly owned subsidiary of BSI, offers medical case management, utilization review, medical bill review, pharmacy benefits management and other ancillary services designed to control claim costs. Visit www.comppointmc.com.

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Market Trends, Studies, Books & Opinions


Fred Hunt's State of the TPA Industry & Forecast for 2017

MyHealthGuide Source: Fred Hunt, SPBA Active Past President, 1/2017, www.SPBATPA.org

Preface: I normally send these Forecasts in the Fall.  However, I waited to see the outcome of the elections and make-up of the new Administration. Brace yourself for exciting times! This is candid, but non-partisan and non-political.

The consistent good news over the 36 years (and today) is that the State of the TPA Industry and market gets stronger and stronger. Barring some unforeseen upheaval such as mandatory national health insurance imposed on everyone (the broadly-used term "single-payer"), the forecast remains for stronger and stronger.

Stay Calm and Carry on

Speaking of upheaval, I am writing this at a time of great angst, with everyone in the media and public either envisioning imminent doomsday in every aspect of American life (Mrs. Obama calls it "loss of hope" …. or conversely…. people who are excited about overly-optimistic expectations (such as total disappearance of all 424 parts of ACA + all regs disappear + insurance and health costs plummeting). I have lived amid political over-despair and/or over-expectation all my life. From that and from historical examples, I can tell you that both fears and happy-talk will pan out as far less than expected. So, the best advice is that famous English saying, "Stay calm and Carry on."

TPA Advantages, Roles and History

TPAs are independent, so they give both the client plan (and SPBA to share with govt. policy-makers) an unbiased view. An estimated 75% or more of the US workforce not in federal plans are in plans of the type TPAs administer (including the insurance company term for their TPA services, ASO).

In 2010, the State of the TPA Industry would have been an obituary, because Obamacare originally would have included TPAs and self-funded plans under all the insurance company rules. It would have been an unworkable square peg in a round hole. At one of our typical SPBA meetings in 2009, we had the key people coordinating what ACA would be. About 90 minutes in active very candid constructive discussion with about 400 SPBA obviously-knowledgeable SPBA member attendees, and the drafters of ACA realized that the insurance company rules would kill the health coverage source for the majority of Americans. So…instead of a death notice, subsequent State of the Industry reports have been optimistic about ever stronger role for TPAs and Self-Funding (not to say that all the other rags and micro-management of the past 8 years haven't been an avalanche of headaches).

Self-Funding is the main marketplace for TPAs and Stop-Loss. (It is also sometimes called Self-Insurance, but I avoid that because it leads to confusion with fully-insured. It can also lead to unnecessary panic and anger among workers who think it means the employer will make them pay all their own medical costs.)

Vocabulary Clarification of 'ASO' and 'TPA'

When Self-Funding began to boom in the 1980's, and customers flocked to TPAs from fully-insured policies, insurers wisely began an "if you can't beat me, join me" strategy to offer TPA services for self-funding, and called it Administrative Services Only (ASO). Legally, it is the same functions and laws.

  • The difference I have noticed is a cultural one, even with TPAs that may be owned or related to insurers.
  • Entities that call themselves TPAs focus intensively on ever-shifting government compliance rags etc., and frequent personalized interaction with personalized plan design etc. of client plans and sponsors. (One TPA described it, "We're compliance nerds who are good at holding clients' hands through the process.") That close personalized approach is usually not practical for a large insurance company.
  • Also, I notice that entities that use the term ASO tend to think of themselves as the insurance company (though applicable laws, and thus the thought process, are different for self-funding).

So, think of TPAs and ASO as siblings with different personalities. If the insurance industry should decide that the health insurance market in the US is no longer profitable or practical (a consideration first seriously raised to me by top insurance company officials in 2008, and things have not gone well for health insurance companies since), I assume that orphaned ASO would meld with their TPA corporate siblings who are already SPBA members, or join SPBA as new separate entities. This is all hypothesis for now, but should be on your radar as a possibility.

Early Self-funding

Though one of our early SPBA members had been doing Self-Funding as early as 1933, the Taft Hartley law of 1945 gave structure via the Employee Retirement Income Security Act (ERISA), which was designed to be….and remains today…the ultimate consumer-protection law with fiduciary responsibility that exceeds normal business law and insurance law (a fact that reformers never seem to know when they naively want to "create" and impose consumer protection…aright).

Plan size: Early Self-funded plans, and thus the market was deemed to be only "prudent" for employee groups of at least 5,000. The "safe" size dropped quickly over the yearly years to 2,500, then 1,000, then 500, then 250, then 100, and expertise of Stop-Loss (same function as what insurance companies call re-insurance as backstop if they have excess losses) and some impressive technology and other services gearing specifically to serve the TPA industry, self-funding applicability is becoming practical for even smaller groups. (As noted in the caveat below, size is not the key factor.) SPBA embraces Stop-Loss and Service Partners geared to serving TPAs. This not only maximizes the teamwork in smoothly selecting and providing services to client plans and employers…but also broadens the information for the whole association's efforts to represent the industry.

When Not to Self-fund

Caveat: Though TPAs do Self-funded plans as their business, they are the quickest to warn and dissuade from using Self-Funding in inappropriate situations. Self-Funded plan sponsors should be financially stable good cash-flow entities, with a mix of old/young healthy, etc. participants to make the plan actuarially feasible. This applies to any shared-risk arrangement (note the ACA Exchanges actuarial weakness and thus unsustainable losses by those insurers). It's just universal common sense. The nice part is that TPAs have shown tremendous professionalism in advising plan sponsors prudently. The moral of this story is that Self-Funding, is, by far, the largest form of health coverage in employee benefits (which is over 177 million Americans, including 75 million Millennials, who are now the largest and fastest-rising segment of US employment). TPAs (and insurer-twin ASO) administer almost all of these Self-Funded plans.

Other advantages for past and continued future TPA success: Government regulation has been dubbed the #1 bane to every type of business and function in the US. Employee benefits is probably the head of that line, since so many agencies and laws apply to various parts of the work. However, TPAs have immediate hands-on familiarity + (important) ongoing close candid communication and cooperation with the client plans. (This is also why SPBA has been able to warn regulators and policy-makers that hundreds of government ideas would trigger far more problems that they might solve, and those ideas have evaporated or been greatly eased.) So, my State of the TPA Industry and Forecast as we enter 2017 is that constant up-close hands-on insight + background of what the govt. is thinking makes TPAs an ever-more popular and needed source of employee benefits plan administration.

About SPBA

Established in 1975, Society of Professional Benefit Administrators (SPBA) helps TPAs navigate a complex and ever-changing employee benefits landscape by keeping them educated and informed with the latest information. SPBA TPAs, along with their Stop-Loss and Technology Service Partners, serve the largest segment of non-federal employee benefit participants today. SPBA is unique in that its members represent every size and type of employment, industry and area of the United States. This all-encompassing perspective, plus a thorough grasp of the compliance picture and a strong relationship with government regulators, makes the SPBA and its hundreds of members an invaluable resource.  Visit. www.SPBATPA.org.

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The Employer Stop-loss Insurance Marketplace Since the Affordable Care Act

MyHealthGuide Source: Mehb Khoja, 1/10/2017, Milliman

Introduction

Most large employers self-insure their medical benefits (based on Kaiser's 2016 Employee Benefits Survey indicating 82% of large employers are covered by partially or completely self-insured plans).  But with the enacting of the Affordable Care Act (ACA) in 2010, small and mid-sized employers are also evaluating the benefits of self-insurance.

A self-insured group health plan is one in which the employer assumes the financial risk for providing healthcare benefits to its employees. Self-insured employers pay for claims by their members as they use healthcare services as opposed to paying a fixed premium to an insurance carrier. With self-insurance, employers bear the risk of high cost or catastrophic claims, which can exceed $1 million and create cash flow and volatility issues for employers. Cancer treatments, organ transplants, high cost pharmaceuticals, and premature births are just a few conditions and procedures known to exceed $1 million in treatment expense. According to the National Business Group on Health's 2016 healthcare survey, high cost claimants are the number one cost driver for 43% of large employers. Employer stop-loss insurance is meant to mitigate that risk by allowing employers to shift risk for claims above a fixed threshold to insurance carriers.

Impact of the ACA on self-insurance

The stop-loss market is believed to be a roughly $15 billion industry, up from $8 billion to $10 billion pre-ACA. Its growth is related to the increased prevalence of self-funding along with the changes from ACA which increased premiums, plan enrollment, or both for stop-loss insurance carriers. Kaiser Family Foundation, in its 2016 Employer Health Benefits Survey, indicated that the prevalence of self-insuring was up to 63% in 2015 from 59% in 2010. The interest in self-insuring is primarily due to cost savings as self-insured plans avoid state-mandated benefits as well as premium tax -- an estimated 2% to 3% lower cost for self-insured plans. With additional taxes for health insurers and the looming excise tax (originally scheduled to commence in 2018 but postponed to 2020), self-insurance can be a meaningful strategy for benefit advisors to help clients curb or delay costs associated with ACA. Other benefits of self-insuring include more flexibility in benefit plan design and access to member utilization data, which can be used to identify population health concerns.

Impact of ACA on stop loss

ACA has considerably increased the need for and expanded employer interest in stop-loss coverage due to several factors:

  • Removal of annual and lifetime maximums (prior to ACA, a cap on annual expenses on an employer-sponsored plan was common and allowed stop-loss insurance carriers to limit their exposure)
  • Removal of pre-existing condition exclusions (prior to ACA, employers could temporarily exclude high risk members)
  • The individual mandate and extending dependent coverage to age 26 have all increased membership in employer-sponsored plans
  • Expanded taxes on fully insured health plans

From an underwriting perspective, the first two items above represented considerable uncertainty that needed to be priced into coverage. Prior to unlimited maximums, many healthcare providers would cap their charges at $1 million, knowing that recouping charges in excess would be difficult. With ACA, the frequency of claims in excess of $1 million has increased significantly as confirmed by data shown in Sun Life's Spring 2016 Stop-Loss Research Report (estimated 25% annual increase in frequency from 2012--2015).

In contrast, the individual mandate and age 26 dependent coverage expanded membership among employers with what can be considered largely low-risk individuals (typically young and healthy individuals who previously decided to forego coverage). This allowed insurers to spread known and unknown risk across a larger population. The increased enrollment provided organic growth for stop-loss carriers as many of their clients saw an increase in membership due to new enrollees or new dependents covered under existing enrollees.

The health insurer tax (along with other taxes and fees that employers needed to prepare for) paved the way for fully-insured employers to enter the self-insured market with stop-loss coverage. These new entrants typically secured stop- loss coverage with their plan administrator as a lack of access to appropriate underwriting data kept many third-party carriers from being able to quote coverage.

Stop-loss marketplace changes

With the growth seen since ACA, the stop-loss industry has seen heightened merger and acquisition activity as well as new entrants into the space. Two large acquirers were Japanese life insurers (Tokio Marine purchased HCC in June 2015 and Sumitomo purchased Symetra in January 2016).

These acquisitions allow for exposure to the U.S. medical insurance market as well as a more favorable interest rate environment. Acquisitions were also made by property/casualty reinsurers (Swiss Re and Houston International Insurance Group) looking to diversify into a market largely dominated by specialty life insurers. The market today consists of nearly 30 to 40 third-party carriers and another 30 to 40 direct writers/health plans, such as the large national carriers like Aetna, Cigna, and United Healthcare, regional health plans, and local licensees of the Blue Cross brand. This count does not include several additional carriers that provide coverage through managing general underwriters. The trend in consolidation is expected to continue as smaller insurers seek to gain economies of scale to compete with the larger insurers.

The growth of the market will likely attract new entrants as well, especially those carriers already providing other types of employer coverages such as life, disability, dental, and critical illness. Fueling that activity is the expectation that the industry will continue to grow organically with a combination of new self-insured employers and leveraged trend (typically 10% to 25% depending on the deductible). Assuming the market grows between 7.5% and 15% per year, the industry is expected to be $19 billion to $23 billion over the next three years. These estimates are based on the current structure of employer-sponsored plans and may change as a result of decisions made by the new administration.

Tracking growth for specific insurers will be tough to measure as the excess capacity in the industry could cause insurers to hold or even reduce current rates in order to renew policies. Further capping individual insurer growth (or net revenue growth) is the growing emergence of products with various combinations of rate caps, dividend/refund programs, and no-new laser policies.

The Donald Trump administration is not in favor of ACA and has advocated for a "Repeal and Replace" strategy. House Speaker Paul Ryan, in his "A Better Way" vision for America, also supports the repeal of ACA and protecting employers' flexibility for self-insurance. While repealing ACA is likely focused on the individual and small group/small business market, the impact could be felt in the employer self-funded market, which could translate to stop-loss carriers. Early indications are that the Trump administration will not hinder the growth of the employer self-insured market -- but time will tell and further evaluation will be needed once the Trump administration announces its strategy. To date, the Trump administration has not put forth any proposal that would hinder the growth of the employer self-insured market.

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Legislative & Regulatory News


Eighth Circuit Rules That ERISA Expressly Preempts Iowa Pharmacy Benefit Law

MyHealthGuide Source: McDermott Will & Emery, 1/13/2017, National Law Review

Case: Pharmaceutical Care Management Association v. Gerhart, No. 15-3292 (8th Cir. Jan. 11, 2017)]  U.S. Court of Appeals for the Eighth Circuit Ruling

The United States Court of Appeals for the Eighth Circuit recently held that ERISA expressly preempts an Iowa law that imposes onerous regulatory requirements on pharmaceutical benefit managers operating in Iowa. The reversal carries national significance and was unanimous.

In Depth

On January 11, 2017, the United States Court of Appeals for the Eighth Circuit reversed an Iowa federal district court's dismissal of the Pharmaceutical Care Management Association (PCMA)'s complaint and entered judgment in favor of PCMA on its ERISA express preemption claims, conclusively terminating the litigation in PCMA's favor. The Eighth Circuit's decision in the above Pharmaceutical case , is of nationwide importance to the pharmacy benefit manager (PBM) industry and the broader health care industry.

The case arose out of a 2014 Iowa law that imposed onerous regulations on PBMs operating in Iowa. PBMs administer prescription drug benefits to over 220 million Americans covered by health benefit plans governed by ERISA. The Iowa law interfered with PBMs' discretion to negotiate prices with retail pharmacies, required PBMs to report proprietary information on their pricing methodologies and interfered with claims-processing procedures.

PCMA's federal court complaint alleged several theories, including express preemption under the Employee Retirement Income Security Act of 1974 (ERISA). The Iowa federal district court later dismissed PCMA's claims.

Court's Ruling

On appeal, a unanimous panel of the Eighth Circuit

  • Reversed the Iowa federal district court's dismissal of PCMA's ERISA express preemption claims,
  • Holding that the Iowa law impermissibly interferes with the PBM function of ERISA plans operating in Iowa.
  • The court explained that the Iowa law "imposes mandates and restrictions on a PBM's relationship with Iowa and its pharmacies that run counter to ERISA's intent of making plan oversight and plan procedures uniform."
  • Significantly, the Eighth Circuit also accepted PCMA's invitation not only to reverse the district court's dismissal, but also to enter judgment as a matter of law for PCMA on its purely legal claims--terminating the litigation in PCMA's favor in a single stroke.

The Eighth Circuit's decision not only has significance because of its effects in Iowa, but also because of its national implications. Several other states are considering enacting legislation similar to the Iowa law. The court's decision, which is binding precedent in the seven states of the Eighth Circuit (Arkansas, Iowa, Minnesota, Nebraska, North Dakota and South Dakota), may help stem the advance of similar legislation in states outside the Eighth Circuit that would impermissibly encroach upon the PBM function of ERISA health plans.

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Hospital's ERISA Claims Can Go Before Jury

MyHealthGuide Source: Jacklyn Wille, 1/10/2017, BNA Pension & Benefits Daily

Case: Keokuk Area Hosp., Inc. v. Two Rivers Ins. Co. , 2017 BL 4312, S.D. Iowa, No. 3:16-CV-00066-SMR-SBJ, 1/7/17 ).  Court Ruling via BNA.

An Iowa hospital that allegedly lost millions of dollars at the hands of an inexperienced benefits plan administrator can bring its fiduciary breach claims before a jury for the above Keokuk case.

A federal judge on Jan. 7 found that the hospital's claim for fiduciary breach under Section 502(a)(2) of the Employee Retirement Income Security Act could go before a jury because the hospital was "merely attempting to recover overpayments" that it was forced to make due to the administrator's alleged breach. Because those losses were "unconnected to distribution of benefits," the judge found the claim legal in nature and thus suitable for a jury trial.

Jury trials in ERISA cases are rare, with most courts holding that the law prohibits jury trials for lawsuits seeking plan benefits or certain equitable remedies--the vast majority of claims brought under the statute. In this case, the Iowa-based federal judge said that courts are split on whether jury trials are available in cases brought under ERISA Section 502(a)(2), which seek restoration of losses tied to a fiduciary breach.

The judge noted that the U.S. Court of Appeals for the Eighth Circuit--the binding authority over federal judges in Iowa--has "expressly held" that there's no right to a jury trial in the most common types of ERISA cases, which are those brought under sections 502(a)(1)(B) and 502(a)(3). Although these Eighth Circuit decisions used "broad language" suggesting that jury trials are prohibited in any claim brought under Section 502, the judge nevertheless allowed a jury trial in this case, explaining that the Eighth Circuit never expressly disallowed them.

Background

The dispute stems from an arrangement between Keokuk Area Hospital Inc. and the administrator of its employee welfare plans, Employee Benefit Systems Inc. The hospital accused EBS of mismanagement that caused the hospital's welfare plan to go from a $1.2 million surplus to a $1.8 million deficit in less than four years.

EBS failed to do proper actuarial studies and didn't negotiate discounts with providers, causing the hospital to significantly overpay for its employees' medical care, according to the hospital. EBS had it paying 90 percent of the costs of medical care, when similarly situated employers pay only 50 percent to 60 percent, the hospital claimed.

Although the judge allowed the hospital to try its fiduciary breach claim against EBS before a jury, she nevertheless dismissed the hospital's negligence claim as preempted by ERISA.

Judge Stephanie M. Rose of the U.S. District Court for the Southern District of Iowa wrote the decision.

McDonald Law Office and Fee Smith Sharp & Vitullo LLP represented the hospital. Pappas O'Connor PC and Clausen Miller PC represented EBS.

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Medical News


Smartphone Apps are Found to Reduce Depression, Anxiety

MyHealthGuide Source: Greg Slabodkin, 1/9/2017, Health Data Management and Sara Ahmed, et al, Journal of Medical Internet Research

A suite of smartphone apps developed by Northwestern Medicine has successfully reduced depression and anxiety symptoms in study participants by 50 percent, an efficacy rate similar to that typically achieved through psychotherapy or antidepressant medication.

That's the finding of a research study funded by the National Institutes of Health and recently published in the Journal of Medical Internet Research.

Northwestern's IntelliCare is a suite of 13 apps that, when used together, target common causes of depression and anxiety, such as sleep problems, social isolation, lack of activity and obsessive thinking.

"We saw that depression and anxiety rates dropped by about half, which is equivalent to what we see with most forms of psychotherapy and with medications," says Emily Lattie, a postdoctoral fellow in the Center for Behavioral Intervention Technologies, Department of Preventive Medicine at Northwestern University.

The study included 96 participants who had access to the IntelliCare apps and received eight weeks of coaching to help with their use. Coaching included an initial phone call plus two or three text messages per week over the eight weeks of the study. An algorithm recommended new apps each week to help participants learn different skills and strategies.

Most of the study's participants used the apps on their smartphones as many as three or four times per day, or an average of 195 times total. At the same time, the average length of use for each app was less than one minute, according Lattie. "This is a pretty low time commitment," she says. "There's not a lot reading or content in these apps. It's really prompts to do things differently."

Although more than 20 percent of Americans experience significant symptoms of anxiety and depression annually, Lattie notes that the vast majority of those with mental health problems do not get treatment.

"There are a lot of barriers to treatment, including cost, availability and people being uncomfortable with traditional treatment methods," she says. However, with more than 70 percent of Americans currently having smartphones, Lattie believes the IntelliCare apps can make effective solutions more accessible to consumers.

Among the 13 apps developed at Northwestern's Center for Behavioral Intervention Technologies are:

  • Daily Feats: designed to motivate people to add worthwhile and rewarding activities into their day to increase overall satisfaction in life.
  • Purple Chill: meant to help users unwind with audio recordings that guide them through exercises to de-stress and worry less.
  • Slumber Time: designed to ease people into a good night's rest.
  • My Mantra: intended to help users create motivating mantras to highlight their strengths and values.

Individual apps or the entire IntelliCare suite can be downloaded for free from the Google Play online store. According to Lattie, the apps will also be available online later this year at the iTunes Store.

She adds that a larger randomized control trial funded by NIH has been launched that will include 300 participants, with a control arm. In that trial, some participants will get coaching and app recommendations based on past use while others will not.

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Recurring Resources



Medical Stop-Loss Providers Ranked by Annual Premium Survey (last updated 11/11/2016)

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

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

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

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

Stop-loss Premium Volume is not the Whole Story

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

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

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

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The Value of Self-Funding

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

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

About the SIEF

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

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Video Highlighting Captive Solutions for Mid-market Companies

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

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

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

About SIEF

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

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ICD-10 Stop Loss Trigger Diagnosis Tools

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

In the early 2000s a group of industry professionals collectively known as the Industry Study Group ("ISG") created a Standard Disclosure Notification form and a standardized list of ICD-9 diagnosis codes, known as the Trigger list. On October 1, 2015, our industry transitions to the new ICD-10 coding system. The ISG has once again undertaken the development of a new Trigger list based on the ICD-10 diagnosis codes. The new ICD-10-CM Trigger list is endorsed by SIIA and HCAA and supported by SPBA.  

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

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Upcoming Conferences


January 18, 2017 - Webinar 1-2:15 PM EST
Data-Driven Medicare Reference Contracting presented by The Self-Insurance Institute of America (SIIA).  The State of Montana and other employers have expressed a desire for transparency, comparability, consistency, and predictability in healthcare pricing. Using data comparing allowed amounts to Medicare as a common reference, contracts have been developed that keep the more efficient providers revenue neutral while encouraging broader financial efficiency. This presentation will discuss the goals, process and outcomes of the development of a network of Medicare reference-based contracted providers. Click here to register.

  • Ron Dewsnup, President & General Manager, Allegiance Benefit Plan Management
  • Marilyn Bartlett, Administrator, Health Care and Benefits Division, State of Montana
  • MODERATOR: Mike Ferguson, President & CEO, Self Insurance Institute of America, Inc. (SIIA)
January 19, 2017 - Webinar 1:00 PM (EST) to 2:00 PM
Back to The Self-Funding Future - Which Echoes of 2016 Will Continue to Impact Self-Funding in 2017 presented by The Phia Group. The past decade has ushered in both outrage and opportunity for self-funded plans, and 2016 was no different. The characteristics of self-funded plans continued to alter in concert with new laws and regulations. While these bureaucratic efforts often hindered our ability to self-fund, for those daring enough to change with the times, we saw increased growth and prosperity. We will no doubt see these issues and opportunities continue to evolve in 2017, and only those that prepare will thrive. Join The Phia Group's team of attorneys for a review the most troublesome and costly issues of 2016 and opportunities that were born from strife - and examine how they will impact self-funding in 2017 while offering some solutions for the new year. Registration: http://www.phiagroup.com/media/webinars

January 25, 2016 - Webinar 1-2:15 PM EST
The Evolving Use of Enterprise Risk Captives presented by The Self-Insurance Institute of America (SIIA).  The use of Enterprise Risk Captives (ERC) has steadily increased over the past few years as smaller and mid-sized companies have established these ART programs for more diverse risk exposure. With recent tax code changes increasing the annual premium limit to $2.2 million and imposing some ownership restrictions to qualify for the 831(b) tax election, the evolution of ERC use may accelerate further. Leading industry experts will share their opinion and perspectives on this topic as part of a moderated panel discussion. Click here to register.

  • Michael Serricchio, Senior Vice President, Marsh Captive Solutions
  • Patrick Theriault, Managing Director, Strategic Risk Solutions, Inc.
  • MODERATOR: Jeff Simpson, Esq., Partner, Gordon, Fournaris & Mammarella, PA

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

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

February 1, 2017 - Webinar 1-2:15 PM EST
Medical Travel Trends for Mid-Market Self-Insured Employers presented by The Self-Insurance Institute of America (SIIA).  Taking a page from the travel surgery playbooks that the large, high-profile companies have followed over the past few years, mid-size or smaller employers and plan sponsors now recognize that the site of service significantly impacts the cost of care and is a key determining factor in selecting where to have procedures performed - everything from MRIs and diagnostics to complex surgeries. Learn how Third Party Administrators and employers are educating and incentivizing employees to make better choices - from reducing coinsurance to eliminating copayments, paying travel expenses or cash rewards. The goal is to help employees seek the right care at the right time in the right place. Click here to register.

  • Mark Kendall, Senior Partner, HUB International
  • Simeon Schindelman, CEO, Brighton Health Plan Solutions
  • Carrie Hatch, Chief Operating Officer, Ameriben
  • MODERATOR: Laura Carabello, Publisher, Media Travel Today

February 8, 2017 - Webinar 1-2:15 PM EST
The Enemy Within: Dealing With Fraud in Your Workers' Compensation Fund presented by The Self-Insurance Institute of America (SIIA). No one wants to hear that even though you believe you are doing everything "right" - rigorous annual clean audits, regular external reviews by reinsurance partners, an active internal audit function, and rigorous policies regularly reviewed through the AGRIP Recognition Standards - things can still go wrong. In this case, we will hear about one pool's very personal experience - recently concluded with the criminal sentencing of a long-time employee - and the lessons learned. From discovering the fraud - which involved embezzlement of over $1 million over a 10 year period - to working with the authorities, managing the public relations, and dealing with employee morale. By sharing this experience, it may prevent it from happening in other pools / funds. Click here to register.

  • Shelly Brotzge, Senior Client Advisor, Midwest Employers Casualty Company
  • Dubravka Romano, Associate Exec. Director for Risk Management Services, Texas Assoc. of School Boards
  • MODERATOR: Mike Ferguson, President & CEO, Self Insurance Institute of America, Inc. (SIIA)

February 8-10, 2017
Executive Forum 2017
presented by Health Care Administrators Association (HCAA). Bellagio, Las Vegas, NC. Kicking off just 19 days after our country's new president is sworn into office, you can bet we'll have plenty to talk about. We've lined up what may be our most impressive slate of presenters ever to:

  • Examine the impact on the self-funding industry of the electorate's choice of a new administration,
  • Explore tech and social communication changes that may well disrupt your current strategies, and
  • Expose you to new and unique ways for your business to thrive in in this Brave New World.

Schedule and registration: www.hcaa.org/?page=2017EFSchedule

February 15, 2017 - Webinar 1-2:15 PM EST
Referenced Based Pricing - The Hospital's Perspective presented by The Self-Insurance Institute of America (SIIA). While there has been increased discussion within the self-insurance industry on the relative merits of various reference-based pricing approaches, this session will look at this trend from the opposite direction. An attorney who has advised multiple hospitals on how to respond and interact with self-insured payers taking RBP approaches shares her unique insights on how hospital administrators view common points of contention, as well as opportunities for more collaborative payment arrangements. Click here to register.

  • SPEAKER: Emily Scott, Esq., Attorney, Hirschler Fleischer
  • MODERATOR: Mike Ferguson, President & CEO, Self Insurance Institute of America, Inc. (SIIA)

February 22, 2017 - Webinar 1-2:15 PM EST
Cost Containment Strategies and Opportunities for Employers in Stop-Loss Captive presented by The Self-Insurance Institute of America (SIIA). Self-Insured employers continue to be trailblazers on implementing effective health care cost containment strategies. This session will explore strategies that can work particularly well when employers are pooled together as part of stop-loss captive programs. It will also highlight certain cost management services that smaller and mid-sized self-insured employers can only access, or access at a lower cost, when pooled with other employers. Click here to register.

  • Scott Byrne, RVP - Western Territory, Berkley Accident & Health
  • Michael Madden, Division Senior Vice President, Artex Risk Solutions
  • MODERATOR: Mike Ferguson,, President & CEO, Self Insurance Institute of America, Inc. (SIIA)

March 8-9, 2017
National Health Policy Conference presented by AHIP.  AHIP's National Health Policy Conference delves deeply into our nation's top policy priorities as we work together to improve our health care system. Learn what's working now, and what's on the horizon for our health care system. The agenda will be filled with the expert speakers you want to hear from and the topics you need to know more about. You'll gain insight into ways to help your organization develop sound solutions to our industry's most challenging issues.  We're talking about value, innovation, outcomes, and accessibility. We're talking about successful collaborations that help increase the quality of care. Location: The Ritz-Carlton Washington, 1150 22nd Street, NW, Washington, D.C. 20037.  Registration: AHIP National Health Policy Conference

March 8-9, 2017
National Conference on Individual and Small-Group Markets presented by AHIP.  AHIP's National Conference on Individual and Small-Group Markets will deliver expert guidance from policymakers, scholars, thought leaders, and industry stakeholders on key policy and operational changes in serving the Individual and Small-Group markets.
The ACA will see significant changes in 2017. Stay abreast of the landscape as policymakers begin the revision process, and discover tactics to help support current customers while adapting to possible new mechanisms that may be used to provide coverage.  You'll uncover lessons learned from real-life experiences serving Individual and Small-Group markets. You'll gain insight into new opportunities as we explore market trends and uncover ways to develop consumer-focused strategies moving forward.  Find solutions that deliver short-term stability and long-term improvement. Be prepared for the possibilities. Location: The Ritz-Carlton Washington, 1150 22nd Street, NW, Washington, D.C. 20037. Registration: AHIP National Conference on Individual and Small-Group Markets

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

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

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

  • Health care industry thought leader Dave Chase will deliver a TED-style talk on how self-insured employers are playing an increasingly important role in helping to save the country's dysfunctional health care system.
  • A panel of technology visionaries will discuss winning technology strategies for companies involved in the self-insurance marketplace.
  • SIIA lobbyists will provide updates on key legislative/regulatory developments at both the state and federal level, and detail the association's advocacy strategy for 2017.
  • As a follow-up to sessions held at SIIA's recent National Conference & Expo covering referenced-based pricing/Medicare-plus topics, we'll have a session focused specifically about how to best defend against balance billing.
  • Captive insurance experts will highlight business development opportunities for self-insurance industry service providers in connection with stop-loss captive programs.

For sponsorships, contact Justin Miller at jmiller@siia.org. The Forum will be held at the beautiful JW Marriott Tucson Starr Pass Resort and Spa. Information and Registration

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

May 3-4, 2017
SIIA Legislative Conference presented by The Self-Insurance Institute of America, Inc. Washington Marriot Metro Center Hotel. Washington, DC.  Visit www.SIIA.org

May 10-11, 2017
Roundstone Medical Captive Forum presented by Roundstone.  Forum brings employers, advisors and health care industry experts together designed to help make the most of their Medical Captive program. Topics including plan design, wellness programs and health improvement strategies.  Free event.  Employers will also receive complimentary hotel accommodations at the Hyatt Regency Cleveland at The Arcade.  Advisors are welcome to attend this free event with two or more employer clients in attendance. Information: Roundstone 2017 Forum Employer Brochure

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

June 7-9, 2017
Institute & Expo 2017 presented by AHIP.  Essential discussions and essential decisions focused on strengthening our health care system.  Leading thinkers gather to share ideas, learn from each other, and tackle some of our industry's toughest challenges including quality of care, mounting health care costs, and building a sustainable system focused on value. You'll enjoy

  • A mix of long-term vision and laser focus on shorter-term priorities.
  • Industry best practices -- you'll discover what's working, and how to apply lessons learned to your organization
  • Idea sharing -- join thousands working together, sharing ideas and uncovering solutions in a host of interactive events and sessions

Known as the Essential Event for the Health Care Industry, Institute & Expo, get ready to join thousands in Austin in June. Information and Registration: AHIP Institute & Expo 2017

July 17-19, 2017
HCAA TPA Summit 2017 presented by Health Care Administrators Association.  Hilton Hotel at the Ballpark. St. Louis, MO

October 2-4, 2017
Annual Self Funding Employer & Workers Compensation Conference hosted by The Self Funding Employer Association.  Los Angeles, CA.  www.selffundingconference.com

October 8-10, 2017
37th Annual National Educational Conference & Expo presented by The Self-Insurance Institute of America. JW Marriott Phoenix Desert Ridge Resort & Spa. Phoenix, AZ. www.SIIA.org

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

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April 4-6, 2018
SPBA Fall Meeting (members only). Capital Hilton, Washington DC. Society of Professional Benefit Administrators (SPBA). www.SPBATPA.org 

September 26-28, 2018
SPBA Fall Meeting (members only). The Peabody Memphis, Memphis, TN. Society of Professional Benefit Administrators (SPBA). www.SPBATPA.org

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Editorial Notes, Disclaimers & Disclosures


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

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Clevenger Ernie Clevenger
President & Publisher
MyHealthGuide, LLC
Clevenger@MyHealthGuide.com