May 2017 www.sipconline.net The World’s Leading Alternative Risk Transfer Journal Since 1984 THE Enemy Within Texas Association of School Boards offers cautionary tale for workers’ comp risk pooling standards and practices following dramatic discovery of massive fraud by trusted employee
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www.sipconline.net The World’s Leading Alternative Risk Transfer Journal Since 1984 Self-Insurer’s Publishing Corp. THE May The Self-Insurer (ISSN 10913815) Enemy 2017 Volume 103 is published monthly by Within Self-Insurers’ Publishing Corp. (SIPC) 4 By Bruce Shutan Postmaster: Send address changes to 10 Inside the Beltway The Self-Insurer House Overwhelmingly Passes P.O. Box 1237 SIIA-Backed Self-Insurance Bill – Simpsonville, SC 29681 Seeking Similar Senate Result Editorial Staff 14 Outside the Beltway New Minnesota Stop-Loss Law Expands PUBLISHING DIRECTOR Self-Insurance Options Erica Massey 24 ACA, HIPAA and Federal SENIOR EDITOR Health Benefit Mandates Gretchen Grote The Affordable Care Act (ACA), the Health Insurance Portability and CONTRIBUTING EDITOR Accountability Act of 1996 (HIPAA) Mike Ferguson and other federal health benefit mandates DIRECTOR OF OPERATIONS Justin Miller 18 DIRECTOR OF ADVERTISING Shane Byars EDITORIAL ADVISORS Bruce Shutan Karrie Hyatt Editorial and Advertising Office P.O. 1237, Simpsonville, SC 29681 (888) 394-5688 2017 Self-Insurers’ Publishing Corp. Officers James A. Kinder, CEO/Chairman Erica M. Massey, President Lynne Bolduc, Esq. Secretary IRS 28 Don’t Let Your LOAs Leave You DOA Continues to Investigate Captives Choosing the 36 SIIA Endeavors 831(b) Tax Option 42 News from SIIA Members By Karrie Hyatt May 2017 | The Self-Insurer 3
THE Enemy Within By Bruce Shutan Texas Association of School Boards offers cautionary tale for workers’ comp risk pooling standards and practices following dramatic discovery of massive fraud by trusted employee It was right out of a movie or riveting crime novel. Dubravka Romano was in London for meetings with reinsurance underwriters in March 2013 when the phone rang.“Are you sitting down?” a caller asked the associate executive director for risk management services with the Texas Association of School Boards. Whenever such a foreboding rhetorical question is posed, it’s almost always followed by terrible or shocking news. In this case, a red flag waved wildly back in the Lone Star State. Roughly $200,000 worth of self-funded workers’ compensation payments made to a medical provider were curiously traced to one of TASB’s most trusted, respected and affable employees – in a supervisory role, no less.
ENEMY WITHIN | FEATURE Hmm, she thought.There must be much Romano was dumbfounded.When she Fraud-prevention strategies more to the story than meets the eye. first confronted Wilks, there was a long Indeed, there was. Suspicious activities led and uncomfortable silence – confirming What makes this story even harder to investigators to uncover a series of brazen her fear that serious wrongdoing had been comprehend is that massive fraud took place crimes committed intermittently over a committed. at TASB in spite of rigorous annual audits, decade using three separate theft schemes regular external reviews by reinsurance and two fictitious vendors. “Fraud really can and does partners, an active internal audit function happen,” she recalls one of TASB’s and regularly scheduled policy reviews that The culprit was none other than Herman adhered to industry standards. G.Wilks, director or TASB’s workers’ comp board members, a retired IRS agent, saying claims administration who later pled guilty Could a similar scenario occur within other to charges of embezzling more than $1 prior to this revelation. “It was such a self-insured entities? Apparently so, according million from the fund’s workers’ comp shock to our organizational to Romano. Upon hearing the details of and employee benefit programs. It was a consciousness because we see her account, several people have sheepishly fox-guarding-the-henhouse moment that ourselves as a bunch of do- admitted to uncovering fraudulent activity in shattered trust and stirred emotion right gooders in the world.” their own organization, though on a smaller alongside the terrible toll it took on time, scale. financial matters and morale. May 2017 | The Self-Insurer 5
ENEMY WITHIN | FEATURE She has given about 10 presentations on the topic (aptly entitled “The Enemy Within”) in present to your board of trustees or the hopes that it helps prevent a reoccurrence of the TASB debacle. Each talk deepens the level public that you’re doing everything you can of catharsis that helped power her organization through this crisis. to detect and prevent fraud,” Bacon explains. After nearly 40 years in business, Bacon has Romano suggests that employers pay particularly close attention to reviewing their vendor- never heard of anything quite like TASB’s tale management process, as well as verify the legitimacy of all service providers and remove occurring among peers. those with whom they no longer do business. Another tip is to verify system security, which TASB now does on a quarterly basis. In addition, she says there must be an audit trail with Fraudulent or criminal behavior in this sector detailed records, which can be bolstered by a response plan and crisis communications is exceedingly rare, reports Ann Gergen, strategy. executive director for the Association of Government Risk Pools.The group’s Her dramatic account of this story, which Romano gave at SIIA’s national conference last fall mission is to provide public entity risk and a recent webinar, was “incredibly heartbreaking” to Freda Bacon, who administers the pool education and networking, as well as Alabama Self-Insured Worker’s Compensation Fund and is on SIIA’s Workers’ Compensation operational and best practices support, to Committee.“To have that type of fraud occur right under your nose, it’s an eye-opener,” she more than 200 members in the U.S.There says. are 78 AGRiP recognition standards that are based upon a self-audit process for these This is especially true for fellow public entities that she believes are expected to go the pools to follow and continually improve over extra mile from a fiduciary standpoint.“You have to have very firm guidelines that you can time. 6 The Self-Insurer | www.sipconline.net
ENEMY WITHIN | FEATURE “An audit is designed to identify process In addition, two separate internal control audits by a Big 4 accounting firm were done to improvements,” Gergen says.“We see pools determine how the theft occurred before a U.S. attorney began prosecution.TASB soon actively engaging in conversation to share discovered that Wilks was able to circumvent a four-step claims adjudication process because how they’re improving their own operations. of his intimate knowledge of the system. Our pool members are highly collegial and very collaborative.They view themselves But he obviously tripped himself up along the way.The dead giveaway was having an as extensions of the public entities that employee with his own LLC, surmises Stu Thompson, CEO of The Builders Group, they serve, and by and large, they’re people a construction self-insured group started in 1997, and member of SIIA’s Workers’ who are passionate about providing local Compensation Committee.“I was amazed at how much he was able to get away with, government public entity service.” especially over a long period of time,” he says of Wilks. Peeling back the onion A key takeaway from Romano’s presentation is to know who’s being paid, whether they’re staffers or contractors, according to Thompson, and ensure that all necessary forms that When TASB investigated Wilks’ wrongdoing, must be filed are accurate, including name, address, federal ID number, etc. Romano and her crew wondered how he went undetected for so long. Eventually they “We have Positive Pay,” he explains, “so if there’s any type of learned that he had requested a report on questionable payment from our bank, they alert us, and then large hospital bills to identify actual workers’ we can say yes or no.” comp claimants who received medical implants. The information was then used to create fictitious medical bills with codes for implantables into the claims system with a slightly altered date of service to circumvent system controls that were in place to detect duplicate payments. Payments were surreptitiously entered, adjudicated and released after work hours. Wilks also changed the address for a claimant’s explanation-of-benefits form in the system to his own so that it would not go to the employee, then changed back the address after the check was issued to himself. The crime triggered a comprehensive probe by a former FBI agent whom Romano describes as “straight out of Central Casting with a crew cut, blue suit, white shirt and dark tie.” Since TASB is a public entity with dismayed taxpayers to consider, this theft necessitated the involvement of additional law enforcement officials. May 2017 | The Self-Insurer 7
ENEMY WITHIN | FEATURE The TASB crimes made him reevaluate his own operation, which pays more than $20 million in claims each year. He believes that having a TPA to adjust and pay claims adds another layer of protection.When Thompson returned home from the SIIA conference he made sure he had an updated certificate of insurance from his TPA so he knew what their fidelity limit was in the unfortunate event of a crime occurring. TASB has since taken corrective steps to prevent this type of fraud from ever happening again.They included changes to the vendor set up and maintenance process, IT system security and set up, and segregation of duties. Other actions involved greater focus on fraud awareness, as well as TASB ethics and values. Wilks pled guilty to 10 counts of mail fraud in January 2014 and was sentenced to 63 months in federal prison just two months later when he also was ordered to pay full restitution for his crimes. He also wrote a letter of apology to his supervisor and will be eligible for release in November of this year. One of the painful lessons TASB staffers learned was that internal controls are everyone’s responsibility, not just the finance department, which reviewed its internal-control recommendations from purely a financial and not also operational lens.While compliance can be burdensome, it’s also seen as necessary. But beyond that, Romano says collateral damage actually can be much worse than financial losses. She cites a long list of unfortunate consequences that included a profound sense of shock and disbelief, loss of trust and confidence, resentment and extra work to review processes. She also mentions that Wilks’ actions triggered serious betrayal, shame and embarrassment, particular among his fellow African-American employees for whom feelings of disappointment perhaps ran deepest among all TASB staffers. In short, she says many of them were at once mortified and apologetic. Romano recalls how Wilks was genuinely remorseful, but that did not change the fact that unraveling his crimes proved to be time-consuming for her staff as well as emotionally draining on a personal level. Her sage advice to others: “Be prepared with a response plan, be prepared with a crisis communication plan, which we did not have, and be prepared for a recovery plan.” Bruce Shutan is a Los Angeles freelance writer who has closely covered the employee benefits industry for nearly 30 years. 8 The Self-Insurer | www.sipconline.net
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INSIDE the Beltway written by Dave Kirby House Overwhelmingly Passes SIIA- Backed Self-Insurance Bill – Seeking Similar Senate Result When the U.S. House of Representatives approved H.R. 1304 The Self-Insurance Protection “This issue has been like the Act (SIPA) by a landslide vote of 400-16, SIIA and the self-insurance industry were halfway sword of Damocles hanging toward gaining strengthened protection against the government being able to define stop- over our heads for decades,” loss insurance as health insurance with all the resulting taxation and regulatory challenges. said Larry Thompson, chairman of SIIA’s It remains for the U.S. Senate to pass comparable legislation for the industry to breathe a Government Relations Committee and great sigh of relief. regional president of Pomco Administrators, Inc. of Fresno, California, who has nearly 30 years of involvement with the organization including a term as chairman. 10 The Self-Insurer | www.sipconline.net
SIPA was sponsored in the House by Dr. House, our hope is to continue with bipartisan and broad support in the Senate,”Work said. Phil Roe (R-TN). It would clarify existing law to ensure that federal regulators would The victory in the House had its own challenges. SIPA was first introduced during the prior not be able to re-define stop-loss insurance administration and never reached the floor for a vote. SIIA government relations staff and as traditional “health insurance” under the members were determined to leave no margin of error for the bill’s success during the ERISA law or the Internal Revenue Service current session. Work estimates that more than 100 meetings were held by SIIA members tax code. SIIA stated that the law would and staff with pivotal members of the House. result in small- and mid-size private sector employers as well as smaller Taft-Hartley Bob Clemente, SIIA chairman-elect, was a leading advocate of SIPA during visits to House plans and public sector employers being members and staff. Founding chairman of Specialty Care Management of Lahaska, secure in continuing to provide high-quality Pennsylvania, Clemente made six trips to Washington, each time visiting several House offices health benefits to their workers and with Ryan Work. He was encouraged by the bipartisan reception of the SIPA message which members through self-insured group health resulted in the strong 400-16 acceptance of the bill. plans. “We were apparently able to separate SIPA from other health care issues in the minds Now SIIA is campaigning for a SIPA mirror of legislators,” he said. “Both Democratic and Republican Congressmen each have many bill in the Senate according to Ryan Work, thousands of constituents whose health coverage is provided by self-funded plans, and stop- vice president of government relations. loss insurance is an integral element of that. Now our job is to take this same message to Sponsors were being lined up and bill members of the Senate.” language was written in the wake of the House vote. “With a 400 to 16 vote in the May 2017 | The Self-Insurer 11
A pivotal point in SIPA’s progress in the “Stop-loss is what makes self-insurance work,” he said. “If regulators are permitted to House was the hearing by the House redefine stop-loss coverage as health insurance, the availability and access to stop-loss will Education and Workforce Committee titled be significantly reduced.This would eliminate the most valuable aspects of self-insurance and “Legislative Proposals to Improve Health restrict plans to a limited amount of health insurers. Care Coverage and Provide Lower Costs for Families” on March 1, 2017. Health This would also lead to self-insurance being available for the largest organizations and care, of course, had been the hot topic we would see its benefits and advantages eliminated for the small- and medium-sized in Washington as the administration and organizations that need access to it the most.” House leaders attempted to repeal and replace the Affordable Care Act (ACA). Ritchie told committee members that SIPA simply seeks to amend the definition of “health Even as that attempt was suspended, insurance coverage” under the Public Health Services Act (PHSA) and parallel sections observers note that the appetite for health of ERISA and the Tax Code to clarify that stop-loss insurance is not health insurance. The care coverage improvements had been legislation does not amend the ACA and – a popular point with legislators – it carries no stimulated. cost. Jay Ritchie, SIIA chairman and executive vice Now SIIA’s campaign continues in the Senate to protect the ability of self-insurance to be president of Tokio Marine HCC Stop-Loss the most efficient and effective form of U.S. health care. Group, testified that morning, delivering a ringing endorsement for SIPA based on SIIA member inquiries about this or other federal government relations issues are welcome to the coverage provided for an estimated contact Ryan Work at [email protected] or (202) 595-0642. 100 million Americans by self-insured employers and Taft Hartley plans. Much of his testimony dealt with the importance of stop-loss insurance to plans that are not large enough to self-fund the largest claims. 12 The Self-Insurer | www.sipconline.net
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OUTSIDEthe Beltway written by Dave Kirby The new regulation changed a stop-loss policy aggregate attachment point to 110 percent of expected claims for groups of 51 or fewer – leveling the playing field between large and small employers related to the level of stop-loss insurance they can access in the marketplace. Previously the aggregate attachment point for small employers was set at the greater of $4,000 per group member or l20 percent of expected claims. The specific attachment point for claims incurred per individual remained unchanged at $20,000.“It was apparent that the $4,000 per group member attachment point presented significant financial challenges to smaller businesses,” Brackemyre noted. New Minnesota Stop-Loss Law Expands The other significant element of the law Self-Insurance Options was to change stop-loss contract terms from 12-24 to 12-15, meaning the “run-out period” of claims submission and payment was reduced from 12 months following New Minnesota stop-loss insurance regulations enacted by the a12-month period of claims incurrence to legislature are expected to make self-insurance of employee benefit three months following a 12-month period. plans less costly and more convenient for the state’s small businesses. “This should also help reduce costs for plan “The new law allows employers more options and possibly lowers sponsors,” Brackemyre said, explaining that their costs,” reports SIIA Vice President of State Government plan sponsors would now be less vulnerable Relations Adam Brackemyre, who led SIIA’s advocacy of the new law to claims they didn’t expect. that was pursued for eight years by state business organizations. MINNESOTA “The lessons for future government relations projects is to be persistent, set realistic goals and be ready to compromise,” Brackemyre said of the campaign initiated in 2009 by the Minnesota Association of Health Underwriters (MAHU). The resulting regulations could comprise a goal model for future regulations in other states, he said. 14 The Self-Insurer | www.sipconline.net
These significant changes in the rules Wiest said that MAHU faced a long uphill self-insurance would ruin the small group governing Minnesota stop-loss insurance educational campaign among the evolving market. have been a continuing effort initiated by membership of the legislature and the Dave Wiest, Legislative Chairman of MAHU, governor’s office. “Lawmakers were not “But when the Chamber got involved it who is president and CEO of EMEX Benefit quick to understand the elements of self- changed everything,”Wiest said of the Systems, Inc. of Medina, Minnesota. funding or stop-loss insurance and how welcome participation on the issue by the these serve to benefit a large portion of the Minnesota Chamber of Commerce along “In working with state’s business community,” he said.“Some with the National Federation of Independent my clients I found the state years we were just breaking through to a Business (NFIB).Wiest noted that the stop-loss regulations to be level of understanding of our issue as the Chamber’s and NFIB’s vast membership unfairly restrictive and I legislative session ended.” of state employers weighed heavily with brought that to the attention legislators. of MAHU leaders in 2009,” Wiest said that MAHU went into Wiest recalls. “Gradually, other successive legislative seasons in St. Paul members became interested with experienced lobbyist Tim Wilken but in the issue and we began was seemingly outgunned by the legislative to push for corrective clout of the traditional insurance industry: legislation.” “They never let up on the assertion that May 2017 | The Self-Insurer 15
Bentley Graves, director of health care and transportation policy for the Minnesota Chamber, SIIA members who wish to join the state government relations advocacy team are said, “We got involved in this issue because it’s important to invited to contact Adam Brackemyre at the us that smaller employers in Minnesota have a level playing Washington, DC, office, (202) 463-8161 or field and the coverage options they need. We viewed this [email protected]. legislation as a way to accomplish that. Our data for two years prior to 2016 showed that about one-third or 8,000 small employers left the fully-insured benefits market.” “Even with our united effort and some Democratic support, we still lost out for seven years as bills failed to pass both houses or were vetoed by the governor,”Wiest said. He described this year’s compromise breakthrough when Gov. Mark Dayton (D) allowed the legislation to go forward with a stipulation that provides rebates for state health care exchange policy- holders ineligible for advance premium tax credits (APTC). The revised stop-loss regulations have sparked new interest among stop-loss insurance carriers in entering the Minnesota market, and should bring increased interest by employers to sponsor self-insured health plans, according to Wiest. “Now our mission is to educate our industry here in Minnesota and through them, the employers,” he said. SIIA Chairman Jay Ritchie has communicated his encouragement of SIIA members in Minnesota to participate in educational events with MAHU. “Joining in state advocacy efforts strengthens self-insurance in the eyes of each state’s government and business communities,” he said. MAHU held its Tech Expo last month with industry exhibits and presentations on the new stop-loss law, and will begin offering sponsorships next month for its annual fall convention. Information is available at the organization’s website www.emahu.org. 16 The Self-Insurer | www.sipconline.net
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IRS Continues to Investigate Captives Choosing the 831(b) Tax Option By Karrie Hyatt A fter five years of investigating small captives that choose the 831(b) tax option, the Internal Revenue Service has stepped up its investigations by releasing Notice 2016-66 last November and again listing captives to their annual “Dirty Dozen” list of potential tax scams. 831(b) captives are generally small to medium- sized companies that elect to take advantage of the Internal Revenue Service 831(b) tax code. Small captives are referred to by several different names—micro captives and Enterprise Risk Captives (ERCs) are two of them—but not all small captives take the 831(b) tax designation. Just like any other alternative risk transfer vehicle, these small captives must qualify as actual insurance companies. Opting for the 831(b) designation can give captives a tax advantage.What seems to be provoking the IRS’s suspicions of 831(b)s are their use for mitigating certain risks—especially regarding estate planning and wealth transfer—that may not qualify them as proper insurance companies.
IRS INVESTIGATES CAPTIVES | FEATURE Smaller captives choosing the 831(b) designation are probably the fastest growing segment IRS’s Micro Captives of the captive industry.There are a growing number of state domiciles that specialize in their formation.With their expansion in the last decade, these smaller captives have gained For the third year in a row, the IRS has more criticism stemming from three main issues: some may seek to use them for tax shelter named captives operating under the 831(b) purposes; there have been a number of “promoters” engaging in setting up captives who may tax designation to their “Dirty Dozen” not have a background in insurance; and some have been used for wealth transfer planning. list—a list the department releases each year warning tax payers of potential tax dodges In the wake of a difficult insurance market throughout the 1970’s and early 1980’s, Congress and scams.This list, released at the beginning enacted 831(b) as part of the 1986 tax reform legislation in an effort to make it easier for of tax season, highlights tax schemes that rural mutual insurance companies, as well as small and medium sized business, to access target consumers. Called “micro captives” insurance not readily available or too expensive in the general insurance marketplace. in the IRS press releases, it says that some Captives using the designation have expanded since this time to include additional types of captives using the 831(b) designation are risks and are in wide-spread use throughout the country. using it for wealth transfer rather than insuring genuine risk. “From the IRS standpoint,” said Kevin Doherty, a lawyer with the law firm Dickinson Wright, “The current way the 831(b) designation is used was not the intention of Congress.The fact of it is that it is the law and it’s permitted.” May 2017 | The Self-Insurer 19
IRS INVESTIGATES CAPTIVES | FEATURE The captive industry has been swift and Les Boughner, chairman of Advantage Notice 2016-66 steady in the IRS’s general and broad condemnation. According to Doherty, Insurance Management, said “The IRS Last November, the IRS issued Notice “It makes no sense to sweep captives up has always been critical of 2016-66 which named 831(b) captives under the same category. [The industry has captives and has a history as “transactions of interest” and sought pushed back], but the IRS is going to have to of challenging captive to require additional financial disclosures. be convinced that there are very few bad structures. They also have a According to the IRS website,“Transaction actors. It’s sort of like saying that if you’re history of losing their legal of Interest” (TOI) is defined as a transaction in the dry cleaning business and there are challenges…. Labeling them that the IRS and the Treasury Department maybe 15 dry cleaners across the country a transaction of interest believe is a transaction that has the who have cheated on their taxes, that is intended to identify potential for tax avoidance or evasion, but obviously means dry cleaning is a really bad questionable structures and lack sufficient information to determine business.That’s the logic the IRS is using and it would be more appropriate whether the transaction should be identified we’d like to see that changed.” to list ‘abusive captive specifically as a tax avoidance transaction.” structures’ rather than With Notice 2016-66, the IRS requested ‘captives’ on the ‘Dirty Dozen’ specified entities to file additional financial list.” disclosures by January 30, 2017—90 days after the Notice was issued. Lockton Associates and Partners Are Experts At: Medical Life & Retirement Risk FOCUSED ON CLIENTS. Benefits Disability DEDICATED TO RESULTS. Services Management Serving Employers Around the World COMMITTED TO MAKING YOUR BUSINESS BETTER. Locwktwonw.Dloucnkntoinng.cBoemnefits WE LIVE SERVICE!® Insurance • Risk Management • Surety Expertise 444 W. 47th Street, Suite 900 Kansas City, MO 64112 • 816.960.9000 © 2017 Lockton Companies. All rights reserved. 20 The Self-Insurer | www.sipconline.net
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IRS INVESTIGATES CAPTIVES | FEATURE Once the IRS and Treasury Department The captive industry has been very vocal in its disapproval. SIIA led the campaign to modify have collected enough information to and withdraw Notice 2016-66, along with dozens of trade associations, captive managers, make a decision, Notice 2016-66 states and regulators joining in, including a letter from Kevin Doherty on behalf of the Tennessee that one or more of three actions will Captive Insurance Association. SIIA was one of the only industry groups to meet with the IRS happen:“Removing the transaction from the to discuss their concerns regarding the notice.Their meeting had a direct impact on the IRS transactions of interest category in published extending the reporting deadline by 90 days. guidance, designating the transaction as a listed transaction, or providing a new Criticism was initially pointed towards the fact that there was no comment period before category of reportable transaction.” the deadline was set and that only 90 days was an unreasonable amount of time to put together the disclosures required. At the end of December, the IRS extended the deadline According to Doherty, Notice 2016-66 to May 1, 2017. Other points of complaint from the industry were the potential for duplicate is “an attempt by the IRS to get as much financial filings and the broad requirements in Notice 2016-66 that sweeps up nearly all information as possible about these small 831(b) captives. captives. I think the effect of it, whether intended or not, is to create a burden on CIC Services, a Tennessee-based captive manager, has filed a lawsuit against the IRS and small captives, adding an extra cost. One Treasury Department arguing that Notice 2016-66 was unlawfully issued and did not meet way to look at it is the increase cost makes the authority or “reasoned analysis” requirements of the Administrative Procedure Act.The it more difficult for the smaller companies to original lawsuit was filed last December and a second suit was filed at the end of March with justify using a captive or a cell in a captive. It Ryan, LLC, a Texas-based tax firm, named as co-plaintiff. effectively favors large companies and hurts the smaller companies.” HEALTHIER IS HERE A company is only as strong as its people, so keeping them healthy is a great investment. As a health services and innovation company, we continue to power modern health care through data and technology. optum.com 22 The Self-Insurer | www.sipconline.net
IRS INVESTIGATES CAPTIVES | FEATURE A Premature Action Even with the deployment of the PATH Act and the upcoming decision in the Avrahami Another criticism leveled at the IRS and the Treasury Department is that Notice 2016-66 case, the IRS and the Treasury Department was issued prematurely. chose to list 831(b) captives as a TOI and continued listing them to the “Dirty Dozen” The Protecting Americans from Tax Hikes Act of 2015 (PATH Act) went into effect on list. January 1st of this year.The law creates tax relief benefits for business and families, and for the captive insurance industry the PATH Act increases the limit of net annual written premiums This has put the industry on edge. As to 2.2 million dollars for 831(b) captives.The Act also changes the qualifications regarding Doherty said,“Legitimate domiciles, and ownership diversity for those captives. It will require any captive electing for the 831(b) most of us in the industry, are working very designation to meet a “Diversification Requirement” in ownership. hard to make sure there are no abuses. Certainly there are people on the fringe The PATH Act is now in effect and should help stem many of the abuses the IRS believes to who float in from time to time, captive be taking place, while also allowing these smaller captives to grow. Additionally, the captive managers that are a little bit questionable, industry is looking to Congress to clarify some of the parameters of the Act, which should but the regulators work hard to make sure help to strengthen captives’ standing. SIIA requested these clarifications by Congress and guys like that don’t get licensed.” they were introduced at the end of last year. According to Ryan Work, vice president of Government Relations with SIIA,“Understanding that the IRS would not provide needed This year will be a proving ground for 831(b) clarification surrounding the PATH Act, as directed by Congress, prior to its implementation, captives.With the additional disclosures the SIIA spearheaded a letter with 15 state captive associations formally requesting that the IRS is seeking, the PATH Act requirements, IRS do so.To this date, the IRS has yet to respond or issue this guidance.This is one of the and a Tax Court decision, 831(b) captives sticking points with the Notice—if they don’t have the willingness or time to issue guidance might finally see themselves clear of their on the PATH Act, which has already gone into effect, and don’t understand its implications, controversy. how can they spend time and issue the Notice without comment?” The captive industry will be there to back “Here is the contradiction,” said Boughner. “Unless Treasury them up. As Doherty said,“This is our and the IRS operate in a complete vacuum the IRS had to business, we’re not going to be deterred.” be aware of Treasury liberalizing the 831(b) election in the PATH act by increasing the threshold to $ 2,200,000. Karrie Hyatt is a freelance writer who has The PATH act also imposes ownership restrictions which been involved in the captive industry for more limits a captives ability for family wealth transfer, another than ten years. More information about her IRS concern. These changes highlight that a captive should work can be found at: www.karriehyatt.com. be used for fundamental corporate risk management purposes. My interpretation is that they worked in tandem and that, while the IRS is concerned about abuses, they support the proper application of a captive structure for risk management purposes.” A U.S.Tax Court decision in the case of “Avrahami v. Commissioner” should be decided during the next few months. In this case, a Phoenix-based jewelry company is suing the IRS in response to a multi-million dollar notice of deficiency.The captive is suspected by the IRS of misusing the 831(b) tax designation as a tax-avoidance scheme. However the case is decided, case law will be established which will help define the tax designation. May 2017 | The Self-Insurer 23
ACA, HIPAA AND FEDERAL HEALTH BENEFIT MANDATES: Q APractical & The Affordable Care Act (ACA), the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other federal health benefit mandates (e.g., the Mental Health Parity Act, the Newborns and Mothers Health Protection Act, and the Women’s Health and Cancer Rights Act) dramatically impact the administration of self-insured health plans. This monthly column provides practical answers to administration questions and current guidance on ACA, HIPAA and other fed- eral benefit mandates. Attorneys John R. Hickman, Ashley Gillihan, Carolyn Smith, and Dan Taylor provide the answers in this column. Mr. Hickman is partner in charge of the Health Benefits Practice with Alston & Bird, LLP, an Atlanta, NewYork, Los Angeles, Charlotte and Washington, D.C. law firm. Ash- ley Gillihan, Carolyn Smith and Dan Taylor are members of the Health Benefits Practice. Answers are provided as general guidance on the subjects covered in the question and are not provided as legal advice to the questioner’s situation. Any legal issues should be reviewed by your legal counsel to apply the law to the particular facts of your situation. Readers are encouraged to send questions by E-MAIL to Mr. Hickman at [email protected]. 24 The Self-Insurer | www.sipconline.net
THE MENTAL HEALTH PARITY The 21st Century Cures Act COMPLIANCE: Further supporting the notion that the REVAMPED FOR 2017 MHPAEA will not be affected by post- election changes, the 21st Century Cures As noted in our October Self Insurer column1, comprehensive regulations have been issued Act (the “Cures Act”), which includes under the Paul Wellstone and Pete Dominici Mental Health Parity and Addiction Equity provisions relating to MHPAEA, was signed Act of 2008 (“MHPAEA”), and we have seen an uptick in Department of Labor (“DOL”) into law on December 13, 2016. investigation and enforcement activity with respect to the MHPAEA. We suggested in that column that employers focus on MHPAEA compliance. This article updates activity in this The Cures Act has a broad ranging effect on area since the election and the passage of the 21st Century Cures Act in December. mental health issues. Of note to sponsors of employee benefit plans, the Cures Act Legislative Background includes a directive to the Secretaries of Labor,Treasury and Health and Human The MHPAEA amended Section 712 of ERISA, Section 2705 of the Public Health Services Services (HHS) to develop and issue a Act and Section 9812 of the Internal Revenue Code, and is designed to require true benefit compliance program guidance document parity between medical benefits for physical conditions and mental health and substance (the “Guidance Document”) to help abuse benefits. The MHPAEA applies to mental health and substance abuse benefits offered improve compliance with the MHPAEA, in connection with group health plans. as incorporated in Section 712 of the Employee Retirement Income Security If a plan provides medical/surgical benefits and mental health or substance abuse benefits, Act of 1974 (ERISA), Section 9812 of the the plan must provide parity with respect to (i) financial requirements (e.g., deductibles, Internal Revenue Code and Section 2726 copayments, coinsurance and out-of-pocket maximums), (ii) quantitative treatment limitations of the Public Health Services Act (PHSA). (e.g., number of visits or treatments or days of coverage) and (iii) nonquantitative treatment This is intended to supplement information limitations (“NQTLs”)(e.g., medical management standards). previously provided by the enforcement agencies. MHPAEA generally became effective for plan years beginning on or after October 3, 2009 (January 1, 2010 for calendar year plans). For years prior to 2010, the Mental Health Parity The Guidance Document under the Cures Act (MHPA), the precursor to MHPAEA, applied. MHPA’s more limited equality provisions Act would be required to include illustrative only required parity between annual and lifetime dollar limits examples of previous findings of compliance applicable to medical benefits and mental health benefits. and non-compliance, including: We note that the MHPAEA pre-dates the Affordable Care Act (ACA). Accordingly, even if Congress undertakes to repeal and replace the ACA in 2017, a rollback of MHPAEA requirements is unlikely. May 2017 | The Self-Insurer 25
• Examples illustrating requirements Penalties for information disclosures and nonquantitative treatment Potential enforcement actions should be cause for concern for employers and insurers, as limitations; and significant penalties can result under the Code. MHPAEA violations can give rise to a $100/ day/employee excise tax under Code § 4980D. Certain limitations and exceptions apply for • Descriptions of violations employer sponsors of small fully insured plans as set forth in Code § 4980D.2 In addition to uncovered during the course of the IRS taxes, participant claims may be asserted and DOL might choose to sue employers investigations. for breach of fiduciary duty based on their failure to comply with MHPAEA. The examples will include sufficient detail Summary to fully explain the findings, including a full description of the criteria involved for Given the potential for significant penalties, employers should focus (or re-focus) their approving medical and surgical benefits and attention on compliance with the MHPAEA. Employers should watch for issuance of the the criteria involved for approving mental Guidance Document and use that guidance to ensure their health plans comply with the health and substance use disorder benefits. MHPAEA. This will likely require coordination with insurers and claims administrators. This additional information in the Guidance References: Document should provide valuable assistance to employers seeking to confirm 1 http://www.alston.com/advisories/mental-health-parity/pdf compliance with the MHPAEA. This can 2 Code § 4980D(d) provides an exemption from the excise tax for employers with between 2 and 50 be very important given the potential for employees. significant liability associated with non- compliance. 26 The Self-Insurer | www.sipconline.net
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Don’t Let Your LOAs Leave You DOA Written by Kelly E. Dempsey Imagine a scenario where an employer has a long-time reliable employee that suddenly has a stroke of bad luck and is diagnosed with stage four cancer after being relatively asymptomatic and having never been diagnosed with cancer previously.The employee works with a team of medical professionals to come up with a game plan for beating this terrible disease.The employee quickly begins what will hopefully be life-saving treatment as soon as a game plan is mapped out. The claims start rolling in and the treatment starts taking its toll.The employee starts missing an hour here and there for appointments – and then a few hours for appointments and sickness –and then full days of work during treatment.When the employee is at work, the employee struggles to perform normal job functions and the employee is now unable to work because the rigorous chemotherapy regiment. 28 The Self-Insurer | www.sipconline.net
The employee decides it’s time to take a with Disabilities Act (ADA)1. Ah ha! The employer tells the employee they have just the leave of absence to focus on treatment.To solution – take a leave under ADA and the employment and leave situation can be re- the dismay of the employee, though, the evaluated in a few months. employee doesn’t have any additional leave available under The Family and Medical The employer tells the employee not to worry about anything except becoming cancer- Leave Act (FMLA), since the full allotment free; the health plan coverage will continue as long as the employee needs it, even though of FMLA leave was recently exhausted the last of the employee’s paid time off is exhausted and no additional FMLA is available. while the employee and the employee’s In other words, the employer, via its health plan, is taking care of its employee, as so many spouse were finally bringing home their employers try so hard to do.The employee is then signed up for the short-term disability new adopted baby that they had waited so policy which will help replace some income during the leave, and the employee is all set – long for. Is this pulling at your heart strings there is continuing health plan coverage and some income replacement to boot. All is well. yet? Fast forward in time.Three months have passed, and the employee is making miraculous The employer recalls that sometime recovery.The employee is not ready to come back to work yet, but things are looking up in 2016, the U.S. Equal Employment and the employee is respected to return to work at some point in the near future.With Opportunity Commission issued guidance the end of the health plan year approaching, the employer is attempting to get its ducks in on a leave associated with The Americans a row for renewal season, which includes a stop-loss policy renewal.The cancer treatment May 2017 | The Self-Insurer 29
WSHIOTWHESRAVYIONUGRSPLAN Using Renalogic’s services can make the savings pour in. Renalogic improves the health and outcomes of Chronic Kidney Disease patients. We specialize in avoiding or drastically reducing dialysis costs. Call (866) 265-1719 or visit www.renalogic.com claims are continuing to roll in and, as coverage seems to have terminated? The The employer pulls out the employee expected, the dollars keep adding up – but stop-loss carrier questions the employer handbook and skips to page 42 – Employer unfortunately, as anticipated, stop-loss is and requests additional documentation Leave Policies.The employer starts reading, going to become a factor before renewal to support eligibility; the carrier even “In addition to FMLA, employees that have (ugh). generously says the employee handbook is exhausted paid time off and FMLA may be acceptable. eligible for an additional extended leave of Claims are filed with the stop-loss carrier absence; referred to as non-FMLA leave.This and all the typical supporting documents As everyone knows, the stop-loss policy is non-FMLA leave is created to comply with are provided. During the stop-loss carrier’s underwritten based on the plan document the ADA’s requirement to provide a leave of review, the carrier starts scratching its head. alone; anything contained within the absence as a reasonable accommodation and This individual has been on a non-FMLA employee handbook is entirely separate will be offered in addition to FMLA. leave of absence for over three months. from the plan document and the stop-loss The health plan document discusses FMLA underwriting generally won’t take into and COBRA, but no other types of leave. account anything within the employee Why was this employee still on the plan? handbook.The employer thinks “boy, am I Why was COBRA not offered when plan lucky!” *queue the suspenseful music* 30 The Self-Insurer | www.sipconline.net
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Thus the non-FMLA leave will not run concurrently with FMLA. Additional information regarding All the while, the employer just thinks how to request this leave and the additional requirements associated with this leave is further detailed herein:” “How did I end up here? All I wanted was to take care of The employer’s wheels start turning: okay, this ADA leave doesn’t run concurrently with my employees and give them FMLA – great, that helps, but where’s the part about continuing health plan coverage? That the best benefits possible. must be in this handbook somewhere.The employer starts frantically turning pages looking Where did I go wrong?” for those magical words “employees are entitled the health plan benefits during a non-FM LA leave of absence.” It’s intuitive to think that a leave of absence from employment is coupled with a But alas, no such wording is contained within the 163-page employee handbook. The continuation of health plan coverage, employer’s internal dialogue starts racing.“How can this be? We never meant for our especially if the leave is illness related; to employees to be out sick and not have health coverage. Doesn’t the ADA say we have to the dismay of many, however, a continuation provide coverage to employees while they’re out on leave?” So you ask,“What now?”The of coverage (other than COBRA) isn’t bottom line is that there is no stop-loss reimbursement for the cancer claims, and quotes always coupled with a leave of absence. for renewal just added a few extra zeros. As shown in the scenario above, many employers struggle to align their health No need to review the gory details in depth – but one can imagine what happened during plan documents with their employee the plan and stop-loss renewal.The employer’s bank account is looking bleak, as are the handbooks (and other internal policies) proposed stop-loss renewal rates.The employer starts shopping other options despite which subsequently increases the potential having been with the same stop-loss carrier for years. for a gap to arise between all the relevant documents. 32 The Self-Insurer | www.sipconline.net
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While most federal and state laws do not require a continuation of coverage, employers References: can choose to provide the benefit of continued coverage – but if the employer wants to ensure stop-loss reimbursement, the terms of continuation of coverage need to be clearly 1 https://www.eeoc.gov/eeoc/publica- spelled out not only in the employee handbook, but also in the health plan document. tions/ada-leave.cfm The health plan document is key to showing proof of continued coverage, especially in a situation where stop-loss is relevant. Many employers don’t even realize they have gaps between their policies and the health plan documents until it’s too late. All it takes is one large medical event - a cancer claim, an ESRD diagnosis, premature twins, a transplant – to discover that the documents the employers has aren’t airtight, and may not even align with the employer’s intent. In summary, most employers need to do some homework. Go back to the office and take a look at the health plan document and the employee handbook. Do the two documents reference the same types of leave? Do the documents clearly indicate when coverage under the health plan is maintained during a leave? Do the terms of these documents meet the intent of the employer? What does the stop-loss policy say about eligibility determinations? Can the handbook be used to document eligibility in the health plan? What (if any) changes need to be made to minimize or eliminate gaps, to the extent possible? Don’t let large unexpected claims leave you dead on arrival. Do the leg work now, and figure out what needs to be done to avoid being caught by surprise. Kelly E. Dempsey is an attorney with The Phia Group. She is one of The Phia Group’s consulting attorneys, specializing in plan document drafting and review, as well as a myriad of compliance matters, notably including those related to the Affordable Care Act. Kelly is admitted to the Bar of the State of Ohio and the United States District Court, Northern District of Ohio. 34 The Self-Insurer | www.sipconline.net
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SIIAEndeavors SIIA held its annual Self-Insured Health Plan Executive Forum (formerly known as the TPA/ MGU Excess Insurer Executive Forum) March 28-29, 2017 at JW Marriott Tucson Starr Pass Resort & Spa, in Tucson, Arizona. JW Marriott Tucson Starr Pass Resort & Spa, in Tucson,Arizona 36 The Self-Insurer | www.sipconline.net
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The Board of Directors of the Self-Insurance Education Foundation (SIEF) would like to thank the participants in their always popular golf tournament, and congratulate the winners: First Place Team Vance Sible Sam Sletager Zach Walker David West Second Place Team The First Place Team Charley Erwin Matthew Herrera Greg Rudisill Russ Krueger Third Place Team Fred Toncone Jonathen Socko Joghn Foley Hole Contests Zach Walker Longest Drive Zach Walker R6 Closest to the pin Abby Zipoy R8 Closest to the pin Charley Erwin RR1 Closest to the pin Fred Troncone RR3 Closest to the pin 38 The Self-Insurer | www.sipconline.net
The 2nd Place Team May 2017 | The Self-Insurer 39
Conference attendees participated in a How Self-Insurers variety of networking events and educational Can Help Restore sessions. Highlights of the educational the American program included: Dream by Curbing the Healthcare Legislative/Regulatory & Heist Political Advocacy Update Ryan Work,Vice President, Federal In this TED-style talk, Government Relations for SIIA and Adam Brackemyre,Vice President, State Dave Chase, Executive Government Relations for SIIA provided detailed updates of important legislative/ Producer of The Big Heist, regulatory developments and the association’s political advocacy strategy at connected the dots on both the state and federal levels. Regulatory Compliance “Hot Spots” for Self- how healthcare’s status Insured Health Plans Chris Condeluci, Esq.,Washington Counsel quo represents a significant David Chase for SIIA, discussed current regulatory developments affecting self-insured threat to the American employers with specific compliance guidance useful to employers and their business Dream and how employers who sponsor self-insured health plans are playing an increasingly par tners. important role in providing real solutions that bring hope to a dysfunctional health care system. Winning Technology Strategies for the Self-Insurance Marketplace Joe Hodges, President, Inetico, moderated a discussion of senior executives of companies operating within the self-insurance marketplace guidance on how to view and evaluate technology strategies in a way that will help them grow their business and strengthen their corporate brands. Networking reception in the Exhibit area 40 The Self-Insurer | www.sipconline.net
Networking reception in the Exhibit area Actuarial Advisor Our Complete First Dollar and Excess Loss Pricing Manual for Medical and Rx Plans www.windsorstrategy.solutions THE MOST COMPREHENSIVE AND FLEXIBLE ACTUARIAL RATING MANUAL AVAILABLE TODAY May 2017 | The Self-Insurer 41
NEWSMfromeSmIIAbers 2017 MAY MEMBER NEWS SIIA Diamond, Gold & Silver Member News SIIA Diamond, Gold, and Silver member companies are leaders in the self- insurance/captive insurance marketplace. Provided below are news highlights from these upgraded members. News items should be submitted to Wrenne Bartlett at [email protected]. All submissions are subject to editing for brevity. Information about upgraded memberships can be accessed online at www.siia.org. For immediate assistance, please contact Jennifer Ivy at [email protected]. If you would like to learn more about the benefits of SIIA’s premium memberships, please contact Jennifer Ivy and [email protected]. Diamond Members Zelis™ Healthcare Announces Acquisition of Strenuus® Zelis Healthcare, a market-leading healthcare information technology company, is pleased to announce the purchase of Strenuus. Overland Park, Kansas-based Strenuus is a healthcare information technology company and provider of healthcare provider network analytics. Strenuus is the largest collector of managed health care data in the U.S., delivering actionable network insights to health plans, data analytics and healthcare provider data companies, healthcare exchange platforms and employee benefits consultants. 42 The Self-Insurer | www.sipconline.net
This isn’t rodeoour first WE’VE DONE THIS BEFORE. Being in the medical self-insurance stop loss market isn’t new to Houston International Insurance Group (HIIG). The experts and seasoned employees that founded the Company have decades of experience in this industry. In fact, HIIG was built using strategy, sound judgment, and business savvy from some of the same leaders who made this industry great from the very beginning. Don’t get thrown for a loss. Make HIIG Accident & Health your partner in stop loss. Learn more at hiigah.com or call us at 800.796.9165. 2 The Self-Insurer | www.sipconline.net
The Strenuus acquisition further enhances Zelis’ healthcare data analytics product portfolio About Zelis Healthcare supporting payer clients. Strenuus is now a part of the Zelis Network Solutions business unit led by Tina Ellex, President. Zelis Healthcare is a healthcare information technology company and market-leading “The combination of Zelis and Strenuus further expands our Zelis integrated cost provider of end-to-end healthcare claims cost management and payments platform and enables Zelis to provide our payer clients with management and payments solutions. Zelis enhanced support of network access, quality and cost optimization efforts.This is particularly Healthcare focuses on network solutions, important as many payers seek to deliver high performing, cost effective, narrower networks claims integrity and electronic payments for that meet the changing needs of employers and members,” said Doug Klinger, CEO of Zelis healthcare payers, providers and consumers Healthcare. in the medical, dental and workers’ compensation markets nationwide. Zelis “We welcome the Strenuus team to Zelis. They have Healthcare is backed by Parthenon Capital technology and provider data coupled with their deep Partners. experience and background in provider analytics that have positioned them as the premier company in our industry. I About Strenuus look forward to offering their solutions to our healthcare payer clients in an evolving marketplace,” saidTina Ellex, President of Strenuus is the leader in healthcare provider network analysis and data management. Network Solutions for Zelis Healthcare. Their flagship platform, Network360®, delivers actionable network intelligence “We are thrilled to join Zelis.We look forward to providing greater impact for the healthcare services to payer clients nationwide. Strenuus community with our continued focus on product enhancements and new product also powers consumer-facing solutions for development,” said Matthew Mellor, CEO of Strenuus. leading benefit consultant and healthcare IT companies with the only unified provider search in the marketplace and manages the industry’s largest network dataset, sourcing from thousands of commercial medical, dental, Medicare, Medicaid and specialty business lines. ® 29343B 44 The Self-Insurer | www.sipconline.net
QBE Announces • Jon Tolzin has been named Regional Vice President in the Northwest, heading our Appointments: Jon Tolzin, Minneapolis Regional Office. His responsibilities include, managing underwriting, Regional Vice President, marketing and risk management services for QBE›s Medical Stop Loss products. Northwest Region and Ed His regional office serves brokers and TPA partners throughout 14 states.With 23 Wadhams, Vice President, years of insurance experience,Tolzin moved to increasing levels of responsibility in A&H National Partnerships underwriting at both ASO and standalone stop loss carriers. He holds a Bachelor of Arts degree in Economics from the University of Minnesota. As an integrated specialist insurer and one of the largest insurance companies in the • Ed Wadhams has been appointed Vice President, A&H National Partnerships. In world, QBE applies deep technical expertise this role,Wadhams will be responsible for positioning our business priorities with to deliver future-ready products, customized top producers in the U.S. In conjunction with our global strategy, Ed will work underwriting solutions and superior claims collaboratively with our Field Operations team to focus on increased visibility and service.Working through preferred and profitable growth with select national partners. In addition,Wadhams will further limited distribution partners, they mobilize collaborate and execute the strategy with our regional vice presidents, regional and synchronize market-facing functions underwriters and business development staff. He holds a Bachelor of Science to write multiple lines of coverage for our degree in Communications from the University of Tennessee. customers.They write over $14 billion in gross written premium and trade in all major insurance markets. Backed by the strength of their strong balance sheet and a well- diversified global portfolio, QBE provides customers the certainty they need to manage their business at home, and around the world. A key to their success as a business is our people, and they remain committed to recruiting, retaining and developing the best talent in the industry. At the heart of their culture is a commitment to our employees, their professional development, and providing them with career opportunities by promoting from within. QBE North America’s Accident & Health division is proud to announce the following appointments: May 2017 | The Self-Insurer 45
“These appointments demonstrate the importance we place Primary responsibilities on underwriting excellence, industry expertise and customer service,” said Steve Gransbury, President -- Accident & Health, QBE North America. • Serve as the primary trainer and “By identifying employees with unique skills and experience, resource for UW, new hire, and while providing them with opportunities for impact in key general product training. leadership positions, we further invest in our development culture and our organization’s greatest asset, our people,” he • Work with SL leadership team to assess baseline and prospective added. learning and development needs. About QBE • Evaluate data from Employee Engagement Survey, Brighter QBE North America is part of QBE Insurance Group Limited, one of the largest insurers and Way Initiatives, and varying VoC reinsurers worldwide. QBE NA reported Gross Written Premiums in 2016 of $4.6 billion. QBE collection activities to identify key Insurance Group’s 2016 results can be found at www.qbena.com. Headquartered in Sydney, areas of focus. Australia, QBE operates out of 37 countries around the globe, with a presence in every key insurance market.The North America division, headquartered in New York, conducts business • Collaborate with leaders to assess through its property and casualty insurance subsidiaries. QBE insurance companies are rated specific needs by functional area “A” (Excellent) by A.M. Best and “A+” by Standard & Poor’s. Contact Amy Sandusky, AVP, and identify expected resource Marketing Business Partner, Marketing & Communications, at [email protected] and commitment required to develop visit www.qbena.com. and deliver training content. Sun Life Seeks Associate Director, Stop-Loss Training and • Develop and implement Learning Development learning strategy aligned with overarching Stop Loss strategic Role Summary plan and identified learning and development needs. The Associate Director, Stop-Loss Training and Learning Development will drive the business unit’s training and learning development strategy with the goal of increasing the expertise • Drive plan for comprehensive and talent across the collective organization.The Associate Director will work closely learning and organizational with stop-loss business leaders to assess learning and talent development needs across development initiatives across Stop the business, and then develop and execute on a robust multi-year strategy to meet the Loss. identified needs aligned to our key business goals, imperatives, and initiatives. Initially, a key focus will be on underwriting training. Overwhelmed by yourGeneric Utilization Challenges Prior Authorizations Specialty Costs pharmacy spend? Maybe it’s timeRising costs of brands Member Restrictions to get back to basics.Coverage decisions Compound Drugs Copay Tiers Contact Script Care to learn how simple changes can maximize your rebate return formularyNetwork Access Find out more at scriptcare.com WE ARE . SCRIPT CARE, LTD. May 2017 | The Self-Insurer 47
• Coordinate, design, and implement • Ability to create and build learning and training programs that are innovative, training across all facets of the stop comprehensive, and repeatable loss business. • Demonstrated expertise in leading through influence / can manage without • Design and develop new hire authority training curriculum. • Direct experience with training or coaching -- has developed learning and • Research and model best practices knowledge solutions for a variety of roles in learning in order to ensure • Proficient facilitation skills innovative, best-in-class training and performance support for Stop Loss • Experience in partnering with SME’s to help facilitate or deliver training content organization. • Partner with various subject matter • Can manage complexity -- distributed learners, centralized teams, and multi-site experts to facilitate and deliver locations specific topic / expertise level • Demonstrated ability to manage change throughout all levels of the organization training sessions Interested candidates should email resume to Margaret Peterson at Margaret.Peterson@ • Schedule, coordinate, and ensure sunlife.com. successful execution of planned About Sun Life training sessions Sun Life offers a variety of stop-loss insurance products and services that provide a great • Create metrics and reports to source of financial protection -- allowing companies to limit their liability for claims and evaluate and present findings maintain the budget.You can depend on their excellent sales, underwriting, and claims service. related to training impact and Plus, they deliver opportunities for companies to save money through cost-containment effectiveness. resources that can help lower health care costs even before a stop-loss claim occurs. Visit www.sunlife.com/us/. • Establish a framework for Silver Members continuously measuring success of learning initiatives. Qualifications • Bachelor’s degree • 7+ years of experience working with Stop-Loss product in UW, Claims, Product Pricing, Quality, or Stop-Loss Operations • Ability to define strategy, overall direction, and effectively communicate vision to key stakeholders • Experience in collaborating with business leaders, supporting evolving business strategies, and driving to a collective identified goal 48 The Self-Insurer | www.sipconline.net
HHC Group Launces New About HHC Group For additional information about HHC Group, Website its new website and our services, email info@ HHC Group is a leading national health hhcgorup.com or contact Bob Serber at HHC Group announces the launch of its insurance consulting company providing a [email protected], 301-963-0762 ext. new, updated website – www.hhcgroup. wide range of cost containment solutions 163, and visit www.hhcgroup.com. com.This site is designed to give insurers and for Insurers,Third Party Administrators, those who manage their cost-containment Self-Insured Employee Health Plans, Health efforts an introduction to the company and Maintenance Organizations (HMOs), ERISA its suite of highly-effective, cost-containment and Government Health Plans. HHC Group services. utilizes a combination of highly skilled professionals and advanced information The site is also designed for use by HHC technology tools to consistently deliver Group’s clients. It enables them to effectively targeted solutions, significant savings and and efficiently manage their claims-related, exceptional client service. cost-containment efforts. Using the website, they can now securely submit claims, track HHC Group’s services include Claim claim status.They can download processed claims files, review their claim history, create Negotiation, Claim Repricing, Medicare Based reports and more, 24 hours a day seven days a week. Pricing, DRG Validation, Medical Bill Review (Audit), Claims Editing, Medical Peer Reviews/ Independent Reviews, Independent Medical Examinations (IME), Case Management Utilization Review, Data Mining, Disease Management and Pharmacy Consulting. INNOVATIVE STOP LOSS AND ANCILLARY SOLUTIONS At BenefitMall, we know that employer groups benefit most from treating their health plan as an investment rather than an expense. Our team of self funded consultants can help you succeed by offering: U 1L>Ãi`Ê Ý«iÀÌÃiÊ>`Ê,iÛiÜ U ÊÌ>Ê*>ViiÌ]Ê«iiÌ>ÌÊ>` ,iiÜ>ÊvÊ ÛiÀ>}i U Ê >ÃÊÕ`Ì]Ê-ÕLÃÃ]Ê/À>V}] >`Ê,iÃÕÌÊ-iÀÛVià U ,Ê i«ÀÌ}]Ê «>ViÊ-iÀÛViÃÊ>` *>Ê VÕiÌÊ,iÛiÜ U }Ê>`Ê*ÀiÕÊ iVÌ U V>ÀÞÊ*À`ÕVÌÃÊ>`Ê-iÀÛVià ª#FOFmU.BMM\"MMSJHIUTSFTFSWFE XXXCFOFGJUNBMMDPN#SPLFST4UPQ-PTT8IBUJT4UPQ-PTT May 2017 | The Self-Insurer 49
We appreciate the positive response our medical stop loss coverage has received coast to coast. We look forward to bringing our iconic brand name, stellar balance sheet, and decades of underwriting experience to the medical stop loss marketplace for years to come. anks. Asheville | Atlanta | Boston | Chicago | Houston | Irvine | Indianapolis Los Angeles | New York | San Francisco | San Ramon | Seattle | Stevens Point Auckland | Brisbane | Düsseldorf | Hong Kong | Kuala Lumpur London | Macau | Melbourne | Singapore | Sydney | Toronto www.bhspecialty.com/msl
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