Self-Insurer Mar 2015

March 2015

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March 2015 | The Self-Insurer 3

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12 ART Gallery (Police) State of the Union

16 Cadillac Tax Contemplation

20 PPACA, HIPAA and Federal Health Benefi t Mandates Agencies Issue New

Proposed Rules for

the Summary of

Benefi ts and Coverage

28 For Captive Reinsurers,

is Transparency the Answer?

34 SIIA Endeavors Understanding Taft-Hartley

Health Plans

40 RRGs Report Financially

Stable Results Through

Third Quarter 2014

46 SIIA State Government Relations SIIA Engaged at State

Level to Protect

Self-Insurance Marketplace

50 Hospital Claim Payments

– Due Diligence for Payers

56 Knowing Whether an

Enterprise Risk Captive Makes

Sense for Your Company

Bruce Shutan

4

36

March 2015 Volume 77

The Self-Insurer (ISSN 10913815) is published monthly by Self-Insurers’ Publishing Corp. (SIPC)

Postmaster : Send address changes to The Self-Insurer P.O. Box 1237 Simpsonville, SC 29681

Editorial StaffPUBLISHING DIRECTORErica Massey

SENIOR EDITORGretchen Grote

CONTRIBUTING EDITORMike Ferguson

DIRECTOR OF OPERATIONSJustin Miller

DIRECTOR OF ADVERTISINGShane Byars

EDITORIAL ADVISORSBruce ShutanKarrie Hyatt

Editorial and Advertising Offi ceP.O. 1237, Simpsonville, SC 29681(888) 394-5688

2015 Self-Insurers’ Publishing Corp. Offi cers

James A. Kinder, CEO/Chairman

Erica M. Massey, President

Lynne Bolduc, Esq. Secretary

www.sipconline.net

24

MEDICAL TOURISM TREND:

DomesticTravel Seen Trickling

Down Market

Andrew Silverio, Esq.

The Fiduciary

HOT POTATO

International Conference

April 13-15

2015Panama City, Panama

4 The Self-Insurer | www.sipconline.net

Written by Bruce Shutan

When it comes to shopping for bargains on the so-called medical tourism

market, self-insured employers might

just be better off sending their infi rmed

employees to Peoria than Pretoria.

For years, Corporate America

has turned to international medical

travel as a low-cost alternative to

anything from heart-bypass surgery

and angioplasty to knee and hip

replacements, but domestic medical

travel has been quietly gaining traction

among self-insured groups of all sizes.

Employers are not only able to

avoid risks associated with unstable

parts of the world and raise the

comfort level of employees who’ve

never even been on an airplane

before, but also avoid concerns

about the quality of care being

provided abroad. U.S. prices also are

Seen Trickling Down Market


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TRAVEL | FEATURE

increasingly transparent and much more competitive because of bundled payments with preferred providers.

“I think it’s perfectly suited to self-insured employers because they can have greater control over their benefits design and deciding what best suits the needs of their workforce,” says Laura Carabello, editor of the Medical Travel Today newsletter as well as a principal with Strategic Marketing Communications. She moderated a panel discussion on this topic at SIIA’s annual conference last October.

Fear FactorThe cost of care obviously varies

from one part of the world to another, with some spots offering better deals than others. Savings opportunities aren’t very significant in Europe and other countries where there’s more westernized medicine relative to the U.S., opines Ruth Coleman, CEO of Health Design Plus, a national leader in managing domestic travel. “Where you start to get really low costs are places like Asia and some parts of Central America, but sometimes it’s a crap shoot with those places and people don’t want to travel that far,” she adds.

Heart bypass operations, for example, averaged $144,000 in the U.S. in 2013 compared with $27,000 in Mexico and just $5,200 in India, notes list of prices published on the Medical Tourism Association’s website.

Most Americans don’t even own a passport, according to the U.S. government, with Carabello noting that many are afraid to travel, or would rather not be too far from home and don’t want to leave behind their support system during such a vulnerable or challenging time.

“Employers are very sensitive to this,” she says. “They don’t want to make it difficult for people to access the health care that they need…

“There are places like Mexico which have some great hospitals and providers. But frankly, the drug traffic trade there is significant and very frightening to a lot of people.”

Olivia Ross, associate director of the Pacific Business Group on Health’s (PBGH) Employers Centers of Excellence Network (ECEN), agrees that there’s some reluctance or fear from employees to travel to another country for a medical procedure, especially when there’s a language barrier.

“We have people who traveled through our program who’ve never left their state, so it’s a big deal to go from Oklahoma to Missouri versus Oklahoma to Thailand,” says Ross, whose nonprofit, member-driven organization serves roughly 60 employers. About 40% of ECEN patients are able to drive to their treatment destination, which she believes is “much more realistic and accessible for some of these employees.”

One big downside to international travel for a self-insured employer is that there may not be much value if just two employees end up seeking treatment, Ross observes, whereas stateside travel offers greater potential for a much higher uptake. She points to a significant variation in cost, even within the domestic market and intensive competition over both cost and quality on a region basis.

Domestic medical travel will continue to pressure local providers across various markets to offer more reasonable prices for groups of employees and generally hold them more accountable, according to Keith Smith, M.D., managing partner at the Surgery Center of Oklahoma.

“If a hospital knows that someone is flying to my facility and getting their procedure for $50,000 less than what they would have charged the employer, then it won’t take very many patients walking out of town before that hospital begins to step up and at least lower their prices,” he observes.

One significant driver behind the self-funding trend is that the Affordable Care Act has created self-funded entities out of individuals who are looking to reduce their growing out-of-pocket costs, which Smith says has been great for his business.


TRAVEL | FEATURE

“We have patients that have come here from all 50 states except Hawaii,” he reports, referencing about 150 arrangements and direct contracts with very small companies that are self-funded or their third-party administrators.

“There aren’t any forces of economies of scale because our prices are online and they’re good for everyone,” he explains. “And there are a lot more facilities that are doing what we’re doing. It’s happening all over the country. There’s actually not even any negotiation required because the prices are all transparent and visible.”

Some of the nation’s largest and well-known employers, including Walmart, Lowe’s and McKesson, have launched the ECEN benefit for their employees and the hope is that a half-dozen more employers come on board in the next year or so. “We had 2,000 calls about the program, 1,000 cases referred and 506 cases that went through the program,” reports Ross, who said the expectation was to reach 200 or 300 cases.

After Walmart announced in 2013 that it would develop a network with multiple centers, PBGH realized that domestic medical travel could be taken to the next level if enough other employers banded together to leverage their purchasing power and developed the ECEN program.

ECEN’s four centers share guidelines and best practices. They also conduct monthly collaborative phone calls and recently held their first annual in-person summit featuring surgeons and other representatives from each of those centers. So as a result, Ross says a Lowe’s employee seeking treatment at a facility in Seattle or Springfield, Mo., will receive the same quality of care both in terms of outcomes and their entire experience.

“That’s very different from anything else you’ll see on the market,” she

Medical Procedure USA COLOMBIA COSTA RICA

Heart Bypass $144,000 $14,802 $25,000

Angioplasty $57,000 $4,500 $13,000

Heart Valve Replacement $170,000 $18,000 $30,000

Hip Replacement $50,000 $6,500 $12,500

Hip Resurfacing $50,000 $10,500 $12,500

Knee Replacement $50,000 $6,500 $11,500

Spinal Fusion $100,000 N/A $11,500

Dental Implant $2,800 $1,750 $900

Lap Band $30,000 $9,900 $8,500

Breast Implants $10,000 $2,500 $3,800

Rhinoplasty $8,000 $2,500 $4,500

Face Lift $15,000 $5,000 $6,000

Hysterectomy $15,000 N/A $5,700

Gastric Sleeve $28,700 $7,200 $10,500

Gastric Bypass $32,972 $9,900 $12,500

Liposuction $9,000 $2,500 $3,900

Tummy Tuck $9,750 $3,500 $5,300

Lasik (both eyes) $4,400 $2,000 $1,800

Cornea (both eyes) N/A N/A $4,200

Retina N/A N/A $4,500

IVF Treatment N/A N/A $2,800

Medical Procedure MEXICO ISRAEL THAILAND

Heart Bypass $27,000 $27,500 $15,121

Angioplasty $12,500 $8,000 $3,788

Heart Valve Replacement $18,000 $29,712 $21,212

Hip Replacement $13,000 $125,250 $7,879

Hip Resurfacing $15,000 $20,000 $15,152


Spinal Fusion $12,000 $35,000 $9,091

Dental Implant $1,800 $2,150 $3,636

Lap Band $6,500 $12,500 $11,515

Breast Implants $3,500 $21,000 $2,727

Rhinoplasty $3,500 $9,500 $3,901

Face Lift $4,900 $16,000 $3,697

Hysterectomy $5,800 $14,000 $2,727

Gastric Sleeve $9,995 $11,500 $13,636

Gastric Bypass $10,950 $11,500 $16,667

Liposuction $2,800 $7,242 $2,303

Tummy Tuck $4,025 $11,000 $5,000

Lasik (both eyes) $1,995 N/A $1,818

Cornea (both eyes) N/A $16,700 $1,800

Retina $3,500 $13,000 $4,242

IVF Treatment $3,950 $2,800 $9,091

International Medical Tourism Prices

Prices are based on 2013 figures. Source: Medical Tourism Association.


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Stop Loss insurance products are underwritten by ReliaStar Life Insurance Company (Minneapolis, MN) and ReliaStar Life Insurance Company of New York(Woodbury, NY). Within the state of New York, only ReliaStar Life Insurance Company of New York is admitted, and its products issued. Both are members of the Voya®family of companies. Product availability and specifi c provisions may vary by state. © 2015 Voya Services Company. All rights reserved. LG12231 12/08/2014 164932


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TRAVEL | FEATURE

Medical Procedure INDIA JORDAN KOREA

Heart Bypass $5,200 $14,400 $28,900

Angioplasty $3,300 $5,000 $15,200

Heart Valve Replacement $5,500 $14,400 +valve $43,500

Hip Replacement $7,000 $8,000 $14,120

Hip Resurfacing $7,000 $10,000 $15,600


Special Fusion $6,500 $10,000 $15,400

Dental Implant $1,000 $1,000 $4,200

Lap Band $3,000 $7,000 N/A

Breast Implants $3,500 $3,500 $12,500

Rhinoplasty $4,000 $3,000 $5,000

Face Lift $4,000 $4,400 $15,300

Hysterectomy $2,500 $6,000 $11,000

Gastric Sleeve $5,000 N/A N/A

Gastric Bypass $5,000 N/A N/A

Liposuction $2,800 $4,000 N/A

Tummy Tuck $3,000 $4,000 N/A

Lasik (both eyes) $500 $5,000 $6,000

Cornea (both eyes) N/A N/A $7,000

Retina $850 N/A $10,200

IVF Treatment $3,250 $2,700 $2,180

Medical Procedure VIETNAM AFRICA MALAYSIA

Heart Bypass N/A $10,000 $11,430

Angioplasty N/A $8,000 $5,430

Heart Valve Replacement N/A $10,130 $10,580

Hip Replacement $8,250 $10,480 $7,500

Hip Resurfacing N/A $7,640 $12,350

Knee Replacement $8,500 N/A $7,000

Spinal Fusion $6,150 N/A $6,000

Dental Implant N/A $5,340 $345

Lap Band N/A N/A N/A

Breast Implants $3,850 $2,930 N/A

Rhinoplasty $2,100 $3,935 $1,293

Face Lift $4,150 $4,620 $3,440

Hysterectomy N/A $3,270 $5,250

Gastric Sleeve N/A $8,770 N/A

Gastric Bypass N/A $3,935 $9,450

Liposuction $2,850 $5,060 $2,299

Tummy Tuck $3,850 $2,530 N/A

Lasik (both eyes) $1,640 $4,200 $477

Cornea (both eyes) N/A $6,460 N/A

Retina N/A $3,370 $3,000

IVF Treatment N/A $5,620 $3,819

International Medical Tourism Prices (continued)

Prices are based on 2013 figures. Source: Medical Tourism Association.

notes, adding that the result is lower complication rates and fewer inappropriate cases.

ECEN uses bundled payments and because it does consistent reviews of each patient and all four centers on an annual basis, “they know they’re getting what they’re paying for,” she adds. “The bundle allows them to have predictable costs ahead of time.”

While ECEN focuses on companies with 5,000 to 10,000 lives, Ross anticipates that the domestic medical travel trend will trickle down market. “Self-insured employers have the ability to make their own changes,” she says, “and to do these kinds of programs like ours as a carve-out. I think we’ll see more and more employers who are recognizing that change has got to happen. And if they can make a contribution to that positive change, they will.”

About 15% of large U.S. companies are estimated to offer domestic medical travel to their employees. Carabello agrees that the next frontier is going to be smaller and midmarket employers that finance these treatments or aggregate their purchasing power.

“I think employers realize now that they can shop around for the best price,” Carabello says. “They can leverage their buying power by coming together in coalitions and strategic alliances.”

Focusing on ValueWhile Coleman’s clients want

bundled rates that are affordable, she says their top priority is high quality care, along with a certain level of support for their associates and family members. The expectation is that a higher quality of care will be more cost-effective and raise the level of employee satisfaction.

She says to a certain extent, there needs to be enough volume of


surgeries to make implementing a domestic medical travel program a worthwhile investment, adding that it’s already trickling down market to smaller employers.

It’s harder for fully insured employers to benefit from these programs, according to Coleman. “One is they generally are smaller, but the other thing is that they’re not at risk financially, so there wouldn’t be as much benefit to them,” she says, unless insurance carriers are willing to reduce the premium based on program utilization. She noted a recent partnership between UnitedHealthcare and the University of Texas MD Anderson Cancer Center, which could be a precursor of similar arrangements from other carriers.

The trend toward domestic medical travel dovetails into other noteworthy developments. Ross, for example, notes how Medicare wants to shift 50% of its payments to value-based structures by 2018. “These self-insured employers are saying, ‘we need to be doing this, too. We don’t want to be paying these ridiculous fee-for-service prices with no emphasis on quality,’” she says.

Before employers decide whether to embrace domestic vs. international medical tourism, it might be worth first polling employees about their preferences, especially if they’re skittish about air travel or seeking care halfway around the world.

“If their employees don’t embrace these options, then there’s not much sense in offering them in the first place,” Smith says, noting how traveling to another country may be seen as a daunting proposition. ■

Bruce Shutan is a Los Angeles freelance writer who has closely covered the employee benefi ts industry for more than 25 years.

Company Employees

1. Walmart 2,100,0002. IBM 436,0853. McDonald’s 400,0004. United Parcel Service 400,6005. Target 355,0006. Kroger 338,0007. Sears Holdings 312,0008. General Electric 287,0009. Citigroup 267,00010. Albertson’s 240,00011. FedEx 222,30012. General Motors 210,00013. United Technologies 208,20014. CVS 201,00015. Altria Group 199,00016. Verizon Communications 195,40017. Aramark 195,00018. Berkshire Hathaway 192,01219. AT&T 189,95020. Home Depot 189,39021. Delphi 185,20022. Safeway 180,00023. Bank of America 176,63824. JP Morgan Chase 168,84725. Yum Brands 165,92026. HCA 165,45027. Lowe’s 164,79428. Ford Motor 164,00029. PepsiCo 157,00030. Walgreen 155,20031. Wells Fargo 153,50032. Boeing 153,00033. Darden Restaurants 150,10034. Hewlett-Packard 150,00035. Gap 150,00036. JC Penney 150,00037. Starbucks 149,00038. Starwood Hotels & Resorts 145,00039. Marriott International 143,00040. Sara Lee 137,00041. Lockheed Martin 135,00042. Walt Disney 133,00043. Alcoa 129,00044. Northrop Grumman 123,60045. Electronic Data Systems 117,00046. Honeywell 116,00047. Johnson & Johnson 115,60048. Lear 115,11349. Tyson Foods 115,00050. Emerson Electric 114,200

Largest U.S. Employers Using Domestic Medical TravelSource: www.statisticbrain.com/u-s-largest-employers/

Statistic Verification – Source: US Department

of Labor, SEC Date Verified: 1.1.2014

TRAVEL | FEATURE


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(Police) State of the Union

ART GalleryWritten by Dick Goff

GalleryWritten by Dick Goff

Gallery

My usual wry humor fails me today because my message is of such a serious nature. I believe that we, as American citizens, are experiencing an erosion of our rights that is nearly unprecedented this side of a historically totalitarian government. The kind of government that we

describe as a “police state.”

Many of us in a law-abiding industry are being increasingly harassed and persecuted by an arm of the United States government to such a degree that we fear losing certain rights which were the reason we learned the word “inalienable:”

– The right to equal justice under the law.

– The right to be considered innocent until proven guilty.

– The right not to be held guilty by association.

These rights are being trampled by the Internal Revenue Service when it audits certain captive insurance companies in a threatening tone of skepticism and

negativity – as if the agency were trying to squash them with intimidation rather than factual evidence.

The companies I’m describing are grouped in the description of enterprise risk captives (ERC). Their common element is election of IRS Code 831(b) status, a lawful option provided by Congress nearly 30 years ago that allows insurance premiums up to a certain level to be deducted from the captive owner’s tax bill.

This tax break has enabled many companies to afford the kind of insurance coverage that would be unavailable or unaffordable through traditional means. But to tar every such company as a “tax cheat” makes no more sense than to describe every homeowner who deducts mortgage interest as a “tax cheat.” Both make lawful use of tax relief offered by the government.

The increasing popularity of ERCs among small-to-midsize businesses has boomed recently, with thousands of small captives growing toward the tens-of-thousands. With their popularity has come increased – and increasingly aggressive – attention by the IRS.

ERC owners are commonly notified of an IRS audit with a questionnaire that seemingly eliminates the right to be assumed innocent before being proven guilty. ERCs begin the process “guilty” through an inquiry that leaves


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them almost powerless to respond. It’s impossible to prove a negative – in this case, that favorable tax treatment didn’t influence formation of the captive.

But here’s the reality of the situation. I am personally aware of dozens of cases of ERCs taken by the IRS through the audit process and I know of none where wrongdoing was found on the part of a captive owner. Rampant abuse of the tax code by ERCs just isn’t happening. If it were, we would be reading about successful IRS cases in our insurance trade publications, on websites and other media because the agency’s own publicity machine would be cranking them out.

But none. Zero. Zilch. No guilty parties. But still we continue to be harassed by our government’s daily attacks on our integrity.

Now, that’s not our only problem. We also must defend ourselves from sniping by members of our own industry who somehow find us beneath their contempt. We’re not “real captives” or even “real insurance” in many views stimulated by competitive zeal or plain old ignorance.

Meanwhile, many ERC owners are covering risks that they were unable to defend against by traditional means. Rather than using ERCs for commonplace coverage that the

commercial market does so well, they provide an affordable opportunity to cover special risks that typically occur with low frequency and high severity – you know, the kind of risks that can put a smaller firm out of business.

These include business interruption for any number of reasons, loss of key personnel or customers, loss of licenses, accreditations or franchises, loss of reputation and – increasingly now – losses due to breakdown of cyber security. These and many other possible risks are those that cause a business owner to lose sleep far more than the prosaic risks covered by usual means. Before the ERC structure there was no efficient way to cover these risks and now there is.

But still, the attacks by the government and our own industry continue to wear us down. The need for an industry defender has been picked up by SIIA in the early stages of an educational and lobbying campaign in defense of ERCs.

“SIIA has accepted the challenge to defend the small captives industry because there is no other organization that can effectively and credibly explain the legitimate business benefits of ERCs,” says Jeff Simpson, chairman of SIIA’s Alternative Risk Transfer (ART) Committee.

“This is an important risk management tool that is serving smaller

businesses by providing coverages that previously could not be efficiently obtained,” Simpson says. “Anyone who believes in risk sharing through insurance of any form should be a supporter of ERCs.”

Simpson, an attorney with Gordon, Fournaris & Mammarella, P.A. of Wilmington DE, lists targets of SIIA’s educational campaign as the general business community, members of the self-insurance industry, insurance regulators, tax agencies and Congress.

“The great risk of not defending our industry is that we could win all the IRS audit battles but lose the war because of an overall negative impression of ERCs,” Simpson says.

Along the way, perhaps wiser heads in Washington will agree that this is still America and that citizens conducting lawful business should be treated with respect and courtesy by agencies of our government. It’s not too much to ask. ■

Readers who wish to comment on this column or write their own article are invited to contact Editor Gretchen Grote at [email protected]. Dick Goff is managing member of The Taft Companies LLC, a captive insurance management fi rm. Email [email protected] and visit

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Cadillac Tax Contemplation

Written by Cori M. Cook, J.D.

CMC CONSULTING, LLC

Many employers and their TPAs are still working through the 26 USC § 4980H analysis (Shared Responsibility for Employers Regarding Health Coverage) and whether the coverage being offered is good enough so as to avoid excise taxes. However, it is already time to

start contemplating and preparing for the Cadillac Tax and the analysis of whether

the coverage being offered is too good so as to avoid excise taxes.

Beginning January 1, 2018, the Patient Protection and Affordable Care

Act (PPACA) will impose the Cadillac Tax. The Cadillac Tax is an excise tax

on applicable employer-sponsored health coverage that provides benefits to

employees (current and former employees) and other covered individuals that

exceeds specific pre-determined thresholds (“excess benefits”.) The excise tax

was intended to be a permanent, non-deductible tax touted to help slow the

growth rate of health costs (particularly premium growth), reduce health care

usage, encourage employers to offer cost-effective benefits, encourage employee

engagement and practically speaking – to help finance the expansion of health

coverage under PPACA.

Final regulations have not been issued and we are anticipating further guidance

on many unanswered questions. However, based on our current understanding

the applicable coverage to be taken into account to determine if a plan meets the

qualifications includes all applicable employer-sponsored health coverage including,


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but not limited to, coverage provided for medical, prescription drugs, dental, vision, health FSA, HRA, HSA and on-site clinics. Dental and vision may be excluded if provided to employees under a separate plan, as well as “excepted benefits.”

The Cadillac Tax will be imposed on the cost of the applicable employer-sponsored health coverage that exceeds the yearly allowable pre-determined threshold. The cost of coverage is the sum of the employee and employer shares, which includes premiums paid by the employee and employer, as well as the employee and employer contributions to health FSAs, HRAs, HSAs, on-site clinics and any other applicable coverage.

To calculate the Cadillac Tax, all monthly excess benefit amounts must be aggregated to determine the yearly amount of excess benefits. The aggregated excess benefit amount is then multiplied by 40%. For planning purposes and for 2018, the threshold amounts are expected to be $10,200 for single coverage ($850 per month) and $27,500 for family coverage ($2,291.67 per month) which will likely increase each year based on increases in health care costs, cost-of-living adjustments, as well as age and gender adjustments. The annual threshold amounts will also be adjusted for high-risk professions and qualified retirees.

ExampleCompany XYZ offers a comprehensive, self-funded medical plan to its

full-time employees in 2018. The total cost of coverage (employee share and employer share) for each employee covered on the plan electing self-only coverage is $12,000 and the total cost of coverage for each employee covered on the plan electing family coverage is $30,000.

Self-only Coverage Annual Calculation$12,000 - $10,200 = $1,800 x 40% = $720 excise tax per covered employee

Family Coverage Annual Calculation$30,000 - $27,500 = $2,500 x 40% =

$1,000 excise tax per covered employee

Employers are ultimately responsible for calculating the excise tax for the applicable employer-sponsored health coverage regardless if they are fully insured or self-funded and in either case, the employer and/or plan size is irrelevant.

Although many observers are hoping for repeal, the Cadillac Tax is expected to be a significant source of revenue to assist in keeping the PPACA programs alive. Many of the funding mechanisms for PPACA have already been delayed or set aside and many argue that it may not survive another financial hit.

Is the Cadillac Tax a “tax” or is it simply the elimination of an existing tax break?

Advocates contend that the excise tax is necessary due to the long-standing unequal tax benefit that has existed for decades. Employers receive a tax incentive for offering health benefits to their employees in lieu of wages

and the benefits are provided to the employee on a tax-free basis. Some advocates have argued that the higher paid employees receive a higher level of income due to the tax-free value of the health benefits provided to them. By excluding the full value of employer-sponsored health insurance from individuals’ taxable income, one estimate is that the federal government is currently providing Americans with more than $250 billion each year in tax subsidies. Since both employers and employees presently benefit from the tax incentives currently in place, any attempt to eliminate them has been met with significant opposition.

Critics of the Cadillac Tax claim that employers, in their quest to obey the law but avoid an additional excise tax, may make changes resulting in decreased benefits provided to their employees and will likely attempt to impose significant changes in cost-sharing differentials. By increasing deductibles and co-payments, employers may shift a larger portion of the cost of health care on to the employee which may result in increased individual debt and/or deferred medical treatment.

It is not too soon for TPAs to begin consulting with their respective clients in contemplation of developing a long-term deliberate health care strategy for the employer. Employers should be considering, at a minimum:

1. Will the current offering be subject to the Cadillac Tax?

2. What would the amount of the excise tax be?

3. What thresholds does the plan currently qualify for?

4. What are the current cost-drivers for the health plan?

5. What cost-containment strategies could be implemented now and over the next several years, to significantly impact claim costs.


One method of managing excess benefits provided to employees is managing the cost of the health plan. Effective cost-containment strategies may allow employers to manage plan costs while continuing to provide high quality benefits. Some examples of these strategies include, but by no means are limited to: case management and disease management intervention opportunities for those individuals identified as having a chronic condition; travel benefits (domestically and internationally) to obtain high quality low cost treatment; reference-based pricing strategies; incentivized wellness programs; custom network arrangements with preferential rates; implementation of narrow networks; and detailed auditing programs. If it hasn’t already occurred, now is the time for TPAs to assist employers in exploring cost-containment strategies that are appropriate for a particular employer’s population.

The industry eagerly awaits regulations that will provide more specific information and guidance and whether the Cadillac Tax will survive is a hotly debated topic. In the meantime, it is important that employers and TPAs work together to control the cost of health coverage for their employees in order to minimize or avoid any excise tax that may apply. TPAs are perfectly positioned to assist their clients through this analysis, assist their clients with the calculation and with any subsequent reporting. Failure to properly plan ahead could significantly impact an employer and the viability of its benefit offering. ■

This article is intended for general informational purposes only. It is not intended as professional counsel and should not be used as such. This article is a high-level overview of regulations applicable to certain health plans.

Please seek appropriate legal and/or professional counsel to obtain specifi c advice with respect to the subject matter contained herein.

Cori M. Cook, J.D., is the founder of CMC Consulting, LLC, a boutique consulting and legal practice focused on providing specialized advisory and legal services to TPAs, employers, carriers, brokers, attorneys, associations and providers, specializing in health care, PPACA, HIPAA, ERISA, employment and regulatory matters. Cori may be reached at (406)647-3715, via email at [email protected] or at www.corimcook.com.

We are an innovative underwriting management organization specializing in Employer Excess of Loss in Self-Insurance and Medical Excess of Loss in Managed Care as well as Personal Accident Products. We take the time to learn about your business, providing a consultative approach to achieve the best risk solution.

At StarLine, the difference is in our people, our products and our passion. To learn more about our customized solutions, visit starlinegroup.com or call (508) 495-0882 today.


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PPACA, HIPAA and Federal Health Benefi t Mandates:

PracticalQ&AAgencies Issue New Proposed Rules for the Summary of Benefi ts and Coverage

On December 30, 2014, the Departments of the U.S. Treasury (Treasury), Labor (DOL) and Health and Human Services (HHS) (the “agencies”) jointly published proposed rules (the “Proposed Rules”) that update and clarify the fi nal regulations regarding the Summary of

Benefi ts and Coverage (SBC) published in 2012.

Practice Pointer: The new regulations are only proposed regulations,so some aspects could change before they are finalized. If finalized, however, the new SBC rules, template and glossary should be used for all SBCs issued on or after September 1, 2015.

The Proposed Rules incorporate previous subregulatory guidance issued in the


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form of Frequently Asked Questions (FAQs), as well as make some new changes. The proposed template and the proposed glossary can be found on the DOL’s website.1

Changes to the SBC Template and Glossary

A template and glossary for the SBC were issued in connection with the 2012 final regulations. The Proposed Rules make a number of additions and deletions to these form documents and the glossary. First, the Proposed Rules would require the SBC to state whether the coverage offers minimum essential coverage and minimum value. This would end the current safe harbor that allows this information to be delivered through a separate letter.2 The Proposed Rules would also require the SBC to add a third coverage example, an emergency room visit for a simple foot fracture, to the two previously required examples involving a routine delivery and the management of type 2 diabetes.

Despite these new additions, the Proposed Rules actually shorten the completed SBC template to two and a half pages from the original four pages. This is accomplished by removing some information that is not required by statute. For example, references to annual limits for essential health benefits and pre-existing condition exclusions would be removed. Conversely, the glossary is expanded from four to six pages. The Proposed Rules will add definitions for several new terms, including “claim,” “cost sharing” and “individual responsibility requirement.” Several existing definitions are also changed slightly. Furthermore, changes are proposed to the SBC instruction sheet and the “Why This Matters” language.

In addition, the continuation of coverage, minimum essential coverage

and minimum value disclosures are revised in an effort to provide more useful information.

Changes to the SBC Delivery Requirement

Plan and/or insurer’s requirement to provide SBCs to participants

The Proposed Rules make several clarifications regarding the provision of the SBC to participants, all of which are discussed in previous FAQs issued by the agencies. For instance, the Proposed Rules state that an SBC must be provided to participants upon automatic re-issuance or re-enrollment.3 They also codify the safe harbor providing for electronic delivery of SBCs in connections with online enrollment, renewal or online request from a participant or beneficiary.4

The Proposed Rules also extend previous safe harbors in an attempt to streamline the SBC delivery process to participants and reduce duplication issues that may arise when SBCs are delivered by a third party.5 A plan or issuer that contracts with a third party to provide an SBC will be considered to satisfy the requirement to provide an SBC if the plan or issuer monitors the performance of the contract, corrects noncompliance with the contract “as soon as practicable” and communicates with participants and beneficiaries affected by the noncompliance and takes “significant steps as soon as possible to avoid future violations.”

Furthermore, if a group health plan contracts with more than one issuer to provide benefits for a single plan, the Proposed Rules require the plan administrator to provide a consolidated SBC for the plan.6 An issuer has no obligation to provide an SBC containing information for benefits that it does not insure, but a plan administrator may contract with an issuer to do so.

In addition, the safe harbor allowing plan administrators to either synthesize information into a single SBC or provide multiple SBCs is left in place.7

The antiduplication rules cover individual student health insurance plans as well.8 The Proposed Rules state that a higher education institution’s requirement to provide an SBC to an individual will be considered satisfied if another party, such as a health insurance issuer, provides a timely and complete SBC.

Insurer’s requirement to provide SBCs to a plan

The Proposed Rules make several clarifications regarding the provision of the SBC to plans by insurers, all of which were discussed in previous FAQs. First, insurers will not be required to provide updated SBCs during coverage negotiations.9 If a plan sponsor is still negotiating coverage terms following the application for coverage, the issuer is not required to provide an updated SBC to the plan until the first day of coverage. However, a plan sponsor’s request for an updated SBC must otherwise be honored at any time.

In addition, the rules reaffirm that insurers will not be required to provide new SBCs upon application if they were provided prior to application.10 If a plan or issuer provides an SBC prior to an application for coverage, such as part of its pre-enrollment materials, the plan or issuer is not required to provide another SBC upon application if there is no change to the information.

Summary for Plan Administrators

The Proposed Rules codify many existing SBC practices that plan administrators are probably already taking to deliver the SBC to participants. No new proposed rules would change existing delivery


practices. The biggest change for plan administrators will be the use of the new

template and glossary, which should be used exclusively after September 1, 2015.

Practice Pointer: Many of the delivery practices discussed in the

Proposed Rules simply codify delivery practices provided in previous

agency FAQs. The FAQs can be found here. The Proposed Rules would

make the FAQ guidance permanent.

Penalties for NoncomplianceThe 2012 regulations provided that a willful failure to provide an SBC can result

in a fine of $1,000 for each such failure, which can be enforced by the DOL, HHS or

IRS. The Proposed Rules provide some clarity about DOL and IRS enforcement. For

instance, in assessing fines against plans, the Proposed Rules clarify that the DOL will

use the same process and procedures it currently uses to enforce the Form 5500

filing rules. The Proposed Rules further clarify that the DOL is not authorized to

assess this fine against a health insurance issuer, per ERISA § 502(b)(3). Furthermore,

the Proposed Rules state that the IRS will enforce the SBC rules using a process

consistent with Internal Revenue Code Section 4980D for failure to meet the

Code’s group health plan requirements.

The agencies are accepting comments through March 2, 2015, including through

www.regulations.gov ■

The Affordable Care Act (ACA), the Health Insurance Portability and Accountability Act

of 1996 (HIPAA) and other federal health benefi t 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 federal benefi t mandates.

Attorneys John R. Hickman, Ashley Gillihan, Johann Lee, Carolyn Smith and Dan Taylor

provide the answers in this column. Mr. Hickman is partner in charge of the Health

Benefi ts Practice with Alston & Bird, LLP, an

Atlanta, New York, Los Angeles, Charlotte

and Washington, D.C. law fi rm. Ashley

Gillihan, Carolyn Smith and Johann Lee are

members of the Health Benefi ts 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 email to Mr. Hickman at

[email protected].

References1The proposed template can be found at www.dol.gov/ebsa/pdf/sbctemplateproposed.pdf

The proposed glossary is at www.dol.gov/ebsa/pdf/sbcuniformglossaryproposed.pdf

2As found in FAQ XIV, Q2. www.dol.gov/ebsa/faqs/faq-aca14.html

3Codifi ed from FAQ VIII, Q9. www.dol.gov/ebsa/faqs/faq-aca8.html

4Codifi ed from FAQ VIII, Q10. www.dol.gov/ebsa/faqs/faq-aca8.html and FAQ IX, Q1. www.dol.gov/ebsa/faqs/faq-aca9.html

5Codifi ed from FAQ VIII, Q5. www.dol.gov/ebsa/faqs/faq-aca8.html

6Codifi ed from FAQ IX. Q10. www.dol.gov/ebsa/faqs/faq-aca9.html

7Codifi ed FAQ IX, Q10. www.dol.gov/ebsa/faqs/faq-aca9.html.

8Codifi ed from FAQ XIV, Q7. www.dol.gov/ebsa/faqs/faq-aca14.html

9Codifi ed from FAQ IX, Q2. www.dol.gov/ebsa/faqs/faq-aca9.html

10Codifi ed from FAQ IX, Q3. www.dol.gov/ebsa/faqs/faq-aca9.html


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The US market for self-funded health plans, captives and all the services related to the development

of this business has been nothing short of hectic for the past fi ve years.

At the same time, markets outside the US have been equally active and we’ve seen many carriers, brokers, reinsurers and service organizations expanding their reach to Central and Latin America.

Your SIIA International Committee tracks this development and sees a greatly increased opportunity to build our business outside our borders.

The economies of Central and Latin American countries are healthy and growing. With few exceptions, we’re seeing political stability, higher levels of education and broad-based business growth. In many cases, governments are actually investing in the business community to help and encourage growth.

International Conference

April 13-15, 2015Panama City, Panama

Self-Insurance Institute of America, Inc.


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Imagine that all this is happening within just a couple of hours travel time of major US airports.

While health benefits in these countries are generally socialized, many corporations are increasing their health coverage for technical and managerial employees. In addition, they are adding dental, life and other ancillary benefits through private carriers or self-funding themselves.

We’re seeing an active interest in Captives throughout these countries as well.

For years Panama has worked to be a destination for businesses looking to locate a Central American venture, service their Latin business or find tax breaks for developing business.

Suffice it to say, all this development has our attention and we’ve decided to host this year’s SIIA International Conference in Panama City, Panama, the gateway to Central and Latin America. Panama is a beautiful country with a vibrant capital in Panama City, beautiful beaches, cool highlands and very friendly people. The new airport is easily accessible from Texas, Miami and New York airports. You’ll find a great variety of things to do including golf, sport fishing, touring, nightlife, great restaurants and entertainment, all of this reasonably priced using the American dollar. Panama has ports on both the Caribbean and Pacific coasts and the Panama Canal, one of the Seven Wonders of the World, generates significant economic activity and plenty of business opportunity. Be sure to join us early to participate in the optional add-on tour of the Canal Zone, hosted by The Self-Insurance Educational Foundation, Inc. (SIEF) and the newly opened third canal built to accommodate jumbo ships, followed by a tour of the beautiful city of Panama.

We’ll be staying at the new Panama Hilton. Be sure to call them for the special SIIA rate.

Plan to come in on Sunday, April 12th, in time for our opening reception and the first activity on Monday morning. We’ll start with the Canal tour and end the day with a welcome reception on Monday evening, April 13th.

We have worked very hard to line up a world-class group of presentations that will focus on developing business opportunities in Central and Latin America and are pleased to offer simultaneous translation services to accommodate all attendees. Our sessions will kick off on Tuesday with a thorough overview of the regulatory environment with recognized expert, John Rooney. Throughout the day, we’ll look at captive opportunities, multi-national pooling strategies and a great session on developing self-funding opportunities in Central America.

We’ll finish the program on Tuesday with a presentation from a major Panama based carrier. Our friends from Willis will be hosting an off-site

group dinner and entertainment Tuesday evening that you won’t want to miss.

On Wednesday, we’re privileged to hear from the Risk Manager of the

I would also like to take this opportunity to thank all of our sponsorsComplete Health Systems

Equian

Fairmont Specialty, a Division of Crum & Forster

Global Benefits Group, China

Health Portal Solutions

Hi-Tech Health, Inc.

Niki’s International Ltd.

Nueterra

PartnerRe America Insurance Co.

Passport For Health, a Medical Travel Company

Re-Solutions, LLC

SIEF

Willis North American Captive & Consulting Practice

PANAMA | FEATURE


Panama Canal Zone, including an overview of the recently completed project. Our other sessions Wednesday include an update on self-funding and captives in the Caribbean, including one of the more active venues, Trinidad. We’ll finish the educational program with a look at self-insurance business in the Caribbean and an update on medical travel to Central America.

All this with a great opportunity to share camaraderie with your fellow members and meet many of the people who are leaders in Central and Latin America. Make your reservations now to be sure you get a spot, as this conference will be well worth your time. ■

See you in Panama!Bob RepkeInternational Committee Chair

SIIA’s International Conference would not be

possible without the support and hard

work from our International Committee

Joseph AntonellSenior Vice President, Business DevelopmentEquian

Greg ArmsCOO, Accident & Health Div.Chubb Group of Insurance Companies

Stephen Barry Vice President, Strategic Relationship and Global AccountsVoya Financial, Inc.

Jeff Gavlick Vice President, Product Development and Management - Stop LossAIG Benefit Solutions

Todd A. HancockExecutive Vice President and Chief Operating OfficerInternational Medical Group, Inc.

Dennis E. HeinzigPresident, HealthPartnerRe

Chacko KurianPresident & CEOComplete Health Systems, LC

John O’ConnorPresidentGlobal Benefits Group

Matthew Smith Senior Vice PresidentRe-Solutions, LLC

Robb A. SucheckiVP, International Group InsurancePan-American Life Insurance Group

Michael Tuomey Business Development and Vendor RelationsWLT Software

Alejandro Vazquez External ConsultantCooperativa La Cruz Azul, S.C.L.

Nigel WallbankPresidentNew Horizons Insurance Solutions

PANAMA | FEATURE


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Want to get the best savings and the best service from your Reference Based Reimbursement provider? Call or email AMPS now to find out more about how we can help you.

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Captive reinsurance has been rapidly growing since the early 2000s and so far they have not been a source of fi nancial instability, despite the warnings of critics. Both critics and supporters of captive reinsurers believe that more transparency in fi nancial reporting would help

improve reinsurance captive’s standing. Yet questions remain regarding how much

transparency would be enough, how it should be regulated and, even more

importantly, how to implement greater transparency nationally without sacrifi cing

the captive model.

A Little BackgroundInvestigations into captive reinsurers began in 2012 when the National

Association of Insurance Commissioners (NAIC) Financial Condition (E)

Committee formed a subgroup, the Captive and Special Purpose Vehicle Use (E),

to examine reinsurance captives covering life insurance companies transferring

risk that was not self-insured risk. The committee’s findings were released in mid-

2013 about the same time that the New York Department of Financial Services’

(DFS) white paper on the subject was released. The DFS’s report criticized these

types of life insurance reinsurance captives as a “shadow industry” – a term used

to describe a financial intermediary that is not subject to regulatory oversight. The

DFS called for a moratorium on captive formation.

For Captive Reinsurers, is Transparency the Answer?

Written by Karrie Hyatt


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In December 2013, a Federal Insurance Office (FIO) report, titled “How to Modernize and Improve The System of Insurance Regulation in the United States,” recommended changes to the regulation of captive reinsurers. This paper was soon followed, in early 2014, by the NAIC Financial Regulation Standards and Accreditation (F) Committee’s proposed change to the definition of multi-state reinsurers that would include captive reinsurers. Also in 2014, several scholarly studies were published both in favor of and against these types of captives. Most recently, the Office of Financial Research (OFR), in its 2014 Annual Report to Congress, called for more transparency in the regulation of captive reinsurers.

What Is at Stake?Much of the criticism surrounding

captive reinsurers is a fear that these companies, valued at $364 billion in 2012, could cause another financial crisis if they should begin to fail on a national level. That is where the idea of more financial transparency comes in. However, when proposals are made to increase transparency, they very often include a range of captive types and are not limited to captive reinsurers.

“Requiring all size and shapes of captives to be equally transparent in practices is another thing. Regulation needs to fit the entity being regulated,” said Dana Hentges Sheridan, general counsel and chief compliance officer for Active Captive Management, LLC. “You’d hardly hold a captive that has less than a million dollars in net premium revenue annually to the same standardized set of rules as an AIG. Such a captive is very unlikely to have a big impact on the nationwide insurance market or the U.S. economy.”

According to Mark E. Morris, senior vice president of Risk Finance, Lockton Companies, “Captive structures are unique and I can see a lot of harm coming from developing broad measures that are trying to address a fairly minor area of the greater captive reinsurance market.”

What the Reports Have to Say

The FIO’s December 2013 report on modernizing the insurance industry includes suggestions for the reinsurance captive marketplace. The report lists as one of its findings that “States should develop a uniform and transparent solvency oversight regime for the transfer of risk to reinsurance captives.” It suggests that states should implement consistent disclosures and oversight standards for captives, which should include public disclosure of financial statements. The complete suggested changes break down as follows:

• States should develop and adopt a uniform standard for transparency policies for captive reinsurers that includes both liabilities and assets.

• States should develop and adopt uniform capital requirements for reinsurance captives.

• These requirements should prohibit transactions that do not provide the protections intended by the Credit for Reinsurance Model Law. Any such transactions should be disclosed in financial statements.

• States should develop and adopt national standards for oversight of captive reinsurance marketplace which would include public disclosure of financial statements for both captive reinsurance and captive insurance companies.

• The standards developed should be part of the NAIC’s accreditation program.

In the 2014 annual report from

the Treasury Departments’ Office of

Financial Research, the department

found that captive reinsurance, along

with nonbank mortgage servicers

and single-family rental securitizations,

could pose financial stability risks and

should be monitored accordingly.

The report contends that captive

reinsurance is an innovative financial

model that appears to be helping the

insurance sector meet the needs of

its policyholders. However, because it

is an evolving entity it can also pose

a threat to financial stability if not

“subject to prudential regulation.”

Citing both the DFS and the FIO

papers, the OFR report concluded

that “While the growing use of

captive reinsurance could be driven

by factors such as differences in tax

and regulatory regimes, it remains

difficult not only for policyholders

and investors, but also in some cases

for state regulators, to determine the

capital adequacy and financial strength

of captive reinsurers.” The report

suggested that further investigation and

monitoring of the sector was needed.

While these recommendations in

both the FIO and the OFR reports

are ostensibly pertaining to a small

slice of the captive insurance industry

– reinsurance captives, particularly

life insurance captive reinsurers –

implementation of any transparency

measures could have unintended

consequences industry-wide. The

main concerns are that increased

transparency and regulation could

cause harm to a growing industry, could

send business to offshore domiciles

– where regulation is even less

transparent, or could unintentionally

include all captives. An additional

concern is how new standards would

be implemented – through the NAIC

or a federal institution.


Changes are almost certainly forthcoming for the industry, but what those changes will be and how long it will take to implement them are still a long way off.

Where Should the Changes Come From?

While those working in the industry believe that changes to need to be made in order to improve the sector’s reputation, they are cautious about how to go about making those changes. “A major shift in reinsurance captive regulation is likely to have unintended consequences,” said Morris. “There is a risk that public policy and protectionist measures could be blended here into a mix that creates unnecessary friction in the market.”

As more states become domiciles for captives, getting the states to agree on standards and implementing them accordingly could be a “herculean

effort,” said Sheridan. “I’m not against the idea of model or uniform regulation, it’s just that I am not sure it’s feasible given how many states are currently new to the business of regulating captives, how each of the states have very different local reasons to regulate as they do... and that there are so many states now that would need to be involved.”

The FIO report did not exclude the idea that standards be implemented nationally on a federal level. Yet most people would prefer that the federal government not involve itself in captive regulation. “We are concerned that federal action can lead to overreach and create legislation that has unintended and potentially very negative consequences,” said Lockton’s Morris.

He continued, “The NAIC is effective in driving standards on state consistency. When, necessary, state support and consolidation is preferred to federal statutes. Federal acts often miss matters of local importance or have an impact that was not intended as federal agencies are further removed from the issue.”

Sheridan could see a hybridized version of a state and federal system of insurance regulation, but would prefer to leave the regulation to states. “Generally speaking, I cannot think of one area pertaining to captives where it makes sense that federal involvement in regulation is warranted. It seems that the FIO has come to the same conclusion as their recommendations relative to captives are that the states should get on the same regulatory page, not that any federal entity should regulate or ‘modernize’ rules applicable to captives.”

She sees the NAIC’s involvement as “crucial” to any nationally adopted standards. “The NAIC is at the center of efforts to study and standardize state regulation through, among other efforts, the promulgation of model legislation,

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but could any outside entity – whether it is the FIO or the NAIC – really obtain quick, coordinated and cohesive action from the states? Transparency between the states is perhaps more easily achieved and perhaps should be the goal.”

Morris agreed that “focused regulatory responses seem to be most effective.”

“After all, so much of the insurance industry remains local in nature yet this

consideration needs to be weighed against the fact that we have a much different insurance

environment today than ever before in the past,” added Sheridan. “The insurance industry is a

multi-trillion dollar a year industry. Nowadays, a strike to the insurance

industry can be a shot heard round the world from an economic perspective.”

Even while industry supporters and critics, captive administrators and captive regulators, agree that changes need to be made, additional transparency for reinsurance captives and nationally-consistent standards will take time and effort to achieve. Over the next few years this will continue to be a hot topic for the captive industry. ■

It’s all about you at Meritain HealthClient-centric, customized healthcare plans

Your employee population has unique needs. We get it.

That’s why Meritain Health works with youfor custom-fit benefits. You can pick andchoose from our product suite, or opt foryour own preferred vendors. And you canrest easy that you’ve chosen the benefitsyour workforce needs for good health.

To learn more about our customized benefit plans, contactMeritain Health at 1.800.242.6226.

Or visit us online at www.meritain.com.

© 2015 Meritain Health, Inc. For self-funded accounts, benefits coverage is offered by your employer, with administrative services only providedby Meritain Health, a subsidiary of Aetna Life Insurance Company (Aetna). 2014285

Karrie Hyatt is a freelance writer who has been involved in the captive industry for nearly ten years. More information about her work can be found at: www.karriehyatt.com.


Understanding Taft-Hartley Health Plans

SIIA Endeavors

The majority of Taft-Hartley health plans operate on a self-insured basis, which provides certain advantages over fully-insured arrangements. SIIAis pleased to present a new educational event to help plan trustees andadministrators maximize these advantages though educational sessions

led by top industry experts. The inaugural Self-Insured Taft-Hartley Plan Executive Forum will be held April 29-30th at the Marriott Metro Center in Washington, DC.

Sessions Include...Understanding the Value of Your Self-Insured Plan

While most trustees and administrators of self-insured Taft-Hartley plans

recognize this is a good option for their members, they may not fully understand

how valuable this plan funding strategy is given the rapidly changing health care

environment. To help you understand “just how good you have it,” Edward Kaplan,

Senior VP & National Health Practice Leader, The Segal Company will explain why

there has never been a better time to be self-insured.

Plan Design Strategies to Control CostsPerhaps the greatest advantage of being self-insured is the ability to customize

benefit offerings to best meet specific workforce needs and incorporate cost

containment strategies. Michael Jordan, President, Labor and Strategic Accounts

Division of MagnaCare, Kim Wood, Consultant, American Benefit Corporation

and Jim Conlon, Principal & Consulting Actuary at Milliman will highlight some

of the most innovative plan design strategies that Taft-Hartley plans may want

to consider. Included as part of their discussion will be guidance on how to start

preparing for the “Cadillac” tax in 2018.

Knowing Your Provider Payment OptionsMike Flammini, Head of Strategy and Business Development at Brighton

Health Partners will explore emerging trends in health care, including provider

payment reform, public and private exchanges and consumer engagement and

new opportunities that every plan administrator should consider in developing

new strategies for contracting and partnering with providers.

The Stop-Loss Insurance Carrier PerspectiveStop-loss insurance has become an increasingly important risk tool for Taft-

Hartley plans given the removal of

annual limits on claims. A panel of

executives including Dan Wolak,

President of Ullico, Mike Remeika,

Vice President at HCC Life Insurance

Company, Carolyn M. Coleman,

Regional Sales VP of HM Insurance

Group and Tom Costello, Vice

President, Benefits Division of Symetra

will discuss the value of stop-loss,

market trends and what plans should

consider when purchasing policies.

Self-Insurance Legislative/Regulatory Update

Learn the latest about important

legislative/regulatory developments

at the federal and state level affecting

self-insured Taft Hartley plans. Randy DeFrehn, Executive Director of

National Coordinating Committee for

Multiemployer Plans and Ed Smith,

CEO of Ullico will discuss Labor’s

response to the changing health care

reform environment.

Approaches for Providing Coverage for Early Retirees

With an increasing number of

Taft-Hartley plan participants

approaching retirement, the time is

now to make sure your fund’s self-

insured plan is properly structured

to ensure there is no disruption in

benefit delivery and important cost


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control components are incorporated. Dan Cunningham, President of Integrity Underwriters & Brokers will also address issues related to a plan’s decision to move some or all participants to the ACA exchanges.

The Forum will conclude with a re-cap and wrap-up session led by Leo Garneau, Senior Vice President of PHX. He will review everything you learned and discuss how this information can be best applied when you return to your offices. ■

As with all SIIA educational events, there will also be several unique networking opportunities. For more information, including registration forms, hotel information and sponsorship opportunities, please visit www.siia.org or call (800)851-7789. We look forward to your participation!

For more information, visit us online at hcc.com/life.A subsidiary of HCC Insurance Holdings, Inc. msl2208 - 11/14

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For firms with self-funded health plans, it’s never been more

important to understand potential risks and choose quality stop

loss coverage. HCC Life brings you over 35 years of medical

stop loss experience, industry-leading financial ratings and

experts who know what to do with it all. Intelligence beats the

odds every time. We call it Mind over risk.

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hcc.com/life


The Employee Retirement

Income Security Act

(“ERISA”), enacted in

1974, provides the federal

regulatory framework for private

sector employee benefi t plans. As

one of the primary goals of ERISA

is to establish a uniform statutory

framework for employee benefi t

plans, a major feature of ERISA is the

preemption of most state regulation

which touches on employee benefi t

plans falling within its scope. It is

because of this that a self funded

employee benefi t plan under ERISA

is essentially immune to most forms

of state regulation and must look

primarily to ERISA (and of course,

the Affordable Care Act in the case

of health and welfare plans) for

regulatory guidance.

ERISA establishes standards of

conduct for plan fiduciaries, those

exercising discretionary authority over

plan assets, plan management, or both.

ERISA holds these plan fiduciaries

to a high standard; such fiduciaries

have significant duties toward their

respective benefit plans and their

participants and must carry out these

duties prudently, faithfully adhere to

the applicable plan document (unless

it conflicts with ERISA) and always act

in the best interests of the plan and

its participants. A significant aspect of

this fiduciary status and the reason it

is so important to know whether one

is acting as a fiduciary, is the personal

liability imposed on fiduciaries for

breaches of their duties. In the context

of a health plan, a breach of fiduciary

duty can result in enormous damage

to the plan, damages which can then

be claimed from the responsible

fiduciary’s personal assets. So, what can

one do ensure that they are not held

to this fiduciary standard and subject

to its corresponding liabilities? Written by Andrew Silverio, Esq.

THE PHIA GROUP, LLC

The Fiduciary

HOT POTATO


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Just about any contract between

a plan and a TPA, a TPA and a vendor

or indeed any agreement the subject

of which touches on a plan’s

operation, will contain numerous

disclaimers and indemnifications,

purporting to evade any fiduciary

liability and adamantly denying

fiduciary status. These provisions,

perhaps out of trust in their

effectiveness or perhaps merely

out of caution, are ubiquitous in just

about any agreement within the self

funded sphere.

However, many plans, TPAs

and vendors focus far too much

on contractual disclaimers and

indemnifications and too little on the

nature of their actual activities. While

it is required that an ERISA plan

have at least one “named” fiduciary

pursuant to its plan document, this is

by no means the only way to attain

fiduciary status. “An entity’s status as a

fiduciary hinges not solely on whether

it is named as such in a benefit plan,

but also on whether it ‘exercises

discretionary control over the plan’s

management, administration, or

assets.’” Hartsfield, Titus & Donnelly v.

Loomis Co., 2010 WL 596466, 2 (Dist.

N.J. 2010), citing Mertens v. Hewitt

Assocs., 508 U.S. 248, 252 (1993). In

Hartsfield, the plan’s TPA, Loomis Co.,

was found to be a fiduciary despite

expressly disclaiming fiduciary status

in its contract with the plan. Loomis

Co. was then found to have negligently

made overpayments and was held

liable to the plan for breaching its

fiduciary duty in doing so. To make

this case even more frightening for

TPAs, the fact that Loomis made

overpayments in contradiction to the

terms of the plan was sufficient to

establish negligence, with essentially no

further evidentiary showing.

In addition to precluding any attemptto disclaim fiduciary status, ERISA also does

not allow one to disclaim fiduciary liability. See 29 U.S. Code §1110(a),

“Any provision in an agreement or instrument which purports to relieve a fiduciary

from responsibility or liability for any responsibility, obligation or duty under this part shall be void as against public policy.”

So, What Can a TPA or Vendor (which exercises some discretionary control over

plan assets or management) Do to Avoid Fiduciary Status or Lliability?

Unfortunately (or fortunately for plans), the answer is not much. However,

although this liability cannot be “extinguished”, it can be allocated, by one who

understands the nature of the fiduciary status and its corresponding duties and

liabilities. Pursuant to 29 U.S. Code § 1105(c), the “instrument under which a plan

is maintained” may expressly provide for an allocation of fiduciary responsibilities

(other than those of a trustee) among named fiduciaries. Additionally, the

instrument may allow such named fiduciaries to designate persons or entities other

than named fiduciaries to carry out fiduciary responsibilities. More importantly, if

a fiduciary allocates such a responsibility to another person, “...then such named

fiduciary shall not be liable for an act or omission of such person in carrying out

such responsibility...” 29 U.S. Code § 1105(c)(2). In other words, once a named

fiduciary properly delegates away a fiduciary duty, they are released from liability

to the extent of the scope of the duty delegated. They are not released from all

liability, however. The original fiduciary still has fiduciary duties in prudently selecting

a party to appoint as a fiduciary, as well as following the proper plan procedure for

doing so and reasonably monitoring the actions of the appointed fiduciary. Once

a fiduciary duty is properly allocated, the original fiduciary can be held liable for a

breach of that duty only through ERISA’s rules on liability between co-fiduciaries (or

through his own breach in imprudently selecting or failing to monitor the designated

fiduciary). Under these rules, one is liable for the actions of a co-fiduciary only

if he knowingly participates in or conceals the co-fiduciary’s breach, enables the

co-fiduciary’s breach through his own breach of fiduciary duties of prudence and

diligence, or has knowledge of the co-fiduciary’s breach and makes no effort to cure

the breach. 29 U.S. Code § 1105(a).

What can a TPA or Vendor Do with This Knowledge? A threshold question should be whether your company’s activities render it

a plan fiduciary, subjecting it to liability as such. Interpreting the plan document in order to approve or deny claims, without consulting the employer on each specific decision, conducting appeals, providing subrogation and reimbursement services for the plan, making amendments to the plan document or summary plan description... all of these are activities commonly undertaken by TPAs or contracted out to vendors which can subject one to fiduciary liability.

Once an examination of an entity’s activities in relation to the plan is complete, the next question is of course what to do about this liability. An option, perhaps

HOT POTATO


unwise but the most commonly utilized option nonetheless, is to continue business as usual and hope for the best. Fiduciary liability is of no concern so long as your organization never makes a mistake on a claim, botches an appeal or contracts with a vendor which may put its own interests before those of the plan. Another option is to identify activities which subject your company to fiduciary liability and manage this liability by delegating them out to another party as discussed above, making sure to follow proper plan procedure in doing so. A third option is to acknowledge this responsibility and ensure adequate protections are in place. Fiduciary liability insurance is available and can protect a company and its employees from damages resulting from fiduciary breaches, including the costs of defending against such claims. Other common forms of commercial insurance such as directors and officers liability, commercial general

liability, or errors and omissions policies can also protect your company from fiduciary liability, although alteration to the policy is probably necessary, as most insurance policies not aimed specifically toward fiduciary liability will disclaim it. It is important to note that the “fidelity bond” required by ERISA will not protect a fiduciary from personal liability. This bond, required for any person who handles plan funds, is in place to protect the plan in the event of dishonest conduct which damages the plan. It will not help the responsible party in the event of a breach.

No matter which course of action is undertaken, a thorough understanding of one’s responsibilities and liabilities in any given situation gives crucial insight into the true value of the services being provided. There is a good reason agreements which openly assume fiduciary status and liability come with higher fees than those which

disclaim such status. If the activities to be performed under an agreement will subject one to fiduciary liability regardless of contract language, why not assume that liability in the agreement? If assuming additional liability in the agreement, this risk and its potential costs should be taken into account in calculating the TPA’s fee. Additionally, an entity armed with this knowledge is better equipped to assess the extent of the liability it truly wishes to take on. ■

Andrew Silverio, Esq. joined The Phia

Group, LLC as an attorney in the summer

of 2014. In addition to conducting

research into novel and developing areas

of the industry, his primary focus is on

subrogation and reimbursement and he

handles many of the company’s more

challenging and complex recovery cases.

Andrew is licensed to practice in the

Commonwealth of Massachusetts and can

be reached at [email protected].


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A review of the reported fi nancial results of risk retention groups (RRGs) reveals insurers that continue to collectively provide specialized coverage to their insureds. Based on third quarter 2014 reported fi nancial information, RRGs have a great deal of fi nancial

stability and remain committed to maintaining adequate capital to handle losses.

It is important to note that ownership of RRGs is restricted to the policyholders

of the RRG. This unique ownership structure required of RRGs may be a driving

force in their strengthened capital position.

The financial metrics and ratios presented below have been materially

impacted by a Contribution Agreement and a merger made by separate

companies. First, a Contribution Agreement of an RRG that transpired in the first

quarter 2014. On January 1, 2014, Attorney’s Liability Assurance Society Inc., RRG

(ALAS) entered into a Contribution Agreement with its parent, ALAS Investment

Services Limited (AISL). ALAS assumed significant assets and liabilities of the

parent. According to the filed first quarter 2014 statement of ALAS, as a result

of the transaction, “loss reserves historically ceded by (ALAS) to the parent...

were reassumed by the company.” More than $2 billion in total assets and more

than $1.5 billion in total liabilities were contributed to ALAS. The most significant

liability assumed by ALAS was $1.2 billion of loss reserves. The net capital

RRGs Report Financially Stable Results Through Third Quarter 2014

Written by Douglas A Powell

Senior Financial Analyst,

DEMOTECH, INC.

This article originally appeared in “Analysis of Risk Retention Groups – Third Quarter 2014”


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contribution of this transaction was more than $513 million.

The second transaction materially impacting the financial metric and ratios of RRGs was a series of mergers. On May 1, 2014, MCIC Vermont Inc. (A Risk Retention Group) executed two mergers. The parent of MCIC Vermont Inc., MCIC Vermont Holdings Inc., was merged into MCIC Vermont Inc. Also on May 1, 2014, 2014, The Medical Centre Insurance Company, Ltd. was merged into MCIC Vermont Inc. Then MCIC Vermont Inc. converted from a risk retention company to a reciprocal risk retention company, thus changing its name to MCIC Vermont (A Reciprocal Risk Retention Group).

Balance Sheet AnalysisDuring the last five years, cash

and invested assets, total admitted assets and policyholders’ surplus have increased at a faster rate than total liabilities. The level of policyholders’ surplus becomes increasingly important in times of difficult economic conditions by allowing an insurer to remain solvent when facing uncertain economic conditions.

Since third quarter 2010, cash and invested assets increased 83 percent and total admitted assets increased 64.8 percent. More importantly, over a five year period from third quarter 2010 through third quarter 2014, RRGs collectively increased policyholders’ surplus 72.5 percent. This increase represents the addition of over $2 billion to policyholders’ surplus. During this same time period, liabilities have increased 59.7 percent. These reported results indicate that RRGs are adequately capitalized in aggregate and able to remain solvent if faced with adverse economic conditions or increased losses.

Liquidity, as measured by liabilities to cash and invested assets, for third

quarter 2014 was approximately 65.7 percent. A value less than 100 percent is considered favorable as it indicates that there was more than a dollar of net liquid assets for each dollar of total liabilities. This also indicates an improvement for RRGs collectively as liquidity was reported at 66.6 percent at third quarter 2013. This ratio has improved steadily each of the last five years.

Loss and loss adjustment expense (LAE) reserves represent the total reserves for unpaid losses and LAE. This includes reserves for any incurred but not reported losses as well as supplemental reserves established by the company. The cash and invested assets to loss and LAE reserves ratio measures liquidity in terms of the carried reserves. The cash and invested assets to loss and LAE reserves ratio for third quarter 2014 was 219.2 percent and indicates an improvement over third quarter 2013, as this ratio was 238.1 percent. These results indicate that RRGs remain conservative in terms of liquidity.

In evaluating individual RRGs, Demotech, Inc. prefers companies to report leverage of less than 300 percent. Leverage for all RRGs combined, as measured by total liabilities to policyholders’ surplus, for third quarter 2014 was 142.8 percent and indicates a diminishment compared to third quarter 2013, as this ratio was 127.8 percent.

The loss and LAE reserves to policyholders’ surplus ratio for third quarter 2014 was 99.1 percent and indicates a diminishment compared to third quarter 2013, as this ratio was 80.6 percent. The higher the ratio of loss reserves to surplus, the more an insurer’s stability is dependent on having and maintaining reserve adequacy.

Regarding RRGs collectively, the ratios pertaining to the balance sheet appear to be appropriate and conservative.

Premium Written AnalysisSince RRGs are restricted to liability coverage, they tend to insure medical

providers, product manufacturers, law enforcement officials and contractors, as well as other professional industries. RRGs reported direct premium written in eleven lines of business through third quarter 2014.

RRGs collectively reported nearly $2.5 billion of direct premium written (DPW) through third quarter 2014, an increase of 2.1 percent over third quarter 2013. RRGs reported over $1.5 billion of net premium written (NPW) through third quarter 2014, an increase of 32.4 percent over third quarter 2013.

$6

$8

$10

$12 Short‐term Assets

Net Admitted Assets

Liabilities

Policyholders Surplus

$‐

$2

$4

2014 Q32013 Q32012 Q32011 Q32010 Q3


The DPW to policyholders’ surplus ratio for RRGs collectively through third quarter 2014 was 68.1 percent, down from 91.5 percent at third quarter 2013. The NPW to policyholders’ surplus ratio for RRGs through third quarter 2014 was 42.8 percent and indicates a decrease over 2013, as this ratio was 44.4 percent. Please note that these ratios have been adjusted to reflect projected annual DPW and NPW based on results through the third quarter.

An insurer’s DPW to surplus ratio is indicative of its policyholders’ surplus leverage on a direct basis, without consideration for the effect of reinsurance. An insurer’s NPW to surplus ratio is indicative of its policyholders’ surplus leverage on a net basis. An insurer relying heavily on reinsurance will have a large disparity in these two ratios.

A DPW to surplus ratio in excess of 600 percent would subject an

individual RRG to greater scrutiny during the financial review process. Likewise, a NPW to surplus ratio greater than 300 percent would subject an individual RRG to greater scrutiny. In certain cases, premium to surplus ratios in excess of those listed would be deemed appropriate if the RRG had demonstrated that a contributing factor to the higher ratio is relative improvement in rate adequacy.

In regards to RRGs collectively, the ratios pertaining to premium written appear to be conservative.

Income Statement Analysis

RRGs collectively reported a $63.8 million underwriting loss through third quarter 2014. The third quarter result was impacted heavily by the underwriting loss reported by ALAS due to the Contribution Agreement the company entered into. The

collective underwriting losses were offset by strong investment gains and other sources of income. RRGs reported an aggregate net investment gain of $209.4 million and a net income of $134.9 million.

The loss ratio for RRGs collectively, as measured by losses and loss adjustment expenses incurred to net premiums earned, through third quarter 2014 was 80.2 percent, an increase over 2013, as the loss ratio was 68.5 percent. This ratio is a measure of an insurer’s underlying profitability on its book of business.

The expense ratio, as measured by other underwriting expenses incurred to net premiums written, through third quarter 2014 was 20.6 percent and indicates an improvement compared to 2013, as the expense ratio was reported at 23.7 percent. This ratio measurers an insurer’s operational efficiency in underwriting its book of business.

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The combined ratio, loss ratio plus expense ratio, through third quarter 2014 was 100.8 percent and indicates a diminishment compared to 2013, as the combined ratio was reported at 92.2 percent. This ratio measures an insurer’s overall underwriting profitability. A combined ratio of less than 100 percent indicates an underwriting profit.

Regarding RRGs collectively, the ratios pertaining to income statement analysis appear to be appropriate. Moreover, these ratios have remained fairly stable for each of the last five years and within a profitable range.

Conclusions Based on Third Quarter 2014 ResultsDespite political and economic uncertainty, RRGs remain financially stable and

40%

60%

80%

100%

120%Combined Ratio Loss Ratio Expense Ratio

0%

20%

40%

2014 Q32013 Q32012 Q32011 Q32010 Q3

continue to provide specialized coverage to their insureds. The financial ratios calculated based on the reported results of RRGs appear to be reasonable, keeping in mind that it is typical and expected that insurers’ financial ratios tend to fluctuate over time.

The results of RRGs indicate that these specialty insurers continue to exhibit financial stability. It is important to note again that while RRGs have reported net income, they have also continued to maintain adequate loss reserves while increasing premium written year over year. RRGs continue to exhibit a great deal of financial stability. ■

Douglas A Powell is a Sr. Financial Analyst at Demotech, Inc. Email your questions or comments to [email protected]. For more information about Demotech visit www.demotech.com.

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SIIA Engaged at State Level to Protect Self-Insurance Marketplace

SIIA RelationsState Government

New Legislation Would Limit Employer Self-Insurance Options

SIIA has mobilized to kill new legislation in Maryland that would harm the self-insurance marketplace in that state. This mobilization includes activating grassroots member advocacy and retaining a

contract lobbyist with close ties to Maryland Legislature.Companion legislation introduced last week, House Bill (HB) 552 and Senate

Bill (SB) 703, would dramatically increase minimum stop-loss attachment points and introduce new carrier reporting and disclosure requirements. Both bills propose increasing the minimum attachment point to $40,000 ($10,000 currently) and aggregate attachment to 125% (115% currently) for all stop-loss policies, making it extremely difficult for smaller businesses to self-insure.

There is a provision allowing stop-loss policies written before January 1, 2015, to renew indefinitely under the current law. However, there are a few concerns. First, it is unclear what policy changes, if any, can be made at renewal. Second, since policies can only be renewed, a business cannot seek stop-loss coverage with another carrier without being required to buy coverage with potentially higher individual and aggregate attachment points.

There are a number of new consumer protections in the proposed legislation. Stop-loss carriers would be lawfully required to:

• Guarantee rates for 12 months without adjustment unless there is a benefit change in the health plan;

• Pay claims submitted within 12 months of the contract’s expiration;• Disclose to the small employer:

- The total costs of the contract - Provisions for contract renewal - The aggregate and individual attachment points - Any coverage limitations

• File a form with the Maryland Insurance Administration every year by April 1st certifying company compliance with the law

Members interested in supporting the association’s lobbying effort are encouraged to contact SIIA Director of State Government Relations, Adam Brackemyre at [email protected] right away. Both bills will be heard in hearings relatively soon. HB 552 will be heard on February 26th. SB 300 will be

heard on March 4th so this is extremely time sensitive.

The Self-Insurance Institute of America, Inc. (SIIA) prepares and disseminates to its members a weekly update on state government relations developments. We are publishing a recent report here to showcase the information provided for those association members who may not have taken the opportunity to read these updates and to show non-members what they are missing.

MARYLAND


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SIIA Relations

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AIG Benefit Solutions® is the marketing name for the domestic benefits division of American International Group, Inc.

The underwriting risks, financial and contractual obligations, and support functions associated with products issued by American General Life Insurance Company, The United States Life Insurance Company in the City of New York, and National Union Fire Insurance Company of Pittsburgh, Pa., are the issuing insurer’s responsibility. The United States Life Insurance Company in the City of New York is authorized to conduct insurance business in New York. National Union Fire Insurance Company of Pittsburgh, Pa., maintains its principal place of business in New York, NY, and is authorized to conduct insurance business in all states and the District of Columbia. NAIC No. 19445. Not all policies are available in all states.

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Stop-Loss Legislation and Albany Day on the Hill

SIIA Continues to recruit members and other stakeholders to participate in a lobby day on March 11th in Albany, NY to push for passage of legislation (A. 1154/S. 2366) that will protect the state’s small group self-insurance market.

All SIIA members are invited to participate, but we are particularly interested in those who do business in the state. The day will begin with a breakfast and briefing near the Capitol at the Albany Hilton. The bill sponsors have been invited as breakfast speakers.

After breakfast, SIIA members and other interested parties will meet with influential Assembly Members, Senators, administrative staff and regulators. Meetings should conclude by early afternoon. SIIA will share additional details of the day’s schedule as they are available.

As previously reported, New York State prohibits insurance carriers from writing stop-loss coverage for “small groups.” Under current law, the largest “small employer” will increase from 50 to 100 effective January 1st, 2016, and employers of 51-100 will lose access to stop-loss insurance. This stop-loss ban can affect individual employers as well as employers insured through a captive. What A.1154/S.2366 will do is maintain the current state law and ensure no business loses access to stop-loss coverage.

If you are interested in participating as part of this lobby day or would like more information, please contact Adam Brackemyre, SIIA’s Director of State Government Relations, at [email protected].

Stop-Loss Legislation

New stop-loss legislation has been introduced in Minnesota.

The two bills are House File (HF) 294 and Senate File (SF) 300. The legislation proposes to change the state’s law to require an individual attachment point that is the greater of $6,500 or twice the individual plan deductible and harmonize the minimum aggregate of 110% for all group sizes.

SIIA has been in contact with the individuals who wrote the legislation, provided advice and the SIIA Government Relations Committee is now reviewing the legislation.

Stop-Loss Legislation

On February 12th another stop-loss bill was introduced.

House Bill (HB) 731 is legislation that contains a small provision changing the state’s aggregate attachment point minimum to the greatest of:

• Two thousand dollars times the number of employees;

• One hundred twenty percent of expected claims; or

• Ten thousand dollars.

SIIA is working with contacts in Florida to urge the House Banking and Insurance Subcommittee of the Regulatory Affairs Committee to move the legislation. ■

Do you aspireto be a published author? Do you have any stories or opinions on the self-insurance and alternative risk transfer industry that you would like to share with your peers?

We would like to invite you to share your insight and submit an article to The Self-Insurer! The Self-Insurer! The Self-InsurerSIIA’s o� cial magazine is distributed in a digital and print format to reach over 10,000 readers around the world. The Self-Insurer has The Self-Insurer has The Self-Insurerbeen delivering information to the self-insurance/alternative risk transfer community since 1984 to self-funded employers, TPAs, MGUs, reinsurers, stop-loss carriers, PBMs and other service providers.

Articles or guideline inquiries can be submitted to Editor Gretchen Grote at [email protected].

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Hospital Claim Payments – Due Diligence for Payers

Hospital claims are typically the largest and most challenging risk for health plans and payers. Although clinical outcomes may be favorable, inappropriate billing practices and errors, signifi cant infl ation of charge and non-covered services may not be identifi ed, resulting in excessive

claim payments. Negotiated contract terms should be applied to correctly billed

charges and using discounts alone is not an effective strategy to mitigate risk.

Ensuring claim payment integrity either prospectively or retrospectively is a

necessity which can be challenging due to the complexity and high level of detail

inherent in hospital claims.

Recent healthcare reform changes resulting in unlimited benefits increase the

risk threshold from hospital claims. According to a 2011 report by the consulting

firm Milliman, the average cost of health care for American families doubled from

2002 through 2011. Costs will continue to escalate, adding increased risks to

payers and their insureds.

In a recent Time Magazine article, journalist and author Steven Brill presented

his very timely and provocative 11-page cover story, Bitter Pill. In his article,

Steven Brill gives numerous examples of hospital charges:

“What are the reasons, good or bad, that cancer means a half-million- or

million-dollar tab? Why should a trip to the emergency room for chest pains that

turn out to be indigestion bring a bill that can exceed the cost of a semester of Written by Jakki Lynch


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college? What makes a single dose

of even the most wonderful wonder

drug cost thousands of dollars? Why

does simple lab work done during

a few days in a hospital cost more

than a car? And what is so different

about the medical ecosystem that

causes technology advances to drive

bills up instead of down? When we

debate health care policy in America,

we seem to jump right to the issue of

who should pay the bills, blowing past

what should be the first question: Why

exactly are the bills so high?”

This is a key point because if the

chargemaster rates are significantly

inflated, payers, even with the

most leverage due to volume, are

negotiating contractual discounts from

potentially inflated chargemaster rates.

The inflation of charge cannot be

ignored as this can be as important

as the accurate billing for the services

received. Both impact the cost

significantly. Hospitals should receive

a reasonable margin over the cost

of their services and payers should

understand and monitor charge levels

as well as billing practices.

What can be done to address

these issues? By dissecting the medical

bills, Brill says we can understand

how and why we are potentially

overspending and where the dollars

are going.

Key considerations for payers include the following: Hospital charges – the fi nancial signifi cance

According to the Centers for Medicare and Medicaid Services, hospitals are the largest segment of U.S. health expenditures at 31%. Payments to U.S. hospitals are expected to increase over 76% from $794 billion in 2010 to $1.4 trillion dollars annually in 2020.

Industry guidelines for hospital claims

Hospitals submit claims using

the UB-04 form which contains a

summary of charges in categories

and record formats defined by the

National Uniform Billing Committee

(NUBC). The NUBC was established

to develop a single billing form and

standard data set that could be used

nationwide by institutional providers

and payers for handling health care

claims. The NUBC was formed by

the American Hospital Association

(AHA) in 1975 and it includes the

participation of all the major national

provider and payer organizations.

The UB-04 form is summary data

only. Hospital claims are typically paid

based on the two or three page UB-

04 form only. The itemized detail of

charges comprising the summary data

is generally not requested or reviewed

by payers. However, this is a critical

piece. Often a series of errors can

be uncovered by going beyond the

summary data and doing a “deep dive”

for details.

In addition to the NUBC

Guidelines, payers may also have

their own supplemental guidelines

for hospital claim payments including

claim review policies, provider manuals,

the definitions of covered and non-

covered services and payment policies

for distinct medical services.

Claim Reviews and Due Diligence

An effective review of facility

claims requires a flexible yet

thorough process including coding

and regulatory compliance as well as

clinical expertise. Payers typically do

not have these skill sets available as

internal staff resources nor do they

have the ability to devote the time

necessary for an in-depth review. The

payer’s provider agreements should

also be considered to ensure that

payment guidelines are specified and

payment integrity practices confirm

the right to review claims based on

industry standard and plan specific

references. The selection of claims for

review should be based on recognition

of the amount of the requested

contracted payable and the financial

risk. In and out of network claims

should be considered for review prior

to payment based on the pre-audit

payable amount of $150,000 or more.

The following case studies demonstrate the importance and financial significance of performing facility claim reviews:Case Study – Claim Review #1

• Prospective Payment Review

• Payable Charges without Review:

$2,005,998

• Payable Charges After Review:

$1,611,191

• Claim Review Savings:

$394,807 – 19.7%

Claims were incurred for twin

preterm babies with 4 month inpatient

NICU stays. The health plan received

the medical records prior to claim

payments. The specialty clinical and

coding compliance teams identified

significant room and board acuity

adjustments based on the NUBC

Guidelines. The billed room charges

were not consistently supported

by documented nursing resources

received by the babies. The claim

payments were prospectively adjusted

to address the overstatement of

patient acuity and related daily room

and board charges for selected dates

of service. The facility agreed with the

recommended payment adjustments.


Case Study – Claim Review #2• Retrospective Payment Review

• Payable Charges Without Review: $2,366,414

• Payable Charges After Review: $1,039,742

• Claim Review Savings: $1,326,672 – 56.1%

An adult was admitted to the ICU for transplant evaluation and surgery. Pharmacy charges comprised 54% of the claim. The claim review team clinicians evaluated the reasonableness of units charged for a pulmonary vasodilator which was administered throughout the stay. Based on the prescribed dosage and a daily assessment of medication administration, the clinicians identified a billing error of $1.3 million which the facility agreed to refund since the claim had already been paid by the health plan. The refund was obtained even though the payer waived the right to audit as a condition for a 50% discount under the terms of the single case agreement.

Case Study – Claim Review #3• Prospective Payment Review

• Payable Charges Without Review: $135,159

• Payable Charges After Review: $95,042

• Claim Review Savings: $40,117 - 29.7%

An adult with a genetic metabolic disorder received outpatient specialty drug infusions. The payer had access to a 50% contractual discount. The unit price of the drug was evaluated based on estimated facility cost and margin benchmarking.

The pre review contracted amount payable resulted in a markup of approximately 422% over the facility’s cost. A case specific carve out rate was negotiated for this patient based on a reasonable margin for the facility as well as recognition of ongoing health plan exposure for the treatment. Annual claim savings from the review were approximately $321,000. Although the payer had a significant contractual discount, it did not reasonably address the high charge level for this specialty drug.

These case studies demonstrate that an effective claim review process needs to be thorough, supported by experts with a broad range of subject matter and clinical expertise with the results communicated effectively and professionally to providers. The reviews should be based on a claim specific risk management perspective rather than a standardized formula

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[email protected] (630) 203-5126

Don’t forget to join our Mailing List while you are there!

Broadvision Underwriters: 225 Smith Rd. St. Charles, IL 60174 | 855.346.2397Broadvision Reinsurance: 6685 Telegraph Rd. St. Louis, MO 63129 | 314.293.9708


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Would you climb a mountain without a guide?

Healthcare is complicated. As a risk management expert, Berkley Accident and Health can guide you in the right direction.

Our creative, nimble approach to risk, backed by the strength of a Fortune 500 company, gives us a unique perspective. Count on Berkley to show you the way.

Stop Loss | Group Captives | Managed Care | Specialty Accident

BAH AD-2014-0140 www.BerkleyAH.com

Insurance coverages are underwritten by Berkley Life and Health Insurance Company and/or StarNet Insurance Company, both member companies of W. R. Berkley Corporation and both rated A+ (Superior) by A. M. Best. Coverage and availability may vary by state.

©2015 Berkley Accident and Health, Hamilton Square, NJ 08690. All rights reserved.


H.H.C. Group, A Partner You Can TrustVisit www.hhcgroup.com for more information.

H.H.C. Group is a full-service health insurance consulting organization,

trusted by some of the industry’s largest insurance payors, to provide

the highest level of cost containment services.

H.H.C. GroupHealth Insurance Consultants

438 North Frederick Avenue | Gaithersburg, MD 20877 | 301.963.0762

The Right Rate Reference Based Pricing Solution

Immediate Savings

Responsive Customer Service Detailed Reporting

Protection Against Irresponsible Billing

With H.H.C. Group’s Reference Based Pricing Solution, you will receive:


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based approach. References to support claim review adjustments should be transparent and based on accepted industry standards.

Resources for Hospital Claims Due DiligenceSome companies may utilize a partner to implement effective claim reviews

with optimal financial outcomes. Successful resolution of the review findings with a facility is an important detail to highlight as this process requires a special skill set to address the discoveries as well as time to come to an agreement. It is important that during this course, payers hold firm as successful settlements are about patience and persistence for a positive mutual outcome. ■

Jakki Lynch BSN, RN, CCM, CMAS is Vice President, Clinical Director, Critical Response Team, PULSE + Plus™, the medical management program for PartnerRe Health. Jakki developed PULSE + Plus™ - a unique program to assist health plans with the complex tools and expert resources needed. The PULSE + Plus™ resources are customized for each payer’s needs to achieve signifi cant savings with no impact on provider relationships, patient balance billing or additional staffi ng requirements. The PULSE + Plus™ team has signifi cant experience supporting health plans providing collaborative and consultative solutions.


Enterprise Risk Captives (ERCs) have become increasingly popular self-insurance solutions for smaller and mid-sized, closely-held companies. Also known as Micro-captives or 831(b) captives, ERCs are small insurance companies (up to 1.2 million in annual premium) that are used to insure a

variety of risks, including deductibles for self-insured and fully-insured arrangements.

These captives can offer risk management, estate planning and tax advantages.

But like all other major business decisions, undertaking appropriate due diligence

is critical to determine whether establishing an ERC makes sense for your company.

Since most companies considering ERCs typically work with captive managers and/

or other consultants as part of the evaluation process, it is important to know what

questions to ask.

In this regard, the Self-Insurance Institute of America, Inc. (SIIA) Alternative Risk

Transfer Committee developed the following questions, divided by category, which

companies are encouraged to ask their captive manager and/or other business

consultant as part of any ERC evaluation process. This committee is comprised of

recognized experts involved in captive insurance marketplace.

Please note that this list of questions should be not considered exhaustive, but

simply offered as a resource for companies assessing this self-insurance solution.

Learn more about SIIA at www.siia.org.

Knowing Whether an Enterprise Risk CaptiveMakes Sense for Your Company


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Suggested Questions

Feasibility ? What makes our company a good candidate?

? How does this help our company manage risk?

? Will there be an initial feasibility study, and is there a separate fee for it?

? What is the capital requirement?

? Can you provide a financial model with all projected fees and expenses?

Insurance Program ? How will we select/underwrite risks?

? Who sets premium and how is this done?

Annual Underwriting Review with Re-Rating ? What kind of claims activity do you expect and what will the process be for managing them?

Risk Distribution ? How will our company achieve risk distribution/what mechanism?

? How is our company protected from excessive pool losses?

? What amount of third party risk do you deem acceptable and why?

? Do you own/operate/manage your own pool?

? How does your risk pool operate? (the basic terms and provisions)

Relationship with Captive Manager ? How long have you been in the business and how many captives do you manage?

? Can I see the engagement agreement in advance?

? Are you supporting professionals in-house or independent?

Exit Strategy ? Do you help design my exit strategy?

Domicile Issues ? What domiciles do you recommend and why?

Insurance Program ? Do you restrict or manage the risks in the program?

? Will there be any third party liability exposures?

? How are the insurance policies structured (the basic terms and provisions)

Other Comments from ART Committee Members

Feasibility ? How does this compare with other risk management options that I may consider?

Insurance Program ? How do I make sure this program will have all criteria necessary for me to comply with applicable law?

? Are there any nuances or issues I should consider for the insurance program based on the states I am doing business?

Underwriting or Costs ? What factors will be most important on underwriting and what are their related cost factors?

? How does this break down and compare with other options?

Relationship with Captive Manager

? What is the role, responsibility, experience of the captive manger?

Exit Strategy ? What issues should I be considering now that may affect the difficulty or ease of transitioning to a different risk management solution?

? Are there any particular timing issues I should be aware of?

? Are there any program details or structure criteria I should consider now for ease of exiting the program in the future?

? What considerations should be given to developing an exit strategy?

Transparency for Participants and Claims

? Is pooled risk compatible with my risk?

? Is there a tax opinion letter?

? How much information will I receive on claims filed by others?

? What information will I receive on the other pool participants? ■


SIIA would like to recognize our leadership and welcome new members Full SIIA Committee listings can be found at www.siia.org

SIIA New Members

Regular MembersCompany Name/Voting Representative

Tiana BrajkovichBusiness Development SpecialistAvalon Insurance CompanyHarrisburg, PA

Lauren MetsigSenior Director of MarketingMaestro HealthHighland Park, IL

Sawyer ClarkSenior Marketing SpecialistMaxorPlus Ltd.Amarillo, TX

Regis BernardiNational Sales DirectorPharmacy Benefi t DimensionsBuffalo, NY

Nancy LeeMedical Stop Loss SpecialistPhysicians InsuranceSeattle, WA

Norman Chandler, CPATaylorChandler LLCMontgomery, AL

Todd HeisermanExec. Director Reseller & TPA SalesTeladocDallas, TX

Troy CookVP-Sales/Business DevelopmentTelligen WestDes Moines, IA

Silver MembersAndrew KuykendallAlt. Funding Strategy ConsultantNeovia Integrated Ins. ServicesPasadena, CA

David MillerPresident Nueterra Global AllianceNueterraLeawood, KS

Employer MembersStan Harris, President & CEOLouisiana Restaurant Association Self-Insurer’s FundMetairie, LA

Gaston ReinosoExecutive DirectorLouisiana State UniversityBaton Rouge, LA

2015 Board of Directors

CHAIRMAN OF THE BOARD*Donald K. DrelichChairman & CEOD.W. Van Dyke & Co.Wilton, CT

CHAIRMAN ELECT*Steven J. LinkExecutive Vice PresidentMidwest Employers Casualty Co.Chesterfi eld, MO

PRESIDENT*Mike FergusonSIIASimpsonville, SC

TREASURER & CORPORATE SECRETARY*Ronald K. DewsnupPresident & General ManagerAllegiance Benefi t Plan Management, Inc.Missoula, MT

Directors

Andrew CavenaghPresidentPareto Captive Services, LLCPhiladelphia, PA

Robert A. ClementeCEOSpecialty Care Management, LLCBridgewater, NJ

Duke NiedringhausVice PresidentJ.W. Terrill, Inc.Chesterfi eld, MO

Jay RitchieSenior Vice PresidentHCC Life Insurance CompanyKennesaw, GA

Adam RussoChief Executive Offi cerThe Phia Group, LLCBraintree, MA

Committee Chairs

ART COMMITTEEJeffrey K. SimpsonAttorneyGordon, Fournaris & Mammarella, PAWilmington, DE

GOVERNMENT RELATIONS COMMITTEEJerry CastelloeCastelloe Partners, LLCCharlotte, NC

HEALTH CARE COMMITTEERobert J. Melillo2nd VP & Head of Stop LossGuardian Life Insurance CompanyMeriden, CT

INTERNATIONAL COMMITTEERobert RepkePresidentGlobal Medical Conexions, Inc.Novato, CA

WORKERS’ COMP COMMITTEEStu ThompsonFund ManagerThe Builders GroupEagan, MN

*Also serves as Director


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