The Self-Insurer March 2024

There’s No Place Like Home Care

Pandemic, technology and patient preferences driving hospitals to offload more services into a home-based setting

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ARTICLES

4 THERE’S NO PLACE LIKE HOME CARE: PANDEMIC, TECHNOLOGY AND PATIENT PREFERENCES DRIVING HOSPITALS TO OFFLOAD MORE SERVICES INTO A HOME-BASED SETTING

12 FEMTECH SOLUTIONS SUPPORT WOMEN’S HEALTH IN THE WORKPLACE:  HELPS SELF-INSURED EMPLOYERS RECRUIT & RETAIN KEY EMPLOYEES.

31 COMPANIES TURNING TO CAPTIVES TO MANAGE INFLATION

36 SELF-FUNDED HEALTH PLANS CAN OPTIMIZE VALUE WITH NO SURPRISE!

52 MOOP, MOOP: IT’S HIT OR MISS FOR OUT-OF-POCKET MAXIMUM CALCULATIONS

65 NEWS FROM SIIA MEMBERS

The Self-Insurer (ISSN 10913815) is published monthly by Self-Insurers’ Publishing Corp. (SIPC). Postmaster: Send address changes to The Self-Insurer Editorial and Advertising Office, P.O. Box 1237, Simpsonville, SC 29681, (888) 394-5688

PUBLISHING DIRECTOR Bryan Irland, SENIOR WRITER Bruce Shutan, CONTRIBUTING EDITORS Mike Ferguson, Jennifer Ivy and Ryan Work, PRESIDENT/CEO Erica M. Massey, CFO Grace Chen

There’s No Place Like Home Care

Pandemic, technology and patient preferences driving hospitals to offload more services into a home-based setting

say that home is where the heart is, and these days, it is becoming a preferred setting to actually care for the heart, as well as other body parts, including the mind. Advances in medical technology now enable hospitals to offload a myriad of services into the home for convenience, safety, cost-effectiveness, improved clinical outcomes and greater member satisfaction. As a result, providers, payers and patients are reaping those benefits, while self-insured entities and their partners have taken note of these promising developments.

It’s not surprising that the pandemic was a massive accelerator for hospital care at home, according to Jennifer Collier, president of health and risk solutions for Sun Life, which last year partnered with OptiMed to allow for specialty infusion therapy in the home.

“Nobody wanted to be in a hospital,” she says, especially the immunocompromised – reflecting on widespread concern over exposure to COVID-19 as well as hospital infections during a public health emergency. When patients are stuck in an inpatient setting for a period of time, she notes that they’re prone to hospital delirium and pressure sores from being inactive.

Technology has made quantum leaps in recent years with respect to medical applications that have paved the way for hospital-level care in the home. One example involves consumer electronics. Collier, who has a nursing background, recalls being at an industry conference six or seven years ago “where you could literally do an EKG with your Apple Watch,” which was mind-boggling at the time. “Today, we all have cameras in our houses, but the ability to have true remote sensing of the patient in real-time, whether it’s monitored by humans or AI, the reality is we’re going to find that AI will be more consistent and more quickly pick up deviations in or changes in status.”

The Information Age has obviously enabled hospitals to embrace the home-based care trend.

Once broadband supported the transmission of patient data, it made remote monitoring of patients possible, says Amy L. Hester, Ph.D., a registered nurse who is chairwoman and CEO of HD Nursing, LLC.

DRIVEN BY DEMAND

But as with any industry, the onus for change is driven by demand. A driving force behind this movement isn’t so much from hospitals as it is patients who prefer to avoid a hospital stay unless absolutely necessary, observes Lois Irwin,

president of EZaccessMD, which treats urgent care in the home with a combination of virtual appointments and in-person visits.

“We experienced it going back 20 years when an X-ray wasn’t possible in a nursing home or private home because radiology exists in hospitals,” she recalls. “As people get older and have more experience, they’re scared of going to the hospital not only because of the cost but because they know that they may end up staying there longer. So as alternatives are developed where care can be given safely outside of the hospital, it can be a very desirable thing, and if it’s as efficacious as in the hospital, then why not?”

Helping transition patients from hospitals to homes is an excellent example of addition by subtraction. “Look at all the things that happen when you’re in the hospital,” Hester notes. She sees tremendous value in removing a host of risk factors, including hospital-acquired conditions and infections, as well as medication errors from overburdened staffers.

Last year, her company initiated an individualized fall and pressure injury prevention program designed for the hospital-at-home setting. It’s easy to see why: after patients are discharged from the hospital, she reports that 15% of readmissions are caused

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by someone falling and hurting themselves badly enough to be re-hospitalized within 30 days.

The hospital-to-home concept bridged off from obstetrics, Hester notes, expanding to other patient populations for the purpose of reducing readmissions within 30 to 90 days of discharge and meeting value-based purchasing benchmarks.

“If I discharge a patient that had COPD or congestive heart failure, and they were readmitted within 30 days, I’m not going to get paid for that readmission because it’s part of their global admission” in keeping with value-based care, Hester explains.

Under this scenario, hospitals are incentivized to carefully monitor patients, so they’re not discharged too soon or held for too long. She says that keeping individuals with chronic conditions at home will help eliminate errors that occur with transitions in care. It also helps them learn how to take better care of themselves and gain access to community resources without burdening tertiary care centers whose services they don’t need.

VASTLY IMPROVED OUTCOMES

The home is a ripe setting for more hospital care than meets the eye. For example, Roderick Bennett, chief medical officer of SOS Care Solutions, says that on some days, as many as 90% of the emergency department (ED) patients he sees can be cared for in the home. Among the urgent care and non-life-threatening emergencies that he says can be done at home are administering IV antibiotics or supplemental

oxygen, as well as ICU-level care involving a patient ventilator. Hospice patients represent another natural fit for this setting.

The hospital-to-home field will continue to grow as demand for these services mounts, according to Bennett, whose firm prevents ED and hospitalization claims by providing high-acuity care at home or an onsite clinic. There are numerous reasons to expect such growth.

“Patients win because they get better care and more attention,” he explains. “The hospital is really a place where you have an acute problem that needs to be treated, not a place to get better. Home environments are much better for rest and recovery without all the noises and lights that interrupt sleep patterns and food people don’t like to eat.” Moreover, he notes that nosocomial injuries that happen in the hospital “are among some of the highest mortality rates and tremendously frequent events that occur.”

Outcomes are significantly improved, Bennett adds, and this body of data will continue to grow. The lion’s share of that result is tied to the strategic value of allowing a more convenient and comfortable convalescence. “You have much more time to interact with a patient

in the home setting where you can do thorough exams without having to be called away to see other patients,” he says.

In one of the more dramatic cases Bennett was involved with, a hospice patient who had a pathologic fractured femur and wasn’t responding to pain medication dispensed at home was moved into an inpatient hospice unit. “I performed what’s called a femoral nerve block in which I was able to anesthetize the nerve, pull his leg out from an S shape, and apply a splint to hold it in a straight position,” he reports. “His pain had completely resolved. The result was that he was able to go back home where he wanted to be.”

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EYEING EPISODIC CARE

Various companies now provide virtual access to physical or occupational therapists who are also available for in-home appointments. From a supply perspective, Collier says PT and OT professionals are now pursuing those visits for very specific pieces that are needed, while labs and diagnostics are also easy enough to do in the home “as long as you have the technician and you have to have the equipment,” such as portable X-rays.

In addition, she sees more episodic complex care, such as infusion therapies moving to the home – a convenient and costeffective option that significantly saves on travel time. Kidney

dialysis falls into this category, as does hemodialysis, a procedure wherein a dialysis machine and special filter are used to clean blood. “We actually teach patients and their families how to do it on their own,” she reports.

Here’s where home-based care is immensely beneficial: the most common time people with kidney disease have a crisis is Monday if they have skipped weekend dialysis. “You don’t have to have a gap in your dialysis when you’re doing it at home,” Collier notes. “So that’s obviously better for your body and more convenient.”

Over time, she believes there will be continued improvements that couple sensing and robot remote technology with AI that’s been augmented by human command centers. “The complexity of hospital care at home does require nurses being at the house throughout a 24-hour period of time, and a physician being able to check in with patients both remotely and on-site,” she says.

FATE OF CMS’S PILOT

This trend has caught the attention of policymakers. More than 300 health systems nationwide have participated in the federal government’s Acute Hospital Care at Home (AHCaH) model, which, since November 2020, packaged a mix of virtual and in-person care

in response to a shortage of inpatient beds and staff. Funding for the program, supported by a waiver for Medicare reimbursement from the Centers for Medicare & Medicaid Services as part of the public health emergency response to COVID-19, stops at the end of this year.

Whether hospitals have the appetite to seed more of these initiatives across the commercial market is anyone’s guess. Irwin has her doubts, given that the

program funding is about to run out. She says hospitals haven’t embraced more extensive measures to set up equipment in the home other than through the AHCaH. One explanation is the emphasis on keeping their buildings fully utilized before encouraging patients to receive care at home, she says, noting that sometimes not every hospital bed is occupied.

This thinking, no doubt, may prove to be short-sighted, considering that home healthcare programs are meant to help prevent hospital readmissions within a certain time period. “Otherwise,” Irwin notes, “the hospital gets penalized by the payers, and it’s a bad financial outcome. So, they have a lot of incentive to provide skilled nursing, occupational therapy, physical therapy, speech therapy, etc., to help a patient transition into staying at home.”

What’s important is making sure that group health plans encourage care at home, especially on a broad basis, according to Collier. “We expect self-insured employers to know all of these nuances and be thinking about all of the complexities to make sure that they actually have access to these things, whether negotiating direct contracts or ensuring that it’s actually going to be covered and supported by the plan,” she points out.

Bruce Shutan is a Portland, Oregon-based freelance writer who has closely covered the employee benefits industry for more than 35 years.

FemTech Solutions

Support Women’s Health in the Workplace:

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WhileWthe term FemTech may be unfamiliar to some, there is wide and growing recognition among self-insured employers that are joining the legions of supporters who champion the adoption of FemTech solutions: diagnostic tools, products, services, wearables and software that use technology to address women’s health issues, including menstrual health, fertility/reproductive health, pelvic and sexual health, contraception, maternal health, behavioral health and menopause.

First coined by Danish entrepreneur Ida Tin in 2016, FemTech industry trackers estimate the market size to be in the billions and overall interest in the sector is on the rise. Erin Weenum, chief strategist, Employee Benefits, Leavitt Great West Insurance, is quite familiar with the term and like most benefits consultants, she says there is increased interest and demand from employers looking to integrate these solutions.

“Speaking on behalf of employer groups that I advise, I see a combination of solutions being offered,” says Weenum. “The most common focus has been on health plan coverage of infertility treatments. There are many creative ways to do this, from simply implementing standardized coverages to renegotiating the cost of in vitro fertilization (IVF) cycles with certain providers. Employers are increasingly identifying ways to support working parents: flexible work schedules, postpartum mental health resources, on-site childcare, eldercare, and breast milk donation, storage and shipping.”

FemTech is a term that also encompasses products that address general health conditions that affect more women than men or affect them differently than they affect men, such as osteoporosis or cardiovascular disease. The sector spans all innovations designed to solve health concerns suffered solely, differently or disproportionately by women – covering everything from health during pregnancy and menopause to Alzheimer’s and HIV.

Dani Kimlinger, CEO, MINES and Associates, characterizes FemTech as incredibly important to address the unique needs of women, adding, “Personally, I appreciate FemTech as a consumer in a number of ways. My smart watch tracks a variety of important data points such as the woman’s menstrual cycle and offers information such as when is an optimal time to try for pregnancy -- as well as optimal times for endurance exercise.”

Through her organization, FemTech solutions are part of their Employee Assistance Programs. For example, they offer virtual lactation coaching and parenting coaching as well as access to virtual points to counseling, such as therapists who are sensitive to the needs of women.

“We also offer a variety of FemTech support to our employees such as virtual parenting and lactation coaching, digital therapy and psychiatry, and mindfulness services as well as anonymous 24/7 peer support,” she continues. “Through our health plan, smartwatches with hormone tracking provide enrollees in our health plan to “work off” an Apple Watch through steps, exercise, and movement.”

Women's Health in the Workplace

From the FemTech perspective, David Adamson, MD, FRCSC, FACOG, FACS, reproductive endocrinologist, surgeon, founder and CEO of ARC Fertility, shares, “Empowering women in the workforce through FemTech is paramount for both individual well-being and organizational success. Fertility and familyforming are a cornerstone of FemTech solutions designed to address various aspects of women’s health – from pregnancy and postpartum support to resources for menopause. FemTech plays a crucial role in supporting women at every stage of their professional and personal journeys.”

For self-insured employers, Dr. Adamson advises that by offering comprehensive FemTech support, companies not only enhance employee well-being but also contribute significantly to recruitment and retention efforts.

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“By fostering a supportive environment that prioritizes women’s health, organizations can attract and retain top talent, creating a workplace that values inclusion of a chosen lifestyle.”

Any tool or service offered by an employer that gives women better insight into their well-being can positively impact recruitment and retention rates, contributes Diane Deinhart, VP, strategic partnerships, Nova Healthcare Administrators.

“For employers looking for ways to provide more holistic and inclusive benefits, tools or technology to support women’s health, a FemTech solution is a great place to start,” says Deinhart. “It is my understanding that FemTech empowers women to take greater control of their health by providing access to personalized health information and resources. In turn, this technology helps women track their symptoms over time, identify patterns and potential health issues, and make more informed decisions, resulting in better health outcomes.”

She says that by prioritizing the unique needs and experiences of women, employers who incorporate FemTech into their health benefits may significantly impact the health and well-being of female employees, thereby creating a more supportive and inclusive workplace culture.

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Women's Health in the Workplace

Brittany Barreto, PhD, CEO, FemHealth Insights, observes that employer-supported models have become increasingly popular, noting, “Women make up approximately half of the workforce, and the majority of women’s working years are spent during their reproductive and menopausal stages.”

She cites the company Milk Stork as an example of a company that helps breastfeeding mothers in the workplace by contracting with employers to help women ship their breast milk when they are traveling for work: “These unique solutions provide ways for employers to support their workforce by meeting employees where they are at and supporting an employee’s full well-being.”

Dr. Barreto explains that while FemTech support was traditionally limited to big tech and Fortune 100 companies, “We are now seeing the tides change with millions of lives covered through their employersupported programs. You now see academic institutions, insurance companies, and even auto manufacturers starting to show up for their employees by offering coverage through major players in the FemTech industry. Benefits to employees include more holistic medical coverage for all of life’s stressors (not just preventive care), and benefits to employers include greater productivity, a more engaged workforce and lower medical costs in the long run.”

At Spring Consulting Group, they are familiar with FemTech and help clients assess a wide range of point solutions. Teri Weber, MBA, PMP, GBA, ICCIE, senior vice president, Spring Consulting Group, An Alera Group Company, LLC, says, “This includes those in the FemTech space and related fertility and women’s health solutions. The market continues to expand, and there is an increasing interest from employers to invest in related services for their female workforce.”

IMPORTANCE OF PROFESSIONAL GUIDELINES IN REPRODUCTIVE MEDICINE

When it comes to reproductive care, employers should ascertain that physicians participating in their contracted FemTech solution are adhering to the professional guidelines in fertility care. There are two prominent US-based organizations that establish practice guidelines,

laboratory guidelines and ethics guidelines:

The American Society for Reproductive Medicine is dedicated to advancing the science and practice of reproductive medicine. The Society accomplishes its mission by pursuing excellence in evidence-based, life-long education and learning, growing and supporting innovative research, developing and disseminating the highest ethical and quality standards in patient care, and advocating for physicians and affiliated health providers and their patients.

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Society for Assisted Reproductive Technology is the primary organization of professionals dedicated to the practice of In Vitro Fertilization (IVF) or assisted reproductive technology. The organization represents the majority of the ART clinics in the U.S. The mission of SART is to establish and maintain standards for ART so that people receive the highest level of care. https:// www.sart.org/

As past president of both ASRM and SART, Dr. Adamson notes, “There’s a lot of evidence out there that has to be considered -- some of which is better than others. While the development of guidelines is difficult, they’re really, really important because they do help both physicians and patients do the right thing. It’s important that guidelines are used when making medical decisions.”

He says the most important aspect of guidelines is that people who are very knowledgeable about the field do very extensive research of the literature, and all who are involved have to be unbiased and disclose any potential conflicts of interest that are assessed.

“The result is that people who are really committed to the best possible care and who are knowledgeable about the evidence are developing the guidelines as state-of-theart, fact-based information,” he continues. “The caveat to employers is this: unfortunately, some sources without much knowledge are putting out opinions as well as others who are quite knowledgeable but who have commercial interests or

other reasons are offering perspectives that may not be completely unbiased and may not take a really objective look at the evidence. Guidelines that come from these two organizations should instill confidence.”

EFFECTIVELY ADDRESSING WOMEN’S HEALTH STATUS

McKinsey & Company advises that women spend more of their lives in poor health and with degrees of disability -- the “health span” rather than the “life span.” According to their recent report, a woman will spend an average of nine years in poor health, which affects her ability to be present and/or productive at home or in the workforce.

This report defines women’s health as covering both sex-specific conditions, for example, endometriosis and menopause and general health conditions that may affect women differently than men. Relevant to employers, they say women are most likely to be affected by a sex-specific condition between the ages of 15 and 50, but nearly half of the health burden affects women in their working years.

The issue of health equity is also important, encompassing access to the interventions and options that are right for each individual, regardless of their gender, sex, sexual identity, sexual orientation, age, race, ethnicity, religion, disability, education, income level, or any other distinguishing characteristic. For women, this can start with a better understanding of and access to interventions that lead to the best outcomes.

Women's Health in the Workplace

WIDE RANGE OF FEMTECH COMPANIES

In addition to fertility-focused organizations, there are several unique FemTech companies:

 Elvie is the company behind an electric breast pump that slips inside a wearer’s bra and lets them gather breast milk wherever they are. The device is also wirelessly controlled through a smartphone app.

 NextGen Jane is taking a health-focused approach with its smart tampons. There have been various efforts to develop improved tampons over the years by focusing on things such as comfort, absorbency and ease of use. However, these products will look for signs of health problems within the cells of a user’s endometrial lining during her period.

 Gabbi is the developer of healthcare software that accurately and inclusively predicts a woman’s risk for breast cancer and equips her to take action with community support. The Gabbi Risk Assessment Model uses A.I. to predict a woman’s two-year risk of breast cancer and is used to create a personalized action plan.

 Work & Mother provides a network of fully equipped lactation facilities that support working moms and make it easier for employers to comply with FLSA regulations. Work & Mother’s suites have everything needed to pump during the workday, including private rooms, hospital-grade pumps and accessories, fridges, storage, a private booking system and more.

 Lattice Medical is an implantable medical device company that develops and manufactures breakthrough technologies for post-cancer breast reconstruction. While silicon implants bear long-term risks and autologous surgeries require several invasive surgeries, Lattice Medical offers a bioabsorbable, tissue-generated implant that allows for natural reconstruction by regenerating in a single, hour-and-a-half-long surgery. Once regenerated, the implant slowly disappears for full reabsorption over 18 months and the patient recovers with a full breast with their own tissue.

FEMTECH OVERCOMES BARRIERS TO ACCESS

The entry of FemTech solutions signals a market response to multiple studies that show that women face unique logistical and financial barriers to healthcare access. Women contend with scheduling challenges, balancing work and family responsibilities, barriers related to insurance and cost, and dismissive or negative in-person encounters. Study participants frequently pointed to a lack of resources for care postpartum, while clinician interviewees noted a lack of knowledge of disease burden, overmedicalization of women’s care, deficits in care during postpartum, and trends around changes in primary care.

Among the findings of a KFF Women’s Health Survey (WHS) on women’s health status, use of healthcare services and costs, responses showed that while the majority of women ages 18-64 report being in excellent, very good, or good health (82%), nearly one in five (18%) women describe their health as fair or poor. Half of women (49%) report having an ongoing health condition that requires regular monitoring, medical care, or medication and 18% report having a disability or chronic disease that keeps them from participating fully in work, school, housework, or other activities, with higher rates among older women. Ten percent of women with a disability or ongoing health condition do not have a regular doctor or healthcare provider.

HERE’S WHY SELF-INSURED COMPANIES AND EMPLOYEES VALUE FEMTECH

• Flexibility of scheduling: FemTech solutions improve the overall delivery of care, offering options for virtual clinic appointments, direct-to-consumer prescription delivery services and innovative physical clinics that provide greater convenience and consumer-friendly opportunities for easier access to care.

• Boosts recruitment and retention of key employees: Companies that integrate FemTech solutions report that these benefits are highly sought-after by female executives and staff. Offering these options positions employers to attract and retain the talent of many women who may not have these opportunities in another employment setting.

• Advances self-care: FemTech programs often include wearable devices, healthcare trackers and at-home diagnostics that support women in taking better charge of their own health and managing health-related data and information.

• Shines a light on stigmatized issues: FemTech companies are taking the lead in addressing topics that were once considered taboo or off limits, such as sexual health, menopause and menstrual health.

• Promotes health equity -- inclusive and culturally sensitive: Look to FemTech companies for products and services that serve previously marginalized groups, including Black women, under-resourced populations worldwide and LGBTQ populations.

• Tuned-in to the needs of women: Built by women, for women, FemTech startups are much likelier to be established and led by female entrepreneurs, positioning their organizations to better understand women’s needs and problems. In fact, one analysis found that more than 70% of FemTech companies had at least one female founder, while non-FemTech companies hovered around 20%.

Women's Health in the Workplace

• Taps into valuable female technicians and scientists: Advancing gender equality in the tech sector, FemTech companies are overcoming gender stereotyping. These companies recognize the talent and capabilities of women who pursue a career in technology but may have been largely overlooked.

Erin Weenum reports that over the last several years, her organization has seen a dramatic shift in parents leaving the workforce due to childcare shortages and burnout.

“This has been especially true in healthcare and education sectors,” she observes. “Employers need attractive benefits to recruit newly licensed professionals and to retain talent. Infertility coverage has been a consistent demand and differentiator in hard-to-recruit industries. Postpartum support for working parents, including paid leave, is no longer an optional benefit for most employers looking to recruit skilled workers.”

Kimlinger reinforces that benefits are incredibly important for employer retention and recruiting, emphasizing, “I am a believer that the benefits package says a lot about the culture and how an organization thinks about employee well-being -- we need to continue to see employees as whole people.”

She says the workplace can serve as a significant safety net for employees and the concept of “checking work at the door when we start the workday” is antiquated.

“Work/life is integrated,” says Kimlinger. “If a woman is coming back to work after having a baby and doesn’t have access to support around mental health and her new life structure, it will not only impact the person but also their team and workplace.”

When building a benefits structure, it’s important to consider the lowest-earning employees: “If you have employees making nearly minimum wage and then have pricey payroll contributions for a high deductible health plan that makes access nearly impossible, insurance really isn’t useful for proactive care,” stresses Kimlinger.

“If a woman is going back to work with postpartum depression and cannot afford therapy because they are paying dollar-for-dollar up to their deductible or she doesn’t have the time to drive to a session, then this woman is at a significant disadvantage.”

Dr. Barreto echoes this perspective, adding, “In a post-pandemic world, many employees are seeking employers that allow them to show up at work fully and authentically. They are seeking employers who support their full lived experience– not just the person who shows up between the hours of 9 to 5.”

She says that many people don’t realize that these FemTech-supported solutions aren’t just for women -- men are beneficiaries of these programs as the women in their lives (wives, daughters) can tap into the services as well.

“This allows the reach of these programs to go that much further,” she continues. “These are also more than ‘just in time benefits’. ‘While some employers may lean towards offering a home office stipend or a

professional development stipend to attract and retain talent, there is really no comparison to helping an employee expand their family and/ or live their life in good health.”

FEMTECH SERVICES DESIGNED FOR EMPLOYERS

Readers may be surprised to learn about some of the unique services now tailored to self-insured employers’ needs. For example, Dr. Adamson points to ARC Fertility’s range of programs and benefits designed to meet the diverse needs of individuals and couples on their family-forming journeys, including:

• Intrauterine Insemination (IUI)

• In vitro Fertilization (IVF)

• Preconception Genetic Testing and Preimplantation Genetic Testing (PGT)

• Male fertility treatments, including testicular sperm aspiration (TESA) and microsurgical epididymal sperm aspiration (MESA)

• Egg freezing and banking

• Sperm, egg, and embryo donation

• Surrogacy

• Adoption

• Family-forming financing

• Emotional support

• FertilityNow app, a go-to source, provides easy-to-use, evidence-based information at one’s fingertips.

“Key to this approach is the commitment to affordability, quality, outcomes, cost-effectiveness, scalability and flexibility,” says Dr. Adamson.

According to the U.S. Bureau of Labor Statistics, the workforce participation rate for women in July 2023 was 57.4%, 10.6 percentage points lower than for men. Dr. Adamson advises that given ongoing talent supply chain challenges—in which skills shortages could cost companies worldwide trillions in unrealized revenue in the future -organizations simply can’t afford to leave talent pools untapped: “By offering family-forming benefits, employers can better attract women who are interested in starting a family – and find this support

a lever for joining a specific company.”

COUPLES FACE INFERTILITY

Infertility is usually defined as the inability of a couple to conceive even after one year of unprotected, frequent sexual intercourse. While men’s perceived support did not seem to influence their partners’ stress, according to one study, evidence shows that partner support is significant in alleviating the burden of infertility and can affect the way men deal with these challenges. Male partners and social and family support influence infertility treatment and should be involved throughout the whole treatment process.

Experts report that the male is solely responsible in about 20% of cases and is a contributing factor in another 30% to 40% of all infertility cases. Industry sources say as male and female causes often co-exist, it is important that both partners are investigated for infertility and managed together.

According to several authorities, infertility affects about 15% of all couples in the United States, with male infertility defined as the inability of a male to make a fertile female pregnant after one year of unprotected intercourse. They say the male is solely responsible about 20% of the time and is a contributing factor in another 30% to 40% of all infertility cases. As male and female causes often co-exist, it is important that both partners

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are investigated for infertility and managed together. Some male fertility problems can be directly treated medically or surgically and assisted reproductive technologies (ART) can help almost all men conceive a pregnancy.

From the opposite perspective, a recently reported clinical trial showed interesting and promising data on an ‘IUD for Men.’ Adam is a male birth control product in which a nonhormonal gel is reported to be capable of blocking the flow of sperm to the vas deferens, with no serious adverse events having been reported. Stay tuned for updates and other products that are bound to follow.

THE TIME IS NOW

The FemTech market is set to grow over the next decade, in part because of the increased adoption of telemedicine, advances in technology, and the growing emphasis on sexual empowerment and reproductive health. Additionally, women are becoming more aware of the value of preventative care, the significance of timely detection and the importance of pro-actively managing conditions to potentially halt disease progression.

At the 2024 Nevada CES, one of the largest technology trade shows in the world where thousands of engineers, entrepreneurs, dealmakers and tech companies shared their visions of what’s next, several FemTech solutions were featured to help people with more personal health issues. Coverage of the event highlighted one startup based in Ireland that plans to release a wearable sensor that tracks the frequency and severity of menopause symptoms, while another from South Korea claims to have developed a gadget targeting male fertility that will increase a wearer’s sperm motility.

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PROJECTED GROWTH OF FEMTECH MARKET

According to Precedence Research, the global FemTech market size accounted for USD 47.02 billion in 2022 and is expected to surpass around USD 108.78 billion by 2032, poised to grow at a compound annual growth rate (CAGR) of 8.8% during the forecast period 2023 to 2032.

Industry observers agree that FemTech solutions effectively address the historic lack of public discussion about women’s health and reproductive issues. They can be credited for changing this landscape, as many startups have raised these issues and brought them into the mainstream. From January through August 2021, U.S. digital health startups catering to women raised $1.3 billion -- almost twice the $774 million raised throughout 2020, according to a report by Rock Health, a venture capital firm that supports digital health startups.

Some experts say the term FemTech is a misnomer as it implies that the women’s healthcare market is a small, specialized market. Rather, many view this opportunity as a chance to offer healthcare advances for the billions of women in the workforce. According to the Bureau of Labor and Statistics (BLS), a review

of the 2014–24 projected labor force data reveals that the share of women in the labor force is projected to increase from 46.8 percent in 2014 to 47.2 percent in 2024.

For those readers concerned about population growth and the value of FemTech, BLS states that in the long run, the fertility assumptions have the most impact on national population projections since fertility is often the largest component of population change. They report that it also has the greatest cumulative effect on population growth, because each extra birth adds not only to the next year’s population, but also to the projected population for the person’s entire lifespan.

Teri Weber advises that, as with every strategic endeavor, “We encourage employers to first do a deep dive into its employee demographics and what is desired/expected from a benefits standpoint. Then, use those insights to find an intersection between what is valuable to employees and what enables the organization to achieve more overarching objectives related to retention, productivity, DEI and the like.”

She says budget must also be a consideration, noting, “We do believe FemTech and, more broadly, a benefits program that supports comprehensive well-being as critical components to recruitment and retention. We also advise our employer clients not to fall victim to point solution fatigue and that everything implemented can be properly measured, monitored and promoted within the workplace.”

Bottom line: Self-insured employers want to be ahead of the curve when it comes to supporting women’s health. They are keenly interested in innovation, exemplified by FemTech solutions, as an opportunity to not only proactively address healthcare costs but also create a workplace environment that places high value on female employees by delivering women-centered holistic benefits.

Women's Health in the Workplace

Laura Carabello holds a degree in Journalism from the Newhouse School of Communications at Syracuse University, is a recognized expert in medical travel, and is a widely published writer on healthcare issues. She is a Principal at CPR Strategic Marketing Communications. www. cpronline.com

Teri Weber, MBA, PMP, GBA, ICCIE is a Senior Vice President with Spring Consulting Group, An Alera Group Company, LLC.  She has fifteen years of experience in health and welfare plan strategy, design, pricing, and implementation.  She also works with absence management programs, including disability, family medical leave and leave of absence tracking.  Her areas of expertise have allowed her to work with diverse employers and vendors to streamline processes and programs to meet the needs of insurers, administrators, employers and employees.  Prior to joining Spring, Teri worked with Watson Wyatt, Buck Consultants and AON Consulting.  Teri earned a BS at the University of Connecticut and a MBA at the University of Massachusetts.  She is a licensed broker in the states of MA and CT, has ACI and PMP certifications and is on the Board of Directors for the New England Employee Benefit Counsel (NEEBC). Teri was one of five finalists for BenefitPro’s 2020 Broker of the Year Award.

Women's Health in the Workplace

Sources:

Driving Innovation in Women’s Health for Employers – How Payer Organizations Can Lead the Way (wildflowerhealth.com)

https://explodingtopics.com/blog/femtech-startups

https://www.techtarget.com/whatis/definition/femtech

The femtech industry - statistics and facts | Statista

FemTech | McKinsey

Femtech Market - Size, Industry Report & Trends (mordorintelligence.com)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8784032/#:~:text=Women%20face%20unique%20 logistical%20and,well%20researched%20and%20warrant%20exploration.

https://femtechinsider.com/what-is-femtech/

https://www.mckinsey.com/industries/healthcare/our-insights/the-dawn-of-the-femtech-revolution

Global FemTech Market Size and Analysis Report 2025 | MTI (meditechinsights.com)

https://www.precedenceresearch.com/femtech-market#:~:text=The%20global%20femtech%20 market%20size,forecast%20period%202023%20to%202032.

https://www.bls.gov/opub/mlr/2015/article/labor-force-projections-to-2024.htm

http://www.cdc.gov/nchs/data/series/sr_21/sr21_052.pdf

http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_01.pdf

https://pubmed.ncbi.nlm.nih.gov/24218401/

https://www.ncbi.nlm.nih.gov/books/NBK562258/#:~:text=Infertility%20is%20usually%20defined%20 as,40%25%20of%20all%20infertility%20cases.

Trial Data Looks Promising for ‘IUD For Men’ - MedCity News

Male Infertility - StatPearls - NCBI Bookshelf (nih.gov)

Trial Data Looks Promising for ‘IUD For Men’ - MedCity News

https://www.forbes.com/sites/magnit/2023/08/31/female-participation-in-the-workforce-is-laggingopportunities-in-your-contingent-workforce-can-be-a-solution/?sh=6f696a3b7314

https://www.washingtonpost.com/technology/2024/01/08/tech-trends-2024/

Closing the women’s health gap: A $1 trillion opportunity to improve lives and economies | McKinsey

PMC8784032/#:~:text=Women%20face%20unique%20logistical%20and,well%20researched%20and%20 warrant%20exploration.

Women's Health in the Workplace

https://femtechinsider.com/what-is-femtech/

https://www.mckinsey.com/industries/healthcare/our-insights/the-dawn-of-the-femtech-revolution Global FemTech Market Size and Analysis Report 2025 | MTI (meditechinsights.com)

https://www.precedenceresearch.com/femtech-market#:~:text=The%20global%20femtech%20 market%20size,forecast%20period%202023%20to%202032.

https://www.bls.gov/opub/mlr/2015/article/labor-force-projections-to-2024.htm

http://www.cdc.gov/nchs/data/series/sr_21/sr21_052.pdf

http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_01.pdf

https://pubmed.ncbi.nlm.nih.gov/24218401/

https://www.ncbi.nlm.nih.gov/books/NBK562258/#:~:text=Infertility%20is%20usually%20defined%20 as,40%25%20of%20all%20infertility%20cases.

Trial Data Looks Promising for ‘IUD For Men’ - MedCity News

Male Infertility - StatPearls - NCBI Bookshelf (nih.gov)

Trial Data Looks Promising for ‘IUD For Men’ - MedCity News

https://www.forbes.com/sites/magnit/2023/08/31/female-participation-in-the-workforce-is-laggingopportunities-in-your-contingent-workforce-can-be-a-solution/?sh=6f696a3b7314

https://www.washingtonpost.com/technology/2024/01/08/tech-trends-2024/

Closing the women’s health gap: A $1 trillion opportunity to improve lives and economies | McKinsey

COMPANIES TURNING TO CAPTIVES TO MANAGE INFLATION

IInflation is an ever-present challenge that organizations must deal with. According to the U.S. Inflation Calculator with data from the U.S. Bureau of Labor Statistics, inflation has risen from 1.4 percent in December 2020 to 3.4 percent in December 2023. The cost of living rose from 2.3 percent in 2020 to 6.0 percent in February 2024.

That increase can impact many areas, including payroll, healthcare, the cost of merchandise and equipment, gasoline, and shipping. But most importantly, it can drive up insurance market rates.

INFLATION’S IMPACT ON INDUSTRIES

“Medical inflation is beginning to pick up again. It’s forecasted at 7 percent for 2024. It had dipped down to 5.5 percent in 2022,” said Mike Madden, division senior vice president at Artex Risk Solutions.

“The places where we are seeing the largest impact on insurance premiums is on the property side, and health insurance and medical stop-loss premiums,” Madden said.

On the property side, “driving the property market increases are catastrophic claims from hurricanes and wildfires, as well as replacement costs,” he said. “When you are looking at replacement costs, the cost of goods has increased, so replacement costs are much higher than anticipated, and this is driving claims inflation, which is affecting market pricing.”

George Papagelis, regional vice president, national accounts at OneDigital, noted, “It’s all about claim trends, which is really about inflation. The rise of healthcare insurance has probably been several hundred percent over the last 15-20 years. But when you look at the increase in people’s wages, it’s more like one-tenth of that, 3 or 4 percent. This is a major issue in the health insurance world, so how do you combat that?”

Papagelis said that the same kind of inflationary pressures we see in groceries and gasoline “are also impacting the cost of healthcare. Health insurance is offered by most employers and is usually one of the top three expenses for those organizations.”

Healthcare jumps out, he said, because it’s a sizable expense for organizations as well as their employees. Adding to this, “There has been a post-pandemic delay on treatment that has had an impact. People with medical issues often had to put off treatment, leading to worsened cases,” Papagelis said.

He observed that there are also new technologies in research and development. “Lastly, there are a lot of new medications now,” Papagelis said. “Most are very good and provide a better quality of life for people in some conditions. They also can be very expensive.” In fact, some medicines, like gene therapy and stem-cell therapy, “can have a price tag of $3 million.”

CAPTIVES STRATEGIES

Randy Sadler, principal at CIC Services, LLC, said that captives are an effective inflation strategy. “The great power of a captive is that it gives you tremendous flexibility.”

At the top of the list, he said, is that “If replacement costs for damaged property and damaged vehicles go up – which they have – then insurance premiums will inevitably rise.”

That pain has to be shared, Sadler said. “When a business has a captive, whether pre-inflation or during inflation, writing all or part of that premium check to your captive versus to the commercial market allows a business – as long as they can reasonably control losses – to put that money away instead of paying it to the commercial market.” It also gives cost control at a time when it’s needed, he added.

The first key, Sadler said, “is to have an investment strategy.” Captives, he said, will benefit from being taxed as an insurance company, “therefore, you have a solid amount of capital to outrun inflation. If an § 831(a) election is made and your loss reserves are set aside, you can invest those,” Sadler said.

Secondly, he added, is having a financial focus and a risk management focus. “You need a financial strategy focus because a well-run captive will build up reserves, so making investments to beat inflation is the second key to winning.”

Madden agreed. “We’re seeing that our captive owners are reevaluating their investment policies,” he said. “Captives tend to have a more conservative investment policy traditionally,

but with higher interest rates as a reaction to inflation, a lot of captive owners are looking to get more benefit or to change up their investment strategy.”

INFLATION AND HEALTH INSURANCE

Papagelis, who works with captives on the health insurance side, noted that “Companies join captives for many reasons: workers compensation, commercial liability, and in the last ten years, they started using them more for health insurance,” he said.

Captives have grown exponentially for a number of

reasons, he said. One is that they can help employers to mitigate risk on the pharmacy side, such as the cost of specialty drugs. “You can’t always do this when you are fully insured with a carrier, but you can do it when you’re self-funded and your own plan sponsor,” he explained.

Another reason, Papagelis said, is an increase in cancer claims. “So, what is the center of excellence? A concierge cancer program that not only helps them through that journey in their lives but also helps account for the costs of that situation,” he said.

The advantage of a group captive is both qualitative and quantitative, he explained. “Quantitative advantages are being self-funded, more transparent and building a surplus.”

The qualitative advantages, “are being part of a group where you are bringing different ideas to the table and sharing them. It is a community, so there is an element of sharing and implementing best practices,” Papagelis said. For example, “If there is a prevalence of diabetes, we can put in place a program where people are getting access to resources that can help them manage that disease.”

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With these strategies, he noted, most captives have outpaced the traditional markets. “We’re starting to see testimonials from employees, where companies are giving back benefits to employees and putting in place centers of excellence to support people with difficult chronic diseases,” he said.

“What we’re achieving has a positive impact on the company and the employees,” Papagelis noted.

HOW IT WORKS

In a group that is fully insured by a carrier, “There is not as much transparency, flexibility or control, so they are stuck doing what the carrier tells them to do,” Papagelis said. “It’s not a great way to create employee satisfaction.”

A captive, he said, is beneficial for employers, particularly in the range of 50 to 1,000 employees.

What a captive does, he said, is to optimize transparency, flexibility, and control. “So, you’re joining a pool of other like-minded employers. For the really expensive claims, like gene therapy and therapy for hemophiliac and cancer claims, you’re pooling your funds. You’re also sharing in the risk and reward of your plan,” he said.

The key element of a captive, Papagelis said, is self-funding. “The second is joining a captive where a number of employers are sharing in the risk and reward. If I’m an employer on my own, I might have $300,000 in stop-loss premium, and I might absorb some percentage of that,” he said.

With a captive, however, “your $300,000 could be $20 million,” he said. This is the case “because, as a group, you can absorb some of the rare high-cost claims that generally drive your renewals. So now the risk of a hemophiliac claim can be absorbed by the group.” In the theory of large numbers, he added, “the captive runs in a surplus, which means that employers in the captive get some money back.”

Another important aspect is proactive and purposeful risk management. “While a captive may not be a silver bullet, being self-funded and part of a group is a piece that will help everybody,” Papagelis said. “It’s about looking at the data as an employer: Do you have a high prevalence of cancer or diabetes within your population, and what are some things you can do to mitigate risk?”

Madden noted, “The beauty is that the captive provides employers with more control over claim drivers through risk management activities.” On the medical health side, “there are data analytics and the ability to be more creative, both getting in front of claims and also helping to deal with the costs of some ongoing claims activity,” he said.

Caroline McDonald is an awardwinning journalist who has reported on a wide variety of insurance topics. Her beat includes in-depth coverage of risk management and captives.

SELF-FUNDED HEALTH PLANS CAN OPTIMIZE VALUE WITH NO SURPRISE!

FFederal

legislation that took effect more than two years ago, on January 1, 2022, empowered self-funded health plan participants with specific protections against certain charges by out-of-network providers. It also enabled participants to access prices charged by providers in the past.

Participants do not know, in advance, what the provider will charge for its services. Other than office visits, preventive services, and certain Rx, they generally don’t know, in advance, what their plan will pay or what their out-of-pocket costs will be.

This is the result of the complexity of healthcare. Participants won’t know the billing codes, whether the plan will accept all of those charges, what portion of the billed charges are eligible under the plan, and how deductibles, copayments and coinsurance will apply. Many times, when participants receive a bill for the balance they owe, it will be a complete surprise.

Participants are often “surprised” whenever they get a “balance bill,” expected or unexpected, regardless of whether the balance bill meets state or federal law’s definition of “surprise.”

This is an opportunity for claims administrators to assist plan sponsors in actions that will achieve greater value at a lower cost where participants are more engaged with their health coverage.

LEGISLATIVE EFFORT TO MANDATE PRICE TRANSPARENCY

A combination of U.S. government agencies issued its final rules on pricing transparency with the goal of reducing consumer confusion. The Centers for Medicare & Medicaid Services (CMS) also issued guidance.

Under the final rules, hospitals and other providers are required to make pricing information available online. The new rules also require plans to offer online tools that include personalized information regarding members’ cost-sharing responsibilities for covered items and services, including prescription drugs.

PROVIDER TRANSPARENCY RULES

Hospital price transparency is intended to provide pricing in advance of receiving services. This information is intended to enable patients to shop and compare prices across hospitals and estimate the cost of

care before going to the hospital. Each hospital operating in the United States is required to provide clear, accessible pricing information online about the items and services they provide in two ways:

• As a comprehensive machine-readable file with all items and services

• In a display of shoppable services in a consumer-friendly format

PAYER TRANSPARENCY RULES

New requirements for payers under CMS Transparency in Coverage require payers to disclose in-network provider rates for covered items and services, out-of-network allowed amounts and billed charges for all covered items and services and negotiated rates and historical net prices for covered prescription drugs administered by providers.

Starting in 2023, payers had to provide an internet-based price comparison tool that allows members to receive an estimate of their cost-sharing responsibility for a specific item or service from a specific provider or providers for 500 items and services. Price comparison tools must include all services, including prescription drugs, starting this year.

Plans subject to the rule include individual and group plans (selfinsured and level-funded). These rules do not apply to accountbased group plans and programs (HRAs, FSAs, HSAs). Payers not in compliance could face fines of up to $100 per day for each violation and for each individual affected by the violation.

PROTECTION AGAINST SURPRISE BILLING

Typically, balance billing occurs when patients receive care from an out-of-network provider.

For example, a patient may receive emergency care from an outof-network facility. Or a patient may be directly billed by an out-ofnetwork physician even when the patient is receiving medical care at an in-network facility. These are often high-dollar costs. They constitute the difference between what a provider charges and the amount covered by the plan.

The balance comes as an unpleasant surprise as the balance bill often arrives after all benefits have been paid and after the participant has paid their deductible, copayment or coinsurance.

While in-network providers generally agree to accept the plan’s determination of covered charges, out-of-network providers are under no legal obligation to do so.

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Percent of Providers Who Bill Out-of-Network, Prior to the No Surprises Act

Table Source: Health Care Cost Institute

However, according to this 2020 Health Care Cost Institute study, most providers who bill out of network do so less than 10 percent of the time.

Prior to the No Surprises Act, more than 30 states had statelevel protections against balance bills for fully insured plans. However, states do not have regulatory authority over selfinsured plans, which are subject to the Employee Retirement Income Security Act (ERISA).

As a result, more than 70% of Americans do not benefit from these state law protections.

Map: State Laws Protecting Consumers Against Balance Billing, Prior to the No Surprises Act, As of February 5, 2021

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Map Source: Maanasa Kona et al., Center on Health Insurance Reforms, Health Policy Institute, Georgetown University.

Some states responded to the Not Surprises Act by updating their own legislation and protections regarding Balance Billing. Four states, Colorado, Georgia, Illinois and Washington, updated their state law to better align with or exceed NSA protections. Three states, Maryland, Vermont and West Virginia, consolidated NSA enforcement authority in the department of insurance. Two states enacted or revised laws governing payment for out-of-network services – Illinois and New York.

Beginning January 1, 2022, all healthcare providers were required to make information on patients’ rights regarding balance billing publicly available. The No Surprises Act (NSA) specifically applies to out-of-network provider services delivered at in-network facilities, as well as emergency services, regardless of location. Providers will be prohibited from balance-billing members for items and services received in three situations: emergency, out-of-network, nonemergency services at in-network facilities and out-of-network air ambulances.

The NSA establishes an Independent Dispute Resolution (IDR) system. This is a form of arbitration where the out-of-network provider is unwilling to accept the payor’s determination of the covered charge.

NSA FINAL RULES

The tri-agencies published final rules in the federal register on August 26, 2022.

Combines the interim final rules Part 1 and Part 2, plus the final rules:

• Preclude balance billing of participants by outof-network providers who deliver services in a network facility, provide emergency services regardless of location, and provide air ambulance services,

• Require claims for services subject to the No Surprises Act qualify for in-network benefits,

• Implement the good faith estimate requirement,

• Implement the Qualified Payment Amount (QPA) and Independent Dispute Resolution (IDR) requirements and processes.

While the legislation and rules and the sub-regulatory guidance in the form of FAQs greatly expand participant protections, including expanding the definition of emergency services, it is important to note that Balance Billing was not completely eliminated. It may still occur where a non-network provider delivers non-emergency services and ground ambulance transportation at a facility that is not in the network.

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IMPLEMENTATION HAS SUFFERED MANY CHALLENGES

Among all the challenges of implementing the NSA, three stand out:

• Initially, there was widespread hospital non-compliance with transparency requirements,

• The most effective consumer tool created by the No Surprises Act is the Advanced Explanation of Benefits, which was to take effect for plan years beginning on or after January 1, 2022; however, the requirement has been suspended pending Department of Labor regulations, and while those regulations were once a priority, they apparently aren’t anymore.

• Whatever Congress was thinking, the IDR process is an all but complete failure. During the period between April 15, 2022 and June 30, 2023, 490,000 IDR disputes were initiated — more than 22 times the number of disputes anticipated by the Departments of Health and Human Services, Labor, and Treasury (the “Departments”). Worse, more than 60% of the disputes still have not been decided.

THE KEY LEGAL CHALLENGES

Since the passage of the No Surprises Act (NSA), nearly 20 federal lawsuits have been filed against the Department of Health and Human Services (HHS), challenging statutory provisions, agency regulations and guidance, and adjudications made through the provision of an Independent Dispute Resolution (IDR) process.

A ruling in the case of Texas Medical Association v. HSS declared the regulatory guidance outlining the method to determine the Qualified Payment Amount (QPA) was unlawful. A court order vacated certain portions of QPA regulations and related guidance. Read more here.

The federal government prevailed at summary judgment in the case of Association of Air Medical Services v HSS, marking the government’s first major victory in the string of challenges to the NSA. The court found that certain government regulations on how to define and calculate the QPA for air ambulance services were consistent with the NSA.

Given Ongoing litigation and NSA uncertainties, administrators of self-insured plans should consider employing “pure” reference-based pricing designed to avoid the administratively cumbersome and costly IDR process.

Additional details on NSA litigation can be found here.

A STRATEGIC AND COMPLIANCE-ORIENTED RESPONSE TO NSA

Health plans need to understand their rights under the price transparency mandates and NSA legislation designed to reveal the true cost of provider health services before receiving care and submitting a claim. Plan sponsors should work with claims administrators to ensure plans are amended as necessary to comply with the No Surprises Act – and updated as necessary because NSA provisions continue to evolve with litigation and additional sub-regulatory/FAQ guidance.

Fully optimizing plan value requires a holistic approach to plan design, as well as initiating changes to ensure the most effective strategies are implemented to meet NSA requirements and to support the ‘health and wealth’ of participants. The most effective way to respond to the NSA is through a combination of strategic and compliance-oriented approaches.

REFERENCE-BASED PRICING: A SELF-FUNDED PLAN’S MVP

(MOST VALUABLE PROVISION)

Even with greater transparency, price variations can still exist across hospitals and providers. To mitigate this, many self-funded health plans have adopted reference-based pricing (RBP) strategies. RBP strategies typically base health plan fees on a multiple of Medicare pricing. This establishes a benchmark fee schedule and payment ceiling. Plan sponsors and participants benefit from the consistent application across all providers and health networks.

FACILITY PRICES RELATIVE TO MEDICARE BY STATE

While RBP can offer value by leveling the playing field, risks remain RBP plans that use narrow networks or have negotiated contracts with certain providers and plans that utilize RBP as the mechanism to price out-of-network claims will still be affected by the NSA legislation. In both instances, there would be a network rate that could be used to calculate a Qualifying Payment Amount (QPA).

The most effective way to address the NSA legislation may be to adopt a “pure” RBP plan that puts the patient in the driver’s seat as a healthcare consumer. Pure RBP plans that do not contract with providers should remain unaffected by NSA because there aren’t any out-of-network claims, nor is there any determination of a median in-network rate. NSA may prompt a significant expansion in the prevalence of pure RBP plans since RBP often eliminates the negative effects of excessive charges – charges that would otherwise be shared by the employer and the participant.

Adopting a “pure” RBP structure, coupled with tech-driven data support, may avoid unreasonable or excessive provider charges – potentially lowering both the cost of coverage and employee point of purchase cost sharing. Given the wide variation of provider charges for the same services, without any difference in quality, a pure RBP design offers an opportunity to avoid excessive and unreasonable provider fees and charges.

NSA GUIDANCE ON REFERENCE-BASE PRICING FOR EMERGENCY SERVICES

The Department of Labor (DOL), the Department of Health and Human Services (HHS), and the Internal Revenue Service (IRS) issued a set of FAQs addressing the NSA, including how the NSA applies to plans that incorporate RBP:

• Non-emergency services provided by out-of-network providers at in-network facilities;

• Out-of-network emergency services; and

• Out-of-network air ambulance services.

For each plan, the No Surprises Act specifically defines the Qualifying Payment Amount (QPA) as:

“the median of the contracted rates recognized by the plan … that are offered within the same insurance market … as the total maximum payment (including the cost-sharing amount imposed for such item or service and the amount to be paid by the plan) … for the same or a similar item or service that is provided by a provider in the same or similar specialty and provided in the geographic region in which the item or service is furnished…”

A ”pure” RBP plan has no network, so there are no in-network facilities. There are no contracts with providers. Consequently, there is no Qualified Payment Amount (QPA), and the NSA will simply never apply to non-emergency services under an RBP plan.

Plans and insurers that use RBP, however, cannot limit or exclude spending towards emergency services from a provider that does not accept the RBP. This out-of-pocket spending must count toward the annual out-of-pocket maximum. In the latest guidance, federal officials extend this to post-stabilization services that are included in the definition of “emergency services.” Thus, plans and insurers should not limit or exclude spending on providers that do not accept an RBP when that spending is on NSA-covered poststabilization services.

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If emergency or non-emergency services are otherwise covered by the plan or policy but provided by an out-of-network provider, the NSA’s protections apply even if the plan or policy does not otherwise include coverage for out-of-network items or services. As such, a closed network plan or insurer might end up providing benefits for out-of-network care because of the NSA.

We are mindful that government agencies adopt regulations that extend the reach of or conflict with the original text of the legislation. That’s why litigation challenging Part I, Part II, and the Final Rule of the Requirements Related to Surprises Billing (the “Rules”) issued by the Department of Health and Human Services under the federal NSA was no surprise.

While we wait for further guidance, the parties should use their best judgment and provide complete and detailed submissions to the IDR Entities. An even better practice is to adopt a reference-based pricing plan, which allows the parties to avoid certain NSA provisions (including the IDR process) and potentially eliminate the negative effects of excess charges otherwise shared by the employer and the participant.

A NEW GENERATION OF INNOVATIVE SERVICE SUPPORT

Compliance will remain a top priority for administrators. Achieving and staying compliant will require new levels of support from medical billing partners equipped with digital solutions to alleviate administrative burden. An innovative billing partner strategically employs information technology and data to support plan administrators with powerful intelligence, enabling a stronger defense against complex billing and greater success in efforts to recover overpayments. Online data analysis tools provide real-time pricing and insights by harnessing data electronically – allowing fee comparisons that identify fair and reasonable prices.

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FINDING THE RIGHT MEDICAL BILLING PARTNER

It’s important to look for a medical billing partner that is an agent of change, one that embraces innovation and advocates for “what is fair and just” in the marketplace. The right partner also provides value-added services to a health plan through turnkey solutions, administrative support, and legal representation. This support assistance will be invaluable in helping plan administrators navigate complex federal and state healthcare regulations and advocacy of complex medical billing issues.

Christine Cooper is the CEO of aequum LLC and the Co-Managing Member of Koehler Fitzgerald LLC, a law firm with a national practice. Founded in 2020, aequum serves third-party administrators, medical cost management companies, stop-loss carriers, employer-sponsored health plans and brokers nationwide, defending medical balance bills and delivering savings to employer-sponsored health plans. Find aequum at aequumhealth.com.

TIPS FOR NSA COMPLIANCE

• Understand how implementation of NSA provisions and IFRs affect the cost of coverage and the self-funded plan’s revenue cycle.

• Analyze any differences between the code and regulatory guidance, as well as identify any gaps where there appears to be insufficient guidance or outstanding issues.

• Confirm current processes, procedures, agreements and contracts with emergency and ancillary providers to determine potential areas of concern and risk exposure.

• Know how changes will impact plan design and clarify the process for resolving claims disputes with out-of-network providers.

• Include disclosure requirements on EOBs and ensure communication materials and plan documents (plan document, SPD, SBC, etc.) are updated as necessary.

• Understand options plan sponsors can deploy to leverage this new legislation for the benefit of both the participants and the plan.

After confirming compliance requirements, identify actionable rewards and benefits solutions that will leverage provisions to optimize the outcome from compliance – for both the participants and the plan sponsor. Communicate plan updates so members and their dependents can fully understand their healthcare coverage and provider options.

MOOP, MOOP: IT’S HIT OR MISS FOR OUTOF-POCKET MAXIMUM CALCULATIONS

MMany health plans have adopted the practice of excluding the value of drug manufacturer rebates and coupons (collectively coupons) from counting toward deductibles and out-of-pocket maximums (MOOP). Others may apply coupons towards the deductible and/ or out-of-pocket maximum, but as noted below, such practice may cause compliance concerns under the IRS rules applicable to HSAcompliant HDHPs. In this month’s article, we trace through recent agency (HHS) guidance and court developments and the challenges such rulings create for health plan administration. Although the Notice of Benefit and Payment Parameters (NBPPs) are issued by HHS, the rulemaking likely indicates how the tri-agencies may view the issues for self-insured plans (even if such rules are not directly applicable through portions of the Public Health Service Act incorporated into ERISA).

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HHS first addressed the practice of excluding the value of drug manufacturer coupons from MOOP through copay accumulator programs in the 2020 Notice of Benefits and Payment Parameters (2020 NBPP). However, the language in the regulatory text of the 2020 NBPP created confusion over whether counting the value of the coupons in MOOP was required or discretionary. The text of the rule itself permitted plans and issuers to disregard the value of the coupons as long as a medically appropriate generic equivalent was available (and as long as the practice was consistent with state law), but the rule did not codify any requirement to include the value of the coupons in MOOP if a generic equivalent was not available. In response to the confusion over the 2020 NBPP and potential conflict with the IRS HDHP requirements applicable to HSA-compatible HDHPs, federal regulators issued nonenforcement relief (through FAQs Part 40) until the 2021 NBPP could be issued and put into effect, stating that no enforcement action would be initiated if a plan or issuer excluded the value of the coupons, even if no generic equivalent was available. The 2021 Notice of Benefit and Payment Parameters (“2021 NBPP”) clarified that plans and issuers had total discretion (subject to state law applicable to insured plans) to decide whether to count the value of these coupons towards MOOP, regardless of the availability of any generic equivalent.

Advocacy groups challenged the 2021 NBPP in the D.C. district court, arguing that its treatment of drug manufacturer coupons conflicted with the statutory definition of “cost-sharing” under the Affordable Care Act (“ACA”) and with the pre-existing regulatory definition. In its September 2023 ruling in HIV and Hepatitis Policy Institute et al. v. HHS, the D.C. district court agreed with the advocacy groups, vacating 2021 NBPP and remanding it back to HHS. This ruling meant that the 2020 NBPP was now in effect again.

The Department of Health and Human Services (“HHS”) initially appealed the ruling but dropped its appeal of the D.C. district court’s order in mid-January 2024. The immediate consequence of this ruling was that the previous rule announced sprang back into effect. Under that 2020 NBPP, plans and issuers were not required to count the drug manufacturer coupons towards MOOP as long as a medically appropriate generic equivalent was available (and the practice was consistent with state law). Although this rule implies that the coupons must be counted if no generic equivalent is available, the text did not expressly state any such requirement, leaving plans and issuers in a state of confusion. Until HHS issues a new rule or other binding guidance, plans and issuers are left guessing whether it is permissible to exclude the value of the coupons from MOOP when a generic equivalent is not available.

Practice Pointer: It is important to note that selfinsured, non-grandfathered ERISA plans need to be mindful of Affordable Care Act rules for costsharing limits on essential health benefits (“EHBs”). If the drug at issue is not considered an EHB under the plan, then the plan is likely free to include or exclude the value of the coupon or discount. But if the drug is considered an EHB under the plan, then HHS’ rulemaking in the NBPPs for these copay accumulator programs is likely relevant. Self-insured plans should review the terms of their programs to ensure compliance with the EHB rules.

IMPACT OF COUPONS ON THE PLAN’S ADMINISTRATION OF THE MOOP

At first glance, this might all seem like much ado about nothing; however, a closer look reveals challenges for health plans. For all health plans, applying coupons to the out-of-pocket maximum increases the plan’s cost. And for HDHP plans, it likely creates HSA eligibility issues in the absence of sophisticated administrative systems that can exclude the coupons from the deductible but not the out-of-pocket maximum. The following example illustrates the issue with counting (or not counting) coupons and

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This example is illustrative only and not indicative of actual past or future results. Stop Loss is underwritten by Berkley Life and Health Insurance Company, a member company of W. R. Berkley Corporation and rated A+ (Superior) by A.M. Best, and involves the formation of a group captive insurance program that involves other employers and requires other legal entities. Berkley and its affiliates do not provide tax, legal, or regulatory advice concerning EmCap. You should seek appropriate tax, legal, regulatory, or other counsel regarding the EmCap program, including, but not limited to, counsel in the areas of ERISA, multiple employer welfare arrangements (MEWAs), taxation, and captives. EmCap is not available to all employers or in all states.

discounts towards MOOP: If a participant uses a coupon with a value of $150 for each month’s supply of a prescription drug, the annual value of the coupon is $1800. If the plan counts the value of the coupon, then $1800 of the participant’s deductible and MOOP is funded by the drug manufacturer. If the plan excludes the value of that coupon, then $1800 would not be counted towards MOOP, and the participant would be left to make up the $1800 by paying for other medical expenses out-of-pocket.

HOW DRUG MANUFACTURER COUPONS ARE TREATED UNDER THE 2020 NBPP

The 2020 NBPP grants discretion to plans and issuers to count the value of a drug manufacturer’s coupon towards MOOP if a medically appropriate generic equivalent is available (and if consistent with state law). The preamble to the 2020 NBPP goes on to add that the value of such coupons must be counted towards MOOP when no medically appropriate generic drug is available. Although the preamble states, “We have added language to the regulation text to address this clarification,” the addition was never actually made, and the regulators did not include this requirement in the text of the regulation itself. This glaring omission led to confusion over whether there really was any requirement to count the value of the coupons when no medically appropriate generic equivalent is available. That said, the wording of the text that did make it into the regulation—that plans and issuers “are not required” to count direct support from drug manufacturers when a generic equivalent is available—strongly implies that such direct support is required to be counted when no generic equivalent is available.

NONENFORCEMENT RELIEF: FAQS PART 40 AND THE HDHP/HSA PROBLEM

In August 2019, in response to the confusion over 2020 NBPP, the tri agencies released FAQ Part 40, in which they reconsidered the policy on how to count drug manufacturer coupons, taking into consideration the conflict that applying the coupons to the out-of-pocket maximum might have on HSA eligible, as described in IRS Notice 2004-50. In order to be eligible to contribute to an HSA, an individual must be enrolled in an HDHP and have no other disqualifying health coverage that would pay for medical care before the HDHP deductible is reached. Any coverage or benefits received prior to meeting the HDHP deductible could disqualify a person from being eligible to contribute to an HSA (unless an exception exists). IRS Notice 2004-50 stated that the value of a discount from a drug manufacturer will not lead to disqualification as long as the individual is otherwise responsible for paying costs until the deductible is met. In other words, the value of the drug discount would apparently be disqualifying if it were counted towards the individual’s HDHP deductible, and therefore, the discount must be excluded from the calculation in order for the individual to maintain HSA eligibility.

Interestingly, the conflict between the 2020 NBPP and the HSA rules highlights an administrative issue. The 2020 NBPP only requires that the coupons be applied to the out-of-pocket maximum –not the deductible. HSA eligibility is only impacted if the coupons are applied to the deductible. This suggests that the two rules could co-exist in theory; however, such is not the case in practice. First, plan administrators are simply not able to apply a cost share to the out-of-pocket maximum without also applying it to the deductible. Second, the coupons would likely exhaust the out-of-pocket maximum before the participant incurred significant other

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deductible expenses necessary to satisfy the HSA rules.

Consequently, regulators announced relief from complying with 2020 NBPP in FAQs Part 40, stating that no enforcement action would be initiated if a plan were to exclude drug manufacturer assistance from MOOP, even if no medically appropriate generic drug is available. This nonenforcement relief was set to expire once the 2021 NBPP was issued and in effect.

2021 NBPP: A “FIX” THAT FELL FLAT

HHS issued the 2021 NBPP in May 2020, marking the end of the nonenforcement relief once 2021 NBPP went into effect. Rather than imposing any specific practice on plans, the 2021 NBPP simply granted permission for plans to choose whether to apply the value of drug manufacturer assistance to MOOP. As long as the plan’s actions were consistent with state law, the 2021 NBPP placed no mandate on how to treat drug manufacturer coupons for MOOP, regardless of whether a medically appropriate generic equivalent was available. Regulators explained in the preamble of 2021 NBPP that the term “cost-sharing,” which is defined in the statute and further interpreted by regulations, is “subject to interpretation” when it comes to whether to include or exclude drug manufacturer coupons in MOOP. And the interpretation for this purpose is left not to regulators but to plans and issuers. Advocacy groups challenged the discretion granted to plans and issuers in 2021 NBPP in HIV and Hepatitis Policy Institute et al. v. HHS and were ultimately victorious, but the victory only reinstated the 2020 rule, which was not clear to begin with. However, as discussed below, the arguments raised in the lawsuit may force HHS to be more decisive in its next round of rulemaking.

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COURT CHALLENGE TO 2021 NBPP

In 2022, several advocacy groups filed a lawsuit against HHS for, among other things, conflicts between HHS’s interpretation of “cost-sharing” in the 2021 NBPP and the statutory and regulatory definitions (see HIV and Hepatitis Policy Institute et al. v. HHS):

The ACA defines “cost-sharing” to include the catch-all “any other expenditure required of an individual which is a qualified medical expense.”

The regulatory definition from 2012 defines cost sharing as “any expenditure required by or on behalf of an enrollee […].”

[45 CFR Section 155.20]

Although some may parse the difference between the phrases “required of (statutory) and “required by” (regulatory) and conclude that the two mean the same thing, it could be argued that the additional phrase “or on behalf of” in the regulatory definition tilts in favor of including coupons in MOOP. In either case, the advocacy groups argued that opposing interpretations based on the same statutory and regulatory language could not both be true; that is, it cannot be true that the value of the coupons is cost-sharing for one plan but is not cost-sharing for another, absent any difference in state

In its September 2023 opinion, the D.C. district court agreed with the advocacy groups that the exact same statutory and regulatory text cannot have two opposing meanings when applied to drug manufacturer coupons and that the discretion to choose between the two opposing meanings cannot be left to the discretion of the parties being regulated. The court set aside 2021 NBPP and remanded it back to HHS. The vacatur meant that the 2020 NBPP was back in effect, but the court refused to weigh in on the legality of the nonenforcement relief in FAQs Part 40.

WHERE DO WE GO FROM HERE?

So, what can we expect from HHS? Leaving plans and issuers to decide for themselves whether direct support from drug manufacturers is “cost-sharing” under the ACA is now apparently off the table. HHS may go back to its regulatory definition of “cost-sharing” and propose removing the problematic “on behalf of” language and provide an interpretation that is closer to the statutory language. Or HHS may make a decisive statement that drug manufacturer support must or must not be included in cost-sharing calculations. If HHS were to issue a decisive rule that all drug manufacturer assistance had to be included in MOOP, such a rule would have to take into account IRS rules for HDHPs, and self-insured plans would need to address potential compliance

issues with the EHB and MOOP rules.

For now, 2020 NBPP is technically in effect, which apparently means the following for plans and issuers:

• State law is controlling for plans and issuers subject to state law.

• Plans and issuers are apparently not required to include direct support from a drug manufacturer coupon in MOOP if a medically appropriate generic drug is available.

What about that nonenforcement relief in FAQs Part 40 from 2019?

Did the D.C. district court opinion that revived the 2020 NBPP also

revive the nonenforcement relief? In a motion for clarification on the ruling, HHS stated that it does not intend to take any enforcement action against plans based on treatment of manufacturer assistance. Although advocacy groups pushed for the court to rule that the non-enforcement policy was illegal, the court stated that the nonenforcement policy was not an issue before the court. So far, we have not seen any recent enforcement activity in this area from the agencies.

Attorneys John R. Hickman, Ashley Gillihan, Steven Mindy, Ken Johnson, Amy Heppner, and Laurie Kirkwood provide the answers in this column. John is partner in charge of the Health Benefits Practice with Alston & Bird, LLP, an Atlanta, New York, Los Angeles, Charlotte, Dallas and Washington, D.C. law firm. Ashley and Steven are partners in the practice, and Ken, Amy, and Laurie are senior members in the Health Benefits Practice. Answers are provided as general guidance on the subjects covered in the question and are not provided as legal advice to the questioner’s situation. Any legal issues should be reviewed by your legal counsel to apply the law to the particular facts of your situation. Readers are encouraged to send questions by E-MAIL to John at john.hickman@ alston.com.

NEWS FROM SIIA MEMBERS

2024 MARCH MEMBER NEWS

SIIA Diamond, Gold, and Silver member companies are leaders in the self-insurance/captive insurance marketplace. Provided below are news highlights from these upgraded members. News items should be submitted to membernews@siia.org.

All submissions are subject to editing for brevity. Information about upgraded memberships can be accessed online at www.siia.org.

If you would like to learn more about the benefits of SIIA’s premium memberships, please contact Jennifer Ivy at jivy@siia.org.

Zakipoint Health Inc. Secures Investment from Industry Veterans of the Self-Funded Employer Space

Zakipoint Health Inc., a cutting-edge A.I. technology company with a mission to bring price transparency, direction, and personalization to healthcare consumers, announced the successful completion of a funding round by Ansley Capital and several industry veterans. This strategic investment will propel Zakipoint Health Inc. towards achieving its ambitious goals and solidifying its position as a leader in delivering data and A.I.-driven proactive member engagement tools to the self-funded employer market.

Zakipoint Health has garnered attention for its innovative approach of providing an end-to-end platform for identifying predictive risks and cost drivers, driving actions at the member level, a digital front door tool for member engagement, and a reporting tool to empower selffunded employers, third-party administrators, payors, benefits, and consultants. Zakipoint Health has established strategic partnerships with leading healthcare entities such as Valenz Health, PLEXIS Healthcare Systems, Ebix Health, and Eldorado.

Ramesh Kumar, CEO and Co-Founder of Zakipoint Health, expressed gratitude for the support from Ansley Capital and other industry leaders. Spike Dietrich and Russ Burks from Ansley Capital recognize the immense potential of Zakipoint Health’s disruptive solutions and are enthusiastic about the collaboration. As part of the investment, Russ took a seat on the Company’s board of directors, and Spike chairs its commercial advisory board.

Marpai Hires John Powers as President

Marpai, Inc., an independent national Third-Party Administration company transforming the $22 billion TPA market supporting self-funded employer health plans, announced the appointment of John Powers as the Company’s President. Powers is an accomplished healthcare benefits executive with over 30 years of experience. Powers was previously CEO of Homestead Smart Health Plans.

benefits space. Previous roles included Vice President of HealthComp Holdings, a privately held third-party administrator (TPA). John managed the integrated solutions while driving an industry-leading Client-based Net Promoter Score (NPS) of 80. Additionally, John served as EVP and principal of Advanced Medical Pricing Solutions (AMPS) – a leading healthcare cost containment company. In these positions, John was instrumental in driving tens of millions of dollars in savings for his clients.

“Marpai’s robust data analytics, combined with industry-leading partnerships and the recent leadership changes focusing on client savings and high growth, was extremely compelling,” said Mr. Powers. “Moreover, I look forward to leveraging the Company’s recent successes and support the key strategic initiatives of rapid efficiencies in operations, improving benefit savings opportunities for our clients, and leading our efforts in achieving a high growth, cash flow positive Company with a strong track record of innovation.”

Powers brings deep operations knowledge and an extensive industry network developed over his professional career in the healthcare

Damien Lamendola, Chief Executive Officer, commented, “We are very excited to have John join the Marpai Team. His leadership and business acumen are critical to strengthening our foundation and positioning the Company for our next growth

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phase. John’s impressive industry knowledge and professional record of achieving crucial operational targets, working closely with customers, and executing significant revenuegenerating opportunities is a great fit for Marpai.”

Woodruff Sawyer Names New President of Employee Benefits

Woodruff Sawyer, one of the largest independent insurance brokerages in the US, announced today that Ryan Meissner has been appointed the firm’s President of Employee Benefits. Ryan was previously Practice Leader of Woodruff Sawyer’s

Employee Benefits practice. Before that, Ryan served four years as the firm’s Vice President of Data Analytics. He was named Partner in 2022.

Andy Barrengos, Woodruff Sawyer’s Chairman and CEO, comments, “We’re excited to have Ryan leading our Employee Benefits practice. His passion and commitment to our people and clients, combined with his deep expertise in developing data-driven solutions that improve the outcomes for our clients’ employees and organizations, are vital components of the practice’s growth initiatives.

Ryan adds, “I’m excited to build on the foundation we’ve laid in Employee Benefits. Our business is built around great people, fierce advocacy, and hands-on partnerships with our clients to implement solutions using data and technology that make their lives simpler. Our goal is to provide great client service and empower them to make informed decisions for their employees. That is a win for our clients and our team.”

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Healthjoy, a care navigation platform that transforms healthcare outcomes, today announced the appointment of Marc Salois as Chief Revenue Officer. Before joining HealthJoy, Salois served as Chief Revenue Officer at Optavise, where he was responsible for revenue growth, client success, and alliances.

HealthJoy’s care navigation platform empowers employees to actively engage in their health, redirects to high-quality, affordable care, and delivers the most personalized benefits experience possible. As Chief Revenue Officer, Salois will oversee HealthJoy’s sales, revenue operations, and marketing teams.

“We are delighted to welcome Marc to the HealthJoy team,” said Justin Holland, CEO and co-founder of HealthJoy. “Marc’s notable success as a strategic sales leader, understanding of digital therapeutics, and depth of knowledge in the benefits consulting space will enable us to guide more employees to affordable, high-quality

healthcare. I look forward to working with him as part of the leadership team.”

“I am thrilled to be joining the HealthJoy team,” said Salois. “I love the way HealthJoy serves their clients by bringing true value to the individual, the customer, and their consultant/broker partners. On top of this, the HealthJoy culture is infectious. The commitment to excellence, humility, and taking action is something I really wanted to be a part of.”

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Stone Point Capital Invests in ClearPoint Health to Offer

Medical Stop-loss to Small and Mid-Sized Employers

ClearPoint Health, a medical stop-loss captive platform for small and mid-sized employers, has announced a strategic investment from Stone Point Capital. ClearPoint’s platform empowers employers and benefit advisors to transition employee health benefits to highly transparent, affordable, and clinically integrated insurance programs, benefiting employers and employees.

ClearPoint’s expansion in the medical stop-loss marketplace comes as captives enter a new phase of growth, with broadening commercial market adoption led by the continued migration of employers transitioning from fully insured insurance products to more transparent and affordable level-funded and self-funded arrangements. ClearPoint partners with health benefit advisors who wish to offer customizable, white-labeled captive solutions and underwriting services to their small and mid-sized employer customers.

“We’re thrilled to partner with Stone Point Capital to accelerate growth for our national captive platform,” said Jeb Dunkelberger, Founder & CEO of ClearPoint Health. “Employer health insurance expenses will only stop growing when we create a ‘win-win-win’ for employers, clinical providers, and carriers – the ClearPoint platform enables this, yielding not only affordability but sustainability. Stone Point’s expertise in the employee benefits space and track record of backing and helping build highly successful platforms makes them the ideal partner for ClearPoint.”

Chuck Davis, CEO of Stone Point Capital, said, “We are excited to help launch a company whose mission is to make employee benefits more affordable and higher quality for small and mid-sized employers and their employees. We believe the cost of employer-sponsored health insurance is one of the largest and most common issues facing US employers. Partnering with the ClearPoint team represents a significant opportunity to leverage our experience in the space to help provide scalable, sustainable solutions for employers and benefit advisors across the country.”

M3 Insurance Adds Senior Pharmacy Solutions Executive

Connie Perry has joined M3 Insurance as the managing director of pharmacy solutions, bringing a new level of expertise, specialization, and service to M3 clients. In her role, Perry is expected to use her clinical background as a PharmD and decades of experience in the PBM space to create a comprehensive pharmacy solutions stack for employers and pair it with the transparent and independent approach that has become a signature of M3.

Perry has over 25 years of industry experience and a doctorate in pharmacy from the University of Illinois College of Pharmacy, specializing in critical care during her residency. Her experience spans across various sectors, including clinical roles in hospitals,

academia and a Pharmacy Benefit Manager (PBM) (Walgreens Health Initiatives).

Perry was a lead consultant for national insurance brokers before joining M3. As a seasoned leader, she has successfully led national pharmacy practices and played a pivotal role in launching a pharmacy coalition tailored for mid-market employers.

According to a company announcement, “M3 is excited to welcome Connie Perry, launch our pharmacy solutions specialization, and provide our clients with expanded resources and leverage to strategically manage their pharmacy benefits.”

Vitable Health Names

Vance Sible as Head of TPA Partnerships

Vitable Health, a leading enhanced direct primary care built to reduce claims cost under self-funded groups, is thrilled to announce the appointment of Vance Sible, CSFS, RHU, HIA, as the Head of TPA Partnerships. In his new role, Vance will spearhead collaborations with Third-Party Administrators

(TPAs), Stop-Loss companies, and Broker partners to help expand the reach of Vitable Health nationwide. Vitable’s TPA and Stop-Loss partnerships will deliver active reductions in overall healthcare costs for self-insured employers while providing additional delightful health benefits to their members.

Vance Sible, CSFS, RHU, HIA Head of TPA Partnerships Vitable Health

Vance brings over 38 years of invaluable experience in the health insurance industry, specializing in senior leadership roles in sales and account management. His extensive career includes notable tenures at major carriers such as Cigna, United Healthcare, and Aetna. However, over the past two decades, Vance has dedicated his expertise to bringing innovative solutions to National and Regional TPAs, driven by his focus on delivering unique costcontainment solutions and customization for self-funded employers.

Mike Coghlan to Help Lead HMIG Stop-Loss Underwriting Team

HM Insurance Group has announced the hiring of Mike Coghlan, who serves as Senior Vice President, Underwriting. In this role, he will lead the development of HM Insurance Group’s Stop-Loss underwriting and related pricing strategies.

With more than 20 years of experience in insurance and reinsurance, Mike’s areas of expertise include medical underwriting, risk management, self-funding, and employee benefits and program design. Before joining HM in 2024, Mike served as senior vice president and underwriting leader at QBE

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Re. Prior to that, Mike held leadership roles at reinsurance broker Guy Carpenter (a division of Marsh), Partner Re and Munich Re. Mike is a graduate of LaSalle University.

Advanced Medical Strategies Welcomes Jesse Carabase as Senior Vice President of Customer Success

Advanced Medical Strategies (AMS), a leading healthcare affordability software company providing clinical insights and financial analysis for complex medical claims, proudly announces the appointment of Jesse Carabase as Senior Vice President of Customer Success.

Jesse Carabase brings a wealth of experience to his role, having held various leadership positions within the CVS Health organization. Most recently, he served in senior leadership roles at Meritain Health, where he showcased his expertise in driving medical and pharmacy savings through network strategy and innovative medical cost containment/Pharmacy Benefit Management (PBM) solutions.

Before joining Meritain Health, Jesse successfully completed Aetna’s Experienced Financial Leadership Program, contributing significantly in high-profile roles across the payer landscape. His experience encompasses value-based care, self-funded and fully insured plans, as well as commercial and government health plans.

2024 SELF-INSURANCE INSTITUTE OF AMERICA

BOARD OF DIRECTORS

CHAIRMAN OF THE BOARD*

John Capasso

President & CEO

Captive Planning Associates, LLC

CHAIRMAN ELECT*

Matt Kirk

President

The Benecon Group

TREASURER AND CORPORATE SECRETARY*

Amy Gasbarro

Chief Operating Officer

Vālenz

DIRECTOR

Stacy Borans

Founder/Chief Medical Officer

Advanced Medical Strategies

DIRECTOR

Mark Combs

CEO/President

Self-Insured Reporting

DIRECTOR

Orlo “Spike” Dietrich

Operating Partner

Ansley Capital Group

DIRECTOR

Deborah Hodges

President & CEO

Health Plans, Inc.

DIRECTOR

Mark Lawrence

President

HM Insurance Group

DIRECTOR

Adam Russo CEO

The Phia Group, LLC

DIRECTOR

Beth Turbitt

Managing Director

Aon Re, Inc.

VOLUNTEER COMMITTEE CHAIRS

Captive Insurance Committee

Jeffrey Fitzgerald

Managing Director, SRS Benefit Partners

Strategic Risk Solutions, Inc.

Future Leaders Committee

Erin Duffy

Director of Business Development

Imagine360

Price Transparency Committee

Christine Cooper

CEO

aequum LLC

* Also serves as Director

SIIA NEW MEMBERS

MARCH 2024

GOLD MEMBERS

Duncan Hopegood

Chief Executive Office

Secan & Partners Ltd London, England

REGULAR CORPORATE MEMBERS

Charles Carlson Consultant

Benefit Intelligence Mesa, AZ

SILVER MEMBERS

Clay Wilemon

CEO

4L Data Intelligence

San Ramon, CA

Steven Baek

VP of Marketing

Vitable Health Woodlyn, PA

Sean Ganoe Vice President

Henderson Brothers Pittsburgh, PA

Quinn Kekelis

Sales Support Specialist

Levrx Technology, Inc. Troy, NY

Stanley Clymer

Regional VP, Labor & Health Plan Services

MaxorPlus Plano, TX

Turner Fixen Vice President

MB Schoen & Associates, Inc. Fargo, ND

Julian Bannach

Senior Vice President

Old Republic Accident & Health Chicago, IL

Michael Kalman

CEO

Pilea Systems, Inc. Beachwood, OH

Justyna Wisniewski

Commercial Marketing

Rx Concierge by Lifetime Benefit Solutions

Syracuse, NY

Ime Ekpenyong

CEO SGRX

Grosse Pointe Park, MI

Brian Miller

AVP Business Development

Slate Rx

Las Vegas, NV

Yvonne Daugherty

Global Head of Industries

Ushur

Santa Clara, CA

Streamline, balance, and clarify the healthcare financial experience.

Doesn’t sound possible. But Zelis is delivering. We’ve saved over $27B in network and claim costs while helping healthcare carriers, TPAs, and self-insured employers modernize the healthcare financial experience.

Zelis is your trusted partner to optimize financial performance for your clients.