cmonfils | February 26, 2012
MyHealthGuide Source: Thomas A. Croft, Esq., CROFT LAW LLC, 2/24/2012, Editor, www.StopLossLaw.com
Case: Evangelical Presbyterian Church v. American Fidelity Assurance Company, et al., No. 299625, in the Michigan Court of Appeals, January 12, 2012.Court’s Opinion (more…)
cmonfils | January 18, 2012
Employer’s Guide to Self-Insuring Health Benefits January 2012 | Vol. 19, No. 4
A claims administrator lost an attempt to dismiss negligence and breach of contract charges relating to its failure to process and pay a large claim before the final day of a stop-loss policy’s run-out period.
The self-insured Hebrew Home health plan sued administrator CoreSource and stop-loss insurer Sun Life for negligence and breach of contract under state law, alleging that the administrator dragged its feet paying the claim and ended up missing a March 31 deadline that would have enabled the plan to collect $180,000 in stop-loss reimbursement. (more…)
cmonfils | January 8, 2012
MyHealthGuide Source: Fred Hunt, Active Past President, SPBA, 12/2012, www.SPBATPA.org
The state of TPAs and the forecast for the future is the brightest it has been for many years (not to say that it is not an extremely tight marketplace).
Background and Mood
TThis article is useful for perspective in shaping corporate strategy, but also serves as a candid analysis for outsiders such as investors, researchers and others who want to understand the TPA world today and into the future. As a result of hearing often from SPBA members, we have an unmatched repository of real-world hands-on totally-candid insight. (more…)
cmonfils | January 3, 2012
Employer’s Guide to Self-Insuring Health Benefits December 2011 | Vol. 19, No.3
The attempted treatment of stop-loss coverage as “health insurance” subject to state insurance law has been a thorn in the sides of self-funded plans seeking to maintain ERISA preemption of state insurance laws.
In Goyen v. Vail Corp., 2011 WL 4479091 (D. Colo., Sept. 26, 2011), a federal district court rejected a plaintiff’s argument that a plan stopped being self-funded and lost ERISA preemption, all because it had taken out a stop-loss policy. (more…)
cmonfils | December 16, 2011
The Self-Insurer November 2011 Issue & Volume 37
From the Bench By Thomas Croft, Esq.
(Goyen v. Vail Corp., No. 10-cv-02392, in the United States District Court for the District of Colorado, September 26, 2011).
If it weren’t for the recent brouhaha spawned by the NAIC’s criticisms of stop loss insurance, this case would be somewhat akin to an announcement that no tsunami occurred today—greatly reassuring, but somehow not so newsworthy.
The plaintiff plan participant sued her employer and its TPA in state court for benefits denied under the Plan, relying on state law causes of action. The defendants removed the case to federal court and then moved to dismiss on the grounds of ERISA pre-emption. The Court converted the motion to a motion for summary judgment. Plaintiff argued that the Plan’s purchase of what the court termed “stop-gap insurance” rendered it no longer self-funded, such that ERISA’s “deemer clause” did not operate to insulate the Plan from state law based claims under the Supreme Court’s ruling in FMC Corp. v. Holiday, 498 U.S. 52 (1990). (more…)
cmonfils | December 16, 2011
Two new requirements imposed by the health care reform act (ACA) make the issue of self-funding and the need for stop loss insurance more compelling for plan sponsors.
First, ACA adds new federal taxes on health insurer providers beginning in 2014. These new taxes will add to state insurance premium taxes and make the savings from self-funding more compelling for many fully insured medical plans. Second, the ACA requirement to remove annual and lifetime limits beginning in 2014 will increase interest in stop loss coverage for self-funded groups without stop loss coverage in force. Medical stop loss insurance is a layer of coverage designed to protect self-funded plan sponsors from the risk of unpredictable, high-cost claim activity.
cmonfils | December 5, 2011
MyHealthGuide Source: Thomas Croft, Esq., King & Croft LLP, 12/2/2011, www.StopLossLaw.com
Case: Hebrew Home of Greater Washington, Inc. v. CoreSource, Inc. and Sun Life Assurance Co. of Canada; No.11-cv-00710, in the United States District Court for the District of Maryland, 11/3/2011. Court’s Opinion
Mr. Croft’s Comment: A Maryland federal court has determined that a self-insured group’s claims against its TPA are only partially pre-empted by ERISA and that a payment outside a stop loss policy’s run-out period is ineffective to trigger coverage, despite a claim that the payment “substantially complied” with the policy’s terms. (more…)
cmonfils | November 29, 2011
MyHealthGuide Source: Joanne Wojcik, 11/20/2011, Business Insurance Article
As more and more middle-market employers turn to self-funding their benefits as part of their cost-containment strategy, some stop-loss insurers are lending a helping hand with incentives to adopt medical management programs. (more…)
cmonfils | November 29, 2011
MyHealthGuide Source: Allison Bell, 11/21/2011, LifeHealthPro Article
Karin James, an assistant vice president in the U.S. stop-loss operations at Sun Life Financial Inc., Toronto (NYSE:TSX), says, “Stop-loss is a very tough market. Very competitive.” during a recent interview.
The Patient Protection and Affordable Care Act of 2010 (PPACA) has increased interest in stop-loss for employers to give self-funding and stop-loss a new look by exempting self-funded plans from many of the new PPACA mandates. (more…)
cmonfils | November 20, 2011
Employer’s Guide to Self-Insuring Health Benefits
Thompson Publishing November 2011 Vol. 19, No. 2
The federal agencies in charge of implementing health reform and the National Association of Insurance Commissioners (NAIC) keep saying stop-loss policies with low attachment points mean an employer-sponsored health plan is really not self-funded. Contributing Editor Adam V. Russo and Attorney Ron Peck say that NAIC experts are trying to reduce the number of employers that choose self-funding because they: (1) want to force more healthy employees into state-run insurance exchanges; and (2) feel that if they can’t regulate ERISA plans, ipso facto, consumers are put in danger. In doing this they are ignoring a tidal wave of legal precedent holding that self-funded health plans remain that way regardless of the kind of stop-loss insurance the sponsor chooses. Eliminating the option to purchase stop-loss for smaller groups would raise health insurance costs for everybody, Russo and Peck say. (more…)
cmonfils | November 16, 2011
Employer’s Guide to Self-Insuring Health Benefits October 2011 | Vol. 19, No. 1
A self-funded group health plan extended COBRA benefits to a retiree for 10 years after he stopped working, but never told its stoploss (S-L) insurer about the special terms between the retiree and plan, beyond merely listing his name as an eligible participant. After the S-L insurer refused to pay claims for the retiree, a federal district court rejected the company’s narrow definition of “qualifying event” (as meaning only involuntary separation) and held that the patient was not eligible under the S-L policy. The outcome might have been better if the plan had approved its policy of prolonging COBRA benefits for certain retirees with the S-L insurer, integrated it in the plan and referenced it in the S-L policy. (more…)
cmonfils | October 27, 2011
In a strongly-worded letter addressed today to New Jersey Insurance Commissioner Thomas Considine, the Self-Insurance Institute of America, Inc. (SIIA) requested that Insurance Department Bulletin No. 11-20 (Selected Marketing of Stop-Loss Insurance) be rescinded immediately.
cmonfils | October 21, 2011
Representatives of the Self-Insurance Institute of America, Inc. (SIIA) today met with senior officials of the U.S. Department Health & Human Services (HHS) to discuss proposed regulations implementing a transitional reinsurance program as required by the Affordable Care Act (ACA). (more…)
cmonfils | October 17, 2011
www.myhealthguide.com
MyHealthGuide Source: Hobson D. Carroll, FSA, MAAA, President, Entrust Risk Management Services, Inc., 10/16/2011
Preface by Mr. Hobson: This article was submitted in response to a Call for Papers 2011 contest made by the Society of Actuaries’ Reinsurance Section. This paper was chosen for one of only two awards given for entries in the competition. (more…)
cmonfils | October 13, 2011
The Self-Insurance Institute of America, Inc. (SIIA) releases white paper: Self-Insured Group Health Plans, Stop-Loss Insurance & Adverse Selection.
This white paper was published to respond to state and federal policy-makers on how the self-insurance marketplace really operates. Over the past year, federal regulators from the IRS, HHS and DOL have expressed concerns that smaller employers rely on stop-loss insurance with “low” attachment points to self-insure in order to escape various state and federal regulatory requirements. The criticism continues that these represent “sham” self-insured plans and that a growing number of such plans will contribute to adverse selection in the group health insurance marketplace. (more…)
