The Summer of Stop-Loss

While this blog took the summer off, we have been keeping a close eye on the numerous developments related to stop-loss attachment point regulation.  Now that most of these developments have slowed down, at least for now, some exclusive reporting and commentary should be useful as those in the self-insurance industry (including those involved with employee benefit captives) take a collective breath.

 Pushed and prodded by a collection of health care reform advocates, federal regulators invited interested parties to submit written comments regarding the smaller insured group health plans facilitated by stop-loss insurance with �low� attachment points.

 About 150 comment letters have been submitted to date and the talking points are largely predictable. 

For the critics of self-insurance, the usual canards are widely repeated.  This request for information (RFI) process signaled a clear focus on self-insurance unlike anything that has been seen in recent years.  But the path forward remains unclear.

 That�s because the Affordable Care Act does not provide any explicit statutory authority for regulators to promulgate new rules relating to stop-loss insurance arrangements�yet that may not preclude action that could achieve the same objective.

 The HHS, DOL and/or Treasury Department (tri-agencies) could potentially rely on their general rule-making authority under ERISA or the Public Health Services Act, to play with definitions or to engage in other revisionist rule-making mischief.   The most likely scenario is that a new definition of a self-insured group health plan is crafted based on risk retention/risk transfer arrangements � thereby allowing the feds to indirectly regulate stop-loss insurance.

 So how serious is this potential threat?   The answer is complicated.

 In a private meeting with self-insurance industry representatives over the summer, a senior DOL official downplayed the prospects that any action is imminent or even likely, explaining that they felt the RFI was necessary for the agencies to get a better understanding of how the self-insurance marketplace operates in the real world.

 But conspicuously absent from the meeting, despite previously confirming their attendance, were senior HHS officials involved with the stop-loss RFI process.  This was notable because it is believed that HHS has the most aggressive regulatory agenda when it comes to self-insurance.  The Treasury Department was represented at the meeting but that agency has remained guarded about its interest and intent. 

 Any of the three agencies could initiate a rule-making process, but it is less likely if there is not a consensus among the three.

 So with that in mind, industry lobbyists have been making the rounds to congressional oversight committees to encourage that they become engaged on this issue and request that the agencies stand down now that the RFI process has been concluded and there is no �smoking gun� which would justify new regulatory action.

The most substantive meeting took place just a few weeks ago with the senior policy advisors for the Senate Finance Committee.  Given that the committee is chaired by Democratic Senator Max Baucus, who has been supportive of self-insurance in the past, it is best positioned to intervene.

The biggest push back by committee staffers was centered on the fact that the ACA does not require that self-insured employers cover essential health benefits (EHBs).   They argued that because of this �loophole� there is incentive for smaller employers to self-insurer, facilitated by stop-loss insurance with low attachment points, in order to be able to offer skimpy health care coverage as a way to save money.

Industry experts at the meeting, including executives from two leading TPAs, explained why this fear is unfounded for practical reasons.  It was then pointed out that while self-insured employers are not required to cover EHBs, they will be subject to �minimum value� requirements, which essentially accomplish the same public policy objective.

 But a final argument seemed to box in the Senate staffers.  Even if you concede the EHB �loophole� (which this blog does not), the fact is that the law was drafted in a very deliberate way to distinguish self-insured group health plans from health insurance carriers.  In this regard, any proposed changes should come back to Congress in the form of legislation as opposed to letting unelected regulators arbitrate substantive policy issues.

 The discussion was concluded with a formal request that Chairman Baucus consider exercising the committee�s oversight authority and communicate to the Treasury Department accordingly.   We understand that the request is still under consideration, so be sure to check back with this blog for updates.

Of course, the focus on self-insured plans with stop-loss insurance extends beyond Washington, DC. 

Many of our friends at the National Association of Insurance Commissioners (NAIC), have been led by the nose over the past year by health care reform advocates to take action on making it more difficult for smaller employers to self-insurer through tighter stop-loss attachment point regulation.

 At the NAIC summer meeting held a few weeks ago in Atlanta, the ERISA (B) Working Group considered a proposal to endorse �guideline amendments� to the current stop-loss insurance model act related to attachment point requirements. 

 Clearly aware of the blowback that would be directed at the NAIC if it took aggressive action that was seen to be disruptive to the health care marketplace, Working Group Chair Christina Goe of Montana tried to diffuse concerns by explaining the proposal is only advisory in nature and that the NAIC does not intend to formally amend the model act for a variety of procedural reasons.  And for good measure, committee members made it clear that they did not overstep their charge and attempt to redefine stop-loss insurance as health insurance.

 Well, it is certainly nice to hear this self-awareness of the limitations to their �charge,� but multiple federal court rulings have already confirmed that stop-loss insurance cannot be defined as health insurance, so no real favor here.

 And as far as considering a guideline amendment versus an amended model act, it�s a distinction without a meaningful difference.

 Of the 26 states that currently regulate stop-loss attachment points, only a few have adopted the model act without variation.  So it is unlikely that an amended model act would take root across the country any time soon.   No matter, as a simple NAIC recommendation on how states should regulate stop-loss attachment points could accomplish the same objective (restricting the ability of smaller employers to self-insure) much quicker.

That is because individual insurance commissioners who are already inclined to push stop-loss legislation in their states will use the NAIC recommendation as justification for action.  Given the technical nature of this issue, it�s easy to understand how this would be enough to persuade most state legislators to go along without asking too many questions.

 The NAIC working group deferred action on the proposal until its winter meeting, which in hindsight was predictable because insurance commissioners, like all political creatures, normally put off major policy decisions when Election Day looms.  Let the dust settle after November 6 and get ready for more action.

This brings us to California.

 As this blog has previously reported, the state�s insurance commissioner, Dave Jones, is a political creature who is interested in beefing up his credentials within the Democratic Party.  So it should not be surprising that he has come out as a major proponent of health care reform, and more specifically the establishment of California�s health insurance exchange, which is expected to come online in 2014.

 Self-insurance therefore became a target for political reasons every bit as much as for misinformed policy reasons in order for Commissioner Jones and his allies in the Legislature to claim credit for protecting the viability of the state�s health insurance marketplace as the exchange begins to be implemented.   A nice populist message for sure.

 One health care broker in California perhaps summed it up best when he referred to SB 1431 as the �California Health Insurance Exchange Protection Act of 2012.�

 Now that it has been confirmed that SB 1431 has been shelved, at least until a special session this December, we can look at the past as prologue.

The same stale arguments are certain to be dredged back up when some version of SB 1431 is brought back for consideration after the November elections, and the political posturing will be predictably crass.

 Equally unfortunate is that many stakeholders who will oppose SB 1431 �2.0� will likely concede the central principle once again of whether stop-loss attachment points should be regulated at all and immediately begin negotiating the numbers and formula.   Yes, political realities often dictate short term lobbying strategies based on compromise, but the longer view should not be ignored in this case.

It�s been a long hot summer for stop-loss insurance indeed, which has ended without much certainty for the future of the self-insurance marketplace.    We will see whether the coming autumn chill cools off the debate or if partisan health care reform advocates continue to overplay their hand.

EuroTrippin'2012: London (Week 1)

Day 1: 14th May 2012

Twinkle came over to spend the day with me before my flight at night which was super sweet of her cuz she still had another exam to study for. I did most of my packing the night before so I had to make some final packing. I brought about 2 sets of clothes, a dress and a romper (for 45 days) LOLOL. Wanted to bring jeans but decided I'd buy over there. When I had finally packed everything my luggage was completely full. That's great. I panicked but Dad just said it's cuz I didn't pack properly and since he's a seasoned traveler I decided to trust him.


Later on I found out that I had been scammed by him cuz his trips are always 4 days long and for the rest of my 45 days, every day I was just questioning my luggage choice while Ida sat near by laughing and shouting "Bring a smaller bag la why! Smaller la!!!" or making sarcastic remarks at how my bag is "seriously too big". -_-


We picked up my bro and my dad before going to the airport and my brother laughed like shit when he found out Twinkle was coming to 'send me off' and I didn't really know how to tell him I had like 6 other friends coming HAHAHA.

We ate KFC for dinner and I was feeling damn nervous because it's my first trip ALONE and I didn't know the boarding procedure or anything at all cuz usually my dad does everything. And I was damn worried I'd go to the wrong gate or miss my flight or die somewhere in Europe and my friends were all telling me not to die which was seriously making me damn scared because I also thought I was going to die. True story.

Went to the departure hall and said bye to all my sweet friends who came. (Thanks Nadia, Charlotte, Charis, Twinkle, Par, Ashes, Jane, Sharan) The last time I went to the departure hall was when i said bye to Ida in Sept and could naht stop crying. Anyway I was seriously SO close to having panic attacks at the thought of being without my family for 45 days in a foreign place. My mom still can tell me "It's not too late to turn back now" HAHAHAHAAH DAMN. TOO. MUCH. And she was completely serious.


Anyway hugged everyone goodbye and went straight to my gate C24 cuz it was opened. Was BBMing korkor that I'm damn scared and he told me C in C24 stands for China. That's great also. I took Thai Airways so I flew from SG to BKK and then from BKK to London. My dad booked biznez class for me and I didn't know how freaaaaaking shiok it was until I got on the plane and they served me CHAMPAGNE and my seat was super huge.

I have a light right next to me and they give you comforters as blankets and the seat can recline all the way to become a bed and there's a 'massage' function. I'm not sure if you understand how totally friggin awesome I think this is but let's just say that if typing in CAPS wan't so annoying this whole paragraph would be in caps. Also, the seat next to me was empty on both flights so I had two pillows and 2 fluffy comforters. So I made a fortress.

From SG to BKK, they served dinner and i watched 40 year old virgin. I had foie gras and kahlua and then I was too full to eat anything else (That's just the appetizer). They also kept giving us hot towels and the service was seriously damn good like my own personal butler. The flight was too short so I couldn't finish my show hahaha.

Then from BKK to LONDON, I had my 3rd dinner (tuna ravioli) then seriously wanted to vomit. I think I was also started to get too high from the alcohol so I watched 3 half an hr episodes of some lame show (Suburgatory) and took a nap. (My plan was to watch as many movies as possible) WELL GUESS WHAT. I woke up when they served breakfast and after breakfast the pilot said we're reaching in half an hour. Srsly I was like wad........da................ and the flight was 12 hours by the way. So i basically slept about 9 hrs straight and didn't watch a single mowie.

In total it felt like I was on the plane for 20 minutes, I really wished it could have been longer. Sobs.

Mandatory flying in the sky photo.

Day 2:

Reached London and went by the 'Fast Track' Lane. Turns out Fast Track was slower than Normal Track and I waited from 6:40am till 8am (London Time). I had to wait till 12pm to meet Ida cuz that's when she finished her exam (her exams were postponed to a week later than we had previously planned). I sat at the airport for a couple of hours reading my Europe book that Mr Imran got for me. I went outside the airport to look around and that was when I knew SHIT WAS ABOUT TO GET REAL because it was so cold that my breath became visible. Now, I had never been to London and I was told it's summer in London so i packed two VERY thin jackets, no, not even jackets. Like cardigans. And sleeveless shirts and short dresses and I DIDNT EVEN HAVE JEANS.

Anyway I followed the directions Ida mailed me and found my way to Whitechapel pretty easily. Waited for Ida at the station and she came AND I CRIED. I joked about crying but didn't think I would really cry cuz that's just lame. Anyway the area Ida lives in is kind of low-income with a lot of Pakistanis and African-Americans. Ironically there were very few angmohs. I saw about 1 for every 10 Pakistanis. Was weird being in Ida's room cuz I had been seeing it over skype the past 6 months and now I was actually in it. haahaha.

You can see my jacket on the floor next to ida's feet. And the floor was also my bed for the next two weeks.

We went to Sainsburys which is like SG's NTUC except a billion times bigger and cheaper. We went wild and bought a shitload of food. Ate leftover pizza for lunch and Ida cooked noodles w pork for dinner. I wanted to stay up til Ida slept cuz she was studying but I think I had jetlag so I wanted to pass out from 3pm onwards but really basically fainted at about 11pm.

Day 3:

Had breakfast with Ida then I went with her to the school building where she was having her exam. I walked around the area alone while she had her exam.

Part of Ida's School & the first picture I took with my camera

Cute vine covered houses

Tesco! Kinda like petrol kiosk shops in SG.

Walked and found a place called Watney Market

 Watney Market (Reminded me of Khaosan in Bangkok, minus the bars)

 RAINBOWWW

 Gigantic Cokes at Iceland

Lololol. Everything is gigantic.

 Cute houses

 Postman delivering mail. I think this is my favourite photo of the trip.

Cool Toilets

Met Ida back at Floyer House

Took a bus to St Paul's

Went to the mall next to St Paul's to shop!!! Didn't buy anything tho cuz it was quite expensive.

Pretty building on the way home.

Slept at 11:30pm cuz I was dead tired from jetlag.

Day 4:

Woke up at 6+ am again with a massive headache. Talked to Ida before she went for her exam then I slept till 11am when we went to Tesco to buy coconut milk to make Greeeeeeeen Curryyyyyyy!!!!



Best green curry ever.

We talked about school after lunch and Ida took a nap.

Chinese Food @ Canary Wharf

In the evening we took the overground tube to Canary Wharf and shopped a bit. Then we RAN from the shopping centre all the way to the river side (like 10minute walk) cuz we were late for our dinner appointment. It was damn funny because we kept laughing while running. We were seriously super tired after.

 Ate Char Siew, Wanton soup, Jellyfish, Dumplings & Hor fun.

 Riverside



The Gherkin

Cabbed home at 9:45pm and slept at 12:45pm. Felt less tired, think my jetlag got bettur.

Day 5:

Shopping @ Westfield Mall at Stratford

Woke up at 11am when Ida got back from her last exam YEY!!!! And we went shopping DOUBLE YEYYY!!!!!!



Took the tube to Stratford station.

Westfield Shopping Mall!!! (It's huge and has F21, Topshop, River Island and PRIMARKKK)

Ida (on the left in the brown coat) walking to Westfield

They have a gigantic F21. I think it's two storeys but probably same size as SG's F21 in 313. Lurve the neon pink bag.

Our feet were dying after F21 so we went for a lunch break at Marks & Spencer's

Fresh Pasta!

We went to Primark next, which is officially my favourite store in London. It's huge and their clothes damn hip & trendy (I did naht just say that) and SUPER CHEAP. Like I think generally 5-10 pounds. and the quality isn't compromised (that much).  Really Craysee. But ofc queues for the changing room are damn long and it's v crowded because shit is really damn cheap. Another downside is that the fitting is damn weird sometimes so you HAVE to try the clothes. They sell everything from clothes to shoes to luggages. My second fave shop is Boots and Superdrugs which is London's drugstores like our Watsons and Guardian. They sell a shitload of mekkup and they always have awesome promos so it's v cheap :)

Another break. This time for teaaa~~~ Ida posing w my Primark bag. As you can see I tore the bag within seconds of holding it. Le sigh.



 The soap HAD GLITTER. Sooooo preeeeeetteeeeeeeee.

Checked out a few more shops then went home cuz we were damn tired.

 7 hrs of shopping later...

Bought Moscato at M&S on the way home in preparation of our first night in da club^^

I didn't like the moscato since I was still paying for my night at Filter in SG when I got so smashed I came home w/o my shoes and didn't even know and my parents came into my room at 3am to watch me vomit (Gr8 memories). So i mixed 5ml of sherry with 500ml of OJ. We decided to just have a chill night so we went to Mother Bar at Shoreditch High Street which had free entry. It was more like a house party than a club (probably because of the wooden floors). We had a great time dancing to hip-hop/old school music w the occasional dubstep. Went opposite to the cab office. It's a special cab system that calls the cab for u. It's basically just normal cars with Indian drivers and they don't go by meter so you agree on a price beforehand. Came home at 3:30am.





Day 6:

We basically spent the whole day eating and sleeping. Went grocery shopping at Sainsburys again and Korkor told me about the game between Chelsea and Bayern in the UEFA Champion's League. So we figured it'd be a good experience to watch it with the locals. Headed to The Good Samaritan Pub which is about 5 minutes away from Floyer.

 Generally not a fan of watching sports. But if it's big games/interesting I dont mind.

Unfortunately, it was boring as hell so we went to Tesco to get alcohol. Went into some other club/bar we found while on the way to Mother Bar. The club was very cosy and old school. The DJ spun on a wooden table. They played Outkast/Craig David remixes and alot of "Black but not Ghetto" music. Went to the cab office and Raheel from the office got us a cab again. Cabs are pretty expensive. Like, these cabs that we take after clubbing (not London cabs) are already 10 pounds for like a ten minute drive.

 

Day 7:

Sunday Roast @ Good Samaritan Pub

It's Sunday!!!~ We headed to the pub again for Sunday Roast!!! It's a traditional British meal served on Sundays for Brunch or Lunch.

 

 

The packaging is so cute.

 



 It wasn't fantastic but I guess it's the same as going to any random hawker centre 5 minutes from your house and eating chicken rice.

Ida says I look like a dog.

 

 

 

Mass @ St Paul's Cathedral

Took a bus to St Paul's Cathedral for mass.

 Had to run home to get jackets before coming here cuz it was way too cold. Ida lent me her Marshmellow

 

 

 I don't think they allow photos inside but we took some quick shots with Da's iphone lolol. The photos DON'T do the Cathedral justice at all.

 

 It's gigantic inside and the ceiling is mega high. So beautiful.

Walked to PAUL afterwards which is a yummy high end bakery. They have a shop in SG also in Takashimaya. I know their stuff is a little overpriced. Like a strawberry tart is SGD $8.

Apple Turnover

London Bus

 

Went to the mall to shop abit again. Then Ida wanted to bring me to do some 'touristy stuff' and wanted to show me the London Tower. We took a bus there. Ida pointed at it while we were on the bus. Then we tried to walk to it but got lost. Used Google Maps but Ida doesn't know how to use it. I confidently told her to STEP ASIDE and let the master (me) lead us there. We walked for about 15 minutes and I told her we were getting closer. Turns out I was following the pin that points to where we currently were. So we gave up and went home.

 

Indian Food @ Tayyabs 

Then we went home to rest for awhile because we had a dinner appointment at Tayyabs.

Story of Dinner at Tayyabs:

 One day earlier, Raheel from the cab office told us that he works at Tayyabs. Since he was very nice and helpful with getting our cabs we told him we'd drop by to say hi to him and have dinner because Tayyabs is apparently a famous Michelin star restaurant in the neighbourhood of Whitechapel so it's also 3 minutes from Floyer. 30 minutes before dinner, Raheel asked if he should SEND A CAR to pick us. It's a 3 min walk so we said no. We made it to the restaurant and turns out, Raheel's family OWNS THE RESTAURANT. Which is great for him. BUT THEN, he wasn't working (we thought he was the waiter) so he sat beside us and talked about the food. We thought he was gonna go away so we excitedly decided what to order. Then he said "Oh, my cousin is coming to join us for dinner" WTF is "JOIN US"??? WHO INVITED YOU? At first Ida thought he was joking. Then she realised he was not. Then her face immediately became a dark ass thunder cloud. So that's the story of how we got scammed into dinner with two men.

 

Raheel's cousin Billard, thankfully, was pretty funny and I also think he is gay but Ida doesn't think so. He makes inappropriate jokes and points out the awkwardness which I found hilarious and so enjoyed his company. But the whole time i just really wanted to pluck his unibrow.

 

 The food was mega fantastic. We sat in the VIP room. Then Raheel took me on a tour of the restaurant LOLOLOL and made me meet his brother while Ida and Billard continued eating.

 

 Then he wanted to go out so I reluctantly agreed and we stood outside and I took pictures and he told me all about Tayyabs history. It's 3 shops and 3 storeys. Has been around for 35 years, has a seating capacity of 600 and has 65 staff.

Went to show me his brother's Matte BMW w the 'Tayyabs' plate. -_-

 

Needless to say, dinner was preeeeedy dayum awkward since we were surprise attacked.

Ida and I finally made a run for it when she said she'd finish her ice cream later and Billard was like... It'll melt. Then she was like... Yea..... Then Billard was like. Ok guess you need to go home now. HAHAHAHAHAHA. and he was making it soooooo awkward and so funny.

 

In the end they were gentlemen and paid for the bill and walked us home. They kept telling us they wanted to bring us shopping/club/dinner but we were like B.I.T.C.H. PLS.

 

Watched Sweeney Todd with Da at home. It's a story filmed in London of some guy's wife who was kidnapped and he had to go into hiding. Then he met a new woman and killed people with her and she made pies with their bodies. Nasty.

 

Great first week!

 BTW, this was the most boring week of the trip so it only gets better! :)