100 Summit Lake Drive, Valhalla, NY 10595 tel 914.745.4000 www.towersperrin.com 

May 28, 2009 

CC:PA:LPD:PR (REG-120692-09) 

Room 5205 

Internal Revenue Service 

P.O. Box 7604 

Ben Franklin Station 

Washington, D.C. 20044 

Office of Health Plan Standards and Compliance Assistance, 

Employee Benefits Security Administration 

Room N-5653 

Department of Labor 

200 Constitution Avenue, NW 

Washington, D.C. 20210 

Attention: MHPAEA Comments 

Centers for Medicare & Medicaid Services 

Department of Health and Human Services 

Attention: CMS-4137-NC 

P.O. Box 8017 

Baltimore, MD 21244-8010 

RE: Request for Information on the Paul Wellstone and Pete Domenici Mental Health 

Parity and Addiction Equity Act of 2008 (MHPAEA) 

Dear Sirs and Mesdames: 

We are writing on behalf of our firm, Towers Perrin, to submit comments in response to 

your request at Volume 74, Federal Register, 19155, dated April 28, 2009, regarding future 

rulemaking under the MHPAEA. Our comments are set forth below. 

Towers Perrin is a global professional services firm that helps organizations improve 

performance through effective people, risk and financial management. The firm provides 

innovative solutions in the areas of human capital strategy, program design and 

management, and in the areas of risk and capital management, insurance and reinsurance 

intermediary services, and actuarial consulting. Towers Perrin has offices and alliance 

partners in the world's major markets. 

The Human Capital business of Towers Perrin provides global human resource 
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consulting and related services that help organizations effectively manage their 

investment in people. We offer clients actuarial and related consulting services in areas 

such as employment benefits, compensation, communication, change management, 

employee research and the delivery of HR services. 

We appreciate this opportunity to comment. 

INTRODUCTION 

Our comments are informed by our experience with large employers that sponsor group 

health plans providing mental health (MH) and substance use disorder (SUD) benefits. In 

most instances, these MH/SUD benefits are administered by third party vendors which are 

either different companies than those administering the medical/surgical benefits under the 

plan, or the medical/surgical and MH/SUD benefits are administered by different divisions 

within the same company, using different claims systems. 

Towers Perrin’s comments on the MHPAEA pertain, in particular, to situations where 

MH/SUD benefits have been “carved out” of the group health plan and are administered by 

a separate entity. These entities are known as Managed Behavioral Healthcare 

Organizations or MBHOs. The six largest MBHOs administer MH/SUD benefits for 

approximately 45 million participants in self-funded group health plans. 1

BACKGROUND 

A few background comments on the state of carved out MH/SUD benefits are necessary 

before we address the questions in the Request for Information regarding the differences 

between medical/surgical and MH/SUD benefits, and the clarifications that we suggest be 

included in upcoming regulations. 

• In 2008, 6.2% of the enrolled population received MH/SUD treatment. This figure is 

based on cost and utilization data we gathered in 2009 for the 2008 plan year from the 

six largest MBHOs on the self-funded group health plans they administer. This figure 

has grown steadily in recent years from 4.3% in 2002. 2

 

1

 Enrollment data requested by Towers Perrin for the 2009 plan year. 

2

 Towers Perrin requests book-of-business, self-funded MH/SUD cost and utilization data from the 

largest MBHOs each year and creates MBHO norms from this data. Unless otherwise noted, the cost 

and utilization statistics presented below are derived from this annual data. 
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• Approximately three out of four people complete their MH/SUD treatment in 10 

outpatient visits or less. About .4% of the population is admitted to a psychiatric 

hospital. 3

• MH/SUD plans cover MH/SUD diagnoses treated by MH/SUD clinicians. Physicians −

other than psychiatrists − also treat MH/SUD conditions. For example, most children 

with Attention Deficit Disorder – a psychiatric diagnosis – are treated exclusively by 

pediatricians. Depression, the most common psychiatric diagnosis, is more likely to be 

treated by a physician (other than a psychiatrist) than an MH/SUD clinician. According 

to a recent study, 85% of new prescriptions for SSRI (selective serotonin reuptake 

inhibitors) antidepressants were written by physicians other than psychiatrists. 4

MH/SUD costs in carved out plans, as expressed in claims expense per employee per 

year, have decreased sharply over the last 20 years. In 1988, MH/SUD claims accounted 

for 10.9% of medical plan costs. By 2008, this figure had dropped to 1.5%. 5

Some of the methods now used to control MH/SUD costs will not be available after the 

MHPAEA becomes effective (generally, for plan years beginning after October 3, 2009); 

the continued acceptability of certain other cost management mechanisms are uncertain, 

pending regulatory guidance. These methods are discussed below. 

• With respect to both medical/surgical and MH/SUD benefits, group health plans often 

encourage participants to use network providers through incentives such as lower outof-pocket costs and, in most cases, the absence of treatment limitations. MH/SUD 

network arrangements differ from medical/surgical in several ways: 

- The primary care versus specialty care distinction commonly present for 

medical/surgical treatments does not typically apply to MH/SUD. Most MH/SUD 

outpatient visits (67%) are with clinicians other than psychiatrists, who are medical 

doctors (MDs). 6

 Some patients are in treatment with both a non-MD clinician for 

“talk therapy” and a psychiatrist, who prescribes and monitors medications. 

 

3

 In 2002, Towers Perrin obtained outpatient visit data from three leading MBHOs. The data showed 

that 73% received 10 visits or less. Since 2001, several MBHOs have stated that the percentage 

completing treatment in 10 or fewer visits has remained stable. 

4 http://psychservices.psychiatryonline.org/cgi/reprint/55/5/494.pdf

5

 The denominator for MH/SUD claims was obtained through Towers Perrin’s annual MH/SUD cost and 

utilization data referenced above. Medical plan costs were obtained from nationally available employer 

surveys. Towers Perrin calculated the percentage of medical plan costs attributable to MH/SUD. 

6

 Towers Perrin periodically asks the MBHOs to report the distribution of outpatient visits by provider 

type in connection with a market study. In 2003, four of the largest MBHOs reported – on average – that 

33% of outpatient visits were with psychiatrists. 
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- A large oversupply of non-MD MH/SUD clinicians has existed for at least two 

decades. Because of the competition for patients, the MBHOs have used the same 

fee schedules for the past 15 years. The majority of non-MD MH/SUD clinicians 

have not seen an increase in network fees since the early 1990s. In contrast, 

psychiatrists are in short supply, due, in part, to the growing percentage of the 

treatment population taking psychotropic medications, which can be prescribed only 

by MDs. Medical students specializing in psychiatry have also declined. 

- Billed charges from clinicians unaffiliated with networks have risen over time, as 

expected. Even though network providers are typically reimbursed at approximately 

80% of billed charges versus 50% for out-of-network providers, the latter group’s 

reimbursement per visit now averages 28% higher. 

The bullet points immediately above pertain to professional services rendered by 

clinicians other than psychiatrists. Another distinction between MH/SUD and 

medical/surgical provider networks is the use of alternatives to acute inpatient care in 

the MH/SUD environment. Alternative care (sometimes called intermediate care) 

facilities and programs are less intensive than inpatient treatment but more intensive 

than outpatient office visits. The most common examples are listed below. 

Alternative Level of Care Description 

Residential Treatment Centers (RTCs) Facility offering 24/7 care, most often used 

for the treatment of troubled youth, eating 

disorders and SUD 

Partial Hospitalization Therapeutic sessions rendered five days per 

week in an inpatient facility. Patient returns 

home at night. 

Structured Outpatient Programs Similar to partial hospitalization only primarily 

for those with SUD diagnoses. 

About .3% of plan participants receive treatment in alternative care settings each year, 

half of whom are being treated for SUD disorders. About 20% of claim expenses are 

incurred in these facilities and programs, most of which (85%) is delivered in network 

facilities and programs.
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CURRENT MEDICAL/SURGICAL AND MH/SUD BENEFIT DESIGNS 

Among the questions identified in the Request for Information are the following. 

• What policies, procedures, or practices of group health plans and health insurance 

issuers may be affected by MHPAEA? 

• Do plans currently impose financial requirements or treatment limitations on benefits 

other than those specifically identified in the MHPAEA? 

• How do plans currently apply financial requirements or treatment limitations to (i) 

medical and surgical benefits and (ii) mental health and substance use disorder 

benefits? 

• Are these requirements or limitations applied differently to both classes of benefits? 

The practices of group health plans with respect to medical/surgical and MH/SUD benefits 

that will be affected by the MHPAEA fall into two categories. The first category includes 

practices where there is widespread agreement among behavioral healthcare industry 

experts regarding the changes required by the MHPAEA. The second category includes 

practices that may be affected by the MHPAEA, depending on the regulatory guidance 

issued. 

MH/SUD BENEFIT CHANGES REQUIRED BY THE MHPAEA 

The MHPAEA will result in three major changes to MH/SUD benefit administration in 

carved out MH/SUD plans: 

• Commonly used annual limitations will, for the most part, need to be eliminated. 

• Coinsurance levels paid by plan participants will generally need to be decreased for 

MH/SUD benefits with respect to out-of-network coverage, as MH/SUD out-of-network 

benefits are almost always lower than provided for medical/surgical. 

• Where applicable, single MH/SUD benefit designs will be replaced with multiple 

MH/SUD benefit designs to bring those benefits into parity with medical/surgical 

benefits provided under each group health plan. 

Elimination of out-of-network annual limitations: Virtually all group health plans with 

carved out MH/SUD benefits limit out-of-network (OON) treatment, both inpatient and 

outpatient. The plan provision we see most often limits OON inpatient days to 20 per year, 

which also applies to treatment rendered in alternative care settings. A similar cap (e.g., 20 
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visits) is applied to OON office visits. In contrast, these plans typically do not impose any 

visit limits on OON medical/surgical treatments. 

Although precertification and medical necessity reviews are routinely performed with OON 

inpatient facilities, this practice is much less likely to be applied to outpatient visits. 

Essentially, OON MH/SUD visits are “managed” by the annual visit limit. 

The elimination of the annual visit limits for MH/SUD benefits to bring the plans into 

compliance with the MHPAEA will require new approaches to the application of medical 

necessity on OON outpatient treatment. Because of the fee schedule history with MH/SUD 

providers described in the background section, a good deal of animosity between MH/SUD 

clinicians and the MBHOs has arisen. Over time, treatment limitations came into 

widespread use as a solution to OON providers’ refusal to cooperate with medical 

necessity reviews, and the complaints and appeals filed by participants when claims were 

denied. 

The development of new procedures for managing OON outpatient treatment is influenced 

by the absence of objective clinical data such as laboratory or radiology results to 

document medical necessity. Because of the nature of psychiatric conditions, the 

establishment of medical necessity is a more labor-intensive endeavor on the part of both 

the plan administrator and the health care provider. The MBHOs will need to develop new 

methods for engaging in medical necessity reviews for OON outpatient treatment and 

additional clinical management resources may also be required.

Alignment of MH/SUD out-of-network coinsurance with that for medical: As noted 

above, out-of-network coinsurance that must be paid by plan participants for MH/SUD 

services is usually higher than that imposed for medical/surgical. A fairly common 

difference is 70% benefit reimbursement levels for OON medical/surgical and 50% for 

MH/SUD. Based on the 70%/50% benefit level difference commonly found today, bringing 

the plan into compliance with the MHPAEA will result in the cost of an average OON visit 

increasing by 40% or, based on 2008 MBHO norms, $25/visit. 

If the current plan payment for the average network visit is compared to the projected 

payment for an average OON visit in 2010 (after the MHPAEA takes effect and assuming 

that the MH/SUD coinsurance for plan participants decreases from 50% to 30%), OON 

providers will receive a plan payment of about $40 more for an OON visit than for a 

network visit. In addition, OON providers will no longer be confronted with the problem of 

collecting the full amount of billed charges from the member after the maximum visits per 

year which are covered by the plan have been exhausted. 

The sharp increase in benefit reimbursements for OON visits, combined with the removal 

of treatment limitations (i.e., visit limitations), may impact the size and/or availability of 

network MH/SUD providers. Network providers may terminate their contracts with the 
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MBHOs in the hope that they can increase their private pay practices enough to 

compensate for the loss of network referrals. 

Single to multiple MH/SUD benefit plans: Most plan sponsors with carve out MH/SUD 

benefits adopt one MH/SUD schedule of benefits for several group health plans. And these 

group health plans often have varying financial requirements and treatment limitations for 

medical/surgical benefits. Under the MHPAEA, a single MH/SUD benefit schedule will 

generally need to be replaced with separate MH/SUD benefit schedules, each aligned with 

the medical/surgical financial requirements and treatment limitations under each group 

health plan. 

MH/SUD BENEFIT CHANGES THAT MAY OR MAY NOT BE REQUIRED BY THE 

MHPAEA, DEPENDING UPON REGULATORY GUIDANCE 

Common versus separate-but-no-greater-than out-of-pocket maximums: Behavioral 

health experts differ in their interpretations of the permissibility of separate out-of-pocket 

maximums for medical/surgical and MH/SUD under the MHPAEA. The uncertainty stems 

from the following provision in the MHPAEA: “. . . and there are no separate cost sharing 

requirements that are applicable only with respect to mental health or substance use 

disorder benefits” [ERISA § 712(a)(3)(A)(i); IRC § 9812(a)(3)(A)(i)] A “common” out-ofpocket maximum is one that applies to both medical/surgical and MH/SUD claims. A 

“separate-but-no-greater-than” out-of-pocket maximum applies one out-of-pocket 

maximum to medical/surgical covered expenses and a separate, but not larger, out-ofpocket maximum to MH/SUD covered expenses. One of the clarifications requested below 

pertains to the MHPAEA requirements regarding annual out-of-pocket maximums. 

In group health plans, there are often two separate out-of-pocket maximums, applicable to 

medical/surgical benefits: one for covered expenses for network services and the other for 

out-of-network covered expenses. In contrast, carved out MH/SUD benefits rarely include 

out-of-pocket maximums, for either network or out-of-network treatment. However, network 

MH/SUD coverage is usually designed in other ways to minimize out-of-pocket costs. For 

example, for network MH/SUD services, out-of-pocket expenses are minimized by capping 

expenses for higher levels of care (e.g., $250/year) and often use a $15 copay for office 

visits. 

If “separate-but-no-greater-than” out-of-pocket maximums are not permitted under the 

MHPAEA, then medical/surgical and MH/SUD plan administrators will need to create a 

mechanism for exchanging claim data in order to adjudicate a shared out-of-pocket 

maximum. Claims administration experts have reservations about the ability of two entities, 

which often are marketplace competitors, to ensure that the interface will function properly, 

especially absent a clear point of accountability. 
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Another factor that bears consideration is that participants are reluctant to enlist their 

employer in helping to resolve claims problems in connection with MH/SUD claims, due to 

the stigma that continues to surround these conditions. 

Finally, according to an MBHO with extensive experience with cross-platform claim 

adjudication, the creation and testing of such an arrangement requires at least 90 days to 

establish the data exchange procedures, complete the required programming and verify 

that the interface functions as intended. If the group health plans involved have limited 

experience with such arrangements, more time will be required. 

CLARIFICATIONS REQUESTED 

Towers Perrin recommends that clarifications to the MHPAEA be provided in the following 

areas: 

• The acceptability of separate-but-no-greater-than deductibles and out-of-pocket 

maximums for medical/surgical versus MH/SUD benefits 

• The use of primary care versus specialty care physician copays as the “predominant” 

financial requirement for purposes of determining the applicable copay for MH/SUD 

office visits 

• Coverage of out-of-network alternative care 

• The use of different financial penalties for failure to precertify MH/SUD versus 

medical/surgical treatment 

• The degree to which “reasonable and customary” reductions for out-of-network 

MH/SUD services must be comparable with medical/surgical services 

What terms or provisions require additional clarification to facilitate compliance? 

What specific clarifications would be helpful? 

1. Separate cost sharing: “ ... there are no separate cost sharing 

requirements that are applicable only with respect 

to mental health or substance use disorder 

benefits” [ERISA § 712(a)(3)(A)(i); IRC § 

9812(a)(3)(A)(i)] 

Question: Does the MHPAEA provision above mean that a separate-but-notgreater-than out-of-pocket maximum can be applied to MH/SUD benefits as that 

applied to medical/surgical? Or does this provision mean that any out-of-pocket 

maximum that applies to medical/surgical must also be applied to MH/SUD on a 
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combined basis? Do deductibles have to be treated the same as out-of-pocket 

maximums for this purpose? 

For example, under the first interpretation, a $1,500 out-of-pocket maximum could 

apply to covered medical/surgical expenses and an additional, separate $1,500 outof-pocket maximum could apply to MH/SUD expenses. 

Under the second interpretation, if an out-of-pocket maximum were available for 

medical/surgical expenses, MH/SUD expenses would have to be applied to the 

same out-of-pocket maximum, such that once $1,500 in medical/surgical and/or 

MH/SUD covered out-of-pocket expenses were incurred, all covered expenses 

would be paid at 100% for the remainder of the plan year. 

2. Predominant: “ ... mental health or substance use disorder 

benefits are no more restrictive than the 

predominant financial requirements [or treatment 

limitations] applied to substantially all medical and 

surgical benefits...” [ERISA § 712(a)(3)(A); IRC § 

9812(a)(3)(A)] 

 “A financial requirement or treatment limit is 

considered to be predominant if it is the most 

common or frequent of such type of limit or 

requirement.” [ERISA § 712(a)(3)(B)(ii); IRC § 

9812(a)(3)(B)(ii)] 

Group health plans often impose different copays for primary care physicians than 

for specialists. Specialist copays tend to be higher. Generally, primary care 

physicians include family physicians, general practitioners, internists, obstetriciangynecologists and pediatricians. Psychiatrists – medical doctors that treat MH/SUD 

conditions – are widely viewed as specialists. However, if the incidence of office 

visits by plan participants is tallied, the number of primary care visits in a population 

typically exceeds that of specialty care visits. 7

Question: Is the term “predominant” to be interpreted in this context to mean that 

MH/SUD office visit financial requirements are to be in parity with those imposed for 

primary care physicians? Or, can plan sponsors apply the specialty office visit 

copay (and other financial requirements) since psychiatry is widely viewed as a 

medical specialty? 

 

7 http://www.aafp.org/online/etc/medialib/aafp_org/documents/press/charts-and-graphs/
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3. Treatment limitation: “The term ‘treatment limitation’ includes limits on 

the frequency of treatment, number of visits, days 

of coverage, or other similar limits on the scope or 

duration of treatment.” [ERISA § 712(a)(3)(B)(iii); 

IRC § 9812(a)(3)(B)(iii)] 

Alternative care settings (described above) are used when an MBHO clinician has 

reviewed the patient’s condition/treatment needs and determined that an alternative 

care setting is able to render appropriate care. A parallel in medical/surgical 

services occurs when patients are transferred from a hospital to a Skilled Nursing 

Facility, which are similar to Residential Treatment Centers. Treatment at the least 

intensive level of care suited to the patient’s needs is a basic tenet of the definition 

of medical necessity for MH/SUD and medical/surgical services. 

Out-of-network residential treatment centers (RTCs) present the most significant 

challenges to MH/SUD plans, both from a quality and cost perspective. RTCs for 

troubled youth have been the subject of thousands of allegations of abuse and even 

death. The Federal Trade Commission published a set of recommendations for 

parents considering residential treatment for youth in July 2008. 8

In October of 2007, the U.S. Government Accountability Office (GAO) published an 

investigation of 10 criminal and civil cases involving teenagers who died while 

enrolled in RTCs and reported the findings below: 

GAO found significant evidence of ineffective management in most of the 10 

cases, with program leaders neglecting the needs of program participants and 

staff. This ineffective management compounded the negative consequences of 

(and sometimes directly resulted in) the hiring of untrained staff; a lack of 

adequate nourishment; and reckless or negligent operating practices, including a 

lack of adequate equipment. These factors played a significant role in the deaths 

GAO examined. 9

As the two federal government documents cited above suggest, the cost and quality 

challenges likely to be posed by out-of-network RTCs will increase if regulations 

require that out-of-network RTCs be covered the same as out-of-network 

medical/surgical inpatient stays. 

Question: Does the term “treatment limitation” apply to alternative care settings 

and require that they be covered? Or can the decision to cover alternative care 

 

8 www.ftc.gov/bcp/edu/pubs/consumer/products/pro27.pdf 9 www.gao.gov/new.items/d08146t.pdf
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remain with clinical care managers, based on clinical and medical necessity 

criteria? If the MHPAEA’s requirement to provide parity in “treatment limitations” is 

to be applied to alternative care, does parity have to be achieved with inpatient 

medical/surgical or is the intent to require that alternative care be covered the 

same as a comparable level of medical/surgical services (e.g., Skilled Nursing 

Facilities and Residential Treatment Centers)? 

4. Financial requirement: “The term ‘financial requirement’ includes 

deductibles, copayments, coinsurance, and out-ofpocket expenses...” [ERISA § 712(a)(3)(B)(i); IRC 

§ 9812(a)(3)(B)(i)] 

Most group health plans require participants to obtain precertification for certain 

medical/surgical and MH/SUD treatment. Precertification requires the participant to 

notify the plan administrator prior to receiving certain services so that a medical 

necessity determination can be made. 

Precertification for inpatient treatment is commonly required for medical/surgical as 

well as MH/SUD. Outpatient treatment is also subject to precertification. 

Medical/surgical examples include certain outpatient surgical procedures, private 

duty nursing and durable medical equipment in excess of a specified amount. 

MH/SUD outpatient precertification is commonly required for psychological testing. 

Precertification penalty − reduction in benefits: The penalties for failure to 

precertify care vary and are commonly different for medical/surgical than for 

MH/SUD. Usually, the financial penalties for MH/SUD are larger than those for 

medical/surgical. For example, participants are sometimes required to obtain 

precertification for all treatment from network providers (both inpatient and 

outpatient). If precertification for MH/SUD treatment is not obtained, network 

benefits may be reduced to the out-of-network level, which are generally 

considerably lower (e.g., a reduction from 80% coverage to 50%). This reduction 

may occur even if the participant is under the care of a network provider. In 

contrast, failure to precertify medical/surgical care is commonly subject to a smaller 

reduction in benefits (e.g., 20%) or a flat dollar amount (e.g., $500). 

Question: Do the financial penalties for failure to precertify MH/SUD treatment 

need to be no higher than the financial penalties for failure to precertify 

medical/surgical treatment? 

Precertification penalty − denial of benefits: Failure to precertify may result in a 

denial of the claim. Generally, a medical/surgical claim is denied after a 

retrospective review is conducted and the care is deemed not medically necessary. 

Here again, it is not uncommon for a denial of an MH/SUD claim to occur absent a 
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retrospective review while medical/surgical denials are almost universally based on 

such a review. 

Question: If medical/surgical benefits are denied only if a retrospective review 

establishes that the services were not medically necessary, must a similar review 

process be undertaken before such MH/SUD claims are denied? 

Reasonable and Customary: Out-of-network professional services claims are 

subject to “reasonable and customary” (R&C) reductions in determining the amount 

the plan will pay. Generally, R&C reductions involve a two step process: (i) creating 

a distribution of billed charges for a specific procedure code (Current Procedure 

Terminology or CPT code) in a geographic area and (ii) obtaining the percentile 

(e.g., the 80th percentile) in the distribution that the plan sponsor wants used in 

calculating the R&C reduction. For example, if a psychiatrist bills $120 for CPT 

code 90862 (a medication management visit), the R&C may be $110. The out-ofnetwork benefit level (e.g., 70%) is then applied to the R&C amount. In this case, 

the plan would pay $77.00 and the member pays $43.00 (see table below). 

Because different companies often administer medical/surgical and MH/SUD 

benefits, the methodology for establishing R&C can yield significantly different 

financial requirements for participants. Sometimes the MH/SUD plan administrator 

has been instructed to use the network fee schedule as a basis for R&C, while the 

medical/surgical plan administrator uses the methodology described above. 

Because the network fee schedule is generally considerably lower than R&C for 

MH/SUD, the out-of-network plan payment is lower than would be the case using a 

more standard R&C reduction methodology. Currently, the medication management 

visit fee schedule averages $55. If the 70% benefit level is applied to the network 

fee schedule amount, the plan pays $38.50 and the member pays $81.50. 

 R&C @ 80th percentile R&C based on network fee

Billed charges $120.00 $120.00

R & C reduction $110.00 $55.00

Plan pays $77.00 $38.50

Member pays $43.00 $81.50

Question: Do out-of-network R&C plan payments for MH/SUD professional 

services need to be in parity with the methodology applied to medical/surgical 

services? 

We thank you for the opportunity to submit our comments. We would welcome the 

opportunity to discuss any of these comments in further detail. If you have any questions, 

please contact any of us below. 
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Sincerely, 

Richard Gisonny 

Principal 

(914) 745-4296 

rich.gisonny@towersperrin.com 

Mandie Conforti, LCSW, CEAP 

Senior Consultant 

(312) 201-5601 

mandie.conforti@towersperrin.com