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Simplifying Insurance Insurance | Employee Benefits | Risk Management | Financial Strategies Surviving a Department of Labor (DOL) Audit.

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Presentation on theme: "Simplifying Insurance Insurance | Employee Benefits | Risk Management | Financial Strategies Surviving a Department of Labor (DOL) Audit."— Presentation transcript:

1 Simplifying Insurance Insurance | Employee Benefits | Risk Management | Financial Strategies Surviving a Department of Labor (DOL) Audit

2 simplifying Insurance | Background  The Employee Retirement Income Security Act of 1974 (ERISA) establishes reporting provisions and participant requirements for all private employer health & welfare benefit plans.  Expanded several times to include other health laws.  COBRA, HIPAA  DOL enforces ERISA

3 simplifying Insurance | General ERISA Requirements  Plan Document  A Plan Document is the written document(s) describing plan terms and conditions, including some general ERISA-required provisions  Includes insurance contracts, policies, riders and third party administrator (TPA) service agreements  Must be distributed upon request (within 30 days after written request, to avoid penalties).

4 simplifying Insurance | General ERISA Requirements  Summary Plan Description (SPD)  A SPD is the written document(s) summarizing the plan (WRAP is the common format as most benefit books do not contain all the required items)  Time frames for distribution:  upon plan enrollment; and  every 5 years (plan has been modified) or  every 10 years (no plan modifications)  Must be distributed to participants and any beneficiaries entitled to benefits

5 simplifying Insurance | General ERISA Requirements  Summary of Material Modifications (SMM)  A SMM is the written document summarizing the changes to the SPD  Must be distributed within 210 days after the end of the plan year  If an updated SPD is distributed, no SMM is required  Must be distributed to participants and any beneficiaries entitled to benefits

6 simplifying Insurance | General ERISA Requirements  Summary of Material Reduction in Covered Services/ Benefits (SMR)  A SMR is the written document summarizing the reductions to the health (medical) plan  Must be distributed within 60 days  Must be distributed to participants and any beneficiaries entitled to benefits

7 simplifying Insurance | General ERISA Requirements  Annual Report  An Annual report is the 5500 filed with the DOL and Internal Revenue Service (IRS) disclosing financial aspects of the plan  Exemption for small plans with less than 100 participants at the beginning of the plan year  Must be filed annually within 7 months of the end of the plan year; and  Must be distributed to participants upon request

8 simplifying Insurance | General ERISA Requirements  Summary Annual Report (SAR)  A SAR is the written document summarizing the Annual Report (5500)  Must be distributed within 60 days of the 5500 filing  Must be distributed to participants and any beneficiaries entitled to benefits

9 simplifying Insurance | General ERISA Requirements  Internal and External Claims and Appeal Procedures  These are the written document(s) describing the procedures for claims and appeals  Generally distributed by the insurer or TPA  Recommendation: Include PPACA amended language in all WRAP documents  Must be distributed to participants and any beneficiaries entitled to benefits

10 simplifying Insurance | General ERISA Requirements  COBRA Requirements  Initial COBRA notice  COBRA election notice  Notice of unavailability of COBRA  Notice of COBRA early termination  Exemption for Government & Church plans and small plans (less than 20 employees)  Specific timing and distribution requirements for bullets 1-4

11 simplifying Insurance | General ERISA Requirements  HIPAA Portability Requirements  Certificate of Creditable Coverage  This is the document that certifies the time the participant was covered under another group health plan  Must be distributed upon loss of coverage (generally distributed by the insurer or TPA)  Must be distributed to participants and beneficiaries who lose coverage

12 simplifying Insurance | General ERISA Requirements  HIPAA Portability Requirements cont.  Notice of Preexisting Condition Exclusion  Must be distributed with enrollment materials  Must be distributed to participants  Individual notice must be distributed to participants who present a certificate of creditable coverage  Notice of Special Enrollment Rights  This is the document that describes all of the special enrollment rules (marriage, birth, etc.)  Must be distributed prior to or during enrollment to all covered employees

13 simplifying Insurance | General ERISA Requirements  Misc. Notices  Women’s Health and Cancer Rights Act  Must be distributed with initial enrollment materials (all covered employees) and annually (participants)  Newborns’ and Mothers’ Health Protection Act  Must be distributed with initial enrollment materials (all covered employees) and annually (participants)

14 simplifying Insurance | General ERISA Requirements  Misc. Notices cont.  CHIPRA  Must be distributed annually to all employees  Michelle’s Law  Must be distributed at the time that a plan requires certification of student status to any applicable participants  HIPAA Wellness Program  Must be distributed if there is a reward based on outcome annually to all employees

15 simplifying Insurance | General ERISA Requirements  Misc. Notices cont.  Medical Child Support Order  Must be distributed upon receipt and qualification to the applicable participant  USERRA  Needs to be posted in the workplace (no distribution requirement if posted)  FMLA Notice and Written Guidance  Needs to be posted in the workplace (no general distribution requirement if posted)  Must be distributed to any applicable participants

16 simplifying Insurance | General ERISA Requirements  Misc. Notices cont.  HIPAA Privacy and Security  Notice of Privacy Practices  Notice of Breach of unsecured PHI  Specific timing and distribution requirements for the above items  PPACA Grandfather Status  If any part of the plan is grandfathered, this must be distributed whenever plan information is provided  Must be distributed to all participants

17 simplifying Insurance | General ERISA Requirements  Misc. Notices cont.  GINA  Needs to be posted in the workplace (no general distribution requirement if posted)  W-2 Reporting of Health Insurance  Aggregate cost of coverage must be disclosed  Effective beginning January 2013 for 2012 coverage  Summary of Benefits Coverage (SBC) and Advance Notice of Mid-Year Changes  Look for an update on this soon!

18 simplifying Insurance | Penalties  Generally $110/ day per participant who requests the document (SPD, SAR, all notices, etc.)  Penalties can be increased if the issue is brought before the court  Special Exceptions:  Up to $1,100/ day per return  HIPAA Breach- Specific (significant) penalties

19 simplifying Insurance | Conclusion QQuestions?


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