Wrap Plan Document Language What to Know and What to Watch out For

Reasons for an Employer to create a Wrap Plan Document and Distribute an SPD  Required by ERISA  Combines several benefit offerings into one plan for 5500 filing or other purposes  Allows employer to define elements that are often inconsistent or missing in certificates issued by insurance carriers  Allows employer to create plan features that the carrier will not document in insurance certificate

SPD Content RequirementsSPD Content Requirements  Name of the Plan  Name and Address of the Plan Sponsor  EIN of Plan Sponsor  Plan Number  Plan Year  Plan Eligibility provisions (definition of employee, hours worked, classification restrictions, waiting periods, actively at work conditions, retirees)  Type of administration (insured or self-funded)

SPD Content RequirementsSPD Content Requirements  Name, address and telephone number of the plan administrator  Named Fiduciary  Information about collective bargaining agreements  Description or summary of the benefits  Description of QMCSO procedures with information about how the participants can obtain a full copy without charge  Cost sharing provisions – premium, copayment coinsurance, deductible  Annual or lifetime caps or limits

SPD Content RequirementsSPD Content Requirements  Extent to which preventive services are covered  Coverage for new and existing drugs  Whether and to what extent medical devices, procedures and tests are covered  Composition of the provider network, if any, including a statement that a list of providers will be provided without charge upon request  Information about network and out-of-network coverage

SPD Content RequirementsSPD Content Requirements  Conditions for obtaining emergency care  Circumstances which may result in disqualification, ineligibility, or denial, loss, forfeiture, suspension, offset, reduction, or recovery  Authority to amend or terminate the plan  Statement of ERISA Rights  Claims Procedures  Description of COBRA rights

Additional ProvisionsAdditional Provisions  Notice of Special Enrollment Rights  Newborns and Mothers Health Protection Act Notice  Genetic Information Non-Discrimination Act Notice  ACA Notices  Information about Related Employers whose employees participate  Medical Loss Ratio Rebate Information  HIPAA Privacy wording

Foreign Language RequirementsForeign Language Requirements  Foreign Language Requirements  If 25% literate only in same non-English language; OR  If > 100 employees with lesser of 500 employees or 10% literate only in same non- English language, then:  Must include prominent notice, in non- English language, offering assistance  Assistance does not need to be in writing

Key Things to Think aboutKey Things to Think about  What documents are part of the Plan?  Are the documents consistent?  SPD, certificate or evidence of coverage, wrap SPD, employment policies  If not which one supersedes the other?  Are terms repeated or incorporated by reference?  Is it clear who can be covered and when coverage begins and ends?  Have the documents been distributed as required by ERISA?

Potential ProblemsPotential Problems  No SPD  Conflicting Terms  Eligibility  Continuation of Coverage  Termination  Missing Information

Penalties  No specific penalties in ERISA, but could be fines as part of DOL audit  Plan participants and beneficiaries may bring a civil action  Plan Administrator may be fined up to $110 per day for failure to provide a plan document or SPD within 30 days of a request by a participant or beneficiary  Plan Administrator may be fined up to $110 per day for failure to provide a SPD within 30 days of a request by the DOL  Criminal penalties may be imposed on any individual or company that willfully violates any requirements of Title I of ERISA  Up to $100,000 per conviction ($500,000 for a company);  Up to 10 years in prison; or  Both

Polestar Benefits, Inc. 412 Jefferson Parkway, Suite 202 Lake Oswego, OR (855) com 12 Questions? Comments?Questions? Comments? We are happy to help!We are happy to help!