This webinar covers a basic review of the requirements under ERISA, including: what is an ERISA benefit, what documentation requirements have to be met, what disclosure requirements have to be met, what reporting requirements need to be met, what is a fiduciary, and what are other requirements.
HIPAA in 2023: Changes, Updates, and Best PracticesConference Panel
HIPAA 2023 Guidance and Compliance refers to the latest regulations and guidelines for protecting patient privacy in healthcare. Healthcare organizations need to stay current on the rules and guidelines related to privacy, security, and breach notification. This includes understanding the key changes to HIPAA regulations, ensuring compliance for covered entities and business associates, implementing best practices for maintaining HIPAA compliance, and addressing the impact of technology and innovation on healthcare privacy and security. Training, risk assessments, audits, and patient rights are also essential aspects of HIPAA compliance.
Register for the HIPAA 2023 Guidance and Compliance Webinar,
https://conferencepanel.com/conference/hipaa-2023-latest-guidance-and-compliance-focus
The Health Insurance Portability and Accountability Act (HIPAA) was created primarily to modernize the flow of healthcare information, stipulate how Personally Identifiable Information maintained by the healthcare and healthcare insurance industries should be protected from fraud and theft, and address limitations on healthcare insurance coverage – such as portability and the coverage of individuals with pre-existing conditions.
https://www.hipaajournal.com/hipaa-training-requirements/
You may get the format of rent agreement on the web, but can not make an agreement itself online. Rent Agreement needs to be clearly drafted on stamp paper and should either get registered at the Registrar office Or else it should be duly attested by the the Notary Public .
Agreement in Contract: Objective PrinciplePreeti Sikder
Learning Outcome:
After completion of this lesson students will -
a) be acquainted with the objective principle followed in law of contract
b) learn about the exceptions of this general principle
Cases: Centrovincial Estates v Merchant Investors, Leaonard v Pepsico, Hartog v Colin and Shields, Scriven Bros v Hindley
(HEPE) Introduction To Health Disparities 1antz505
Many youth leaders are compelled to do work with community based non-profit and local public health agencies as both a service learning and philanthropic component in their development as young professionals. However, despite invaluable experiential learning, students often don\'t comprehend key overarching issues such as health disparities, social determinants of health, health policy and community organizing. To address this gap and optimize their community based work, the Health Disparities Student Collaborative (HDSC), a Boston-based student group under Critical MASS for eliminating health disparities and the Center for Community Health Education Research and Service Inc. (CCHERS), developed a curriculum for students designed to broaden their perspectives while working with local public health, non-profit/community organizations and to develop their interest and ability to visualize the power of their collective voice as students and contributors to social justice work. The curriculum utilizes peer education and webinar software and covers three main topics: Current State of Health Disparities, Social Determinants of Health, and Youth Activism on Health Disparities/Social Determinants of Health. HDSC has collaborated with local partners CCHERS/Critical MASS and the Community Based Public Health Caucus (CBPHC) Youth Council to develop this comprehensive “Health Equality Peer Education” training.
Review all of the requirements of the Employee Retirement Income Security Act of 1974. Training will go over which employers have to comply, which benefits are subject to ERISA, what documentation employers must provide, and penalties for noncompliance.
HIPAA in 2023: Changes, Updates, and Best PracticesConference Panel
HIPAA 2023 Guidance and Compliance refers to the latest regulations and guidelines for protecting patient privacy in healthcare. Healthcare organizations need to stay current on the rules and guidelines related to privacy, security, and breach notification. This includes understanding the key changes to HIPAA regulations, ensuring compliance for covered entities and business associates, implementing best practices for maintaining HIPAA compliance, and addressing the impact of technology and innovation on healthcare privacy and security. Training, risk assessments, audits, and patient rights are also essential aspects of HIPAA compliance.
Register for the HIPAA 2023 Guidance and Compliance Webinar,
https://conferencepanel.com/conference/hipaa-2023-latest-guidance-and-compliance-focus
The Health Insurance Portability and Accountability Act (HIPAA) was created primarily to modernize the flow of healthcare information, stipulate how Personally Identifiable Information maintained by the healthcare and healthcare insurance industries should be protected from fraud and theft, and address limitations on healthcare insurance coverage – such as portability and the coverage of individuals with pre-existing conditions.
https://www.hipaajournal.com/hipaa-training-requirements/
You may get the format of rent agreement on the web, but can not make an agreement itself online. Rent Agreement needs to be clearly drafted on stamp paper and should either get registered at the Registrar office Or else it should be duly attested by the the Notary Public .
Agreement in Contract: Objective PrinciplePreeti Sikder
Learning Outcome:
After completion of this lesson students will -
a) be acquainted with the objective principle followed in law of contract
b) learn about the exceptions of this general principle
Cases: Centrovincial Estates v Merchant Investors, Leaonard v Pepsico, Hartog v Colin and Shields, Scriven Bros v Hindley
(HEPE) Introduction To Health Disparities 1antz505
Many youth leaders are compelled to do work with community based non-profit and local public health agencies as both a service learning and philanthropic component in their development as young professionals. However, despite invaluable experiential learning, students often don\'t comprehend key overarching issues such as health disparities, social determinants of health, health policy and community organizing. To address this gap and optimize their community based work, the Health Disparities Student Collaborative (HDSC), a Boston-based student group under Critical MASS for eliminating health disparities and the Center for Community Health Education Research and Service Inc. (CCHERS), developed a curriculum for students designed to broaden their perspectives while working with local public health, non-profit/community organizations and to develop their interest and ability to visualize the power of their collective voice as students and contributors to social justice work. The curriculum utilizes peer education and webinar software and covers three main topics: Current State of Health Disparities, Social Determinants of Health, and Youth Activism on Health Disparities/Social Determinants of Health. HDSC has collaborated with local partners CCHERS/Critical MASS and the Community Based Public Health Caucus (CBPHC) Youth Council to develop this comprehensive “Health Equality Peer Education” training.
Review all of the requirements of the Employee Retirement Income Security Act of 1974. Training will go over which employers have to comply, which benefits are subject to ERISA, what documentation employers must provide, and penalties for noncompliance.
Webinar | Training the Technique: Advanced ERISA Compliancebenefitexpress
If your organization offers any form of retirement plan, chances are you have questions about ERISA. This advanced compliance training will go beyond the basics of the requirements of the Employee Retirement Income Security Act of 1974.
Attend our one-hour training to learn:
- Which employers are affected by ERISA regulations
- Which benefits plans are subject to ERISA
- What documentation employers must provide to prove
compliance
- Penalties for noncompliance
ERISA attorney Larry Grudzien will share industry inside knowledge to help participants ensure total compliance with ERISA regulations.
With Department of Labor audits on the rise, this presentation reviews all the requirements under ERISA. This includes the requirements for plan documents, disclosures and reporting.
This powerpoint goes into depth and explains FSAs, HRAs and HSAs, how they work together, who can participate, and what types of rules apply. It's a little boring, long, and somewhat detailed. However, you can use just portions of the slides if you'd like. The last 20 or so slides may be useful if an employer is offering high deductible health insurance plans, with an HSA - and already has an FSA in place This is a Continuing Education Course in California, under the Department of Insurance.
Watch our free one-hour webinar reviewing the rules for the new Individual Coverage HRA and the new Excepted Benefit HRA (ICHRA and EBHRA).
In June 2019, Treasury, DOL and HHS released final regulations that are effective for plan years beginning on or after January 1, 2020. These regulations created two new HRAs, Individual Coverage HRAs (ICHRA) and Excepted Benefit HRAs (EBHRA).
These new HRAs will be subject to ERISA and COBRA, but will not be subject to the nondiscrimination rules under Code Section 105(h). Any employer can offer these new HRAs to their employees. They can be offered to common law employees, but cannot be offered to self-employed individuals, partners and more than 2% S-Corporation shareholders.
Facilitated by ERISA attorney Larry Grudzien, and moderated by Chief Marketing Officer Julia Goebel, this webinar will cover the following:
-Why are these new HRAs so important?
-Which employees can be included or excluded
-What documentation is needed to be completed by employers to adopt them
-What reporting and disclosure requirements must be met
-What types of expenses can be reimbursed
-The pros and cons of establishing and participating in these new HRAs for employers
Health Care Reform and the Basics of BenefitsBeyondPay
This webinar will answer questions you have about the insurance you offer employees. It covers all things ACA and benefits administration, including COBRA, ERISSA, and HIPAA. Don't miss the latest ACA updates in 2016 to find out how they will affect you and your company.
Eliott Dear Lawyer is explaining the Role of Employee Benefits. Eliott Dear is a regarded legal advisor in New York. He has over ten years of involvement with his legitimate work.
Developments in Health and Welfare Plans in 2016benefitexpress
Kick off enrollment season with a comprehensive review of the legislative changes for 2016. This webinar focuses on what you need to know for successful enrollment and ACA reporting. Learn about new legislation from DOL, HHS, IRS, and EEOC. It’s a webinar you (and your compliance strategy) can’t afford to miss.
Webinar: Mid-Year Election Changes for Cafeteria Plansbenefitexpress
Let's talk about cafeteria plans. When can participants make election changes?
While cafeteria plans can be a great option for employees wishing to pick and choose benefits based on cost, when and how to facilitate election changes outside of open enrollment can be tricky to navigate for employers. As the use of cafeteria plans continue to grow, we take a deeper look at the rules and regulations of these plans, particularly as they pertain to mid-year election changes.
COVID-19 Health & Welfare: Compliance for Employersbenefitexpress
As part of our continuing ERISA Compliance series, we covered such compliance topics and more in our April 9th webinar discussing COVID-19 and updates from the IRS and DOL concerning the Families First Coronavirus Response Act.
Plan Sponsor Webinar: Navigating COVID-19 for Employersbenefitexpress
In this webinar, we take a deeper look into how the novel coronavirus is not only affecting the way we live, but changing the way we work. From remote work environments, FMLA, contract agreements and more, we discuss how to navigate the changing workforce during this time of uncertainty, and answer questions to help you make the best decisions for the health and safety of your employees.
Medicare & Employer Health Coverage - a Coordination Conversationbenefitexpress
Let's talk about Medicare and Employer Health Coverage. The rules on coordinating Medicare and employer coverage can be complex. How it complements other programs (such as COBRA, HSAs and the ACA) are also areas of question for both employees and their employers.
Part of our ERISA Compliance Series, this webinar is hosted by ERISA Attorney Larry Grudzien and moderated by chief marketing officer Julia Goebel. This webinar will discuss the top wage and hour issues that may be unknowingly lurking within your company.
The Affordable Care Act touches the lives of most Americans. In fact, nearly 21 million will be at risk if Obamacare is struck down, and may even lose health insurance completely if the law is ruled unconstitutional. This webinar will discuss what the outcome may be if ACA is repealed.
In today's multi-generational workforce, health and wellness benefits are weighted equally with salary expectations. This is why it's important for small and large businesses alike to embrace health and wellness benefits to recruit top talent as well as retain valued employees.
While offering these benefits has been shown to improve employee engagement and productivity, it comes with some challenges. This webinar reviews common questions human resources professionals confront when offering health and welfare benefits to employees.
Facilitated by ERISA attorney Larry Grudzien, this webinar covers the following:
- Questions Surrounding Tax
- Reporting Disclosures
- ERISA, COBRA & FMLA
- Workers Compensation
- Affordable Care Act (ACA)
Benefits are a critical piece of an employee compensation package, with health care benefits reigning most important. Whether you're already offering these benefits or considering adding them to your benefits offerings, view our webinar to learn more and remain competitive in the talent marketplace.
How to Administer Wellness Programs in Today's Regulatory Environmentbenefitexpress
Are you struggling to make sense of the recent legislative updates surrounding employer sponsored wellness programs? Perhaps you are trying to decide whether to continue with current wellness plans, modify your plans without guidance from the EEOC, postpone new wellness programs or discontinue them all together.
It’s a complicated landscape ripe with several options for “next steps” for employees and plan sponsors of wellness plans in 2019 — with perhaps the biggest barrier of all being that employers cannot measure the risk of wellness plans at this time.
To help guide you through this maze of options, watch our one-hour webinar on-demand to learn what rules remain after the EEOC’s regulations were found invalid and what rules have to be met in 2019 in order to offer a valid wellness program.
How to administer wellness programs in today's regulatory environment
This webinar covers:
Requirements under HIPAA
Requirements under the Internal Revenue Code
Requirements under ERISA
Requirements under GINA
Requirements under ADA
Requirements under ACA
HIPAA Training: Privacy Review and Audit Survival Guidebenefitexpress
HIPAA Privacy Overview for Employers. Review a helpful checklist of requirements an employer must adopt to stay compliant with HIPAA and to survive an audit by Health and Human Services (HHS).
Webinar | Texas vs. United States - The Repeal of ACA?benefitexpress
Recently a Federal District Court held in Texas, et al. v. United States of America, et al. that the individual mandate in the Patient Protection and Affordable Care Act (ACA) is unconstitutional, and that the other provisions in the ACA are invalid because they are inseverable from the individual mandate.
Our ACA compliance webinar reviews:
- What the Federal District Court decided.
- The basis for the decision.
- The impact of the decision.
- What may happen over the next months or year.
- What Congress may do to address the situation.
Healthcare Check-in: The Latest Developments in Health and Welfare Plansbenefitexpress
We work in an exciting industry – which means quick changes are the norm, and adaptability is a necessity. Keep your compliance plans up to date with a download of all legislative changes since our last update webinar. This webinar covered legislation that's passed in the last six months, what's on the way, and what it means for your organization.
Webinar | From Analysis to Action: How Personalization Can Lower Employer Cos...benefitexpress
Personalization is everywhere – from Amazon to Spotify, and is now the expectation for consumers. Personalization in benefits elections is also the new normal, thanks to decision support tools and data analytics. Modern decision support tools draw on data points including demographics, preferences and medical need, all highly relevant towards personalization ... as opposed to the "one-size fits all" modeler of the past that relied on strict business rules.
Using data to advise clients can be a game changer for a broker. With analytics, you can quantify your benefit plan suggestions based on hard evidence, and advise based on unbiased data versus mere opinion. But where does this data come from? And how do you know which data to use?
This webinar shows how decision support tools can provide data to simplify health benefit decisions, allowing employees to feel more confident in their decisions, leading to lower costs for employers and client retention for brokers as a result.
In this webinar, brokers will learn how decision support analytics can reinforce their role as a trusted adviser by:
• Helping employer clients understand which health plans and programs are being used and which ones are the most cost-effective
• Minimizing the number of employees who are over-insured or under-insured, helping to save on annual and long-term costs for healthcare premiums, leading to better client retention over time
• Supporting healthy employee behaviors, resulting in lower health care expenses overall
FSAs can do some heavy lifting for your benefits plan – they allow employees to save pretax dollars for healthcare costs without the price tag of other financial wellness initiatives.
However, many HR professionals lack a deep understanding of the compliance requirements to offer and administer a well-rounded program for their employees. Engage your employees with a financial wellness benefit that works.
Key webinar takeaways:
- How different types of FSAs interact with benefit plans as a whole
- FSA and reimbursement limits for 2018
- Legal implications of offering an FSA to employees
- Best practices for administering a successful FSA benefit plan
Webinar | COBRA Pitfalls: Common Mistakes and How to Avoid Thembenefitexpress
Leaving the organization isn't the end of the benefits cycle for employees. This webinar focuses on how to avoid one of the most common compliance pitfalls in benefits ... COBRA administration.
Some of the top takeaways were:
• The basics of successful COBRA administration
• Required notices associated with COBRA coverage
• How Medicare interacts with COBRA for employees and dependents
• Penalties for noncompliance
Smooth and successful off-boarding of departing employees is as important as well-planned on-boarding of new hires. Log on to your roadmap for a smooth ride into COBRA compliance.
Webinar | Clients Calling “Mayday”? Design a Benefits Technology Strategy to ...benefitexpress
Benefits administration can be a delicate, and even difficult balancing act for employers. From managing costs and administrative demands, to maintaining compliance, and integrating with workforce wellness plans, it’s not surprising that three in four employers called “mayday” and turned to benefits administration outsourcing in 2017. With the administrative difficulty level rising, and advisory competition increasing, it is now critical to become the partner of choice to relieve this distress. But how?
Join Scott Evans, chief product officer at benefitexpress, this May Day, as he guides benefits advisers through the top considerations for building, buying or borrowing benefits administration technology solutions to offer clients. If you and your clients have benefits technology questions, Scott has answers.
Webinar takeaways include:
• How to assess your readiness: learn and identify the benefits administration business model that is right for you
• Key criteria for evaluating potential benefits technology partners, plus a valuable checklist
• How to create a benefits technology strategy for your business which is seen as an imperative – not a “value-add” – by your clients
• Tips for staying competitive in a changing market, using your solutions portfolio
Factors of Self-Funding: Evaluating the Pros and Consbenefitexpress
In a changing healthcare landscape, employers are increasingly considering taking the funding of their healthcare benefits into their own hands. If you're one of them, this webinar is the one-hour guide you must see.
Participants will learn:
- The legal implications associated with self-funding
- Common administrative pitfalls
- Solving employee issues involved in self-funded plans
- A full overview of laws and regulations governing self-funding
Our compliance expert will weigh in during a compact, one-hour guide.
Healthcare check in the latest developments in health and welfare plansbenefitexpress
We work in an exciting industry—which means quick changes are the norm, and adaptability is a necessity.
Keep your compliance plan up-to-date with a download of recent legislative changes.
We'll cover legislation that's passed, what's on the way, and what it means for your organization.
Topics Covered Include:
• IRS Information Letters
• Tax Reform Legislation
• Wellness Regulations - EEOC, AARP
• Comprehensive Guidance on QSEHRAs
• ACA: Elimination of Individual Mandate Penalty
• Employer Tax Credit for Paid Family and Medical Leave
• DOL Annual Adjustments to Employee Benefit Plan Penalties
• “Good Faith” Penalty Relief
• Final Disability Claim Regulations
• Cadillac Tax Updates
• And More!
Presented by Larry Grudzien, Attorney at Law
Healthcare check in the latest developments in health and welfare plans
ERISA for Employers 101
1.
2.
3. What is ERISA?
• “ERISA” stands for the Employee Retirement Income Security
Act of 1974 (Pub.L. 93-406, 88 Stat. 829, enacted 1974-09-02).
• ERISA is comprehensive federal legislation, first enacted in 1974
and amended many times since then.
• Title I of ERISA is part of the labor laws of the United States and
governs the structure of “employee benefits plans.”
• For most plans, it requires detailed disclosure to covered
individuals, employees and beneficiaries).
• For many plans, it requires detailed reporting to the government
(mainly on Form 5500).
4. What is ERISA?
• ERISA Title I also imposes a strict fiduciary code of conduct on
many of those who sponsor and administer ERISA plans.
• In addition, there is a federal mechanism for enforcing rights and
duties with respect to ERISA plans, and it preempts a large body
of state law.
• The Department of Labor (DOL) enforces ERISA Title I, mainly
through its Employee Benefits Security Administration (EBSA)
(formerly called PWBA).
• Failure to comply with ERISA’s requirements can be quite costly,
either through DOL enforcement actions and penalty assessments
or through employee lawsuits.
5. Who must Comply?
• Virtually all private-sector employers are subject to ERISA - there
is no size exemption.
• This includes corporations, partnerships, and sole proprietorships.
• Remember, non-profit organizations are covered as well .
• However, the plans of governmental employers and of churches
are exempt from the application of ERISA Title I.
6. Why is it important to determine if employer
sponsors an ERISA plan?
If an employer sponsors a plan subject to ERISA, it must comply
with its many requirements, but it also enjoys many protections.
Advantages of ERISA status:
• Employees and beneficiaries may not sue in state court.
• Courts apply a standard of review more favorable to the plan.
7. What Plans Must Comply?
• Many employee benefit arrangements that provide non-pension
fringe benefits are “employee welfare benefit plans” covered by
ERISA.
• However, there are important exemptions and safe harbors
provided for certain categories of employee benefits.
• The definition of ERISA welfare benefit plan contains the following
three basic elements:
there must be a plan, fund or program;
that is established or maintained by an employer, and
for the purpose of providing the specified benefits to participants and
beneficiaries.
8. Is there a Plan, Fund, or Program?
In determining whether there is a “plan, fund or program” within the
meaning of the ERISA definition, the courts ask whether from the
surrounding circumstances a reasonable person could ascertain:
• the intended benefits;
• a class of beneficiaries;
• the source of financing; and
• the procedures for receiving benefits
In addition, under Fort Halifax Packing Co. v. Coyne (482 U.S.1, 8
EBC 1729(1987) S. Ct. provides that a plan exists only when there
is a commitment to pay benefits systematically, including an ongoing
administrative responsibility or scheme to determine eligibility and
calculate benefits.
9. Is there a Plan, Fund, or Program?
Some Arrangements Do Not Qualify
• Even though it is easy to satisfy the basic “plan, fund or program”
test, some arrangements do not qualify.
• For example, where an employer offered only a one-time, lump-
sum severance bonus, there was no ongoing administrative
scheme and therefore the bonus was not an ERISA benefit .
Written Document Is Needed to Create a Plan, Fund or Program
• It should be recognized that no document is necessary for a plan
to exist under ERISA, if from the surrounding circumstances the
above elements of a plan, fund or program can be ascertained .
• When the necessary elements of a plan can be ascertained,
however, maintaining the plan without a written document is a
violation of ERISA.
10. • An Employer need not to do much to establish or maintain a plan.
• Issue is resolved in self-insured arrangements.
• Issue is more uncertain in insured arrangements
Purchasing Insurance is employer maintenance.
Effect of Voluntary Plans Safe Harbor.
• Individual insurance policies can create an ERISA plan.
Is the Plan, Fund or Program Employer-
Established/Maintained?
11. Specified listed benefits include:
• medical, surgical or hospital care or benefits
• benefits in the event of sickness, accident, disability, death or
unemployment,
• vacation benefits
• apprenticeship or other training benefits,
• daycare centers
• scholarship funds
• pre-paid legal services
• holiday and severance benefits and
• housing assistance benefits
Does the Plan Provide the type of Benefits
Listed in ERISA?
12. Who are Participants and Beneficiaries?
• Current employees.
• Beneficiaries a person designated by a participant .
• Retired employees and COBRA qualified beneficiaries can be if
they are entitled to benefits.
Plans Covering Self-Employed Individuals or partners:
• Not considered an ERISA plan.
Plans Covering Only One Employee (or Former Employee):
• Can be if covers non-executive.
Are Plan Benefits Provided to Participants or
Beneficiaries?
13. Important Statutory and Regulatory Exemptions
Statutory and Regulatory exemptions include:
• Government, Church and Other Statutory Exemptions
• These include programs maintained solely to comply with state
law requirements:
Workers Compensation;
Unemployment; or
Disability Laws.
14. Important Statutory and Regulatory Exemptions
Statutory and Regulatory exemptions include:
• Payroll Practice Exemptions - This includes payment of:
wages, overtime pay, shift premiums, and holiday or weekend
premiums;
unfunded sick-pay or income replacement benefits; and
vacation, holiday, jury duty and similar pay.
• To qualify for this exemption, the amounts must be paid out of the
employer’s general assets.
15. Important Statutory and Regulatory Exemptions
Statutory and Regulatory exemptions include:
• “Voluntary Employee-Pay-All” Exemption - The employer allows
an insurance company to sell voluntary policies to interested
employees who pay the full cost of the coverage.
Permits employees to pay their premiums through payroll deductions
and permits the employer to forward the deductions to the insurer.
However, the employer may not make any contribution toward
coverage and the insurer may not pay the employer for being allowed
into the workplace.
The employer may not “endorse” the program - This element is the key
element in treating the program as an ERISA benefit. What makes up
an endorsement?
• Selecting insurers
• Negotiating terms or design
• Linking plan coverage to
employee status
• Using employer’s name
• Recommending plan to
employees
• Doing more than permitted
payroll deduction
16. Examples of Benefits | Are they subject?
• Cafeteria Plan – No, but Health FSA is covered
• Insured Major Medical Coverage - Yes
• HMOs - Yes
• Dental coverage - Yes
• DCAP - No
• AD&D Coverage -Yes
• GTL coverage -Yes
• LTD Coverage - Yes
• PTO Coverage – No, payroll practice
• Adoption Assistance - No
• Educational Assistance - No
• STD Coverage – Maybe if not payroll practice
• Severance Coverage - Yes
• Voluntary Insurance - no
17. Key ERISA Requirements
• Plan document must exist for each plan.
• Plan terms must be followed .
• Strict fiduciary standards must be followed.
• Fidelity bond must be purchased to cover every person who
handles plan funds.
• Summary plan description (SPD) must be furnished automatically
to plan participants.
• Summary of material modification (SMM) must be furnished
automatically to plan participants when a plan is amended.
• Copies of certain plan documents must be furnished to
participants and beneficiaries on written request.
18. Key ERISA Requirements
• Form 5500 must be filed annually for each plan (subject to
important exemptions, especially for small plans).
• Summary annual report (summarizing Form 5500 information)
must be furnished automatically to plan participants for a plan that
files a Form 5500 (except totally unfunded welfare plans).
• Claim procedures must be established and carefully followed
when processing benefit claims and when reviewing appeals of
denied claims.
• Plan assets, including participant contributions, may be used only
to pay plan benefits and reasonable administrative expenses.
• For a few welfare plans, plan assets may have to be held in trust.
• Group health plans must conform to applicable mandates like
COBRA and HIPAA.
19. Plan Document Requirements
• Plan must be established and maintained through a written
document.
ERISA requires that every welfare plan “be established and maintained
pursuant to a written instrument.”
A written instrument does the following:
• Participants are on notice of benefits and their own benefits under the plan.
• Plan administrator is provided guidelines by which to make decisions
• ERISA does not provide specific format or content requirements.
• Insured benefit requirements – use of “wrap documents.”
• A wrap document fills in missing ERISA requirements.
• Can a single document serve as both plan document and SPD?
20. Plan Document Requirements
Consequences of Failure to Comply:
• No Specific Penalties
• Inability to Respond to Written Participant Requests
• Benefits Lawsuits May Be Based on Past Practice and Similar
Evidence
• Less Favorable Standard of Review in Benefits Lawsuits
• Limited Ability to Amend or Terminate Plan
• Fiduciary Duty to Follow Plan Document
21. Plan Document Requirements
ERISA Required Plan provisions:
• Named Fiduciary
• Procedures for allocation of responsibilities
• Funding policy
• How payments are made
• Claims procedures
• Amendment procedures
• Distribution of assets on plan termination
• Required provisions for group health plans:
COBRA & USERRA rules
HIPAA Portability, Special enrollment and nondiscrimination rules
HIPAA Privacy and Security
Minimum hospital stays after childbirth
QMCSO rules
Disclosures regarding remaining Federal Mandates and other Laws
22. Fiduciary Requirements
ERISA’s fiduciary rules are distinguished from many other rules
of behavior by the following major characteristics:
• the rules incorporate a broad, functional definition of the term
“fiduciary,” which sweeps in all kinds of individuals and business
entities depending on the duties they actually perform in
connection with ERISA plans;
• the standard of behavior expected from ERISA fiduciaries is very
high;
• broadly-defined fiduciary responsibilities apply to every act taken
in a fiduciary capacity;
• certain specifically-enumerated transactions between an ERISA
plan and persons acting in connection with the plan are absolutely
prohibited; and
• ERISA fiduciaries who breach their duties can be personally liable
for damages to the ERISA plan and for DOL penalties imposed in
connection with fiduciary breaches.
23. Fiduciary Requirements
Automatic Fiduciaries:
• Named Fiduciaries
• Plan Administrators
• Trustees
• Others
A plan must provide for one or more names fiduciaries who jointly or
severally have authority to control and manage the operation and
administration of the plan.
24. Fiduciary Requirements
Functional Fiduciaries Persons or entities become ERISA
fiduciaries to the extent that they:
• Have discretionary authority or discretionary control regarding the
management of an ERISA plan;
• Have any authority or control respecting management or
disposition of plan assets;
• Render investment advice for a fee; or
• Have discretionary authority or discretionary responsibility in the
administration of the plan.
25. Fiduciary Requirements
Fiduciary Standard of Behavior One of Highest in Law
• The duties of care and integrity imposed on fiduciaries have been
among the highest, if not the very highest, in the common law .
• In enacting the ERISA fiduciary duty rules, Congress intended to
incorporate principles of the common law of trusts, tailored as
necessary to employee benefit plans.
26. Fiduciary Requirements
The principal duties of ERISA fiduciaries are:
• To act solely in the best interest of plan participants and
beneficiaries (the duty of undivided loyalty);
• To use plan assets for the exclusive purpose of paying plan
benefits or reasonable expenses of plan administration (the
exclusive benefit rule);
• To act with the care, skill, prudence and diligence that a prudent
person in similar circumstances would use ;
• To diversify the plan’s investments (if any) to minimize the risk of
large losses; and
• To act in accordance with the documents governing the plan.
27. Fiduciary Requirements
Fiduciaries are liable for breaches that occur while they serve as
fiduciaries, but not for breaches in the period before they become
fiduciaries or after they cease to be fiduciaries.
Liability includes:
• personal liability for losses caused to the plan;
• personal liability to restore to the plan any profits the fiduciary
made through the use of plan assets ; and
• other equitable or remedial relief, as a court may deem
appropriate, including removal of the fiduciary.
28. Fiduciary Requirements
Fiduciary bonding requirements
• It is required if there are plan assets.
• Who must be bonded?
• Amount of Bond?
An amount equal to at least 10% of the funds handled during the prior
reporting year, subject to a minimum of $1,000 and a maximum of
$500,000.
29. Summary of Disclosure Requirements
• Summary Plan Description
• Summary of Material Modifications
• Summary of Benefits & Coverage
• Summary Annual Reports
• Providing copies of documents on written request
• Making documents available at principal office
30. Disclosure Requirements
Which plans must comply?
Almost every employee benefit plan must comply
Are there any plans that are exempt?
• Exemption of employer-provided daycare centers
• Exemption of welfare plans for certain select employees
• Cafeteria plans - considered a fringe benefit plan, but health FSA
must comply
Note: No small plan exemption
31. Disclosure Requirements
Who is responsible for complying?
Plan Administrator is responsible .
Who must be furnished with SPD and SMMs
• In general, covered participants, but not beneficiaries
• Exceptions, the following must receive copy:
COBRA Qualified Beneficiary
QMCSO Alternative Recipient
Spouse/Dependent of Deceased Participant
Representatives or Guardians of Incapacitated Persons
32. Summary Plan Description (“SPD”)
When must it be provided?
• Within 90 days for newly-covered participants.
• Within 120 days for new plans.
• Updated SPD is required every 5 (or 10) years.
How must it be provided?
• Must be furnished in a way ”reasonably calculated to ensure
actual receipt of the material.”
• Must use method ”likely to result in full distribution”.
• Satisfactory method will depend on facts and circumstances.
Furnish by Mail
Furnish by In-hand delivery
Electronic means
33. Summary Plan Description
General format and style requirements:
• Be sufficiently accurate and comprehensive to inform plan
participants and beneficiaries of their rights and obligations under
the plan.
• Be written in a manner understandable to the average plan
participant.
• Not have the effect of misleading, misinforming or failing to inform
participants and beneficiaries.
• Any description of exceptions, limitations, reductions, and other
restrictions of plan benefits must be apparent in the SPD.
34. Summary Plan Description
The items to be included in a welfare plan SPD:
• Plan-identifying information
• Description of plan eligibility provisions
• Description of plan benefits
• Statement clearly identifying circumstances that may result in loss
or denial of benefits
• Description of plan amendment and termination provisions
• Description of plan subrogation provisions (if any)
• Information regarding plan contributions and funding
35. Summary Plan Description
The items to be included in a welfare plan SPD:
• Information regarding plan contributions and funding.
• Information regarding claims procedures.
• Model statement of ERISA rights.
• Prominent offer of assistance in a non-English language, if it
applies.
• Explanation of Plan’s Policy regarding Recovery of Overpaid
benefits.
• Explanation of plan’s allocation policy for insurer refunds and
similar payments.
• Discretionary authority to interpret plan terms and resolve factual
disputes.
36. Summary Plan Description
The following additional items must be included in the SPD for
a group health plan:
• Detailed description of group health plan benefit provisions;
• Description of the role of health insurers (i.e., whether a related
insurer actually insures plan benefits or merely provides
administrative services for the plan);
• Description of group heath plan claims procedures;
• Description of effect of group health plan provider discounts;
• Group health plan provider incentives disclosure required.
• Information regarding COBRA coverage; and
• Disclosures regarding other federal mandates.
37. Summary of Material Modifications (“SMM”)
Who must be provided SMM?
Same rules as SPD.
What must the SMM report?
Any “material” change in plan or any change in the information
required in the SPD.
When must it be provided?
Must be furnished within 210 days after the end of the plan year in
which change is adopted.
Special rules for group health plans -– 60 days if change is a
material reduction.
38. • SPD will generally control where it conflicts with plan document.
• What constitutes sufficient conflict for rule?
• Effect of SPD disclaimers.
• Non-SPD summaries do not control over conflicting plan
documents.
• SPD ambiguities may be construed against plan sponsor.
Conflicts Between SPD/SMM & Plan or
Insurance Contract
39. Summary of Benefits and Coverage
• HHS developed standards for plans to use in summarizing plan
benefits and coverage for participants.
• The required summaries will be a short “highlights” description of
the plan.
• It must not exceed 4 pages in length and must not include print
smaller than 12-point font.
• The statute describes the information that must be covered by the
summary.
40. Summary of Benefits and Coverage
Employers and plan sponsors must provide an SBC:
• At annual enrollment.
• At initial enrollment
• At Special enrollment
• Upon Request
41. Summary of Benefits and Coverage
Deadline for summaries of material modification:
A notice of any material modification must be given to participants at
least 60 days prior to the date the plan modification is to become
effective.
42. Summary of Benefits and Coverage
Penalty for failure to provide new summary or SMM:
A penalty of not more than $1,000 may apply for each willful failure
to provide the required plan summary or advance summary of a
material modification.
Each participant who fails to receive a required summary (or
summary of material modification) is counted separately in
determining the amount of the penalty, so it appears that a willful
failure to timely provide 5 participants with a summary could result in
a fine of up to $5,000.
43. Summary of Benefits and Coverage
Standardized definitions:
• HHS promulgate regulations providing for the standardized
definitions of terms used in insured plans.
• The required four-page plan summary discussed previously must
include these definitions, to enable participants to better
understand and compare coverage.
• The terms for which standardized definitions include many
common terms.
44. Other Disclosures
Written requests:
• What must provided?
Copy of SPDs, plan documents, contracts and agreements.
• Must provide within 30 days of request.
• Failure to provide - penalty -$110 per day.
Documents available for inspection:
• At the principal office of the plan administrator or employer (if
different).
• Within 10 days of request.
45. Other Disclosures
Summary Annual Report (SARs)
• Summarizes the information on Form 5500,
• Plan administrator must furnish SARs to participants and others
entitled to receive SPD,
• Provided within 9 months of filing From 5500,
• Information required to be included in SAR is provided in Model
SAR,
46. Reporting Requirements
The plan administrator of each separate ERISA plan must report
specified plan information annually to DOL .
Exemption for certain plans:
• Complete exemption for small unfunded plans.
Plans must have fewer than 100 “covered participants” at start of the
plan year .
• Plans for certain select employees.
• Daycare centers.
• GIAs.
47. Penalties for Non-Compliance
• Penalties apply for late or unfiled Forms 5500s.
• DOL may assess a civil penalty against a plan administrator of up
to $1,100 per day from the date of failure or refusal to file.
• Penalties are cumulative - against each Form 5500 not filed.
• No statute of limitations.
48. How Many Forms are Required?
One form 5500 may be used for multiple ERISA benefits under
single plan.
How many Form 5500s are maintained by more than one employer?
49. Form 5500: When? What? Where?
Due date of return:
• By end of 7th month after plan year, unless extended
• Extended by filing Form 5558 or extending employer’s return.
What must be filed?
• Form 5500
• Schedule A
• Schedule C
• Financial schedules and accountant’s opinion, if funded
Filed with DOL - paper or electronically.
50. Claim Procedures
• ERISA plans must establish and maintain procedures under which
benefits can be requested by participants and beneficiaries and
disputes about benefit entitlements can be addressed.
• Claimant must exhaust plan’s procedures before filing suit.
• If plan has inadequate procedures, claimants may skip
procedures and directly to court.
51. Basic Structure of Claims Procedures
• The basic steps in any claims procedure are:
a claim for benefits by a claimant or authorized representative;
a benefit determination by the plan, with required notification to the
claimant;
an appeal by the claimant or authorized representative of any adverse
determination ;and
the determination on review by the plan, with required notification to
the claimant.
• Procedures can vary depending on the type of claim involved.
• Plan administrator is responsible for complying with procedures.
52. Initial Benefit Claim
• Claim must be in writing.
• Claim must be processed within certain timeframes:
Health
Disability
Other
• Special notice requirements.
53. Processing Initial Claims
Timeframes for deciding claims
URGENT CARE CLAIM ASAP < 72 hours (24 hours) |
no extensions
PRE-SERVICE CLAIM reasonable period < 15 days |
15-day extension w/ notice
POST-SERVICE CLAIM reasonable period < 30 days |
15-day extension w/ notice
CONCURRENT CARE when plan reverses pre-approval, in time to
permit appeal before treatment ends or is
reduced, or when request for extension involves
urgent care, ASAP < 24 hours (if request is
made w/in 24 hours of end of treatment series)
DISABILITY CLAIM reasonable period < 45 days |
two 30-day extensions w/ notice
ALL OTHER CLAIMS reasonable period < 90 days |
90-day extension w/ notice
54. Initial Benefit Claim
All adverse determinations must be in writing, understandable
and must address:
• The specific reasons for the denial and the plan provisions relied
on.
• A description of any additional information required from the
claimant.
• A description of the appeals process.
55. Initial Benefit Claim
A statement that a copy of “internal rules or guidelines” relied on in
denying the claim may be obtained on request and without cost; and
A statement that a written explanation of any “scientific or clinical
judgment” relied on in denying the claim may be obtained on request
and without cost.
56. Appeal Process
• Appeal must be filed at least 180 days after adverse
determination.
• If no appeal, claimant loses right to file further claim with plan or in
court.
• Once appeal is filed, claimant must receive “full and fair review” by
named fiduciary.
• Claimant must be permitted to submit written comments and
access documents.
57. Appeal Process
Adverse determinations must contain the following
information:
• The specific reasons for the denial and the plan provisions relied
on.
• A description of any additional information required from the
claimant.
• A statement of the claimant’s right (discussed earlier) to obtain
relevant documents and other information.
58. Appeal Process
Adverse determinations must contain the following
information:
• A description of any additional required or voluntary appeals and a
statement of the claimant’s right to sue
• For group health and disability claims, a statement that a copy of
“internal rules or guidelines” relied on in denying the claim may be
obtained without cost upon request and
• For group health and disability claims, a statement that a written
explanation of any “scientific or clinical judgment” relied on in
denying the claim may be obtained on request and without cost.
59. Processing Benefit Appeals
Timeframes for deciding claims
URGENT CARE CLAIM ASAP < 72 hours (24 hours) |
no extensions
PRE-SERVICE CLAIM reasonable period < 30 days |
no extensions
POST-SERVICE CLAIM reasonable period < 60 days |
no extensions
CONCURRENT CARE when plan reserves pre-approval, before
treatment ends or is reduced
DISABILITY CLAIM reasonable period < 45 days |
45-day extensions w/ notice
ALL OTHER CLAIMS reasonable period < 60 days |
60-day extension w/ notice
60. External Appeal Process
In the case of most insured plans, the appeals regulations
essentially transfer the external review obligation from the plan itself
to the plan's insurer.
If state insurance law provides an external review process that
includes certain minimum standards under the NAIC Uniform Model
Act, 425 then insurers must comply with the state provisions (and
are not required to comply with the federal external review
procedures established by HHS.
61. External Appeal Process
• In states that do not have a compliant state process, insurers
must comply with a federally administered external review
process.
• Similarly, insurers whose external review processes are found not
to meet the minimum standards under the NAIC Uniform Model
Act must participate in a federally administered external review
process.
• Such insurers may choose to participate in the federal external
review process administered by HHS agreement through the
Office of Personnel Management (OPM), or engage in a private
accredited IRO process meeting the federal external review
standards applicable to self-insured plans
62. External Appeal Process
Federal external review procedures apply to self-insured ERISA
group health plans (and to insurers that are not subject to compliant
state law).
The appeals regulations and subsequent guidance establish
standards that the federal external review procedures must satisfy,
and address what claims are eligible for external review.
63. External Appeal Process
• Claimants must be permitted to request external review with the
plan, provided that the request is filed within four months after the
date of receipt of the benefits denial notice.
• The plan must complete a preliminary review of the claimant's
external review request within five business days after receiving
the request. The preliminary review must determine whether—
the claimant is (or was) covered under the plan when the health care
item or service was requested; for retroactive reviews, the plan must
determine whether the claimant was covered under the plan when the
health care item or service was provided;
the benefit denial does not relate to the claimant's failure to meet the
plan’s eligibility requirements (e.g., worker classification);
the claimant has exhausted the plan’s internal appeals process (unless
the claimant is not required to do so under the appeals regulations);
and
the claimant has provided all the information and forms needed to
process the external review.
64. External Appeal Process
• The plan must assign an accredited Independent Review
Organization(IRO) to perform the external review.
• The plan must also ensure against bias and ensure
independence.
• The plan should contract with at least three IROs for assignments
under the plan and rotate claims assignments among the IROs.
• If the IRO's decision is to reverse the plan's benefits denial, the
plan must immediately provide coverage or payment for the claim.
This includes immediately authorizing or paying benefits.
65. Recordkeeping Requirements
• Specific recordkeeping requirements are imposed.
• Requires retention of records sufficient to document information
that is required by Form 5500.
• Retain the records to document the information on From 5500 for
a period of not less than 6 years after From 5500 is filed or would
have been filed.
66. Who must retain records?
• Those “persons” who have reporting or certification requirements
must maintain records.
• Requirements apply to plan administrator, insurer, TPA and CPA.
• Applies to those plans who do not file Form 5500.
• Responsibilities can not be delegated.
67. What records must be maintained?
• Records sufficient to verify information on Form 5500.
• Records subject to rules are defined broadly and include claims
record.
• Summaries or recaps of actual records are not sufficient.
• Electronic records requirements.