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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).
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.
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.
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.
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.
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.
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.
• 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?
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?
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?
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.
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.
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
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
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.
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.
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?
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
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
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.
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.
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.
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.
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.
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.
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.
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
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
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
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
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.
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
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.
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.
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.
• 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
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.
Summary of Benefits and Coverage
Employers and plan sponsors must provide an SBC:
• At annual enrollment.
• At initial enrollment
• At Special enrollment
• Upon Request
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.
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.
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.
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.
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,
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.
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.
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?
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.
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.
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.
Initial Benefit Claim
• Claim must be in writing.
• Claim must be processed within certain timeframes:
 Health
 Disability
 Other
• Special notice requirements.
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
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.
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.
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.
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.
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.
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
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.
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
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.
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.
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.
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.
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.
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.
Questions?
Contact
Larry Grudzien
Phone(708) 717-9638
Email larry@larrygrudzien.com
Site www.larrygrudzien.com

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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.
  • 69. Contact Larry Grudzien Phone(708) 717-9638 Email larry@larrygrudzien.com Site www.larrygrudzien.com