Summary Plan Descriptions (SPD)
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1 Descriptins (SPD) SPDs What Are They and Wh Needs Them? What is an SPD? The DOL defines the SPD as the Primary vehicle fr infrming participants and beneficiaries abut their plan and hw it perates. Must be written fr average participant and be sufficiently cmprehensive t apprise cvered persns f their benefits, rights, and bligatins under the plan. Must accurately reflect the plan s cntents as f the date nt earlier than 120 days prir t the date the SPD is disclsed. Wh needs t prvide SPDs? Plan administratrs. Under ERISA, the plan administratr - nt the insurer r the TPA - is respnsible fr the SPD. This is true even where anther party prepares r distributes the SPD and where that ther party has cntractually bligated itself t perfrm such services. Carriers d nt furnish SPDs. What plans require an SPD? Virtually every emplyee benefit plan. All Health: Medical, EAP, Dental, Health Care FSA, Visin, HRA, Disability & Life/AD&D. Are there exceptins? Yes. Because gvernmental and church plans are exempt frm Title I f ERISA, the SPD requirements d nt apply t them. Als, Cafeteria plans are exempt frm the SPD requirement. (Hwever, cmpnent plans within a cafeteria plan, e.g., health cverage, health flexible spending arrangements, r grup term life insurance, will be subject t ERISA.) Emplyer-prvided day care centers are exempt frm the SPD requirement. An unfunded r insured welfare plan maintained by an emplyer fr the purpse f prviding benefits t a select grup f management r highly cmpensated emplyees wuld nt need t prvide an SPD. Unlike the Frm 5500 exemptin fr small plans, there is n small plan exemptin frm the SPD requirement. Wh receives the SPD? The emplyer must distribute the SPD t all participants cvered under the plan but nt t beneficiaries. Althugh beneficiaries and participants nt cvered by a plan wn t be distributed an SPD, they have a right under ERISA Sectin 104(b)(4) t receive a cpy f the latest SPD after making a written request t the plan administratr.
2 Descriptins (SPD) When must plan participants receive the SPD? Fr a participant newly cvered under an existing plan, an SPD must be autmatically furnished within 90 days after the participant first becmes cvered under the plan. Fr new plans, the plan administratr must autmatically furnish an SPD within 120 days after the plan first becmes subject t ERISA. In additin, a plan administratr must autmatically furnish an updated SPD at least every five years if there have been any material changes made within that five-year perid. If n material changes were made during the immediately preceding 10-year perid, a cpy f the mst recently distributed SPD must be furnished by the plan administratr within 210 days fllwing the last day f the 10th plan year after a material change wuld have been reflected in the mst recently distributed SPD. Wh creates the SPD? There are n mdel SPDs available, as each SPD is unique t the emplyer. An emplyer can create the SPD themselves, emply a TPA, law firm r cnsulting cmpany. If smene ther than the emplyer creates the SPD, the emplyer is still respnsible fr the distributin. The fllwing are the steps t drafting an SPD. Assemble existing dcumentatin: This dcumentatin might include the participant bklet r certificate f insurance; additinal insurer-prvided bklets (insured plans); existing wrap SPDs and Summaries f Material Mdificatin (SMM) prepared by the plan spnsr; the cntract with the insurer; internal dcuments that describe benefits (such as initial enrllment and pen enrllment materials, electin change frms, claims frms, new emplyee infrmatin, and plicies and guidelines fr human resurces and supervisry emplyees); benefit descriptins prepared by an emplyer- r third-party administratr (TPA) (if self-funded); ther TPA dcuments (e.g., a descriptin f the TPA's claims prcedures, a TPA services cntract addressing which party is respnsible fr different aspects f plan administratin); Dcuments abut changes in state and federal law that impact the plan and may need t be described in the SPD; Ntices that have been distributed t emplyees (e.g., COBRA ntices, Ntice f HIPAA Privacy Rights); r Emplyer-related changes (e.g., changes in EIN, plan number r cntact infrmatin; changes in wnership r therwise due t mergers, acquisitins r clsures). Review existing dcumentatin fr ERISA cmpliance; Determine hw many plans exist; Determine what frm the SPD will take (wrap, mega-wrap, stand-alne); Check fr ERISA-required cntent;
3 Descriptins (SPD) Check specifically fr cntent required fr grup health plans; and Review and adpt the plan. Hw are SPDs distributed? SPDs must be furnished in a way reasnably calculated t ensure actual receipt f the material. In additin, because it must be furnished t all participants cvered by the plan an SPD must be delivered using ne r mre methds likely t result in full distributin. An SPD can be prvided in paper frmat as lng as it is free f charge, and can be distributed alng with ther plan materials and cmmunicatins. An SPD can als be prvided electrnically but there are a number f stipulatins: Emplyees must have the ability t effectively access the dcument in electrnic frm at any lcatin where they are emplyed and can access the emplyer s infrmatin system. The emplyer must have prf either electrnically r in writing that the emplyee received it. The file frmat must be easily accessible, such as a PDF file And the SPD must be prvided in paper frmat at n charge, upn request. The SPD can als be psted and available n an emplyer s website as lng as emplyees have been ntified it is there. What must be included in an SPD? Accrding t the Federal Register, 29 CFR , the fllwing infrmatin shall be included in the summary plan descriptin f bth emplyee welfare benefit plans and emplyee pensin benefit plans: 1. ERISA Sectin 102 and accmpanying DOL regulatins require the fllwing items f basic plan-identifying infrmatin t appear in the SPD: The name f the plan; In the case f a single emplyer plan, the name and address f the emplyer whse emplyees are cvered by the plan; The plan spnsr's emplyer identificatin number (EIN) assigned by the IRS; The plan number assigned t the plan by the plan spnsr; The type f welfare plan (grup health plan, disability plan, prepaid legal service plan, etc.); The type f administratin f the plan (e.g., cntract administratin, insurer administratin, spnsr administratin);
4 Descriptins (SPD) The name, business address and business telephne number f the plan administratr as that term is defined in ERISA Sectin 3(16); The name, title and address f the principal place f business f each trustee f the plan (if the plan has a trust); The name f the persn designated as agent fr service f legal prcess and the address at which prcess may be served n such persn. In additin, a statement that service f legal prcess may be made n a plan trustee (if any) r the plan administratr; A statement referring t the cllective bargaining agreement and infrmatin n hw t btain a cpy f that agreement if the plan is maintained pursuant t ne r mre cllective bargaining agreements; and The date f the end f the plan year and whether the recrds f the plan are kept n a calendar plicy r fiscal-year basis. 2. A statement f the eligibility requirements fr participatin and any cnditins that must be met in rder t receive benefits. 3. A general descriptin f the benefits the plan prvides and excludes. 4. A statement clearly identifying circumstances that may result in disqualificatin and ineligibility, and in denial, lss, frfeiture, suspensin, ffset, reductin r recvery f any benefits that a participant r beneficiary may reasnably expect the plan t prvide. 5. Detailed descriptins regarding plan amendment and terminatin, including the fllwing: A clearly stated summary f any plan prvisins gverning the authrity f the plan spnsrs r thers t terminate the plan r t amend r eliminate plan benefits, and the circumstances, if any, under which the plan may be terminated r benefits may be amended r eliminated; A summary f any plan prvisins gverning the benefits, rights and bligatins f participants and beneficiaries under the plan n terminatin f the plan r amendment r eliminatin f benefits under the plan (e.g., a descriptin f any right t btain a cnversin plicy n terminatin f cverage); and A summary f any plan prvisins gverning the allcatin and dispsitin f plan assets upn terminatin. 6. Clear identificatin f circumstances that may result in recvery f benefits by the plan (e.g., by exercise f subrgatin r reimbursement rights). 7. Disclsure f surces f cntributins t the plan (e.g., emplyer cntributins, emplyee cntributins r bth) and the methd by which the amunt f cntributins is calculated. The regulatins als require that SPDs include a summary f any prvisins that may result in the impsitin f a fee r charge n a
5 Descriptins (SPD) participant r beneficiary - the payment f which is a cnditin t the receipt f benefits under the plan. 8. Descriptin f the prcedures t be fllwed in presenting benefit claims and appealing benefit denials. 9. A statement describing the ERISA rights f participants and beneficiaries. Infrmatin if the plan permits recvery f amunts paid in errr (e.g., payments t prviders that shuld nt have received payment). Additinal requirements fr grup health plans: 1. Alng with a general descriptin f benefits, the fllwing infrmatin must als be cntained in a grup health plan SPD: Any cst-sharing prvisins, including premiums, deductibles, cinsurance and cpayment amunts fr which the participant r beneficiary will be respnsible; Any verall r benefit-specific annual r lifetime caps r ther limits n benefits under the plan; The extent t which preventive services are cvered under the plan; Whether, and under what circumstances, existing and new drugs are cvered under the plan; Whether, and under what circumstances, cverage is prvided fr medical tests, devices and prcedures; Prvisins gverning the use f netwrk prviders, cmpsitin f the prvider netwrk and whether (and under what circumstances) cverage is prvided fr ut-f-netwrk services; Any cnditins r limits n the selectin f primary care prviders r prviders f specialty medical care; Any cnditins r limits applicable t btaining emergency medical care; and Any prvisins requiring pre-authrizatins r utilizatin review as a cnditin t btaining a benefit r service under the plan. 2. Descriptin f certain infrmatin when a health insurance issuer is respnsible in whle r in part fr the financing r administratin f a grup health plan. In such a case, the SPD must include a) the name and address f the health issuer; b) whether, and t what extent, benefits under the plan are guaranteed under a cntract r plicy f insurance issued by the health issuer; and c) the nature f any administrative services (e.g., claims prcessing and payment) prvided by the health issuer.
6 Descriptins (SPD) 3. Infrmatin regarding prcedures fr btaining pre-authrizatins, apprvals r utilizatin review decisins. In additin, grup health plans may have multiple claims prcedures requiring descriptin because f the different types f benefits ffered (e.g., pre-service, urgent care, pst service, cncurrent claims) and the different decisins that are cnsidered adverse benefit determinatins fr purpses f the claims prcedures. 4. Infrmatin abut COBRA cntinuatin cverage, including infrmatin cncerning qualifying events and qualified beneficiaries, premiums, ntice and electin requirements and prcedures, and duratin f cverage. 5. A reference t cntinuatin cverage rights that may apply under the Unifrmed Services Emplyment and Reemplyment Rights Act f 1994 (USERRA). Mrever, the existence f numerus federal mandates such as HIPAA, Qualified Medical Child Supprt Orders and thers, as well as requirements under health care refrm, will necessitate special SPD disclsure fr affected grup health plans, either due t express requirements r simply because it makes sense t include descriptins f the applicable rules in a grup health plan SPD. Penalties Criminal penalties including jail time may be impsed n any individual r cmpany that willfully vilates any requirement f Title I f ERISA, which includes the SPD rules. This Legislative Brief is nt intended t be exhaustive nr shuld any discussin r pinins be cnstrued as legal advice. Readers shuld cntact legal cunsel fr legal advice.
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