SBAM Health & Welfare Benefits Compliance Checklist Including ERISA, ACA, Section 125, HIPAA, and other applicable federal statutes and regulations

Transcription

1 SBAM Health & Welfare Benefits Compliance Checklist Including ERISA, ACA, Section 125, HIPAA, and other applicable federal statutes and regulations As an employer that sponsors a group benefits program, including health, dental, vision, life and disability insurance, Section 125 (Pre-Tax Premium Payment, Flexible Spending Account, HSA), or a Health Reimbursement Arrangement, you are responsible for maintaining compliance with a wide variety of federal and state statutes and regulations. The checklist we have developed for your review is meant to highlight many of the areas for which are responsible, and is meant to bring to light potential compliance concerns. Checking no on any of the following items highlights an area of concern and should be reviewed. This checklist is not meant to be exhaustive or a safe harbor for compliance, merely a guide to draw attention to potential areas of concern. Compliance Checklist Standard ERISA Documents and Notices Do you have a Summary Plan Description (SPD) for all benefit programs? o Does the SPD include information identifying the plan and plan sponsor, such as: plan name; plan number; plan year; plan sponsor s name, address, telephone number and EIN; and address for process of service? o Does the Summary Plan Description accurately describe your plan s eligibility rules? o Does the Summary Plan Description describe the circumstances under which someone will lose coverage? o Does your SPD accurately describe each benefit provided under the plan, including benefit exclusions, benefit limits, coordination of benefits, and other circumstances under which benefits may be denied or forfeited? o Does the Summary Plan Description include a description of plan amendment and termination procedures? o Does the Summary Plan Description include a description of the plan s rights to subrogation, reimbursement and recovery of overpayments? o Does the Summary Plan Description include a detailed description of the claims and appeal procedures, including the plan administrator s discretionary authority to interpret and administer the plan? o Does the Summary Plan Description include a statement of ERISA rights? o For health plans, does the Summary Plan Description also address the following:

2 Procedures for Qualified Medical Child Support Orders? COBRA rights (if applicable)? Rights to continue coverage during military leave under USERRA? Rights to continue coverage while on FMLA leave (if applicable)? How benefits are funded and the role of and contact information for insurers/third-party administrators? o Do you provide (or does someone provide on your behalf) the necessary annual notices, including: Notice of special enrollment rights? Women s Health and Cancer rights Act enrollment notice and annual notice? Newborns Act notice related to hospital stays? Medicaid or CHIP notice related to premium assistance available? Michelle s Law notice? o If you have more than 100 plan participants, have you filed a Form 5500 for all applicable plan years? If yes, did you provide a Summary Annual Report (SAR) to employees within 2 months of the 5500 filing? Pre-Tax Benefits If employee premium contributions are deducted on a pre-tax basis, do you have a Plan Document and Summary Plan Description (SPD) for a Section 125 plan? o Do employees make annual pre-tax premium elections? o May employees only make mid-year changes to their annual elections if they have a Qualified Change in Status? o If you offer Health and/or Dependent Care Flexible Spending Accounts (FSAs), do you have an up-to-date Plan Document and Summary Plan Description (SPD)? o Do employees make annual FSA elections? o May employees only make mid-year changes to their annual elections if they have a Qualified Change in Status? o If you offer Health Savings Accounts (HSAs), are they included in your Section 125 Plan Document and Summary Plan Description (SPD)? o Are employee contributions to the HSA included in the annual discrimination testing? Complying with non-discrimination requirements: o Are your health and welfare plans designed to avoid discrimination? Do you exclude certain classes of employees entirely from participating in your benefit plans?

3 o Is there a difference in the eligibility rules for different classifications of employees (i.e. part time vs. full time, salary vs. hourly, etc.)? Is there a difference in the available benefits for different classifications of employees (i.e. part time vs. full time, salary vs. hourly, etc.)? Is there a difference in the employee contributions required and/or employer premium subsidy for different classifications of employees (i.e. part time vs. full time, salary vs. hourly, etc.) or based on years of service or income levels? Do highly paid executives receive any benefits not provided to non-highly paid employees? Do different employers within the same controlled group of companies provide different benefits and/or under different terms? Do you conduct the following types of non-discrimination testing? For cafeteria plans: Annual testing to ensure that Key employees are not receiving a discriminatory percentage of pre-tax benefit? Annual eligibility testing to ensure that eligibility rules do not result in disproportionately participation by highlycompensated employees? Annual contribution and benefits testing to ensure that highly-compensated employees do not receive a discriminatory percentage of the pre-tax benefits? For Dependent care FSAs: Annual eligibility testing to ensure that eligibility rules do not result in disproportionately high participation rates by highly-compensated employees? Annual contribution and benefits testing to ensure that highly-compensated employees do not receive a discriminatory percentage of the pre-tax benefits? Annual testing to ensure that more than 5%-owners do not receive more than 25% of the dependent care FSA benefits? Annual testing to ensure that average benefits provided to highly compensated employees are not more than 55% of average benefits provided to non-highly compensated employees? For health plans (medical, dental, vision, HRAs and health FSAs): Annual eligibility testing to ensure that eligibility rules do not result in disproportionately high participation rates by highly-compensated employees? Annual review of plan changes to ensure plan is not discriminatory in operation?

4 COBRA Continuation If you had 20 or more full time employees (or equivalent total hours) on a typical business day in the previous year, you are required to comply with COBRA continuation of applicable benefits to employees with Qualifying Events. Did you have 20 or more full time employees (or equivalent total hours) last year? o If yes, did you provide the following required notices? Initial Notice for all enrolled employees (and their covered family members) when they first became covered under the plan? Election Notice to individuals covered by plan who lose coverage because of a qualifying event (e.g., termination/reduction of hours, loss of dependent status, divorce, etc.) Termination Notice to individuals whose COBRA coverage is ending before the end of the maximum coverage period (18, 29 or 36 months)? HIPAA Medical Privacy Do you offer any self-insured health plan benefits (e.g., medical, dental, vision, Health FSA or an HRA)? If yes: o Do you have written HIPAA policies and procedures that address the following requirements: HIPAA Privacy Policies and Procedures? HIPAA Security Policies and Procedures? HIPAA Breach Notification Policies and Procedures? Have employees received their Notice of Privacy Practices as a newly eligible employee, and then every three years? Do you have a signed Business Associate Agreement (BAA) with your TPA and any other entity that could have access to your employees Protected Health Information (PHI)? Have you obtained a health plan identifier (HPID)? Do your plan documents include mandated provisions requiring the plan sponsor to protect the privacy and security of PHI and implement administrative safeguards preventing use for non-health plan purposes? Affordable Care Act (ACA) Notice and Reporting Requirements Notice requirements for health plans include: o Are you providing an Exchange notice to all newly hired employees? o Do your open enrollment and new enrollment materials include a Summary of Benefits and Coverage (SBC) for each medical plan option that you offer? o If your plan claims grandfathered status, do plan materials include a disclosure of the plan s grandfathered status?

5 o Do plan materials state that the plan does not impose annual or lifetime limits on essential health benefits? o If the plan provides coverage for dependents, do eligibility rules explain the employee s right to cover his or her child through age 26? o If you retroactively terminate someone s coverage, do you provide advance notice of the rescission? o For plans that are not claiming grandfathered status, do plan documents include the following: Description of rights to preventive care services without cost-sharing? Description of annual limits on out-of-pocket expenses? Description of rights to have out-of-network emergency care services covered to same extent as in-network emergency care services? Description of coverage of participation in clinical trials? Description of rights to an external claim appeal once plan s internal appeals process has been exhausted? If the plan requires designation of a primary care provider, an explanation of the participant s right to designate a primary care provider and pediatrician? o Reporting requirements include: If you file at least 250 W-2 forms, does the W-2 include in Box 12, using Code DD, the aggregate cost of employer-sponsored health plan coverage? If you have at least 50 full-time equivalent employees during 2014: Is your payroll system set up to identify full-time employees and whether they are eligible for coverage under your health plan each month during 2015 and succeeding years)? Are you prepared to send 1095-C forms to employees for 2015 in January of 2016? Are you prepared to file 1094-C return and 1095-C forms with IRS for 2015 in February/March of 2016?