Plan Documents, Plan Summaries, Plan Administrators and You Presented by Tom Kramer for the Willamette Valley Association of Health Underwriters

Transcription

1 August 10, 2017 Plan Documents, Plan Summaries, Plan Administrators and You Presented by Tom Kramer for the Willamette Valley Association of Health Underwriters

2 Looking at Me

3 Looking at You

4 Agenda What is a plan document for a health plan? Why have a plan document? What is a summary plan description? What is your role with respect to documents and summaries?

5 Let s Get Started

6 Plan Documents What? Could the plan document be the Insurance policy? TPA agreement? Booklet (SPD or certificate of insurance)? Employee handbook/personnel policies? Could multiple documents be the plan? Can a single document be plan and summary?

7 Plan Documents Why?

8 ERISA Plans must be established and maintained pursuant to a written instrument. ERISA doesn t apply to governmental plans or church plans

9 U.S. Supreme Court 1995 A written plan is... required in order that every employee may, on examining the plan documents, determine exactly what his [sic] rights and obligations are under the plan. This rule applies equally to ERISA and non- ERISA plans

10 No Plan Document Possible Penalties No specific civil penalty (absent unfulfilled request for copy) Possible court order to create document Possible criminal penalties (up to 10 years in prison) for willful violation of ERISA

11 No Plan Document Participant Requests Duty to respond to participant requests ERISA penalty of up to $110 per day if document not provided within 30 days of request Enforcement of plan restrictions

12 No Plan Document Administrative Issues Standard of review Use abuse of discretion standard May not help insurer Ability to amend or terminate Is right to amend or terminate reserved? Reservation may be critical for retiree coverage

13 Wrap Document Why? Simplify response to requests Grant of discretion to plan administrator Single Form 5500 annual report (if required); simpler correction of omission HIPAA privacy provisions

14 Wrap Document Form 5500 Reporting No Form 5500 required for unfunded or insured plans with < 100 participants If no exemption, Form 5500 required for each subject plan Wrap document can be one plan (one 5500) with multiple components (and Schedules) Non-filing penalty now up to $2,097 per day 45 days to supplement rejected, incomplete form

15 HIPAA Privacy Provisions Group health plans may disclose PHI to a plan sponsor for plan administration functions only if the plan document is amended to prohibit improper use of PHI Wrap document may include this provision permitting disclosure to plan sponsor

16 What Should Be in the Plan Document?

17 Obvious Required Plan Provisions Eligibility rules and exclusions Benefits (and exceptions and limitations) Plan administration Provisions required by other laws (COBRA, FMLA, NMHPA, WHCRA)

18 Non-Obvious Required Plan Provisions Named fiduciary Procedure for allocating administrative responsibility Claim and appeal procedures Amendment procedure HIPAA privacy sharing with employer Qualified medical child support orders

19 Plan Documents Suggested Contents Discretionary authority Subrogation, reimbursement, coordination Assignment of benefits Plan termination Governing law No contract of employment No guarantee of tax consequences Plan components (for wrap document)

20 Makes You Think

21 Summary Plan Descriptions Required for virtually all ERISA plans USDOL: The SPD is the primary vehicle for informing participants and beneficiaries about their rights and benefits under... employee benefit plans. Non-ERISA plans will want to disclose, too, but without implying ERISA coverage

22 SPD Obligation Plan administrator is responsible (not insurer or TPA) Administrator should be designated in plan and SPD; if not, administrator is plan sponsor

23 Insurance Booklets May Be Inadequate Administrator responsible for supplementing, as necessary Be careful not to contradict insurance documents

24 What Should Be in the SPD?

25 SPD Contents Formal Information Plan name Plan sponsor Plan number Plan type Plan administration (and plan trustee, if any) Agent for service of process

26 SPD Contents Substance Eligibility (including QMCSOs) Benefits Potential for loss or denial of eligibility or benefits Amendment and termination Subrogation, coordination, offsets, overpayments and assignments Contributions and funding

27 SPD Benefits Provisions Cost-sharing (including premiums, deductibles) Co-insurance and co-payments Coverage of preventive services Coverage of drugs, tests, devices and procedures Coverage of network and out-of-network providers; composition of provider networks Limits on primary care providers, specialists and emergency services Preauthorization or utilization review conditions

28 SPD and Statutory Requirements COBRA FMLA HIPAA special enrollment GINA USERRA NMHPA MHPA WHCRA QMCSOs ACA

29 SPD Miscellaneous Provisions Claim and appeal procedures Statement of ERISA rights Offer of assistance in foreign language, if required Grant of discretion Deference to plan document and insurance documents

30 What to Do?

31 What Is Your Role? Contract with or introduce client to vendors? Provide service yourself? Provide information to client?

32 Creating a Plan Document Does client want or need wrap document? (See slides above) Might wrap vendor offer desired additions? Pre-tax premium documentation? Flexible spending accounts? HRA program? SPD preparation? Statutory notices? Form 5500 preparation? Calendar reminders?

33 Creating an SPD Is there a booklet that is nearly an SPD? Can TPA, you or client supplement booklet? Can wrap plan vendor supplement booklet?

34 Caution About Charging Fees Producers may charge fees instead of or in addition to commissions RCW ORS (no fee for small-group insurance) Both states require disclosure if producer charges fees ORS requires disclosure of services and fees by consultants

35 Thank You! Tom Kramer