1, 2, 3 Ways Compliance Makes Brokers Indispensable. Dan Bond, Principal

Transcription

1 1, 2, 3 Ways Compliance Makes Brokers Indispensable Dan Bond, Principal

2 What We Will Cover How Can Broker/Advisers Become Indispensable? 1. Simplify Documentation 2. Simplify Health Care Reform 3. Simplify HIPAA Privacy & Security Compliance Awareness: New Benefit Trends

3 Compliance Opportunities Health Care Reform and compliance complexity are leading more companies to re-think how they administer benefits and to consider outsourcing the function.

4 Reasons for Outsourcing Benefits Administration Large Midsize Ensure compliance 49% 54% Access to knowledge/expertise Reduce admin burden of staff 41% 43% 50% 50% Complexity of health care reform Lack of internal resources/staff 29% 34% 33% 33% Too difficult/complex to handle 20% 32% * ADP Research Institute SM. (2012). ADP Survey Finds Health Care Reform and Increasing Compliance Complexity May Drive Outsourcing of Benefits Administration [Press Release]. Retrieved from

5 Cost Of Compliance in 2013 Plan Admin/Fiduciary Liability Prepare/Distribute Notices Summary of Benefits and Coverage Summary Annual Report Women s Health and Cancer Rights Act Notice Children s Health Insurance Program Notice HIPAA Preexisting Condition Exclusion Notice HIPAA Certificates of Creditable Coverage HIPAA Notice of Privacy Practices HIPAA Preexisting Condition Exclusion Notice HIPAA Special Enrollment Notice Medicare Part D Creditable Coverage Notice Notice of the Health Benefit Exchange Patient Protections Disclosure USERRA Rights Notice Reporting & Disclosure Prepare Disclosure Language/Materials Qualified Medical Child Support Orders Newborns Protection Act HIPAA Nondiscrimination Grandfathered Plan Status Research and Education Working Families Tax Relief Act FMLA Continuation of Coverage On-Site Clinic ERISA Compliance ERISA Safe Harbor Delivery Methods Employee and Dependent Eligibility Requirements Nondiscrimination Rules (beyond HIPAA) Maintaining Grandfathered Plan Status Disclosure COBRA Administration and monitoring Participant tracking Eligibility compliance Send/document notices HIPAA Privacy & Security Implement/Review policies and procedures Risk assessment/breach notification procedures Implement/Review administrative, technical and physical safeguards Audit plan documentation Workforce training Bonding Requirements Every person who handles plan assets Audit Plan Provisions Recordkeeping Requirements Mental Health Parity Act Subrogation Claim Procedures Prohibition of preexisting condition exclusions for enrollee s under 19 Prohibition of annual and lifetime dollar limits Prepare Disclosure Language & Materials Qualified Medical Child Support Orders Newborns and Mothers Health Protection Act HIPAA Nondiscrimination Grandfathered Plan Status Prepare Forms/Report to Government Form 5500 Creditable Coverage to CMS W-2 Reporting Prepare/Distribute Plan Documents Plan Summary Plan Description Summary of Material Modifications Cafeteria Plan

6 Where to Start?

7 1. Simplify Documentation How? Identify ERISA Benefits Combine Plans Where Possible Understand and Utilize Electronic Delivery

8 What is an ERISA Plan? Definition There must be a plan, fund, or program, That is established or maintained by an employer, For the purpose of providing specifically listed benefits, through the purchase of insurance or otherwise, To participants and their beneficiaries.

9 What is an ERISA Plan? ERISA Benefits Medical, surgical, or hospital care Benefits in the event of sickness, accident, disability, death or unemployment Vacation benefits Apprenticeship or other training programs Daycare centers Scholarship funds Prepaid legal services

10 How to ID ERISA Plans 1. List All Plans, Funds, or Programs 2. Disregard Benefits Not Maintained by an Employer 3. Disregard Benefits Not Provided to Employees or Their Beneficiaries 4. Disregard Benefits Exempted From ERISA 5. Disregard Benefits Exempted Under DOL Regulations

11 How to ID ERISA Plans What About?: Voluntary Benefits EAPs Executive Plans Health FSA Health Savings Account (HSA) Business Travel Insurance On-Site Clinics Wellness Plans

12 How to ID ERISA Plans Voluntary Benefit Safe Harbor No contributions by employer Participation is completely voluntary Employer sole functions Collect/remit premiums to insurers Permit insurer to publicize the program Employer receives no consideration ($$) May be reimbursed for administrative expenses

13 Requirements Why Does It Matter? Plan Administrator / Fiduciary Liability Form 5500 Plan Documents ERISA Notices ERISA Disclosures COBRA

14 Who Cares? Department of Labor (DOL) ERISA Audits Health & Human Services HIPAA Audits COBRA Lawsuits Merger and Acquisition Audits Lawsuits Brought by Participants

15 Combine Plans Insurance Policy/Certificate is not an SPD Use wrap document to add ERISA language Bundle Plans Use Mega-wrap (or Umbrella) document Can combine fully insured, self-funded or combination of both

16 Safe Harbor Electronic Distribution Reasonably calculated to ensure actual receipt Methods or attachment to Post to company web site Magnetic disk, CD or DVD

17 Recipients Electronic Distribution Ability to access as part of regular work Access to electronic information system is an integral part of duties Otherwise: Must have consent

18 Electronic Distribution Additional Requirements use return receipt, undelivered feature, or periodic review Provide notice of significance Merely making documents available (e.g., Kiosk) does not ensure receipt Employer must comply with HIPAA if PHI

19 2. Simplify Health Care Reform How? Provide Consistent, Accurate Information Ensure Past Requirements are Covered Put Resources in Place for Near-Term Provisions Put Future Requirements on Employer s Radar Understand Excepted Benefits

20 Health Care Reform Checklist of Requirements Now Effective Checklist of Current/Upcoming Requirements Checklist of Future Requirements Remember Grandfathered Plan Requirements

21 Employers that are Highly Confident of Understanding Responsibilities under ACA 100% 80% 60% 40% 20% 0% Small Midsize Large * ADP Research Institute SM. (2012). ADP Survey: HR and Benefits Decision Makers Believe U.S. Health Care Landscape is Experiencing Profound Change [Press Release]. Retrieved fromhttp://

22 Current/Upcoming Requirements All Plans: W-2 Reporting Summary of Benefits and Coverage Notice of Material Changes PCORI Fee FSA Cap of $2,500 Health Benefit Exchange Notice No Deduction for Med D Subsidies

23 Future Requirements All Plans: 2014 No Annual Maximums No Pre-ex Condition Exclusion No Waiting Period > 90 Days Wellness Incentives up to 30% of Coverage Cost Report to Employees/Govt. if Min. Essential Coverage Automatic Enrollment Play or Pay Penalty Contributions to Reinsurance Program

24 Future Requirements New/Non-Grandfathered Plans: 2014 Clinical Trial Coverage Nondiscrimination in health care providers Cost Sharing Limitations Essential Health Benefits Coverage

25 All Plans: 2018 Future Requirements Excise Tax on Cadillac Plans

26 Watch For Delayed Requirements New/Non-Grandfathered Plans Non-Discrimination Rules for Insured Plans Quality of Care Reporting

27 What If HCR Is Repealed? Broker Advisors are Indispensible with OR without Health Care Reform If ACA Repealed, long (and probably complex) wind-down process

28 3. Simplify HIPAA Privacy/Security How? Limit Access to Protected Health Information (PHI) Know the Difference Between Fully Insured and Self-Funded Plan Requirements Utilize Audit Tools

29 HIPAA Privacy/Security Ask Your Clients (and Yourself): Why Do You Need Access to PHI??

30 Fully Insured Plans Fully Insured Limited Scope Should Only Receive: De-Identified Summary Information Enrollment / Disenrollment Information Always Have Written Authorization If discuss individual claim

31 Fully Insured Plans What to Watch For: Inadvertent Claims Access by Carrier Online or Telephonic Health FSAs Exempt: Self-Administered and <50 Participants HIPAA Compliance: Outsource Administration or >50 Participants

32 Self-Funded Plans HITECH: Follow the Minimum Necessary Standard De-Identified Summary Information Enrollment / Disenrollment Information Claim Appeals: Redacted Information Written Authorization for Claims Involvement

33 Review Vendor Lists HITECH: Updated BA Agreements Broker Adviser TPA COBRA Administrator Auditor Other Consultants Stop Loss: Not Required

34 What s New: On-Site Clinics When is Clinic Benefit an ERISA Plan? Treatment Beyond Minor Injuries/First Aid Primary Care for Illnesses Annual Physicals Wellness Visits Prescription Drugs

35 What s New: On-Site Clinics ERISA Requirements Reporting and Disclosure SPD, Form 5500 Wrap into Existing Documentation COBRA All Eligible Participants

36 What s New: On-Site Clinics Coordination with HSA Disqualifying Coverage Charge at Fair Market Value HIPAA Privacy/Security? Vendor/Provider Responsibility ACA? Typically an Excepted Benefit

37 What s New: Wellness When is Wellness an ERISA Plan? Generally, Wellness Plans that Include a Health Screening are ERISA Plans

38 What s New: Wellness Reporting and Disclosure SPD, Form 5500 Wrap into Existing Documentation COBRA Consider Take Home Kits HIPAA Privacy & Security

39 What s New: Wellness HIPAA Nondiscrimination Limited Reward (20% Now, 30% in 2014) Reasonable Design Annual Opportunity to Qualify Uniform Availability Disclosure of Reasonable Alternatives No Genetic Information Questions on HRA

40 What s New: Wellness Is a Premium Differential Between Smokers and Nonsmokers Allowed? Yes Must Follow Nondiscrimination Rules

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42 Thank You Dan Bond Principal Compliancedashboard, LLC