by Lexi Garcia | Jul 11, 2024 | Blog
When it comes to health insurance coverage, understanding special enrollment rights is crucial. In this article, we’ll explore the scenario where an employee previously dropped group health coverage due to obtaining other coverage but subsequently loses that other coverage. Let’s dive in!
What Are Special Enrollment Rights? Special enrollment rights are provisions that allow eligible employees and their dependents to enroll in a group health plan outside of the regular enrollment period. These rights are triggered by specific life events, such as losing other health coverage.
The Scenario: Employee Drops Coverage and Subsequently Loses Other Coverage Imagine an employee who initially enrolled in their company’s group health plan but later dropped the coverage after obtaining other group health coverage through their spouse’s new employer. Now, the spouse’s employment has terminated, and both of them are losing their coverage. Does this situation trigger special enrollment rights under the plan?
HIPAA Requirements: Loss of Eligibility and Other Triggers Under the Health Insurance Portability and Accountability Act (HIPAA), group health plans must provide special enrollment opportunities in certain situations. These include:
- Loss of Eligibility for Other Coverage: If an employee or dependent had other health coverage when enrollment was offered and declined, losing that coverage can trigger special enrollment rights.
- Termination of Employment: Even if an employee didn’t elect COBRA coverage, they still retain their special enrollment right if they lose eligibility due to termination of employment.
Applying Special Enrollment Rights in This Case: In our view, the employee’s circumstance qualifies for special enrollment rights. Here’s why:
- The employee was previously offered coverage but declined it when other health coverage was in place.
- Dropping coverage after enrollment doesn’t change the underlying reason—the existence of other coverage.
Conclusion: Re-Entering the Plan Midyear Given the situation, the special enrollment right for loss of other coverage should apply. Both the employee and their spouse can re-enter the group health plan midyear. Employers should ensure clear communication about these rights to support their employees during critical life events.
Remember, understanding special enrollment rights empowers employees and ensures comprehensive health coverage.
Source: Thomson Reuters
by Lexi Garcia | Jun 27, 2024 | Blog
As a plan sponsor of a self-insured health plan, it’s crucial to maintain accurate records and ensure that all enrolled employees meet the eligibility criteria. However, situations can arise where outdated information leads to ineligible employees being enrolled in the health plan. If you’ve discovered that employees working 25 hours per week have been enrolled based on old handbook information, while your plan documents and Summary Plan Description (SPD) correctly state a 30-hour threshold, swift and strategic action is required.
Immediate Steps for Plan Sponsors
Upon discovering such errors, you must act promptly to minimize complications and potential liabilities. Here are two primary options to consider:
Allow Ineligible Employees to Remain Enrolled:
- Fairness Consideration: Allowing employees to remain in the plan for the rest of the plan year can be seen as fair, especially if they relied on the outdated handbook information. This approach reduces the risk of employees seeking equitable relief due to miscommunication.
- Stop-Loss Insurance Risk: Check with your stop-loss insurer before proceeding. Stop-loss coverage typically adheres to the terms in the plan document, not ancillary documents like handbooks. Without insurer approval, claims from these employees might not be covered under your stop-loss policy.
Remove Ineligible Employees from the Plan:
- Consistency with Plan Terms: Removing these employees aligns with the plan document and SPD, mitigating the risk of significant uncovered claims under your stop-loss policy.
- Prospective Removal: Ensure the removal is prospective, not retroactive, to avoid the impermissible “rescission” of coverage. Retroactive removal could lead to significant legal and ethical issues.
- Equitable Relief Risk: Be aware of the potential for employees to claim equitable relief for lost benefits due to reliance on the outdated handbook.
Ensuring Compliance and Fair Treatment
Consistency is key in handling such situations. Treat all similarly situated employees alike to avoid claims of discrimination under various laws. Disparate treatment can lead to claims of discrimination based on sex, race, age, or health status. Additionally, adhere to the nondiscrimination rules under Code § 105(h) for self-insured health plans.
Discovering ineligible employees enrolled in your health plan requires careful consideration and prompt action. Whether you decide to keep the employees enrolled for the remainder of the plan year or remove them, ensure that your actions are consistent with plan terms and fair to all employees. By addressing the issue swiftly and consulting with your stop-loss insurer, you can mitigate potential risks and maintain the integrity of your health plan.
Source: Thomson Reuters
by Lexi Garcia | Jun 20, 2024 | Blog
When an employee passes away, employers often face challenging questions regarding benefits and compensation. A common question that arises is whether an employer can pay a deceased employee’s unused Health Reimbursement Arrangement (HRA) balance to the surviving spouse. This article delves into the regulations and best practices surrounding HRAs in such scenarios, ensuring compliance and clarity.
HRAs and Their Restrictions
Health Reimbursement Arrangements (HRAs) are designed to reimburse employees for qualifying medical expenses, as outlined in Code § 213(d). Importantly, HRAs are not allowed to disburse cash payments to employees or their beneficiaries at any time, including after the employee’s death. Any attempt to convert HRA balances into cash would disqualify the HRA for all participants, rendering all reimbursed amounts taxable—even those for legitimate medical expenses.
The Concept of Post-Death Spend-Downs
While direct cash payments are prohibited, HRAs can include a provision known as a post-death “spend-down.” This feature allows the remaining HRA balance to be used to cover qualifying medical expenses for the deceased employee’s surviving spouse, tax dependents, and qualifying children. Employers should check their HRA plan documents to see if this feature is included and, if not, consider amending the plan to incorporate it.
Compliance and Nondiscrimination Rules
Amending an HRA plan to include a post-death spend-down feature must comply with several nondiscrimination rules. These rules ensure that benefits are not skewed in favor of highly compensated individuals. Specifically, all benefits provided to highly compensated participants must also be made available to all other participants.
Additionally, IRS Notice 2015-87 casts some uncertainty on whether family members without major medical coverage can utilize a post-death spend-down feature. Until further clarification from the IRS, a cautious approach would be to limit these reimbursements to family members who also have major medical coverage.
Administering Post-Death Spend-Downs
Proper administration of the post-death spend-down feature is crucial. Only qualifying medical expenses for eligible individuals should be reimbursed. Failure to adhere to this can result in all HRA reimbursements becoming taxable, not just those for ineligible expenses. Employers must also remember their obligations under COBRA. If a deceased employee’s death triggers a COBRA qualifying event, then qualified beneficiaries must be given the opportunity to continue their HRA coverage for the duration prescribed by COBRA, regardless of the presence of a post-death spend-down feature.
Conclusion
While it may seem compassionate to pay out a deceased employee’s unused HRA balance to their surviving spouse, doing so would jeopardize the tax-advantaged status of the HRA for all participants. Instead, employers should explore the option of a post-death spend-down feature, ensuring they comply with all relevant nondiscrimination rules and administrative guidelines. By carefully navigating these regulations, employers can support their employees’ families while maintaining the integrity of their HRA plans.
Source: Thomson Reuters
by Lexi Garcia | Jun 13, 2024 | Blog
Introduction
The Consolidated Omnibus Budget Reconciliation Act (COBRA) provides employees with the option to continue health insurance coverage after leaving their job. However, certain circumstances, such as gross misconduct, can affect the availability of this coverage. This blog post explores a unique case where an employee’s gross misconduct was discovered after retirement and the implications for COBRA coverage.
The Case
Three months ago, a bookkeeper retired from a company, electing COBRA coverage under the company’s medical plan. Recently, it was discovered that she had embezzled thousands of dollars during her tenure. The question arose: Could the company retroactively terminate her COBRA coverage due to this gross misconduct?
The Verdict
The short answer is probably not. While COBRA coverage need not be offered to employees terminated due to gross misconduct, in this case, the bookkeeper voluntarily retired and elected COBRA before her misconduct was discovered.
The Legal Perspective
If an employee is terminated for gross misconduct, there is no COBRA qualifying event for the employee or any covered dependents. However, employers should exercise caution when denying COBRA coverage due to gross misconduct. This is because COBRA does not clearly define “gross misconduct,” and courts have not agreed on a common standard. Therefore, denying COBRA coverage due to gross misconduct carries a higher-than-usual risk of litigation.
The After-Acquired Evidence
In this case, the company faces an additional obstacle. While embezzlement likely constitutes gross misconduct for COBRA purposes, the employee’s termination was due to voluntary retirement, not gross misconduct. Courts generally evaluate an employer’s decision to deny COBRA based on evidence available at the time of the employee’s discharge. The use of after-acquired evidence of gross misconduct to justify termination of employment has been rejected by the U.S. Supreme Court and several other courts in the COBRA context. Therefore, it is unlikely that a court would allow COBRA coverage to be terminated—retroactively or going forward—when gross misconduct is discovered after an employee has elected COBRA.
Conclusion
This case serves as a reminder for employers to consult with legal counsel and insurers when considering the denial of COBRA coverage due to gross misconduct. It also highlights the complexities involved in COBRA coverage termination, especially when evidence of misconduct is discovered post-employment. As always, each case is unique and should be evaluated on its own merits.
Source: Thomson Reuters
by Lexi Garcia | Jun 6, 2024 | Blog
Providing a Summary of Benefits and Coverage (SBC) that is culturally and linguistically appropriate is not just a good practice—it’s a legal requirement for many group health plans. Whether your plan is self-insured or fully insured, it’s essential to understand and comply with these regulations to avoid penalties and ensure your members can access and understand their benefits. In this blog post, we’ll break down what you need to know about furnishing the SBC in languages other than English.
Understanding the Requirement
The SBC must be presented in a “culturally and linguistically appropriate” manner. This requirement is part of a broader effort to ensure that individuals who are literate only in a non-English language can understand their health coverage options. The specific conditions under which this requirement is triggered are based on U.S. Census data.
When Does the Requirement Apply?
The requirement applies if your plan’s SBC is provided to individuals in any county where at least 10% of the population is literate only in the same non-English language. The Department of Health and Human Services (HHS) regularly updates a list of such counties and the languages that apply. As of January 1, 2025, a new list will come into effect, and it’s crucial for plan administrators to stay updated with these changes.
Compliance Steps for Group Health Plans
To comply with the “culturally and linguistically appropriate” requirement, follow these steps:
- Identify Applicable Counties: Check the latest HHS list to see if any counties where your plan members reside meet the 10% threshold for non-English language literacy.
- Provide Interpretive Services: In applicable counties, offer interpretive services in the relevant languages. This includes answering questions and providing assistance in the non-English language.
- Include a One-Sentence Statement: On the SBC, include a one-sentence statement in the applicable non-English languages. This statement should clearly indicate how to access language services. It must be placed on the same page as the “Your Rights to Continue Coverage” and “Your Grievance and Appeals Rights” sections.
- Offer Written Translations: Upon request, provide a written translation of the SBC in the applicable non-English language. The agencies have provided an SBC template that includes this one-sentence statement in all required languages for plan years beginning before 2025.
- Stay Updated: Keep an eye on updates from the HHS, DOL, and IRS regarding additional translations and template updates. These resources will assist in maintaining compliance with the latest requirements.
Voluntary Compliance
Even if your plan does not operate in a county meeting the 10% threshold, you may choose to include the one-sentence statement in any non-English language. If you opt for this, ensure you are prepared to provide the necessary language services.
Differentiating SBC Requirements from ERISA
It’s important to note that the requirements for SBCs differ from ERISA’s rules on language assistance for Summary Plan Descriptions (SPDs) and Summary of Material Modifications (SMMs). Ensure you are familiar with both sets of regulations to avoid confusion and non-compliance.
Meeting the requirement for a culturally and linguistically appropriate SBC is vital for compliance and member satisfaction. By following the steps outlined above, your self-insured group health plan can ensure that all members understand their coverage options, regardless of their primary language. Stay informed, be proactive, and provide the necessary language services to comply with federal regulations and support your diverse member base.
Source: Thomson Reuters
