by Lexi Garcia | Apr 27, 2023 | Blog
QUESTION: Due to the COVID-19 emergency, we have been required to extend deadlines for participants and beneficiaries to submit claims and appeals under our employee benefit plans. How does the end of the COVID-19 national emergency affect these extensions?
ANSWER: As you note, various plan-related deadlines have been extended—but for no longer than one year—by disregarding (tolling) the COVID-19 “outbreak period,” which ends 60 days after the end of the national emergency unless another end date is announced by the agencies. The COVID-19 national emergency ended on April 10, 2023. Although 60 days later would be June 9, 2023, the DOL has informally commented that, consistent with FAQs issued in March 2023, the outbreak period will end on July 10, 2023.
The outbreak period relief extends the deadlines for individuals to file claims for benefits and appeals of adverse benefit determinations under employee benefit plans that are subject to ERISA or the Code—including group health plans, disability and other employee welfare benefit plans, and retirement plans. For group health plans, the extension also applies to deadlines for requesting external review following exhaustion of the plan’s internal appeals procedures and for perfecting an incomplete request for review. The disregarded period lasts until the earlier of (1) one year from the date the individual was first eligible for outbreak period relief, or (2) the end of the outbreak period. Once the disregarded period has ended, the regular timeframes resume. Thus, the extended deadline must be determined on an individual basis. For example:
Alex, a participant in a group health plan that normally requires claims to be submitted within one year after the date of service, received medical care on July 1, 2022. The disregarded period begins on the service date (July 1, 2022) and ends on the earlier of one year later (July 1, 2023) or the end of the outbreak period (July 10, 2023). Thus, the plan’s regular one-year timeline begins to run on July 1, 2023, so the deadline for Alex to submit a claim is July 1, 2024. For medical care received on August 1, 2022, the disregarded period would end on July 10, 2023 (the earlier of the end of the outbreak period or one year after the service date), and then the plan’s regular one-year timeline would begin to run, so the deadline for submitting a claim would be July 10, 2024.
Note that a different interpretation of the extension—applying the plan’s timeline first and the outbreak period relief after the end of the regular timeline—would produce a different result in some circumstances. Applying this interpretation to the first example above, the claim submission deadline would be July 10, 2023 (the earlier of July 10, 2023, or one year after the July 1, 2023, regular claim submission deadline). Given that the agencies, in the FAQs, encouraged plans to allow participants and beneficiaries more time to act, it seems advisable to take the approach that results in the later deadline. In any event, clear communication and consistency in application will be important.
Although plans were not expressly granted more time to process and decide claims, the DOL recognized that the COVID-19 emergency may present challenges in achieving “full and timely compliance” with ERISA’s claims procedure requirements and said that its approach to enforcement would emphasize compliance assistance. But at this late stage of the pandemic, it seems unlikely that the DOL would grant plans much leeway in this regard.
Source: Thomson Reuters
by Lexi Garcia | Mar 31, 2023 | Blog
QUESTION: One of our employees just noticed that her 2023 pay reflects a salary reduction for DCAP benefits. Initially, she said she never elected DCAP benefits. But when we showed her the DCAP election on her election form, she responded that she had made a mistake in completing the form and asked if we could fix it. Can we do this under the IRS rules?
ANSWER: Possibly, if you conclude that (1) there is “clear and convincing evidence” that your employee made a mistake; (2) the mistake is of a type that can be corrected; and (3) the correction is appropriate. (You may need more information before you can reach these conclusions.) While IRS cafeteria plan regulations do not address election changes for mistakes, IRS officials have informally commented that an employee’s election may be undone when there is clear and convincing evidence of a mistake. Some plans use an “impossibility” approach for evaluating whether such evidence exists, while others use a “facts and circumstances” approach. When the impossibility approach is used, an election change is allowed only if the evidence indicates that it was impossible for the employee to benefit from the mistaken election. For example, you could undo your employee’s DCAP election if she has no qualifying individuals. This approach is more cautious and is easier to administer because it does not involve examining an employee’s intentions or motives.
With the facts-and-circumstances approach, mistakes may be corrected if the plan administrator can reasonably ascertain that a mistake actually occurred. (This may involve inquiry into an employee’s intentions.) When this approach is used, we suggest adopting and consistently following written guidelines that require consideration of factors such as the employee’s past elections and benefit usage (e.g., whether your employee has elected DCAP benefits in the past or has consistently used her spouse’s DCAP); plausible evidence of a clerical mistake (e.g., an employee might easily write $5,000 instead of $500, but it is less likely that $5,000 was written instead of $2,400); assessment of the employee’s truthfulness; proximity to the first payroll date after the new election is in force; and any change in the employee’s circumstances that might indicate reconsideration rather than mistake. In addition, we suggest obtaining a signed certification from the employee describing the mistake and the intended election (e.g., if she intended to elect health FSA benefits instead, the appropriate correction would be an election of such benefits). A plan might also establish a time limit for requests to correct mistaken elections.
Under either approach, if the clear and convincing standard is met, an employee’s clerical, arithmetic, and data-entry errors may be corrected retroactively. (Note that the correction may also involve correcting mistaken payroll withholding.) But mistakes as to a benefit’s scope or tax treatment generally cannot be corrected. For example, your employee could not change her election because she mistakenly believed that the DCAP provided greater tax savings than the dependent care tax credit.
To reduce the likelihood of election mistakes surfacing after the plan year has begun, many employers provide employees with written confirmation of their elections after open enrollment and before the beginning of the new plan year. Employees are instructed to review their elections and notify the employer before the plan year begins if any corrections are needed.
Source: Thomson Reuters
by Lexi Garcia | Mar 23, 2023 | Blog
The IRS has issued FAQs that explain when certain costs related to nutrition, wellness, and general health are medical expenses under Code § 213 that may be paid or reimbursed under a health FSA, HSA, or HRA. As background, Code § 213 defines medical care as amounts paid for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting a structure or function of the body. The FAQs explain that medical expenses must be primarily to alleviate or prevent a physical or mental disability or illness, and do not include expenses that are merely beneficial to general health.
The FAQs confirm that the costs of dental, eye, and physical exams are medical expenses that can be paid or reimbursed by a health FSA, HSA, or HRA because these exams diagnose whether a disease or illness is present. The costs of smoking cessation programs and programs that treat drug-related substance use or alcohol use disorders are also medical expenses because they treat a disease. For the cost of therapy to be a medical expense, the therapy must treat a disease—thus, amounts paid for therapy to treat a diagnosed mental illness are medical expenses, while amounts paid for marital counseling are not. Likewise, the costs of nutritional counseling and weight-loss programs are medical expenses only if the counseling or program treats a specific disease diagnosed by a physician (e.g., obesity or diabetes); otherwise, these costs are not medical expenses. The cost of a gym membership is a medical expense only if the membership was purchased for the sole purpose of affecting a structure or function of the body (e.g., a prescribed plan for physical therapy to treat an injury) or treating a specific disease diagnosed by a physician (e.g., obesity or heart disease). However, the cost of exercise for the improvement of general health is not a medical expense, even if recommended by a doctor.
The FAQs also explain the circumstances under which the cost of food or beverages purchased for weight loss or other health reasons will qualify as medical expenses, and that the cost of non-prescription drugs can be paid or reimbursed by a health FSA, HSA, or HRA even though these items (except for insulin) are not deductible under Code § 213. The FAQs confirm that the cost of nutritional supplements is not a medical expense unless the supplements are recommended by a medical practitioner as treatment for a specific medical condition diagnosed by a physician.
Source: Thomson Reuters
by Lexi Garcia | Mar 21, 2023 | Blog
QUESTION: Our company sponsors a high-deductible health plan (HDHP) in conjunction with employee HSAs. Can the medical expenses of our employees’ adult children who otherwise qualify for tax-free coverage under the HDHP be reimbursed tax-free from the employees’ HSAs?
ANSWER: Not necessarily—it depends on whether the adult children qualify as tax dependents under the HSA rules. As group health plans, HDHPs that provide dependent coverage of children must make the coverage available until a child turns age 26. (The age 26 mandate does not generally apply to HSAs because they are not group health plans.) The income exclusion for employer-provided health coverage includes employees’ children who are under age 27 as of the end of the taxable year, regardless of whether those children qualify as tax dependents. But similar provisions do not appear in the HSA tax-free reimbursement rules. Instead, whether an adult child’s medical expenses can be reimbursed tax-free from a parent’s HSA depends on whether the child qualifies as a tax dependent for HSA distribution purposes—i.e., whether the adult child is a qualifying child (for example, due to disability) or a qualifying relative (where the parent provides over one-half of the child’s support). Distributions from a parent’s HSA that reimburse a nondependent adult child’s medical expenses are taxable and may be subject to an additional 20% tax.
Thus, the medical expenses of some adult children who are enrolled as dependents in your company’s HDHP will not qualify for tax-free reimbursement from the employee-parent’s HSA. It is possible, however, that these children may be HSA-eligible themselves. If they cannot be claimed as tax dependents and they meet the other HSA eligibility requirements, they could open HSAs of their own.
Source: Thomson Reuters
by Lexi Garcia | Mar 9, 2023 | Blog
HHS has proposed regulations that would adopt a set of standards for the electronic exchange of clinical and administrative data to support prior authorizations and health care claims adjudication. As background, HIPAA requires that covered entities (and their business associates) comply with rules designed to standardize the format and content of specified electronic transactions. Specifically, the proposed regulations would adopt standards for “health care attachments” transactions that would support both health care claims and prior authorization transactions, along with a standard for electronic signatures. Regulations proposed in September 2005 would have adopted certain standards for health care attachments but were never finalized.
Explaining that the prior regulations were not finalized due to comments about the standards’ “lack of technical maturity and stakeholders’ lack of readiness to implement electronic capture of clinical data,” the preamble to the new proposed regulations notes that despite the subsequent widespread deployment of electronic health records and greater industry experience with the HIPAA standards, transmitting health care attachments is still primarily a manual process. The preamble provides detailed information about the organizations responsible for developing and maintaining the transactions standards and advises that the timing for implementation is right because the industry consensus-based standards are now mature, and covered entities are ready to implement them. The regulations do not propose to adopt attachments standards for all health care transaction business needs. Instead, the approach is for covered entities to gain experience with several standard electronic attachment types so that technical and business issues can be identified to inform potential future rulemaking for other electronic attachments standards.
Source: Thomson Reuters
