by Lexi Garcia | Sep 21, 2023 | Blog
QUESTION: At the beginning of the year, we distributed new SPDs to participants in our company’s ERISA-covered group health plan. We are planning to make some changes to the plan’s terms. When and how do we need to communicate these changes to participants?
ANSWER: ERISA requires that participants be notified of any material modification in a welfare plan’s terms or any change in the information required to be in an SPD. This can be done by providing a summary of material modifications (SMM) describing the change. In addition, under a special rule for group health plans, notice must be provided when there is a material modification in plan terms that affects content required to be included in the summary of benefits and coverage (SBC) and is not reflected in the most recently provided SBC. Here is an overview of the SMM rules:
- What Is a “Material” Change? Except for the definition of a material reduction in group health plan covered services (discussed below), there is no guidance regarding when a modification is material. It appears to be a facts and circumstances determination. We suggest that you err in favor of preparing and distributing SMMs.
- Who Must Receive SMMs? SMMs must be provided to the same individuals who must receive SPDs—generally, participants but not beneficiaries. Note that individuals who do not have the right to automatically receive SPDs or SMMs may have the right to receive a copy upon written request to the plan administrator.
- Deadlines for Providing SMMs. The timing requirements depend on the nature of the change. Any modification that is considered a “material reduction in covered services or benefits provided under a group health plan” must be disclosed no later than 60 days after the date the modification was adopted. (If participants regularly receive SMMs at intervals of not more than 90 days, a plan administrator may wait beyond the 60-day limit to describe the modification in the regularly published form.) Reductions in covered services or benefits include, among other things, the elimination or reduction of benefits payable under the plan, a premium increase, and the imposition of new conditions or requirements. For other changes (i.e., group health plan changes that are not material reductions and changes to plans other than group health plans), the SMM must be provided no later than 210 days after the end of the plan year in which the modification or change was adopted. We suggest a common-sense approach to these deadlines—depending on the type of modification, it may be advisable to provide the SMM before the statutory deadline. This is particularly true if the plan administrator wants the modification to apply on its effective date. Delivery methods must comply with the SPD distribution rules. If the change is included in an SPD that is distributed by the applicable SMM deadline, a separate SMM need not be furnished.
- Style and Content. Like SPDs, SMMs should be written in plain language and must comply with general understandability requirements. The SMM also must work in an understandable way with the SPD it is modifying—for example, by clearly identifying the SPD being modified and the affected SPD provisions. The DOL has provided no prescribed format or model language for SMMs. We suggest including the plan name, the SPD to which the SMM relates, a description of the changes (or the language to be substituted in the SPD) and their effective dates, an explanation that the SMM and SPD must be read together and should be kept together, and whom to contact with questions.
Source: Thomson Reuters
by Lexi Garcia | Aug 28, 2023 | Blog
QUESTION: We’ve heard that the rules governing the emergency services covered by our group health plan changed in 2022. What are the revised requirements?
ANSWER: The Affordable Care Act (ACA) patient protections applicable to group health plans that provide benefits for emergency services were revised and expanded for plan years beginning on or after January 1, 2022. The revised requirements are as follows—
- No Prior Authorization. The services must be covered without the need for any prior authorization, even if provided out-of-network.
- No Participating Provider Requirement. The services must be covered without regard to whether the provider is a “participating provider” or “participating emergency facility” (i.e., without regard to whether the provider or facility is in-network or otherwise has a contractual relationship with the plan).
- Limited Out-of-Network Provider Restrictions. If the services are provided by a nonparticipating provider or nonparticipating emergency facility, the restrictions that may be applied are limited. For example, the plan may not impose any administrative requirement or coverage limitation that is more restrictive than the requirements or limitations that apply to emergency services received from participating providers and facilities. And cost-sharing may not be greater than the cost-sharing that would apply if the services were provided by a participating provider or facility. A host of rules regulate the process for plan payments to nonparticipating providers—and the amount that must be paid—including intricate rules for how cost-sharing is calculate.
- Restricted Use of Diagnosis Codes. The plan must not use diagnosis codes as the sole basis for limiting required coverage of an emergency medical condition.
- Limited Application of Other Terms or Conditions. The services must be covered without regard to any other coverage term or condition of the plan, other than the exclusion or coordination of benefits, a permissible waiting period, and applicable cost-sharing.
Source: Thomson Reuters
by Lexi Garcia | Aug 17, 2023 | Blog
QUESTION: How does the annual limit on health FSA salary reductions apply when employees join our company midyear and elect to participate in our health FSA? Does a reduced limit apply to new employees who were participating in their former employers’ health FSAs earlier in the year?
ANSWER: In general, and unless the plan provides otherwise, employees hired midyear may elect to make salary reductions of up to the annual limit, just like employees who are employed for the full plan year. (The limit is indexed for inflation—for $2023 it is $3,050.) Employees who participate in more than one employer’s health FSA during a plan year may make salary reductions of up to the annual limit under each employer’s health FSA unless the employers are treated as a single employer under the Code’s controlled group or affiliated service group rules. (These rules treat two or more employers as a single employer if there is sufficient common ownership or a combination of joint ownership and common activity.) Thus, your company need not apply a reduced limit to a midyear hire who was participating in an unrelated employer’s health FSA before joining your company. Likewise, an employee who works for your company and another unrelated employer at the same time could make salary reductions of up to the annual limit under your company’s health FSA and any health FSA sponsored by the other employer. But if your company and the other employer are members of a controlled group or affiliated service group, then a single limit applies, and the employee’s salary reductions to the two health FSAs must be aggregated.
Of course, employees should minimize their risk of loss by basing their elections on a careful estimate of the eligible medical expenses they expect to incur during their period of coverage. (Grace periods and carryovers are plan design choices employers may make that can also minimize risk of loss for employees.) Employers, too, may wish to minimize their risk of loss by limiting annual health FSA salary reductions to an amount lower than the limit. Note that nonelective employer contributions to a health FSA (e.g., matching or seed contributions, or flex credits) generally do not count toward the limit. However, if employees may elect to receive the employer contributions in cash or as a taxable benefit, then the contributions will be treated as salary reductions and will count toward the limit if contributed to the health FSA.
Source: Thomson Reuters
by Lexi Garcia | Aug 4, 2023 | Blog
QUESTION: Our company sponsors a group health plan that offers coverage to eligible employees and dependent children. We understand that we must make coverage available until a child is age 26. At what point during the month of the child’s 26th birthday is it permissible for our plan to terminate coverage for the child?
ANSWER: Group health plans that offer dependent coverage are required to continue making coverage available for an employee’s child until the child’s 26th birthday—regardless of the child’s residency, financial dependence, student status, employment, or other factors. Your plan will satisfy the dependent coverage requirement if coverage is provided until a child attains 26 years of age. As an example, assume an employee’s child’s birthday is July 17. The plan need only offer coverage for the child through the day before his or her 26th birthday—i.e., July 16.
Keep in mind, however, that if your company is an applicable large employer (i.e., if you employed an average of 50 or more full-time employees (or equivalents) in the preceding year), you could face potential employer shared responsibility penalties if you do not offer coverage to an employee’s child through the last day of the month containing the child’s 26th birthday. Applicable large employers may be subject to these penalties if they fail to offer adequate health insurance to full-time employees “and their dependents.” For this purpose, “dependents” means an employee’s children, but excluding stepchildren and foster children, who are under 26 years of age. Regulations implementing the penalties specifically provide that a child is a dependent for the entire calendar month during which he or she attains age 26. Thus, in the example above, coverage must be offered through July 31 to avoid potential penalties. Absent information to the contrary, employers may rely on employees’ representations concerning the identity and ages of the employees’ children.
Source: Thomson Reuters
by Lexi Garcia | Jul 27, 2023 | Blog
QUESTION: Our company’s major medical plan offers a choice of self-only or family coverage. Dependent coverage is provided under the family coverage option for participants’ children who have not yet reached age 26. May our plan impose an additional premium surcharge for children who are older than age 18?
ANSWER: A premium surcharge for coverage of children over age 18 is not permitted because your plan would be impermissibly varying the terms for dependent coverage of children based on age. The Affordable Care Act (ACA) requires group health plans that provide dependent coverage of children to make such coverage available for a child until age 26. In addition, the terms and conditions under which dependent coverage is provided for children cannot vary based on age, except for children who are age 26 or older. This rule is known as the “uniformity requirement.”
Although your plan may not impose a surcharge for these children, revising or repricing the plan’s coverage tiers without making the structure age-based may allow your company to accomplish the same financial goals. For example, a plan design in which the cost of coverage increases for tiers with more covered individuals would not violate the ACA’s age 26 mandate, so long as the increase applies without regard to the age of any child. Although you did not specify whether your plan is grandfathered, it is important to note that changing coverage tiers can adversely affect a plan’s status as a grandfathered plan.
Source: Thomson Reuters
