by admin | Mar 20, 2025 | Blog
Navigating the requirements for Summary Plan Descriptions (SPDs) under ERISA health and welfare plans can be complex. Ensuring compliance is crucial for plan administrators, especially for COBRA qualified beneficiaries. This guide will help you understand who must receive SPDs and the specific considerations for COBRA compliance.
Who Must Receive SPDs?
Plan administrators must automatically furnish SPDs to all participants covered under ERISA health and welfare plans. This includes current employees, former employees who are or may become eligible for benefits, and their beneficiaries.
COBRA Qualified Beneficiaries
COBRA qualified beneficiaries are a key group that must receive SPDs. These individuals have the right to continue their health coverage under the plan after certain qualifying events, such as termination of employment or reduction in hours. Here are the specific considerations:
- Automatic Provision of SPDs: COBRA qualified beneficiaries must receive SPDs automatically.
- Single SPD for Same Address: Separate SPDs are generally not required for qualified beneficiaries living at the same address.
Other Categories of Individuals Who Must Receive SPDs
In addition to COBRA qualified beneficiaries, the following categories must also receive SPDs:
- Employees or Former Employees Covered Under the Plan: Current plan participants and former employees, such as retirees, who remain covered under the plan.
- Alternate Recipients Under QMCSOs: Typically furnished to the child’s custodial parent or guardian.
- Spouses or Dependents of Deceased Participants: Those who continue to receive benefits under the plan.
- Representatives or Guardians of Incapacitated Persons: Sent to the individual’s representative or guardian.
Triggering Events for Automatic SPDs
ERISA specifies the events that trigger the requirement to automatically furnish SPDs. Additionally, SPDs must be provided to plan participants and beneficiaries who request them.
Understanding who must receive SPDs and the specific requirements for COBRA qualified beneficiaries is essential for compliance with ERISA health and welfare plans. By following these guidelines, plan administrators can ensure they meet their obligations and provide necessary information to all eligible participants.
Source: Thomson Reuters
by Lexi Garcia | Sep 26, 2024 | Blog
As the deadline for the 2024 HIPAA Privacy Rule approaches, companies sponsoring ERISA group health plans must take specific actions to ensure compliance. This rule introduces new prohibitions on the use and disclosure of protected health information (PHI) related to reproductive health care, along with new attestation requirements and updates to privacy practices. Here’s a comprehensive guide to help your company navigate these changes.
Modify HIPAA Policies and Procedures
Review and update your HIPAA policies and procedures to align with the 2024 Privacy Rule. Key updates include:
- Definitions: Add or revise definitions of reproductive health care, person, and public health.
- Prohibited Uses and Disclosures: Include language prohibiting the use or disclosure of PHI for:
- Investigations against individuals seeking or providing lawful reproductive health care.
- Identifying individuals for investigation or liability purposes related to lawful reproductive health care.
- Attestation Process: Describe the attestation process and required content for requests related to reproductive health care PHI. Utilize the model attestation form provided by HHS.
- Reporting and Requests: Revise provisions for reporting abuse, neglect, or domestic violence, and for law enforcement administrative requests.
- Personal Representatives: Clarify when to treat a person as an individual’s personal representative.
Conduct Training
Update your HIPAA training programs to incorporate the 2024 Privacy Rule requirements. Ensure that workforce members understand the new processes for handling PHI requests related to reproductive health care.
Review Business Associate Agreements
Examine and update business associate agreements to ensure compliance with the 2024 Privacy Rule. Verify that business associates are adhering to the new requirements.
Update Risk Analysis and Risk Management Plans
- Risk Analysis: Review and update the risk analysis to address the risk of impermissible disclosures of ePHI related to reproductive health care.
- Risk Management Plans: Evaluate and update risk management plans to address identified risks and vulnerabilities.
Conclusion
By taking these steps, your company can ensure compliance with the 2024 HIPAA Privacy Rule to Protect Reproductive Health Care. Staying proactive and informed will help safeguard PHI and uphold the privacy rights of individuals seeking reproductive health care.
Source: Thomson Reuters
by admin | Sep 5, 2024 | Blog
When considering design changes to a self-insured group health plan, it’s crucial to understand the regulations surrounding annual dollar limits on benefits. Specifically, group health plans and insurers are prohibited from establishing annual limits on the dollar amount of essential health benefits for any individual. This means that your plan cannot be amended to impose a $1.5 million annual dollar limit on benefits.
Key Points to Consider
- Prohibition of Annual Limits:
- Since January 1, 2014, group health plans cannot impose annual dollar limits on essential health benefits.
- Essential health benefits include categories such as emergency services, hospitalization, and prescription drugs.
- Permissible Limits:
- While annual dollar limits on essential health benefits are prohibited, limits can be imposed on specific covered benefits that are not considered essential health benefits.
- These limits must comply with other federal and state laws.
- Definition of Essential Health Benefits:
- Essential health benefits encompass a range of categories and services within those categories.
- Self-insured health plans and insured plans in the large group market are not required to cover all essential health benefits but cannot impose annual dollar limits on those they do cover.
- Flexibility in Defining Essential Health Benefits:
- Group health plans not required to cover all essential health benefits have the discretion to define these benefits for the purpose of the dollar-limit prohibition.
- This definition is generally based on any state benchmark plan.
Understanding these regulations is vital for ensuring compliance and making informed decisions about your self-insured group health plan. While you cannot impose an annual dollar limit on essential health benefits, there is flexibility in defining these benefits and imposing limits on non-essential benefits within the bounds of federal and state laws.
Source: Thomson Reuters
by admin | Aug 23, 2024 | Blog
Health plans must communicate effectively with all members, regardless of their language. The Affordable Care Act (ACA) mandates that claims and appeals notices be provided in a culturally and linguistically appropriate manner. Here’s how health plans can meet these requirements.
Key Requirements
1. Population Threshold: If 10% or more of a county’s population speaks a non-English language, notices must include a statement in that language explaining how to get help. This is based on U.S. Census data and updated on government websites.
2. Oral Language Services: Health plans must offer phone assistance in the non-English language to answer questions and help with claims and appeals.
3. Written Notices: All English notices must have a clear statement in the non-English language about how to access language services.
4. Translation Upon Request: Full notices must be provided in the non-English language if requested.
Implementation Tips
- Stay Updated: Regularly check the Department of Labor (DOL) and Health and Human Services (HHS) websites for the latest information.
- Use Provided Language: Utilize the sample statements provided by the agencies to ensure compliance.
- Train Staff: Ensure customer service representatives are trained to assist in multiple languages.
Conclusion
Providing notices in different languages is crucial for fair access to healthcare information. By following these guidelines, health plans can better serve their diverse members and comply with the ACA.
Source: Thomson Reuters
by admin | Jan 25, 2024 | Blog
QUESTION: Our company has just received a letter from a participant in our health plan, asking for copies of numerous documents relating to the plan. What are our responsibilities?
ANSWER: ERISA § 104(b)(4) requires a plan administrator to furnish copies of specified plan documents within 30 days after a written request from a participant or beneficiary. Failure to timely provide requested documents could lead to financial penalties, so it is important to quickly evaluate the participant’s request and provide copies of the documents that are subject to the disclosure obligation. Here are some issues to consider in responding to the request.
- Plan Administrator’s Responsibility. The ERISA disclosure obligation and penalties for noncompliance fall on the plan administrator. Unless the plan document designates a different person or entity, the plan administrator is the plan sponsor, which in a single employer plan is the employer. We assume that your company is the “plan administrator” under ERISA. Courts are authorized, in their discretion, to impose penalties of up to $110 per day for each day that requested documents are not provided, starting on the 31st day after the request.
- Covered Documents. The specified documents that must be furnished upon request are the latest updated SPD (including any interim SMMs); the latest Form 5500; any final Form 5500 for a terminated plan; and any applicable bargaining agreement, trust agreement, contract, or “other instruments under which the plan is established or operated.” It can be challenging to determine what documents fall within the “other instruments” category. This is ultimately a facts-and-circumstances determination. The DOL and the courts have found this category to include plan documents, insurance policies, usual and customary fee schedules and guidelines, TPA contracts (if they affect plan administration), and minutes of plan meetings (affecting plan administration). The plan administrator is generally not obligated to furnish documents that are not within the plan administrator’s possession—for example, an insurer’s or claims administrator’s claim processing guidelines.
- How to Furnish. While the statute specifically refers to mailing requested documents, it appears that, like other ERISA-required disclosures, these documents are to be furnished using a method “reasonably calculated to ensure actual receipt of the material.” This would include any of the methods appropriate for furnishing SPDs, including mail, hand-delivery, or electronically (preferably in a manner that satisfies the DOL’s safe harbor for electronic delivery). A reasonable charge may be imposed for copying (up to 25 cents per page but not more than the actual cost), but not for postage or other tasks associated with handling the request.
Keep in mind that other situations may trigger an obligation to furnish documents to participants or beneficiaries. In addition to the requirement to furnish SPDs and other materials automatically, ERISA’s claims procedure rules require that a claimant be given, upon request and free of charge, “reasonable access to, and copies of, all documents, records, and other information relevant to the claimant’s claim for benefits.” Also, the courts and the DOL have sometimes relied on a generalized fiduciary duty to require that additional information be provided to participants and beneficiaries in individual situations.
Source: Thomson Reuters
