Key Actions for Plan Sponsors When Ineligible Employees Are Enrolled in a Health Plan

Key Actions for Plan Sponsors When Ineligible Employees Are Enrolled in a Health Plan

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 However, situations can arise where outdated information leads to ineligible employees being enrolled in the health plan.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employees to remain in the plan for the rest of the plan year can be seen as fair, especially if they relied on the outdated handbook information.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Relief Risk: Be aware of the potential for employees to claim equitable relief for lost benefits due to reliance on the outdated handbook.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

Key Actions for Plan Sponsors When Ineligible Employees Are Enrolled in a Health Plan

IRS Announces 2025 HSA Contribution Limits

The IRS recently announced the 2025 limits for Health Savings Accounts (HSAs) and High Deductible Health Plans (HDHPs). HSA contribution and plan limits will increase to $4,300 for individual coverage and $8,550 for family coverage. Changes to these limits will take effect January 2025.

HSAs are tax-exempt accounts that help people save money for eligible medical expenses. To qualify for an HSA, the policyholder must be enrolled in an HSA-qualified high-deductible health plan, must not be covered by other non-HDHP health insurance or Medicare, and cannot be claimed as a dependent on a tax return.

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Key Actions for Plan Sponsors When Ineligible Employees Are Enrolled in a Health Plan

Understanding IRS Rules: The Importance of Substantiating Health FSA and DCAP Claims


In the realm of cafeteria plans, health Flexible Spending Accounts (FSAs) and Dependent Care Assistance Programs (DCAPs) play a crucial role. However, the process of claim substantiation often raises questions among administrators. This blog post aims to shed light on the IRS rules regarding claim substantiation for health FSAs and DCAPs.

The Necessity of Claim Substantiation

According to IRS rules, all health FSA and DCAP claims must be substantiated. This substantiation requires information from an independent third party describing the service or product, the date of the service or sale, and the amount of the expense. These requirements are designed to ensure that health FSAs and DCAPs reimburse only legitimate claims.

The Role of Debit Card Programs

IRS rules regarding debit card programs also require that claims be substantiated and reviewed. However, certain categories of expenses are treated as automatically substantiated without any receipts or review beyond the swipe.

The Risk of Substantiation Shortcuts

Administrators might be tempted to engage in substantiation shortcuts such as reviewing only a percentage of claims (i.e., sampling) or automatically reimbursing claims that are below a “de minimis” dollar threshold or that appear to be from medical or dependent care providers. However, these actions could jeopardize the income exclusion that would otherwise apply to reimbursements from these arrangements under the Code. This could result in all reimbursements becoming taxable, not just those approved using the impermissible techniques.

The Consequences of Non-Compliance

If a health FSA or DCAP fails to comply with applicable substantiation requirements, all employees’ elections between taxable and nontaxable benefits under the entire cafeteria plan will result in gross income. A March 2023 IRS Chief Counsel’s office memorandum reconfirms the substantiation requirements for medical and dependent care expenses, as well as the prohibition and consequences of sampling and other substantiation shortcuts.

While the process of claim substantiation might seem daunting, it is a necessary step to ensure the legitimacy of claims under health FSAs and DCAPs. Administrators must adhere to IRS rules and avoid substantiation shortcuts to maintain the tax benefits of these programs.

Source: Thomson Reuters

Key Actions for Plan Sponsors When Ineligible Employees Are Enrolled in a Health Plan

Maximizing Employer HSA Contributions: A Comprehensive Guide for Timing Strategies

In today’s ever-evolving landscape of healthcare benefits, Health Savings Accounts (HSAs) have become a cornerstone for both employers and employees. With the rising deductibles of High Deductible Health Plans (HDHPs), employers are increasingly considering making contributions to HSAs to alleviate the financial burden on their workforce. However, the question arises: when should these contributions be made?

Here, we delve into the intricacies of timing employer HSA contributions to optimize benefits for both employers and employees.

Understanding the Contribution Window

HSA contributions for a taxable year cannot precede the start of that year or extend beyond the due date for the account holder’s federal income tax return for that year. Typically, contributions must fall between January 1 of the contribution year and April 15 of the following calendar year.

Factors Influencing Timing

Several factors come into play when determining the optimal timing for employer HSA contributions:

  1. Prorating Based on Employment: Employers may prorate contributions for employees who haven’t worked the full year, either by making contributions ratably over the year or with prorated year-end contributions.
  2. Risk of Overcontribution: Employers need to be cautious of exceeding the HSA contribution limit, which aggregates employer and employee contributions. Delaying employer contributions until year-end can mitigate this risk.
  3. Employer’s Tax Deduction: For corporate taxpayers, the filing deadline without extensions is March 15. Contributions made by this date enable the company to take the deduction on the corporate tax return.
  4. Nondiscrimination Testing: Employer contributions are subject to cafeteria plan nondiscrimination rules, necessitating careful consideration of timing to avoid issues.
  5. Expense-Timing Considerations: Accelerated contributions may be beneficial for employees facing increased out-of-pocket expenses due to higher deductibles. However, this approach comes with its own set of challenges.

Ensuring Compliance and Administration

Cafeteria plan documents may need amending to accommodate new employer contributions, and timely communication with HSA trustees or custodians is crucial for crediting contributions to the correct year.


Navigating the timing of employer HSA contributions requires a nuanced understanding of regulatory requirements, tax implications, and employee welfare. By strategically evaluating these factors, employers can maximize the benefits of their HSA programs while ensuring compliance and efficient administration.

In conclusion, proactive planning and thoughtful execution are key to leveraging employer HSA contributions effectively, ultimately benefiting both employers and employees alike.

Source: Thomson Reuters

Key Actions for Plan Sponsors When Ineligible Employees Are Enrolled in a Health Plan

IRS Reminder: Not All Health Expenses Qualify for Deductions

In a recent news release, the Internal Revenue Service (IRS) has reiterated important guidelines regarding the eligibility of health and wellness expenses for deductions and reimbursements under health Flexible Spending Arrangements (FSAs), Health Reimbursement Arrangements (HRAs), Health Savings Accounts (HSAs), and Medical Savings Accounts (MSAs).

What Qualifies as a Medical Expense? According to the IRS, for an expense to be considered a medical expense under Code § 213, it must be directly related to the diagnosis, cure, mitigation, treatment, or prevention of disease, or must affect the structure or function of the body. This definition excludes expenses that are solely for general health benefits.

The Risk of Nonmedical Reimbursements: The IRS warns that if health FSAs or other account-based health plans reimburse nonmedical expenses, it could result in all plan payments, including those for legitimate medical expenses, being included in participants’ taxable income.

Misleading Claims and the Importance of Diagnosis-Specific Documentation: The IRS has expressed concerns about companies misleading individuals by suggesting that a doctor’s note can transform general food and wellness expenses into medical expenses. However, without a clear connection to a diagnosis-specific treatment or activity, these expenses do not qualify as medical expenses.

Case in Point: The Denied Claim Highlighting the issue, the IRS shared an instance where an individual with diabetes was denied reimbursement for healthy food expenses through his health FSA. Despite obtaining a doctor’s note from a company that advertised such services, the claim was rejected because the food did not meet the criteria for a medical expense.

Guidance for Taxpayers: For those seeking clarity on what constitutes a reimbursable medical expense, the IRS points to its FAQs on nutrition, wellness, and general health expenses. These resources clarify that food or beverages purchased for health reasons, such as weight loss, can only be reimbursed if they do not fulfill normal nutritional needs, are used to alleviate or treat an illness, and are substantiated by a physician’s prescription.

Understanding the fine line between general wellness and medical care is crucial for taxpayers and plan administrators. As the IRS emphasizes, only expenses that meet the stringent criteria set forth in the Code will be considered for deductions and reimbursements, ensuring the integrity of health-related financial plans.

Source: Thomson Reuters

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