Health & Welfare Plan Reporting & Disclosure Obligations

Any Size

SPD

Summary of employee rights and benefits under an employer-sponsored plan. All participants should receive a copy of this within 90 days of becoming covered by the plan and then at least every 5 years after that. Must meet certain content requirements.

Any Size

SMM

Describes material modifications to a plan and reflects changes made to the SPD before the SPD is revised. No later than 210 days after the end of the plan year in which the change is adopted, unless a revised SPD is provided.

Any Size

Notification of Benefit Determination

Claims notices or EOBs.

Any Size

Plan Documents

Must be maintained by the plan administrator (usually the employer) and provided within 30 days of a written request. A copy must be available at the business location. Generally includes, among other things, most recent SPD (and any interim SMMs) and Form 5500 filing, and any contracts or other instruments governing the plan and the plan’s operations. This should be updated annually.

Generally, 100+ participants

Form 5500

Generally, applies to employee welfare plans covering 100 or more employees at the beginning of the plan year must submit this electronically to the DOL by the end of the 7th month after the end of the plan year. A one-time 2½ month extension is available by submitting Form 5558 to the IRS by the date the Form 5500 would have otherwise been due.

Generally, 100+ participants

SAR

Narrative summary of information on Form 5500. Distributed to all participants within 9 months of the end of the plan year, or 2 months after the Form 5500 is due. Not required for a plan under which benefits are paid solely from the general assets of the employer or employee organization.

Any Size

Summary of Material Reduction in Covered Services or Benefits

Summary of group health plan amendments, provided within 60 days of adoption of material reduction in benefits, unless earlier notice is required pursuant to ERISA fiduciary obligation.

Consistent with the SBC requirements (see below), any advance notification of a material modification to the SBC will satisfy this requirement.

20+ employees

COBRA Notices:If you have a COBRA administrator, it is probably handling all these notices on your behalf. However, you should be familiar with the requirements as the employer is ultimately responsible for COBRA compliance. These notification requirements include the following:

COBRA Reasonable Procedures

Included in the SPD and General COBRA Notice.

General COBRA Notice (Initial Notice)

No later than 90 days after the date on which such individual's coverage under the plan commences.

COBRA Election Notice

Within 44 days after the qualifying event date or loss of coverage if provided by the plan.

Notice of Unavailability of COBRA

Notice that individual is not entitled to COBRA coverage. Provided within 14 days after the plan administrator (employer) receives notice of a qualifying event.

Notice of Early Termination of COBRA

As soon as practicable after determining that coverage will end.

COBRA Conversion Notice

Where required, within 180 days of the end of the COBRA coverage period.

Any Size

HIPAA Notices:There are various required notifications and some are issued from the insurer although the ultimate responsibility for disclosure is the plan sponsor’s.

Special Enrollment Rights

Include with enrollment materials.

Notice of Privacy Rights

Include with initial enrollment materials; again within 60 days after a material change; upon request; send a reminder every three years. However, if health benefits are provided through an insurance contract with a health insurance issuer or HMO, the plan must merely maintain a notice and provide such notice upon request.

Wellness Program Disclosure

For plans with a standard-based wellness program. Include in SPD and any materials describing the wellness program.

Any Size

WHCRA Notice

This should be provided upon initial enrollment and on an annual basis.

Any Size

QMCSO or NMS

Includes various requirements when a medical child support order has been received and describes the plan’s qualification process. Should be included in the certificate/SPD.

Any Size

NMHPA (Newborn’s and Mother’s Health Protection Act)

This should be included in the certificate/SPD.

Any Size

Michelle’s Law

If a plan covers dependents past age 26 or certain dependents such as grandchildren based on student status, Michelle’s Law will apply and the disclosure will be required. This disclosure should be included in the certificate and the SPD.

Any Size

Medicare Part D: Participant Notice

Discloses the “creditable” status of prescription drug coverage to participants. Must be provided in specific time frames, including annually and at initial enrollment. Your insurance carrier will let you know if your plan is Creditable or Non-Creditable. It is important to note that the font and page requirements for this notice are very specific, so it is best to use the sample notice from the government website.

Any Size

Medicare Part D: Disclosure to CMS

This disclosure must be sent through the CMS website within the first 60 days of the plan year; within 30 days after termination of the prescription drug plan; and 30 days after any change in creditable status of the prescription drug plan.

Any Size

MSP Reporting

This disclosure is to CMS for purposes of coordination of benefits for Medicare-enrolled individuals. Unless the plan is both self-funded and self-administered, the carrier or TPA will be doing this disclosure.

Any Size

CHIPRA

This notice must go out before the first day of the plan year on an annual basis. Usually included in the enrollment materials. Disclosure to the state Medicaid or CHIP programs must also be completed once model forms are available from the respective states.

Any Size

MHPA/MHPAEA

Employers claiming a cost exemption must provide notice to the DOL and participants.

Any Size

Grandfathered Health Plans

This notice should be provided to all plan participants in all plan materials (including the SPD and enrollment materials).

Any Size

Patient Protection Disclosure

Non-grandfathered plans that require designation of a primary care provider; can be provided with the open enrollment materials.

Any Size

Claims, Appeals and External Review Process

Non-grandfathered plans are subject to new and additional requirements including, among other things, new notices of adverse benefit determinations and external review decisions. These changes should be documented in the certificate of insurance/SPD (self-insured plans need to coordinate with TPAs).

Any Size

Advance Notice of Rescissions

Notice of at least 30 calendar days is required to an individual before coverage may be retroactively cancelled (rescinded). Coverage may only be rescinded in limited circumstances (e.g., fraud).

Any Size

SBC and Uniform Glossary

This is a summary of the health plan benefits that must be provided to all participants and beneficiaries. The DOL provides a model template. Plans must provide to newly eligible individuals (e.g., new hires, special enrollees) and in connection with renewal.

Generally employers filing 250+ Form W-2

W-2 Reporting

Many employers will be required to report the value of health insurance coverage provided to employees on the employee’s Form W-2. Employers that file fewer than 250 Form W-2s for the preceding calendar year are not subject to he report requirement in the current calendar year.

Any Size

Comparative Effectiveness/PCOR Fee

For self funded health plans (including HRAs), there is a fee to fund a Patient-Centered Outcome Research program that equals $1 in the first year ($2 in year two, $2.08 in year three) multiplied by the average number of lives insured under a group health plan policy. Form 720 should be filed each July 31 for the calendar year immediately following the last day of the plan year.

The insurance carriers are responsible for paying and reporting this fee for fully-insured plans.

Expected Sunset - Plans that renew prior ro 10-01-19

All Employers Subject to the FLSA

Notice of Coverage Options

Notice of the new Marketplace, regardless of whether the employer offers a health plan, to each new employee at the time of hire. For 2014, the DOL will consider a notice to be provided at the time of hire if the notice is provided within 14 days of an employee’s start date.

Large Employers

6055/6056 Reporting

First effective in 2016 for the 2015 calendar year:

• A report to the IRS and to a primary insured reporting which individuals are enrolled in minimum essential coverage for individual mandate purposes, handled by the carrier for an insured plan and by the employer for a self-funded plan;
• An information return to the IRS and to all full-time employees that reports the terms and conditions of the employer-sponsored health plan coverage, handled by large employers for employer penalty purposes.

15+ employees for 20+ calendar weeks (current or preceding year)

ADEA (20 employees)

Usually posted.

ADA

PDA

GINA

50+ employees

FMLA Notices

If you have an FMLA administrator, it is probably handling all of these notices on your behalf. However, the employer is ultimately responsible for FMLA compliance. These notification requirements include the following:

General Notice

In addition to the posted notice requirement, notice of employer and employee general rights and responsibilities with respect to FMLA.

Nonpayment of Premiums

When an employee’s premium payment is more than 30 days late and employer intends to drop coverage.

Other Notices

Examples are: Eligibility notice, Rights and Responsibilities notice, Certification form, Designation notice.

Any Size

USERRA Notices

In addition to the posted notice requirement, this notice should be provided at the beginning of any leave for uniformed service and may be provided along with the COBRA election notice.

Any Size

Cafeteria Plans

Written plan document is required if offering benefits on a pre-tax basis. Annual nondiscrimination testing must be performed.

Any Size

Self-Insured Reimbursement Plans

Any self-insured reimbursement plan (e.g., major medical, dental, FSA, HRA) must have a written plan document and is subject to nondiscrimination rules under Code Section 105(h).

Any Size

HIPAA Privacy & Security Policies

All self-insured health plans and fully insured group health plans that create or receive PHI/e-PHI (other than summary information) must implement privacy and security procedures. Does not apply to fully-insured plans that to not create or receive PHI/e-PHI.

Any Size

HIPAA Privacy and Security Plan Amendments

For plans subject to the HIPAA privacy and security rule (see above), ensure plan documents contain information on privacy and security rules rule.

Any Size

HIPAA Business Associate Agreements

Health plans should have business associate agreements with their business associates who use and disclose PHI/e-PHI for certain health plan functions including claims processing, legal advice, consulting and actuarial determinations.

Any Size

Medicare Part D Application for Subsidy

Applies only to retiree health plans providing prescription drug coverage. Plans may apply for a retiree subsidy from CMS within 90 days from the start of the plan year.

Any Size

Record Retention

ERISA plans are subject to record retention requirements. General rule is to retain records for 8 years.

Any Size

Record Retention – Grandfathered Plans

Grandfathered group health plans must retain record of grandfathered status for as long as the plan claims that status.