Slides - Polestar Benefits

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Slides - Polestar Benefits
Wrap Plan
Document Language
What to Know and What to Watch out For
Reasons for an Employer to create a Wrap
Plan Document and Distribute an SPD

Required by ERISA
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Combines several benefit offerings into one plan for 5500 filing or
other purposes
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Allows employer to define elements that are often inconsistent or
missing in certificates issued by insurance carriers

Allows employer to create plan features that the carrier will not
document in insurance certificate
SPD Content Requirements
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Name of the Plan
Name and Address of the Plan Sponsor
EIN of Plan Sponsor
Plan Number
Plan Year
Plan Eligibility provisions (definition of employee, hours
worked, classification restrictions, waiting periods,
actively at work conditions, retirees)
Type of administration (insured or self-funded)
SPD Content Requirements

Name, address and telephone number of the plan
administrator
Named Fiduciary
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Information about collective bargaining agreements
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Description or summary of the benefits
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Description of QMCSO procedures with information
about how the participants can obtain a full copy without
charge

Cost sharing provisions – premium, copayment
coinsurance, deductible

Annual or lifetime caps or limits
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SPD Content Requirements
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Extent to which preventive services are covered
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Coverage for new and existing drugs
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Whether and to what extent medical devices,
procedures and tests are covered

Composition of the provider network, if any, including
a statement that a list of providers will be provided
without charge upon request

Information about network and out-of-network
coverage
SPD Content Requirements

Conditions for obtaining emergency care

Circumstances which may result in disqualification,
ineligibility, or denial, loss, forfeiture, suspension,
offset, reduction, or recovery
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Authority to amend or terminate the plan
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Statement of ERISA Rights
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Claims Procedures
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Description of COBRA rights
Additional Provisions

Notice of Special Enrollment Rights
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Newborns and Mothers Health Protection Act Notice
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Genetic Information Non-Discrimination Act Notice
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ACA Notices
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Information about Related Employers whose
employees participate

Medical Loss Ratio Rebate Information

HIPAA Privacy wording
Foreign Language Requirements

Foreign Language Requirements

If < 100 employees with > 25% literate only in
same non-English language; OR

If > 100 employees with lesser of 500
employees or 10% literate only in same nonEnglish language, then:

Must include prominent notice, in nonEnglish language, offering assistance
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Assistance does not need to be in writing
Key Things to Think about
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What documents are part of the Plan?
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Are the documents consistent?

SPD, certificate or evidence of coverage, wrap SPD,
employment policies
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If not which one supersedes the other?

Are terms repeated or incorporated by reference?
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Is it clear who can be covered and when coverage begins
and ends?
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Have the documents been distributed as required by
ERISA?
Potential Problems

No SPD
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Conflicting Terms

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Eligibility
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Continuation of Coverage
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Termination
Missing Information
Penalties

No specific penalties in ERISA, but could be fines as part of DOL
audit

Plan participants and beneficiaries may bring a civil action

Plan Administrator may be fined up to $110 per day for failure to
provide a plan document or SPD within 30 days of a request by a
participant or beneficiary

Plan Administrator may be fined up to $110 per day for failure to
provide a SPD within 30 days of a request by the DOL

Criminal penalties may be imposed on any individual or company
that willfully violates any requirements of Title I of ERISA

Up to $100,000 per conviction ($500,000 for a company);

Up to 10 years in prison; or

Both
Questions? Comments?
Polestar Benefits, Inc.
412 Jefferson Parkway, Suite 202
Lake Oswego, OR 97035
(855) 222-3358
www.polestarbenefits.com
We are happy to help!
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