Enhancing Compliance Delivery- Dan Bond, Principal, Compliancedashboard, LLC
Annual
Weekly
Monthly
Employers Need a Process to Cope with
Compliance ChangesDaily
Compliance Changes
Compliance Changes
Compliance Changes
Opportunities
* ADP Research InstituteSM. (2012). ADP Survey Finds Health Care Reform and Increasing Compliance Complexity May Drive Outsourcing of Benefits Administration [Press Release]. Retrieved from http://www.adp.com/media/press-releases.aspx
Too difficult/complex to handle
Lack of internal resources/staff
Complexity of health care reform
Reduce admin burden of staff
Access to knowledge/expertise
Ensure compliance
32%
33%
34%
43%
50%
54%
20%
33%
29%
50%
41%
49%
Large Midsize
Reasons for Outsourcing Benefits Administration
Opportunities
2014 Compliance CostPlan Admin/Fiduciary Liability•ERISA Title I
Prepare/Distribute Notices• Summary of Benefits and Coverage• Summary Annual Report• Women’s Health and Cancer Rights Act Notice• Children’s Health Insurance Program Notice• HIPAA Preex Condition Exclusion Notice• HIPAA Certificates of Creditable Coverage• HIPAA Notice of Privacy Practices• HIPAA Preex Condition Exclusion Notice• HIPAA Special Enrollment Notice• Medicare Part D Creditable Coverage Notice• Notice of the Health Benefit Exchange• Patient Protections Disclosure• USERRA Rights Notice Reporting & Disclosure
Prepare Disclosure Language/Materials• Qualified Medical Child Support Orders• Newborns’ Protection Act• HIPAA Nondiscrimination• Grandfathered Plan Status
Audit Plan Provisions• Recordkeeping Requirements• Mental Health Parity Act• Subrogation• Claim Procedures• Prohibition of preexisting condition exclusions for enrollee’s under 19• Prohibition of annual and lifetime dollar limits
Prepare Disclosure Language & Materials• Qualified Medical Child Support Orders• Newborns’ and Mothers’ Health Protection Act• HIPAA Nondiscrimination• Grandfathered Plan Status
Prepare Forms/Report to Government• Form 5500• Creditable Coverage to CMS• W-2 Reporting
Prepare/Distribute Plan Documents• Plan• Summary Plan Description• Summary of Material Modifications• Cafeteria Plan
Research and Education• Working Families Tax Relief Act• FMLA Continuation of Coverage• On-Site Clinic ERISA Compliance• ERISA Safe Harbor Delivery Methods• Employee and Dependent Eligibility Requirements• Nondiscrimination Rules (beyond HIPAA)• Maintaining Grandfathered Plan Status Disclosure
COBRA• Administration and monitoring• Participant tracking• Eligibility compliance• Send/document notices
HIPAA Privacy & Security• Implement/Review policies and procedures• Risk assessment/breach notification procedures• Implement/Review administrative, technical and physical safeguards• Audit plan documentation• Workforce training
Bonding Requirements• Every person who handles plan assets
Employer Roles
Legal Responsibilities
FiduciaryPlan
Administrator
ERISA
Over Reliance On:
• Insurance Company
• TPA
• COBRA Administrator
Compliance Gaps
Perception of responsibility
Compliance Gaps
Does not match actual legal obligations
Empl
oyee
Issu
es
Law
suits
Aud
its
Doc
umen
tatio
n
Gaps inevitably
result
Compliance Gaps
Where To Start?
“Gov’t agencies will
redouble efforts for
reviewing internal
controls in order to
facilitate compliance”
Compliance Process
• Call to Action
• Progress Tracking
• Audit Reports
Compliance Engagement
Turnkey System
• You Determine Involvement
• Reduce Workload
• Web Based: Easy Updates
Compliance Engagement
Customized Calendar
• Plan Year
• Employer Type/Size
• Plan Type and Coverages
Compliance Engagement
1
2 3
Best Practices
Engage Your Practice
Engage Your Clients
Stay Engaged
• Point Person (Champion)
• Training Plano Account Managerso Producers
• Incorporate in Renewals/Proposals
Let Us Help!!!
Best Practices
1 Engage Your Practice
• Educate
• Develop Rollout Plano Phaseso By Account Managero By Producer
Let Us Help!!!
Best Practices
2 Engage Your Clients
• Compliance Reports
• Compliance Blogs
• Compliance Updates
Let Us Help!!!
Best Practices
3 Stay Engaged
Engage Clients
Tactics
Tactics
Eligibility
Unique Opportunity to Coordinate Plans
Practices & Policies ≠ Contracts & Plan Documents
Clearly Define Participants
Monitor and Enforce Rules
Tactics
Documentation
Who is Preparing Your Clients Documentation?
Documentation Rules the Plan
Health Certificate ≠ SPD
Fill the Documentation Gaps
Tactics
Reporting
Form 5500: Identify ERISA Plans
Identify Roles for Notice Distribution
Identify Roles for Plan Disclosures
Electronic Distribution
Tactics
Health Care Reform
Transitional Reinsurance Fee
Section 6055 & 6056 Reporting
Shared Responsibility Payments
Health Plan Identifiers
Tactics
HIPAA Privacy
Final Rule
Privacy Breach
Business Associate Agreements
Privacy Notice
ERISA Penalties (DOL)
Failure to Furnish DocumentsFor Example: SPDs, SMMs, documentation, Form 5500 or Summary Annual Report (SAR)
Penalty• $110 per day per occurrence after the 30th day of request
Liability• Plan Administrator• Document failures frequently precede lawsuits
o Eligibility, denied claims, lost benefits
ERISA Penalties (DOL)
Failure to Timely File a Form 5500ERISA Plans with 100 or more employee participants at the beginning of the plan year
Penalty• $1,100 per failure per day
Liability• Plan Administrator
Identify ERISA Plans!!
HIPAA Portability & Nondiscrimination (IRS)
Violation of HIPAAFor Example: GINA, Women’s Health and Cancer Rights Act, Mental Health Parity
Penalty• $100 per participant per day during noncompliance
(Form 8928)
Liability• Employer
o Does not apply to Gov’t plans (but possible enforcement by HHS)
HIPAA Privacy/Security/EDI (HHS)
Penalties Scaled Based on Knowledge
Penalty
• $100 - $50,000 per violationo Would not have known with due diligence
• $1,000 - $50,000o Reasonable cause – not willful neglect
• $10,000 - $50,000o Willful neglect – but corrected
• $50,000+o Willful neglect and not corrected
Liability
• Covered entities and business associates
COBRA Penalties (IRS)
COBRA FailureFor Example: timely provide required notices, charge appropriate premiums and provide required levels of coverage
Penalty• $110 per beneficiary per day
Liability• Plan Administrator• COBRA Administrator (if provides benefits and is
responsible under written agreement)
ACA (DOL, HHS, IRS)
ACA FailureACA’s market reforms for health care reform
Penalty• $100 per participant per day during
noncompliance (Form 8928)
Liability• Plan Sponsor• Insurer
ACA (DOL)
SBC FailureTimely distribute a Summary of Benefits and Coverage
Penalty• $1,000 per failure per participant
Liability• Plan Administrator• Fully insured plans may contract with insurance
company
ACA (IRS)
W-2 Reporting FailuresAggregate cost of applicable employersponsored coverage on an employee’s W-2 (250+ W-2s in the preceding calendar year)
Penalty• $50 per statement (same penalty as not
providing a W-2)
Liability• Employer
ACA (IRS)
PCORI Fee FailuresFiled with employer’s Form 720
Penalty• Same penalty as not providing a Form 720
(100% of unpaid tax)
Liability• Employer (sponsor of self-insured plan). Insurer
responsible for PCORI fees under a fully insured arrangement.
DEMO
Advantages
Differentiate Your Service
• Client Retention Tool
• Prospecting Tool
Advantages
Product Markup or Resale
• Additional Income Source
• Fee Based Consulting
Advantages
Information Resource
• Increase Product Knowledge
• Health Care Reform Consulting
Questions
Thank You!
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