Benefits Check-up: 6 Compliance Issues Affecting Your Clients’ Health

Benefits Check-up: 6 Compliance Issues Affecting Your Clients’ Health

A health plan is more than a product or service; it’s a relationship. All productive and healthy relationships—especially in the benefits space—rely on trust. When an employer extends trust in a broker or insurance carrier to purchase something as critical as healthcare—for people as critical as their workers and families—we’re obligated to raise all factors that affect that purchase.

Assisting employers with benefits compliance requires understanding key benefits laws to effectively engage, educate, and be a better partner to employer clients. The six compliance obligations listed below are just as important to check on when talking with clients about their organizational health.

1. Employee Retirement Income Safety Act (ERISA)

Dating back nearly a half century, ERISA is essentially the heart of benefits law—setting the standards of protection for employees and their families when they enroll in employer-sponsored benefit plans. Meeting those standards can cause a compliance migraine for employers—particularly when it comes to creating, updating, and distributing Summary Plan Descriptions (SPDs).

Compounding the pain, employers might think their SPD will be created by their insurance carrier or broker, but this isn’t typically the case. It’s important that employers understand their responsibility to know which benefits are subject to ERISA rules, to have these documents created through a reputable vendor or an attorney, and to adhere to ERISA’s distribution requirements.

2. Affordable Care Act (ACA)

Upheld after a contentious congressional approval and multiple Supreme Court challenges, this 2010 law changed the landscape of health insurance in many ways, not least of which was creating new compliance obligations for employers. ACA requires employers to distribute a Summary of Benefits and Coverage (SBC) to participants and beneficiaries—including enrolled, nonactive employees—plus additional requirements for ALEs (applicable large employers), those with 50 or more full-time and full-time equivalent employees.

ACA’s hidden health hazard for employers is that the law requires commonly or jointly owned businesses to count all employees together. An HR professional for one business may not know that their employer owns multiple businesses (since commonly owned businesses may not share resources like HR and benefits departments). So, asking about ALE status is an important question brokers and carriers can ask clients as a way to open the conversation about overall ACA compliance obligations.

3. Transparency in Coverage

Signed into law in 2021, the No Surprises Act builds on ACA transparency rules by requiring group health plans to:

  • Post in-network negotiated rates, and out-of-network allowed amounts on a public-facing website.
  • Provide a web-based price comparison tool that allows individuals to estimate their cost-sharing responsibility for a specific item/service from a particular provider.
  • Annually report detailed information related to prescription drug costs, including most frequently dispersed brand-name drugs and most costly drugs.

Although fully insured plans will rely heavily on insurance carriers to make the information available, self-funded groups will bear the compliance obligations. It is critical for plan sponsors to work with carriers and third-party administrators to outline and clearly document who is responsible for each requirement.

4. Family and Medical Leave Act (FMLA)

FMLA, specifically designed to protect employees and their jobs when taking leave to care for themselves or a family member, exposes employers to compliance risk—especially as it pertains to maintaining employee health benefits.

The law requires employers to maintain an employee’s coverage, including employee contributions, as if they had not taken leave, and prohibits benefits termination while on leave except in limited circumstances.

To keep a compliance cold from turning into a full FMLA flu, broker partners must help employer clients understand their FMLA obligations, including: which benefits fall under the group health category, how to collect employee premiums while on FMLA leave, and how to provide mandatory information and notices while an employee is on FMLA leave.

5. COBRA

The Consolidated Omnibus Budget Reconciliation Act (COBRA), passed in 1985, applies to most employers with 20 or more employees that sponsor group health plans. The law is relatively straightforward, a rarity in benefits regulations.

Still, it is imperative to know help clients understand COBRA’s key provisions to effectively support them in meeting compliance obligations, including the rules for removing an ineligible dependent if an employee neglects to notify their employer for six months after a divorce is final.

6. Medicare

As employees stay in the workforce longer, employers must understand Medicare rules related to:

  • Prescriptions—in particular, calculating whether their plan offers creditable coverage (compared to the standard Part D plan) and notifying Medicare-eligible employees about the creditable/non-creditable coverage calculation.
  • Disclosures—specifically, preparing and submitting to CMS (Centers for Medicare and Medicaid Services) disclosure about whether the plan provides creditable coverage.
  • Plan limits for cost-shifting when Medicare-eligible employees have dual coverage. The rules differ for employers with fewer than 20 employees, 20 to 99 employees, and 100 or more employees. For employers with 20 or more employees, Medicare rules limit employer plans as the primary payer from shifting an individual’s healthcare costs onto Medicare. Employers need to understand the interaction between their plan and Medicare to meet their compliance obligations.

It’s important for all parties involved to have a baseline understanding of benefits compliance obligations so they can effectively support employer clients in finding a benefits administration platform, a broker to assist with enrollment meetings, a carrier to find an in-network provider for a specialty service, and other scenarios. Compliance rules and regulations are complex. Partnering with other industry professionals, such as Mineral, is an excellent way to ensure that employer groups are educated, supported, and compliant.

Originally posted on Mineral

Ask the Experts: Flu and FMLA  | CA Employee Benefits Team

Ask the Experts: Flu and FMLA | CA Employee Benefits Team

Question:

Is the common flu considered a serious health condition under the Family and Medical Leave Act (FMLA)?

Answer:

Most cases of the common flu do not meet the definition of “serious health condition” and would not be eligible for Family and Medical Leave Act (FMLA) leave.

Some cases of the flu, however, are severe or result in complications, and these have the potential to meet the FMLA definition of “serious health condition.” This is defined as an illness, injury, impairment, or physical or mental condition that involves inpatient care or continuing treatment by a healthcare provider. Continuing treatment means:

  • The employee has been incapacitated for a period of more than three full days; and
  • Consults with a doctor two or more times within 30 days, or
  • Has one consult with a doctor and a regimen of continuing treatment.

If an employee is out sick with the flu for more than three days, consider whether the need for FMLA leave may exist. This doesn’t mean that you need to go through the whole FMLA process to determine eligibility for each flu absence; just that you shouldn’t automatically reject FMLA requests for the flu either.

Review each case based on the facts, keep the “serious health condition” definition in mind, and if the illness is severe, ask the employee to submit certification from a health care provider to support their need for leave protection under the FMLA.

Originally posted on thinkhr.com

6 Ways to Keep the Flu from Sidelining Your Workplace

6 Ways to Keep the Flu from Sidelining Your Workplace

This year’s flu season is a rough one. Although the predominant strains of this year’s influenza viruses were represented in the vaccine, they mutated, which decreased the effectiveness of the immunization. The flu then spread widely and quickly, and in addition, the symptoms were severe and deadly. The U.S. Centers for Disease Control and Prevention (CDC) reported that the 2017 – 2018 flu season established new records for the percentage of outpatient visits related to flu symptoms and number of flu hospitalizations.
Younger, healthy adults were hit harder than is typical, which had impacts on the workplace. In fact, Challenger, Gray & Christmas, Inc. recently revised its estimates on the impact of this flu season on employers, raising the cost of lost productivity to over $21 billion, with roughly 25 million workers falling ill.
Fortunately, the CDC is reporting that it looks like this season is starting to peak, and while rates of infection are still high in most of the country, they are no longer rising and should start to drop. What can you do as an employer to keep your business running smoothly for the rest of this flu season and throughout the next one?

  1. Help sick employees stay home. Consider that sick employees worried about their pay, unfinished projects and deadlines, or compliance with the company attendance policy may feel they need to come to work even if they are sick. Do what you can to be compassionate and encourage them to stay home so they can get better as well as protect their co-workers from infection. In addition, make sure your sick leave policies are compliant with all local and state laws, and communicate them to your employees. Be clear with the expectation that sick employees not to report to work. For employees who feel well enough to work but may still be contagious, encourage them to work remotely if their job duties will allow. Be consistent in your application of your attendance and remote work rules.
  2. Know the law. Although the flu is generally not serious enough to require leaves of absence beyond what sick leave or PTO allow for, in a severe season, employees may need additional time off. Consider how the federal Family and Medical Leave Act (FMLA), state leave laws, and the Americans with Disabilities Act (ADA) may come into play for employees who have severe cases of the flu, complications, or family members who need care.
  3. Be flexible. During acute flu outbreaks, schools or daycare facilities may close, leaving parents without childcare. Employees may also need to be away from the workplace to provide care to sick children, partners, or parents. Examine your policies to see where you can provide flexibility. Look for opportunities to cross-train employees on each other’s essential duties so their work can continue while they are out.
  4. Keep it clean. Direct cleaning crews to thoroughly disinfect high-touch areas such as doorknobs, kitchen areas, and bathrooms nightly. Provide hand sanitizer in common areas and encourage frequent handwashing. Keep disinfecting wipes handy for staff to clean their personal work areas with.
  5. Limit exposure. Avoid non-essential in-person meetings and travel that can expose employees to the flu virus. Rely on technology such as video conferencing, Slack, Skype, or other platforms to bring people together virtually. Consider staggering work shifts if possible to limit the number of people in the workplace at one time.
  6. Focus on wellness. Offer free or low-cost flu shots in the workplace. If your company provides snacks or meals for employees, offer healthier options packed with nutrients.

Get it all

AGENCY RESOURCES: Get the latest weekly flu stats from the CDC. Learn more about how the FMLA and ADA may be used during pandemic flu from the U.S. Department of Labor.

By Rachel Sobel
Originally published by www.ThinkHR.com