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A self-funded compliance checklist for 2019

Read on for an overview of form filing deadlines and annual communications for self-funded health plans.

In addition to managing employee enrollment and engagement, HR teams and benefits brokers also help ensure health plan compliance with state and federal regulations. To help, our compliance team has created a one-stop resource.

This 2019 compliance checklist provides an overview of form filing deadlines and list of annual communications. For a complete overview of health plan administration compliance, refer to this resource from the Department of Labor. This update provides information of general interest and is not intended as legal or tax advice of any kind.

 

Reports and filings

Action required

Deadline

Furnish Form 1095-C to employees March 4, 2019

Source: IRS Notice 2018-94

File Forms 1094-C / 1095-C with the IRS Paper Filing: February 28, 2019
e-Filing: April 1, 2019Source: IRS.gov
Furnish Form 1095-B to enrollees (self-funded plan) March 4, 2019

Source: IRS Notice 2018-94

File Forms 1094-B and 1095-B’s with the IRS Paper Filing: February 28, 2019
e-Filing: April 1, 2019Source: IRS.gov
File Form 720 and remit final PCORI Fee July 31, 2019

Source: IRS.gov

Form 5500: if Plan has at least 100 employee participants as of first day of plan year The last day of the 7th month after the plan year ends (July 31st for calendar-year plans)

Source: IRS.gov

Massachusetts 1099 January 31, 2019 if reporting amounts in Box 7 (nonemployee compensation)
March 31, 2019 if you are not reporting amounts in Box 7Source: Mass.gov
NY Public Goods Pool Annual Report:

January 30, 2019 (for Covered Period January 1 to December 31, 2018)

Source: health.ny.gov

Monthly Report: on/before midnight, EST, of the 30th day following the report month (adjusted for weekends and holidays)

Source: health.ny.gov (with exact monthly breakdown)

 

 

Plan documents and communications

Disclosure

Timing

Additional notes

Create and distribute Summary Plan Description (“SPD”) to plan participants Annually. Acceptable delivery methods include: first-class mail, hand-delivery, and electronic distribution (if employees have access to computers in the workplace and can print a copy easily).
Notice of Coverage Options Notice must be provided to all new employees. Sample Notices: dol.gov
COBRA Notices General Notice: within first 90 days of coverage Additional resource: dol.gov
Qualifying Event Notice (from employee / beneficiary to Plan): As set forth in SPD
Election Notice: provided by Plan within 14 days of receipt of notice of qualifying event
Notice of Unavailability: provided by Plan within 14 days after request for coverage is received
Notice of Early Termination: as soon as practicable after decision is made
For more details, view an additional resource from dol.gov
Summary of Benefits and Coverage (“SBC”) SBC must be provided to participants and beneficiaries with enrollment materials and upon renewal or reissuance of coverage. SBC must also be provided to special enrollees no later than the date by which an SPD is required to be provided (90 days from enrollment). The SBC and a copy of the Uniform Glossary must also be provided, upon request, within 7 days. Required SBC Template: dol.gov

 

Uniform Glossary: cms.gov

Summary Plan Description (SPD) Furnish 90 days after participant becomes eligible; every 5 years if plan is amended; every 10 years if plan is not amended (unless otherwise directed by the IRS). Resource: dol.gov

 

Required notices

Disclosure

Description

Timing

Grandfather Plan Disclosure/Notice Notice must disclose that the Plan is grandfathered and must include contact information. Notice must be included in any Plan materials describing the benefits or health coverage (often, the SPD).
Genetic Information Nondiscrimination Act (GINA) Notifies wellness program participants what information will be collected, how it will be used, who will receive it, and what will be done to keep it confidential.

Source: eeoc.gov

Employees must receive it before providing any health information, and with enough time to decide whether to participate in the program.
HIPAA (Notice of Privacy Practices for Protected Health Information) The Privacy Rule provides that an individual has a right to adequate notice of how a covered entity may use and disclose protected health information about the individual, as well as his or her rights and the covered entity’s obligations with respect to that information.

 

Source: hhs.gov

A covered entity must:

  • Make its notice available to any person who asks for it.
  • Prominently post and make available its notice on any web site it maintains that provides information about its customer services or benefits.

Health Plans must also:

  • Provide the notice to new enrollees at the time of enrollment.
  • Provide a revised notice to individuals then covered by the Plan within 60 days of a material revision.
  • Notify individuals then covered by the Plan of the availability of and how to obtain the notice at least once every 3 years.
Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA) If you are in a group health plan, the notice will usually be included in the SPD and describe the benefits covered under your Plan.

Source: cms.gov

Typically included in SPD.
Women’s Health and Cancer Rights Act (WHCRA) A statement that for participants and beneficiaries who are receiving mastectomy- related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient. Upon enrollment in the Plan and annually after enrollment in the Plan.
Children’s Health Insurance Program (CHIP) Potential opportunities currently available in the State in which the employee resides for premium assistance under CHIP or Medicaid for health coverage for the employee or the employee’s dependents. May be provided with enrollment packets or the SPD.
Mental Health Parity and Addiction Equity Act (MHPAEA) Claims Denial Notice Notice must provide the reason for any denial of reimbursement or payment for services with respect to mental health/substance use disorder benefits. Notice must be provided to any current or potential participant, beneficiary, or contracting provider upon request.
Internal Claims and Appeals and External Review Notices Plans must provide notice of adverse benefit determination and notice of final internal adverse benefit determination. For plans following the independent review organization (IRO) process, the IRO must issue a notice of final external review decision. For plans following a State process, the state office administering external appeals process for health insurance companies must issue a notice of final external review decision. For internal claims and appeals, timing of the notices vary based on the type of claim. For external review the timing of the notice may vary based on the type of claims and whether the state or the federal process applies.

 

Medicare Part D Creditable Coverage Furnish notice to Medicare-eligible employees.

Source: cms.gov

Prior to October 15th each year and at the following times:

  • Prior to an individual’s initial enrollment period;
  • Prior to the effective date of coverage for any Medicare-eligible individual that joins your plan;
  • Whenever prescription drug coverage ends or changes so that it is no longer creditable or becomes creditable; or,
  • Upon the request of a beneficiary.
Medicare Part D Creditable Coverage Notify CMS by online filing

Source: cms.gov

Annually, no later than 60 days from the beginning of a plan year, within 30 days after termination of a prescription drug plan, or within 30 days after any change in creditable coverage status

 


For additional self-funding resources, access our open enrollment guide designed for HR leaders, or contact our team directly.

 

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