Self-Insured Group Health Plans: Key Benefits Compliance Considerations

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Amber Posthauer: Thank you for joining us today. We're going to get started here in 60 seconds to allow for

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Amber Posthauer: Get connected. We'll get started.

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Amber Posthauer: Welcome, everyone, to Self-Insured Group Health Plans, Key Benefits Compliance Considerations.

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Amber Posthauer: Thank you all so much for joining us.

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Amber Posthauer: The Benefits Compliance team will be answering the questions you send through the Q&A today. We'll try our best to answer all of your questions, but if for whatever reason we're unable to get to your question today, please follow up with your advisor for further assistance.

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Amber Posthauer: Today's presentation is being recorded. We'll be sharing the recording in the follow-up email and on the NFP website. If there are any portions of this call that you missed, by Monday, you'll receive an email with a link to the full recording. The PowerPoint slides used during this presentation will be shared in the same email. At this time, I'll hand it over to Carol Wood, Vice President and Counsel of NFP Benefits Compliance.

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Amber Posthauer: Abramson, Regional Vice President and Counsel of the Atlantic Region of NFP Benefits Compliance, and Aaron Shea, Vice President and Managing Consultant and Regional Operations Leader of Corporate Benefits at NFP. Carol, I'll turn it over to you now.

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Carol Wood: Thank you so much, Amber, and thank you, everybody, for joining us this afternoon. I'll be co-presenting today with my colleague, Roger Abramson from the Larger Benefits Compliance Team, and we're thrilled to have Erin Shea joining us. She's worked with many employers.

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Carol Wood: who are considering self-insuring, or self-insuring their group health plans now, with their compliance issues. So she'll be joining and providing commentary throughout.

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Carol Wood: And before we begin, we do need to remind you that this presentation is intended to be used for general guidance purposes only. It's not intended as tax or legal advice.

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Carol Wood: Any question regarding the application of the law to your specific benefit should always be addressed to your legal or tax counsel, and this information is current as of today, June 17th, 2026.

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Carol Wood: Now, the agenda follows our new publication on self-insured group health plan.

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Carol Wood: compliance considerations. So we'll be discussing first the decision to self-insure. Now, this particular section is designed, perhaps a little more for the employer who… who hasn't, who's still fully insuring, and they haven't, transitioned over to self-insuring.

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Carol Wood: But they want to, to know the factors that they should be considering. So we'll touch on, on things like cost comparisons, risk tolerance, stop loss insurance. Then Roger will be discussing the plan sponsor's role. You know, this expands with self-insuring.

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Carol Wood: big factors are the ERISA fiduciary duties, which include vendor selection and claims governance. Then I will touch on the… some main plan design considerations under ERISA, the ACA,

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Carol Wood: the mental health parity rules, and also Section 105 non-discrimination rules. Roger will then highlight some plan implementation considerations, primarily COBRA,

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Carol Wood: and HIPAA privacy and security requirements, and then we'll wrap it up with some distinctions and disclosure and reporting obligations for self-insured plans.

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Carol Wood: Okay, and one thing I want to mention,

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Carol Wood: before we begin this first section, is that we're covering a lot of material, and we're going to be doing it quickly, and at the end of each section.

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Carol Wood: We do have a checklist that summarizes it. In the interest of time, Roger and I are not going to run through that, but know that it's there. And we also have, at the end of the presentation, a list of publications that go into more depth

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Carol Wood: on some of the compliance topics that we'll be touching upon. So know those resources are available.

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Carol Wood: Let's start just by defining self-insurance. What is self-insurance? Self-insuring means the employer, and not an insurer or other third party, is directly responsible for paying participants' healthcare claims.

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Carol Wood: So this means the employer is assuming the risk of paying claim costs, which are variable, instead of fixed premiums to the carrier.

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Carol Wood: Self-insuring eliminates certain costs that are baked into the

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Carol Wood: The fully insured plan premium, such as the insurer's profits and state premium taxes, but there are new considerations, such as administrative expenses and also stop loss coverage.

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Carol Wood: Stop-loss coverage that we'll be discussing is a type of reinsurance that provides some financial protection against higher-than-expected claims.

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Carol Wood: And with self-insuring, one of the benefits is that the plan design can usually be more customized,

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Carol Wood: Because the self-insured plan isn't subject to coverage mandates any longer that fully insured plans are. So this means the employer can maybe have more exclusions or limitations on certain benefits, or carve out programs, such as pharmacy benefits.

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Carol Wood: Importantly, and we'll be emphasizing this point, the employer assumes heightened fiduciary and compliance obligations. Our emphasis on that is no…

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Carol Wood: By no means intended to discourage employers from self-insuring, but we think it's important that employers understand the compliance obligations so they can successfully implement and maintain that self-insured plan.

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Carol Wood: And just one note, although level-funded plans often appear like fully insured plans, for compliance purposes, they are considered self-insured plans. So when we reference obligations throughout this presentation of self-insured plans, we are referring to level-funded plans in that category.

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Carol Wood: And this is just a chart if you want a comparison between fully insured and self-insured plans and the concepts that we just discussed, so I won't review that again.

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Carol Wood: For the employer who's considering self-insuring, one of the first questions they're going to ask is, you know, what are the projected self-insured plan costs going to be?

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Carol Wood: And in estimate, we normally take into account what we call projected matured plan claims, administrative expenses, and stop loss premiums, among some other items. The projections are typically built by analytics teams, underwriters, in some cases, actuaries.

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Carol Wood: And the projections are based primarily on historical claims history. Sometimes it may be, say, for a 3-year period, and factors such as the plan design, demographics, and expected costs and utilization trends.

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Carol Wood: Now, in some cases, claims history, coming from fully insuring may not be available because the carrier can't or won't provide it. So in those cases, there are resources like carrier manuals and the fully insured rates.

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Carol Wood: That may assist. The bottom line here is that, the projections are designed to show the employer weather over the long term.

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Carol Wood: The self-insuring will likely cost more or less than continuing to pay fully insured premiums.

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Carol Wood: The employer also has to consider their risk tolerance and understand the cash flow dynamics of self-insuring.

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Carol Wood: We've said self-insuring removes the insurer as the buffer against claims exposure.

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Carol Wood: So employers need to have the financial ability to handle claims and cash flow volatility.

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Carol Wood: Smaller plans generally face greater volatility and financial risk because one or two high-cost claims can materially affect costs. Larger plans are better able to absorb the variability.

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Carol Wood: Monthly claims can vary significantly, and employers must plan for unexpected spikes. Well, how do they plan?

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Carol Wood: This is where a concept, the concept of, IBNR awareness comes into play. IBNR stands for incurred, but not yet reported, meaning payable claims.

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Carol Wood: So there's normally a lag time between when a claim is incurred and when it's payable. Depending on the type of claim, it could be even a few months. So, employers really need to have budgeting discipline.

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Carol Wood: and be prepared to pay those IB&R claims when they become payable, and usually this means they must establish a reserve to fund those claims. And just a note for an employer who's newly self-insuring.

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Carol Wood: They may notice in the first few months, wow, there's really low claims, but, you know, before they get too gleeful about it, it's normally not due to favorable claims experience necessarily, it's just that, that delay, because the claims have not yet become payable.

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Carol Wood: Okay, let's take a look at the role of stop-loss coverage. As I mentioned earlier, it's reinsurance that limits the employer's exposure to higher-than-expected or catastrophic claims. Now, there's no requirement that an employer obtain stop-loss coverage, but almost all employers that self-insure choose to do so. How does it work? The carrier reimburses the employer

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Carol Wood: Or the plan, in most cases, the contract is with the employer, for claims above an agreed-upon attachment point.

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Carol Wood: That attachment point is a claims threshold. It can be per participant, or an aggregate one, meaning the total plan-wide, or both in many cases.

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Carol Wood: The policy can be standalone, or in some cases, built into the TPA service agreement.

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Carol Wood: In the end, though, the employer and not the carrier remains ultimately responsible for paying participant claims. So what does that mean when we're reviewing a policy? It's important to, of course, weigh not only the pricing, but look at the carrier reputation, financial rating.

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Carol Wood: Review the specifics of the coverage period and benefits, identify exclusions and lasers on high-cost individuals. So lasers would be a higher, a higher,

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Carol Wood: Attachment points that are set on high claimants.

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Carol Wood: Consider engaging consultants with specialized expertise to assist with screening policies. You may want to ask your broker or consultant about NFP's Stop Loss Center of Excellence, who can provide assistance in that area.

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Carol Wood: And very importantly here with stop loss coverage, it's crucial that the policy that you do select is coordinated with your plan document's eligibility rules.

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Carol Wood: And Erin, with that, I'm going to turn the next slide over to you to explain why that last point is so important.

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Erin Shea: Yes, thank you. So, what we have seen, obviously, with trends increasing, is more and more

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Erin Shea: Individuals hitting those stock loss levels.

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Erin Shea: And at that point, when somebody hits the stop loss level, the stop-loss carrier is going to reach out and ask for information from you as the employer to confirm that the person is truly eligible for the plan.

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Erin Shea: The questions around spouses and dependents will be lower, they'll just make sure that the employee tied to them is actively working, but if it's an actual employee, they're going to ask more questions. They're going to ask when was the last day they worked, when…

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Erin Shea: when did FMLA start? Where are you with the tracking? So you need to make sure that you have your leave policy in place within your handbook or separate leave policy, and that that is submitted to the stop-loss carrier before the plan begins.

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Erin Shea: That also includes providing the summary plan description from the medical carrier.

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Erin Shea: So that they… you have proof of what is covered, and how it should be covered.

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Erin Shea: So what we often see, the biggest kind of lesson learned we've gotten from stop loss coverage, is for those employer groups that don't have a defined leave policy that says… so say if you have a leave policy that covers people for 6 months while they're out on leave, and then at that 6-month point, you terminate them, if you don't have that written into a policy, the stop loss

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Erin Shea: carrier is going to just go off of FMLA, so as soon as FMLA stops, that person's no longer going to be eligible. If you want to be

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Erin Shea: Nicer, or have a richer policy in place.

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Erin Shea: You can, but it has to be written within a leave policy, so you have to state that and show that as proof when a person is out. And you need to make sure that you are tracking FMLA leaves appropriately, because they will ask for information on that. So, it's not to scare you, but just to know to make sure you have those leave policies in place.

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Erin Shea: And that you provide all those documents ahead of the stop loss policy going into place, and then the stop loss carrier will ask fewer questions, and you'll have no issues with getting reimbursements at that point.

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Carol Wood: Thank you, Aaron. And you've really covered that, having that documented leave policy, that's so important. And generally, I mean, you have to just make sure also that you're operating your ERISA plan document as it's written, in terms of eligibility in general. We can't have those ineligible dependents on the plan.

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Carol Wood: And we can't be making exceptions, and covering individuals or any benefits.

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Carol Wood: That are outside those specific plan terms, because the stop loss coverage is just going to be… be looking at those documents, the plan document, and the leave policy.

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Carol Wood: And if you are planning to do anything, that's out of the box, or any plan amendments, any deviation from standard operating procedures, you know, it's best to connect directly with the stop loss carry before doing so.

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Carol Wood: And then finally, just to wrap up this section, just be prepared to have the human capital, the resources in place, both internally.

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Carol Wood: your HR, benefits folks, finance, payroll, and the outside service providers, many we've already spoken about. There are TPAs, actuaries, brokers, and consultants, because you normally will need some additional resources to administer that self-insured plan.

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Carol Wood: And with that, I'm going to turn the presentation over to you, Roger, to discuss the role of the plan sponsor.

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Roger Abramson: Thank you, Carol.

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Roger Abramson: Yeah, let's talk about the self-insured plan sponsor's role.

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Roger Abramson: And how it's different, and of course, much more expansive than the fully insured plan sponsor's role in general.

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Roger Abramson: Turn to the next slide.

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Roger Abramson: And I want to emphasize this, we're going to talk about ERISA fiduciary duties. The main theme of this section, the next few slides, is that self-insuring shifts many responsibilities from the carrier to an employer, and this is especially important to remember in the context of ERISA,

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Roger Abramson: As we know, almost all private group health plans are subject to ERISA, and ERISA imposes significant fiduciary obligations on employers as plan administrators.

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Roger Abramson: The ERISA fiduciary Standards consider one of the highest levels of care and accountability under federal law. And if you're a frequent attendee to these webinars that we've had at Wise Wednesday and otherwise, you know that this is a subject we spend a lot of time talking about for that very reason. And guess what? We're about to talk about it again, so buckle up.

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Roger Abramson: Starting with noting that the ERISA fiduciary must adhere to the duty of loyalty.

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Roger Abramson: And must act solely in the interest of plan participants.

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Roger Abramson: An ERISA fiduciary must also act prudently, not rashly, unthinkingly, negligently, recklessly, and so on. Prudently.

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Roger Abramson: And a prudent process, Enhances plant administration, protects plant participants, and helps insulate.

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Roger Abramson: Employers for litigation risk.

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Roger Abramson: Employers who are looking to self-insure.

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Roger Abramson: Should strongly consider establishing an employer

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Roger Abramson: Employee Benefits Committee, my apologies, to facilitate and document prudent decision making.

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Roger Abramson: On the next slide, we're going to talk about one of the main duties.

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Roger Abramson: Of a self-insured plan sponsor, and that is the not-so-small matter of the selection and monitoring of service providers for a self-insured plan.

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Roger Abramson: So remember, Self-insurance, as Carol has discussed, ultimately means the employer.

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Roger Abramson: Is taking on the financial risk of covering claims.

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Roger Abramson: It does not necessarily mean that the employer is actually going to perform the day-to-day nitty-gritty plan operations, such as claims processing and so forth. And while that's theoretically possible, very few employers, and does happen sometimes, very few employers are really equipped to do that, and so they contract with

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Roger Abramson: third-party administrators, PBMs, and the like to perform those services on behalf of the employer plan sponsor.

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Roger Abramson: Now, that essentially means that these service providers are performing those services on behalf of and for the benefit of plan participants, and it is the plan sponsor's fiduciary duty to make sure the plan service providers are doing exactly that.

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Roger Abramson: That starts…

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Roger Abramson: With the plan sponsor's selection of those service providers, including, but not limited to, evaluating their qualifications, their services, and the compensation they require for those services.

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Roger Abramson: It also includes ensuring that their cybersecurity procedures are up to snuff, and I'll take a moment here to remind everyone that cybersecurity is, and very likely will remain for a very long time, a high DOL enforcement priority, and obtaining

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Roger Abramson: And reviewing, also, the service provider's 408 compensation disclosures.

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Roger Abramson: This selection process should be well and thoroughly documented, whether it's a formal RFP or other structured approach.

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Roger Abramson: So, once the selection is made.

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Roger Abramson: The plan sponsor's obligation with regard to a service provider and or service providers doesn't stop there. Once the selection's made, now it's time to make sure the service provider that has been selected

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Roger Abramson: is doing what it's supposed to do. Once a plan sponsor's selected the provider, the fiduciary obligation shifts, therefore, to monitoring those service providers.

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Roger Abramson: And this can include, but is not necessarily limited to monitoring the provider's performance fees and compensation on a regular basis, as well as periodically benchmarking service provider costs for reasonableness.

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Roger Abramson: Part of the… Fiduciary responsibilities will.

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Roger Abramson: Includes being mindful of the ever-evolving legal and regulatory landscape.

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Roger Abramson: with regard to a recent fiduciary oversight. Our resources, if we can toot our own horn just for a second, such as our Compliance Corner e-newsletter, an edition of which come out today, and includes an FAQ about self-insured plans, in fact, as well as our very other excellent

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Roger Abramson: Publication of the resources are perfect for keeping apprised for those developments, for self-insured sponsors.

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Roger Abramson: Go to the next slide, and I want to talk about two of the most well-known.

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Roger Abramson: excuse me, well-known service provider acronyms, and those are TPAs and ASOs, but before I do, I would like Erin to speak a little bit about some observations she may have regarding TPA analysis.

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Erin Shea: Yes, so just going off of what Roger said, I would say that best practice is that we are marketing TPA services at least every 3 years, taking a look at pricing, taking a look at network access.

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Erin Shea: It may even involve having the carriers meet with you as the client and the employer.

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Erin Shea: to go through capabilities, and then just making sure that you're noting the selection that you're making. So gone are the days where we just stay with the same carrier for 30-something years without any marketing. We really need to make sure that we're documenting that process and noting why we're staying where we are. From a stop-loss perspective, that's something that we would…

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Erin Shea: actually quote every year for you, and look at pricing, and then PBMs are going to range between every year to 3 years as well, and just making sure all of that information is documented, just in case

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Erin Shea: And an employee does approach you and have issue with any of the costs of the plan.

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Roger Abramson: That's perfect. Thank you, Aaron. And this slide right here on the TPA versus ASO arrangement provides a great overview of comparison to these two types of self-insured plan service providers. As you can see, generally speaking, TPAs provide a wide range of administrative services and claim processing services, and they also generally offer greater flexibility to customize services, including the ability to use different provider networks.

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Roger Abramson: As well as carving out benefits, and so on.

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Roger Abramson: Now, an ASO, on the other hand, as the name makes clear, generally provide administrative services only.

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Roger Abramson: They offer similar administrative and claim services to TPAs, but only contract with one insurer in general. So which one is better? Well, it depends on what a plan sponsor's looking for, and this decision, of course, is part of the overall service provider selection.

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Roger Abramson: process.

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Roger Abramson: Now let's move to another major aspect of a self-insured plan sponsor's ERISA fiduciary obligations, and that is claim adjudication and appeals.

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Roger Abramson: So let's be very clear, deciding claims appeals is a major and vital fiduciary function under ERISA, and a key decision

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Roger Abramson: for sponsors of self-insured plans is to determine whether they want to participate directly in the internal appeals process. In short, when it comes to claims appeals.

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Roger Abramson: Do self-insured plan sponsors want to be hands-on, or do they want to be hands-off?

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Roger Abramson: As the NFP observation.

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Roger Abramson: The bottom of the slide makes clear, employers considering the hands-on route need to deliberate very carefully before making that ultimate decision.

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Roger Abramson: While taking on a hands-on role with claims appears, appeals.

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Roger Abramson: As a major lift.

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Roger Abramson: I beg your pardon. Taking on a hands-on role with claims appeals is a very major lift that many employers are simply not equipped to do properly, but it's certainly not impossible. Many employers can and do take on this role, but only after careful planning and deliberation for other… and naturally after consultation with their legal counsel.

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Roger Abramson: Now, for employers who prefer, like, a hands-on approach, the most important considerations are ensuring that the TPA's Administrative Service Agreement

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Roger Abramson: expressly reflects the TPA fiduciary status in that, as well as ensuring that agreement ensures the right of the employer to have access to data, as well as audit rights, to monitor the TPA's performance.

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Roger Abramson: And I think, Aaron, you wanted to speak a little bit regarding the uptick in appeals with regard to self-insured plans in general.

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Erin Shea: Yes, so we have definitely seen or heard, at least on my cases, more people who may receive a denial from the insurance company wanting to

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Erin Shea: actually appeal that denial. And so, the best recommendation, like Roger said, is first off, you need to make sure that the summary plan description from the carrier, if you're doing the hands-off approach, really outlines what the appeal process is.

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Erin Shea: And that you, as the plan sponsor, knows what that process is and knows where to point those employees. So making sure that you're making that summary plan description available. If someone reaches out, you're providing it to them and telling them what page to find.

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Erin Shea: hit on is really important. And the other thing I would just point out here is going back to a previous slide when Carol had mentioned exceptions.

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Erin Shea: This is also, if you're in the hands-off approach, which most clients are, is making sure that you're sticking to the, we do not make exceptions for any of this. You need to go through vet regular measures,

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Erin Shea: for appeals.

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Erin Shea: And that really just helps you, yeah. It really helps you…

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Roger Abramson: Yeah.

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Erin Shea: Stay away from any discrimination issues as well, because one of the other things that you may encounter, because I have seen it happen, is if an employee or a member calls member services at the insurance company, sometimes the member services person may mention to the person that you have a self-funded plan, so basically the employer can make the decision.

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Erin Shea: And so go to the employer.

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Erin Shea: And that it's so much easier to say, no, as the employer, we do not make any exceptions.

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Roger Abramson: Absolutely, that's great background advice, thank you.

00:26:04.260 - 00:26:07.129
Roger Abramson: I think with that, we got on our next slide.

00:26:07.440 - 00:26:15.499
Roger Abramson: A little final checklist for that section. Of course, we have one of these for each of the sections, and I'm going to turn it back over to Carol with regard to plan design considerations.

00:26:15.920 - 00:26:25.679
Carol Wood: Thank you. Thank you so much, both of you. Yes, let's move ahead with plan design considerations. We'll touch on some main ones. There are obviously many.

00:26:25.720 - 00:26:43.619
Carol Wood: First, I want to discuss ERISA preemption of state insurance laws, and we did sort of touch on this earlier. Fully insured plans are… have to cover state-mandated benefits, and often there are many, and they can restrict plan design and also raise plan costs.

00:26:43.700 - 00:27:01.249
Carol Wood: But self-insured plans, due to ERISA preemption, are not subject to those state insurance mandates. So, for example, a New York site is fully insured plan has to follow New York's in vitro fertilization mandate.

00:27:01.250 - 00:27:04.850
Carol Wood: But a New York employer self-insured plan does not.

00:27:04.960 - 00:27:14.570
Carol Wood: So this means the employer, has the ability to better tailor, their benefits to their workforce and budget.

00:27:14.630 - 00:27:26.169
Carol Wood: Of course, it's always important to coordinate with your TPA, because your design choices may be limited by what they can administer.

00:27:26.230 - 00:27:44.089
Carol Wood: Just a point here, too, though, when we talk about, you know, this ERISA preemption, ERISA setting aside state law, there are some cases it may not, because if you have, for example, a non-ERISA plan, if it's a government or the church plan, and it's not subject to ERISA, then that preemption may not apply.

00:27:44.090 - 00:27:55.690
Carol Wood: And also, an exception would be your multiple employer welfare arrangements. They're subject to both state insurance laws and federal laws, so there's no ERISA preemption there.

00:27:55.710 - 00:28:10.859
Carol Wood: Pbm laws, that's, that's a tough one. I guess you'd say it's a mixed bag, right? It depends on the specific law, and there's much debate, and litigation over, whether, whether or not certain PBM laws are preempted.

00:28:12.910 - 00:28:21.909
Carol Wood: I want to discuss the selection of a benchmark plan. Now, this involves essential health benefits, which

00:28:22.190 - 00:28:42.130
Carol Wood: certain plans, generally smaller, fully insured plans, are required to cover under the ACA. Self-insured plans aren't required to cover these essential health benefits, we'll just call them EHBs, but they can impose annual or lifetime dollar limits on any EHBs that they do cover.

00:28:42.280 - 00:28:43.610
Carol Wood: So…

00:28:44.780 - 00:28:52.629
Carol Wood: Importantly here, the self-insured plans, EHBs, are defined by a benchmark plan that's actually chosen by the plan sponsor.

00:28:52.740 - 00:29:01.569
Carol Wood: Theoretically, a sponsor in any state can adopt from among 51 state or DC-based benchmark plans.

00:29:01.680 - 00:29:13.260
Carol Wood: And then, again, only the… only the EHBs in that selected benchmark would be subject to the annual or lifetime dollar limit prohibition.

00:29:13.320 - 00:29:19.369
Carol Wood: Now, if we go to the observation, what does this really mean? It means that an employer

00:29:19.380 - 00:29:23.730
Carol Wood: Given the selection, is going to choose the benchmark

00:29:23.730 - 00:29:42.190
Carol Wood: of a state that's least restrictive, that has the least AHBs that are going to be subject to those annual and lifetime dollar limit prohibitions. And Utah is a very popular choice, so an employer, for example, in New York, could choose the Utah benchmark, and perhaps many do.

00:29:42.190 - 00:29:53.450
Carol Wood: So… so that's a… that's an important choice. Understand, though, as a practical matter, the sponsor's choices may be limited. I'm told by people like Aaron, no, they don't have

00:29:53.450 - 00:30:04.549
Carol Wood: 50 choices, it's probably… it could be Utah, and one or two others, because, you know, they're limited by their TPA's ability to administer, the particular benchmark plan.

00:30:04.670 - 00:30:10.269
Carol Wood: The benchmark selection should be reflected in the TPA agreements and documented by the sponsor.

00:30:13.050 - 00:30:23.100
Carol Wood: Okay, let's move ahead to, mental health parity rules. Now, I just want to mention up front that,

00:30:23.150 - 00:30:38.550
Carol Wood: ensuring access to mental health benefits is a 2026 DOL enforcement priority, so the DOL has told us that, so thank you to them for signaling to us, but it's certainly something we want to stay aware of.

00:30:38.590 - 00:30:50.549
Carol Wood: So we know the mental health parity rules require that plans offering mental health and substance use disorder benefits, which is almost all plans, must provide parity with medical and surgical benefits.

00:30:50.550 - 00:30:59.469
Carol Wood: That parity, encompasses financial requirements, or deductibles, co-pays, quantitative treatment limitations, the number of visits.

00:30:59.500 - 00:31:12.210
Carol Wood: And a real focus has been the non-quantitative treatment limitations, or NQTLs, as we call them. There are so many. Examples are prior authorization requirements, step therapy protocols.

00:31:12.310 - 00:31:21.989
Carol Wood: provider, healthcare provider admission standards, and that last one can really, can really affect, you know, network adequacy. So…

00:31:22.140 - 00:31:29.229
Carol Wood: So this has been a real focus, well, what should the employer do? You know, if you're a employer.

00:31:29.230 - 00:31:43.890
Carol Wood: a self-insured employer, you really want to, as you're vetting your TPAs, review their standard plan design for any parity issues, and see if you can get them to make any necessary changes before you adopt it.

00:31:45.160 - 00:32:02.429
Carol Wood: Watch for red flags. There… we have a publication on red flags that you may want to review. There are some red flags, like the DOL has pointed out for years, it's amazing that there's still implants, like excluding ABA therapy for autism as experimental.

00:32:02.430 - 00:32:17.300
Carol Wood: Given the proven track record of effectiveness at this point, restricting residential treatment benefits, for mental health benefits beyond comparable medical and surgical benefits.

00:32:17.300 - 00:32:24.329
Carol Wood: And always consult with Council before you're adding any further restrictions on mental health benefits.

00:32:26.300 - 00:32:27.860
Carol Wood: Okay, and…

00:32:28.130 - 00:32:35.359
Carol Wood: Continuing on this topic, besides satisfying the mental health parity requirements, we know that the Consolidated Appropriations Act

00:32:35.570 - 00:32:51.230
Carol Wood: of 2021 required plans to prepare and maintain a written comparative analysis, to demonstrate parity in how those, non-quantitative treatment limitations apply. So…

00:32:51.580 - 00:33:03.990
Carol Wood: to ensure that they are indeed in parity. There's no filing required of this analysis, but it has to be available on request by regulators, state agencies, or even plan participants.

00:33:04.050 - 00:33:17.099
Carol Wood: So, this has been sort of a thorn in the side of many plan sponsors. How should the employer approach it? Well, expect complexity. Identifying these NQTLs, preparing the analysis.

00:33:17.130 - 00:33:24.539
Carol Wood: Takes a deep plan design knowledge. Now, the federal regulators, expect the TPA to provide it.

00:33:25.150 - 00:33:27.139
Carol Wood: Unfortunately,

00:33:27.270 - 00:33:41.689
Carol Wood: the, as we know, the practical reality doesn't always live up to the regulator's expectations, and, you know, there are some cases where a TPA, you know, is not willing to provide it, so you do want to address that up front.

00:33:41.810 - 00:33:58.980
Carol Wood: determine whether your TPA can prepare that analysis, or if they partner with a third party, maybe to prepare it, and then you'd want to clarify any additional costs, and make sure everything that you agree upon is memorialized in that administrative services agreement.

00:33:59.260 - 00:34:13.009
Carol Wood: And as Roger emphasized, you do have to own accountability because, you know, even when a TPA or third party prepares the analysis, you as a sponsor stay responsible for compliance and for monitoring their work.

00:34:14.850 - 00:34:25.459
Carol Wood: And then last, I want to touch on the Section 105 non-discrimination rules. Now, these currently only apply to self-insured plans.

00:34:25.650 - 00:34:27.859
Carol Wood: And they're similar in…

00:34:27.949 - 00:34:37.180
Carol Wood: They're similar to the Section 125, nondiscrimination rules applicable to pre-tax benefits that many employers are familiar with.

00:34:37.179 - 00:34:51.009
Carol Wood: And that they're designed to make sure that, you know, if the IRS is giving tax-free benefit treatment, they want to make sure it's going to all employees, the rank and file, and not just those who are highly compensated.

00:34:51.040 - 00:35:02.850
Carol Wood: So the key requirements here, plan eligibility, contributions, and benefits must not disproportionately favor highly compensated employees, or HCEs as we call them.

00:35:02.910 - 00:35:16.850
Carol Wood: Now, HCEs under Section 105 include the top 5 highest paid officers, greater than 10% owners, and the highest paid 25% of all employees. So, recognize that last category there.

00:35:17.440 - 00:35:31.860
Carol Wood: all plans, all employers are going to have highly compensated employees. Very importantly here, these rules apply on a controlled group basis, so all entities in a controlled group are considered.

00:35:32.590 - 00:35:34.770
Carol Wood: The…

00:35:34.900 - 00:35:48.170
Carol Wood: Rules specifically prohibit variances in waiting periods, maximum benefits, or any employer contributions that are based on age, salary, or years of service. Now, are we just…

00:35:48.620 - 00:36:03.770
Carol Wood: go down to the second bullet point in the observation. On that last point, there is a school of thought that says, well, you know, one of those things, let's say cost sharing, is inversely related to salary, so the HDs are the ones paying more.

00:36:03.770 - 00:36:09.520
Carol Wood: And the non-highly compensated are paying less. You know, the HCEs are getting the worst benefit.

00:36:09.540 - 00:36:26.949
Carol Wood: It's kind of the, you know, the… not the letter of the law, but the spirit. So there's a school of thought that says, well, that seems okay. I understand it in principle. The IRS has never officially blessed that, so, we can't either, but, you know, be aware of that, that thinking.

00:36:27.180 - 00:36:32.079
Carol Wood: Cobra subsidies that favor HCs are also problematic.

00:36:32.210 - 00:36:40.589
Carol Wood: And importantly here, failed tests result in adverse tax consequences for those highly compensated employees.

00:36:40.750 - 00:36:55.819
Carol Wood: And they can't be corrected after the plan year ends. That's similar to the Section 125 rules, but I know it's different. I used to work on the retirement side than the retirement plan side. Sometimes, you know, you got a little more leeway there. Oh, you can fix it after the plan year ends.

00:36:55.820 - 00:37:10.580
Carol Wood: But there really isn't a way to do that, so what does that really mean? Ongoing testing is critical. Conduct non-discrimination testing throughout the plan year, and you do have to comply with, if you have pre-tax benefits.

00:37:10.640 - 00:37:23.080
Carol Wood: pre-tax contributions for a self-insured plan, you're complying with both the Section 105 and Section 125 tests and rules. Those tests have to be passed. Both tests have to be passed.

00:37:23.100 - 00:37:33.460
Carol Wood: Erin, I just wanted to reach out to you to see if you had any commentary. I know, you've mentioned sometimes, employers aren't aware of those control group rules.

00:37:33.770 - 00:37:41.079
Erin Shea: Yeah, so oftentimes, people might offer more than one medical plan, just based on tax ID,

00:37:41.080 - 00:37:56.500
Erin Shea: Which is allowed, but as soon as you make one of those plans self-funded, you just have to know that you are now flagging Section 105 rules for the whole control group, so not just Section 125 anymore. So that, that has come up a few times with employers.

00:37:56.500 - 00:38:08.629
Erin Shea: that have groups that have different… or one control group, but have different medical plans, that once one thing becomes self-funded, that Section 105 will apply on the control group level.

00:38:10.290 - 00:38:23.709
Carol Wood: Yeah, we can't emphasize that enough. I think employers… and it makes sense, of course, too, right? We're not… we can't put all the highly compensated in a richer plan and the others here, you know, the IRS would not find that acceptable, so…

00:38:24.070 - 00:38:25.629
Carol Wood: Thank you, Erin.

00:38:28.120 - 00:38:37.160
Carol Wood: And with that, I'm going to turn the presentation back over to… to you, Roger, to discuss, plan implementation.

00:38:37.930 - 00:38:41.330
Roger Abramson: Alright, thank you, Carol. Yeah, we've, discussed…

00:38:41.470 - 00:38:57.999
Roger Abramson: sort of the… making the decision to self-insure, some considerations becoming the role of becoming a self-insured plan sponsor, talked about the considerations previously, and we're all good to go there. Now it's time to talk about implementing the plan.

00:38:58.290 - 00:39:00.249
Roger Abramson: So, as we discuss on the next slide.

00:39:00.360 - 00:39:06.129
Roger Abramson: One of the first things determined during the plantation process, and this seems very elementary, right, is

00:39:06.250 - 00:39:10.730
Roger Abramson: the premium equivalent. That is, how much does it cost to operate the plan?

00:39:10.780 - 00:39:13.780
Roger Abramson: The IRS has two recognized methods for doing this.

00:39:13.810 - 00:39:31.829
Roger Abramson: And you see them on this slide here. The first, of course, is the actuarial method, which is primarily used. That's very obvious, since, you know, that is the method, the usual method for insurance carriers to determine plan costs using their actuaries. And indeed, that is the method that many self-insured employers choose as well.

00:39:31.830 - 00:39:43.350
Roger Abramson: Now, the IRS also recognizes an alternative method for circumstances which maybe the actuarial method may not be practical, or for other reasons, and that's called the pass-cost method, which you see

00:39:43.510 - 00:40:01.879
Roger Abramson: at the bottom of the slide, and that's essentially what it sounds like. Take the past year's cost of the plan, use that to determine the premium equivalent for the subsequent plan year. The past cost method has some obvious limitations, however, which are discussed further on this slide, but it can serve as a decent substitute for the actuarial method in certain instances.

00:40:02.950 - 00:40:06.170
Roger Abramson: On the next slide, we'll talk about one of the,

00:40:07.220 - 00:40:21.109
Roger Abramson: reasons to have this premium equivalent, aside from the obvious, which is charging of the premiums, and that is, of course, it's an important factor in the context of COBRA continuation coverage. Federal COBRA continuation rules.

00:40:21.180 - 00:40:35.810
Roger Abramson: apply to self-insured group health plans, just as they do to fully insured plans. I know everyone, this audience already knows that, but it's important to emphasize a couple of things, one or two, about COBRA continuation coverage that can arise in the self-insured context.

00:40:36.000 - 00:40:47.659
Roger Abramson: So take a look at that NFP observation on the slide. It's an important reminder that employers should resist any temptation to set their COBRA rates above the actual determined rate to provide a cushion

00:40:48.310 - 00:40:58.819
Roger Abramson: So to speak, on… against higher than expected claims. That is a big and major no-no for self-insured plans, just as, of course, it would be for fully insured plans.

00:40:59.110 - 00:41:00.930
Roger Abramson: And I also want to take a moment to

00:41:01.170 - 00:41:17.309
Roger Abramson: talk about the topic at the bottom of the slide, which is state continuation coverage laws. These are commonly known as mini COBRA laws. They, generally apply most times to small employers, employers under 20, but sometimes a few states take federal COBRA and they extend

00:41:17.620 - 00:41:23.830
Roger Abramson: COBRA rights, duration, and so forth, beyond the minimum COBRA requirements, the minimum federal

00:41:24.320 - 00:41:38.750
Roger Abramson: COBRA requirements. Now, it's important to know ERISA generally preempts state mini COBRA laws for self-insured plans, but sometimes things come up, and it'll be like, well, small sponsor special, oh, you know, maybe, you know, we want to… this, even though it…

00:41:38.880 - 00:41:44.200
Roger Abramson: probably shouldn't apply to us, it's preempted by ERISA, but maybe, you know, this employee, we could just, you know.

00:41:44.540 - 00:41:50.769
Roger Abramson: have state and continuation coverage, just, you know, take those rules and apply them to ourselves. Well, that's a very…

00:41:50.910 - 00:41:56.399
Roger Abramson: A little dangerous game to play a little bit, especially with yourself, your, excuse me, your stop-loss carrier.

00:41:56.530 - 00:42:09.110
Roger Abramson: So, what you'll need to do, small sponsors, is confirm your stop-loss carrier's position on these sorts of things, and avoid ever implying or suggesting that there are continuation rights beyond federal COBRA.

00:42:09.270 - 00:42:12.430
Roger Abramson: That's something to definitely coordinate with your stop loss carrier.

00:42:12.760 - 00:42:15.560
Roger Abramson: We move to another important topic with regard to

00:42:16.040 - 00:42:23.450
Roger Abramson: Being a self-insured plan sponsor, and that is the very, very huge and massive expansion in terms of

00:42:23.710 - 00:42:26.829
Roger Abramson: HIPAA privacy and security obligations.

00:42:26.940 - 00:42:32.370
Roger Abramson: When you compare Fully insured plans to self-insured plans.

00:42:32.780 - 00:42:34.980
Roger Abramson: Sponsors moving to a self-insured plan

00:42:35.180 - 00:42:54.839
Roger Abramson: must satisfy both the HIPAA Privacy Rule, which regards protected health information, and the HIPAA Security Rule, which applies to protected health information in electronic form. The risks of that, of which, the latter especially, are of course enormous in this day and age, and will just continue to grow exponentially in the future.

00:42:54.900 - 00:43:07.910
Roger Abramson: Now, in the fully insured context, employers have a generally hands-off role, as you see in the slide there. They receive generally only enrollment, disenrollment, summary health information, while the insurer carries most privacy and security obligations.

00:43:07.980 - 00:43:10.419
Roger Abramson: In the self-insured context, though.

00:43:12.260 - 00:43:18.409
Roger Abramson: Sponsors are hands-on, by definition. They are hands-on by definition. I have had discussions

00:43:18.530 - 00:43:33.909
Roger Abramson: Not so much in the NFP world, but in this space, generally, where some people have self-insured plans. Well, I know we have the TPA, the ASO, so we're still hands-off. No, you're not. By definition, you're hands-on. You're insuring the plan. You have access to this information. We cannot just pretend

00:43:34.240 - 00:43:52.509
Roger Abramson: that you don't, and I know most everybody on here already knows that, but it's extremely important. Self-insured sponsors are hands-on by definition, and therefore have many responsibilities and obligations that are enormous. It's not that you can't do them, but you need to know them. On the next slide, we're going to talk about a few of them.

00:43:55.060 - 00:44:10.769
Roger Abramson: So, what does it mean? Look at this list. This is not, by the way, an exclusive list. It's limited… it's not limited to those things. Take a look at these items, including developing and maintaining extensive written HIPAA policies.

00:44:10.960 - 00:44:28.970
Roger Abramson: Implementing extensive workforce training, implementing extensive administrative, physical, and technical safeguards for electronic PHI, and so forth. Remember what we said a little earlier about ensuring that your service providers, cybersecurity policies and procedures are up-to-date and up to snuff? Well, that's part of this as well.

00:44:29.130 - 00:44:39.789
Roger Abramson: We generally recommend that a self-insured plan sponsor engage a competent and reliable HIPAA vendor to advise on and offer support with regard to these

00:44:39.920 - 00:44:45.809
Roger Abramson: obligations, and you'll see that in the NFP observation there on the right side of the slide.

00:44:47.100 - 00:44:50.309
Roger Abramson: On the next slide, we have a little checklist, as usual, which we…

00:44:51.230 - 00:44:59.920
Roger Abramson: Featured in the slides with the garden plan implementation, but now we're going to turn to the, disclosure and reporting requirements as applied to self-insured plans.

00:45:00.520 - 00:45:04.449
Roger Abramson: So, on the first slide, We're gonna talk about

00:45:04.860 - 00:45:09.330
Roger Abramson: Disclosure and reporting, the obligation to apply under ERISA, ACA, and so on.

00:45:09.390 - 00:45:28.190
Roger Abramson: For the most part, the same disclosure and reporting obligations apply to self-insured plans just as they do to fully insured plans. The big difference is who is ultimately responsible for doing them. In the fully insured context, carriers handle many of those responsibilities, while in the self-insured context.

00:45:28.270 - 00:45:36.449
Roger Abramson: If you've followed us closely this far, you're probably going to know where this is going. Plan sponsors bear ultimate responsibility for virtually all of them, though

00:45:36.810 - 00:45:43.719
Roger Abramson: What they will often do is contract with the service providers and other vendors to handle those obligations on their behalf.

00:45:44.000 - 00:45:54.809
Roger Abramson: However, as with anything else regarding service providers, particularly here in the service self-insured context, the plan sponsor is still ultimately responsible for getting those done, and that means

00:45:55.000 - 00:46:00.760
Roger Abramson: Monitoring the service providers that they have selected to make sure they fulfill those obligations.

00:46:02.100 - 00:46:04.250
Roger Abramson: On the next slide, I'll talk about

00:46:04.450 - 00:46:22.940
Roger Abramson: these, disclosure requirements with regard to ERISA. I think everybody on here is fairly familiar with the plan document reporting requirements under ERISA, at least at a high level. I'm certainly not going to go through those in detail. But I do just want to say those same requirements generally apply in the self-insured context as well.

00:46:23.070 - 00:46:38.690
Roger Abramson: A couple of takeaways that I do think are important to point out is that since there's no insurance policy from a carer describing coverage, the plan document in the self-insured context has to fill in some of those gaps, including setting out eligibility, benefits, claims, plan asset handling provisions, and so forth.

00:46:38.780 - 00:46:50.369
Roger Abramson: With regard to plan document requests, sponsors are directly responsible for the such requests from those participants. Can't necessarily go to, oh, go to the carrier. Well, there isn't one, at least in this context. However.

00:46:50.460 - 00:47:06.019
Roger Abramson: They may not always be the party responding. Self-insured plans are also, of course, subject to similar Form 5500 requirements as fully insured plans. They generally do not include Schedule A's, and they are also exempt from the summary annual report requirement, unless, of course, they are part of a RAP plan.

00:47:06.220 - 00:47:11.039
Roger Abramson: With fully insured benefits, which of course is a fairly common situation.

00:47:11.290 - 00:47:17.299
Roger Abramson: Self-insured plan sponsors also need to ensure that all the plan documents and other items are consistent

00:47:17.630 - 00:47:27.920
Roger Abramson: With each other, and should coordinate eligibility, benefits, limitations, and the like with their stop-loss carrier to avoid unexpected gaps and coverage disputes.

00:47:29.650 - 00:47:32.879
Roger Abramson: Now, the next slide… We'll turn to…

00:47:33.070 - 00:47:36.879
Roger Abramson: Everyone's favorite fee, the PCOR fee. I love the PCOR fee.

00:47:37.260 - 00:47:43.159
Roger Abramson: This, I don't love it. But it's always fun, because it's still around, and no one thought it would be. It's like a…

00:47:43.310 - 00:48:01.240
Roger Abramson: It's like an annual party you go to, and there's that one person who's there at that party, and no one knows why they were ever there. They were invited a long time ago, and they still show up, and you never see them in any other aspect of your life, but there they are. Eventually, however, we may no longer have the P4 feet, but we still do. The big takeaway here is that in the fully insured context.

00:48:01.500 - 00:48:10.820
Roger Abramson: The insurer pays the per-head fee, whereas the self-insured world, it's the responsibility of the self-insured plan sponsor. This often happens sometimes. People go from

00:48:11.180 - 00:48:25.200
Roger Abramson: fully insured plans, they start self-insured plans, and this is something that is sometimes overlooked, which makes some sense. It's not really the highest priority in people's lives. However, you as a self-insured plan sponsor now are on the hook for

00:48:25.340 - 00:48:41.889
Roger Abramson: reporting and paying that fee, so make sure to coordinate with the accounting or tax department to ensure that the fee is reported and paid by July 31st of each year on Form 720. And with that, I'm going to turn it back over to Carol to talk about some more reporting

00:48:42.180 - 00:48:45.720
Roger Abramson: obligations, particularly those under the ACA.

00:48:46.400 - 00:48:50.320
Carol Wood: Okay, thanks so much, Roger. And we're still waiting for the form, right, for the…

00:48:50.320 - 00:48:51.549
Roger Abramson: Yeah, we are.

00:48:51.550 - 00:48:53.329
Carol Wood: Second quarter forms, so the.

00:48:53.330 - 00:48:53.750
Roger Abramson: Yeah.

00:48:53.750 - 00:48:54.610
Carol Wood: Yeah, I guess.

00:48:54.610 - 00:49:00.269
Roger Abramson: It's the same, they put the same, you know, priority on that as other folks do. Like I say, it's just, you know, you just always.

00:49:00.270 - 00:49:00.780
Carol Wood: No, I won't.

00:49:00.780 - 00:49:01.289
Roger Abramson: Go ahead to the park.

00:49:01.290 - 00:49:02.400
Carol Wood: To… to get there.

00:49:03.400 - 00:49:08.729
Erin Shea: And I checked as early as, an hour ago, and it was still not there, so…

00:49:09.290 - 00:49:15.540
Carol Wood: Okay, well, thank you there, Erin. I know we've been checking, too, because we've received a lot of questions about it.

00:49:15.540 - 00:49:31.760
Carol Wood: But as Roger said, we'll move on to, other ACA reporting, Sections 6055 and 6056. Those terms may not be familiar to employers, but they probably are familiar with IRS Forms 1094 and 5, so that's really what we're speaking of here.

00:49:31.760 - 00:49:38.730
Carol Wood: I think the main distinction for self-insured plans is that there's the Section 6055 reporting.

00:49:38.730 - 00:49:54.240
Carol Wood: that any self-insured, plan, regardless of size, level of funding, regardless of size, they do have to complete the Section 6055 reporting, that reports the months an individual is enrolled in the coverage, the minimum essential coverage.

00:49:54.250 - 00:50:09.769
Carol Wood: And this, this involves reporting member-level data. Excuse me. And this one, like the PCOR fee, it often catches employers off guard. Small employers aren't aware that they have this filing obligation when they become

00:50:09.770 - 00:50:18.890
Carol Wood: self-insured, maybe they have 40 employees, and they're not subject to the 6056 reporting, which of course requires larger employers else.

00:50:18.890 - 00:50:35.919
Carol Wood: To report, that they made offers of, hopefully, affordable minimum value coverage to full-time employees. So it's just, it's something to be aware of, especially if you're a small, and new to self-insuring. Erin, did you have any other comments there?

00:50:35.920 - 00:50:45.209
Erin Shea: Yeah, so even for those clients that are large, employers, just making sure most people are utili- they're utilizing their payroll vendor.

00:50:45.210 - 00:51:02.590
Erin Shea: to complete the reporting, so making sure that you're giving your payroll vendor, if that's the case, a heads up at the beginning of the plan year that you're self-funded now, because there are additional fields that need to be filled out. So just making sure that you're making them aware of it at the beginning of the plan year, so that they're tracking appropriately.

00:51:03.060 - 00:51:04.080
Carol Wood: Okay.

00:51:05.040 - 00:51:06.790
Carol Wood: Thank you.

00:51:06.950 - 00:51:26.519
Carol Wood: And then I just want to wrap it up by talking about transparency. I love talking transparency, and it seems like we have endless transparency legislation these days. The first item I want to talk about is the No Surprises Act, also under the Consolidated Appropriations Act of 2021.

00:51:26.560 - 00:51:30.189
Carol Wood: There's, like, mental health parity rules.

00:51:30.210 - 00:51:43.799
Carol Wood: Is a DOL 2026 enforcement priority. This was a new one on their list. They're going to be looking closely at the No Surprises Act, which of course governs surprise billing provisions.

00:51:43.800 - 00:51:57.410
Carol Wood: As a reminder, it bans surprise billing for certain out-of-network emergency air ambulance and air ambulance services, and also certain non-emergency services at in-network facilities that

00:51:57.410 - 00:52:04.279
Carol Wood: You schedule a surgery in-network, but the anesthesiologist is out of network. There's protection for that, too.

00:52:04.280 - 00:52:07.460
Carol Wood: Participant cost sharing is limited to in-network rates.

00:52:07.500 - 00:52:13.989
Carol Wood: And then the, the… Provider and the plan, the self-insured plan.

00:52:13.990 - 00:52:36.249
Carol Wood: has to negotiate to determine what the out-of-network provider is going to be paid for the rest of their services. They have to negotiate the remainder of that bill, and that's through an arbitration process known as the Federal Independent Dispute Resolution Process. And there's been a lot of controversy and inefficiencies in that process, and it's become a

00:52:36.250 - 00:52:38.360
Carol Wood: A real focus recently.

00:52:38.360 - 00:52:56.880
Carol Wood: For self-insured plans, the NSA generally applies, because we talked about state laws being preempted, so ERISA self-insured plans, they're subject to these rules. With fully insured plans, in some cases, if there is a state surprise billing law, that's going to apply first. So you just want to be aware of this.

00:52:56.880 - 00:53:15.130
Carol Wood: Now, as far as the NSA, the enforcement efforts, what do you need to do as an employer? Certainly watch for claim denial patterns. You want to track participant complaints, make sure your TPA, inquire how they're processing.

00:53:15.200 - 00:53:26.629
Carol Wood: And are they applying the correct cost sharing for NSA-protected claims? Also, you also want to inquire about how that independent dispute resolution process is handled.

00:53:26.630 - 00:53:40.490
Carol Wood: Are they doing it directly? Maybe they subcontracted? And, you know, see if you can get some reports from the TPA, so you can monitor the activity there, because it essentially is going to affect your plan costs.

00:53:40.870 - 00:53:51.590
Carol Wood: And then the last, item I want to discuss is other transparency items, your gag clause prohibition, Roger touched on the service provider compensation disclosures.

00:53:51.590 - 00:54:09.839
Carol Wood: These two are really for your benefit. You want to make sure that your contracts are free of those clauses that are going to prevent you from getting access to data and claims information. That's just the information that you're going to need to be able to monitor your service providers.

00:54:09.840 - 00:54:21.030
Carol Wood: The service provider compensation disclosure, again, that fiduciary obligation to prudently select, and monitor your service provider, so it's designed to help you there.

00:54:21.030 - 00:54:33.370
Carol Wood: The RXDC reporting, that's something you normally rely on your TPA or PBMs to do, but just want to make sure ahead of time, that you're, you know.

00:54:33.370 - 00:54:51.930
Carol Wood: contracting, it's in your contract, that they're going to be taking care of that for you. And also, if any information is needed to complete that reporting, just be sure that you respond promptly. You don't want to be taking on obligations that your TPA will handle, as long as you'll provide that information.

00:54:53.010 - 00:55:06.859
Carol Wood: Under the transparency and coverage rule, a separate rule, we have those machine-readable files. Again, your TPA is probably posting those of your in-network rates and historical out-of-network amounts.

00:55:06.970 - 00:55:18.809
Carol Wood: Hopefully, we'll soon see, rules and regulations that pertain to the posting of the prescription drug information. That has not been implemented yet, so look for that.

00:55:18.930 - 00:55:23.719
Carol Wood: And then the participant self-service tool, so your participants can

00:55:23.910 - 00:55:41.729
Carol Wood: shop for services and compare costs. Your TPA may be handling that, but again, monitor them. That's really a form of disclosure, just like an SPD is, so you're ultimately responsible. And then I'll just end by saying that the

00:55:41.800 - 00:55:47.429
Carol Wood: This is an area just to… to… to monitor generally for…

00:55:47.430 - 00:56:06.969
Carol Wood: legislation. We have so many provisions of the Consolidated Appropriations Act and the Transparency and Coverage Rule that still have not been implemented, so you have… well, we're awaiting that. Then there's also talk in Congress now about passing more transparency legislation, and…

00:56:06.970 - 00:56:08.070
Carol Wood: There's…

00:56:08.080 - 00:56:22.870
Carol Wood: Apparently, it's one issue we have bipartisan support for, so we may see some more laws, and, you know, it's just an area that's really evolving, so you want to stay on top of that. We certainly provide updates in Compliance Corner.

00:56:22.870 - 00:56:28.730
Carol Wood: You know, so… so hopefully, you're reading that and, stay… stay tuned to that.

00:56:28.850 - 00:56:36.720
Carol Wood: And with that, I just want to wrap it up and then point to the resources that I mentioned earlier.

00:56:37.580 - 00:56:48.970
Carol Wood: This is the new publication on self-insured group health plan compliance considerations. We covered a lot of it here. Obviously, we couldn't cover everything that's in the, publication, so…

00:56:48.970 - 00:56:58.069
Carol Wood: If you're interested, please ask your broker or consultant for a copy. And the same holds true for our other publications on topics that we've touched upon, COBRA, ERISA,

00:56:58.070 - 00:57:10.790
Carol Wood: HIPAA, MAPIA, the non-discrimination rules, Section 105 and 125, and transparency obligations. So, we have a whole library for you if you'd like more information.

00:57:11.000 - 00:57:26.370
Carol Wood: And with that, I think we're just about at time. I do thank you so much. I think Aaron and Roger, I know, do as well for joining us this afternoon to discuss this important topic, and we hope you enjoy the rest of your afternoon.

00:57:26.670 - 00:57:29.400
Carol Wood: Amber, I'm going to turn it back to you to close us out.

00:57:29.570 - 00:57:46.659
Amber Posthauer: All right. Well, thank you, Carol, Roger, and Aaron, for sharing your valuable time and expertise with us today. To reiterate, today's presentation was recorded. We'll be sharing the recording in the follow-up email and on the NFP website. If there are any portions of this call that you missed, by Monday, you'll receive an email with a link to the full recording.

00:57:46.660 - 00:57:50.620
Amber Posthauer: The PowerPoint slides used during this presentation will be shared in the same email.

00:57:50.620 - 00:58:01.960
Amber Posthauer: At the end of this call, a survey will populate in a new window. Please take a brief moment to complete the survey, as it lets us know what topics are important to our listeners, and helps make our education program as current and relevant as possible.

00:58:02.160 - 00:58:06.889
Amber Posthauer: That concludes our webinar for today. Thank you, everyone, for joining us, and have a great day!