Do You Have a Plan?
Every week I get asked questions that require quite a bit of research – either because there’s some obscure bit of regulation involved or it’s just something we’ve never dealt with in the past. Those are fun (well, “fun” in the geeky “I love regulations” kind of way) because it’s something new and usually interesting, or at least useful to know.
Then there are “those” questions. “I have an employee out on leave…when do their benefits end?” Or “How should claim appeals be handled?” The best: “How do I know if this person is eligible for benefits?” The answer to these – and a whole host of other questions – is simple: “What does your plan document say?”
“What’s a plan document?” is the typical response. A plan document is, well, a document (go figure) that formally determines how the benefit plan functions, and includes a wide range of policies regarding everything from claims to eligibility to privacy, and more. For employers subject to ERISA, it’s a required item – the very first thing you’ll be asked for in an audit situation is a copy of your plan document.
Clients that are self-funded usually know about this requirement and have a plan document, but they don’t always keep it consistent with their employee handbooks (the questions on leaves of absence usually stem from a disconnect – the handbook will say one thing while the plan document will say another). Fully-insured clients on the other hand usually don’t know about this requirement, or if they do assume the carrier’s certification booklet covers this responsibility. The cert books usually cover most of the required elements in a plan document, but there’s inevitably something that’s missed specific to the employer in the cert books. Carriers write those as boiler-plate booklets, not as customized plan documents for the employer.
Do you have a plan document? If not, it’s time to look into it. If you do, when was the last time it was reviewed? Have you updated it for the ACA? The plan document is the answer – to the questions you haven’t yet asked yourself.
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