13 Employer Tips For Coping With Health Care Reform Now!


Since the Supreme Court’s June 28, 2012 National Federation of Independent Business v. Sebelius health care reform ruling upholding the “pay or play” mandates of the Patient Protection & Affordable Care Act (ACA), most business leaders, plan fiduciaries, health insurers, administrators of employment-based group health plans have accepted the need to prepare for health care reform changes taking effect in 2014.  

Unfortunately, delays in the release of anticipated regulatory guidance, the development and implementation of federal and state exchanges and other regulatory and market reforms have made it difficult for many businesses to understand their obligations, options, and their associated costs. 

Most business and industry leaders report frustration with the continuing lack of clarity and uncertainty about rules and costs.  Meanwhile, sequester just made life (and costs) worse for many small employers whose current 2013 health plan budget depends upon plans to benefit from he Small Business Health Care Tax Credit (SBHCTC) enacted as part of ACA. 

Despite these continuing uncertainties and challenges, the impending January 1, 2014 deadline for compliance doesn’t allow most businesses the luxury for waiting for clarification.  To complete the necessary arrangements, businesses unfortunately must decide the direction they plan to take and start working to implement their choice despite these existing uncertainties while managing their existing health benefit programs and costs through 2013.

Small Employers Relying On Health Plan Tax Credit Should Adjust Budgets In Response To Sequester Cut

For small employers and tax-exempt employers counting on the Small Business Health Care Tax Credit (SBHCTC) enacted as part of ACA to afford health care coverage for their employees, health benefit planning needs to begin with determining and dealing with any new problems that an almost 9% cut in the 2013 SBHCTC tax credit triggered by sequester may have on the amount of the credit for the current 2013 tax year.

ACA added the SBHCTC to the Internal Revenue Code (Code) to help and encourage qualifying small businesses to provide health coverage for their employees.  For tax years 2010 through 2013, the maximum credit is 35 percent for a qualifying small business employer and 25 percent for small tax-exempt employers such as charities. See IRS 3 Simple Steps Publication for help estimating the credit. An enhanced version of the credit is scheduled to increase the tax credit rate to 50 percent and 35 percent, respectively in 2014.

Many small businesses are unaware that sequester automatically cut their 2013 SBHCTC tax credit.   Under the sequester requirements of the Balanced Budget and Emergency Deficit Control Act of 1985, as amended, certain automatic budget cuts went into effect on March 1, 2013. These required cuts include an 8.7% reduction to the refundable part of the SBHCTC for otherwise qualifying small employers under Code Section 45R. As a result, qualifying employers counting on the SBHCTC credit to pay for employee health coverage need to know that this credit effectively is reduced by 8.7% percent. The sequestration reduction rate will apply until the end of the fiscal year on September 30, 2013 or intervening Congressional action, at which time the sequestration rate is subject to change.

Health Care Reform Coping Steps For All Businesses

While the sequester SBHCTC cut uniquely affects small businesses employing 25 or fewer workers, almost all businesses regardless of size are struggling to cope with the challenges of health care reform. The following steps may be helpful for many businesses working to chart a path for moving forward amid these uncertainties:

1.  Know Your Workforce & Proper Worker Classifications For Purposes of Health Plan Rules

Whether and how ACA’s “pay-or-play” employer shared responsibility payment, default enrollment, insured health plan non-discrimination and other federal health plan rules apply to your company’s health plan requires a correct understanding of what workers considered employed by your business and how these workers are counted and classified for purposes of ACA and other federal health plan mandates is the first step to projecting the potential costs and liabilities of your business under Code Section 4980H. 

ACA and other federal health plan rules decide what rules apply to which businesses or health plans based on the number of employees a business is considered to employ, their hours worked, their seasonal or other status, and other relevant classification as determined by the applicable rule.  The ACA and other rules vary in the relevant number of employees that trigger applicability of the rule and how businesses must count workers to decide when a particular rule applies.

Trying to predict the employer shared responsibility payment, if any under Code Section 4980H or model the burden or cost of any other federal health benefit mandate requires each business know who counts and how to classify workers for each of these rules.  Most of these rules start with a “common law” definition of employee then apply rules to add or ignore various workers.  Because most federal health plan rules also take into account “commonly controlled” and “affiliated” businesses’ employees when determining rule coverage, businesses also may need to know that information for other related or commonly owned businesses.  

2.  Make Rough Cost Projection To Preliminarily Decide Whether To “Pay” or “Play”

Under ACA, each business retains the option not to offer any health coverage for any employee or employee groups provided the business can tolerate the resulting consequences.  When a business along with all commonly controlled or affiliated employers, if any, employ a combined workforce of 50 or more “full-time” and “full-time equivalent employees” (Large Employer) does not offer “affordable,” “minimum essential coverage” to every full-time employee and his dependents under a legally compliant health plan that provides “minimum essential value” within the meaning of ACA after 2013, the business generally should expect to pay a shared responsibility payment under Code Section 4980H for each month after 2013 that any “full-time” employee  receives a tax subsidy or credit for enrolling in one of ACA’s health care exchanges.  The amount of this required shared responsibility payment will be calculated under Code Section 4980H based on the plan design and coverage the employer health plan offers and the required employee contribution for employee only coverage. Consequently, most businesses should project the relative cost to their business of paying the shared responsibility payment under Code Section 4980H against the cost of providing coverage to decide if it makes sense to even consider continuing to offer health coverage.

While not yet final, recently proposed Internal Revenue Service (IRS) regulations that would implement Code Section 4980H (4980H Regulations) provide a fairly good roadmap for business leaders to use to project their likely shared responsibility payment if the business assumes that the cost of offering coverage to avoid paying the shared responsibility payment will not be less than its existing health plan costs.  Starting with this assumption, the 4980H Regulations provide some roadmap that the business can use to project its likely shared responsibility payment if the business fails to offer health coverage under a plan offering minimum essential coverage to each full-time employee and their dependents.  Using this assumption, a businesses also can get a rough comparison of the projected cost difference per full-time employee if the offers a plan providing minimum essential coverage to all full-time employees and their dependents with minimum essential value that turns out to be “unaffordable” to some of these employees under ACA.   

While refinement of the data in the time and other employment records might help a business refine these estimates, the preliminary projections made using existing data and these assumptions generally will help a business decide if it wants to go ahead under the assumption it will pay or play.  If the business plans only to pay the shared responsibility payment, its efforts should focus on collecting and retaining the data needed to prove compliance and minimize its liability by planning its workforce and taking advantage of any safe harbor or other elections available to it under the 4980H Regulations for counting and classifying its workers. 

3. If Business Decides To Offer Health Coverage After 2013, Decide Plan Design

If the business intends to continue to offer health coverage, the business also needs to decide the plan coverage and terms of that plan.  In all cases, any health coverage offered generally must be designed so the business prudently can afford to pay benefit and administration costs of the plan and also meet all applicable mandates.  The mandates applicable to the plan generally are based on the size of the employer as determined by the applicable federal rules. 

Within these parameters, the business generally has the following choices:

  • Offer health plan that provides minimum essential coverage with minimum essential value to all full-time employees, but pay a shared responsibility payment for full-time employees electing exchange coverage whose employee only contribution would be considered “unaffordable” under ACA because it exceeds 9.5% of their wages;
  • Offer health plan that provides minimum essential coverage with minimum essential value to all full-time employees, and subside the cost of coverage for any low-paid workers as necessary to prevent that coverage from being unaffordable for any worker;
  • Offer a health plan providing minimum essential coverage to some but not all full-time employees and pay the shared responsibility payment calculated under Code Section 4980H(b) for any full-time employee that elects coverage under the exchange to whom the plan is either unaffordable or doesn’t offer minimum essential coverage; or
  • Some combination of these options, designed to meet the other federal health plan rules applicable for health plans offered by businesses employing that number of workers.

When making these decisions, uncertainty about the cost of coverage, the income of the workers, and which low-income employees, if any, actually will choose to enroll in the health plan versus choose to get coverage from the exchange creates some uncertainty to the predictions.  As guidance continues to emerge, however, the modeling of these issues becomes increasingly more reliable.  In the meantime, businesses that plan to continue to offer coverage must make their best guess to project costs and design their health programs while keeping a careful eye on the emerging guidance and market cost data.

4.  Understand The Cast Of Characters & What Hat(s) (Including You) They Wear

Employers and their management rely upon many vendors and advisors and assumptions when making plan design and risk management decisions.  Many times, employer and members of their management unknowingly assume significant risk because of misperceptions about these allocations of duties and operational and legal accountability.   Business and plan leaders need a correct understanding of these roles and responsibilities to understand the risks and to what extent they can rely upon a vendor or advisor to properly design and administer a health plan or carry out related obligations, what risks cannot be delegated, and how to manage these risks.

Under the Employee Retirement Income Security Act (ERISA), any party that exercises discretion or control over health plan administration, funds or certain other matters generally is considered a plan “fiduciary.” Fiduciaries generally are personally liable for prudently and appropriately administering their health plan related responsibilities prudently in accordance with ERISA and other applicable laws and the plan terms.  Knowing who is acting as a fiduciary and understanding those duties and liabilities and how to manage these risks significantly affects the exposure that an employer or member of its management risks as a result of an employer’s sponsorship in a group health plan or other employee benefit program.  Also, knowing what duties come first and how to prove that the fiduciary did the right thing is key to managing risks when an individual who has fiduciary responsibilities under ERISA also is responsible for carrying out other management duties of the sponsoring employer, a vendor or elsewhere that carries duties or interests that conflict with his health plan related fiduciary duties.

The plan sponsor or members of its leadership, a service provider or members of their staff generally may be a fiduciary for purposes of ERISA if it either is named as the fiduciary, it functionally exercises the discretion to be considered a fiduciary, or it otherwise has discretionary power over plan administration or other fiduciary matters.  Many plan sponsors and their management unwittingly take on liability that they assume rests with an insurer or service provider because the company or members of its management are named as the plan administrator or named fiduciary with regard to duties that the company has hired an insurer or service provider to provide or allowed that service provider to disclaim fiduciary or discretionary status with regard to those responsibilities.  Management also can have fiduciary exposure based on their authority for selecting plan fiduciaries and vendors. 

Also, by not knowing who the fiduciaries are, plans and their fiduciaries often fail to confirm the eligibility of some parties serving as fiduciaries, to arrange for bonding of service providers or fiduciaries as required to comply with Title I of ERISA.  Failing to properly understand when the plan sponsor, member of its management or another party is or could be a fiduciary can create unnecessary and unexpected risks and lead to reliance upon vendors who provide advice but leave the employer or a management member holding the bag for resulting liability.

A correct understanding of the risks and who bears them is critical to understand the risks, opportunities to mitigate risk through effective contracting or other outsourcing, when outsourcing does not effectively transfer risks, where to invest resources for contract, plan or process review and changes or other risk management, and where to expect costs and risks and implement processes and procedures to deal with risks that cannot be outsourced or managed.

5.  Know What Rules Apply To Your Plan, The Sponsoring Employer, The Plan Its Fiduciaries & Plan Vendors & How This Impacts You & Your Group Health Plan

The requirements for health plans and the resulting liabilities have undergone continuous changes.   ACA adds to an already extensive list of complicated federal rules about health plans and their administration.   ACA, the Code, ERISA, the Social Security Act, the Privacy, Security, and Administrative Simplification and Breach Notification rules of the Health Insurance Portability & Accountability Act (HIPAA) and various other federal laws also impose certain health plan related obligations and liabilities on health plan fiduciaries, their employer or other health plan sponsors and other parties.  These ever-expanding requirements increasingly impose civil or criminal sanctions, excise tax or other liability on plan administrators or other parties for failing to maintain legally compliant plans, file required reports, give required notifications or meet other requirements.  In many instances, this includes a requirement to know and self-report violations of some of these federal rules. 

Beyond these exposures, employers who sponsor group health plans that violate certain federal group health plan mandates have a duty to self-report certain regulatory plan failures and pay excise taxes where such failures are not corrected in a timely fashion once discovered, or are due to willful neglect. Code Section 6039D imposes excise taxes for failure to comply with health care continuation (COBRA) , health plan portability (HIPAA), genetic nondiscrimination (GINA), mental health parity (MHPAEA) , minimum hospital stays for newborns and mothers (Newborns’ and Mothers’ Health Protection Act), coverage of dependent students on medically necessary leaves of absence (Michelle’s Law), health savings account (HSA) and Archer medical savings account (Archer MSA) contribution comparability and various other federal requirements incorporated into the Internal Revenue Code.   

Since 2010, IRS regulations have required employers sponsoring group health plans not complying with mandates covered by Internal Revenue Code Section 6039D to self-report violations and pay related excise taxes.  Under these regulations, the sponsoring employer (or in some cases, the insurer, HMO or third-party administrator) must report health plan compliance failures annually on IRS Form 8928 (“Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code”).  Beyond any specific liability under ERISA or the particular law for such violations, the potential excise tax liability that can result under these provisions can be significant.  For example, COBRA, HIPAA, and GINA violations typically carry excise tax liability of $100 per day per individual affected. Compliance with applicable federal group health plan mandates is critical to avoid these excise taxes as well as other federal group health plan liabilities.

6.   Update Health Plan Documents, SPDs & Other Communications, Administrative Forms & Procedures, Contracts & Processes To Meet Requirements & Manage Exposures

Along with knowing what rules apply, timely updating written plan documents, communications and administration forms, administrative practices, contracts and other health plan related materials processes and procedures has never been more critical. 

A tightly written plan document and other plan communications have never been more important.  Federal law generally requires that health plan be established, maintained and administered in accordance with legally complaint, written plan documents and impose a growing list of standards and requirements governing the design and administration of these programs. In addition to the existing and impending ACA mandates, ERISA, the Code , the Social Security Act, federal eligibility and coverage continuation mandates of laws like the Consolidated Omnibus Budget Reconciliation Act (COBRA), the Uniformed Services Employment and Reemployment Rights Act (USERRA), the Health Insurance Portability & Accountability Act, the Family & Medical Leave Act, the Genetic Information and Nondiscrimination Act (GINA), Michelle’s Law, mental health parity and other laws regulate the eligibility, coverage, administration and other design features of employment-based health plans and their administration.    ACA and other laws also require that employers, health plan administrators and fiduciaries protect the privacy of data, as well as comply with claims and appeals, communication, fiduciary responsibility, bonding, record keeping, reporting and other requirements.

Failing to update documents, communications, administrative forms and processes and other materials and practices can unleash a host of exposures. ERISA requires that that all material plan terms be set forth in a written plan document.  Many other federal health plan mandates require that this plan document include certain specific provisions.  Beyond these mandated terms, the ability to uphold and enforce plan terms often can be hurt or hindered by the tightness or sloppiness of the plan language. 

Among other things, noncompliant plan documents, communications and practices can trigger unanticipated costs and liabilities by undermining the ability to administer plan terms and conditions.  They also may expose the plan, plan fiduciaries and others to lawsuits, administrative enforcement and sanctions and other enforcement liabilities. 

For this purpose of deciding what and how much to do, it is critical to keep in mind the devil is in the details.  Not only must the documentation meet all technical mandates, the language, its clarity and specificity, and getting the plan document to match the actual processes that will be used to administer the plan and ensuring that the plan documents and processes match the summary plan description, summary of benefits and coverage, administrative forms and documentation and other plan communications and documentation in a legally compliant way significantly impacts the defensibility of the plan terms and the expense that the plan, its sponsor and fiduciaries can expect to incur to defend it.

7.  Clean Up Claims and Appeals, SPDs & Other Practices To Enhance Defensibility

Proper health plan claims and appeals plan and summary plan description language, procedures, processing, notification and documentation is critical to maintain defensible claims and appeals decisions required to enforce plan terms and manage claims denial related liabilities and defense costs.  Noncompliance with these requirements may prevent health plans from defending their claims or appeals denials, expose the plan administrator and plan fiduciaries involved or responsible for these activities to penalties, prompt unnecessary lawsuits, Labor Department enforcement or both; and drive up plan administration costs.

Unfortunately, most group health plans, their insurers and administrators need to substantially strengthen their plan documentation; handling; timeliness; notifications and other claims denials; and other claims and other appeals processes and documentation to meet existing regulations and otherwise strengthen their defensibility. 

Among other things, existing court decisions document that many plans existing plan documents, summary plan descriptions and explanations of benefits, claims and appeals investigations and documentation and notifications often need improvement to meet the basic plan document, summary plan description and reasonable claims rules of the plan document, summary plan description, fiduciary responsibility, reasonable claims and appeals procedures of ERISA and its implementing regulations.  Court precedent shows that inadequate drafting of these provisions, as well as specific provisions coverage and benefit provisions frequently undermines the defensibility of claims and appeals determinations. In addition to requiring that claims be processed and paid prudently in accordance with the terms of written plan documents, ERISA also requirements that plan fiduciaries decide and administer claims and appeals in accordance with reasonable claims procedures. 

Although the Labor Department updated its regulations implementing this reasonable claims and appeals procedure requirement more than 10 years ago, the Department of Labor updated its ERISA claims and appeals regulations to include detailed health plan claims and appeals requirements, many group health plans, their administrators and insurers still have not updated their health plans, summary plan descriptions, claims and appeals notification, and claims and appeals procedures to comply with these requirements.   

These omissions only become more significant under ACA.  The external review and other detailed additional requirements that the Affordable  Care Act dictates that group health plans not grandfathered from its provisions and its provisions holding these non-grandfathered plans strictly liable for deficiencies in their claims and appeals procedures makes the need to address inadequacies even more imperative for those non-grandfathered group health plans.  Inadequate attention to these concerns can force a plan to pay benefits for claims otherwise not covered as well as additional defense costs and penalties.

8.  Consistency Matters:  Build Good Plan, Then Follow It

Defensible health plan administration starts with the building and adopting strong, legally compliant plan terms and processes that are carefully documented and communicated in a prudent, legally compliant manner.  The next key is to actually use this investment by conducting plan administration and related operations consistent with the terms and allocated responsibilities to administer the plan in a documented, legally compliant and prudent manner. 

Good documentation and design on the front end should minimize ambiguities in the meaning of the plan and who is responsible for doing what when. 

With these tools in place, delays and other hiccups that result from confusion about plan terms, how they apply to a particular circumstance or who is responsible for doing what, when should be minimized and much more easily resolved by timely, appropriate action by the proper responsible party.  This facilitation of administration and its consistency can do much to enhance the defensibility of the plan and minimize other plan related risks and costs.

9.  Ensure Correct Party Carries Out Plan and Communications Plan Functions And Communications Compliant, Timely, Prudent, Provable Manner

Having the proper party perform plan related responsibilities and respond to claims and inquiries in a compliant, timely, prudent manner is another key element to managing health plan risk and promoting enforceability.  Ideally, the party appointed to act as the named fiduciary for purposes of carrying out a particular function also should conduct all plan communications regarding that function in terms that makes clear its role and negates responsibility or authority of others. 

When an employer or other plan sponsor goes to the trouble to appoint a committee, service provider or other party to serve as the named fiduciary then chooses to communicate about the plan anyway, the Supreme Court in FMC v. Halliday made clear it runs the risk that the plan related communications may be considered discretionary fiduciary conduct for which it may be liable as a functional fiduciary.  Meanwhile, these communications by nonfiduciaries also may create binding obligations upon the plan and its named fiduciaries to the extent made by a plan sponsor or conducted by a staff member or service provider performing responsibilities delegated by the plan fiduciary.

Beyond expanding the scope of potential fiduciaries, communications conducted by nonfiduciaries also tend to create defensibility for many other reasons.  For instance, allowing unauthorized parties to perform plan functions may not comport with the plan terms, and are less likely to create and keep required documentation and follow procedures necessary to promote enforceability.  Also, the communications, decisions and other actions by these nonfiduciary actors also are unlikely to qualify for discretionary review by the courts because grants of discretionary authority, if any in the written plan document to qualify the decisions of the named fiduciary for deferential review by courts typically will not extend to actions by these nonfiduciary parties.  Furthermore, the likelihood that the communication or other activity conducted will not comply with the fiduciary responsibility or other requirements governing the performance of the plan related functions is significantly increased when a plan sponsor, service provider, member of management, or other party not who has not been appointed or accepted the appointment  act as a named fiduciary undertakes to speak or act because that party very likely does not accept or fully appreciate the potential nature of its actions, the fiduciary and other legal rules applicable to the conduct, and the potential implications for the nonfiduciary actor, the plan and its fiduciaries.

10.  Clean Up Date Collection, Protection & Reporting

Existing and impending ACA and other federal mandates require that group health plans, their sponsors collect, maintain and administer is exploding. Existing eligibility mandates, for example, already require that plans have access to a broad range of personal identifying, personal health and a broad range of other sensitive information about employees and dependents who are or may be eligible for coverage under the plan.

While employers and their health plans historically have collected and retained the names, place of residence, family relationships, social security number, and other similar information about employees and their dependents, these data collection, retention and reporting requirements have and will continue to expand dramatically in response to evolving legal requirements. 

Already, health plans also from time to time need employee earnings, company ownership, employment status, family income, family, medical, military, and school leave information, divorce and child custody, enrollment in Medicare, Medicaid and other coverage and a broad range of other additional information.  Under the ACA, these data needs will explode to include a whole new range of information about total family income, availability and enrollment in other coverage, cultural and language affiliations, and many other items.   

Collecting, retaining and deploying this information will be critical to meeting existing and new plan administration and reporting requirements.  How this data collection is conducted, shared, safeguarded against misuse or other legally sensitive contact by the employer, service providers, the plan and others will be essential to mitigate exposures to federal employment and other nondiscrimination, HIPAA and other privacy, fiduciary responsibility and other legal risks and obligations. 

To the extent that payroll providers, third party administrators or other outside service providers will participate in the collection, retention, or use of this data, time also should be set aside both to conduct due diligence about their suitability, as well as to negotiate the necessary contractual arrangements and safeguards to make their involvement appropriate. 

Finally, given the highly sensitive nature of this data, employers, health plans and others that will collect and use this data will need to implement appropriate safeguards to prevent and monitor for improper use, access or disclosure and to conduct the necessary training to suitably protect this data.

11.  Monitor, Assess Implications & Provide Relevant Input to Regulators About Emerging Requirements & Interpretive Guidance Implementing 2014 Affordable Care Act & Other Mandates.

While the Supreme Court’s decision upheld as Constitutional ACA’s individual and employer shared responsibility mandates as a tax, many opportunities to impact its mandates remain.

Beyond the highly visible, continuing and often heated debates ranging in Congress and the court of public opinion on whether Congress should change its provisions, a plethora of regulatory interpretations issued or impending release by the implementing agencies, the IRS, HHS and Labor Department, and state insurance regulators will significantly impact what requirements and costs employers, insurers, individuals and governments will bear when the law takes effect.  Businesses sponsoring health plans should carefully scrutinize this regulatory guidance and provide meaningful, timely input to Congress, the regulators or both as appropriate to help influence the direction of regulatory or Congressional actions that would materially impact these burdens.

12.  Help Employees & Their Families Build Their Health Care Self-Management Skills

Whether or not your company plans to continue to sponsor employee health coverage after 2014, providing training and tools to help employees and their families strengthen their ability to understand and manage their health, health care needs and benefits can pay big dividends.  Beyond the financial costs to employees and employers of paying to care for a serious illness or injury, productivity also suffers while employees dealing with their own or a family member’s chronic or serious health care condition.  Wellness programs that encourage and support the efforts of employees and their families to stay healthy may be one valuable component of these efforts.  Beyond trying to prevent the need to cope with illness behind wellness programs, however, opportunities to realize big financial, productivity and benefit value recognition rewards also exist in the too often overlooked opportunity to provide training, education and tools that employees and their families need to better understand and self-manage care, benefits, finances and life challenges that commonly arise when dealing with their own or a family member’s illness. Providing education, tools and other resources that can help employees access, organize and effectively use health care and benefit information to manage care and the consequences of illness, their benefits and how to use them, to participate more effectively in care and care decisions, to recognize and self-manage financial, lost-time and other challenges associated with the illness not addressable or covered by health benefit programs, and other practical skills can help reduce lost time and other productivity impacts while helping employees and their families get the most out of the health care dollars spent.

13.  Pack Your Parachute-Plan Your Defense & Exist Strategies

With the parade of expense and liabilities associated with health plans, businesses sponsoring health plans and the management, service providers and others involved in their establishment, continuation, maintenance or administration are well advised to pack their survival kit and develop their exit strategies to position to soften the landing in case their health plan experiences a legal or operational disaster. 

Employers and other health plan sponsors and fiduciaries typically hire and rely upon a host of vendors and advisors to design and administer their health plans.  When selecting and hiring these service providers, health plan sponsors and fiduciaries are well-advised to investigate carefully their credentials as well as require the vendors to provide written commitments to stand behind their advice and services. 

Too often, while these service providers and advisors encourage plan sponsors and fiduciaries to allow the vendor to lead them or even handle on an ongoing basis plan administration services by touting their services, experience, expert systems and process and commitment to stand behind the customer when making the sale or encouraging reliance upon their advice when tough decisions are made, they rush to stand behind exculpatory and on-sided indemnification provisions in their service contracts to limit or avoid liability,   demand indemnification from their customer or both when things go wrong. 

While ERISA may offer some relief from certain of these exculpatory provisions under some circumstances, plan sponsors and fiduciaries should work to credential service providers and require service providers to commit to being accountable for their services by requiring contracts acknowledge all promised services and standards of quality, require vendors to commit to provide legally compliant and prudently designed and administered services that meet or exceed applicable legal requirements, to provide liability-backed indemnification or other protection for damages and costs resulting from vendor imprudence or malfeasance, to allow for contract termination if the vendor becomes unsuitable for continued use due to changing law or other circumstances and requiring the vendor to return data and other documentation critical to defend past decisions and provide for ongoing administration.  Keep documentation about advice, assurances and other relevant evidence received from vendors which could be useful in showing your company’s or plan’s efforts to make prudent efforts to provide for the proper administration of the plan.  When concerns arise, use care to investigate and redress concerns in a timely, measured fashion which both shows the prudent response to the concern and reflects sensitivity to the fiduciary and other roles and responsibilities of the employer sponsor and other parties involved.

Get Moving Now

Since many compliance deadlines already have past and the impending deadlines allow plan sponsors and fiduciaries limited time to finish arrangements, businesses, fiduciaries and their service providers need to get moving immediately to update their health plans to meet existing  and impending compliance and risk management risks under ACA and other federal laws, decisions and regulations.

Even as businesses move forward to respond to health care reform’s challenges, their leaders should continue to give input to Congress and regulators about the need to improve the rules and reduce business uncertainty and burdens.  With many regulations still in proposed or interim form and health care reform and its costs still a concern for many Congressional leaders, significant opportunity still exists to provide input to federal and state regulators on many key aspects of ACA and its relationship to other applicable laws.  Businesses and other health plan sponsors, plan fiduciaries, insurers and administrators, and other vendors must stay involved and alert.  Zealously monitor new developments and share timely input with Congress and regulators about existing and emerging rules that present concerns and other opportunities for improvement even as you position to respond to these rules before they become fully implemented.

For Help or More Information

If you need help reviewing and updating, administering or defending your group health or other employee benefit, human resources, insurance, health care matters or related documents or practices to respond to emerging health plan regulations, monitoring or commenting on these rules, defending your health plan or its administration, or other health or employee benefit, human resources or risk management concerns, please contact the author of this update, Cynthia Marcotte Stamer.

A Fellow in the American College of Employee Benefit Council, immediate past Chair of the American Bar Association (ABA) RPTE Employee Benefits & Other Compensation Group and current Co-Chair of its Welfare Benefit Committee, Vice-Chair of the ABA TIPS Employee Benefits Committee, a council member of the ABA Joint Committee on Employee Benefits, and past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, Ms. Stamer is recognized, internationally, nationally and locally for her more than 24 years of work, advocacy, education and publications on cutting edge health and managed care, employee benefit, human resources and related workforce, insurance and financial services, and health care matters. 

A board certified labor and employment attorney widely known for her extensive and creative knowledge and experienced with these and other employment, employee benefit and compensation matters, Ms. Stamer continuously advises and assists employers, employee benefit plans, their sponsoring employers, fiduciaries, insurers, administrators, service providers, insurers and others to monitor and respond to evolving legal and operational requirements and to design, administer, document and defend medical and other welfare benefit, qualified and non-qualified deferred compensation and retirement, severance and other employee benefit, compensation, and human resources, management and other programs and practices tailored to the client’s human resources, employee benefits or other management goals.  A primary drafter of the Bolivian Social Security pension privatization law, Ms. Stamer also works extensively with management, service provider and other clients to monitor legislative and regulatory developments and to deal with Congressional and state legislators, regulators, and enforcement officials on regulatory, investigatory or enforcement concerns. 

Recognized in Who’s Who In American Professionals and both an American Bar Association (ABA) and a State Bar of Texas Fellow, Ms. Stamer serves on the Editorial Advisory Board of Employee Benefits News, the editor and publisher of Solutions Law Press HR & Benefits Update and other Solutions Law Press Publications, and active in a multitude of other employee benefits, human resources and other professional and civic organizations.   She also is a widely published author and highly regarded speaker on these matters. Her insights on these and other matters appear in the Bureau of National Affairs, Spencer Publications, the Wall Street Journal, the Dallas Business Journal, the Houston Business Journal, Modern and many other national and local publications.   You can learn more about Ms. Stamer and her experience, review some of her other training, speaking, publications and other resources, and register to receive future updates about developments on these and other concerns from Ms. Stamer here.

About Solutions Law Press, Inc.

Solutions Law Press, Inc.™ provides business risk management, legal compliance, management effectiveness and other resources, training and education on human resources, employee benefits, compensation, data security and privacy, health care, insurance, and other key compliance, risk management, internal controls and other key operational concerns. If you find this of interest, you also be interested in exploring other Solutions Law Press, Inc. ™ tools, products, training and other resources here.

Other Helpful Resources & Other Information

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For important information about this communication click here. THE FOLLOWING DISCLAIMER IS INCLUDED TO COMPLY WITH AND IN RESPONSE TO U.S. TREASURY DEPARTMENT CIRCULAR 230 REGULATIONS.  ANY STATEMENTS CONTAINED HEREIN ARE NOT INTENDED OR WRITTEN BY THE WRITER TO BE USED, AND NOTHING CONTAINED HEREIN CAN BE USED BY YOU OR ANY OTHER PERSON, FOR THE PURPOSE OF (1) AVOIDING PENALTIES THAT MAY BE IMPOSED UNDER FEDERAL TAX LAW, OR (2) PROMOTING, MARKETING OR RECOMMENDING TO ANOTHER PARTY ANY TAX-RELATED TRANSACTION OR MATTER ADDRESSED HEREIN.

©2013 Cynthia Marcotte Stamer, P.C.  Non-Exclusive License To Republish Granted To Solutions Law Press, Inc.  All Other Rights Reserved.

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