ERISA Compliance FAQs

The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets minimum standards for employee benefit plans maintained by private-sector employers. ERISA includes requirements for both retirement plans (for example, 401(k) plans) and welfare benefit plans (for example, group health plans). ERISA has been amended many times over the years, expanding the protections available to welfare benefit plan participants and beneficiaries.

The Department of Labor (DOL), through its Employee Benefits Security Administration (EBSA), enforces most of ERISA’s provisions. Violating ERISA can have serious and costly consequences for employers that sponsor welfare benefit plans, either through DOL enforcement actions and penalty assessments or through participant lawsuits.


This Compliance Overview includes a set of frequently asked questions (FAQs) to help employers understand how ERISA’s requirements for welfare benefit plans are enforced.

Links And Resources

Department of Labor resources:

·       Web page on ERISA enforcement

·       2018 fiscal year audit summary

·       Voluntary Fiduciary Correction Program

·       Delinquent Filer Voluntary Compliance Program

HEALTH PLAN INVESTIGATIONS

  • The DOL audits employee benefit plans for compliance with ERISA, the Affordable Care Act (ACA) and other federal laws.

  • Participants may also sue their welfare benefit plans for violations.

  • Noncompliance may result in civil penalties or criminal charges. 

COMMON VIOLATIONS

  • Failures to file complete/correct Form 5500

  • Failures to respond to participant requests for information

  • Breaches of fiduciary duties

 


In this Compliance Overview, we will answer the following questions:

  • How does the DOL enforce ERISA?

  • What are the possible consequences of a DOL investigation?

  • Why does the DOL select certain health plans for audit?

  • How can an employer minimize its risk of being audited by the DOL?

  • How do employers know if they are selected by the DOL for an audit?

  • How can employers prepare for a DOL audit?

  • If an employer discovers a compliance mistake, are there any correction programs available to correct it?

  • Can participants bring their own lawsuits under ERISA?


HOW DOES THE DOL ENFORCE ERISA?

The DOL has broad authority to investigate or audit an employee benefit plan’s compliance with ERISA. The DOL’s EBSA division handles audits of employee benefit plans. To perform these audits, EBSA employs investigators working out of field offices, many of whom are lawyers or CPAs or who have advanced degrees in business or finance.

DOL audits often focus on violations of ERISA’s fiduciary obligations and reporting and disclosure requirements. The DOL may also investigate whether an employee benefit plan complies with ERISA’s protections for plan participants. The DOL also uses its investigative authority to enforce compliance with the Affordable Care Act (ACA).

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WHAT ARE THE POSSIBLE CONSEQUENCES OF A DOL INVESTIGATION?

Being selected for a DOL audit can have serious consequences for an employer. According to a DOL audit report for the 2018 fiscal year, 64.7 percent of civil investigations resulted in penalties or required other corrective action, such as paying amounts to restore losses, disgorging profits and ensuring claims were properly processed and paid. In addition, a DOL audit may negatively affect an employer’s normal business operations because the audit process can be both stressful and time-consuming.

The DOL has the authority to assess civil penalties for many different types of ERISA violations. Common penalty assessments involve the following:

In addition, a DOL audit may lead to a criminal investigation of a plan sponsor, fiduciary or service provider if criminal activity (such as embezzlement, kickbacks and false statements) is discovered during an audit. Whether a matter is referred for criminal prosecution depends on a number of factors, including:

  • The egregiousness and magnitude of the violation;

  • The desirability and likelihood of incarceration both as a deterrent and as a punishment; and

  • Whether the case involves a person who violated ERISA’s requirements before.

WHY DOES THE DOL SELECT CERTAIN HEALTH PLANS FOR AUDIT?

A DOL audit can be triggered for a variety of reasons. In most cases, the DOL investigator will not disclose to an employer why its health plan was selected for audit. However, there are some common audit triggers that an employer should keep in mind.

Common triggers for a DOL audit include:

  • Participant complaints to the DOL about potential ERISA violations. According to the DOL, when it becomes aware of repeated complaints with respect to a particular plan, employer or service provider, or when there is information indicating a suspected fiduciary breach, the matter is referred for investigation.

  • Answers on the plan’s Form 5500. For example, if a plan’s Form 5500 is incomplete, or if inconsistent information is reported from year to year, the DOL may investigate the issue further.

  • The DOL’s national enforcement priorities or projects, which target the DOL’s resources on certain issues. For example, the DOL’s Health Enforcement Initiatives project focuses on making sure health plans and health insurance issuers comply with group health plan mandates, including mental health parity requirements.

HOW CAN AN EMPLOYER MINIMIZE THE RISK OF BEING AUDITED BY THE DOL?

As a practical matter, an employer has little control over whether it will be audited by the DOL. However, an employer can take the following steps to help minimize its exposure to a DOL audit:

  • Respond to participants’ benefit questions and requests for information on a timely basis;

  • File Form 5500 on time and make sure it is complete and accurate;

  • Distribute participant notices required by law (for example, the summary of benefits and coverage) by the deadline; and

  • Make timely updates to plan documents and summary plan descriptions (SPDs) to reflect legal and design changes.

HOW DO EMPLOYERS KNOW IF THEY ARE SELECTED BY THE DOL FOR AN AUDIT?

When the DOL selects an employer’s health plan for audit, the DOL will send out an investigatory letter. This letter serves to notify the employer that a DOL investigation will take place. Investigations can be in the form of a “limited review” or a full-scale investigation.

Generally, the initial letter from the DOL will include a request for a list of plan-related documents. Employers that receive audit letters may be surprised and overwhelmed by the number of documents requested by the DOL auditor. Although employers generally have no way of knowing whether they will be selected for an audit, it is important for them to maintain employee benefit documents in an organized fashion so they can respond to a DOL audit request in the event this occurs.

Typically, the audit letter will request that the documents be provided by a specified date. Inadequate or late responses could trigger additional document requests, interviews, on-site visits and even DOL enforcement actions.

HOW CAN EMPLOYERS PREPARE FOR A DOL AUDIT?

Just because an employer has been selected for an audit does not mean that the employer has violated an employee benefits law. Even an employer in compliance can encounter an unexpected audit. A DOL audit is not a simple process and being prepared can potentially save an employer a large amount of money, time and stress.

The best way to prepare for a DOL audit is to remain in compliance with the law and establish a recordkeeping system for maintaining all of the important documents relating to your employee benefit plans. Retaining complete and accurate records will help move along the audit process and provide an accurate picture of an employer’s benefit package. As a general rule, these records should be retained for seven years

Employers should consider reviewing their health plans for compliance now, before they are selected for audit. It is important for employers to get their health plans’ paperwork in order as part of this process. Employers may want to designate one location for maintaining records relating to their health plans, such as plan documents and insurance contracts, SPDs and notices required under the ACA and other federal laws (for example, the Women’s Health and Cancer Rights Act). Even though a compliance review will require some time and effort now, it will likely pay off in the future in the event the employer is selected for a DOL audit.

IF AN EMPLOYER DISCOVERS A COMPLIANCE MISTAKE, ARE THERE ANY CORRECTION PROGRAMS AVAILABLE TO CORRECT IT?

If an employer reviews its health plan’s compliance with employee benefit laws and discovers a violation, there may be a way to address the mistake before the DOL discovers it and assesses a penalty. The DOL has self-correction programs for certain violations that an employer discovers prior to being audited. These programs offer incentives for an employer to file delinquent Forms 5500 and correct fiduciary breaches.

  • The Delinquent Filer Voluntary Compliance Program (DFVCP) encourages plan administrators to bring their plans into compliance with ERISA’s Form 5500 filing requirements. The DFVCP gives delinquent plan administrators a way to avoid potentially higher civil penalty assessments by voluntarily filing late Forms 5500 and paying reduced penalties.

  • The Voluntary Fiduciary Correction Program (VFCP) allows plan officials who have identified certain violations of ERISA to take corrective action to remedy the breaches and voluntarily report the violations to EBSA, without becoming the subject of an enforcement action.

CAN PARTICIPANTS BRING THEIR OWN LAWSUITS UNDER ERISA?

Participants may sue their welfare benefit plans, as well as the plan administrator and other plan fiduciaries, to enforce their rights under ERISA. ERISA permits lawsuits by participants for benefits under a plan, for breaches of fiduciary duty or to obtain other appropriate equitable relief to remedy an ERISA violation or to enforce the terms of the plan. In addition, participants can sue for intentional interference with their ERISA protected rights.

Benefits litigation (that is, claims by participants seeking benefits under a plan) is by far the most common type of ERISA litigation. When a benefit claim is successful, ERISA limits the remedies that can be awarded by the court. In addition, claims that are based on state law are generally preempted by ERISA. Due to these factors, courts rarely provide any relief to participants other than restoring benefits that were denied under the plan, along with the possibility of awarding interest and attorney’s fees.


This Compliance Overview is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice.


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Vision Insurance: What You Need to Know

Driving to work, reading a news article and watching television are likely activities you perform every day. Your ability to do all of these, however, depends on your vision and eye health. Routine eye exams will help maintain your vision as well as detect various eye problems and concerns about your overall health. Obtaining vision insurance is a way to make sure you can continue enjoying good health as well as the sights around you.

What Is Vision Insurance?

Vision coverage is similar to regular medical insurance and is one of the voluntary benefit options commonly offered through employers. When you have vision insurance, you pay a premium and the insurance company will cover part or all of the cost for vision care. Vision coverage is available in two basic types of plans:

  • Vision benefits plan—This type of plan is regular insurance coverage. Depending on the specific plan, coverage may differ between in- and out-of-network eye doctors. You will typically pay a portion of your eye care cost through a deductible and coinsurance or copayments.

  • Discount vision plan—With this option you can choose to reduce vision costs without regular insurance coverage. You pay for all your vision care, but at a reduced rate.

Why Should I Have Vision Insurance?

A visit with your eye doctor can determine whether you need corrective lenses and, if so, the correct prescription. Other eye concerns that will be addressed in an eye exam include checking for conditions or diseases such as glaucoma and cataracts, which can lead to vision loss.

Regular eye exams can also identify overall health concerns, such as diabetes, high cholesterol and risk of heart disease or stroke before you are even aware of any symptoms. You can then follow up with a medical doctor, minimizing the effects of these conditions on your health and finances.

What Is Covered Under Vision Insurance?

Vision insurance generally provides coverage for basic care and eyewear. Most vision plans will cover the following services:

  • Annual or biannual eye exams, including dilation

  • Eyeglass frames

  • Eyeglass lenses

  • Contact lenses

Some plans may also cover other services, including laser vision care programs or even prescription protective eyewear that is compliant with ANSI and OSHA safety guidelines.

Vision plans typically do not cover replacements for frames, eyeglass lenses or contact lenses, medical or surgical treatment, vision training or experimental vision services or treatments.

How Does Vision Insurance Work?

For vision coverage, you pay a premium or membership fee. Then, when you visit your eye doctor or purchase corrective lenses, you pay a reduced amount for services. Eye exams will typically be covered at 100 percent or have a small copay. Corrective lenses are usually covered with a copay or a maximum allotted amount per year. If you are given an allotted amount, you would only have to pay if the eyewear exceeds that amount. For example, if your insurance covers eyeglass frames up to $120 and the frames cost $160, you would only have to pay the additional $40. Other services, such as eye surgery or treatment for eye diseases, are usually covered at a reduced rate.  

Most plans will place limits on their coverage for eyewear. For example, a plan might cover a new set of eyeglass lenses once a year, eyeglass frames once every two years and contact lenses once a year. Many plans will further limit coverage to either eyeglasses or contact lenses during a plan year. Plans vary, so make sure you read your benefit information carefully.

How Has Health Care Reform Affected Vision Insurance?

The Affordable Care Act (ACA) does affect some vision benefit plans. If your vision coverage falls under the new ACA rules, then the vision plan will have to cover adult children up to age 26, and lifetime and annual limits on coverage will be eliminated. If the vision plan is of limited scope, then it is considered an excepted benefit and does not have to follow the new rules. Limited-scope plans include vision benefits provided under a policy separate from regular medical benefits, or vision benefits that are not an “integral part” of the group health plan.

In addition, under the ACA, pediatric vision care is considered an essential health benefit. This means that vision coverage must be available for children under the age of 19. The ACA does not consider vision care an essential health benefit for adults, so vision care is not mandatory for individuals 19 years and older. Unlike medical insurance, there will be no penalty for not purchasing vision insurance.

For further information on the ACA and vision insurance, visit www.dol.gov/ebsa/faqs/faq-aca2.html.


This article should be used for informational purposes. It is not intended to replace advice from an insurance professional. For more information, contact service@apexbenefitgroup.com.