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Summary Plan Description


The Summary Plan Description, or SPD, is a summary of the terms of the plan so that it may be understandable to each plan member.

 

Content Requirements

There is an extensive list of items which must be included in the Summary Plan Description. Those items are as follows:

 

Plan Name

Plan Sponsor/Employer's Name & Address

Plan Sponsor's EIN

Plan Administrator's Name, Address & Phone Number

Designation of any named fiduciaries, if other than the plan administrator, e.g., claim fiduciary

The plan number for ERISA Form 5500 purposes, e.g., 501, 502, 503, etc. (Note—each ERISA plan should be assigned a unique number.)

Type of plan or brief description of benefits, e.g., life, medical, dental, disability

The date of the end of the plan year for maintaining the plan's fiscal records

Each trustee's name, title, and address of principal place of business, if the plan has a trust

The name and address of the plan's agent for service of legal process, along with a statement that service may be made on a plan trustee or administrator

The type of plan administration, e.g., administered by contract, insurer, or sponsor

Eligibility terms, e.g., classes of eligible employees, employment waiting period, and hours per week, and the effective date of participation, e.g., next day or first of the month following satisfaction of an eligibility waiting period

The plan sponsor's amendment and termination rights and procedures, and what happens to plan assets, if any, in the event of plan termination

A summary of any plan provisions governing the benefits, rights, and obligations of participants under the plan on termination or amendment of the plan or elimination of benefits

A summary of any plan provisions governing the allocation and disposition of assets upon plan termination

Claims procedures and time limits for lawsuits, if the plan imposes them

A statement clearly identifying circumstances that may result in loss or denial of benefits (e.g., subrogation, coordination of benefits, and offset provisions)

The standard of review for benefit decisions

ERISA model statement of participants' rights

The sources of plan contributions, whether from employer and/or employee contributions, and the method by which they are calculated

The fact that the employer is a participating employer or a member of a controlled group

Interim SMMs since the SPD was adopted or last restated

Whether the plan is maintained pursuant to one or more collective bargaining agreements, and that a copy of the agreement may be obtained upon request

A prominent offer of assistance in a non-English language (depending on the number of participants who are literate in the same non-English language)

 

  • Additional requirements for Group Health Plan SPDs:

    •  Detailed description of plan provisions and exclusions (e.g., copays, deductibles, coinsurance, eligible expenses, network provider provisions, prior authorization and utilization review                  requirements, dollar limits, day limits, visit limits, and the extent to which new drugs, preventive care, and medical tests and devices are covered). A link to network providers should also be          provided. Plan limits, exceptions, and restrictions must be conspicuous.

    •  Information regarding COBRA, HIPAA, and other federal mandates such as the Women's Health Cancer Rights Act, preexisting condition exclusion, special enrollment rules, mental health              parity, coverage for adopted children, Qualified Medical Support Orders, and minimum hospital stays following childbirth.

    •  Name and address of health insurer(s), if any

    •  Description of the role of health insurers (i.e., whether the plan is insured by an insurance company or the insurance company is merely providing administrative services)

 

Summary of Material Modification (SMM)

An SMM must be provided to the plan participants to disclose just the changes which have been made rather than drafting a new SPD. The SMM must be delivered within 210 days after the end of the plan year, or within 60 days after a "material reduction" in benefits of a group health plan. There is a penalty of up to $110/day for not delivering an SMM within 30 days after a participant requests it.

 

SPD Delivery Requirements

The plan administrator/employer is responsible for delivering the SPD to their covered employees, terminated COBRA participants, parents or guardians of children covered under a qualified medical support order, and dependents of a deceased retiree under a retiree medical plan.

 

An SPD should be delivered to participants within 90 days after they become covered, whether they request it or not. Plan administrators of a new plan must distribute an SPD within 120 days after the plan is established. An updated SPD must be furnished to all covered participants every 5 years, and every 10 years even if the SPD has not changed.

 

SPD Electronic Distribution Requirements

Requirements for employees with work-related computer access. The employee must have the ability to access documents at any location where they reasonably could be expected to perform employment duties. In addition, access to the employer's electronic information system must be an integral part of the employee's employment duties.

 

1.  Electronic materials must be prepared and delivered in accordance with otherwise applicable requirements (e.g., timing and format requirements for SPDs/SBCs/Amendments as outlined       
     under ERISA/PPACA.)

2.  A notice must be provided to each recipient, at the time that the electronic document is furnished, detailing the significance of the document.

 

    1.  The notice must advise the participant of their rights to have the opportunity, at their work site, to access documents furnished electronically and to request and receive
         (free of charge) paper copies of any documents received electronically.

 

3.  The employer must take appropriate measures to ensure the electronic distribution will result in actual receipt of information by the participants (i.e. return-receipt.)

4.  If the disclosure includes personal information relating to an individual's accounts and benefits, the plan must take reasonable and appropriate steps to safeguard the confidentiality of the
     information.

 

Additional requirements for non-employees (i.e. spouse and dependents) or employees with non-work related computer access.

 

1.  Affirmative consent for electronic distribution must be obtained from the individual. Before consent can be obtained, a pre-consent statement must be furnished that explains:

 

    a)  The types of documents that will be provided electronically;

    b)  The individual's right to withdraw consent at any time without charge;

    c)  The procedures for withdrawing consent and updating information (e.g. updating the address for receiving electronic disclosure);

    d)  The right to request a paper version and its cost (if any and if permitted); and

    e)  The hardware and software requirements needed to access the electronic document.

 

2.  The regulations permit the pre-consent statement to be provided electronically if the employer has a current and reliable e-mail address.

3.  If system hardware or software requirements change, a revised statement must be provided and renewed consent from each individual must be obtained.

4.  If the documents are to be provided via the Internet, the affirmative consent must be given in a manner that reasonably demonstrates the individual's ability to access the information in
     electronic form, and the individual must have provided an address for the receipt of electronically distributed documents.

5.  The Employer must keep track of individual electronic delivery addresses, individual consents and the actual receipt of e-mailed documents by recipients.

 

This content is being provided as an informational tool. It is believed to be accurate at the time of posting and is subject to change. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this information, Meritain Health is not exercising discretionary authority or assuming a plan fiduciary role, nor is Meritain Health providing legal advice.