Wrap Plan Document Language

1. Wrap Plan Document Language What to Know and What to Watch out For

2. Reasons for an Employer to create a Wrap Plan Document and Distribute an SPD • Required by ERISA • Combines several benefit offerings into one plan for 5500 filing or other purposes • Allows employer to define elements that are often inconsistent or missing in certificates issued by insurance carriers • Allows employer to create plan features that the carrier will not document in insurance certificate

3. SPD Content Requirements • Name of the Plan • Name and Address of the Plan Sponsor • EIN of Plan Sponsor • Plan Number • Plan Year • Plan Eligibility provisions (definition of employee, hours worked, classification restrictions, waiting periods, actively at work conditions, retirees) • Type of administration (insured or self-funded)

4. SPD Content Requirements • Name, address and telephone number of the plan administrator • Named Fiduciary • Information about collective bargaining agreements • Description or summary of the benefits • Description of QMCSO procedures with information about how the participants can obtain a full copy without charge • Cost sharing provisions – premium, copayment coinsurance, deductible • Annual or lifetime caps or limits

5. SPD Content Requirements • Extent to which preventive services are covered • Coverage for new and existing drugs • Whether and to what extent medical devices, procedures and tests are covered • Composition of the provider network, if any, including a statement that a list of providers will be provided without charge upon request • Information about network and out-of-network coverage

6. SPD Content Requirements • Conditions for obtaining emergency care • Circumstances which may result in disqualification, ineligibility, or denial, loss, forfeiture, suspension, offset, reduction, or recovery • Authority to amend or terminate the plan • Statement of ERISA Rights • Claims Procedures • Description of COBRA rights

7. Additional Provisions • Notice of Special Enrollment Rights • Newborns and Mothers Health Protection Act Notice • Genetic Information Non-Discrimination Act Notice • ACA Notices • Information about Related Employers whose employees participate • Medical Loss Ratio Rebate Information • HIPAA Privacy wording

8. Foreign Language Requirements • Foreign Language Requirements • If < 100 employees with > 25% literate only in same non-English language; OR • If > 100 employees with lesser of 500 employees or 10% literate only in same non-English language, then: • Must include prominent notice, in non-English language, offering assistance • Assistance does not need to be in writing

9. Key Things to Think about • What documents are part of the Plan? • Are the documents consistent? • SPD, certificate or evidence of coverage, wrap SPD, employment policies • If not which one supersedes the other? • Are terms repeated or incorporated by reference? • Is it clear who can be covered and when coverage begins and ends? • Have the documents been distributed as required by ERISA?

10. Potential Problems • No SPD • Conflicting Terms • Eligibility • Continuation of Coverage • Termination • Missing Information

11. Penalties • No specific penalties in ERISA, but could be fines as part of DOL audit • Plan participants and beneficiaries may bring a civil action • Plan Administrator may be fined up to $110 per day for failure to provide a plan document or SPD within 30 days of a request by a participant or beneficiary • Plan Administrator may be fined up to $110 per day for failure to provide a SPD within 30 days of a request by the DOL • Criminal penalties may be imposed on any individual or company that willfully violates any requirements of Title I of ERISA • Up to $100,000 per conviction ($500,000 for a company); • Up to 10 years in prison; or • Both

12. Questions? Comments? Polestar Benefits, Inc. 412 Jefferson Parkway, Suite 202 Lake Oswego, OR 97035 (855) 222-3358 www.polestarbenefits.com We are happy to help!