Group Health Plans and Health Insurance Toolkit | Practical Law

Group Health Plans and Health Insurance Toolkit | Practical Law

A collection of compliance resources addressing requirements for employer-sponsored group health plans under the Employee Retirement Income Security Act of 1974 (ERISA), the Internal Revenue Code (Code), and the Public Health Service Act (PHSA). Many of the group health plan mandates also apply to health insurers that offer coverage in connection with plans.

Group Health Plans and Health Insurance Toolkit

Practical Law Toolkit w-007-4935 (Approx. 21 pages)

Group Health Plans and Health Insurance Toolkit

by Practical Law Employee Benefits & Executive Compensation
A collection of compliance resources addressing requirements for employer-sponsored group health plans under the Employee Retirement Income Security Act of 1974 (ERISA), the Internal Revenue Code (Code), and the Public Health Service Act (PHSA). Many of the group health plan mandates also apply to health insurers that offer coverage in connection with plans.
Employee welfare benefit plans, as defined under the Employee Retirement Income Security Act of 1974 (ERISA), are subject to ERISA's general compliance obligations (which include disclosure requirements, reporting rules, and fiduciary standards of conduct). ERISA generally defines an employee welfare benefit plan as a plan, fund, or program established or maintained by an employer to provide specified benefits (including medical benefits) to participants or beneficiaries, through the purchase of insurance or otherwise (29 U.S.C. § 1002(1)).
Additional ERISA compliance obligations apply to a subset of employee welfare benefit plans known as group health plans (see Article, ERISA at 50: The Rise of Health Plan Compliance and Litigation). For example, group health plans must meet expanded requirements under the Department of Labor's claims procedure regulations (29 C.F.R. § 2560.503-1). ERISA defines a "group health plan" as an employee welfare benefit plan that provides medical care to employees or their dependents (directly or through insurance, reimbursement, or otherwise). Medical care includes amounts paid:
  • For the diagnosis, cure, mitigation, treatment, or prevention of disease—or for the purpose of affecting any structure or function of the body.
  • For transportation that is primarily for and essential to medical care referred to in the above bulleted item.
  • For insurance covering medical care in either of the above two bulleted items.
The Internal Revenue Code (Code) and the Public Health Service Act (PHSA) include their own definitions of (and requirements for) group health plans (ERISA § 733(a) (29 U.S.C. § 1191b(a)); 26 U.S.C. §§ 9832(a) and 5000(b)(1); PHSA § 2791 (42 U.S.C. § 300gg-91)). Plan sponsors must self-report many group health plan compliance failures to the Internal Revenue Service using IRS Form 8928 (see Practice Note, Excise Tax Reporting for Group Health Plans (IRS Form 8928)).
Many of the group health plan mandates—including those added under the Affordable Care Act (ACA) and more recent legislation—also apply to health insurers that offer coverage relating to group health plans (in addition to health insurers offering individual market coverage). Under ERISA, the Code, and the PHSA, health insurers are defined to include insurance companies and other organizations (for example, health maintenance organizations (HMOs)) that are:
  • Licensed to engage in the business of insurance in a state.
  • Subject to state laws regulating insurance.

Recently Added Group Health Plan and Health Insurer Mandates

This toolkit is a collection of resources addressing requirements for group health plans and health insurers under ERISA, the Code, and the PHSA. These statutes have been amended over the years to include additional mandates—for example, the mental health parity rules. Additional mandates for group health plans and health insurers were added during 2020 as a result of statutory and regulatory developments that included:

Practice Notes Addressing Group Health Plan and Health Insurance Compliance