Click to edit Master title style Compliance: Can’t This Be Easier for Us All? What We Wish Carriers (and TPAs) Knew about Employer Obligations

Fiduciary Discretion – Where are the Lines to be Drawn? Eligibility (& employer concerns)  Versus administrative role of carrier / TPA “Written plan document” requirements and “sole benefit” rules of ERISA Claims determinations and discretion / overriding claims conclusions Self-funded client concerns  Delegation versus involvement at various levels Avoiding red flags and setting of precedents

Flexibility Needed in the (Ugly) Face of PPACA Communications to employees  Preferred approaches Interpretation of new rules & perspective  Keep in mind who is at greatest risk Flexibility in design  Example of annual limit rules Business integrity and competitiveness

Tell Us Your Business Plan for Reform Preparation for future and new responsibilities… or not National carrier approach Prevent ugly surprises

Change in Status Rules Common carrier failures in group insurance area: Service center phone responses Impact on clients --IRS audit area Training (and retention) issue

Transparency State & federal concerns and reporting Example of egregious, avoidable mistake Rebating Media attention

Written Materials: ERISA Disclosures and PPACA Requirements Completeness PPACA  Coverage reporting  Mini-summary Defining “plan” Voluntary benefits & special issues

Proper Payment Concerns under Medicare Secondary & Emerging Rules Overview of Medicare Secondary Rules Emerging rules Non-compliant carrier due to implementation CMS audits & approach to penalties Impact on client & relationship

Claims Administration Federal Agency Focus on “Enforcement Examples” ERISA Standards New PPACA requirements  New claims and appeals rules – what is your approach?  Minimum Loss Ratios – what is your approach?

Client Relationships: Liability & Responsibility One should flow from the other Assume liability & responsibility where proper E&O coverage and practical outcomes