Welcome to Your Compliance Roadmap

Employees and dependents who are eligible for health care coverage under an employer-sponsored health plan, but are not enrolled, must be permitted to enroll in the plan if they lose eligibility for Medicaid or CHIP (Children’s Health Insurance Program) coverage or become eligible for a premium assistance subsidy under Medicaid or CHIP.

CHIPRA Overview

Notices

Health Insurance Portability and Accountability Act (HIPAA)

What is HIPAA? What is the privacy rule? What is the security rule? Who is subject to HIPAA rules? What is protected health information (PHI)?

What is HIPAA?

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is
a broad federal law regarding health coverage. It contains provisions
related to the portability of health coverage and provisions prohibiting
discrimination by a health plan based upon an individual's health status.
HIPAA also includes provisions relating to the privacy and security of
personal health information.

What is the privacy rule?

What is the security rule?

Who is subject to HIPAA rules?

The HIPAA Privacy and Security Rules directly apply to covered entities. Covered entities include health plans, health care clearinghouses, and health care providers that conduct certain transactions electronically. The HIPAA Privacy and Security Rules indirectly regulate health plan sponsors. The extent of an employer’s obligations under the HIPAA Privacy and Security Rules generally depends on whether the employer has access to PHI for plan administration purposes. Other third parties that use PHI to provide services to covered entities (known as business associates) must also comply with certain provisions of the Privacy and Security Rules.

What is protected health information (PHI)?

PHI is oral, written or electronic individually identifiable health information that is created or received by a covered entity and relates to past, present or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present or future payment for the provision of health care to an individual. The Privacy Rule applies to all types of PHI (written, oral and electronic). The Security Rule’s requirements, however, only apply to electronic PHI (ePHI).

Documents and Notices

HIPAA Employer Education

HIPAA Privacy and Security Employer Education

Employee Education

Notices and Forms

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Employers with 15 or More Employees

In addition to the requirements above, employers with 15 or more employees must comply with the Americans with Disabilities Act and Genetic Information Nondiscrimination Act.

Americans with Disabilities Act

GINA

Americans with Disabilities Act

Employers covered by the ADA Practices covered by the employment nondiscrimination requirements Qualified applicant with a disability vs. other applicants Reasonable Accommodations Modifying Existing Facilities

Employers covered by the ADA

The employment provisions of title I of the ADA apply to private employers, state and local governments, employment agencies and labor unions. Employers with 15 or more employees are covered.

Practices covered by the employment nondiscrimination requirements

Qualified applicant with a disability vs. other applicants

No. An employer is free to select the most qualified applicant available and to make decisions based on reasons unrelated to the existence or consequence of a disability. For example, if two persons apply for a job opening as a typist, one a person with a disability who accurately types 50 words per minute, the other a person without a disability who accurately types 75 words per minute, the employer may hire the applicant with the higher typing speed, if typing speed is needed for successful performance of the job.

Reasonable Accommodations

Reasonable accommodation is a modification or an adjustment to a job or the work environment that will enable a qualified applicant or employee with a disability to participate in the application process or to perform essential job functions. Reasonable accommodation also includes adjustments to ensure that a qualified individual with a disability has rights and privileges in employment equal to those of nondisabled employees.

Modifying Existing Facilities

An employer may be required to modify facilities to enable an individual to perform essential job functions and to have equal opportunity to participate in other employment-related activities. For example, if an employee lounge is located in a place inaccessible to a person using a wheelchair, the lounge might be modified or relocated, or comparable facilities might be provided in a location that would enable the individual to take a break with coworkers.

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Documents

ADA Employer Education

ADA Employee Education

Genetic Information Nondiscrimination Act

The Genetic Information Nondiscrimination Act of 2008 (GINA) provides broad protections in employment and health coverage against the improper collection, use or disclosure of individuals’ genetic information.

Title I prohibits group health plans and health insurance issuers from discriminating based on genetic information and from collecting genetic information.

Title II, which applies to employers with 15 or more employees, protects job applicants and employees from employment discrimination based on their genetic information.

Documents and Notices

GINA Information

For Health Plans

For Employers

Employers with 20 or more Employees

In addition to the requirements above, employers with 20 or more employees on more than 50 percent of the typical business days during the previous calendar year must comply with COBRA requirements. COBRA Administration is another vital HR responsibility, but it can be complex. Government and church plans are exempt.

COBRA

Documents, Notices, and Forms

Employer Education

Employee Education

State Guidelines

Model Notices and Forms

Common Questions

What employers are subject to COBRA? What is COBRA? What are the maximum coverage periods?

What employers are subject to COBRA?

Employers who employed 20 or more employees on more than 50 percent of the business days in the prior calendar year are subject to COBRA. Small-employer plans, church plans and governmental plans are not subject to COBRA. However, state and local governments are required to comply with parallel continuation coverage requirements under the Public Health Service Act. Individuals covered under the Federal Employees Health Benefit Program are provided with similar, but not identical, rights to continue coverage.

What is COBRA?

What are the maximum coverage periods?

Common Q's: Definitions

Common Q's: Administration

Common Q's: Notification Requirements

Employers with 50 or More Employees

In addition to the requirements above, employers with 50 or more employees in 20 or more workweeks in the current or preceding calendar year must comply with Family and Medical Leave Act (FMLA). Complying with the FMLA is an important responsibility for HR and benefit managers. Private sector employers, public agencies, and all public and private elementary and secondary schools must comply with the FMLA.

Family and Medical Leave Act

Documents and Notices

General Information

For Employers

For Employees

State Specific Guidelines

Click the image to the right to learn more about the steps you should take as an employer to ensure that you are complying with FMLA requirements.

Common Questions

What employers are covered by the FMLA? Who is eligible for FMLA leave? What are the qualifying reasons for FMLA leave?

What employers are covered by the FMLA?

The FMLA applies to private employers with 50 or more employees on each working day during each of 20 or more calendar workweeks in the current or preceding calendar year. It is not necessary that an employee actually performs work on each working day or receives compensation for the week to be counted as employed, as long as the employee’s name appears on the employer’s payroll. Employees on leave are counted as employed if the employer has a reasonable expectation that they will return to active employment.

Who is eligible for FMLA leave?

An employee is eligible for FMLA leave if the employee has been employed by a covered employer for at least 12 months and has worked at least 1,250 hours for that employer during the previous 12-month period. An eligible employee must also be employed at a worksite where the employer employs at least 50 employees within a 75-mile radius of the worksite. For purposes of determining whether an employee who is a flight crew member meets the hours of service requirement above, the employee will be considered to meet the requirement if he or she has worked or been paid for not less than 60 percent of the applicable total monthly guarantee for the previous 12-month period; and has worked or been paid for not less than 504 hours during the previous 12-month period.

What are the qualifying reasons for FMLA leave?

The following circumstances qualify for 12 workweeks of FMLA leave:

- Birth and care of an employee’s son or daughter;

- Placement of a son or daughter with the employee for adoption or foster care;

- Care for an employee’s spouse, son, daughter or parent who has a serious health condition;

- An employee’s own serious health condition that makes the employee unable to perform any one of the essential functions of the employee’s position; or

- Any qualifying exigency arising out of the fact that a family member (spouse, son, daughter or parent of the employee) is a covered military member on covered active duty or has been notified of an impending call or order to covered active duty in the Armed Forces.

In addition, eligible employees may take 26 workweeks of leave in a single 12-month period to care for a spouse, son, daughter, parent or next of kin who is a covered service member with a serious injury or illness.

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Do you offer prescription drug coverage?

Medicare Part D governs group health plan sponsors that provide prescription drug coverage, except entities that contract with or become a Part D plan. Assist your clients in staying in compliance with Medicare Part D legal requirements with the resources below.

Medicare Part D

Common Questions

What is Creditable Coverage? Who is required to comply with Medicare Part D? Who is a Medicare Part D eligible individual?

What is Creditable Coverage?

A group health plan’s prescription drug coverage is considered creditable if it is at least as generous as Medicare Part D prescription drug coverage. There are two permissible methods to determine whether coverage is creditable —a simplified determination method and an actuarial determination method.

Who is required to comply with Medicare Part D?

Generally, employer-sponsored group health plans offering prescription drug coverage to individuals who are eligible for coverage under Medicare Part D must comply with mandates on the disclosure of creditable coverage and coordination of benefits. A group health plan sponsor may also voluntarily choose to comply with certain requirements in order to apply for a federal tax-free subsidy (the Retiree Drug Subsidy).

Who is a Medicare Part D eligible individual?

An individual is eligible for Medicare Part D if the individual is entitled to Medicare Part A and/or enrolled in Part B and the individual resides in the service area of a prescription drug plan (PDP) or a Medicare Advantage plan that provides prescription drug coverage (MA-PD). In general, an individual becomes entitled to Medicare Part A when the person actually has Part A coverage, and not just when the person is first eligible.

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Documents, Notices, and Forms

Employer Education

Notices

Do you offer pre-tax plans?

Section 125 plans are a common and attractive way to administer benefits, allowing employees to contribute premium or other plan contributions pre-tax. However, these plans must comply with specific IRS regulations. Learn more about these regulations with the informational pieces below.

Section 125

Midyear Election Changes

Plan Designs

Nondiscrimination Tests

Section 125 Overview

Do you offer welfare benefit plans?

The Employee Retirement Income Security Act of 1974 (ERISA) governs employee welfare benefit plans, unless exempted.

Employee Retirement Income Security Act

What is ERISA? Plan Document/SPD Form 5500

What is ERISA?

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.

Plan Document/SPD

Form 5500

Documents and Notices

Employer Education

DOL Audit Guide: Employee Benefit Plans

Basics of ERISA Welfare Benefit Plans

Determining Whether a Welfare Benefit Plan Arrangement is an ERISA Plan

Summary Plan Descriptions and Annual Reports

Common Mistakes

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Welcome to Your Compliance Roadmap

Clarke and Company is focused on ensuring that your business is in compliance with all federal and state insurance laws. Use this page to learn more about recent regulations and more. Click below for more information on our upcoming compliance webinars.

Compliance Requirements

Looking for a specific requirement or group size? Click the icon below. Otherwise, keep scrolling to learn more about your federal employee benefit notice, disclosure, and reporting responsibilities.

Applicable to All Employers

Affordable Care Act

ACA Documents and Notices

Children's Health Insurance Program Reauthorization Act (CHIPRA)

Health Insurance Portability and Accountability Act (HIPAA)

Documents and Notices

Employers with 15 or More Employees

Americans with Disabilities Act

Documents

Genetic Information Nondiscrimination Act

Documents and Notices

Employers with 20 or more Employees

COBRA

Documents, Notices, and Forms

Common Questions

Employers with 50 or More Employees

Family and Medical Leave Act

Documents and Notices

Common Questions

Do you offer prescription drug coverage?

Medicare Part D

Common Questions

Documents, Notices, and Forms

Do you offer pre-tax plans?

Section 125

Do you offer welfare benefit plans?

Employee Retirement Income Security Act

Documents and Notices

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