What do employers need to consider regarding benefits recordkeeping and disclosures? The Employee Retirement Income Security Act (ERISA) provides extensive reporting and disclosure and other administrative requirements for employee benefit plans. The law and regulations also provide for numerous exemptions from the various requirements.

Additional disclosure requirements apply to health plans. The Affordable Care Act (ACA) added many additional reporting, disclosure, and notice requirements for health plans and insurers, including additional internal and external appeal requirements for health insurers and group health plans.

Employers must also consider the Medicare Part D prescription drug coverage provisions that impose reporting and disclosure requirements on health plans that cover Medicare-eligible individuals. Additionally, the Pension Protection Act of 2006 (PPA) imposes reporting and notice requirements.

ERISA has extensive reporting and disclosure requirements for pension, profit-sharing, stock bonus plans, and most “welfare plans” (i.e., health care, life insurance, prepaid legal services, disability insurance). Forms and documents may have to be filed with the Internal Revenue Service (IRS), the Department of Labor (DOL), and the Pension Benefit Guaranty Corporation (PBGC). Others go directly to plan participants.

In general, ERISA “preempts” (i.e., overrides) state law. However, there are a few exceptions to this rule. ERISA does not supersede state insurance laws, so group health and life insurance plans are subject to state insurance mandates. Self-insured plans are exempt from state regulation.

The DOL is authorized to grant partial and complete exemptions from ERISA's reporting and disclosure requirements. For example, welfare plans with fewer than 100 participants that are unfunded (paid out of general company funds and not a separate trust fund) or paid through insurance contracts are exempted from most filing and reporting requirements (but not the summary plan description (SPD) requirement) (29 CFR 2520.104-20 and 29 CFR 2520.104-44). There is also an alternative method of compliance available for unfunded or insured pension plans that are established to provide benefits for a select group of highly paid or management employees (29 CFR 2520.104-23).

Even if DOL regulations exempt a plan from reporting and disclosure requirements, the IRS may require it to file tax returns and other reports.

SPDs, summaries of material changes to the plan, summary annual reports, changes to information included in the SPD of group health plans, benefit statements, and other documents that must be distributed to plan participants and beneficiaries generally may be distributed electronically under final regulations issued by the DOL (29 CFR 2520.104b-1(c)).

Electronic distribution system requirements. Before using electronic distribution, the plan administrator must take steps to ensure that the distribution system:

Electronic document requirements. The electronically distributed documents must be prepared and furnished in a manner that is consistent with the style, format, and content requirements applicable to the particular document. In addition, notice must be provided to each participant or beneficiary to whom an electronic document is being delivered that apprises the recipient of a document's particular significance and of the participant's right to request and receive, free of charge, a paper copy of the document from the plan administrator. This notice must be provided at the time a document is furnished electronically, but may be provided in electronic or nonelectronic form.

Electronic distribution without prior consent. Benefit plan documents may be provided electronically without prior consent to plan participants:

Electronic distribution requiring prior consent. Participants, beneficiaries, or any other persons entitled to receive benefit plan documents may affirmatively consent, in electronic or nonelectronic form, to receiving documents through electronic media. If the documents are to be furnished through the Internet or other electronic communication network, the individual must have affirmatively consented or confirmed consent electronically, in a manner that reasonably demonstrates the individual’s ability to access information in the electronic form that will be used to provide the information that is the subject of the consent and has provided an address for the receipt of electronically furnished documents.

Before consenting, the individual must be provided, in electronic or nonelectronic form, a clear and conspicuous statement indicating:

Retirement plan safe harbor. In 2020, the DOL created a new disclosure safe harbor for retirement plans. Plan administrators that satisfy certain conditions may notify retirement plan participants that SPDs and other required disclosures will be posted on a website. At the same time, participants can choose to opt out of electronic delivery or request paper copies of disclosures.

The final rule, published on May 27, 2020 (85 Fed. Reg. 31884), allows retirement plan administrators to furnish certain required disclosures using a “notice-and-access” model, or to e-mail disclosures directly to participants.

Plan administrators must notify plan participants about these online disclosures, provide information on how to access the disclosures, and inform participants of their rights to request paper or opt out completely. The rule also includes additional protections such as accessibility and readability standards for online disclosures and system checks for invalid electronic addresses.

The U.S. Department of Health and Human Services (HHS), the IRS, and the DOL issued national standards for providing a summary of benefits and coverage (SBC) explanation that accurately describes the benefits and coverage under group health plans and group or individual health insurance coverage as required by the ACA. The SBC and a uniform glossary of terms are to be provided to applicants, enrollees, reenrollees, and policyholders or certificate holders (29 CFR 2590.715-2715).

The following documents, available online at https://www.cms.gov, are provided to assist in preparing an SBC:

Standardized comparison tool. Regulations provide that an SBC must include a standardized health plan comparison tool for consumers known as “coverage examples.” The tool uses a format modeled on the nutrition facts label required for packaged foods. The coverage examples illustrate, for comparison purposes, what proportion of the cost of care a health insurance policy or plan would cover for a sample patient for common medical situations. These examples are intended to help consumers understand and compare a sample patient’s share of the costs of care under a particular plan and have a better idea of how valuable the health plan will be at times when the consumer may need the coverage.

Uniform glossary. Health insurance companies and group health plans are required to make available a uniform glossary of health coverage and medical terms commonly used in plan documents, such as “deductible” and “copay.” The uniform glossary is intended to help consumers understand some of the most common, and sometimes confusing, language used in health insurance documents.

SBC format and appearance. Regulations provide that an SBC may be provided either as a stand-alone document or in combination with other summary materials (for example, an SPD) if the SBC information is intact and prominently displayed at the beginning of the materials (such as immediately after the table of contents in an SPD).

SBC template requirement. Group health plans and health insurance issuers in the group and individual markets are required to use the full SBC template. To the extent a plan’s terms that are required to be described in the SBC template cannot reasonably be described in a manner consistent with the template and instructions, the plan must accurately describe the relevant plan terms while using its best efforts to do so in a manner that is still consistent with the instructions and template format as is reasonably possible.

Language requirements. The ACA requires group health plans and health insurers to provide the SBC in a culturally and linguistically appropriate manner. The regulations provide that a plan satisfies this requirement by following the rules for providing claims and appeals notices in a culturally and linguistically appropriate manner. Under those rules, plans and issuers must provide notices in a non-English language when 10 percent or more of the population residing in the claimant’s county are literate only in the same non-English language, as determined based on American Community Survey data published by the U.S. Census Bureau. Translations of the SBC template and related language resources are available from the Centers for Medicare and Medicaid Services (CMS) (see above link).

Benefits summary distribution. An SBC may be provided in paper or electronic form. The regulations provide flexibility to plans and insurers for distribution. Assuming certain consumer safeguards are met, in the vast majority of cases, the SBC can be provided electronically, allowing a plan or issuer to post the SBC on its website or provide it by e-mail. Additionally, the regulations provide flexibility in the instructions for completing the SBC in recognition of unique plan designs.

Entities that must provide an SBC include the health insurance issuer (including a group health plan that is not a self-insured plan) offering health insurance coverage within the United States and, in the case of a self-insured group health plan, the plan sponsor or designated administrator of the plan.

Notice of modifications. If a group health plan or health insurance issuer makes any material modification in any of the terms of the plan or coverage involved (as defined for ERISA Sec. 102) that is not reflected in the most recently provided SBC, the plan or issuer must provide notice of the modification to enrollees at least 60 days before the modification will become effective.

Preemption. The national SBC standard will preempt any related state standards that require a summary of benefits and coverage that provides less information to consumers than the national standard.

Penalty for failure to provide. An entity that willfully fails to provide an SBC may be fined not more than $1,000 for each failure (adjusted periodically for inflation since the ACA’s enactment). A failure with respect to each individual enrollee is a separate offense.

Section 3607 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act amended ERISA Section 518 to give the DOL authority to postpone certain deadlines during a public health emergency. The DOL responded with Disaster Relief Notice 2020-01, giving plan sponsors and administrators more time to furnish benefit statements, annual funding notices, and other ERISA-required notices and disclosures, as long as they made a good-faith effort to do so as soon as administratively practicable.

For this purpose, “good faith” included the use of electronic alternative means of communicating with plan participants and beneficiaries who were reasonably believed to have effective access to electronic means of communication, including e-mail, text messages, and continuous access websites. The DOL notice also included compliance assistance guidance on plan loans, participant contributions and loan payments, blackout notices, Form 5500 and Form M-1 filing relief, and other ERISA fiduciary issues.

Expiration. Section 518 sets a 1-year limit on this emergency deadline relief. According to Disaster Relief Notice 2021-01, this meant that each specific action by a plan or individual had a deadline 1 year later than would otherwise apply, unless the COVID-19 “outbreak period” ended sooner. The outbreak period ended on July 10, 2023.

The most important of the ERISA reports is the SPD, which is a basic information package provided to participants and beneficiaries (29 USC 1022). Often, much of the information that is to be given to participants is provided by the insurance carrier that ultimately pays the benefits.

The plan administrator must automatically furnish the SPD to participants covered under the plan within 90 days of the participant becoming covered under the plan, or within 90 days of a beneficiary first receiving benefits (29 USC 1024(b)(1)(A)). For a new plan, the SPD must be furnished within 120 days after the plan becomes subject to ERISA (29 USC 1024(b)(1)(B)). After a participant has received the SPD initially, the plan administrator must furnish an updated SPD every 5 years if changes are made to the SPD or plan. In the unlikely event that no changes are made to the SPD or plan, the plan administrator must furnish the SPD every 10 years after the SPD is initially furnished.

SPDs must include the following information, if applicable:

Health benefit information. The SPD of a group health plan must also often contain more items, including the following, as appropriate:

Note: The claims procedure may be provided as a separate document if the SPD itself so states. The listing of providers may be furnished as a separate document that accompanies the plan's SPD if the SPD contains a general description of the provider network and states that the provider lists are furnished automatically, without charge, as a separate document.

Avoid litigation. Lack of care in the wording of SPDs can give rise to unintended liability and, if misleading, could also subject an employer to legal penalties. Courts will interpret ambiguous language in an SPD in favor of plan participants. If there is a conflict between the content of the plan document and the SPD, courts will generally apply the provision that is most favorable to the participant. For this reason, the SPD should be formulated in consultation with an attorney, accountant, or benefits specialist and should be frequently reviewed.

If your plan covers a certain percentage of participants who are literate only in the same non-English language, the plan administrator does not need to issue an SPD in a non-English language. However, the SPD must include a prominent notice written in the non-English language common to these participants that notifies the participants that assistance with the SPD is available in their own language (29 CFR 2520.102-2(c)). The notice must clearly explain in the same non-English language the procedures that must be followed in order to obtain assistance with the SPD.

This foreign language assistance applies in the cases of:

Many self-funded group health plan sponsors have adopted, or are considering adopting, a wrap document. In some cases, the "wrap" approach is used to combine otherwise unrelated welfare plan benefits into a single, integrated welfare benefit plan (i.e., the unrelated benefits are "wrapped" together). In other cases, separate benefits are not "wrapped"; rather, the plan document consists of a "shell" that "wraps around" the benefit provisions contained in an SPD to comprise the formal ERISA plan.

The touted advantages of taking a "wrap" approach include easier document administration and maintenance, reduction in potential litigation attributable to discrepancies between the plan and the SPD, and a possible reduction in the number of required Form 5500 filings. Disadvantages include ERISA compliance headaches (such as Form 5500, audit, and trust requirements) that may arise when previously unrelated ERISA plans are "wrapped" imprudently.

An SMM describes material modifications to a plan and changes in the information required to be in the SPD (29 CFR 2520.104b-3). When a plan is amended or an SPD is changed, participants must be informed of the change through an SMM. Distributing an updated SPD satisfies the SMM requirement. An SMM must be distributed automatically to participants and pension plan beneficiaries receiving benefits no later than 210 days after the end of the plan year in which the change is adopted.

An SAR is a narrative summary of Form 5500 (29 CFR 2520.104b-10). Plan sponsors must automatically distribute the SAR to participants and pension plan beneficiaries receiving benefits within 9 months after the end of plan year or 2 months after the due date for filing Form 5500 (if there is an approved extension).

ERISA and the IRC allow participants in certain individual account plans that hold publicly traded employer stock to divest these investments (26 USC 401(a)(35)). The requirements do not apply to an employee stock ownership plan (ESOP) if there are no elective, employee, or matching contributions to the plan, and the plan is separate from any other defined benefit plan or individual account plan maintained by the same employer. A participant must be allowed to direct the plan to immediately divest any employer securities attributable to employee contributions and elective deferrals and to reinvest an equivalent amount in other specified investment options. In the case of the portion of the account attributable to employer contributions other than elective deferrals, which is invested in employer securities, a participant who has completed at least 3 years of service must be allowed to direct the plan to divest any such securities and to reinvest an equivalent amount in other specified investment options. Please see the Retirement Savings and Pension Plans section.

No later than 30 days before the first date on which a participant is eligible to divest employer securities, the plan administrator must provide that participant with a notice that explains the right to divest and describes the importance of diversifying the investment of retirement account assets. The IRS has issued a model notice, which is included in IRS Notice 2006-107 and can be found at http://www.irs.gov.

ERISA requires that the administrator of an individual account plan furnish benefit statements at least once each calendar quarter if participants or beneficiaries have the right to direct the investment of assets in their plan accounts (29 USC 1025). The statement is required at least once each calendar year to participants or beneficiaries who have their own accounts under the plan but do not have the right to direct the investment of assets in that account. The statements must also be furnished upon written request to a plan beneficiary not listed above. Active, vested participants in a defined benefit plan must be provided with a statement at least once every 3 years or a notice describing the availability of the statement. The statement must be written in a manner calculated to be understood by the average plan participant and may be delivered in written, electronic, or other appropriate form to the extent the form is reasonably accessible to the participant or beneficiary.

Content of the statement. The statement is to indicate, based on the latest available information, the total benefits accrued and the vested benefits, if any, that have accrued, or the earliest date on which benefits will become vested. The statement must also include an explanation of any permitted disparity under IRC Sec. 401(l) or any floor-offset arrangement that may be applied in determining the amount of accrued benefits.

In the case of individual account plans, the statement must include the value of each investment to which assets in the participant's account have been allocated, determined as of the most recent valuation date under the plan, including the value of any assets held in the form of employer securities, whether the securities were contributed by the plan sponsor or acquired at the direction of the plan or of the participant or beneficiary.

In the case of pension benefit statements to participants and beneficiaries who can direct investments, the statement must also include the following:

Under the Setting Every Community Up for Retirement Enhancement (SECURE) Act, passed in 2019, periodic pension benefit statements must include a “lifetime income disclosure” that quantifies the payments a defined contribution (401(k) or 403(b)) plan would yield if structured as a lifetime annuity.

The DOL fleshed out these requirements in an interim final rule published on September 18, 2020 (85 Fed. Reg. 59132). Plan administrators must provide lifetime income illustrations as estimated monthly payments based on a single life annuity, as well as a qualified joint and 100% survivor annuity. The rule took effect on September 18, 2021, meaning the first disclosure had to be provided for a reporting period that ended before September 18, 2022.

Alternative notice. The requirements to provide notice of the vested pension benefits, if any, that have accrued, or the earliest date on which benefits will become vested are met if, at least annually, the plan updates this information and provides in a separate statement the information needed to enable a participant or beneficiary to determine their vested benefits. In the case of a defined benefit plan, the requirement to provide a statement every 3 years is met if at least once each year, the plan administrator provides the participant with a notice of the availability of the pension benefit statement and the ways in which the participant may obtain such statement. This notice may be delivered in written, electronic, or other appropriate form to the extent such form is reasonably accessible to the participant.

Many special notice requirements apply to group healthcare plans, including, for example:

A number of notices are also required by the ACA.

Group health plans must provide participants and beneficiaries with a summary of any material reduction in covered services or benefits within 60 days after such a plan modification is adopted (29 CFR 2520.104b-3). Alternatively, plan sponsors may provide such descriptions at regular intervals of no more than 90 days. The requirement may be satisfied by an insert in a union newspaper or company publication that is regularly furnished to participants at intervals of not more than 90 days. Participants and beneficiaries who do not receive these publications must be notified within 60 days after the date of adoption.

To maintain status as a grandfathered health plan under the ACA, a plan or health insurance coverage must include a statement, whenever a summary of plan benefits is provided to participants or beneficiaries describing the benefits provided under the plan and explains that the plan is believed to be grandfathered within the meaning of Section 1251 of the ACA. The notice also must provide contact information for questions and complaints (29 CFR 2590.715-1251).

Employers are required to report on Form W-2 the total cost of group health coverage, including the portion paid by the employer and the portion paid by the employee. However, this reporting requirement does not mean such coverage is taxable. It is only meant for informational purposes and is designed to provide employees with useful and comparable consumer information regarding the cost of their healthcare coverage.

Employers are to provide existing employees and new employees at the time of hiring with a written notice informing them of the following:

Model notices can be found at https://www.dol.gov.

If a group health plan or insurer requires the designation of a primary care provider, the plan or insurer must provide a notice informing each participant of the provision on naming a primary care provider and the participant's rights in this regard (29 CFR 2590.715-2719A). The notice must be included whenever the plan or insurer provides a participant with an SPD or other similar description of benefits under the plan or coverage.

A provision of the ACA would have required group health plans and their insurers to report information on benefits and healthcare provider reimbursement structures that improve health outcomes through the implementation of certain activities (42 USC 300gg-17). However, these requirements were never implemented.

Section 6056, enacted by the ACA, concerns information reporting by “applicable large employers” (ALEs) on health insurance coverage offered under employer-sponsored plans. The same ALEs that are subject to the “play or pay” provision (generally, employers with 50 or more full-time employees, including full-time equivalent employees) are also subject to these reporting requirements.

ALEs must report certain information to the IRS, including details about the healthcare coverage (if any) they offer to full-time employees. This reporting is designed to help the IRS administer the play or pay provision. These employers also must provide related statements to employees, to help them determine whether they may claim a premium tax credit on their individual tax return. Generally, these requirements are met by filing an annual Form 1095-C and, in the submittal to the IRS, a transmittal Form 1094-C. For more information, see https://www.irs.gov/affordable-care-act.

Section 6055 concerns information reporting requirements for providers of minimum essential health coverage. Although Section 6055 is mainly geared toward health insurers, it does concern certain employers. ALEs with self-funded group health plans must include this information on Forms 1094- and 1095-C. Self-funded employers not filing those forms (i.e., because they are not ALEs) must use Form 1095-B and transmittal Form 1094-B.

Electronic filing requirement. Beginning with forms filed in 2024 (covering tax year 2023), any employer filing 10 or more ACA forms must file them electronically (the prior threshold was 250). The rule, finalized February 23, 2023 (88 Fed. Reg. 11754), applies if an employer submits at least 10 total forms of certain types, including Forms 1094-B/C and 1095-B/C as well as W-2 and 1099.

As a result, many smaller employers must use the IRS’s electronic ACA filing system for the first time, and should allow time to prepare in case arrangements with a third-party service provider are needed. Waivers may be granted in cases of “undue hardship.”

Web posting safe harbor. After the ACA individual mandate penalty was eliminated, the IRS established a safe harbor whereby a reporting entity (health insurer or self-funded employer) required to furnish the 1095-B will not face penalties for failing to do so, provided the entity:

As before, self-funded employers that provide the Section 6055 information on Form 1095-C usually still must distribute that form because they are also ALEs subject to Section 6056. However, the alternative method would be available for providing Form 1095-C to part-time employees or retirees, the IRS explained (87 Fed. Reg. 76575, December 15, 2022).

The ACA (IRC Sec. 4375(a)) imposed an annual fee on the issuers of specified health insurance policies (including self-insured plans). The Comparative Effectiveness Research Fee, based on the average number of lives covered under the policy/plan, funds the Patient-Centered Outcomes Research Institute (PCORI). The PCORI performs research that helps patients, clinicians, purchasers, and policymakers make informed health decisions by advancing the quality and relevance of evidence-based medicine by publicizing comparative clinical effectiveness research findings.

Reporting and paying the fee. Form 720, Quarterly Federal Excise Tax Return, which reports liability for the PCORI fee, must be filed by July 31 of the calendar year immediately following the last day of the policy year or plan year to which the fee applies. Issuers and plan sponsors that must pay the fee but are not required to report any other liabilities on Form 720 are required to file Form 720 only once a year. Instructions for how to fill out Form 720 and calculate the fee are located at http://www.irs.gov/pub/irs-pdf/i720.pdf.

Covered policies and plans. IRS regulations define the term “specified health insurance policy” to include only accident and health insurance policies that are issued for individuals residing in the United States. More specifically, the following types of insurance coverage or arrangements are subject to the fee:

However, the following types of insurance coverage or arrangements are not subject to the fee:

There is a special rule for coverage under multiple applicable self-insured health plans. Generally, separate fees apply for lives covered by each specified health insurance policy or applicable self-insured health plan. However, two or more applicable self-insured health plans may be combined and treated as a single applicable self-insured health plan for purposes of calculating the fee if the plans have the same plan sponsor and the same plan year.

For example, if amounts in an HRA may be used to pay deductibles and copays under a specified health insurance policy, the HRA (an applicable self-insured health plan) and the policy would be subject to separate fees. But, an HRA that may be used to pay deductibles and copays under the applicable self-insured health plan is not subject to a separate fee (and the fee will apply only to the applicable self-insured health plan) if both the HRA and the applicable self-insured health plan have the same plan sponsor and the same plan year.

Because it is often difficult for an FSA or HRA sponsor to know how many dependents are covered, a special rule permits the plan sponsor to assume one covered life for each employee with an HRA and for each employee with a health FSA that is not an excepted benefit.

Fee calculation. The fee must be calculated using the applicable dollar amount in effect for the plan year and one of the permitted methods for determining the average number of lives covered under the plan during the plan year.

For specified health insurance policies, the permitted methods for determining the number of covered lives are:

For applicable self-insured plans, the permitted methods are:

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule requires that individuals be provided with adequate notice of the uses and disclosures of their protected health information that may be made by a covered entity and of their privacy rights and the covered entity's legal duties with respect to protected health information. Please see the national Health Information Privacy (HIPAA) section.

The Medicare Modernization Act (MMA) created Medicare Part D, the retiree drug benefit. The MMA mandates that entities that provide prescription drug coverage to Medicare beneficiaries, including employer-sponsored health plans, disclose to all Part D-eligible individuals who are covered under, or who apply for, the plan's prescription drug coverage whether or not the coverage is "creditable prescription drug coverage" (42 USC 1395w-113(b)(6) and 42 CFR 423.56). This requirement applies whether or not the employer-sponsored coverage is primary or secondary to Part D coverage. Thus, the notice must be provided to Medicare-eligible retirees and their Medicare-eligible dependents who are covered under an employer-sponsored plan and Medicare-eligible active employees and Medicare-eligible dependents of active employees who are covered under the plan.

Employers must notify Medicare-eligible individuals about the status of the employer’s drug coverage at the following times:

This requirement was created because a penalty applies to individuals who do not enroll in Medicare Plan D when first eligible to do so unless the individual has had creditable coverage following their initial enrollment period, with no breaks of longer than 63 days, until the individual does eventually enroll in Part D. Thus, knowing whether they have creditable coverage is a key factor in a Medicare-eligible individual's decision whether or not to enroll in a Part D plan.

Definition of “creditable coverage.” Coverage is "creditable" if its actuarial value equals or exceeds the actuarial value of standard prescription drug coverage under the Medicare prescription drug benefit, in effect at the start of such plan year, not taking into account the value of any discount or coverage provided during the coverage gap, and demonstrated through the use of generally accepted actuarial principles and in accordance with CMS guidelines.

Notice to the CMS. In addition to the disclosure to Part D-eligible individuals, a plan must also provide a disclosure of creditable coverage status to the CMS on an annual basis (42 CFR 423.56). This disclosure must be made whether or not the prescription drug coverage offered to Medicare Part D-eligible individuals is creditable. Disclosure forms are posted at http://www.cms.gov. Because a plan sponsor that has applied for the Retiree Drug Subsidy (RDS) must provide an attestation that its prescription drug coverage is at least actuarially equivalent to the standard prescription drug coverage under Part D and because the actuarial equivalence standard includes the creditable coverage standard, a sponsor that has been approved for the RDS is exempt from filing the Disclosure Notice with the CMS for those qualified covered retirees for whom the sponsor is claiming the RDS.

When to provide notice to the CMS. The Disclosure Notice must be made to CMS annually and upon any change that affects whether the drug coverage is creditable. At a minimum, disclosure to the CMS must be made at the following times:

The MSP provisions of the Social Security Act require mandatory reporting to CMS by group health plan arrangements, liability insurers, workers' compensation insurers, and no-fault insurers of information needed to enforce the secondary payer requirements (42 USC 1395y(b)(7) and 42 USC 1395y(b)(8)).

Group health plan reporting. The reporting requirements apply to a group health plan’s “responsible reporting entity” (RRE), which is a plan’s insurer, third-party administrator (TPA), or—if the plan is self-funded and self-administered—the plan administrator or fiduciary. As an employer, you may need to cooperate with your insurer or TPA so it can provide the required information.

There are several things you may be asked to do, such as to help the insurer or TPA gather information to determine the entitlement of your employees or their spouses to Medicare. For example, you may have to provide the Medicare identification numbers or Social Security numbers (SSNs) of your employees and their spouses. Your insurer or TPA may also ask you for the number of full-time and part-time employees in your organization. For detailed guidance, see the CMS website.

Other reporting. If an employer has purchased commercial liability, no-fault, or workers’ compensation insurance, the insurer must report certain information (42 USC 1395y(b)(8)). If an employer has a self-funded plan for these types of insurance, the employer must report the required information. Information that must be reported includes information on claims, such as the claimant involved, claim payments, the ongoing responsibility for medical treatment, and information on settlements, judgments, etc.

Notice to employees. An employer that maintains a group health plan must annually provide to each employee residing in a state that provides premium assistance for the purchase of group health plan coverage through a Medicaid plan or CHIP a written notice informing the employee of potential opportunities currently available in the employee’s home state. The DOL maintains a list of states offering the required assistance, which is included in the model Employer CHIP Notice at https://www.dol.gov.

Employers subject to the Employer CHIP Notice requirement. If a group health plan provides benefits for medical care directly (such as through a health maintenance organization) or through insurance, reimbursement, or in some other way to participants, beneficiaries, or providers in any state listed by the DOL, the plan is required to provide the Employer CHIP Notice, regardless of the employer’s location or principal place of business (or the location or principal place of business of the group health plan, its administrator, its insurer, or any other service provider affiliated with the employer or the plan).

Employees who must be provided with the Employer CHIP Notice requirement. An Employer CHIP Notice must inform each employee, regardless of enrollment status, of potential opportunities for premium assistance in the state in which the employee resides. Thus, the notice must go to all employees who reside in one of the states listed by the DOL. The state in which the employee resides may or may not be the same as the state in which the employer, the employer’s principal place of business, the health plan, its insurer, or other service providers are located.

Notice to state Medicaid and CHIP agencies. The plan administrator of a group health plan that has participants or beneficiaries who are covered under a state Medicaid plan or a CHIP plan must disclose to the relevant agency, on request, information about the benefits available under the group health plan. This disclosure is to allow the agency to make a determination concerning the cost-effectiveness to the agency of providing medical or child health assistance by subsidizing premiums for the purchase of coverage under the employer's group health plan or to provide supplemental benefits instead. The CHIP Coverage Coordination Disclosure Form that is to be used for this purpose may be downloaded at https://www.cms.gov.

The Mental Health Parity and Addiction Equity Act (MHPAEA), enacted in 2008, applies to most employers with more than 50 employees and is designed to provide mental health parity by making sure mental health and substance use disorder (MH/SUD) benefits offered by health plans are equivalent to the medical/surgical benefits the plans offer. Please see the Healthcare Insurance section. Under the Consolidated Appropriations Act of 2021 (CAA), group health plans that impose nonquantitative treatment limits (NQTLs) must perform comparative analyses of how these limits are designed and applied, and have them available in case the DOL or another agency requests them. An NQTL is a limitation that is not expressed numerically but otherwise limits the scope or duration of benefits for treatment.

These analyses must address:

These comparative analyses should be sufficiently specific, detailed, and reasoned to demonstrate whether the processes, strategies, evidentiary standards, or other factors used in developing and applying an NQTL are comparable and applied no more stringently to MH/SUD benefits than to medical/surgical benefits, according to DOL guidance. A general statement of compliance, coupled with a conclusory reference to broadly stated processes, strategies, evidentiary standards, or other factors, will not be considered sufficient.

Proposed rule changes. Changes to the MHPAEA rules published August 3, 2023 (88 Fed. Reg. 51552) would not only tighten the underlying parity provisions but also make the comparative analysis process more burdensome.

A compliance analysis would need to identify all the factors and underlying evidentiary standards used to design or apply an NQTL, and demonstrate that these are applied no more stringently to MH/SUD benefits than to medical/surgical benefits in any of six major benefit categories—e.g., in-network, outpatient—either in the written plan terms or in operation. For ERISA plans, the fiduciary would be required to certify that the analysis meets the rule’s content requirements.

A series of new rules on health cost transparency is imposing elaborate disclosure requirements on many group health plans and their service providers.

Final regulations published on November 12, 2020 (85 Fed. Reg. 72158), require plans to create specified machine-readable files and comparison tools on the cost of healthcare services. The rule does not apply to health plans that remain grandfathered under the ACA.

Starting with plan years that began in 2022, a group health plan must make detailed pricing information available to the public in machine-readable files. These files must detail the in-network rates the plan negotiates with network providers and historical data on billed and allowed amounts for covered items or services furnished by out-of-network providers.

For plan years beginning on or after January 1, 2023, plans and their insurers must make available to enrolled participants and beneficiaries personalized out-of-pocket cost information for all covered healthcare items and services through an Internet-based self-service tool and in paper form on request. These cost estimates are at first being required for only 500 of the most shoppable items and services, which are listed in the final rule. For plan years beginning in 2024, however, all items and services must be included.

The rule also calls for public disclosure in a machine-readable file of negotiated rates and historical net prices for covered prescription drugs. Initially, the DOL, HHS, and Treasury postponed enforcement of this requirement out of concern that it might duplicate the drug reporting requirements enacted in the CAA (see below). In September 2023, however, the agencies announced an end to this leniency, having decided that the two requirements are not actually duplicative because they call for different information.

The Consolidated Appropriations Act (CAA) of December 2020 included additional transparency requirements. These do apply to ACA-grandfathered health plans, but not to excepted benefits or to account-based or retiree-only plans. In addition to the requirements detailed below, they include disclosures on plan identification cards and updated provider directories.

Advanced EOB. Health plans must provide certain information on the cost of a service in advance of treatment or on request. This “advanced explanation of benefits” (AEOB) will be triggered by receiving a healthcare provider’s “good faith estimated amount” as required by a separate provision.

Between 1 and 3 business days after receiving this notice from the provider (depending on the timing of the service), the plan must issue an AEOB to the individual that includes the following:

The advanced EOB requirement has been delayed pending the issuance of regulatory guidance.

Gag clauses. The CAA also prohibits plans from agreeing to “gag clauses” in their contracts with healthcare providers, TPAs, or other service providers. That is, plans may not agree to restrictions on:

Group health plans and insurers must submit an annual compliance attestation. The agencies addressed this and other compliance issues in February 2023 guidance.

Service provider disclosures. Certain service providers to group health plans will be required to make detailed disclosures of their services and fees to a responsible plan fiduciary. “Covered service providers” are defined as those paid $1,000 or more for brokerage or consulting services. These requirements apply to contracts entered into on or after December 27, 2021.

Noncompliance could expose both the service provider and the fiduciary itself to “prohibited transaction” liability under ERISA. According to Field Assistance Bulletin (FAB) 2021-03, however, the DOL will not bring an enforcement action as long as the service provider “made disclosures in accordance with a good faith, reasonable interpretation” of the amended ERISA provision (Section 408(b)(2)(B)).

FAB 2021-03 includes a set of questions and answers that, pending further guidance, are designed to explain the department’s view about what constitutes a good-faith, reasonable interpretation of the statute with respect to several key issues that have been raised. The DOL also encouraged service providers to consult the agency’s 2012 disclosure rules for retirement plans (29 CFR §2550.408b-2(c)).

Prescription drugs. An interim final rule published on November 23, 2021 (86 Fed. Reg. 66662), set out detailed requirements for employers to report prescription drug costs as directed by the CAA.

Issued by the DOL, HHS, and Treasury, the rule calls for annual reporting of certain drug and other healthcare spending through a federal portal. Submittals are due June 1 for the previous year’s data. HHS has issued detailed reporting instructions.

For self-funded health plans, the DOL, HHS, and Treasury expect that the TPA or pharmacy benefits manager (PBM) will submit the reports in most cases. However, the self-funded plan itself will remain liable for any noncompliance with the rule. On the other hand, fully insured plans may satisfy the rule simply by having their insurers agree in writing to submit the required reports. The insurer, not the plan, will then be on the hook for any noncompliance.

The scope of information required is considerable, and much of it is beyond the easy access of employers. The agencies have not taken substantial steps to shift reporting responsibility away from self-funded employers.

If the employer or other plan sponsor maintains a public website but the group health plan itself does not, the plan is not required to create its own website just to link to a location where the machine-readable files are publicly available. Instead, a plan may comply by entering into a written agreement whereby a service provider (such as a TPA) posts the machine-readable files on its public website on behalf of the plan, according to guidance from the DOL, HHS, and Treasury. Again, however, the plan is still liable for any noncompliance if the service provider fails to live up to the agreement.

The CAA also included the No Surprises Act (NSA), the product of repeated congressional efforts to protect patients from unexpected medical bills. These provisions, which took effect January 1, 2022, allow patients to pay only the in-network cost-sharing amount for out-of-network services provided on an emergency basis and in certain other situations.

If a group health plan covers any emergency services, it must cover all such services, whether in network or out of network, without preauthorization. Patient cost sharing and provider reimbursement are then based on a “recognized amount” calculated from in-network rates and other factors. Note that the NSA rule applies to a broader range of emergency services than did the ACA rule and extends to ACA-grandfathered plans.

If the provider considers this payment inadequate and negotiations fail to resolve the disagreement within 30 days, either party may initiate independent dispute resolution (IDR).

A final rule published August 26, 2022 (87 Fed. Reg. 52618), explains how to calculate the cost-sharing rate a participant will owe, the amount the plan must pay the healthcare provider, and how a DOL-certified arbitrator will weigh the competing claims of the plan and provider when they go to IDR.

However, this rule was vacated by a federal district court after the payment formula was challenged by provider groups. While the case is under appeal, arbitrators must simply consider the criteria listed in the statute.

Similar limits on cost sharing apply to air ambulances (though the law does not address “ground” ambulances) and to nonemergency services performed by nonparticipating healthcare providers at participating facilities. The patient may opt out of the latter protections if notice and consent requirements are met, except for certain “ancillary” services such as anesthesiology.

In August 2022, the agencies clarified how the NSA requirements apply to certain types of health plans, such as those that employ reference-based pricing in lieu of a network or do not cover out-of-network services at all.

Most plan sponsors will delegate many of the nuts and bolts of compliance to third-party administrators or other service providers. But because the plan itself bears the legal responsibility for compliance, it’s important to check the contracts with these outside parties and make sure they’re working on all of the required items.

CMS provided a model notice for meeting the NSA disclosure requirements, which include posting on a public website and including in any EOB for services subject to the NSA. If a group health plan does not have a website, the plan may satisfy the disclosure requirements by entering into a written agreement for the plan’s insurer or TPA, as applicable, to post the information on its public website.

A separate rule proposed in September 2021 would require health plans to report certain information on air ambulance costs beginning in 2023 (for 2022 claims). However, the rule has not been finalized, so these requirements do not yet apply.

The litigation surrounding the NSA rules is ongoing and complex, so plan sponsors and their service providers will need to follow these developments closely. For the latest DOL rulemaking steps and other actions to implement the NSA, see the agency’s website.

The Form 5500 Annual Return/Report of Employee Benefit Plan and the Form 5500-SF Short Form Annual Return/Report of Small Employee Benefit Plan are used by plan administrators to satisfy various annual reporting obligations under ERISA and the IRC.

Filing. Plan administrators must file all 5500 and 5500-SF forms electronically using the ERISA Filing Acceptance System (EFAST2). Filers may file online using EFAST2’s Web-based IFILE filing system, or they may file through an EFAST2-approved vendor. Additionally, all delinquent and amended filings of Title I plans must be submitted electronically through EFAST2. More information about electronic filing under EFAST2 can be located at efast.dol.gov.

The Form 5500 filing requirements vary according to the type of filer. There are three general types of Form 5500 filers:

Form 5500-SF. Form 5500-SF is a simplified version of Form 5500 that certain small plans may be eligible to file instead of the Form 5500. More specifically, pension plans and welfare plans with fewer than 100 participants at the beginning of the plan year that are not exempt from filing an annual return/report may be eligible to file Form 5500-SF. In addition to the limitation on the number of participants, Form 5500-SF may be filed only for a plan that:

Filing deadline. Form 5500 and Form 5500-SF filed by plan administrators are due by the last day of the 7th calendar month after the end of the plan year (not to exceed 12 months in length). Extensions may be allowed in certain circumstances.

Filing assistance. Individuals can receive assistance with completing Form 5500 or Form 5500-SF and answers to their questions about the forms by calling the DOL EFAST2 Help Line at 866-GO-EFAST (866-463-3278) or by going online to efast.dol.gov.

Form 5500 reporting. Form 5500 filing consists of Form 5500 itself along with any necessary schedules and attachments. Forms and instructions are located at https://www.dol.gov.

Form 5500 asks basic questions about a plan, such as:

Form 5500 schedules. There are nine schedules for Form 5500, but some apply only to pension plans. The pension plan schedules include:

The other general schedules include:

The IRS provides additional resources at the “Form 5500 Corner”: https://www.irs.gov.

Pension benefit plans. The following pension benefit plans are not required to file, and should not file, a Form 5500:

Welfare benefit plans. The following welfare benefit plans are not required to file, and should not file, a Form 5500:

The DOL established the Delinquent Filer Voluntary Compliance (DFVC) Program to encourage voluntary compliance with the annual reporting requirements of ERISA. The DFVC Program gives delinquent plan administrators a way to avoid potentially higher civil penalty assessments by satisfying the program’s requirements and voluntarily paying a reduced penalty amount. To increase incentives for delinquent plan administrators to voluntarily comply with ERISA’s annual reporting requirements, the DOL further reduced penalties under the DFVC program and simplified the rules for participation in the program.

Eligibility. Eligibility for the DFVC Program is limited to plans with filing obligations under ERISA's reporting requirements that comply with the provisions of the program and that have not been notified in writing by the DOL of a failure to file a timely annual report. Participation in the program is a two-part process. The first step is electronically filing with EFAST2 a complete Form 5500 or, if eligible, Form 5500-SF, Annual Return/Report, including any required schedules and attachments, for each year relief is requested. To ensure proper processing, box "D" on Form 5500 or Form 5500-SF must be marked. Special simplified rules apply to “top hat” plans and apprenticeship and training plans. The second step is electronically submitting the filing information and payment to the DFVC Program using the DFVCP Penalty Calculator at https://www.askebsa.dol.gov. However, employers may also submit their payment and filing information to the DFVC Program through the mail. The plan administrator is personally liable for the penalty. Therefore, amounts paid under the DFVC Program may not be paid from the assets of an employee benefit plan.

Penalties. The basic penalty under the program is $10 per day for delinquent filings. The maximum penalty for a single late annual report is $750 for a small plan (generally a plan with fewer than 100 participants at the beginning of the plan year) and $2,000 for a large plan. The DFVC Program also includes a “per plan” cap designed to encourage reporting compliance by plan administrators who have failed to file an annual report for multiple years. The “per plan” cap limits the penalty to $1,500 for a small plan and $4,000 for a large plan, regardless of the number of late annual reports filed at the same time. There is no “per administrator” or “per sponsor” cap.

A special “per plan” cap of $750 applies to a small plan sponsored by an organization that is tax-exempt under IRC Sec. 501(c)(3), which applies regardless of the number of late annual reports filed for the plan at the same time. It is not available, however, if, as of the date the plan files under the DFVC Program, there is a delinquent annual report for a plan year during which the plan was a large plan.

The penalty amount for “top hat” plans and apprenticeship and training plans is $750.

For more information on the DFVC Program, visit https://www.dol.gov (Fact Sheet) and/or https://www.dol.gov (FAQs).

Benefit plans covered by ERISA must have a reasonable claims procedure that must be set out in the plan's SPD (29 CFR 2560.503-1). The description of the claims procedure must include the circumstances that might result in the loss or denial of benefits and the procedure for making a claim for benefits, including the procedures for appealing a claim denial. ERISA requires that claim denials be in writing and include a clear explanation of the specific reasons for the denial. The plan document and the SPD must provide a procedure for appealing a denial to an authorized plan official or committee for a full and fair review.

ACA requirements. In addition, the ACA added a requirement that health plans and insurers implement effective internal and external claims and appeals processes. Implementing rules from the DOL, HHS, and the IRS (29 CFR 2590.715-2719) built on the existing ERISA claims procedure regulations for group health plans described below.

The regulations set out notice requirements for internal claims and appeals and external review processes. Grandfathered plans are generally exempt. However, NSA rules that took effect in 2022 (see above) extend the external review requirement to adverse determinations under the NSA’s surprise billing and cost-sharing provisions, and apply to grandfathered as well as nongrandfathered plans.

For pension benefit plans and welfare plans other than health and disability plans, initial benefit claims have to be answered in 90 days, with a possible extension of another 90 days (29 CFR 2560.503-1(f)(1)). Appeals must be filed within 60 days of a denial (29 CFR 2560.503-1(h)).

Shorter time limits for health plans. Claims of health plans must be processed much more quickly. The time limits for claims decisions depend on the type of claim. For claims involving urgent care, the decision must be made within 72 hours after the claim is received (29 CFR 2560.503-1(f)(2)). Claimants must be informed within 24 hours if an urgent claim is incomplete. They then will have 48 hours to provide the needed information, and the plan must respond within 48 additional hours.

Decisions on claims where receipt of the benefit depends on approval before receiving medical care must be made within 15 days. These claims are called "preservice" claims. The decision period may be extended for 15 days for reasons beyond the plan's control. If the extension is needed because of a lack of information submitted with the claim, the claimant must be informed that the claim is defective and be given at least 45 days to provide the necessary information.

Decisions on postservice claims (where no prior approval is needed) have to be provided within 30 days, subject to the same 15-day extension provision.

Appeals. Claimants will have 180 days to appeal a denied claim (29 CFR 2560.503-1(h)(3)). A plan may require that such requests be in writing, except for urgent care claims.

If a group health plan decides to reduce or terminate a previously approved course of treatment before it was scheduled to end, there is an adverse benefit determination that triggers the claimant's appeals rights (29 CFR 2560.503-1(f)(2)). The plan must give the claimant a reasonable amount of notice of the reduction or termination to allow an appeal.

Urgent care definition. A claim is an urgent care claim if application of the time limits for non-urgent care could seriously jeopardize the life or health of the claimant or if delay in treatment would subject the claimant to severe pain (29 CFR 2560.503-1(m)(1)). In determining whether a claim involves urgent care, a plan must apply the judgment of a prudent layperson who possesses an average knowledge of health and medicine. However, if a physician with knowledge of the claimant's condition asserts that a claim is an urgent care claim, the claim must be so treated.

A request to extend a previously approved course of treatment, by increasing either the number of treatments or the period of time for treatment, that is determined by the treating physician to involve urgent care must be decided as soon as possible after it is made (29 CFR 2560.503-1(f)(2)). If the request is made at least 24 hours before the previous expiration date, the claimant must be notified within 24 hours of receipt of the claim. If the request is made less than 24 hours before the expiration date, the regular urgent care time frame applies.

Shorter time limits for disability plans. Disability plan claims must generally be decided in 45 days, with the possibility of 2 30-day extensions for circumstances beyond the plan's control (29 CFR 2560.503-1(f)(3)).

A claims procedure may not include any provision that unduly inhibits or hampers the filing or processing of a claim (29 CFR 2560.503-1(b)(3)). ERISA imposes a strict time frame on plan administrator decisions on claims for benefits. The clock starts when a participant makes a claim for benefits in accordance with the plan’s procedures (29 CFR 2560.503-1(e)).

The DOL has issued a series of questions and answers that clarify what requests for determinations and other questions directed at a plan are benefit claims covered by the claims procedure. These questions can be located at https://www.dol.gov.

Claims-processing requirements. The claims procedure regulations set out the following rules for processing benefit claims:

Health claim procedures. Additional requirements may apply to health plans, including, for example:

Disability claims procedures. Regulations that took effect in 2018 impose detailed requirements on the claims and appeals process. A plan must avoid conflicts of interest, and if a claim is denied, the denial notice must include a sufficient explanation of the rationale—especially if the plan’s findings differ from those of the beneficiary’s treating healthcare provider, or from a disability determination made by the Social Security Administration.

The beneficiary must be given full access to his or her claim file on request. The rules also afford new rights to appeal an adverse decision and to seek review in court. In addition, the set of adverse disability requirements subject to these procedures now includes retroactive rescissions of coverage.

Interaction with state laws. The required claims procedures do not supersede any applicable state insurance review process unless that process prevents the application of the required procedures (29 CFR 2560.503-1(k)). It is not necessary to utilize the state procedures before suing for benefits.

The ACA added its own layer of claims and appeals requirements to those in the ERISA claims procedure regulations (29 CFR 2590.715-2719):

Broader definition of adverse benefit determination. An adverse benefit determination now includes any rescission of coverage (whether or not the rescission has an adverse effect on any particular benefit at that time).

Full and fair review requirement. A plan and insurer must allow a claimant to review the claim file and to present evidence and testimony as part of the internal claims and appeals process. In addition to complying with the current claims procedure requirements:

Requirement for avoiding conflicts of interest. A plan must ensure that all claims and appeals are adjudicated in a manner designed to ensure the independence and impartiality of the persons involved in making the decision. Decisions on hiring, compensation, termination, promotion, or other similar matters of any individual (such as a claims adjudicator or medical expert) must not be made based on the likelihood that the individual will support the denial of benefits.

Notice requirements. Plans and insurers must provide notice to individuals, in a culturally and linguistically appropriate manner, and must also comply with the following additional requirements:

Culturally and linguistically appropriate notice requirement. Notices of available internal claims and appeals and external review processes must be provided in a culturally and linguistically appropriate manner. Plans and insurers are considered to satisfy this requirement if notices are provided in a non-English language when there are a threshold number of people who are literate in the same non-English language.

Specific requirements. The plan must provide oral language services (such as a telephone customer assistance hotline) that include answering questions in any applicable non-English language and providing assistance with filing claims and appeals (including external review) in any applicable non-English language. The plan must provide, on request, a notice in any applicable non-English language and must include, in the English versions of all notices, a statement prominently displayed in any applicable non-English language clearly indicating how to access the language services provided by the plan or issuer.

Applicable non-English language threshold. For an address in any U.S. county to which a notice is sent, a non-English language is an applicable non-English language if 10 percent or more of the population residing in the county is literate only in the same non-English language.

Deemed exhaustion of internal claims and appeals processes. In the case of a plan or insurer that fails to strictly adhere to all the claims procedure requirements, the claimant is deemed to have exhausted the internal claims and appeals process and may seek immediate external review or court action, as applicable, unless the violation was:

In addition, the claimant would be entitled, on written request, to an explanation of the plan’s basis for asserting that it meets this standard so that the claimant can make an informed decision whether to seek immediate review. If the external reviewer or the court rejects the claimant’s request for immediate review on the basis that the plan met this standard, the claimant may resubmit and pursue the internal appeal of the claim.

The claimant is also entitled to pursue any available remedies under ERISA or under state law, as applicable, on the basis that the plan or insurer has failed to provide a reasonable internal claims and appeals process that would yield a decision on the merits of the claim. If a claimant chooses to pursue remedies under ERISA Sec. 502(a), the claim or appeal is deemed denied on review without the exercise of discretion by an appropriate fiduciary.

Continued coverage pending the outcome of an appeal. A plan and insurer are required to provide continued coverage pending the outcome of an appeal. Benefits for an ongoing course of treatment cannot be reduced or terminated without providing advance notice and an opportunity for advance review.

PHSA Sec. 2719 provides that either a state external review process or a federal external review process must apply for health plans and insurers. This requirement is specifically incorporated into ERISA and the IRC. The ACA regulations provide rules for determining which process applies, as well as guidance on each process.

Determining whether a state or federal external review process applies. The regulations set when plans must comply with an applicable state external review process and when they must comply with the federal external review process. If a state external review process that applies and is binding on the insurer includes, at a minimum, the consumer protections in the National Association of Insurance Commissioners (NAIC) Uniform Model Act, the state external review process and not the federal external review process applies.

If a self-funded group health plan is subject to a state external review process that applies to and is binding on the plan (e.g., is not preempted by ERISA) and the state external review process includes at a minimum the consumer protections in the NAIC Uniform Model Act, then the plan must comply with the applicable state external review process and is not required to comply with the federal external review process.

Any plan not subject to a state external review process must comply with the federal external review process.

Minimum state external appeals process requirements. An applicable state external review process must meet certain minimum consumer protections, and HHS will determine whether state external review processes meet these requirements. For example, such state external review processes must:

The federal external review process. The federal standards are intended to be similar to the state requirements. The federal external review process applies to claims that involve:

The NSA surprise billing rules issued in 2021 added claims that involve that law’s surprise billing and cost-sharing protections (see above).

Expedited reviews. The federal external review process, like the state external review process, provides for expedited external review and additional consumer protections for external review for claims involving experimental or investigational treatment.

Model notices. A revised model notice of adverse benefit determination, a revised model notice of final internal adverse benefit determination, and a revised model notice of final external adverse benefit determination can be located at https://www.dol.gov.

The reporting and filing requirements for employee pension, profit-sharing, and welfare benefit plans are detailed and numerous, and they tend to change with little notice. For updated information, visit https://www.dol.gov/agencies/ebsa.

Additionally, helpful charts summarizing the reporting and disclosure requirements for retirement plans can be found at https://www.irs.gov.