ERISA Compliance FAQs: Fiduciary Responsibilities

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1 Brught t yu by Mrris & Reynlds Insurance ERISA Cmpliance FAQs: Fiduciary Respnsibilities The Emplyee Retirement Incme Security Act f 1974 (ERISA) is a federal law that sets minimum standards fr emplyee benefit plans maintained by private-sectr emplyers. ERISA includes requirements fr bth retirement plans (fr example, 401(k) plans) and welfare benefit plans (fr example, grup health plans). ERISA has been amended many times ver the years, expanding the prtectins available t welfare benefit plan participants and beneficiaries. ERISA includes standards f cnduct fr thse wh manage an emplyee benefit plan and its assets, wh are called fiduciaries. This Legislative Brief includes a set f frequently asked questins (FAQs) t help emplyers understand the basic fiduciary respnsibilities applicable t grup health plans under ERISA. WHO IS A FIDUCIARY? The key t determining whether individuals r entities are fiduciaries is whether they are exercising discretin r cntrl ver the plan. Many f the actins invlved in perating an emplyee benefit plan make the persn r entity perfrming them a fiduciary. Using discretin in administering and managing a plan r cntrlling the plan s assets makes that persn a fiduciary t the extent f the persn s discretin r cntrl. Thus, fiduciary status is based n the functins perfrmed fr the plan, nt just a persn s title. Grup health plans can be structured in a variety f ways. The structure f the plan will affect wh has fiduciary respnsibilities. Mst emplyers spnsring self-funded grup health plans exercise sme discretinary authrity and therefre are fiduciaries. If the emplyer spnsrs a fully-insured plan, fiduciary status depends n whether the emplyer exercises discretin ver the plan. A plan must have at least ne fiduciary (a persn r entity) named in the written plan, r thrugh a prcess described in the plan, as having cntrl ver the plan s peratin. The named fiduciary can be identified by ffice r by name. Fr sme plans, it may be an administrative cmmittee r a cmpany s bard f directrs. A plan s fiduciaries will rdinarily include: Plan administratrs, trustees and investment managers; Individuals exercising discretin in the administratin f the plan; and Members f a plan s administrative cmmittee (if applicable) and thse wh select cmmittee fficials. WHO IS NOT A FIDUCIARY? Attrneys, accuntants and actuaries generally are nt fiduciaries when acting slely in their prfessinal capacities. Similarly, a third-party administratr (TPA), recrdkeeper r utilizatin reviewer wh perfrms slely ministerial tasks is nt a fiduciary; hwever, that may change if the entity exercises discretin in making decisins regarding a participant s eligibility fr benefits. 1

2 ERISA Cmpliance FAQs: Fiduciary Respnsibilities Als, a number f decisins are nt fiduciary actins, but, rather, are business decisins made by the emplyer. Fr example, the decisins t establish a plan, determine the benefit package, include certain features in a plan, amend a plan and terminate a plan are emplyer business decisins nt gverned by ERISA. When making these decisins, an emplyer is acting n behalf f its business, nt the plan, and, therefre, is nt a fiduciary. Hwever, when an emplyer (r smene hired by the emplyer) takes steps t implement these decisins, that entity is acting n behalf f the plan and, in carrying ut these actins, may be a fiduciary. WHAT DOES IT MEAN TO BE A FIDUCIARY? Fiduciaries have imprtant respnsibilities and are subject t standards f cnduct because they act n behalf f participants in a grup health plan and their beneficiaries. ERISA requires fiduciaries t discharge their duties with respect t emplyee benefit plans: Slely in the interest f plan participants and their beneficiaries; Fr the exclusive purpse f prviding plan benefits, r fr defraying reasnable expenses f plan administratin; With the care, skill, prudence and diligence that a prudent persn in similar circumstances wuld use; By diversifying the plan's investments t minimize the risk f large lsses; and In accrdance with the plan's dcuments (unless incnsistent with ERISA). The duty t act prudently is ne f a fiduciary s central respnsibilities under ERISA. It requires expertise in a variety f areas. Lacking that expertise, a fiduciary will want t hire smene with that prfessinal knwledge t carry ut thse functins. Prudence fcuses n the prcess fr making fiduciary decisins. Therefre, it is wise t dcument decisins and the basis fr thse decisins. Fr instance, in hiring any plan service prvider, a fiduciary may want t survey a number f ptential prviders, asking fr the same infrmatin and prviding the same requirements. By ding s, a fiduciary can dcument the prcess and make a meaningful cmparisn and selectin. Fllwing the terms f the plan dcument is als an imprtant respnsibility. The plan dcument serves as the fundatin fr plan peratins. Emplyers will want t be familiar with their plan dcument, especially when it is drawn up by a third-party service prvider, and peridically review the dcument t make sure it remains current. Fr example, if a plan fficial named in the dcument changes, the plan dcument must be updated t reflect that change. In additin, a fiduciary shuld be aware f thers wh serve as fiduciaries t the same plan, since all fiduciaries have ptential liability fr the actins f their c-fiduciaries. Fr example, if a fiduciary knwingly participates in anther fiduciary s breach f respnsibility, cnceals the breach r des nt act t crrect it, that fiduciary is liable as well. WHAT ARE THE POSSIBLE CONSEQUENCES OF A FIDUCIARY BREACH? A persn wh is an ERISA fiduciary can be liable fr a breach f fiduciary duty. Fiduciaries wh d nt fllw the basic standards f cnduct may be persnally liable t restre any lsses t the plan, r t restre any prfits made thrugh imprper use f the plan s assets resulting frm their actins. A fiduciary s liability fr a breach may als include a 20 percent penalty assessed by the Department f Labr (DOL), remval frm his r her fiduciary psitin and, in extreme cases, criminal penalties. This Legislative Brief is nt intended t be exhaustive nr shuld any discussin r pinins be cnstrued as legal advice. Readers shuld cntact legal cunsel fr legal advice. 2

3 ERISA Cmpliance FAQs: Fiduciary Respnsibilities WHAT STEPS CAN FIDUCIARIES TAKE TO LIMIT THEIR LIABILITY? Fiduciaries can limit their liability in certain situatins. One way fiduciaries can demnstrate that they have carried ut their respnsibilities prperly is by dcumenting the prcesses used t carry ut their fiduciary respnsibilities. A fiduciary can als hire a service prvider r prviders t handle fiduciary functins, setting up the agreement s that the persn r entity then assumes liability fr thse functins selected. If an emplyer cntracts with a plan administratr t manage the plan, the emplyer is respnsible fr the selectin f the service prvider, but is nt liable fr the individual decisins f that prvider. Hwever, an emplyer is required t mnitr the service prvider peridically t ensure that it is handling the plan s administratin prudently. As an additinal prtectin fr plans, every persn, including a fiduciary, wh handles plan funds r ther plan prperty generally must be cvered by a fidelity bnd. A fidelity bnd is a type f insurance that prtects the plan against lss by reasn f acts f fraud r dishnesty n the part f individuals cvered by the bnd. Many individuals dealing with grup health plans that pay benefits frm the general assets f an emplyer r unin (unfunded) r grup health plans that are insured (benefits are paid thrugh the purchase f a grup health insurance cntract frm a licensed insurer) may be eligible fr exemptins frm the fidelity bnding requirements. In additin, the DOL maintains a vluntary crrectin prgram fr fiduciary breaches. The Vluntary Fiduciary Crrectin Prgram (VFCP) allws plan fficials wh have identified certain vilatins f ERISA t take crrective actin t remedy the breaches and vluntarily reprt the vilatins t the DOL, withut becming the subject f an enfrcement actin. HOW DO THE FIDUCIARY DUTY RULES AFFECT THE PLAN OPERATION? Emplyee Cntributins If a plan prvides fr salary reductins frm emplyees paychecks fr cntributin t the plan r participants make payments directly, such as the payment f COBRA premiums, the emplyer must depsit the cntributins in a plan trust in a timely manner. ERISA requires that participant cntributins be depsited in the plan as sn as it is reasnably pssible t segregate them frm the cmpany s assets, but n later than 90 days frm the date n which the participant cntributins are withheld r received by the emplyer. If emplyers can reasnably make the depsits sner, they need t d s. Fr plans with fewer than 100 participants, salary reductin cntributins depsited with the plan n later than the seventh business day fllwing withhlding by the emplyer will be cnsidered cntributed in cmpliance with the law. Imprtant Exceptins t ERISA s Trust Requirement: Fr participant cntributins t cafeteria plans (als referred t as Sectin 125 plans), the DOL will nt assert a vilatin slely because f a failure t hld participant cntributins in trust. Other cntributry health plan arrangements may btain the same trust relief if the participant cntributins are used t pay insurance premiums within 90 days f receipt. Hiring Service Prviders Hiring a service prvider in and f itself is a fiduciary functin. When cnsidering prspective service prviders, an emplyer shuld prvide each f them with cmplete and identical infrmatin abut the plan and the desired services s that the emplyer can make a meaningful cmparisn. This Legislative Brief is nt intended t be exhaustive nr shuld any discussin r pinins be cnstrued as legal advice. Readers shuld cntact legal cunsel fr legal advice. 3

4 ERISA Cmpliance FAQs: Fiduciary Respnsibilities Sme actins fiduciaries need t cnsider when selecting a service prvider include: Getting infrmatin frm mre than ne prvider; Cmparing prviders based n same infrmatin (fr example, services ffered, experience and csts); Obtaining infrmatin abut the prvider itself, including financial cnditin and experience with grup health plans f similar size and cmplexity; Evaluating infrmatin abut the quality f the firm s services, including the fllwing (as applicable): The identity, experience and qualificatins f prfessinals wh will be handling the plan r prviding medical services; Any recent litigatin r enfrcement actin that has been taken against the prvider and the prvider s experience r perfrmance recrd; Ease f access t medical prviders and infrmatin abut the peratins f the health care prvider; The prcedures fr timely cnsideratin and reslutin f patient questins and cmplaints; The prcedures fr the cnfidentiality f patient recrds; and Enrllee satisfactin statistics. Ensuring that any required licenses, ratings r accreditatins are up t date (fr example, insurers, brkers, TPAs, health care service prviders). An emplyer shuld dcument its selectin (and mnitring) prcess, and, when using an internal administrative cmmittee, shuld educate cmmittee members n their rles and respnsibilities. Evaluating Fees Fees are just ne f several factrs fiduciaries need t cnsider in deciding n service prviders. When the fees fr services are paid ut f plan assets, fiduciaries will want t understand the fees and expenses charged and the services prvided. While ERISA des nt specify a permissible level f fees, the law des require that fees charged t a plan be "reasnable." After careful evaluatin during the initial selectin, the plan's fees and expenses shuld be mnitred t determine whether they cntinue t be reasnable. In cmparing estimates frm prspective service prviders, emplyers shuld ask which services are cvered fr the estimated fees and which are nt. Sme prviders ffer a number f services fr ne fee, smetimes referred t as a bundled services arrangement. Others charge separately fr individual services. Emplyers shuld cmpare all services t be prvided with the ttal cst fr each prvider and cnsider whether the estimate includes services the emplyer did nt specify r want. Remember, all services have csts. Sme service prviders may receive additinal fees frm third parties, such as insurance brkers. Emplyers shuld ask prspective prviders whether they get any cmpensatin frm third parties, such as finder s fees, cmmissins r revenue sharing. This Legislative Brief is nt intended t be exhaustive nr shuld any discussin r pinins be cnstrued as legal advice. Readers shuld cntact legal cunsel fr legal advice. 4

5 ERISA Cmpliance FAQs: Fiduciary Respnsibilities Plan expenses may be paid by the emplyer, the plan r bth. In any case, the plan dcument shuld specify hw fees are paid, and the fiduciary must ensure that thse fees and expenses are reasnable, necessary fr the peratin f the plan, and nt excessive fr the services prvided. Mnitring Service Prviders An emplyer shuld establish and fllw a frmal review prcess at reasnable intervals t decide if it wants t cntinue using the current service prviders r lk fr replacements. When mnitring service prviders, emplyers shuld: Review the service prviders perfrmance; Read any reprts they prvide; Check actual fees charged; Ask abut plicies and practices (such as a TPA s claims prcessing systems); Ensure that plan recrds are prperly maintained; and Fllw up n participant cmplaints. Maintaining the Plan s Benefits Claims Prcedure Under ERISA, grup health plans must establish and maintain reasnable claims prcedures that allw participants and beneficiaries t apply fr and receive the plan s prmised benefits. Fiduciaries must maintain the plan s prcedures. DOL regulatins prvide minimum standards fr benefit claims determinatins fr ERISA plans (including insured and self-funded plans). While many plans hire benefits prfessinals r insurance cmpanies t prcess claims, it is imprtant fr an emplyer t understand the requirements befre selecting a service prvider wh can cmply with the standards. A claim fr benefits is a request fr a plan benefit made in accrdance with the plan s prcedures by a claimant (participant r beneficiary) r a claimant s authrized representative. Questins cncerning plan benefits, cverage and eligibility questins, and casual inquiries are generally nt cnsidered claims fr benefits. The key issues t becme familiar with are the timeframes fr deciding claims, the cntents fr the ntices f benefit denials and the standards fr appeals f benefit denials. Mre infrmatin n the benefit claims prcedures fr grup health plans is available n the DOL s webpage fr health plan cmpliance assistance. ARE THERE SOME TRANSACTIONS THAT ARE PROHIBITED? Certain transactins are prhibited under ERISA t prevent dealings with parties wh may be in a psitin t exercise imprper influence ver the plan. In additin, fiduciaries are prhibited frm engaging in self-dealing and must avid cnflicts f interest that culd harm the plan. Prhibited parties (called parties-in-interest) include the emplyer, the unin, plan fiduciaries, service prviders and statutrily defined wners, fficers and relatives f parties-in-interest. Sme f the prhibited transactins are: A sale, exchange r lease between the plan and party-in-interest; Lending mney r ther extensin f credit between the plan and party-in-interest; and Furnishing gds, services r facilities between the plan and party-in-interest. This Legislative Brief is nt intended t be exhaustive nr shuld any discussin r pinins be cnstrued as legal advice. Readers shuld cntact legal cunsel fr legal advice. 5

6 ERISA Cmpliance FAQs: Fiduciary Respnsibilities Other prhibitins relate slely t fiduciaries wh use the plan s assets in their wn interest r wh act n bth sides f a transactin invlving a plan. Fiduciaries cannt receive mney r any ther cnsideratin fr their persnal accunt frm any party ding business with the plan related t that business. ERISA includes a number f exemptins that prvide prtectins fr the plan in cnducting necessary transactins that wuld therwise be prhibited. The DOL has authrity t grant additinal exemptins. ERISA includes exemptins fr many dealings that are essential t the nging peratins f the plan. One f these exemptins allws the plan t hire a service prvider as lng as the services are necessary t perate the plan and the cntract r arrangement under which the services are prvided and the cmpensatin paid fr thse services is reasnable. The exemptins issued by the DOL can invlve transactins available t a class f plans r t ne specific plan. Bth class and individual exemptins are available n the DOL s webpage fr technical guidance fr emplyee benefit plans. Mre infrmatin n applying fr an exemptin is available in the DOL s Exemptin Prcedures under Federal Pensin Law. This publicatin and the prcedures als apply t grup health plans. Surce: Department f Labr This Legislative Brief is nt intended t be exhaustive nr shuld any discussin r pinins be cnstrued as legal advice. Readers shuld cntact legal cunsel fr legal advice. 6

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