Employers that provide group health plan coverage to their employees are subject to numerous compliance requirements throughout the year, such as requirements for reporting, participant disclosure, and certain fee payments. For example, employers with group health plans may be required to:
- File a Form 5500 by the last day of the seventh month following the end of the plan year (or request a filing extension)
- Provide Medicare Part D creditable coverage disclosures to plan participants by October 15 of each year
- Pay Patient-Centered Outcomes Research Institute (PCORI) fees by July 31 of each year
This Compliance Calendar contains a high-level summary of the various compliance requirements and associated deadlines that health plan sponsors should be aware of throughout the year. It also summarizes annual notice requirements for group health plans. Please note that certain deadlines for non-calendar year plans may vary.
CALENDAR YEAR DEADLINES
This chart addresses recurring calendar year compliance requirements. The chart does not include other requirements that are not based on the calendar year. For example, a plan administrator must provide a COBRA Election Notice to a qualified beneficiary after a qualifying event occurs. This type of notice requirement is not addressed in this chart. State and local laws may impose additional obligations. Users of this chart should refer to the specific federal or state law at issue for complete information.
- Health plan sponsors should work with their advisors to determine which recurring requirements apply to them.
- The rules have been changing at an accelerating Therefore, it’s important for plan sponsors to monitor legislative and regulatory developments.
Annual Compliance requirements
Deadline: Jan. 31
Requirement: Form W-2
Description: The ACA requires employers that file 250 or more Forms W-2 to report the aggregate cost (i.e., the sum of the employer and employee costs) of employer-sponsored group health plan coverage on their employees’ Forms W-2.
This Form W-2 reporting requirement is currently optional for small employers (those who file fewer than 250 Forms W-2).
Deadline: Feb. 28 (March 31, if filing electronically)
Requirement: Section 6055 and 6056 Reporting
Description: Applicable Large Employers (ALEs) subject to the ACA’s employer shared responsibility rules are required to report information to the IRS about the health coverage they offer (or do not offer) to their full-time employees. ALEs must file Form 1094-C and Form 1095-C with the IRS annually.
ALEs that sponsor self-insured plans are required to report information to the IRS about health coverage provided and offers of health coverage. ALEs that sponsor self-insured plans generally use a combined reporting method on Form 1094-C and Form 1095-C to report information under both Sections 6055 and 6056.
All forms must be filed with the IRS annually, no later than Feb. 28 (March 31, if filed electronically) of the year following the calendar year to which the return relates. Reporting entities that are filing 250 or more returns must file electronically. This deadline applies to non-calendar year plans regardless of the plan year.
Deadline: March 1 (calendar year plans; adjust the dates accordingly for non-calendar year plans)
Requirement: Medicare Part D
Disclosure to CMS
Description: Group health plans providing prescription drug coverage to Medicare Part D-eligible individuals must disclose to the Centers for Medicare & Medicaid Services (CMS) whether prescription drug coverage is creditable. Generally, a plan’s prescription drug coverage is considered creditable if its actuarial value equals or exceeds the actuarial value of the Medicare Part D prescription drug coverage. Disclosure is due:
Within 60 days after the beginning of each plan year
Within 30 days after the termination of a plan’s prescription drug coverage
Within 30 days after any change in the plan’s creditable coverage status
Plan sponsors must use the online disclosure form on the CMS Creditable Coverage webpage.
Deadline: March 2
Requirement: Form 1095-C or Form 1095-B
Annual Statement to Individuals
Description: Applicable large employers (ALEs) subject to the ACA’s employer-shared responsibility rules (i.e., the “pay or play” requirement) must furnish Form 1095-C (Section 6056 statements) annually to their full-time employees.
Employers with self-insured health plans that are not ALEs must furnish Form 1095-B (Section 6055 statements) annually to covered employees.
Forms 1095-B and 1095-C are due on or before Jan. 31 of the year immediately following the calendar year to which the statements relate. There was a permanent extension to the filing deadline to 30 days after Jan. 31 (which will typically fall on March 2). That deadline had been extended on an ad hoc basis previously, and a reasonable, good faith standard would be applied to avoid penalties if the deadline was missed. The deadline was recently permanently extended, and the reasonable, good faith standard relating to the imposition of penalties was eliminated.
Deadline: June 1, 2023
Requirement: Drug Cost Reporting with the Centers for Medicaid and Medicare Services (CMS)
Description: All employer sponsored group health plans, regardless of size, must submit a report outlining prescription drug costs for the plan to the CMS. Fully insured plans can rely on the filing by the insurance carriers. However, all self-funded plans, including level-funded plans and minimum premium plans must comply at the plan level. That also applies to minimum essential coverage (MEC) plans that are self-funded.
Most plans will rely on the plan’s Pharmacy Benefit Manager (PBM) and Third-Party Administrator (TPA) to comply with the filing obligation. Nevertheless, the employer has the ultimate responsibility and should follow up with the plan vendors to ensure they are complying with the obligation.
Deadline: July 31
Requirement: PCORI Fee
Description: Deadline for filing IRS Form 720 and paying Patient-Centered Outcomes Research Institute (PCORI) fees for the previous year. For fully insured health plans, the issuer of the health insurance policy is responsible for the PCORI fee payment. For self-insured plans, the PCORI fee is paid by the plan sponsor. The filing deadline is the same for calendar and non-calendar year plans. However, the fee is determined based on the last day of the plan’s year.
Deadline: July 31 (calendar year plans; adjust the dates accordingly for non-calendar year plans – 7 months following the end of the plan year)
Automatic extension to October 16 (calendar year plans) if requested.
Requirement: Form 5500
Description: Employee benefit plans must file Form 5500 by the last day of the seventh month following the end of the plan year. (Non-ERISA plans, such as church plans and non-electing government plans, do not have this requirement.) Form 5500 reports information on a plan’s financial condition, investments (not a typical issue for welfare benefit plans), and operations.
Form 5558 is used to apply for an extension of two and one-half months (Oct. 16 in 2023) to file Form 5500 (and is automatic if requested).
Small health plans (fewer than 100 participants) that are fully insured, unfunded, or a combination of insured/unfunded, are generally exempt from the Form 5500 filing requirement. In fact, the instructions specifically provide that such plans should not file the 5500. The Department of Labor’s (DOL) website and the latest Form 5500 instructions provide information on who is required to file and detailed information on filing.
Deadline: Sept. 30
Requirement: Medical Loss Ratio (MLR) Rebates
Description: The deadline for issuers to pay medical loss ratio (MLR) rebates is Sept. 30. The ACA requires health insurance issuers to spend at least 80 to 85 percent of their premiums on health care claims and quality improvement activities. Issuers that do not meet the applicable MLR percentage must pay rebates to consumers.
If the rebate is a “plan asset” under ERISA, the rebate should, as a general rule, be used within three months of when it is received by the plan sponsor. Thus, employers who decide to distribute the rebate to participants should make the distributions within this three-month time limit.
Deadline: Sept 30. (calendar year plans; adjust the dates accordingly for non-calendar year plans)
Requirement: Summary Annual Report
Description: Plan administrators must automatically provide participants with the summary annual report (SAR) within nine months after the end of the plan year, or two months after the due date for filing Form 5500 (including any extension).
Plans exempt from the annual 5500 filing requirement are not required to provide an SAR. Large, completely unfunded health plans are also generally exempt from the SAR requirement. A sample SAR for welfare plans is available from the DOL.
Deadline: Oct. 14
Requirement: Medicare Part D – Creditable Coverage Notices
Description: Group health plans providing prescription drug coverage to Medicare Part D-eligible individuals must disclose whether the prescription drug coverage is creditable. Medicare Part D creditable coverage disclosure notices must be provided to plan participants (which includes any non-employee beneficiaries) before Oct. 14 each year.
Coverage is creditable if the actuarial value of the coverage equals or exceeds the actuarial value of coverage under Medicare Part D. This disclosure notice helps participants make informed and timely enrollment decisions.
Disclosure notices must be provided to all Part D-eligible individuals who are covered under, or apply for, the plan’s prescription drug coverage regardless of whether the prescription drug coverage is primary or secondary to Medicare Part D. Because employers may not know whether any specific individual is enrolled in Medicare most employers will send a creditable coverage notice to all participants.
Many employers will include these notices with open enrollment materials if they are sent by Oct. 14. The Oct. 14 deadline also applies to non-calendar year plans. Model disclosure notices are available on CMS’ website.
ANNUAL NOTICES - NOT TIED TO SPECIFIC DATES
Type of Notice: WHCRA Notice
Description: The Women’s Health and Cancer Rights Act (WHCRA) requires group health plans that provide medical and surgical benefits for mastectomies to also provide benefits for reconstructive surgery. Group health plans must provide a notice about the WHCRA’s coverage requirements at the time of enrollment and annually after enrollment. The initial enrollment notice requirement can be satisfied by including information on WHCRA’s coverage requirements in the plan’s summary plan description (SPD). The annual WHCRA notice can be provided at any time during the year. Employers with open enrollment periods are generally well advised to include the annual notice with their open enrollment materials to make it a part of the general plan practice. Employers that redistribute their SPDs each year can satisfy the annual notice requirement by including the WHCRA notice in their SPDs. Model language is available in the DOL’s compliance assistance guide.
Type of Notice: CHIP Notice
Description: If an employer’s group health plan covers residents in a state that provides a premium subsidy under a Medicaid plan or CHIP, the employer must send an annual notice about the available assistance to all employees residing there. The annual CHIP notice can be provided at any time during the year. Employers with annual enrollment periods are generally well advised to provide the CHIP notice with their open enrollment materials to make it a part of the general plan practice. The DOL has a model notice that employers may use.
Type of Notice: Summary of Benefits and Coverage (SBC)
Description: Group health plans and health insurance issuers must provide an SBC to applicants and enrollees each year at open enrollment or renewal time. The purpose of the SBC is to allow individuals to easily compare their options when shopping for or enrolling in health plan coverage. Federal agencies have provided a template for the SBC, which health plans and issuers must use.
The issuer for fully insured plans typically prepares the SBC, which is the form the employer should distribute (assuming the issuer does not). The SBC must be included in open enrollment materials. If renewal is automatic, the SBC must be provided no later than 30 days before the first day of the new plan year. However, for insured plans, if the new policy has not yet been issued 30 days prior to the beginning of the plan year, the SBC must be provided as soon as practicable, but no later than seven business days after the issuance of the policy.
Type of Notice: Grandfathered Plan Notice
Description: To maintain a plan's grandfathered status, the plan sponsor or the group health insurance coverage must include a statement of the plan's grandfathered status in plan materials provided to participants describing the plan's benefits (such as the summary plan description, insurance certificate, and open enrollment materials). The DOL has provided a model notice for grandfathered plans. This notice only applies to plans that have grandfathered status under the ACA.
Type of Notice: Notice of Patient Protections
Description: If a non-grandfathered plan requires participants to designate a participating primary care provider, the plan or issuer must provide a notice of patient protections whenever the SPD or asimilar description of benefits is provided to a participant. This notice is often included in the SPD or insurance certificate provided by the issuer (or otherwise provided with enrollment materials). The DOL provides a model notice of patient protections for plans and issuers to use.
Type of Notice: HIPAA Privacy Notice
Description: The HIPAA Privacy Rule requires self-insured health plans to maintain and provide privacy notices. Special rules apply, however, for fully insured plans. Under these rules, the health insurance issuer, and not the health plan itself (provided the employer is “hands-off” on protected health information), is primarily responsible for the privacy notice.
Self-insured health plans are required to send privacy notices at certain times, including to new enrollees at the time of enrollment. Thus, the privacy notice should be provided with the plan’s open enrollment materials. Also, at least once every three years, health plans must either redistribute the privacy notice or notify participants that the privacy notice is available and explain how to obtain a copy. However, since a three-year cadence can be easily missed, employers with open enrollment periods are generally well advised to include this notice with their open enrollment materials to make it a part of the general plan practice.
The Department of Health and Human Services (HHS) has model Privacy Notices for health plans to choose from.
Type of Notice: HIPAA Special Enrollment Notice
Description: At or prior to the time of enrollment, a group health plan must provide all eligible employees with a notice of their special enrollment rights under HIPAA. This notice should be included with the plan’s enrollment materials. It is often included in the health plan’s SPD or insurance booklet. Model language is available in the DOL’s compliance assistance guide.
Type of Notice: Wellness Notice HIPAA
Description: Employers with health-contingent wellness programs must provide a notice that informs employees that there is an alternative way to qualify for the program’s reward. This notice must be included in all plan materials that describe the terms of the wellness program. Employers with open enrollment periods are generally well advised to include this notice with their open enrollment materials to make it a part of the general plan practice. Sample language is available in the DOL’s compliance assistance guide.
Type of Notice: Wellness Notice ADA
To comply with the Americans with Disabilities Act (ADA), wellness plans that collect health information or involve medical exams must provide a notice to employees that explains how the information will be used, collected, and kept confidential. Employees must receive this notice before providing any health information and with enough time to decide whether to participate in the program.
Employers that are implementing a wellness program for the upcoming plan year should include this notice in their open enrollment materials to make it a part of the general plan practice. This is not an annual requirement so employers can decide whether to continue to include the notice in open enrollment materials. The Equal Employment Opportunity Commission has provided a sample notice for employers to use.
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