Plan Documents Again

mrsbowden

I know this is crazy, but I have been here for about 5 months and ever since have been trying to find the plan documents for all insurances our company has and it took for ever to find them..we found something that represented a plan document for a few things Flex spending etc. but are not able to find plan documents for many other programs....in one of my previous posts I was told that the TPA generally writes these Plan Documents, when we called some of our TPA's to retrive a copy of the document they stated they did not have them...any other suggestions on where I may look for them? I realize b/c our WC is self insured we are responsible for this with it, but on other programs we are using TPA's for it just seems they should have more of a position in this. This company seems to have passed Benefits people around quit a bit and so the plan documents seem to have been misplaced, we are thinking of having our lawyer draft them again...but doesn't our TPA at least need to be apart of that and are we crazy for having them drafted again....I am not sure how much work is put into these or if a lot of it is boiler plate language? Sorry if this is just a repeat but I am at a loss, everyone at the company claims they dont have them and out TPA's claim they don't have copies...so sounds to me like they are also saying they did not draft them...sorry so long and wordy..any help? x:)

Hunter1

Well, you're going to have to get them from somewhere, but I'd still put some pressure on your TPA's. They have to have some kind of document in order to administer your plans. How are they determining benifits if they don't have a plan? I don't know about WC, I've always been fully insured, and have a policy, but not a plan document, but for health, STD, LTD, dental, etc, you have an obligation to provide the participants with at least a summary plan description, and to have the plan document available for inspection, so it's not an option. Maybe have your attorney contact the TPA's, and suggest that they're not doing their job if they don't have plan documents from which to administer the plans. Good luck.

LindaS

I agree with Hunter - the SPD is what the TPA uses to determine payment of benefits, etc.. Basically the SPD is the insurance policy in layman's terms so that all participants know what is covered and how much as well as limits, etc.. If your TPA is telling you they don't have one, I would question, seriously, their ability to administer your plan. I would not contact your attorney at this point but instead put the pressure on your TPA. Question how they can administer your plan in absence of a SPD. As for WC, I have not seen an actual SPD that is provided to the employees. Medical, Dental, LTD, STD, and Life insurance are all policies that require SPDs is something that should be provided by the TPA.

irenesmsaclaims

Agree with all but to clarify - if any of these coverages is insured, ie., life insurance, the carrier can provide the master contract(policy) and SPD. If you have a TPA, then I assume that the plan(s) they administer are self-funded. Possibly, they "built" the plan on the computer in order to pay claims, and then over the years lost the hard copy of the plan document. This is not good, they should have it on file. They should have SOMETHING to back up claim determination decisions based on the plan itself. Are you subject to ERISA? Could the document(s) be on a computer within your company? Or the TPA?

Mentel

One other route that I would try. Did you use an agent or insurance agency to contract with the TPA? If you did, I would contact the agent and tell them that I need the SPD now. The TPA has one, they just need to get it to you and an agent would be helpful in this.

SMace

You said you contacted "some" of your TPA's for a plan document. You should only have one TPA that processes your claims. You must not have called the correct one. As others have said a TPA CANNOT process your claims without a plan document or SPD. Make sure you know who processes your claims and call them. Their phone number should be on your insurance card. You should also be able to get info from your insurance broker if they were involved. I cannot believe you cannot find a SPD. There would be some TPA's and brokers on my chopping block if I were in your situation.

mrsbowden

Believe it or not...once we stated that we couldn't find any plan documents and would have to turn to our attorney to help us out...magically we started getting calls and new documents starting appearing...you know from those files that "we forgot about".

Side BAR:

Also I was told recently that some fully insured plans do not have a "PLAN Document" with our Health carrier, I was told the way it was set up ...we have a "certificate" and a "contract" and that is all we need...and we issue a "summary of benefits" each year at open enrollment. is this correct.

SMace

Does this summary of benefits give the ee's their COBRA and HIPPA rights? How about claim review and appeal process, or exclusions, or precert requirements, or eligibility requirements, or pre-existing condition rules? I would not feel comfortable without that info given out. Keep in mind we are self-insured.

irenesmsaclaims

Just to straighten up some terminology issues with this. A fully insured plan will have a master contract, which is the policy, which is the plan document, (for the employer/policyholder). It will also have an SPD, or a certificate (for the participants). A summary of benefits at open enrollment would not suffice (especially if you are subject to ERISA) because the SPD has many things other than benefits in it. It has subrogation, coordination of benefits, claims procedures (the new DOL regs. from last year), eligibility, COBRA, HIPAA, FMLA, exclusions, etc. Also there are COBRA requirements of a general notice to new participants, which is contained in an SPD. Your documents should be reviewed, and the SPD requirements examined for compliance.