Compliance Dashboard Assessment

Please, answer the below questions to generate your risk assessment score and identify needed actions to be compliant.

Company Profile

Please write your information below:

Company name:

Contact person name:

Contact person email address:

Contact person telephone number:

Total # Employee or Full-time Equivalent (FTE):

# Medical plan participants:

Do you offer medical insurance?

Yes No

Indicate how your medical plan is funded: Fully-Funded or Self-Funded

Fully-funded Self-funded or Partially Self-funded

Does someone at your organization handle plan assets for medical or retirement benefit plans where they could access funds or have power to transfer funds? (Note: Mark “No” if paying direct to providers)

Yes No

Does your health plan include health or wellness elements with rewards tied to individual participant health factors?

Yes No

Business Type:

Corp

S-Corp

LLC.

Gov

Limited Partnership

Sole Proprietor

Non-Profit Organization

Benefit Compliance Assessment

If you have a self-funded plan, do you submit the annual PCORI fees and accompanying paperwork to the IRS by July 31st each year?

Yes No Uncertain N/A

If you are an Applicable Large Employer (ALE) with 50 or more employees or FTE, do you offer medical insurance that meets minimum essential coverage requirements and is considered affordable? Or meets Minimum Value and is considered affordable?

Yes No Uncertain N/A

Do you provide all eligible employees with required ACA IRS Form 1095-C if you have a fully-insured plan that has 50 or more fulltime equivalent employees over the prior calendar year or IRS Form 1095-B if you have a self or partially funded plan? (Common ownership rules apply)

Yes No Uncertain N/A

Do you file form 1094-B or -C with the IRS along with copies of form 1095-B or -C?

Yes No Uncertain N/A

Do you obtain a written or electronically signed application or participant waiver for all eligible employees for each benefit?

Yes No Uncertain N/A

Do you have a defined measurement period to monitor variable hour employee’s eligibility for medical insurance coverage?

Yes No Uncertain N/A

Do you have a system in place to track work hours for variable hour employees that identifies them as eligible if they meet minimum hour’s (usually 30 hours) requirements during your measurement period?

Yes No Uncertain N/A

Do you provide, or use a COBRA administrator to provide initial notices of COBRA rights to employees and dependents?

Yes No Uncertain N/A

Do you offer COBRA continuation coverage options to participants who experience a qualifying event, if you have 20 or more employees?

Yes No Uncertain N/A

Do you offer participants with state continuation coverage, in all applicable states, if you have less than 20 employees?

Yes No Uncertain N/A

Do you provide an initial General COBRA Rights Notification to new eligible participants and their beneficiaries within 90 days of joining a medical plan?

Yes No Uncertain N/A

Do you have a process in place to clearly document who was given which notices, on which date?

Yes No Uncertain N/A

Do you have an organized documentation system to be able to demonstrate to the DOL, IRS and HHS you have required documents and are providing notices to participants?

Yes No Uncertain N/A

If you offer life and/or disability insurance that allows conversions upon employment termination, do you provide a conversion notice and keep record of the notice?

Yes No Uncertain N/A

If offering life and/or disability to you maintain beneficiary information on file?

Yes No Uncertain N/A

If you have a family medical leave program, do you have a clear process for how the employee’s portion of premiums will be handled while they are out?

Yes No Uncertain N/A

Do you provide participants with the following required notices?

Creditable Coverage of Medicare Part D
Children's Health Insurance Program Reauthorization Act (CHIPRA)
HIPAA Special Enrollment Right
Women's Health and Cancer Rights Act
Genetic Information Non-Discrimination Notice Act (GINA)
Patient Protection
Newborns' and Mother's Health Protection Act
MHPA (Mental Health Parity & Addiction Equity Act) (50 or more only employees only)

Yes No Uncertain N/A

Do you perform the annual Creditable Coverage Disclosure to CMS? (Done online)

Yes No Uncertain N/A

Do you provide the required Summary of Benefits & Coverages and the Uniform Glossary to employees at initial enrollment, upon request, within 7 days of HIPAA Special Enrollment Requests and at open enrollment?

Yes No Uncertain N/A

If providing the required notices via electronic delivery, do you have permission from the participant?

Yes No Uncertain N/A

Do you provide the Family Medical Leave Act (FMLA) notice and protection rights if you have 50 or more employees within a 75 mile radius for eligible individuals?

Yes No Uncertain N/A

Do you provide the following notices and disclosures to non-participants (not on medical plan)?

HIPAA – Notice of Privacy Practices
HIPAA – Eligibility Rights
USERRA
Special Enrollment Rights
Genetic Information Non-Discrimination Notice Act (GINA)
Qualified Medical Child Support Order (QMCSO), if applicable
Wellness Plan Notice, if plan includes health or wellness factors with rewards tied to individual health factors.
FMLA

Yes No Uncertain N/A

Do you have the required Fidelity Bond in place for every person who handles plan assets or other property? (At least 10% of the total of the funds handled, with a minimum of $1,000 and a maximum of $500,000)

Yes No Uncertain N/A

Do you provide all new hires with the ACA required Health Exchange Notice within 14 days of the date of hire? Did you previously provide all employees with the Health Exchange Notice?

Yes No Uncertain N/A

Do you have a Health Insurance Portability and Accountability (HIPAA) policy to secure Protected Health Information (PHI)?

Yes No Uncertain N/A

Do you have a HIPAA Business Associate Agreements with any outside party who has access to PHI?

Yes No Uncertain N/A

Do you have an assigned HIPAA officer in charge of securing PHI and interfacing with outside entities who may access PHI?

Yes No Uncertain N/A

Is HIPAA training provided to your HIPAA Compliance Officer, and if applicable, others who handle or access Protected Health Information (PHI) (e.g. all healthcare provider organizations)?

Yes No Uncertain N/A

Do you have a HIPAA privacy and security policy in place that is distributed to employees?

Yes No Uncertain N/A

Do your secure all Protected Health Information (PHI) preventing access from all outside parties both physically and electronically, if applicable?

Yes No Uncertain N/A

Do you participate in a Multiple Employer Welfare Arrangement MEWA? (MEWA, is defined as a single plan that covers the employees of two or more unrelated employers)

Yes No Uncertain N/A

Have you completed your annual M1 form?

Yes No Uncertain N/A

If you received a Medical Loss Ratio (MLR) rebate from your medical insurance carrier, under the requirements of the Public Health Services Act, did you meet requirements and kept documentation of how the rebate was disbursed to employees?

Yes No Uncertain N/A

Do you have a 125 Premium Only Plan (POP) document, if you are allowing participants to pay for any portion of allowable insurance premiums on a pre-tax basis?

Yes No Uncertain N/A

Do you have a 125 Flexible Spending Account (FSA) document, if you are allowing participants to deduct on a pre-tax basis for uncovered medical cost, allowable dependent care or allowable insurance premiums?

Yes No Uncertain N/A

Is your 125 POP or FSA document newer than 2014?

Yes No Uncertain N/A

Do you follow applicable maximum limits for all cafeteria plans (e.g. FSA limit to allowable medical and childcare)?

Yes No Uncertain N/A

Do you conduct 125 POP or FSA plan non- discrimination testing annually to meet IRS non-discrimination requirements?

Yes No Uncertain N/A

Do you conduct nondiscrimination testing for your 401(k) Retirement Plan, if applicable?

Yes No Uncertain N/A

Do you conduct nondiscrimination testing for your self-funded medical insurance plan making sure it does not favor highly compensated employees for premiums and participation?

Yes No Uncertain N/A

If you offer a Health Savings Account (HSA) with a high deductible plan do you make contributions to the HSA equally for all eligible participants?

Yes No Uncertain N/A

Do you file form 5500 for each health and welfare plan that has 100 or more participants at the beginning of the plan year? Or file one form 5500 for your health and welfare plans combined using your SPD Wrap?

Yes No Uncertain N/A

Do you file form 5500 SF (less than 100 employees) or regular form 5500 (100 or more employees) for a self-funded or partially self-funded plan?

Yes No Uncertain N/A

Do you provide a Summary Annual Report (SAR) to all participants annually, if you have 100 or more participants on a plan?

Yes No Uncertain N/A

Do you provide participants with a Summary of Material Modification (SMM) whenever there are changes to a benefit plan that is considered material (value of the benefit plan goes up or down)?

Yes No Uncertain N/A

Do you provide participants with an ERISA required summary plan description (SPD) or SPD Wrap document within 90 days of participation?

Yes No Uncertain N/A

Do you provide participants with a new SPD or SPD Wrap every 5 years?

Yes No Uncertain N/A

Do you provide participants with Certificates of Coverage, brochures and any other documentation provided to plan participants regarding rules for eligibility, limitations and benefit coverage under the plan, in conjunction with the SPD or WRAP SPD?

Yes No Uncertain N/A

Did you release 250 or more W-2 the previous year?

Yes No Uncertain N/A

Do you show medical insurance premium information on W-2 forms at year end for all participants?

Yes No Uncertain N/A

If you offer a wellness program that offers a reward based on an individual's ability to meet a standard related to a health factor, does the plan meet requirements of offering a reasonable alternative standard, and provide participants with a wellness program disclosure statement?

Yes No Uncertain N/A

Are you providing a value for and taxing the rewards given to the members as part of your wellness plan?

Yes No Uncertain N/A

Is participation in the wellness program limited based on health, disability or genetic information?

Yes No Uncertain N/A

Please answer all questions at Company Profile Section above.

All content is copyright protected to be used with permission only.

Compliance Dashboard Assessment

Company Profile

Benefit Compliance Assessment

ACA

COBRA

Documentation & Notices Tracking

Employee Notices

Fidelity Bond

HIPAA and HITECH

MEWA

MLR

Cafeteria Plans

NonDiscrimination Testing

5500 Reporting

SAR

SMM

SPD Wrap

Medical Exp. On W-2

Wellness Program