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It is a highly critical exercise in health plan compliance for employers, insurance providers and third-party administrators (TPA). The healthcare coverage and benefits are in compliance with federal and state regulations including but not limited to HIPAA, ACA mandates, ERISA, and COBRA requirements. Non-compliance could be financially taxing and tarnish a reputation. While health plan compliance must meet the legal purpose, there is a trust between the employer and the employee or any beneficiary that must, therefore, be built.

Business organizations must know the laws concerning employee benefit plans to be able to stay compliant. Coverage for basic health benefits is required to be provided under the provisions of the Affordable Care Act (ACA), the privacy of health information is guaranteed by HIPAA, and ERISA plans require the submission of Form 5500. Laws of mental health parity, PCORI fees, and non-discrimination testing are also important. Knowing how these laws relate to each other will enable the establishment of a sound compliance program from both a federal and state insurance regulatory perspective.

It is important to have a checklist prepared in advance so one can act before an event occurs. Important points include updating Summary Plan Descriptions (SPD), conducting internal audits, timely COBRA notices, and stop-loss insurance contract reviews. Regular compliance training conducted with implementation support from qualified benefits consultants or legal counsel should also greatly reduce the chances of an inadvertent violation.

Common traps into which employers easily fall include failure to provide notices, non-discrimination testing, or plan amendment. Others often neglect compliance obligations concerning data privacy under HIPAA, more so when using electronic Protected Health Information (ePHI). Spotting these red flags early could help businesses address compliance barriers, securing their operations and, just as importantly, the plans' participants.

The efficient administration of health benefits software and compliance management platforms can assist organizations in streamlining their documentation process, automate deadlines, and highlight inconsistencies. Getting into a trusted relationship with TPAs, HRIS vendors, or legal partners conversant with employee benefits enables organizations to pursue their core objectives in the full confidence of their compliance framework. In the fast-changing regulatory landscape of today, compliance means also being technology aware.