Fiduciaries of the Sierra Pacific Industries Health Benefits Plan have agreed to settle claims they did not comply with the Affordable Care Act (ACA) and the Employee Retirement Income Security Act (ERISA) when providing health care benefits and deciding worker claims for health care benefits.
The company has agreed to comply with the ACA and ERISA, to pay past benefit claims in compliance with the ACA, and to correct the way it makes decisions on future claims.
An investigation by the Department of Labor’s (DOL)’s Employee Benefit Security Administration (EBSA) found problems with certain aspects of the plan’s claims processing, with the clarity of plan documents, and with the application of certain plan procedures for deciding claims. The agency’s investigators also found that the plan was not a “grandfathered” plan, was not exempt from certain ACA requirements and was required to comply with the law. Specifically, the department found that as of January 1, 2013, the plan relinquished its grandfathered status because changes were made to the plan that precluded it from meeting the regulatory exceptions that would allow it to retain grandfathered status.
As a result of the investigation and subsequent negotiations with the department, the plan fiduciaries have agreed to comply with the ACA’s requirements for plans that are not grandfathered, including requirements for internal claims and appeals and coverage of preventive health services.
They have agreed to:
- Revise plan documents and internal procedures;
- Re-adjudicate past claims for preventive services, out-of-network emergency services and claims affected by an annual limit and pay claims in compliance with the ACA and ERISA;
- Submit to an independent review organization claims were eligible for external review;
- Pay claims that had been left on hold for a long time;
- Comply with timelines for deciding claims as provided in the department’s claim regulation; and
- Forego for the 2017 plan year any increases to participant premiums, annual out-of-pocket limits, annual deductibles and coinsurance percentages in effect for the 2016 plan year.