HMOS -- Certificate of Coverage or SPD?

[Guest justbe]

Is an HMO only obligated to provide a certificate of coverage to participants or must it also provide a SPD to plan participants? If the HMO is only required to issue the certificate of coverage is the employer responsible for the SPD? The only item missing out of most certificates of coverage (for purposes of the SPD regulations) is the ERISA statement of claims? Would an employer be responsible for providing this separately?

[GBurns]

HMO's and other insurers are required by state law to provide the Certificate of Coverage. HMO's and insurers do not provide SPD.

A Certificate of Coverage is not an SPD nor does it have the required language.

An SPD is a Summary Plan Description of the Plan provided by the employer or Plan Sponsor. In essence the SPD summarizes the Plan Document.

HMOs and insurers do not provide plans and are not Plan Sponsors.

HMOs and insurers are providers of benefits and services, they do not provide health plans. Employers and Plan Sponsors provide health plans, hence the phrase "employer provided".

The Employer or Plan Sponsor is responsible for providing the SPD and Plan Document.

[QDROphile]

The plan administrator is responsible for delivering an SPD, not the employer or plan sponsor. The employer or plan sponsor could also be the plan administrator but that should be given serious consideration and usually avoided.

The products from insurance companies that most plans use as SPDs (even those that have the ERISA rights language) typically fall short of the SPD requirements or are not accurate in some way. The pan administrator will probably have to wrap the product with addtional explanation in order to be compliant.

[KIP KRAUS]

What I have done in the past with HMO plans id to draft an SPD supplement to the HMO certificate. ERISA attorneys have advised me that the supplement can refer to pertinent items in the employee’s certificate rather than including them in total in the SPD supplement.

A statement in the supplement should also inform participants that when there is a conflict between the SPD supplement and the employee certificate that the certificate will take precedence over the supplement language.