ERISA Section 607 defines the term group health plan as an employee welfare benefit plan providing “medical care” to participants or beneficiaries:

1. Directly
2. Through insurance
3. Through reimbursement 
4. Or otherwise

ERISA Section 607 refers to Section 213(d) of title 26 to generally define the term medical care as amounts paid for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body.

Employers should be aware if their benefits programs are considered group health plans under the ERISA law. When a group health plan exists certain compliance obligations may apply, such as providing participants a Summary Plan Description (SPD), offering the program to COBRA beneficiaries, and reporting information about the program under Form 5500.

The programs listed below generally fall into the category of a group health plan: 

Programs that directly provide medical care to employees:

• On-site medical clinics that provide more than basic first -aid
• Workplace flu shot programs
• Wellness programs that provide biometric health screenings
   

Programs that provide medical care through insurance:

• Health insurance
• Dental insurance
• Vision insurance
• Cancer and critical illness insurance that coordinate benefits with health insurance
• Fixed indemnity and hospital indemnity insurance that coordinate benefits with health insurance 
   

Programs that provide medical care through reimbursement:

• Health Flexible Spending Accounts (Health FSAs)
• Health Reimbursement Arrangements (HRAs)
• Executive Medical Reimbursement Plans 
   

Programs that provide medical care otherwise:

• Telemedicine plans
• Programs that provide grief counseling and/or alcohol and substance abuse counseling, such as certain Employee Assistance Programs (EAPs)
• Discount programs for dental, vision, prescriptions or other medical care 

As you can see, the definition of a group health plan extends well beyond health insurance coverage. Employers and brokers who assist employers with benefits should take a close look at all programs to determine if a group health plan exists under the ERISA law. It’s best to know compliance responsibilities and other obligations so that appropriate actions can be taken.  

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