EWS - Risk Assessment Tool

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Why ERISA, CAA & DPC?

ERISA requires you as the employer to do what is best for your employees when it comes to their healthcare.
CAA requires you to make it clear and easy for them to see that you are spending money wisely while doing what is best.
DPC/DCNs make it easy for you to do what is best, make it transparent, and save money for you and your employees.

The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets standards for employee benefit plans in the private sector, including group health plans. It governs how employers manage these plans to protect employees and ensure transparency, fairness, and fiduciary responsibility. Here's how ERISA compliance relates to the Consolidated Appropriations Act (CAA) and how businesses can address potential risks with Direct Primary Care (DPC) and Direct Care Networks (DCNs).

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What is your current approach to employee health benefits?* This field is required.https://litigationtracker.law.georgetown.edu/issues/erisa/

Traditional insurance plans

Self-funded plans

Direct Primary Care (DPC) or alternative care models

Other

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ERISA Key Requirements for Group Health Plans

Fiduciary Responsibility:

Employers and plan administrators must act in the best interest of participants, ensuring that fees are reasonable and services are appropriate.

Plan Documentation and Disclosures:

Plans must provide accurate and timely information, including Summary Plan Descriptions (SPDs) and other disclosures about plan terms and benefits.

Reporting Requirements:

Plans must file annual reports (e.g., Form 5500) and keep records to demonstrate compliance.

Claims and Appeals Processes:

Plans must have a fair and timely process for handling participant claims and appeals.

4

How much visibility do you have into the actual cost drivers of your healthcare spend?* This field is required.https://www.healthaffairs.org/content/forefront/self-insured-employers-using-price-transparency-improve-contracting-health-care

Complete visibility

Some visibility, but not actionable

Minimal or no visibility

5

What would saving 10–30% on your healthcare costs mean for your business? Complete the free assessment to see your opportunities to save.* This field is required.https://pmc.ncbi.nlm.nih.gov/articles/PMC8504342/

6

What is your first name?* This field is required.

7

What is your last name?* This field is required.

8

What is the name of your company?* This field is required.

9

What phone number can we use to reach you?* This field is required.

Area Code

Phone Number

10

What is the best email address for you?* This field is required.(Please use work email)

example@example.com

11

What is your website URL?

12

How would you describe your biggest healthcare challenge right now?

13

* This field is required.

14

Are you reviewing your health plan to ensure all fees charged by third-party administrators (TPAs) and vendors are reasonable and documented?

YESNO

15

Have you established a process to evaluate vendor contracts for potential conflicts of interest?

YESNO

16

Are you actively monitoring and documenting fiduciary decisions to demonstrate compliance?

YESNO

17

Have you implemented the necessary tools to comply with the Transparency in Coverage rule, such as public disclosure of in-network and out-of-network pricing?

YESNO

18

Are you providing clear disclosures about compensation received by brokers and consultants?

YESNO

19

Do you distribute Summary Plan Descriptions (SPDs) and other required documents to employees within ERISA timelines?

YESNO

20

Are you completing and filing accurate Form 5500 reports annually for your group health plan?

YESNO

21

Are you maintaining records of all compliance reviews, claims audits, and vendor performance assessments?

YESNO

22

Have you documented compliance with all CAA-related transparency and parity requirements?

YESNO

23

Are you conducting comparative analyses of your medical/surgical benefits vs. mental health/substance use disorder benefits?

YESNO

24

Do you have processes to ensure compliance with parity in cost-sharing, treatment limits, and network adequacy for mental health services?

YESNO

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Using DPC/DCNs to Mitigate ERISA Risks

Cost Containment:

DPC/DCNs reduce overall healthcare costs by offering flat-rate, transparent pricing and eliminating the middleman (e.g., insurance for routine care).
Simplified fee structures ensure compliance with fiduciary standards.

Improved Employee Access:

DPC allows employees to access primary care without barriers, reducing the need for high-cost claims or ER visits.
Direct care networks prioritize preventive and coordinated care, aligning with mental health parity requirements.

Enhanced Transparency:

Partnering with DPC or DCNs ensures straightforward pricing models that are easy to document and disclose under the CAA.

Vendor Oversight:

Using DPC/DCNs minimizes reliance on opaque third-party administrators, simplifying fiduciary oversight and reducing administrative burden.