A question in response to last week’s post on self-funding of employer group health plans assumed that stop-loss coverage under a level-funded plan could be provided under a group captive medical captive. However, it cannot (at least not without first obtaining a prohibited transaction exemption from the US Department of Labor (DOL)). While group medical stop-loss coverage can be structured to avoid the Employee Retirement Income Security Act (ERISA) prohibited transaction rules by scrupulously avoiding contact with ERISA plan assets in the plan’s stop-loss layer, it is not possible to prevent such contact in level-funded products.

The early years of group captives saw no shortage of handwringing over fundamental compliance issues. For example: Are group captives multiple employer welfare arrangements (MEWAs) (and should they be regulated as such)? To what extent are states free to constrain or restrain their operation? And which state insurance licensing laws apply?

For the most part, these and other compliance-related questions have been answered, if not completely, then at least substantially so. There is now broad agreement that the group medical stop-loss captive rests on a sound legal and regulatory foundation, which we explained at length in our Special Report. When properly structured, they are not MEWAs; states are free to regulate the stop-loss policy, and the fronting carrier must be licensed in each state in which the captive operates (i.e., where plan participants reside). Critical to their operation, however, is that the group medical stop-loss captive itself does not traffic in plan assets. This means that participant contributions, which are always plan assets, must never be applied to the purchase of stop-loss coverage.

The treatment of stop loss premiums, and their status as plan assets, are set out in two DOL Advisory Opinions:

Advisory Opinion 92-02

A stop-loss insurance policy purchased by an employer sponsoring a self-insured welfare benefit plan to which employees did not contribute is not an asset of the plan if certain conditions are satisfied. These conditions include that the insurance proceeds from the policies are payable only to the plan sponsor, which is the named insured under the policy, and no representations are made that the policy will be used to pay benefits.

Advisory Opinion 2015-02A

Where a stop-loss policy is purchased by a plan that includes participant contributions, the stop-loss policy would not be a plan asset if the facts surrounding the purchase of the stop-loss policy satisfies Advisory Opinion 92-02 and if the employer puts in place an accounting system that ensures that the payment of premiums for the stop-loss policy includes no employee contributions. Also, the stop-loss policy must reimburse the plan sponsor only if the plan sponsor pays claims under the plans from its own assets so that the plan sponsor will never receive any reimbursement from the insurer for claim amounts paid with participant contributions.

In the above-cited Special Report, we provided the following example of how an employer might comply where, as is typically the case, the plan includes participant contributions:

Employer A hires a third-party administrator to manage its group health plan claims processing, adjudication, and other related tasks and services. The employer establishes an account at Bank X in the name of the employer in which it deposits funds necessary to pay the plan’s obligations. The plan’s third-party administrator has drawing rights on the account that are limited to the payment of plan claims and other plan-related expenses. The employer issues a separate check from its general operating account to cover stop-loss premiums.

Sponsors of level-funded plans pay a fixed monthly amount that covers claims, fixed costs, stop-loss premiums and administrative expenses. Employer and employee contributions are commingled as a matter of plan design. The plan sponsor’s receipt of any stop-loss policy reimbursements means that the requirement that stop-loss coverage be purchased solely with employer contributions and be separately paid and accounted for is not satisfied. The problem, of course, is that the sponsor’s receipt of plan assets amounts a transfer of assets from a plan to a disqualified person, thereby giving rise to one or more prohibited transactions.