Self-Funded Health Plan Regulations and Reporting to Review with Your Clients

Self-funding gives employers greater control over their health plan, and those benefits come with reporting requirements.

Fortunately, plan partners (like Point C) can support much of that work, from supplying data to completing certain filings on the plan’s behalf. The employer, however, should understand which requirements apply to the plan and how responsibilities are assigned.

Wondering where to start? Keep reading to learn the major reporting areas brokers should clarify to clients as the year comes to a close.

What is Reporting and Who is Responsible for it?

Reporting refers to the federal disclosure laws employers must comply with if they self-fund healthcare, and employers may need to address different areas depending on their specific plan because requirements vary.

Responsibility for understanding the plan’s applicable requirements falls to the employer, while specific reporting tasks may be divided among the other organizations supporting the plan.

Typical Administrative Structure

• The employer or plan sponsor, which retains responsibility for the plan and should understand which requirements apply.
• The TPA, which may provide claims, eligibility, enrollment, and administrative data needed for reporting.
• The PBM, which may supply or submit pharmacy information, including portions of RxDC reporting.
• Brokers and consultants, who can help employers identify requirements to coordinate plan partners and prepare for upcoming deadlines.
• Legal or compliance advisors, who can help interpret regulatory requirements and address circumstances specific to the plan.

Point C’s Building Blocks of Self-Funded Health Plans offers an overview of how these responsibilities fit into the self-funded model.

Common Reporting Areas for Client Overview

Employers need to keep track of several important forms to stay compliant when self-funding, and brokers can help them stay ahead of those. Notable upcoming deadlines for next year include:

• ACA Information Reporting | Due March 1 (Paper), March 31 (Electronically), 2027
• Prescription Drug Data Collection/RxDC | Due June 1, 2027
• Form 5500 | Due August 2, 2027 (Calendar Year Plans)
• Annual Gag Clause Compliance Attestation | Due Dec. 31, 2027

These documents detail coverage, plan operations, prescription drug spending, and compliance with federal transparency requirements, which makes completing them on time essential.

ACA Information Reporting

Employers sponsoring self-funded coverage have reporting responsibilities under the Affordable Care Act.

If a business has 50 or more full-time employees (Applicable Large Employer) or self-funds its employees’ health benefits, it must file annual returns with the IRS and provide those statements to employees.

Applicable Large Employers generally use Forms 1094-C and 1095-C, while self-funded employers that are not in this category tend to use Forms 1094-B and 1095-B. Brokers should be ready to guide clients through the IRS reporting instructions with the help of an experienced TPA partner.

Prescription Drug Data Collection

Federal law requires group health plans to report prescription drug and healthcare spending information through RxDC.

The employer should confirm who is responsible for each submission and whether the plan sponsor must provide additional information. Plan partners can take on reporting responsibilities, though, so brokers and employers should discuss their options with partners.

Form 5500

Many ERISA-covered health and welfare plans must file Form 5500 annually, although exemptions can apply based on plan size and funding structure.

The Department of Labor’s Form 5500 guidance is a useful resource for brokers to help familiarize employers with which requirements apply.

Annual Gag Clause Compliance Attestation

Group health plans must annually confirm that certain agreements do not restrict access to provider cost or quality information. The formal filing, the Gag Clause Prohibition Compliance Attestation, is due by December 31 each year. With this deadline coming up, it’s a key area for brokers to start the conversation and flag to employers now.

A service provider may submit the attestation, but employers should still confirm that the form has been assigned and completed. CMS also provides guidance and submission resources.

How Can Brokers Help Employers Prepare for Reporting Deadlines?

Making reporting responsibilities part of the plan’s regular operating calendar is one of the easiest ways brokers can keep clients ready for upcoming deadlines.

Reporting To-Dos

• Build a reporting calendar. Record each applicable filing, its deadline, and the party responsible for completing it.
• Confirm responsibilities early. Do not assume a filing is covered because a vendor has access to the underlying data. Confirm who owns submission and what the employer must provide.
• Review information before submission. Give the appropriate plan partners time to identify missing or inconsistent information before the deadline.

Choose a TPA That Takes Reporting Compliance Seriously

Reporting failures can carry significant financial penalties and create legal exposure, so oversight is important well before any deadline.

IRS guidance, for example, states penalties for when applicable ACA information returns are not filed correctly. Regular conversations among employers and their plan partners can keep responsibilities visible as requirements shift.

Point C works with brokers and employers to support the administration and reporting processes behind self-funded health plans, helping keep plan information organized and responsibilities coordinated among those involved. Explore Point C's Building Blocks of Self-Funded Health Plans for an overview on how administrative roles and responsibilities fit into the self-funded model.