Direct Billing Terms & Conditions

Published: 10/28/2020

Direct Billing Services:
1. Definitions: For the purposes of the Direct Billing Services the following definitions shall apply:
  1. “Administrator” means Client’s human resources/benefits administrator.
  2. “Open Enrollment Period” means the period during which a Participant may enroll in or change coverage under a Plan.
  3. “Participant” means any individual who is subject to a direct billing arrangement and has the direct billing functionality enabled for the applicable Plan(s), as designated by Client.
  4. “Plan” means any benefit plan established by Client.
  5. “Premium Invoice” means an invoice that provides a Participant a notice outlining monthly premiums due for benefits covered, instructions for payment and payment due date.
  6. “Unpaid Leave of Absence” means a status when a benefit eligible employee is not receiving a regularly scheduled paycheck where benefits may be deducted.
  7. “Retiree” means a former Client employee loaded within the system that is flagged with a “Retiree” indicator.
2. Direct Billing Implementation Services:
  Benefitfocus will work with Client to complete the following steps for the implementation of the Direct Billing Services. Direct Billing Implementation Services include
  1. Discovery sessions to gather eligibility, plans, billing start dates and business rules that are in scope for Direct Billing
  2. Documentation
  3. Configuration of the billing application
  4. Testing
  5. Process and operational overview for Administrators
  6. Production deployment
3. Direct Billing Services: Benefitfocus has been engaged by Client to provide certain services in connection with Client Plan(s). Accordingly, Client authorizes Benefitfocus to use their respective standard procedures for the provision of the Direct Billing Services. The Direct Billing Services shall be provided in accordance with the framework of policies, interpretations, rules, practices and procedures as set forth in the Plan documents, and as otherwise mutually agreed upon. Benefitfocus, shall:
  1. Identify Participants who are eligible for Direct Bill benefits based on either the Leave of Absence Manager or use of categories as defined during discovery.
  2. Provide the following standard communications to Direct Bill eligible Participants during the Direct Billing period:
    1. Monthly or Annual Premium Invoice notice.
    2. Late Payment Notice on the 15^th of the month when participant is past payment due date.
    3. Nonsufficient funds notice if funds are returned insufficient.
    4. Refund notice, in the event a Participant has returned from leave and has overpaid Direct Bill premiums.
    5. Provide Direct Bill participants a monthly consolidated invoice for all active, enrolled benefits.
    6. Monthly invoices are sent by US Mail to Participant’s mailing address.
    7. Postage is included.
    8. Open Enrollment and Qualified Event Changes will be included in Participant’s Direct Bill so long as Client has made the necessary update and approval in the Benefitfocus Benefitplace.
    9. Manage retro‑active adjustments based on effective dates entered by client into the Benefitfocus Benefitplace.
    10. Provide participant payment options that include ACH electronic check, credit card, money order, and check. Only ACH payments will be accepted over the phone.
    11. Premium payments shall be considered timely if postmarked by the U.S. Postal Service or paid electronically on or before the applicable due date.
    12. Payments that have been received and have cleared the bank will be remitted to the Benefitfocus FBO account on the 3rd business day after settlement.
    13. Provide Client access to generate a standard monthly Direct Billing report to view Participant status.
    14. Remit payments collected from Participants to the Client via ACH deposit to the Client’s designated account and provide Client access to a Monthly Payment Remittance Report (a detailed report reflecting Participants payment associated benefits).
    15. Provide Client access to a Monthly Activity Report displaying Participant invoice and payment activity (“Cash Activity Report”).
    16. Provide Client with a client services representative to answer phone or email inquiries regarding the Direct Billing Services during the period of 8:00 a.m. EST to 8:00 p.m. EST, Monday through Friday, excluding holidays and other non‑business days.
    17. Provide Participants with 24/7 access (excluding downtime for system maintenance) to the Benefitfocus Benefitplace where Participants can access invoice and payment history and pay their bills online.
4. Client Responsibilities for the Direct Billing Services: Client is the Plan Administrator and fiduciary as described under ERISA and the Internal Revenue Code. As such, only Client shall have the power to waive, alter, breach or modify any of the terms and conditions of Client Plan(s), and Client exercises all discretion, control or authority with respect to the disposition of the available benefits. As such, Client shall:
  1. Determine which benefit plans and individuals are eligible for Direct Billing Services through the Benefitfocus Benefitplace.
  2. Communicate eligible benefit plans and category types to Benefitfocus for proper configuration.
  3. Provide accurate and timely changes to Participant enrollment and eligibility data, including, but not limited to, information that modifies a Participant’s eligibility, status or election under a Plan.
  4. Responsible to communicate and manage company policies and rules directly with retirees and leave of absence Participants, including but not limited to:
    1. Plan and enrollment options upon retirement
    2. Termination of enrollment due to non‑payment
    3. Handling of partial payments & non‑payments for Direct Bill Participants upon return from leave
  5. Provide an account to which premiums collected on behalf of the Client will be deposited.
  6. Notify Benefitfocus in writing of any changes in carriers and/or Plan(s) at least sixty (60) days prior to the effective date of the change.
  7. Notify Benefitfocus in writing of any changes in premiums that shall apply at least sixty (60) days prior to the effective billing date of the new premium.
  8. Reconcile all carrier invoices and notify Benefitfocus CSM and the carrier of any discrepancies.
  9. Comply with all applicable laws (e.g., HIPAA and ERISA) with respect to Client Plan(s) and make any required filings with the appropriate governmental agencies, including the DOL and the IRS.
  10. Provide the release of any information necessary for Benefitfocus to perform the Direct Billing Services provided under this Appendix.
5. Invoicing:
  1. Multi‑carrier, multi‑product, consolidated premium invoices will be provided to Direct Bill Participants.
  2. Initial monthly premium invoices will be generated and sent to participants via USPS mail. Subsequent invoices may be delivered via USPS mail or via secure electronic delivery if Participant has elected this method of delivery.
6. Payment Acceptance:
  1. A web‑based user interface will be provided to participants through the Benefitfocus Benefitplace for the purposes of displaying invoices, capturing payment information, and displaying payment history.
  2. The following payment options will be made available:
    1. Check or money order from Individual
    2. ACH debit transactions from Individual (one‑time or recurring depending on what Participant elects)
    3. Credit Card (payments not allowed via the phone)
  3. All valid and timely payments received will be entered into the billing application.
  4. All valid, full and timely payments received will be deposited into the Client’s designated bank account the second week of each month.
  5. Charge‑backs and NSF payments will be supported.
7. Payment Management:
  1. Benefitfocus will provide Client access to a monthly activity report (“Cash Activity Report”) to reflect all payment activity of subscribers including monthly billing activity, non‑sufficient funds and refunds.
8. Premium Remittance:
  1. Benefitfocus will deposit all funds collected from Client’s participants into a designated bank account via ACH Direct Deposit each month for premiums collected the prior month.
  2. Access to premium remittance advice will be provided each month to reflect all premiums collected and remitted to Client.
Additional Terms and Conditions:
1. For the Direct Billing Services:
  1. Benefitfocus shall not be responsible for inaccurate notification or premium payment errors, except to the extent such inaccurate notification or errors are caused by Benefitfocus.
  2. Participants and Plans not set up within the Benefitfocus Benefitplace in accordance with Benefitfocus requirements will not be included in the Direct Billing Services.
  3. Client shall be solely responsible for complying with ERISA, the Internal Revenue Code, HIPAA, COBRA and any other applicable federal, state and local laws with respect to the Client Plan.
  4. Benefitfocus and Client intend and agree that Client Funds are and shall remain the general assets of Client, are not the general assets of Benefitfocus and are not plan assets within the meaning of ERISA.
  5. Benefitfocus and Client acknowledge and understand that Benefitfocus may receive interest income from time to time on the funds held by Benefitfocus and that any such interest income received by Benefitfocus on such funds shall be the sole property of Benefitfocus. Client acknowledges and understands that compensation otherwise charged by Benefitfocus for the Direct Billing Services under the Appendix would be higher if it did not retain such interest on these funds.
  6. Fiduciary Status: In addition to the rights and obligation of the Parties, the following provisions shall also be incorporated into this Appendix:
    1. Plan Fiduciary: Benefitfocus and Client agree that Benefitfocus is not the plan administrator, the Named Fiduciary and are not a plan fiduciary under the Plan(s), as such terms are described under ERISA. Benefitfocus shall have no power or authority to waive, alter, breach or modify any terms and conditions of the Plan. Benefitfocus shall make payments or distributions from the Custodial Account in accordance with the framework of policies, interpretations, rules, practices and procedures set forth in the Plan, this Appendix and as otherwise agreed upon or directed by Client. Benefitfocus shall neither have nor shall be deemed to exercise any discretion, control, or authority with respect to the disposition of Client funds. Client agrees that use of or offset of amounts in the Custodial Account to pay for fees or other amounts due to Benefitfocus under this Appendix or any other agreement between the parties shall constitute a Client action that is authorized by Client under this Appendix. Client agrees that such actions are not discretionary acts of Benefitfocus and do not create fiduciary status for Benefitfocus. Benefitfocus agrees that it will perform the Direct Billing Services on the Plan’s behalf, as set forth in this Appendix and any attachments or other exhibits. However, Benefitfocus will not undertake any duties or responsibilities, regardless of whether they are set forth in the Plan, if such actions are in violation of any applicable laws or regulations.
  7. Client Plan Data: Upon termination of this Appendix, Benefitfocus will maintain Client’s records in an electronic format as required by law. Following such termination, Benefitfocus shall cooperate with Client (or Client’s subsequent service provider) to affect an orderly transfer of Client Data covered by the Appendix in a generally commercially available media and format.
  8. Notwithstanding anything to the contrary within this Appendix, the Agreement or the applicable Order Form, Benefitfocus reserves the right to increase fees to Client at any time that are caused by Federal postal rate increases, are due to Federal legislative changes or are due to the provision of additional services to Client by Benefitfocus that were not included in or contemplated by this Appendix on the Effective Date. Benefitfocus shall provide Client with thirty (30) days written notice of fee changes resulting from Federal postal rate increases or Federal legislative changes.
  9. Client agrees to assist Benefitfocus as needed with any communication or issue resolution with any required third parties and Authorized Users.
  10. Neither Party shall be liable for any delay caused by the other Party, or their respective contractors, agents, employees, or vendors.
  11. Benefitfocus shall not make or be liable for any determinations regarding eligibility, and Client shall be responsible for making all determinations regarding Authorized User eligibility for Client’s Plan(s).