Below are two separate sample templates. The “Sample Wrap Document (to meet Plan Document and SPD requirements)” can be used along with the Certificate of Coverage, Member Payment Summary, and Provider & Facility Directory to satisfy both the Plan Document and SPD ERISA requirements in situations where SelectHealth is the only plan/carrier offered to the employees.
The second document called “Sample Wrap Document (to meet SPD requirements)”, can be used in situations where employers need to create an SPD for the SelectHealth benefits offered under their plan. This is commonly needed when employers offer more benefits than those offered by just SelectHealth (e.g. dental, health, life, or PBM offered through another carrier). This template, along with the SelectHealth Certificate of Coverage, Member Payment Summary, and Provider & Facility Directory will only assist in satisfying the SPD portion (and not the Plan Document portion) of the ERISA requirements. The employer must compile the plan information for all other benefits and carriers to satisfy the Plan Document requirement.
Please note that these are samples only and will need to be customized by you to meet your ERISA obligations. When customized with your employer-specific information, and approved by your legal counsel, the resulting document could be used in conjunction with the Certificate of Coverage, Member Payment Summary, and Provider & Facility Directory supplied by SelectHealth to create the applicable Plan Document or Summary Plan Description. SelectHealth does not customize this form for you or file any documents that may be required from you by ERISA, and it makes no representations about the legal adequacy of these documents in your specific circumstances. Please consult your own legal counsel.