ISCEBS Fellow cheat sheet

Premium-setting formula: experience-rated premium = expected claims (incurred and paid) + retention (admin, margin, risk charge) − interest on reserves; community rating pools all risks and bars individual experience adjustment.

Medical loss ratio (MLR) rebate rule: individual and small-group minimum is 80%, large-group 85%; if actual MLR falls below the minimum, the issuer rebates the difference to enrollees (employer for group coverage).

Cost-sharing tiers: deductible, coinsurance, copay, and out-of-pocket maximum. The OOP maximum excludes premiums and generally excludes non-covered services; embedded individual limits apply inside family coverage.

Preventive services must be covered without cost-sharing when delivered in-network, including immunizations, screening tests, and well-child visits; this requirement overrides deductible and coinsurance design.

COBRA continuation: applies to employers with 20+ employees; qualified beneficiaries get 18 months (29 months if Social Security disability determined within the first 60 days), 36 months for dependents after death, divorce, or Medicare entitlement of the employee.

HIPAA portability: group health plans must credit prior creditable coverage against preexisting-condition exclusion periods; certificates of creditable coverage document the credit.

Consumer-directed health plan pairing: an HSA requires a qualifying high-deductible health plan, no disqualifying coverage, and IRS annual contribution limits; HSA funds roll over and are portable, whereas FSA funds are generally use-it-or-lose-it with limited carryover or grace period.

Pharmacy benefit mechanics: formulary tiers, prior authorization, step therapy, and quantity limits control utilization; rebates from manufacturers reduce net cost but are not always passed to plan sponsors.

Wellness incentive limits: under HIPAA/ACA rules, outcome-based rewards tied to a health factor are capped at 30% of the cost of coverage (50% for tobacco cessation), and reasonable alternative standards must be offered.

Defined benefit funding: minimum required contribution is based on the target normal cost plus shortfall amortization over seven years; the funding target is generally 100% of the present value of accrued benefits.

Benefit formulas: flat-benefit, unit-benefit, and final-average-pay. Final-average-pay = years of service × accrual rate × average compensation over a stated period.

Vesting schedules: cliff vesting at 3 years or graded 2-6 years for employer nonelective contributions; safe-harbor 401(k) match and nonelective contributions vest immediately or per the plan's schedule.

Contribution limits: 402(g) elective deferral limit, 415(c) annual additions limit, and 401(a)(17) compensation cap are indexed annually; catch-up contributions apply at age 50 and above.

Nondiscrimination testing: ADP and ACP tests compare highly compensated and non-highly compensated employee deferral and match rates; top-heavy rules require minimum contributions when key employees exceed 60% of plan assets.

Required minimum distributions: begin at the applicable age (73 for those born 1951-1959, 75 for 1960 and later) with penalties for missed distributions; Roth accounts may have different timing.

Pension benefit guarantees: PBGC covers single-employer plans up to statutory monthly maximums based on age at termination; multiemployer guarantees are separate and lower.

Hybrid plans: cash balance plans express benefits as a hypothetical account with pay credits and interest credits; they are defined benefit plans subject to lump-sum and market-rate conversion rules.

Fiduciary duties under ERISA: loyalty, prudence, diversification, and plan-document compliance; prohibited transactions include self-dealing and party-in-interest dealings unless an exemption applies.

ERISA preemption: ERISA preempts state laws that relate to employee benefit plans, but state insurance laws regulate insured plans; self-funded plans are largely exempt from state insurance mandates.

Fiduciary standard: the prudent expert standard applies to plan administration and investment selection; co-fiduciaries share liability and can be liable for another fiduciary's breach if they know of it and fail to act.

Reporting and disclosure: Form 5500 annual return, summary plan description, summary of material modifications, and summary annual report have defined deadlines and content requirements.

COBRA and HIPAA interplay: COBRA continuation coverage is creditable coverage; group health plans must issue certificates and honor special enrollment rights triggered by marriage, birth, or loss of other coverage.

Leave benefits: FMLA provides 12 weeks of unpaid job-protected leave for eligible employees (50+ employees within 75 miles, 12 months of service, 1,250 hours); intermittent leave rules apply.

Disability benefits: short-term and long-term disability definitions differ (own occupation vs. any occupation); coordination with Social Security and workers' compensation offsets reduces plan payout.

Executive compensation: 409A governs deferred compensation timing and elections; 280G limits golden parachute payments; 162(m) caps deductible compensation for covered employees.

Benefits communication and enrollment: annual open enrollment windows, qualifying life events, and evidence of insurability requirements for late entrants.

Plan governance: benefits committees, vendor benchmarking, and cybersecurity controls for plan data are emerging fiduciary concerns.

Public health foundation: the Canada Health Act requires provinces to provide medically necessary hospital and physician services that are universal, accessible, portable, comprehensive, and publicly administered.

Employer plans supplement public coverage: extended health, dental, vision, and prescription drug coverage are typically insured through group contracts; provincial drug plans fill gaps for specific populations.

Retirement income pillars: Old Age Security (OAS) plus Guaranteed Income Supplement (GIS), Canada Pension Plan/Quebec Pension Plan (CPP/QPP), and employer registered pension plans or RRSPs.

Registered plans: RRSP contributions are deductible and grow tax-deferred; TFSA contributions are not deductible but withdrawals are tax-free; RRIF minimum withdrawals apply after conversion.

Pension standards: provincial and federal pension benefits standards legislation sets funding, vesting, and portability rules; defined benefit solvency funding rules vary by jurisdiction.

Group benefits taxation: employer-paid premiums for group health and dental are generally not a taxable benefit, but employer contributions to a group RRSP or DPSP may be taxable or deferred depending on plan type.

CPP/QPP enhancement: the enhanced portion increases replacement earnings, with higher contribution rates phased in; benefits are indexed to inflation.

EI and leaves: Employment Insurance provides maternity, parental, sickness, and compassionate benefits; provincial employment standards set job-protected leave lengths.

Quebec differences: QPP replaces CPP, and the Quebec Drug Insurance Plan requires residents to have prescription drug coverage through an employer plan or the public plan.