Operating Health, Welfare, and Absence Programs (U.S. and Canada)
What is managed
Part 2 moves from framework to operations: medical, dental, vision, prescription drug, life, accidental death and dismemberment, short- and long-term disability, and absence programs. Candidates must understand funding alternatives - fully insured versus self-funded with administrative-services-only arrangements and stop-loss - and the risk transfer each represents. Know the vendor lifecycle: request for proposal, performance guarantees, claims auditing, service-level metrics, and renewal negotiation.
Compliance touchpoints in the U.S.
COBRA continuation (employer count thresholds), HIPAA portability, special enrollment, and privacy, ACA mandates and reporting, mental health parity, FMLA leave, ADA accommodation, and coordination with workers' compensation. Coordination-of-benefits order-of-payment rules and subrogation/reimbursement provisions decide who pays first and whether recoveries are returned.
Compliance touchpoints in Canada
Provincial health coverage as the base, employer drug and paramedical plans on top, provincial workers' compensation, EI sickness benefits, and human-rights-based accommodation duties. Disability management emphasizes early intervention, return-to-work planning, and consistent adjudication.
Worked example
An employee earning $60,000 has a long-term disability plan paying 60% of salary with a 180-day elimination period and a 70% all-source cap. LTD before offset is $36,000 annually. If the employee also receives $12,000 in workers' compensation, the plan pays $24,000, not $36,000, because total income cannot exceed $42,000.
Traps and rule of thumb
Traps: borrowing one statute's headcount for another (COBRA, FMLA, and ACA each count differently); assuming self-funding removes state insurance mandates on stop-loss; forgetting that offsets are applied per the plan document, not intuition. Rule of thumb: read the definition of disability and the offset clause before estimating any benefit.