Employee Benefits Compliance

2017 List of Notices for Group Health Plans

group health plan

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Here is Leavitt’s annual List of Open Enrollment Notices and Action Items for Group Health Plans. If you are a Leavitt client, you can contact your Leavitt Advisor for an electronic copy of sample Open Enrollment Notices you can customize. If your health benefits are insured, your carrier may have sent many of these notices or included them in Open Enrollment materials or in the Evidence of Coverage Booklet, and your carrier should have amended its policies to make required changes.  Confirm with your carrier that these actions were taken. The employer does not have to re-send notices if the carrier has already sent them.

Recommended and Mandated Participant Notices – ALL Plans

Notice or Action Item DetailsApplicable ToProvided by / Provided toDelivered by Date (Timing)
Uniform Summary of Benefits & Coverage (SBC) & Glossary of TermsSummary of covered benefits, and it also provides examples of how plan will pay benefits in specific circumstances. Glossary is of common health plan terms.All plansPlan sponsor or carrier/ Provides to all participants and eligible employees

Most carriers are preparing SBCs but requiring plan sponsors to actually provide them to participants

Self-insured plans: TPA or employer must prepare

With Open Enrollment materials;  Also at initial enrollment,

Within 7 business days after requested,

Within 90 days after HIPAA special enrollment, If auto re-enrollment at least 30 days before 1st of Plan Year

Women’s Health and Cancer Rights ActInforms participants about benefits covering mastectomies and related services and how to get detailed information on available benefitsAll plansPlan Administrator (can be delegated to the carrier)/

Send to all plan participants

Annually & upon initial enrollment/

Usually sent at Open Enrollment

HIPAA Notice of Special Enrollment RightsTells all eligible employees what circumstances give rise to special mid-year enrollment rights (even if they do not enroll)All plansPlan Administrator (Sponsor), can be delegated to Carrier/ Send or give to eligible employeesInitial Eligibility and each Open Enrollment; and also must be in SPD
Medicare Part D Creditable or Non-Creditable Coverage NoticeIndicates whether the plan’s prescription drug coverage is creditable or non-creditable with Medicare prescription drug coverage.All plansPlan sponsor is only required to send to all Medicare-eligible participants (including COBRA participants and eligible dependents), but usually just sends to all participantsAnnually, must send before October 15 (regardless of plan year)

If included with Open Enrollment materials before Oct 15, need not send again until next year

CHIP Notice – Medicaid and Children’s Health Insurance ProgramInforms employees about possible state financial assistance for health insurance coverage.All plans, if participants reside in a state with CHIP financial assistancePlan sponsor/

Send to all eligible employees in states listed on the CHIP Notice. Note that California no longer is.

Annually, before beginning of plan year/

Recommend to include with Open Enrollment materials;

And upon initial eligibility

Newborns’ and Mothers’ Health Protection ActExplains federal and state hospitalization time provisions for newborns and mothersAll plansMust be in SPD/

Often sent by Plan Administrator or carrier/ Send to all plan participants

Must include in SPD/

May want to send annually with Open Enrollment materials


Required Notices—All Plans, but Not Required Annually or at Open Enrollment

Notice or Action Item DetailsApplicable ToProvided by / Provided toDelivered by Date (Timing)
HIPAA Privacy Notice

(Carrier’s Notice, or self-insured Plan’s Notice,  or Employer’s Notice for plan overall)

Tells plan participants about their HIPAA Privacy rights, the plan’s Privacy obligations, and the contact information for the Privacy Official if a participant wants to file a complaintAll plansInsured plan: Carrier must send to all plan participants if employer does not get Protected Health Information (PHI).

-If employer does get PHI it must also have its own separate Privacy Notice Self-funded plan: Employer or TPA must send to all plan participants

General distribution rules:

·   At initial enrollment; &

·   If relevant information changes; &

·   Upon request; &

·   Every 3 years must notify of right to request new Notice.

Exchange Notice

(Notice of Coverage Options)

Tells employees about Health Insurance Exchanges/Marketplace; that employees might be eligible for federal subsidies;  info about employer coverage, if availableAll employersEmployers/ Provide Notice to all employees (full-time & part-time, whether eligible for coverage or not)

Can use Model Notices issued by DOL

Within 14 days of date of hire, must give to all employees.

Can also include with open enrollment materials and when an employee terminates


Recommended and Mandated Participant Notices – Plans that Meet Specific Criteria

Notice or Action ItemDetailsApplicable ToProvided by / Provided toDelivered by Date (Timing)
Wellness Program HIPAA disclosures
Applies only for certain types of  Wellness Programs
Tells eligible individuals they can satisfy an alternate standard if they are medically unable to meet Wellness Program’s standard that is related to a health factor.Wellness programs with a reward or penalty that affects employee’s cost for coverage under the GHP & requires achievement of performance standardsPlan administrator/

Send to all plan participants

Annually, at open enrollment;   and

Prior to or at offering of Wellness Program

Wellness Program

New EEOC Notice

Tells individuals what information will be collected, how it will be used, who will receive it, and how it will be kept confidential.Wellness programs that collect EE health information (e.g., Health Risk Assessments) [or require medical exams or lab tests?]ERs subject to the Americans with Disabilities Act (ADA) (ERs with at least 15 EEs)/ Send to all employees eligible to participateBy first day of 2017 plan year. Thereafter, participants must receive it (annually) before providing any health information, and with enough time to decide whether to participate in the program.
Summary Annual ReportSummary of benefits under the plan and total amount paid by planLarge plans 100+

(All plans that file Form 5500)

Plan administrator/

Send to all participants.

(Within 60 days after Form 5500 was filed)

Annually, within 60 days after filing of Form 5500 (or 9 months after end of Plan Year)
Form 1095-CTells individuals about the health coverage they were offered by their employer, or if they were not offered coverage.“Applicable Large Employers” (ALES) –ERs who had at least 50 FT EEs or FTEs in the prior calendar year.Employer/

Send to all individuals who were FT EEs in at least one month of the prior calendar year, whether or not ER offered health benefits

Annually, by January 31 (has information about prior calendar year)


Mandated Participant Notices – Plans that Meet Specific Criteria

Notice or Action ItemDetailsApplicable ToProvided by/ Provided toDelivered by Date (Timing)
Patient Protection “Provider Choice” DisclosureTells participants they can designate a pediatrician as primary care provider (PCP) and that no referral is required to see an OB-Gyn provider.NON-grandfathered plans with PCP selection requirement and/or network providers and facilitiesCarrier or Plan/ Send or give notice to all participantsAnnually, with carrier’s Certificate of Coverage; and upon initial enrollment, and whenever Plan sponsor provides SPD;
HIPAA/HITECH Breach Notice (if breach involved more than 500 individuals)Notifies affected participants and Health and Human Services (HHS) that there was a breach of Protected Health Information (PHI) during the prior 60 daysPlans that had a breach of PHI during the past 60 daysPlan sponsor/

Must provide notice to Affected Plan participants (directly) and HHS (on HHS website)

Without unreasonable delay & not more than 60 days after discovery of breach
HIPAA/HITECH Breach Notice (if breach involved 500 or fewer individuals)Notifies affected participants & Health and Human Services (HHS) that there was a breach of Protected Health Information (PHI)Plans that had a breach of PHI (During the past plan year for notice to HHS; During past 60 days for notice to participants)Plan sponsor/

Must provide notice to Affected Plan participants (directly)

And HHS (on HHS website)

Notice to HHS: Within 60 days after end of plan year. Notice to affected participants: without unreasonable delay & not more than 60 days after discovery of breach.
General Notice of Pre-existing Condition ExclusionExplains the plan’s Pre-Ex limit provision and how prior creditable coverage can reduce the limitation periodSmall insured plans that were allowed to renew as non-PPACA-compliantMost plans will no longer provide this notice because will no longer have pre-existing condition exclusions after 2014 PYIf must provide this Notice, do so at initial enrollment and open enrollment; also must be in SPD