Benefits Compliance


It’s Open Enrollment season for many employers, so here’s 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.


Notice or Action Item 


Applicable To 

Provided by/ 

Provided to 

Delivered  by Date (Timing) 

Recommended and Mandated Participant Notices – ALL Plans 

Uniform Summary of Benefits & Coverage (SBC) 

Summary 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 plans 

Plan 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 

With Open Enrollment materials as of first open enrollment beginning on or after Sept. 23, 2012; 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 PY 

Women’s Health and Cancer Rights Act 

Informs participants about benefits covering mastectomies and related services  and how to get detailed information on available benefits 

All plans 

Plan Administrator (can be delegated to the carrier)/ 

Send to all plan participants 

Annually & upon initial enrollment/ 

Usually sent at Open Enrollment 

CHIP Notice – Medicaid and Children’s Health Insurance Program 

Informs employees about possible state financial assistance for health insurance coverage. 

All plans 

Plan sponsor/ 

Send to all eligible employees who reside in a state with CHIP financial assistance 

Annually, before beginning of plan year/ 

Recommend to include with Open Enrollment materials; 

And upon initial eligibility 

Part D
Creditable or Non-Creditable Coverage Notice

Indicates whether the plan’s prescription drug coverage is creditable  or non-creditable with Medicare prescription drug coverage. 

All plans 

Plan sponsor is only required to send to all Medicare-eligible participants (including COBRA participants and eligible dependents), but usually just sends to all participants 

Annually, must send before October 15 (regardless of plan year) 

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

Notice or Action Item 


Applicable To 

Provided by/ 

Provided to 

Delivered  by Date (Timing) 

Newborns’ and Mothers’ Health Protection Act 

Explains federal and state hospitalization time provisions for newborns and mothers 

All plans 

Must 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 

HIPAA Notice of Special Enrollment Rights 

Tells all eligible employees what circumstances give rise to special mid-year enrollment rights (even if they do not enroll) 

All plans 

Plan Administrator (Sponsor), can be delegated to Carrier/ Send or give to eligible employees 

Initial Eligibility and each Open Enrollment; and also must be in SPD 

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 complaint 

All plans 

Insured plan: Carrier must send to all plan participants if employer does not get PHI.Self-funded plan: Employer or TPA must send to all plan participants

At initial enrollment;
If relevant information changes;
Upon request; &

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

Notice of Health Insurance Exchanges 

Tells employees that Health Insurance Exchanges will become operative in 2014, that employees might be eligible for federal subsidies, other info 

All plans
(Beginning in 2013)

Provide Notice to all employees
(HHS is expected to issue Model Exchange Notices, but has not as of Oct. 29, 2012)

By March 1, 2013; and thereafter at time of hire 

Recommended and Mandated Participant Notices    Plans that Meet Specific Criteria 

General Notice of Pre-existing Condition Exclusion 

Explains the plan’s Pre-Ex limit provision and how prior creditable coverage can reduce the limitation period 

Plans that have Pre-existing Conditions Exclusions 

Carrier or Plan Administrator/
Provide to all eligible employees
If no notice, Plan cannot impose pre-ex limitation

At initial enrollment and open enrollment; also must be in SPD 

Patient Protection “Provider Choice” Disclosure 

Tells 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 facilities 

Carrier or Plan/
Send or give notice to all participants

Annually, with carrier’s Certificate of Coverage; and upon initial enrollment, and whenever Plan sponsor provides SPD; 

Summary Annual Report 

Summary of benefits under the plan and total amount paid by plan 

Large plans100+ 

(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) 

Notice or Action Item 


Applicable To 

Provided by/ 

Provided to 

Delivered  by Date (Timing) 

Wellness Program 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 standards 

Plan administrator/
Send to all plan participants 

Annually, at open enrollment;  and 

Prior to or at offering of Wellness Program 

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 days
Plans that had a breach of PHI during the past 60 days
Plan 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.
Annual Limits on “Essential Benefits”
For 2013 calendar year, plan cannot impose an annual limit on “essential benefits” of less than $2 million 

All plans 

If your plan imposes an annual limit of less than $2 million, you must amend your plan to comply 

The $2  million limit applies for plan or policy years beginning on or after September 23, 2012 and before December 31, 2013. 

Loss of Grandfathered (GF) Status
Examples of actions that will cause loss of GF  status include:
-Any increase in employee co-insurance rate,
-Decrease in ER contribution rate by > 5 percentage points below rate on 3/23/10

Group health plans that have been grandfathered but will lose grandfather status in 2013 

Amend your plan to comply with requirements on non-grandfathered plans and comply in operation, if your plan will lose grandfathered status 

Any required amendments should be made prior to beginning of plan year (but plan must comply even if not yet formally amended) 

Notice or Action Item 


Applicable To 

Provided by/ 

Provided to 

Delivered  by Date (Timing) 

Notice of Waiver from Restrictions on Annual Limits 

Tells participants or eligible employees that plan/policy received a waiver from HHS. (Must get written permission from CCIIO to use language different from Model Notice) 

Only applies to plans that have applied for and received a waiver from HHS (These are usually “mini-med” plans) 

Carrier or Plan Administrator/
Provide notice to all plan participants

Annually, prior to open enrollment. Must be in 14-point bold type.