It will soon be Open Enrollment season for many employers, so here is Leavitt’s annual List of Open Enrollment Notices and Action Items for Group Health Plans. First on the list are NEW notices and ones that require revisions due to recent guidance. 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 | Details | Applies To | Provided by/ Provided to | Delivered 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 complaint | All Plans | Insured plan: Carrier must send to all plan participants if employer does not get Protected Health Information (PHI).Self-funded plan: Employer or TPA must send to all plan participants | Alert! Must update for final HIPAA rule & post on website by Sept 23, 2013 or distribute by Nov 22! General distribution rules: At initial enrollment; & If relevant information changes; & Upon request; & Every 3 years must notify of right to request new Notice. |
| Notice of Coverage Options (Exchange Notice) | Tells employees that Health Insurance Exchanges/Marketplaces will become operative in 2014; that employees might be eligible for federal subsidies; info about employer coverage, if available | All Plans (By October 1, 2013) | Employers/Provide Notice to all employees (full-time & part-time, whether eligible for coverage or not) Can use Model Notices issued by DOL | By Oct 1, 2013; and thereafter at time of hire Can include (as a separate notice) with open enrollment materials in 2013, if these are provided before October 1. Also must give to non-eligible employees |
| Uniform Summary of Benefits & Coverage (SBC) & Glossary of Terms | 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 Self-insured plans: TPA or employer must prepare | 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 |
| Medicare 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 included with Open Enrollment materials before Oct 15, need not send again until next year |
| 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 |
Recommended and Mandated Participant Notices – Plans that Meet Specific Criteria
| Notice or Action Item | Details | Applicable To | Provided by/ Provided to | Delivered by Date (Timing) |
|---|---|---|---|---|
| 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(Not required after Dec. 2013) |
| 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 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) |
| 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; andPrior 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. |
| Self-certification of Religious Organization Status | Applies only to religious organizations that do not want to cover women’s contraceptive services | Religious employers and religiously-affiliated employers | Religious employer to insurers and/or TPA | Must self-certify and provide copy to insurer or TPA prior to beginning of plan year. This is not an annual requirement. |
| No Annual Dollar Limits on “Essential Health Benefits” (EHBs) | As of Jan 1, 2014, plans cannot impose an annual limit on “essential health benefits” | All plans | If your plan imposes an annual limit on EHBs, you must amend your plan to comply | No annual dollar limit as of January 1, 2014. In the prior plan or policy year, (beginning on or after September 23, 2012) the maximum annual limit was $2 million. |
| 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 of Waiver from Restrictions on Annual Limits Waivers expire at end of 2013! | Told participants or eligible employees that plan/policy received a waiver from HHS. | Only applied to plans that had applied for and received a waiver from HHS (These are usually “mini-med” plans) | Carrier or Plan Administrator/ Provide notice to all plan participants | WAS required annually, prior to open enrollment. Had to be in 14-point bold type.Waivers expire at end of 2013. |