With the 2020 calendar year fast approaching as Labor day has passed and Halloween decorations are starting to populate the store shelves, let us not forget to check in with our annual, mundane, yet required annual notice requirements.
This 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.
Most notices can be provided electronically to employees who have work-related access to the employer’s Intranet or to the Internet. This applies even if the employee is not able to print out a paper copy at the place where he or she has computer access, and even if the employee does not consent in writing to receive electronic disclosure of the documents. However, prior written consent is required for non-employees and for employees who do not have work-related access. Additionally, a print copy of the notices must be available at no charge on request.
Recommended & Mandated Participant Notices: All Plans, Annually or at Open Enrollment
|Notice or action item||Details||Applicable to||Provided by / Provided||Delivered by date (timing)|
|Uniform Summary of Benefits & Coverage (SBC) & Glossary of Terms Must use updated SBC template after April 2017!||Summary of covered benefits. 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; Also at initial enrollment, Within 7 business days after requested, Within 90 days after HIPAA special enrollment, If auto reenrollment at least 30 days before 1st of Plan Year.|
|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.|
|HIPAA Notice of Special Enrollment Rights||Tells all eligible employees what circumstances give rise to special midyear 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.|
|Medicare Part D Creditable or Non-Creditable Coverage Notice||Indicates whether the plan’s prescription drug coverage is creditable or noncreditable 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.
|CHIP Notice – Medicaid and Children’s Health Insurance Program||Informs employees about possible state financial assistance for health insurance coverage.||All plans, if participants reside in a state with CHIP financial assistance||Plan 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 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.|
Recommended & Mandated Participant Notices: All Plans, Various Distribution Times
|Notice or action item||Details||Applicable to||Provided by / Provided||Delivered by
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). 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:
|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 available||All employers||Employers/ Provide Notice to all employees (full-time & part-time, whether eligible for coverage or not). Can use Model Notice 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 & Mandated Participant Notices: Only for Plans that Meet Specific Criteria
|Notice or action item||Details||Applicable to||Provided by / Provided||Delivered by
|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 standards.||Plan administrator/Send to all plan participants.||Annually, at open enrollment; and Prior to or at offeringof Wellness Program.|
|Wellness Program 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 participate.||By 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 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).|
|Form 1095-C||Tells 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).|
|Form 1095-B||Tells individuals about the health coverage they were provided by their employer.||Small ERs who sponsored self-funded group health plans must provide 1095-B.||Small ER/ send to all EEs who participated in plan.||Annually, by January 31 (has information about prior calendar year).|
|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;|
|HIPAA/HITECHBreach 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/HITECHBreach 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 Exclusion||Explains the plan’s Pre-Ex limit provision and how prior creditable coverage can reduce the limitation period||Small insured plans that were allowed to renew as non- PPACAcompliant.||Most plans will no longer provide this notice because will no longer have preexisting condition exclusions after 2014 PY.||If must provide this Notice, do so at initial enrollment and open enrollment; also must be in SPD.|