United States: Employee Benefits Alert: New Health Plan Notices Required Under Health Care Reform

PPACA Notice

From Whom?

To Whom?

When?

How?

Dependent coverage until age 26—PPACA special enrollment notice—
see model notice at http://www.dol.gov/ebsa/.

Group health plans and health insurance issuers providing dependent coverage.

Employees eligible
to participate in
the plan.

Not later than
the first day of
the first plan year beginning on or after September 23, 2010.

ONE TIME notice.

May be included with other enrollment materials that a plan distributes, provided the statement is prominent.

Elimination of Lifetime Limits—PPACA special enrollment notice—see model notice at http://www.dol.gov/ebsa/.

Group health plans and health insurance issuers.

Individuals who reached a lifetime limit under a plan or health insurance coverage prior to the effective date and are otherwise still eligible under the plan or health insurance coverage.

Not later than
the first day of
the first plan year beginning on or after September 23, 2010.

ONE TIME notice.

May be included
with other enrollment materials that a plan distributes to employees, provided the statement is prominent.

Grandfathered plan statement—see
model statement at http://www.dol.gov/ebsa/.

See also distribution guidance in Employee Benefits Security Administration's (EBSA) FAQs About the Affordable Care Act Implementation, Part IV.

Grandfathered group health plans and health insurance issuers.

Statement must appear in any plan materials provided
to a participant
or beneficiary describing the benefits provided under the plan or health insurance coverage.

Notice requirement appeared in regulations which were effective
June 14, 2010. Include so long as
the plan wishes
to maintain grandfathering.

Language must be included whenever a summary of the benefits under the plan is provided to participants and beneficiaries.

Include in summary plan descriptions upon initial eligibility to receive benefits under the plan or coverage, during an open enrollment period, or upon other opportunities to enroll in, renew, or change coverage.

Also include in other communications in which disclosure of grandfather status would be appropriate and consistent with the goal of providing participants and beneficiaries the information necessary to understand and make informed choices regarding health coverage.

Patient protections—notice regarding right to select primary care providers—see model notice at http://www.dol.gov/ebsa/.

Non-grandfathered group health plans and health insurance issuers.

Plan participants.

According to model notice: no later than the first day of the first plan year beginning on or after September 23, 2010.

According to regulations: whenever the plan or issuer provides a participant with a summary plan description or other similar description of benefits.

The notice must be provided whenever the plan or issuer provides a participant with a summary plan description or other similar description of benefits under the plan or health insurance coverage.

Rescissions—
PPACA advance
notice requirement.

Group health plan or a health insurance issuer offering group or individual health insurance coverage.

To each participant who would be affected by
the rescission.

At least 30 calendar days advance notice to an individual before coverage may be rescinded.

No further
information as of
the date of this Alert.

Claims Procedures—
new PPACA rules enhance existing Employee Retirement Income Security Act (ERISA) claims requirements.

Non-grandfathered group health plans and health insurance issuers.

Participants and beneficiaries.

New rules are effective for
non-grandfathered plans for plan years beginning on or after September 23, 2010. However, the Department of Labor (DOL) has indicated that an enforcement grace period is
in effect until
July 1, 2011.

Key enhancements:

Urgent care claims must now be decided in writing within
24 hours (formerly,
72 hours).

External review must now be provided through Independent Review Organization (IRO). If external review is requested:

• Initial written response required within five days
  of request.
• IRO response required within 45 days (72 hours if expedited review requested).

Notices of available internal claims and appeals and external review processes must be provided in a culturally and linguistically appropriate manner.

W-2 Form—aggregate cost of major medical coverage must be included on W-2.

W-2 issuers.

Employees
receiving W-2.

Generally effective for the 2012 W-2
(i.e. the W-2 issued
in 2013). However,
if any employee terminates in 2012 and requests a W-2, the aggregate cost
of coverage must
be included.

No further
information as of
the date of this Alert.

PPACA uniform summary of coverage.

A health insurance issuer (including a group health plan that is not a self-insured plan) offering health insurance coverage within the United States; or in the case of a self-insured group health plan, the plan sponsor or plan administrator.

Enrollees.

No later than
March 23, 2012.

60 days prior to any material modification in benefits.

Model disclosures
to be developed; no further information
as of the date of
this Alert.