Required Notices for Group Health Plans: A Checklist
This article comes from our Summer 2011 Water Cooler Newsletter
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Most group health plans are required under applicable federal law to supply certain notices to plan participants. These notices are required to be delivered in person, mailed via first class mail, or delivered by electronic media in accordance with the guidelines established by the Internal Revenue Service and Department of Labor. The following is a checklist of the required notices:
- COBRA Notices: (i) Initial Notice: Must be distributed when group health-plan coverage begins. (ii) Qualifying Event Notice: Must be provided to COBRA Qualified Beneficiary generally within 44 days after the date on which the qualifying event occurred, or if later, the date of loss of coverage. (iii) Notice of Unavailability: Must be provided within 14 days of notice of qualifying event. (iv) Notice of Early Termination of COBRA Coverage: Must be provided as soon as practicable after decision to terminate coverage. (v) Notice of Conversion Rights: If applicable, must be provided within 180 days of the expiration of the maximum COBRA coverage period.
- Certificate of Creditable Coverage: Must be provided automatically upon losing group health-plan coverage, becoming eligible for COBRA coverage and when COBRA coverage ceases. An individual may also request a Certificate of Creditable Coverage free of charge anytime prior to losing coverage and within 24 months of losing coverage.
- General Notice of Preexisting Condition Exclusion: This is a notice describing the group health plan's preexisting condition exclusion and how prior creditable coverage can reduce the preexisting condition period. The notice must be provided as part of any written application materials distribute for enrollment.
- Individual Notice of Period of Preexisting Condition Exclusion: Notice that a specific preexisting condition exclusion period applies to an individual upon consideration of creditable coverage evidence and an explanation of appeal procedures to be followed if the individual disputes the plan's determination. Must be provided to individual as soon as possible following the determination of creditable coverage.
- Wellness Program Disclosure: Notice given by any group health plan offering a wellness program that requires individuals to meet a standard related to a health factor in order to obtain a reward. The notice must disclose the availability of a reasonable alternative standard. Must be provided in all plan materials that describe the terms of the wellness program.
- HIPAA Special Enrollment Notice: Notice describing the group health plan's special enrollment rights including the right to special enroll within 30 days of the loss of other coverage, or as a result of marriage, birth of a child, adoption or placement for adoption. Must be provided at or before the time an employee is initially offered the opportunity to enroll in the group health plan.
- Women's Health and Cancer Rights Act Notice: Notice describing required benefits for mastectomy-related reconstructive surgery, prostheses and treatment of physical complications of mastectomy. Notice must be furnished annually and upon enrollment.
- Summary of Material Reduction in Covered Services or Benefits: Describes material reductions in covered services or benefits. Must be provided within 60 days of adoption of material reduction in group health-plan services or benefits.
- Medicare Part D Notice: This notice provides participants with information as to whether the prescription drug coverage under the employer's group health plan is credible with Medicare Part D. This notice must be provided in five circumstances, but will be deemed to satisfy these five circumstances if it is provided annually and upon hire.
- CHIPRA Notice: This notice is required to be provided annually by employers that maintain a group health plan in a state that provides premium assistance under Medicaid or CHIP. Required to be sent before the beginning of each plan year.
- Grandfathered Status*: If a group health plan is taking the position that it is grandfathered, the group health plan must include the model notice language on all materials pertaining to the group health plan.
- Lifetime Limit*: Individuals who lost coverage under the group health plan due to meeting the annual limit of benefit set forth in the plan were to be provided a notice as part of their open enrollment rights. Must be provided by the first day of the first plan year beginning on or after September 23, 2010.
- Dependent Age 26*: Dependents who lost coverage under a group health plan due to meeting the age restrictions were to be provided a notice as part of their open enrollment rights. Must be provided by the first day of the first plan year beginning on or after September 23, 2010.
- Summary of Material Modifications to SPD: Must provide employees with 60-day prior notice of material changes to group health plan.
- Notice of Cancellation of Coverage*: Individuals must be provided with prior notice of cancellation of coverage.
- Notice of Patient Protection Provisions*: If the group health plan is not grandfathered and offered previously restricted patient protections, participants must be provided with notice of the right to choose a primary care provider or pediatrician, and notified of the right to obtain obstetrical or gynecological care without prior authorization.
- External Review Notice*: If the group health plan is not grandfathered, you must provide participants with a description of the new external review process.
- Internal Adverse Benefit Determination Notice*: If the group health plan is not grandfathered, notice must be provided at both the initial claim and appeal level. This notice adds new detail to the explanation of benefits already required under DOL claims procedures.
- Preliminary Review Notice for External Review*: If the group health plan is not grandfathered, you must provide notice to participants filing an external review claim that states whether the participant is eligible for external review.
- Notice of Final External Review Decision*: If the group health plan is not grandfathered, an external review organization must provide notice describing the outcome of any external review.
- HIPAA Privacy Practices Statement: This notice is required to be provided every three years.
*Denotes a notice required by Health Care Reform.