Employers that sponsor group health plans should provide certain benefit notices in connection with their plans’ open enrollment periods. Some of these notices must be provided at open enrollment time, such as the summary of benefits and coverage (SBC).
Other notices, such as the Women’s Health and Cancer Rights Act (WHCRA) notice, must be distributed annually. Although these annual notices may be provided at different times throughout the year, employers often choose to include them in their open enrollment materials for administrative convenience. Some notices are provided by the Health Insurance Issuer (Carrier) or must be provided by the Group.
Employers should review their open enrollment materials to confirm that they accurately reflect the terms and cost of coverage. In general, any plan design changes for 2019 should be communicated to plan participants either through an updated summary plan description (SPD) or a summary of material modifications (SMM).
Open enrollment notices
- Employers should provide certain benefit notices to their employees at open enrollment time.
- Some benefit notices apply to all group health plans
- Other benefit notices only apply to certain group health plans, based on plan design and coverage
- Medicare Part D Notice
- HIPAA Privacy Notice
- WHCRA Notice
- CHIP Notice
- SPD (and SMM, if applicable)
- Notice of Patient Protections
- Wellness Program Notices
Here’s a list of notices and where you can obtain sample notices.
SBC – Summary of Benefits and Coverage. This notice applies to Group Health Plans and Health Insurance Issuers.
- Group health plans and health insurance issuers are required to provide an SBC to applicants and enrollees each year at open enrollment or renewal time. Federal agencies have provided a template for the SBC, which health plans and issuers are required to use.The issuer for fully insured plans usually prepares the SBC. If the issuer prepares the SBC, an employer is not also required to prepare an SBC for the health plan, although the employer may need to distribute the SBC prepared by the issuer.
Medicare Part D Notice of Creditable or Non-Creditable Coverage. This notice applies to all group that include Prescription Drug Coverage as part of their medical plan.
- Employers must notify Medicare Part D eligible individuals before Oct. 15 each year about whether the drug coverage is at least as good at the Medicare Part D coverage (in other words, whether the prescription drug coverage is “creditable” or “non-creditable”).Because employers may not be able to identify which individuals are eligible for Medicare Part D, they often provide the Medicare Part D disclosure to all plan participants. Employers will satisfy the timing requirements for this notice if it is provided to all plan participants annually, prior to Oct. 15 of each year.CMS has provided model notices for employers to use.
WHCRA Notice – Women’s Health and Cancer Rights Notice. This notice applies to all groups plans where benefits are provided for medical and surgical mastectomies. Basically – all plans.
- Group health plans must provide a notice about the WHCRA’s coverage requirements at the time of enrollment and on an annual basis after enrollment. The annual WHCRA notice can be provided at any time during the year. Employers often include the annual notice with their open enrollment materials. Employers that redistribute their SPDs each year can satisfy the annual notice requirement by including the WHCRA notice in their SPDs. Model language is available in the DOL’s compliance assistance guide.
CHIP Notice – Childrens Health Insurance Protection Notice. This notice must be provided by group health plans that cover residents in a state that provides a premium assistance subsidy under a Medicaid plan or CHIP.
- If an employer’s group health plan covers residents in a state that provides a premium subsidy under a Medicaid plan or CHIP, the employer must send an annual notice about the available assistance to all employees residing in that state. The DOL has a model notice that employers may use.
- The annual CHIP notice can be provided at any time during the year. Employers often provide the CHIP notice with their open enrollment materials.
SPD – Summary Plan Description. This notice applies to all groups who are subject to ERISA. Generally, Governmental Entities and certain church groups are exempt from ERISA and this applies to everyone else.
- An SPD must be provided to new health plan participants within 90 days of when their plan coverage begins. Employers may include the SPD in their open enrollment materials to make sure employees who newly enroll receive the SPD on a timely basis. Also, an employer should include the SPD with its enrollment materials if it includes notices that are required to be provided at the time of enrollment, such as the WHCRA notice.In addition, an updated SPD must be provided to participants at least every five years, if material modifications have been made during that period. If no material modifications have been made, an updated SPD must be provided at least every 10 years.
COBRA General Notice. This applies to all groups subject to COBRA. Generally speaking, this is any employee with more than 20 or more employees.
- Group health plans must provide a written General Notice of COBRA rights to covered employees within 90 days after their health plan coverage begins. Employers may include the General Notice in their open enrollment materials to ensure that employees who newly enroll during open enrollment receive the notice on a timely basis.The DOL has a COBRA Model General Notice that can be used by group health plans to meet their notice obligations.
Grandfathered Plan Notice. If you have a plan that is grandfathered, you must provide this notice.
- To maintain a plan’s grandfathered status, the plan sponsor or must include a statement of the plan’s grandfathered status in plan materials provided to participants describing the plan’s benefits (such as the SPD, insurance certificate and open enrollment materials). The DOL has provided a model notice for grandfathered plans.
Notice of Patient Protections. This notice must be provided by Non-grandfathered group health plans that require designation of a participating primary care provider
- If a non-grandfathered plan requires participants to designate a participating primary care provider, the plan or issuer must provide a notice of patient protections whenever the SPD or similar description of benefits is provided to a participant. This notice is often included in the SPD or insurance certificate provided by the issuer (or otherwise provided with enrollment materials).The DOL provided a model notice of patient protections for plans and issuers to use.
HIPAA Privacy Notice – This notice applies to all self insurance group health plans.
- The HIPAA Privacy Rule requires self-insured health plans to maintain and provide their own privacy notices. Special rules, however, apply for fully insured plans. Under these rules, the health insurance issuer, and not the health plan itself, is primarily responsible for the privacy notice.Self-insured health plans are required to send the privacy notice at certain times, including to new enrollees at the time of enrollment. Thus, the privacy notice should be provided with the plan’s open enrollment materials. Also, at least once every three years, health plans must either redistribute the privacy notice or notify participants that the privacy notice is available and explain how to obtain a copy.The Department of Health and Human Services has model privacy notices for health plans to choose from
HIPAA Special Enrollment Notice. This applies to all group health plans.
- At or prior to the time of enrollment, a group health plan must provide each eligible employee with a notice of his or her special enrollment rights under HIPAA. This notice should be included with the plan’s enrollment materials. It is often included in the health plan’s SPD or insurance booklet.
Wellness Notice – HIPAA – This applies to groups with health plans that require a health or wellness component to receive a reward or discount on health plan cost.
- Employers with health-contingent wellness programs must provide a notice that informs employees that there is an alternative way to qualify for the program’s reward. This notice must be included in all plan materials that describe the terms of the wellness program. If wellness program materials are being distributed at open enrollment (or renewal time), this notice should be included with those materials. Sample language is available in the DOL’s compliance assistance guide.
Wellness Notice – ADA – This notice applies to wellness programs that collect health information.
- To comply with the Americans with Disabilities Act (ADA), wellness plans that collect health information or involve medical exams must provide a notice to employees that explains how the information will be used, collected and kept confidential. Employees must receive this notice before providing any health information and with enough time to decide whether to participate in the program. Employers that are implementing a wellness program for the upcoming plan year should include this notice in their open enrollment materials. The Equal Employment Opportunity Commission has provided a sample notice for employers to use.
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