Employee Notices and Communications

What Employee Notices and Communications are required by Health Care Reform?
The following notices may be required, depending on your factual circumstances and on whether your health plan is grandfathered or non-grandfathered.   If the Federal government has provided a Model Notice, it can be accessed at: http://www.dol.gov/ebsa/healthreform/

• Adult Children.  Dependent Coverage for Adult Children under age 26, and Enrollment Notice
  
• Patient Protections.  Elimination of Lifetime Limits, and Special Enrollment Notice for former participants who previously exceeded lifetime limits
  
• Grandfathered Status.  If the sponsor and/or carrier maintain grandfathered status of  the plan or policy, one of them must notify employees whenever they distribute other materials explaining plan benefits.
  
• Prior Notice of Rescission.  This applies if a plan or carrier intends to retroactively terminate coverage due to a participant's fraud or misrepresentation of a material fact.  Must provide 30 days prior notice  before terminating coverage retroactively

• Provider Choice:  Plans that use a network and require participants to designate their primary care provider (PCP) must notify participants of their right to choose a primary care provider and also to receive obstetrical or gynecological care (OB/GYN) without prior authorization. For calendar year plans, this notice must be provided no later than January 1, 2011 for the 2011 plan year. The notice must be included in the plan’s summary plan description (SPD) or provided as a separate notice with the SPD. The Dept. of Labor’s model notice is at: http://www.dol.gov/ebsa/patientprotectionmodelnotice.doc
  
• Claims Appeals:  When a plan denies a participant’s benefit claim, the claimant must be provided notices describing the plan’s internal and external appeals procedures. The Dept. of Labor has provided several model notices for claims and appeals:
  • Notice of adverse benefit determination 
  • Notice of final internal adverse benefit determination 
  • Notice of final external review decision

Future Disclosures and Communications required by HCR

The following notices will be required in years after 2011:

• Uniform Summary of Benefits.  Insurers and sponsors of self-funded plans must provide these as of the first day of the plan year beginning on or after March 23, 2012, which is within 24 months of the date of Health Care Reform's enactment.
  
• 60-day prior Notice of Plan changes.  This rule takes effect as of the first plan year beginning after March 23, 2012.
  
• Quality of Care Annual Report .   Group health plans and insurers will be required to submit a Quality of Care Report annually to the Secretary of HHS and to provide the Report to enrollees at open enrollment.  The Secretary of HHS is required to develop the reporting requirements no later than March 23, 2012, and it is expected that the regulations will specify the date by which plans must begin submitting the Annual Report to HHS.  Grandfathered plans are not required to submit this Annual Report.
  
• W-2 Reporting.  January 2013: Employers must report the value of health coverage on W-2s, effective for tax years beginning on January 1, 2012. Employers may voluntarily report such information in January 2012 for tax year 2011. This reporting is for informational purposes only; health benefits reported will not be included in taxable income.
  
• Notice of Insurance Exchange.  As of March 1, 2013, employers must provide notices to all employees regarding the new Insurance Exchanges which will be operational in 2014.   The Dept. of Labor will issue regulations implementing this requirement, but has not yet indicated whether it will provide a Model Notice.
  
• Certification of HCR Compliance.  2014: Group health plans and insurers will be required to file an annual report certifying their compliance with various HCR requirements, such as rules on eligibility, claims information, enrollment and disenrollment, premium payment.  Insured plans seeking certification as a “qualified health plan” (QHP) must comply with this filing requirement whether or not they are grandfathered, but plans that do not want QHP status are only required to meet the annual certification requirement if they are not grandfathered.