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July 12, 2010

HRB 9 - New Model Notices Issued

Released July 12, 2010I Download as a PDF

July 12, 2010 -- In response to several notice requirements contained in recently issued regulations implementing the new health reform law, the DOL’s Employee Benefit Security Administration (EBSA) issued four new model notices, as follows:

Extension of Dependent Coverage to Age 26

Dependents who age off a group health plan must be given a special enrollment opportunity of 30 days (see CBIZ Health Reform Bulletin:Health Reform’s Coverage for Dependent Children Explained).  The 30-day enrollment opportunity must be provided to:

  • Dependents who were not eligible when the parent first became covered under the plan;
  • Dependents who have lost eligibility; and
  • Dependents currently on COBRA, due to loss of eligibility.

Dependent children who become newly eligible by virtue of this law must be given a special enrollment opportunity to enroll in any of the benefit packages offered by the employer.

Notice Requirement. A written notice explaining the special enrollment opportunity, and the 30-day enrollment period, must be provided no later than the first day of the first plan year beginning on or after September 23, 2010. The notice must include a statement that children whose coverage ended, or who were denied coverage (or were not eligible for coverage), because the availability of dependent coverage of children ended before attainment of age 26 are eligible to enroll in the plan or coverage. The notice may be provided to an employee on behalf of the employee’s child. In addition, the notice may be included with other enrollment materials that a plan distributes to employees, provided the statement is prominent.  Enrollment must be effective as of the first day of the first plan year beginning on or after September 23, 2010. 

Model Notice:  Click here forModel Language for Notice of Opportunity to Enroll in connection with Extension of Dependent Coverage to Age 26

Lifetime Limits

Group health plans are required to provide written notice to individuals when the lifetime limit on the dollar value of all benefits is no longer applicable, and that an individual, if covered, is once again eligible for benefits under the plan.  For individuals whose coverage has dropped due to reaching the plan’s lifetime limit, a special enrollment opportunity must be made available (see CBIZ Health Reform Bulletin:Patient’s Bill of Rights).  

The affected individual must be allowed to enroll in any of the benefit packages offered by the employer, as long as he/she meets the eligibility criteria.  This enrollment period must be for a minimum of 30 days.

The individual must be given notice of the open enrollment opportunity; such notice may be included with other enrollment materials that a plan distributes to employees, provided the statement is prominent.  The notice and enrollment opportunity must be provided beginning no later than the first day of the first plan year beginning on or after September 23, 2010; coverage must take effect no later than the first day of the first plan year beginning on or after September 23, 2010.

Model Notice.  Click here forModel Language Notice: Lifetime Limit No Longer Applies and Enrollment Opportunity

Patient Protections: Choice of PCP and Access to OB/GYN Services

  • Choice of Health Care Provider.  The law requires that if a plan requires designation of a primary care provider (PCP), a participant must be allowed to designate a participating in-network PCP or pediatrician, who is available to accept him/her. 
  • Direct Access to OB/GYN Services.  Plans must provide direct access to OB/GYN providers, without prior authorization or a referral from the individual’s PCP.                  

Model Notice: Right to Designate Providers and Right of Access to OB/GYN Services.

The notice must be provided whenever the plan provides a participant with a summary plan description, or other similar description of benefits under the plan.  This notice must be provided no later than the first day of the first plan year beginning on or after September 23, 2010. Click here for model notice:  Patient Protection Model Notice

Background: CBIZ Health Reform Bulletin: Patient’s Bill of Rights

Grandfathered Health Plans

Grandfathered health plans must provide a notice to covered individuals, as a condition of maintaining grandfathered status, explaining what this means (seeCBIZ Health Reform Bulletin:  Grandfathered Health Plan Rules).  Such notice may be included in any plan materials provided to participants and beneficiaries, and must include the plan’s contact information for questions and complaints.

Model Notice:  Click here forModel Language – Grandfathered Health Plans

 

About the Author:  Karen R. McLeese is Vice President of Employee Benefit Regulatory Affairs for CBIZ Benefits & Insurance Services, Inc., a division of CBIZ, Inc.  She serves as in-house counsel, with particular emphasis on monitoring and interpreting state and federal employee benefits law.  Ms. McLeese is based in the CBIZ Leawood, Kansas office.

 

The information contained herein is not intended to be legal, accounting, or other professional advice, nor are these comments directed to specific situations. The information contained herein is provided as general guidance and may be affected by changes in law or regulation. This information is not intended to replace or substitute for accounting or other professional advice. You must consult your own attorney or tax advisor for assistance in specific situations.

This information is provided as-is, with no warranties of any kind. CBIZ shall not be liable for any damages whatsoever in connection with its use and assumes no obligation to inform the reader of any changes in laws or other factors that could affect the information contained herein.

As required by U.S. Treasury rules, we inform you that, unless expressly stated otherwise, any U.S. federal tax advice contained herein is not intended or written to be used, and cannot be used, by any person for the purpose of avoiding any penalties that may be imposed by the Internal Revenue Service.

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