Open enrollment is right around the corner, and now is the time to start gearing up for this crucial season. For employers who sponsor group health plans, the to-do list is long, and one of those to-dos is providing certain benefits notices to employees.

As you develop your open enrollment communications plan, reference this checklist to keep track of required and relevant notices that must be incorporated.

Summary of Benefits and Coverage (SBC)

The ACA requires health plans and health insurance issuers to provide a Summary of Benefits and Coverage (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. To comply with the SBC requirements, employers should include an updated SBC with open enrollment materials.

Medicare Part D Notices

Group health plan sponsors must provide a notice of creditable or non-creditable prescription drug coverage to Medicare Part D-eligible individuals covered by, or who apply for, prescription drug coverage under the health plan. This creditable coverage notice alerts individuals whether their prescription drug coverage is at least as good as the Medicare Part D coverage.

This notice generally must be provided at various times, including when an individual enrolls in the plan and each year before October 15 (when the Medicare annual open enrollment period begins).

Annual CHIP Notices

Group health plans covering residents in a state that provides a premium subsidy to low-income children and their families to help pay for employer-sponsored coverage must send an annual CHIP notice regarding the available assistance to all employees residing in that state. Employers should confirm they are using the most recent model notice, as the DOL updates it regularly.

Summary Plan Description

Plan administrators must provide an SPD to new participants within 90 days after plan coverage begins. Any changes made to the plan should be reflected in an updated SPD booklet or described to participants through a Summary of Material Modifications (SMM). Also, an updated SPD must be furnished every five years if changes are made to SPD information or the plan is amended. Otherwise, a new SPD must be provided every 10 years.

Initial COBRA Notices

COBRA applies to employers with 20 or more employees who sponsor group health plans. Group health plan administrators must provide an initial COBRA notice to new participants and certain dependents within 90 days after plan coverage begins. The initial COBRA notice can be incorporated into the plan’s Summary Plan Description (SPD), but it is important to note that including the initial COBRA notice in the SPD alone is insufficient, as this notice must be given to all qualified beneficiaries and the SPD is only required to be given to plan participants.

If you choose to incorporate the initial COBRA notice in the plan’s SPD, ensure that the notice is also mailed to plan participants’ home address and addressed to all qualified beneficiaries.

Notices of Patient Protections

Under the ACA, group health plans and issuers that require the designation of a participating primary care provider must permit each participant, beneficiary and enrollee to designate any available participating primary care provider, including a pediatrician for children.

Additionally, plans and issuers that provide obstetrical/gynecological care and require a designation of a participating primary care provider may not require preauthorization or referral for such care. If a health plan requires participants to designate a participating primary care provider, the plan or issuer must provide a notice of these patient protections whenever the SPD or similar description of benefits is provided to a participant.

While this is not an annual notice requirement, it is necessary to include the information in the SPD or related benefits description.

Grandfathered Plan Notices

If an employer has a grandfathered plan, they should make sure to include information about the plan’s grandfathered status in plan materials describing the coverage under the plan, such as SPDs and open enrollment materials.

Notices of HIPAA Special Enrollment Rights

At or before the time of enrollment, an employer’s group health plan must provide each eligible employee with a notice of their special enrollment rights under HIPAA. This notice may be included in the plan’s SPD.

HIPAA Privacy Notices

The HIPAA Privacy Rule requires covered entities, including group health plans and issuers, to provide a Notice of Privacy Practices (or Privacy Notice) to each individual who is the subject of protected health information (PHI). Health plans are required to send the Privacy Notice at certain times, including to new enrollees at the time of enrollment. 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.

Self-insured health plans must maintain and provide their own Privacy Notices. However, special rules apply for fully insured plans, where the health insurance issuer, not the plan itself, is primarily responsible for the Privacy Notice.

Special Rules for Fully Insured Plans

The sponsor of a fully insured health plan has limited responsibilities with respect to the Privacy Notice, including the following:

• If the sponsor of a fully insured plan has access to PHI for plan administrative functions, they are required to maintain a Privacy Notice and provide the notice upon request; and  
• If the sponsor of a fully insured plan does not have access to PHI for plan administrative functions, they are not required to maintain or provide a Privacy Notice.  

A plan sponsor’s access to enrollment information, summary health information and PHI that is released pursuant to a HIPAA authorization does not qualify as having access to PHI for plan administration purposes.

Women’s Health and Cancer Rights Act (WHCRA) Notices

Plans and issuers must provide a notice of participants’ rights to mastectomy-related benefits under the WHCRA at the time of enrollment and on an annual basis.

Summary Annual Reports

Plan administrators required to file Form 5500 must provide participants with a narrative summary of the information in Form 5500, called a summary annual report (SAR). Group health plans that are unfunded (that is, benefits are payable from the employer’s general assets and not through an insurance policy or trust) are not subject to the SAR requirement.

The plan administrator generally must provide the SAR within nine months of the close of the plan year. If an extension of time to file Form 5500 is obtained, the plan administrator must furnish the SAR within two months after the close of the extension period.

Wellness Program Notices

Group health plans that include wellness programs may be required to provide certain notices regarding the program’s design. As a general rule, these notices should be provided when the wellness program is communicated to employees and before employees provide any health-related information or undergo medical examinations. These notices are required in the following situations:

• HIPAA Wellness Program Notice — HIPAA imposes a notice requirement on health-contingent wellness programs offered under group health plans. Health-contingent wellness plans require individuals to satisfy standards related to health factors (e.g., not smoking) to obtain rewards. The notice must disclose the availability of a reasonable alternative standard to qualify for the reward (and, if applicable, the possibility of waiver of the otherwise applicable standard) in all plan materials describing the terms of a health-contingent wellness program.  
• Americans with Disabilities Act (ADA) Wellness Program Notice — Employers with 15 or more employees are subject to the ADA. Wellness programs that include health-related questions or medical exams must comply with the ADA’s requirements, including an employee notice requirement. Employers must give participating employees a notice that tells them what information will be collected as part of the wellness program, with whom it will be shared and for what purpose. This notice should also include the limits on disclosure and how information will be kept confidential.  

Individual Coverage Health Reimbursement Arrangement (ICHRA) Notices

Employers may use individual coverage health reimbursement arrangements (ICHRAs) to reimburse their eligible employees for insurance policies purchased in the individual market or for Medicare premiums. Employers with ICHRAs must provide a notice to eligible participants about the ICHRA and its interaction with the ACA’s premium tax credit.

In general, this notice must be provided at least 90 days before the beginning of each plan year. Employers may provide this notice at open enrollment time if it is at least 90 days prior to the beginning of the plan year. A model notice is available for employers to use to satisfy this notice requirement.

Connect with CBIZ’s Regulatory & Compliance Specialists for Tailored Guidance

Our team of regulatory and compliance experts at CBIZ is focused on reviewing and interpreting state and federal mandates that may impact your employee benefit plans. Using our knowledge and awareness of laws, court decisions, administrative rulings and pronouncements, we work hand-in-hand with employee benefits consultants to help identify and resolve complex compliance issues. Click here to learn more.