It’s that time of year again, when fall weather brings with it a host of legal obligations for plan sponsors running open enrollment. Here’s what you need to know to survive the season.
Summary Of Benefits And Coverage
The Patient Protection and Affordable Care Act (ACA) requires plan sponsors to provide a summary of benefits to all applicants and enrollees before enrollment or reenrollment. The idea behind the requirement is to allow employees to easily compare plans offered by their employer to those offered by a spouse’s employer or in the ACA marketplace. For this reason, there is a prescribed format for the notice that must be carefully followed. An SBC template is available on the DOL and HHS websites.
The Women’s Health and Cancer Rights Act (WHCRA) requires group health plans to provide two separate notices, including written notice upon enrollment of required coverage.
The statute prescribes the language that must be used, including that coverage for a participant who undergoes a mastectomy will be provided, in consultation with the attending physician, for 1) all stages of reconstruction of the breast on which the mastectomy was performed; 2) surgery and reconstruction of the other breast to produce a symmetrical appearance; 3) prostheses; and 4) treatment of physical complications of the mastectomy, including lymphedemas. The notice must also describe any cost-sharing provisions applicable to such coverage.
The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) extends and expands the State Children's Health Insurance Program, and provides for matching federal funds to states for certain families with children who do not qualify for Medicaid.
The statute provides for special enrollment rights for families that become eligible or lose eligibility for the program, and requires plan sponsors to provide notice of these rights on an annual basis. A model notice, which is updated each year by the government, can be found on the DOL website.
HIPAA Notice Of Special Enrollment Rights
The Health Insurance Portability and Accountability Act (HIPAA) requires group health plans to distribute a notice of special enrollment rights at open enrollment. The final regulations include model language that can be used to satisfy the notice requirement.
Notice Of Grandfathered Status
The ACA requires plans intending to maintain grandfathered status to provide a statement that the plan or coverage is believed to be a grandfathered plan and contact information for questions or complaints. This notice must be included in all plan materials describing benefits, including open enrollment packets.
HIPAA Notice Of Privacy Practices
Employers with self-insured plans, or plans otherwise subject to the privacy and security provisions of HIPAA must distribute a Notice of Privacy Practices at open enrollment and provide the notice online if the plan maintains a website for participants to review information about the plan.
Summary Plan Description
The Employee Retirement Income Security Act (ERISA) requires plans subject to the act to maintain a summary of the major provisions of an employee benefit plan written in language that is easy for the average participant to understand. Although there is no requirement for the SPD to be handed out with open enrollment materials, many employers find it is a convenient time to distribute or redistribute the summary to comply with disclosure obligations to hand out the summary to existing employees every five years if there is a material modification to the plan and ten years if not.
Medicare Part D
Medicare Part D disclosures of creditable or non-creditable prescription drug coverage must be provided to Medicare Part D eligible employees prior to the annual coordinated election period of October 15 through December 7 each year, for each employee upon initial eligibility prior to their initial enrollment period, and upon request. Some employers choose to hand out these notices at open enrollment.