Notices and Disclosures: Upon Certain Events


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This information is typically provided to employee participants and/or beneficiaries upon the occurrence of certain events.

ALL PLANS

Coverage Options (Exchange Notice) Event: Upon Hire
Employers subject to the Fair Labor Standards Act (FLSA) must provide notice to employees of their coverage options, including options available in the Health Insurance Marketplace.
Distribution Requirements: Distribute to all full-time and part-time employees, regardless of plan enrollment status, within 14 days of an employee’s start date. Follow the DOL Safe Harbor for electronic distribution.

 

Summary of Material Modifications Event: Change to SPD
A plan must provide written notice to participants if there is a material modification during the plan or policy year that would affect the content of material required to be included in the Summary Plan Description (SPD).
Distribution Requirements: Provide to participants no later than 210 days after the end of the plan year in which the change was adopted. If the change was a material reduction in benefits or services, provide to participants within 60 days of adoption of the material reduction. The plan can also send an updated SPD to satisfy this requirement. Follow the DOL Safe Harbor for electronic distribution.

 

Notice of Modifications to SBC Event: Change to SBC
A plan must provide written notice to participants if it makes a material modification during the plan or policy year that would affect the content of material required to be included in the Summary of Benefits and Coverage (SBC).
Distribution Requirements: The notice must be provided to enrollees no later than 60 days prior to the date on which the change will become effective. The plan can also send an updated SBC to satisfy this requirement. Please note that for fully insured plans, the insurer is jointly responsible with the plan administrator (generally, the employer) for furnishing the Notice or SBC to participants. See Footnote 1 for electronic distribution.

 

Notice of MCSO Receipt, Procedures and Determination Event: Receipt of MCSO
Upon receipt of a Medical Child Support Order (MCSO), a plan must notify the participant and each alternate recipient of its receipt; the plan’s procedures for determining whether it is “Qualified” (QMCSO); and the plan administrator’s determination as to whether the order is a QMCSO.
Distribution Requirements: The plan administrator must promptly notify the participant and each alternate recipient of receipt of the MCSO and include the determination procedures.  Within a reasonable period after receipt of the MCSO, the plan administrator must notify the participant and each alternate recipient of the determination as to whether the MCSO is qualified. See Footnote 2 for electronic distribution. See the DOL’s QMCSO compliance guide for more information.

 

Notice of Recission of Coverage Event: Retroactive Termination of Benefits
A group health plan must provide notice to participants whose coverage is rescinded retroactively. Please note that coverage may only be rescinded retroactively in cases of where an individual has engaged in fraud, intentionally misrepresented material facts or fails to pay premiums.
Distribution Requirements: The plan must provide written notice to each participant who would be affected by the rescission of coverage at least 30 days before it implements the rescission.

 

SELF-INSURED PLANS

HIPAA Notice of Privacy Practices Event: Upon Change or 3 Year Anniversary
A covered entity must provide to individuals a notice of the plan’s privacy practices upon enrollment and whenever there is a change to the Notice. The plan must also notify individuals then covered by the plan of the availability of and how to obtain the notice at least once every three years after the last distribution or notification.
Please Note: A fully insured plan with no access to PHI other than summary health and enrollment information does not have to provide a privacy notice. If a fully insured plan has access to PHI, then the plan has to provide the notice only upon request.
Distribution Requirements: Special or separate mailings are not required. The covered entity may include the privacy notice with other written materials that are distributed to individuals (except that the notice may not be combined in a single document with an authorization). Follow the DOL Safe Harbor for electronic distribution.
Other Disclosure Requirements: A covered entity must provide to individuals a notice of the plan’s privacy practices upon enrollment in the plan.

 

Breach Notification Event: Breach of Unsecured PHI
Following a breach of unsecured protected health information (PHI), covered entities must provide notification of the breach to affected individuals and Health and Human Services (HHS). If the breach affects more than 500 residents of a State or jurisdiction, notice must be made to prominent media outlets serving the State or jurisdiction.
Distribution Requirements: The notice to individuals must be provided in written form by first-class mail, or alternatively, by e-mail (if the affected individual has agreed to receive such notices electronically) within 60 days following discovery of the breach. HHS must be notified by submitting a form on the HHS web site within 60 days if the breach affects 500 or more individuals, or within 60 days after the end of the calendar year in which the breach is discovered if fewer than 500 individuals are affected. Notice to media outlets can be made in the form of a press release no later than 60 days after discovery.

 

Notice of Adverse Benefit Determination Event: Upon Claim Denial
The plan administrator must provide a claimant with written or electronic notification of any adverse benefit determination (claim denial).
Distribution Requirements: The notice of adverse benefit determination must be provided within a reasonable period of time, but no later than 90 days after receipt of the claim by the plan, unless special circumstances require an extension of time. If the claim involves urgent care, the claimant must be notified of the plan’s benefit determination (whether adverse or not) as soon as possible, taking into account the medical exigencies, but no later than 72 hours after receipt of the claim by the plan, unless the claimant fails to provide sufficient information for a claim determination.

 

PLANS SUBJECT TO COBRA

Election Notice Event: Upon Qualifying Event
The plan administrator must provide a notice to qualified beneficiaries that describes their rights to continuation coverage and how to make an election. The plan may also have to provide an Unavailability of Continuation Coverage Notice and a Termination Notice if and when applicable.
Distribution Requirements: Provide within 14 days after the plan administrator receives the notice of a qualifying event (or 44 days after notice of a qualifying event if the employer is also the plan administrator and the qualifying event is a termination or reduction of hours of employment, the employee’s death, or the employee’s becoming entitled to Medicare). See Footnote 2 for electronic distribution.

 

Footnotes:

[1] The SBC safe harbor allows the Notice of Modification or the SBC to be provided electronically to participants and beneficiaries in connection with their online enrollment or renewal of coverage. If online enrollment is not available, the Notice or SBC may be provided electronically according to the DOL safe harbor for participants covered under the plan. For participants and beneficiaries who are eligible but not enrolled, the Notice or SBC may be provided electronically if the format is readily accessible, which includes an Internet posting if the individuals are notified in paper form (such as a postcard) or via email that the documents are available on the Internet. Special rules may apply for non-federal governmental plans.
Back to Notice of Modification to SBC

[2] Electronic distribution is allowed via the DOL Safe Harbor, but not recommended due to the consent and notice requirements for individuals who do not have access to an employer’s system (such as covered spouses, beneficiaries or alternate recipients).
Back to Notice of MCSO Receipt, Procedures and Determination
Back to Election Notice