Notices and Disclosures: Upon Initial Enrollment


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These notices and disclosures should generally be provided to participants upon initial enrollment in the group health plan.

Placing them in the plan’s Summary Plan Description (SPD) may satisfy this distribution requirement as specified in the notice’s distribution requirements; however, it is not required that they be placed in the SPD. By contrast, the Notices and Disclosures: SPD chart shows disclosures that must specifically appear in the SPD.

ALL PLANS

Women’s Health and Cancer Rights Act (WHCRA) Distribute Electronically: See DOL Safe Harbor
Group health plans that provide coverage for medical and surgical benefits with respect to mastectomies must disclose a woman’s rights after a mastectomy. This requirement can be met by including the disclosure in an SPD that is distributed upon enrollment. Plans sponsored by self-funded, nonfederal governmental employers may elect to opt-out of this provision, which would require that an “opt-out notice” be provided upon enrollment.
Other Disclosure Requirements: In addition to the disclosure upon enrollment, participants must be given an annual notice.

 

PLANS SUBJECT TO COBRA

COBRA Initial (General) Notice Distribute Electronically: See Footnote 1
The plan administrator must inform participants and their beneficiaries of their continuation coverage rights and requirements under COBRA within 90 days after coverage commences. The 90-day window makes it easier to provide the initial notice and SPD at the same time or to include the initial notice in the SPD. Because the plan must disclose COBRA rights to participants AND covered spouses, the COBRA Initial Notice is often mailed to the employee participant’s home address. If COBRA administration is outsourced, an employer should determine whether it (as the plan administrator) or the COBRA Administrator is responsible for distributing the COBRA Initial Notice.
Other Disclosure Requirements: Additional notices are required when a participant or beneficiary experiences a qualifying event.

 

SELF-INSURED PLANS

HIPAA Notice of Privacy Practices Distribute Electronically: See DOL Safe Harbor
A covered entity must provide to individuals a notice of the plan’s privacy practices upon enrollment in the plan. The covered entity may include the privacy notice with other written materials that are mailed to the individuals (except that the notice may not be combined in a single document with an authorization).
Other Disclosure Requirements: A new privacy notice must be provided within 60 days after a material change to the notice and the plan must notify participants at least once every three years that a notice of privacy practices is available.

 

GRANDFATHERED PLANS

Grandfathered Status Distribute Electronically: Follow Guidelines for SBC 2
All group health plans claiming “grandfathered status” under the ACA must disclose this status in any plan materials describing benefits under the plan (including the SPD) that are distributed to participants upon enrollment. A Non-Grandfathered plan does not have to disclose its status.
Other Disclosure Requirements: A plan’s grandfathered status should be included in all materials that describe benefits under the plan, regardless of when they are distributed.

 

NON-GRANDFATHERED PLANS THAT REQUIRE DESIGNATION OF A PCP

Patient Protections Distribute Electronically: Follow Guidelines for SBC 2
Non-Grandfathered plans that require the designation of a primary care provider (PCP) must provide information relative to a participant’s rights under the ACA. The notice is required to be provided whenever a summary plan description or other similar description of plan benefits is provided to a participant or beneficiary. This requirement can be met by including the disclosure in an SPD that is distributed upon enrollment.
Other Disclosure Requirements: A participant’s rights under the ACA relative to selection of a PCP should be included in all materials that describe benefits under the plan, regardless of when they are distributed.

 

PLANS WITH WELLNESS PROGRAMS THAT OFFER A STANDARD-BASED INCENTIVE

Wellness Incentive Disclosure (HIPAA Requirements) Distribute Electronically: See DOL Safe Harbor
The plan must disclose the availability of a wavier or alternative standard to receive a standard-based wellness incentive in all plan materials describing the standard-based incentive (including the SPD) that are distributed to participants upon enrollment.
Other Disclosure Requirements: A notice of the availability of a waiver or alternative standard must be included in all plan materials that describe the standard-based wellness incentive, regardless of when they are distributed.

 

Footnotes:

[1] 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 ). Therefore, the COBRA Initial Notice is  often mailed to the employee participant’s home address.
Back to COBRA Initial (General) Notice

[2] The SBC safe harbor allows 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 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 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 Grandfathered Status
Back to Patient Protections