Notices and Disclosures: When Eligible


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Unless otherwise specified below, these notices and disclosures should generally be provided to employees when they become eligible to participate in a group health plan. They are often included in enrollment materials.

Placing them in the plan’s Summary Plan Description (SPD) will satisfy the distribution requirement only if the SPD is provided to all eligible employees on or before enrollment or as otherwise specified in the notice’s distribution requirements.

ALL PLANS

Special Enrollment Rights Distribute Electronically: See DOL Safe Harbor
The Special Enrollment Rights disclosure must explain the participants’ and beneficiaries’ right to benefits and when that right may be lost. The disclosure should be made at or before the time an employee is initially offered the opportunity to enroll in a group health plan.

 

Medicare Part D Creditable Coverage Notice Distribute Electronically: See Footnote 1
Plans must notify Medicare Part D eligible participants whether the current employer sponsored prescription drug benefit provides creditable coverage. Notification must be given prior to the effective date of coverage under the employer’s plan. Because an employer may not always be aware of which employee participants and their beneficiaries are (or will be) eligible for Medicare Part D, many employers take the cautious approach and provide the notice to all employees.
Other Disclosure Requirements: The notice must also be provided annually on or before October 15th of each year and following changes in creditable coverage status.

 

SELF-INSURED PLANS

Summary of Benefits and Coverage (SBC) Distribute Electronically: See Footnote 2
The SBC for a self-insured plan must be provided to all eligible employees no later than the first date an employee is eligible to enroll. The plan administrator (generally, the employer) is responsible for creating and furnishing the SBC to participants. Unless the plan has knowledge of a separate address for a beneficiary, the SBC may be provided to the participant on behalf of the beneficiary, including when the SBC is distributed electronically.
Other Disclosure Requirements: The SBC must also be provided as part of any written application materials. In addition, the SBC must be provided upon request, prior to renewal and prior to a special enrollment. A Notice of Material Modification or a new SBC must be provided when there is a change during the plan year that would affect the content of the SBC.

 

FULLY INSURED PLANS

Summary of Benefits and Coverage (SBC) Distribute Electronically: See Footnote 2
The SBC for a fully insured plan must be provided to all eligible employees no later then the first date an employee is eligible to enroll. The insurer is responsible for creating the SBC and is jointly responsible with the plan administrator (generally, the employer) for furnishing the SBC to participants. Unless the plan or issuer has knowledge of a separate address for a beneficiary, the SBC may be provided to the participant on behalf of the beneficiary, including when the SBC is distributed electronically.
Other Disclosure Requirements:  The SBC must also be provided as part of any written application materials. In addition, the SBC must be provided upon request, prior to renewal and prior to a special enrollment. A Notice of Material Modification or a new SBC must be provided when there is a change during the plan year that would affect the content of the SBC.

 

GRANDFATHERED PLANS

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

 

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. This disclosure should be included in all plan materials distributed to participants describing benefits under the plan, including enrollment materials.
Other Disclosure Requirements: A participant’s rights under the ACA relative to selection of a PCP should also be disclosed in the SBC and SPD. In addition, it should be included in any materials that describe benefits under the plan.

 

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. If the enrollment materials include information on the standard-based wellness incentive, it should also include information about the availability of a waiver or alternative.
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.

 

Footnotes:

[1] Electronic distribution is allowed via the DOL Safe Harbor, but the CMS prefers using paper documents because Part D eligible individuals are more likely to receive and understand them.
Back to Medicare Part D Creditable Coverage 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.
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