Information contained in this publication is intended for informational purposes only and does not constitute legal advice or opinion, nor is it a substitute for the professional judgment of an attorney.
The Department of Labor’s Employee Benefits Security Administration (EBSA) has made a series of model notices available on its website to help employers comply with various provisions of the Patient Protection and Affordable Care Act (PPACA or “Affordable Care Act”). Specifically, the EBSA has issued model notices that employers or other health plan issuers can use to inform plan participants of their patient protection rights, plan lifetime limits, grandfathered status of their health plans, and dependent coverage.
Section 2719A of the Affordable Care Act requires non-grandfathered health plans and issuers to provide notice to plan participants of their rights to: (1) choose a primary care provider or a pediatrician when a plan or issuer requires designation of a primary care physician; and (2) obtain obstetrical or gynecological care without prior authorization. This notice is required to be provided whenever a summary of benefits – such as a summary plan description – is provided to the participant, but no later than the first day of the first plan year beginning on or after September 23, 2010. The EBSA’s Patient Protection Model Notice can be used to satisfy this mandate.
Under PPACA, health plans and issuers are required to provide written notice to participants informing them that the lifetime limit on the dollar value of all benefits no longer applies and that an individual, if covered, is once again eligible for benefits under the plan. Those individuals whose coverage ended by reason of reaching the lifetime limit must be notified that they have 30 days in which to re-enroll in the plan. These notices and enrollment opportunities also must be provided by the first day of the first plan year beginning on or after September 23, 2010. The EBSA’s Lifetime Limits Model Notice would satisfy this notice requirement.
As explained in the recently-issued rules governing “grandfathered” health plans, in order to maintain their status as grandfathered, plans must include a statement that describes the benefits provided and the fact that the plan or coverage considers itself grandfathered under PPACA in any plan materials given to participants or beneficiaries. The statement also must include contact information that a participant can use to ask questions or lodge a complaint. Employers and/or plan providers can use the Grandfathered Health Plans Model Notice for this purpose.
In May, the DOL issued interim final regulations governing PPACA’s extension of dependent health coverage to adult children up to age 26. These regulations require that plan participants be given notice that they have the opportunity to enroll their eligible adult children by the first day of the first plan year beginning on or after Sept. 23, 2010. The EBSA’s Extension of Coverage For Adult Children Model Notice contains the requisite information that must be sent to plan participants.
This entry was written by Ilyse Schuman.