Stay Compliant: Notices to Include in Your Annual Employee Benefits Open Enrollment Materials – Part Two

Compliance, Employee Benefits, Health Plans, Online Enrollment

This is part two of a two-part article on a comprehensive list of notices to include in your employee’s open enrollment benefits. In part one, we reviewed details on Summary Plan Description (SPD), Summary of Benefits and Coverage (SBC), Summary of Material Modifications (SMM), CHIPRA and HIPAA Notices.

In part two, we continue the rundown of the notices you might wish to include in your open enrollment communication efforts.

Availability of Health Insurance Marketplace Notice

Under the PPACA, employers covered by the Fair Labor Standards Act (FLSA) are required to provide a notice to employees about the health insurance marketplace/exchanges of the state(s) in which they operate. The notice must inform the employee:

  • Of the existence of the marketplace/exchange including a description of the services provided by the marketplace, and the manner in which the employee may contact the marketplace to request assistance.
  • That they may be eligible for a premium tax credit, under section 36B of the Internal Revenue Code, if the employee purchases a qualified health plan through the Marketplace.
  • That if they purchase a qualified health plan through the Marketplace, the employee may lose the employer contribution (if any) to any health benefits plan offered by the employer and that all or a portion of such contribution may be excludable from income for Federal income tax purposes.

Current employees must receive the notice in writing. New hires must receive the notice at the time of hire. The notice may be distributed electronically or by hard copy.

COBRA Notice

COBRA (Consolidated Omnibus Reconciliation Act) gives employees the right to take over and pay premiums to keep group health insurance they would otherwise lose in the event of a loss or job or qualifications for coverage (e.g. loss or hours). The law requires that each plan participant (and any covered spouse) be notified of their COBRA rights when coverage under any health plan begins (this is referred to as the initial COBRA notice).

Providing this initial notice can prevent certain COBRA administration problems. For example, COBRA allows a plan to require participants (or others) to provide timely notices of certain events, such as a divorce. DOL regulations stipulate, however, that plans cannot deny COBRA rights based on failure to provide notice of an event if the participant and his or her covered spouse have not received an explanation of this notice requirement in the notice required when coverage begins or in the SPD.

Medicare Part D Creditable (or Non-Creditable) Coverage Notice

This annual notice must be provided to any participant (employee or dependent) who has coverage under Medicare Part A or coverage under Medicare Part B and who lives in the service area of a Medicare Part D prescription drug plan. While employers usually know whether an employee is eligible for Medicare, employers often do not have this information regarding dependents. As a result, providing the notice to all participants ensures compliance.

Note that this notice should be provided by October 15. This is because the notice must be provided before the Medicare Part D annual election period, which begins on October 15 each year. If the SPD is reissued each year, the notice can be included in the SPD. Otherwise, a separate notice should be included in your annual open enrollment and new-hire materials.

Internal Claims and Appeals and External Reviews Notice

The Patient Protection and Affordable Care Act (ACA) requires group health plans and health insurers to implement an “effective” process for appeals of coverage determinations and claims, including an internal claims appeal process and employee notification. 

The appeals process must include, at a minimum, the following: an established internal claims appeal process; a notice to participants, in a “culturally and linguistically appropriate manner,” of available internal and external appeals processes, including the availability of assistance with the appeals processes; and a provision allowing an enrollee to review his or her file, to present evidence and testimony as part of the appeals process, and to receive continued coverage during the appeals process.

Women's Health & Cancer Rights Act of 1998 Notice

The WHCRA (Women’s Health and Cancer Rights Act of 1998) requires group health plans to make certain benefits available to participants who have undergone a mastectomy. In particular, a plan must offer mastectomy patients benefits for:

  • All stages of reconstruction of the breast on which the mastectomy was performed
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance
  • Prostheses
  • Treatment of physical complications of the mastectomy, including lymphedema

The WHCRA requires annual distribution of a notice to all participants and beneficiaries in a group medical plan advising them of their rights to post-mastectomy breast reconstruction. If the SPD is reissued each year, the notice can be included in the SPD. Otherwise, a separate notice should be included in your annual open enrollment and new-hire materials.

KBI Benefits - An Invaluable Resource

Before sending out any relevant benefit documents, be sure to take the time to have them reviewed by an attorney, to ensure that they are compliant and contain all necessary information. This is an easy step to overlook, but it is actually the most important, because it can save you from major legal hassles down the road. Be sure to find out what you need to do in order to be a compliant communicator.

At KBI, we're equipped with vast HR knowledge and experience to help you navigate these tricky situations and have powerful resources available to help with your circumstances. Call us at (408) 366-8880 today!

Tagged: Compliance, Employee Benefits, Health Plans, Online Enrollment