Welfare Plan Notices: Managing the Tsunami Chase Cannon Vice President, Deputy CCO 512 697 6860 ccannon@nfp.com
This presentation is for informational purposes only. Any statements provided in the presentation or by the speaker cannot be relied upon as tax or legal advice. The information is current as of April/ May 2017. 2
Ride the Wave… 3
…or Get Tossed By It! 4
Myriad of Notices 5
Summary White Papers 6
Summary White Papers 7
Agenda • Notices to Employees – New Hires/Upon Eligibility for Health Plan – Upon Enrollment in Plan – Ongoing – Upon Coverage Termination • Poster Requirements • Filings to Government • Miscellaneous Notice Thoughts 8
Notices To Employees: New Hires/Upon Eligibility for Health Plan 4/24/2017
New Hires/Upon Plan Eligibility • Include these in an enrollment packet • That means — upon eligibility! • Since many new hires are eligible upon hire, some employers will include in new hire packet. 10
New Hires/Upon Plan Eligibility • Employer CHIP Notice • HIPAA Notice of Special Enrollment Rights • Medicare Part D Creditable/Non-Creditable Notice to Individuals • Notice of Exchange • SBC • Wellness Program: Notice of Availability of Reasonable Alternative Standard 11
Employer CHIP Notice • Applies to employers providing health coverage to employees residing in states that offer Medicaid or CHIP assistance • The current states are: AL, AR, AK, CO, FL, GA, IN, IA, KS, KY, LA, ME, MA, MN, MO, MT, NE, NV, NH, NJ, NY, NC, ND, OK, OR, PA, RI, SC, SD, TX, UT, VT, VA, WA, WV, WI, WY • Employer required to distribute based on residence of employee • Model Notice: https://www.dol.gov/ebsa/pdf/chipmodelnotice.pdf 12
Employer CHIP Notice Just a 3-pager! 13
HIPAA Notice of Special Enrollment Rights • Purpose: avoid claims for benefits by employees and dependents who may assert they were not informed of special enrollment rights/enrollment deadlines • Required to provide “at or before the time an employee is initially offered the opportunity to enroll in a group health plan.” aka - include with enrollment materials. • Model Notice: https://www.dol.gov/ebsa/pdf/chipmodelnotice.pdf 14
HIPAA Notice of Special Enrollment Rights Reminder on HIPAA SER Events: • A loss of eligibility under other coverage; • A loss of eligibility under Medicaid/CHIP; • Birth of a child; • Marriage of an employee; • Adoption (or placement for adoption) of a child with the employee; and • Gain of eligibility for Medicaid/CHIP premium assistance 15
HIPAA Notice of Special Enrollment Rights • Simple 1-pager! 16
Medicare Part D: Notice to Individuals • Meant to assist Part D-eligible employees in determining whether they want to enroll in Part D during CMS open enrollment period (Oct. 15 – Dec. 7) • Must be distributed: • Upon eligibility for the plan • Upon a change in the plan’s creditable status • On an annual basis prior to Oct. 15 • Prior to an individual’s initial enrollment for Part D • Upon request • Applies to Medicare Part D eligible employees; but recommend distributing to all employees who are eligible • Also applies to COBRA and retiree participants 17
Medicare Part D: Notice to Individuals • Model Notices: https://www.cms.gov/Medicare/Prescription-Drug- Coverage/CreditableCoverage/Model-Notice-Letters.html • Simple 4-pager (fillable) 18
Exchange Notice • Meant to educate individuals on the availability of the state heath insurance exchanges • Distribute to: • All employees: By Oct. 1, 2013 • New Hires: Within 14 days of hire date • No penalties! • Model Notices: • ERs w/ plan: http://www.dol.gov/ebsa/pdf/FLSAwithplans.pdf • ERs w/o plan: http://www.dol.gov/ebsa/pdf/FLSAwithoutplans.pdf 19
Exchange Notice • Simple One-Pager! 20
Summary of Benefits & Coverage (SBC) • Plans must provide SBC with enrollment materials annually • SBC is a 4-page double-sided document that summarizes plan benefits • Template provided by the DOL (new final form, to be used in 2017) • Common Issue: Receiving SBC from the insurer, but not distributing it to employees • SBC Template: http://www.dol.gov/ebsa/pdf/correctedsbctemplate2.pdf • New final form: http://www.dol.gov/ebsa/pdf/sbc-template-final.pdf 21
Summary of Benefits & Coverage (SBC) • Five-pager! 22
Wellness Program: Notice of Availability of Reasonable Alternative Standard • The health plan must disclose, in all plan materials describing the standard-based wellness program, that reasonable alternative standards are available • Sample language: • “If it is unreasonably difficult due to a medical condition for you to achieve the standards for the reward under this program, or if it is medically inadvisable for you to attempt to achieve the standards for the reward under this program, call us at [insert telephone number] and we will work with you to develop another way to qualify for the reward.” • “Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all employees. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact us at [insert contact information] and we will work with you (and, if you wish, your doctor) to find a wellness program with the same reward that is right for you in light of your health status.” • Common Issue: Just giving employees info with different premiums for smokers or those who don’t meet certain metrics 23
Notices To Employees: Upon Enrollment in Health Plan 4/24/2017
Summary Plan Description (SPD) • Plans must distribute to covered participants upon the following: • Within 90 days of plan enrollment • Within 120 days after plan first becomes subject to ERISA • Automatically every 5 years (even if no amendments have been made) • In Practice: Attach SMM to SPD (or provide an updated SPD) at open enrollment (that captures the changes to the plan) • Interaction with SBC requirement: • If changes made @ open enrollment, no need to send updated SBC • If changes made outside OE, may need to send 60-day advance notice SBC • Common Issue: Distribute the insurance policy or contract (which is missing certain required ERISA language) • No Template or Model Notice (SPD is too specialized) 25
Grandfathered Health Plan Notice • For GF plans only • To maintain GF status, the plan must (among other things) provide an annual notice to employees stating that plan has GF status • Can go in SPD • Common Issue: Just forget this notice requirement altogether! 26
Grandfathered Health Plan Notice • Model Notice (two paragraphs!): https://dol.gov/ebsa/grandfatherregmodelnotice.doc 27
Newborns’ and Mothers’ Health Protection Act • Applies to plans that offer maternity coverage for at least a 48-hour hospital stay following childbirth (96-hour stay for C-section) — can go in SPD • Common Issue: Just forget this notice requirement altogether! • Model Notice (one paragraph!): http://www.dol.gov/ebsa/faqs/faq_consumer_newborns.html 28
Patient Protections Notice • Meant to notify covered individuals about certain patient protections guaranteed under PPACA – Can designate any PCP, including pediatrician for children – Obtain OB/GYN care w/o prior authorization • Most likely complying, just need to double check SPD • Model Notice (two paragraphs): www.dol.gov/ebsa/patientprotectionmodelnotice.doc 29
Women's Health and Cancer Rights Act (WHCRA) Enrollment Notice • Meant to notify individuals that they have certain mastectomy benefits relating to breast reconstruction; can go in SPD • Model Notice: 30
Internal Appeals and External Review Procedures • PPACA expands requirements for internal/external appeals/reviews • Fully insured: Insurer primarily responsible • Self-insured: Plan administrator is primarily responsible • Employers should review SPDs to ensure compliance • Model Notices exist for: • Adverse Benefit Determination • Final Internal Adverse Benefit Determination • Final External Review Decision 31
HIPAA Notice of Privacy Practices • For self- insured plans; for fully insured plans that are “hands on” • Must describe uses/disclosure of PHI, the individual’s rights, covered entity’s legal duties for PHI, and contact info for privacy official • Must be sent to covered participant (not spouses/dependents); and if entity maintains website — must be posted on the website • Exception for heath plans (including FSAs) that are self-administered and have fewer than 50 participants • Most self-insured plans outsource administration to TPA or other third party • Common Issue: Self-insured plans may not realize they are subject to HIPAA and/or notice requirements. • Model Notice: http://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/npp_booklet_hc_provider.pdf 32
HIPAA Notice of Privacy Practices • 8-page Model Notice (in color!): 33
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