The Department of Labor ("DOL"), along with the Departments of Treasury and Health and Human Services, recently published interim final regulations ("Regulations") related to preexisting condition exclusions, lifetime and annual limits, rescissions of coverage and patient protections under the Patient Protection and Affordable Care Act, as amended ("PPACA"). The Regulations include new notice requirements for plan sponsors, and the DOL also provided model notices with respect to enrollment of dependents until age 26, elimination of lifetime limits and patient protection. The notices are brief and generally may be included in plan enrollment materials or the summary plan description ("SPD").
Model Notice of Opportunity to Enroll in Connection with Extension of Dependent Coverage to Age 26. The Regulations extending dependent coverage to age 26 provide transitional relief for a child whose coverage ended, or who was denied coverage (or was not eligible for coverage) under a group health plan because the availability of dependent coverage for children ended before age 26. A plan must give such a child an opportunity to enroll that continues for at least 30 days, regardless of whether the plan offers an open enrollment period and when any open enrollment period might otherwise occur, including written notice of the opportunity to enroll. The written notice and enrollment opportunity must be provided by the first day of the first plan year beginning on or after September 23, 2010, and enrollment must be effective as of such first day. This model notice requirement applies to grandfathered plans, except that they are not required to provide coverage to adult children through age 26 with access to other employer-sponsored health coverage until 2014.
Model Notice on Lifetime Limits No Longer Applying and Enrollment Opportunity. Plans are required to give written notice that the lifetime limit on the dollar value of essential benefits no longer applies. An individual who has already reached a maximum must be provided a one-time right to reenroll in coverage that continues for at least 30 days, including written notice of the opportunity to enroll. The notice and enrollment opportunity must be provided not later than the first day of the first plan year beginning on or after September 23, 2010, and coverage must take effect not later than such first day. This notice requirement applies to grandfathered plans.
If the notices described above are provided to an employee, they are treated as also provided to the employee's dependent. The notices may be included with other enrollment materials as long as they are prominent.
Model Notice on Patient Protections. Plans that use provider networks must notify participants of their rights to (1) choose a primary care provider or a pediatrician when the plan requires designation of a primary care physician, and (2) obtain obstetrical or gynecological care without prior authorization. The notice must be provided when the plan provides a participant with an SPD or similar description of benefits and must be provided no later than the first day of the first plan year beginning on or after September 23, 2010. This notice need not be provided by grandfathered plans.
Plan sponsors should review these notices and coordinate with their insurers or third-party administrators to determine whether they need to integrate some or all of the notices into their plan materials for first plan year beginning on or after September 23, 2010. Regardless of a plan's grandfathered status, the first two notices discussed above must be provided, if applicable, and the third must be provided unless a plan is grandfathered.
The Regulations may be accessed here.