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BENEFIT NOTICES TIMELINE

There are many Act’s in force and the various laws mandate compliance.  ERISA, COBRA, HIPAA & The Affordable Care Act (ACA) all have unique requirements and notices which must be sent and/or made available to employees & beneficiaries.

Failure to comply with the various timelines and benefit notices can put your organization at risk of fines and law suits.  Our software assists you in getting compliant!

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TIMELINE OF BENEFIT NOTICES GROUP HEALTH PLANS

 

Date Due

Benefit Notice

Explanation

To Whom Notice is Given

NOTICE DUE UPON HIRE

No later Than 14 days after the employee’s hire date Notice regarding Availability of Health Insurance Marketplace Coverage Options (aka Employer Exchange Notice) Informs employee of the existence of the Marketplace (Exchange), its services, and how to contact the Marketplace for assistance

Model Notice for employers who offer a health plan to some or all employees

Model Notice for employers who do not offer a health plan

For more information, see Technical Release 2013-02

All new employees

NOTICE DUE BY A CERTAIN DATE

Prior to October 15 each year

Prior to an Individual’s initial enrollment period for Part D

Prior to the date of enrolling in the employer’s plan And upon any change that affects whether The coverage is “creditable”

Medicare Part D – Notice of Creditable (or Non-creditable) Coverage Disclosure Notice Informs Medicare-eligible participants as to whether the group plan’s Prescription drug coverage is creditable For model notices and instructions, see Creditable Coverage Model Notice Letters and Creditable Coverage Medicare-eligible plan Participants (e.g., employees, Dependents, COBRA enrollees, and retirees participating in employer’s Group health plan)
Generally within 9 months after the end of each plan year

ERISA plans only

Summary Annual Report Summary of the plan’s Form 5500 report, if any Plan participants and beneficiaries

NOTICES DUE WHEN ENROLLMENT IS OFFERED

With enrollment materials and upon renewal of coverage

Within 90 days of special enrollment

No later than 7 business days following request

Summary of Benefits and Coverage (SBC) and Uniform Glossary A short, easy-to-understand summary of the plan’s benefits and coverage, and a uniform
glossary of standard terms.For more information, see section on Summary of Benefits and Uniform Glossary
 Persons eligible to enroll
 At or before each enrollment period Notice of Special Enrollment Rights Describes the plan’s special enrollment rules Persons eligible to enroll
With any materials describing the plan’s benefits

Grandfathered plans only

Disclosure of Grandfathered Plan Status Statement that the plan is grandfathered and contact information Persons eligible to enroll
At enrollment and annually Women’s Health and Cancer Rights Act (WHCRA) Notices Describes required plan benefits for mastectomy-related services Persons eligible to enroll
At enrollment and annually Employer CHIP Notice Provides information about possible premium assistance under a state’s Medicaid or Children’s Health Insurance Program All employees

NOTICES DUE WHEN ENROLLMENT IS MADE

Upon enrollment in the plan

(Also provide notice, or reminder that notice is available, at least once every 3 years)

HIPAA Notice of Privacy Practices for Protected Health Information Describes ways the plan my use and disclose individual protected health information, employee’s rights, and the plan’s duties to protect said information Plan participants and beneficiaries
Within 90 days after health coverage begins General Notice of COBRA Rights Explains right to purchase temporary extension of group health coverage when coverage is lost due to a qualifying event Plan participants and beneficiaries
With materials describing the terms of a wellness program Wellness Program Disclosure Describes terms of a health-contingent wellness program Eligible Participants
Within 30 days of participant’s written request

ERISA plans only

Plan Document Documents, including latest updated SPD, contracts and other instruments, under which the plan is established and operated Plan participant or beneficiary making the request
Within 90 days of becoming covered

ERISA plans only

Summary Plan Description (SPD) Describes the plan and how it operates and explains the participant’s rights and responsibilities under ERISA Plan participants and beneficiaries
When participants recieve an SPD or other benefits summaries

Non-grandfathered plans

Notice of Patient Protections

May be included in SPD

Describes the plan’s patient protection provisions, e.g., designation of an primary care provider, OB/GYN care without prior authorization Plan participants and benefiiciaries

NOTICES DUE UPON CERTAIN EVENTS (in connection with plan changes)

No later than 60 days before change affecting SBC content Notice of Modification (of SBC) Advance notice of material changes in the plan that affect the content of the SBC Plan participants and beneficiaries
Within 60 days of adoption of material reduction in group health benefits or services

ERISA plans only

Summary of Material Reduction (SMR)

(Updated SPD can be provided in lieu of SMR)

Describes changes in group health benefits or services that constitute a material reduction and changes in the SPD’s content Plan participants and beneficiaries
Within 210 days after the end of the plan year in which the material modification is adopted

ERISA Plans only

Summary of Material Modification (SMM)

(updated SPD can be provided in lieu of SMM)

Describes material modifications to a plan and changes in the SPD’s content Plan participants and beneficiaries

NOTICES DUE UPON CERTAIN EVENTS (in connection with coverage changes)

At least 30 days before rescission of coverage Notice of Rescission of Coverage Advance written notice of rescission (which may be retroactive), including date of, and reason for,m rescission Affected participants and beneficiaries
Upon request for certification of student status

For plans offering coverage for students age 26 and older

Michelle’s Law Enrollment Notice Describes child’s right to continue coverage during medically necessary leave of absence from post-secondary educational institution Plan Participants

NOTICES DUE UPON CERTAIN EVENTS (in connection with federal COBRA)

Within 30 days of a covered dependent losing coverage (e.g., due to divorce, child attaining limitine age) Notice of Qualifying Event Notice of covered dependents’s loss of eligiblity if a qualifying event triggers COBRA Plan administrator
Within 14 days after receiving notice of COBRA qualifying event or within 44 days of the qualifying event if the employer is also the plan administrator COBRA Election Notice Describes right to COBRA continuation coverage, along with election form and cost information Qualified beneficiaries
Within 14 days after receiving notice of a qualifying event Notice of Unavailability of COBRA Coverage Notice that the individual is not entitled to COBRA with reasons for denial Individuals not qualified for COBRA
No less than 30 days after COBRA payment deficiency Notice of Underpayment of COBRA Premium Used when COBRA participant makes a timely but incorrect amount of payment for the COBRA premium Participant making the underpayment
As soon as practicable following determination that COBRA will terminate Notice of Early Termination of COBRA Coverage Provides notices that COBRA will teminate earlier than the maximum period of coverage, including date of, and reason for, termination as well as alternative coverage options Qualified beneficiaries whose COBRA will terminate earlier than the maximum period of coverage

NOTICES DUE UPON CERTAIN EVENTS (other)

Varies, depending on the type of benefit claim involved Notice of Benefit Determination (Claim Notice or “Explanation of Benefits”) Information regarding benefit claim determinations

Additional information based upon adverse decisions and/or appeals

Claimants
Promptly upon recipt of the medical child support order Medical Child Support Order (MCSO) Notice Notification regarding receipt of a support order and description of the plan’s procedures for determining its qualified status Participants, any child named in the order and the child’s representative
No later than 20 days of the date of the notice, send Part A to the state agency or Part B to the plan administrator

Must also notify affected persons of receipt as soon as is practicable

Plan administrators must complete and return Part B to the state agency and affected persons within 40 business days

National Medical Support (NMS) Notice Notice used by state child support enforcement agencies direction the employer’s plan to enroll the child State agencies, employers, plan administrators, participants, custodial parents, child representatives
Upon request Mental Health Parity & Addition Equity Act Disclosure Describes criteria for determining medical necessity for mental health or substance use disorder benefits Current or potential participants, beneficiaries, or contracting healthcare providers
For Affected Individuals: No later than 60 calendar days after discovery of breach

For annual Report:  If breach affects fewer than 500 individuals, no later than 60 days after the end of the calendar year in which the breaches occurred.  If breach affects more than 500 individuals, no later than 60 calendar days after discovery

HIPAA Notice of Breach of Unsecured Protected Health Information Provides information related to the discovery of a breach of unsecured protected health information with steps individuals should take to to protect themselves and what the administrator is doing to fix the situation Affected individuals, U.S. Department of Health and Human Services (and media outlets for large breaches affecting more than 500 residents of a state or jurisdiction)

This timeline provides general information regarding federal benefit notice requirements for employer-sponsored health plans. Additional requirements may apply under state or local laws, including state insurance laws. This material does not provide tax or legal advice.

Table is reposted from ThinkHR.com – last edited May/2015

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