Model Notices Under the Affordable Care Act

The Affordable Care Act (PPACA) requires several new notices for employees to receive when an employer-sponsored group health plan distributes materials on the plan.  To help plans comply with these notice requirements, the U.S. Department of Labor has released Model Notices that employers or their plan administrators can use.  These notice requirements and Model Notices are provided below.

 

If You Think Your Plan is a “Grandfather” Plan

The regulation on grandfathered plans requires a plan to disclose to consumers every time it distributes materials whether the plan believes that it is a grandfathered plan and therefore is not subject to some of the additional consumer protections of the Affordable Care Act.  The plan must also provide contact information for enrollees to have their questions and complaints addressed.  Click here for Model Language that can be used to satisfy this disclosure requirement.  Model language is also provided in the interim final rules

 

Click here to view the Spanish version.

 

Opportunity to Enroll in Connection with Extension of Dependent Coverage to Age 26 The interim final 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 or health insurance coverage because, under the terms of the plan or coverage, the availability of dependent coverage of children ended before the attainment of age 26.  This enrollment opportunity (including the written notice) must be provided not later than the first day of the first plan year beginning on or after September 23, 2010.  For more information and to view the Model Notice, please click here

 

Click here to view the Spanish version.   

 

 

Patient Protection Model Disclosure Individuals enrolled in a plan or health insurance coverage must be notified 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; or (2) obtain obstetrical or gynecological care without prior authorization.  This notice must be provided no later than the first day of the first plan year beginning on or after September 23, 2010.  For more information and to view the Model Notice, please click here

 

Click here to view the Spanish version.   

 

Model Language Notice Lifetime Limit No Longer Applies and Enrollment Opportunity Plans and issuers are required to give written notice 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.  Additionally, if the individual is not enrolled in the plan or health insurance coverage, or if an enrolled individual is eligible for but not enrolled in any benefit package under the plan or health insurance coverage, then the plan or issuer must also give such an individual an opportunity to enroll that continues for at least 30 days (including written notice of the opportunity to enroll).  The notices and enrollment opportunity must be provided beginning not later than the first day of the first plan year beginning on or after September 23, 2010.  For more information and to view the Model Notice, please click here

 

Click here to view the Spanish version.

 

Internal Claims and Appeals and External Review Decisions

The U.S. Departments of Labor (DOL), Treasury and Health and Human Services (HHS) have released interim procedures and related Model Notices for claims, appeals and reviews under the Affordable Care Act.  The Affordable Care Act sets standards for plans and issuers regarding both internal claims and appeals and external review.  Plans and issuers in States without an applicable external review process are required to implement an effective external review process that meets certain minimum standards.  An interim safe harbor provided by Technical Release 2010-01 applies to non-grandfathered, self-insured group health plans not subject to a state external review process.  The standards include a number of notice requirements for internal appeals and external reviews.  Click here to view the Spanish version. 

 

Model notices that can be used to satisfy the disclosure requirements of the interim final regulations are being posted on the Department of Labor’s website at http://www.dol.gov/ebsa and the Department of HHS/Office of Consumer Information and Insurance Oversight website at http://www.hhs.gov/ociio/.  They include:

 

• Model Notice of Adverse Benefit Determination

• Model Notice of Final Internal Adverse Benefit Determination

• Model Notice of Final External Review Decision

 

• Model Notice of Adverse Benefit Determination (Spanish version)

• Model Notice of Final Internal Adverse Benefit Determination (Spanish version)

• Model Notice of Final External Review Decision (Spanish version)

 

To visit the DOL’s webpage dedicated to the Affordable Care Act, including Model Notices, please click here

 


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