SUMMARY:

To maintain grandfathered plan status, a plan administrator or health issuer must include a statement of grandfathered status in plan materials provided to participants describing the plan’s benefits (such as the SPD and open enrollment materials). A model notice is available from the DOL.

SUMMARY:

Group health plans and health insurance issuers may not rescind coverage once the enrollee is covered, except in cases of fraud or intentional misrepresentation. Plan coverage may not be rescinded without prior notice to the enrollee.

SUMMARY:

Group health plans and health insurance issuers that require designation of a participating primary care provider must permit each participant, beneficiary and enrollee to designate any available participating primary care provider (including a pediatrician for children). Group health plans and issuers that provide obstetrical/gynecological care and require a designation of a participating primary care provider may not require preauthorization or referral for obstetrical/gynecological care.

This notice is often included in the SPD or insurance certificate provided by the issuer (or otherwise provided with enrollment materials). A model notice is available from the DOL.

SUMMARY:

Group health plans are required to provide a uniform summary of the plan’s benefits and coverage to applicants and enrollees. The Departments of Labor, Health and Human Services and the Treasury (Departments) have provided a template for the SBC that plans and issuers must use, as well as additional instructional guidance and sample language for completing the template. The Departments have also provided a uniform glossary of health-coverage-related terms and medical terms for plans and issuers to make available to plan participants and beneficiaries.

The template, glossary and other related guidance are available on the DOL’s website.

The issuer for fully insured plans usually prepares the SBC. If the issuer prepares the SBC, an employer is not also required to prepare an SBC for the health plan, although the employer may need to distribute the SBC prepared by the issuer.

SUMMARY:

A health plan or issuer must provide 60 days’ advance notice of any material modifications to the plan that are not reflected in the most recent SBC. This notice requirement is limited to material modifications that do not occur in connection with a renewal or reissuance of coverage.

A “material modification” is any change to a plan’s coverage that independently, or in connection with other changes taking place at the same time, would be considered by the average plan participant to be an important change in covered benefits or other terms of coverage.

A material modification may include:

• An enhancement in covered benefits or services or other more generous plan or policy terms (for example, reduced cost-sharing or coverage of previously excluded benefits); or
• A material reduction in covered services or benefits or more strict requirements for receiving benefits (for example, a new referral requirement or increased premiums or cost-sharing).

SUMMARY:

MRF requirements were generally applicable for plan years beginning on or after Jan. 1, 2022. Federal agencies deferred enforcement of the first and second MRFs related to disclosing in-network and out-of-network data until July 1, 2022. Enforcement of the third MRF relating to prescription drugs was temporarily delayed. However, the enforcement delay has been rescinded. Future guidance will specify an implementation timeline for this MRF.

Files must be publicly available on an internet website and accessible free of charge without any restrictions.

SUMMARY:

An initial list of 500 shoppable services had to be made available via the internet based self-service tool for plan years that began on or after Jan. 1, 2023. A list of the remainder of all items and services was required for plan years that began on or after Jan. 1, 2024.

Because the Consolidated Appropriations Act (CAA) created a similar price comparison tool requirement, federal agencies have indicated that they will likely view compliance with the internet-based self-service tool to satisfy the CAA’s price comparison tool requirement. However, the CAA also requires plans and issuers to provide cost comparison information over the telephone upon request.

SUMMARY:

Employers must disclose the aggregate cost of applicable employer-sponsored coverage provided to employees on the employees’ W-2 forms. The Form W-2 and Instructions, including a category for reporting the cost of employer-sponsored coverage, are available on the IRS’ website.

Employers must file Forms W-2 with the Social Security Administration and furnish Forms W-2 to employees by Jan. 31 of each year, unless an extension applies.

SUMMARY:

Employers must provide all new hires with an Exchange notice that:

• Includes information regarding the existence of the Exchange, as well as contact information and a description of the services provided by the Exchange;
• Explains how an employee may be eligible for a premium tax credit if the employee purchases a qualified health plan through the Exchange; and
• Contains a statement informing the employee that, if the employee purchases a qualified health plan through an Exchange, 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 this employer contribution may be excludable for federal income tax purposes.

The DOL has provided model Exchange notices for employers to use, which will require some customization.

SUMMARY:

Code section 6056 requires ALEs to report to the IRS information about the health care coverage, if any, they offered to full-time employees. ALEs must also provide employees with information about their health coverage. However, they are no longer required to automatically furnish IRS Form 1095-C to employees. Instead, an ALE may post a timely notice on its website informing individuals that they can request a copy of the statement.

According to the IRS, this information reporting is necessary in order to administer the employer shared responsibility “pay or play” rules. The return gives the IRS information about the employer’s compliance with the pay or play rules. These rules impose penalties on ALEs that do not offer required coverage to full-time employees and dependents.

The employee statements provide information to employees about coverage that was provided in the prior year. The information is used to determine whether employees can claim a premium tax credit on their tax returns for coverage purchased through an Exchange.

SUMMARY:

The ACA requires health insurance issuers, self-insured health plan sponsors, government agencies that administer government-sponsored health insurance programs and any other entity that provides MEC to report information on that coverage to the IRS, as well as to covered individuals. This requirement is found in Code section 6055. However, these entities are no longer required to automatically furnish IRS Form 1095-B to covered individuals. Instead, a reporting entity may post a timely notice on its website informing individuals that they can request a copy of the statement.

These reporting requirements are intended to provide the IRS with information necessary to administer certain ACA mandates, such as the shared responsibility penalties for ALEs and the individual mandate.

To simplify the reporting process, the IRS allows ALEs with self-insured plans to use a single combined form for reporting the information required under both section 6055 and section 6056.

SUMMARY:

Many wellness programs ask employees to answer questions on an HRA or to undergo biometric screenings for risk factors (such as high blood pressure or cholesterol). These inquiries and exams are permitted under the ADA if they are part of a voluntary wellness program. One of the requirements for a voluntary wellness program is that employers must give participating employees a notice that tells them what information will be collected as part of the wellness program, with whom it will be shared and for what purpose, the limits on disclosure and the way information will be kept confidential.

The EEOC has provided a sample notice to help employers comply with this ADA requirement.

SUMMARY:

Notice to covered employees and covered spouses of the right to purchase temporary extension of group health coverage when coverage is lost due to a qualifying event.

A model General COBRA Notice is available from the DOL.

SUMMARY:

Notice of certain qualifying events must be sent to plan administrator when employer is not plan administrator (for example, employer has contracted with a third party to administer COBRA).

The following qualifying events trigger the employer’s notice requirement: (a) employee’s termination or reduction in hours; (b) employee’s death; (c) employee’s Medicare entitlement; and (d) employer’s bankruptcy.

SUMMARY:

Notice to qualified beneficiaries of their right to elect COBRA coverage upon occurrence of qualifying event.  Qualified beneficiaries may be covered employees, covered spouses and dependent children.

A model COBRA Election Notice is available from the DOL.

SUMMARY:

Plan administrator must send a notice that an individual is not entitled to COBRA coverage to those individuals who provide notice to the plan administrator of a qualifying event whom the plan administrator determines are not eligible for COBRA coverage.

SUMMARY:

Notice to qualified beneficiaries that COBRA coverage will terminate earlier than the maximum period of coverage. The notice must include the reason for early termination, date of termination and any rights that qualified beneficiary may have to elect alternative group or individual coverage.

SUMMARY:

Plan administrator must notify qualified beneficiary that payment for COBRA was not significantly less than the correct amount before coverage is terminated for nonpayment. A payment is not significantly less than the amount required if the deficiency is no greater than the lesser of $50.00 or 10 percent of the amount the plan requires to be paid.

SUMMARY:

COBRA does not explicitly require advance notice of a premium increase. However, COBRA regulations provide that if a COBRA premium payment is short by an amount that is insignificant, the qualified beneficiary must be provided notice of such underpayment and a reasonable amount of time to make the payment difference.

Also, COBRA requires equal coverage and, to some extent, equal treatment between COBRA qualified beneficiaries and similarly situated non-COBRA beneficiaries.

SUMMARY:

The notice must describe, in plain language, the restrictions against balance billing in certain circumstances, including any applicable state law balance billing protections, and information on contacting appropriate state and federal agencies.

Insurers can contractually agree to fulfill the disclosure requirement for fully insured plans. Self-insured plans may agree with insurers, TPAs or PBMs to assist in fulfilling these requirements, but the plan must monitor the other party to ensure compliance.

A model notice is available for use to satisfy this notice requirement.

SUMMARY:

This is an annual reporting requirement; plans and issuers will generally submit these reports by June 1 each year, reporting information for the prior calendar year. This means that data for 2025 must be reported by June 1, 2026.

SUMMARY:

Attestations are due by Dec. 31 each year.

If the issuer for a fully insured health plan provides the attestation, the plan does not also need to provide an attestation. Also, employers with self-insured health plans can enter into written agreements with their TPAs to provide the attestation, but the legal responsibility remains with the health plan.

SUMMARY:

This requirement is effective for 2022 plan years. Until further rulemaking is issued to implement the provider directory requirements, plans and issuers are expected to implement these provisions using a good faith, reasonable interpretation of the law.

SUMMARY:

The SPD is the primary vehicle for informing participants and beneficiaries about their plan and how it operates. Must be written for average participant and be sufficiently comprehensive to apprise covered persons of their benefits, rights and obligations under the plan.

SUMMARY:

Describes material modifications to a plan and changes in the information required to be in the SPD. Distribution of updated SPD satisfies this requirement.

SUMMARY:

The plan administrator must furnish copies of certain documents upon written request by a participant and/or beneficiary and must have copies available for examination. The documents include the latest updated SPD, latest Form 5500, trust agreement, and other instruments under which the plan is established or operated.

SUMMARY:

The Form 5500 is the annual return or report for an employee benefit plan. The filing requirements vary according to the type of plan. Certain employee benefit plans are exempt from the annual reporting requirements or are eligible for limited reporting options.

The latest Form 5500 instructions provide information on who is required to file and detailed information on filing. These instructions are available on the DOL’s website.

SUMMARY:

Form M-1 is the annual report that must be filed by multiple employer welfare arrangements (MEWAs) and entities claiming exception from MEWA status. In general, a MEWA offers health benefits to the employees of two or more employers. More information about the M-1 filing requirement, and the online filing system, is available on the DOL’s website.

SUMMARY:

The summary annual report is a narrative summary of the Form 5500 and includes a statement of the right to receive the annual report. The DOL has a sample SAR for welfare plans.

SUMMARY:

The Form 8928 excise tax reporting requirement applies to failures to comply with certain group health plan mandates included in the tax code, such as:

• COBRA continuation coverage requirements;
• HIPAA’s portability, access and renewability and nondiscrimination rules;
• Genetic information nondiscrimination requirements;
• Mental health parity requirements; and
• ACA mandates.

SUMMARY:

All covered employers are required to post a notice explaining the FMLA, regardless of whether they have eligible employees. In addition to displaying a poster, if a covered employer has any FMLA eligible employees, it must also provide each employee with a general notice about the FMLA in the employer’s employee handbook or other written materials about leave and benefits. If no handbook or written leave materials exist, the employer must distribute this general notice to each new employee upon hire.

The DOL has a model poster for employers to use.

SUMMARY:

Written guidance must be provided to an employee upon the employee’s notice to the employer of the need for FMLA leave.  The employer must detail the specific expectations and obligations of the employee, and explain the consequences of the failure to meet these obligations.

The DOL has issued a model notice that may be used to satisfy this requirement.

SUMMARY:

Within five days of receiving sufficient information to grant or deny FMLA leave, the employer must provide a designation notice informing the employee whether the leave is designated as FMLA leave. The DOL has issued a model notice that may be used to satisfy this requirement.

SUMMARY:

The notice must be posted prominently, where it can be readily seen by employees and applicants for employment. The notice provides information concerning the laws and procedures for filing complaints of violations of the laws. In addition to physically posting the notice, the EEOC encourages employers also to post similar electronic notices on their internal websites in a conspicuous location.

The poster is available on the EEOC’s website.

SUMMARY:

Title I of GINA prohibits health plans and health insurance issuers from requiring or requesting that an individual undergo a genetic test, subject to some narrow exceptions. The research exception allows a health plan or issuer to request (but not require) that an individual undergo a genetic test if the information is not used for underwriting and some additional requirements are met. The plan or issuer must:

• Make the request in writing to the participant;
• Clearly indicate that the test is voluntary and will not impact plan eligibility or contributions; and
• Complete a Notice of Research Exception

SUMMARY:

Any receipt of genetic information in response to the request for medical information will be deemed inadvertent if the employer’s request includes the model (or similar) language. The model language can be found at EEOC Reg. § 1635.8(b)(1)(i)(B)

SUMMARY:

Employers that want to obtain genetic information of employees in order to monitor the biological effects of exposure to toxic substances in the workplace must provide each affected employee with:

• Written notice of the genetic monitoring; and
• The individual monitoring results.

The employee must authorize the monitoring, unless it is required by law.

SUMMARY:

Employers generally may not disclose an employee’s genetic information. Certain exceptions apply to this rule, including disclosure of genetic information in response to a court order or to public health agencies regarding contagious, life-threatening illness. Notice to the employee is required if the employer discloses genetic information for these purposes.

SUMMARY:

Health-contingent wellness programs, or wellness programs that require individuals to satisfy a standard related to a health factor in order to receive a reward, violate federal nondiscrimination rules unless the program satisfies a number of conditions:

• Limit reward to 30 percent of cost of coverage (or 50 percent for health-contingent wellness programs designed to prevent or reduce tobacco use);
• Designed to reasonably promote health and prevent disease;
• Provide annual opportunity to qualify;
• Provide reasonable alternative standard for obtaining the reward for certain individuals; and
• Disclose availability of an alternative standard.

The disclosure must include contact information for obtaining the alternative and a statement that recommendations of an individual’s personal physician will be accommodated. If plan materials merely mention that a wellness program is available, without describing its terms, this disclosure is not required. Sample language is available in the DOL’s model notice guide.

SUMMARY:

HHS regulations require that participants be provided with a detailed explanation of their privacy rights, the plan’s legal duties with respect to protected health information, the plan’s uses and disclosures of protected health information, and how to obtain a copy of the Notice of Privacy Practices.

There are special rules for fully insured health plans. If an employer with a fully insured health plan has access to PHI, the plan must have its own privacy notice and provide it upon request. If an employer with a fully insured health plan does not have access to PHI, the plan is not required to maintain or provide a privacy notice.

HHS has developed four model privacy notices for health plans—a booklet version, a full-page version, a layered version and a plain text version. These model notices, as well as instructions on how to use them, are available on HHS’ website.

A final rule issued by HHS in April 2024 requires covered entities to update their privacy notices if they receive or maintain patient records regarding substance use disorder (SUD) treatment provided by a federally assisted treatment program. Health plans that use the model notices should update them to incorporate the new requirements for SUD records (the deadline is Feb. 16, 2026).

SUMMARY:

Following a breach of unsecured PHI, covered entities must provide notification of the breach to affected individuals, HHS and, in certain circumstances, to the media. If the unsecured PHI is held by a business associate, the business associate must notify the covered entity that a breach has occurred.

SUMMARY:

Notice to employees eligible to enroll in a group health plan describing the group health plan’s special enrollment rules including the right to enroll within 30 days of the loss of other coverage or of marriage, birth of a child, adoption, or placement for adoption, or within 60 days of the loss of coverage under a Medicaid plan or CHIP, or within 60 days of a determination of eligibility for a premium assistance subsidy under Medicaid or CHIP. This notice is often included in the health plan’s SPD or insurance booklet.

Model language is available in the DOL’s model notice guide.

SUMMARY:

States may offer eligible low-income children and their families a premium assistance subsidy to help pay for employer-sponsored coverage. If an employer’s group health plan covers residents in a state that provides a premium subsidy, the employer must send an annual notice about the available assistance to all employees residing in that state. Employers may use the model notice provided by the DOL to meet their obligations under CHIPRA.

SUMMARY:

Employers of all sizes may implement an ICHRA to reimburse their eligible employees for insurance policies purchased in the individual market or Medicare premiums. Employers with ICHRAs must provide written notice to eligible participants including, among other things, the following information:

• A description of the terms of the ICHRA;
• A statement of the participant’s right to opt out of and waive future reimbursement under the ICHRA; and
• A description of the premium tax credit eligibility consequences for a participant who accepts the ICHRA.

A model notice is available for employers to use to satisfy this notice requirement.

SUMMARY:

Group health plan sponsors — or entities that offer prescription drug coverage on a group basis to active and retired employees and to Medicare Part D eligible individuals — must provide, or arrange to provide, a notice of creditable or non-creditable prescription drug coverage to Medicare Part D eligible individuals who are covered by, or who apply for, prescription drug coverage under the entity’s plan. This creditable coverage notice alerts the individuals as to whether or not their prescription drug coverage is at least as good as the Medicare Part D coverage.

Model forms are available from CMS.

SUMMARY:

Employers must disclose to CMS whether the coverage is creditable. An entity is required to provide the Disclosure Notice through completion of the Disclosure Notice form, unless specifically exempt as outlined in related CMS guidance. This is the sole method for compliance with the disclosure requirement.

SUMMARY:

An employer who wishes to sponsor a prescription drug plan with retiree prescription drug coverage that is at least as good as Part D coverage may apply for the retiree drug subsidy, which is exempt from federal income tax. The subsidy is available to employers with group health plans that cover retirees who are entitled to enroll in Part D but who elect not to do so.

SUMMARY:

The cost exemption will apply to a group health plan if its cost increase exceeds 2 percent in the first plan year and 1 percent in a subsequent year. If the 2-percent or 1-percent increased cost is incurred, the plan is exempt for the plan year following the year the cost was incurred. Thus, the exemption lasts one year and then the plan is required to comply again.

A group health plan or health insurance issuer must promptly notify the Secretaries of the DOL, HHS and the Treasury, the appropriate state agencies, and participants and beneficiaries in the plan of such election. A notification to the Secretaries must include:

• A description of the number of covered lives under the plan (or coverage) involved at the time of the notification, and as applicable, at the time of any prior election of the cost-exemption by such plan (or coverage);
• For both the plan year upon which a cost exemption is sought and the year prior, a description of the actual total costs of coverage with respect to medical and surgical benefits and mental health and substance use disorder benefits under the plan; and
• For both the plan year upon which a cost exemption is sought and the year prior, the actual total costs of coverage with respect to mental health and substance use disorder benefits under the plan.

SUMMARY:

The plan administrator or the health insurance issuer must disclose the criteria for medical necessity determinations with respect to MH/SUD benefits to any current or potential participant, beneficiary or contracting provider upon request and the reason for any denial of reimbursement or payment for services with respect to MH/SUD benefits to the participant or beneficiary.

SUMMARY:

FAQs address the following:

• When plans and issuers must make their NQTL comparative analyses available;
• What information plans and issuers must make available;
• Reasons why documentation of comparative analyses of NQTLs might be insufficient;
• What types of documentation should be made available; and

What actions the Departments might take for noncompliance.

SUMMARY:

If a group health plan (or insurance issuer providing coverage for the plan) requires a certification of student status for coverage under the plan, it must send a Michelle’s Law Notice along with any notice regarding the certification requirement. The Michelle’s Law Notice must be written in language understandable to a typical plan participant and must describe the terms of the continuation coverage available under Michelle’s Law during medically necessary leaves of absence.

*Under the ACA, group health plans are required to cover dependent children up to age 26, regardless of student status. The ACA’s coverage mandate for adult children limits the impact of Michelle’s Law. However, group health plans that extend coverage past the age of 26 for adult children who are students will still be subject to the requirements of Michelle’s Law.

SUMMARY:

The plan’s SPD must include a statement describing any requirements under federal or state law applicable to the plan, and any health insurance coverage offered under the plan, relating to any hospital length of stay in connection with childbirth for a mother or newborn child. If the federal law applies in some areas in which the plan operates and state law applies in other areas, the SPD should describe the different areas and the federal or state requirements applicable in each.

Model language is available in the DOL’s model notice guide.

SUMMARY:

This is a notification from the plan administrator regarding receipt and qualification determination on a medical child support order directing the plan to provide health insurance coverage to a participant’s noncustodial children.

SUMMARY:

Notice used by State agency responsible for enforcing health care coverage provisions in a medical child support order. Depending upon certain conditions, employer must complete and return Part A of the National Medical Support notice to the State agency or transfer Part B of the notice to the plan administrator for a determination on whether the notice is a qualified medical child support order.

SUMMARY:

The notice must include the following information:

• The employee’s maximum benefit under the QSEHRA for the year;
• A statement that, if the employee is applying for advance payment of the premium assistance tax credit, the employee should provide the Exchange with information about the QSEHRA’s maximum benefit; and
• A statement that, if the employee is not covered under minimum essential coverage for any month, reimbursements under the QSEHRA may be includible in gross income.

SUMMARY:

Employers must provide notice of rights, benefits and obligations of persons entitled to USERRA and of employers. A poster is available from the DOL.

SUMMARY:

Enrollment notice should include a statement that for participants and beneficiaries who are receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, 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, and treatment of physical complications of the mastectomy, including lymphedema. Notice should also include a description of any deductibles and coinsurance limitations applicable to such coverage.

Annual notice should include a copy of the WHCRA enrollment notice, or a simplified disclosure providing notice of the availability of benefits for the four required coverages and information on how to obtain a detailed description.

Model language is available in the DOL’s model notice guide.