DOL Releases Model Notices for Patient Protection, Lifetime Limits and Dependent Coverage

Included in recent regulations implemented pursuant to the Patient Protection and Affordable Care Act are requirements for group health plans to provide new notices to participants related to their selection of physicians (Section 54.9815-2719AT), lifetime limits on benefits (Section 54.9815-2711T(e)(2)), and coverage of adult children up to age 26 (Section 54.9815-2714T).

Model Notice for Selection of Physicians

Where applicable based on plan design, group health plans must provide notice to participants of their rights to choose a primary care provider or a pediatrician when a plan requires designation of a primary care physician; or obtain obstetrical or gynecological care without prior authorization. Notice must be provided whenever the plan provides a participant with an SPD or similar description of benefits. Notice must be provided no later than the first day of the first plan year beginning on or after September 23, 2010.

Employers may use the following model notice whenever a plan requires designation of a primary care physician:

[Name of group health plan] generally [requires/allows] the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. [If the plan or health insurance coverage designates a primary care provider automatically, insert: Until you make this designation, [name of group health plan] designates one for you.] For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the [plan administrator] at [insert contact information].

If a plan requires or allows for the designation of a primary care provider for a child, employers may use the following model notice: "For children, you may designate a pediatrician as the primary care provider."

If a plan provides coverage for obstetric or gynecological care and requires the designation by a participant or beneficiary of a primary care provider, employers may use the following model notice:

You do not need prior authorization from [name of group health plan] or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the [plan administrator] at [insert contact information].

Model Notice for Lifetime Limits on Benefits

Employers must give notice to group health plan participants that lifetime limits no longer apply, and that an individual, if covered, is once again eligible for benefits under the plan. If individuals are no longer enrolled in the plan due to a previous lifetime limit, the plan must provide them an enrollment opportunity, including written notice of the opportunity to enroll. Notices and the enrollment opportunity must be provided beginning no later than the first day of the first plan year beginning on or after September 23, 2010. Notices may be included with other enrollment materials that a plan distributes to employees, provided the statement is prominent. Employers may use the following model notice:

The lifetime limit on the dollar value of benefits under [Insert name of group health plan] no longer applies. Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan. Individuals have 30 days from the date of this notice to request enrollment. For more information contact the [insert plan administrator] at [insert contact information].

Model Notice for Coverage of Adult Children to Age 26

Where a child of a participant was not covered under a plan because the availability of dependent coverage of children ended before the attainment of age 26, the group health plan must provide notice of the opportunity to enroll that continues for at least 30 days (including written notice of the opportunity to enroll). Written notice and the new enrollment opportunity must be provided no later than the first day of the first plan year beginning on or after September 23, 2010. Employers may use the following model notice:

Individuals whose coverage ended, or who were denied coverage (or were not eligible for coverage), because the availability of dependent coverage of children ended before attainment of age 26 are eligible to enroll in [Insert name of group health plan]. Individuals may request enrollment for such children for 30 days from the date of notice. Enrollment will be effective retroactively to [insert date that is the first day of the first plan year beginning on or after September 23, 2010]. For more information contact the [insert plan administrator] at [insert contact information].

Please contact your LMV attorney at (205) 326.3002 if you have questions about this Employment Law Advisory or any other matter of labor and employment law.