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Home =C2=BB EBIA Weekly=20 Archives =C2=BB Statutes

EBIA Weekly Archives

DOL Issues Model Notices on Coverage to Age 26 Requirement, Lifetime = Limits,=20 and Patient Protections

From the July 01, 2010 EBIA Weekly

[Model Notices: Dependent Coverage to Age 26; Lifetime Limits; = Patient=20 Protection (June 2010)]

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Coverage to Age 26: http://www.dol= .gov/ebsa/dependentsmodelnotice.doc=20
Lifetime Limits: http://www= .dol.gov/ebsa/lifetimelimitsmodelnotice.doc=20
Patient Protection: http://= www.dol.gov/ebsa/patientprotectionmodelnotice.doc=20

The DOL has issued model notices for three of the new health care = reform=20 requirements that take effect for plan years beginning on or after = September 23,=20 2010 (i.e., January 1, 2011 for calendar-year plans): (1) extension of = dependent=20 coverage to age 26; (2) prohibition on lifetime limits; and (3) certain = patient=20 protections. The notices include background information regarding each=20 requirement, followed by model language that may be used to satisfy the = notice=20 obligation. Here are some highlights:

Dependent Coverage for Children Under Age 26. Group health plans = and=20 insurers that offer dependent coverage must continue making such = coverage=20 available for adult children until age 26 (see our Checkpoint = Newsstand=20 article). Children who become (or are required to become) eligible to = enroll=20 because of this coverage requirement must be provided written notice = of their=20 enrollment rights and 30 days to enroll, by no later than the first = day of the=20 first plan year beginning on or after September 23, 2010. This notice = may be=20 included with a plan=E2=80=99s enrollment materials, provided the = disclosure is=20 prominent. [EBIA Comment: The model language states that enrollment = will be=20 effective retroactively to the first day of the first plan year = beginning on=20 or after September 23, 2010. However, plans and insurers that provide = the=20 required notice at least 30 days in advance of the first day of the = first plan=20 year before this requirement takes effect can avoid having to = administer=20 retroactive enrollment.]

Lifetime Limits. Group health plans and insurers may not impose a = lifetime=20 limit on the dollar value of =E2=80=9Cessential health = benefits,=E2=80=9D as defined by the=20 statute and applicable (but not yet issued) regulations. Individuals = who=20 reached a lifetime limit under a group health plan or insurance = coverage=20 before the prohibition became effective and who are otherwise still = eligible=20 under the plan or coverage must be given a written notice that the = lifetime=20 limit no longer applies. Individuals who are no longer enrolled must = be=20 provided a written notice (no later than the first day of the first = plan year=20 beginning on or after September 23, 2010) informing them of an = enrollment=20 opportunity that must continue for at least 30 days. The model = language can be=20 used to satisfy these notice requirements. The notice, which may be = provided=20 to an employee on behalf of the employee=E2=80=99s dependent, can be = included with a=20 plan=E2=80=99s enrollment materials, provided the statement is = prominent. [EBIA=20 Comment: Like the dependent coverage extension, those eligible for = this=20 enrollment opportunity must be treated as special enrollees, i.e., = they must=20 be given the right to enroll in all of the benefit packages available = to=20 similarly situated individuals upon initial enrollment.]

Patient Protection. When applicable, group health plans and = insurers are=20 required to notify participants of their rights to (1) choose a = primary care=20 provider or a pediatrician from within the plan=E2=80=99s network; or = (2) obtain=20 obstetrical or gynecological care without prior authorization. This = notice=20 must be provided whenever the plan or issuer provides a participant = with an=20 SPD or other similar description of benefits under the plan or=20 coverage=E2=80=94starting no later than the first day of the first = plan year beginning=20 on or after September 23, 2010. [EBIA Comment: The model language and = timing=20 rules contained in this notice were previously provided in interim = final=20 regulations implementing the patient protections (see our Checkpoint = Newsstand=20 article).]

EBIA Comment: These notices are new requirements = under=20 health care reform, and employers, insurers, and advisors should = carefully=20 review the rules for providing them. For example, the delivery = requirements for=20 the notices are not the same=E2=80=94while two of the notices can be = provided in open=20 enrollment materials, the third (regarding patient protections) is = expressly an=20 SPD obligation. For more information, see EBIA=E2=80=99s Health Care = Reform manual at=20 Sections V.C (=E2=80=9CLimitations on Lifetime and Annual Dollar = Limits=E2=80=9D), VI=20 (=E2=80=9CDependent Coverage for Children Under Age 26=E2=80=9D), and = VII.B (=E2=80=9CPatient=20 Protections=E2=80=9D); see also EBIA=E2=80=99s HIPAA Portability, = Privacy & Security manual=20 at Section XI (=E2=80=9CProhibitions on Health Status & Genetic = Nondiscrimination,=20 Annual & Lifetime Dollar Limits, and Rescission=E2=80=9D), and = EBIA=E2=80=99s Group Health=20 Plan Mandates manual at Sections VII.B (=E2=80=9CRequired Coverage for = Adult Children=E2=80=9D)=20 and XIII.B (=E2=80=9CPatient Protections=E2=80=9D). EBIA=E2=80=99s = newest publication, =E2=80=9CHealth Care=20 Reform for Employers and Advisors,=E2=80=9D is now available on = Checkpoint. Sign up for=20 a 30-day free trial at http://ria.thomsonreuters.com/EStore/detail.aspx?ID=3DEH= CQ&site=3DEBIAWeekly.=20

Contributing Editors: EBIA Staff.

Copyright and Use Notice: The content of this article was current as = of the=20 date shown above (the date the article appeared in the EBIA Weekly). You = should=20 check with your legal counsel for up-to-date information and advice. = EBIA does=20 not provide legal advice. This article is copyrighted by EBIA and may = not be=20 reproduced, forwarded, posted on a website, or otherwise used without an = EBIA-granted license to do so.

=C2=A9 2009 EBIA - Employee Benefits Institute of = America