What Notices Are Required by PPACA

September 21, 2010 (PLANSPONSOR.com) - Many of the insurance market reform provisions of PPACA are effective for plan years starting after September 23, 2010 (which is this week!). 


A number of the new provisions require plans to provide notices, either to specific groups of participants or in the plan’s general benefits materials.  Many plans are incorporating these notices into their Annual Enrollment materials or their 2011 summary plan descriptions. 

The agencies have issued model notices for several of the new requirements, which can be found on the Department of Labor (DOL) website at http://www.dol.gov/ebsa/healthreform/.

What notices are required to be provided related to enrollment?

Plans must provide notice for two special enrollment events:

(1)        for adult children under age 26; and

(2)        for individuals who previously reached an overall lifetime maximum. 

A model notice for each can be found on the DOL website.  Both of these notices are required regardless of grandfathered plan status.  Plans must provide a one-time special enrollment period for adult children under age 26 whose eligibility for coverage previously ended or who were not eligible for coverage due to age.  This enrollment period must begin on or before the date the plan year starts and last for at least 30 days.  A similar enrollment period must be provided for individuals who previously reached a lifetime maximum (and are still otherwise eligible under the plan), since plans are no longer allowed to have a lifetime maximum on essential benefits. 

What notices are required to be provided related to benefits?

The PPACA statute and regulation require the following notices to be provided (where applicable) related to the benefits a plan offers.  Most plans are incorporating these notices into their summary plan descriptions.

  • Grandfathered Plan Notice – This notice alerts participants where a plan has determined it is grandfathered.  A model notice can be found on the DOL website.
  • Provider Choice (n/a to grandfathered plans) – Where a plan requires designation of a primary care provider, this notice describes a participant’s choice, including the ability of a child to choose a pediatrician.  A model can be found on the DOL website (called Patient Protection Model Notice).

  • OB-GYN Notice (n/a to grandfathered plans) – This notice states that a woman can see a health care professional specializing in gynecology without prior authorization or referral.  A model can be found on the DOL website (as part of the Patient Protection notice).

What notices are required to be provided related to claims and appeals?

DOL has issued several model notices to be used in the new claims and appeals process.  These new rules and notices do not apply to grandfathered plans.

  • External Review Notice – Plans must provide a description of the new external review process (no model language yet).  Many plans are providing this notice in their summary plan descriptions.
  • Internal Adverse Benefit Determination Notices – Plans must provide a denial notice at both the initial claim and appeal level (model language for both notices on DOL website).  This notice adds new detail to the explanation of benefits already required under the DOL claims procedure rules.
  • Preliminary Review Notice for External Review – Plans must provide a notice to participants filing an external review claim that states whether the participant is eligible for external review (no model language).
  • Notice of Final External Review Decision – This notice is provided by the external review organization describing the outcome of external review (model language on DOL website).
  • Notice of Rescission – Plans also must provide an advance notice of rescission or cancellation of coverage (no model language provided).  These decisions are considered adverse benefit determinations under the new claims and appeals rules (so subject to internal and external review).

Got a health-care reform question?  You can ask YOUR health-care reform legislation question online at http://www.surveymonkey.com/s/second_opinions


You can find a handy list of Key Provisions of the Patient Protection and Affordable Care Act and their effective dates at http://www.groom.com/HCR-Chart.html  


Christy Tinnes is a Principal in the Health & Welfare Group of Groom Law Group in Washington, D.C.  She is involved in all aspects of health and welfare plans, including ERISA, HIPAA portability, HIPAA privacy, COBRA, and Medicare.  She represents employers designing health plans as well as insurers designing new products.  Most recently, she has been extensively involved in the insurance market reform and employer mandate provisions of the health-care reform legislation.

Brigen Winters is a Principal at Groom Law Group, Chartered, where he co-chairs the firm’s Policy and Legislation group. He counsels plan sponsors, insurers, and other financial institutions regarding health and welfare, executive compensation, and tax-qualified arrangements, and advises clients on legislative and regulatory matters, with a particular focus on the recently enacted health-reform legislation.

PLEASE NOTE:  This feature is intended to provide general information only, does not constitute legal advice, and cannot be used or substituted for legal or tax advice.