Employee Benefits-EBSA Issues Model Notices For The Patient Protection, No Lifetime Limits And Dependent Coverage Until Age 26 Requirements Under The Affordable Care Act

The recently enacted Affordable Care Act, and the interim final regulations just issued for this Act, have introduced a myriad new rules pertaining to health care. Among them are rules for patient protection, the elimination of lifetime limits on benefits and mandatory dependent coverage until age 26. Participants in an employer-sponsored health care plan (a “Plan”) must be notified about these new rules, and the Employee Benefits Security Administration (“EBSA”) has now issued model notices for this purpose. The model notices are here (patient protection), here (no limits) and here (coverage until age 26). The notice requirements are summarized below.

Patient Protection. A participant in a Plan now has the right to (1) choose a primary care provider or a pediatrician, when the Plan requires the participant to designate a primary care physician and (2) obtain obstetrical or gynecological care without prior authorization. Accordingly, the Plan must notify a participant about these rights. The notice must be provided whenever the Plan provides the participant with a summary plan description or other similar description of benefits under the Plan. Also, the notice must be furnished no later than the first day of the first plan year beginning on or after September 23,2010.

No Lifetime Limits. A Plan is required to give written notice that lifetime limits on benefits no longer apply, and that an individual to whom the limits had applied, if still covered, is once again eligible for benefits under the Plan. Further, if the individual is not enrolled in the Plan, or if an enrolled individual is eligible for, but not enrolled in, any benefit package under the Plan, then the Plan must also give this individual an opportunity to enroll that continues for at least 30 days (including written notice of the opportunity to enroll). The notice 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 an individual who enrolls in the Plan under this opportunity, coverage must take effect not later than the first day of the first plan year beginning on or after September 23,2010.

Dependent Coverage Up To Age 26. The interim final regulations provide transitional relief for a child whose coverage under the Plan has ended, or who was denied coverage (or was not eligible for coverage) under the Plan because, under the Plan’s terms, the availability of coverage ended before the attainment of age 26. The regulations require the Plan to give the child an opportunity to enroll that continues for at least 30 days (including written notice of the opportunity to enroll), regardless of whether the Plan has an open enrollment period and regardless of when any open enrollment period might otherwise occur. 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. The notice may be included with other enrollment materials that the Plan distributes, provided that the information on coverage until age 26 is prominent. Enrollment in the Plan must be effective as of the first day of the first plan year beginning on or after September 23,2010.