• Model Notices Released for Dependent Coverage, Lifetime Limits, and Patient Protections Under Health Care Reform
  • July 29, 2010 | Authors: Eric D. Altholz; Diane M. Fitzgerald; Misti D. Munster
  • Law Firm: Verrill Dana LLP - Portland Office
  • The Department of Labor has issued three separate model notices to help employers comply with extension of dependent coverage to age 26, prohibition on lifetime limits, and certain patient protection requirements under the Patient Protection and Affordable Care Act (PPACA).  The notices include background information regarding each requirement and model language that may be used to satisfy notice obligations imposed by the requirements.

    These mandates take effect for plan years beginning on or after September 23, 2010 (January 1, 2011 for calendar year plans).

    Dependent Coverage for Children Under Age 26

    Group health plans and insurers offering dependent coverage must make this coverage available to adult children until age 26.  A plan or issuer must provide adult children who become eligible to enroll because of this new requirement written notice of their enrollment rights by no later than the first day of the first plan year beginning on or after September 23, 2010.  This notice may be included with the plan's enrollment materials as long as the statement is prominent and may be provided to an employee on behalf of the employee's child.  The child must be given at least 30 days to enroll, and enrollment will be retroactive to the first day of the first plan year beginning on or after September 23, 2010.  Click here to view the model notice on dependent coverage.

    Lifetime Limits

    Group health plans and insurers may no longer impose a lifetime limit on the dollar value of "essential health benefits" (as defined by PPACA and regulations to be issued in the future).  Group health plan participants, as well as individuals who reached a lifetime limit under a group health plan or insurance coverage before this requirement became effective, must be provided written notice that the lifetime limit no longer applies and that the individual, if covered, is once again eligible for benefits.  This notice must be provided no later than the first day of the first plan year beginning on or after September 23, 2010, may be included with the plan's enrollment materials as long as the statement is prominent, and may be provided to an employee on behalf of the employee's dependent.  Individuals who are no longer enrolled must be given at least 30 days to enroll, and enrollment will be retroactive to the first day of the first plan year beginning on or after September 23, 2010.

    Patient Protections

    When applicable, group health plans and insurers must notify participants of their rights to (1) choose any primary care provider or pediatrician from within the plan's network; and (2) obtain obstetrical or gynecological care without prior authorization.  This notice must be provided whenever the plan or issuer provides a participant with a summary plan description (SPD) or similar description of benefits.  This notice must be given no later than the first day of the first plan year beginning on or after September 23, 2010.