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Annual Compliance for Insured Group Health Plans Overview

By February 29/March 1 (For Calendar Year Plans)

2. Medicare Part D Disclosure to CMS

3. Screen shots of the CMS reporting site

By July 29 (For Calendar Year Plans) 7. Summary Plan Description and Summary of Material Modifications

By July 31/October 15 (For Calendar Year Plans) 9. Form 5500

By September 30/December 15 (For Calendar Year Plans)

11. Summary Annual Report (SAR)

13. Template SAR

By October 14

15. Medicare Part D Notice to Individuals

18. Model creditable coverage notice

22. Model non-creditable coverage notice

Annual - No Specific Due Date

26. Children’s Health Insurance Program (CHIP) Notice

28. Model CHIP notice

32. Women’s Health and Cancer Rights Act (WHCRA) Notice

33. Model WHCRA notices

With Open Enrollment Materials

34. Summary of Benefits and Coverage (SBC)

37. Model SBC

42. Wellness program notices

45. Sample HIPAA wellness program notices

46. Model ADA wellness program notice

Every Three Years 47. HIPAA Privacy Practice Notice

Reference 50. Definitions

This resource contains instructions for complying with a number of recurring reporting and disclosure obligations applicable to insured group health plans. The information and models included in this resource are current as of November 1, 2016. This information is not intended as legal advice, and readers should consult with legal counsel for any questions regarding their reporting and disclosure obligations. Additional notice obligations apply to newly hired employees and following a violation of law. Additional requirements may apply under state law.

COMPLIANCE CONNECTION Annual Compliance 1

Michael Fidlow | | 845.521.7518 |

A Medicare Part D plan provides prescription drug coverage under Medicare. The Medicare Part D disclosure to the Centers for Medicare & Medicaid (CMS) provides information to the federal government about whether theemployer-providedprescriptiondrugcoverageiscreditableandthereforehelpsCMSconfirmwhetheranemployee who is enrolls in Medicare is subject to a late enrollment penalty.

Who Must Comply?

All sponsors of group health plans that offer prescription drug coverage.

Deadline to Comply:

Disclosure to CMS must be provided:

•Within 60 days after the beginning of the plan year; and•Within 30 days of a change in creditable coverage status.

Method of Disclosure:

Disclosure must be submitted electronically through the CMS website. To access the CMS disclosure form, please visit: https://www.cms.gov/Medicare/Prescription-Drug Coverage/CreditableCoverage/CCDisclosureForm.html.

Content of Disclosure:

To complete the reporting form, a plan sponsor will need the following information:

• Plansponsor'sname,address,employeridentificationnumber,andphonenumber;• Whether each medical plan option is creditable or non-creditable;• The plan year;• Total number of individuals who are (i) enrolled in Medicare and (ii) covered under the plan onthefirstdayoftheplanyear;

Note: If some options are creditable while other options are not, the information must be broken down by plan option.

• Ofthetotalidentifiedabove,howmanyindividualsareexpectedtobecoveredunderaretireeplan;• The date that the last Medicare Part D notice was provided to individuals; and• Whether creditable coverage status has changed in the past year.

Penalties for Failure to Comply:

TherearenospecificpenaltiesforfailuretoprovidetheMedicarePartDnoticestoCMS.

Medicare Part D Disclosure to CMS

Annual Compliance for Insured Group Health Plans 2

Disclosure to CMS Screen Shots Step 1: Enter the Disclosure Information

Note: All fields are required unless otherwise Indicated.

Step 1 - Enter Disclosure Information

Please complete the following information for each Type of Coverage offered by the Entity/Plan Sponsor.

Entity/Plan Sponsor Information:

Entity Name

Entity Federal ID Number

Entity Street Address

City

State (US Only)

Zip Code

Country

Phone Number

Coverage Type

I Select one

I United States

(Format: ### ### I.W.'nt)

I Select one

Choose Status of Coverage

Creditable/Non-Creditable Offer:

Please select ONE of the following to continue and ,complete the required disclosure infonnation.

0 All Options Offered Are Creditable

0 All Options Offered Are Non .. Creditable

0 There are Some Creditable and Non-Creditable Options Offered


I

1) Benefit Options offered are Creditable

All Options Offered Are Credit.able:

• Note: A plan year should contain a maximum of 365 days; unless it is a leap year then there would be a maximum of

366 days. Example, if a plan year beginning date is 10/01/2010 then the plan year ending date should be no later than 09/30/2011.

Ptan Year Beginning Date

(Format: MMIDDIYYYY)

Ptan Year Ending Date

(Format: MMIDDIYYYY)

Total Number of Medicare Part D Eligible Individuals expected to be covered under these Option(s) a s o f the Plan Year Beginning Date stated above

(Please enter e numeric value OHL Y.)

Out o f the estimated number o f those Medicare Part D Eligible ln<ividuals stated above. how many are expected to be covered through an Employer/Union Retiree Group Healt

;..h...c

Pt...c

acc

n _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ �

(Please enter a numeric value OHL Y.)

Date that the Annual Creditable Coverage Disclosure notice to Eligible Individuals form was provided by the Entity

Has your Creditable Coverage Status (Creditable, Non.Creditable, Creditable/Non-Creditable Options Offered) changed from the last plan year?

Example 1: Last year Company ABC had creditable coverage through Carrier 123. This year they have non-creditable coverage through Carrier 123. This is a change in the status, since the coverage was creditable and naw is non-creditable. Example 2: Last year Company ABC had creditable coverage through Carrier 123. This year they have creditable coverage through Carrier 456. Even though the company changed carriers, this is not a change in the status of the creditable coverage. It was creditable last year and it remains creditable. so there is no change in the status.

O Y e s O N o

2) Benefit Options offered are Non-creditable

All Options o,r.,.d Are Non-C,.dltable:

• Note: A plan year should contain a maximum of 365 days; unless it is a leap year then there would be a maximum of 366 days. Example, if a plan year beginning date is 10/01/2010 then the plan year ending date should be no later than 09/30/2011.

Ptan Year Beginring Date (Fo,ms/: MMIDDIYYYY)

Ptan Year Ending Date

(Fo,met: MMIDDIYYYY)

Total Nooiber of Medicare Pait D Eligi>le Individuals expected to be covered under the68 Oplion(s) as Ptan Year Beginning Date stated above

(Please enter a numeric value ONLY)

Out of the estimated number of 1hose Medicare Part D Eligible Individuals stated above, how many are expected to be covered through an Employer/Union Retiree Group H e a l r t h _ P t a n - - ' - - ' - - - - - - - - - - - - - - �

(Please enter a numeric value ONLY)

Dale that !he Annual Creditable Coverage OisclOSt.We notice to Eligi>le Individuals form was provided by the Entity

Has your Cre<itable Coverage Status (Creditable, Non-Creditable, Creditable/Non-Creditable Options Offered) changed from the last plan year?

Example 1: Last year Company ABC had creditable coverage through Carrier 123. This yeat they have non· creditable coverage through Carrier 123. This is a change in the status, silce the coverage was creditable and row is non-creditable. Example 2: Last year Company ABC had creditable coverage through Carrier 123. This yeat they have creditable coverage through Carrier 456. Even though the c ° " " " " y changed carriers, this is not a change in the status of the creditable coverage. It was creditable last year and ij remains creditable, so there is no change in the status.

Oves ONo


3) Benefit Options offered are Creditable and Non-creditable:

Th•,. are Some Credit.able and Non-Creditable Options Offered:

• Note: A plan year should contain a maximum of 365 days; unless it is a leap year then there would be a maximum of366 days. Example, if a plan year beginning date is 10/01/2010 then the plan year ending date should be no later than 09/30/2011.

Plan Year Beginning Date

(Format: MMIDD/YYYY)

Plan Year Ending Date


How many Options offered under this Plan are c r e d i t a b l e � ? - - - - - - - - - - - - - - - - - - �

(Please enter a numeric value OHL Y )

Total Number o f Medicare Part D Eligible Individuals expected to be covered under these creditable Benefit Option (s) as of the Plan Year Beginning Date stated above


Out of the estimated number of those Medicare Part D Eligible Individuals stated above, how many are expected to be covered through an Employer/Union Retiree Group Healtrh_P_la_n _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

�


How many Options offered under this Plan are not credita�ble_? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ �


Total Number o f Medicare Part D Eligible Individuals expected to be covered under these Option(s) as Plan Year Beginning Date stated above


Out of the estimated number of those Medicare Part D Eligible Individuals stated above, how many are expected to be

covered through an Employer/Union Retiree Group Healt�h_P_la_n _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ �


Date that the Annual Creditable Coverage Disclosure notice to Eligible Individuals form was provided by the Entity

Has your Creditable Coverage Status (Creditable, Non-Creditable, Creditable/Non-Creditable Options Offered) changed from the last plan year?

Example 1: las t year Company ABC had creditable coverage through Carrier 123. This year they have non-creditable coverage through Carrier 123. This is a change in the status, since the coverage was creditable and now is non-creditable. Example 2: las t year Company ABC had creditable coverage through Carrier 123. This year they have creditable coverage through Carrier 456. Even though the company changed carriers, this is not a change in the status of the creditable coverage. It was creditable last year and it remains creditable, so there is no change in the status.

O Y e s O N o


Step 2: Verify and Submit Disclosure Information

I understand and agree to the following statements:

1. That this submission supersedes any previous submission of this information with dates prior to the date below;

2. That the entity/plan sponsor agrees to disclose to CMS and all Medicare Part D eligible individuals any changesthat would affect the creditable status of the above coverage as outlined under §423.56.

3. That I am authorized to supply this disclosure of creditable coverage on behalf of the Entity; and

4. That the information provided in this disclosure is true, correct, and complete to the best of my knowledge and belief.

Entity's Authorized Individual Name

Entity's Authorized Individual Title

Entity's Authorized Individual Email

Today's Date

Review and Submit

(If no email address is available, Please enter: [email protected])


Step 3: Receive a Submission Confirmation

Once the disclosure form has been submitted, a confirmation page will appear that states "Thank you! Your disclosure to CMS form has been successfully submitted to CMS. Please print a copy of this confirmation page for you records."


ASummaryPlanDescription(SPD)isasummaryoftheplanthatexplainsparticipants'rightsandobligationsinaclear,understandablemanner.ASummaryofMaterialModifications(SMM)isasummaryofanymaterialchange to any information contained in the SPD.

Who Must Comply?

TheplanadministratorofanyplanthatissubjecttoERISA.Certainexceptionsapply,includingfor so-called"tophat"plans.Contactlegalcounseltodeterminewhetheranyoftheseexceptionsapply.

Note: The plan administrator remains responsible for the content and distribution of these documents even if they are prepared and/or distributed by a third party administrator or insurer.

Deadline to Comply:

SPDs must be distributed every 5 years if there has been material change or every 10 years if there has been no material change. SMMs must be distributed within 210 days after the end of the plan year in which a material change is adopted. However:

• Ifthechangeisamaterialreductioninplanservicesorbenefits,participantsmustbenotifiedwithin60 days after that change; and

• Ifthechangeimpactsthesummaryofbenefitsandcoverageinthemiddleofaplanyear,participantsmustbenotifiedatleast60daysinadvanceofthechange.

Who must Receive?

All participants who are covered under the plan must receive an SPD or SMM. This includes current employees,formeremployeesthatareeligibleforCOBRAbenefits,coveredretirees,andchildrenunderaqualifiedmedicalsupportorder.Thereisnorequirementtodistributetocovered dependentsunlesstheparticipant is deceased.

Method of Distribution:

SPDs and SMMs can be delivered electronically:

• to employees who (i) have the ability to access electronic documents where they are reasonablyexpectedtoperformdutiesand(ii)needaccesstothecompany'selectronicinformationsystemasanintegral part of their job;

• to individuals who consent to receiving the information electronically;1 or• if the employer can otherwise demonstrate that electronic delivery is reasonably calculated to ensure

actual receipt of the material.


Criminal penalties may apply for any willful failures to provide an SPD or SMM. These penalties can be up to $100,000 and/or imprisonment up to ten years for an individual, and up to $500,000 for a company.

Further, for any failures to provide an SPD or SMM upon a written request, a plan sponsor may be charged up to $147 per day. This amount may be adjusted in future years.

Additionally, a court may not enforce plan terms that are included in an SPD that has not been provided. If a plan administrator wishes to enforce the terms of the plan, the administrator should properly distribute the SPD and/or SMM.

Summary Plan Description and Material Modifications

1 Consult legal counsel if seeking to distribute notices by gaining consent.



The SPD for a single-employer welfare plan must include the following information:

• name of the plan;

• name and address of the employer;

• plansponsor'semployeridentificationnumber;

• the 3-digit plan number for the plan;

• type of welfare plan and type of administration;

• plan administrator's name, address and telephonenumber;

• if a plan has a trust, the name, title and address ofthe trustee;

• name and address of person acting as an agent oflegal process;

• a statement that service of legal process may bemade upon a plan trustee (if applicable) or the planadministrator;

• a statement indicating that the plan is subject to oneor more collective bargaining agreements (ifapplicable);

• a description of plan eligibility provisions (includingany conditions that must be met in order to receivebenefits);

• adescriptionoftheplanbenefitsthatareoffered;

• a description of the plan's QMCSO procedures or astatement that such procedures can be obtained freeof charge upon request to the plan administrator;

• a description of any cost-sharing provisions,including premiums, deductible, coinsuranceand co-payments;

• anylimitsonplanbenefits;

• theextenttowhichpreventiveservicesarecoveredunder the plan;

• whether,andunderwhatcircumstances,existingandnew drugs are covered under the plan;

• whether, and under what circumstances, coverage isprovided for medical tests, devices and procedures;

• provisions governing the use of network providers, the composition of the provider network, and whether, and under what circumstances, coverage is provided for out-of-network services;

• any conditions or limits on the selection of primary care providers or providers of specialty medical care;

• any conditions or limits applicable to obtaining emergency medical care;

• any provisions requiring pre-authorizations or utilizationreviewasaconditiontoobtainingabenefit or service under the plan;

• a description of any circumstances that will cause a lossordenialofbenefits;

• a description of the authority to amend or terminate the plan;

• a summary of any plan provisions governing the benefits,rightsandobligationsofparticipantsandbeneficiariesuponterminationoftheplanor amendmentoreliminationofbenefitsundertheplan;

• a description of the rights and obligations of participantsandbeneficiarieswithrespectto COBRA continuation coverage (if applicable), including reasonable notice procedures;

• the sources of contributions to the plan(e.g., employee and/or employer) and method by which contributions are calculated;

• a description of how the plan is funded(e.g., through an insurance policy);

• The name and address of any health insurance issuerresponsibleforbenefitsundertheplanand the nature of any administrative services provided by the issuer;

• the date of the end of the plan year;

• information regarding the plan's claims and appeals procedures;

• the model statement of ERISA rights;

• a statement describing any applicable requirements under federal or state law relating to hospital length of stay in connection with childbirth for the mother or newborn child.

Insurancecompaniesmayprovideacertificateofcoveragethatcontainsmostoftheinformationlistedinthissection.However,many insurancebookletsor certificatesdonot containall of the information thatmustbeincludedinanSPD.Planadministratorsshouldreviewthecertificateandsupplementit,asnecessary,toprovidea complete SPD.

SPDs should be reviewed by legal counsel (especially if the plan is self-insured) to ensure compliance with legal requirements and to ensure that the document adequately protects the plan.

Summary Plan Description and Material Modifications Continued...


A Form 5500 is an annual report required by the Department of Labor and the Internal Revenue Service to ensurethatemployeebenefitplansarebeingadministeredincompliancewithERISAregulations.

Who Must Comply?

TheplanadministratorofanERISAwelfarebenefitplan.However:

• Welfareplansthatdonotcoveratleast100participantsonthefirstdayoftheplanyeararenotrequiredtofileaForm5500.2

• Certainotherexceptionsapply,includingforfully-unfundedwelfareplansandforso-called"tophat"plansContactlegalcounseltodeterminewhetheranyoftheseexceptionsapply.

ThefollowingbenefitsareexamplesofbenefitsthatareofferedunderanERISAwelfarebenefitplan:medical,dental,vision,lifeinsurance,disability,healthcareflexiblespendingaccounts,certainseveranceprograms,certain employee assistance programs, certain on-site clinics, on-site day care, and prepaid legal services certainexceptionsmayapply.

Note: A group health plan must complete a separate Form 5500 for each benefit unless the sponsor has adopted a so-called wrap plan to combine all of the benefits into a single plan. In other words, an employer that offers medical insurance and dental insurance must file a Form 5500 for the medical insurance and a separate Form 5500 for the dental insurance unless the employer has a wrap plan document to confirm that the two benefits are part of a single plan.

Deadline to Comply:

AForm5500mustbefiledannuallybythelastdayoftheseventhcalendarmonthaftertheendoftheplanyear(i.e.,July31forcalendaryearplans)unlessanextensionisfiled.Iftheplanfilesforanextension,theForm 5500 is due two and a half months later (i.e., October 15 for calendar year plans).

Method of Disclosure:

A Form 5500 must be submitted electronically. To access a Form 5500 and its instructions, please visit:https://www.dol.gov/ebsa/5500main.html


Criminal penalties can apply for willful failure to complete a Form 5500. These penalties can be up to $100,000 and/or imprisonment up to ten years for a plan administrator, and up to $500,000 for a company.

Inaddition,aplanadministratormaybesubjecttopenaltiesofupto$2,063perdayforfailuretofileorfullycomplete a Form 5500. This amount may be adjusted in future years.

Form 5500

2TheDepartmentofLaborhasproposedeliminatingthisexceptionbeginningwiththe2019planyear.Employerswithsmallplansshouldwatchforfinalregulationstodeterminewhethertheywillberequiredtofileinthefuture.


Extension to File Form 5500:

A Form 5558 grants a 2 1/2monthextensiontofileaForm5500.AutomaticapprovalwillbegivenfortheextensionsolongasaForm5558isfiledpriortooriginalduedate.

To complete the Form 5558, the following information will be needed:

• theplansponsor'sname,addressandemployeridentificationnumber;• the plan name, number and plan year ending date.

UnlikeaForm5500,aForm5558mustbefiledinpaperformandsenttotheInternalRevenueserviceatDepartment of the Treasury, Internal Revenue Service Center, Ogden, UT 84201-0045.

Content of Notice:3

The following information will be needed in order to complete a Form 5500 for a single-employer welfare plan:

• the name of the plan;

• the 3-digit plan number;

• the original effective date of the plan;

• the plan year;

• theplansponsor'sname,address,telephonenumberandemployeridentificationnumber;

• ifdifferent,theplanadministrator'sname,address,telephonenumberandemployeridentificationnumber;

• thetotalnumberofactiveandformeremployeeswhowerecoveredundertheplanasofthefirstdayof the plan year (including former employees covered under COBRA);

• thetotalnumberofactiveemployeeswhowerecoveredundertheplanasofthefirstdayoftheplanyear;

• the total number of active employees who were covered under the plan as of the last day of the year;

• the number of former employees who were covered under the plan through COBRA as of the last dayof the plan year;

• alistofthebenefitsprovidedundertheplan(e.g.,medical,dental);

• whether the plan is funded in part or in whole through insurance contracts, a trust, and/or the assets ofthe plan sponsor; and

• Schedule A reports for each insurance policy offered under the plan.

3TheDepartmentofLaborhasproposedsignificantlyincreasingtheamountofinformationthatwelfareplanswillberequiredtoreportontheForm5500,beginningwiththereport for the 2019 plan year.

Form 5500 Continued...


Asummaryannualreport("SAR")isasummaryoftheForm5500,whichisanannualreportthatmanybenefitplans are required to submit to the Department of Labor. An SAR provides information to individuals on what benefitsarereportedtothefederalgovernment.

Who Must Comply?

TheplanadministratorofaplanthatfilesaForm5500.Certainexceptionsapplybutarenotgenerallyavailable to most plans.4

Deadline to Comply:

An SAR must be distributed within nine months from the close of the plan year (e.g. by September 30th for a calendar year plan).However,ifanextensionoftimeisgrantedtofileaForm5500,thenanSARmustbedistributedwithintwomonthsaftertheextendedfilingduedate(e.g. by December 15th for a calendar year plan).

Who Must Receive?

All of the following people must receive the SAR:

• every employee or former employee who is enrolled in the group health plan;• any other person (such as ex-spouses) enrolled in COBRA coverage under the plan; and• thecustodialparentofachildenrolledintheplanunderaqualifiedmedicalsupportorder.

Method of Delivery:

Notices can be delivered electronically:• to employees who (i) have the ability to access electronic documents where they arereasonablyexpectedtoperformdutiesand(ii)needaccesstothecompany'selectronicinformation system as an integral part of their job;




Criminal penalties can apply for willful failure to provide a summary annual report. These penalties can be up to $100,000 and/or imprisonment up to ten years for an individual, and up to $500,000 for a company.

In addition, if there is failure to respond to an individual's request for a copy of an SAR, the plan administrator may be subject to a penalty of up to $147 per day. This penalty amount may be adjusted in future years.

Summary Annual Report

4Consultlegalcounseltodetermineifanexceptionappliestoyourplan.5 Consult legal counsel if seeking to distribute notices by gaining consent.


Content of Notice:

The government template must be customized with the following information, which can be obtained from the Form 5500 sections noted below:

• the reporting period that Form 5500 covers (Part 1);• the plan's name (Part II, 1a);• plansponsor'semployeridentificationnumber(PartII,2b);• the documents in the annual report that are applicable to the plan;

Note: For unfunded insured welfare benefit plans, the insurance information including sales commission paid by insurance carriers will likely be the only applicable document.

• ifsomeorallofthebenefitsareself-insured,thetypesofclaimsthattheemployerisdedicatedtopaying (e.g. medical); and

• ifsomeorallofthebenefitsareinsured;• the types of claims the insurers are required to pay (e.g. life insurance, long-term disability);• the name of each insurer;• the total premiums paid for the year (the sum of the amounts reported on line 10(a) or 9(a)(4) of all

Schedules A); and• ifoneormorecontractsare"experiencerated"(meaningthatthepremiumsareaffectedbythe

number and size of claims);• thetotalpremiumspaidunderallexperience-ratedcontractsfortheyear(thesumoftheamounts

reported on line 9(a)(4) of all Schedules A); and• thetotalbenefitsincurredunderallexperience-ratedcontractsfortheyear(thesumoftheamounts

reported on line 9(b)(3) of all Schedules A).

Summary Annual Report Continued...


Summary Annual Report for (name of plan)

This is a summary of the annual report of the (name of plan, EIN and type of welfare plan) for (period covered by this report). The annual report has been filed with the Employee Benefits Security Administration, as required under the Employee Retirement Income Security Act of 1974 (ERISA).

[If any benefits under the plan are provided on an uninsured basis:]

(Name of sponsor) has committed itself to pay (all, certain) (state type of) claims incurred under the terms of the plan.

[If any of the funds are used to purchase insurance contracts:]

Insurance Information

The plan has (a) contract(s) with (name of insurance carrier(s)) to pay (all, certain) (state type of) claims incurred under the terms of the plan. The total premiums paid for the plan year ending (date) were ($ _ _ ).

[If applicable add:]

Because (it is a) (they are) so called "experience-rated" contract(s), the premium costs are affected by, among other things, the number and size of claims. Of the total insurance premiums paid for the plan year ending (date), the premiums paid under such "experience-rated" contract(s) were($) and the total of all benefit claims paid under the(se) experience-rated contract(s) during the plan year was($).

[If any funds of the plan are held in trust or in a separately maintained fund:]

Basic financial statement

The value of plan assets, after subtracting liabilities of the plan, was($) as of (the end of plan year), compared to($) as of (the beginning of the plan year). During the plan year the plan experienced an (increase) (decrease) in its net assets of($). This (increase) (decrease) includes unrealized appreciation and depreciation in the value of plan assets; that is, the difference between the value of the plan's assets at the end of the year and the value of the assets at the beginning of the year or the cost of assets acquired during the year. During the plan year, the plan had total income of($) including employer contributions of($), employee contributions of($), realized (gains) (losses) of($) from the sale of assets, and earnings from investments of($). Plan expenses were ($). These expenses included ($) in administrative expenses, ($) in benefits paid to participants and beneficiaries, and ($) in other expenses.

Your Rights to Additional Information

You have the right to receive a copy of the full annual report, or any part thereof, on request. The items listed below are included in that report: [Note-list only those items which are actually included in the latest annual report].


1. an accountant's report;

2. financial information and information on payments to service providers;

3. assets held for investment;

4. fiduciary information, including non-exempt transactions between the plan and parties-in-interest (thatis, persons who have certain relationships with the plan);

5. loans or other obligations in default or classified as uncollectible;

6. leases in default or classified as uncollectible;

7. transactions in excess of 5 percent of the plan assets;

8. insurance information including sales commissions paid by insurance carriers; and

9. information regarding any common or collective trusts, pooled separate accounts, master trusts or 103-12 investment entities in which the plan participates.

To obtain a copy of the full annual report, or any part thereof, write or call the office of (name), who is (state title: e.g., the plan administrator), (business address and telephone number). The charge to cover copying costs will be ($) for the full annual report, or($) per page for any part thereof.

You also have the right to receive from the plan administrator, on request and at no charge, a statement of the assets and liabilities of the plan and accompanying notes, or a statement of income and expenses of the plan and accompanying notes, or both. If you request a copy of the full annual report from the plan administrator, these two statements and accompanying notes will be included as part of that report. The charge to cover copying costs given above does not include a charge for the copying of these portions of the report because these portions are furnished without charge.

You also have the legally protected right to examine the annual report at the main office of the plan (address), (at any other location where the report is available for examination), and at the U.S. Department of Labor in Washington, D.C. or to obtain a copy from the U.S. Department of Labor upon payment of copying costs. Requests to the Department should be addressed to: Public Disclosure Room, Room N-1513, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210.


A Medicare Part D plan provides prescription drug coverage under Medicare. The Medicare Part D notice provides information to individuals enrolled in Medicare about whether employer-provided prescription drug coverage is creditable and the consequences of failing to enroll in a Medicare Part D plan in timely manner.

Who Must Comply?

All sponsors of group health plans that offer prescription drug coverage.

Deadline to Comply:

Medicare Part D notices must be distributed before October 15th of each year. Revised notices must be provided whenever prescription drug coverage ends or changes so that it is no longer creditable or becomes creditable.

Who Must Receive?

The following people must receive the notice if they are enrolled in Medicare Part A or B:

• all employees and former employees who are enrolled in the employer's group health plan;• all eligible employees who are not enrolled in the employer's group health plan; and• all eligible dependents whose last known address is different than that of the employee.

Note: It may be difficult to know which individuals are enrolled in Medicare, so an employer may provide Medicare Part D notices to all eligible employees.

Method of Delivery:

Notice can be delivered electronically:• to employees that have the ability to access electronic documents where they are reasonablyexpectedtoperformdutiesandneedaccesstothecompany'selectronicinformationsystemasanintegral part of their job; and

• to individuals who consent to receiving the information electronically.6

Otherwise, notice must be provided in hard copy.

Notice can be delivered with other plan materials so long as the notice is "prominent and conspicuous," which means that the notice portion of the document must be prominently referenced in at least 14-point font in a separatebox,bold,oroffsetonthefirstpage.

If notice is being provided electronically to an employee, the employee must be informed that he or she has an obligationtoprovideacopyofthatnoticetocoveredMedicare-eligibledependents.Thissampletextmaybeincluded in an email:

"The attached notice provides information about prescription drug coverage under our plan and about prescription drug coverage that is available under Medicare. It can help Medicare-eligible individuals decide whether to join a Medicare prescription drug plan. We are providing this notice to you, but it also applies to your dependents. You are responsible to share this information with any Medicare-eligible dependent covered under our plan."

Medicare Part D Notice to Individuals



Medicare Part D Notice to Individuals Continued...

Content for a Creditable Medicare Part D Notice:

If an employer's prescription drug coverage is creditable,7thenoticemustexplain:

• that the employer has determined that its plan's coverage is creditable;• the meaning of creditable coverage;• why creditable coverage is important; and• that if individual has a break in creditable coverage for 63 days or longer before enrolling in a Part D

plan, he or she may be required to pay higher premiums for Medicare Part D coverage.

It is recommended, but not required that the notice also contain the following information:

• whenindividualscanexpecttoreceiveanoticeandwhentheycanrequestacopy;• anexplanationoftheplanprovisions/optionsthataffectMedicare-eligibleindividuals(ortheirdependents)relatedtoPartDandtheirplan(e.g.,thattheymayretainexistingcoverageandchoose not to enroll in Part D);

• whether the individuals and their dependents will still be eligible to receive their current healthcoverage if they enroll in a Part D plan;

• any circumstances under which individuals could get their prescription drug coverage back if theydrop it and enroll in Part D; and• howPartDeligibleindividualscangetextrahelppayingforaPartDplan.

The government model notices can be provided with minimal alterations. To access the model Medicare Part D notices, please visit: https://www.cms.gov/Medicare/Prescription-Drug Coverage/CreditableCoverage/Model-Notice-Letters.html.

The model notice must be customized with the following information:

• company name;• plan name;• anexplanationoftheprescriptiondrugcoverageofferedundertheplantoMedicare-eligible

employees (e.g. individual can keep coverage and this plan will coordinate with Part D coverage, orcoverage will cease under this plan if elect Part D coverage); and

• a contact person's name or title, address and phone number.


TherearenospecificpenaltiesforfailuretoprovideaMedicarePartDnotice.However,failuretoprovidethenotice could disadvantage employees and result in lawsuits.

7 Employersofferinginsuredpresciptiondrugcoverageshouldasktheinsurancecompanytoconfirmwhetherthecoverageiscredibleornon-credible.


Medicare Part D Notice to Individuals Continued...

Content for a NON-Creditable Medicare Part D Notice:

If an employer's prescription drug coverage is not creditable,8thenoticemustexplain:

• that the employer has determined that its plan's coverage is not creditable;• the meaning of creditable coverage;• that an individual generally may enroll in Medicare Part D from October 15th through December31st of each year;

• why creditable coverage is important; and• an individual may be required to pay higher premiums for Medicare Part D coverage if the individualfailstoenrollinMedicarePartDwhenfirsteligible.

It is recommended, but not required that the notice also contain the following information:

• whenindividualscanexpecttoreceiveanoticeandwhentheycanrequestacopy;• anexplanationoftheplanprovisions/optionsthataffectMedicare-eligibleindividuals(ortheirdependents)relatedtoPartDandtheirplan(e.g.,thattheymayretainexistingcoverageandchoose not to enroll in Part D);

• whether the individuals and their dependents will still be eligible to receive their current healthcoverage if they enroll in a Part D plan;

• any circumstances under which individuals could get their prescription drug coverage back if theydrop it and enroll in Part D; and• howPartDeligibleindividualscangetextrahelppayingforaPartDplan.

The government model notices can be provided with minimal alterations. To access the model Medicare Part D notices, please visit:

https://www.cms.gov/Medicare/Prescription-Drug Coverage/CreditableCoverage/Model-Notice-Letters.html.


• company name;• plan name;• anexplanationoftheprescriptiondrugcoverageofferedundertheplantoMedicare-eligibleemployees (e.g. individual can keep coverage and this plan will coordinate with Part D coverage, orcoverage will cease under this plan if elect Part D coverage); and

• a contact person's name or title, address and phone number.


TherearenospecificpenaltiesforfailuretoprovideaMedicarePartDnotice.However,failuretoprovidethenotice could disadvantage employees and result in lawsuits.

8 Employersofferinginsuredpresciptiondrugcoverageshouldasktheinsurancecompanytoconfirmwhetherthecoverageiscredibleornon-credible.


MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE0Mso93s.0990 FOR USE ON OR AFTER APRIL 1, 2011

Important Notice from [Insert Name of Entity] About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with [Insert Name of Entity] and about your options under Medicare's prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicare's prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone withMedicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescriptiondrug coverage. All Medicare drug plans provide at least a standard level ofcoverage set by Medicare. Some plans may also offer more coverage for a highermonthly premium.

2. [Insert Name of Entity] has determined that the prescription drug coverage offeredby the [Insert Name of Plan] is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is thereforeconsidered Creditable Coverage. Because your existing coverage is CreditableCoverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

When Can You Join A Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December ? 1 h _

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

CMS Form 10182-CC Updated April 1, 2011

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.


MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE oMa o93e-0990FOR USE ON OR AFTER APRIL 1, 2011

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current [Insert Name of Entity] coverage will [or will not] be affected. [The entity providing the Disclosure Notice should insert an explanation of the prescription drug coverage plan provisions/options under the particular entity's plan that Medicare eligible individuals have available to them when they become eligible for Medicare Part D (e.g., they can keep this coverage if they elect part D and this plan will coordinate with Part D coverage; for those individuals who elect Part D coverage, coverage under the entity's plan will end for the individual and all covered dependents, etc.). See pages 7- 9 of the CMS Disclosure of Creditable Coverage To Medicare Part D Eligible Individuals Guidance (available at http://www.cms.hhs.gov/CreditableCoverage/), which outlines the prescription drug plan provisions/options that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D.]

If you do decide to join a Medicare drug plan and drop your current [Insert Name of Entity] coverage, be aware that you and your dependents will [or will not] [Medigap issuers must insert "will not '1 be able to get this coverage back.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?

You should also know that if you drop or lose your current coverage with [Insert Name of Entity] and don't join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1 % of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For More Information About This Notice Or Your Current Prescription Drug Coverage ...

Contact the person listed below for further information [or call [Insert Alternative Contact] at [(XXX) XXX-XXXX]. NOTE: You'll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through [Insert Name of Entity] changes. You also may request a copy of this notice at any time. CMS Fonn 10182-CC Updated April 1, 2011



MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE oMB o93e-0990 FOR USE ON OR AFTER APRIL 1, 2011

For More Information About Your Options Under Medicare Prescription Drug Coverage ...

More detailed information about Medicare plans that offer prescription drug coverage is in the "Medicare & You" handbook. You'll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

• For more information about Medicare prescription drug coverage:• Visit www.medicare.gov

Call your State Health Insurance Assistance Program (see the inside back cover ofyour copy of the "Medicare & You" handbook for their telephone number) for

• personalized helpCall 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a hi her remium a enalt .

[Optional Insert - Entities can choose to insert the following information box if they choose to provide a personalized disclosure notice.] Medicare Eligible Individual's Name: [Insert Full Name of Medicare Eligible Individual] Individual's DOB or unique Member ID: [Insert Individual's Date of Birth], or [Member ID]

The individual stated above has been covered under creditable prescription drug coverage for the following date ranges that occurred after May 15, 2006:

From: [Insert MM/DD/YY] To: [Insert MM/DD/YY] From: [Insert MM/DD/YY] To: [Insert MM/DD/YY]

Date: Name of Entity/Sender:

CMS Form 10182-CC

[Insert MM/DD/YY] [Insert Name of Entity]

Updated April 1, 2011

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. I f you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.


MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE oMs o93s-0990

FOR USE ON OR AFTER APRIL 1, 2011

Contact--Position/Office: Address:

Phone Number:

CMS Form 10182-CC

[Insert Position/Office] [Insert Street Address, City, State & Zip Code of Entity] [Insert Entity Phone Number]




MODEL INDIVIDUAL NON-CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE0Mso93a.0990 FOR USE ON OR AFTER APRIL 1, 2011

Important Notice From [Insert Name of Entity] About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with [Insert Name of Entity] and about your options under Medicare's prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

There are three important things you need to know about your current coverage and Medicare's prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyonewith Medicare. You can get this coverage if you join a Medicare PrescriptionDrug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offersprescription drug coverage. All Medicare drug plans provide at least a standardlevel of coverage set by Medicare. Some plans may also offer more coverage fora higher monthly premium.

2. [Insert Name of Entity] has determined that the prescription drug coverageoffered by the [Insert Name of Plan] is, on average for all plan participants, NOTexpected to pay out as much as standard Medicare prescription drug coveragepays. Therefore, your coverage is considered Non-Creditable Coverage. This isimportant because, most likely, you will get more help with your drug costs ifyou ioin a Medicare drug plan, than if you only have prescription drug coveragefrom the [Insert Name of Plan]. This also is important because it may mean thatyou may pay a higher premium (a penalty) if you do not join a Medicare drugplan when you first become eligible.

3. You can keep your current coverage from [Insert Name of Plan]. However,because your coverage is non-creditable, you have decisions to make aboutMedicare prescription drug coverage that may affect how much you pay for thatcoverage, depending on if and when you join a drug plan. When you make yourdecision, you should compare your current coverage, including what drugs arecovered, with the coverage and cost of the plans offering Medicare prescriptiondrug coverage in your area. Read this notice carefully - it explains your options.

When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 TH to December i h .

CMS Fonn 10182-NC Updated April 1, 2011



MODEL INDIVIDUAL NON-CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGEoMso93a-0990 FOR USE ON OR AFTER APRIL 1, 2011

[INSERT IF EMPLOYER/UN/ON SPONSORED GROUP PLAN: However, if you decide to drop your current coverage with [Insert Name of Entity], since it is employer/union sponsored group coverage, you will be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan; however you also may pay a higher premium (a penalty) because you did not have creditable coverage under [Insert Name of Plan.]

[INSERT IF PREVIOUS COVERAGE PROVIDED BY THE ENTITY WAS CREDITABLE COVERAGE: Since you are losing creditable prescription drug coverage under the [Insert Name of Plan], you are also eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.]

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?

Since the coverage under [Insert Name of Plan], is not creditable, depending on how long you go without creditable prescription drug coverage you may pay a penalty to join a Medicare drug plan. Starting with the end of the last month that you were first eligible to join a Medicare drug plan but didn't join, if you go 63 continuous days or longer without prescription drug coverage that's creditable, your monthly premium may go up by at least 1 % of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current [Insert Name of Entity] coverage will [or will not] be affected. [The entity providing the Disclosure Notice should insert an explanation of the prescription drug coverage plan provisions/options under the particular entity's plan that Medicare eligible individuals have available to them when they become eligible for Medicare Part D (e.g., they can keep this coverage if they elect part D and this plan will coordinate with Part D coverage; for those individuals who elect Part D coverage, coverage under the entity's plan will end for the individual and all covered dependents, etc.). [See pages 9 - 11 of the CMS Disclosure of Creditable Coverage To Medicare Part D Eligible Individuals Guidance (available at http://www.cms.hhs.gov/CreditableCoverage/), which outlines the prescription drug plan provisions/options that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D.]

CMS Form 10182-NC Updated April 1, 2011

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. I f you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.


MODEL INDIVIDUAL NON-CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGEoMB093s-0990 FOR USE ON OR AFTER APRIL 1, 2011

If you do decide to join a Medicare drug plan and drop your current [Insert Name of Entity] coverage, be aware that you and your dependents will [or will not] [Medigap issuers must insert "will not'] be able to get this coverage back.

For More Information About This Notice Or Your Current Prescription Drug Coverage ... Contact the person listed below for further information. [or call [Insert Alternative Contact] at [(XXX) XXX-XXXX). NOTE: You'll get this notice each year. You will also get it before the next period you can join a Medicare drug plan and if this coverage through [Insert Name of Entity] changes. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverage ... More detailed information about Medicare plans that offer prescription drug coverage is in the "Medicare & You" handbook. You'll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information

• about Medicare prescription drug coverage:• Visit www.medicare.gov

Call your State Health Insurance Assistance Program (see the inside back cover ofyour copy of the "Medicare & You" handbook for their telephone number) for

• personalized helpCall 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

[Optional Insert - If a beneficiary has had creditable coverage under the entities plan for any period of time since May 15, 2006, entities can insert the following information box if they choose to provide a personalized disclosure notice.]

Medicare Eligible Individual's Name: [Insert Full Name of Medicare Eligible Individual] Individual's DOB or unique Member ID: [Insert Individual's Date of Birth], or [Member ID]

The individual stated above has been covered under creditable prescription drug coverage for the following date ranges that occurred after May 15, 2006:

From: [Insert MM/DD/YY] To: [Insert MM/DD/YY) From: [Insert MM/DD/YY] To: [Insert MM/DD/YY]

CMS Form 10182-NC Updated April 1, 2011



MODEL INDIVIDUAL NON-CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE0Mso93s-0990 FOR USE ON OR AFTER APRIL 1, 2011

Date: Name of Entity/Sender:

Contact--Position/Office: Address:

Phone Number:

CMS Fonn 10182-NC

[Insert MM/DDNY] [Insert Name of Entity] [Insert Position/Office] [Insert Street Address, City, State & Zip Code of Entity] [Insert Entity Phone Number]


According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the infonnation collection. lfyou have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.


The Children's Health Insurance Program (CHIP) is a state administered program that provides health insurance to children that are not eligible for or not enrolled in Medicaid. The CHIP notice provides informationaboutfinancialassistance(a"subsidy")thatisavailableundercertainstates'MedicaidorCHIPprograms to help eligible individuals pay for employer-provided health coverage.

Who Must Comply?

Any employer that maintains a group health plan and employs employees who live in a state that provides a subsidy. The applicable states are listed on the model notice.

Deadline to Comply:

CHIPnoticesmustbedistributedannually,butthereisnospecificdateduringtheyearbywhichthenoticesmust be provided.

Who Must Receive?

Every employee who lives in a state that provides a subsidy, regardless of whether the employee is eligible for or enrolled in the employer's group health plan.

Method of Delivery:

Notice may be delivered electronically only to those employees who (i) have the ability to access electronicdocumentswheretheyarereasonablyexpectedtoperformdutiesand(ii)needaccesstothecompany's electronic information system as an integral part of their job. Notice must be provided in hard copy to all other employees.

Notice does not need to be delivered separately but can be delivered with enrollment materials or the plan's summary plan description. If the notice is combined with these materials, the notice must appear separately inawaythatanemployeewhoiseligibleforaCHIPsubsidywouldbereasonablyexpectedtoappreciateitssignificance.

Content of Notice:

The government model notice can be provided without alteration. To access a current version of the model CHIP notice, please visit: https://www.dol.gov/ebsa/compliance_assistance.html#section2


A civil penalty of up to $100 per day may be imposed on employers for failure to provide proper notice to employees. Each employee affected will be considered a separate violation.

Children's Health Insurance Program (CHIP) Notice


Premium Assistance Under Medicaid and theChildren’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has aprogram that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of August 10, 2017. Contact your State for more information on eligibility –

ALABAMA – Medicaid FLORIDA – MedicaidWebsite: http://myalhipp.com/Phone: 1-855-692-5447

Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268

ALASKA – Medicaid GEORGIA – MedicaidThe AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: [email protected] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: http://dch.georgia.gov/medicaid - Click on Health Insurance Premium Payment(HIPP)Phone: 404-656-4507

ARKANSAS – Medicaid INDIANA – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other MedicaidWebsite: http://www.indianamedicaid.com Phone 1-800-403-0864

COLORADO – Health First Colorado (Colorado’s Medicaid Program) &

Child Health Plan Plus (CHP+)

IOWA – Medicaid


http://www.indianamedicaid.com/

http://www.in.gov/fssa/hip/

http://myarhipp.com/

http://dch.georgia.gov/medicaid

http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

mailto:[email protected]

http://myakhipp.com/

http://flmedicaidtplrecovery.com/hipp/

http://myalhipp.com/

http://www.askebsa.dol.gov/

http://www.insurekidsnow.gov/

http://www.healthcare.gov/

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711CHP+: Colorado.gov/HCPF/Child-Health-Plan-PlusCHP+ Customer Service: 1-800-359-1991/State Relay 711

Website: http://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp Phone: 1-888-346-9562

KANSAS – Medicaid NEW HAMPSHIRE – MedicaidWebsite: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218

KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIPWebsite: http://chfs.ky.gov/dms/default.htmPhone: 1-800-635-2570

Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

LOUISIANA – Medicaid NEW YORK – Medicaid Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447

Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831

MAINE – Medicaid NORTH CAROLINA – MedicaidWebsite: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711

Website: https://dma.ncdhhs.gov/ Phone: 919-855-4100

MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – MedicaidWebsite: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-862-4840

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIPWebsite: http://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/medical-assistance.jsp Phone: 1-800-657-3739

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

MISSOURI – Medicaid OREGON – MedicaidWebsite: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

MONTANA – Medicaid PENNSYLVANIA – MedicaidWebsite: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

Website: http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htm


http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htm



http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP

http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP

http://www.oregonhealthcare.gov/index-es.html

http://healthcare.oregon.gov/Pages/index.aspx

http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

http://www.insureoklahoma.org/

http://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/medical-assistance.jsp




http://www.nd.gov/dhs/services/medicalserv/medicaid/

http://www.nd.gov/dhs/services/medicalserv/medicaid/

http://www.mass.gov/eohhs/gov/departments/masshealth/

http://www.mass.gov/eohhs/gov/departments/masshealth/

https://dma.ncdhhs.gov/

http://www.maine.gov/dhhs/ofi/public-assistance/index.html

http://www.maine.gov/dhhs/ofi/public-assistance/index.html

https://www.health.ny.gov/health_care/medicaid/

http://dhh.louisiana.gov/index.cfm/subhome/1/n/331

http://dhh.louisiana.gov/index.cfm/subhome/1/n/331

http://www.njfamilycare.org/index.html

http://www.state.nj.us/humanservices/dmahs/clients/medicaid/

http://www.state.nj.us/humanservices/dmahs/clients/medicaid/

http://chfs.ky.gov/dms/default.htm

http://www.dhhs.nh.gov/oii/documents/hippapp.pdf

http://www.dhhs.nh.gov/oii/documents/hippapp.pdf

http://www.kdheks.gov/hcf/

http://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp

http://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp

https://www.healthfirstcolorado.com/

Phone: 1-800-692-7462

NEBRASKA – Medicaid RHODE ISLAND – MedicaidWebsite: http://www.ACCESSNebraska.ne.gov Phone: (855) 632-7633 Lincoln: (402) 473-7000 Omaha: (402) 595-1178

Website: http://www.eohhs.ri.gov/ Phone: 855-697-4347

NEVADA – Medicaid SOUTH CAROLINA – MedicaidMedicaid Website: https://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900

Website: https://www.scdhhs.gov Phone: 1-888-549-0820

To see if any other states have added a premium assistance program since August 10, 2017, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement

SOUTH DAKOTA - Medicaid WASHINGTON – MedicaidWebsite: http://dss.sd.gov Phone: 1-888-828-0059

Website: http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-program Phone: 1-800-562-3022 ext. 15473

TEXAS – Medicaid WEST VIRGINIA – MedicaidWebsite: http://gethipptexas.com/ Phone: 1-800-440-0493

Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIPMedicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdfPhone: 1-800-362-3002

VERMONT– Medicaid WYOMING – MedicaidWebsite: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531

VIRGINIA – Medicaid and CHIPMedicaid Website: http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282


http://www.coverva.org/programs_premium_assistance.cfm




https://wyequalitycare.acs-inc.com/

http://www.greenmountaincare.org/

https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf

https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf

http://health.utah.gov/chip

https://medicaid.utah.gov/

http://gethipptexas.com/

http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-program



http://dss.sd.gov/

http://www.cms.hhs.gov/

https://www.dol.gov/agencies/ebsa

https://www.scdhhs.gov/

https://dwss.nv.gov/

http://www.eohhs.ri.gov/

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137 (expires 12/31/2019)


mailto:[email protected]

TheWomen'sHealthandCancerRightsAct(WHCRA)requiresgrouphealthplanstoprovidebenefitsforre-constructivesurgeryiftheplanprovidesmedicalorsurgicalbenefitsforamastectomy.TheWHCRAnoticeprovides information about a health plan's coverage of re-constructive surgery for employees who elect to have a mastectomy performed.

Who Must Comply?

Allgrouphealthplansthatprovidemedicalandsurgicalbenefitsformastectomies.Plansthatcoverfewerthantwo current employees are not required to provide the notice.

Deadline to Comply:

WHCRAnoticesmustbedistributedannually,butthereisnospecificdateduringtheyearbywhichthenoticesmust be provided.

Who Must Receive?

Every employee who is enrolled in the group health plan. If a covered dependent's last known address is different than that of the employee, a separate notice must be provided to the dependent.

Method of Delivery:

Notices can be delivered electronically:

• to employees who (i) have the ability to access electronic documents where they are reasonablyexpectedtoperformduties&(ii)needaccesstothecompany'selectronicinformationsystemasanintegral part of job;



The notice may be delivered within a summary plan description or by itself.

Content of Notice:

The notice must describe the coverage required under WHCRA and identify a health plan contact that can provideamoredetaileddescriptionofthemastectomyrelatedbenefitsundertheplan.

The notice may use the government model for the annual notice or the government model for the initial enrollment notice. Access the model WHCRA notices, please visit: https://www.dol.gov/ebsa/pdf/cagappc.pdf

The model notice must be customized by adding the phone number for a contact person who can discuss the plan's coverage. The plan may identify the employer or the administrator/insurer as the contact.


Anyviolationwillresultinanexcisetaxgenerallyequalto$100perdayperpersonwhofailstoreceivethenotice.Thisexcisetaxmustbeself-reportedonForm8928.Interestandpenaltiesmayapplyforfailuretotimely self-report.

Women's Health and Cancer Rights Act (WHCRA) Notice



Model WHCRA Notices

The Department of Labor has provided the following model WHCRA notices in its Compliance Guide, which is available at https://www.dol.gov/ebsa/publications/CAG.html

Model Initial Enrollment Notice:

If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women's Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

• All stages of reconstruction of the breast on which the mastectomy was performed;• Surgery and reconstruction of the other breast to produce a symmetrical appearance;• Prostheses; and• Treatment of physical complications of the mastectomy, including lymphedema.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. Therefore, the following deductibles and coinsurance apply: [insert deductibles and coinsurance applicable to these benefits]. If you would like more information on WHCRA benefits, call your plan administrator [insert phone number].

Model Annual Notice

Do you know that your plan, as required by the Women's Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema? Call your plan administrator at [insert phone number] for more information


ASummaryofBenefitsandCoverage(SBC)isastandardnoticethatisintendedtosummarizetheprovisionsof a health plan and to allow individuals to easily compare different coverage options.

Who Must Comply?

Planadministratorsofgrouphealthplans,exceptthatthefollowinggrouphealthplansdonotneedtoprovidean SBC:

• plansthatcoverfewerthantwocurrentemployeesonthefirstdayoftheplanyear;

• HIPAAexceptedbenefits,suchasstand-alonedentalandvisionplans,certainemployeeassistanceprograms,andhealthcareflexiblespendingaccounts;and

• expatriateplans.

Insurance companies are also required to provide an SBC. If the insurance company properly provides the SBC, the plan administrator will not also need to also provide the SBC.

Deadline to Comply:

An SBC must be provided on or before the date that open enrollment materials are provided. Additional rules apply if there is no open enrollment period for the plan.

Who Must Receive?

Every employee or former employee who is enrolled in the group health plan (including through COBRA). If a covered dependent's last known address is different than that of the employee, a separate notice must be provided to the dependent.

Content of Notice:

An employer creating an SBC must use a government template. To access a current template provided by the Department of Labor, please visit

https://www.dol.gov/ebsa/healthreform/regulations/summaryofbenefits.html

It is important to note that the government template must be prepared in a manner consistent with instructions that are available at the above website.


Insurers or plan sponsors that willfully fail to provide a timely SBC will be subject to a penalty of up to $1,087 (tobeadjustedinfutureyears)perviolationforeachparticipantorbeneficiary.Thispenaltymaynotbepaidfrom trustassetsortheplan.Additionally,anexcisetaxgenerallyequalto$100 perdaycanimposedforeachindividual to which the failure relates.

Summary of Benefits and Coverage


Method of Delivery:

An SBC may be delivered electronically if:

• plan enrollment is done Online;

• the individual is enrolled in the plan and either:

» the employee (i) has the ability to access electronic documents where he or she is reasonablyexpectedtoperformdutiesand(ii)needsaccesstothecompany'selectronicinformationsystemasan integral part of his or her job;

» consents to receiving the information electronically; 10 or

» the employer can otherwise demonstrate that electronic delivery is reasonably calculated to ensureactual receipt of the material; or

• the individual is eligible for but not enrolled in the plan and

» the electronic format is readily accessible;

» a paper version of an SBC is available for the participant upon request, free of charge; and

» iftheSBCispostedonline,theindividualreceivespaperoremailnotificationthattheSBCisavailableontheInternet,providestheInternetaddress,andnotifiestheindividualthatthedocuments are available in paper form upon request.

An SBC does not need to be delivered separately but can be delivered with any summary materials. If the notice is combined with these materials, the notice must appear separately in a way that is prominently displayed at the beginning of the materials.

Summary of Benefits and Coverage Continued...


An SBC does not need to be delivered separately but can be delivered with any summary materials. If the notice is combined with these materials, the notice must appear separately in a way that is prominently displayed at the beginning of the materials.

Content of Notice:

An employer creating an SBC must use a government template. To access a current template provided by the Department of Labor, please visit:

https://www.dol.gov/ebsa/heaIthreform/regulations/summaryofbenefits.htmI


Insurers or plan sponsors that willfully fail to provide a timely SBC will be subject to a penalty of up to $1,087 (to be adjusted in future years)perviolationforeachparticipantorbeneficiary.Thispenaltymaynotbepaidfrom trustassetsortheplan.Additionally,anexcisetaxgenerallyequalto$100 perdaycanimposedforeachindividual to which the failure relates.

Summary of Benefits and Coverage Continued...


This is only a summary. For more information about your coverage, or to get a copy o f the complete terms o f coverage, [insert contact information]. For general definitions o f common terms, such as allowed amount, balance billing. coinsurance, copayment, deductible, provider, or other bolded terms see the Glossary. You can view the Glossary at www.[insert).com or call 1-800-[insert] to request a copy.

Important Questions What is the overall deductible? Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses? What is not included in the out-of-nocket limit? Does this plan use a network of nroviders? Do I need a referral to see a snecialist?

Answers Why This Matters:

$

$

$


Common Medical Event

If you visit a health care nrovider's office or clinic

If you have a test

If you need drugs to treat your illness or condition

More information about nrescrintion dru_g cover e is available at www. [insert]. If you have outpatient surgery

Ifyouneed immediate medical attention

If you have a hospital stay

If you have mental health, behavioral health, or substance abuse needs

If you are pregnant

Services You May Need

Prima r y care visit to treat an injury or illness Snecialist visit Other practitioner office visit Preventive care/ screeni /immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRis) Generic drugs Preferred brand drugs Non-preferred brand drugs

Snecialty dru_gs

Facility fee (e.g., ambulatory surgery center) Physician/ surgeon fees Emergency room services Emergen medical transnortation Urgent care Facility fee (e.g., hospital room) Physician/ surgeon fees Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services Prenatal and postnatal care Delivery and all inpatient services

Your Cost If Your Cost If You Use an You Use an Limitations & Exceptions In-network Out-of-network

Provider Provider


Common Medical Event

If you need help recovering or have other special health needs

If your child needs dental or eye care

Services You May Need

Home health care Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice services Eye exam Glasses Dental check-up

Excluded Services & Other Covered Services:

Your Cost If You Use an In-network Provider

Your Cost If You Use an

Out-of-network Limitations & ExceptionsProvider

S e r v i c e s Your Plan D o e s NOT Cover (This isn't a complete list. Check your polic y or plan document for other excluded services.)

• • •

Other Covered S e r v i c e s (This isn't a complete list. Check your polic y or plan document for other covered services and your costs for these services.)

• • •

Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to continue health coverage after it would otherwise end. For more information, contact us at [insert contact information] or contact: [insert State, HHS, and/ or D O L contact information, as applicable]. Other options to continue coverage are available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: I f you have a complaint or are dissatisfied with a denial o f coverage for claims under your plan, you may be able to appeal or file a grievance. For more information about your rights, this notice, or assistance, contact: [insert applicable contact information from instructions].


Individual Responsibility: [insert applicable language from instructions].

[Insert heading and applicable tagline(s):

Language Access Services: [Spanish (Espanol): Para obtener asistencia en Espanol, llame al [insert telephone number].] [Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa [insert telephone number].] [Chinese (tp::Z): to*m: cpj(l'.f] WJ, ·,ittH -1'- ii!?i [insert telephone number].][Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' [insert telephone number].]]

- - - - - - - - - - T o see examples of how this plan might cover costs f a r a sample medical situation, see the next s e c t i o n . - - - - - - - - - -


About these Coverage Examples:

These examples show how this plan might cover medical care in a few situations and show how deductibles, copayments, and coinsurance can add up. Use these examples to see, in general, how much financial protection a sample patient might get from coverage under this plan compared to other plans by comparing the "Patient Pays" section for the same example under each plan's Summary o f Benefits and Coverage.

This is not a cost estimator. Don't use these examples to estimate your actual costs under this plan. Treatments shown are just examples and your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Also, costs don't include premiums you pay to buy coverage under a plan.

Having a baby Managing type 2 diabetes Simple fracture (n< >rm al dl'II\ n J (r<>lltll1l' ll1all1tl'l1al1Cl' <>f (\\·1th l'l11lTgl'llC\ room \"tslt)

a \\l'll-e<>l1tn>lkd c<inditi<>ll)

• Cost of care $14,150 • Cost of care $6,100 • Cost of care $2,400• Plan pays$• Patient pays $

• Plan pays$• Patient pays $

• Plan pays$• Patient pays $

Sample care costs: Sample care costs: Sample care costs: Hospital charges (mother) $6,700 Prescriptions $3,300 Emergency Services $1,400 Routine obstetric care $2,500 Medical Equipment and Supplies $1,300 Medical Equipment and Supplies $400 Hospital charges (baby) $2,100 Office Visits and Procedures $800 Office Visits and Procedures $300 Anesthesia $1,200 Education $300 Physical Therapy $200 Laboratory tests $1,000 Laboratory tests $200 Laboratory tests $90 Prescriptions $200 Vaccines, other preventive $200 Prescriptions $10 Radiology $200 Total $6,100 Total $2,400 Education $200 Vaccines, other preventive $50 Patient a s: Patient pa s: Total $14,150 Deductibles $ Deductibles $

Copayments $ Copayments $ Patient pays: Coinsurance $ Coinsurance $ Deductibles $ Llmits or exclusions $ Llmits or exclusions $ Copayments $ Total $ Total $ Coinsurance $ Llmits or exclusions $ Total $


Wellness programs might be required to provide notices under Health Insurance Portability and Accountability Act (HIPAA), the Americans with Disabilities Act (ADA) and/or the Genetic Information Nondiscrimination Act (GINA), depending on the design of the wellness program.

HIPAA Notices

Who Must Comply?

Group health plans that provide rewards to participants who meet standards that relate to a health factor. Examplesincludehealthplanpremiumdiscountsforcompletingawalkingchallenge,achievingacertainBMIor being tobacco free.

If a wellness program's reward is not based on meeting a standard relating to a health factor, the HIPAA noticesarenotrequired(buttheADAnoticesmightberequired).Examplesincludehealthplanpremiumdiscountsforcompletingahealthriskassessmentorreimbursementofafitnesscentermembership.

Deadline to Comply:

The notice must be provided in any materials that describe the terms of the program and in any notice informing an individual that he or she failed to meet an initial outcome-based standard required for a reward.

Who Must Receive?

Anyone who receives the materials or notice in which the notice must be included.

Method of Delivery:

The rules do not specify a required method of delivery.

Content of Notice:

The notice must disclose the availability of a reasonable alternative standard to qualify for the reward and, if applicable, the possibility of waiver of the otherwise applicable standard, including contact information for obtaining a reasonable alternative standard and a statement that recommendations of an individual's personal physician will be accommodated. The Department of Labor has provided sample notice language in regulations.


Anyviolationwillresultinanexcisetaxgenerallyequalto$100perdayperpersonwhofailstoreceivethenotice.Thisexcisetaxmustbeself-reportedonForm8928.Interestandpenaltiesmayapply forfailuretotimely self-report.

Wellness Program Notices


• The type of medical information that will be requested;

• How the medical information will be used;

• The restrictions on the disclosure of the medical information; and

• The actions that will be taken to protect the privacy of the medical information (including whether thewellness program complies with the HIPAA privacy regulations).

Anemployermay,butisnotrequiredto,usetextfromtheEEOC'smodelnotice.ToaccessthemodelEEOCwellness program notices, please visit: https://www.eeoc.gov/laws/regulations/ada-wellness-notice.ftm


TherearenospecificpenaltiesforfailuretoprovideanADAwellnessprogramnotice,butanemployermaybesubjec to an EEOC investigation and enforcement, and employees may sue the employer under the ADA for legal and equitable relief, reasonable attorney's fees and other reasonable costs of the action.

Wellness Program Notices Continued...Wellness programs might be required to provide notices under Health Insurance Portability and Accountability Act (HIPAA), the Americans with Disabilities Act (ADA) and/or the Genetic Information Nondiscrimination Act (GINA), depending on the design of the wellness program.

ADA Notices

Who Must Comply?

Anemployerthatasksemployeestoundergomedicalexaminationsand/orrespondtodisabilityrelatedinquiries as part of a wellness program.

Deadline to Comply:

Thenoticemustbeprovidedbeforetheemployeeprovideshisorhermedicalinformation,andsufficientlyinadvance to allow the employee to make an informed choice about whether to participate in the program.

Who Must Receive?

Anyone employee who is eligible for the wellness program.

Method of Delivery:

The notices must be written clearly enough to be understood by an employee who is eligible for the wellness program and must describe


Wellness programs might be required to provide notices under Health Insurance Portability and Accountability Act (HIPAA), the Americans with Disabilities Act (ADA) and/or the Genetic Information Nondiscrimination Act (GINA), depending on the design of the wellness program.

GINA Notices

Who Must Comply?

An employer that asks employees to provide genetic information (which includes medical information of afamilymember).Examplesincludeemployersthatincludefamilymedicalhistoryquestionsaspartofawellness program and employers that provide incentives for spouses to complete a health risk assessment.

Deadline to Comply:

The notice must be part of an authorization form that the employee and/or spouse signs before providing the requested information.

Who Must Receive?

Any employee who is asked to provide genetic information and any spouse who is asked to provide medical information as part of a wellness program.

Method of Delivery:

The rules do not specify the method of delivery, but indicate that it may be electronic.

Content of Notice:

The notice must be written clearly enough to be understood by an employee who is eligible for the wellness program and must describe:

• The type of genetic information that will be requested;

• How that genetic information will be used;

• The restrictions on the disclosure of the genetic information;

Anemployermay,butisnotrequiredto,usetextfromtheEEOC'smodelnotice.ToaccessthemodelEEOCwellness program notice, please visit: https://www.eeoc.gov/laws/regulations/ada wellness-notice.com


TherearenospecificpenaltiesforfailuretoprovideaGINAauthorizationandnotice,butanemployermaybe subject to an EEOC investigation and enforcement, and employees may sue the employer under GINA for compensatory and punitive damages, reasonable attorney's fees, and injunctive relief.

Wellness Program Notices Continued...


Sample HIPAA Wellness Program Notices The Department of Labor has provided the following sample wellness program notices in final regulations.

General Sample

Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all employees. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact us at [insert contact information] and we will work with you (and, i f you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status.

Smoking/Tobacco Program Sample

Stop smoking today! We can help! If you are a smoker, we offer a smoking cessation program. If you complete the program, you can avoid this surcharge. [Must add contact information and the individual's option to involve his or her personal physician.]

Activity-Only Program Sample

Fitness is Easy! Start Walking! Your health plan cares about your health. If you are considered overweight because you have a BMI of over 26, our Start Walking program will help you lose weight and feel better. We will help you enroll. (**If your doctor says that walking isn't right for you, that's okay too. Contact us at [insert contact information] and we will work with you (and, if you wish, your own doctor) to develop a wellness program that is.)

Outcome-Based Program Sample

Your health plan wants to help you take charge of your health. Rewards are available to all employees who participate in our Cholesterol Awareness Wellness Program. If your total cholesterol count is under 200, you will receive the reward. If not, you will still have an opportunity to qualify for the reward. Contact us at [insert contact information] and we will work with you and your doctor to find a Health Smart program that is right for you.


A U A W t:llflt:SS l'WllCt:

• U.S. Equal Employment Opportunity Commission

Sample Notice for Employer-Sponsored Wellness Programs New rules published on May 17, 2016, under the Americans with Disabilities Act (ADA) require employers that offer wellness programs that collect employee health information to provide a notice to employees informing them what information will be collected, how it will be used, who will receive it, and what will be done to keep it confidential. The EEOC has published the sample notice below to help employers comply with the ADA:

NOTICE REGARDING WELLNESS PROGRAM [Name of wellness program] is a voluntary wellness program available to all employees. The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to participate in the wellness program you will be asked to complete a voluntary health risk assessment or "HRA" that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You will also be asked to complete a biometric screening, which will include a blood test for [be specific about the conditions for which blood will be tested.] You are not required to complete the HRA or to participate in the blood test or other medical examinations.

However, employees who choose to participate in the wellness program will receive an incentive of [indicate the incentive] for [specify criteria]. Although you are not required to complete the HRA or participate in the biometric screening, only employees who do so will receive [the incentive].

Additional incentives ofup to [indicate the additional incentives] may be available for employees who participate in certain health-related activities [ specify activities, if any] or achieve certain health outcomes [ specify particular health outcomes to be achieved, if any]. If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive, you may be entitled to a reasonable accommodation or an alternative standard. You may request a reasonable accommodation or an alternative standard by contacting [name] at [contact information].

The information from your HRA and the results from your biometric screening will be used to provide you with information to help you understand your current health and potential risks, and may also be used to offer you services through the wellness program, such as [indicate services that may be offered). You also are encouraged to share your results or concerns with your own doctor.

Protections from Disclosure of Medical Information We are required by law to maintain the privacy and security of your personally identifiable health information. Although the wellness program and [name of employer] may use aggregate information it collects to design a program based on identified health risks in the workplace, [name of wellness program] will never disclose any of your personal information either publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment.

Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements. The only individual(s) who will receive your personally identifiable health information is (are) [indicate who will receive information such as "a registered nurse," "a doctor," or "a health coach") in order to provide you with services under the wellness program.

In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records, information stored electronically will be encrypted, and no information you provide as part of the wellness program will be used in making any employment decision. [Specify any other or additional confidentiality protections if applicable.] Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the wellness program, we will notify you immediately.

You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program, nor may you be subjected to retaliation if you choose not to participate.

If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact [insert name of appropriate contact] at [contact information].


The Health Insurance Portability and Accountability Act (HIPAA) requires group health plans and other covered entities to protect an individual's protected health information (PHI). The HIPAA notice of privacy practices describes how an individual's PHI may be used and disclosed.

Who Must Comply?

Allgrouphealthplansexcept:

• Fully-insured health plans that do not create or receive PHI other than summary health information orenrollment information.

Note: If the fully-insured health plan creates or receives PHI other than summary health information or enrollment information, the plan must provide the notice upon request, but need not distribute it as described below.

Note:Flexiblespendingaccountsandhealthreimbursementarrangementsareself-insuredbenefits.Therefore,ifanemployeroffersahealthcareflexiblespendingaccountorahealthreimbursementaccountinadditiontoinsuredmedical/dental/visionbenefits,theplanwillberequired to comply with the HIPAA notice rules.

• Self-administered, self-insured group health plans for which fewer than 50 employees are eligible.

Deadline to Comply:

Thenoticemustbedistributedatthetimetheindividualfirstenrollsinthegrouphealthplananduponrequest.The notice must also be re-distributed anytime there is a material change to the privacy practices.

Otherwise, group health plans must remind individuals about the notice every three years. The notice itself does not need to be re-distributed.

Who Must Receive?

Any employee or former employee that is covered by the plan. Additional notice to covered dependents is not required.

HIPAA Privacy Notice:

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that health plans protect the confidentialityofyourhealthinformation.[Company's]healthplanmaintainsaprivacynoticewhichexplainsHIPAA 's privacy protections, your rights under HIPAA, and the circumstances under which our health plan may use or disclose your personal health information without your authorization. Please contact [insert contact information] for a copy of this notice or for help with any other HIPAA privacy questions you may have.

HIPAA Notice of Privacy Practices


11 Consult legal counsel if seeking to distribute notices by gaining consent

Method of Delivery:

ThenoticemustbeprovidedinhardcopyunlesstheindividualhasexpresslyconsentedtoreceivingHIPAAnotices electronically.11

If the covered entity has a website for its group health plan, the notice must be posted and accessible on the website.

The notice may be delivered with other materials, such as an SPD or enrollment materials.

• abriefdescriptionofhowtheindividualmayfileacomplaintwiththeplan;

• astatementthattheindividualwillnotberetaliatedagainstforfilingacomplaint;

• thenameortitleandtelephonenumberofapersonorofficetocontactforfurtherinformation;and

• the effective date of the notice.

Additional information is required if the plan intends to make fundraising communications, or use PHI for underwriting purposes.

The Department of Health and Human Services has provided a model notice, which is available at the following address: http://www.hhs.gov/hipaa/for-professionals/privacy/guidance/model-notices privacy-practices/


• the health plan's name, address and website;• any special rules that apply to the employer's health plan;• the HIPAA contact person's name or title, email address and phone number; and• the effective date of the notice.

Tofulfillthethree-yearnoticerequirement,employersmayprovideareminderoftheprivacypracticesratherthantheentirenotice.Thissampletextmaybeused:

HIPAA Privacy Notice:

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that health plans protecttheconfidentialityofyourhealthinformation.[Company's] health plan maintains a privacy noticewhichexplainsHIPAA'sprivacyprotections,yourrightsunderHIPAA,andthecircumstancesunder which our health plan may use or disclose your personal health information without your authorization. Please contact [insert contact information] for a copy of this notice or for help with any other HIPAA privacy questions you may have.


Civil penalties can vary depending on the knowledge of the covered entity and the steps taken to correct the violation. Penalties can range from $100 per violation to $50,000 per violation.

HIPAA Notice of Privacy Practices Continued...



The notice must contain the following information:

• The following statement as a header or otherwise prominently displayed:

"THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY."

• adescriptionandexamplesofthetypesofusesanddisclosuresthatthehealthplanmaymakefortreatment, payment, and health care operations;

• a description of each of the other purposes for which the plan is permitted or required to use ordisclose protected health information without the individual's written authorization;

• a description of the types of uses and disclosures that require an authorization;

• a statement that the plan can disclose PHI to the plan sponsor;

• a statement that other uses and disclosures not described in the notice will be made onlywith the individual's written authorization;

• a statement that the individual may revoke an authorization as provided under the HIPAArules;

• a brief description of how the individual may:

» request restrictions on certain uses and disclosures of PHI;

» receiveconfidentialcommunicationsofPHI;

» inspect and copy PHI;

» have PHI amended;

» receive an accounting of disclosures of PHI;

» obtain a paper copy of the notice.

• a statement that the plan is required by law to maintain the privacy of PHI, to provide thenotice, and to notify affected individuals following a breach of unsecured PHI;

• a statement that the plan is required to abide by the terms of the notice currently in effect;

• a statement that the plan reserves the right to change the terms of its notice and to make the newnotice provisions effective for all PHI that it maintains;

• a description of how the plan will provide individuals with a revised notice;

• a statement that individuals may complain to the plan and to the Department of Health and HumanServices if they believe their privacy rights have been violated.

HIPAA Notice of Privacy Practices Continued...


Thefollowingdefinitionsareintendedtoprovidegeneralunderstandingoftermsusedinthisresource.Morespecificdefinitionscanbefoundinapplicablelaw.

• ADA -Americans with Disabilities Act, which prohibits employers from discriminating against employeeswith disabilities.

• Children's Health Insurance Program ("CHIP") - a state administered program that provides healthinsurance to children that are not eligible for or not enrolled in Medicaid.

• CMS - The Centers for Medicare & Medicaid Services, which is part of the Department of Health andHuman Services (HHS) and is responsible for enforcement of the Medicare rules.

• Creditable Coverage-prescriptiondrugcoveragethatisexpectedtopayonaverageasmuchasthestandard Medicare prescription drug coverage. An individual who maintains creditable coverage will not besubjecttoapenaltyforfailingtoenrollinMedicareprescriptiondrugcoveragewhenhe/shefirstbecomes eligible for that coverage.

• DOL - Department of Labor, which is one of the agencies responsible for enforcement of ERISA.• ERISA - the Employee Retirement Income Security Act, which contains a number of requirementsapplicabletoemployeebenefitplans.

• Form 5500-anannualreportrequiredbytheDOLandIRStoensurethatemployeebenefitplansarebeingadministered in compliance with ERISA regulations.

• GINA - Genetic Information Nondiscrimination Act, which prohibits group health plans and employers fromdiscriminating against individuals based on their genetic information.

• Group Health Plan-anemployeebenefitplanthatismaintainedbyanemployerandthatprovideshealthcare, such as medical, dental or vision care.

• HHS - Department of Health and Human Services, which is responsible for enforcement of the Medicarerules and the HIPAA privacy and security rules.

• HIPAA - Health Insurance Portability and Accountability Act, which contains a number of requirements forgroup health plans.

• IRS - the Internal Revenue Service, which is part of the Department of Treasury, is responsible forenforcement of the Internal Revenue Code, and is one of the agencies responsible for enforcement of ERISA.

• Medicare Part D - Medicare's prescription drug coverage.• Plan Administrator-thepersonorentitythathasthefiduciaryobligationtoadministeranemployeebenefit

plan. If no Plan Administrator is named in the plan document, the Plan Administrator is the employer thatsponsors the plan.

• Plan Sponsor-Theemployerthatsponsorsanddesignsanemployeebenefitplan.• Summary Annual Report (SAR) - a summary of the Form 5500 report.• SummaryofBenefitsandCoverage(SBC) - a standard notice that is intended to summarize the provisions

of a health plan and to allow individuals to easily compare different coverage options.• SummaryofMaterialModifications(SMM) - a summary of any material change to any information

contained in an SPD.• Summary Plan Description (SPD)-asummarythatexplainsparticipants'rightsandobligationsunderanemployeebenefitplaninaclear,understandablemanner.

• Wellness Program - a program offered by an employer to encourage good health and healthy lifestyles.• WHCRA-Women'sHealthandCancerRightsAct,whichrequiresgrouphealthplanstoprovidebenefitsforreconstructionsurgeryiftheplanprovidesmedicalorsurgicalbenefitsforamastectomy.

Definitions


annual compliance for insured group health plans overview · annual compliance for insured group...

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