Health Insurance Events/Documents
Summary Plan Descriptions (SPD), Summary Material Modifications (SMM), Loss of Coverage notices. Qualified Life Events, Special Enrollment Periods, Notices of Privacy Policies, COBRA notices, and Accounting of Disclosures are all important events or documents an individual might experience or obtain regarding activities associated with their health insurance plan. The website of the Department of Health and Human Services, the Department of Labor, and Healthcare.gov are all excellent resources and contain a wealth of additional information on the subject.
Summary Plan Descriptions (SPD) and Summary of material modifications (SMM)
- A Summary Plan Description (SPD) is a document that informs participants and beneficiaries about the details of their health insurance plan.
- SPDs are mandated by federal law, ERISA (The Employee Retirement Income Security Act), and must be made readily available, either through an employer or other means, to any plan participants within 90 days of initial enrollment.
- An SPD must be written using language that is clear and comprehensive, detailing all benefits, rights, and obligations of the participant and the provider under the plan.
- An SPD must be current, including accurate details within the last 120 days prior to the SPD's disclosure.
- SPDs must also include the details of participants' COBRA rights associated with the plan.
- A Summary of Material Modifications (SMM) is required if there are changes made to the plan and should be provided to participants no more than 210 days following the end of the plan year in which the changes took effect.
- If an SMM includes a material reduction in plan benefits or covered services, the SMM must be provided to covered individuals no later than 60 days after the reduction becomes effective.
Loss of coverage notice
- A Loss of Coverage notice is issued to a plan participant either by the plan provider, former employer, or both. It is required when attempting to enroll in new healthcare coverage following that coverage loss, due to either loss of employment or other qualifying circumstances.
- According to COBRA, the Consolidated Omnibus Budget Reconciliation Act, and additional state laws, when a participant loses a job, an employer is required to send a Loss of Coverage notice letter that must be on the employer's stationery or letterhead and include the employer’s signature.
- A Loss of Coverage notice must include the participant's name and the names of any dependents that were covered under the plan the participant was enrolled in during the employment period, and the date that the healthcare plan coverage ceased.
- Loss of coverage due to job loss, qualifying life events, or other special circumstances entitles an individual to access and enroll in a variety of new health coverage options outside of the prospective plan's open enrollment period.
Qualifying life events
- Qualifying Life Events include but are not limited to:
3) Losing the minimal essential coverage, as defined by the Affordable Care Act, due to events such a losing a job or loss of eligibility as a dependent.
- Qualifying life events entitle plan participants to change or update current healthcare coverage, or enroll in new coverage, within the prescribed period as outlined by the coverage plan, which is generally 90 days, but may be different depending on the qualifying circumstance and the plan rules.
- The responsibility to report a qualifying event in order to elect continuing coverage under COBRA depends on the type of event that is being reported.
- Employers are required to notify plan providers in the case of a participant's death, loss of a job, loss of coverage due to a decrease in hours worked, an employee becomes eligible for Medicare coverage, or the employer declares bankruptcy.
- An employee is responsible for notifying his or her healthcare plan provider of loss of coverage due to a qualifying life event if the qualifying event is a divorce or a separation, or if a covered child loses dependent eligibility.
Special enrollment period
- There are some circumstances that may qualify an applicant to be eligible for a special enrollment period, outside of qualifying life events. Some examples include:
1) If a participant experienced a serious medical condition or a natural disaster that prevented them from selecting
benefits during the open enrollment period.
2) If a participant received misinformation or was deceived by someone working as a representative of an insurance
company, a certified application counselor, or broker.
3) If a technical error occurred when an applicant attempted to select coverage during an open enrollment period that
either prevented them from enrolling in a plan or resulted in the health insurance company not receiving correct
4) If the participant had a change in address in the last 60 days that made him/her eligible for Medicaid (a move from a state that does not
participate in expanded Medicaid to a state that does, for example).
5) If a participant becomes responsible for a new dependent or became a dependent of someone else. For instance, a
parent is court-ordered to provide healthcare coverage for a child dependent outside of the open enrollment period.
6) An appeal regarding a denial of coverage is ruled in the participant favor after the open enrollment period has expired.
- Special enrollment periods for extenuating circumstances are not always available to participants that are enrolled through a private insurance company or have group health insurance coverage through an employer.
Notice of privacy practices
- Healthcare plan providers and physicians are required to give plan participants and/or patients a Notice of Privacy Practices.
- A Notice of Privacy Practices tells you how the healthcare plan or provider may use or share his or her personal health information.
- A Notice of Privacy Practices from a healthcare plan provider is shared with participants at the time of enrollment and at least once every three years thereafter. It also must be available on the provider's website.
- A Notice of Privacy Practices from a physician or healthcare facility is generally provided to patients during an initial visit or at the time of service. It must also be posted on any associated website.
- A new Notice of Privacy Practices must be provided to a participant or patient any time there are changes to the way a plan or provider uses or shares private health information.
- COBRA, the Consolidated Omnibus Budget Reconciliation Act, is a government-mandated program that allows employees to continue coverage after they have lost their job with that employer.
- COBRA can be prohibitively expensive as it involves paying the participant's portion of the monthly plan premium and the employer's portion, and an administrative fee.
- The maximum amount a participant can be charged for COBRA coverage is 102% of the total combined premium paid by both employee and employer before the participant separated from the employer.
- When a plan provider receives a notice of a qualifying event, the plan must provide an election notice, which details the participant's rights and explains how to continue coverage.
- A COBRA election notice must be provided by the plan administrator to participants within 14 days after the plan receives notice of the qualifying event.
- COBRA election notices should contain any information participants will need to continue coverage and make an informed decision on which, if any, coverage they would like to elect, including the name of and contact information for the plan’s COBRA administrator.
- COBRA extends healthcare plan coverage for 18 to 36 months from the date of the qualifying event, depending on the nature of the qualifying event and other factors such as the participant's eligibility for Medicare.
Accounting of disclosures
- Identity thieves can obtain and use victims' names and health insurance information to seek medical treatment, obtain prescription drugs, and file claims with healthcare insurance providers.
- Victims of medical identity theft then may have incorrect information in their health records that can affect treatment, insurance benefits and eligibility, and even credit reports.
- To avoid medical identity theft, individuals should ask health plans and medical providers for an Accounting of Disclosures from their medical records.
- An Accounting of Disclosures is a record of any entity that received copies of someone's private medical records from a healthcare plan or medical care provider, and individuals are legally entitled to ask for one free copy from each healthcare plan or medical provider every 12 months.
- Once received, an Accounting of Disclosures should be reviewed and any incorrect information that has been shared with a patient's healthcare plan or other providers can be corrected.
- An Accounting of Disclosures will show who has copies of any mistaken records and healthcare plans. Providers are legally obligated to contact them and correct any erroneous information.
- There are numerous additional forms and events that affect participants and are regulated by federal law, most covered by two laws, ERISA (The Employee Retirement Income Security Act) and HIPAA (Health Insurance Portability and Accountability Act).
- The Employee Retirement Income Security Act of 1974 (ERISA) sets minimum standards for voluntarily retirement and health plans offered by private employers to protect individuals participating in these plans.
- ERISA requires plans to provide participants with plan information, including information about features and funding. It mandates financial responsibilities of the plan administrators, and also requires that all plans incorporate an appeals process for participants who are denied coverage of any kind under the plan.
- ERISA gives plan participants the right to sue for benefits if they believe plan administrators have acted illegally. (Source 6)
- The Health Insurance Portability and Accountability Act (HIPAA) is an amendment to ERISA and is intended to protect working Americans and their dependents and beneficiaries from health coverage discrimination based on factors such as preexisting conditions.
- HIPAA gives participants and patients the right to view what is in their medical records and also define any third parties that should have access to those records.