Model Notice to Enrollees in a Self-Funded Nonfederal Governmental Group Health Plan

Under a 1996 Federal law, group health plans must generally comply with the requirements listed below. However, the law also permits State and local governmental employers that sponsor health plans to elect to exempt a plan from these requirements for any part of the plan that is self-funded by the employer, rather than provided through a health insurance policy. (Name of plan sponsor) has elected to exempt (name of plan) from (all) (or specify which ones) of the following requirements [the bracketed material may be omitted]:

1. Limitations on preexisting condition exclusion periods. [A preexisting condition exclusion period generally may not exceed 12 months, and must be reduced, under certain circumstances, by prior health coverage an individual has had.]
2. Special enrollment periods. [Group health plans are required to provide special enrollment periods for individuals who do not initially enroll in the plan because they have other coverage, but subsequently lose that coverage. Also, if a plan provides dependent coverage, the plan must provide a special enrollment period for new dependents within 30 days after a marriage, birth, adoption or placement for adoption.]
3. Prohibitions against discriminating against individual participants and beneficiaries based on health status. [A group health plan may not discriminate in enrollment rules or premium contributions based on certain health status-related factors: health status, medical condition (physical and mental illnesses), claims experience, receipt of health care, medical history, genetic information, evidence of insurability, and disability.]
4. Standards relating to benefits for mothers and newborns [Group health plans offering health coverage for hospital stays in connection with the birth of a child generally may not restrict benefits during the first 48 hours for a normal vaginal delivery, and 96 hours for a cesarean section.]
5. Parity in the application of certain limits to mental health benefits [Group health plans offering mental health benefits may not set annual or lifetime dollar limits on mental health benefits that are lower than limits for medical and surgical benefits. A plan that does not impose an annual or lifetime dollar limit on medical and surgical benefits may not impose that type of limit on mental health benefits. These requirements do not apply to benefits for substance abuse or chemical dependency.]
6. Required coverage for reconstructive surgery following mastectomies [Group health plans that provide medical and surgical benefits with respect to a mastectomy must provide certain benefits in connection with breast reconstruction.]

The exemption from these Federal requirements will be in effect for the (plan year)(period of plan coverage) beginning (specify date) and ending (specify date). The election may be renewed for subsequent plan years.

(If the Plan provides protections similar to any of the exempted requirements, either voluntarily or in accordance with State law, identify those protections.)

The law also requires the Plan to provide covered employes and dependents with a certificate of creditable coverage when they cease to be covered under the Plan. There is no exemption from this requirement. The certificate provides evidence that you were covered under this Plan, because if you can establish your prior coverage, you may be entitled to certain rights if you join another employer's health plan, or if you wish to purchase an individual health insurance policy.

(If someone will be available to answer questions, an appropriate contact, such as a third party administrator, or personnel office may be identified).