How to Translate the DOL Health Care Reform Notices Into English

This week I spoke about communicating health care reform at the IFEBP Benefit Communication and Technology Institute in Boston. I talked to a number of highly-engaged folks eager to translate the complicated technical language of benefits into normal, everyday speech.

Like many of us, these people wear many hats and juggle multiple responsibilities. Translating legal notices into plain language sometimes falls to the bottom of the to-do list. These three new notices need work:

  • Annual and lifetime limit changes
  • Revised dependent eligibility for older kids
  • Primary care physician designation and OB/GYN self referral change

So fellow HR practitioners, we submit to you revisions of them. [Please DO involve your lawyers in your final plan. These are legally required disclosures.]

Notice #1: The new dependent eligibility rules

Here’s the legal gobbledygook from the DOL:

Individuals whose coverage ended, or who were denied coverage (or were not eligible for coverage), because the availability of dependent coverage of children ended before attainment of age 26 are eligible to enroll in [Insert name of group health plan or health insurance coverage]. Individuals may request enrollment for such children for 30 days from the date of notice. Enrollment will be effective retroactively to [insert date that is the first day of the first plan year beginning on or after September 23, 2010]. For more information contact the [insert plan administrator or issuer] at [insert contact information].”

Huh? What was that you said?

American lawyers speak another language in addition to their mother tongue. Most of your employees don’t speak it. Try this template language for your enrollment newsletter:

Is your child uninsured?

If your child lost eligibility for our health plan when they turned 19 or when they were no longer a full-time student, the rules have changed. If you would like to enroll your child who is under age 26 on our plan, you may do so from [date] to [date] for coverage effective [date].

Notice #2: The elimination of lifetime limits

Here’s the legal gobbledygook from the DOL:

The lifetime limit on the dollar value of benefits under [Insert name of group health plan or health insurance issuer] no longer applies. Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan. Individuals have 30 days from the date of this notice to request enrollment. For more information contact the [insert plan administrator or issuer] at [insert contact information].”

Now, how about this plain-spoken version instead:

Have you reached the health plan’s lifetime limit?

In the past, our plans shared in the cost of your health care expenses up to a specific dollar amount of [insert amount] over the course of your lifetime. As of [first day of the first plan year beginning on or after September 23, 2010], our plans no longer have lifetime limits. If you lost eligibility for our health plans when your health care costs reached the lifetime limit, you can now re-enroll in our plans. Learn about how we share in the cost of your health care at [insert name of benefits website or other year-round benefits communication vehicle].

Notice #3: Primary care designation notice, if required

Honestly, this one isn’t that bad. And, it’s only required for HMO-like plans that require a gatekeeper doctor to coordinate your care — definitely not the majority of plans. It’s got three separate parts, that for our purposes, we’ll string together.

[Name of group health plan or health insurance issuer] generally [requires/allows] the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. [If the plan or health insurance coverage designates a primary care provider automatically, insert: Until you make this designation, [name of group health plan or health insurance issuer] designates one for you.] For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the [plan administrator or issuer] at [insert contact information].

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For children, you may designate a pediatrician as the primary care provider.

You do not need prior authorization from [name of group health plan or issuer] or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the [plan administrator or issuer] at [insert contact information].

Understandable, but let’s see if we can shorten it up a little, and give a little context.

You should choose a primary care provider or an OB/GYN at enrollment

When you choose [name of group health plan] during enrollment, you will be asked to choose the doctor who will coordinate your health care—sometimes called a primary care provider (PCP)—within the plan’s network. Your primary doctor may refer you to specialists, when necessary. If you suspect you need the help of a specialist, you’ll need your primary doctor to formally refer you to a specialist.

There are a few exceptions:

  • Women: You may seek obstetrical or gynecological care without prior permission from your primary care doctor. If necessary, your OB/GYN will coordinate care on your behalf. This might mean complying with certain rules from your health plan, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or following procedures for making referrals.
  • Children: Parents may choose a pediatrician.

To see if your current doctor is within the plan’s network or to find a new doctor near you, [insert contact information]. If you’d like to change your primary doctor at any time, just [insert contact information] before your next appointment.

Common sense caveat: This article was originally published by Benz Communications, an employee benefits communication consulting firm. We know benefits. We know what your employees care about. We know how to help you bridge the two. We are not attorneys and nothing in this constitutes legal advice or anything coming close to it. In addition, as we all know, the legislation and regulations are in flux. This information is accurate at the time it was published but you should consult the HHS website or other sources for the most up-to-date information at the time you communicate to employees.

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