Model Notices

The Women’s Health and Cancer Rights Act

(WHCRA) requires that an annual notice be distributed to participants.  The document informs participants of their right to certain benefits following a mastectomy.​Download File

The Exchange Notice FLSA

Form if anyone is thinking about moving to a Marketplace Exchange insurance plan.

The Medicare Part D Disclosure Notice (Creditable Coverage)

To eligible Individuals notifies participants as to whether the plan’s prescription drug coverage is creditable compared to Medicare Part D prescription drug coverage.  In other words, is the group prescription drug coverage equal to or better than the prescription benefits provided under Medicare Part D.  This has a deadline of October 15, to give out to employees. Go on the CMS website and file there before 10/15 as well.

Newborns and Mothers Health Protection Act

To eligible individuals notifies eligible participants of Federal Laws surrounding hospital stays.

The Employer CHIP Notice ​

(CHIP) Must be provided annually to eligible employees.  It describes the employee’s and any dependents’ right to enroll in the plan at a later date if they lose eligibility for Medicaid or CHIP or become eligible for state premium assistance.  The notice is only required to be distributed to eligible employees who live in states that have state premium assistance programs.

The USERRA Private Notice

Protects the job rights of individuals who voluntarily or involuntarily leave employment positions to undertake military service or certain types of service in the National Disaster Medical System. ​

HIPPA Notice of Special Enrollment Rights 

To Eligible individuals notifies of special enrollments rights such as if you declined benefits during open enrollment, under certain circumstances you can become eligible for our plan coverage during the year.

Initial COBRA Notice ​

To participants informing of option to enroll in COBRA if eligible.
* See full benefit summaries for details, exclusions, out of network co-pays, & other coverage.  Covered expenses only. This web site is not a legal document.  This web site is not a guarantee of coverage, eligibility, or provider status and is designed for informational illustration only.  Benefits outlined on this web site are subject to change at any time.  Please consult your benefit plan provider(s) or administrator(s) for legal documents regarding your plan and to check coverage and/or eligibility