The Affordable Care Act (ACA) requires that major medical group health plans provide certain notice to participants if the plan requires designation of a primary care provider.

The law requires both the plan itself and any health insurance company providing insured major medical benefits to provide the notice. Plans that are fully insured could rely on the insurer to handle this notice, but a careful employer will make sure the insurance company is timely providing both types of notices. Self-insured plans are all on their own to ensure compliance with the ACA provider choice notice requirement.

The provider choice notice is fairly straightforward. The DOL has provided model notices that you can download in both English and Spanish.

Under the implementing regulations, the provider choice notice "must be included whenever the plan or [insurance carrier] provides a participant with a summary plan description or other similar description of benefits under the plan or health insurance coverage." Neither HHS, nor DOL or IRS have provided guidance on what "other similar description" means, but at a minimum, the notice must be given at open enrollment and initial or special enrollment.

Because the regulations say the notice must be provided any time another description of benefits is provided, the recipient and delivery requirements for the provider choice notice piggyback the other benefit description's recipient and delivery requirements. Generally (very generally), such disclosures must be provided to all new employee-participants and to dependent/spouse beneficiaries when the plan sponsor or the plan administrator knows that the address of a beneficiary is different than the last known address of the employee-participant.