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Group Health Plan Disclosures: What Employers Must Tell Participants

Adapted from Understanding Your Fiduciary Responsibilities Under A Group Health Plan, published by the U.S. Department of Labor; selected section: How Do Employees Get Information About the Plan? How Are Employers Required to Report Plan Activities?. The source text is reproduced with headings and formatting adjusted for this guide.

How Do Employees Get Information About the Plan? How Are Employers Required to Report Plan Activities?

Plan administrators must furnish plan information to participants and beneficiaries and submit reports to government agencies.

Informing Participants and Beneficiaries

The following documents must be furnished automatically to participants and beneficiaries.

The Summary Plan Description (SPD) – the basic descriptive document – is a plain language explanation of the plan and must be comprehensive enough to apprise participants of their rights and responsibilities under the plan. It also informs participants about the plan features and what to expect of the plan. Among other things, the SPD must include basic information such as:

  • Plan name, address, and contact information;
  • Plan benefits;
  • How to file a claim for benefits; and
  • Duties of the plan and/or employee.

More specific information must also be provided, including:

  • The plan's claims procedure (either in the document or as separate attachment);
  • Participants' basic rights and responsibilities under ERISA (model language is provided in the SPD rules);
  • Information on premiums, cost-sharing, deductibles, co-payments, etc.;
  • Procedures for using network providers and composition of network;
  • Conditions regarding pre-certification;
  • A description of plan procedures governing Qualified Medical Child Support Orders (see below); and
  • Notices and descriptions of certain rights under the Health Insurance Portability and Accountability Act (HIPAA) and other health coverage laws, described below.

A plan must give employees a summary plan description within 90 days after they are covered by the plan and within 30 days of a request. Generally, summary plan descriptions also must be redistributed every 5th year. The SPD must be current within 120 days.

The Summary of Material Modification (SMM) apprises participants and beneficiaries of changes made to the plan or to the information required to be in the SPD. The SMM or an updated SPD for a group health plan must be furnished automatically to participants not later than 210 days after the end of the plan year in which the change was adopted. If the change is a material reduction in covered services or benefits, the plan administrator must furnish the SMM within 60 days after the reduction is adopted. A material reduction is any plan change that:

  • Eliminates benefits,
  • Reduces benefits payable,
  • Increases premiums, deductibles, coinsurance or co-payments,
  • Reduces the service area an HMO covers, or
  • Establishes new conditions or requirements (such as pre-authorization) for obtaining services or benefits.

A Summary of Benefits and Coverage (SBC) is a uniform template that uses plain language to summarize the key features of a plan, such as covered benefits, cost-sharing provisions and coverage limitations. It must include an internet address where an individual can review a Uniform Glossary of medical and insurance-related terms designed to help consumers compare the terms of their coverage and the extent of medical benefits, as well as contact information for obtaining a paper copy. Plans and insurance companies must provide the summary of benefits and coverage to participants and beneficiaries with the plan's enrollment or application materials, upon renewal or reissuance of coverage, or within 90 days of special enrollment. The summary of benefits and coverage and a copy of the Uniform Glossary also must be provided within seven business days of a request. A template for the summary of benefits and coverage and the Uniform Glossary is available.

A Summary Annual Report (SAR) outlines in narrative form the financial information in the plan's annual return/report, the Form 5500, filed with the Federal Government (see Reporting to the Government for those plans required to file this report). The plan administrator must furnish it annually to participants in plans that are required to file the Form 5500.

Other Group Health Plan Notices

ERISA requires notices under other provisions, such as:

  • The Consolidated Omnibus Budget Reconciliation Act (COBRA),
  • The Health Insurance Portability and Accountability Act (HIPAA),
  • The Affordable Care Act,
  • The Newborns' and Mothers' Health Protection Act, and
  • The Women's Health and Cancer Rights Act.

The SPD may include some of these notices, and others must be provided separately due to the timeframes when they must be provided. For more information on these notices, see the publication Reporting and Disclosure Guide for Employee Benefit Plans. For more information on COBRA, HIPAA, the Affordable Care Act, and the other health plan-related provisions in ERISA, see the resources in the back of this booklet.

Note: If an employer offers Individual Coverage Health Reimbursement Arrangements (HRAs) to reimburse employees (and sometimes their family members) for their medical care expenses, the HRA must provide a notice to eligible employees. They also have to substantiate that participating employees and their families have enrolled in individual insurance. You can find a model notice and model attestation form, as well as more information about Individual Coverage HRAs here.

Disclosures upon Request

In addition to the summary plan description, participants can request the plan document, insurance contracts, and other documents governing the plan's operations. These documents might include, for instance, the criteria for determining whether benefits are medically necessary, as well as the comparative analyses required under the Mental Health Parity and Addiction Equity Act (MHPAEA). A reasonable copying fee may be charged.

Qualified Medical Child Support Orders (QMCSO)

Plans may receive either private medical child support orders (MCSOs) or an order from a state agency about an employee's medical child support obligations. Plans must have procedures to receive, process, and implement qualified medical child support orders. If a plan receives an MCSO, the plan administrator has to provide notice to the participant and any named child (and the child's representative) of the receipt of the MCSO and the plan administrator's determination whether the MCSO is qualified. The plan administrator must provide the notice within a reasonable time period after receipt of the MCSO. For more information on QMCSOs and the standards plans must use to determine whether MCSOs are qualified, request a copy of Qualified Medical Child Support Orders (see "Resources" in the back of the booklet).

Reporting to the Government

Plan administrators generally are required to file a Form 5500 Annual Return/Report with the Federal Government. The Form 5500 provides information about the plan, its finances, and its operation. This information is used by the U.S. Department of Labor, the Internal Revenue Service (IRS), other government agencies, organizations, and the public. Participants and beneficiaries can receive a copy of the Form 5500 from the plan upon request. Depending on the number of participants covered and the plan design, there may be exemptions from the full filing requirements. A group health plan with fewer than 100 participants that is either fully insured or self-funded (or a combination of both) does not need to file an annual report. Plans with 100 or more participants that are fully insured or self-funded (or a combination) can file a limited report. Plans that have relief from the trust requirement discussed in "Employee Contributions" above are considered self-funded.

The form is filed and processed under EFAST2. For more information on the forms, their instructions, and the filing requirements, see DOL's EFAST2 website. See the "Resources" section to obtain a copy of the publication Reporting and Disclosure Guide for Employee Benefit Plans.

Administrators of multiple employer welfare arrangements (MEWAs) generally must file a Form M-1 Report with the Federal Government. The Form M-1 provides information on a MEWA's compliance with the requirements of Part 7 of ERISA, including HIPAA, the Newborns' Act, the Womens' Health and Cancer Rights Act, the Mental Health Parity and Addiction Equity Act (MHPAEA) and the Affordable Care Act. The form must be filed electronically every year. For more information on the Form M-1, see DOL's website on reporting and filing.

Plans required to file the Form M-1 must file the Form 5500. There are penalties for not filing required reports and not providing required information to participants.

This guide concerns U.S. workplace benefits and the federal rules described by the Department of Labor. The type of plan, its governing documents, and the facts of a claim matter. Government, church, and other excluded plans may follow different rules.

Source and scope

Understanding Your Fiduciary Responsibilities Under A Group Health Plan — U.S. Department of Labor. Accessed October 28, 2026. This public domain federal guidance is an educational reference; use the source publication and the applicable plan or employment documents for the full context and later updates. Fynoptic is independent and is not endorsed by the Department of Labor.

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