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(A) IN GENERAL.—A group health plan, 
and a health insurance issuer that provides cov-
erage in connection with health insurance cov-
erage, shall provide for the disclosure to partici-
pants, beneficiaries, and enrollees—
(i) of the information described in 
subsection (b) at the time of the initial en-
rollment of the participant, beneficiary, or 
enrollee under the plan or coverage; 
(ii) of such information on an annual 
basis—
(I) in conjunction with the elec-
tion period of the plan or coverage if 
the plan or coverage has such an elec-
tion period; or 
(II) in the case of a plan or cov-
erage that does not have an election 
period, in conjunction with the begin-
ning of the plan or coverage year; and 
(iii) of information relating to any 
material reduction to the benefits or infor-
mation described in such subsection or 
subsection (c), in the form of a notice pro-
vided not later than 30 days before the 
date on which the reduction takes effect.
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(B) PARTICIPANTS, BENEFICIARIES, AND 
ENROLLEES.—The disclosure required under 
subparagraph (A) shall be provided—
(i) jointly to each participant, bene-
ficiary, and enrollee who reside at the same 
address; or 
(ii) in the case of a beneficiary or en-
rollee who does not reside at the same ad-
dress as the participant or another en-
rollee, separately to the participant or 
other enrollees and such beneficiary or en-
rollee. 
(2) PROVISION OF INFORMATION.—Information 
shall be provided to participants, beneficiaries, and 
enrollees under this section at the last known ad-
dress maintained by the plan or issuer with respect 
to such participants, beneficiaries, or enrollees, to 
the extent that such information is provided to par-
ticipants, beneficiaries, or enrollees via the United 
States Postal Service or other private delivery serv-
ice. 
(b) REQUIRED INFORMATION.—The informational 
materials to be distributed under this section shall include 
for each option available under the group health plan or 
health insurance coverage the following:
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(1) BENEFITS.—A description of the covered 
benefits, including—
(A) any in- and out-of-network benefits; 
(B) specific preventive services covered 
under the plan or coverage if such services are 
covered; 
(C) any specific exclusions or express limi-
tations 
of 
benefits 
described 
in 
section 
104(d)(3)(C); 
(D) any other benefit limitations, including 
any annual or lifetime benefit limits and any 
monetary limits or limits on the number of vis-
its, days, or services, and any specific coverage 
exclusions; and 
(E) any definition of medical necessity 
used in making coverage determinations by the 
plan, issuer, or claims administrator. 
(2) COST SHARING.—A description of any cost-
sharing requirements, including—
(A) any premiums, deductibles, coinsur-
ance, copayment amounts, and liability for bal-
ance billing, for which the participant, bene-
ficiary, or enrollee will be responsible under 
each option available under the plan;
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(B) any maximum out-of-pocket expense 
for which the participant, beneficiary, or en-
rollee may be liable;
(C) any cost-sharing requirements for out-
of-network benefits or services received from 
nonparticipating providers; and 
(D) any additional cost-sharing or charges 
for benefits and services that are furnished 
without meeting applicable plan or coverage re-
quirements, such as prior authorization or 
precertification. 
(3) DISENROLLMENT.—Information relating to 
the disenrollment of a participant, beneficiary, or en-
rollee. 
(4) SERVICE AREA.—A description of the plan 
or issuer’s service area, including the provision of 
any out-of-area coverage. 
(5) PARTICIPATING PROVIDERS.—A directory of 
participating providers (to the extent a plan or 
issuer provides coverage through a network of pro-
viders) that includes, at a minimum, the name, ad-
dress, and telephone number of each participating 
provider, and information about how to inquire 
whether a participating provider is currently accept-
ing new patients.
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(6) CHOICE OF PRIMARY CARE PROVIDER.—A 
description of any requirements and procedures to 
be used by participants, beneficiaries, and enrollees 
in selecting, accessing, or changing their primary 
care provider, including providers both within and 
outside of the network (if the plan or issuer permits 
out-of-network services), and the right to select a pe-
diatrician as a primary care provider under section 
116 for a participant, beneficiary, or enrollee who is 
a child if such section applies. 
(7) PREAUTHORIZATION
REQUIREMENTS.—A 
description of the requirements and procedures to be 
used to obtain preauthorization for health services, 
if such preauthorization is required. 
(8) EXPERIMENTAL
AND
INVESTIGATIONAL 
TREATMENTS.—A description of the process for de-
termining whether a particular item, service, or 
treatment is considered experimental or investiga-
tional, and the circumstances under which such 
treatments are covered by the plan or issuer. 
(9) SPECIALTY CARE.—A description of the re-
quirements and procedures to be used by partici-
pants, beneficiaries, and enrollees in accessing spe-
cialty care and obtaining referrals to participating 
and nonparticipating specialists, including any limi-
116
tations on choice of health care professionals re-
ferred to in section 112(b)(2) and the right to timely 
access to specialists care under section 114 if such 
section applies. 
(10) CLINICAL TRIALS.—A description of the 
circumstances and conditions under which participa-
tion in clinical trials is covered under the terms and 
conditions of the plan or coverage, and the right to 
obtain coverage for approved clinical trials under 
section 119 if such section applies. 
(11) PRESCRIPTION DRUGS.—To the extent the 
plan or issuer provides coverage for prescription 
drugs, a statement of whether such coverage is lim-
ited to drugs included in a formulary, a description 
of any provisions and cost-sharing required for ob-
taining on- and off-formulary medications, and a de-
scription of the rights of participants, beneficiaries, 
and enrollees in obtaining access to prescription 
drugs under section 118 if such section applies. 
(12) EMERGENCY
SERVICES.—A summary of 
the rules and procedures for accessing emergency 
services, including the right of a participant, bene-
ficiary, or enrollee to obtain emergency services 
under the prudent layperson standard under section 
113, if such section applies, and any educational in-