§ 2520.102-5 - Limited exemption with respect to summary plan descriptions of welfare plans providing benefits through a qualified health maintenance organization.

(a) The summary plan description of an employee welfare benefit plan under which some or all benefits are provided through membership in one or more qualified health maintenance organizations, as defined in section 1310(d) of the Public Health Service Act, as amended, 42 U.S.C. 300e-9(d), shall not be required to include, with respect to any such qualified health maintenance organization, the information described in § 2520.102-3(j)(2), (l), (q) and (s) of this part, provided that:

(1) Such summary plan description contains a notice of the type described in paragraph (b) of this section;

(2) Any request made in the manner described in paragraph (b)(4) of this section is transmitted promptly by the plan administrator to any such organization in which the person making the request is eligible for membership as a benefit under the plan; and

(3) The plan administrator furnishes, in the manner described in § 2520.104b-1 of this part, to each person to whom such summary plan description is furnished, the identity of all such qualified health maintenance organizations in which such person is eligible for membership as a benefit under the plan at a date no later than the date when the option of membership in the qualified health maintenance organization is offered to such person.

(b) The notice referred to in paragraph (a) of this section shall indicate:

(1) The availability of membership in one or more qualified health maintenance organizations as defined in section 1310(d) of the Public Health Service Act, as amended, 42 U.S.C. 300e-9(d), as an option under the plan;

(2) Whether such membership is made available as the sole benefit under the plan, in addition to one or more other benefits, or as an alternative to one or more other benefits;

(3) That each such organization in which membership is available to the participant or beneficiary will supply him or her upon request, written materials concerning (i) the nature of services provided to members; (ii) conditions pertaining to eligibility to receive such services (other than general conditions pertaining to eligibility for participation in the plan) and circumstances under which services may be denied; and (iii) the procedures to be followed in obtaining such services, and the procedures available for the review of claims for services which are denied in whole or in part; and

(4) That requests for the materials described in paragraph (b)(3) of this section may be addressed to the plan administrator.