Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 3, app 1
Small Employer Notice of the Plan's Election of Exemption from Mental Health and Substance Use Disorder Parity for [This Plan Year]
You are receiving this notice as an employee of [name of employer group]. This notice is to inform you that [name of employer group] qualifies and elects to be exempt from the state nervous and mental disorders and substance use disorders coverage parity requirements for this plan year, beginning [insert date of the first day of the plan year]. The employer is eligible to elect this exemption based upon having fewer than 10 eligible employees. Benefits may change as of [insert the date of the first day of the plan year].
Despite the exemption from the state nervous and mental disorders and substance use disorders coverage requirements, state law requires [name of employer group] to comply with the minimum mandated coverage requirements and limitations contained in s. 632.89(2), 2007 Stats., for treatment services for nervous and mental disorders and substance use disorders.
For this plan year, your plan provides the following coverage related to nervous and mental disorders and substance use disorders:
[Insert plain language benefits summary]
Carefully review your health plan's benefits, limitations, and exclusions for detailed information on services and coverage available to you and your family this plan year. If you have additional questions please contact [insert contact name, phone number and e-mail address if available].
Wis. Admin. Code Office of the Commissioner of Insurance, ch. Ins 3, app 1