(a) Unless such notice is otherwise provided to a participating employee or former employee pursuant to another provision of this part, a multiple-employer welfare arrangement, in connection with an employee welfare benefit plan, that is self-funded shall provide to each participating employee or former employee covered by the plan the written notice containing, at a minimum, the items described in subdivisions (a)(1) – (5) of this section, at the time the coverage of such participating employee or former employee becomes effective:

1. (1) That individuals covered by the plan are only partially insured;
2. (2) That in the event the plan or the multiple-employer welfare arrangement does not ultimately pay medical expenses that are eligible for payment under the plan for any reason, the participating employer or its participating employee covered by the plan may be liable for those expenses;
3. (3) That the plan does not participate in the guaranty fund;
4. (4) The toll-free telephone number for the complaints section of the State Insurance Department; and
5. (5) That a copy of the summary plan description may be obtained from the plan administrator, employer, or trustee, as applicable.