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Health Plan Audits: What You Need

Much as the Internal Revenue Service has the authority to audit tax returns, the Department of Labor (DOL) has a broad mandate to investigate and audit an employee benefits plan’s compliance with the Employee Retirement Income Security Act (ERISA).

Audits are performed by the DOL’s Employee Benefits Security Administration (EBSA), and will often focus on violations of ERISA’s fiduciary obligations, as well as reporting and disclosure requirements.

Employers receiving notice of an audit are often surprised and overwhelmed by the sheer number of documents requested. Keeping files current and carefully organized is vital, and will greatly streamline the process of preparing for an audit. Employers should also keep careful records showing that participant notices and required disclosures have been provided in a timely fashion.

Here’s a checklist of documentation likely to be requested:

Plan Documents:

  • Plan document (or insurance booklet/certificate for an insured plan)
  • Summary plan description (SPD), including updates or summaries of material modifications (SMMs)
  • Forms 5500 and attachments, including supporting documentation (if applicable)
  • Summary annual reports (if required for plan)
  • List of all plan service providers and related contracts
  • All contracts with insurance companies
  • Open enrollment materials, including documents describing cost responsibilities for the employer and employees
  • Any trust documents relating to plan assets

Administrative Documents:

  • Insurance billing invoices, premium schedules, employer and employee contribution schedules, and payroll records of withholdings for benefits
  • Documents evidencing payroll deductions for employee premiums to the plan
  • Documents evidencing current outstanding medical claims
  • List of COBRA participants, including COBRA start date and amount of COBRA payment
  • Copy of any rebate paid pursuant to the medical loss ratio (MLR) requirements and documentation of what was done with the rebate

Health Plan Compliance Documents:

  • Newborns’ and Mothers’ Health Protection Act notice (may be included in the SPD)
  • Women’s Health & Cancer Rights Act notice
  • Annual Children’s Health Insurance Program (CHIP) notice
  • Materials describing any wellness programs or disease management programs offered by the plan, including rewards based on a health factor
  • Documents showing compliance with HIPAA’s portability rules, including special enrollment rights
  • Documents showing compliance with COBRA, including general notice, election notice, notice of COBRA unavailability, notice of early termination and notice of insufficient payment
  • If the plan has grandfathered status under the ACA, documents that verify the plan’s status (such as records documenting the terms of the plan in effect on March 23, 2010, and/or documentation relating to the terms of cost sharing and the contribution rate of the employer or employee organization toward the cost of any tier of coverage) and the notice of grandfathered plan status
  • If the plan has rescinded coverage, a list of those participants and dependents whose coverage has been rescinded, the reasons for the rescission and the notice of rescission
  • Plan provisions regarding lifetime and annual limits and the notice describing enrollment opportunities for individuals who previously lost coverage due to a lifetime limit
  • Summary of Benefits and Coverage and any 60-day advance notice of a midyear material change to the plan
  • Health Insurance Exchange notice (Notice of Coverage Options)
  • For non-grandfathered plans, notice of patient protections and selection of providers
  • For non-grandfathered plans, information on the plan’s claims and appeals procedures, including copies of notice documents and any contracts or agreements with any independent review organization or third-party administrator providing external review
  • A notice describing enrollment opportunities for children up to age 26 for plans with dependent coverage

You can see why many employers are overwhelmed, and why careful preparation and organization are critical to meeting the strict deadlines associated with providing information for an audit.

Questions about benefit plan audits or other benefits issues? Contact Consolidated Insurance.