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DOL Audit of Health Plan


Guest Quicksilver
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Guest Quicksilver

Out of the blue a client has received notice of a DOL audit of their health plan.

They are fully insured, and under 100 participants, so no 5500 has been filed. They have requested all plan documents and forms. Has anyone seen this activity from DOL?

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Is the ER involved in any litigation with a former EE?

In my experience, the DoL usually does not do these type of document requests without responding to a complaint from a former employee--or upset current employee. The DoL is usually so requesting to see if a claim denial is consistent with or contrary to the plan documents.

John Simmons

johnsimmonslaw@gmail.com

Note to Readers: For you, I'm a stranger posting on a bulletin board. Posts here should not be given the same weight as personalized advice from a professional who knows or can learn all the facts of your situation.

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Guest ERISAdiagnostics
Out of the blue a client has received notice of a DOL audit of their health plan.

They are fully insured, and under 100 participants, so no 5500 has been filed. They have requested all plan documents and forms. Has anyone seen this activity from DOL?

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Guest ERISAdiagnostics

yes, my client received a similar request in January 2008; it was around the time of the first 5500 filing due to exceeding 100 for the first time; completely insured; I helped my client gather all the requested information, draft responses to those items that were not applicable. The information was sent to the DOL; a little over a year later and no response one way or the other. I heard (whether it is true or not) that various DOL offices have to conduct a certain number of audits.

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Guest mcapuano
Out of the blue a client has received notice of a DOL audit of their health plan.

They are fully insured, and under 100 participants, so no 5500 has been filed. They have requested all plan documents and forms. Has anyone seen this activity from DOL?

The DOL is stepping up their efforts to audit welfare benefit plans. It certainly may be true that an employee has filed a complaint, but if that were the case the DOL would be specific in their inquiry. Most likely what your client received is a "random" benefit audit. We have had a handful of smaller fully-insured clients receive these same notices. One client was only 35 Plan Participants, another had only 2! Form 5500 is not the issue here - if your client has less than 100 Plan Participants, generally Form 5500 is not required, BUT, as with most smaller fully-insured employers (under 100 participants and more) the biggest area of non-compliance is under ERISA where every employer - regardless of size - and whether fully-insured or self-insured are required to furnish a Summary Plan Description (SPD) in addition to the Certificate of Coverage (COC) issued by the insurance carrier, because the COC rarely, if ever, (unless it's for a self-insured plan) includes the information required to be included in an SPD. We created a "DOL Benefit Audit Service Pack" for our fully-insured clients that includes the use of an SPD Wrap Document. This is a document that simply "wraps" around the COC.

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Guest erisafried

The reason for the audit may also depend on where you are and any non-vanilla features of the plan or funding mechanism that could be divined from the 5500. I had a health plan (fully insured) that got audited on the West Coast because the DOL's San Francisco regional office had a particular enforcement initiative going. Does the plan use an experience-rated contract or other other funding vehicle where there can be refunds if claims experience is favorable? That was the issue (picked up from a 5500) that triggered the audit -- at least that is what I inferred from talking to the agent.

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  • 4 weeks later...
Guest Quicksilver

Thanks for all the input, I thought I would let everyone know the outcome.

They will send us the audit results in about two months. He did let me know the letter will say we are not in compliance with ERISA, but the "complaint" will only include the missing Newborns' Act notice (DOL list 12), the Women's Health and Cancer Rights Act notice (DOL list 13) and missing written procedures to provide employees with certificates of creditable coverage (DOL list 8). The DOL will help us put together a "Wrap Document" as an addendum to our employee manual, which will then be distributed to all full time employees. There will also be a request for our Ins Comp. Documentation and/or Website document access to include the Newborns' Act Notice in the summary plan description.

The DOL is looking for the annual mailing of these notices, and not just their availability on-line. We have asked the Ins. carrier if they will be changing their notice procedures

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What does the requirement for those (and other) notices have to do with your insurance carrier? These notices are Plan requirements and not dependent on method of providing health benefits coverage.

George D. Burns

Cost Reduction Strategies

Burns and Associates, Inc

www.costreductionstrategies.com(under construction)

www.employeebenefitsstrategies.com(under construction)

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