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DOL Audit Letters Revised for PPACA: Asking for Specifics

Posted in Plan Administration, Welfare Plans

By off chance, a client sent me a letter from the Department of Labor conducting an audit of their self-funded health plan.  While I have responded to many audit requests in the past, this most recent audit letter was unique in that it is the first one I have received that specifically requests information related to compliance with PPACA.  Looking at what was specifically requested by the DOL in it’s audit can go a long way toward preparing plan sponsors for compliance with these requests, so let’s consider the PPACA specific documents the DOL asked to see.

The DOL requested that, if a plan is claiming grandfathered status, it provide a copy of the "grandfathered health plan status disclosure statement" as well as each document the plan maintained substantiating it retained grandfathered status.  The DOL also requested a copy of each written notice describing the opportunity to enroll dependents up to age 26 as well as copies of all notices relating to lifetime or annual limits, or the elimination of those limits.  Also included was a request for copies of all summary material modifications related to any plan changes instituted to effect PPACA compliance.

The audit request included a request for the process and procedure for administering external appeals, as well as a contract hiring an external appeals administrator and the process for evaluating that administrator.  The DOL also requested copies of the last five appeals filed after September 23, 2010, with all information relating to the highest level appeal that was completed.  There was a request for the notice informing participants of the rights to designate primary care physicians if the plan is not grandfathered, samples of all adverse benefit determination notices and copies of all documents issued in a non-English language required for counties with 10% or more of the population speak a particular language.

Of course, to the extent all of this documentation should now be a part of a plan’s administrative process, it should not come as complete surprise that it was requested.  But it does serve as a reminder of the reporting and documentation requirements that existed before, and was modified by, PPACA.  If you don’t have some of these documents, or were not aware they were required, now would be a good time to find out more about them so that if you are audited in the future, you have the documents at the ready.  And if you do receive an audit notice, make sure you ask for assistance from your attorneys at Fox Rothschild.