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August 28, 2014

Department of Labor (DOL) Audit Letters Requesting Proof of Compliance with Health Care Reform Requirements

The U.S. Department of Labor (DOL) audits already evaluate a company’s compliance on a spectrum of laws, statutes and regulations.  However, the DOL has updated and revamped its audit letter to now also capture compliance aspects of the Patient Protection and Affordance Care Act.   Not only is the DOL looking for certain compliance information on health plans, but also for the various records and documents related to the plan.

The U.S. Department of Labor (DOL) recently expanded its health plan audit letter to request documents demonstrating compliance with the Patient Protection and Affordable Care Act (ACA).

All Plans (Regardless of Grandfathered Status)

  • If a plan provides dependent coverage, samples of the written notice describing enrollment opportunities related to dependent coverage of children up to age 26
  • A list of any individuals whose coverage has been rescinded, the reasons for the rescissions and copies of the written notices of rescission that were provided
  • If a plan has imposed a lifetime limit at any time since September 23, 2010, (1) documents showing the limits applicable for each plan year, and (2) samples of each form of notice sent to participants stating that the lifetime limit on the dollar value of all benefits no longer applies
  • If a plan has imposed an annual limit at any time since September 23, 2010, documents showing the limits applicable for each plan year, including any waivers

Grandfathered Plans

  • Copies of the required grandfathered health plan status disclosure statements
  • Records documenting the terms of the plan in effect on March 23, 2010, and any other documents necessary to verify, explain or clarify status as a grandfathered health plan (including terms of cost sharing, contribution rates, annual and lifetime limits on benefits, and any contract with a health insurance issuer in effect on March 23, 2010)

Non-Grandfathered Plans

  • Copies of the plan’s disclosure notices informing participants of the right to designate a primary physician and a list of participants who received the notices
  • Samples of adverse benefit determinations and external review decision notices utilized by the plan on or after September 23, 2010
  • If applicable, any contract or agreement with an independent review organization or third-party administrator providing external review

The DOL has also begun requesting documents related to compliance with the Mental Health Parity and Addiction Equity Act, and health plan sponsors must continue to provide documentation of compliance with the Health Insurance Portability and Accountability Act, the Newborns’ and Mothers’ Health Protection Act, the Women’s Health and Cancer Rights Act, and COBRA.  Health plan sponsors are also asked to provide general plan documents, including copies of plans and amendments, summary plan descriptions and summaries of material modifications, documents sent to participants regarding plan benefits and claims, contracts with third-party providers, and any documents describing wellness or disease management programs offered by the plan.

Not only should health plan sponsors regularly review their plans’ compliance with the requirements of the ACA and other applicable legislation, but they should also review their document retention procedures to ensure they have comprehensive records that could be provided to the DOL in the event of an audit. 

© 2014 McDermott Will & Emery

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About this Author

Associate

Maggie McTigue is an associate in the law firm of McDermott Will & Emery LLP and is based in the Firm’s Chicago office.  She focuses her practice on a variety of employee benefits matters relating to pension and 401(k) plans, health and welfare benefit plans, and executive compensation.

312 984 5812
Partner

Susan M. Nash is a partner in the law firm of McDermott Will & Emery LLP and is based in the Firm’s Chicago office.  Susan focuses her practice primarily in the area of health and welfare benefit plans, including compliance with COBRA, HIPAA, ERISA, the Affordable Care Act, the Internal Revenue Code, and other federal laws affecting group health plans.

312-984-7660
Partner

Mary K. Samsa is a partner in the law firm of McDermott Will & Emery LLP and is based in the Firm’s Chicago office.

Mary has more than 15 years of experience and has represented a wide range of organizations including, but not limited to, Fortune 100 public companies, privately held companies, multinational organizations and not-for-profit hospital systems as well as educational institutions.  Mary’s primary practice focuses on executive compensation (for both taxable and tax-exempt entities) where she regularly advises on nonqualified deferred...

312-984-2142