DOL Health Plan Audit: Overview and Triggers | Generous Benefits

Why Would the Department of Labor Audit Your Health Plan? Why Now?

Before we dive into our Department of Labor (DOL) health plan audit overview and triggers, let’s take a quick review of the two main acronyms we use when discussing DOL health plan audits:

ERISA: Employee Retirement Income Security Act

• Established in 1974 and set minimum standards for pension and welfare plans
• Designed to protect employee benefit rights
  
  

EBSA: Employee Benefits Security Administration

• One of the many entities within the Department of Labor (DOL Organizational Chart)
• EBSA focuses on ERISA Title I compliance:  Fiduciary obligations, reporting & disclosure, group health plan requirements and compliance with the Affordable Care Act (ACA).
• Traditionally, audits have focused on retirement plans like the 401(k),  but recently the EBSA has shifted to enforcing health plan compliance surrounding ACA regulations and reporting requirements.

Now that we have those two definitions clear, let’s talk about what a DOL Health Plan Audit is and why would they audit your health plan?

What Triggers a DOL Health Plan Audit?

There are three main triggers for your health plan being audited.

#1. Someone Complained 

People can complain directly to the EBSA, potentially triggering an audit.  In 2022, “EBSA Benefits Advisors closed more than 168,000 inquiries and recovered $422.1 million in benefits on behalf of workers and their families through informal resolution of individual complaints.”

#2.  Bad Answers or Missing Form 5500 Filings

These are required for all retirement plans as well as any other benefit plan with over 100 participants.  Small groups are exempt from these on their health plan filings, but are required for their retirement/401(k) offerings.  Large groups get to fill out several of these per plan year. Inconsistency is the main trigger here.

#3.  It’s a New Priority

Not really all that new anymore is the addition of ACA compliance.  However, this addition of the nations newest health law has brought more attention to regulation, increased the number of auditors and put a spotlight not only on ACA compliance, but also the older regulations for COBRA, HIPAA, Mental Health Parity, Genetic Information Nondiscrimination and Multiple Employer Welfare Arrangements.

Preparation is Key to Avoiding an Audit

It is much easier to prepare and analyze whether you are ready before the DOL knocks on your door.  A DOL audit is not a simple process. And, it will save a large amount of money and stress to get ahead of the inevitable.

You need to establish a record keeping system and maintain all important documents surrounding your employee benefits program as well as focus on:

• Respond to participant (employees) benefit questions and request for information in a timely manner
• File Form 5500 on time and make sure it is complete and accurate
• Distribute participant notices required by law (for example the Summary of Benefits and Coverage each plan year or the Notice of Exchange during hiring)
• Make timely updates to plan documents and summary plan descriptions (SPDs) to reflect legal and design changes.

Oh, and a SPD is not the same as a Benefits Summary.  I know, this doesn’t make sense when you read their titles, but it just isn’t the same.

And, we can partner to help overcome all of these hurdles with you.