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No one wants to receive a notice that they’re being investigated by the DOL. But health investigations are happening with increased frequency, and you should be prepared for when a letter arrives.
Sources for an investigation can vary, and include everything from random selection and public statements like annual reports to participant complaints and private litigation. Once the DOL identifies a target, it will start the process with an inquiry letter. Before you receive one, it’s wise to get your documents in order.
A major component of the investigations involving a group health plan or service provider is a compliance review of ERISA’s group health plan requirements under ERISA parts 6 and 7 relating to applicable health laws, including:
- Consolidated Omnibus Budget Reconciliation Act (COBRA)
- Health Insurance Portability and Accountability Act (HIPAA)
- Mental Health Parity Act (MHPA)
- Mental Health Parity and Addiction Equity Act (MHPAEA)
- Women’s Health and Cancer Rights Act (WHCRA)
- Newborns’ and Mothers’ Health Protection Act (Newborns’ Act)
- Genetic Information Nondiscrimination Act (GINA)
- Michelle’s Law
- Children’s Health Insurance Program Reauthorization Act (CHIPRA)
- Patient Protection and Affordable Care Act (Affordable Care Act)
The letters will seek information about your health plan like your ERISA-compliant plan document, SPDs, SBCs, Form 5500s; documentation that you’ve fulfilled notice requirements; and details about administration of the plan. Since the fines for violations can be significant, It’s a good idea to review every record now, address areas that need to be corrected, and maintain compliant versions in one location so that you can respond quickly in the event you receive a notice.
If and when you do get a letter, assign one person to coordinate all communication with the DOL. That individual should make a list of what the DOL has asked for and provide exactly what’s requested — and nothing more. And a timely response is key to show your cooperation and avoid the risk of further action like an on-site interview. You may also want to notify your legal counsel if you have one to get their advice on how to proceed.
While an audit could happen at any time, here are some tips to avoid an investigation:
- Respond to any participant questions or requests for information in a timely manner
- File required forms like the Form 5500 fully, accurately, and on time
- Distribute required notices to participants on time and maintain records that demonstrate they were provided
- Update plan documents and SPDs to reflect legal and design change
- Make sure the benefit plans comply with relevant laws
- Have procedures in place for handling disputes and claims
Rob Calise is the Managing Director, Employee Benefits of The Hilb Group of New England, where he helps clients control the costs of employee benefits by focusing on consumer-driven strategies and on how to best utilize the tax savings tools the government provides. Rob serves as Chairman of the Board of United Benefit Advisors, and is a board member of the Blue Cross & Blue Shield of RI Broker Advisory Board, United HealthCare of New England Broker Advisory Board and Rhode Island Business Healthcare Advisors Council. He is also a member of the National Association of Health Underwriters (NAHU), American Health Insurance Association (AHIA) and the Employers Council on Flexible Compensation (ECFC), as well as various human resource associations. Rob is a graduate of Bryant University with a BS in Finance
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