Health Plan Audits Underway

December 14, 2012 ( – The Department of Labor (DOL) has updated its audit protocols for group health plans.

An increase in Patient Protection and Affordable Care Act (PPACA) enforcement is underway, and many plan sponsors have already received notices in response to updated audit protocols from the DOL’s Employee Benefits Security Administration (EBSA), according to a Jackson Lewis client alert.   

The updated protocols include a review of plans’ compliance with the PPACA, the Genetic Information Nondiscrimination Act (GINA) and wellness programs. Also under consideration will be plans’ compliance with federal statutes and regulations, including the Employee Retirement Income Security Act (ERISA), the Health Insurance Portability and Accountability Act (HIPAA), the Consolidated Omnibus Budget Reconciliation Act (COBRA) and the Women’s Health and Cancer Rights Act.   

Audit notices from the DOL, such as the example here, provide insight into the kind of information EBSA is requesting.   

Employers currently preparing for the impending changes under the health care reform law can expect to be asked to provide information and documentation concerning particular aspects of the PPACA, such as their plans’ grandfather status, coverage for adult children, lifetime and annual limits, and claims and appeals procedures.   

The DOL will also be looking at the design of wellness programs (see “Regulators Issue Guidance About Wellness Programs”) offered in conjunction with group health plans and the related, required notices that have to be provided with outcome-based programs.   


Sara Kelly