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Dependent eligibility audits are commonly used by employer-sponsored health plans to verify that employees have enrolled only eligible dependents. Identifying ineligible dependents and removing them from coverage, either retroactively or prospectively, can reduce health plan costs and provide evidence of good plan management. In addition, employers that perform services for governmental agencies are often subject to expense audits that include review of health plan costs. If the employer cannot provide proof of dependent eligibility to the government auditors, the employer may find itself with a reduction in its reimbursement or subject to penalties for inaccurate claims.
There are no hard and fast rules for dependent eligibility audits, and employers and insurers can design an eligibility audit program in many ways—for example, audits can be done on a regular schedule or randomly; employees may or may not be given an amnesty period to remove ineligible dependents voluntarily; ineligible dependents can be removed from coverage prospectively as of a date set by the health plan or retroactively to the date of enrollment. But the health care reform law placed new limits on retroactive cancellation of coverage, which the law refers to as "rescission," and employers need to understand the new rescission rules in order to avoid triggering penalties. The new rules apply to grandfathered and non-grandfathered health plans, insured and self-funded plans, and impose notice and external review requirements. In addition, plans should review and many will need to revise their eligibility language to state eligibility rules as clearly as possible and to advise employees that enrolling ineligible dependents is prohibited and constitutes fraud or misrepresentation of material facts.
This program will address common dependent eligibility audit design issues and provide detail on the new health care reform limitations on retroactive cancellation of coverage.
Who Should Participate
Any HR or Benefits Professional with responsibility for health plan design, management, compliance, or cost control.
What You Will Learn
• Common designs for health plan eligibility audits, including documentation requirements, amnesty periods, timing, and coordination with insurance carriers or claims administrators
• What requirements the health care reform law imposes on retroactive cancellation of health plan coverage
• What plan language should be reviewed and how it should be revised to support retroactive cancellation of coverage
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