Frequently Asked Questions
Q: What is a dependent eligibility audit?
A: A dependent eligibility audit is a process that self-insured/self-funded plan sponsors use to ensure that only eligible dependents (as outlined in the Summary Plan Document) are receiving coverage/benefits under the health plan.
Q: Why should I conduct a dependent eligibility audit?
A: It is considered an ERISA violation if a self-funded medical plan uses employee contributions to fund the claim payments of ineligible dependents. Additionally, Sarbanes-Oxley requires stringent fiduciary oversight of publicly-traded companies, including the administration of benefits spending.
Q: How is the audit conducted?
A: Provide ACA GPS with your enrollment census (plan participants and dependents). Review the Summary Plan Document(s) to determine which dependent types are eligible and which document types are acceptable. Polite, professional communications are sent to the plan participants explaining why the audit is being performed, what information is required, and how they need to respond. ACA GPS reviews the incoming documentation, submits additional requests to those that are non-responsive and/or have submitted incorrect/inadequate information.
Q: The documentation requested from plan participants could contain sensitive data. Is the information secure?
A: Document storage is secure and Personally Identifiable Information (PII) is kept secure and confidential. ACA GPS is SOC 2, Type II certified and is also AZ Ramp Approved, NIST Moderate Compliant.
Q: Are we required to use ‘Phases’ and ‘Milestones’?
A: No. Phases and Milestones are created to keep everyone on track during the audit, but they are not required. You can also use Phases without Milestones, or Milestones without Phases.
Q: How do we determine which documents are required for proof of eligibility?
A: Acceptable documents for determining eligibility are generally outlined in the Summary Plan Document (SPD). A list of these documents, and which are required for each dependent type, will be created in DECATool® so that communications to plan participants clearly outline the requirements.
Q: Can we use our own letterhead on outgoing letters?
A: Yes. The company letterhead can be used for all plan participant communications.
Q: Can a plan participant upload their documents using their cell phone?
A: Yes, plan participants can upload documents using their cell phone, tablet, computer, or other electronic device. They can also email, fax, or mail the documents for processing.
Q: Is there a limit to the number of dependents per plan participant?
A: No there is no limit. A plan participant can have an unlimited number of dependents.
Q: If a plan participant has a new addition to the family after the audit has begun, can we notify ACA GPS to have them added to the audit?
A: Yes, new dependents and/or new plan participants can be added during the audit.
Q: If we offer multiple plans, and they require different documents for eligibility, is DECATool able to differentiate which documents are required based on the plan chosen by the participant?
A: Yes. An acceptable document list can be created for each of the plans.
Q: If a plan participant has been imported in error, can they be removed?
A: Yes. Any plan participant that should not be included in the audit can be removed from DECATool®.
Q: Can I delete a document that was imported/uploaded in error?
A: Yes. There is an option to delete a document within DECATool®.
Q: What happens if a plan participant uploads a group of documents as a single file?
A: While reviewing the document within DECATool®, an auditor can ‘split’ the documents into separate pages for distribution to the correct dependent(s).
Q: What is the ‘Issuer Code’ and how is it used?
A: The ‘Issuer Code’ is unique to each audit and is provided to plan participants in all audit communications. The plan participant needs the code to securely upload their documents electronically.
Q: What happens if an ineligible dependent is identified in the audit process?
A: Reasons for ineligibility are not necessarily attempts to deceive and should never be treated as such. The majority of ineligible dependents are those that have aged out of eligibility or are ex-spouses/non-domestic partners. The plan sponsor is given a final report containing the audit results and should notify the plan participant directly that an ineligible dependent has been identified and will be removed from coverage according to procedures outlined in the plan.