St. Thomas has authorized an audit of its health care plan to identify and remove from coverage any employees’ ineligible spouses or dependents who are receiving benefits.
Federal regulations require employers to verify that all individuals covered by health care plans meet eligibility requirements. Human Resources, working in collaboration with the faculty-staff Fringe Benefits Advisory Committee, recommended that an audit be conducted at St. Thomas, and the Academic and Administrative Leadership group and Father Dennis Dease, president, concurred.
Ineligibility generally occurs after divorce or death or when a dependent child is no longer a full-time college student or has reached age 25, said Edna Comedy, associate vice president for human resources. The audit will require employees who insure a spouse or dependent on their St. Thomas health plan to provide proof of eligibility.
Last year, St. Thomas provided health care coverage for 1,200 spouses and dependent children of employees, and the average annual claim was $4,100. Industry statistics indicate that audits typically reveal between 5 percent and 12 percent of all insured spouses and/or dependents are ineligible for coverage; thus, a 5 percent ineligibility finding at St Thomas could yield an annual reduction of $246,000 or more in expenses.
Human Resources will contract with an external vendor, ContinuousHealth of Roswell, Ga., to perform the audit. ContinuousHealth will preserve the privacy of employees and meet all federal privacy requirements, with all interactions occurring through the vendor’s Web portal. ContinuousHealth will provide information on affordable alternative insurance coverage to any ineligible spouses or dependents.
Amnesty will be granted for all ineligible medical expenses incurred until the date of the audit. If an employee appeals the audit finding, a spouse or dependents will remain eligible. If the ineligibility determination is upheld, the employee will be liable for all medical expenses incurred by ineligible dependents that St. Thomas paid during the appeal process. In such an instance, the employee also will be liable for all ineligible dependent medical expenses paid by St. Thomas during plan year 2010, which began Jan. 1.
Here is the timeline for the audit:
- May: Publicize the audit through Bulletin Today and mail a letter to employees notifying them of the audit and steps that they will need to take.
- June 10-July 10: Verification phase, in which ContinuousHealth will conduct the audit.
- July 11-Aug. 30: Appeals phase: Employees may appeal an ineligible dependent determination. ContinuousHealth will handle all appeals.
- Sept. 1-30: Implementation phase: Ineligible spouses and dependents will be removed from St. Thomas’ medical plans.
Employees with questions about the audit should contact Human Resources, (651) 962-6510.