Dependent Eligibility Verification

Every health plan is paying claims for ineligible dependents. Based on our experience, approximately 2%-6% of dependents are ineligible for coverage for a variety of reasons – divorces, non-biological children, “domestic partners”, etc. With average annual benefit costs per ineligible dependent ranging from $3,000 to $5,000, Dependent Eligibility Verification projects pay for themselves in less than one year.

When evaluating the merits of a Dependent Eligibility Verification project, we recommend our clients to consider the following key elements, in addition to the savings from eliminating ineligible dependents:

  • Enhanced COB Through Collection of Other Insurance Information
  • Highest Response Rate – Positive Employee Relations
  • Return-on-Investment and Response Rate Guarantees

The collection of other insurance coverage information, for spouses and children, is included in our service, at no additional cost. In every project we are able to supplement the information already contained in the Claims Payers’ databases. Once gathered, this other insurance coverage will be shared with your Insurance Carrier or TPA, and can be analyzed when done in conjunction with a Medical and Pharmacy Claims Audit, to maximize COB opportunities and ensure that claim costs were appropriately shifted to other insurers and Medicare.

The Seneca Group has one of the highest participant response rates in the industry, achieving an average 99.6% across all clients, and has never had an employee appeal. The importance of this statistic is that when we finish a project we have received documentation from nearly every employee with eligible dependents. Most vendors “finish” a project without receiving a response from 5-20% of the employees and then recommend cancelling dependent coverage for all non-respondents. This leads to negative employee relations, costly grievances/appeals, and time-consuming reinstatements. SENECA is able to achieve a nearly perfect response rate through customized communications, unlimited outbound calls to encourage a response and an employee-sensitive “high touch” approach.

Steps in the Verification Process

1. Planning Meeting

  • Determine eligibility rules to ensure an understanding of requirements (ex. domestic partners, non-biological children, legally separated).
  • Determine how best to communicate to covered employees intent and reason for conducting a Dependent Eligibility Verification project.
  • Decide on acceptable documentation to substantiate dependent eligibility such as marriage license and/or certificate, first page of IRS 1040, birth certificates, domestic partner affidavit, or divorce decree denoting responsibility for health care coverage.
  • Confirm the consequences for failure to provide supporting documentation as requested.

2. Project Setup

  • Obtain files from insurance Carrier / TPA, of active employees enrolled in the Plan, including employees with “single” coverage, spouse/dependent records and COBRA data.
  • The Eligibility Verification forms will be pre-populated with enrollment data. Test forms will be produced for approval by client.
  • Seneca will provide a Call Center to handle in-bound calls from employees and outbound calls to resolve questions and assist employees with compliance.
  • Seneca will track and verify information received in the project, and track calls received by the Call Center.

3. Implementation

  • Initial mailing will be prepared for households with covered spouse and/or child(ren). Forms will be mailed requesting documentation to verify that the dependent(s) meet the Plan’s eligibility requirements.
  • Employees verify the enrollment information for their spouses and/or child(ren), denote any changes in information and send the form with all requested supporting documentation to SENECA via a postage paid business reply envelope (all included in the cost of the project).
  • A follow-up mailing will be scheduled and sent to those individuals who either did not submit complete information, indicating what is still missing, or did not submit a response, reminding them of their need to comply with the project.
  • Undeliverable forms will be routed by the post office to Seneca for follow-up to obtain a correct address and re-send.
  • During weekly project calls, SENECA will discuss alternative methods of contacting employees who have not responded.
  • SENECA will follow-up with non-respondents as applicable via email, phone, supervisor contact, etc. to encourage timely submission of eligibility-related documentation.
  • SENECA’s extensive employee communication and follow-up results in SENECA’s industry-leading 99% response rate.
  • SENECA will verify the information and input the responses into the proprietary Dependent Verification Tracking System.
  • SENECA’s Call Center will answer incoming employee questions on the process, timing, verification form and documentation requested.
  • Routine conference calls/meetings will be held to provide Client with project status and review of ineligible dependent cases.

4. Reporting

SENECA will prepare ongoing and final reporting of project results, including respondents, missing information, completed forms, non-respondents, and information changes and corrections.

About The Seneca Group

The Seneca Group is a licensed and insured third party administrator (TPA) that has been providing self-funded, split-funded, flexible spending account, Health Reimbursement Arrangement (HRA) administration since 2006.

Contact us today to learn more! 866-487-4157

The Seneca Group/TPA Exchange
960 Wheeling Road, Suite 5367
Hauppauge, NY 11788
The Seneca Group/TPA Exchange
1234 Mann Dr
Matthews, NC 28105
Phone: 866-487-4157
Web: www.thesenecagroup.com