Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: October 07, 2014

Program Area: Reinsurance-Contributions (RIC)

Question: How will the number of covered lives be audited?

Answer: Applicable to All Reinsurance Contributions Benefit Years: Pursuant to 45 CFR 153.405(i), the U.S. Department of Health and Human Services (HHS) or its designee may audit a Contributing Entity to assess its compliance with the requirements of 45 CFR Part 153 Subpart E. The Centers for Medicare & Medicaid Services (CMS) anticipates that any audit of a Contributing Entity will focus on records related to enrollment in the applicable self-insured or insured plan, to confirm that the number of covered lives was correctly calculated and that the correct amount of reinsurance contributions was paid. Additionally, these audits may be used to identify entities that were required to but did not make reinsurance contributions. CMS also notes that pursuant to 45 CFR 153.405(h), a Contributing Entity must maintain documents and records, whether paper, electronic, or in other media, sufficient to substantiate the enrollment count submitted pursuant to this section for a period of at least 10 years, and must make those documents and records available upon request from HHS, the Office of Inspector General (OIG), the Comptroller General, or their designees, to any such entity, for purposes of verification, investigation, audit, or other review of reinsurance contribution amounts.

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