A little-known requirement but most important under Affordable Care Act (ACA) is for Health Insurers must waive their minimum employer-contribution and employee-participation rules once a year. ACA requires a one-month Special Open Enrollment Window for January 1st coverage.
The special open enrollment period occurs November 15th through December 15th of each year, allowing eligible small group employers to enroll for coverage effective January 1st of the following year.
Background
The ACA has a section in it called the “guaranteed issuance of coverage in the individual and group market.” It stipulates that “each health insurer that offers health insurance coverage in the individual or group market in the state must accept every employer and individual in the state that applies for such coverage.” The section also states that this guaranteed issuance of coverage can only be offered during (special) open enrollment periods, and that plans can only be offered to applicants that live in, work in, or reside in the plans’ service area(s).
Participation and Contribution Requirements
In many states (including California and Nevada), carriers can decline to issue group health coverage if fewer than 70% of employees elect to enroll in coverage. Some carriers may have even tighter participation requirements.
Generally speaking, employees with other coverage (Medicare, other group coverage, individual coverage through the Exchange, etc.) are removed from the participation requirement calculation – though it varies by insurance carrier.
Furthermore, employer contribution rules require employers to contribute a certain percentage of premium costs for all employees in order to attain group health coverage. Some businesses struggle to meet these contribution requirements for a variety of financial reasons.
Problem Solved: Special Open Enrollment Period
Many employers want to offer coverage to their employees, but are denied because they struggle to meet participation and/or contribution requirements. Employers cannot force employees to enroll in coverage unless the employer pays for 100% of the employees’ premiums, which many employers cannot afford. Even with moderate to generous employer contributions, many employers still find young and lower-income employees waiving coverage. This was even more evident in 2019 with the ACA’s federal Individual Mandate non-compliance penalty reduced to $0.00.
The U.S. Department of Health & Human Services provides final guidance on this in regulation 147.104(b)(1): “In the case of health insurance coverage offered in the small group market, a health insurance issuer may limit the availability of coverage to an annual enrollment period that begins November 15 and extends through December 15 of each year in the case of a plan sponsor that is unable to comply with a material plan provision relating to employer contribution or group participation rules.”
If your employer groups are struggling with participation and/or contribution, the Special Open Enrollment Window is the time to enroll them in coverage.
This Compliance Overview is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice.
In preparation for open enrollment, Employers should review their plan documents in light of changes for the plan year beginning Jan 1, 2021. Below is an Employer 2 Open Enrollment Checklist including some administrative items to prepare for in 2020.
Health plan sponsors should also confirm that their open enrollment materials contain certain required participant notices, when applicable—for example, the summary of benefits and coverage (SBC). There are also some participant notices that must be provided annually or upon initial enrollment. To minimize costs and streamline administration, employers should consider including these notices in their open enrollment materials.
PLAN DESIGN CHANGES
Out-of-pocket Maximum
Effective for plan years beginning on or after Jan. 1, 2014, non-grandfathered health plans are subject to limits on cost-sharing for essential health benefits (EHB). The ACA’s out-of-pocket maximum applies to all non-grandfathered group health plans, including self-insured health plans and insured plans.
$8,700 for self-only coverage and $17,400 for family coverage out-of-pocket maximum.
$7,050 for self-only coverage and $14,100 for family coverage HSA Maximum. For 2021 plan years, the out-of-pocket maximum limit for HDHPs is $7,000 for self-only coverage and $14,000 for family coverage.
Preventive Care Benefits
The ACA requires non-grandfathered health plans to cover certain preventive health services without imposing cost-sharing requirements (that is, deductibles, copayments or coinsurance) for the services. Health plans are required to adjust their first-dollar coverage of preventive care services based on the latest preventive care recommendations. If you have a non-grandfathered plan, you should confirm that your plan covers the latest recommended preventive care services without imposing any cost-sharing.
The ACA imposes a dollar limit on employees’ salary reduction contributions to a health flexible spending account (FSA) offered under a cafeteria plan. An employer may impose its own dollar limit on employees’ salary reduction contributions to a health FSA, as long as the employer’s limit does not exceed the ACA’s maximum limit in effect for the plan year.
The ACA set the health FSA contribution limit at $2,500. For years after 2013, the dollar limit is indexed for cost-of-living adjustments. For 2022 plan years, the health FSA limit is $2,850. The DFSA Rollover Maximum is $570.
Communicate the health FSA limit to employees as part of the open enrollment process.
HDHP and HSA Limits for 2022
If you offer an HDHP to your employees that is compatible with an HSA, you should confirm that the HDHP’s minimum deductible and out-of-pocket maximum comply with the 2020 limits. The IRS limits for HSA contributions and HDHP cost-sharing increase for 2022. The HSA contribution limits will increase effective Jan. 1, 2022, while the HDHP limits will increase effective for plan years beginning on or after Jan. 1, 2022.
Check whether your HDHP’s cost-sharing limits need to be adjusted for the 2022 limits.
If you communicate the HSA contribution limits to employees as part of the enrollment process, these enrollment materials should be updated to reflect the increased limits that apply for 2022.
The following table contains the HDHP and HSA limits for 2022 as compared to 2021. It also includes the catch-up contribution limit that applies to HSA-eligible individuals who are age 55 or older, which is not adjusted for inflation and stays the same from year to year.
Type of Limit
2021
2022
Change
HSA Contribution Limit
Self-only
$3,600
$3,650
Up $50
Family
$7,200
$7,300
Up $100
HSA Catch-up Contributions (not subject to adjustment for inflation)
Age 55 or older
$1,000
$1,000
No change
HDHP Minimum Deductible
Self-only
$1,400
$1,400
No change
Family
$2,800
$2,800
No change
HDHP Maximum Out-of-pocket Expense Limit (deductibles, copayments and other amounts, but not premiums)
Self-only
$7,000
$7,050
Up $50
Family
$14,000
$14,100
Up $100
ACA EMPLOYER MANDATE AND OTHER REQUIREMENTS
Applicable Large Employer Status (ALE)
Under the ACA’s employer penalty rules, applicable large employers (ALEs) that do not offer health coverage to their full-time employees (and dependent children) that is affordable and provides minimum value will be subject to penalties if any full-time employee receives a government subsidy for health coverage through an Exchange.
To qualify as an ALE, an employer must employ, on average, at least 50 full-time employees, including full-time equivalent employees (FTEs), on business days during the preceding calendar year. All employers that employ at least 50 full-time employees, including FTEs, are subject to the ACA’s pay or play rules.
Determine your ALE status for 2022
Calculate the number of full-time employees for all 12 calendar months of 2020. A full-time employee is an employee who is employed on average for at least 30 hours of service per week.
Calculate the number of FTEs for all 12 calendar months of 2021 by calculating the aggregate number of hours of service (but not more than 120 hours of service for any employee) for all employees who were not full-time employees for that month and dividing the total hours of service by 120.
Add the number of full-time employees and FTEs (including fractions) calculated above for all 12 calendar months of 2021.
Add up the monthly numbers from the preceding step and divide the sum by 12. Disregard fractions.
If your result is 50 or more, you are likely an ALE for 2022.
Identify Full-time Employees
All full-time employees must be offered affordable minimum value coverage. A full-time employee is an employee who was employed on average at least 30 hours of service per week. The final regulations generally treat 130 hours of service in a calendar month as the monthly equivalent of 30 hours of service per week. The IRS has provided two methods for determining full-time employee status—the monthly measurement method and the look-back measurement method.
Determine which method you are going to use to determine full-time status
The monthly measurement method involves a month-to-month analysis where full-time employees are identified based on their hours of service for each month. This method is not based on averaging hours of service over a prior measurement method. Month-to-month measuring may cause practical difficulties for employers, particularly if there are employees with varying hours or employment schedules, and could result in employees moving in and out of employer coverage on a monthly
The look-back measurement method allows an employer to determine full-time status based on average hours worked by an employee in a prior period. This method involves a measurement period for counting/averaging hours of service, an administrative period that allows time for enrollment and disenrollment, and a stability period when coverage may need to be provided, depending on an employee’s average hours of service during the measurement
Audit FTEs for FMLA Compliance
Audit your FTEs to determine if you have reached or exceeded 50 employees and are required to comply with the Family Medical Leave Act (FMLA) in 2022. Employers covered by the FMLA are obligated to provide their employees with certain important FMLA notices, so both employees and the employer have a shared understanding of the terms of the FMLA leave. Note that FMLA compliance requirements are different from ACA compliance.
Offer of Coverage
An ALE may be liable for a penalty under the pay or play rules if it does not offer coverage to “substantially all” (95%) full-time employees (and dependents) and any one of its full-time employees receives a premium tax credit or cost-sharing reduction for coverage purchased through an Exchange. For employees who are offered health coverage that is affordable and provides minimum value are generally not eligible for these Exchange subsidies. The IRS lowered the 2022 employer health plan affordability threshold, or cost-sharing limit, to 9.61% of an employee’s income. The threshold in 2021 was 9.83%.
Offer minimum essential coverage to all full-time employees
Ensure that at least one of those plans provides minimum value (60% actuarial value)
Ensure that the minimum value plan offered is affordable to all full-time employees by ensuring that the employee contribution for the lowest cost single minimum value plan does not exceed 78% of an employee’s earnings based on the employee’s W-2 wages, the employee’s rate of pay, or the federal poverty level for a single individual.
Reporting of Coverage
The ACA requires ALEs to report information to the IRS and to employees regarding the employer-sponsored health coverage on Form 1095-C. The IRS will use the information that ALEs report to verify employer-sponsored coverage and to administer the employer shared responsibility provisions (Code Section 6056).
In addition, the ACA requires every health insurance issuer, sponsor of a self-insured health plan, a government agency that administers government-sponsored health insurance programs and any other entity that provides minimum essential coverage (MEC) to file an annual return with the IRS and individuals reporting information for each individual who is provided with this coverage (Code Section 6055).
Determine which reporting requirements apply to you and your health plans
Determine the information you will need for reporting and coordinate internal and external resources to help compile the required data for the 1094-C and 1095-C
Complete the appropriate forms for the 2020 reporting year. Furnish statements to individuals on or before January 31, 2021 has been extended to March 2, 2021 IRS Notice 2020-76., and file returns with the IRS on or before February 28, 2020 (March 31, 2020, if filing electronically).
ACA Requirement
Deadline
1095 forms delivered to employees
Jan. 31 (extended to March 2)
Paper filing with IRS*
Feb. 28
Electronic filing with IRS
March 31
Comparative Effectiveness Research Fee (PCORI)
Sponsors of self-funded plans and health insurance issuers of fully insured plans are required to pay a fee each year, by July 31st, to fund comparative effectiveness research. Fees will increase to $2.45 per covered life in 2020 and are next due July 31, 2021.
W-2 Reporting
Healthcare Reform requires employers to report the aggregate cost of employer-sponsored group health plan coverage on their employees’ Forms W-2. This reporting requirement was originally effective for the 2011 tax year. However, the IRS later made reporting optional for 2011 for all employers.
The IRS further delayed the reporting requirement for small employers (those that file fewer than 250 Forms W-2) by making it optional for these employers until further guidance is issued. For the larger employers, the reporting requirement was mandatory for the 2012 Forms W-2 and continues.
ACA DISCLOSURE REQUIREMENTS
Summary of Benefits and Coverage
The ACA requires health plans and health insurance issuers to provide an SBC to applicants and enrollees to help them understand their coverage and make coverage decisions. Plans and issuers must provide the SBC to participants and beneficiaries who enroll or re-enroll during an open enrollment period. The SBC also must be provided to participants and beneficiaries who enroll other than through an open enrollment period (including those who are newly eligible for coverage and special enrollees).
In connection with a plan’s 2020 open enrollment period, the SBC should be included with the plan’s application materials. If coverage automatically renews for current participants, the SBC must generally be provided no later than 30 days before the beginning of the new plan year.
For self-funded plans, the plan administrator is responsible for providing the SBC. For insured plans, both the plan and the issuer are obligated to provide the SBC, although this obligation is satisfied for both parties if either one provides the SBC. Thus, if you have an insured plan, you should confirm that your health insurance issuer will assume responsibility for providing the SBCs.
Grandfathered Plan Notice
If you have a grandfathered plan, make sure to include information about the plan’s grandfathered status in plan materials describing the coverage under the plan, such as SPDs and open enrollment materials. Model language is available from the DOL.
Notice of Patient Protections
Under the ACA, non-grandfathered group health plans and issuers that require designation of a participating primary care provider must permit each participant, beneficiary and enrollee to designate any available participating primary care provider (including a pediatrician for children). Also, plans and issuers that provide obstetrical/gynecological care and require a designation of a participating primary care provider may not require preauthorization or referral for obstetrical/gynecological care.
If a non-grandfathered plan requires participants to designate a participating primary care provider, the plan or issuer must provide a notice of these patient protections whenever the SPD or similar description of benefits is provided to a participant. If your plan is subject to this notice requirement, you should confirm that it is included in the plan’s open enrollment materials. Model language is available from the DOL.
OTHER NOTICES
Group health plan sponsors should consider including the following enrollment and annual notices with the plan’s open enrollment materials.
Initial COBRA Notice
The Consolidated Omnibus Budget Reconciliation Act (COBRA) applies to employers with 20 or more employees that sponsor group health plans. Plan administrators must provide an initial COBRA notice to new participants and certain dependents within 90 days after plan coverage begins. The initial COBRA notice may be incorporated into the plan’s SPD. A model initial COBRA notice is available from the DOL.
Notice of HIPAA Special Enrollment Rights
At or prior to the time of enrollment, a group health plan must provide each eligible employee with a notice of his or her special enrollment rights under HIPAA. This notice may be included in the plan’s SPD. Model language for this disclosure is available on the DOL’s website.
Annual CHIPRA Notice
Group health plans covering residents in a state that provides a premium subsidy to low-income children and their families to help pay for employer-sponsored coverage must send an annual notice about the available assistance to all employees residing in that state. The DOL has provided a model notice.
WHCRA Notice
Plans and issuers must provide notice of participants’ rights to mastectomy-related benefits under the Women’s Health and Cancer Rights Act (WHCRA) at the time of enrollment and on an annual basis. Model language for this disclosure is available on the DOL’s website.
NMHPA Notice
Plan administrators must include a statement within the Summary Plan Description (SPD) timeframe describing requirements relating to any hospital length of stay in connection with childbirth for a mother or newborn child under the Newborns’ and Mothers’ Health Protections Act. Model language for this disclosure is available on the DOL’s website.
Medicare Part D Notices
Group health plan sponsors must provide a notice of creditable or non-creditable prescription drug coverage to Medicare Part D eligible individuals who are covered by, or who apply for, prescription drug coverage under the health plan. This creditable coverage notice alerts the individuals as to whether or not their prescription drug coverage is at least as good as the Medicare Part D coverage. The notice generally must be provided at various times, including when an individual enrolls in the plan and each year before Oct. 15th(when the Medicare annual open enrollment period begins). Model notices are available on the Centers for Medicare and Medicaid Services’ website.
HIPAA Privacy Notice
The HIPAA Privacy Rule requires covered entities (including group health plans and issuers) to provide a Notice of Privacy Practices (or Privacy Notice) to each individual who is the subject of protected health information (PHI). Health plans are required to send the Privacy Notice at certain times, including to new enrollees at the time of enrollment. Also, at least once every three years, health plans must either redistribute the Privacy Notice or notify participants that the Privacy Notice is available and explain how to obtain a copy.
Self-insured health plans are required to maintain and provide their own Privacy Notices. Special rules, however, apply for fully insured plans. Under these rules, the health insurance issuer, and not the health plan itself, is primarily responsible for the Privacy Notice.
Model Privacy Notices are available through the Department of Health and Human Services
Summary Plan Description (SPD)
Plan administrators must provide an SPD to new participants within 90 days after plan coverage begins. Any changes that are made to the plan should be reflected in an updated SPD booklet or described to participants through a summary of material modifications (SMM).
Also, an updated SPD must be furnished every five years if changes are made to SPD information or the plan is amended. Otherwise, a new SPD must be provided every 10 years.
Summary Annual Report
Plan administrators that are required to file a Form 5500 (> 100 participants in plan) must provide participants with a narrative summary of the information in the Form 5500, called a summary annual report (SAR). The plan administrator generally must provide the SAR within nine months of the close of the plan year. If an extension of time to file the Form 5500 is obtained, the plan administrator must furnish the SAR within two months after the close of the extension period.
Wellness Program Notices
Group health plans that include wellness programs may be required to provide certain notices regarding the program’s design. As a general rule, these notices should be provided when the wellness program is communicated to employees and before employees provide any health-related information or undergo medical examinations.
HIPAA Wellness Program Notice—HIPAA imposes a notice requirement on health-contingent wellness programs that are offered under group health plans. Health-contingent wellness plans require individuals to satisfy standards related to health factors (for example, not smoking) in order to obtain rewards. The notice must disclose the availability of a reasonable alternative standard to qualify for the reward (and, if applicable, the possibility of waiver of the otherwise applicable standard) in all plan materials describing the terms of a health-contingent wellness program. Final regulations provide sample language that can be used to satisfy this requirement.
ADA Wellness Program Notice—Employers with 15 or more employees are subject to the Americans with Disabilities Act (ADA). Wellness programs that include health-related questions or medical examinations must comply with the ADA’s requirements, including an employee notice requirement. Employers must give participating employees a notice that tells them what information will be collected as part of the wellness program, with whom it will be shared and for what purpose, the limits on disclosure and the way information will be kept confidential. The Equal Employment Opportunity Commission (EEOC) has provided a sample notice to help employers comply with this ADA requirement.
Enhance Your Employee Benefits Package. A competitive benefits package is key to keeping and attracting top talent.Assess your current benefits package and consider making necessary adjustments to include options, such as expanded mental health support, for example.
GENERAL HR
Review Employee Records. The fourth quarter is a good time to review your employee records and check record retention guidelines. Don’t forget to dispose of outdated termination and outdated job applications properly. With W2s around the corner, make sure all addresses and information are updated.
Develop and Distribute Your 2022 Calendar. Create and distribute a calendar outlining important dates, vacation time, pay dates, and company-observed holidays for 2022.
Review and Update Employee Handbook. Review your employee handbook to make sure it is up-to-date and addresses areas, such as employment law mandates, new COVID-related policies, guidelines for remote working, privacy policies, compensation and performance reviews, social media policies, attendance, and time-off, break periods, benefits, and procedures for termination, discipline, workplace safety, and emergency procedures.
PLEASE NOTE: This information is for general reference purposes only. Because laws, regulations, and filing deadlines are likely to change, please check with the appropriate organizations or government agencies for the latest information and consult your employment attorney and/or benefits advisor regarding your responsibilities. In addition, your business may be exempt from certain requirements and/or be subject to different requirements under the laws of your state. (Updated Oct. 3, 2021)
Contact us at (855) 667-4621 or email us at info@medicalsolutionscorp.com
Although millions of presidential ballots are still being counted, total voter turnout is already approaching 2016’s level. Joe Biden appears to be increasingly getting closer to winning the presidency but at the same time, the Senate is likely to still be a Republican stronghold since 2014.
With a number of mail-ballots and absentee ballots to be tallied in states across the country, it is presumed that a clear winner may not be identified until the end of the week, at the very least. So what does a Biden victory mean for healthcare?
Rollbacks
If Joe Biden is declared the new U.S. President, the Affordable Care Act is expected to be strengthened. While States like NY/NJ have created their own Individual Mandate this is expected to be trite with likely rollback of the Federal Individual Mandate repeal. Rolling back of Medicaid spending back to the States is likely. Additionally, likely rollback of Trump association health plan rules, or even completely remove them. Trump administration made adjustments to the rules of these types of plans and essentially lessened the requirements for employers forming these types of associations.
Single-Payer
Lowering Medicare eligibility to age 60. And creating a “public option” government health plan.
Medicare for All
Medicare for All proposals call for the repeal of the ACA and replace it with rapid, nationalized health care for all Americans. Instead of co-pays and deductibles, Medicare for All would be funded instead by increased taxes on employers and certain segments of the public and pay for all health care through a “single-payer” (the federal government) system. Dental and vision would be included as well. The role of private insurers would be limited only to niche plans covering elective and other non-essential medical procedures.
Medicare for All Who Want It
Medicare for All Who Want It proposals increase access to Medicare to all while maintaining a role for private insurers through supplemental Medicare plans to provide additional coverage. Babies may be born into Medicare, depending on the proposal, while leaving the opportunity for parents to opt-out of that coverage for their children. The system would be paid for in part through premiums and partly through taxes. Proponents of this approach look to maintain a role for private Insurers while establishing a foundation of government negotiated rates, designed plans while reducing the uninsured rate.
For now, the ACA remains law of the land, and employers are encouraged to make ACA compliance a priority, especially with penalties increasing in 2021. Contact us to learn more about your organization’s 2021 renewal options.
This Compliance Overview is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice.
In preparation for open enrollment, Employers should review their plan documents in light of changes for the plan year beginning Jan 1, 2021. Below is an Employer 2 Open Enrollment Checklist including some administrative items to prepare for in 2020.
Health plan sponsors should also confirm that their open enrollment materials contain certain required participant notices, when applicable—for example, the summary of benefits and coverage (SBC). There are also some participant notices that must be provided annually or upon initial enrollment. To minimize costs and streamline administration, employers should consider including these notices in their open enrollment materials.
PLAN DESIGN CHANGES
Out-of-pocket Maximum
Effective for plan years beginning on or after Jan. 1, 2014, non-grandfathered health plans are subject to limits on cost-sharing for essential health benefits (EHB). The ACA’s out-of-pocket maximum applies to all non-grandfathered group health plans, including self-insured health plans and insured plans.
$8,550 for self-only coverage and $17,100 for family coverage out-of-pocket maximum.
$7,000 for self-only coverage and $14,000 for family coverage HSA Maximum. For 2021 plan years, the out-of-pocket maximum limit for HDHPs is $7,000 for self-only coverage and $14,000 for family coverage.
Preventive Care Benefits
The ACA requires non-grandfathered health plans to cover certain preventive health services without imposing cost-sharing requirements (that is, deductibles, copayments or coinsurance) for the services. Health plans are required to adjust their first-dollar coverage of preventive care services based on the latest preventive care recommendations. If you have a non-grandfathered plan, you should confirm that your plan covers the latest recommended preventive care services without imposing any cost-sharing.
The ACA imposes a dollar limit on employees’ salary reduction contributions to a health flexible spending account (FSA) offered under a cafeteria plan. An employer may impose its own dollar limit on employees’ salary reduction contributions to a health FSA, as long as the employer’s limit does not exceed the ACA’s maximum limit in effect for the plan year.
The ACA set the health FSA contribution limit at $2,500. For years after 2013, the dollar limit is indexed for cost-of-living adjustments. For 2021 plan years, the health FSA limit is $2,750.
Communicate the health FSA limit to employees as part of the open enrollment process.
HDHP and HSA Limits for 2021
If you offer an HDHP to your employees that is compatible with an HSA, you should confirm that the HDHP’s minimum deductible and out-of-pocket maximum comply with the 2020 limits. The IRS limits for HSA contributions and HDHP cost-sharing increase for 2020. The HSA contribution limits will increase effective Jan. 1, 2020, while the HDHP limits will increase effective for plan years beginning on or after Jan. 1, 2020.
Check whether your HDHP’s cost-sharing limits need to be adjusted for the 2020 limits.
If you communicate the HSA contribution limits to employees as part of the enrollment process, these enrollment materials should be updated to reflect the increased limits that apply for 2020.
The following table contains the HDHP and HSA limits for 2020 as compared to 2019. It also includes the catch-up contribution limit that applies to HSA-eligible individuals who are age 55 or older, which is not adjusted for inflation and stays the same from year to year.
Type of Limit
2020
2021
Change
HSA Contribution Limit
Self-only
$3,500
$3,600
Up $50
Family
$7,100
$7,200
Up $100
HSA Catch-up Contributions (not subject to adjustment for inflation)
Age 55 or older
$1,000
$1,000
No change
HDHP Minimum Deductible
Self-only
$1,400
$1,400
No change
Family
$2,800
$2,800
No change
HDHP Maximum Out-of-pocket Expense Limit (deductibles, copayments and other amounts, but not premiums)
Self-only
$6,900
$7,000
Up $100
Family
$13,800
$14,000
Up $200
ACA EMPLOYER MANDATE AND OTHER REQUIREMENTS
Applicable Large Employer Status (ALE)
Under the ACA’s employer penalty rules, applicable large employers (ALEs) that do not offer health coverage to their full-time employees (and dependent children) that is affordable and provides minimum value will be subject to penalties if any full-time employee receives a government subsidy for health coverage through an Exchange.
To qualify as an ALE, an employer must employ, on average, at least 50 full-time employees, including full-time equivalent employees (FTEs), on business days during the preceding calendar year. All employers that employ at least 50 full-time employees, including FTEs, are subject to the ACA’s pay or play rules.
Determine your ALE status for 2021
Calculate the number of full-time employees for all 12 calendar months of 2020. A full-time employee is an employee who is employed on average for at least 30 hours of service per week.
Calculate the number of FTEs for all 12 calendar months of 2020 by calculating the aggregate number of hours of service (but not more than 120 hours of service for any employee) for all employees who were not full-time employees for that month and dividing the total hours of service by 120.
Add the number of full-time employees and FTEs (including fractions) calculated above for all 12 calendar months of 2020.
Add up the monthly numbers from the preceding step and divide the sum by 12. Disregard fractions.
If your result is 50 or more, you are likely an ALE for 2021.
Identify Full-time Employees
All full-time employees must be offered affordable minimum value coverage. A full-time employee is an employee who was employed on average at least 30 hours of service per week. The final regulations generally treat 130 hours of service in a calendar month as the monthly equivalent of 30 hours of service per week. The IRS has provided two methods for determining full-time employee status—the monthly measurement method and the look-back measurement method.
Determine which method you are going to use to determine full-time status
Monthly measurement method involves a month-to-month analysis where full-time employees are identified based on their hours of service for each month. This method is not based on averaging hours of service over a prior measurement method. Month-to-month measuring may cause practical difficulties for employers, particularly if there are employees with varying hours or employment schedules, and could result in employees moving in and out of employer coverage on a monthly
Look-back measurement method allows an employer to determine full-time status based on average hours worked by an employee in a prior period. This method involves a measurement period for counting/averaging hours of service, an administrative period that allows time for enrollment and disenrollment, and a stability period when coverage may need to be provided, depending on an employee’s average hours of service during the measurement
Offer of Coverage
An ALE may be liable for a penalty under the pay or play rules if it does not offer coverage to “substantially all” (95%) full-time employees (and dependents) and any one of its full-time employees receives a premium tax credit or cost-sharing reduction for coverage purchased through an Exchange. Employees who are offered health coverage that is affordable and provides minimum value are generally not eligible for these Exchange subsidies.
Offer minimum essential coverage to all full-time employees
Ensure that at least one of those plans provides minimum value (60% actuarial value)
Ensure that the minimum value plan offered is affordable to all full-time employees by ensuring that the employee contribution for the lowest cost single minimum value plan does not exceed 78% of an employee’s earnings based on the employee’s W-2 wages, the employee’s rate of pay, or the federal poverty level for a single individual.
Reporting of Coverage
The ACA requires ALEs to report information to the IRS and to employees regarding the employer-sponsored health coverage on Form 1095-C. The IRS will use the information that ALEs report to verify employer-sponsored coverage and to administer the employer shared responsibility provisions (Code Section 6056).
In addition, the ACA requires every health insurance issuer, sponsor of a self-insured health plan, a government agency that administers government-sponsored health insurance programs and any other entity that provides minimum essential coverage (MEC) to file an annual return with the IRS and individuals reporting information for each individual who is provided with this coverage (Code Section 6055).
Determine which reporting requirements apply to you and your health plans
Determine the information you will need for reporting and coordinate internal and external resources to help compile the required data for the 1094-C and 1095-C
Complete the appropriate forms for the 2020 reporting year. Furnish statements to individuals on or before January 31, 2021 has been extended to March 2, 2021 IRS Notice 2020-76., and file returns with the IRS on or before February 28, 2020 (March 31, 2020, if filing electronically).
ACA Requirement
Deadline
1095 forms delivered to employees
Jan. 31 (extended to March 2)
Paper filing with IRS*
Feb. 28
Electronic filing with IRS
March 31
Comparative Effectiveness Research Fee (PCORI)
Sponsors of self-funded plans and health insurance issuers of fully insured plans are required to pay a fee each year, by July 31st, to fund comparative effectiveness research. Fees will increase to $2.45 per covered life in 2020 and are next due July 31, 2021.
W-2 Reporting
Healthcare Reform requires employers to report the aggregate cost of employer-sponsored group health plan coverage on their employees’ Forms W-2. This reporting requirement was originally effective for the 2011 tax year. However, the IRS later made reporting optional for 2011 for all employers.
The IRS further delayed the reporting requirement for small employers (those that file fewer than 250 Forms W-2) by making it optional for these employers until further guidance is issued. For the larger employers, the reporting requirement was mandatory for the 2012 Forms W-2 and continues.
ACA DISCLOSURE REQUIREMENTS
Summary of Benefits and Coverage
The ACA requires health plans and health insurance issuers to provide an SBC to applicants and enrollees to help them understand their coverage and make coverage decisions. Plans and issuers must provide the SBC to participants and beneficiaries who enroll or re-enroll during an open enrollment period. The SBC also must be provided to participants and beneficiaries who enroll other than through an open enrollment period (including those who are newly eligible for coverage and special enrollees).
In connection with a plan’s 2020 open enrollment period, the SBC should be included with the plan’s application materials. If coverage automatically renews for current participants, the SBC must generally be provided no later than 30 days before the beginning of the new plan year.
For self-funded plans, the plan administrator is responsible for providing the SBC. For insured plans, both the plan and the issuer are obligated to provide the SBC, although this obligation is satisfied for both parties if either one provides the SBC. Thus, if you have an insured plan, you should confirm that your health insurance issuer will assume responsibility for providing the SBCs.
Grandfathered Plan Notice
If you have a grandfathered plan, make sure to include information about the plan’s grandfathered status in plan materials describing the coverage under the plan, such as SPDs and open enrollment materials. Model language is available from the DOL.
Notice of Patient Protections
Under the ACA, non-grandfathered group health plans and issuers that require designation of a participating primary care provider must permit each participant, beneficiary and enrollee to designate any available participating primary care provider (including a pediatrician for children). Also, plans and issuers that provide obstetrical/gynecological care and require a designation of a participating primary care provider may not require preauthorization or referral for obstetrical/gynecological care.
If a non-grandfathered plan requires participants to designate a participating primary care provider, the plan or issuer must provide a notice of these patient protections whenever the SPD or similar description of benefits is provided to a participant. If your plan is subject to this notice requirement, you should confirm that it is included in the plan’s open enrollment materials. Model language is available from the DOL.
OTHER NOTICES
Group health plan sponsors should consider including the following enrollment and annual notices with the plan’s open enrollment materials.
Initial COBRA Notice
The Consolidated Omnibus Budget Reconciliation Act (COBRA) applies to employers with 20 or more employees that sponsor group health plans. Plan administrators must provide an initial COBRA notice to new participants and certain dependents within 90 days after plan coverage begins. The initial COBRA notice may be incorporated into the plan’s SPD. A model initial COBRA notice is available from the DOL.
Notice of HIPAA Special Enrollment Rights
At or prior to the time of enrollment, a group health plan must provide each eligible employee with a notice of his or her special enrollment rights under HIPAA. This notice may be included in the plan’s SPD. Model language for this disclosure is available on the DOL’s website.
Annual CHIPRA Notice
Group health plans covering residents in a state that provides a premium subsidy to low-income children and their families to help pay for employer-sponsored coverage must send an annual notice about the available assistance to all employees residing in that state. The DOL has provided a model notice.
WHCRA Notice
Plans and issuers must provide notice of participants’ rights to mastectomy-related benefits under the Women’s Health and Cancer Rights Act (WHCRA) at the time of enrollment and on an annual basis. Model language for this disclosure is available on the DOL’s website.
NMHPA Notice
Plan administrators must include a statement within the Summary Plan Description (SPD) timeframe describing requirements relating to any hospital length of stay in connection with childbirth for a mother or newborn child under the Newborns’ and Mothers’ Health Protections Act. Model language for this disclosure is available on the DOL’s website.
Medicare Part D Notices
Group health plan sponsors must provide a notice of creditable or non-creditable prescription drug coverage to Medicare Part D eligible individuals who are covered by, or who apply for, prescription drug coverage under the health plan. This creditable coverage notice alerts the individuals as to whether or not their prescription drug coverage is at least as good as the Medicare Part D coverage. The notice generally must be provided at various times, including when an individual enrolls in the plan and each year before Oct. 15th(when the Medicare annual open enrollment period begins). Model notices are available on the Centers for Medicare and Medicaid Services’ website.
HIPAA Privacy Notice
The HIPAA Privacy Rule requires covered entities (including group health plans and issuers) to provide a Notice of Privacy Practices (or Privacy Notice) to each individual who is the subject of protected health information (PHI). Health plans are required to send the Privacy Notice at certain times, including to new enrollees at the time of enrollment. Also, at least once every three years, health plans must either redistribute the Privacy Notice or notify participants that the Privacy Notice is available and explain how to obtain a copy.
Self-insured health plans are required to maintain and provide their own Privacy Notices. Special rules, however, apply for fully insured plans. Under these rules, the health insurance issuer, and not the health plan itself, is primarily responsible for the Privacy Notice.
Model Privacy Notices are available through the Department of Health and Human Services
Summary Plan Description (SPD)
Plan administrators must provide an SPD to new participants within 90 days after plan coverage begins. Any changes that are made to the plan should be reflected in an updated SPD booklet or described to participants through a summary of material modifications (SMM).
Also, an updated SPD must be furnished every five years if changes are made to SPD information or the plan is amended. Otherwise, a new SPD must be provided every 10 years.
Summary Annual Report
Plan administrators that are required to file a Form 5500 (> 100 participants in plan) must provide participants with a narrative summary of the information in the Form 5500, called a summary annual report (SAR). The plan administrator generally must provide the SAR within nine months of the close of the plan year. If an extension of time to file the Form 5500 is obtained, the plan administrator must furnish the SAR within two months after the close of the extension period.
Wellness Program Notices
Group health plans that include wellness programs may be required to provide certain notices regarding the program’s design. As a general rule, these notices should be provided when the wellness program is communicated to employees and before employees provide any health-related information or undergo medical examinations.
HIPAA Wellness Program Notice—HIPAA imposes a notice requirement on health-contingent wellness programs that are offered under group health plans. Health-contingent wellness plans require individuals to satisfy standards related to health factors (for example, not smoking) in order to obtain rewards. The notice must disclose the availability of a reasonable alternative standard to qualify for the reward (and, if applicable, the possibility of waiver of the otherwise applicable standard) in all plan materials describing the terms of a health-contingent wellness program. Final regulations provide sample language that can be used to satisfy this requirement.
ADA Wellness Program Notice—Employers with 15 or more employees are subject to the Americans with Disabilities Act (ADA). Wellness programs that include health-related questions or medical examinations must comply with the ADA’s requirements, including an employee notice requirement. Employers must give participating employees a notice that tells them what information will be collected as part of the wellness program, with whom it will be shared and for what purpose, the limits on disclosure and the way information will be kept confidential. The Equal Employment Opportunity Commission (EEOC) has provided a sample notice to help employers comply with this ADA requirement.
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Happy 2020! A new year. A new decade. So who doesn’t love a restart? Instead of making broad resolutions I focus on attainable goals. A few days before the New Year begins, I find some time to reflect on the current year and then write down a list of what I will accomplish in the upcoming year.
As you prepare your personal 2020 goals, take time to prepare your company goals as well. Your annual objectives should be financial as well as operational. Think through the different aspects of your business and make goals specific for each area. As you focus on each department, don’t forget human resources. Whether your business is large or small, your people are your most important asset. Here are some suggestions on ways to elevate HR in 2020:
Review Policies.
It is important to review your handbook and employee policies annually for any legal adjustments. Also, read your policies carefully and make sure that you are practicing what is written. Pay attention to the Paid Time Off policy; many times, there is a disconnect between the written policy and how PTO is practiced.
Rethink Performance Evaluations.
Mention employee reviews to supervisors, and you will hear a collective groan. The process often feels time-consuming and ineffective. It is time to rethink the process. Tie goals to the process, consider self-evaluations, separate compensation review from performance, or scrap the annual process altogether and implement weekly check-ins.
Implement More Training.
Education is the key to improving performance. Add more to your training budget, and it will be a positive return on investment.
Audit Payroll.
2020 is bringing some changes that may affect your employees’ pay. Many states have new minimum wage requirements, and the salary threshold for exempt employees increases to $648 per week. Make sure your company’s pay processes are up to date.
EvaluateEmployee Benefits.
A 2020 NY Small Group Health Plans page is a good starting point. Don’t let your renewal date sneak up on you, start the conversation with your benefits broker at least 60 days in advance. Review renewals and consider options to get the best coverage for your employees at the best price.
Consider Using a PEO.
By partnering with a Professional Employer Organization (PEO), your company can able alleviate much of the HR burden, offer top tier benefits, and propel your business forward by freeing you up to focus on business growth. Plus, companies that use a PEO have 15 percent lower employee turnover.
2020 is a new year with new opportunities. Take time to reflect and plan all that you can accomplish this year. Now, get to work! Start checking off those tasks and make this year the best ever!
The number of small and medium-sized employers using professional employer organizations (PEO) continues to increase each year. Often, it is thought that the growth of the PEO industry is due mainly to the benefits business owners see from this partnership. However, owners aren’t the only ones who gain from working with a PEO.
Small business employees, too, stand to benefit from the services and solutions offered by PEOs today. Let’s take a look at a few examples of the positive outcomes that small business workers see when their employer works with a PEO.
Congress has voted to fully repeal the Cadillac Tax and Health Insurance Tax effective January 1, 2021. This means the Health Insurance Tax will still be in place for 2020 and will be gone in 2021.
Both unpopular taxes with bipartisan approval delayed the Cadillac Tax but put the Health Insurance Tax(HIT) back in for 2020 earlier this summer. See Cadillac Tax Out Health Insurance Tax (HIT) Back In. Below are summaries of these two taxes that are now fully repealed.
Whats is the Health Insurance Tax (HIT)?
Health Insurance Tax: This tax included in the Affordable Care Act (ACA) increased the cost of health care coverage for consumers and employers in every state. The ACA imposed a new sales tax on health insurance that started at $8 billion in 2014, increased to $14.3 billion by 2018, and continued to increase each year.
The HIT costing an estimated 2.5%-3% added surcharge or an estimated $500/family annually and $241 for Seniors. Website Stop The Hit calculates $5,000 as the average tax for a 10 man small business for example.
Update:On December 20, 2019, President Trump signed into law a full repeal – with varied effective dates – of three ACA taxes: the Cadillac Tax, the Health Insurance Industry Fee (a.k.a. the Health Insurer Tax), and the Medical Device Tax. Additionally, the agreements extended the Comparative Effectiveness Research Fee (CERF) through 2029.
The HIT fee is in effect in 2020, then fully repealed and will no longer exist in and after 2021.
Whats is the Cadillac Tax?
The Cadillac Tax was to take effect in 2022 and had been twice delayed since its original inception scheduled for Jan 2014. This tax called for a 40% excise tax on the amount of the aggregate monthly premium of each primary insured individual that exceeds the year’s applicable dollar limit, which will be adjusted annually to the Consumer Price Index plus 1%.
The 40% excise tax applies to the cost of employer health plan coverage exceeding certain threshold amounts, which were originally set for 2018 at $10,200 for individuals or $27,500 for families.
Originally, the Cadillac Tax was pushed back by the behest of Unions to 2018 from the original proposed 2014 date. Most Unions with generous health care packages would not be complaint within that time frame. For average Gold Plans in regions such as NY, the widely unpopular Cadilac Tax would have been felt.
Learn more about how we are successfully helping navigate SMB for 20+ years. If you have any questions or would like additional information, please contact us at 855-667-4621 or info@medicalsolutionscorp.com.
