Affordable Care Act

Employer Payment Plans Prohibited: This is an arrangement where the employer reimburses the employee (in whole or in part) for premium expenses incurred for an individual health policy or pays the premium direct. This is prohibited.

90 Day New Hire Waiting Period: New hire waiting periods cannot exceed 90 days. Your new hire must be enrolled ON the 91st day following their date of hire or you may choose the first of the month following 60 days of employment (which will never exceed 90 days). Variable hour employees may use look back periods.

W-2 Reporting: Most employers that file 250 or more W-2's in the prior year must report the cost of medical coverage on each form W-2. The W-2 must be given to the employees by January 31st of each year.

Health Insurance Marketplace Notice (FLSA): The model notice (which can be found on the department of labor's website www.dol.gov) must be given to a new employee within 14 days of their start date.

Summary of Benefits and Coverage (SBC): This is a uniform benefits summary that an employee must be provided with for each medical plan offered by the employer prior to the initial enrollment into the plan, at renewal of the plan, within 90 days of a special enrollment, and within 7 business days of an employee's request.

"Pay or Play" Penalties: Large Employers may be subject to the "pay or play" penalty if they do not offer affordable coverage (as defined by the PPACA) that provides minimum value to at least 95% of their employees and their dependents in 2016 (70% in 2015). If the Employer does not offer coverage, the penalty is $166.67 per month or $2,000 annually per employee over the 80th employee in 2015 and over the 30th employee in 2016. The penalty for offering insurance that does not meet the minimum standards or is not considered affordable by ACA standards is $250/month or $3,000 per year for each employee that qualified for a premium tax credit (subsidy) AND enrolled.

1094-C and 1095-C Reporting Requirements: A large employer must report, for all 12 months of a calendar year, that each full time employee and their dependents were offered minimum essential coverage that met the ACA's minimum value requirements and was affordable. You must report on all employees that worked full time for at least one or more months during the calendar year. A third party vendor may assist in fulfilling the reporting requirements and you may file electronically (those groups that require 250 or more 1095-c forms to be files are required to file electronically). The penalty for not filing is $250 per notice not given out to the employee. The penalty max is up to $3,000,000. Blatant non filing doubles the penalty. For more detailed information and deadlines visit www.irs.gov.

Medical Loss Ratio (MLR) Rebates: If an MLR rebate is received from an insurance carrier, the rebate must be distributed to eligible plan participants as appropriate. The MLR requires insurance companies to spend at least 80% or 85% of premium dollars on medical care. If they fail to meet these standards, the insurance companies will be required to provide a rebate. More information can be found at www.dol.gov

Employer Payment Plans Prohibited: This is an arrangement where the employer reimburses the employee (in whole or in part) for premium expenses incurred for an individual health policy or pays the premium direct. This is prohibited.

90 Day New Hire Waiting Period: New hire waiting periods cannot exceed 90 days. Your new hire must be enrolled ON the 91st day following their date of hire or you may choose the first of the month following 60 days of employment (which will never exceed 90 days). Variable hour employees may use look back periods.

W-2 Reporting: Most employers that file 250 or more W-2's in the prior year must report the cost of medical coverage on each form W-2. The W-2 must be given to the employees by January 31st of each year.

Health Insurance Marketplace Notice (FLSA): The model notice (which can be found on the department of labor's website www.dol.gov) must be given to a new employee within 14 days of their start date.

Summary of Benefits and Coverage (SBC): This is a uniform benefits summary that an employee must be provided with for each medical plan offered by the employer prior to the initial enrollment into the plan, at renewal of the plan, within 90 days of a special enrollment, and within 7 business days of an employee's request.

PCORI Fees: The PCORI fee is a fee that helps to fund the Patient-Centered Outcomes Research Institute (PCORI). The IRS states that the institute will assist, through research, patients, clinicians, purchasers and policy-makers, in making informed health decisions by advancing the quality and relevance of evidence-based medicine. The institute will compile and distribute comparative clinical effectiveness research findings. The amount of the PCORI fee is equal to the average number of lives covered during the policy year or plan year multiplied by the applicable dollar amount for the year. For policy and plan years ending after Sept. 30, 2014, and before Oct. 1, 2015, the applicable dollar amount is $2.08 . For policy and plan years ending after Sept. 30, 2015, and before Oct. 1, 2019, the applicable dollar amount is further adjusted to reflect inflation in National Health Expenditures, as determined by the Secretary of Health and Human Services. They must be files no later than July 31st of the year following the last day of the plan year to which the fee applies.

Transitional Reinsurance Program Fee's: As per the IRS, these fee's help stabilize premiums for coverage in the individual market during the years 2014 through 2016. The statute requires all health insurance issuers and third-party administrators on behalf of self-insured group health plans to make contributions under this program to support payments to individual market issuers that cover high-cost individuals. In other words, this fee will help pay for high claimants in the individual (non-group) marketplace and your TPA will file them for you.

"Pay or Play" Penalties: Large Employers may be subject to the “pay or play” penalty if they do not offer affordable coverage (as defined by the PPACA) that provides minimum value to at least 95% of their employees and their dependents in 2016 (70% in 2015). If the Employer does not offer coverage, the penalty is $166.67 per month or $2,000 annually per employee over the 80th employee in 2015 and over the 30th employee in 2016. The penalty for offering insurance that does not meet the minimum standards or is not considered affordable by ACA standards is $250/month or $3,000 per year for each employee that qualified for a premium tax credit (subsidy) AND enrolled.

1094-C and 1095-C Reporting Requirements: A large employer must report, for all 12 months of a calendar year, that each full time employee and their dependents were offered minimum essential coverage that met the ACA's minimum value requirements and was affordable. You must report on all employees that worked full time for at least one or more months during the calendar year. A third party vendor may assist in fulfilling the reporting requirements and you may file electronically (those groups that require 250 or more 1095-c forms to be files are required to file electronically). The penalty for not filing is $250 per notice not given out to the employee. The penalty max is up to $3,000,000. Blatant non filing doubles the penalty. For more detailed information and deadlines visit www.irs.gov.

Employer Payment Plans Prohibited: This is an arrangement where the employer reimburses the employee (in whole or in part) for premium expenses incurred for an individual health policy or pays the premium direct. This is prohibited.

90 Day New Hire Waiting Period: New hire waiting periods cannot exceed 90 days. Your new hire must be enrolled ON the 91st day following their date of hire or you may choose the first of the month following 60 days of employment (which will never exceed 90 days). Variable hour employees may use look back periods. You are allowed an orientation period that lasts no longer than 1 month and the 90 day waiting period must begin the first day after the orientation period. This will not impose a penalty in small group.

Health Insurance Marketplace Notice (FLSA): The model notice (which can be found on the department of labor's website www.dol.gov) must be given to a new employee within 14 days of their start date.

Summary of Benefits and Coverage (SBC): This is a uniform benefits summary that an employee must be provided with for each medical plan offered by the employer prior to the initial enrollment into the plan, at renewal of the plan, within 90 days of a special enrollment, and within 7 business days of an employee's request.

Medical Loss Ratio (MLR) Rebates: If an MLR Rebate is received from an insurance carrier, the rebate must be distributed to eligible plan participants as appropriate. The MLR requires insurance companies to spend at least 80% or 85% of premium dollars on medical care. If they fail to meet these standards, the insurance companies will be required to provide a rebate. More information can be found at www.dol.gov

Small Business Health Care Tax Credit: Your Company could be eligible for a small business tax credit through the SHOP Exchange only (Marketplace) if the employer employs no more than 25 employees with an average income of less than $50,000. The maximum credit is 50% of premium and available for up to two years. The smaller the company and lower the income, the higher the credit.