FAQ

Has there been a delay in the application of penalties for mid-size employers with 50-100 full-time equivalents?

If a company offers coverage with a mid-calendar plan year date, does the company need to offer qualified coverage to all full-time employees on January 1 to avoid penalties or can the employer transition coverage at the start of the plan year?

What is a common law employee?

What is a variable hour employee?

Does the minimum value requirement apply to self-insured groups?

How do the employer mandate penalties work if an employer does not offer coverage?

What is a controlled group?

How does the “no offer” penalty work with a controlled group? For example, what if one company within a controlled group offers minimum value and affordable coverage to all eligible employees and another company does not offer employees coverage at all?

How will the hours of part-time professors at colleges be counted for the application of the employer shared responsibility requirements? If a professor teaches six hours a week, does the prep time for that class have to be included? If so, how and who determines the number of hours to assign to them?

Our agency insures numerous restaurant and hospitality businesses. They have expressed concern over tip income. Most employees who work on a cash tip basis do not report 100% of their wages. How can employers protect themselves when calculating affordability if workers do not report 100% of their wages? The difference in a small amount of income could be the difference in the employer getting a penalty for offering unaffordable coverage.

For the 9.5% affordability, I know you go off the Box 1 total on the individual’s W-2, but does that Box 1 include FSA contributions made by the employee?

We have a group that is out of compliance on the single rate so he is adjusting his deductions to meet the 9.5% affordable mark. My question is this: He was paying 50% on the family rate and now is going to payroll-deduct the entire difference in the single and family rate so it will be a large amount. I thought I read somewhere that if the family portion being deducted is more than eight percent of their household income they could possibly get the subsidy. I realize if the other spouse is working and all of the other requirements, but let’s just say the spouse is not working and the deduction would be more than eight percent. Could they qualify for a subsidy?

Are age rates a problem for employer contribution strategies?

I heard that the definition of a seasonal employee was changed by the employer responsibility final rules. How is a seasonal employee defined?

Can summer paid interns be classified as seasonal employees if they work less than 120 days?

Is it possible to be penalized by both Penalty A and B?

What happens if you have a company domiciled in Canada that has 200 employees but they have a facility here in the states with 10 employees, and they offer the US employees benefits. Is the company subject to Play or Pay rules for the employees located in the US?

Is additional transition relief available for employers with at least 50 but fewer than 100 full-time employees (including full-time equivalents)?

Do employers between 50 and 99 full-time equivalents need to file a form for employer reporting? If so, which form?

What categories can an employer use for different measurement periods or to use measurement periods that differ in duration or starting or ending dates?

Can an employer have an initial measurement period for new full-time employees?

What if an ongoing employee experiences a change in employment status before the end of the stability period?

How do you calculate hours if a person is off on maternity leave, FMLA or if they are injured off the job?

I have a client who is using the measurement periods for variable hour employees. One variable hour employee that was eligible declined because she was still on her parent’s plan. Mid-way through the year she is losing their coverage (age 26) and now needs coverage. It is in the middle of the next measurement period. Does she have to wait until she is measured again or since she would have already qualified for this year, but declined, is this a qualifying event to come on mid-year?

Employer Reporting

What do we need to know about ACA employer reporting requirements?

Who must complete the forms for Section 6055 (individual mandate) reporting?

Who must complete the forms for Section 6056 (employer mandate) reporting?

What are the forms numbers and their purposes?

Do small employers have to report?

What do large employers have to report?

What do self-funded employers have to report?

When will employers have to report?

Is there a summary regarding employer reporting that I can use with my clients?

Clients with individual coverage are asking me about the 1095-A form. What is it?

Does a large employer who doesn’t offer coverage have to do anything for ACA employer reporting?

Subsidies and Individual Penalties

Under what circumstances could an employee qualify for subsidies yet the employer not be penalized?

If a family has a household income that is below 400% of the FPL, but the husband has employer-sponsored coverage (that meets the minimum value and affordability requirements) offered to him and his family, would the spouse and children still be eligible to receive a subsidy if they (the spouse and children) purchase health insurance on the state (federally facilitated) exchange?

Is there any definitive information on “cost sharing” for people under 250% of FPL?

How are cost-sharing reductions provided?

If an individual receives an excess subsidy due to higher than expected income, how much may they be required to pay back?

An individual goes to the exchange and qualifies for some form of subsidy due to family income meeting the guidelines. In that year, their income situation improves which now disqualifies them for a subsidy on the premium. This is either charged back to them on their income tax or withheld from their refund if they have one, correct?

Does it make a difference if a group is a large or small group when determining whether employees are eligible for a subsidy?

I heard that a married couple HAD TO file jointly to get a subsidy in the exchange. Is that correct?

What is the maximum penalty cap for an individual who didn’t have coverage in 2014? I understand the cap is based on a national average premium for a bronze level plan as determined by the IRS.

What is the short term coverage gap for individuals to not be subject to a penalty under the ACA?

Exchanges

In areas along the border between states, which rules apply for the resident when looking for exchanges — where they live or where they work?

Small Business Tax Credit

In 2014, the small-business tax credit will only be available to those small businesses that purchase their insurance through the public exchange. Since at least 26 states will not have a public exchange available until 2015, doesn’t this mean the tax credit is not available in 2014 for those small businesses in those 26 states? Would the law need to be amended through Congress to allow for an extension?

Notices

I believe that PPACA required that employers notify employees, in writing, at least 60 days in advance of any proposed plan change. Has this been postponed?

Should an employer decide to make a plan change at renewal, is there a time period these changes must be made and employees receive notification before hand – i.e., 30days or 60-days?

If a group implements changes to the group health plan at any time other than the group renewal, what timeline and notification is required by the employer to the employee, if any?

If a group decides to cancel group coverage due to health care reform, is there a required notification period the employer needs to notify the employee in advance? If so, what do they need to provide to employee? (I’m mainly thinking about groups under 50 not subject to mandate.)

I understand that before agents/brokers help an individual with the Marketplace enrollment, they have to present a privacy notice to the client. Do you know where I can get a copy of this notice?

If a plan sponsor/employer makes no changes to the medical plan offered to employees from one year to the next, is distribution of the SBC at plan renewal necessary?

When must an employer provide an SBC in a non-English language?

Can an employer provide ERISA and other benefit documents electronically instead of in print?

HIPAA Privacy

My client is moving into a new building and will no longer be in a closed office. She is concerned about HIPAA as it relates to assisting employees with claim issues. They are looking for something within the HIPAA law that will confirm the need for a closed-door space for these discussions. Can you point me in the right direction?

Pediatric Dental

Are large groups (with more than 50 employees) required to offer pediatric dental? If the group does not offer the rider, if it is not mandated to, are individuals required to meet the responsibility if they have children on their plan (court orders, etc.)?

Essential Health Benefits

Has NAHU done any research on what obesity coverage will be covered under the new healthcare law? I am looking to see what types of new benefits will be available to the various groups based on what type of plan they have in place. I know it’s covered under the preventive portion and the U.S. Preventive Task Force has some things in place. I’m also interested in small groups/individuals — what coverage will be under the essential benefits section.

HSAs and HRAs

Must an employer have a Section 125 cafeteria plan established in order to pay HSA funds pre-tax?

Is it true that beginning with plan years in 2016, that an HDHP can have a family deductible, for example $10,000, but the plan must still observe a maximum individual out-of-pocket of $6,600 for an individual?

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