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Benefit Insights Understand the ACA Reporting Requirements

We thought it helpful to provide an outline of the Affordable Care ACT (ACA) reporting requirements under IRS Sections 6055 & 6056. While some mandates continue to be delayed, we fully expect 2016 to be the year of full compliance with reporting requirements. There is a great deal of confusion regarding the use of the […]


Posted in Healthcare

We thought it helpful to provide an outline of the Affordable Care ACT (ACA) reporting requirements under IRS Sections 6055 & 6056. While some mandates continue to be delayed, we fully expect 2016 to be the year of full compliance with reporting requirements. There is a great deal of confusion regarding the use of the newly required 1095 and 1094 forms. This primer hopes to shed light on the subject and hopefully clear up questions on your responsibility.

This should not be construed as tax advice. We are sharing our understanding of the ACA requirements and how they apply to each market segment, but we are not operating as a tax advisor. As always, we strongly suggest that anyone should consult with a licensed tax professional or CPA before filing any IRS documents.

SUMMARY

  • Most Small Group Employers (under 50 full-time and full-time equivalent employees) are exempt from filing any documents under Sections 6055 and 6056
  • Large Employers are required to file 1095-C and 1094-C forms
  • 1095-B forms are filed directly by the Insurance Carriers unless you are an employer that offers a self-insured group plan
  • 1095-A forms impact individuals that purchase their insurance directly from a State or Federal Exchange and have no impact on group plans

FORM REQUIREMENT & RESPONSIBILITY MATRIX

 

Insurance Type Required Form 6055 Reporting
Insurer Responsibility
Required Form 6056 Reporting
Employer Responsibility
Individual (On-Exchange) N/A
Form 1095-A sent by Marketplace
N/A
Individual (Off-Exchange) Form 1095-B
Form sent by Insurance Carrier
N/A
Small Group Fully-Insured
Including SHOP Marketplace
Form 1095-B
Form sent by Insurance Carrier
N/A
Small Group Self-Insured Form 1095-B
Form sent by Employer not Carrier
N/A
Applicable Large Employer (ALE)   Fully Insured Form 1095-B
Form sent by Insurance Carrier
Form 1095-C
Sections I, II
Applicable Large Employer (ALE)   Self-Insured N/A Form 1095-C
All Sections 6055 + 6056

DEFINITIONS & EXPLANATIONS

FORM 1095-A

If you bought health insurance through one of the Health Care Exchanges, also known as Marketplaces, you will receive a Form 1095-A which provides information about your insurance policy, your premiums (the cost you pay for insurance) and the people in your household covered by the policy. The 1095-A form, only applies to those individuals that purchased their own plans directly from a State sponsored or Federal (www.healthcare.gov)

The Affordable Care Act, also known as Obamacare, requires most U.S. residents to have health insurance, but it also offers a tax break, the Premium Tax Credit, to help offset the costs of health coverage. If you bought coverage through one of the health insurance marketplaces, you should receive a copy of Form 1095-A, which provides information needed to claim the tax credit.

The 1095-A does not apply to any Small or Large Group plans and does not impact an company, medical plans.

FORM 1095-B

A Company is responsible for filing IRS Form 1095-B only if two conditions apply: It offers health coverage to its employees, and it is “self-insured.” This means that the company itself pays its employees’ medical bills, rather than an insurance company. A company that doesn’t meet both conditions won’t have to deal with Form 1095-B. Its employees might still receive a 1095-B, but this comes direct from their insurer carrier, not the employer. The 1095-B reports information showing that an employee or individual had the required minimum essential coverage required under the law. This is proof that an individual meets the ACA Insurance Mandate to have coverage. If an employee or individual cannot provide this proof, they may be subject to the ACA fines for not having insurance coverage.

FORM 1095-C

The Affordable Care Act requires certain employers to offer health insurance coverage to full-time employees and their dependents. Those employers must also send an annual statement to all employees eligible for coverage describing the insurance available to them. The Internal Revenue Service (IRS) created Form 1095-C to serve as that statement.

The health care law defines which employers must offer health insurance to their workers. The law refers to them as “applicable large employers,” or ALEs. A company or organization is an ALE if it has at least 50 full-time workers or full-time equivalents. A full-time worker, according to the law, is someone who works at least 30 hours a week.

Small Group employers with less than 50 full-time workers and full-time equivalents are not responsible for sending or reporting 1095-C information to the Federal Government or their employees. They are exempt as a small employer.

FORM 1094-B

Form 1094-B is the cover sheet used by insurance providers when they send the IRS information about who has health coverage that meets the standards of the Affordable Care Act. The 1094-B is brief and only takes up less than a page. This form is also used by any employer that offers health care coverage to its employees and is “self-insured”.

If an employer falls short of 50 full-time and full-time equivalents and is not “self-insured”, they are not required to send out 1095-C’s, 1095-B’s and do not need to report their health plan information to the IRS. Your insurer will report directly to the Federal Government using the 1095-B. Most employees on group coverage should receive a 1095-B directly from the insurance carrier.

FSAs, HSAs and HRAs are not subject to the Form 1095-B filing requirement (because they do not provide Minimum Essential Benefits and therefore by themselves do not relieve the employee from the individual mandate penalty tax).

FORM 1094-C

IRS Forms 1094-C and 1095-C are filed by employers that are required to offer health insurance coverage to their employees under the Affordable Care Act. The main difference between them is that the 1095-C provides information about health insurance (see above) and is sent to both employees and the IRS, while the 1094-C is a cover sheet about the 1095-C and is sent only to the IRS. If an employer is exempt from filing a 1095-C, the 1094-C is not required.

Contact Denis Squeri for more information – dsqueri@fp-ins.com

Benefit Insights – Educating Employees on Health Benefits

Employers are responsible for educating their employees about the health coverage options they offer. Employees have the right to receive clearly presented health and benefit information and assistance reading health materials, if needed. More specifically, employers are responsible for informing employees of: What benefits are covered in the offered health plan(s) Cost-sharing requirements and arrangements […]


Posted in Healthcare

Employers are responsible for educating their employees about the health coverage options they offer. Employees have the right to receive clearly presented health and benefit information and assistance reading health materials, if needed.

More specifically, employers are responsible for informing employees of:

  • What benefits are covered in the offered health plan(s)
  • Cost-sharing requirements and arrangements
  • Procedures for resolving complaints and appealing decisions
  • Licensure, certification and accreditation status
  • Methods for measuring consumer quality and satisfaction
  • Composition of the provider network
  • Obtaining referrals to specialists
  • Cost of emergency care services
  • Price, quality and safety of health benefits provided by the offered plans

Required Documents

The Employee Retirement and Income Security Act (ERISA) requires health plan administrators to give plan participants specific information about the benefits to which they are entitled, including covered benefits, plan rules, financial information and documents about the plan’s operation and management. This information must be provided in writing on a regular basis or upon request.

There are certain materials that a plan sponsor must provide to each participant and beneficiary in a plan, even if not requested:

  • Summary plan description
  • Summary of material modifications (whenever the plan is amended)
  • Summary annual report (contains information on the financial condition of the plan)
  • Summary of Benefits and Coverage

These materials can be provided electronically, as long as certain requirements are met, including the requirement that the plan member gave consent to receive the documents electronically.

 

Caveat Emptor – When Buying Health Insurance, let the “Buyer Beware”

As a health insurance broker, I don’t often use the term “Obamacare” when discussing the Affordable Care Act (ACA), simply because for some this is a positive, hopeful reference while for others it is evil incarnate. This clear, politically biased split highlights the reality of a law that is neither as good as one side […]


Posted in Healthcare

As a health insurance broker, I don’t often use the term “Obamacare” when discussing the Affordable Care Act (ACA), simply because for some this is a positive, hopeful reference while for others it is evil incarnate. This clear, politically biased split highlights the reality of a law that is neither as good as one side maintains, nor as bad as the other side preaches. As with most controversial political topics, the truth lies somewhere in the middle.

With two years of implementing changes and new plans under the ACA, I can provide one clear observation; despite all the promises, our healthcare purchasing process has become more complicated than ever before.  Yes, the ACA did provide a simple Bronze, Silver, Gold and Platinum set of choices for consumers, intended to force insurance carriers to offer easily comparable plans as they do in Medicare. Unfortunately, the law of unintended consequences overwhelmed their best intentions. New subscribers can now get their coverage through large group employers, small group employers, state exchanges like Covered California, private exchanges, directly from insurance carriers and finally expanded Medicaid. The expanded markets have just added to the confusion.

The law allows insurance carriers to stagger the way they provide “comparable” coverage as long as the plans were actuarially comparable. How many Americans even know what actuarial means? You must still go line by line, coverage option by coverage option, sorting through arcane language to understand what is actually covered. While this is hard enough, it is simple compared to the biggest problem we have struggled with under the new rules.

To pile on the complexity, the ACA allows carriers to implement different doctor networks for different plans, even ones that are identical in terms of coverage and cost. This has been the truly nasty surprise for many new subscribers that thought they were purchasing a solid HMO or PPO plan. If they just asked their doctor, “do you take Anthem Blue Cross PPO”, they may get a positive response. This could lead to sticker shock when they find out the doctor was not in their specific “Skinny” PPO network. What they should have said is, “do you accept the Anthem Blue Cross, Bronze Pathway 5000/25, Off Exchange plan as an In Network provider”? To add to the frustration, most doctors’ offices just say, “you have to check with your insurance company.” The insurance company in turn will ask you “what plan are you on?” If you have not made your decision yet and don’t know which plan, it is impossible to get a definitive answer. You have to research each plan option to see if your doctor is In Network or not.

There are tools to help research doctor networks, but experience has shown these to be less than 100% accurate. As a broker, we now spend more time researching doctor availability in specific plan choices than we do on the coverage options and costs, but our greatest frustration is the inability to absolutely guarantee doctor choice for our clients. Networks change with greater frequency due to the ACA’s mandates to offer affordable coverage. We do our best to steer frustrated clients through this exceedingly complex set of options, but the law is still evolving. Stay tuned for more changes as they try to fix this leaky ship called the ACA and always remember…”let the buyer beware!”

Are you OSHA Compliant? Find out by taking our safety program “Quick-Check”

This is a quick survey of some of the key written programs that may be required by OSHA in your Injury and Illness Prevention Program (IIPP). While this is not a complete list of the various OSHA requirements, it is a summary of the major issues typically identified in an audit. Safety Program Topic Written […]



This is a quick survey of some of the key written programs that may be required by OSHA in your Injury and Illness Prevention Program (IIPP). While this is not a complete list of the various OSHA requirements, it is a summary of the major issues typically identified in an audit.

Safety Program Topic

Written Plan or Work Instruction

  Training  Level
Accident Reporting & Investigating Process Yes No NA 1 2 3 4 5
Blood borne Pathogens Exposure Control Plan Yes No NA 1 2 3 4 5
Emergency Action/Disaster Plan Yes No NA 1 2 3 4 5
Ergonomics Plan Yes No NA 1 2 3 4 5
Fire Prevention Plan Yes No NA 1 2 3 4 5
Hand Tool Safety Program Yes No NA 1 2 3 4 5
Hazard Communication Program Yes No NA 1 2 3 4 5
Housekeeping Program Yes No NA 1 2 3 4 5
Inspection Forms Yes No NA 1 2 3 4 5
Ladder Safety Program Yes No NA 1 2 3 4 5
Personal Protective Equipment Program Yes No NA 1 2 3 4 5
Recordkeeping Practices & Requirements Yes No NA 1 2 3 4 5
Safety & Health Management System Policy Yes No NA 1 2 3 4 5
Safety Committee Organizational Plan Yes No NA 1 2 3 4 5
Workplace Violence Prevention Plan Yes No NA 1 2 3 4 5

 

  Bold indicates required program or required documentation by OSHA.

Training  Effectiveness Scale
5 = Excellent / Everyone Trained
4 =  Good /Most Trained
3 =  Average/ Some Trained
2 =  Needs your  attention/ Few Trained
1 =  Danger Will Robinson! /No one trained!  

 

If you need help creating any of these programs or processes, give us a call! We have many templates, tools, and other resources in our risk management library that will save you time and keep OSHA off of your back! Just contact Daniel Costello at 415-493-2503 or dcostello@fp-ins.com.

Three Ways to Save Money on Healthcare Costs

The quick and simple answer to this question: Don’t get sick or injured! Seriously, the topic is more complex and challenging than any one blog—or than countless health consultants and analysts, Congressmen or the President can easily solve. Here are three suggestions for saving money on your individual medical insurance and out-of-pocket costs: Find out […]


Posted in Healthcare

save-moneysmThe quick and simple answer to this question: Don’t get sick or injured!

Seriously, the topic is more complex and challenging than any one blog—or than countless health consultants and analysts, Congressmen or the President can easily solve.

Here are three suggestions for saving money on your individual medical insurance and out-of-pocket costs:

  1. Find out if your employer offers a Health Savings Account (HSA) plan. This plan is a fantastic way to hedge your bet against future costs, get help from the IRS and possibly your employer. If your employer doesn’t offer one, ask anyway. It may benefit the company to consider one. If an HSA is not available through work, it’s a good idea to look into one for yourself.
  2. Never pay the first bill for medical services you receive from a doctor, hospital or other provider. Wait for the Explanation of Benefits (EOB) from your insurance company to be sure you’ve been charged correctly. (The percentage of incorrectly billed procedures, office visits, tests, etc. is staggering!) Once you have your EOB, match it to the bills received from healthcare providers. When the amounts match and you believe the insurance company paid according to your coverage, you can confidently pay the bill.
  3. If you are covered through a Preferred Provider Organization (PPO), be diligent about your network choices. When you schedule a procedure, surgery, etc., ask your primary provider for the names and contact numbers of each of the separate entities who will be charging you. You may have 4 or 5 different entities (surgeon, anesthesiologist, surgical center, etc.) billing you for what you think of as one procedure. Before the procedure, contact each of them and ask directly: “Are you an In-Network PPO provider with (your insurance company’s name) who accepts its negotiated rates?” Do not assume they do—many times there’s a mix of In- and Out-of-Network hands involved. You will be charged more if you use Out-of-Network providers. That may be unavoidable, but at least you won’t be surprised.