Affordable Care Act Employer Provisions Chapter 11 pp. 411 - 463 2015 National Income Tax Workbook™ pp. 412-413 Types of Health Coverage Minimum Essential Coverage (MEC) ▪ Individual must have ▪ Large employer must provide to full-time EEs Excepted Benefits: Not = MEC ▪ Will not satisfy employer mandate ▪ Will not satisfy individual mandate 2 pp. 412-413 Types of Health Coverage – MEC Eligible employer plans Individual state Marketplace plans Certain Government plans Grandfathered plans Coverage recognized by HHS 3 Types of Health Coverage Excepted Benefits pp. 413-414 Always Excepted Benefits – listed p. 413 Limited Excepted Benefits ▪ ▪ ▪ ▪ ▪ ▪ FSA Limited-scope dental or vision benefits Benefits for long-term care/nursing home Employee Assistance Program (EAP) Noncoordinated and supplemental Wraparound Coverage 4 Types of Health Coverage Excepted Benefits p. 414 Wraparound Coverage – Pilot Program ▪ Offer coverage no earlier than 1/1/2016 ▪ Offer coverage no later than 12/31/2018 ▪ Coverage to end 3 years after 1st offered ▪ Annual reporting requirements ▪ Wraparound eligible individual coverage or coverage in a multistate plan 5 Types of Health Coverage Excepted Benefits p. 414 Wraparound Coverage – Individual ▪ Eligible individuals • Cannot be in health FSA • Limited to part-time EEs or retirees • Can cover spouse/dependents • ER must offer full-time EEs coverage substantially similar to ACA coverage 6 Types of Health Coverage Excepted Benefits p. 414 Wraparound Coverage –Multi-state Plan ▪ Coverage must be approved by OPM ▪ Provides benefits in conjunction w/ multistate plan ▪ In 2013 & 2014 Employer • • Offered coverage substantially similar to ACA required offers to full-time in 2015 Offered affordable, minimum value coverage to “substantial portion” of full-time ▪ Annual employer payments for primary and wraparound coverage ≥ 80% of 2013 or 2014 $ 7 p. 415 ACA Employer Timeline -2015 Employer & insurer reporting required ▪ All large ERs & small ERs if self-insured No ESRP for some ERs with 50 – 99 FTEs Excise tax relief ▪ Small employers through 6/30/15 ▪ For health care arrangements re: 2% S corp S/H through 12/31/15 p. 416 ACA Employer Timeline - 2016 Employer & insurer reporting required ▪ All large ERs & small ERs if self-insured ESRP could apply to all ALEs Excise tax relief ▪ For health care arrangements re: 2% S corp S/H if no guidance issued yet SHOP available to ERs with ≤ 100 FTEs ▪ 2015 PACE Act: 100 to be State decision p. 417 Whistleblower Protection § 1558 of ACA expands protection to EEs who Received a PTC Provided/will provide info relating to any act or omission employee believes violates ACA Testified/will testify regarding such violation Assisted/participate in related proceeding Objected to/refused to participate in activity EE believes to be in violation of any part of ACA p. 417 Whistleblower Protection Prohibited Acts Demotion or reassignment to less desirable job Denial of overtime, benefits, promotion Harassment, intimidation, threatening behavior Reduction in pay or hours Wrongful discharge/termination p. 417 Whistleblower Protection Effects on Employer Adverse OSHA determination – reinstate, back pay w/interest, damages, related fees Substantial ESRP penalty ▪ Financial reward to EE of 15% to 30% of collected ESRP Practitioner Note: Staff Education a Must! p. 418 Employer Shared Responsibility Payment (ESRP) Applicable large employer (ALE) liable if ≥ 1 full-time employee (FT EE) gets premium tax credit (PTC) AND ALE did not offer MEC to FT EEs or offers MEC to < 95% of FT EEs and dependents or MEC not affordable, w/o minimum value (MV), or MEC not offered to FT EE getting PTC 2015 Transition Relief pp. 418-419 50-99 Employee Relief No potential ESRP in 2015 if ▪ FTEs in 2014 were at ≥ 50 < 100 ▪ No reduction in # of EEs or EE hours from 2/9/14-12/31/14 ▪ No elimination or material reduction in coverage offered 2/9/14-12/31/14 Applies to plan years beginning in 2015 2015 Transition Relief pp. 418-419 50-99 Employee Relief Not considered elimination or material reduction in coverage if: ▪ ER contributions ≥ 95% of $ or ≥ % of cost paid on 2/9/14 ▪ Benefits changed but still MV ▪ Class of EEs covered not narrowed or reduced from those covered 2/9/14 2015 Transition Relief pp. 418-419 50-99 Employee Relief Relief applies to all months of a plan that begins in 2015 (includes those in 2016) If qualifies for relief, still an ALE in 2015 Required to file information returns ER certifies qualification on Form 1094-C ▪ Box 22C in Part II 2015 Transition Relief > 100 Employees Relief p. 419 Coverage requirement met if offer to ≥ 70% of full-time EEs Check Box 22C, Part II, on Form 1094-C p. 419 Applicable Large Employer (ALE) Employer with ≥ 50 FTEs in 2014 For-profit, nonprofit, or gov’t entity Businesses under common control ▪ One employer for ALE determination ▪ Separate for ESRP determination p. 419 Businesses Under Common Control Ex. 11.1 Corp Z owns 100% of Y and X 2015 FTEs: Z: 0 Y: 30 X: 40 FTEs combined ≥ 50, each is an ALE If 70 in 2014 & group met all 3 conditions, could qualify for 50-99 relief in 2015 p. 420 Businesses Under Common Control Ex. 11.2 Business as sole prop 2015: 15 FTEs Owns 80% of ABC P/S 2015: 40 FTEs Sole prop and ABC P/S = 1 Employer Sole prop and ABC P/S are ALEs for 2016 If 2014 FTEs of 55, will be ALE for 2015 but may qualify for 2015 50-99 relief p. 420 Businesses Under Common Control If businesses under common control determined to be an ALE Each separate business treated as an ALE ESRP determined separately for each Each must file reporting forms for 2015 Qualification for 50-99 relief made by the group combined, not each separately p. 420 First Year of Existence Not in existence any business day of prior year Will be ALE in current year if: ▪ Expects to employ average of 50 FTEs and ▪ Does employ average of at least 50 FTEs For 2015 can qualify for 50-99 relief if for 2015 ▪ Reasonably expects to employ < 100 FTEs ▪ Reasonably expects & does meet tests for workforce, hours, coverage from first day p. 420 Full-Time Employees Full-time = 30 hour/week average or 130 hours any given month All employees in for ALE determination Must include those exempt from coverage Must include those eligible for other coverage Seasonal worker exception Religious order exception – vow of poverty p. 421 Full-Time Equivalents Using those working < 30 hours/week Total hours per month (up to 120 each) Divide total by 120 Round to nearest one hundredth p. 421 ALE Determination Determine average FTE count of prior year ▪ Total full-time employers and full-time equivalents for each month ▪ Add together all months totals ▪ Divide yearly total by 12 For 2015 determination only, may use any consecutive 6-month period in 2014 Example 11.2 p. 422 Hours of Service Hour worked or not worked for which EE paid or is entitled to pay ▪ Includes vacation, holiday, illness, layoff, jury duty, military duty, disability, any paid absence Does not include: ▪ Bona fide volunteer for a government or taxexempt entity in federal work-study program ▪ Compensation constituting income from sources outside the U.S. pp. 422-423 Hours of Service Seasonal Workers ▪ One performing labor or services on a seasonal basis (farm, holiday retail workers) ▪ Counted in number of FTEs ▪ If average FTEs > 50 for ≤ 120 days in year & seasonal workers caused excess, no ALE ▪ 4 calendar months = 120 days ▪ 120 days/4 months need not be consecutive pp. 422-423 Hours of Service Adjunct faculty: 2.25 hours/teaching hour + 1 hour for each hour outside classroom Paid interns counted same as other employees Shared employees ▪ Treated as 1 employer, all hours counted ▪ Treated as separate, allocate hours Layover hours – p. 423 On-call hours – p. 423 pp. 423-424 Coverage ALE must offer coverage to full-time employees ▪ Affordable AND ▪ Provides minimum value 2015: Offer to 70% of full-time 2016 and later: Offer to 95% of full-time Offered for a calendar month if for FULL month January 2015: Coverage offer by first day of first pay period treated as January coverage p. 424 Full-time Employees - Coverage Methods to determine is full-time for coverage requirement (who must be offered coverage?) ▪ Monthly measurement method ▪ Look-back measurement method Look-back method cannot be used in determining full-time for ALE determination p. 424 Full-Time Employees – Coverage Monthly Measurement Method Identify full-time based on hours of service per month 130 hours/month (30/week) New Employee: ▪ No ESRP if (must meet both) • Coverage by day after 3 full calendar mos. • Coverage provided has MV • Applies only once per employment period • Relief even if employee leaves < 3 months p. 424 Full-Time Employees – Coverage Monthly Measurement Method Rehired Employee ▪ Treated as continuing employee if period with no hours of service is • Less than 13 weeks • Less than 26 weeks if educational org. • May treat as new hire if period of no hours is ≥ 4 consecutive weeks & such period exceeds length of immediately preceding employment p. 424 Full-Time Employees – Coverage Look-Back Measurement Method Full-time status determined for future period (stability period) based on hours worked in prior period (measurement period) Measurement Period ▪ At least 3 months but not more than 12 ▪ Employer chooses start and end • Must be uniform w/in EE category pp. 424-425 Full-Time Employees – Coverage Look-Back Measurement Method Administrative Period ▪ Optional period ▪ Time to determine EE’s status and notify EEs of status and eligibility ▪ No > 90 days (can differ for EE categories) ▪ Between measurement and stability ▪ Overlaps prior stability – no coverage break p. 425 Full-Time Employees – Coverage Look-Back Measurement Method Stability Period ▪ EE averaging 30 hours/week treated as full-time in subsequent stability period • Regardless of hours in stability period • At least 6 consecutive months long • No shorter than measurement period p. 425 Full-Time Employees – Coverage Look-Back Measurement Method Example 11.6 - 2015 JAN FEB MAR Measurement Period for May 2015 – Oct 2015 Stability Period APR MAY Administrative Period (Stability period begins) JUNE JULY AUG SEPT Measurement Period for Nov 2015 – Apr 2016 Stability Period OCT NOV Administrative Period (Stability period ends) (Stability period begins) DEC p. 425 Employee Categories Measurement, stability, admin periods may vary in length, start, end for each employee category ▪ Collectively bargained EEs and noncollectively bargained EEs ▪ Each collectively bargained group under separate agreement ▪ Salaried and hourly employees ▪ Employees primarily in different states pp. 425-426 Full-Time Employees – Coverage Look-Back Measurement Method New Employees: Reasonably expected to be full-time employee ▪ Determine status based on hours/month worked ▪ Becomes ongoing EE after employed for one complete standard measurement period ▪ Once an ongoing EE, the ER may apply the look-back method for future periods p. 425 Full-Time Employees – Coverage Look-Back Measurement Method New Employees: Variable-hour employee, seasonal, part-time ▪ Determine status with initial measurement period of 3-12 months ▪ Initial measurement must begin employee’s start date up to 1st day of next calendar month ▪ Stability period must = that of ongoing EEs p. 426 Full-Time Employees – Coverage Look-Back Measurement Method Factors for “reasonably expected” ▪ Replacing a full-time or variable-hour employee ▪ Service hours of those in same or comparable positions in recent measurement periods ▪ Whether job was advertised or otherwise communicated as involving certain level of hours per week pp. 426-427 Minimum Value Minimum Value (MV) is covers at least 60% of total costs of plan benefits expected (bronze) Options for determining ▪ HHS website calculator ▪ Plan designed to meet safe harbors ▪ Actuarial Certification HSA/HRA (integrated with ER plan) contributions by ER count as costs if cannot pay plan premiums p. 427 Minimum Value – Notice 2014-69 Minimum value ONLY if meets 60% test PLUS Benefits include substantial coverage of inpatient hospital services & physician services New definition applies to 2015 plan years Certain plans in process at 11/4/14 excepted p. 427 Minimum Value – Notice 2014-69 ALEs with nonhospital/nonphysician plans will not be subject to ESRP on 2015 plan if: ▪ Binding written commitment to adopt such a plan prior to 11/4/2014 ▪ Enrolled employees prior to 11/4/2014, relied on HHS MV calculator and plan year begins no later than 3/1/2015 EEs may treat all such plans as without MV for purposes of PTC p. 427 Affordable Coverage ER coverage not affordable if self-only premiums exceed 9.56% of EE’s 2015 household income Employer safe harbors – Employee premium for lowest cost self-only plan does not exceed ▪ 9.5% Form W-2 wages ▪ 9.5% Employee’s rate of pay ▪ 9.5% Federal poverty line Safe harbor used reported on Form 1095-C p. 427 Liability for ESRP ALE liable for an ESRP if ≥ 1 full-time employee gets premium tax credit AND Employer failed to offer MEC to 70% of full-time employees for 2015 (95% for 2016) OR Coverage offered not affordable, not of minimum value, or not offered to employee getting the PTC p. 431 Offer of Health Coverage Offer made if employee has effective opportunity to enroll or decline once per plan year If coverage continued, provide chance to opt out First year as an ALE – no ESRP for Jan-Mar if coverage offer by April 1 ▪ Not first year as ALE in 2015 (2016) if met ALE definition in a prior year 2014 (2015) pp. 431-432 Dependent Coverage - Transition Relief 2015 plan year - no ESRP if ▪ Dependent coverage not offered, ▪ Dependent coverage offered not of MV, or ▪ Dependent coverage offered to some but not all N/A if dependent coverage offered in 2013 or 2014 plan year and was dropped Applies to dependents not offered in 2013/14 if steps taken in 2014/15 to extend them coverage p. 432 Notices to Employers Section 1411 Certification ▪ Sent to employer by Exchange when an employee determined eligible for PTC ▪ Employer may appeal – within 90 days ▪ Appeal determination sent to employer and employee ▪ Appeal determination does not affect employer ability to challenge a later IRS ESRP proposal p. 433 ESRP Calculation - § 4980H(a) 2015 Offer not made to 70% of FT EEs and ≥ 1 FT EE gets PTC (based on Section 1411 certifications) ESRP = $2,080 x (# full-time employees – 80) FT equivalents and employees in a limited nonassessment period not in # of full-time 80 reduction is allocated if in related group Computed monthly if offer made for some months 49 p. 433 ESRP Calculation - § 4980H(a) Example 11.12 102 FTEs in 2014 => ALE in 2015 92 full time in 2015 Offer to 50 full time, 50/92 = 54% 2 full-time employees qualify for PTC ESRP = $2,080 x (92 – 80) = $24,960 50 pp. 433-434 ESRP Calculation - § 4980H(a) Example 11.13 102 FTEs in 2014 => ALE in 2015 92 full time in 2015 Offer to all full-time employees beginning 9/2015 2 full-time employees qualify for PTC Jan-Aug ESRP = ($2,080 x 9/12) x (92 – 80) = $16,640 51 p. 434 ESRP Calculation - § 4980H(b) ALE meets coverage requirement but ≥ 1 employee gets PTC because coverage: ▪ Does not provide minimum value ▪ Is not affordable for an employee (self-only premiums > 9.56% household income - 2015) ▪ Not offered to employee getting PTC (in 30%) Computed monthly ESRP = # FT getting PTC x $3,120/12 Limited to what 4980H(a) ESRP would have been 52 p. 434 ESRP Calculation - § 4980H(b) Example 11.14 Dillon offered coverage to all full-time employees Not affordable for 2 employees – purchased Marketplace coverage/received PTC for 12 mos Employer did not qualify for any affordability safe harbor ESRP = $6,240 $3,120 / 12 x 2 PTC employees x 12 months $6,240 < $24,960 if coverage % not met 53 p. 434 ESRP – Other Considerations ESRP is non tax deductible Dollar amounts subject to annual inflation adjustmt Full-time employee count for computation of ESRP ▪ Excludes full-time equivalents ▪ Excludes EEs in Limited Nonassessment Period (Period in which an employer is not assessed an ESRP regardless of whether an offer made) 54 p. 434 Limited Nonassessment Period For § 4980H(a) only if coverage is offered by the 1st day of the 1st month following the end of the period or For § 4980H(b) only if coverage offered at the end of the period provides minimum value 1. First year as ALE – runs January thru March – applies only to EEs not offered coverage in past 55 pp. 434-435 Limited Nonassessment Period 2. Waiting period / monthly measurement method ▪ Begins 1st full month EE otherwise eligible ▪ Ends 2 full calendar months after 1st full month 3. Waiting period / look-back measurement method ▪ EE reasonably expected to be full-time ▪ Begins on EE’s start date ▪ Ends at end of 3rd full calendar month of employment 56 p. 435 Limited Nonassessment Period 4. Initial measurement period & admin period under look-back measurement method ▪ Variable-hour, seasonal, or part- time EE only 57 p. 435 Limited Nonassessment Period 5. Period following EE status change occurring in initial measurement period in look-back method ▪ Begins on date EE’s status change ▪ Ends no later than end of 3rd full calendar month following status change ▪ Only if: • Variable-hour, seasonal, part-time @ start • In new position/status would have reasonably been expected to be full-time 58 p. 435 Limited Nonassessment Period In all cases: 6. First partial calendar month of employment ▪ If 1st day is other than the 1st day of a month 59 p. 437 Health Coverage Reporting Form 1095-C and Form 1094-C ▪ Employers with > 50 FTEs Form 1095-B and Form 1094-B ▪ Health insurance issuers – individual market coverage and employer plans (includes SHOP) ▪ Small employer sponsoring self-insured plans Form 1095-A ▪ Marketplace coverage 60 p. 437 Form 1095-C Due dates to IRS – same as W-2 ▪ 30-day extension with Form 8809 Furnish to employee same date as W-2 ▪ Mail or electronic (if consent) One per EE who was FT any time during the year Limited nonassessment period EE ≠ full time One per any EE with self-insured coverage for EE or any family member whether FT or not Used for ESRP and PTC purposes 61 pp. 437-439 Form 1095-C Part II, Line 14: Codes for whether or not coverage was offered Month by month entries or “all 12 months” box Offers for a month only if coverage for every day Terminated EE, coverage for the month if would have been covered every day if stayed Codes in Figure 11.7, page 439 62 pp. 439-440 Form 1095-C Part II, Line 15: Entry only if code 1B, 1C, 1D or 1E in line 14 Lowest cost monthly premium for self-only – including cents If no employee cost for self-only, enter 0.00 Part II, Line 16 Codes for eligibility for safe harbors/other relief Figure 11.8, page 441 Entry not required but in the ER’s best interest 63 pp. 440-441 Form 1095-C Part III Employer sponsored self-insured coverage ▪ List any employee and/or family members ▪ List nonemployee and/or family members (1G) ▪ Date of birth entered only if SSN unknown ▪ Check any month with at least 1 day coverage 64 pp. 442-443 Form 1095-C Example 11.15 – New Employee Joyce employed 5/1/2015 through 12/31/2015 3 month waiting period Enrolled in coverage August 1, 2015 Form 1095-C on page 443 (insert $100 in line 15 for Aug through Dec) Note: If Joyce had Marketplace coverage with PTC, she could continue it until the end of July. 65 pp. 443-444 Form 1095-C Example 11.16 – Terminated Employee Bob employed 1/1/2015 through 9/30/2015 Offered MEC with MV but declined Form 1095-C on page 444 Note: Employer’s affordability safe harbor eligibility does not affect Bob’s possible PTC if 9.56% of his actual household income is < the self-only premiums 66 pp. 444-445 Simplified Reporting Methods Qualifying Offer Method (N/A is self-insured plan) Qualifying offer for all 12 months to the FT EE Form 1095-C to IRS - Simplified statement to EE Qualifying Offer Method Transition Relief for 2015 Qualifying offer for ≥ 1 month to 95% of FT EEs Form 1095-C to IRS - Simplified statement to EE 98% Offer Method Safe harbor affordable, MV to 98% EE’s & dep. 67 pp. 445-448 Form 1094-C Transmittal of Forms 1095-C Summarizes Form 1095-C information If filing one for each division, one must be designated as “authoritative transmittal” Each member of ALE group files it owns ▪ Identifies other member in Part IV Part II, #22 – Eligibility certifications Part III – monthly information or “all 12 months” 68 pp. 448-449 Form 1095-C Penalties Information return penalties - § 6721, § 6722 ▪ Increased penalties after 12/31/2015 ▪ 2015 penalty relief if incomplete or incorrect • Can show good faith effort to comply and • Form timely filed (IRS) or furnished (EE) Can avoid if reasonable cause met under § 6724 69 pp. 449-451 Form 1095-B Filed by health insurance issuer ▪ Individual marketplace policies ▪ Employer sponsored insured plans ▪ SHOP plans Filed by small employer sponsoring self-insured Filed for Government-sponsored plan coverage Filed for other coverage as designated by HHS Filing/furnishing dates same as 1095-C / W-2 70 pp. 452-456 Failure to Comply w/ Market Reforms $100 per day per person excise tax if employer’s plan fails to meet market reforms N/A to excepted benefits if separate policy Notice 2013-54 ▪ Employer payment plan – Subject to tax • Reimburses individual policy premiums ▪ HRA – Not subject if integrated with group plan ▪ FSA – Subject if not an excepted benefit ▪ EAP – Not subject if excepted benefit 71 Notice 2015-17 pp. 456-459 Excise Tax Transition Relief Employer Payment Plan – no excise tax ▪ If employer not an ALE ▪ Applies January 1, 2014 thru June 30, 2015 ▪ NOT: stand-alone HRAs/other reimbursement arrangements Healthcare arrangements for 2% S corp S/H-EEs ▪ No excise tax until the later of the end of 2015 or when additional guidance issued 72 Notice 2015-17 pp. 456-459 Excise Tax Transition Relief Medicare Premium Reimbursement Arrangements ▪ Cannot be integrated with Medicare coverage ▪ May be integrated with another employer plan ▪ If plan for < 2 current EEs, not subject to reform TRICARE-Related HRAs ▪ Cannot be integrated with TRICARE ▪ May be integrated with another employer plan 73 Notice 2015-17 pp. 456-459 Excise Tax Transition Relief Increase in compensation not tied to purchase of health coverage is not an employer payment plan Reimbursements of insurance premiums cannot be on an after-tax basis ▪ Rev. Rul. 61-146 holds nontaxable Note: Only way after 6/30/2015 to help employees pay premiums is no-strings-attached compensation 74 Excise Tax pp. 459-461 Nondiscrimination Rules PHS § 2716 bars fully insured plans from favoring the highly paid IRS will not enforce penalty until it issues guidance for plan sponsors I.R.C. § 105(h) tests both eligibility and benefits actually provided Shareholder plans are vulnerable 75 p. 461 Expatriate Health Plans Granted relief from market reforms ▪ Temporary relief through 12/31/2016 ▪ 2014 EHCCA made relief permanent for certain contracts on or after July 1, 2015 ▪ EHCCA extended relief to self-insured plans Exempt from PICORI fee, transitional reinsurance fee, health insurance provider fee Subject to reporting requirements May be subject to Cadillac Tax in 2018 76 pp. 462-463 SHOP Marketplace If ≤ 50 FTEs can use SHOP Bronze, silver, gold, platinum plans Employer chooses plan or plans Employer determines contribution Must offer to all FT employees (30 hours/week) 70% FT EEs enrollment needed to apply outside 11/15-12/15 period NOTE: 2015 PACE Act allows states to determine if SHOP eligibility to be up to 100 FTEs in 2016 77 Questions? 78