Health Care Reform: Employers Should Prepare Now for 2015 to Avoid Penalties

Under the Patient Protection and Affordable Care Act (PPACA), beginning in 2015, certain large employers who do not offer affordable health insurance that provides minimum value to their full-time employees may be subject to significant penalties.

 

In a nutshell, in 2015, “applicable large employers” will be subject to an annualized employer “shared responsibility” penalty of $2,000 (indexed) per full-time employee (minus the first 80 full-time employees in 2015) if the employer does not offer health insurance to at least 70% of their full-time employees and their dependents. This amount will be increase from 70% to 95% after 2015. This is commonly referred to as the “Pay or Play” penalty.

 

Even if an applicable large employer offers insurance coverage to full-time employees, the employer still could be subject to an annualized penalty of $3,000 (indexed) per employee who receives an Exchange subsidy if  the offered employer-sponsored health coverage does not meet minimum value standards or is not affordable. This $3000 penalty is capped at the amount that would apply if the $2,000 penalty described above were to apply.

 

What should an employer do now to prepare for these penalties?

 

(A) Determine if they are an “applicable large employer” -To do this, employers should count both full-time employees and part-time employee hours as follows:

 

1) Count the full-time employees for each month in the prior year.

 

2) Count the full-time equivalents for each month in the prior year.

 

a) Add total hours for non-full-time employees but count no more than 120 hours per month for any one non-full-time employee.

 

b) Divide the number obtained in (a) by 120. This is the full-time equivalent number.

 

3) Add the numbers obtained in (1) and (2) above (i.e., the full-time employee and full-time equivalent numbers) for each month.

 

4) Add the 12 sums obtained in (3) and divide by 12. This is the average number of full-time employees and full-time equivalents.

 

5) If this number obtained in (4) is under 50 (or under 100 for the 2015 determination for certain employers), the employer is not an applicable large employer for the year being determined.

 

Note: The applicable large employer is determined on a controlled group basis. For example, if there are three companies, each of which is wholly owned by the same parent company, the companies are all considered one employer for this calculation. Also note that, special transition rules apply in determining applicable large employer status for 2015 and that a special seasonal employee exception may apply even if the threshold in (5) is exceeded.

 

(B) If an employer will be an applicable large employer in 2015, it should determine whether it could be subject to penalties in 2015. For example, the employer should review its group health plan to determine if the insurance coverage is “offered” to full-time employees meets minimum value standards and is considered affordable to employees.

 

© An employer also will need to address how it will determine the full-time status of employees – will it use the “monthly measurement period” or the “look back measurement period.” This is particularly important for employers who have many variable-hour employees or seasonal employees.

 

(D) If the employer’s group health plan does not meet the threshold tests to avoid the penalties noted above, the employer should evaluate whether it wants to restructure its health care offerings or pay the penalties (which are non-deductible).

 

 

(E) Finally, employers should review their data collection procedures to ensure that they will be able to report the healthcare information required to be reported for 2015 (the actual reporting will occur in 2016 for the 2015 calendar year). Insurers, sponsors of self-insured plans, and other entities that provide minimum essential coverage during a calendar year will be required to report certain information to the IRS and to participants. In addition, applicable large employers will be required to report about the coverage they provide to both the IRS and to their employees. Drafts of the IRS forms to be used in reporting this information have recently been published (Form 1095-B, Form 1095-B Transmittal, Form 1095-C, Form 1095-C Transmittal). Employers should review these forms to understand the data that will need to be reported. 

 

It is not too late for employers to take action now to avoid penalties in 2015. 

Health Care Reform: What Do Employers Need to Do Now?

Employers struggling with how to meet the Affordable Care Act (ACA) regulations received some relief in July 2013 when the U.S. Treasury announced a one-year delay on implementation of the “pay or play” mandate. This mandate would have required most employers with the at least 50 full-time equivalent employees to provide affordable, minimum value health insurance coverage to their full-time employees by January 1, 2014, or pay a penalty.

 

However, the delay on implementation of the “pay or play” mandate did not delay the individual mandate, which will require most individuals to purchase health insurance coverage in 2014, or pay a tax penalty. The Treasury has also indicated that the delay in the employer mandate will not affect an employee’s access to the premium tax credits available to individuals who purchase coverage through the Exchange beginning January 1, 2014.

 

There are many other ACA provisions that will require compliance by January 1, 2014, including:

 

• Minimum value compliance for employer-sponsored group health plans still needs to be determined for the 2014 plan year. This information is reported both in written notices about the new health insurance exchanges, (which most employers should have distributed by October 1, 2013), and in summaries of benefits and coverage (aka SBCs)
• New fees and assessments, such as the PCORI and transitional reinsurance fees and health insurer tax.
• Summaries of benefits and coverage (SBCs) must be updated, prepared and distributed for 2014 during open enrollment to everyone eligible for benefits, as well as new hires and anyone experiencing a qualifying event during the plan year
• Elimination of annual dollar limits on essential health benefits under group health plans, beginning January 1, 2014.
• No more pre-existing condition exclusions for adults as well as children for plan years beginning in 2014.
• Grandfathered health plans can no longer exclude adult children under age 26 who have access to other employment-based coverage, effective January 1, 2014.
• Benefit coverage waiting periods can’t be longer than 90 days effective for plan years beginning in 2014.
• Coverage of clinical trials is required for non-grandfathered group health plans, along with prohibition on discrimination based on participation in a clinical trial.
• New wellness incentive rules for plan years beginning in 2014.
• Maximum out-of-pocket limitation will prohibit, for both insured and self-insured non-grandfathered plans, out-of-pocket limits that that exceed $6,350 (self) and $12,700 (family) coverage, for plan years beginning in 2014.

 

So, What Should Employers Be Doing Now?

Employers should first make sure their plans comply, or will comply in 2014, with all ACA provisions that have not been delayed. Next, employers should plan for eventual application of the pay or play mandate to their workforce. This should include:

• For a smaller employer, confirming whether or not it will meet the threshold to be subject to the “pay or play” mandate in 2015, particularly if the organization could be considered under common control with other entities that share some common ownership.
• Confirming how the employer will comply with the mandate—whether it will pay or play and how to implement its compliance strategy in 2015.
• If 2014 coverage expansions were planned to achieve compliance, deciding whether to proceed, delay until 2015 or consider another compliance strategy.
• Identifying which employees are full-time, seasonal or variable hour employees.
• Considering whether and how to utilize the safe harbor “look-back measurement method” of determining full-time status of some or all ongoing employees or new variable hour and seasonal employees (which would include selecting appropriate measurement, administrative and stability periods).

 

The one-year delay also gives employers more time to see whether changes in the law may relieve them from expanding coverage to workers who average more than 30 hours per week or perform only seasonal labor. As of mid -September, at least four bills had been introduced to change the full-time employee standard to 40 hours. At this point, the chances of passage are unclear, so this will be an important issue to watch.

 

While the delay in the pay or play mandate gives employers additional time, the clock is ticking for many other ACA compliance efforts, and employers should be prepared and seek guidance now.