health care reform shared responsibility presentation

Health Care Reform Roundtable:A Step-by-Step Guide to the

Shared Responsibility Requirements

Bret Busacker208.388.4885

[email protected]

Bret Clark208.388.4938

[email protected]

Shared Responsibility – the Big Picture• Effective January 1, 2014:

– Individual mandate forces most employees to obtain coverage or pay a tax

– Exchanges become available where individuals and small businesses can obtain coverage

– Individuals with household income of up to 400% of the poverty level ($94,200 for a family of 4 in 2013) and who are not eligible for qualifying coverage from an employer will be eligible for Premium Assistance for exchange coverage

– Shared responsibility requires employers to provide coverage to employees or pay a shared responsibility penalty

• Employers need to review requirements now so that they have time to modify plans, if needed

• Key Concepts:– Large Employer – Shared responsibility penalties only apply

to employers with 50 or more full-time (and full-time equivalent) employees

– Minimum Essential Coverage – Coverage that provides standard medical benefits

– Minimum Value – Minimum Essential Coverage that pays at least 60% of medical costs (determined actuarially)

– Affordability – Coverage with Minimum Value that costs the employee 9.5% or less of the employee’s household income for self-only coverage

Shared Responsibility – the Big Picture

• Shared Responsibility Penalties. Large Employers will be subject to a penalty if one or more employees obtain Premium Assistance on an exchange and either:– The employer fails to offer Minimum Essential Coverage to at least

95% of its full-time employees and their dependents, or– The coverage provided does not have Minimum Value or is not

Affordable• No Coverage Penalty. The penalty for not offering Minimum Essential

Coverage to all full-time employees and their dependents is $2,000 per full-time employee (less 30 full-time employees)

• Insufficient Coverage Penalty. The penalty for not offering coverage with Minimum Value that is Affordable is $3,000 per full-time employee receiving Premium Assistance (capped at the No Coverage Penalty)

• Penalties are not tax deductible

Shared Responsibility – the Big Picture

Steps for Shared Responsibility Compliance

1. Determine whether you are a Large Employer2. Analyze your workforce to identify employees who

must be offered coverage3. Determine your full-time employees4. Monitor changes in status5. Determine whether you provide Minimum Essential

Coverage to 95% of full-time employees6. Determine whether your plan provides Minimum

Value and is Affordable

Step 1: Determine Whether You are a Large Employer

• You are a Large Employer for a year if you averaged 50 or more full-time employees plus full-time equivalents during the prior year

• First, calculate full-time employees during each month of the prior year– Employees who work at least 130 hours or more in a month

are full-time employees– Add full-time equivalencies - the total number of hours

worked by non full-time employees in a month divided by 120• Then, add the totals for all 12 months and divide by 12• Round average down (i.e., 49.7 is 49)

Step 1: Determine Whether You are a Large Employer

• Seasonal employees – If an employer exceeds 50 employees for 4 or fewer months because of seasonal employees, the seasonal employees may be disregarded

• Transitional relief – For determining whether the 50-employee threshold is reached for 2014 only, average employment in 2013 may be determined using any consecutive 6-month period in 2013

Step 2: Analyze Your Workforce

• Large Employers must determine which employees are full-time employees (disregarding full-time equivalents) who must be covered to avoid penalties

• Employee defined– Employees generally include all “common law” employees

• Confirm independent contractors/leased employees are not common law employees

– All employees of the same “controlled group” and/or “affiliated service group” are counted together, but penalties are assessed separately to each employer


• Employees are full-time if they work 30 hours per week• Counting hours

– For hourly employees, must use actual hours worked– For salaried employees, may use actual hours or

equivalencies of 8 hours per day or 40 hours per week– In addition to hours worked, must count hours during

paid leave (for example, vacation leave, sick leave)• Use a reasonable method to determine full-time status

of non-traditional employees (for example, commissioned sales people, truck drivers)


• Place each employee in one of three buckets– Full-time Bucket – Full-time employees – employees

reasonably expected to work 30 or more hours per week

– Part-time Bucket – Part-time employees – employees that will never work 30 or more hours per week

– Variable-hour Bucket – Employees that may be part-time or may be full-time (for example, variable-hour employees, seasonal employees)

Step 3: Determine Your Full-Time Employees

• Full-time Bucket should be offered coverage (plan may have 90-day waiting period)

• Part-time Bucket is not required to be covered• Variable-hour Bucket options:

1. Assume employees in Variable-hour Bucket are full-time• If less than 5% of workforce, may be safe to exclude• If more than 5% of workforce, consider covering or

tracking full-time status (see item 2)2. If Variable-hour Bucket is not covered, develop and

implement procedures for determining full-time status


Margin of error

50 employees 5 employees






• Analyze margin of error:


• For employees in the Variable-hour Bucket:– An employer may establish measurement periods of

between 3 and 12 months during which the employer determines whether the employee is a full-time employee

– Then the employee will be treated as a full-time employee during the following stability period, generally the length of the measurement period

– The employer may also establish an administrative period between the measurement period and stability period for enrollment, up to 90 days

Step 3: Determine Your Full-Time Employees• Ongoing employees

– An employee determined to be a full-time employee during a measurement period is treated as a full-time employee during the following stability period

– Employers may want to structure periods so that stability periods are plan years and coordinate measurement periods and administrative periods accordingly

– Employees who change employment status during a stability period may not lose coverage until the end of the stability period

• Example:

Step 3: Determine Your Full-Time Employees• New employees

– May be excluded during initial measurement period– Initial measurement period + administrative period may not extend beyond the

end of the month following the first anniversary of the employee’s start date– 2 measurement periods may run at the same time (new hire measurement

period and first ongoing employee measurement period beginning after hire date)

• Example (June 1, 2014 hire date):


• For 12-month stability periods beginning in 2014, measurement periods may be as short as 6 months if they:– Begin no later than July 1, 2013, and– End within 90 days of the beginning of the 2014 plan year

• Example:

Step 4: Monitor Changes in Status• Employees who perform no services for an employer for 26

consecutive weeks are treated as new hires– Rule of parity – If employment prior to service break was less than 26

weeks, employee will be treated as new hire if service break was (i) at least 4 weeks and (ii) longer than the length of employment before the break in service

• Employers should develop written procedures for– Tracking full-time status of Variable-hour Bucket– Tracking employment status changes between Buckets

• A new employee who moves to Full-time Bucket during his initial measurement period must be allowed to participate by the first day of the fourth month following the status change

• Ongoing employees who change buckets during a stability period retain full-time or non-full-time status until the end of the stability period

Step 5: Determine Whether You Provide Minimum Essential Coverage to 95% of Full-

Time Employees• Minimum Essential Coverage

– Generally includes all health coverage except:• Limited scope dental or vision benefits • Coverage only for a specified disease or illness • Long-term care insurance• Other insurance coverage under which health care is not the

primary benefit– Major medical plans generally constitute minimum essential

coverage

• No Coverage Penalty– If the employer does not provide Minimum Essential Coverage to at

least 95% of its full-time employees and, effective 2015, their dependents and

– At least one full-time employee receives Premium Assistance on an exchange

– Then the Coverage Penalty applies• $2,000 per full-time employee• Disregarding 30 full-time employees

• If you do not currently provide Minimum Essential Coverage to 95% of full-time employees, consider plan design change• Example, change service requirement from 32 hours per week to 30

hours per week

Step 5: Determine Whether You Provide Minimum Essential Coverage to 95% of Full-Time Employees

Step 5: Determine Whether You Provide Minimum Essential Coverage to 95% of Full-

Time Employees

Margin of error No coverage penalty

50 employees 5 employees $40,000






• Analyze penalty exposure:

Step 6: Determine Whether Your Plan Provides Minimum Value and is Affordable

• Minimum Value– A plan has Minimum Value if it pays 60% or more of the

costs of medical benefits (determined actuarially)– Proposed regulations provide that Minimum Value may be

calculated as follows• Minimum Value calculator to be provided by HHS/IRS• Safe harbors established by HHS/IRS• Certification by actuary

– Additional guidance is needed before Minimum Value can be certified, but insurers/brokers/TPAs should be able to estimate minimum value


• Affordability– Coverage is not Affordable if the employee’s

premium for employee-only coverage exceeds 9.5% of the employee’s household income

• Potential incentive to make coverage unaffordable to low wage earners so that their dependents qualify for subsidized coverage on the exchange


• IRS safe harbors– W-2 Safe Harbor - Coverage is Affordable if it is 9.5% or less of the

employee’s W-2 income for the year (for the 2014 penalty, the 2014 W-2 issued in 2015 is used) • Consider charging a monthly premium of a specified amount or, if less, 9% of

the employee’s W-2 income for the pay period– Rate of Pay Safe Harbor - Coverage is Affordable if it is 9.5% or less of the

employee’s monthly rate of pay as of the beginning of the year• For hourly employees, the monthly rate of pay is the hourly rate times 130

hours• Not available if wages are reduced during the year

– Federal Poverty Line Safe Harbor. Coverage is Affordable if the cost is 9.5% or less of the federal poverty level for a single individual (2013 federal poverty level for a single individual is $11,490, making coverage affordable if it is $1,091.55 per year or less - $90.96 per month)


• Insufficient Coverage Penalty – If you do not provide coverage with Minimum Value that is Affordable– Then the Insufficient Coverage Penalty applies

• $3,000 per full-time employee who receives Premium Assistance on an exchange

• Capped at the No Coverage Penalty amount• If current coverage does not have Minimum Value or is not Affordable,

consider plan design change– Reduce cost-sharing/add benefits/add HSA/HRA (Minimum Value)

balanced against reduced premiums (Affordability) – Example, reduce employee premium for self-only coverage under least

expensive coverage option with Minimum Value to $90 per month

Shared Responsibility Penalty Procedures• When individuals apply for coverage on an exchange (during open

enrollment for 2014) they will self-report the information required by the exchanges to determine eligibility for Premium Assistance

• Employers may be required to verify some information reported by employees to an exchange

• After the coverage year, individuals will substantiate eligibility for Premium Assistance on their tax return for the year of the Premium Assistance (initially, 2014 returns filed in 2015)

• Employers will also be required to file information returns reporting compliance with the shared responsibility requirements

• Based on this reporting, the IRS will determine whether an employer is required to pay a shared responsibility penalty and provide notice of the penalty to the employer

• After the employer has had an opportunity to respond, the IRS will assess the applicable penalty

Shared Responsibility Penalty Procedures

• In order to respond efficiently to shared responsibility-related reporting requirements and any IRS shared responsibility penalty notice, employers need to:– Develop comprehensive procedures for determining full-time

status and eligibility for coverage– Document the following:

• Minimum Essential Coverage, Minimum Value and Affordability determinations

• Compliance with coverage timing rules (90-day period, coverage during stability periods)

• Justification for classifying employees as non-full-time• Negative elections

Compliance Checklist Develop initial list of potential areas of risk Address risks with Board/Benefits Committee Prepare comprehensive shared responsibility action plan to address

risk/compliance– Evaluate full-time status, Minimum Essential Coverage, Minimum Value,

Affordability– Evaluate controlled group/affiliated service group structures, temporary,

part-time and seasonal employees, independent contractors, staffing agency/leasing agency arrangements

– Etc. Implement any plan changes during open enrollment for 2014 Prepare employee communications (revised SBCs, notice of exchanges) Prepare plan amendments, policies, notices to document compliance Report compliance efforts to Board/Benefits Committee

Transitional Reinsurance Program Fee• $25 billion will be collected from health plans and insurance

companies to help stabilize the individual insurance market• The fee applies from 2014 to 2016 and is estimated to be

– $63 per average covered life in 2014– $42 per average covered life in 2015– $26.25 per average covered life in 2016– Actual fee will vary based on several factors determined by HHS

• Covered lives include participants, spouses and dependents• Payment

– Employees must report average covered lives to HHS by November 15 of the year (2014 report due by November 15, 2014)

– HHS will provide notice of fee within 15 days – Fee is due within 30 days of notice

Transitional Reinsurance Program Fee

• Methods for calculating average number of covered lives– Actual Count Method – count covered lives on each day during the

first 9 months of the year– Snapshot Count Method – count covered lives on at least one day

per quarter during the first three quarters of the year– Snapshot Factor Method – count participants on at least one day per

quarter during the first three quarters of the year and multiply participants with spouse/family coverage by 2.35

– Form 5500 Method – add participant count on most recently filed Form 5500 on first day to participant count on last day (for employee-only plans, divide by 2)

• Retirees and COBRA beneficiaries are counted, except retirees with coverage that pays secondary to Medicare

Transitional Reinsurance Program Fee

• Only comprehensive medical plans are subject to the fee– HRAs integrated with major medical, FSAs

and HSAs are excluded– If insured, insurer pays the fee– If self-insured, plan pays the fee (it is a

permissible plan expense)– No double counting

www.hawleytroxell.com

Thank You!

Bret Busacker208.388.4885

[email protected]

Bret Clark208.388.4938

[email protected]

health care reform shared responsibility presentation

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