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Word & Brown makes it easy for you to determine your clients’ group size, whether they are subject to Affordable Care Act (ACA) "play or pay" mandates, Internal Revenue Code (IRC) reporting data calculations, the “affordability” of coverage offered to employees, the amount of any potential ACA penalty, and possible premium or small business health care tax credits. Check out each of our available calculators below.

Section 6056 of the Internal Revenue Code requires annual information reporting to the IRS by Applicable Large Employers with fully insured plans relating to the health insurance that the employer offers (or does not offer) to FT employees and their dependents.

Section 6055 requires annual information reporting to the IRS by health insurance issuers, employers with self-insured plans, government agencies, and other providers of health coverage.

Employers are required to give employees a copy of the information reported for them. The IRS uses these reports to determine whether the Applicable Large Employer has to pay any penalties and whether the employees are eligible for Premium Tax Credits.

Under the ACA, employers with 50 or more Full-Time and Full-Time Equivalent Employees (FT+FTE) are required to offer FT employees and their dependents (children to age 26) health care coverage that meets ACA requirements; otherwise, they face a penalty. 

While the federal statute defines "full-time" as an employee who provides an average of 30 hours of service per week or 130 hours of service per month, there is some confusion as to how full-time equivalent is calculated and applied, particularly with respect to part-time, variable-hour, and seasonal employees.

One of the ACA’s provisions is a requirement that insurers spend 80% of premium income for Individual and Small Group plans – and 85% of premium income for Large Group plans – on health care and improving health care quality. This is referred to as the Medical Loss Ratio (MLR) Standard, which is intended to ensure consumers get value for their health care dollars. 

If a carrier/plan fails to meet the federal MLR requirements, the medical plan must refund the difference to policyholders by an ACA-mandated deadline. This provision does not apply to self-funded plans.

Rebate checks are issued directly by the insurer to those with individual plans and to the policyholder (employer) for groups. Employers are responsible for distributing appropriate rebates to eligible employees or using the funds to benefit current enrollees. ERISA guidelines mandate plan sponsors use rebated funds within three months of receipt to pay premiums or provide refunds to eligible employees. 

Many groups offer employees a choice of products, which could be offered through one or more legal entities. Because rebates are calculated separately for each legal entity, rebates to the policyholder (employer) under a group medical policy or plan will be based on the product in which employees are enrolled. (For example: Some Aetna plans are filed under Aetna Health Inc. and others are filed under Aetna Life Insurance Company.) Some employers may receive more than one MLR rebate. 

If you have questions about the MLR, click here to visit the IRS web page on Frequently Asked Questions.

An Applicable Large Employer can face a penalty if a full-time employee purchases insurance through a state health insurance marketplace (like Covered California or the Nevada Health Link) and qualifies for a premium tax credit. 

An employer could face a penalty if it does not offer:
  • Coverage to at least 95% (all but the greater of either 5% or five) of full-time employees and their dependent children to age 26, and at least one full-time employee receives subsidized coverage from a state health insurance marketplace (like Covered California or the Nevada Health Link). 
  • Coverage that is affordable and/or does not meet minimum value, and at least one full-time employee receives subsidized coverage a state marketplace. 
​​​​​Affordability Calculator

If your client is an ALE, we recommend using Word & Brown’s proprietary Affordability Calculator to find out if the coverage offered to FT employees meets affordability criteria under the ACA. 

Affordability is based off the self-only premium on the lowest cost plan offered to each FT employee by the ALE. Affordability for the 2022 tax year is 9.61%, slightly down from the 2021 affordability ratio which was 9.83%.