Understanding Healthcare Reform
What’s next for healthcare reform and how can you stay in step with change?
Our compliance team has provided easy-to-understand, actionable guidance and resources to help employers better understand and comply with the myriad of mandates imposed by healthcare reform.
Take a look at the following toolkits available for you to download below.
Sections 6055 and 6056 Reporting Requirements
Created by our Compliance experts, this valuable toolkit for IRS Sections 6055 & 6056 reporting requirements will help reporting employers comply with the requirements & avoid penalties.
Two pillars of the Patient Protection and Affordable Care Act (“PPACA”) are the individual mandate and the employer mandate. Central to the ability of the government to administer both mandates is the gathering of information.
With regards to the individual mandate, IRS Code Section 6055 enacted by PPACA requires employers providing minimum essential coverage to report certain information to the IRS about the coverage provided and who it is provided to.
With regards to the employer mandate, IRS Code Section 6056 enacted by PPACA requires applicable large employers to report information regarding the coverage offered to their employees. Both Sections 6055 and 6056 also require statements to be furnished to the individuals that are mentioned in the reports to the IRS. Although the penalty for the individual mandate was reduced to $0 on January 1, 2019, employers are still required to report to the IRS and provide statements to employees.
Compliance experts at Gallagher have created this valuable toolkit filled with practical and useful information to help you comply with these important requirements.
- Article: Employer and Issuer 6055 and 6056 Reporting Requirements
- Employer FAQs: Reporting Requirements Under Sections 6055 and 6056
- Decision Tree: Sections 6055 and 6056 Reporting Decision Tree
- Matrix: Sections 6055 and 6056 Forms Matrix
- Article: Understanding the Essentials: Sections 6055 and 6056 Final Forms
- Information Collection Checklist: Section 6056 Reporting for Applicable Large Employers with Fully-Insured Health Plans
- Information Collection Checklist: Information Collection Checklist: Sections 6055 and 6056 Reporting for Applicable Large Employers with Self-Insured Health Plans
- Action Item Checklist: IRS Reporting for Applicable Large Employers with Fully-Insured Plans
- Action Item Checklist: IRS Reporting for Applicable Large Employers with Self-Insured Plans
- Flowchart: Which Simplified IRS Reporting Method is Available?
- Article: Availability and Use of Simplified Section 6056 Reporting and Furnishing Methods
- Article: Employer Considerations under Simplified Section 6056 Reporting
- Sample Employee Communications for Sections 6055 and 6056 Reporting Purposes
- Sample Employee FAQs on Forms 1095-B and 1095-C for Employers with Self-Insured Health Plans
- Sample Employee FAQs on Forms 1095-B and 1095-C for Employers with Fully Insured Health Plans
- Article: Sample Simplified 1095-C Employee Statements for Applicable Large Employers with Fully Insured Plans using one of the Qualifying Offer Methods
- Article: Logistics of Filing and Providing Forms 1094-B, 1095-B, 1094-C, and 1095-C, Including Extensions and Waivers
- Article: Procedures for Correcting Errors in Forms 1095-B, 1094-C, and 1095-C
- Reporting Examples on Form 1095-C
- Article: Reporting Offers of Coverage to COBRA Qualified Beneficiaries and Non-Employees using Form 1095-C
- Tools You Can Use: Transitional Relief Flowcharts
- Sample Procedure for Electronic Furnishing Consent
- Webinar: PPACA Reporting for 2016 and Beyond
- Webinar: Sections 6055 and 6056: “MEC” and “ALE” Reporting to the IRS
- Webinar: PPACA Reporting for Applicable Large Employers: Updates and Lessons Learned
Counting Hours Toolkit
Determining who is a full-time employee for purposes of the Employer Mandate is not as simple and straightforward as it seems. An employer must be mindful of temporary, seasonal, and variable hour employees, among others. The final regulations for the Employer Mandate attempt to provide a framework by which employers can count the hours and determine the full-time status of their employees. This complex set of regulations nestled within the larger set of regulations that govern the Employer Mandate dictate how employers must count hours.
To assist our clients through the complicated maze of regulation that they face, we have developed the Counting Hours Toolkit, which includes articles deconstructing the convoluted counting hours regulations, employer FAQs, provides a series of considerations for employers as they approach this issue, as well as providing pieces directed towards questions from and communications with employees.
- Determining Full-Time Employee Status for Purposes of the Employer Shared Responsibility Provisions under PPACAK
- Article – What Counts as an Hour of Service?
- Article – Handling Changes in Employment Status When First Position is Subject to the Look-Back Method
- Article – Handling Changes in Employment Status When First Position is Subject to the Monthly Measurement Method
- Employer FAQs: Counting Hours
- Employer Considerations When Implementing Counting Hours Rules
- Sample Employee FAQs Explaining Benefits Eligibility
- Sample Employee Communications Explaining Eligibility for Health Benefits Using Measurement, Administrative, and Stability Periods
- Webinar: Counting Hours Under the Final Rules
- Webinar presentation slides: Counting Hours Under the Final Rules
DOL Audits Toolkit
An audit of health and welfare plans by the Department of Labor (“DOL”) can be a trying experience for any business. This stress can be particularly amplified when considering that you have been trying to keep your health and welfare plans up-to-date with the voluminous requirements of the existing laws, as well as, with the frequent deluge of requirements from the Patient Protection and Affordable Care Act (“PPACA”). The breadth of requirements creates many opportunities for errors to occur. The first step to successfully surviving an audit is knowing what to expect and being prepared. In light of recent audit activity from the DOL, Gallagher has prepared this toolkit to provide you with an understanding of what a DOL audit looks like – from the initial DOL audit letter to self-compliance tools to sample response letters.
The toolkit begins with GBS’ articles on current audits, what to expect during an audit, an overview of the audits, and employer considerations. We also provide you with a Compliance Continuity article with a focus on DOL Audits and a checklist for DOL claims regulations (which may be the subject of an audit). Links are provided to two self-compliance tools provided by the DOL, which, in addition to being useful checklists, give an understanding of what is the DOL’s audit focus. We also provide links to our webinar on audits and the handouts for the webinar. Finally, we provide valuable sample DOL audit letters and responses.
- Article: DOL Audit Process: What to Expect
- Article: DOL Growth Spike
- Article: Overview of Potential DOL Penalties
- Article: DOL Audit Employer Considerations
- Compliance Continuity: Focus on DOL Audits
- Article: Top Ten Tips for Working with the EBSA
- Article: Warning Signs of Potential Noncompliance with MHPAEA
- DOL Self-Compliance Tool for Health Care-Related Provisions
- DOL Self-Compliance Tool for the Mental Health Parity and Equity Addication Act
- Webinar: What to Expect and How to Prepare - DOL Audits of Health and Welfare Plans
- Webinar: What to Expect and how to Prepare - DOL Audits of Health and Welfare Plans - Presentation Slides
Sample DOL Audit Letters:
- Sample DOL Audit Letter 1
- Sample DOL Audit Letter 2
- Sample DOL Audit Letter 3
- Sample DOL Audit Letter 4
Sample Audit Responses:
Employer Shared Responsibility Mandate Toolkit
Beginning on January 1, 2015 the employer shared responsibility mandate requires applicable large employers to offer, to substantially all of their full-time employees and their dependents, eligible employer-sponsored coverage or face potential penalties. In an effort to provide clarity to the many aspects of the mandate, regulators have issued an immense amount of guidance over an extended period of time. This has overwhelmed employers as they work to understand and calculate their potential penalties and chart a course to full compliance.
To assist employers in their efforts to fully understand this important provision of healthcare reform, the compliance experts at Arthur J. Gallagher (“AJG”) have constructed this toolkit that covers all aspects of the mandate through the use of a flyer that relates potential penalties, a whitepaper that provides substantive background on the employer mandate, a set of FAQs for employers, flowcharts that visualize the transitional relief rules, and webinars covering the entirety of the employer shared responsibility rules.
- Whitepaper: Employer Shared Responsibility & Its Key Considerations
- 1-page Flowchart: Employer Shared Responsibility Requirements & Potential Penalties
- Flowcharts: Transitional Relief
- FAQs: Employer Shared Responsibility Mandate
- Webinar: Counting Hours Under the Final Rules
- Webinar Slides: Counting Hours Under the Final Rules
- Webinar: Employer Mandate: The Final Rules
- Webinar presentation slides: Employer Mandate: The Final Rules
Employer Shared Responsibility Penalty Assessment Toolkit
The Patient Protection and Affordable Care Act requires applicable large employers (“ALEs”) to offer affordable, minimum value coverage to substantially all full-time employees, or to pay penalties. The IRS has begun assessing penalties, referred to as Employer Shared Responsibility Payments (“ESRPs”), on ALEs that failed to offer coverage in accordance with the ESR mandate in 2015. To assist employers in understanding the process associated with receiving a ESRP letter (via Letter 226J) and the possible courses of action that they may take, we have developed an Employer Shared Responsibility Payment Toolkit. The toolkit consists of an article, employer FAQs, a flowchart that provides fundamental information needed to understand and respond to an ESRP letter, as well as, matrices to assist employers in understanding the codes and the transitional relief that was available in 2015 Form 1095-C filings – all of which is essential for employers to evaluate and properly respond to a penalty assessment letter from the IRS.
- Article: Employer Shared Responsibility Payment: Employer Considerations
- FAQs: Employer Shared Responsibility Payment
- Webinar: IRS Enforcement of Employer Mandate
- Webinar Slides: IRS Enforcement of Employer Mandate
- Flowchart: Employer Shared Responsibility Payment: Timeline and IRS Resources
- Matrix: Employer Shared Responsibility Payment: Reporting 4980H Transitional Relief on 2015 Forms 1094-C and 1095-C
- Matrix: Employer Shared Responsibility Payment: Form 1095-C Abbreviated Code Summary
- Tools You Can Use: Transitional Relief Flowcharts
Healthcare Reform Fees Toolkit
One thing has been clear since the Patient Protection and Affordable Care Act was signed into law: there are lots of moving parts and keeping track of them can be difficult for an employer. One of the more difficult aspects of compliance with the healthcare law will be keeping tabs on the fees and taxes brought forth by the new law. GBS has developed this toolkit to help our clients gain a better understanding of and be better prepared for the fees that lay ahead. This toolkit emphasizes four major fees: the Patient-Centered Outcome Research Institute Fee (PCORI Fee), the Transitional Reinsurance Fee, the Health Insurer Fee and the Excise Tax on High-Cost Health Coverage ("Cadillac Tax").
- Article: PCORI Fee
- Article: Form 720 Revised to Accommodate the Payment of the PCORI Fee
- IRS Examines Some PCORI Fee Payments
- PCORI Fee Timetable
- PCORI Fee Worksheet
- PCORI Fee for HRAs Worksheet
- Article: Annual Health Insurer Fee
- Article: Excise Tax on High-Cost Health Coverage ("Cadillac Tax")
- Webinar: Planning Ahead for the Cadillac Plan Tax
- Webinar: Planning Ahead for the Cadillac Plan Tax – Presentation Slides
- Chart: Fully Insured Fees and Taxes
- Chart: Self Insured Fees and Taxes
- FAQs on PPACA Fees
Medical Loss Ratio Toolkit
The Patient Protection and Affordable Care Act requires that insurance companies spend at least 80% of premiums collected on medical care and quality improvement activities in the small group and individual markets (85% in the large group market). Rebates are provided to consumers by insurers that do not meet this standard – the 80/20 rule. Insurers that fail to meet the standard must send a notice of the failure to their customers explaining the purpose of the rule, the amount by which the insurance company missed the goal, and the percentage of the premium being returned.
The following links will provide a comprehensive overview of the MLR requirements, assist you with better understanding the MLR requirements, and link you to notices developed by the federal government.
Summary of Benefits and Coverage Toolkit
Given the large number of mandates required under healthcare reform and the voluminous amount of guidance issued by the federal government to date, it is no wonder that many employers have been feeling overwhelmed. One of the mandates currently facing employers is the requirement to provide participants and beneficiaries a form of disclosure - a “Summary of Benefits and Coverage” (“SBC”). The requirement has left many employers to wonder:
- What information must be included in the SBC?
- When must the SBC be provided to employees?
- What should employers do to prepare for the implementation of this new mandate?
To help you navigate through the numerous nuances of the SBC requirements, Gallagher has developed this toolkit, composed of a variety of tools and resources to help you understand, prepare, and comply. The SBC Disclosure Toolkit has incorporated all guidance issued by the federal government through May 2019.
- Article: Summary of Benefits and Coverage and Uniform Glossary Requirements
- SBC Coverage Example Calculator
- SBC FAQs for Employers
- SBC Electronic Distribution Matrix
- County Data for Providing Culturally and Linguistically Appropriate Notices
- Agency Instructions for Completing the SBC – Plan Years After April 2017
- Quick Facts and Chart on the Distribution Requirements and Timing
- Webinar: The Basics of SBC
- Webinar: The Basic of SBC - Presentation Slides
W-2 Reporting Toolkit
Healthcare reform amended the Internal Revenue Code to require that employers report the aggregate cost of "applicable employer-sponsored coverage" on employee W-2s. As a result of this requirement, many employers have been:
- Wondering if their plans are subject to the healthcare reform W-2 reporting requirement
- Puzzled about how to correctly calculate the value of the benefits provided
- Confused about the types of benefits to be included on employees' W-2s
In an effort to help you navigate the W-2 requirements, Gallagher has developed multiple tools to help you understand, comply with, and communicate these changes to your employees.
- Article: What Employers Need to Know About W-2 Reporting
- FAQs on W-2 Reporting
- W-2 Reporting: Comparison of Amounts Reportable in Code DD, Box 12 and Box 1
- Quick Reference Tool
- Checklist for W-2 Reporting
- Webinar: Form W-2 Reporting under PPACA
- Webinar: Form W-2 Reporting under PPACA - Presentation Slides
- Sample Employee Communication
How has healthcare reform impacted your wellness programs? Employer-sponsored wellness programs that come in all shapes and sizes. In general, these programs attempt to address body, mind and pocketbook―helping employers reduce benefit costs and lost work time, while increasing employees' productivity and satisfaction. Prior to the passage of healthcare reform, HIPAA prohibited group health plans from discriminating against plan participants in terms of eligibility, benefits or premiums based on a health factor.
An exception was permitted for wellness programs that would allow a limited amount of rewards, or penalties, in return for adherence to a wellness program. In general, while healthcare reform adopted many aspects of the HIPAA Rule related to wellness programs, there were a number of significant changes introduced by the final HIPAA (as amended by PPACA) regulations issued in June 2013. In addition, the EEOC issued final regulations under the ADA and GINA in May 2016. This toolkit helps employers understand how healthcare reform, ADA and GINA impact employer-sponsored wellness programs.
- Navigate Wellness Regulations: How ADA, GINA and HIPAA/PPACA May Impact Your Journey
- Article: Final Wellness Regulations Under HIPAA, PPACA, ADA and GINA
- Guide for Designing a Compliant Wellness Program
- FAQs on Wellness Programs
- Technical Bulletin – 2016 Issue 5 – EEOC Issues Final Wellness Rules under ADA and GINA
- Wellness Programs under Final HIPAA/PPACA, ADA, and GINA Regulations
Healthcare Reform FAQs
Are you overwhelmed with all the details of healthcare reform? As regulations are issued, you may need further clarification. Gallagher has compiled an extensive list of frequently asked questions with answers provided by our compliance experts.
Sections of the FAQs include Employer Responsibility, Individual Responsibility, Taxes and Subsidies, and Miscellaneous.
Updated July 2019.