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Tag Archive for: Affordable Care Act

FAQs: ACA and ALEs – What You Need to Know

March 5, 2023/in ACA Compliance

As an ALE, understanding the regulations set forth by the Affordable Care Act (ACA) can be a daunting task. The employer mandate, minimum essential coverage (MEC), minimum values, and affordability are all crucial guidelines that must be understood to avoid penalties.

In this blog, we will answer some frequently asked questions about ACA and ALEs to help you stay informed and compliant. We will cover topics such as what is an ALE, how to calculate workforce size, common ownership impact on ALE status, timing impact on ALE status calculation, the employer mandate, minimum essential coverage, and more. So, let’s get started!

First, What is an ALE?

An ALE, or applicable large employer, is a company or organization that employs at least 50 full-time equivalent (FTE) employees. The IRS defines a full-time employee as someone who works at least 30 hours per week or 130 hours of service per calendar month.

 Even if a company doesn’t have 50 full-time employees at all times, it just needs to average at least 50 FTEs per month in the current calendar year to be considered an ALE for the following calendar year.

How Does an Employer Calculate Workforce Size to Determine if They’re an ALE?

To determine if your company is considered an ALE, you must add the number of full-time employees and the full-time equivalent of your part-time employees. only U.S employees should be counted. 

To calculate the full-time equivalent of your part-time employees, take the total hours worked by all part-time workers in a month and divide by 120. Then add this number to the total number of full-time employees to get your total FTE count. If you have seasonal workers, they must be included in the FTE count, but you may be able to apply for an exemption if their hours cause the count to exceed 50 or more.

You are eligible for the seasonal worker exemption if you meet the following conditions:

  • Your total number of full-time employees (including FTEs) exceeds 50 for a maximum of 120 days in a calendar year.
  • The excess employees during this period are considered seasonal workers.

How Does Common Ownership Impact ALE Status?

To determine if a group of businesses are considered an ALE, they must be evaluated together as a controlled group. This applies even if the businesses are separate legal entities. If the controlled group is determined to be an ALE, each individual business within the group is considered an ALE, regardless of the total number of employees and is subject to the employer shared responsibility provisions (ESRP) of the ACA.

How Does Timing Impact ALE Status Calculation?

When determining ALE status, it is important to consider the preceding calendar year. Employers who were established during part of the previous year will have their calculations adjusted accordingly. New businesses that did not exist on any day in the previous year will be considered an ALE if they anticipate and do employ an average of 50 or more full-time employees, including full-time equivalentsduring the current calendar year.

What is the Employer Mandate?

The employer mandate, also known as the Employer Shared Responsibility Provisions (ESRP), is a requirement under the Patient Protection and Affordable Care Act (ACA) that applies only to businesses that are considered Applicable Large Employers (ALEs). These employers are required to offer health insurance coverage that meets minimum essential coverage (MEC) and is considered affordable to their full-time employees and their dependents, or they may face penalties. 

Businesses that do not qualify as ALEs are not subject to these requirements or penalties. Only full-time employees, not full-time equivalents, are counted for the purpose of calculating penalties and the first 30 full-time employees are not factored into the calculation.

What is Minimum Essential Coverage?

The Affordable Care Act (ACA) requires that ALEs provide a minimum level of health insurance coverage, known as minimum essential coverage (MEC), to at least 95% of their full-time employees. This is to avoid paying penalties under the employer shared responsibility provisions (ESRP). 

To meet this requirement, ALEs must offer their employees the opportunity to enroll in a health insurance plan that meets the standards set forth by the ACA, such as those offered in the small or large group market, grandfathered health plans, or certified by the Health Insurance Marketplace.

How is Affordability Defined and Calculated?

To be considered “affordable” under the Affordable Care Act, a health plan’s cost for an employee cannot exceed 9.12% of their annual household income in 2023. This calculation is based on the employee’s salary and the lowest cost silver plan available for their age and location.

Does the Employer Mandate Require Coverage be Offered to Dependents?

The employer mandate under the ACA stipulates that ALEs must provide qualified and affordable health coverage options to their employees and their eligible dependents. According to the mandate, dependents are defined as an employee’s child under the age of 26, including adopted or placed for adoption children. It should be noted that spouses, stepchildren, foster children, or non-U.S. citizen children not living in the U.S. or a contiguous country do not fall under the definition of dependents.

When Would an Employer be Subject to Potential Employer Shared Responsibility Penalties?

There are two types of financial penalties for ALEs (Applicable Large Employers) under Section 4980H of the Internal Revenue Code. The first penalty (4980H(a)) applies to ALEs that do not offer Minimum Essential Coverage (MEC) to at least 95% of their full-time employees and dependents. The second penalty (4980H(b)) applies to ALEs that do not offer affordable coverage to their full-time employees and dependents.

If an ALE fails to meet these requirements and at least one full-time employee receives federal subsidies, such as premium tax credits for purchasing essential coverage through the Marketplace, the ALE will be subject to penalties. 

How Much are the Penalties for Failing to Meet the Employer Mandate?

The IRS updates the penalties for employer mandates annually. In 2023, the penalties are as follows:

 

  • Section 4980H(a) penalty: ALEs that do not provide Minimum Essential Coverage to 95% of full-time employees will face a penalty of $2,880 per full-time employee.
  • Section 4980H(b) penalty: ALEs that do not offer affordable or minimum value coverage will face a penalty of $4,320 per full-time employee.

These penalties may be adjusted based on the number of employees who received subsidies for coverage and how many months employees were not covered. The IRS will apply the higher penalty of the two options, meaning that both penalties cannot be imposed simultaneously.

Still Have Questions?

The best way for employers to remain compliant with healthcare laws is to consult with a team of professionals. Our team at SBMA understands the ACA and can help you stay up-to-date on any changes to the law. 

https://www.sbmabenefits.com/wp-content/uploads/2023/02/iStock-843617064.jpg 1330 2254 Nathan Ines https://www.sbmabenefits.com/wp-content/uploads/2021/12/SBMA_Website-Logo_250x150.png Nathan Ines2023-03-05 09:00:552023-02-09 10:28:31FAQs: ACA and ALEs – What You Need to Know

ACA is Here to Stay

November 20, 2022/in ACA Compliance

The Affordable Care Act, also known as Obamacare, was one of the biggest healthcare overhauls in recent history. It aimed to provide affordable health insurance coverage for all Americans. After several failed attempts to repeal the act, it seems that ACA is here to stay. 

In this blog post, we will take a closer look at what this means for American taxpayers and businesses.

What Is the Affordable Care Act (ACA)?

The Affordable Care Act was passed in 2010 and since then it has been under constant threat of repeal. The law required all Americans to have health insurance coverage or face a tax penalty. It also expanded Medicaid coverage and provided subsidies to help people afford private health insurance plans.

In 2017, Republican lawmakers attempted to repeal the Affordable Care Act but were unsuccessful. This led to a lot of uncertainty about the future of the law. However, it now seems that ACA is here to stay, at least for the time being.

What Does this Mean for American Taxpayers?

For starters, it means that the tax credits and subsidies that help people afford their health insurance coverage are still in place. It also means that the Medicaid expansion, which has provided coverage for millions of low-income Americans, is still in effect.

Taxpayers will continue to be responsible for funding the ACA. This includes the subsidies that help people pay for health insurance and the Medicaid expansion. The good news is that, because the ACA is no longer being repealed, there will be no need for major changes to the tax code.

What Does this Mean for Businesses?

The Affordable Care Act requires businesses with 50 or more employees to provide health insurance coverage for their workers. This requirement is still in place, so businesses will need to continue to comply with it.

There may be some changes to the way this is done in the future. For example, the government may provide more subsidies to help businesses cover the cost of health insurance. 

Overall, the news that ACA is here to stay is good news for American taxpayers and businesses. It provides stability and certainty in an uncertain time.

Final Thoughts

The Affordable Care Act has provided many benefits, including increased access to healthcare, lower costs for prescription drugs, and free preventive care services. These benefits are worth billions of dollars each year and help to improve the lives of millions of Americans.

There is still some uncertainty about the future of the Affordable Care Act, but for now, it seems that the law is here to stay. This is good news for American taxpayers and businesses who have benefited from the law’s many provisions.

If you’re interested in learning more about the ACA, read our articles on the advantages of the ACA and  what business owners should know about ACA benefits. 

https://www.sbmabenefits.com/wp-content/uploads/2022/11/iStock-1141247654.jpg 1414 2121 Nathan Ines https://www.sbmabenefits.com/wp-content/uploads/2021/12/SBMA_Website-Logo_250x150.png Nathan Ines2022-11-20 08:00:452022-11-18 09:30:25ACA is Here to Stay

Preventative Services Covered by MEC

August 7, 2022/in MEC, News

Minimum essential coverage is health insurance that meets the Affordable Care Act requirements. Employers have a requirement to offer at least Minimum Essential Coverage to any benefit-eligible employee. Non-compliance can result in a penalty of $214.17 PER eligible employee per month without coverage.

 

Take a look at our MEC calculator to discover how much you can save by investing in MEC for your employees.

 

At SBMA, we aim to offer affordable, flexible, and compliant coverage for all employers.

What Does Basic MEC Cover?

Our Basic MEC plans cover 100% of preventive services and wellness visits to the doctor. In addition, all members have access to 24/7/365 telehealth services and discounts on generic and brand prescriptions. 

 

These plans are the most affordable option under Minimum Essential Coverage. 

What Does Ultimate MEC Cover?

Ultimate MEC covers the preventative services and wellness visits mentioned above, as well as primary care and specialist visits with a $15 copay. As well as urgent care, labs, and X-rays with a $50 copay. 

 

24/7/365 telehealth services are included under this plan, along with access to behavioral health telehealth services

 

Prescriptions under the Ultimate MEC plan are covered based on your coverage tier.

 

*$50 fee max 3 per year

Preventative Services Covered Under MEC

Both plans cover preventative services and wellness visits. The services covered depend on age and gender. Here’s a look at the coverage offered under preventative services:

Covered Preventative Services for Adults

  • Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
  • Alcohol misuse screening and counseling
  • Aspirin used to prevent cardiovascular disease in men and women of certain ages
  • Blood pressure screening for all adults
  • Cholesterol screening for adults of certain ages or at higher risk
  • Colorectal cancer screening for adults over 50
  • Depression screening for adults
  • Diabetes (Type 2) screening for adults with high blood pressure
  • Diet counseling for adults at higher risk for chronic disease
  • Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over
  • Hepatitis B screening for people at higher risk
  • Hepatitis C screening for adults at increased risk, and one time for everyone born 1945 –1965
  • HIV screening for everyone ages 15 to 65, and other ages at increased risk
  • Immunization vaccines for adults — doses, recommended ages, and recommended populations vary: Hepatitis A, Hepatitis B, Herpes Zoster, Human Papillomavirus, Influenza (flu shot), Measles, Mumps, Rubella, Meningococcal, Pneumococcal, Tetanus, Diphtheria, Pertussis and Varicella
  • Lung cancer screening for adults 55 – 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
  • Obesity screening and counseling for all adults
  • Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
  • Statin preventive medication for adults 40 to 75 years at higher risk
  • Syphilis screening for all adults at higher risk
  • Tobacco use screening for all adults and cessation interventions for tobacco users
  • Tuberculosis screening for certain adults with symptoms at higher risk

Covered Preventative Services for Women

  • Anemia screening on a routine basis for pregnant women
  • Breast Cancer Genetic Test Counseling (BRCA) for women at higher risk for breast cancer (counseling only; not testing)
  • Breast cancer mammography screenings every 1 to 2 years for women over 40
  • Breast cancer chemoprevention counseling for women at higher risk
  • Breastfeeding comprehensive support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
  • Cervical cancer screening
  • Chlamydia Infection screening for younger women and other women at higher risk
  • Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
  • Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
  • Domestic and interpersonal violence screening and counseling for all women
  • Folic acid supplements for women who may become pregnant
  • Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes
  • Gonorrhea screening for all women at higher risk
  • Hepatitis B screening for pregnant women at their first prenatal visit
  • HIV screening and counseling for sexually active women
  • Human Papillomavirus (HPV) DNA Test every 5 years for women with normal cytology results who are 30 or older
  • Osteoporosis screening for women over age 60 depending on risk factors
  • Preeclampsia prevention and screening for pregnant women and follow-up testing for women at higher risk
  • Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
  • Sexually transmitted infections counseling for sexually active women
  • Syphilis screening for all pregnant women or other women at increased risk
  • Tobacco use screening and interventions for all women, and expanded counseling for pregnant tobacco users
  • Urinary tract or other infection screening, including urinary incontinence
  • Well-woman visits to get recommended services for women under 65

Covered Preventative Services for Children

  • Alcohol and drug use assessments for adolescents
  • Autism screening for children at 18 and 24 months
  • Behavioral assessments for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
  • Bilirubin concentration screening for newborns
  • Blood pressure screening for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
  • Blood screening for newborns
  • Cervical dysplasia screening for sexually active females
  • Depression screening for adolescents
  • Developmental screening for children under age 3
  • Dyslipidemia screening for children at higher risk of lipid disorders at the following ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
  • Fluoride chemoprevention supplements for children without fluoride in their water source
  • Fluoride varnish for all infants and children as soon as teeth are present
  • Gonorrhea preventive medication for the eyes of all newborns
  • Hearing screening for all newborns, and for children once between 11 and 14 years, once between 15 and 17 years, and once between 18 and 21 years
  • Height, weight, and Body Mass Index measurements for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
  • Hematocrit or hemoglobin screening for all children
  • Hemoglobinopathies or sickle cell screening for newborns
  • Hepatitis B screening for adolescents ages 11 to 17 years at high risk
  • HIV screening for adolescents at higher risk
  • Hypothyroidism screening for newborns
  • Immunization vaccines for children from birth to age 18 — doses, recommended ages and recommended populations vary: Diphtheria, Tetanus, Pertussis, Haemophilus influenza type B, Hepatitis A, Hepatitis B, Human Papillomavirus, Inactivated Poliovirus, Influenza (Flu Shot), Measles, Meningococcal, Pneumococcal, Rotavirus and Varicella
  • Iron supplements for children ages 6 to 12 months at risk for anemia
  • Lead screening for children at risk of exposure
  • Maternal depression screening for mothers of infants at 1, 2, 4, and 6-month visits
  • Medical history for all children throughout development at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
  • Obesity screening and counseling
  • Oral Health risk assessment for young children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years.
  • Phenylketonuria (PKU) screening for this genetic disorder in newborns
  • Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
  • Tuberculin testing for children at higher risk of tuberculosis at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
  • Vision screening for all children.

Read on for more information on MEC insurance plans and what they cover.

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Understanding the Affordable Care Act Individual Mandate

July 17, 2022/in ACA Compliance, Employee Retention, Employer Resources, MEC

The Affordable Care Act (ACA) implemented the individual mandate, also known as the “individual shared responsibility provision” that requires that most Americans have a qualifying Minimum Essential Coverage (MEC).

Until 2018, those who did not prove themselves to have health insurance when filing taxes were penalized. The Tax Cuts and Jobs Act of 2017 then eliminated that requirement. This bill effectively eliminated the individual mandate penalty, as of 2019 on a federal level.

Read more
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Review: “Biden Bid to Expand Health Subsidies: ‘Family Glitch’ Explained“

July 3, 2022/in ACA Compliance, MEC, News

President Joe Biden continues seeking ways to make healthcare more affordable for Americans. His efforts include aiding over five million people who fall into the ‘family glitch’ of the Affordable Care Act (ACA).

The ‘family glitch’ is a section of the ACA that decreases the ability for families to qualify for health subsidies that make healthcare more affordable.

Read more
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Penalties vs the Cost of MEC- How Much Can You Save?

January 10, 2021/in ACA Compliance, Employee Retention, Healthy Living, MEC, Personal, Voluntary Benefits, Worksite Benefits

Under the Affordable Care Act, applicable large employers (ALE) are required to provide minimum essential coverage to 95% of their full-time or full-time equivalent employees. If you fail to do so, your company will be subject to various penalties that could cost you! If you do a cost-benefit analysis, investing in MEC for your employees can save you millions, while also increasing employee engagement.

Read more
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Minimum Essential Coverage Plans- What Do They Really Cover?

December 13, 2020/in ACA Compliance, COVID-19, Employee Retention, Healthy Living, MEC, Personal, Voluntary Benefits

Minimum essential coverage, also known as Obamacare, is designed to give coverage to those who need it most. However, there is quite a bit of confusion surrounding what minimum essential coverage actually covers for patients with this healthcare. MEC was designed to provide patients with 10 essential benefits. So what exactly are these essential health benefits?

Read more
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What’s the Difference Between the Affordable Care Act and Obamacare?

November 24, 2020/in ACA Compliance

While you’ve likely heard of Obamacare, you may not know Obamacare is the same thing as the Affordable Care Act. This healthcare law that passed in 2010, goes by a few different names. You may also see this law referenced as the PPACA or the ACA (the acronym Affordable Care Act). 

Read more
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What Does Minimum Essential Coverage Entail?

July 21, 2020/in ACA Compliance, MEC

Minimum Essential Coverage was created when the Affordable Care Act was enacted. Before the Affordable Care Act began, people who already had medical conditions or had used too much medical care in the past were able to be denied coverage by insurers. Minimum Essential Coverage ensures that all ACA-compliant health care plans offer insurance to all enrollees regardless of health status or which plan they select. What exactly does minimum essential coverage entail?

Read more
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