employee benefits Archives

Common Health Insurance Terms to Help You Understand Your Plan

March 12, 2023/in News

If you’re considering purchasing health insurance, you may feel overwhelmed by the variety of terminology associated with it. From coinsurance to deductibles, there are numerous health insurance terms you should know before you enroll. But don’t worry; we’ve got you covered. We have translated some of the confusing terminologies around health insurance into plain English to help you better understand your health insurance coverage.

Let’s dive in.

Coinsurance

Coinsurance is a health insurance term that refers to the percentage of the cost of a healthcare service that you are responsible for paying after you have met your health insurance plan’s deductible.

For example, if your healthcare bill is $1,000 and you have already met your deductible, and your coinsurance is 20%, you will be responsible for paying $200 (20% of $1,000), while your insurance company will pay the remaining $800. Coinsurance is one of the ways in which health insurance companies share the cost of healthcare services with their policyholders.

Copay

Copay refers to a fixed amount of money that you may need to pay out-of-pocket for a covered healthcare service or supply. For example, your health plan may require a $20 copay for an office visit or a $10 copay for a generic prescription. After you pay the copay, your health insurance plan will cover the remaining cost of the healthcare service or supply.

Copays are a way for health insurance companies to share the cost of healthcare services with their policyholders. Copay amounts may vary depending on the type of healthcare service or supply, and the specifics of your health insurance plan.

Deductible

A deductible is the amount of money that you need to pay out-of-pocket for healthcare services before your insurance plan starts covering those services. For example, if your plan has a $1,000 deductible, you will need to pay the first $1,000 of healthcare services you receive during the year before your plan starts contributing to the cost of covered services. Once you’ve met your deductible, your insurance plan will begin to share the cost of healthcare services with you. The amount of the deductible can vary depending on the specifics of your insurance plan and is an important factor to consider when choosing a plan, as it can significantly impact your out-of-pocket costs for healthcare.

Essential Health Benefits

Let’s talk about Essential Health Benefits – a set of healthcare services that must be covered by plans in the Health Insurance Marketplace, as required by the Affordable Care Act. These benefits include emergency services, hospitalization, maternity and newborn care, mental health, prescription drugs, preventive and wellness services, pediatric services, and more.

In-Network Providers

Understanding the difference between in-network and out-of-network providers is critical. In-network providers are a group of doctors, hospitals, and other healthcare providers that your health insurance plan has partnered with to provide care to its members.

Out-of-Network Providers

When you receive healthcare services from a provider that has not partnered with your insurance plan to provide care to its members, this is known as an out-of-network provider. It’s important to note that using an out-of-network provider may result in additional costs for you, so it’s crucial to know which providers are in-network before receiving care.

Another important term to be familiar with is out-of-pocket cost, which refers to the amount you pay for health care services. This may include your deductible, coinsurance, and co-pays.

The out-of-pocket maximum is the most you’ll pay in a policy period, usually one year, before your plan starts to pay 100% of the covered Essential Health Benefits you receive. This limit must include deductibles, coinsurance, and co-payments, but typically does not count premiums toward your out-of-pocket maximum.

Monthly Premiums

Monthly premiums refer to the regular payments that an individual pays to their health insurance company in exchange for coverage. This payment can be made on a monthly, quarterly, or yearly basis depending on the insurance plan.

The amount of the premium varies based on a number of factors, such as the type of coverage, the individual’s age, location, and the level of benefits they choose. It’s important to understand the cost of the monthly premium when selecting a health insurance plan, as it can impact your budget and overall financial health.

Preventative Care

Preventive care is health care services focused on keeping you healthy before you may become sick. These include routine check-ups, patient counseling, screening tests, and immunizations. Plans must offer these services at no cost to you when the services are provided by in-network doctors. This means they can’t charge a copayment or coinsurance, even if you haven’t met your deductible for the year.

Provider

Lastly, it’s important to understand what a provider is. This refers to a person or place you go to receive health care services. Examples include doctors, hospitals, pharmacies, and more. Check with your health insurance plan to find out if a provider is in-network or out-of-network.

By familiarizing yourself with these health insurance terms, you can better understand your coverage and make an informed decision when choosing a health insurance plan.

Still Have Questions?

We serve employers who want to offer their employees affordable benefits. We simplify the complexity of providing those benefits and ensure compliance with the Affordable Care Act. We provide affordable benefits for the everyday person. We are different because of our personal service, speed of implementation, and innovative approach to providing benefits coverage.

Learn more about us and our services, here.

What is Encompassing Health and Why Does the Government Allow it?

February 5, 2023/in News

As healthcare costs continue to rise in the US, reaching a staggering $4.1 Trillion in 2020, it’s no surprise that people are looking for ways to address the issue. But what if there was a way to address healthcare issues before they became serious problems, saving both time and money in the process? Enter preventative healthcare.

In this blog, we will discuss preventative healthcare, why it’s important and how Encompassing Health contributes to the overall well-being of individuals and communities. Let’s dive in.

Let’s Talk Preventative Healthcare: Why Is It Important?

Preventive healthcare is important because it can help to prevent or reduce the likelihood of developing health conditions or diseases in the first place. By proactively addressing potential health issues before they become serious problems, individuals can save time and money on treatment and improve their overall quality of life.

Preventive healthcare can also reduce the burden on the healthcare system by preventing the need for more costly and complex treatments down the line. In addition, preventive healthcare can help to reduce healthcare costs for both individuals and the healthcare system as a whole by addressing issues before they become more serious and costly to treat. By investing in preventative care, the government can potentially save billions of dollars each year on healthcare costs and improve the overall health of the population.

According to the CDC, chronic diseases that are avoidable through preventive care services account for 75% of the nation’s healthcare spending and lower economic output in the US by $260 billion dollars a year. This means that by introducing a preventative healthcare program, the government could potentially save billions of dollars each year.

Encompassing Health

Encompassing Health is a program that offers elective, limited health insurance benefits under Section 125 of the Internal Revenue Code. This means that the benefits provided through Encompassing Health can be paid for using pre-tax dollars, which can help offset the cost of the benefits through payroll tax savings. Essentially, this means that individuals who enroll in Encompassing Health can use pre-tax dollars to pay for their limited health insurance benefits, which can help reduce their overall tax burden.

Encompassing Health was designed with the intention of providing companies of all sizes with the best, most affordable workplace health services.

Encompassing Health is just one example of a preventative healthcare program that could help the government save money. By offering tax savings to encourage people to participate in preventative healthcare services, the government can help address healthcare issues before they become serious and costly problems.

So, Why Would the Government Allow a Program like Encompassing Health?

The answer is simple: to save money and improve the overall health of the population. If you’re interested in learning more about preventative healthcare and how it can benefit you, be sure to check out our Encompassing Health Program.

What is SBMA’s Encompassing Health?

Digital Health Portal

Provides a specialized, fully integrated technology suite, assisting employees to establish a healthy lifestyle while simultaneously improving employee productivity and reducing the need for health services by preventing health issues from arising in the first place.

Personalized Coaching

Provide employees with access to workplace certified health coaches who are personally assigned to them in order to give employees a detailed and effective regiment that will ensure their personal health.

Telemedicine

Telemedicine enables medical consultations to take place through secure, electronic communication including bi-directional video conferencing, telephone and email. This eliminates the need for traveling back and forth to a doctor’s office, and opens up availability for employees who previously may have had trouble getting in to see a doctor for check ups or test results, due to a busy at home schedule.

Behavioral Health

Behavioral clinicians provide assessment, diagnosis, consultation, and brief psychotherapy to address each employees behavioral health needs through live, interactive video conferencing.

Risk Identification

Predict and classify 35 different conditions and identify and rank the health risks of your unique environment.

Genomics Testing

Leveraging this individualistic approach with an emphasis on each employee and offer each participant an opportunity to set goals for his or her physical and mental well-being based on their genetics.

Final Thoughts

In conclusion, the high cost of healthcare in the US is a major concern for many people. However, preventative healthcare services have the potential to address a significant portion of healthcare-related issues, potentially saving the government billions of dollars each year. Encompassing Health is one example of a preventative healthcare program that could help the government save money and improve the overall health of the population. While the tax savings offered by this program may seem small compared to the potential savings, they can still be a valuable incentive for people to participate in preventative healthcare services and help address healthcare issues before they become serious and costly problems.

Full-Time vs Part-Time Benefits: Why It Matters

January 1, 2023/in ACA Compliance, News, Voluntary Benefits

Employers need to make sure they are compliant with the Affordable Care Act (ACA) and the employer shared responsibility regulations, also known as “the employer mandate” or ALE. This means that employers must consider many factors when deciding between offering full-time vs part-time benefits, including the costs associated with providing health coverage and other employee benefits.

In this blog we’ll explore the differences between full-time (FT) and part-time (PT) benefits and why it matters for business owners.

What is the ACA’s Employer Mandate?

The Affordable Care Act’s (ACA) Employer Mandate is a federal law requiring businesses with 50 or more full-time employees to provide health insurance coverage to those employees, or face penalties. The ACA requires employers to offer minimum essential coverage that meets certain affordability and value requirements. Employers must also comply with certain reporting requirements so the government can keep track of employer compliance with the law.

The Employer Mandate is one of the most important elements of the ACA, as it helps ensure that more Americans have access to quality health care coverage. The goal of this law is not only to ensure that employers are providing health insurance to their employees, but also to make sure those plans are comprehensive and affordable.

The ACA’s Employer Mandate requires Applicable Large Employers (ALEs) to provide their full-time employees with affordable Minimum Essential Coverage (MEC), meeting Minimum Value (MV) requirements, that covers at least 95% of the workforce.

The Employer Mandate is enforced by the Internal Revenue Service (IRS), and while penalties can be imposed if an employer fails to comply with the law, there are some exemptions that may apply. For example, employers who offer health coverage but do not meet minimum value requirements may qualify for a “hardship exemption.” Additionally, employers with fewer than 50 full-time employees are not subject to the Employer Mandate.

What is ALE (Applicable Large Employer)?

Applicable Large Employer status is a designation given to certain employers by the Internal Revenue Service (IRS) under the Affordable Care Act (ACA). The ACA requires applicable large employers to offer health insurance coverage to their full-time employees or pay a penalty.

An applicable large employer is any business that has at least 50 full-time employees, or a combination of full-time and part-time employees that are equivalent to at least 50 full-time employees.

What Qualifies an Employee as Full-Time?

Generally, an employee is considered full-time if they work an average of 30 or more hours per week. Certain government agencies may have specific definitions to define full-time employees, such as those that qualify for unemployment benefits. Depending on the situation, an employee may also be considered full-time if they are classified as a salaried or exempt employee, meaning they would receive a set salary regardless of the number of hours worked.

Overall, being aware of an employer’s definition of full-time employment can be beneficial for both employers and employees. Knowing what qualifies as full-time can ensure that employees receive the correct benefits and employers are in compliance with any applicable regulations.

What Benefits are Generally Offered to Full-Time Employees?

Full-time employees typically receive benefits such as health insurance, vacation time, 401(k) plans, and other company-sponsored retirement plans. Some employers may also offer tuition reimbursement programs, life and disability insurance, flexible spending accounts (FSAs), and employee discounts. The specific benefits offered to full-time employees vary greatly depending on the employer and the industry.

Additionally, many organizations are now offering mental health support, remote working options and other perks that may benefit employees in these uncertain times.

Full-time employees must be offered benefits if the employer is subject to ALE, while part-time employees are not eligible for coverage until they meet certain hours thresholds. Employers should carefully consider how their benefits packages will affect the ACA and ALE compliance in order to avoid penalties or fines that could arise from noncompliance.

What Qualifies as Part-Time Employment and Benefits?

Part-time employment typically refers to a worker who is employed for fewer hours per week than a full-time worker. Some employers may offer part-time employees the same benefits as their full-time counterparts, including health insurance, paid time off, and retirement savings plans. However, there can be differences in the amount of benefits offered depending on the employer. For example, some employers may offer reduced health care plans or no retirement savings plan to part-time employees. In addition, some employers may cap the amount of paid time off for part-time workers. It is important for potential and existing part-time employees to know their rights under the applicable labor laws.

Additionally, employers need to be aware of the different rules for eligibility for full-time and part-time employees. For example, if an employer offers a health plan that is limited to full-time employees but also has part-time employees who work more than 30 hours per week, they may not be eligible to receive coverage under this plan. This means that employers must be very careful when establishing eligibility criteria for their benefits plans and make sure that they are compliant with the ACA and ALE regulations.

How PT vs FT Employee Benefits Impact Retention

Employers should also consider how their employee benefit packages affect their employee retention strategies. Offering attractive benefits to full-time employees can help retain them, while providing minimal or no benefits to part-time employees may lead to high turnover rates. Employers need to assess their workforce needs and determine if it is necessary to offer benefits to part-time employees in order to maintain a healthy and productive workforce.

Things to Consider

Overall, employers must take into account the costs of providing employee benefits, as well as the compliance requirements of the ACA and ALE when deciding between offering full-time vs part-time benefits. Employers should also consider their employee retention strategies and make sure they are providing adequate benefits to ensure long-term loyalty from both full-time and part-time employees. With proper planning, employers can create an effective benefits package that meets the needs of their workforce while remaining compliant with all applicable regulations.

The Affordable Care Act (ACA) requires employers to calculate the number of employees that qualify as full-time and full-time equivalent for each month in order to determine if they are an Applicable Large Employer (ALE). This calculation involves taking the total number of full-time designated employees, plus all non-full-time designated employees’ hours for the month and dividing by 120. The resulting number is then added to the full-time employee count to determine ALE status.

To ensure accurate calculations, employers can outsource their ACA compliance process to a service provider who will measure workers’ hours of service and calculate FTEs and ALE status on their behalf. Accurately calculating ALE status is essential for employers to minimize potential penalty exposure from the IRS.

To Sum It Up

The decision to provide full-time or part-time benefits to employees is a complex one that requires careful consideration of various factors such as cost, compliance with ACA and employer shared responsibility regulations. Employers should look into their options and evaluate which option is best for them in order to ensure they are providing their employees with quality benefits. Ultimately, offering the right benefits to employees can help businesses attract and retain talent.

If you’re a business owner that needs help navigating FT/PT employee benefits, reach out to us today!

The Individual Mandate: What Employers Need to Know

August 14, 2022/in News

The California Individual Mandate, originally signed into law in 2019, was a response to the federal individual mandate being struck down by the Trump administration.

This state law requires all California residents obtain Minimum Essential Coverage (MEC) for a minimum of nine months, or they may face a tax penalty unless exempt.

Let’s discuss the individual mandate and what employers need to know, starting with a shorthand list of exemptions.

MEC Exemptions

According to the State of California Franchise Tax Board, some exemptions include:

An individual’s income is below the state tax filing threshold
A coverage gap consists of three consecutive months or less
Coverage is not affordable based on the income reporting in your state income tax return
If the cost of the lowest plan, whether marketplace or employer-sponsored, is more than 8.09% of income on an individual’s tax return
The cost of the lowest employer-sponsored family plan, including dependents, is more than 8.09% of the household income
Non-citizens who are not lawfully present in the state
Those who are living abroad or are residents of another state
Members of a health care sharing ministry
Enrolled in limited or restricted-scope Medi-Cal or other similar coverage
Those in federally recognized tribes are eligible for services through an Indian health care provider or the Indian Health Service
Those in jail, except for incarceration, pending the disposition of charges

These exemptions typically must be claimed on your state income tax return.

While the individual mandate went into effect “to reduce the number of uninsured individuals and families,” it also has implications for employers in California. Moreover, the law requires additional reporting from specific organizations.

Employer Reporting Required by the Individual Mandate

Employers must report insurance information to the Franchise Tax Board (FTB) of California by March 31. The data reported includes the enrollment participation of employees and their dependents.

Employers with an insurance provider who reports to the FTB are not required to report in addition to their provider.

What are the Penalties for Not Reporting Insurance Information to the FTB?

Employers who do not meet the filing deadlines of the FTB are subject to a $50 penalty for every employee receiving coverage.

Individually, there is a flat penalty per household member or 2.5% of the gross household income, whichever is higher. If an individual does not obtain coverage for the entire year, they would be subject to a minimum fine of $800.

Why Are There ACA Reporting Requirements for Employers?

For applicable large employers (ALE), the FTB introduced these reporting requirements to help enforce the state’s healthcare mandate.

Employers who offer self-insured or employer-sponsored plans must report individual enrollment through Form 3895C unless their insurer reports via Form 1095-B.

These reports allow the FTB to verify an individual’s coverage and identify who must pay an individual shared responsibility provision (ISRP).

This sounds like a lot, but don’t worry. At SBMA, we take care of all ACA reporting required for the ALEs we work with. We submit Forms 1095-B and 1095-C to ensure you comply with ACA requirements.

Individual Mandates in Other States

Individual mandates are becoming a more common practice in states other than California. The current states who have individual healthcare mandates include:

California
The District of Columbia
Massachusetts
New Jersey
Rhode Island, and
Vermont

Read our article “Understanding the Affordable Care Act Individual Mandate” for a more detailed look at each state’s requirements.

A Final Word

As an employer, it is essential to understand the individual mandate to ensure you remain compliant with reporting requirements and avoid hefty fines.

The best way to stay on top of these requirements is to partner with an insurance provider who handles your reporting. Look at our employer resources page for more information on how we assist employers with their health coverage needs.

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.

1094/1095 PCORI Compliance: What You Need to Know

June 5, 2022/in ACA Compliance, News

Businesses that provide health benefits for their employee workforce must submit the right forms proving that they offered the required benefits. Now that 1094/1095 filing is complete, it’s time to prepare for federally mandated annual PCORI fees. Are you prepared? Let’s discuss 1094, 1095, and PCORI compliance.

How Can Applicable Large Employers Stay Compliant?

Applicable Large Employers (ALEs), employers with 50 or more full-time employees, must offer Affordable Care Act (ACA) compliant health benefits to at least 95% of their workforce. Failure to do so can result in hefty fines and penalties from the Internal Revenue Service (IRS).

The IRS can issue ALEs Penalty A or Penalty B fines for ea

ch employee that is not offered correct or compliant benefit plans. Employers can avoid unnecessary fines and penalties by offering ACA Compliant Minimum Essential Coverage (MEC). MEC benefit plans allow employers to provide affordable benefits to their employees without compromising their bottom line.

In order to verify employers are, in fact, offering ACA compliant benefits, the IRS requires employers to fill out form 1094 and 1095.

Employers must complete Form 1094, which is used to determine their liability for payment under the employers’ shared responsibility provision. Form 1095, however, is used as a summary of healthcare information the ALE offers employees.

What Can SBMA Do For You?

One of the many services we provide at SBMA Benefits is 1094 and 1095 Form processing. We simplify the complexity of providing employee benefits while simultaneously ensuring ACA compliance.

What’s included in our 1094/1095 processing?

Electronic filing of 1094 and 1095 forms annually
PDF soft copies of 1095 for employee distribution
1095 error corrections refiling (if applicable)
Mail distribution

What Happens After I Submit Forms 1094 and 1095?

After submitting Forms 1094 and 1095 by their due date, March 31st, employers must pay fees to the Patient-Centered Research Institute (PCORI) by July 31st. This year, however, the due date has been extended to August 2nd since the previously mentioned due date lands on a Saturday.

What is PCORI and Why Do I Have to Pay Their Fees?

PCORI was created to improve the quality, quantity, timeliness, and trustworthiness of health information for patients.

According to the PCORI, its mission is to “help people make informed healthcare decisions, and improve healthcare delivery and outcomes, by producing and promoting high-integrity, evidence-based information that comes from research guided by patients, caregivers, and the broader healthcare community.”

Employers are responsible for paying PCORI trust fund fees annually. The amount employers owe depends on the number of people enrolled in their offered benefits program.

The fee is calculated based on the average number of individuals covered in a benefits plan- including spouses, dependents, retirees, and COBRA participants. Currently, PCORI fees are $2.79 per enrollee. In 2021, PCORI fees cost $2.66 per enrollee.

The fee was slated to end in 2019, but was extended via Trump’s Further Consolidated Appropriations Act of 2020. For now, PCORI fees are extended through 2029.

For more information on Forms 1094 and 1095, read our article: What you need to know about 1094/1095 Filing.

How Does SBMA Support Employee Benefits Administration?

May 17, 2022/in Employee Retention, News, Voluntary Benefits

Employee benefits administration can be a pain for any HR department. At SBMA, we aim to simplify the process by giving you access to everything you need in one place. Our enrollment portal houses everything you need for:

Onboarding
Offboarding
Enrollment
Portal assistance

Our employee benefits professionals have the knowledge and expertise that can save your company time and money. We aim to offer comprehensive benefit management, not only with our portal, but also as it pertains to ACA compliance, providing low-cost options, and offering fast and reliable service.

The convenience of SBMA’s employee benefits administration support allows your Human Resources department to work on their daily tasks and responsibilities without the headache of a difficult benefits administrator. Our one-stop-shop portal helps reduce the paperwork your HR department has to deal with and therefore, improves your bottom line.

Employer Resources

Our website is equipped with plenty of employer resources that give easy and secure access to your records and the ability to make plan changes at your fingertips (i.e. (enrollment portal, adding dependents, employee termination, and more). Adjusting benefit plans couldn’t be any easier with SBMA. Additionally, every task includes video tutorials, walkthroughs, and instructions.

Watch the videos below to see just how easy navigating our portal is.

Enrollment Portal Walkthrough

Adding Dependents Walkthrough

Termination Walkthrough

Partnering with us takes the burden off of your HR department and places it on us, your benefits administrator. Ready to get started? Reach out to us today.

In this effort to streamline and simplify our client’s benefits experience, we’ve partnered with Transamerica. Transamerica’s partnership with SBMA brings you quality, affordable health insurance that fits into your budget and removes the hassle of excess submissions to insurance carriers. Take a look at the full explanation of how this partnership impacts your benefits administration here.

Pros and Cons of COBRA vs. Private Health Insurance

April 24, 2022/in COBRA, News

When seeking out health insurance coverage past when it is partially covered by your previous employer, how do you choose between picking COBRA or Private Health Insurance? Both have pros and cons. The right choice, however, depends on your unique circumstances.

Let’s discuss COBRA vs. Private Health Insurance.

Difference Between Hospital Indemnity and Accident Insurance?

October 26, 2021/in MEC, Voluntary Benefits, Worksite Benefits

Navigating insurance policies can be challenging for anyone. There isn’t a way to predict the future, so how can you know what you will need? There are so many options available, how can you decide?
Voluntary benefits can help supplement insurance policies that may not cover all of your employees’ needs. There are many options when it comes to voluntary benefits with a few differences. What’s the difference between hospital indemnity policies and accident insurance? Here’s a breakdown.

How Can You Add Value to Your Existing Benefits Plans?

March 14, 2021/in ACA Compliance, MEC, Voluntary Benefits, Worksite Benefits

Benefit plans serve as a great way to provide value to employees beyond their salary. Because benefits are becoming increasingly important, it’s important that you give your employees the option to tailor their benefits to their needs. At SBMA, we believe in meeting your employee’s medical needs with additional benefit options. We offer our clients the option to choose various voluntary/worksite, ancillary, and virtual health benefit options.

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