Informed decisions about your Medicare coverage

Are you approaching the age when medicaare becomes a part of your healthcare journey? Navigating the complexities of Medicare can be overwhelming. Its like trying to solve a puzzle without all the pieces, isn't it? But fear not! Meet Jeff Metzger your trusted Medicare advisor with years of experience. I have helped countless clients find clarity in the maze of Medicare, saving them time and money. Ready to make informed choices about your Medicare coverage? Call Jeff at 614-975-8233 today and take the first step towards a worry-free Medicare journey. We'll guide you through the process, ensuring you make the right choices for your health and budget. Don't navigate Medicare alone. Call Jeff and let's start your journey towards a healthier, happier retirement.

Financial Wellness is a win-win

As Employees continue to deal with high levels of financial stress, employers are stepping in to offer benefits that address these needs, while gaining a new strategy for recruiting and retaining their workforce. As employers continue to manage the fallout of the Great Resignation, which saw record numbers of employees leave the workforece entirely or switch jobs at a high frequency, benefit leaders have had to get more creative in our efforts to attract and retain talent. For many, promising employees a secure fnancial future is a strategy thats paying off. #jeffmetzger

A Comprehensive Journey through the world of Medicare??

 Whether you're approaching the age of eligibility or simply seeking a deeper understanding of this vital healthcare program, you've found the right place.  Medicare can be a complex landscape to navigate, with its various parts, plans, and enrollment periods.  From its inception in 1965 to its evolution into the multifaceted system it is today, Medicare plays a pivotal role in the lives of millions of Americans.  Designed to provide essential medical coverage for seniors, and certain individuals with disabilities, Medicare consists of different components, each serving a specific purpose. There may be several questions including what is covered, how they differ, and when to enroll: Medicare Part A, Part B, Part C (Medicare Advantage), Part G, and Part D.

But Medicare is not just about parts and plans-its about your health, well-being, and peace of mind.  It's about understanding your options so you can confidently choose the coverage that aligns with your unique healthcare needs and preferences.  My goal is to empower you with the knowledge to navigate the enrollment process, grasp the potential costs, and recognize the benefits available to you.

I can help you with some fundamental questions:  What is Medicare?, who is eligible?, what do each of Medicare parts cover?, When and how to enroll?, How do Medicare Advantage and Medicare Supplement plans fit in?, How about prescription drug coverage?, What potential costs you should be aware of?.

So lets begin this educational journey together, equipping you with the insights you need to make informed decisions about your healthcare coverage and embark on a path to a healthier more secure future.

What is a MEWA

A MEWA is a Multiple Employer Welfare arrangement.  It's an employee welfare benefit plan, trust, or other arrangement that is established or maintained for the purpose of offering group insurance.  It is governed by trustees and bylaws that satisfy the Ohio Department of Insurance requirements.  

 Greater Savings with the SOCA Small Group Benefit Plan

A New Option for your Small Business

Your small business deserves predictable rates and competitive benefits that help keep your employees healthy and your costs in check.  The SOCA Small Business Plan offers a self-funded solution for small businesses that lets you save on overall costs. 

The SOCA benefits Plan is a multiple employer welfare arrangement (MEWA).  MEWA's allow small businesses to join together to share in the overall claims risk.  By being part of a large, self-funded pool, eligible businesses have financial protection backed by Anthem's Stop Loss coverage.

Along with financial protection, eligible businesses receive:

1. Competitive Rates

2. Fixed, predictable monthly payments

3. A variety of plan designs

4. Anthem's broad Blue Access PPO network and Essential Rx Formulary

5. Coverage for claims run-out and terminal liability coverage.  

You also receive expanded wellness offerings and innovative tools, programs and resources that work together to improve health and lower costs.  You have access to special rates and plan options created exclusively for the SOCA Benefit Plan.  This includes vision, life, disability and more. 

Social Determinants of Health

Social determinants of health are also called conditions that influence health in a person's daily life. Food insecurity, loneliness and social isolation are social determinants of health. Food insecurity refers to limited or uncertain access to enough food to live a healthy, active life. Loneliness refers to the quality of relationships within a person's network, while social isolation refers to the quantity and structure of a person's social network.

What to look and listen for:
Friends may give you cues that they are experiencing social determinants of health.  Below are some of the circumstances and comments you should be paying special attention to.

Loneliness cues:

• "I don't want to hang around old people who have nothing better to do than compare health problems"
• They made you aware of an anxiety attach they had during an everyday activity
• They make you aware that they recently lost their spouse or a close family member and have been feeling sad lately
• They live alone or they have kids who are leaving the house
• They rarely leave their home
• They experience a major life event such as retirement, divorce or moving to a new home or area
• They have recently been diagnosed with a chronic condition
• They have a physical or mobility impairment
• They are a caregiver for a family member or friend
• They have a culture/language barrier
• They live in a rural area
• They live in an unsafe community
• They are experiencing financial issues

Food insecurity cues: 

• "I want to start meal planning and find healthier recipes, but its too expensive"
• "I want to lower my cholesterol and improve my diet, but i can't afford healthy foods"
• "I had to choose between food and medication this month, and i chose medication"
• "I have a difficult time grocery shopping and finding healthy foods that won't break my budget"
• They talk about skipping meals or having a difficult time making meals stretch

Southern Ohio Chamber Alliance (SOCA)

The Southern Ohio Chamber Alliance (SOCA) Benefit Plan is a unique self-funded option that is offered by SOCA and administered by Anthem. The SOCA Benefit Plan is a multiple employer welfare arrangement (MEWA) that is backed by Anthem's stop loss and is filed with the Ohio Department of Insurance. It is governed by Trustees and by-laws that satisfy ODI requirements. It is available to small employers that have at least 2 enrolled on their medical plan, with no more that 50 total employees. These employers are required to be members in good standing with a Chamber of Commerce that is qualified to offer the SOCA Benefit Plan. This alternative self-funded solution can be a good fit for small group (2 to 50 total employees) for many reasons including: Competitive rates; Predictable, fixed monthly payments; Protection of being part of a larger self-funded pool backed by Anthem's stop loss; Anthem's broad Blue Access PPO network; Flexibility in choice of benefits plans. Jeffrey Metzger, working with MMA Insurance in Pickerington, has partnered with Anthem and the Pickerington Ohio Chamber to offer this plan to our central Ohio Chamber Members.

Buy-Sell Agreements Funded Using Life Insurance

Concept Description

With a buy-sell, either the business itself, the surviving owners or a key employee can purchase a deceased owner’s share of the business at a previously agreed upon price – and the deceased owner’s estate is obligated to sell for that price.
•Owners of small, closely held businesses
•Owners of sole proprietorships and partnerships
•Business owners who hold at least 10 percent of the business
•Business owners who have very little personal assets outside of their business assets

How it Works

There are three primary ways to structure a buy-sell agreement that is funded with life insurance.
•With a cross-purchase buy-sell, each participating business owner purchases a life insurance policy on the other owners’ lives. Each person owns, pays the premiums for and is the beneficiary of the respective policies. At the death of a business owner, the other owners use the life insurance proceeds to purchase the deceased owner’s share of the business.
•An entity buy-sell is generally used when there are several owners since fewer policies will be required. The business purchases a life insurance policy on each owner’s life. The business owns, pays the premiums for and is listed as the beneficiary of each policy. At the death of a business owner, the business uses the life insurance proceeds to purchase the deceased owner’s share of the business.
•With a wait and see buy-sell, the specific purchaser of the deceased business owner’s share remains unknown until death occurs. Like a cross-purchase agreement, each participating business owner owns, pays the premiums for and is the beneficiary of the respective policies. The business entity has the first opportunity to purchase the deceased owner’s shares and if it chooses not to, the other owners may purchase the interest. If the other owners choose not to buy, then the business entity is required to complete the purchase. If this happens, generally, the owners will contribute the life insurance proceeds to the business in order to fund the business redemption plan.

Bridge to Medicare

What is a Level Funded Health Plan ?

Self Funded Aggregate Only, or LEVEL FUNDING has been developed for employers with 25 to 150 employees and closely resembles a traditional fully insured plan yet provides the potential for a refund of surplus dollars at the end of the plan year. Level funding is a packaged plan that includes stop-loss insurance, administrative services with a guaranteed monthly maximum liability.
• All the benefits of traditional self-funding with the ease, look and feel of a fully-insured group health plan, a True ERISA plan
• Complete flexibility with benefit plan design
• Maximum plan costs are lower than traditional self funding
• More competitive against fully-insured quotes
• Employer writes just one check each month (based on plan enrollment)
• Monthly payment for LEVEL FUNDING includes premium, funding, stop-loss insurance, administrative services and guaranteed maximum liability.
• LEVEL FUNDING is spread over 12 monthly payments that do not fluctuate with claim activity; only with plan enrollment
• LEVEL FUNDING accumulates monthly – claims are based on the accumulated attachment point
• No SPECIFIC retention to satisfy
• LEVEL FUNDING could be satisfied by just one catastrophic claim, Carrier pays the balance
• Employer retains all unused LEVEL FUNDING monies at year after any run out.
• Multiple contract options and Terminal Liability available.
• Standard disclosure statement required within 60 days of the effective date
o Plan Participant Disclosure Statement on all individuals
• Monthly Reporting

Group Self Funded plans

Traditionally, Self-Funding has been a platform only the large employer could use to manage risk and decrease costs. With the changes we have in the Health Care field due to health care reform, even smaller employers are looking to this option to help accomplish their goals, even with the added risks.
A fully insured health plan has burdened employers with new taxes, fees and restrictions with the implementation of the Patient Protection and Affordable Care Act (PPAA). A Self-Funded plan can relieve the employer from new restrictions, and also some of the new taxes and fees. Some other expensive new rules that can be avoided with self-funding are modified community rating and a rise in required benefits that require insurers reduce their coverage options resulting with less plan flexibility. These new rules, and others placed on employer health plans by the Affordable Care Act, have had a negative effect on fully insured health plans.
An effective way for small employers to enter the Self-Funding arena is through a plan called Level Funding, or Aggregate Only. This is a form of Self-Funding which allows small employers the ability to budget its health care while minimizing risk. With a Level-Funded plan, a small employer pays a set amount each month. Plans differ but better TPA plans will allow the employer to use their own bank account for their monthly premium deposits. The TPA (Third Party Administrator) will then pull from their bank account to cover the cost of administration, a stop loss premium and the maximum amount of expected claims. This plan allows the employer to pay a set amount each month. The Groups premiums are paid into the employer’s bank account, building their own asset.
Two important keys to this plan working are monthly accommodation and advance funding provisions. In Level Funding, the employer is responsible to pay their “Expected Claim” amount, which is included in the total monthly premium. This is the maximum amount of expected claims based on underwriting projections. Any amount of claims over that amount is paid by the stop loss carrier. Advanced Funding provision will protect the employer from any month that their claims are over the expected claim planned.
The monthly accommodation will make sure that the amount the employer pays each month remains the same and there is no exposure to the employer for claims above the level amount funded toward the Plan’s cost.
For the smaller employer, advantages to level funding are:
1. If at the end of the policy term, payments exceeded claims, those funds remain with the employer.
2. If claims exceeded what was paid into the claims reserve, depending on the terms of the employer’s stop-loss insurance, the employer will have no liability for the overage amount. With the Advance Funding provision they have been taken care of.
3. Level Funding allows for a group to their claims data. Group Plan Solutions provides claim data on utilization trends giving the employer important information where employees may be causing overspending.
4. Level-Funded plans, offer regulatory oversight because they are partially self-funded plans and therefore exempt from state regulation and subject solely to ERISA.
Level-Funding plans do require a group complete medical questionnaires and go through other rules or guidelines to qualify for participation. The group is medically underwritten on their own claims and not shared in a larger pool.

An Open Letter to Employers:

How do Small and Mid-Size companies deal with the rising cost of Health plans and Healthcare? The tools that were once reserved for only the largest of companies to control their Healthcare costs are now available to groups with as few as 25 employees.
Does your current Health plan:
Reduce or eliminate the need for annual rate increases?
Provide detailed information about your plan’s performance?
Provide the tools necessary to plan for the future?
Eliminate the need to reduce benefits?
Provide a measurable return on Investment?
If NOT we need to talk…It all starts with a long term plan that is flexible with your goals and the ACA and recognizes that you cannot manage what you cannot measure. Your goal is not to spend more money on Healthcare but to spend your money in a more targeted way to minimize the risk while maximizing the plan’s potential.
The first step can be the hardest but to change results it must be recognized that one cannot continue to do the same things that are being done today.
My name is Jeffrey Metzger, Self-Funding Certified of Group Plan Solutions. My team and I specialize in helping employers make that first step and move down the road to accomplishing your goals. Our clients appreciate the fact that we think “outside the box” when it comes to employee benefit plans and seek alternatives that work.
I will call soon to find a convenient time for us to meet. If you wish to contact me, please do so at 614-551-5351. I look forward to our conversation. Thank you.

Sincerely,
Jeffrey Metzger

Get your Health FSA's, HRA's, and HSA,s into compliance

Employers are turning to consumer-directed health care to help lower costs more than ever. Many employers turn to health flexible spending accounts ("health FSAs"), health reimbursement arrangements ("HRAs") and health savings accounts ("HSAs") to accomplish this goal. These are all types of consumer-driven health care, each with its own compliance-related issues. Surprisingly, many employers do not realize that health FSAs and HRAs require ERISA compliance. Plus, healthcare reform and recent IRS regulatory guidance impacts consumer-directed accounts. Employers must be more cautious than ever to ensure they are not inadvertently operating their consumer-directed plans out of compliance with a variety of employee benefits laws.
Please be very aware of the changes and contact me if you need some guidance. Rules have changed.

Should you "Self-Fund" your group health care plan?

Self-funding an employee health benefit plan is a long-term health strategy to save money
because it can provide an excellent opportunity for a company to achieve immediate savings
plus sustainable cost control. However, smaller employers may be hesitant to self-fund their health plan because they commonly perceive it as appropriate only for large companies.
Establishing the right health plan can become an integral part of the growth and success of
your company.
Smaller employers can be hesitant to self-fund a health plan because such plans are perceived as only appropriate for large employers. However, there exists new and innovative products and services specifically designed for employers with fewer than 250 employees that can make a self-funded health plan a compelling option for employers with as few as 25 employees.
This plan is called Level Funded or "Agg" only product. Individual Stop-loss insurance is purchased to protect the employer. With individual stop-loss insurance, when health claims reach a specific dollar limit in a plan year for a covered individual, the stop-loss insurance policy reimburses the employer’s health plan for claim amounts above the individual stop-loss insurance
limit. For example, if an employer has individual stop-loss insurance of $25,000 and an individual has $85,000 worth of claims, the stop-loss insurance policy would reimburse the employer’s health plan $60,000. The cost of stop-loss insurance is a monthly premium, and there are a variety of stop-loss insurance dollar amounts from which to choose. For employers with fewer than 250 employees,Pekin GPS offers stop-loss insurance with individual dollar limits.
They also deal with stop-loss carriers that reimburse the plan promptly when the stop-loss dollar limit is reached. Otherwise,your company could be responsible for covering the full amount of any excess claims until it’s reimbursed under the stop-loss insurance policy.

If claims are lower than predicted, the employer can save money directly, compared to paying the set monthly premium of a fully insured plan, while the stop-loss insurance policy puts a ceiling
on the maximum amount the employer would pay in claims.

China Suspected in Anthem Cyberattack

The massive cyberattack against health insurer Anthem Inc. received significant coverage on television and in print, garnering nearly seven minutes of coverage across all three network newscasts Thursday night. Sources indicate the attack, which compromised the personal information of tens of millions of Americans, may have originated in China. A number of media outlets portray the attack as the latest example of broader cybersecurity issues across the healthcare industry.
Scott Pelley reported in the lead story for CBS Evening News (2/5, lead story, 2:50, Pelley) that “cyber thieves” broke into a database at Anthem Inc., the country’s second-largest health insurer, jeopardizing the privacy of “millions of Americans.” The company “says that database contains 80 million records, including names, birth dates, and social security numbers,” though it’s unclear whether the hackers gained access to health records. Speaking on the potential fallout from the breach, American Medical Association President Robert Wah, MD, said, “If you lose your credit card, we all know you call 1-800-I lost my card and they turn your credit card off. There is no one-800-I lost my health record and you can turn off all that rich information in your health record.” CBS Correspondent Kris Van Cleave added that sources “say the FBI Is looking into the possibility the attack came from overseas, possibly China.”
Correspondent Pete Williams reported on NBC Nightly News (2/5, story 2, 2:40, Williams) that the Anthem cyberattack “is different from the recent big hack attacks of Target and Home Depot,” which “went after credit cards and account numbers.” This time, “the hackers were targeting the kind of personal information that can be used to steal someone’s identity.” Anthem says it appears no medical information or credit card numbers were compromised, “but it says a trove of personal data was stolen – names, social security numbers, birth dates, street and email addresses, and employment information.”

Repeal and Replace

On Tuesday, the House voted for the fourth time to repeal the Patient Protection and Affordable Care Act (PPACA). This was the first time during this congressional session and the 56th overall repeal of all or part of the law. The vote for H.R. 596 was 239-186 and included three Republican 'no' votes from Bob Dold (R-IL-10), John Katko (R-NY-24) and Bruce Poliquin (R-ME-2); all of whom represent districts previously represented by Democrats. There were no Democrats who crossed-over to vote yes, with many of those Democrats who supported repeal no longer in Congress. Speaker Boehner contended that this vote allowed the 47 new House Republican members to have a chance to vote against the law. The repeal includes a six-month delay before it would take effect to allow Congress enough time to develop a replacement plan.
The repeal now heads to the Senate where Senator Ted Cruz (R-TX) introduced companion legislation to repeal with a six-month delay. This bill is likely to skip the committee process under Rule 14, and instead head straight to the Senate floor. Majority Leader Mitch McConnell has not yet announced a schedule for a floor vote. Crossing the 60-vote threshold in the Senate will be a challenge, as few moderate Democrats remain to join the chamber's 54 Republicans in voting for repeal. However, there could be potential to pass a repeal in the Senate by the budget reconciliation process, which only requires 51 votes, and was the process by which PPACA was ultimately passed in 2010. Yet, even with a passage, President Obama has made it clear that he will veto a full repeal of the law.

What is "Minimum Essential Coverage" ?

Question: In 2015, my client is a large employer and has to comply with the employer mandate. What coverage does it have to offer to its full-time employees to avoid the $2,000 penalty under Code Section 4980H(a).

Answer: Beginning in 2015, a large employer will pay a penalty tax for any month that-

(1) the employer fails to offer full-time employees (and their dependents) the opportunity to enroll in "minimum essential coverage" under an "eligible employer-sponsored plan" for that month; and

(2) at least one full-time employee has been certified to the employer as having enrolled for that month in a QHP for which health coverage assistance is allowed or paid.

The $2,000 penalty applies only if the employer fails to offer adequate coverage and at least one employee enrolls for subsidized exchange coverage. If it offers "minimum essential coverage" to full-time employees and dependents, a large employer will not be liable for this penalty. Most employer-provided group health coverage will meet the very broad definition of minimum essential coverage.

The definition includes any coverage under an "eligible employer-sponsored plan"-a term that means a group health plan or group health insurance coverage offered by an employer to an employee that is (1) a governmental plan, or (2) any other plan or coverage offered in a state's small or large group market. IRS regulations clarify that self-insured employer coverage qualifies as an eligible employer-sponsored plan.

Minimum essential coverage does not include certain excepted benefits. HRA coverage that does not consist solely of excepted benefits generally will be considered minimum essential coverage.

Benefits under an EAP-even if the EAP is considered a group health plan-will be considered "excepted benefits" if the EAP does not provide "significant benefits in the nature of medical care or treatment."

It is important not confuse the term "minimum essential coverage" with minimum value. "Minimum value" refers to a requirement that an eligible employer-sponsored plan cover at least 60% of the allowed cost under the plan and is important in determining whether the penalty under Code Section 4980H(b) may apply.

Minimum essential coverage is the term used to describe both the coverage that an individual must have to avoid the individual shared responsibility tax and the coverage that large employer member must offer to full-time employees and dependents to avoid the $2,000 penalty under Code Section 4980H(a).

Essential health benefits, on the other hand, is the term used to describe the benefits that qualified health plans are required to cover. Pending further clarification, it is important to note that coverage under an employer-sponsored health plan can be "minimum essential coverage" even if it does not cover all essential health benefits.

Minimum essential coverage may not necessarily be affordable or provide minimum value. An employee who is eligible for minimum essential coverage that is not affordable or does not provide minimum value may still qualify to purchase subsidized Marketplace coverage. If the employee purchases subsidized Marketplace coverage, the employer may be liable for $3,000 penalty under Code Section 4980H(b).

What to expect from another Health Care enrollment-changes

WASHINGTON (AP) -- HealthCare.gov, the website for health insurance under President Barack Obama's health care law, has been revamped as its second enrollment season approaches. But things are still complicated, since other major provisions of the Affordable Care Act are taking effect for the first time. A look at some of the website and program changes ahead:

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Old: 76 online screens to muddle through in insurance application.

New: 16 screens - for the basic application that most new customers will use. But about a third of those new customers are expected to have more complicated cases, and how they'll fare remains to be seen.

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Old: Prone to crashing, even with relatively few users.

New: Built to withstand last season's peak loads and beyond, at least 125,000 simultaneous users. Actual performance still to be demonstrated.

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Old: Six-month open enrollment season, extended to accommodate customers bogged down by website glitches or stuck in line at the last minute.

New: Shorter open enrollment season, just three months, from Nov. 15 to Feb. 15.

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Old: Everybody was new to the system.

New: As many as 7 million existing customers could be coming back, and that could create a crunch. Returning customers who want to make changes to their accounts must act by Dec. 15 for those changes to take effect Jan. 1. Many will want to at least look, because they could save money. Potential wrinkle: Returning customers have to go back into their long-form application for 2014. It will have the information they already provided, but it's not the new streamlined form.

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Old: Amateur Spanish, to put it kindly.

New: HealthCare.gov's Hispanic-oriented website could still use a going-over from a high school Spanish teacher. But one conspicuous mistake in translating the appeal to "get ready" got fixed quickly. Maybe that's a sign of things to come.

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Old: No way to window-shop anonymously when the system went live.

New: Window-shopping for health insurance plans available without first creating an account. But the site still lacks a way for consumers to search for plans by simply entering their doctor's name. Instead, they'll have to follow links to individual insurance company directories. Tip: Double check with your doctor's office to see whether he or she is still in the plan.

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Old: Subsidies to keep premiums affordable were paid directly to your health insurance plan.

New: The government will keep paying your health plan, but this year you will also have to show the Internal Revenue Service that you got the right subsidy for 2014. If you got more than you were entitled to, your tax refund will be dinged. If you got less than you deserved, your tax refund will be fatter.

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Old: Budget number crunchers for Congress had estimated 7 million people would enroll, but cut that back to 6 million because of website glitches. Eight million actually signed up, beating expectations. About 7 million are still enrolled.

New: The Congressional Budget Office expects enrollment next year to total 13 million - the new yardstick for HealthCare.gov.

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Old: Pent-up demand from people denied coverage by insurance companies because of pre-existing medical conditions, or who were just unable to afford it.

New: Tougher sell to convince customers who sat out last year's open enrollment season, even under threat of fines.

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Old: Fines for staying uninsured the full year start at $95.

New: Fines for staying uninsured all of 2015 start at $325.

Group Health Benefits

This is an exciting time for the employee benefits industry.

The Patient Protection and Affordable Care Act (PPACA) has precipitated a new appreciation for voluntary benefits and a spike in enrollment. Businesses are enhancing their benefits packages to offset rising healthcare costs and to allow employees to fill the gaps left by high-deductible health plans.

Employees are taking a more active role in decisions about coverage. Carriers and brokers are responding with customized products and platforms that ease administration and cost for employers; and that assist employees in the decision-making process.

While the landscape of employee benefits is continually changing, the industry’s message to the market has remained relatively static. Healthcare costs are rising. Emergency savings accounts are shrinking. Employees are shouldering greater accountability and risk. 

While these arguments are valid, ultimately PPACA prompted employers to make fundamental changes in their approach to employee benefits. 

It is time for employers to look at the Self Funded, or Level Funded, options available.  

Contact me for a quote.

IRS releases draft forms for Employer reporting of Health Coverage

The Affordable Care Act (ACA) created new reporting requirements under Internal Revenue Code Sections 6055 and 6056.  Under these new reporting rules, certain employers must provide information to the IRS about the health plan coverage they offer (or do not offer) to their employees.

On July 24, 2014, the Internal Revenue Service released draft versions of the following forms that employers will use to report under Sections 6055 and 6056:

1. Form 1094-B:  Transmittal of Health Coverage Information Returns;
2. Form 1095-B: Health Coverage;
3. Form 1094-C:  Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Return;
4. Form 1095-C:  Employer-Provided Health Insurance Offer and Coverage.

Forms 1094-C and 1095-C will be used by applicable large employers (ALEs) that are reporting under Code Section 6056.  Forms 1094-B and 1095-B will generally be used by entities reporting as health insurance issuers or carriers, sponsors of self-insured group health plans not reporting as ALEs, sponsors of multiemployer plans and providers of government-sponsored coverage under Section 6055.  However, a reporting entity that is reporting under Section 6055 as an ALE will file under a combined reporting method, using forms 1094-C and 1095-C. 

According to the IRS, these are draft forms currently and are intended to help stakeholders prepare for these new reporting provisions.

Overview of Sections 6055 and 6056

The Code Sections 6055 and 6056 reporting requirements are intended to promote transparency with respect to health plan coverage and costs. They will also provide the government with information to administer other ACA mandates, such as the employer and individual mandates. 

Reporting for Medium-sized ALEs

On Feb 10, 2014, the Treasury released final rules implementing the ACA's employer shared responsibility provisions.  These final rules include transition relief delaying compliance for medium-sized ALEs for one year, until 2016.  Medium-sized ALEs are those with at least 50 full-time employees but fewer than 100 full-time employees. 

ALEs eligible for this transition relief will still report under Section 6056 for 2015.  As part of this transition relief, the ALE must certify on its Section 6056 transmittal form (Form 1094-C) for calendar year 2015 (that is, for the Section 6056 transmittal form that will be filed in 2016) that it meets the following eligibility conditions:

1. The ALE employs a limited workforce of at least 50 full-time employees (including full-time equivalents), but fewer that 100 full-time equivalents), but fewer that 100 full-time employees (including full-time equivalents) on business days during 2014
2. Between Feb. 9, 2014 and Dec 31, 2014, the ALE does not reduce the size of its workforce or the overall hours of service of its employees in order to satisfy the workforce size condition
3. During the coverage maintenance period (that is, the period ending Dec 31, 2015 or the last day of the plan year that begins in 2015) the ALE does not eliminate or materially reduce the health coverage, if any, it offered as of Feb 9, 2014.