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Employer Notices and Regulatory Filings


Health plans must abide by numerous regulatory filings and notice requirements.  Some requirements are employer requirements, while others are health plan requirements.  These notices and regulatory filings must be provided to individuals, participants and governmental agencies at various times including annually and at other triggers, depending on the particular requirement. 

 

Below is a brief overview of some of the tax advantaged benefits employers can set up to help employees with healthcare expenses. 

 

6055/6056 Reporting - The 6055 reporting, also knows as minimum essential coverage (MEC) reporting, is used to enforce the individual mandate and applies to all entities that provide MEC.  The 6056 reporting, also known as applicable large employer (ALE) reporting, is used to enforce the employer mandate and applies to all ALEs with 50 or more full time or full time equivalent employees (FTEs).

 

All Payer Claims Database (APCD) - As health care reform initiatives are enacted across the country, there is a need for states to gather comprehensive information on health care use and costs.  To support this need, some states have established APCDs. APCDs are large-scale databases created by state mandate that regularly collect medical claims and pharmacy claims data.

 

CHIPRA - The Children’s Health Insurance Program Reauthorization Act (CHIPRA), was signed into law on Feb. 4, 2009.  The CHIPRA program provides individual States the ability to subsidize premiums for employer-provided group health coverage for eligible children. CHIPRA requires a group health plan to provide to their employees a notification of the availability of subsidized premiums under the Child Health Insurance Program.

 

CMS Data Match - Requires a group health plan to report to CMS information about Medicare beneficiaries' group health plan coverage.  The purpose of the Data Match is to identify situations where another payer may be primary to Medicare.

 

COBRA -  Under COBRA, group health plans must provide covered employees and their families with specific notices explaining their COBRA rights.  Plans must also have rules for how COBRA continuation coverage is offered, how qualified beneficiaries may elect continuation coverage, and when it can be terminated.

 

Creditable Coverage (Medicare Part D) - Requires that a health plan provide an annual notice to active employees and/or retirees notifying the individual if their prescription drug benefit provides creditable coverage.

 

Form 5500 - The Form 5500 series is used to collect financial, actuarial and operational details on employee benefit plans subject to ERISA.  Plans subject to ERISA must file Form 5500.  ERISA plans that do not file a form 5500 include a benefit plan that covered less than 100 participants as of the start of the plan year and is unfunded (meaning its benefits are paid as needed directly from the general assets of the plan sponsor and no employee contributions are made) or is fully insured.

 

MA 1099-HC - Requires employers to provide proof of health insurance coverage for Massachusetts residents age 18 and older to use when completing their Massachusetts state income tax filing.

 

Marketplace Notices – A group health plan is required to provide the employee with written notice informing them of the existence of marketplace coverage, the availability of premium tax credits and that employer contribution to a health plan may be lost if marketplace coverage is taken. 

 

Opt-Out Filings - A self-funded, non-federal governmental health plan is allowed to opt-out of compliance with certain provisions of the Affordable Care Act such as limitations on preexisting conditions, special enrollment periods, discrimination based on health status, benefits for newborns and mothers, mental health parity and mastectomy reconstruction.

 

PCORI - An annual filing of the IRS Form 720 will be used to comply with PCORI until the year 2019.  The fee will be used to fund clinical outcomes effectiveness research. Plans maintaining two or more group health plans that collectively provide major medical coverage for the same covered lives may be regarded as one group health plan. 

 

Prompt Pay - Most states have enacted prompt pay laws that require fully-insured plans, and in some cases self-funded non-ERISA plans to pay or deny a clean claim within specified timeframes.

 

Section 111 - Requires that a group health plan complete a quarterly report to CMS identifying all actively covered individuals who may be Medicare-eligible and are currently employed.

 

Surcharges and Assessments - Currently, there are twelve states with an assessment or similar reporting obligation that requires Meritain to evaluate your membership in those states to determine whether you owe a fee. If Meritain determine that a Plan Sponsor does in fact owe an assessment to one or more of these states, the Plan Sponsor will notice the assessment amount reflected on their monthly bill that represents the amount that Meritain will pay as a plan expense to the appropriate state(s) on the Plan Sponsor Groups behalf.

 

W-2 Reporting - A group health plan is required to report to its employees the aggregate cost of applicable employer-sponsored coverage on an employee's W-2 statement. 

 

WHCRA - The Women's Health and Cancer Rights Act (WHCRA) was signed into law on Oct. 21, 1998. This law requires group health plans to provide certain benefits regarding a mastectomy and to provide their plan participants notice of their rights with regard to mastectomies.

 

For more information:

CHIPRA

Creditable Coverage (Medicare Part D)

MA 1099-HC Requirements

Section 111

Surcharges and Assessments

Form 5500

PCORI Fee

Opt-Out Filings

W2 Reporting

Prompt Pay

All Payer Claims Database

CMS Data Match

WHCRA

Marketplace Notices

6055 and 6056 Reporting

 

This content is being provided as an informational tool. It is believed to be accurate at the time of posting and is subject to change. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this information, Meritain Health is not exercising discretionary authority or assuming a plan fiduciary role, nor is Meritain Health providing legal advice.