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    Marketplace notices define appeals process

    Authored by Bukaty Companies on July 11, 2016

    The Health Insurance Marketplace is issuing letters to company benefit managers in response to employees who enrolled in coverage through healthcare.gov and received a premium tax credit or cost-sharing reduction.

    The letters indicate the enrollee reported that he or she:

    • didn’t have an offer of health care coverage from the employer;
    • did have an offer of health care coverage, but it wasn’t affordable or didn’t provide minimum value; or
    • was in a waiting period and unable to enroll in health care coverage.

    For 2015, an employer with 100 or more full-time equivalents (FTEs) could receive a shared responsibility payment under the Affordable Care Act for failure to offer minimum value, affordable health care coverage to a full-time employee. In 2016, the payment will apply to employers with 50 or more FTEs.

    If an employer believes an employee is entitled to a premium tax credit or cost-sharing reduction, an appeal may not be necessary. For example, an employee who is part-time and isn’t benefit eligible is entitled to a credit or cost reduction. Additionally, a part-time employee won’t trigger an employer shared responsibility payment.

    File an appeal
    The letter advises employers to submit an appeal if the employee wasn’t eligible for assistance through healthcare.gov. Notices will be sent to the name and address provided on the employee’s Marketplace application. Companies with multiple locations should have a coordinated response process to ensure the opportunity to appeal isn’t forfeited.

    It’s important an appeal explains why an employer believes an employee isn’t eligible for a tax credit and attach all supporting documentation. A copy of the Marketplace notice must accompany the appeal. Responses should be completed within 90 days of the date of the notice using the official Employer Appeal Request Form available at healthcare.gov.

    Completed forms should be faxed to 1.877.369.0129 or mailed to:
    Health Insurance Marketplace
    465 Industrial Blvd
    London, KY 40750-0061

    Employers will be notified when an appeal is received. The appeal decisions will be provided to the employer and the associated employee. Submitting an appeal doesn’t necessarily mean an IRS penalty won’t be assessed. The IRS will independently make a determination.

    Bukaty Companies suggest employers submit a comprehensive appeal. Depending on the nature of the appeal, the table below suggests documentation that could reinforce an employer’s position.

    Recommended Supporting Documentation:
    If: Then provide:
    Employee received an offer of coverage Employer waiver of coverage form/verification
    Offer of coverage met affordability and minimum value standard
    • Summary of Benefits & Coverage (SBC)
    • Enrollment materials outlining cost for lowest-cost employee-only coverage
    • Affordability Safe Harbor used and payroll data that suggests affordability requirements that were met

     

    Questions about the appeals process can be directed to your Bukaty Companies benefit consultant or call 913.345.0440.

    As always, we appreciate your business.

    Blog Category: Health Care Reform