Marketplace Appeal Guidance

12 Sep Marketplace Appeal Guidance

One of the major provisions of the Affordable Care Act (ACA) is that employers may be subject to a penalty for failing to offer coverage to 95% of full-time employees or failing to offer a plan that does not satisfy the minimum value or is not affordable.

In late July, the Health and Human Services Marketplace unit started sending notices to employers about employees who did apply for and receive premium tax credits – provided the employees included their employer’s name on the Exchange application. These notices were sent to both applicable large employers and small employers (who are not subject to the ACA mandate) regardless of whether a violation actually occurred. In other words, they did not verify any of the information the employee completed on their application as being eligible for a subsidy! They provided them a subsidy and have now placed the burden on employers to appeal each notice they receive.

Some other items to consider:

  • This notice is being sent to the address the employee indicated on the application so, it could be going to your property locations and not necessarily the Corporate Office. We do suggest you reach out to each property (if applicable) to ensure these notices are sent to Human Resources. They do need to be appealed within 90 days of receipt.
  • Some of the notices are for former employees who were terminated in 2015. Therefore, they were not ever even eligible for health insurance in any month during 2016.

When completing the appeal form, we do recommend employers include the following documentation:

  • Proof that the employer health plan satisfies minimum value;
  • Proof that the plan is affordable under one of the three safe harbors;
  • The employee’s monthly income from the employer;
  • The employee’s share of premium costs for single employee coverage for each month;
  • If the employee was not offered coverage for any month in 2016, the reason for such lapse (as described in IRS Form 1095-C lines 14-16 for 2016); and
  • If the employee was offered coverage and declined, a copy of the employee’s signed waiver of coverage.

When Resource Alliance is responsible for our client’s HR, Payroll Administration and Benefits Administration, we are filing the appeals on their behalf.  We also offer ACA compliance consultation as a standalone service, please contact us for additional information.

Jeff Koch, Director of Benefits & Marketing Communications for Resource Alliance.
Jeff is a consultant, not an attorney, so he shares his opinions, not legal advice, about increasing performance and limiting liability.