Group Health Insurance Plans

When it comes to ongoing changes in health care reform, small businesses need all the help they can get. And for many of those small businesses, a Professional Employer Organization (PEO) — where employees become part of a much bigger benefits and administrative employment group — could be the solution to their health-benefits challenge.

What Are Examples of Health Care Reform Impacting Small Businesses?

When the comprehensive health care reform law known as the Affordable Care Act (ACA) passed in March 2010 it made bold and dramatic changes to the way Americans secure both their health insurance and health care services. The ACA implemented potential tax penalties on businesses and individuals to encourage shared financial responsibility of health insurance costs. Since then, health care reform has gone through some changes.

Although the tax penalty for an individual who does not carry basic health insurance was reduced to zero in the tax year of 2019, the same is not true for businesses. The ACA mandates that applicable large employers (ALEs), employers with in general, an average of at least 50 full-time, including full-time equivalent employees, during the prior calendar year, must offer affordable and adequate coverage to full-time employees and their dependents or risk potentially paying a stiff assessment if at least one full-time employee receives a premium tax credit when purchasing coverage from a government marketplace. These employer-shared responsibility provisions for healthcare coverage are also sometimes referred to as "the employer mandate." But what about small businesses? Even though small employers are not subject to the provision, the effect of health care reform is felt in several ways.

With the continued rise of healthcare costs, benefits that improve healthcare affordability remain popular among employees. To help prevent employees from leaving a position to work for ALEs that must offer affordable and adequate health insurance to full-time employees or risk a potential assessment, small-business employers need to find ways to provide similar health benefits for their workforce. One strategy comes in the form of health benefit accounts. For health insurance, some small business employers are using a PEO to access cost-effective health insurance options.

Health care reform has also given small businesses an opportunity to stand out. It's one thing to provide health insurance to avoid penalties, it's quite another to provide this benefit on your own volition. Opting to provide health insurance sends a strong message that you care about the well-being of your employees. A PEO relationship is a strategic one that could be used to provide affordable health insurance solutions while positioning your business as a desirable place to work.

Small-business employers who responded to health care reform by providing health benefits are well positioned for ancillary advantages. Health insurance and health benefits accounts could help improve the physical and mental well-being of your staff, translating into fewer sick days, increased productivity, fewer health claims, and create an overall happier work environment. Additionally, many pre-tax benefits associated with health benefits can help your workers keep more of their income.

Current Affordable Care Act Requirements

Health care reform and small-business requirements are always in flux. Staying current with health care reform could help employers be prepared. Here's a brief review of ACA requirements that both small and large businesses must meet for 2023.

• Small businesses with 25 or fewer employees earning annual wages under $61,400 (tax year 2023) could take advantage of offering health insurance through the health insurance marketplace, Small Business Health Option Program (SHOP). Please note that states choose whether to define smaller employers as having 1-50 or 1-100 FTEs. In CA, VT, CO, and NY the threshold is at 100 FTEs.
• These small businesses — together with agents and brokers — can create an account, choose a SHOP-certified agent or broker and verify their eligibility for coverage. The small business must also pay 50 percent of the employee premiums.
• Larger employers with in general, an average of 50 or more full-time employees, including FTE employees during the prior calendar year must offer adequate and affordable coverage for their full-time employees and their dependents or potentially face financial assessments. For the tax year 2023, the 4980H(b) assessment is $360 per month or $4,320 annualized. There are no exclusions from the assessment for ALEs.
• Small businesses taking advantage of tax incentives by offering health insurance through the marketplace and ALEs subjected to the health care reform shared responsibility provision must comply with Affordable Care Act (ACA) reporting requirements.

How a PEO Can Help

A professional employer organization or PEO creates a model where a small or mid-size business forms a contractual relationship with a larger benefits and administrative employment group. PEOs are a popular resource for small businesses in search of options for outsourcing administrative services for HR management, payroll processing, payroll tax filing, risk management, employee benefits administration, and assistance with maintaining compliance with state and federal laws and regulations.

When it comes to health care, PEOs can be an efficient lifeline for small businesses. With their comprehensive resources and expertise, a PEO may be the best bet for staying compliant with ACA regulations or taking advantage of health care reform.

How does a PEO reduce costs related to healthcare plans? While it does not assume these responsibilities in full for clients, a PEO could help assist you as you navigate your health care obligations regarding these critical areas:

• Calculating the number of FTE employees*
• Determining eligibility, contributions, and employee classifications
• Reporting of qualified medical coverage
• Compliance with tax-related changes
• Changes related to health savings accounts
• Associated tax reporting
• Providing open enrollment guidance and HR support

Paychex HR PEO offers your business:

• Access to more plan designs at competitive prices
• One-stop shopping for most, if not all, benefit and insurance needs, including medical, dental, life, disability, vision, and other insurance such as workers' compensation.

Navigate Health Care Reform With PEOs

Health care reform and small businesses are more inextricably bound than ever before. Learn more about how a PEO can help you find your way through your health insurance obligations and simplify your life as a small-business owner.

Professional employer organization (PEO) services provided by Paychex Business Solutions, LLC (Florida employee leasing license GL7), Oasis Outsourcing, LLC (Florida employee leasing license GL42), and their affiliates, which are licensed or registered to provide PEO services where required by law.

*Please note that this is not a precise calculation. An employer may need to perform additional calculations when the payroll crosses months.

Business owners need to understand the common terms used regarding the Affordable Care Act (ACA), how to make appropriate calculations, and how to comply with their ACA reporting requirements.

ACA Reporting Deadlines: Important Dates for 2023

For Tax Year 2022, applicable large employer must furnish Form 1095-C to applicable employees by March 2, 2023. The deadline for filing paper Forms 1094-C and 1095-C with the IRS is Feb. 28, 2023. The due date for electronic filing is March 31, 2023. The affordability rate for plan years beginning in 2023 is 9.12% (a decrease from 9.61% for plan years beginning in 2022).

Businesses subject to ACA tracking and reporting requirements have several deadlines to meet if they want to be in ACA compliance. There are deadlines for furnishing forms to employees and for filing forms to the IRS. The IRS permanently provided an automatic 30-day extension from the Jan. 31 due date for Applicable Large Employers (ALEs) to provide forms 1095-C to applicable employees. 

The deadline for ACA filing of all paper forms with the IRS remains Feb. 28. However, the deadline is March 31, if filing electronically. The due date is the next business day if it falls on a weekend or legal holiday. It should be noted that all employers with 250 or more returns to file must do so electronically.

Who Is Required To Report Under the Affordable Care Act?

Applicable large employers (ALEs) are required to report under the Affordable Care Act. ALEs have an average of 50 or more full-time employees, including full-time equivalent employees (FTEs), during the prior year. This distinction is a key metric, since only ALEs are subject to the ACA’s Employer Shared Responsibility (ESR) provisions and must fulfill applicable ACA reporting requirements.

What Are the ACA Reporting Requirements?

Employers that meet the threshold to be considered an ALE are required to submit all the proper forms under the ACA. Failure to do so could result in potential penalties each year.

Calculating Full-Time Equivalents for ACA Reporting

To calculate your full-time equivalents, add the hours of service for all employees who worked less than an average of 30 hours a week or 130 hours a month in a given month. Count no more than 120 hours per employee per month. Then divide the total hours by 120 to get your FTE count for that month. This number is then added to the count of regular full-time employees for each month. The total number of full-time employees, including full-time equivalents for each month in the preceding calendar year divided by 12 then determines whether a business is an ALE subject to employer shared responsibility (ESR) provisions.

ACA Reporting Requirements and Health Coverage Offered to Employees

To fulfill their ACA compliance, employers that meet the ALE threshold must offer adequate and affordable health insurance coverage to full-time employees and their dependents or risk an assessment if at least one full-time employee purchases health insurance coverage from a government marketplace and receives a premium tax credit. ALEs are required to complete Forms 1094-C and 1095-C to report information about health insurance coverage offered to full-time employees and their dependents.

The ACA also provides specifics on what constitutes adequate, affordable coverage. The ACA defines affordable coverage as costing the employee no more than 9.5% (adjusted for inflation each year) of the employee's household income for the lowest cost, self-only minimum essential coverage. Plans must also meet a minimum value (MV) threshold — that is, the plan must cover at least 60% of the total allowed cost of benefits under the plan.

How To Determine Affordability?

Recognizing that it is difficult for employers to know the household income of their employees, the U.S. Department of Treasury provided for the following three safe harbors in the ESR final regulations that can be utilized to assess the affordability of an offer of coverage in lieu of using household income.

• W-2 Safe Harbor: An ALE’s offer of coverage for every month of a calendar year is considered affordable if the employee’s required contribution for the lowest cost, self-only coverage that provides MV for the calendar year does not exceed 9.5% (as adjusted) of the wages paid to the employee by the employer as reported in Box 1 of the Form W-2. Special rules apply for partial years of employment.
• Rate of Pay Safe Harbor: An ALE’s offer of coverage for a calendar month is affordable if the employee’s monthly required contribution for the lowest cost, self-only coverage that provides MV does not exceed 9.5% (as adjusted) of an amount equal to 130 hours multiplied by the lower of the employee’s hourly rate of pay as of the first day of the coverage period or the employee's lowest hourly rate of pay during the month for an hourly employee, or of the employee’s monthly salary for a non-hourly employee.
• Federal Poverty Line Safe Harbor: An ALE’s offer of coverage for a calendar month is affordable if the employee’s required contribution for the calendar month for the lowest cost, self-only coverage that provides MV does not exceed 9.5% (as adjusted) of the federal poverty line for a single individual for the calendar year divided by 12.

Keep in mind, premium incentives under a wellness program might impact the affordability calculation. COVID-19 vaccine-related premium incentives under a wellness program, as with other non-tobacco use premium incentives, are treated as not earned, whereas qualified tobacco-related wellness incentives are treated as earned. This means the impact on the employee’s required contribution will be as if the employees did not receive the COVID-19 vaccine. (Note: An FAQ issued by the U.S. Department of Labor, Health and Human Services, and Treasury provides that the COVID-19 premium incentives must meet requirements of an activity-only health-contingent wellness program.)

Example: An ALE offers coverage to full-time employees and their dependents. The employee monthly share of the lowest cost, self-only coverage is $200.

Discount: If the plan has a $50 per month premium discount for individuals who receive the COVID-19 vaccine under a wellness program, the premium discount is disregarded when determining employee required contribution regardless of whether the employee received the vaccine. The employee’s required contribution per month is $200 for ESR purposes. Whereas, if the discount is related to a tobacco cessation program, the employee’s required contribution would be $150.

Surcharge: If the plan has a $50 per month premium surcharge for individuals not receiving the vaccine, the surcharge is added to the employee required contribution regardless of whether an employee receives the vaccine. The employee’s required contribution is $250 (200 + 50) a month for ESR purposes. If the surcharge is related to a tobacco cessation program, the employee’s required contribution would be $200 for ESR purposes.

Additionally, if an employer offers a payment to an employee in lieu of enrolling in the employer's health insurance plan, this opt-out payment impacts the affordability calculation. For ESR purposes, guidance provides:

• Unconditional opt-out payments increase an employee's required contribution by the amount of the payment.
• Conditional opt-out payments do NOT increase an employee's required contribution by the amount of an opt-out payment.

Similarly, employer contributions to a Health Reimbursement Arrangement (HRA) and health flex credits under the Section 125 cafeteria plan may impact an employee’s required contribution as follows:

• HRAs: The employee required contribution is generally reduced by the amount of the employer's contribution to HRAs, as long as the employee may use the amounts to pay premiums for an eligible employer-sponsored plan; or premiums for an eligible employer-sponsored plan and also cost-sharing and/or health benefits not covered by the plan. The HRA must be integrated with an employer-sponsored health plan.
• Health Flex credits: The employee required contribution is reduced by the amount of the employer's contribution to health flex credits only if the employee is limited in using the amount for health insurance coverage or medical care expenses as defined under Internal Revenue Code §213.

Assessments for Failure to Offer Affordable and Adequate Health Insurance

If an ALE fails to offer minimum essential coverage (MEC) to at least 95% of its full-time employees and their dependents, the employer risks being assessed one type of employer shared responsibility payment (ESRP) if at least one full-time employee purchases health insurance in a government marketplace and receives a premium tax credit. The payment is $2,000 per full-time employee (adjusted each year for inflation), after excluding the first 30 full-time employees. This is a 4980H(a) assessment.

There is also a 4980H(b) assessment, which is applied if the ALE offers coverage to 95% of its full-time employees, but the coverage offered does not meet the minimum value and affordability stipulations listed above. This penalty is $3,000 per employee (adjusted each year for inflation) who received the premium tax credit provided by the IRS for individuals without access to affordable coverage.

Gathering and Submitting Data To Meet ACA Reporting Requirements

Each year, ALEs subject to ACA reporting requirements must compile data on applicable employees and submit this information to the IRS. Attention to detail with all forms and requirements is vital, since any missteps, inaccuracies, or delays in processing can result in penalties and interest.

Required ACA Forms for Reporting: Forms 1095-C and 1094-C

The first reporting requirement for ALEs is to provide a copy of Form 1095-C to every full-time employee, regardless of whether they enrolled in the company-sponsored health plan. Employers must also keep a copy of every 1095-C form to send to the IRS to fulfill ACA reporting requirements. Correctly filling out lines 14 through 16 on this form can be particularly challenging for many people.

Employers must also complete Form 1094-C, which acts as a summary for the aggregated 1095-C forms and provides helpful information to the IRS, including contact information and the employer's Employer Identification Number (EIN), the name of a contact person, and the total number of employees.

Preparing for ACA Year-End Reporting

Part of a solid preparation plan involves gathering the data needed to complete the required IRS forms in time for ACA year-end reporting. An ALE will need a variety of information, including but not limited to:

• Employer Identification Number and business contact information
• Key contact person within the company and that individual's contact information
• Total number of employees each month
• Total number of full-time employees each month
• Average hours worked by each employee each month
• Whether insurance was offered to each full-time employee
• The type of insurance coverage offered (if applicable)
• Monthly cost to each employee for the lowest-cost, self-only minimum essential coverage providing minimum value that is offered
• Individual employee names and Social Security numbers
• Proof that 95% or more of full-time employees and their dependents were offered minimum essential coverage

Submitting Your Required ACA Forms to the IRS

Once the employer completes the required forms with the proper information, they should prepare them for transmission to the IRS. As with traditional business tax returns, ACA reporting forms can be submitted electronically or via regular mail. However, employers with 250 or more Forms 1095-C are required to submit all forms electronically.

Prepare for ACA Year-End Reporting in Advance

Verifying, cataloging, and reporting accurate data takes a considerable amount of time. Starting the process early helps to avoid an unnecessary last-minute rush to gather information and can avoid costly late fees and penalties due to inaccuracies. Beginning in the third or fourth quarter of the previous calendar year, employers should begin verifying employee records with each individual employee to ensure that all personnel data is accurate and up to date. Employers should also cross-reference facts such as employee hire dates and average hours worked, in case employees are newly eligible for benefits.

Simplify ACA Compliance Through Outsourcing

Reporting is difficult and can be costly. Having an integrated solution that combines benefits, payroll, and insurance data can take much of the burden off your shoulders at reporting time.

An ACA reporting service such as the Paychex Employer Shared Responsibility Services monitors your ALE status, FTE hours, and the type and affordability of your offered coverage throughout the year*. You can also receive help with end-of-year reporting, including lines 14, 15, and 16 of Form 1095-C for each employee.

*The Coverage Adequacy Service is available only to payroll clients who receive their health and benefits (H&B) coverage through Paychex Insurance Agency or the Paychex PEO and who are not receiving Paychex Flock Benefits Administration Services.

Employees' healthcare insurance needs may vary, but most U.S. workers look to their employer to provide this important benefit. In addition to health insurance, businesses may also want to offer additional health and wellness programs to attract and retain talent. Flexible spending accounts (FSAs) and health savings accounts (HSAs) are two options that allow employees to pay for medical expenses with pre-tax dollars. When evaluating the alternative features of an FSA vs. HSA, employers should estimate employee utilization and the relative costs and benefits of each.

What Is an HSA?

An HSA is an employee-owned health savings account where pre-tax dollars may be deposited and used to pay for qualifying medical expenses. Employees may set aside a specified amount from their paycheck and divert the funds into an HSA if they participate in a qualified high-deductible health plan (HDHP). Employers may also contribute funds to an HSA. One important feature of an HSA is transferability. Because an HSA belongs to the employee, any remaining balance remains with them when they leave the company. Also, unused funds in an HSA can be rolled over from one year to the next.

What Is an FSA?

An FSA is a flexible spending account that gives employees the opportunity to contribute pre-tax dollars throughout the year and use them to pay for qualifying medical expenses. FSAs are owned by employers, who may also contribute to the account on the employee's behalf. Employees do not need to participate in a HDHP to contribute to an FSA. However, the funds are not transferrable if they leave the company. FSAs also have limitations on the amount and timing of reimbursement. If all funds are not used at the end of the year, employers may choose to provide a grace period or allow for a specific amount of unspent funds to be carried over to the following year.

Read more about the features of FSAs and HSAs.

*Please note, the discussion of FSA in this article refers specifically to Medical FSA, not Dependent Care FSA.

FSA vs. HSA Comparison Chart: How Do These Accounts Differ?

The relative benefits of FSAs vs. HSAs may make one a better choice for an employee based on their individual situation. In the midst of benefit negotiations, employees may request one type of account over the other. Businesses will want to weigh factors such as administrative costs and expected utilization before choosing to implement one or both plans.

Which Is Better: FSA or HSA?

Although both plans offer tax savings for employees and employers, FSAs and HSAs each offer unique features and relative benefits. Depending on your employee demographics and healthcare utilization, one type of reimbursement account may work better for your business. Your choice of healthcare plan will affect your decision to offer an FSA vs. HSA. If your company does not offer a high-deductible health plan, an FSA is the only option.

Benefits of FSAs and HSAs

FSA Benefits

FSAs do not restrict the type of healthcare plan a company must offer. Also, unused funds are reverted to employers at the end of the year, or after a grace period. Employers gain tax savings related to employees' pre-tax contributions as they are not required to pay their share of Social Security tax on these amounts. In terms of employee satisfaction and retention, the small cost of administering an FSA often yields a valuable benefit for employees who choose to participate.

HSA Benefits

Offering an HSA in conjunction with an HDHP will generally yield cost savings for businesses compared to traditional health care plans, because an HDHP is a less expensive option. Like FSAs, HSAs also result in tax savings for employers. Additionally, HSAs offer potential retirement benefits to employees when unused funds are carried over and may be taxably withdrawn for nonmedical expenses when participants reach age 65.

Challenges of FSAs and HSAs

FSA Challenges

FSAs have a lower contribution limit compared to HSAs, which reduces their comparative tax savings. Unused funds generally may not be carried forward. FSAs are also managed by the employer and are subject to some of the limitations of fringe benefits programs.

HSA Challenges

HSAs are offered only to employees participating in an HDHP. This limits the type of healthcare plans you may choose to offer if your company wishes to provide access to an HSA.

Can You Offer Both an FSA and an HSA?

Companies can offer both types of plans, but participants will need to choose one over the other for medical expense reimbursements. A limited FSA plan may be offered for HSA participants wishing to set aside extra funds for dental and vision expenses not covered by an HDHP.

Choosing the Healthcare Plan That's Right for Your Business

Your choice between an FSA or HSA often comes down to the type of healthcare plans you want to provide. If you offer an HDHP, an HSA will allow for larger contributions and additional flexibility to carry over funds from year to year. If you find that an HDHP does not make sense for your employee base, sticking with a traditional healthcare plan and offering an FSA may yield better utilization and employee satisfaction. Whether you choose one type of plan, or both, FSAs and HSAs offer important benefits that will help employers and employees manage the rising cost of health care.

If you need further assistance, Paychex Employee Benefits Services is ready to help you navigate the complexity of healthcare plans. We can work with you to weigh the relative costs and benefits of the many options available.