Affordable Care Act and Benefits Compliance: A Refresher

The Affordable Care Act or ACA was passed back in 2010, but what affected you as an employer was enacted in 2014 and later. With about 23,000 pages of legislation, some aspects of the ACA are unchanged from the original law, but some look very different today.

As an employer, benefits compliance is necessary. Cornerstone Insurance stays up to date on changing ACA and CARES Act legislation and can help you stay informed of any potential appeals to legislation. 

What is Included in the Affordable Care Act?

Important components of ACA include: 

  • Dependent coverage is available to anyone ages 26 and older
  • No cost-sharing for preventative care services such as: 
    • Physicals
    • Mammograms
    • Flu shots
  • Medical loss ratio rebates
  • Enhanced preventative care for women
  • HSA & Health FSA limit
  • W-2 reporting for over 250 W-2s
  • SBC (summary of benefits and coverage) and exchange notification requirements

Before we discuss the employer mandate under the ACA, note that the individual mandate is still in place, but the tax penalty has been reduced to zero dollars, so for all intents and purposes, the individual mandate is not in effect today. 

Who is an Applicable Large Employer?

The employer mandate requires “applicable large employers” (ALEs) to provide affordable health care coverage to full-time employees or pay a penalty.

You are an ALE if you employ 50 or more full-time employees, including full-time equivalents, on average through the previous calendar year. You may be required to calculate each year. All commonly owned entities need to be considered in order to determine the status of ALE. Generally, if two entities have 80% common ownership, they would be considered commonly owned. Since this is a general rule, check with your legal counsel or CPA with any questions. 

Employers need to count anyone who works full-time as one full-timer. All the part-timer employees’ hours are totaled and divided by 30 hours. For example, an employer has 35 full-time employees and 30 part-time employees who work a total of 29,780 hours. 

29,780 hours / 52 weeks / 30 hours = 19 full-time employees

The total of 35 full-time employees plus 19 full-time employees based on part-time hours equals 54 employees. This measurement determines your status for the following year.  

ALE Requirements to Avoid Penalty

If you are an ALE, you are subject to the play or pay mandate and must do the following in order to avoid the penalty: 

  • Establish who is considered to be a full-time employee
  • Offer those full-time employees health insurance that meets “minimum essential coverage”
  • Offer that health coverage to eligible full-time employees at an “affordable” rate
  • Report offer of coverage to the IRS annually

According to the ACA,  there are three types of employees: 

  • Full-time employees who work 30+ hours per week
  • Employees who work less than 30 hours per week
  • Employees who work an unpredictable number of hours per week

A full-time employee is an employee who regularly works 30 or more hours per week — you must offer them coverage. Employers do not need to offer coverage for employees who never work 30 or more hours a week, but there are some employees who you don’t know how many hours a week that they will work. For these employees, you will need to measure hours to determine potential full-time status. 

You must establish a corporate measurement period and consistently measure variable hour employees to determine if they are eligible for health insurance. Employers will need to measure new hires in an initial measurement period to determine if they are eligible for health insurance. If these employees are determined full-time (if they work an average of 30 or more hours during the measurement period), you must offer these employees coverable for an established stability period. 

Most payroll platforms assist with this measurement process. If your payroll does not, please reach out to Cornerstone Insurance for help on setting up the best way to create a measurement process for your variable hour employees. Once you’ve established how many employees you need to offer coverage to, you will need to establish the coverage plan and affordability. 

What is Minimum Essential Coverage?

To be considered a minimum essential coverage plan, a health insurance plan must meet the minimum threshold of coverage as defined by the ACA. These include:

  • No annual lifetime limits
  • No pre-existing conditions
  • Must comply with MLR rules
  • Provide substantial coverage for in-patient care and physician treatment
  • Many others 

Cornerstone can help you provide a healthcare plan to your employees that offers minimum essential coverage and are fully ACA compliant

ACA Penalties — What’s my Risk?

With the ACA requirements, there are potential penalties. The only way you can be penalized is if an employee goes to the exchange or the healthcare marketplace and obtains subsidized coverage as opposed to taking your health insurance. The IRS section 4980H covers the penalties. 

The two questions employers should ask themselves are: 

  • Do you offer minimum essential coverage to 95% of the eligible employees (a)
  • Is your coverage offered at an “affordable” rate (b)?

If you can’t answer yes to part (a), the 2022 penalty is $2,570 or $229.17 per month per eligible employee. There is relief from the IRS for the first 30 employees. The penalty to 4980H (b) in 2022 is $4120 or 343.33 per month per employee who received subsidized coverage on the exchange.


The above image maps out the full process of how a penalty from the IRS is triggered. As the employer, you offer employees a healthcare insurance plan on January 1. The employee may or may not take your insurance. But, if the employee chooses to go to the healthcare market exchange for a subsidized healthcare insurance plan, this triggers an investigation by the IRS. 

If you are submitting your ACA reporting, you are informing the IRS who is eligible for what plans. The employee files a tax return, so the IRS knows what the household earns and ensures the plan you are offering is 9.61% of the household income.

If a penalty is triggered, the IRS provides form letter 226J to ALEs that may owe a penalty for prior tax years. This includes an employer shared responsibility penalty (ESRP) Summary Table itemizing your proposed ESRP by month. The IRS relies on the information from Forms 1095-C and 1094-C filed by ALEs as well as individual tax returns. If you receive a penalty, you have 30 days to respond.

What Can Cornerstone Do for Your Benefits Compliance?

As an employer, it’s important to ensure your employees understand their benefits. You are required to provide an SBC to all eligible employees at open enrollment, upon request and within 90 days of HIPAA special enrollment qualifying event. Cornerstone Insurance can help you keep your employees informed with updated benefit information. 

Cornerstone Insurance is here to offer you assistance with every step of the benefits process. Our skilled team can ensure you offer a healthcare plan for your employees that is ACA compliant.   

If you have any questions or concerns about the Affordable Care Act and how it affects you or your employees, contact Cornerstone today.