The Patient Centered Outcomes Research Institute (PCORI) fee is due July 31, 2019 for employers with any type of self-funded plan and/or a Health Reimbursement Arrangement. The fee helps fund unbiased research that evaluates the clinical effectiveness of medical treatments regardless of the profit potential. This fee is also known as the Comparative Effectiveness Research Fee, or CERF.

Beginning in 2020, the Department of Health Care Policy and Financing will be required to report annual uncompensated costs and expenditure by using data submitted by hospitals. Governor Jared Polis signed the law as part of the bigger goal to reduce health care costs.

The health insurance broker community is not always portrayed in the best light in the media, sometimes with stories of hidden fees and behind-the-scenes bonuses due to the abuses of a few bad actors. Fall River Employee Benefits operates on a higher level, and always with honesty and our clients’ best interests in mind.

Auditing your monthly insurance carrier invoices may not be the most exciting task on the HR to-do list, but it’s absolutely necessary to ensure correct employee enrollments and premiums. In our experience, carriers are much more likely to work with employers on correcting errors caught in the first few months, rather than six months or more down the line.

A Health Reimbursement Arrangement (HRA) is an employer-established account that allows them to reimburse a portion of the member’s out-of-pocket costs, usually while meeting the deductible on their health plan. Under the current regulations established by the Affordable Care Act (ACA) in 2010, HRAs are only allowed in conjunction with an employer group health plan. On October 29^th, 2018, proposed regulations were announced by the Treasury Department, Health and Human Services, and the Department of Labor, that could change this limitation. 

The Family and Medical Leave Act (FMLA) was enacted to grant employees the ability to take unpaid medical leave with job protection for up to 12 weeks for a serious health condition for themselves, their spouse, a child, or parent, as well as certain types of leave for families of members of the National Guard or Reserves. 

FMLA applies to employers with 50 or more employees for at least 20 weeks of the year, with at least 50 employees working at locations within a 75 mile radius.  Although this is a common guideline when determining FMLA, it is certainly not the only deciding factor, since the company could have multiple locations and not all those employees would qualify for the FMLA. An employee is eligible if they have worked for the employer for a total of 12 months, and have worked at least 1,250 hours in those 12 months. 

According to the Labor and Employment Law blog of the Florida Bar Association the following six best practices are critical when administering FMLA:

1.  Know Your Notice Obligations 

You are required to provide a general notice to employees of their FMLA rights via an FMLA poster as well as a notice in your employee handbook and/or ERISA plan document. 

There are also very specific notices that must be given to employees who request leave or need to have their condition or family situation certified.  It is not necessary to use the Department of Labors (DOL) designated notices, however, if you choose to use the forms provided by the DOL, each form contains the appropriate content information required for FMLA.  

Click here to obtain a copy of all the necessary FMLA forms. 

2.  Recognize and Respond Appropriately to Employee Requests for Leave 

An employee may not know to ask for FLMA when they suddenly take leave, but there is an employer responsibility to determine whether the leave ought to be protected.  An employee does not have to disclose all details as to why leave is being taken, however, the employee must provide enough information so that the employer can determined whether it is covered under FMLA. 

       Your next step at that point is to provide the Rights and Responsibility notice given to employee stating the following: 

• If the employee will be required to provide medical certification from their health care provider
• The employee’s rights to use paid leave, and whether paid leave must be used first 
• Whether the employee can maintain their health coverage and if premium payments will be the employee's responsibility
• Definition of the 12 month period used to track the FMLA usage. (i.e. a calendar year, or some other 12 month period)
• The rights the employee has to return to their job at the end of the FMLA leave

3.  Evaluate the Employee’s Documentation and Certification

You may require additional documentation beyond the medical certification mentioned above. For example, you may need to receive proof that the family member with the serious health condition is a qualifying relationship.  If the employee must provide a completed certification, they must be allowed at least 15 calendar days to return it. 

The certification request must include the following information:

• Contact information from healthcare provider
• Health Condition start date
• How long the condition is expected to last
• Medical facts about the condition (i.e. symptoms, hospitalization, doctor visits, etc.)
• Whether employee is unable to work or the family member is in need of care 
• Whether leave will be continuous or intermittent 

There are several different certification model forms at the link above for various situations, which are not required but are highly recommended to avoid requesting disallowed information.  If necessary information is missing from the certification, the employee will need to be notified in writing what still needs to be complete in the certification. The employee must provide this information within 7 calendar days. 

If you have concerns regarding the validity of the certification, a second opinion can be requested at the employer’s cost. If the 1st and 2nd opinion differ, a 3rd opinion can be obtained, again at the employer cost. 

4.  Respond by Officially Designating the Leave as FMLA Protected (or not)

Employers must notify employee about FMLA eligibility within 5 days of the first notification.  If you have determined that the leave is protected, then you will need to state that it will be designated as FMLA leave. If the employee is not eligible for the FMLA then you must state the reason why the employee is not eligible (for example, the employee has not worked a total of 12 months). 

5.  Communicate with employees who are on leave

Ongoing communication between the employer and employee will avoid confusion or misunderstandings about the FMLA process.  Employers can require periodic updates to the condition or the employee’s intent to return to work.

6.  Prepare for the Employee’s Return to Work Following FMLA Leave

The employee will need to be given the same job or similar upon returning to work. If you do not give the employee the same position then it must meet the following guidelines:

• Involve the same or similar duties, responsibility or status
• Include the same skill set 
• Offer identical pay, including overtime and bonus
• Offer identical employee benefits
• Offer same work schedule and location.

Note: Key Employees are not guaranteed reinstatement to their positions after FMLA leave. This special circumstance would apply to those who are salaried and among the highest paid 10% of all employees within a 75 mile radius of the employer worksite. 

If you work at a growing company not yet subject to FMLA but getting close, please This email address is being protected from spambots. You need JavaScript enabled to view it. to better understand your obligations.  Getting up to speed on the FMLA process will definitely save you a potential employee complaint to Department of Labor’s Wage and Hour Division (WHD). 

Please note this information is only a high level summary of your FMLA obligations, and that we cannot provide legal advice.  If you need further information on the FMLA guidelines, we recommend consulting your legal counsel or going to the Department of Labor website.

Large employers who offer an opt-out provision, where the employee “opts out” of the company’s benefits plan in exchange for cash or an increase in the employee’s salary, need to be aware of the impact this could potentially have when determining “affordability” under the employer mandate. 

In 2015, the employer mandate is in effect for large employers (defined as those with 100 or more full-time or full-time equivalent (FTE) employees), who must provide “minimum essential coverage (MEC)” to at least 70% of their full-time employees or potentially pay an assessment if they do not offer coverage, or if they offer coverage that isn’t “affordable”. 

Starting January 1, 2016, employers with 50 to 99 full-time employees or FTEs will be required to comply with the mandate as well.  

Although no guidance has been released with regard to an opt-out provision under the employer mandate, it has been suggested that it will most likely mimic the individual mandate’s calculation of affordability.

What are the IRS Guidelines for the Individual Mandate? 

An employee can be eligible for a tax credit on the individual exchange if their employer coverage is unaffordable, which is defined as the employee’s contribution towards coverage exceeding 9.5% of their income.  The amount they have to contribute to employer coverage also impacts whether they are subject to the individual mandate.  

An employee’s contribution is reduced by the amount the employer contributes, as long as the employee cannot elect to receive the employer contribution as a taxable benefit (such as cash). Therefore, employer opt-out contributions that can be taken as cash must be counted as employee contributions for affordability purposes under the individual mandate.

Potential impact of the affordability requirements under the Employer Mandate

An example:

• An employer requires a $90 per month per employee contribution towards the cost of the plan.
• This amount would almost certainly meet the affordability test for all employees. 
• In addition, the employer offers all employees a $100 per month opt-out credit.
• Based on how they interpret opt-out credits for the individual mandate, it appears the IRS may interpret the employee contribution to be $190 ($90 plus the $100 that the employee must forego to elect the coverage). 

Now, many of the employer’s lowest wage employees could fail the 9.5% affordability test, potentially subjecting the employer to a $3,000 affordability penalty for any of those employees who choose subsidized coverage on the exchange rather than the employer’s plan. Whether or not the coverage is affordable is communicated on each employee’s 1095 form starting in 2016.

Employers offering an opt-out provision should carefully review their benefits plan, and potentially check with legal counsel, to determine if the current arrangement violates the affordability requirements under the employer mandate. We also recommend outsourcing the preparation of your 1095 forms, to alleviate the time and compliance hassles associated with them. 

If you’d like to discuss the potential impact of your opt-out provision, just give us a call or This email address is being protected from spambots. You need JavaScript enabled to view it..  

Many employers benefit by adding employee-paid benefits to the mix of what the employer can afford to pay for.  For example, the employer might sponsor and pay a portion of the medical and dental plans, but leave employees to enroll in their own chosen coverage for life insurance, disability coverage, and vision plans.  Fall River helps our employers decide how these voluntary plans best fit into their strategies.

A new survey has revealed that employers seem to be less focused on these plans, perhaps because the Affordable Care Act is demanding all the attention these days.  Between the ACA, and the hundreds of new ERISA auditors on the street compliments of the Department of Labor, compliance issues have dominated benefits conversations lately.  Yet, the study shows that employees want more choice in benefits and are willing to spend their own money to get what they want.

Check out this article summarizing MetLife’s recent survey, and let us know what you think!

The Patient Centered Outcomes Research Institute (PCORI) fee is due July 31, 2015 for employers with any type of self-funded plan and/or a Health Reimbursement Arrangement. 

The fee helps fund unbiased research that evaluates the clinical effectiveness of medical treatments regardless of the profit potential.  This fee is also known as the Comparative Effectiveness Research Fee, or CERF. 

The amount of the fee depends on your health plan’s effective date.  The fee is $2 per covered life for employers with February 1 through October 1 effective dates, and $2.08 for employers with November 1, December 1, or January 1 effective dates.  You need to calculate the average number of lives (employees and all dependents) over the plan year that ended in 2014. There are several allowable estimation methods for arriving at this average.

Employers must submit payment for the PCORI fee along with the IRS Form 720 (Rev. April 2015). 

All Fall River clients who need to remit the PCORI fee were emailed detailed instructions and assistance several weeks ago.   For other employers, we’ve provided the IRS Form 720 and the instructions for filing links.  

This email address is being protected from spambots. You need JavaScript enabled to view it. if you need help complying with this requirement, as the deadline is upon us now!

As a benefits plan administrator you may have sent or may be thinking about sending your plan documents via email to all your eligible employees, or posting it on your company intranet. The ease of electronic delivery would certainly save time and money, but in doing so, it is important to make sure you are following the rule set forth by the Department of Labor.  

Electronic distribution of ERISA disclosures can be sent to employees if they can:

• Access documents furnished in electronic format at any location where the employee is reasonably expected to perform their duties; and
• Have access to their employer’s electronic information system as an integral part of those duties.

Delivering your plan document to employees who have access to a computer as part of their job falls within electronic deliver guidelines, but what about employees that don’t normally use a work computer?  The guidance suggests that a shared computer kiosk, which is allowed for many other purposes, is not sufficient for your ERISA document distribution.

In these cases, electronic delivery is still allowed, but the plan administrator has to obtain a written consent form signed by the employee prior to sending the ERISA disclosures. 

The consent form will need to include the following content:  

• The types of documents the consent will apply 
• That the consent may be withdrawn at any time
• Email address where the employee will be able to receive future announcements and/or documents if sent by email
• The procedures for withdrawing consent and updating the email address used for the receipt of documents furnished electronically
• The right to request and obtain a printed copy of any document free of charge 
• Any computer hardware or software required to access and retain the documents 

Electronic delivery is convenient, but it is important to follow the appropriate protocol when distributing the plan documents to all your eligible employees to avoid any compliance issues.

To read more about using email to distribute plan documents click on the link below: 

http://digital.benefitnews.com/benefitnews/may_2015?sub_id=VIvIH0WC7tP8#pg36

Fall River understands the importance of ERISA and delivering the essential documents to keep your organization’s benefits plan in compliance. For more information about the electronic distribution process, please feel free to This email address is being protected from spambots. You need JavaScript enabled to view it. Kristen, Tonya or Amy.