What You Need to Cover Group

by Jim Jordan

The 2017 individual enrollment period has ended for ACA coverage.  If you missed the January 31 deadline we may be able to assist with essential health coverage enrollments through a special qualifying event or through a startup by offering group health coverage.  If you are self-employed or have a small business, we can assist with forming a group plan for your business.  If you are curious here are a few technical qualifications we must consider.

 

If it seems overwhelming, or have questions, please just give us a call 904-730-3900 and we can get down to brass tacks.

 

Structure of the Group Health Qualifications

 

  • Groups formed strictly for purposes of insurance are, by Florida Statute, not eligible for group insurance products. (Examples are clubs, fraternal organizations, and consortia.)
  • A company must be actively conducting business in the State of Florida and show taxable income in one of the two previous calendar years to be eligible for a group insurance product.
  • Coverage cannot be offered to a selected class of employees. In other words, management carve-out groups will not be allowed.
  • Small Group Carriers that offer coverage must offer coverage to all of the small employer’s eligible employees and their dependents.
  • Out of state enrollment limit to 15%, no exception, 85% of the group members must live in Florida.

 

Participation and Contribution

 

  • The minimum employer Contribution requirement: (This is the amount employer is required to pay toward the employees premium rates)
Group Size Employees Dependent
   4 – 50     50%      0%
   1 – 3    100%      0%
  • Business with 4-50 employees, the minimum employee Participation is 70%. (This is the minimum percentage of eligible employees that actually enroll into the group plan).
  • Business with 1-3 employees, the minimum participation is 100%
  • Groups contributing less than 100% will be subject to the minimum 70% participation requirement. All full-time employees who have completed their waiting period are counted as eligible. However, employees who are covered by another group plan or other qualifying coverage will be excluded from the participation determination.

 

Definition of Creditable Coverage

 

Creditable coverage is any of the following health care coverage’s under which an individual may have been previously covered:

  • A group health plan;
  • Health insurance coverage
  • Medicare Part A and Part B of Title XVIII of the Social Security Act (Medicare);
  • Title XIX of the Social Security Act (Medicaid, other than coverage consisting solely of benefits under Section 1928 of the program for distribution of pediatric vaccines);
  • a public health plan; and

 

Small Group Acceptable Tax Document Requirements

 

When a Small Group New Sale or Renewal Enrollment Package requires the submission of Acceptable Tax Documents the following is the preferred document/set of documents in order of preference:

 

  • For those forms of business who file a UCT-6, a signed copy of the group’s most recent quarter Unemployment Compensation Tax Form (UCT-6):
  • All pages, including the cover page and the “by name” listing should be submitted.
  • The status of each employee listed on the UCT-6 should be identified (e.g., Enrolled, Terminated, Waiting Period, Other Coverage, Refusal, Part-time) including owners, partners, etc.
  • Please provide a Form K-1 Tax Schedule or Schedule C for any owner and/or partner who does not show up on the UCT-6.
  • If the business is not required to file a UCT-6, ONE document from EACH category below will be required to establish eligibility:

 

 

 Form of Business Category 2 (Required) Category 1*
Sole Proprietorship IRS Form 1040+ Schedule C or

IRS Form 1040+ Schedule F

Current business, State, or Occupational license
Corporation/

S-Corporation

IRS Form 1040 + 1120 or

IRS Form 1040 + 1120S (with K-1’s)

Articles of Incorporation
Partnerships IRS Form1040 + 1065 (with K-1’s) Partnership agreements
Not for Profits IRS Form 941 Employee listings or payroll roster (even if handwritten from the group)