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There are many types of compliance requirements for employers and individuals that are related to health insurance, and benefit programs.  Compliance for employers may include giving notices to employees, documentation procedures, desk reference manuals, etc.  Compliance for individuals includes a mandate to have essential health insurance coverage, or pay a cash penalty to the government, etc.  Compliance is monitored and audited by various government or related agencies including IRS, Department of Health & Human Services, Department of Labor, and other entities.  Regulatory agencies are know to have increased compliance audits, and also increased fines, assessments, penalties, taxes.  The government is also making benefit program agents and brokers personally and financially responsible along with employers for non-compliance within the benefit program activities.  We are asking that all employers please read the compliance requirements below, and take initiatives to complete compliance status, to avoid potential penalties and business disruption.  We have various resources to help you with compliance.  Below is a list of compliance items that are expected for employers and individuals;

Applicable Large Employer Mandate; employers with 50 or more employees, are required to follow the Employer Shared Responsibility Provisions of the Affordable Care Ace.  Large Applicable Employers must provide minimum essential health insurance for all employees who work 30 hours per week or more, or pay a penalty to the government.  Read more here.


The IRS has outlined the process they will utilize to notify employers of ESR penalties.

They will issue letters informing applicable large employers (ALEs) of potential liability for ESR payments before year end.

(This first group of penalty letters will be in reference to any potential liabilities for the 2015 calendar year.)

The IRS will inform ALEs who they believe are responsible for a penalty payment via “Letter 226J”,

The basis for the penalty demand is based on the IRS determination that for at least one month in 2015 one or more of the large employer’s full-time employees was enrolled in Marketplace coverage, received a premium tax credit (PTC) and the large employer did not qualify for an affordability safe harbor or any other relief. Employers who receive Letter 226J will have 30 days to respond to the IRS, based on the date of the letter. The IRS will acknowledge the employer response to Letter 226J and provide a letter (Letter 227 – not available yet) with further action required, if any. If the employer disagrees with the information provided in Letter 227, the employer may request a pre-assessment conference with the IRS Office of Appeals. Any requests should be made in writing generally within 30 days of the date of Letter 227.

This letter will contain a payment summary table, a response form “Form 14764” and full instructions on how to proceed from the IRS, Employers should complete Form 14764, with proper 1095 1 and 2 codes if the codes indicated are incorrect, provide any supporting documentation and mail the response to the IRS.

Employers who do not respond, the IRS will assess the amount of payment and issue a notice and demand for payment via Notice CP220J.

The IRS web site is indicating that audits have been heightened all over the US for employers who are not complying with Shared Responsibility for employers with over 50 full time equivalents.

Employers who are non-compliant can look forward to receiving IRS Letter 226J that include requirements for proof of compliance. There is one other letter employers are receiving to gather information regarding their reporting.

US Department of Labor Compliance web site

Small Employers have fewer than 50 employees;  there are various compliance requirements for small employers, including various notices, procedures, documentation requirements, reference materials in office, and trained staff. 

Employee Benefit Compliance Checklist For Small Employers

Some of the compliance requirements for large and small employers are indicated below;

Affordable Care Act Exchange Model Notice. There are two possible notices that employers must use.  One notice is required for employers who sponsor a health plan with minimum essential coverage, and a second notice is required for employers that do not offer a health plan with minimum essential coverage.  We can help employers determine the correct notice to use, and help complete the notice for distribution to employees.  The forms are on the US Department of Labor web site here.

Medicare Part D Notices; entities that provide prescription drug coverage to Medicare Part D eligible individuals must notify these individuals whether the drug coverage they have is creditable or non-creditable.  Entities may modify the Model Disclosure Notices to notify affected individuals whether their drug coverage is creditable or non-creditable.  You can find the Model Notice Letters at the Centers for Medicare & Medicaid Services web site here.

Women's Health & Cancer Rights Act Notice;  the Women's Health and Cancer Rights Act (WHCRA) includes protections for individuals who elect breast reconstruction in connection with a mastectomy.  WHCRA provides that group health plans and health insurance issuers that provide coverage for medical and surgical benefits with respect to mastecdtomies must also cover certain post-mastectomy benefits, including reconstructive surgery and the treatment of complications (such as lymphedema).  The notice and additional information on this requirement are found at the US Department of Labor web site here.

HIPAA - Health Insurance Portability and Accountability Act; Special Enrollment Notice

HIPAA - Health Insurance Portability and Accountability Act;  This HIPAA Privacy and Security Policy serves as the written framework by which your organization conducts itself in regard to the handling of Protected Health Information (PHI). It is a requirement under the regulations and will aide your training of employees who will be handling PHI. It also serves as a handy resource for responding to inquiries from individuals within your organization.

ERISA - Employee Retirement Income Security Act;

Children's Health Insurance Program Re-authorization Act;

Summary of Benefits and Coverage; this is the governments standardized, universal benefit summary for health insurance plans

OBRA; Omnibus Budget Reconciliation Act – Federal (OBRA) OBRA Specifications. This law affects employers with 100 or more employees. When an active employee/dependent is covered by his/her employer enrolled in the active group and has Medicare due to a disability other than End Stage Renal Disease, the group coverage is primary to Medicare.

COBRA; Consolidated Omnibus Budget Reconciliation Act; Employers with 20 or more employees are required to offer continuation of group health insurance for a period typically 18 months from the date the group plan ended.   Employers must provide newly eligible employees with a cobra initial general notice, and a continuation notice within 15 days form the former covered employees last day of group sponsored health insurance.  

State Continuation; Oregon small employers are required to allow former covered employees the option to keep the group health plan coverage and rates, for up to 9 months. 

Individual Mandate; since 2014, individuals are required to have minimum essential health insurance coverage, or pay a penalty to the government.  If a person's income is below about $1,400 per month, then they may not be required to have health insurance, and may receive free health insurance from the government.  If a person's income is beyond about 400% of the federal poverty level, then these people must purchase health insurance, or pay 2.5% of household gross income to the government as a penalty for not maintaining minimum essential health insurance coverage.  There are no requirements to purchase long term care, life insurance, disability income protection insurance, or dental plans.  Each person receiving the advanced premium tax credit from the government, to help pay for health insurance, must file an annual income tax return.

Medicare part D Pharmacy requirement; when a person becomes Medicare eligibility, they must purchase a Medicare creditable pharmacy plan, or be covered on a creditable pharmacy plan through their employer or through another source.  If a Medicare beneficiary does not obtain creditable part D pharmacy coverage, then this person may be required to pay a penalty to the government of 1% of the national pharmacy part D average rate, multiplied by the number of months with no creditable part D pharmacy coverage, as a lifetime penalty, usually collected by health insurance or pharmacy insurance plans. 

Higher part B and D premiums for those with higher than average income; the government charges some Medicare beneficiaries more for part B and D, because they have higher than average income.