NAHU represents licensed health insurance agents, brokers, consultants and benefit professionals who serve the health insurance needs of employers and individuals seeking health insurance coverage.
Latest on Twitter


Patient Protection and Affordable Care Act (ACA) Basics

The Patient Protection and Affordable Care Act (ACA) was passed by Congress and then signed into law by President Obama on March 23, 2010. It was amended via the budget reconciliation process several days later and President Obama signed the Health Care and Education Reconciliation Act of 2010 on March 30, 2010. Together, these two measures comprise what is known as the federal health reform law. On June 28, 2012 the U.S. Supreme Court rendered a final decision to uphold the health care law, and then on July 24, 2012 the Congressional Budget Office released a revised estimate as to what health reform will cost the federal government over the next 10 years.

The Obama Administration has developed a number of official websites that provide access to information, regulations, guidance and more on the provisions of the health reform law. is the official site of the new Health Insurance Marketplace and the entry point for consumers who wish to shop for exchange-based coverage. For compliance resources regarding Marketplace coverage and consumer assistance, CMS has set up the site.

Most of the insurance market reform provisions of the new law fall under the jurisdiction of the Department of Health and Human Services’ Center for Consumer Information and Insurance Oversight.

The Department of Labor also has jurisdiction over many ACA provisions. The Department’s overview page contains a wealth of information, and their Frequently Asked Questions pages give detailed answers to very specific ACA implementation scenarios.

The Internal Revenue Service has a site dedicated to the tax-related provisions of the health reform law. In addition, they have a separate site with news releases, multimedia and legal guidance.

Finally, the White House Office of Health Reform also is a comprehensive source of information.

Exchange/Marketplace Resources

Marketplace enrollees may experience problems resolving issues with the exchange. As such, the exchange may ask for additional documentation or clarification. This resource discusses tips to resolve these data matching problems and this resource discusses talking points for issuers responding to data matching issues.

ACA Resources for Clients

The health reform law is extraordinarily complicated and all of its provisions become effective at various times. To help you break the insurance coverage provisions and their implementation dates down in a manageable way for your clients we’ve created a detailed timeline of federal healthcare reform law provisions that will impact Individual and employer health insurance consumers. A condensed version of the timeline suitable for distribution to consumers and employer clients. Download and print copies here or you can purchase printed copies via NAHU’s online store.

Other Resources

Frequently Asked Questions

Have a question on the employer responsibility requirements? Perhaps your burning question is about ACA’s subsidies. Now you can get answers 24 hours a day, seven days a week with NAHU’s newest Compliance Corner benefit: Frequently Asked Questions. We’ve posted dozens of the questions that you’ve been asking along with the answers here.

Compliance Information About Specific ACA Provisions

Individual Responsibility Requirements

This FAQ from the IRS addresses the eligibility and reporting aspects of the individual tax credit including the advance premium tax credit (APTC).

The IRS has posted the draft form and instructions that individuals will use to assess any individual penalties. The new form and instructions attempts to simplify the process.

The IRS has a handy premium tax credit flow chart that can help individuals determine if they are eligible for a tax credit.

ACA Implementation (Part XVIII) and Mental Health Parity Implementation

The Department of Labor's Employee Benefits Security Administration has updated its website with FAQs about ACA Implementation Part XVIII and Mental Health Parity Implementation.

Employer Reporting

There are two main purposes for the annual employer reporting requirements of the ACA.

Section 6055 Individual Mandate Reporting—Overview

IRS Code Section 6055 requires insurers, self-insured plans and government agencies and any other entities that provide MEC to employees and dependents to annually report on that coverage to both the IRS and to the covered individuals. The purpose of the reporting is twofold:

From an employer’s perspective, if the employer, regardless of group size, offers a group health insurance benefit plan that is fully or partially self-funded, then the employer group health plan is responsible for completing the section 6055 reporting. If the employer, regardless of group size, offers a fully insured plan, then the health insurance carrier will be responsible for the Section 6055 reporting. If the employer offers both types of plan options, then the employer is responsible for the 6055 reporting for the self-funded group plan.

Section 6056 Employer Mandate Reporting—Overview

IRS Code Section 6056 requires that all applicable large employers subject to the law’s employer responsibility requirements annually file information returns with the IRS regarding whether or not they offer coverage to eligible full-time employees and also provide statements regarding this coverage to the employees. This reporting will be used by the IRS to administer the employer responsibility requirements, also known as the employer mandate.

The IRS will also use the information as part of the verification process of whether an employee is eligible for the premium tax credits available through the exchange.

It is important to note that even though employer mandate penalties may be delayed in 2015 for employers with 50-99 full-time equivalent employees that meet the criteria for transition relief, the employer reporting requirements for these employers are not delayed. That means that all of these employers still need to be tracking coverage offers and participation during 2015 for accurate employer reporting compliance in 2016.

Do small employers have to report?

Based on the new criteria, many small employers will not have to report information under either Code Section 6055 (individual mandate) or 6056 (employer mandate), but some will and a group’s status for either employer reporting requirement could change annually. Therefore, it is important for all employer groups and their licensed health insurance agents and brokers to review the group’s employer reporting status carefully each year.

The employer reporting form requirements are not based on the traditional large group/small group employer group health plan size definitions that HIPAA made commonplace. Instead, they are based on new criteria established by the ACA and the criteria for reporting information applicable to IRS Code Section 6055 and 6056 are different. So all employers, both small and large, must examine the new criteria and determine which, if any, employer reporting requirements are applicable to their group health plan.

The Section 6055 reporting requirements are based on whether or not the employer offers a fully insured group health plan or a self-funded or partially self-funded plan. All employers, regardless of size, that sponsor a self-funded or partially self-funded plan must comply with the reporting requirement, and all fully insured health plans will not be required to file annual reporting forms as a provider of health coverage under Section 6055. Instead, the responsibility for the reporting for fully insured group plans will be borne by the health insurance carrier.

With regard to Section 6056, if an employer is subject to the employer shared responsibility provisions contained in IRS Code Section 4980H, then the employer is also responsible for reporting information under Section 6056 about the coverage it offers to its full-time employees. Most employers that are eligible to purchase coverage in the small group market are not also subject to the ACA’s employer shared responsibility requirements, but some are, particularly if they are part of a larger controlled group or employ a large number of part-time workers. These small employers will be required to report under Section 6056.

IRS Frequently Asked Questions for Code Section 6055 and 6056.

The IRS has developed a brochure that provides a good overview of key terms and reporting requirements for employers.

Video explanation of 1095-A form provided by exchanges regarding coverage through the exchange is available in this 11 minute CMS video.

Forms Numbers and Purposes

The IRS has finalized the employer reporting forms. The forms are:

The final forms and instructions: Additional Resources

Preventive Care Services

All group and individual plans that do not have grandfathered status, including self-funded plans, have to cover specific preventive care services with no cost-sharing in plan years beginning on or after September 23, 2010. Additional specific women’s preventive services must be provided without cost-sharing in plan years beginning after August 1, 2012. This provision in the law applies to most employers unless the employer qualifies for specific religious exemptions.

Grandfathered Health Plans

Individual and group health plans that existed on or before March 23, 2010 had the option to choose grandfathered status once health reform was enacted. However, individuals and employer group plans that elected to keep their current policy on a grandfathered basis can only do so if they maintain essentially the same benefits and follow strict rules that limit increases to employee cost-sharing or out-of-pocket costs. An amendment to the grandfathered plan rules issued in November 2010 allows all group health plans to switch insurance companies and shop for the same coverage at a lower cost and maintain their grandfathered status, so long as the structure of the coverage doesn’t violate one of the other rules for maintaining grandfathered status. Once a plan loses its grandfathered status, it is subject to all of the law’s market reforms when they take effect.

Extension of Coverage for Adult Children

All group and individual plans, including self-funded plans and grandfathered plans, in plan years beginning on or after September 23, 2010, have to cover dependent “children” to age 26.

MLR Rebate Compliance

All individual, small group and large group health plans were subject to medical loss ratio (MLR) requirements beginning on January 1, 2011. Individual and small group insurers must ensure that 80% of their premium revenue is directed towards medical claims and large group insurers must adhere to an 85% MLR. Self-funded plans are exempt from this requirement. Any plan that does not meet these requirements beginning in 2011 must issue a rebate to consumers by August of the following plan year.

Summary of Plan Benefits and Coverage

Beginning with plan years and open enrollment periods that start on or after September 23, 2012, all group plans and group and individual health insurers (including self-funded plans) will have to provide a summary of benefits and a coverage explanation that meets specified criteria to all enrollees when they apply for coverage, when they enroll or reenroll in coverage, when the policy is delivered and when any material modification is made to the terms of their coverage outside of the coverage renewal period. The summary and explanation are commonly referred to as a SBC, and will require substantially more information than current summary plan descriptions.

W-2 Reporting

The health reform law established that eventually all employers must include on Forms W-2 the aggregate cost of employer-sponsored health benefits, for informational purposes only. The provision was originally supposed to apply to benefits provided during taxable years after December 31, 2010. However, enforcement of this provision was delayed for one year and made optional for the 2010 tax year (reported in 2011). The IRS has also specified that for smaller employers (those filing fewer than 250 W-2 forms) this requirement remains optional through at least 2012 (i.e., for 2012 Forms W-2 that generally would be furnished to employees in January 2013). Optional treatment for smaller employers will remain in effect until further guidance is issued, which has not occurred yet.


FSA contributions for medical expenses will be limited to $2500 per year, with the cap annually indexed for inflation.


Out-of-Pocket Limits

ACA’s limit on out-of-pocket expenses will be fully implemented with 2015 plan years. Transition guidance had allowed for a special transition period for 2014 that allowed plans with multiple service providers to exceed the out-of-pocket maximum.

What Does my State Require for Pediatric Dental?

Small Business Health Options Program (SHOP)

The Full-Time Equivalent (FTE) Employee Calculator (Spanish Version) for SHOP provides a quick means to check whether an employer group is eligible for the federal SHOP. Calculating FTEs for SHOP may result in a different outcome than calculating FTEs to determine whether an employer is a large employer.

The SHOP Tax Credit Estimator (Spanish Version) offers a tool to determine if a small employer is eligible for the small business tax credit.

Coverage for American Indians and Alaska Natives

American Indians and Alaska Natives have several unique benefits under the ACA. These resources from the federal Indian Health Service may be helpful.

For more information, please contact Senior Director of Health Reform Compliance Pam Mitroff. For specific compliance questions, requires NAHU membership, click here to login and ask your question.