Benefit Plan Setup focuses on three areas of the ACA – Form 1095-C Box 14 and Box 16, affordability
analysis, and safe harbor calculations. This setup information is also used to monitor least-cost plans
and to identify the plan being offered as a self-insured plan.
It is important to be sure that you have set-up plan information for the entire calendar year. The first
illustration below demonstrates the setup for a calendar year health plan. The second, illustrates a
non-calendar year health plan setup that is self-insured with a Rate of Pay Safe Harbor.
Example of Non-Calendar Year Plan:
Health Care Benefit Plan: Select the Benefit ID. The drop-down list will provide a list of benefit plans
that were checked during the Benefit Code Setup. Choose the Least Cost to the Employee Plan.
The medical plan may span multiple years of coverage. For each year, a record is maintained for that
specific plan date range as defined in the Start Date and End Date. For each plan year, a record needs
to be entered.
Creating a New Plan: If manually setting up a plan without using the implementation wizard, be sure
to click on “Add New Record” and populate the following:
Plan Sponsor: The Plan Sponsor function is an override function used only in certain circumstances.
Normally, when an employee receives more than one 1095-C (works for multiple companies within an
ALE) parts II and III of the 1095-C are reported by the company for which the employee has the most
service hours. The plan sponsor override function allows you to manually set which company will
report dependent coverage on part III of the 1095-C. Please note that part II of the 1095-C reporting is
not affected by this setting. Most of the time this setting will be left as default, set to “none”.
Qualifying Offer (1A): Select Yes or No in the drop-down list.
A qualifying offer is “an offer of minimum value coverage providing minimum value offered to full-time
employee with employee contribution for self-only coverage equal to or less than 9.56% mainland single federal
poverty line and at least minimum essential coverage offered to spouse and dependents.”
Min Essential Coverage: Check if plan provides minimum essential coverage.
Minimum essential coverage (MEC) is defined by the ACA as most group health plans offered by a
large or small employer, or health coverage provided by the government. If a plan meets the requirement of
being offered as group health coverage within a state, that plan usually offers minimum essential coverage.
Min Value: Check if plan provides Minimum Value.
Minimum Value is an ACA requirement that ensures health insurance policies and plans provide
coverage at or above a threshold level. Minimum Value is met when a plan pays on average at least 60% of
the actuarial value of the total allowed cost of benefits under the plan. Keep in mind that a plan may offer
minimum essential coverage but not provide minimum value.
Employee: Check if an employee is covered under this plan.
Spouse: Check if a spouse is covered under this plan.
Conditional: IRS rules for 2017 allow for new codes 1J and 1K for offer of coverage. These codes
reflect the conditional nature of some offers of coverage to spouses. The codes cover the following
scenario (see also IRS rules for 1095-C)
1J. Minimum essential coverage providing minimum value offered to employee and at least minimum essential
coverage conditionally offered to spouse; minimum essential coverage not offered to dependent(s).
1K. Minimum essential coverage providing minimum value offered to employee; at least minimum essential
coverage offered to dependents; and at least minimum essential coverage conditionally offered to spouse.
In ACA Plan Setup, if the conditional checkbox is marked then the Spouse checkbox must also be
marked since conditional offers are related to the spouse. The presence of an offer to dependents or
not in conjunction with a conditional offer to spouse is what drives the difference between the plans
for 1J and 1K.
Before checking the conditional checkbox confirm that the plan offered is indeed spouse conditional.
Dependents: Check if a dependent, other than a spouse, is covered under this plan.
Start Date: Input the start date of the plan year. For a non-calendar year plan, as shown in the
example above input the start date of the year before the 2017 plan begins. Then add an additional
record with the 2017 plan year dates. This is done to display the full 12 months of the current year’s
End Date: Input the end date of the plan year. For a non-calendar year plan, as shown in the example
above, input the end date of the year before the 2017 plan begins. Then add an additional record with
the 2017 year dates. This is done to