What are the reporting and fee requirements under the Affordable Care Act and subsequent rules?

Requirement

Summary

Coverage and Effective Date

Additional Information

W-2 reporting

Employers must report the cost of coverage under the employer-sponsored group health plan in Box 12 of Form W-2.

All employers that provide applicable coverage issuing at least 250 W-2s.

Due to the IRS by January 31.  

W-2 Reporting for Employer-Sponsored Health Plans

Minimum essential coverage reporting

Large employers must file a Form 1095-C, Employer-Provided Health Insurance Offer and Coverage, and Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns, with the IRS annually.

A copy of the 1095-C form, or a substitute form with the same information, must be provided to each full-time employee.

The information reported on Form 1094-C and Form 1095-C is used in determining whether an employer is potentially liable for a payment under the employer shared responsibility provisions under the ACA.

Employers must file the 1095-C and 1094-C with the IRS by March 31, if filing electronically and by Feb. 28, if filing in paper form.

1095-C form must be delivered to employees by each year by March 2. 

Transparency in coverage 

Employers with self-insured group health plans or insurance carriers for fully insured group plans must provide plan enrollees with estimates of their out-of-pocket expenses for services from different health care providers.

Plans are also required to offer online tools and phone support to enable participants to compare cost-sharing amounts for specific network providers in a specific region.

Plans are also required to offer three "machine-readable files" on a public website covering in-network rates, out-of-network allowable amounts, and prescription drug prices.

Effective date delayed pending further regulations. 

Effective Jan. 1, 2023.

U.S. DOL – Transparency in Coverage

U.S. DOL – No Surprises Act

Quality-of-care reporting

Regulatory guidance not yet issued.

Requires health plans to submit reports each year that describe and demonstrate how the plan rewards health care quality through market-based incentives in benefit design and provider reimbursement structures. In other words, it must describe wellness programs and quality of care and health improvement initiatives.

Copies of the report must be made available to enrollees during each open enrollment period.

Employer group health plans, including self-insured plans, individual market plans and qualified health plans sold through the insurance exchanges, are required to submit such reports. Does not apply to grandfathered plans.

Effective date: TBD

See page 16: Federal Requirements on Private Health Insurance Plans

Fees for Patient Centered Outcomes Research Institute

(PCORI)

Two new sections in the IRC require insurers and self-insured plans to pay the comparative effectiveness research fees.

For self-insured plans the plan sponsor is the employer or the union, and for multiemployer plans the plan sponsor is the board of trustees.

Applies to insurers and self-insured plans. IRC §4375 applies to health insurance policies with the fees paid by the issuers of the policies. IRC §4376 applies to self-insured health plans with the fees paid by the plan sponsor. 

Originally effective for plan years ending after Sept. 30, 2012, and before Oct. 1, 2019, PCORI fees have been extended for an additional ten years through Sept. 30, 2029 by the FY2020 Appropriations package.

Patient-Centered Outcomes Research Trust Fund Fee