Marrch10,2017
JS S
Associates
HeaalthBenefitsA
16LakesideDrSte100
371
no,NV89509
Ren
COMPLIAN
NCEVERIFICA
ATION
upforrenewaalon07/01/2
2017.Thepurposeofthisccompliance
Ourrrecordsindiccatethatyourrgroupcoveraageiscomingu
nderACAfedeeralregulation
groupiseligibletorenewun
ns,stateregulations,andgrroup
verrificationistoensureyourg
parrticipationguidelines.
AffordableCa
areAct,(PPA CA),andothe
erFederalregulations1,beeginning
hePatientProtectionandA
A. Underth
musthaveatleeastone“com monlaw”emp
ployeewhoissn’ttheownerrorowner’s
January1,2014,smalllbusinessesm
mallgroupcovverage.Asareesult,thefollowingwillnollongerbe
partner)tobeeligibleforsm
spouse((ordomesticp
abletorenewunderaagroupplan:
 Owner‐only
ybusinesses—Thisisabu
peratedbyanindividual(s)andthathas
usinessthat’s ownedandop
nocommonlawemployeee(anemployeeewithaW‐2w
whoisnotanowner,spousse,ordomesticpartner).
 Husband/w
wifebusinesse
es—Thisisaabusinessthatt’swhollyown
nedandoperaatedbyoneorrboth
dthathasnoco
spousesand
ommonlawem
mployees.
B. TheEmp
dResponsibiilityProvision(ESRP)ofP
PPACArequireesthecollectiionandreporttingofdata
ployerShared
relatedttothenumberrofemployeessyouhave.Th
Worksheetwillprovideus
ull‐TimeEquivvalent(FTE)W
heattachedFu
thedatanecessarytoensurewehav
veyourgroup
psizeclassifie dcorrectly.
C. Stateregulationsreq
oyeestoqualifyforgroup
quireyoutohaaveaminimum
me(30+hours/week)emplo
mof2full‐tim
healthplancoverage.
ployees,and
3eligibleemp
uireyourpartticipationtob
derwritingGu
D. OurUnd
uidelinesrequ
be100%forgrroupswith2‐3
mployees.
75%forgroupswith4
4+eligibleem
ActtionRequired
dbyMarch31,2017
You
umustcompleeteandreturn
ntheitemsreq
questedontheeattachedcheecklistbyMarrch31,2017.
n‐Compliance
eNotice
Non
Ifyoudonotmeeettherequirem
mentsforsmaallgrouphealtthplancoveraage,asprovideedanddefinedabove,orfailtoreturn
therequireddocumentstimely
beterminated
d.
y,yourgrouphealthplanco
overagemayb
ouldyouhaveanyquestionss,pleasecontaactyourProm
hPlanAccoun
ntManager,yo
ourBrokerorme.
Sho
minenceHealth
Sinccerely,
ntDavidson
Ken
nenceHealthP
Plan
ViceePresidentoffSales,Promin
1FederalRegulatoryAuthority
2791.45;42U
USC§300gg‐91
1(d)(5)(6)
y:29CFR§251
10.3‐3[c];PHSSACTSection2
Health Be
enefits Assocciates GR
RP000ϭϮϯϰ 07
7/01/2017 ActionRe
equiredCheccklist
1. Full‐Time Equ
uivalent (FTE) W
Worksheet (atttached) 2. 2017 Small Group Compliance & Particip
pation Form (aattached) 3. Most recent q
quarterly wage & tax reportt (QWT) 4. Proof of incom
me for anyone
e that does no
QWT ot appear on Q
5. Waivers for all employees w
waiving coverage. Employeees waiving with other coveerage should aalso include a copy of the other coveragge ID card. Please return all requested doccumentation
n to your acco
ount manager: ‐
l: h
Fu
ull‐Tim
me Eq
quivallent (FTE) W
Workksheett Th
he collection and
a reporting of
o this data is required undeer the Employyer Shared Ressponsibility Prrovision (ESR
RP) of
PP
PACA. Health
h insurers requ
uire this data to
t ensure prop
per underwritiing and reportting for all New
w Business an
nd Renewing
Grroups. Emplo
oyers are consiidered “Appliccable Large Employers”, allso referred to as ALE’s, if tthey employ 50 or more
fulll-time Employees or a com
mbination of fu
ull-time and paart-time emplo
oyees that equ
uals 50 full-tim
me equivalent eemployees.
M
Month Ste
ep 1: Co
olumn X Nu
umber of Fulll‐Time Em
mployees Step 2: Column YY Step
p 3: Total Houurs Worked by Colu
umn Z Part‐Timee Employeess Colu
umn Y divideed by 120 January Feebruary March Ap
pril May Ju
une Ju
uly Au
ugust Seeptember Occtober No
ovember Deecember Su
ubtotals X C
Column Subto
otal: Z Co
olumn Subtottal: Step 4*: (X + Z) / 12 = *TThe numerical result of Ste
ep 4 equals th
he group size.. If the groupp is equal to o
or less than 50
0, the group iis co
onsidered smaall group. Grroup Name: He
ealth Benefits Associates Ceertified By: Tittle: Datee: 2017 Small Group Com
mpliance & P
Participation
n Form
Und
der the Affordaable Care Act (ACA), small bu
usinesses wherre the only empployees are the owner or thee owner and his or her spo
ouse — known as “owner‐only” businesses — will no longger be eligible ffor group coveerage. Und
der the ACA regulations, beginning Januaryy 1, 2014, small businesses m
must have at leaast one “comm
mon law” employee who isn’t the owner orr owner’s spou
use (or domestic partner) to b
be eligible for ssmall group co
overage. o longer be able
e to renew und
der a group plaan: As aa result, the following will no


Owner‐only businesses — This is a busine
ess that’s own ed and operatted by an individual(s) and th
hat has no w employee (an
n employee witth a W‐2 who iis not an owneer, spouse, or d
domestic partn
ner). common law
Husband/wiffe businesses —
— This is a bussiness that’s wholly owned and operated by one or both spouses and that has no ccommon law em
mployees. _____________
_________, de
eclare as follow
ws: I, *_____
As tthe owner and/or authorized
d company official* of Health
h Benefits Assoociates (the “Co
ompany”), I heereby acknowleedge the currrent employment of the follo
owing: Total number of full‐time emplo
oyees: _____________ Total number of full‐time emplo
oyees waiving w
with creditable
e coverage: _____________ Tottal number of ffull‐time emplo
oyees waiving WITHOUT cred
ditable coveragge _____________ Total number of full‐time emplo
oyees in the waaiting period**
* _____________ (**W
Wages will be re
equired for an em
mployee in the w
waiting period th
hat is eligible witthin 60 days from
m the effective date.) I deeclare under pe
enalty of perjury that the fore
egoing is true aand correct.
________________
____________
_____________
____________
____________
Prin
nted Name & TTitle Sign
nature __________________ Date Ple
ease return alll requested do
ocumentation tto your accoun
nt manager: