Affordable Care Act

The Affordable Care Act (ACA) created a number of federal reporting requirements for employers and health plans. The additional reporting is intended to promote transparency with respect to health plan coverage and costs. It will also provide the government with information to administer other ACA mandates, such as the large employer shared responsibility penalty and the individual mandate.
American Business Consulting is here to help with the following ACA Mandates and regulations:

Applicable large employer health coverage reporting (Code 6056)

Under Code Section 6056, applicable large employers (ALEs) subject to the ACA’s employer shared responsibility provisions must file a return with the IRS that reports the terms and conditions of the health care coverage provided to the employer’s full-time employees for the calendar year. Related statements must also be provided to employees.

As a general method, the Section 6056 return may be made by filing Form 1094-C (a transmittal) and Form 1095-C (an employee statement), or other forms the IRS designates. A substitute form may be used, as long as it includes all of the required information and complies with IRS procedures or other applicable guidance. On July 24, 2014, the IRS released draft versions of Forms 1094-C and 1095-C, along with related draft instructions.

Reporting of health coverage by health insurance issuers and sponsors of self-insured plans (Code 6055)

In general, a reporting entity that is reporting under Section 6055 as health insurance issuers or carriers, sponsors of self-insured group health plans that are not reporting as ALEs, sponsors of multiemployer plans and providers of government-sponsored coverage will report using Form 1094-B and Form 1095-B, or other form designated by the IRS. Substitute statements that comply with applicable requirements may be used, as long as the required information is included. On July 24, 2014, the IRS released draft versions of Forms 1094-B and 1095-B. These forms are draft versions only, and should not be filed with the IRS.

However, a reporting entity that is reporting under Section 6055 as an ALE will file under a combined reporting method, using Form 1094-C and Form 1095-C, or other form designated by the IRS. As part of this combined reporting method, Form 1095-C will be used by ALEs to satisfy the Section 6055 and 6056 reporting requirements, as applicable. On July 24, 2014, the IRS released draft versions of Forms 1094-C and 1095-C.

Transparency in coverage reporting and cost-sharing disclosures

ACA requires health insurance issuers seeking certification of a health plan as a QHP under an Exchange to disclose certain information to the Exchange, Department of Health and Human Services (HHS) and state insurance commissioner. QHP issuers must also make this information available to the public. The information subject to reporting includes, for example, claims payment policies and practices, data on enrollment and disenrollment, data on the number of claims denied, data on rating practices and information on cost-sharing and payments for any out-of-network coverage.

ACA’s transparency in coverage reporting and cost-sharing disclosure requirements also apply to non-grandfathered group health plans and health insurance issuers offering group or individual coverage outside of an Exchange. The reporting requirements are identical to those for QHPs, except plans and issuers outside of the Exchange are not required to report information to an Exchange.

Quality of care reporting

ACA requires group health plans and health insurance issuers to submit an annual report to HHS regarding plan benefits and provider “reimbursement structures” that may affect the quality of care in certain ways. Grandfathered plans are not subject to ACA’s “quality of care” reporting requirement.
In general, the report must address whether the plan or coverage:

  • Improves health outcomes through activities such as quality reporting, effective case management, care coordination, chronic disease management, and medication and care compliance initiatives (including the medical homes model);
  • Implements activities to prevent hospital readmissions using a comprehensive discharge program and post-discharge reinforcement;
  • Implements activities to improve patient safety and reduce medical errors through best clinical practices, evidence-based medicine and health information technology; and​
  • Implements wellness and health promotion activities.