Health Insurance Marketplaces are now sending letters to notify certain employers that one or more of their employees has been determined eligible for advance premium tax credits and cost-sharing reductions and has enrolled in a Marketplace plan. Because these events may trigger penalties under the Affordable Care Act’s “pay or play” provisions for applicable large employers (generally those with 50 or more full-time employees, including full-time equivalents), such employers may seek to appeal an employee’s eligibility determination.
Employer Appeals Process
Employers have 90 days from the date stated on the Marketplace notice to file an appeal. In the appeal, the employer may assert that it provides its employee access to affordable, minimum value employer-sponsored coverage or that its employee is enrolled in employer coverage, and therefore that the employee is ineligible for advance payments of the premium tax credit or cost-sharing reductions.
Employers May Apply a Reasonable, Good Faith Interpretation of the Term ‘Seasonal Worker’
Employers looking to hire seasonal workers this summer are reminded that there is an exception when measuring workforce size to determine whether they are an applicable large employer (ALE) subject to the Affordable Care Act’s employer shared responsibility (“pay or play”) provisions.
