ACA Checklist | Broker Builder Solutions

ACA Only Implementation Checklist

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Company Name*

Company Full Address (Street, City, State, Zip)*

Company Main Phone Number

Company Tax ID#*

Benefits-eligible Monthly Hour Minimum:

Client Primary Contact - Name*

Client Primary Contact - Email*

Client Primary Contact - Phone Number*

Please select from the drop down the Software platform used for enrollment

If Other, please provide name of other software used:

Write Here

If client is an Employee Navigator user, was the system used year round for enrollment to include all of 2022 plan year? Example: If the client is a July renewal, site was used for 2020-2021 enrollment and 2021-2022 enrollment.

Yes

No

Did BBS manage your clients 1094/1095 filing for the 2021 reporting year?*

Yes

No

ACA : Check All That Apply:

	Yes	No
	Yes	No
Is an ALE (Applicable Large Employer; 50+ Full-time Employees)
Member of an ALE Group
Fully-insured
Self-Insured
Medical Plans provide Minimum Value
Medical Plans provide Essential Coverage

Medical Plan Year Begin Date

List All Medical Plans to include Carrier Name

Of the Plans mentioned above, which Plan is the low-cost plan?

If filing for multiple ALE members, please list all ALE members with corresponding Tax ID#s as displayed on your TIN Application, including Address, Name, Phone, and Email of point of contact for the entity.

NOTE: THIS STEP IS NOT REQUIRED IF YOU ARE NOT FILING FOR MULTIPLE TAX IDs

Entity #1

Entity Name (#1)

TIN (#1)

Contact Name (#1)

Contact Phone (#1)

Contact Email (#1)

Contact Mailing Address (#1)

Entity #2

Entity Name (#2)

TIN (#2)

Contact Name (#2)

Contact Phone (#2)

Contact Email (#2)

Contact Mailing Address (#2)

Entity #3

Entity Name (#3)

TIN (#3)

Contact Name (#3)

Contact Phone (#3)

Contact Email (#3)

Contact Mailing Address (#3)

Additional Entity(s)

Entity - Additional

Safe Harbor Selection: Check all that apply

Note: BBS will periodically review and update this information as it is made available and changes.

DEFINITIONS

W-2 Safe Harbor:

The W-2 safe harbor uses the employee’s annual W-2 (Box 1 value) and treats coverage as affordable if the employee contribution for the year does not exceed 9.61% of the W-2 value for the 2022 filing year.

Rate of Pay Safe Harbor:

The Rate of Pay safe harbor uses the employee’s rate of pay and treats coverage as affordable if the employee contribution for the year does not exceed 9.61% of the employee’s rate of pay for the 2022 filing year.

Federal Poverty Line Safe Harbor:

The IRS lowered the employer health plan affordability threshold for 2022 to 9.61% of pay cost-sharing. Under FPL Safe Harbor, the cost is limited to $103.14/mo for self-only coverage.

Please Choose One

W-2 Safe Harbor

Rate of Pay Safe Harbor

Federal Poverty Line Safe Harbor

Note: If Safe Harbor Selection varies based on class, please identify applicable class

ACA Classes: Check All That Apply

Eligible- Always works 30+ hours

Ineligible- Employee will never work 30+ hours

Variable Hour- Hours must be tracked to determine eligibility

Will you need to utilize the Hour Tracking Module? (If yes, please complete the ACA Import Hours Monthly Template that will be available in the ACA only Data Collection Template)

Yes

No

Select Eligibility Rules for Plan Entry

1st of the Month following

Hire Date

1st of the Month coinciding with the 1st

If Other, please specify # of Days (Waiting Period)

Select Termination Rule

Employment Term Date

End of Month

Other

If Other, please specify # of Days (Termination Rule)

Would you like Employees to be able to receive their Forms electronically?*

Yes

No

If the Employee has a mailing address on file, should that be used as the preferred address?*

Yes

No

Do you have Union Employees?*

Yes

No

If Yes, for collectively-bargained (Union) Employees, are you required to contribute to a Multiple Employer Welfare Arrangement?*

Yes

No

N/A - Not Applicable

Data Auditing*

It is highly recommended that clients have an audit/reconciliation process in place to audit and reconcile carrier invoices and enrollment data monthly. If no solution is in place, BBS will schedule a demonstration of the Data Validation Platform with the client to illustrate how the client may use our Data Validation Platform as a Self-Service audit solution. Should the client choose to subscribe to the platform, the cost associated with the subscription of the platform is the responsibility of the client unless otherwise indicated. Do you have an auditing solution in place?

Yes

No

How frequently does your organization audit/ reconcile enrollment data? *

If "Other" selected above, please provide brief description:

Does your current solution include any of the following? *

If "Other" selected above, please provide brief description:

Terms and Conditions*

By checking this box I agree to the Payment Terms and Conditions for these services as outlined in my Agency Support Contract and/or case set up form.

Terms of Service: Our Data Management Solutions products and services adhere to the Broker Builder Solutions Terms of Service. These terms may be accessed by clicking here.

Yes, I agree

Signature for Terms and Conditions *

Please enter your name

Date*

Select Date ×

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ACA Only Implementation Checklist

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ACA Only Implementation Checklist

NOTE: THIS STEP IS NOT REQUIRED IF YOU ARE NOT FILING FOR MULTIPLE TAX IDs

Entity #1

Entity #2

Entity #3

Additional Entity(s)

Entity - Additional

Safe Harbor Selection: Check all that apply

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