ACA Checklist | Broker Builder Solutions

ACA Only Implementation Checklist

If you experience issues with this form please contact registration@brokerbuildersolutions.com

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*

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: If you have more than 3, please email the additional entities to your dedicated Analyst

Entity #1

Entity Name (#1)

TIN (#1)

Contact Name (#1)

Contact Phone (#1)

Contact Email (#1)

Entity #2

Entity Name (#2)

TIN (#2)

Contact Name (#2)

Contact Phone (#2)

Contact Email (#2)

Entity #3

Entity Name (#3)

TIN (#3)

Contact Name (#3)

Contact Phone (#3)

Contact Email (#3)

Safe Harbor Selection: Check all that apply

DEFINITIONS

W-2 Safe Harbor: The W-2 safer harbor uses the employee’s annual W-2 waves (Box 1 value) and treats coverage as affordable if the employee contribution for the year does not exceed 9.56% of the W-2 value.

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 9.56% of the employee’s rate of pay.

Federal Poverty Line Safe Harbor: The Federal Poverty Line safe harbor uses the federal poverty line for the year ($12,060 in 2018), and treats coverage as affordable if the employee contribution for the year does not exceed 9.56% of the federal poverty line value.

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)

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

Select Termination Rule

Employment Term Date

End of Month

Other

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.

Yes, I agree

Signature for Terms and Conditions *

Please enter your name

Date*

Select Date ×

Upon selecting the submit button the system will direct you to the items to be completed and uploaded to your Broker Builder Solutions Sharefile folder.

	Yes	No
	Yes	No
Is an ALE
Member of an ALE Group
Fully-insured
Self-Insured
Medical Plans provide Minimum Value
Medical Plans provide Essential Coverage

ACA Only Implementation Checklist

ACA Only Implementation Checklist

Entity #1

Entity #2

Entity #3

Safe Harbor Selection: Check all that apply

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