ACA Only Implementation Checklist

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ACA Only Implementation Checklist

PLEASE NOTE: THIS FORM WILL AUTOSAVE YOUR ANSWERS AS LONG AS YOU ARE USING THE SAME BROWSER WHEN YOU RETURN TO THE FORM

If you experience issues with this form please contact enroll@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*

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 2020 plan year? Example: If the client is a July renewal, site was used for 2019-2020 enrollment and 2020-2021 enrollment.

Yes

Did BBS manage your clients 1094/1095 filing for the 2019 reporting year?*

Yes

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

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)

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 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 9.78% 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 9.78% 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 ($12,760 in 2020), and treats coverage as affordable if the employee contribution for the year does not exceed 9.78% of the federal poverty line value. This means that if the cost of coverage per month for an employee during the 2020 reporting year does not exceed $101.79 per month, then the FPL Safe Harbor applies. IRS Calculation = (prior year’s federal poverty level) x 9.78% = $101.79.

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

Select Eligibility Rules for Plan Entry

1st of the Month following

Hire Date

1st of the Month coinciding with the 1st

Select Waiting Period

0 Days

30 Days

60 Days

90 Days

Other

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)

Please select one:*

We will using BBS for ACA Support and Filing Services

We will be using BBS for ACA Support only.

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

Yes

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

Yes

Do you have Union Employees?*

Yes

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

Yes

N/A - Not Applicable

Please download the form that corresponds to the services you will be using and email to sales@brokerbuildersolutions.com. Upon receipt of the form and the checklist, and all other documents needed, a BBS Analyst who will reach out to initiate the process.

Download files:

ACA Support Filing Case Setup 2020

ACA Support Only No Filing 2020

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.

Your form has been submitted

Thank you for submitting the ACA CHECKLIST
You are being re-directed to additional Forms needed to complete your implementation,

Broker Builder Solutions

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