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The Harrison Group ACA Reporting Services

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3 Raymond Drive, Suite 201
Havertown, Pennsylvania 19083
(610) 853-9075
aca@theharrisongrouponline.com


"*" indicates required fields

1ACA Service Year
2Employer Details
3Contact Details
4Employer ALE Status
5ICHRA Plan Details
6Employer ACA Data Information for 1/1 Group Health Plan Renewal
7Employer ACA Data Information for Non-Calendar Renewal
8Submission Summary
9Sign and Submit
Company Status*
Type*

ACA Service Year



Submission of this Enrollment Application reserves Employer access to Admin America’s {For which year are you requesting ACA services?:98} ACA Reporting Service.

Employer Details



Address*




The question below pertains to the {For which year are you requesting ACA services?:98} calendar year.


An ACA Service Enrollment Application is required for each entity for which you want Admin America to provide {For which year are you requesting ACA services?:98} ACA services. A link to submit an additional form will be available after submission of the form you are currently completing.

Other Entities Information (other entities information is required even if we do not service)*
List the FEIN of other entity(ies) with employees with which the employer shared common ownership during the year
List the legal name of other entity with employees with which the employer shares common ownership
Do you want ACA services for this group: Yes or No
 
all entity information is required (even if we do not service)


Employer Contact Details

Name*




Brokerage / Agency


Name




Employer ALE Status




ALE Status for is based on payroll counts for the prior year ().

  • Full-time = Full-time employees are those that work more than 120 hours a month
  • FTEs = total monthly hours of all non-full-time employees (cap each at 120) ÷ 120.
  • *If you are part of a controlled group/affiliated service group, determine ALE status at the group level.
  • Seasonal exception: If the monthly average exceeded 50 due to seasonal workers, please consult with AA.

ALE Status Calculator

Quick ALE Calculator — Prior Year ()

ALE Status for is based on payroll counts for the prior year ().

How to fill this in:
  • Full-time employees (FT): number of people who worked 120+ hours in that month.
  • Part-time hours (total): add all part-time hours that month (cap each person at 120).
We’ll compute FTEs = (part-time hours ÷ 120), the monthly total = FT + FTEs, and your average.

Enter counts for each month of .

Jan
0.00
Feb
0.00
Mar
0.00
Apr
0.00
May
0.00
Jun
0.00
Jul
0.00
Aug
0.00
Sept
0.00
Oct
0.00
Nov
0.00
Dec
0.00

Average across months in business: 0.00
Status: —
Threshold: 50. Seasonal exception may apply.


Coverage Details


The question below pertains to the {For which year are you requesting ACA services?:98} calendar year




ICHRA Plan Details



The questions below pertain to the {For which year are you requesting ACA services?:98} year

Were the ICHRA and Group Medical Plan offered to different employees at the same time or during different Plan Years*









Employer ACA Data Information for 1/1 Group Medical Plan Renewal


All questions below pertain to your Group Health Plan(s) for renewal date {What is the Renewal Date of your Medical Plan?:28}/{For which year are you requesting ACA services?:98}


Section Break


Admin America, Inc. will help you make this determination.
We will follow up with you once your application is submitted.

Enter currency format 9,999.99 without the dollar sign










Non-Calendar Plan Year Renewal: Group Medical Plan Information




Employer ACA Data Information Before Renewal


All questions below pertain to your Group Health Plan(s) for coverage period


Admin America, Inc. will help you make this determination.
We will follow up with you once your application is submitted.








Employer ACA Data Information After Renewal



All questions below pertain to your Group Health Plan(s) for coverage period

Admin America, Inc. will help you make this determination.
We will follow up with you once your application is submitted.









Submission Summary

{all_fields}

The details of your submission will be sent to the email address provided below.


The details of your submission will be sent to the email address(es) provided below.

To send to multiple email addresses, separate the email addresses with a comma.


Questions? support@yourcompany.com • (555) 555-5555
© Your Company. All rights reserved.


Section Break

Non-ALE employers with Fully Insured coverage are not required to prepare or file Form 1095-B; the health insurer furnishes and files this form.

Because of this, the Employer ACA Data Information Before & After Renewal sections are not required and have been hidden to streamline your application.

If any of your answers above are changed (for example, if you select a different funding arrangement or ALE status), the section may reappear and additional information could be required.


Under the ACA, the waiting period cannot exceed 90 days; coverage must start by day 91.

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