ACA Reporting Services for Applicable Large Employers (ALEs)

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1ACA Service Year

2Employer Details

3Contact Details

4Employer Status Detail

5Employer ACA Data Information

6ICHRA Plan Details

7Employer ACA Data Information for 1/1 Group Health Plan Renewal

8Employer ACA Data Information Before Renewal

9Employer ACA Data Information After Renewal

10Submission Summary

11Authorized Representative Information

12Billing Information

ACA Service Year

Select the calendar year for which coverage data is being reported*

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

Employer Legal Name*

FEIN*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Employer Contact Details

Name*

First Last

Title*

Email*

Phone*

Brokerage / Agency

Name

First Last

Phone

Employer Status Details

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

Does Company have common ownership with other entities*

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 required (even if we do not service)

Coverage Details

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

Did the Employer sponsor either a group health plan and/or an ICHRA reimbursement plan*

Are the rates age-banded*

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

Different Employees at the Same Time

During Different Plan Years during the year which you are requesting ACA Services

What was the Renewal Date of your Group Health Plan

ICHRA Plan Details

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

What was the first month that the ICHRA was offered*

What was the last month that the ICHRA was offered*

What was the Waiting Period required for ICHRA eligibility*

Explain the Waiting Period for ICHRA benefit eligibility*

What was the coverage start date for the ICHRA Plan*

Explain the coverage start date for ICHRA benefit eligibility*

For ICHRA Participants who terminate employment, when did their ICHRA coverage end*

Explain when coverage ends for ICHRA Plan Participants who terminate employment*

Employer ACA Data Information for 1/1 Group Health 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}

Was your Medical Plan Fully Insured or Self-Funded (Level-Funded)*

All questions below pertain to your {For which year are you requesting ACA services?:98} Group Medical Plan

Was a Medical Plan Option offered that meets the ACA's minimum value standard*

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

What was the required monthly employee contribution for the lowest cost minimum value coverage option*

Enter currency format 9,999.99 without the dollar sign

What was the Waiting Period required for Group Medical benefit eligibility*

Explain the Waiting Period for Medical benefit eligibility*

What was the coverage start date for the Group Medical Plan*

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

Explain the Medical benefit coverage start date*

For Medical Plan Participants who terminate employment, when did their Group Medical Plan coverage end*

Explain when coverage ends for Medical Plan Participants who terminate employment*

List any classes of employees excluded from Medical benefit eligibility below (i.e. part-time) or enter NONE*

Group Medical Plan Information Before Renewal

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

Was your Medical Plan Fully Insured or Self-Funded (Level-Funded)*

This question pertains to your Group Health plan BEFORE Renewal.

Was a Medical Plan Option offered that met the ACA's minimum value standard*

This question pertains to your Group Health plan BEFORE Renewal.

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

What was the required monthly employee contribution for the lowest cost minimum value coverage option*

This question pertains to your Group Health plan BEFORE Renewal.

What was the Waiting Period required for Medical benefit eligibility*

This question pertains to your Group Health plan BEFORE Renewal.

Explain the Waiting Period for Medical benefit eligibility*

This question pertains to your Group Health plan BEFORE Renewal.

What was your Medical benefit coverage start date*

This question pertains to your Group Health plan BEFORE Renewal.

Under the ACA, the waiting period can’t exceed 90 days; coverage must start by day 9/1.

Explain the Medical benefit coverage start date*

This question pertains to your Group Health plan BEFORE Renewal.

For Medical Plan Participants who terminate employment, when did their Group Health Plan coverage end*

This question pertains to your Group Health plan BEFORE Renewal.

Explain when coverage ends for Medical Plan Participants who terminate employment.*

This question pertains to your Group Health plan BEFORE Renewal.

List any classes of employees excluded from Medical benefit eligibility below (i.e. part-time) or enter NONE*

This question pertains to your Group Health plan BEFORE Renewal.