ACA Plan Design for 2017

ACA Plan Design

Your organization’s ACA Plan Design describes your organization’s strategy for ACA compliance. Complete a separate for each Company Code and applicable report year. For instance, for data from 2017, enter 2017 as the report year. Reports are due the year after.

Consult your organization’s preferred ACA expert, benefits broker, attorney, and others regarding your organization’s ACA strategy and ACA Plan Design. Also refer to the IRS instructions and latest information about Forms 1095C and the transmittal information on1094C. The IRS sometimes releases the latest instructions during the year.

Your Organization: Click or tap here to enter text.Date Completed: Click or tap to enter a date.

ALE Group (If Any)

Controlling company for controlled group:Click or tap here to enter text.

(No text is neededif no control group exists.)

Does your organization have more than one company? If so, are any of these part of a “controlled group” for IRS ACA reporting purposes? If so, identify which company is the controlling company.

ACA Company

For each company code, complete an additional copy of this form.

ACA Plan Design

Company Code:Click or tap here to enter text.

ALE Group:Click or tap here to enter text.

Origin Policy:Choose an item.

Contact Name:Click or tap here to enter text.

Contact Phone:Click or tap here to enter text.

ALE Month Start:Choose an item.

ALE Month End:Choose an item.

Qualified Offer Method☐

Qualified Offer Transition☐

Offer Method 98%☐

Self Insured?☐

ACA Plan Design

Minimum Essential Coverage:(Select each month this is applicable.)

1
Jan. / 2
Feb. / 3
March / 4
Apr. / 5
May / 6
June / 7
July / 8
Aug. / 9
Sept. / 10
Oct. / 11
Nov. / 12
Dec.
☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐

ACA Profiles

Use additional copies of this page as needed to define as many ACA Profiles as applicable.

ACA Profile Description: ______

If every employee with this Profile assigned needs to be reported under a specific company regardless of the assigned Company for HCM and payroll purposes, identify the Company Override: ______

Calendar Start Date for ACA Profile: Click or tap to enter a date.

ACA Plan Design

Standard Period

Measure Months:Choose an item.

Admin Months:Choose an item.

Stability Months:Choose an item.

Initial Period (for New Hires/Some Re-Hires)

Measure Months:Choose an item.

Admin Months:Choose an item.

Stability Months:Choose an item.

ACA Plan Design

ACA Profile Description: ______

If every employee with this Profile assigned needs to be reported under a specific company regardless of the assigned Company for HCM and payroll purposes, identify the Company Override: ______

Calendar Start Date for ACA Profile: Click or tap to enter a date.

ACA Plan Design

Standard Period

Measure Months:Choose an item.

Admin Months:Choose an item.

Stability Months:Choose an item.

Initial Period (for New Hires/Some Re-Hires)

Measure Months:Choose an item.

Admin Months:Choose an item.

Stability Months:Choose an item.

ACA Plan Design

ACA Profile Description: ______

If every employee with this Profile assigned needs to be reported under a specific company regardless of the assigned Company for HCM and payroll purposes, identify the Company Override: ______

Calendar Start Date for ACA Profile: Click or tap to enter a date.

ACA Plan Design

Standard Period

Measure Months:Choose an item.

Admin Months:Choose an item.

Stability Months:Choose an item.

Initial Period (for New Hires/Some Re-Hires)

Measure Months:Choose an item.

Admin Months:Choose an item.

Stability Months:Choose an item.

ACA Plan Design

1095 Policies

Use additional copies of this page as needed to define as many ACA 1095 Policies as applicable.

1095 Policy Description: ______(Include Year)

Plan Start Month for the Year’s Plan:Choose an item.

ACA Plan Design

Month Choose an item.to Choose an item.

Offer of Coverage:Choose an item.

MVC Month EE Amt:Click or tap here to enter text.

Safe Harbor:Choose an item.

COBRA MVC Month EE Amt: Click or tap here to enter text.

Will the offered plan change mid-year in this reporting year?

Month Choose an item.to Choose an item.

Offer of Coverage:Choose an item.

MVC Month EE Amt:Click or tap here to enter text.

Safe Harbor: Choose an item.

COBRA MVC Month EE Amt: Click or tap here to enter text.

ACA Plan Design

1095 Policy Description: ______(Include Year)

Plan Start Month for the Year’s Plan:Choose an item.

ACA Plan Design

Month Choose an item.to Choose an item.

Offer of Coverage:Choose an item.

MVC Month EE Amt:Click or tap here to enter text.

Safe Harbor: Choose an item.

COBRA MVC Month EE Amt: Click or tap here to enter text.

Will the offered plan change mid-year in this reporting year?

Month Choose an item.to Choose an item.

Offer of Coverage:Choose an item.

MVC Month EE Amt:Click or tap here to enter text.

Safe Harbor: Choose an item.

COBRA MVC Month EE Amt: Click or tap here to enter text.

ACA Plan Design

1095 Policy Description: ______(Include Year)

Plan Start Month for the Year’s Plan:Choose an item.

ACA Plan Design

Month Choose an item.to Choose an item.

Offer of Coverage:Choose an item.

MVC Month EE Amt:Click or tap here to enter text.

Safe Harbor: Choose an item.

COBRA MVC Month EE Amt: Click or tap here to enter text.

Will the offered plan change mid-year in this reporting year?

Month Choose an item.to Choose an item.

Offer of Coverage:Choose an item.

MVC Month EE Amt:Click or tap here to enter text.

Safe Harbor: Choose an item.

COBRA MVC Month EE Amt: Click or tap here to enter text.

ACA Plan Design

Special Leaves

Any applicable unpaid ACA special leaves? If so, describe.

These will need to be identified on the Attendance Codes Table.

Earnings

Should one or more earnings code’s hours be excluded from hours’ calculations for hours of service for ACA purposes?

Next Steps

Complete the setup using your ACA Plan Design as a guide.
Review the Help system’s ACA topic for more information.
Use the “Manage ACA Profiles” tool to set the ACA Profile, ACA Employment Type, and ACA 1095 data for groups of employees.