How Does Health Care Reform Affect Your Health Insurance Coverage?

Many businesses are confused about the impact of the Affordable Care Act (ACA) on their health insurance coverage. UHA monitors health care reform developments and we are here to answer any questions you may have.

UHA Benefits Changes

Essential Health Benefits (EHB)

Since January 1, 2014, the ACA has required small business medical plans for employers, with 50 or few employees, to include essential health benefits (EHB). A plan with EHB includes required coverage categories along with prescription drugs, pediatric oral (dental), and pediatric vision care. Businesses of 51 or more employees and grandfathered plans are exempt from this requirement. Until December 31, 2019, small business groups with UHA coverage (effective prior to October 1, 2013) that do not already include EHB coverage may elect to keep their current benefits instead of adding EHB coverage. These types of small business medical plans are known as "transitional plans" or "grandmothered plans."

Please check with your plan administrator or legal counsel on ACA compliance if you are a self-funded group.


How do I calculate my Full-Time Equivalent (FTE) Employee count?

If you have an accountant or tax advisor, they can assist you with determining your group's FTE count. There are also a variety of resources available:


A Small Business (50 or fewer employees)

For a small business transitional or grandmothered plan to be EHB compliant, the following coverage must be included:

  • No annual maximum or lifetime maximum
  • Prescription Drugs
    Drug Plan T will has an annual maximum out-of-pocket. When a member's total annual maximum out-of-pocket reaches the annual limit in any calendar year, UHA pays 100% of the eligible charge for covered drugs for the rest of that calendar year. Exclusion: mandatory generic substitution and any other "Dispense as Written" penalties. Please refer to your plan documents on the UHA Member Portal for your current annual maximum out-of-pocket.
  • Pediatric Vision
    These are services for UHA members under the age of 19. UHA pays 100% of the eligible charge for an eye exam and refractions per member, per calendar year. Appliance reimbursement is up to $130 every calendar year towards the purchase of eyeglasses, contact lenses, frames, lenses, or any combination thereof.
  • Pediatric Dental
    These are services for UHA members under the age of 19. Hawaii Dental Service is the third party administrator for UHA to provide this benefit.


A Large Business (51 or more full-time employees) & Grandfathered Plans

For more information, see: ACA Information Center for Applicable Large Employers (ALEs)
  • No annual maximum or lifetime maximum
  • Prescription Drugs
    Drug Plan T has an annual maximum out-of-pocket. When a member's total annual maximum out-of-pocket reaches the annual limit in any calendar year, UHA pays 100% of the eligible charge for covered drugs for the rest of that calendar year. Exclusion: mandatory generic substitution and any other "Dispense as Written" penalties. Please refer to your plan documents on the UHA Member Portal for your current annual maximum out-of-pocket.
  • Vision Plan
    UHA pays 100% of the eligible charge for one routine vision examination and refraction per member, per calendar year. Appliance reimbursement of up to $130 every calendar year towards the purchase of eyeglasses, contact lenses, frames, lenses, or any combination thereof.


W-2 Compliance Report

The Affordable Care Act (ACA) requires employers to report the amount paid in premiums for each employee's medical coverage on the employee's W-2. To assist you with this requirement, contact UHA for a year-end report showing total premiums paid for each employee's coverage.

To comply with the ACA W-2 reporting requirement, please contact your UHA Account Representative at 532-4000 extension 358.
There is transitional relief from this requirement for certain employers. For more information, see: Form W-2 Reporting of Employer-Sponsored Health Coverage.


Forms 1094-B, 1095-B

The Affordable Care Act (ACA) includes many reporting and disclosure requirements. The ACA requires any person, including health insurance issuers and plan sponsors who provide individuals with "minimum essential coverage" to file Forms 1094-B and 1095-B with the IRS. Minimal essential coverage includes eligible employer-sponsored plans such as those purchased by your group through UHA.

1094-B Forms

The 1094-B Forms are the Transmittal of Health Coverage Information Returns, and UHA will complete and submit these to the IRS. This is the responsibility of UHA and not the employer.

1095-B Forms

As required by the ACA, UHA sends the 1095-B forms directly to your employees, and copies are not provided to employers.

Employer groups are responsible for certain additional reporting requirements as well. Please refer to the IRS websites above or consult your accountant or tax advisor for further guidance regarding reporting requirements.


Forms 1094-C, 1095-C

Employers with 50 or more full-time employees (including full-time equivalent employees are considered Applicable Large Employers (ALE)). If an employer falls into this category in the previous calendar year, they must file one or more Forms 1094-C and a Form 1095-C for each employee who was a full-time employee of the employer for any month of the calendar year. The copy of the Form 1095-C (or a substitute form) must be provided to the employee.

For more information, please refer to the IRS website.