What It Is
Employer-sponsored health insurance (ESI) is health insurance offered by an organization as part of a benefits and compensation package. The terms of the insurance plan and the extent of the employee’s contribution will vary depending on the organization. For instance, employees and their dependents may be covered entirely by the organization, or the employee may pay for part of their monthly premiums. The plan may include vision, dental, and prescription drug benefits, or these might be offered separately.
The nature and shape of health insurance coverage in the United States is changing as provisions of the 2010 Patient Protection and Affordable Care Act (ACA) go into effect. A central goal of ACA is get as many Americans covered by insurance as possible. That said, ACA does not require any individual or organization to purchase health insurance. Instead, ACA provides financial incentives and disincentives to encourage individuals to purchase insurance and, in the case of organizations, to offer insurance to employees.
As the name of the act suggest, ACA is also concerned with protecting individuals from having their insurance denied or altered. It will end denial of coverage based on pre-existing conditions, disallow insurance companies from ending a person’s coverage based on technicalities in their application in order to avoid paying claims, and greatly reduce the personal factors an insurance company can consider when pricing an individual’s plan, among other changes.
Additionally, ACA seeks to increase competition among private insurers by setting up marketplaces so that individuals and organizations can more readily compare the cost and benefits of different plans. Though ACA has many other features, in this article we will focus on those features that are most pertinent to employers, including the financial dimensions of the act and the insurance marketplaces. Government and other sources are provided at the end for further reading about ACA.
Why It Matters
Health care costs and cost of health insurance are rapidly rising in the United States. Several studies have shown that over the past 25 years small businesses consistently cite the increasing cost of health insurance as one of the most critical problems that they face. Employer-sponsored insurance provided 69.7% of non-elderly adults (i.e., adults likely to still be in the workforce) with health insurance in 2000. By 2011, this had dropped to 59.5%. This drop has disproportionately affected low-income workers, who are already less likely to receive health insurance through their employers, and are less able to pay for insurance out of pocket. In addition, navigating and negotiating complicated health insurance policies often proves to be a huge administrative burden for organizations. This is particularly true for small businesses.
Nonetheless, there are several good and important reasons to provide health insurance for employees. In this section we’ll review some of these reasons. We’ll also review relevant parts of ACA. This legislation will not require any employer to offer insurance, however, those who do not may incur fines, depending on the size of their business. The legislation will also put into place several measures designed to make health insurance— and health care in general— more affordable, transparent, and competitive.
Benefits of employer-sponsored health insurance for employers and employees
Employer contributions to employee health insurance plans are a deductible business expense, in the same way that wages and other expenses are. The costs of these insurance plans are also excludable from both employee and employer portions of payroll tax. In many states, they are excludable from personal income tax as well. A study by the Kaiser Family Foundation has shown that the tax benefits received—directly or indirectly— by employees who are provided with insurance through their employer are greater than for individuals who purchase insurance on their own. Consequently, for both employers and employees, these benefits have a greater value than an equivalent monetary increase in salary, and provide better tax benefits than individually purchased insurance plans.
Furthermore, for employees, employer-sponsored insurance often has other financial benefits that are harder to calculate but no less real. The first is the comparative advantages that employers, especially large employers, have when negotiating with insurance companies. Organizations are in a better position to negotiate for better rates than individuals. They are also likely to have human resources experts or similarly trained individuals who are able to understand and weigh the pros and cons of various plan features.
When an individual and his or her family is covered by ESI, their coverage is not subject to variations based on their personal health histories and ages, which can drive rates up and down, or cause them to be denied coverage altogether. ESI plans allow all covered parties to receive the same coverage for the same rate. However, when the relevant provisions of ACA go into effect, the variations in the price of plans that insurance companies can charge individuals will be sharply curtailed, though not eliminated. Denial of coverage based on pre-existing conditions for children under age 19 was made illegal in 2010, and will be illegal for adults beginning in January 2014.
Additionally, health insurance serves as an important protection from financial stresses and ruin that can result from illness and injury. Health care costs are not only rising, they are also unpredictable, varying widely by facility and region. This is true even for standard procedures. These costs are therefore very difficult to plan and save for. In one survey, a student attempted to pin down the cost of a hip replacement. She contacted over one hundred hospitals, and could only get prices from 10% of the hospitals she approached. The hospitals that responded gave her estimates ranging from $11,000 to $125,000.
From an employee standpoint, ESI is consequently a very important and valuable benefit, one that is not easily replaced by a raise in salary. The coverage that insurance provides protects employers as well, by ensuring that workers have access to care that will keep them healthy and productive. In combination with short-term disability insurance and solid family and medical leave policies, health insurance can increase retention by greatly reducing the chances that an employee will have to permanently leave their job for medical reasons. Additionally, many studies have shown that employees who have health insurance through their employer are more loyal, and that good benefits are key to attracting talented workers.
Patient Protection and Affordable Care Act: General Features
A central goal of the ACA is to have as many Americans covered by health insurance as possible. Extending coverage to more Americans will reduce the incidence of financial catastrophe due to medical expenses, and mitigate the individual and public health burdens that result from inadequate preventative and therapeutic care.
Consequently, ACA puts policies in place to make insurance affordable for everyone. The act attempts to achieve this in a number of ways. ACA will provide financial assistance for low-income individuals in need of insurance, create policies to ensure insurance plans more competitively priced, encourage employer-sponsored insurance through a system of tax incentives and fines, and put in place measures to reduce actual health care costs.
Some of the earliest features of the Patient Protection and Affordable Care Act (ACA) include the end of pre-existing condition exclusions for children under the age of 19 (meaning that children cannot be denied coverage because of a pre-existing medical condition) and the extension of the age at which children can be covered by their parents’ insurance to age 26. These protections for children and younger adults will affect organizations that extend benefits to dependents.
ACA has also placed limits on the profits that insurers can pocket at the end of the day. This is achieved by requiring that a certain percentage of revenue be invested in patient medical care expenses. Over time, the act will also attempt to control health care costs. It will charge a so-called “Cadillac tax” on expensive insurance plans and transition away from fee-for-service payments to value-based payments in the health care industry. The goal of this latter change is to shift attention more firmly towards preventative health care measures, which costs comparatively less, and result in better health outcomes.
Many features of the ACA have yet to be implemented. As of January 2014, pre-existing condition exclusions will also end for adults, meaning, in effect that after this point no US citizen can be denied health insurance coverage. Additionally, the number of personal factors that insurance companies use to determine plan costs will be sharply curtailed. Insurance companies will be able to factor in age and whether a person smokes, for instance, but not gender or pre-existing conditions in the price of individual health insurance plans. Prior to this legislation women were routinely charged more health insurance, and an individual’s rates could be higher depending on the industry in which they worked. Variations in price along the allowed demographic factors are also constrained by the law. For instance, senior citizens cannot be charged more than three times as much as their younger counterparts.
Affordable Care Act and Employer-Sponsored Insurance
The ACA attempts to preserve the primacy of ESI in the American insurance marketplace. This means that despite popular misconceptions to the contrary, individuals who currently have insurance through their employers can and will be encouraged to keep that insurance as their employer continues to provide it.
ACA reinforces the primacy of ESI by incentivizing employers to offer insurance and by incentivizing employees to accept affordable insurance offered by employers.
Starting in 2015, organizations with 50 or more full-time employees will be fined if they do not provide insurance for their employees and the employees’ dependents. This is called the employer mandate. This fine is $2,000 per year per employee (excluding the first 30 workers). For example, an organization with 55 full-time employees that does not extend coverage will be fined $50,000 a year: $2,000 x (55-30)= $50,000.
Furthermore, this fine will also be applied if the employer offers insurance and one or more employees still qualify for subsidized coverage through an insurance exchange (more on exchanges below). Why is this? Individuals can receive subsidies to buy insurance through an exchange if they cannot afford insurance premiums. This is true for lower- and middle-income individuals without ESI, and also for individuals with ESI if that ESI is unaffordable. Unaffordable in this instance means that the employee would have to pay 9.5% or more of their income to cover premiums, or have a plan that pays for less than 60% of the cost of covered services.
Employees are also incentivized to accept affordable ESI plans. If their ESI is deemed affordable by these measures, they will not qualify for subsidies to purchase insurance on their own through an exchange. Similar to organizations, individuals who do not have health insurance will be fined 1% of their taxable income starting in 2014, with some exceptions. The fine will increase over time.
To sum up, the organizational fines are in place to ensure that larger employers 1) provide health insurance for employees and their dependents, and 2) that the insurance they provide is a reasonable cost for all employees.
The individual fines and subsidy exclusions are a means of 1) motivating employees to accept affordable ESI offers, and 2) encouraging individuals without ESI or affordable ESI purchase coverage on their own.
Any employer offering ESI will also need to report the details of this coverage to the IRS for informational (not tax) purposes.
Depending on the nature of the organization and the cost of available health insurance plans, there may be instances in which paying the fine is a more cost-effective than paying for ESI. Traditionally, not offering insurance coverage would have burdened many employees, especially lower-income employees. As noted earlier, individuals had little to no chance of finding affordable health insurance on their own. If ACA functions in the way that it is supposed to, this should not be as grievous a problem, since the variations in costs between plans will be more tightly regulated and many lower- and middle-income individuals will qualify for subsidized coverage. However, when weighing these financial factors, also take into consideration the demographics of your workforce. Older employees will pay more for insurance than younger employees if they purchase it through an exchange, even under ACA.
ACA also includes a tax credit for small businesses offering ESI. Small businesses with 25 or fewer full-time employees earning an average of $50,000 or less per year can receive a tax credit (not simply a deduction) on the cost of the premiums. This credit will increase in value in 2014, and operates on a sliding scale. For detailed information on how this will work, view the IRS guide Small Business Health Care Tax Credit for Small Employers.
Affordable Care Act and Insurance Exchanges
In October 2013, the federal health care marketplaces will go live. States that have their own exchanges (marketplaces) will be available in October as well. Insurance purchased through these marketplaces will provide coverage starting in January 2014. If your state does not have an exchange, you will use the federally run marketplace. A few state exchanges will be run jointly with the federal government.
Individuals and organizations can use these marketplaces to compare and shop for insurance plans. Insurance providers compete to participate in these online exchanges. The goal of the marketplaces is to provide consumers with a centralized location at which they can readily compare costs and features of various insurance plans.
Vermont is the first state to publish information on the cost of plans offered through its state exchange. In general, the plan rates offered through the state exchange are similar to current rates. This is a useful way to get a kind of preview of what these exchanges will look like, though your state may vary from Vermont. You can read more about Vermont’s rate reveal on the California Healthline website and at the Boston Globe.
There are two types of exchanges: exchanges for individuals and families, and exchanges for small businesses. The Small Business Health Options Program (SHOP) is an exchange for businesses with less than fifty full-time employees. Starting in 2016, SHOP can be used by employers with up to 100 full-time employees. Beginning in 2014, only plans purchased through SHOP will be eligible for the Small Business Health Care Tax Credit.
SHOP is designed to relieve much of the administrative headache that small employers face when attempting to purchase insurance coverage for their employees. It does this by pooling information in one location and ensuring that participating insurers have met federal guidelines established by ACA and met bid requirements established by the exchange. The SHOP exchange provides many of the same services as the individual exchanges. Employers to fill out an application, determine what amount they can put towards premiums, and view and compare plans and costs. There are stipulations about who can enroll in plans offered through SHOP—for instance, 70% of eligible employees must enroll in the plan you choose. Self-employed individuals are required to purchase coverage through and individual and family exchange.
Step One: Familiarize yourself with the Affordable Care Act and understand how it will affect your business.
Step Two: Investigate health insurance options and pricing.
Step Three: Weigh the benefits.
Step Four: Choose a plan and determine how much employees will need to contribute towards premiums.
Step One – Familiarize yourself with the Affordable Care Act and understand how it will affect your business
As stated earlier, the goal of the Affordable Care Act is to ensure that all Americans, with few exceptions, have health insurance. The ACA also attempts to preserve the primacy of employer-sponsored health insurance (ESI). This means that the legislation will require businesses to provide affordable insurance for its employees if the business has 50 or more full time employees. The employer mandate has been delayed until 2015 at the time of this writing.
There are several federal government websites, listed in the “Resources for More Information” section below, with detailed descriptions of the Affordable Care Act, its features, and the timeline for the implementation of different provisions. You will need to determine whether or not your business will face fines if you do not offer ESI, and also what services, such as SHOP, that you may be eligible to use.
Your first step is to determine whether or not you have 50 full-time employees, as defined by ACA. This may not be as clear cut as it seems: review IRS notice 2012-58 and this article by Georgeann Peters available on Mondaq to determine if your business will fall under the employer mandate.
Step Two – Investigate health insurance options and pricing
If you have less than fifty full-time employees, after October 2013 you will be able to use SHOP, the online marketplace, to price and compare ESI plans. Starting in 2016, businesses with up to 100 full-time employees will also be able to use SHOP.
For businesses with more than fifty employees, until 2016 you will need to price group health insurance options with insurance providers operating in your state. In most states, the health insurance market is dominated by a few, large insurance providers. You may already be familiar with the providers in your area.
Groups like NAHU, the National Association of Health Underwriters, have online resources that will guide you through the basics when negotiating with insurance companies. For instance, NAHU provides a Consumer Guide to Group Insurance, as well as a directory of professionals that you could hire as consultants.
Step Three – Weigh the benefits
- How will health insurance change your compensation and benefits package?
- How will any premiums that you pay change your taxes?
- If you are a company that will be fined for not offering coverage, how do the fines compare to coverage costs?
- Are you eligible for the Small Business Health Care Tax Credit?
- Can you purchase a plan that meets the affordability requirements for all covered employees?
- How will offering insurance change your recruitment efforts and employee retention?
- Check in with your existing workforce. What plan features would they like to see, and how would you ideally handle dependent and partner coverage?
Given the complexity of these considerations, you may consider bringing in a human resources consultant if you do not already have a humans resources person at your organization. You should also recruit employee’s input to get a sense of what kinds of insurance and insurance options would be helpful and not helpful.
Step Four – Choose a plan and determine how much employees will need to contribute towards premiums
Choose a plan that makes sense for your organization and your employees. Determine how much employees will contribute towards premiums. Remember that the affordability of the insurance will affect whether or not you face fines, if your organization has more than fifty full-time employees.
Step One: Extend coverage to spouse and dependents.
Step Two: Add dental and vision insurance to your plans.
Step Three: Add a flexible spending account to your plan.
Step One – Extend coverage to spouse and dependents
Under ACA, employers who fall under the employer mandate are required to extend coverage to dependents, but not necessarily to spouses/partners. Affordability rules are different when coverage is extended to dependents, and so you will need to take this into account.
Step Two – Add dental and vision insurance to your plans
Dental and vision insurance are usually not included in health insurance plans, and have to be purchased separately. These insurance options are largely not affected by ACA, except for pediatric plans (meaning persons under age 22). While dental and vision insurance should ideally be extended to adults as well, make sure that you are at least meeting the coverage requirements for any child dependents.
Step Three – Add a flexible spending account to your plan
Flexible spending accounts (FSA) allow your employees to make their dollars go farther by setting aside a portion of their pre-tax income for medical and childcare expenses. Medical and dependent care expenses are usually separated into separate FSA accounts. Employees can choose how much of their income will go into the flexible spending account, though there are limits on how it can be used and how much can be directed into the account. Prior to 2012, the amount of money directed into an FSA could be quite high, but now is limited to $2,500 a year. Funds placed in an FSA are also not subject to pay roll taxes. Employees lose any funds not used within a given period.
Step One: Offer health and wellness options.
Step Two: Offer related benefits, such as short-term disability insurance, paid sick leave, and family and medical leave, that work in tandem with health insurance.
Step One – Offer health and wellness options
Health and wellness options are voluntary programs offered by workplaces to improve the health and well-being of their employees. These programs can be quite diverse, and include everything from benefits fairs to meditation workshops to smoking-cessation programs. They are often offered as incentives or discounts, for instance, gym memberships at a reduced cost. For more information about health and wellness programs, see our Green Plus article on the topic.
Step Two – Offer related benefits, such as short-term disability insurance, paid sick leave, and family and medical leave, that work in tandem with health insurance
The safety-net effect of health insurance coverage often works best in tandem with other benefits and policies, including short-term disability insurance and family and medical leave policies. While ideally a person’s overall health will be improved if they have access to affordable health care, health disasters are not completely preventable. Review your current leave and insurance options. If an employee was to have an unavoidable health catastrophe (such as a serious car wreck, or a dependent with a serious illness), would your current benefits and leave options allow them to take time off work to contend with the issue, or would they be forced to quit? What income would they have over the period of the illness? Consider adopting benefits and drafting leave policies that would mitigate the financial impact of a serious injury or period of illness, and that would reduce the chance that the employee would have to permanently leave the organization.
Resources for More Information
Healthcare.gov: Federal government’s future health insurance marketplace location. This site also links to state exchanges for states that have them. This site will go live in October 2013.
Small Business Health Options Program (SHOP): This is a marketplace specifically for small businesses. It will also go live on October 2013.
US Department of Health and Human Services, Health Care: This website is devoted to explaining the Affordable Care Act and providing related resources.
Patient Protection and Affordable Care Act: This is the full text in PDF form.
Will I qualify for small business health care tax credits? HealthCare.gov
Notice 2012-58, IRS
Studies and Articles on Health Insurance and Employment
Jean Abraham, Peter Graven, Roger Feldman, “Employer Sponsored Insurance and Health Reform: Do the Math,” National Institute for Health Care Reform
Brigette Madrian, “Employment Based Health Insurance and Job Mobility: Is there Evidence of Job-Lock?” The Quarterly Journal of Economics
Heather D. Hill, “Paid Sick Leave and Job Stability,” Work and Occupations
John Holahan and Vicki Chen, “Changes in Health Insurance Coverage in the Great Recession, 2007-2010,” Kaiser Commission on Medicaid and the Uninsured
J. Sonier, B. Fried, C. Au-Yeung, B. Auringer, “State-Level Trends in Employer-Sponsored Health Insurance,” Robert Wood Johnson Foundation
Mark Stanton, “Employer Sponsored Health Insurance,” Agency for Healthcare Research and Quality
2012 Employer Health Benefits Survey, Kaiser Family Foundation
Advantages of Employer-Sponsored Health Insurance, National Business Coalition on Health
Employer-sponsored insurance is an important part of a competitive compensation and benefits package, one that provides a valuable financial and medical safety net for covered employees. The landscape of health insurance in the United States is changing rapidly, in large part due to the Patient Protection and Affordable Care Act of 2010. You or your human resources team will need to stay abreast of these changes to ensure that your insurance options make the most of the resources and guidelines provided under ACA.
Glossary of Related Terms
Patient Protection and Affordable Care Act of 2010 (ACA): ACA is a major federal health care reform law. ACA regulates the health insurance industry more closely, extends legal protections to individuals with health insurance, and seeks to reduce health care costs over time while also extending insurance coverage to as many Americans as possible.
Health Care Exchange/Marketplace: ACA establishes online marketplaces (formerly called exchanges) that individuals and small businesses can use to compare the price and features of insurance plans. Insurance providers compete to participate in these exchanges. Many states will have state marketplaces. Individuals living in states without a marketplace will use the federal marketplace in place of a state exchange.
Small Business Health Options Program (SHOP): Insurance marketplace established through ACA that will allow small businesses to shop for group insurance plans online. SHOP will open on October 1, 2013, and will be limited to businesses with less than 50 employees until 2016. In 2016, SHOP will serve businesses with up to 100 full-time employees.
Flexible Spending Account (FSA): Flexible spending accounts allow your employees to make their dollars go farther by setting aside a portion of their pre-tax income for medical and childcare expenses. Medical and dependent care expenses are usually separated into separate FSA accounts. Employees can choose how much of their income will go into the flexible spending account, though there are limits on how it can be used and how much can be directed into the account. Prior to 2012, the amount of money directed into an FSA could be quite high, but now is limited to $2,500 a year. Funds placed in an FSA are also not subject to pay roll taxes. Employees lose any funds not used within a given period
Employer-Sponsored Health Insurance (ESI): Employer-sponsored health insurance is group insurance coverage offered through an employer. Group insurance coverage allows all individuals covered by the plan insurance benefits at a standard price that does not take into account personal health history or other demographic factors. ESI is usually extended to dependents and spouses as well. Under ACA, larger employers will face fines if they do not extend affordable coverage to their employees.
Family and medical leave: This is leave, often paid, offered by employers to allow employees to care for themselves or others after the birth, adoption, or fostering of a new child or during a medical emergency. Larger organizations are covered by the Family and Medical Leave Act, while smaller organizations may be subject to similar state-level family and medical leave laws that
Disability insurance: Disability insurance pays employees a portion of their income for a set time (usually a period of a few months during a calendar year) in the instance of an injury or illness that prevents them from working. This insurance is often provided by employers as it reduces the chances that an individual will have to quit should a medical emergency arise. In other instances, employers include this as an optional benefit that employees choose to enroll in.
 Holly Wade, Small Business Problems and Priorities (National Federation of Independent Business, August 2012): 7-8.
 J. Sonier, B. Fried, C. Au-Yeung, B. Auringer, “State-Level Trends in Employer-Sponsored Health Insurance,” Robert Wood Johnson Foundation, April 2013, accessed 15 August 2013.
 Sonier, et al., “State-Level Trends in Employer-Sponsored Health Insurance,” SHADAC Report. Minneapolis, MN: University of Minnesota.
 David Walker and Ben Geyerhahn, “Broad Interest in Health Insurance Exchanges Among New York Small Business Owners,” Greenberg Quinlan Rosner Research, 5 December 2011, p. 2.
 Tax Subsidies for Health Insurance: An Issue Brief (The Henry J. Kaiser Family Foundation, July 2008): 1-2.
 Tax Subsidies for Health Insurance: An Issue Brief (The Henry J. Kaiser Family Foundation, July 2008): 14-16.
 “Advantages of Employer-Sponsored Health Insurance,” National Business Coalition on Health,, accessed 15 August 2013.
 That is to say, individuals can no longer be prevented from joining insurance plans based on existing medical conditions that they have or have had, ranging from everything from congenital defects to a history of yeast infections to chronic conditions like asthma. Typically, employer-sponsored insurance has protected covered employees from pre-existing condition clauses. Even with ESI, pre-existing conditions may delay coverage for treatment of these conditions for a stipulated period (for example, one year) if the individual has had a break in insurance coverage before joining an organization.
 Sarah Kliff, “How much does hip surgery cost? Somewhere between $10,000 and $125,000.” Washington Post, 12 February 2013, accessed 15 August 2013.
 Reed Richardson, “The Small Business Case for Offering Health Benefits,” Bank of America Small Business Community, 9 February 2012, accessed 15 August 2013.
 If the child under age 26 receives insurance through their employer, they cannot also receive coverage under their parent’s plan.
 A break down of implementation of ACA by year is available on the US Department of Health and Human Services website here.
 Jason Shafrin, “Does Obamacare Limit Profits for Health Insurance Companies in Your State?” The Health Care Blog, 4 February 2012, accessed 15 August 2013.
 For example, doctors and hospitals currently earn more by treating a person with smoking-related lung cancer than by enrolling individuals in smoking-cessation programs. However, our lung cancer patient would have had better health outcomes if they had enrolled in a smoking cessation program years earlier, and the individual and public costs of their treatment would have been far lower; David Cutler, “The Economics of the Affordable Care Act,” New York Times, 7 August 2013, accessed 16 August 2013.
 This is slightly more complicated with immigrants. For a discussion of this topic, see: Bradford Flecke, “Pre-Existing Conditions Eliminated Ahead of 2014 US Law Change,” Borders, 22 October 2012, accessed 9 August 2013.
 Henry J. Kaiser Family Foundation, “Health Insurance Market Reforms: Rate Restrictions,” Focus on Health Reform, June 2012, p. 1-3.
 Jean Abraham, Peter Graven, and Roger Feldman, “Employer-Sponsored Insurance and Health Reform: Doing the Math,” National Institute For Health Care Reform, December 2012, accessed 15 August 2013.
 Abraham, et al., “Employer-Sponsored Insurance and Health Reform: Doing the Math.”
 See this article for more information about an important caveat in this rule that could adversely affect dependents, especially for individuals receiving ESI through smaller employers. This possible gap in coverage has not yet been fully resolved: Robb Mandelbaum, “In the Affordable Care Act, Some Children Left Behind,” New York Times, 7 August 2013, accessed 16 August 2013.
 A breakdown of these individual fines is available at: “What if someone doesn’t have health coverage in 2014?” HealthCare.gov, accessed 16 August 2013.
 An explanation of this reporting requirement can be found at: “Form W-2 Reporting of Employer-Sponsored Health Coverage,” IRS, 26 April 2013, accessed 16 August 2013.
 Federal and state exchanges can be accessed here: https://www.healthcare.gov/.
 Phil Galewitz and Alvin Tran, “Federal Government Will Be Running Insurance Exchanges in Half the States,” TLNT, 18 February 2013, accessed 16 August 2013.
 J. Holahan, R. Peters, K. Lucia, and C. Monahan, “Insurer Participation and Competition in Health Insurance Exchanges,” Robert Wood Johnson Foundation, July 2013, http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/07/insurer-participation-and-competition-in-health-insurance-exchan.html, accessed 16 August 2013.
 Determining whether or not you have fifty full-time employees may not be as straightforward as it seems. For information on determining this, see IRS notice 2012-58.
 “What is the SHOP Marketplace?” HealthCare.gov, accessed 16 August 2013.
 Georgeann Peters, “Stand and Be Counted: Determining Full-Time Employees Who Must Be Offered Affordable Health Benefit Coverage Under the Employer Mandate,” Mondaq, 15 August 2013, accessed 19 August 2013.
 Hope Gillette, “ACA vision care benefits: Is the health law shortsighted?” Saludify, 29 July 2013, accessed 19 August 2013.
 “Flexible spending account,” Wikipedia, accessed 19 August 2013.