Yes No Checkbox An opt-out may encourage healthy individuals to drop coverage, leaving the employer with a pool of employees who will incur higher-dollar claims. (Photo: Shutterstock)

As a result of the strong economy and the Tax Cuts and Jobs Act of 2017, many employers are considering ways to enhance their benefits packages. Some employers have already increased employer contributions towards their health plans and others have increased their 401(k) matching contributions. Another potential option for employers is to add an opt-out payment for those who waive health coverage.

By opt-out payments, I am referring to payments that:

  1. Are available only if the employee declines or waives coverage under an employer-sponsored health plan; and
  2. Cannot be used to pay for coverage under the employer-sponsored health plan.

An example of such a payment is where ABC Corp offers their full-time employees medical coverage at a cost of $100 per month for individual coverage. They also offer a $50 per month opt-out payment to full-time employees who decline or waive coverage under the ABC Corp plan. Under this arrangement, employees can pay $100 per month to take the coverage or receive $50 if they decline or waive.

Related: Employers’ opt-out health care arrangements may run afoul of the IRS

Here are several important considerations when determining if an opt-out payment is right for your benefits strategy.

ACA affordability considerations

The IRS generally requires that cash opt-out payments be treated as employee contributions for purposes of determining if the plan is affordable under the Affordable Care Act. This applies to any employers subject to the ACA employer mandate. However, plans can avoid this if the employer only pays opt-out funds if certain conditions (a.k.a., the Limited Exception) are met. The requirements include:

  • The employee declines employer-sponsored major medical coverage.
  • The employee provides reasonable evidence that they and their expected tax dependents have, or will have during the plan year, other alternative, minimum essential coverage that is not individual market coverage.
  • Medicare Part A, TRICARE, Medicaid, CHIP, and other employer-sponsored coverage are considered “acceptable alternative coverage.” (NOTE: Medicare and TRICARE mandate that many employers cannot incentivize workers who are eligible for those programs to drop active health coverage. Those rules should never be overlooked.)
  • An employee’s attestation/affidavit is reasonable evidence by itself, unless the employer knows or has reason to know that the attestation/affidavit is wrong. An employer can also request other evidence.
  • Evidence/attestation of alternative coverage must be provided every plan year for which the eligible opt-out arrangement applies.
  • Evidence/attestation must be obtained at a reasonable time before the coverage period begins (e.g., during open enrollment) or after the plan year starts.
  • Employers may continue to exclude from affordability calculations opt-out payments for the entire plan year if the evidence/attestation was obtained at the beginning of the plan year – even if the employee or family members drop the alternative coverage mid-year.

These requirements potentially limit the amount that employers can use as part of an opt-out strategy. This is intentional so that employers couldn’t use these payments to “push” employees to the individual markets, while also satisfying their obligations under the ACA. In our earlier example, if ABC Corp’s opt-out program didn’t qualify for the limited exception, its lowest cost coverage would cost $150 per month (the $100 cost of coverage, plus the $50 the employee forgoes by enrolling in coverage) for ACA affordability purposes.

Overall program objectives

Sometimes the primary objective of these opt-out programs is to simply provide some type of compensation to those who waive coverage. Employers with this frame of mind often focus on the facts that (a) an opt-out payment costs less than covering an employee on the health plan, and (b) employees who enroll in coverage receive greater total rewards than those who waive, and the opt-out payment levels the playing field. Other times, the objective is to influence employees to waive the employer plan. The theory is that perhaps some who are influenced to waive based on the opt-out may incur claims, which negatively impact plan performance.

Both of these can be worthwhile objectives; however employers should consider whether they may just be rewarding employees who would already waive coverage anyway. Alternatively, the opt-out may encourage healthy individuals to drop coverage, leaving the employer with a pool of employees who will incur higher-dollar claims. This is more likely starting next year with the elimination of the individual mandate penalty, since there will no longer be a tax for not having coverage.

In evaluating an opt-out, the employer may want to look at the percentage of employees offered coverage who are currently enrolled, the number of spouses currently enrolled, whether spouses work and are offered coverage (which may be difficult to determine), current plan rates and levels of coverage.

If an employer has low enrollment then an opt-out may simply be rewarding those who would waive coverage anyway.

Likewise, if a large number of employees don’t have a spouse enrolled in the plan, or if the spouse does not have access to coverage elsewhere, employees may not have another option for coverage that qualifies under the Limited Exception. Finally, even if the employee has a working spouse who is offered employer coverage, the opt out may not have much effect if the plan rates or level of coverage is more favorable than the spouse’s plan. There’s no one size fits all approach, but employers would be well served to consider their overall objectives of an opt-out program.

As with many plan design considerations there are potential pitfalls. For example, employers are generally prohibited from offering Medicare-eligible individuals financial or other benefits as incentives not to enroll in, or to terminate enrollment in, a group health plan. If the employer offered an opt-out only to employees who were 65 and older, and thus theoretically Medicare eligible, it could conflict with these rules and expose the employer to significant penalties. Similarly, employers are prohibited under the HIPAA rules from discriminating against plan participants based on health conditions. An opt-out that was offered only to employees with chronic conditions such as diabetes or rheumatoid arthritis could be construed as discrimination on the basis of a health condition.

Opt-outs may also be a better culture fit with some employers rather than others. For example, an employer who is focused on offering market leading benefits may want employees to enroll in their benefits and an opt-out may conflict with this objective. The employer may find instead that the cost of the opt-out better allocated towards enhancing benefits.

Likewise, an employer looking to more closely manage costs while maintaining benchmark level benefits may see significant value in adding an opt-out payment.

Bottom line

Opt-out payments can be a useful way for employers to enhance their benefits offerings for those who don’t enroll in employer benefits. Before pursuing this strategy employers should become familiar with the rules and also consider their overall objectives and motivation behind implementing an opt-out. Finally employers should consider the potential pitfalls and how the opt-out fits in with their overall benefits strategy.


Cory Jorbin is the Central Region Compliance Officer for global insurance brokerage Hub International’s employee benefits practice.