Census Reconciliation Form

1. Total Employee on Wage and Tax Statement. It is estimated that the Wage and Tax for December 31st will be available for the Plan Year submission. The most recent Wage and Tax Statement can be used if that statement is not available. See A refers to the Employer's most recent Quarterly Wage and Tax Statement.
2. Employees On or (Off) as of Census Date. It is understood this will be the net change in employed individuals compared to the date of the census being reconciled. This number can be negative in the event employees have left in the interim time period.
3. Employees Not Working 30 Hours a Week.
4. Total Full Time Eligible Employees (Line 4 = Lines 1 + 2 - 3)
5. Less Those Employees with Qualified Waivers. Employees with qualified waivers for other coverage are deducted at this time.
6. Plus Continuants. Continuants not on the Wage and Tax Statement are identified and added back in this step.
7. Net Eligible Employees. (Line 7 = Lines 4 - 5 + 6)
8. Enter the number of Eligible Employees on the Census. Provide the date of the census being reconciled.
9. Number of FTEs in past calendar year for over 50% of work days. Divide the number of hours worked for those part-time employees under the FTE Hour limit and add to full-time employees for 20 or more weeks in preceding calendar year. This is the number that must be over 20 to be in the COBRA program, otherwise, it's State Continuation.
10. Total number of Full and Part-Time Employees in 20 or more weeks in the current or preceding year. This calculation looks at the number of employees for determining if Medicare can be primary. This represents the highest number of employees reported during a single pay period in the timeframe. To qualify as Medicare primary a group must have fewer than 20 employees on this line and complete additional registration paperwork.
11. Participation Rate. This is calculated line 8 divided by line 7.
12. Continuation Program in Effect. If line 9 is over 19 for over 50% of the work days in the preceding year, the group qualifies for COBRA treatment, otherwise, it's State Continuation.
13. Medicare Primary. If line 10 is under 20 and the Participating Employer has employees over 65 and otherwise eligible, they may be able to apply for the Medicare Primary exemption.

A. Average Employee Rate (Total). This is the rate being charged by the Plan for each additional enrolled employee.

B. Employee Required Contribution (In Dollars). This is the amount employees are required to contribute to employee-only coverage. Provide only the amounts employees must contribute to employee-only coverage and not the contribution cost for family or other tiers of coverage.

C. Contribution Percentage. This should not exceed 75% for employee-only coverage. This is the percentage of the cost of coverage that is Bourne by employees.