Group health participation calculator

Check participation

Participation is enrolled employees divided by eligible employees, after the employees with a valid waiver are taken out of the count. The default is a 12-person group with 2 valid waivers and 6 employees enrolling, against a 70% minimum. Change the minimum to match the carrier's underwriting guide; it is not the same everywhere.

Nothing you enter leaves the browser. You can run it with the client on the phone while they count heads.

How carriers count participation

Every carrier's small group guide has a version of the same rule: a minimum share of eligible employees must enroll for the carrier to issue the plan. Seventy percent is the most common number. Some carriers ask for 50% or 60% on certain products, some ask for 75%, and the rule can differ between a carrier's fully insured and level-funded products. The guide also defines who counts, and that definition matters as much as the percentage.

• Eligible employees are the people the employer's eligibility rule covers, usually employees working 30 or more hours a week once any waiting period ends. Part-time staff the plan does not offer coverage to are not in the count.
• Valid waivers come off the top. Coverage under a spouse's or parent's group plan almost always counts. Medicare, Medicaid, TRICARE and VA coverage usually count. Individual-market coverage often does not, and carriers differ, so check before you rely on it.
• Enrolled employees are the employees who elect coverage. Dependents don't add to participation; an employee who covers a family counts once.
• Owners count like employees in most guides, but a group plan needs at least one enrolled employee who isn't an owner or an owner's spouse to be a group plan at all.

A worked example

Carriers round differently at the margin. This calculator rounds the minimum up to the next whole employee, which is the conservative reading. A carrier that rounds 6.3 down to 6 is more generous than the calculator, never less.

The November 15 to December 15 window

Under the ACA's guaranteed availability rule, a small group carrier may set minimum participation and minimum contribution rules for most of the year. It may not use them to turn down a group that applies between November 15 and December 15 for coverage that starts on January 1. A group that can't meet participation any other time can still buy a plan with a January 1 effective date if it applies in that window.

That window is useful for very small groups, groups with many young employees on a parent's plan, and groups where most employees already have coverage through a spouse. It is not a way around the rest of underwriting: the group still has to be a real employer group, and the carrier can still apply its other rules.

Mark the date in your calendar for every client that failed participation in the past year. A client turned down in April is a January 1 quote in December.

What to do when a group falls short

• Recount the waivers. The most common reason a group misses is a waiver that was never collected. One signed waiver from an employee on a spouse's plan can be the difference.
• Raise the contribution for employee-only coverage. Employees decline when their share of the premium is too high for their pay. Our contribution strategy calculator shows what a higher employee-only contribution costs the employer.
• Add a lower-premium plan option. A second, cheaper plan gives the employees who would otherwise decline something they can afford.
• Move the start date. If the group applies between November 15 and December 15 for January 1, the carrier can't apply the minimum.
• Look at a different product. Some carriers have lower minimums on certain products, and an ICHRA has no participation requirement at all because each employee buys an individual plan.

Participation and contribution move together

Carriers pair the participation minimum with a minimum employer contribution, most often 50% of the employee-only premium. The two rules protect against the same risk: a plan that only the people who expect large claims will join. A group that pays a generous share of the premium almost always meets participation, and a group that pays the minimum often doesn't.

Our guide to the minimum employer contribution covers the contribution rule. When you present a quote, put both numbers on the same page: the contribution the client chose and the participation it is likely to produce.

The employees who decline are usually the youngest and lowest-paid, because their share of the premium is the largest part of their paycheck. If participation is close, model the contribution change for employee-only coverage first; that is where an extra dollar of employer money buys the most enrollment.

Count participation before you quote

Most participation surprises come from a census that wasn't checked against the eligibility rule. Before you send a census to a carrier, go through it with the client line by line:

• Remove anyone the plan won't cover. Employees under the hours threshold, seasonal or temporary staff the eligibility rule excludes, and 1099 contractors are not eligible employees.
• Check the waiting period. New hires still in a waiting period are usually not counted until they become eligible.
• Separate COBRA and retirees. Most carriers leave people on COBRA out of the participation count. Check the guide.
• Ask every non-enrolling employee why. A spouse's plan, Medicare or TRICARE is a valid waiver; "too expensive" is not.
• Note the owners. Count them as the carrier's guide says, and confirm at least one enrolled employee isn't an owner or an owner's spouse.

Do this before the quote, not after the carrier's underwriter asks. A group that learns it misses participation two weeks before its effective date has few options; a group that learns it 60 days out can collect waivers, change the contribution or move the date.

Keep the signed waivers with the group's file. Carriers can ask for them at audit, and they are the evidence that a declining employee was offered coverage, which matters for larger employers under the employer mandate as well.

What this calculator does not check

It does not know the carrier's waiver list, its rounding rule or whether it counts owners. Use the carrier's current small group underwriting guide for those. It also does not check eligibility itself; if the employer's eligibility rule changes, the count of eligible employees changes with it.

It does not apply to an ICHRA, where each employee buys an individual plan, or to a QSEHRA. And it does not cover the larger-group market, where participation rules exist but are negotiated case by case.