Employer Shared Responsibility Notice

Under the Affordable Care Act’s employer shared responsibility provisions, certain employers—applicable large employers (ALEs)—must offer minimum essential coverage that is affordable and provides minimum value to their full time employees and their dependents.

An Applicable Large Employer (ALE) is an employer that employed at least 50 full time employees on average during the prior calendar year. For information on how to determine whether you are an ALE, see the IRS resource “Determining if an Employer is an Applicable Large Employer” →

An ALE may be subject to an assessment from the IRS if it does not offer its full time employees (and their dependents, not including spouses) the opportunity to enroll in affordable, minimum essential coverage that meets minimum value (at least 60% Actuarial Value) AND one of its full time employees receives federal financial assistance in the form of an Advanced Premium Tax Credit (APTC) for use in purchasing health insurance.

If you are an employer and would like the Health Connector to send you information to learn if one or more of your employees have received or are receiving an APTC in Massachusetts, please fill out the form below and submit it to the Health Connector.

If the information you supply matches the information an applicant or applicants has submitted, the Health Connector will send you a notice listing those employee(s) who have received or are receiving an APTC for the purpose of purchasing health coverage.

This notice is for informational purposes, only. The Health Connector will not be making an assessment against your company even if there is a match.

This notice is NOT a notice for the Massachusetts Employer Medical Assistance Contribution Supplement.
If you receive this notice, it does not mean that the IRS is making an assessment against you. If the IRS does assess you in the future, it will provide separate notice.

For more information about the IRS employer assessment, see the IRS resource “Employer Shared Responsibility Provisions” →

Please note that one or more of your employees may be receiving an APTC but their information may not match the information that you supply and, as a result, they will not appear on any notice that you may receive.

If you have any questions regarding this, please send an email to ACAEmployerNotice@mass.gov

Employer Shared Responsibility Notice Request Form

If you are an employer and would like the Health Connector to send you information to learn if one or more of your employees have received or are receiving an Advance Premium Tax Credit (APTC) in Massachusetts, please fill out the form below and submit it to the Health Connector.

* Required fields

Business Information
Employer/Business Name*
Employer/Business EIN*
Is your business an Applicable Large Employer (ALE)?*
An ALE is an employer that employed at least 50 full time employees on average during the prior calendar year.
- Yes
- No
- Unsure
Contact Information
Please provide the primary business contact's information.
Name of Primary Contact*
First Name Last Name
Business Email Address*
Enter Email Confirm Email
Business Phone Number*
Alternate Business Phone Number
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Is your mailing address also your business location?*
- Yes
- No
Do you have any additional business locations in Massachusetts?*
If you have multiple, physical locations, you can add up to five in the next section.
- Yes
- No
Hidden
Business Locations
How many locations would you like to add?
You can add up to five (5) locations in Massachusetts.
1 - Additional Address
Street Address Address Line 2 City State ZIP Code
2 - Additional Address
Street Address Address Line 2 City State ZIP Code
3 - Additional Address
Street Address Address Line 2 City State ZIP Code
4 - Additional Address
Street Address Address Line 2 City State ZIP Code
5 - Additional Address
Street Address Address Line 2 City State ZIP Code
Acknowledgements
Acknowledgement - Informational Only*
I acknowledge that this notice is for informational purposes, only. The Health Connector will not be making an assessment against my company even if there is a match.*
Acknowledgement - EMAC*
I acknowledge this notice is not a notice for the Massachusetts Employer Medical Assistance Contribution Supplement.*
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Employer Shared Responsibility Notice

Employer Shared Responsibility Notice Request Form

Business Information

Contact Information

Business Locations

Acknowledgements