Employee Definition – Blue Cross Explanation
Employee Definition - Blue Cross Explanation

How does ACA/Obamacare Health Reform Define an eligible employee?

§10753 Non Grandfathered Plans  (f) “Eligible employee” means either of the following:

(1) Any permanent employee who is actively engaged

CA DOI Bulletin 94-9A: “Actively at Work” or “Not Disabled”

on a full-time basis in the conduct of the business of the small employer with a normal workweek of an average of 30 hours per week over the course of a month, in the small employer’s regular place of business, who has met any statutorily authorized applicable waiting period requirements. The term includes sole proprietors or partners of a partnership,

[But it doesn’t allow them to be a 1 employee – employer?  See last line of Employer definition 10753 q 1 – only to extent required by PPACA ]

if they are actively  engaged on a full-time basis in the small employer’s business, and they are included as employees under a health benefit plan of a small employer, but does not include employees who work on a part-time, temporary, or substitute basis. It includes any eligible employee, as defined in this paragraph, who obtains coverage through a guaranteed association. Employees of employers purchasing through a guaranteed association shall be deemed to be eligible employees if they would otherwise meet the definition except for the number of persons employed by the employer.

A permanent employee who works at least 20 hours but not more than 29 hours is deemed to be an eligible employee if all four of the following apply:

(A) The employee otherwise meets the definition of an eligible employee except for the number of hours worked. (B) The employer offers the employee health coverage under a health benefit plan. (C) All similarly situated individuals are offered coverage under the health benefit plan. (D) The employee must have worked at least 20 hours per normal workweek for at least 50 percent of the weeks in the previous calendar quarter.

The insurer may request any necessary information to document the hours and time period in question, including, but not limited to, payroll records and employee wage and tax filings. 

View Definition Blue Cross Underwriting Requirement

DE 6 or 9 DE 6 or 9

(2) Any member of a guaranteed association as defined in subdivision (s).

 Participation rules – % of employees required to be on a group health plan Blue Cross eligibility statement for owners not on DE 9 CFR § 31.3401(c)-1  

(a) The term employee includes every individual performing services if the relationship between him and the person for whom he performs such services is the legal relationship of employer and employee.

(d) Whether the relationship of employer and employee exists will in doubtful cases be determined upon an examination of the particular facts of each case.

Section 3598 26 US Code – Real Estate Agents and direct sellers

(a)General ruleFor purposes of this title, in the case of services performed as a qualified real estate agent or as a direct seller—

(1) the individual performing such services shall not be treated as an employee, and
(2) the person for whom such services are performed shall not be treated as an employer.

Other Laws & Government rules defining an employee for THEIR purposes!


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 Technical Links & Resources


National Underwriter Health Reform Facts

ABX1-2 Pan 5.2013  Brings CA into compliance with Health Care Reform

One must read an Insurance Policy or Law THREE times. Then when you think you understand it, read it again.

The term is "In-Network Provider"

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