SFGovAccessibility
Seal of the City and County of San Francisco
City and County of San Francisco

To view graphic version of this page, refresh this page (F5)

Skip to page body

Employer Annual Reporting Form Instructions

 

Reporting Deadline

All Employers covered by the Health Care Security Ordinance or the Fair Chance Ordinance are required to submit the 2014 Employer Annual Reporting Form by April 30, 2015.

Employers by the Health Care Security Ordinance who fail to submit the Annual Reporting Form will be subject to a penalty of $500 per quarter.

 

Before You Begin

You were not covered by the Health Care Security Ordinance (HCSO) or the Fair Chance Ordinance if:

  • You are a private employer and you employed fewer than 20 persons (including those employed outside of San Francisco) in each of the four calendar quarters of 2014.

Employers who were not covered by the HCSO in any of the quarters of 2014 should not complete the 2014 Annual Reporting Form. You do not need to notify the City that you were not covered; no further action is required. If you were covered for one or more quarters, you are required to complete the form.

Please read these instructions before you begin. Note that once you have begun the Annual Reporting Form online, you will not be able to save it and return to it later.

You may want to download screen shots of the Annual Reporting Form (PDF) so you can review and print out the questions before you start the form. 

To complete the Annual Reporting Form, you will need information on:

  • Your Business Account Number;
  • The total number of persons employed (including those outside of SF) for each quarter within specific ranges (i.e. 0-19, 20-49, etc.);
  • The number of employees covered by the HCSO for each quarter;
  • Total health care expenditures made for each quarter of 2014, including:
    • Total payments for health insurance (medical, dental, vision as well as Taft-Hartley plan contributions);
    • Total contributions to the City Option (Healthy San Francisco and MRAs);
    • Total allocations to and total reimbursements from Health Reimbursement Accounts; and
    • Total contributions to Health Savings Accounts
  • Surcharges collected from customers to cover, in whole or in part, the cost of complying with the HCSO
  • Compliance with the Fair Chance Ordinance, including how arrest and conviction history information was used in hiring.

 

Tips for Completing the Annual Reporting Form

  • Do not submit two separate 2014 Annual Reporting Forms using the same Business Account Number unless you are submitting a correction. If multiple businesses or locations share the same Business Account Number, please combine the relevant data into a single Annual Reporting Form. If multiple forms are submitted, only the most recent submission will be recorded.
  • Fill out the form completely. Do not enter commas in numeric fields. Please enter zeroes where appropriate. Enter all dollar amounts in whole dollars; do not include cents. 
  • You may report multiple types of health care expenditures for each employee. For example, if you paid health insurance premiums and also paid into a HRA for a particular employee, the employee would be counted in responses on both the Health Insurance page and the HRA page.
  • Employees who worked for you throughout the year should be counted in each quarter.
  • If you cannot access the online form, please call (415) 554-7892 to request a paper copy of the Annual Reporting Form.
  • The Annual Reporting Form is designed to be viewed with © MS Internet Explorer 9.0.

Business Account Number

Please enter your seven-digit San Francisco Business Account Number and click "Validate.”

This number can be found on the Business Registration Certificate(s) issued by the San Francisco Treasurer & Tax Collector. You can also find your Business Registration Certificate Number by searching the San Francisco Data website.

Please note:

  • If your Business Account Number is only six digits, please add a zero to the beginning of the number.
  • If you do not have a Business Registration Certificate, please contact the Office of the Treasurer & Tax Collector at (415) 554-4400 and register your business before completing the Annual Reporting Form.

Back to top

 

Name and Address

For the Business dba Name, please fill in the trade name (dba), if different than the registered "ownership name" of the business.

For the address, please fill in the business address you would like us to use if we have questions regarding your Annual Reporting Form.

 

Business Type

Check the "nonprofit" check box if you are submitting the form on behalf of an IRS-recognized nonprofit organization.

Check the "control group" check box if you are submitting the form on behalf of more than one entity in the same controlled group of corporations. A "controlled group of corporations" is as a combination of two or more corporations that are under common control as defined in Section 1563(a) of the United States Internal Revenue Code.

 

Business Size

Include all persons who performed work for your business regardless of whether they worked inside or outside of San Francisco. Indicate the size in of the business in each quarter.

In reporting business size, include all employees, regardless of their status or classification as seasonal, permanent or temporary, managers, full-time or part-time, contracted (whether employed directly by the employer or through a temporary staffing agency, leasing company, professional employer organization, or other entity) or commissioned.

If the number of persons who performed work for your business fluctuated during a quarter, answer this question based on the average number of persons who performed work each week during that quarter.

Back to top  

 

Covered Employees

Count the total number of persons who were “Covered Employees” under the HCSO during the quarter. Covered Employees are those who:

  • Qualified as employees entitled to payment of the San Francisco minimum wage (pursuant to the Minimum Wage Ordinance, Chapter 12R of the San Francisco Administrative Code);
  • Were employed by your business for 90 calendar days after his or her first day of work (including any period of leave to which an employee is legally entitled); and
  • Regularly performed at least 8 hours of work per week for your business within the geographic boundaries of San Francisco. For an employee without a regular schedule, you may average his or her hours over the 13 weeks in the quarter.

Covered Employees may include employees for whom you complied with the HCSO by providing health insurance, paying into the City Option, contributing to a reimbursement account, or making other health care expenditure.

Do not include your employees who met any of the following exemption criteria:

  • Persons who were managerial, supervisory, or confidential employees and also earned at least $88,212.00 (or $43.63 hourly) in 2014.
  • Persons who were eligible to receive Medicare coverage;
  • Persons who were eligible for TRICARE (the federal health care program for active duty and retired members of the uniformed services, their families, and survivors);
  • Persons who were “covered employees” under the San Francisco Health Care Accountability Ordinance (HCAO), which applies only to City Contractors (see Section 12Q of the San Francisco Administrative Code for more details about HCAO coverage);
  • Persons who were employed by a nonprofit corporation for up to one year as trainees in a bona fide training program consistent with federal law; or
  • Persons who voluntarily signed a revocable HCSO waiver form and also received health care benefits through another employer (either as an employee or by virtue of being the spouse, domestic partner, or child of another person). The form is effective for one year from the date it is signed, and is available at the HCSO website.

Back to top

 

Health Insurance

For “Number of Persons,” include any employees covered by the HCSO:

  • For whom you paid a health insurance carrier to provide group coverage, including medical, vision and/or dental;
  • For whom you made contributions to a Taft-Hartley plan pursuant to a collective bargaining agreement or union contract; or
  • Who were covered under your self-insured plan.

For “Dollar Amount Spent,” do not count 1) insurance premium contributions made by employees, or 2) expenditures for life insurance, workers’ compensation, or disability insurance.

Tip: Employers with self-insured plans may calculate these expenditures using either the COBRA equivalent rate for the 2014 plan year (minus any administrative fees) or the average actual expenditure amounts. For information, see our Administrative Guidance on this topic.

Back to top

City Option (Healthy San Francisco and MRAs)

If you contributed to the City Option (Healthy San Francisco or the City’s Medical Reimbursement Accounts) for one or more of your covered employees in 2014, report the number of covered employees for whom you made contributions and the total dollar amount contributed for each quarter.

To find this information, refer to the “Employee Rosters” you submitted to the City Option for the four calendar quarters of 2014. You can access this information by logging into your account via the employer login page at http://sfcityoption.org/employers/employer-portal.

Back to top

Health Reimbursement Accounts (HRAs)

A Health Reimbursement Arrangement (HRA) is an employer-funded account or program that reimburses employees for qualified medical expenses up to a maximum dollar amount for a coverage period.

Allocations to an HRA are typically "revocable," meaning that the funds revert to the employer after a specified period. To qualify as a Health Care Expenditure under the HCSO, employers must make funds available for a minimum of 24 months from the date of the contribution, provide notifications to employees about the accounts, and meet other criteria. Please review OLSE's Administrative Guidance on revocable health care expenditures and on HCSO compliance for 2014

 

Stand-Alone HRA - An HRA that is not "integrated" with employer-provided primary health coverage. If a covered employee has access to HRA allocations, but is not actively enrolled in employer-provided primary health coverage (such as medical insurance), that individual has a stand-alone HRA.

If you have questions about whether your HRAs are "stand-alone," please consult your broker.

For “Dollar Amount Allocated,” indicate the amount of money that was made available to the Covered Employees for whom you provided a stand-alone HRA. This is the maximum amount made available for reimbursement for hours payable during the quarter.

For “Dollar Amount Reimbursed,” indicate the amount of money that was actually reimbursed to the Covered Employees during each quarter of 2014 from a stand-alone HRA or paid directly to a health care provider for services rendered.

Check the appropriate box to indicate whether the HRA program was self-administered, meaning the employer administered the program, or whether it was Third-Party Administered, meaning employees sought reimbursements through an independent party.

Check the appropriate boxes to indicate the types of health care costs for which your employees could receive reimbursements under the terms of your stand-alone HRA.




Integrated HRA - An HRA that is integrated with employer-provided primary health coverage. If a covered employee has access to HRA allocations and is also actively enrolled in employer-provided primary health coverage (such as medical insurance), that individual has an integrated HRA. See IRS Notification for more information about these plans.


For “Dollar Amount Allocated,” indicate the amount of money that was made available to the Covered Employees for whom you provided an integrated HRA. This is the maximum amount made available for reimbursement for hours payable during the quarter.

For “Dollar Amount Reimbursed,” indicate the amount of money that was actually reimbursed to the Covered Employees during each quarter of 2014 from an integrated HRA or paid directly to a health care provider for services rendered.

Check the appropriate box to indicate whether the HRA program was self-administered, meaning the employer administered the program, or whether it was Third-Party Administered, meaning employees sought reimbursements through an independent party.

Check the appropriate boxes to indicate the types of health care costs for which your employees could receive reimbursements under the terms of your integrated HRA. 
 

 

Excepted Benefits HRAs

An "excepted benefits HRA" is a Health Reimbursement Account that only reimburses employees for limited types health care costs (such as dental, vision, and long-term care) that are "excepted" from the market reforms of the federal Affordable Care Act. Find more information in the HCSO Administrative Guidance

For calendar year 2014, allocations to an employee's excepted benefits HRA count toward the HCSO employer spending requirement if:

  • the allocations made to that  employee's HRA are less than the amount required for a 20-hour per week employee; or
  • the employer made allocations in excess of 20 hours per week, and the employee actually used the allocations in excess of 20 hours per week for out-of-pocket health care costs in 2014;

And (in addition);

  • The employee has at least a 90-day grace period after a contribution expires to submit claims for reimbursable expenses that the employee incurred before the contribution expired.
  • Subject to the federal tax rules for HRAs, the HRA allocations may be used without restriction for full reimbursement of all excepted benefits that are also qualifying Health Care Expenditures” under the HCSO; and

Find out more in the HCSO Administrative Guidance for 2014.

Excepted Benefits HRAs Questions

- Did you contribute to an Excepted Benefits HRA in excess of the amount required for a 20-hour per week employee?

For a large business, this would mean you allocated more than $2,637.60 (20 hours x 52 weeks x the $2.44 expenditure rate) for an employee who worked during the full year. For a medium sized business, this would mean you allocated more than $1,695.20 (20 hours x 52 weeks x the $1.63 expenditure rate)

- Please report the total number of employees covered by the HCSO for whom you made allocations to an excepted benefits HRA in excess of the amount required for a 20-hour per week employee.

- If you allocated more than the amount required for a 20-hour per week employee, and the employee did not actually use the amount allocated during 2014, Did you "true up" by making replacement health care expenditures for  unused allocations made in excess of 20 hours per week? For more information please review this excerpt on the "true up" from the HCSO Administrative Guidance.

5. Q: If an employer makes revocable contributions to an excepted benefits HRA in excess of 20 hours per week, and the employee does not use the full amount allocated by the end of calendar year 2014, can that employer make additional expenditures to “true up” at the end of the year?

A: Yes, for calendar year 2014 only, these employers may make additional Health Care Expenditures in the manner described below to “true up” at the end of the calendar year.

If, at the end of calendar year 2014, an employee has not used the full amount of revocable contributions to an excepted benefits HRA, and those contributions exceeded the Required Health Care Expenditures for an employee working on average 20 hours per week, the employer may make replacement Health Care Expenditures equivalent to the unused amount in excess of 20 hours. Replacement Health Care Expenditures must be made by April 10, 2015 for the OLSE to count those expenditures toward the 2014 Employer Spending Requirement.

If the employer does not make sufficient replacement expenditures, the employer will not satisfy its Employer Spending Requirement for 2014, and penalties will apply.

- If applicable, what was the total amount of the "true up"? Please report on the total amount of replacement Health Care Expenditures made for Covered Employees.

- How did you spend the replacement “true up” funds? (insurance payments, City Option Contribution, etc.). To count toward the 2014 HCSo spending requirement, "true-up" expenditures may be made for any valid Health Care Expenditure.

Did any of your employees voluntarily choose to "opt out" of HRA balances for amounts contributed before January 1, 2014? The Health Care Security Ordinance permits employees to "knowingly, voluntarily, and permanently waives in writing the unused portion" of HRA allocations from before January 1, 2014. Report on how many of your employees chose to do so.

How much was the total amount relinquished? Please report on the total amount of the HRA allocations that your Covered Employees relinquished.  

 

Back to top

 

 

 

Health Savings Accounts (HSAs)

Health Savings Accounts (HSAs) are tax-exempt accounts that are distinct from HRAs (described above).  An employee must be covered under a high deductible health plan to have an HSA. Funds contributed to these accounts are owned by the employee. See IRS Publication 969 for more information.

If you contributed to an HSA for any of your covered employees, report the total employer contribution to those accounts. Do not count any money contributed by employees.

 

Back to top

Surcharge

If you added a surcharge to your customers’ bills that you described as specifically intended for employees’ health care benefits (such as a “Healthy San Francisco surcharge” “or an “employee health care surcharge” on a restaurant check), select “Yes,” and report the full amount collected through the surcharge.

If you added a surcharge to your customers’ bills that covered health care costs in addition to other costs, such as a charge for “San Francisco Employer Mandates,” select “Yes,” and report only the portion of surcharge that was collected for health care costs.

Back to top

 

 

 

Fair Chance Ordinance Reporting

 

1) Report on the number of employees your company or organization hired to work in San Francisco between August 13, 2014 and December 31, 2014 (after the Fair Chance went into effect on August 13). Include part-time, temporary, seasonal employees, as well as telecommuters who work within the geographic boundaries of San Francisco.

2) Report on whether your company or organization's employment application for jobs in San Francisco ask about arrest or conviction information.  This can include an online application template that is not specific to San Francisco, but that is used by applicants for San Francisco jobs.

3) Report on whether the company or organization conducted background checks on conviction and or arrest records before a live interview (including a telephone interview)?

4) For more information on the types of information that employers may never ask about see Fair Chance Ordinance FAQ #26 (PDF).

5) Report on whether you changed your job application process to comply with the San Francisco Fair Chance Ordinance:

  • Yes, we changed our application and/or background check process. We changed how/whether/when we inquire about conviction and arrest histories.
  • No, our existing application and/or background check process was already compliant with the law. We do inquire about conviction and arrest histories, but how we do already complied with the requirements of the Fair Chance Ordinance.
  • No, we never considered arrest records or convictions, and we still do not.
  • No, we have not yet changed our process to comply with the law.

 

Corrections / Resubmissions

If you made a mistake on your Annual Reporting Form, you may re-submit a corrected form. Start a new form at https://etaxstatement.sfgov.org/OLSE

The corrected submission will replace any form submitted previously with the same Business Registration Certificate Number.

Back to top

 This notice is intended to provide general information and does not establish policy or offer legal advice regarding the HCSO, Chapter 14 of the San Francisco Administrative Code. If you have any questions about your obligations under the ordinance, please visit www.sfgov.org/olse/hcso, call (415) 554-7892 or email hcso@sfgov.org.

 

 

 

 
Last updated: 4/1/2015 10:33:15 AM