Tag Archives: Benefits Package

How Will Obamacare Affect My Wellness Program?

Beginning in 2014, the Affordable Care Act (ACA) imposes “pay or play” requirements on large employers. Under these rules, large employers that do not offer health coverage to their full-time employees and their dependents, or that offer coverage that is either unaffordable or does not provide minimum value, may be subject to a penalty. This penalty is also referred to as a “shared responsibility payment.”

On May 3, 2013, the Internal Revenue Service (IRS) released a proposed rule on ACA’s minimum value and affordability requirements. This proposed rule includes guidance on how health reimbursement arrangements (HRAs) and wellness program incentives are counted in determining the affordability of employer-sponsored coverage.

The regulation is not final. However, employers may rely on the proposed regulation until final regulations or other applicable guidance is issued.


The affordability of any health coverage offered by a large employer is a key point in determining whether the employer will be subject to a shared responsibility penalty. The coverage is considered affordable if the employee’s required contribution to the plan for self-only coverage does not exceed 9.5 percent of the employee’s household income for the taxable year.

“Household income” means the modified adjusted gross income of the employee and any members of the employee’s family, including a spouse and dependents. The IRS established three safe harbors for employers to use, which measure affordability based on the employee’s W-2 wages, the employee’s rate of pay or the federal poverty level for a single individual.

HRA contributions and wellness program incentives

The proposed regulation includes special rules for determining how HRAs and wellness program incentives are counted in determining the affordability of eligible employer-sponsored coverage. Employer contributions to health savings accounts (HSAs) do not affect the affordability of employer-sponsored coverage because HSA amounts generally may not be used to pay for health insurance premiums.

HRA Contributions

The proposed rule provides that amounts made newly available under an HRA that is integrated with an eligible employer-sponsored plan for the current plan year are taken into account only in determining affordability if the employee may either:

  • Use the amounts only for premiums; or
  • Choose to use the amounts for either premiums or cost sharing.

Treating amounts that may be used either for premiums or cost-sharing only toward affordability prevents double counting the HRA amounts when assessing minimum value and affordability of eligible employer-sponsored coverage.

Wellness Program Incentives

The proposed rule also contains clarification on affordability when premiums may be affected by wellness programs. Under the proposal, the affordability of an employer-sponsored plan is determined by assuming that each employee fails to satisfy the wellness program’s requirements, unless the wellness program is related to tobacco use. This means the affordability of a plan that charges a higher initial premium for tobacco users will be determined based on the premium charged to non-tobacco users, or tobacco users who complete the related wellness program, such as attending smoking cessation classes.

Transition relief is provided in the proposed rule for plan years beginning before Jan. 1, 2015. Under this relief, if an employee receives a premium tax credit because an employer-sponsored health plan is unaffordable or does not provide minimum value, but the employer coverage would have been affordable or provided minimum value had the employee satisfied the requirements of a nondiscriminatory wellness program that was in effect on May 3, 2013, the employer will not be subject to the employer mandate penalty.

The transition relief applies for rewards expressed as either a dollar amount or a fraction of the total required employee premium contribution. Also, any required employee contribution to premium determined based upon assumed satisfaction of the requirements of a wellness program under this transition relief may be applied to the use of an affordability safe harbor.

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New Legislation Will Help Businesses Avoid Higher Costs Due to ACA

 From the Texas Association of Health Underwriters

Legislation signed by Gov. Rick Perry will allow thousands of Texas businesses to keep for now their status as large employers and avoid additional regulations that businesses considered to be small employers may face as a result of the Affordable Care Act (ACA).

SB 1332, sponsored by Sen. Robert Duncan (R-Lubbock) and Rep. John Smithee (R-Amarillo) amends Texas law to allow for the inclusion of part-time employees in the methodology used to classify a business as a large or small employer. Current Texas law defines a small employer as an entity that employs 2-50 employees and a large employer as a business with 51 or more employees. Current law does not include part-time employees in that methodology.

SB 1332 redefines large and small employers using the total number of employees, including those that are part-time, rather than defining eligible employees as those who work 30 hours or more. The legislation amends the state insurance code to apply provisions of the Health Insurance Portability and Availability Act to health benefit plans of small and large employers using the new methodology.

Effective January 1, 2014, for the purposes of implementing the ACA, the federal government will define a small employer as an entity that employs 1-100 employees, meaning that some employers currently considered to be large employers in Texas (51-100 employees) will be reclassified as small employers. Actuarial studies of new rating requirements that will apply to small employers have projected premium increases ranging from 40-100 percent. SB 1332 will allow those businesses to avoid the higher premiums and small employer regulations of the ACA.

The ACA’s “pay or play” provision requiring employers with more than 50 employees to provide insurance coverage will still apply.

SB 1332 was a legislative priority of the Texas Association of Health Underwriters. The measure was also supported by the Texas Association of Business and National Federation of Independent Businesses.

“Our goal in championing the legislation was to help this group of Texas employers avoid premium rate shock as a result of changes in federal law,” said Kelly Fristoe, president of TAHU.

Fristoe continued, “The ACA will bring tough changes for many Texas businesses, but SB 1332 will help ease the burden for thousands of employers, workers and their families. We applaud and thank Sen. Duncan and Rep. Smithee for their leadership in providing this relief for Texas businesses”.

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Risk Assess Your Employee Benefits

When it comes to signing up for your Employee Benefits you will want to perform some level of risk assessment. Employee Benefits packages are carefully constructed by your employer and provider and are legally obliged to conform to statutory regulations so it’s unlikely they will contain a large risk. But it’s always advised that you take the time to look at your options and become acquainted with and possible long term risks and be in the position have your questions answered.

Cost of Options

Some employers offer a number of packages available at varying prices. This could include added benefits, variation in cover types or increased coverage. The affordability of the health cover your employer offers is only measured on the lowest available option, additional extras are not subject to the affordability regulations.

For this reason, you might want to take extra time to assess the cost of the your options and look at the affordability on your own terms. You may find you don’t want anything above the lowest cost option or an alternative package may be better value for your situation.

Family coverage

Some companies offer the option of family insurance coverage, but at a cost. Affordability penalties do not apply to the coverage offered to employee families, so there is no guarantee the cost of family coverage will be in line with the affordability of your self-only policy.

Compare the cost of family insurance with an outside provider against the cost of the premium through your employer. Family insurance can be very expensive; including this in your employee benefits may come at a very high price in the long term.


Employee Benefits packages differ from business to business and even within business, with different packages on offer to employees. Many packages include retirement benefits, including pensions and extended health care – but there is no standard requirement. If you have any existing plans for your retirement, look to see how your employee benefits package fits this plan or what changes might take place.

If you haven’t put any plans in place, look to see if the options available appeal to you as an outcome. If your retirement benefits don’t meet your expectations, talk to your employer about your plans or look into alternative options such as outside providers or investments for an option that suits.

Risk assessing your Employee Benefits package has a lot to do with assessing the possible long term affects on your situation. By taking the time to look at these points in the beginning, you are in a good position to bring any queries to your employer and fully understand your options.

If you have questions about Employee Benefits, ask an expert here.

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Healthcare Reform and COBRA FAQ

In 2010, health care reform became a reality with the passage of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010. The U.S. Department of Labor has issued Frequently Asked Questions on how the health care reform law affects COBRA and the COBRA premium subsidy.

Did the health care reform legislation extend the COBRA premium reduction (subsidy)? No. The new health care reform legislation, The Patient Protection and Affordable Care Act (PPACA) as amended by the Health Care and Education Reconciliation Act, did not extend the eligibility time period for the COBRA premium reduction. Eligibility for the subsidy ended May 31, 2010; however, those individuals who become eligible on or before May 31, 2010 can still receive the full 15 months as long as they remain otherwise eligible.

Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.

Individuals who become disabled can extend the 18 month period of continuation coverage for a qualifying event that is a termination of employment or reduction of hours. To qualify for additional months of COBRA continuation coverage, the qualified beneficiary must:

  • Have a ruling from the Social Security Administration that he or she became disabled within the first 60 days of COBRA continuation coverage (or before); and
  • Send the plan a copy of the Social Security ruling letter within 60 days of receipt, but prior to expiration of the 18-month period of coverage. If these requirements are met, the entire family qualifies for an additional 11 months of COBRA continuation coverage.

Did the health care reform legislation eliminate COBRA?
No. The new health care reform legislation, The Patient Protection and Affordable Care Act (PPACA) as amended by the Health Care and Education Reconciliation Act, did not eliminate COBRA or change the COBRA rules. See An Employee’s Guide to Health Benefits Under COBRA-The Consolidated Omnibus Budget Reconciliation Act for more information about COBRA.

How does the new health care reform legislation affect my coverage under my group health plan?
The new health care reform legislation, The Patient Protection and Affordable Care Act (PPACA) as amended by the Health Care and Education Reconciliation Act, makes many changes to employee health benefit plans. Some of the changes go into effect for the first plan year that begins on or after six months after enactment (September 23, 2010), so for calendar year plans, January 1, 2011. However, many changes do not go into effect until the first plan year beginning on or after January 1, 2014.

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Steaming Toward the ObamaCare “Train Wreck”

By Karl Rove

The Wall Street Journal
April 18, 2013

The implementation of this unpopular law is a story of missed deadlines and general bungling.

In congressional testimony last week, Health and Human Services Secretary Kathleen Sebelius blamed Republican governors for her department’s failure to create a “model exchange” where consumers could shop for health-insurance coverage in states that don’t set up their own exchange.

Nice try, but GOP governors aren’t the problem. Team Obama’s tendency to blame someone else for its shortcomings is tiresome. The Affordable Care Act requires HHS to operate exchanges in states that won’t operate their own. Since the act became law in March 2010, it has been abundantly clear that the agency would have to deploy a model exchange. It is Ms. Sebelius’s fault there isn’t one.

There is more to this failure. Even exchanges organized by Democratic and Republican governors may not be functioning by the health-law’s Oct. 1 deadline, because HHS has been slow with guidance and approvals.

Last month Gary Cohen, an official with the Centers for Medicare and Medicaid Services who oversees technology for the exchanges, told members of America’s Health Insurance Plans (a trade association) that he was “pretty nervous” about implementation. He hoped enrollment is “not a third world experience.”

Part of this problem stems from the way the law is crafted. For example, a subsidy to help small businesses provide insurance coverage while ObamaCare ramped up was so complicated and difficult to use that only 1% of its $40 billion budget was spent.

Other provisions have been poorly executed or needlessly delayed. Ms. Sebelius’s HHS has missed dozens of deadlines for major rule-making or program start dates required by the law.
For example, ObamaCare created the Small Business Health Options Programs, where small businesses could select insurance plans beginning in October with coverage starting in January. The program has been set up, but employees are offered only one plan, not a choice among many. HHS announced a full range of plans would be delayed until 2015.

Then there is President Obama’s promise that no American would be denied coverage because of a pre-existing condition. The Affordable Care Act set aside $5 billion to subsidize, through 2014, coverage for an estimated 270,000 to 350,000 people with pre-existing conditions and no insurance. So far 135,000 have been covered but the $5 billion is nearly exhausted. HHS stopped signing up people in February.

A long-term care entitlement, the so-called Class Act, turned out to be so fiscally untenable that Democratic support evaporated before its 2012 start date. The entitlement program was repealed in the December fiscal cliff deal.

Then there is the Independent Payment Advisory Board, the 15-person committee charged with reducing Medicare spending to a “target level” by 2015. Its recommendations take effect automatically unless overruled by a congressional supermajority.

By law, the board cannot “raise revenues or Medicare beneficiary premiums . . . deductibles, coinsurance, and copayments, or otherwise restrict benefits or modify eligibility criteria.” This means that the board would likely have to cut reimbursements to health providers who already receive roughly 80% of what private insurers pay for the same procedures for non-Medicare patients. This will discourage doctors from taking on Medicare patients.

The IPAB’s first recommendations are due Jan. 1, 2014 and are supposed to take effect a year after that. The president hasn’t appointed anyone to the board, and it’s unlikely he can come up with 15 nominees, get them confirmed, and have them in place to deliver recommendations in time. Maybe he plans to leave the recommendations up to the secretary of HHS, which is allowed under the health law, but that ought to concern anyone who’s seen Ms. Sebelius in action.

Or maybe the president will just let the deadline for IPAB recommendations slide. An ugly battle in 2014 over Medicare cuts proposed by a committee he appointed might rile up seniors in the midterm elections, leading to the defeat of House and Senate Democrats who voted for the law.

Still, the administration is eager to get one health-care program under way. ObamaCare provides $54 million to hire individuals and groups to facilitate enrollment when the exchanges begin this October.
There are rumblings in Washington that HHS believes more money is needed for these “navigators” or “helpers.” The House Energy and Commerce Committee wrote Ms. Sebelius this week asking what kind of groups are eligible, how they’ll be selected, what standards must they meet, how they will be trained and supervised, and what the success measures will be. This program could turn into patronage for Mr. Obama’s liberal allies such as unions and community activists.

The Affordable Care Act may be unworkable in the aggregate, but it is also dogged by incompetent implementation. Even Democrats are increasingly concerned. At a hearing on Wednesday, Sen. Max Baucus expressed his frustration about a variety of problems, including whether the health-insurance exchanges will be established on time. “I just see a huge train wreck coming down,” he told Ms. Sebelius.

A version of this article appeared April 18, 2013, on page A13 in the U.S. edition of The Wall Street Journal, with the headline: Steaming Toward the ObamaCare ‘Train Wreck’ and online at WSJ.com.

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HHS Proposes Delay to Key Aspect of SHOP Exchanges

Beginning in 2014, individuals and small employers will be able to purchase health insurance through online competitive marketplaces, or Exchanges. The Affordable Care Act (ACA) directs each state that chooses to operate an Exchange to also establish a Small Business Health Options Program (SHOP). According to the Department of Health and Human Services (HHS), the SHOP will assist eligible small employers in providing health insurance for their employees.

In addition, ACA directs HHS to establish and operate the federally-facilitated Exchange (FFE) in each state that does not establish its own Exchange. The FFE will include both individual market and SHOP components.

Small employers with up to 100 employees will be eligible to participate in the Exchanges. However, until 2016, states may limit employers’ participation in the Exchanges to businesses with up to 50 employees. Beginning in 2017, states may allow businesses with more than 100 employees to participate in the Exchanges.

On March 11, 2013, HHS issued a proposed rule that would amend some of the standards for SHOP Exchanges. Most notably, the proposed rule would create a transition policy regarding an employee’s choice of qualified health plans (QHPs) in the SHOP. The transition policy would delay implementation of the employee choice model as a requirement for all SHOPs until 2015 plan years.

At this point, the transition policy has not been finalized. However, it is a good indicator of the approach HHS intends to take with respect to implementing the SHOPs.

Functions of Shop

On March 27, 2012, HHS issued a final rule on establishment of the Exchanges. This final rule describes the minimum functions of a SHOP. The final rule provides that a SHOP must allow employers the option to offer employees all QHPs at a level of coverage chosen by the employer—bronze, silver, gold or platinum. In addition, the final rule permits SHOPs to allow a qualified employer to choose one QHP for its employees.

In a separate final rule issued in March 2013, HHS provided that the federally-facilitated SHOP (FF-SHOP) would give employers the choice of offering only a single QHP, as employers customarily do today, in addition to the choice of offering all QHPs at a single level of coverage.

Transition Policy 

In the proposed rule, HHS provides a transition policy for 2014 plan years that is intended to provide all SHOPs (both state SHOPs and the FF-SHOP) with additional time to prepare for the employee choice model.

Under the proposed transition policy, for plan years beginning on or after Jan. 1, 2014, and before Jan. 1, 2015, a state SHOP would not be required to permit qualified employers to offer their employees a choice of QHPs at a single level of coverage. However, a SHOP may decide to provide this option to employers for 2014 plan years.

In addition, for plan years beginning on or after Jan. 1, 2014, and before Jan. 1, 2015, FF-SHOPs would not allow qualified employers to offer their employees a choice of QHPs at a single level of coverage. For 2014 plan years, the FF-SHOP would assist employers in choosing a single QHP to offer their qualified employees.

According to HHS, the transition policy would increase the stability of the small group market while providing small groups with the benefits of SHOP in 2014 (for example, choice among competing QHPs and access for qualifying small employers to the small business health insurance tax credit).

The 2012 final rule also included a premium aggregation function for the SHOP that was designed to assist employers whose employees were enrolled in multiple QHPs. Because this function will not be necessary in 2014 for SHOPs that delay implementation of the employee choice model, the proposed rule would make the premium aggregation function optional for plan years beginning before Jan. 1, 2015.

Texas Associates Insurors will continue to monitor health care reform developments and will provide updated information as it becomes available.

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5 Questions Businesses Should Be Asking About Employer Shared Responsibility

Under the Affordable Care Act, employers have new responsibilities towards their employees to provide them with affordable health coverage. These Employer Shared Responsibilities have very specific guidelines – so here are 5 questions you should be asking.

How do I know if this applies to my company?

These regulations concern companies that are deemed to be large employers. This means companies employing 50 full-time employees or the equivalent in a combination of full and part-time employees are liable for Employer Shared Responsibilities and must offer affordable healthcare. If you employ fewer than 50 full-time, or equivalent, employees or already offer affordable health care, this does not apply to you.

How do I calculate whether I meet the employee threshold?

Full-time employees are considered as working a minimum 30 hours a week. Part-time employees are assumed to work half that, 15. If your employees, be it all full-time or a combination, work the equivalent hours of 50 full-time employee then you meet the threshold.

How is an employer to know that the coverage is affordable?

Affordable coverage is defined as being no more than 9.5% of an employee’s annual household income. If the employer does not know the annual household income, it must not be more than 9.5% of the annual wages paid to the employee.

What about companies close to the 50-employee threshold?

Employers can calculate their average number of employees over a six-consecutive-month period in the year and use this to determine whether or not they need to offer a health care plan. There is Transitional Relief available from an Employer Shared Responsibility payment in this case.

When is an employer liable for an Employer Shared Responsibility payment?

If an employer is found to be in breach of the Employer Shared Responsibility provisions set out by the Affordable Care Act, they are liable to make a payment. They are considered liable if they do not offer health care to their full-time employees, or the coverage offered is found to be unaffordable or not providing minimum value. If an employer is offering health care to most of their employees but one or more of their full-time employees receives a premium tax credit for enrolling in a government program, the employer is liable for a payment.

If you have more insurance questions, click here to contact an expert

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Filing Whistleblower Complaints Under the Affordable Care Act

Some very interesting information provided in a recent legislative brief from Texas Associates Insurors…

The Affordable Care Act (ACA) includes whistleblower protections for employees. Employees are protected from retaliation for reporting alleged violations of Title I of the ACA. Employees are also protected from retaliation for receiving a federal health insurance income tax credit or a cost-sharing reduction when enrolling in a qualified health plan.

The U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) published an interim final rule in the Federal Register that governs whistleblower complaints filed under Section 1558 of the ACA. The rule was effective on Feb. 27, 2013. Comments may be submitted until April 29, 2013.


The ACA contains various provisions to make health insurance more affordable and accountable to consumers. To further these goals, the ACA’s section 1558 provides protection to employees against retaliation by an employer for reporting alleged violations of Title I of the Act or for receiving a health insurance tax credit or cost-sharing reductions as a result of participating in a Health Insurance Exchange or Marketplace.

Title I includes a range of insurance company accountability requirements, such as the prohibition of lifetime limits on coverage or exclusions due to pre-existing conditions. Title I also includes requirements for certain employers. Many of the provisions in Title I are not effective until 2014.


The definitions “employer” and “employee” under this whistleblower provision are found in the Fair Labor Standards Act. Therefore, this provision prohibits retaliation by private and public sector employers.


An employer may not discharge or in any manner retaliate against an employee because he or she:

  • Provided information relating to any violation of Title I of the ACA, or any act that he or she reasonably believed to be a violation of Title I of the ACA to the employer, the federal government or a state’s attorney general;
  • Testified, assisted or participated in a proceeding concerning a violation of Title I of the ACA, (or is about to do so); or
  • Objected to, or refused to participate in, any activity that he or she reasonably believed to be in violation of Title I of the ACA.

In addition, an employer may not discharge or in any manner retaliate against an employee because he or she received a credit under section 36B of the Internal Revenue Code of 1986 or a cost-sharing reduction under section 1402 of the ACA for health coverage purchased through an Affordable Health Insurance Exchange (also known as a Health Insurance Marketplace).

If an employer takes retaliatory action against an employee because he or she engaged in any of these protected activities, the employee can file a complaint with OSHA.


An employer may not take unfavorable employment action against an employee based on the employee’s protected activity. Specifically, an employer may be found to have violated the ACA if the employee’s protected activity was a contributing factor in the employer’s decision to take unfavorable employment action against the employee.

Unfavorable employment actions may include:

  • Firing or laying off;
  • Blacklisting;
  • Demoting;
  • Denying overtime or promotion;
  • Disciplining;
  • Denying benefits;
  • Failure to hire or rehire;
  • Intimidation;
  • Making threats;
  • Reassignment affecting prospects for promotion; and
  • Reducing pay or hours of work.


Retaliation complaints must be filed within 180 days after an alleged violation of the ACA occurs. An employee who believes that he or she has been retaliated against in violation of the ACA may file a complaint with OSHA. An employee’s representative may also file a complaint on the employee’s behalf.


An employee can file an ACA complaint with OSHA by visiting or calling the local OSHA office or sending a written complaint to the closest OSHA regional or area office. Written complaints may be filed by facsimile, electronic communication, hand delivery during business hours, U.S. mail (confirmation services recommended) or other third-party commercial carrier.

The date of the postmark, facsimile, electronic communication, telephone call, hand delivery, delivery to a third-party commercial carrier or in-person filing at an OSHA office is considered the date filed. No particular form is required and complaints may be submitted in any language.

For OSHA area office contact information, please visit www.osha.gov/html/RAmap.html or call 1-800-321-OSHA (6742).

Upon receipt of a complaint, OSHA will first review it to determine whether there is a valid complaint allegation (for example, timeliness or coverage). Complaints are then investigated in accord with the statutory requirements.


If the evidence supports an employee’s claim of retaliation and a settlement cannot be reached, OSHA will issue an order requiring the employer to, as appropriate, reinstate the employee, pay back wages, restore benefits and provide other possible relief to make the employee whole.

OSHA’s findings and order become final within 30 days, unless they are appealed within that time period. After OSHA issues its findings and order, either party may request a full hearing before an administrative law judge of the Department of Labor. The administrative law judge’s decision and order may be appealed to the Department’s Administrative Review Board.

If a final agency order is not issued within 210 days from the date the employee’s complaint is filed or within 90 days after the employee receives OSHA findings, then the employee may file a complaint in the appropriate U. S. district court, with a copy provided to OSHA.


For a copy of the Affordable Care Act, the regulations (29 CFR 1984) and other information go to www.whistleblowers.gov.

For information on the Office of Administrative Law Judges procedures and case law research materials, go to www.oalj.dol.gov and click on the link for “Whistleblower.” For information on the Affordable Care Act, go to www.healthcare.gov.

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How Offering Employee Benefits Could Help You Attract New Recruits

Offering Employee Benefits not only benefits your existing employees, it could be a deciding factor for a new recruit to choose to work with your company. Winning over potential employees could be made easier by being able to offer them the best possible benefits program.


Employees with families have a lot to consider when taking on a job offer. A comprehensive employee benefits program could be the deciding factor for them. Dental insurance for their children or medical insurance for their spouses could be vitally important for your employees. Being in a position to offer this to your staff could appear very attractive to new recruits.

Experienced workers

Older, more experienced workers may have reservations when it comes to changing jobs, especially if they are approaching retirement age. If you have offered a position to someone it may be reassuring to them to know of the retirement options you offer as part of your employee benefit. This could give them piece of mind for the future and endear them to the idea of working with you.

Voluntary benefits

Offering your employees the option to take on voluntary benefits could go a long way in promoting a potential employee’s impression of your company. If you offer someone the job, you want to be sure they will choose to come work with you. Offering the option to customize their employee benefits could make your job offer seem even more attractive.

When you offer someone a job, you want to make sure they make an informed decision if they choose to take it. You also want to make sure you don’t loose out on potentially crucial employees because you didn’t sell yourself to them. Being able to offer your employees attractive and comprehensive employee benefits can help you win over those valuable recruits and make your company the one they want to work for.

If you’re looking for advice on employee benefits, click here to contact an expert.

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