Guidance for Form 5500 & PCORI

Self-funded health plans are required to file a Form 5500 to provide information on the funding of the plan to the federal government. There is a general exemption for groups with less than 100 participants if the plan is either fully insured or unfunded. Allied self-funded plans are considered "funded" and therefore all size groups are required to complete the filing within seven months of the end of the plan year.

If you have fewer than 100 participants, you may use the 5500-SF (short form) for your filing. The IRS EFast online system can help you determine the correct form for your plan. 

We've created this web page to help you or your accountant with this process by providing common links and explanations for a 5500-SF filing. For information about your PCORI filing, please scroll to the bottom of the page.

How to File

All 5500-SF filings must be done electronically using the government's EFAST2 processing system. Register as a new user or login to an existing account. 

Sample 5500-SF

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Click on image to download  sample of the 2023 5500-SF form.

5500-SF Instructions

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Click on image to download the complete 5500-SF instructions.

Summary Annual Report (SAR)

The Department of Labor also requires you to make available to plan participants a summary report of your plan(s). There is no "official" form - this is just a text summary of your plan(s) and participant rights. IRS guidelines for the SAR may be found on the IRS website. Examples of SAR reports may be found here.
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An extension of up to 2 1/2 months for filing your 5500 may be requested by completing and returning the Form 5558.

​Click on the image to download the extension request form.

​General Instructions for Completing Form 5500-SF

The following information is not to be considered legal or accounting advice. Allied National does not provide these services and any information on this webpage should not be construed as specific advice to your company on how to complete your 5500 filing obligations. Each company's circumstances may differ. Proper legal or accounting advice should be sought for completion of your filings.​​ 

Important: We encourage you to obtain independent legal and tax advice for your self-funded plan's compliance obligations. The following 5500 filing information is provided only as a courtesy, is limited to general compliance obligations that may or may not apply to your self-funded plan, and is subject to changes in federal law and regulatory interpretation. Allied National is not a legal or tax adviser, makes no representations concerning this information, and disclaims any and all liability resulting from reliance upon its accuracy or completeness.

Allied has provided our self-funded employers with a "5500 filing information" report that provides the information in our systems needed to complete the form. Each employer must provide the breakdown of cost between Employer payments and Participant (employee and dependent) payments for your premium payments for the plan year.  Please refer to the Instructions link above for the specific instructions and explanations needed for your filing. The following breakdown is an example of how a 5500-SF filing might be completed.
  • For calendar plan year or fiscal plan year beginning - complete this information only if you are reporting on other than a calendar year plan year.
  • A.  This return/report is for:  Your self-funded plan is a “single-employer” plan unless you have included participants in another company that causes this to be a “multiple-employer” plan. If participants are from companies outside your “control group” you should discuss this with your tax advisor.
  • B. This return/report is: – If this is your first 5500 filing, check “the first return/report”, if this is the final filing for your group plan, check “final return/report”. If filing for less than 12 months of a plan year, check “short plan year”.  If this is an amended return, check “amended return. Otherwise leave this blank.
  • C. ​If you are filing under any type of extension, please check the appropriate box. 
  • 1a: Name of plan - enter plan name as it appears on your Allied 5500 Filing Information Worksheet
  • 1b: Three Digit Plan Code: Enter this information from your Allied 5500 Filing Information Worksheet 
  • 1c: Effective Date of Plan: Enter effective date from your Allied 5500 Filing Information Worksheet 
  • 2a - 2c: Your employer information
  • 2d: Enter the 6 digit code for your Principle Business Activity from the list given in the EFAST system
  • 3a: Check the box for "Same as Plan Sponsor"
  • 3b-3c: Employer EIN and phone number
  • 4a-d: Answer only if this info has changed since your last filing
  • 5a-b: Info from your Allied 5500 Filing Information Worksheet
  • 5c: Leave blank for your health plan
  • 5d(1)-(2): Same as 5a and 5b
  • 5e: Answer "0" for your health plan
  • 6a: Answer "Yes" for your Allied plan
  • 6b: Answer "Yes" for your Allied plan
  • 6c: Leave blank for your Allied plan​
  • 7a(a) - 7b(b): Enter the plan assets and liabilities for beginning and end of year from your Allied 5500 Filing Information Worksheet. 
  • 8a(1) - 8a(2): Enter the total contributions made by employer and plan participants to plan costs for the plan year. For assistance, Allied has included the Total payments we have received for the plan year on your Allied 5500 Filing Information Worksheet. The sum of 8a(1) and 8a(2) entered by you (that is calculated in 8a(c)) should match the Total Income amount on your  Allied 5500 Filing Information Worksheet
  • 8b: Leave blank
  • 8d: Enter the benefits paid from your Allied 5500 Filing Information Worksheet.  Note: This is NOT the total claims that have been paid by your health plan but is the claims paid LESS any stop loss payments made.
  • 8e: Distributions/Refunds: Enter the amount (if any) from your Allied 5500 Filing Information Worksheet
  • 8f: Enter the Admin Service Providers amount from your Allied 5500 Filing Information Worksheet
  • 8g: Enter the amount for "other expenses". This amount is the stop loss premium paid during the plan year. 
  • 8j: Leave blank​ 
Note about the financial information you enter: the EFAST system validates the financial data entered in this section. The calculated values of 7c(b) minus 7c(a) should equal 8i. In plain terms the change in the net plan assets (7c(a) and 7c(b)) through the course of the year should equal the net income or loss (8i) shown for the year.  Because the efast system supports only whole dollar amounts and your Allied information worksheet provides amounts to the penny, you may have to "creatively" round these amounts to properly balance in this calculation. A $1 error in balancing due to rounding is still an error in the EFAST system. 
  • 9a: Leave Blank
  • 9b: Enter the welfare code from your Allied 5500 Filing Information Worksheet
  • Typically these answers are all NO. Please review for answers that may be unique for your group's situation.
  • 11: Leave blank - not applicable
  • 12: Answer NO and leave remainder of question 12 blank
  • Answer these questions as applicable for your group's situation regarding termination of your plan and disposition of any returned plan assets.  

Patient Centered Outcomes Research Institute (PCORI)

This fee was created as part of the Affordable Care Act to help fund the Institute. The fee expires after October 1, 2029 (plan years ending before that date). The fee is paid on IRS Form 720, the Quarterly Federal Excise Tax Return. The PCORI fee is paid annual only on July 31 of each year.  NOTE: The PCORI fee was set to expire on 9/30/2019 but was reauthorized by Congress as part of the Further Consolidated Appropriations Act of 2020. PCORI fees have been extended through 2029. 
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Generally, plan sponsors of applicable self-insured health plans must use one of the following three alternative methods to determine the average number of lives covered under a plan for the plan year.
  1. Actual Count Method: A plan sponsor may determine the average number of lives covered under a plan for a plan year by adding the totals of lives covered for each day of the play year and dividing that total by the total number of days in the plan year.
  2. Snapshot Method: A plan sponsor may determine the average number of lives covered under an applicable self-insured health plan for a plan year based on the total number of lives covered on one date (or more dates if an equal number of dates is used in each quarter) during the first, second or third month of each quarter, and dividing that total by the number of dates on which a count was made.
  3. Form 5500 Method: An eligible plan sponsor may determine the average number of lives covered under a plan for a plan year based on the number of participants reported on the Form 5500, Annual Return/Report of Employee Benefit Plan, or the Form 5500-SF, Short Form Annual Return/Report of Small Employee Benefit Plan. This number is multiplied times two for use in paying the PCORI fee. 
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Self-Insured Plan Year - Fee per Covered Life
The payment amounts due in 2024 vary based on the employer’s plan year, specifically the plan year’s end date. The PCORI fee is increasing from $3.00 for plans ending January 2023 through September 2023 to $3.22 per covered life for plan years ending in October 2023 through December 2023 and January 2024 through September 2024.

For the PCORI fee, you'll need this form. Fill out your company information on page one and then fill out Part II, #133 on Patient Centered Outcomes Research Fee. Fill out the voucher at the end and mail it in to:

​Department of the Treasury Internal Revenue Service, Cincinnati, OH 45999-0009