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Client Name - PCORI Fee Worksheet
Effective for plan years ending on or after 10/1/12 and before 10/1/19 (i.e., beginning with 2012 plan year for
calendar year plans), health insurance issuers and plan sponsors of self-funded health plans are required to pay an
excise tax to fund the Patient Centered Outcomes Research Institute - often referred to as the “PCORI fee.” The fee
is calculated based on the average number of lives covered under the plan (including employees, dependents,
COBRA participants, and covered retirees) and is due by July 31 following the end of each applicable year.
Methods for determining the fee
Below is a worksheet outlining the calculation methods for 3 of the options available.
Plan sponsors must choose one method to be used for the entire plan year, however a different method may
be chosen for subsequent plan years.
Method 1 - Actual Count Method
A.
Total lives covered for the entire year
25116
B.
Number of months
12
C.
Average Lives (A/B)
2093.00
D.
2015 Fee
$2.17
E.
Total Fee Due (amount remitted to IRS on Form 720)
$4,541.81
Method 2 - Snapshot Count Method
A.
Jan-15 1st of the month
Number of lives
2097
B.
Apr-15 1st of the month
Number of lives
2081
C.
Jul-15 1st of the month
Number of lives
2102
D.
Oct-15 1st of the month
Number of lives
2090
E.
Sum of all 4 quarters
8370
F.
Number of counts
4
G.
Average lives (E/F)
2092.50
H.
2015 Fee
$2.17
I.
Total Fee Due (amount remitted to IRS on Form 720)
$4,540.73