Healthcare Support & Long-Term Care

ICHRA for Healthcare Support & Long-Term Care

Home health agencies, assisted living facilities, and long-term care providers run on a direct-care workforce — aides, CNAs, and support staff — with turnover rates far above most industries and margins that are often tightly constrained by Medicaid or insurance reimbursement rates. A group plan's fixed premium and participation requirements rarely survive contact with that combination.

The Problem

Why group plans struggle here

Direct care turnover in home health and long-term care regularly runs well above general workforce averages, which makes group plan participation minimums difficult to sustain — by the time a group plan renews, a meaningful share of the originally-enrolled population may already be gone. At the same time, reimbursement-driven margins leave little room to absorb a group renewal increase, even as competitive benefits become more important for retention in an industry facing a well-documented staffing shortage.

The Fix

How Healthcare Support & Long-Term Care employers use ICHRA

Set a fixed monthly contribution for full-time direct care staff that doesn't move with turnover — the number stays the same whether a role is filled by the same aide all year or three different ones
No participation minimum to clear, which matters when your eligible population changes as fast as direct care staffing often does
Exclude per-diem or PRN staff from the ICHRA class while still offering a real, budgetable benefit to full-time direct care employees
A genuine benefit to point to in a hiring market where competing agencies often can't offer coverage at all

Sample Structure

What a class structure might look like

Every plan is designed around the specific business, but here's a representative starting point for healthcare support & long-term care:

Employee class	Who's typically in it	Example monthly contribution
Full-time direct care staff	Home health aides, CNAs, direct support professionals at 30+ hrs/week	$300–$425/mo
Administrative/salaried	Office staff, care coordinators, management	$450–$600/mo
PRN/per-diem staff	As-needed or on-call direct care workers	Typically excluded

Figures are illustrative starting ranges, not quotes — actual contribution levels depend on budget, local plan costs, and ACA affordability requirements where applicable.

Worked Example

Example: a home health agency

A home health agency employs 40 direct care aides with annual turnover well above the agency's other roles, alongside 6 administrative and care-coordination staff. A group plan quote required a participation percentage the agency struggled to maintain given how often the direct care roster changed. Under ICHRA, the agency set a $350/month contribution for full-time direct care staff and $500/month for administrative staff, with per-diem workers excluded from the class. The fixed structure meant the agency's benefits cost no longer depended on hitting a moving participation target, and the benefit itself became a real recruiting tool in a tight labor market.

Watch Out For

Common mistakes in healthcare support & long-term care

Underestimating the volume of new-hire notices required when turnover is high — each new eligible hire needs proper and timely notice of the ICHRA offer
Not confirming individual-market plan networks in the service area actually include the providers direct care staff need, which can vary significantly by county
Skipping the affordability calculation if the agency is large enough to be an Applicable Large Employer — easy to overlook when contribution levels are set lower to fit tight margins

Frequently Asked

Healthcare Support & Long-Term Care + ICHRA questions

Does high turnover disqualify us from offering ICHRA?

No — the opposite, actually. ICHRA's lack of a participation minimum is specifically what makes it workable for a workforce with high turnover, unlike a group plan.

Can we offer a lower contribution to direct care staff than administrative staff?

Yes, as long as each group is defined as its own class under permitted criteria (such as salaried vs. hourly) and the contribution is applied consistently within each class.

Will this help with our retention problem?

It can be part of the answer — a real, budgetable health benefit is a meaningful differentiator in an industry where many competitors offer none at all, though it's one factor among several in retention.