SHOP Marketplace: Health Insurance For Small - Centers For Medicare .
SHOP Marketplace: Health Insurance for SmallBusinessesAn Overview for 2016CoverageApril 20, 2016Centers for Medicare & MedicaidServices (CMS)Centers for Consumer Information &Insurance Oversight (CCIIO)1
DisclaimerThe information provided in this presentation is intended only as a generalinformal summary of technical legal standards. It is not intended to take theplace of the statutes, regulations, and formal policy guidance that it is basedupon. This presentation summarizes current policy and operations as of thedate it was presented. Links to certain source documents have been providedfor your reference. We encourage audience members to refer to the applicablestatutes, regulations, and other interpretive materials for complete andcurrent information about the requirements that apply to them.This document generally is not intended for use in the State-basedMarketplaces (SBMs), but some of the material in it might be relevant if youare in a state with an SBM that is using HealthCare.gov for eligibility andenrollment. Please review the guidance on our Agents and Brokers Resourceswebpage (http://go.cms.gov/CCIIOAB) and Marketplace.CMS.gov to learnmore.2
Presentation OverviewThis presentation provides an overview of the benefits of the SmallBusiness Health Options Program (SHOP) Marketplace onHealthCare.gov.Topics Covered: Health and dental coverage optionsHow the SHOP Marketplace works Employee choice SHOP Marketplace enrollment process Health insurance options for the self-employed Who is required to offer health insurancecoverage Minimum participation rates (MPRs) for small group plansHow to pay SHOP MarketplacepremiumsThe Small Business Health Care TaxCreditSHOP Marketplace resources and tools What is the SHOP Marketplace Benefits of the SHOP MarketplaceWhich employers can participate in the SHOPMarketplace and when can they enroll 3
What is the SHOP Marketplace?The Small Business Health Options Program SHOP Marketplace Part of the Health Insurance Marketplace created by the Affordable CareAct (ACA)Offers small employers (generally those with 1-50 full-time employees) achoice of quality health and dental plans provided by private insurancecompaniesStates may choose to allow employers with 1-100 full-time employees toparticipate in the SHOP Marketplace.Small employers who offer coverage through the SHOP Marketplace maybe eligible for the Small Business Health Care Tax Credit that may beworth up to 50% of their contributions to premiums (up to 35% for taxexempt employers).Works with health insurance reforms to help spur competition based onprice and quality4
Benefits of the SHOP Marketplace Convenience and choice:– Complete a group enrollment at any point during the year– Browse, compare, apply, and enroll in SHOP Marketplace health and dentalplans on HealthCare.gov– Offer one (1) or multiple plans– Receive one (1) bill and make one (1) premium payment a month Control over spending:– Employers decide which plan(s) to offer qualified employees and how muchthey want to contribute to health and dental insurance premiums. Access to tax credits:– When you offer coverage through the SHOP Marketplace, you may be eligiblefor a tax credit worth up to 50% of your contributions to premiums (35% for taxexempt employers). Many ways to get help:– Information and assistance are available through HealthCare.gov, the SHOPCall Center, agents and brokers registered with the SHOP Marketplace, andthrough navigators.5
Which employers can participate in the SHOPMarketplace?To be eligible to purchase coverage in the SHOP Marketplace, small employersmust:1Be a “small employer” (generally, a small employer has 1-50 employees)2Offer coverage to all full-time employees (those working 30 or more hoursper week, on average)3Have at least one (1) employee enrolling in coverage4Have a principal business address or eligible employee worksite in the statein which coverage is offeredUse the SHOP FTE Calculator on HealthCare.gov for help counting full-time andfull-time equivalent (FTE) employees for purposes of SHOP Marketplace ators-fte/6
Options for the Self-employedSelf-employed individuals are not eligible to enroll through theSHOP Marketplace unless they have at least one (1) employee whoenrolls.Self-employed individuals with no employees may be able to enroll incoverage through the Health Insurance Marketplace for Individuals &Families on HealthCare.gov.Health Insurance Marketplace for Individuals & Families: Premium tax credits may be available, depending on annual householdincome. Individuals generally must enroll during Open Enrollment period, unless theyhave a life event, such as getting married or having a child. Open Enrollment for 2016 was November 1, 2015 — January 31, 2016.7
What Size Employers Are Required to OfferHealth Insurance Coverage?NOT REQUIREDFEWER THAN 50FTEsREQUIRED50 or MORE FTEs Employers with fewer than 50 full-time and FTEemployees are not required to offer employeeshealth insurance coverage. There are no Employer Shared Responsibilitypenalties if they choose not to do so. Employers must offer coverage that meetsaffordability requirements (does not exceed 9.5% ofhousehold income) and meets the minimum valuestandard to full-time workers and their dependents. Not offering affordable coverage? May be subjectto the Employer Shared Responsibility PaymentFor more information on Employer Shared Responsibility requirements,visit IRS.gov.8
SHOP Marketplace MinimumParticipation RequirementIn most states, 70% of a group’s employees offered coverage must acceptthe offer of SHOP Marketplace coverage or be enrolled in other types ofcoverage for a group to participate in the SHOP Marketplace. Unless the group enrolls between November 15 and December 15when no MPR appliesWhat’s New?For 2016 coverage and beyond, the SHOP Marketplace MPR requirementhas changed—making it easier for employers to enroll in SHOPMarketplace coverageHere’s an example:2015 Participation RequirementEmployees are not counted toward the MPRif they have coverage through another job,another person’s job, or a governmentprogram (e.g., Medicare, TRICARE).2016 Participation RequirementEmployees with non-SHOP Marketplacecoverage, such as through a spouse orgovernment program, will be countedtoward the MPR.9
Calculating the MinimumParticipation RateFor coverage beginning in 2016 and beyond, here’s how the SHOPMarketplace MPR is calculated:MPR Number of Employees Enrolling in CoverageNumber of Employees Offered SHOP Marketplace CoverageHere’s an example for 2016: An employer offers coverage to 10 full-time employees, and two (2) havecoverage through a spouse’s employer, and one (1) is covered by Medicare. 70% of 10 employees seven (7) employees Three employees have other coverage that counts towards the rate, so 4additional employees must accept the employer’s offer of SHOP Marketplacecoverage before the employer can enroll.From November 15th- December 15th, eligible small employers can enroll inSHOP Marketplace coverage without meeting the MPR requirement.10
Health & Dental Coverage Optionsin the SHOP Marketplace Starting in 2016, employers may offer their employees one (1) of three (3)options through the SHOP Marketplace:1. Only health coverage2. Only dental coverage3. Both health and dental coverage If a qualified employee is offered both health and dental coverage,he/she may choose to enroll in both health and dental coverage, onlyhealth coverage, or only dental coverage.Employers may also offer health and dental coverage to their employees’dependents. Dependents must enroll in the same health or dental plan as the qualifiedemployee. If an employee is offered both health and dental coverage, dependents willbe able to enroll in either the health or dental coverage the employeepicks, or in both.11
How the SHOP Marketplace Works: DifferentPlans for Different Budgets SHOP Marketplace health plans are available in four plancategories: Bronze, Silver, Gold, and Platinum. Categories generally reflect how much enrollees pay for premiums, deductibles, copayments, andthe total amount they’d expect to have to spend out-of-pocket for the year.Example: Platinum health plans may be expected to cover 90% of the total cost of covering essential health benefits, but the monthly premium will generally be the highest compared toplans in the other categories.All plans cover “essential health benefits,” but can differ by provider network, prescription drugformularies, or additional benefits offered, among other things.Plans cannot charge higher premiums for enrollees based on high medical costs or pre-existingmedical conditions, raise premiums because an enrollee needs care, or charge women more thanmen based on gender.Plan CategoryTotal cost of care paid by theplan (on average)Total cost of care paidby the employee num90%10%12
How the SHOP Marketplace Works: DifferentPlans for Different Budgets (cont.) SHOP Marketplace dental plans are available in two (2) plancategories: High and Low. Categories generally reflect how much enrollees pay for premiums,deductibles, copayments, and the total amount they’d expect to pay outof-pocket for the year. High dental plans have generally higher premiums but lower copaymentsand deductibles compared to low dental plans. So you’ll generally paymore every month, but less when you go to the dentist. Low dental plans generally have lower premiums but higher copaymentsand deductibles compared to high dental plans. So you’ll generally pay lessevery month, but more when you go to the dentist.13
Employee Choice:Offering Employers Flexibility & ControlEmployers can offer qualified employees:1. A single health or dental plan2. A choice of plans within aplan category the employer chooses– Employees choose any plan within the selectedcoverage category.Advantages of offering qualified employeesa choice of plans:– They can choose plans that best fit their coverage needs.– Employer does not have to predict their health care needs.– Employer receives and pays just one (1) monthly bill per account, evenwhen offering multiple plans with different health insurance companies.– Employer sets choice limits to control health care costs.14
See Plans & Prices on HealthCare.gov1.Browse available SHOP Marketplace health and dental plans beforechoosing coverage.– Save time with the application process by becoming familiar with coverage optionsbefore you get started.– See plan and pricing options that are available in your area without creating anaccount.2.Generate estimates for customized premium and out-of-pocketplan costs.– Choose coverage that is affordable for both employers and employees.3.Compare plans based on product network type, coverage category,insurance company, premium, deductible, and out-of-pocketmaximum.– Make an informed decision that fits employers’ and employees’ budget andcoverage needs.15
How to Pay SHOP Marketplace PremiumsEMPLOYEESgenerally pay SHOPMarketplacepremiums to theiremployer through apayroll deduction orupfront (unless theiremployer is payingtheir entirepremium).EMPLOYERreceives onemonthly bill fromthe SHOPMarketplace in eachstate, even ifemployees areenrolled in differentplans with differentinsurancecompanies.EMPLOYERpays SHOPMarketplacepremiums using one(1) of the followingoptions:- Online- Phone- MailSHOPMARKETPLACEdisburses employer’spremium payment tothe insurancecompany(ies) uponreceipt.NOTE: Employers should make the first premium payment by the 15th of the month forcoverage to start the 1st of the following month.16
Employer Options forPremium ContributionsContribution methods available through the SHOP Marketplace: Fixed percentage Reference Plan ContributionFixed Percentage: Employer chooses a fixed percentage to contribute toemployees and (if applicable) dependents’ monthly 016.pdf).Example: Jane is 25 and her planpremium is 200. John is 60 andhis plan premium is 300. Thefixed percentage is 80%. Theemployer will pay 160 towardJane’s plan premium and 240toward John’s plan tionJaneJohn 200 30080% 160 24017
Employer Options for Premium Contributions(cont.)Reference plan contribution: The employer chooses a definedamount to contribute to employees’ and (if applicable) dependents’monthly premiums based on a percentage of premiums for a “referenceplan” the employer chooses (if only a single plan is offered, this plan isthe “reference plan”).Example: If the reference plan premium is 100 for an employee and the employer’scontribution is 50%, the employer will pay 50 toward the employee’s plan premium—even if the employee chooses a plan otherthan the reference plan.Reference Plan 100Percentage50%EmployerContribution 5018
Contribution ComparisonFixed PercentageEMPLOYEEPLAN APLAN BPLAN C Jane Doe (25) 200x 80% 160 250x 80% 200 275x 80% 220 300x 80% 240 350x 80% 280 375X 80% 300John Doe (60)Reference Plan ContributionEMPLOYEEPLAN APLAN B(Reference)PLAN CJane Doe (25) 200 250x 80% 200 275 350x 80% 280 375 200John Doe (60) 300 280 200 280 Assume an 80%employer contributionfor both examples.In the fixed contribution,employer contributionsvary by plan andemployee age.Assume the employerchooses Plan B as areference plan.Employer contribution isconstant across plans(but still varies for eachenrollee based on age).19
What is the Small BusinessHealth Care Tax Credit? The Small Business Health Care Tax Credit is generally only availablewhen coverage is obtained through the SHOP Marketplace. The SHOP Marketplace gives eligible small employers ability to getback a portion of their premium contributions through the tax credit. The tax credit may be worth up to 50% of eligible employers’ premiumcontributions (up to 35% for tax-exempt employers). To qualify for the tax credit, employers must:1.2.3.4.5.Have employees enrolled in SHOP Marketplace health or dental plan(s)Have fewer than 25 FTEs (based on a 40 hour work week)Pay average wages of less than around 50,000 per year per FTE,adjusted annually for inflationContribute at least 50% toward employee-only premium costsFile for the tax credit with IRS20
Small Business Health Care Tax Credit (cont.) For tax years 2014 and beyond, employers can claim the tax credit fortwo (2) consecutive years. Example: An eligible employer offering coverage through the SHOPMarketplace in 2015 and 2016 can claim the tax credit for both years. Ifthe employer decides to offer coverage again in 2017, the employerwould no longer be able to receive the tax credit because the employerhas already claimed it for two (2) consecutive years.Use the SHOP Tax Credit Estimator on HealthCare.gov to see if you might beeligible and how much the credit could be worth for your business.21
SHOP Marketplace Tools for EmployersSHIP ToolFunctionality & Value1. FTE CalculatorHelps employers determine if they may be a smallemployer for purposes for SHOP Marketplace eligibilityby counting their full-time and FTE employees2. MPR CalculatorHelps employers determine if they meet the minimumparticipation requirements to enroll in the SHOPMarketplace3. Tax CreditEstimatorHelps employers determine if they may be eligible forthe Small Business Health Care Tax Credit, and estimateits valueLooking for the tools? Visit https://www.healthcare.gov/smallbusinesses/22
SHOP Marketplace: Health Insurance for SmallBusinessesAgent and BrokerResources23
CMS Uses Various Means to FieldAgents and Brokers ResourcesDownloadableResources: Availableto you any time online; updatedregularlyDistributedResources: Sent toregistered agents andbrokers (webinars,emails, newsletter),and subscribers(Tweets)Call Center andHelp DeskResources: For morespecific inquiriesYou can find information and help on all FFM topics via all these outlets24
Downloadable Resources:Agents and Brokers Resources Webpage CMS makes a wide variety of resources available online. Searching for information on a certain topic? Check the followingsources, where CMS has compiled information on many topics related tothe FFMs. The Agents and BrokersResources webpage is theprimary outlet for CMSinformation for agents andbrokers.‒ Content is updated regularly.‒‒The webpage containshyperlinks to more detailedresources.Use the “Search” field in theupper right corner of thewebpage and keywords of yourchoosing to search for CMSpublished content.25
Downloadable Resources: Agents andBrokers Resources Webpage (cont.) Other content on the Agents and Brokers Resources webpageincludes:– Resources guiding agents and brokers through the FFM registration process,including links to webinars, videos, and CMS-approved training vendors– The FFM Registration Completion List, which captures the names andNational Producer Numbers of registered agents and brokers– Upcoming CMS-sponsored webinars for agents and brokers, and how toregister– Slides from past webinars– High-level and regulatory guidance on agent and broker participation in theFFMs– Current and previous editions of the “News for Agents and Brokers” monthlynewsletter– Resources specific to assisting consumers in the Individual and Small BusinessHealth Options Program (SHOP) Marketplaces The webpage also includes resources for web-brokers, including the webbroker application process and the FFM Web-broker Entity List.Also see the Marketplace.CMS.gov website,the official Marketplace information source for outreach partners.26
Downloadable Resources: “Agent and BrokerRoadmap to Resources” The “Agent and Broker Roadmap to Resources”provides a quick guide to resources that CMSand its federal partners have developed to helpagents, brokers, and consumers navigate theFFMs. It includes descriptions and “for moreinformation” links on:– Resources generated by CMS and other Federalagencies, state-level agencies, and nongovernmental entities– Health coverage options available through theFFMs and those available outside the FFMs,including CMS policy governing dual coverage– Each step of the eligibility and enrollment process,including application troubleshooting– Immigration statuses eligible for FFM coverage– Materials to help consumers use their coverage– Tax implications of enrollment decisions27
Downloadable Resources: Videos CMS also producesvideos on selectedtopics. You can find links tovideos on:– The Agents and BrokersResources webpage– The CMS YouTubechannel and theHealthCare.govYouTube channel Use the “Search” fieldat the top of thescreen to find videoson topics of interest.28
Downloadable Resources: Webinar Slides CMS posts PDFversions of the slidesfrom past webinars tothe Agents andBrokers Resourceswebpage and to theREGTAP webpage.– Each webinarlisting includes asummary of thecontent covered.– Look for webinarslides in differentsections of thewebpage.See the Upcoming Agent and Broker Webinars section of the Agents and BrokersResources webpage for information on the content of upcoming webinars andinstructions on how to register.29
Downloadable Resources:HealthCare.gov Website HealthCare.gov offers a wealth of information you can use to helpconsumers enroll in qualified health plans and manage their health care.‒ Select the “GetAnswers” link tosee commonlyasked questionsand answers.‒ Use the “Search”field to search bykeywords.‒ Select the linksin the “Still HaveQuestions?”pane for moreresources.30
Distributed Resources: Emails CMS uses emails to provide agents and brokers up-to-theminute information on time-sensitive issues, and on policy andprocess updates. Registered agents and brokers receive these emails.– You can establish an account at the CMS Portal to receive emails byselecting the “Get Email Updates” link in the right panel of thewebpage.31
Distributed Resources: Newsletters CMS publishes the“News for Agents andBrokers” newsletter on amonthly basis.– The newsletter covers awide range of topics tokeep agents and brokersabreast of current issues.– Back issues of thenewsletter are available inthe News for Agents andBrokers section of theAgents and BrokersResources webpage.– Scan the “In This Issue”section of back issues tofind articles withinformation relevant toyour questions.32
Distributed Resources: Tweets CMS also releases current news and updates via its Twitter handles:@CMSGov and @HealthCareGov.– Each Tweet directs recipients to a CMS website, webpage, or resource for moreinformation.– Search on these hashtags for Tweets generated specifically for agents and brokers:#ABFFM (Individual Marketplaces) and #ABFFSHOP (SHOP Marketplace).– Select the image below and use the highlighted links to sign up for a Twitter accountand to follow CMS.33
Call Center and Help Desk Support:Agent and Broker Call Center CMS maintains a help desk and call center specifically to assist agents andbrokers in accessing the resources they need to support consumers.Email the FFM Producer and Assister Help Desk (FFMProducerAssisterHelpDesk@cms.hhs.gov) for assistance with the following types ofquestions:–––– Agent/Broker FFM Registration Completion List issuesIdentity proofing issues“Find Local Help” issuesEligibility and enrollment policy questions related to the Individual MarketplaceCall the Agent and Broker Call Center at 1-855-CMS-1515 (855-267-1515) andselect option “1” Monday through Saturday from 8:00 AM to 10:00 PM EasternTime (ET) Agent and Broker Call Center (1-855-CMS-1515) for assistance withthe following types of questions:–––CMS Portal account issues, including error messages, password resets, andaccount lockoutsGeneral registration and training questions, including SHOP Marketplace-relatedquestionsLog in issues at the HealthCare.gov landing page34
Call Center and Help Desk Support:Other Marketplace Call Centers For questions when workingwith consumers applying andenrolling, call the HealthInsurance MarketplaceCall Center at 1-800-3182596 (TTY: 1-855-889-4325),7 days a week, 24 hours a day. For questions about theSHOP Marketplace, call theSHOP Call Center at 1-800706-7893 (TTY: 711) Mondaythrough Friday, 9:00 AM to7:00 PM ET.35
Call Center and Help Desk Support:Email Help Desk Support Have questions after hours or can wait for a response? Send your queryvia email.– For questions about the agent and broker registration process, andhow agents and brokers can assist consumers in the FFMs, email theFFM Producer and Assister Help Desk at: FFMProducerAssisterHelpDesk@cms.hhs.gov.– For technical or system-specific issues related to the MLMS, userspecific questions about maneuvering the learning managementsystem site, or accessing CMS training and exams on the MLMS,contact the MLMS Help Desk at MLMSHelpDesk@cms.hhs.gov.– For questions about CMS Enterprise Portal password resets andaccount lockouts; HealthCare.gov website issues; and other CMSEnterprise Portal account issues, requests, or error messages, contactthe Exchange Operations Support Center at 1-855-CMS-1515(855)267-1515) or CMS FEPS@cms.hhs.gov.– For questions/comments about web-broker participation in the FFMs:WebBroker@cms.hhs.gov.36
SHOP Marketplace: Health Insurance for SmallBusinessesAdditional SHOPMarketplace Resources37
SHOP Marketplace Resources Top Questions About the SHOP wers Information on the Small Business Health Care Tax Creditirs.gov/Affordable-Care-Act Affordable Care 101 Webinar: What the Healthcare Law Means forSmall Employersbit.ly/AffordableCare101 Agent/Broker Essentials: Information on the SHOP nts-and-brokers SHOP Marketplace Agent/Broker Portal (for tplace\small-businesses\agent SHOP Marketplace Registration Information for Agents ealth-insurancemarketplaces\a-b-resources.html38
SHOP Marketplace Resources (cont.) ACA Rules, Guidance, Agent and Broker Resource insurancemarketplaces\a-b-resources.html Detailed Instructions on How to Enroll for education/shopemployee-enrollment-user-guide.pdf How to Enroll in the SHOP -shop-coverage/enroll-inshop/ Detailed Instructions on How to Enroll for pdf Using Agents and Brokers in the SHOP -shop-coverage/usinginsurance-agents-and-brokers/ SHOP Call Center 1-800-706-7893 (TTY: 711) Available Monday –Friday, 9am – 7pm ET39
Questions?For questions about Agent/Broker participation in the FFMs:FFMProducer-AssisterHelpDesk@cms.hhs.govFor questions on the MLMS: MLMSHelpDesk@CMS.HHS.govFor questions when working with consumers applying and enrolling:1-800-318-2596 (TTY: 1-855-889-4325) available 7 days a week, 24 hours a dayFor questions unrelated to application and enrollment:1-855-CMS-1515 (855-267-1515) and select option “1”For questions about the SHOP Marketplace:1-800-706-7893 (TTY: 711) available M-F 9:00 AM-7:00 PM ETFor questions regarding a CMS-approved vendor’s training, agents and brokers shouldcontact the respective vendor’s help desk. Contact information can be found on theAgents and Brokers Resources webpage at: r questions/comments about web-broker participation in the FFMs:WebBroker@cms.hhs.gov40
participate in the SHOP Marketplace. Small employers who offer coverage through the SHOP Marketplace may be eligible for the Small Business Health Care Tax Credit that may be worth up to 50% of their contributions to premiums (up to 35% for tax-exempt employers). Works with health insurance reforms to help spur competition based on .
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SHOP Marketplace P.O. Box 2130 South Portland, ME 04116 Make checks payable to the SHOP Marketplace and allow 5-7 days for delivery and processing. If you make your payment with a paper check, you won't get a payment confirmation notice. You can call the SHOP Call Center to confirm that the SHOP Marketplace got your payment. 3. Pay by phone.
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