1. Affordable Care Act SHOP Marketplace Implementation Briefing PA ASSOCIATION OF COMMUNITY HEALTH CENTERS July 23, 2014 H EALTH C ARE.GOV Joanne Corte Grossi, MIPP Regional Director U.S. Department of Health & Human Services, Region III Pennsylvania, Delaware, District of Columbia, Maryland, Virginia, West Virginia

2. WHAT IS THE SHOP MARKETPLACE ? SHOP = Small Business Health Options Program Part of the Health Insurance Marketplace created by the Affordable Care Act (ACA) Part of the Health Insurance Marketplace created by the Affordable Care Act (ACA) Offers employers a choice of health plans and dental plans and tools for making informed choices Offers employers a choice of health plans and dental plans and tools for making informed choices Offers qualified small employers access to the enhanced Small Business Health Care Tax Credit – now worth up to 50% of employer’s premium contributions Offers qualified small employers access to the enhanced Small Business Health Care Tax Credit – now worth up to 50% of employer’s premium contributions Works with new insurance reforms to spur competition based on price and quality Works with new insurance reforms to spur competition based on price and quality NOTE: If you have fewer than 50 full-time equivalent (FTE) employees, you are not required to offer health insurance and there is no penalty if you choose not to.

3. WHO CAN BUY FEDERALLY- FACILITATED SHOP COVERAGE Small employers who : Have 50 or fewer employees in 2014 (becomes 100 employees in 2016) Have 50 or fewer employees in 2014 (becomes 100 employees in 2016) Have at least one common law employee Have at least one common law employee Self-employed purchase insurance in the Individual MarketplaceSelf-employed purchase insurance in the Individual Marketplace Offer coverage to all of their full-time employees Offer coverage to all of their full-time employees In the Federally-Facilitated SHOP (FFS) this means employees working on average 30 or more hours per week In the Federally-Facilitated SHOP (FFS) this means employees working on average 30 or more hours per week Can be for-profit or tax-exempt Can be for-profit or tax-exempt Meet minimum participation rates Meet minimum participation rates In many states using the FFS Marketplace, at least 70% of full-time employees must accept the employer’s offer of coverageIn many states using the FFS Marketplace, at least 70% of full-time employees must accept the employer’s offer of coverage

4. For employers: With fewer than 25 FTE employees With fewer than 25 FTE employees Whose employees’ wages average less than $50,000 per year Whose employees’ wages average less than $50,000 per year Who contribute at least 50% of employee’s premium costs Who contribute at least 50% of employee’s premium costs Starting in 2014 the tax credit is: For employers who offer employees a Qualified Health Plan (QHP) through the SHOP For employers who offer employees a Qualified Health Plan (QHP) through the SHOP Worth up to 50% of employer’s premium contribution to SHOP health and dental plans (up to 35% for tax-exempt employers) Worth up to 50% of employer’s premium contribution to SHOP health and dental plans (up to 35% for tax-exempt employers) Available for two consecutive years Available for two consecutive years Visit the SHOP Tax Credit Estimator Healthcare.gov/small-business tax-credit-calculator/ THE SMALL BUSINESS HEALTH CARE TAX CREDIT

5. SHOP FOR PLANS WITH CONFIDENCE All SHOP QHPs: Meet new coverage standards Meet new coverage standards Must offer “essential health benefits” – items and services such as doctor visits, preventive care, hospitalization and prescription drugsMust offer “essential health benefits” – items and services such as doctor visits, preventive care, hospitalization and prescription drugs Benefit from broad protections under the health care law. Insurance companies: Face limits on the portion of premium dollars they can keep for administrative and overhead costsFace limits on the portion of premium dollars they can keep for administrative and overhead costs Must disclose and justify proposed rate hikes, generally of 10% or more, which state or the US HHS can reviewMust disclose and justify proposed rate hikes, generally of 10% or more, which state or the US HHS can review Cannot sell coverage charging higher rates based on an individual’s pre-existing health conditionsCannot sell coverage charging higher rates based on an individual’s pre-existing health conditions Face limits on charging additional premiums for older employeesFace limits on charging additional premiums for older employees Generally must pool risks across a state’s small group marketGenerally must pool risks across a state’s small group market

6. BROWSE BEFORE BUYING IN THE FFS Find premium estimates Online tool shows price estimates for the FFS QHP and QDP in the business area Online tool shows price estimates for the FFS QHP and QDP in the business area Price estimates are based on the age ranges of employees and location of business Price estimates are based on the age ranges of employees and location of business Useful information for employer to have on hand Number of full-time employees Number of full-time employees Age of employees Age of employees Determine if offering coverage to dependents Determine if offering coverage to dependents

7. BUYING SHOP COVERAGE: WHEN & HOW? When can an employer offer a SHOP QHP? Get started now, or offer anytime during the year Get started now, or offer anytime during the year Unlike Marketplace for individuals, no limited Open Enrollment Period for the SHOP Unlike Marketplace for individuals, no limited Open Enrollment Period for the SHOP How does an employer buy a SHOP QHP? For FFS, in 2014 only – must use Direct Enrollment For FFS, in 2014 only – must use Direct Enrollment Work directly with an agent broker or insurance companyWork directly with an agent broker or insurance company Similar to how small businesses have gotten coverage in the pastSimilar to how small businesses have gotten coverage in the past Use the same process for buying a SHOP Qualified Dental Plan (QHP)Use the same process for buying a SHOP Qualified Dental Plan (QHP) With Direct Enrollment an employer will: With Direct Enrollment an employer will: Select a SHOP QHP to offer employees (and a SHOP QDP, if applicable)Select a SHOP QHP to offer employees (and a SHOP QDP, if applicable) Submit a hard copy employer application to the SHOPSubmit a hard copy employer application to the SHOP Have the agent, broker, or insurer help enroll those employees who acceptHave the agent, broker, or insurer help enroll those employees who accept Pay the insurance company, directly or with the help of an agent or brokerPay the insurance company, directly or with the help of an agent or broker In states running their own SHOP Marketplace In states running their own SHOP Marketplace Enrollment processes may differEnrollment processes may differ Many offer online enrollmentMany offer online enrollment

8. FFS ELIGIBILITY: HOW TO APPLY To apply to the FFS Marketplace, an employer can: Ask an agent, broker or insurance company for help Ask an agent, broker or insurance company for help Get help from a Marketplace-approved Navigator or assister Get help from a Marketplace-approved Navigator or assister Get the paper application and instructions from HealthCare.gov Get the paper application and instructions from HealthCare.gov Apply by phone through the SHOP Employer Call Center Apply by phone through the SHOP Employer Call Center Role of the SHOP Marketplace: Determines whether the employer is eligible to participate in the SHOP Determines whether the employer is eligible to participate in the SHOP This determination is a requirement for receiving the tax creditThis determination is a requirement for receiving the tax credit Does not determine whether the employer is eligible to receive the tax credit Does not determine whether the employer is eligible to receive the tax credit This is an IRS matterThis is an IRS matter

9. THE BOTTOM LINE The SHOP helps small businesses by: Giving employers a choice of health plans Giving employers a choice of health plans Providing access to tax credits for qualified small employers Providing access to tax credits for qualified small employers Offering tools to help them make informed choice Offering tools to help them make informed choice How much do SHOP plans cost, and what do they cover?How much do SHOP plans cost, and what do they cover? HealthcCare.gov/find-premium-estimates/ HealthcCare.gov/find-premium-estimates/ How do employers find out if they qualify to use the SHOP?How do employers find out if they qualify to use the SHOP? HealthCare.gov/fte-calculator/ HealthCare.gov/fte-calculator/ How much might the tax credit be worth to a business?How much might the tax credit be worth to a business? HealthCare.gov/small-business-tax-credit-calculator/ HealthCare.gov/small-business-tax-credit-calculator/ More features and options coming for 2015

10. HOW SHOP WORKS: MOVING TOWARDS EMPLOYEE CHOICE A key goal of the SHOP Options for small employers and their employees Such as offering employees a single plan or a choice of plans Such as offering employees a single plan or a choice of plans In 2014: The FFS Marketplace offers employer choice, but no employee choice option The FFS Marketplace offers employer choice, but no employee choice option States running own SHOP can offer employee choice option – many do States running own SHOP can offer employee choice option – many do In 2015: The SHOP in some states may offer small employers an employee choice The SHOP in some states may offer small employers an employee choice 18 states – including Pennsylvania – have asked for a waiver 18 states – including Pennsylvania – have asked for a waiver

11. RESOURCES: SHOP Employer Call Center (For small employers and those assisting them) (For small employers and those assisting them)1-800-706-7893 TTY users should call 711 to access the Call Center Employer SHOP Application HealthCare.gov/downloads/shop-employer-application.pdf Information on the Small Business Healthcare Tax Credit: Irs.gov/uac/Small-Business-Health-Care-Tax-Credit-for-Small- Employers

12. Thank you! Contact: joanne.grossi@hhs.gov