NY State of Health
Small Business Marketplace
(SBM)
Certification Training for Navigators
Objectives
2
• Outline the SBM Employer and Employee Registration and
Enrollment process.
• Describe the benefits for employers who enroll in the Small
Business Marketplace
• Explain the rules of enrollment timing in the Small Business
Marketplace
• Provide an Overview of the Small Business Marketplace
(SBM) rules and regulations.
Small Business Marketplace
Overview
3
Who is Eligible?
4
A Small Business Employer is eligible to purchase a health
plan through the Small Business Marketplace (SBM) if the
business:
• Is based in NYS or has employees with a physical location in NYS.
• Has 100 or fewer Full-Time Equivalent (FTE) employees.
o At least one common law employee must enroll.
Overview
Who is Eligible?
Small Business Employers who elect to offer coverage through
the SBM, must offer health insurance coverage through the
Small Business Marketplace to all eligible employees:
• Eligible employees must include those working 30 or more hours per
week.
• Employers may also offer coverage to part-time employees who work,
on average, 20 hours per week or more. However, it is not required.
o Employees who work less than 20 hours per week are not eligible.
nystateofhealth.ny.gov 5
Overview
What Employers Should Know
6
Overview
• Small employers are not required to offer health coverage or pay for coverage for
their employees.
• Employers employing a least 50 full-time employees (or a combination of full-time and
part-time employees that is equivalent to 50 full-time employees) may be subject to
the Employer Shared Responsibility provisions under section 4980H of the Internal
Revenue Code (added to the Code by the Affordable Care Act).
o The employer may be subject to an Employer Shared Responsibility payment if at least one of its full-
time employees receives a premium tax credit for purchasing individual coverage in the Marketplace.
o Beginning in January 2016 (for 2015 plan years), the federal government will require applicable large
employers and insurers to report annually to employees and the IRS on the health care coverage they
provided.
7nystateofhealth.ny.gov
Businesses can:
• Buy insurance through the NY State of Health
Marketplace, Small Business Marketplace (SBM), or
• Choose to provide insurance through their current
options.
Overview
8
Choice
• Employers can choose whether to offer all, some or a single QHP to their employees.
• Employees can choose from the health plan options made available by their employer
.
Contribution Options
• The Marketplace gives business owners the flexibility to define the coverage tier of the health
plan(s) which will be offered to employees and the amount they would like to contribute
toward the premiums for the employee.
• Employers may pay a percentage of premiums, pay a fixed amount, or pay nothing at all.
Minimum Participation Required
• NY State only requires a minimum of one (1) enrolled common law employee in order to be
eligible as a small business with the NY State of Health SBM.
Administrative Simplicity
• The Marketplace provides monthly billing to employers along with other administrative
simplifications.
Tax Credits
• The Marketplace is the exclusive place to access small business tax credits
Overview
Employer Benefits of Enrolling in the SBM
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What Do Plans Cover?
1. All QHPs must cover the Essential Health Benefits
• Preventive services will be offered at no cost to the consumer
• Each plan must have an adequate network
• All state consumer and provider protections are in place
2. QHP offered within each Metal Level provide standard
plans which offer the same benefit packages.
• The Metal tier of the plan determines the amount of cost sharing
for services.
• Attachment B outlines the Out-Of-Pocket costs for SBM Standard
QHPs in the same way that is does for the Individual Marketplace.
3. Non-Standard QHPs are also available for selection in
the SBM.
Navigators are familiar with these concepts as they
are the same as in the Individual Marketplace.
Employer Choice
Employer Choice
Same
elements as in
the Individual
Marketplace
Specific to
SBM only
QHP
Naming
Format
Field Name Values Meaning
Product Name To be assigned by Insurer
Metal Tier Bronze, Silver, Gold,
Platinum, Child Only
Identifies Metal Level and whether
Child Only Product
Standard/Non-standard ST, ST3PCP or NS Identifies Standard (ST), Standard with
3 PCP Visits, or Non-Standard (NS)
Product
Network Coverage INN or OON Identifies in-network coverage (INN)
or out-of-network coverage (OON)
Dental Coverage Pediatric Dental,
Adult/Family Dental
Identifies type of dental coverage
included, if any, in QHP
Dependent Age
Coverage
Dep25, Dep29 Identifies the maximum age of
covered dependents
Non-Standard Details Adult Vision, Family
Dental,
Family Vision, Wellness,
Other
Identifies additional covered benefits
Domestic Partner DP Identifies that domestic partners are
covered
Family Planning FP Identifies that family planning
benefits are covered
Employer Choice
Qualified Religious Organization Exemption:
• An employer who is determined to be a qualified religious organization
will be able to claim an exemption from the requirement to provide,
without cost-sharing, coverage of certain contraceptive services for
employees.
o Employers who qualify and want to claim this exemption should be helped to
understand that in claiming this exemption, they are restricting family planning services
from their plan’s coverage.
Coverage Options for Employers to choose from to be made
available to their employees through the SBM
1) Select among QHPs offered by a specific carrier
2) Select specific QHPs offered by multiple carriers
3) Select metal levels and carriers
4) Select coverage tier options (i.e employee only
coverage, employee plus spouse, employee plus child,
or employee plus family coverage)
5) Allow employees to select any Marketplace QHP
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Employer Premium Contribution Options
1)No Contribution
2)Uncapped percentage
(e.g., employer pays 55% of premium)
3)Capped percentage
(e.g., employer pays 55% of premium, up to $300)
4)Defined dollar amount
(e.g., employer pays $300/month)
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Small Business Marketplace (SBM)
Administrative Simplicity
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Administrative Simplicity
• The Marketplace provides employers with a single monthly bill.
– Monthly bill will include breakdown of employer/employee contribution
due to each QHP (employers remain responsible for collecting premiums
from employees).
• The Marketplace collects monthly payment from the employer
and remits payment to insurers.
• SBM will provide record maintenance for ten (10) years.
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Billing and Payments
• NY State of Health will maintain books, records and documents as
well as other evidence of accounting procedures and practices of the
premium aggregation program for each benefit year for at least 10
years.
• Invoicing timeline: Employers of participating small businesses will be
billed a month in advance for all plan policies on the 1
st
of each month,
beginning at the start of their selected plan year.
Note: Navigators do not collect premiums.
Administrative Simplicity
Accounting Procedures
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Administrative Simplicity
SBM Dependents who have aged out:
• Dependents who are turning either 26 or 30 years old (depending
on the rider options selected) will have aged out.
• The SBM tracks each enrolled dependents’ age and will send
disenrollment notices 45 days prior to plan termination.
Field Name Values Meaning
Dependent Age
Coverage
Dep25, Dep29 Identifies the maximum age of
covered dependents
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Small Business Marketplace (SBM)
Small Business Tax Credit
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As of January 1, 2014, the Small Business Health Care Tax Credit is only available
through the NY State of Health, Small Business Marketplace (SBM).
• The credit is available to eligible employers for two consecutive taxable
years.
• There is currently no end date to claim the tax credit for groups that have
not yet received it.
• For tax-exempt employer, if there is no taxable income, the employer may
be eligible to receive the credit as a refund.
• The credit is calculated on a sliding scale for up to 50% of premiums paid for
small business employers and 35% of premiums paid for small business
employers that are tax-exempt.
Small Business Tax Credit
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To be eligible, the small business employer must:
• Purchase health care coverage through the Small Business Marketplace (SBM).
• Have fewer than 25 full-time equivalent employees (FTEs).
• Have average employee wages of less than $50,000 a year. This excludes the
owner and their immediate family.
• Contribute at least 50% of the employee-only premium cost (not family or
dependent).
Employer contributions to health savings accounts, health reimbursement
arrangements, and flexible spending accounts are not counted as insurance
premium payments when determining the credit amount.
Employers must use Form 8941 and Form 990T for tax-exempt organizations.
Small Business Tax Credit
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21
Maximum Small Business Tax Credit
• Available to eligible employers for two (2) consecutive taxable years.
o If an employer does not owe taxes during the year, they may be eligible to carry the credit back
or forward per applicable IRS guidelines.
• Up to 50% of a taxable small business’s premium costs.
o Traditional businesses may receive a tax credit, but are ineligible to receive this in the form of a
refund.
• Up to 35% of a tax-exempt small business’s premium costs
o Tax exempt small businesses can receive their tax credit in the form of a refundable credit. If
they take the credit in the form of a refund, then the amount of the refund cannot exceed the
total of the employer’s income tax withholding from employee wages plus the employer’s share
of the Medicare tax withholdings
Credit is reduced on a sliding scale(The smaller the business or charity, the bigger the credit)
• As average wages increase from beyond $25,000 up to $50,000
• As FTEs increase beyond 10 up to 25 employees
Small Business Tax Credit
22
Small Business Tax Credit
Marketplace is the only place to access the tax credit beginning in 2014.
There are a few exceptions to this rule.
NY State of Health Tax Credit Calculator:
https://nystateofhealth.ny.gov/employer
• Scroll to the bottom of the page to the “Overview”
section.
• Under “Tax Benefits” click on “See if you qualify”
IRS Tax Credit Estimator:
http://www.taxpayeradvocate.irs.gov/estimator/small
business2014/estimator.htm
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Firm Size (FTEs) = Total Full Time Employees + (Total Annual Part
Time Hours/2080)
• Owners are excluded from FTE count and employers cannot
receive a tax credit for owner’s insurance.
• All employee hours are counted and based on a 40-hour work
week.
Wages = Total Wages Paid/ FTEs
• Owners and family member wages are excluded from total wages.
Small Business Tax Credit
How is Full Time Equivalent (FTE) Calculated?
• The employer has 9 FTE employees
• The average wage of the employees is $23,000
per employee
• The employer pays $72,000 in premiums for his
employees
Tax Credit for Non-Tax Exempt Employer
The employers credit is calculated as follows:
• 50% x $72,000 =$36,000*
*This is an estimate only. Employers are advised to work with a tax professional to determine eligibility for
and to claim this credit.
The tax credit amounts are as follows:
Up to a maximum potential tax credit 50% of employer contribution for businesses.
Small Business Tax Credit
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Tax Credit for Tax Exempt Employer
Employer has 10 FTE employees with an average wage
of $25,000 per employee. The employer pays $69,000
in health insurance premiums for those employees.
Please note: For tax exempt employers, the amount of
refund cannot exceed the total of the employer’s income
tax withholding from employee wages + the employer’s
share of the Medicare tax withholdings (equals $29,500 in
this scenario).
Tax credit is calculated as follows:
1) The initial amount before any reduction: (35% x $69,000)= $24,150
2) The employer’s withholdings and Medicare taxes are: $29,500
3) The total tax credit is $24,150
*This is an estimate only. Employers are advised to work with a tax professional to determine eligibility for and
to claim this credit.
The tax credit amounts are as follows:
Up to a maximum potential tax credit 35% of employer contribution for a tax-exempt business.
Small Business Tax Credit
25
Tax Credit for Tax Exempt Employer
Employer has 10 FTE employees with an average wage
of $25,000 per employee. The employer pays $69,000
in health insurance premiums for those employees.
Please note: For tax exempt employers, the amount of
refund cannot exceed the total of the employer’s income
tax withholding from employee wages + the employer’s
share of the Medicare tax withholdings (equals $29,500 in
this scenario).
Tax credit is calculated as follows:
1) The initial amount before any reduction: (35% x $69,00 )= $24,150
2) The employer’s withholdings and Medicare taxes are: $29,500
3) The total tax credit is
*This is an estimate only. Employers are advised to work with a tax professional to determine eligibility for and
to claim this credit.
The tax credit amounts are as follows:
Up to a maximum potential tax credit 35% of employer contribution for a tax-exempt business.
Small Business Tax Credit
$100,000
$100,000 $35,000
$29,500
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Small Business Marketplace (SBM)
Employer Enrollment Offering for
Employees
27
nystateofhealth.ny.gov 28
Employer Registration Process
1. Employers will register and enroll through the SBM.
2. Employers will be asked to create an account. In order to do this, employers will go
through the Identity Proofing process to validate their own identity. They will be asked to
answer some personal questions and provide some of their personal information:
• Personal Address
• Personal Phone Number
• Gender
• Date of Birth
• Social Security Number
3. Employers will then be asked specific identifying and contact information about their
company.
• Employer Identification Number (EIN) or Tax Identification Number (TIN).
4. Employers will be asked to check attestations that they meet the requirements of the
Small Business Marketplace and that they have the authority to enter into agreements for
insurance coverage on behalf of the business.
5. Employers must also agree to the Terms, Rights, and Responsibilities, and the Privacy
Attestation.
Employer Enrollment Offering for Employees
nystateofhealth.ny.gov 29
Employer Registration Process
Employers will be required to provide data on:
• Number of full time employees
• FTEs (Full Time Equivalents)
• Average annual wage
• Employee roster data:
o Name
o Email
o Address
o DOB
o SSN
o Hire Date
Employer Enrollment Offering for Employees
nystateofhealth.ny.gov 30
Employer Registration Process
Employers will be able to:
• Find and authorize a Navigator/Broker
• Compare health plans
Employers must:
• Select health plans and coverage tiers
o The Marketplace contains a full list of available QHPs.
o Navigators should know how to compare the SBM QHP options to guide employers
through the process.
o Navigators should serve customers by remaining neutral and helping the employer find
suitable health plans.
• Determine employer premium contributions
Employees must:
• Use the same Navigator that the employer offers
Employer Enrollment Offering for Employees
nystateofhealth.ny.gov 31
Employer Registration Process
Employers may also:
• Set up “classes” of their employees complete with defined new hire waiting
periods, premium contribution amounts, and plan offerings.
• Each class is to be set up for similarly situated employees. Examples of a class
might include:
o Managers
o Full-Time Employees
o Part-Time Employees
o Retiree Beneficiary
o COBRA Beneficiary
If it is the employers initial open enrollment period in the SBM and the employer has existing COBRA
participants to whom the employer would like to offer an SBM enrollment opportunity, the
employer must create a “COBRA” class and assign the COBRA participants to this class.
If employees were enrolled in COBRA during a previous SBM plan year, those individuals will
automatically be assigned to the “COBRA_Internal” class.
Employer Enrollment Offering for Employees
nystateofhealth.ny.gov 32
Employer Registration Process
• An employer that offers coverage through the Small Business Marketplace will
decide whether they will offer coverage to the employee only or to additional
family members as well.
• Employees can then choose from the options their employer provides.
• Qualified Health Plans are available in four standard tiers of coverage:
o Employee only
o Employee and spouse
o Employee and child/ren
o Employee and family
Employer Enrollment Offering for Employees
nystateofhealth.ny.gov 33
Employer Registration Process
Employers have the option to select one or all of the following health option riders:
• Dependent Coverage through age 29 Option
• Domestic Partner Coverage Option
• Qualified Religious Organization Option
The option to cover
Domestic Partners or
claim a Qualified
Religious exemption is at
the “group” level and will
apply to all employee
offerings.
When creating class offerings,
employers may decide to add a
rider for dependents through
age 29 at the class level; i.e.,
they could choose to offer this
benefit for their executive staff
but not their management staff
if they choose to do so.
Employer Enrollment Offering for Employees
nystateofhealth.ny.gov 34
Employer Registration Process
Dental enrollment is linked to enrollment into a QHP; employers cannot offer
dental without also offering QHP coverage.
• Dental Plans are available in five tiers of coverage:
o Employee only
o Employee and spouse
o Employee and child/ren
o Employee and family
o Pediatric only dental
Employer Enrollment Offering for Employees
nystateofhealth.ny.gov 35
Employer Registration Process
Pediatric dental cannot be offered unless a coverage tier that includes children is
offered.
For tiers of coverage that include children, pediatric dental is either embedded in the
QHP or made available as a stand-alone product:
• When creating an offer for a class, if the employer chooses to offer
dental, the employer will be presented with the equivalent dental plan
tiers and Pediatric Only dental.
o For the employee to select Pediatric Only dental, the child dependent must be
included in the QHP enrollment.
• The Pediatric Dental premium that displays during plan selection is per
child and will be multiplied by the number of children covered, capped
at three children (one-child x 3 rate).
Employer Enrollment Offering for Employees
nystateofhealth.ny.gov 36
Employee Registration and Enrollment Process
Completing the Application
• To be able to participate in the SBM, an employee must receive an offer of coverage from
a qualified employer.
• After the employer adds the employee to the company roster and adds the employee to
a class offering, the employee will receive an automated email from the SBM with an
invitation to participate and an employer participation code.
nystateofhealth.ny.gov 37
Employee Registration and Enrollment Process
Completing the Application
• Must use the employer participation code which will be sent to the employee’s email
address.
• Create username, password, choose personal email
• Employee enrollment – (similar to enrollment on the Individual Marketplace)
o Add employee’s identifying information
o Add family details (if applicable)
o Compare plans offered by employer
o Select plan, tier of coverage, and metal level
nystateofhealth.ny.gov 38
Employee Registration and Enrollment Process
Completing the Application
• Navigators should serve consumers by remaining neutral and
helping employees select a suitable health plan from the options
their employer is offering through the SBM.
nystateofhealth.ny.gov 39
Employee Registration and Enrollment Process
Completing the Application
• If the employee does not want to
enroll, they may choose to decline
the coverage and select a reason
from the dropdown.
When the employee clicks the checkbox to waive the offer, the status of the
employee is marked as “Declined” in the employer’s “My Enrollments” tab.
nystateofhealth.ny.gov 40
Employee Registration and Enrollment Process
Completing the Application
• SBM Certified Navigators are positioned to assist in both the Small
Business Marketplace and in the Individual Marketplace.
• If an employee presents to a Navigator for assistance, and has
employee-only coverage, and that employee also has uninsured
family members:
o Navigators should encourage the employee to have his/her
family explore coverage options through the Individual
Marketplace, if needed.
nystateofhealth.ny.gov 41
Employee Registration and Enrollment Process
Completing the Application
• Individuals who have Employee accounts which were created
through their Employer, will automatically have an account set up
for them in the Individual Marketplace.
Navigators can assist employees in accessing their Individual account, if they need
to enroll a dependent, by going to
www.nystateofhealth.ny.gov and clicking on
“Individuals and Families”
Then click on “Returning User” and sign into the Individual account using the same
NY.gov Username and Password which is used to access the Employee Account.
Small Business Marketplace (SBM)
Enrollment Timing
42
An eligible business may enroll in the SBM at any time during the calendar
year. Once a group effective date is selected– the first of any month of the
calendar year – it becomes the start date for that group’s plan year.
• Effective date is always the first of the month. The employer can elect one
group plan effective date to enroll their employer group at the first of any
month throughout the year.
• The Small Business Marketplace allows qualified individuals a special
enrollment period if they experience a change in circumstances that is
deemed a “qualifying event”.
SBM Enrollment Timing
43
44
SBM Open Enrollment End Dates for Employer
Group Effective Dates
Open Enrollment End Dates
Group Effective Dates
December 15 January 1
January 15 February 1
February 15 March 1
March 15 April 1
April 15 May 1
May 15 June 1
June 15 July 1
July 15 August 1
August 15 September 1
September 15 October 1
October 15 November 1
November 15 December 1
SBM Provides Year-Round, Online Open Enrollment
SBM Enrollment Timing
45
Annual Open Enrollment for Subsequent Years of Coverage
Annual Open Enrollment for Employers:
• Annual Open Enrollment begins 90 days prior to the renewal effective date.
• For subsequent years of coverage, employers can only change coverage
options during the annual open enrollment period.
• The annual open enrollment period each year for an employee must be no
less than 30 days after the employer’s annual open enrollment period.
• If an employee remains eligible for coverage through SBM, they will remain
in the same QHP unless they choose another QHP, if such option exists, or
the QHP is no longer available to the employee.
SBM Enrollment Timing
During the Open Enrollment Period the employer can make the following
edits:
• The group effective coverage date can be changed during the initial open
enrollment period only.
o Cannot be changed when renewing coverage
• Health option riders, QHP metal level, carriers, and dental options
• Premium Contributions
• Coverage Tiers
• Add or delete Dental offering
• Edit the employees’ information
• Add or remove employees from the Roster
*If during the Open Enrollment period, the employer makes a change to a plan offering that an employee has
already enrolled in, making that plan no longer available to that employee, then the employee may receive a
new enrollment offering and may have to re-enroll.
SBM Enrollment Timing
46
47
Special Enrollment Periods (SEPs)
Qualifying life events will allow the employee to enroll outside of the
business’s annual open enrollment period.
• Most changes must be reported within 30 days from the date of the
Qualifying Event.
After reporting a Qualifying Event, the effective date will depend on the type of event being
reported. The effective date could be:
• The date of the Qualifying Event
• The day after the Qualifying Event
• The first of the following month after the Qualifying Event
SBM Enrollment Timing
The Small Business Marketplace allows qualified individuals a Special Enrollment
Period (SEP) if they have one of the following changes of circumstances:
Marriage
Divorce/Legal Separation
Birth/Adoption
Relocation
American Indian/Alaskan Native
Legal Orders
Death
Remove Enrolled Dependents
Loss of Medicaid/Child Health Plus Coverage
Loss of Health Insurance for a Qualified Dependent
SBM Enrollment Timing
48
How to enter a qualifying event in the application:
• If the employee has access to their account, they are able to report
most Qualifying Events (QE) by clicking on the “Report Change in
Circumstance” tab.
• The Employer or Navigator can report a QE on behalf of the
Employee. From the Employer Roster, the Employer clicks the
“Manage” button for the Employee with the QE; a Navigator can
access the employee’s account from the Navigator Dashboard.
• Some QEs must be reported through the NY State of Health Call
Center (855-355-5777).
• Changes in Circumstances which involve American Indians/Alaskan Natives or
Legal Orders must be reported by calling the Call Center.
SBM Enrollment Timing
49
Can an employer terminate SBM participation?
An employer can choose to terminate Small Business Marketplace
participation at any time.
• Coverage terminates at the end of the month in which the termination request was
received.
• When an employer terminates Small Business Marketplace participation, the
system will automatically disenroll all enrolled employees (and employer, if
applicable) and send notices to both employee(s) and employer(s) that coverage
has been terminated.
• This notice will also contain information about potential tax implications for the
employer.
• An Employer Group can be terminated for non-payment of premiums – termination
is initiated by the Small Business Marketplace.
o Termination for non-payment occurs on the last day of the month for which payment was
received
SBM Enrollment Timing
50
SBM Training Resource
51
All SBM Certified Navigators will receive resources accompanying this training.
You will receive:
• How to Enroll an Employee
• Simple instructions accompanying each screenshot for your reference.
• How to Create an NY.gov ID for all types of Marketplace
applicants.
NY State of Health Resources available at
info.nystateofhealth.ny.gov/resources
52
• Producer Tools and Resources: https://info.nystateofhealth.ny.gov/ProducerToolkit
o Includes an administrative guide for Producers
o Details on Eligibility and Enrollment Policies
o Step-by-step User Guides
o Videos on account set-up and enrollment
o Benefit and Rate Details
o So much more…..
• Small Business Premiums “Quick Quote”
https://nystateofhealth.ny.gov/employer
• Small Business Marketplace marketing materials (available in
English + 7 additional languages – order online)
https://info.nystateofhealth.ny.gov/sites/default/files/Overview%20for%20Small%20Business%20Owners_1.pdf
http://info.nystateofhealth.ny.gov/sites/default/files/Poster-Small%20Businesses%208.5%20x%2011.pdf
