1 SHOP Direct Enrollment Guide for Authorized Producers Version 1.2 April 2, 2014 In order to help Maryland small businesses to take advantage of tax credit opportunities, the Maryland Health Benefit Exchange (MHBE) has worked with its carrier partners to offer an enrollment option outside of Maryland Health Connection. Beginning April 1, 2014, small businesses in Maryland may work with an Authorized Producer to enroll in SHOP plans directly through the carriers who offer them. This document will help Authorized Producers understand the SHOP Direct Enrollment process. Contents of this Guide 1. Overview of SHOP Direct Enrollment Process 2. Maryland Health Connection SHOP FAQs 3. Maryland SHOP Direct Enrollment Policy & Procedure 4. MHBE Certified SHOP Medical and Dental Plans (by Carrier) 5. SHOP Eligibility Calculation Instructions 6. SHOP Employer Application Form 7. Special Notes on the Application Form 8. Sample Employer Approval Notice 9. Sample Employer Denial Notice 10. Employer Appeals Information 11. Sample Employee Approval Notice 12. Sample Employee Denial Notice 13. Employee Appeals Information
2 Overview of SHOP Direct Enrollment Process
3 SHOP DIRECT ENROLLMENT PROGRAM Maryland Health Connection SHOP FAQs 1. How can I get coverage for my employees through the SHOP Marketplace in Maryland? If you are an employer who is interested in purchasing a SHOP plan for your employees with coverage beginning in 2014, you may participate in this new process, which is referred to as direct enrollment. To access coverage for your employees, you may go to a SHOP-authorized broker and ask about a SHOP Marketplace Plan. These carriers will be offering SHOP-certified plans through the direct enrollment process: CareFirst Coventry Evergreen Health Co-Op Kaiser Permanente United Healthcare BEST Life DentaQuest Dominion Dental Guardian United Concordia For more information about the SHOP Direct Enrollment process, please visit MarylandHealthConnection.gov. 2. How exactly does direct enrollment work for Maryland s SHOP Marketplace? a. You ll contact a SHOP-authorized broker, who will provide you with information about carriers that offer SHOP-certified Qualified Health Plans (QHPs) and Qualified Dental Plans (QDPs). b. Working with a SHOP-authorized broker, you can select Qualified Health Plans and Qualified Dental Plans to offer your employees. c. The broker will help you fill out a MHC SHOP Employer Paper Application for SHOP eligibility and send it to Maryland Health Connection. You are not required to wait to hear back on your eligibility determination from Maryland Health Connection before you and your employees enroll in a SHOP-certified QHP/QDP. You may also submit the MHC SHOP Employer Paper Application yourself, directly to the SHOP. marylandhealthconnection.gov
4 d. Separate from the MHC SHOP Employer Paper Application, the carrier will need you to complete their small group application and related forms. The insurance company can tell you how much coverage may cost and can enroll your employees directly into the plan. If the SHOP later determines that your business is ineligible to participate in the SHOP Marketplace, you would lose eligibility for the Small Business Health Care Tax Credit, but your insurance company is not required to terminate your coverage. If you prefer, you can opt to wait to enroll employees until after you receive an official notice of eligibility from Maryland Health Connection. A decision to delay may impact your desired effective date. 3. Why do I need to complete the SHOP Employer Paper Application and receive an eligibility determination in the SHOP Direct Enrollment Process? This step is important if you are interested in applying for the Small Business Health Care Tax Credit. The first step towards being eligible to receive the tax credit is the determination of your SHOP eligibility by MHBE. You should be aware that you may not be able to access the Small Business Health Care tax credit if you are found ineligible for SHOP coverage. 4. Where do I find more information about the Small Business Tax Credit? The IRS will determine your eligibility for the Small Business Tax Credit. You should refer to the IRS information on the Small Business Tax Credit located at irs.gov/uac/small-business-health-care-tax-credit-for-small-employers. The credit is available only if you obtain coverage for your employees through the SHOP Marketplace. You may qualify for employer health care tax credits if you have fewer than 25 full-time equivalent employees making an average of about $50,000 a year or less. To qualify for the Small Business Health Care Tax Credit, you must also pay at least 50% of your full-time employees premium costs. You don t need to offer coverage to your part-time employees or to dependents. The tax credit is worth up to 50% of your contribution toward employees premium costs (up to 35% for tax-exempt employers). 5. What plans are available? Only SHOP-certified health and dental coverage is available through the SHOP direct enrollment process. For more specific information about the plans offered, please contact a SHOP-authorized broker or visit MarylandHealthConnection.gov. marylandhealthconnection.gov 2014 Maryland Health Benefit Exchange MHC
5 6. If I submit a MHC SHOP Employer Paper Application by myself or through a broker, how will I hear back and when will I know about my eligibility to participate in the SHOP? Maryland Health Connection will notify employers of their eligibility to participate in the SHOP by a mailed written notice. Maryland Health Connection expects to notify employers of their eligibility within 5 days of receiving a fully completed MHC SHOP Employer Paper Application from the employer or broker. By using direct enrollment you can opt not to wait for an eligibility determination from the SHOP Marketplace before enrolling in a QHP and QDP, although you might not be eligible for the Small Business Health Care Tax Credit if Maryland Health Connection later determines you were not eligible to participate in the SHOP. 7. What happens if I, as an employer, am determined ineligible? If you re deemed ineligible for the SHOP Marketplace based on your application, you ll have an opportunity to apply again or to appeal the decision within 90 days of receiving your denial of eligibility notification from Maryland Health Connection. You will receive more information about the appeals process in your eligibility denial notice. If, after appeal, you are still determined to be ineligible, you may still get coverage through a SHOP-certified QHP and QDP for you and your staff, however you will not be able to claim a tax credit for How is SHOP employer eligibility determined? To be eligible to participate in the SHOP Marketplace, you must: Have a principal business address within Maryland, or you can offer coverage to each eligible employee through the SHOP Marketplace serving that employee s primary worksite. Have at least one common-law employee on payroll (not including a business owner or sole proprietor or their spouses if they re on payroll). For the definition of a common-law employee, visit the IRS website at irs.gov/businesses/small-businesses-&-self-employed/ Employee-(Common-Law-Employee) and refer to Question 21 below. Employ 50 or fewer full-time equivalent employees (FTEs), including part-time employees. To calculate FTEs, refer to Questions 20 and 21 below, the MHC SHOP FTE calculator and/or visit the IRS website at irs.gov/uac/small-business-health-care-tax-credit-questions and-answers:-determining-ftes-and-average-annual-wages. Offer coverage to all full-time employees The SHOP will review the employer s application to confirm that the employer meets each of these SHOP eligibility requirements. Maryland Health Connection will provide the employer with a notice of the employer s eligibility determination. Eligibility for the Small Business Tax Credit is determined by the IRS. Please refer to the IRS website at irs.gov/uac/small-business-health-care-tax-credit-for-small-employers for more information. marylandhealthconnection.gov 2014 Maryland Health Benefit Exchange MHC
6 9. How can I find a broker to help me with my MHC SHOP Employer Paper Application? Please refer to our list of brokers who are authorized by Maryland Health Connection at MarylandHealthConnection.gov/assets/Authorized-Broker-Directory pdf. Any broker on this list may assist you with this process. You may also call the Producer Referral Program at or to find a broker near you. 10. What happens if there isn t a broker available to help me or if I prefer not to use a broker? For assistance with the MHC SHOP Employer Paper Application, you may reach out to the Maryland SHOP Marketplace by calling the Consumer Support Center at ( for TTY services for deaf and hard of hearing). HOURS OF OPERATION: Monday Friday: 8 am 8 pm Saturday: 8 am 6 pm Sunday: 8 am 2 pm However, for assistance with plan selection, you must use a SHOP-authorized broker to assist you. 11. Why is Maryland making this direct enrollment process available? We re offering this direct enrollment process to allow small employers and their employees to get the benefits of the SHOP Marketplace coverage quickly, including ensuring that employers can meet the Small Business Tax Credit requirement of employee coverage through a SHOP-certified plan, while we continue making improvements to Maryland Health Connection. 12. When will coverage take effect? The SHOP direct enrollment process will be available starting on April 1, The first possible effective date of coverage will be June 1, Your group s effective date will depend on how quickly you move through the process of selecting the plans that you make available to employees, how long the employees have to select their coverage, and how quickly you make your first payment to your selected insurance company. 13. When will my employees and I be able to apply and enroll in the SHOP online? You and your employees will be able to apply and enroll in SHOP coverage online starting in November 2014 for coverage that takes effect as early as January If you have enrolled in coverage through the SHOP direct enrollment process, you may enroll into SHOP coverage online at the time of your annual renewal. marylandhealthconnection.gov 2014 Maryland Health Benefit Exchange MHC
7 14. Does this mean that I don t need to go to Maryland Health Connection at all? You can go to Maryland Health Connection to view basic information on available plans that can help you choose a plan and insurance company. There are also resources available about the SHOP, a way to calculate the number of employees that you have and information about the Small Business Tax Credit. You can t apply for SHOP eligibility or enroll in SHOP coverage on Maryland Health Connection at this time. 15. What carriers are participating in the SHOP direct enrollment process? The majority of carriers who will be participating in the SHOP online will be participating in the SHOP direct enrollment process. The medical carriers participating in SHOP direct enrollment include: CareFirst, Coventry, Evergreen Health Co-Op, Kaiser Permanente, and United Healthcare. The Dental carriers participating in SHOP direct enrollment include: BEST life, DentaQuest, Dominion Dental, Guardian, and United Concordia. 16. What if my employee already purchased a qualified health plan through Maryland Health Connection? If the employee elects to keep their individual coverage through Maryland Health Connection, they may do so. However, if their employer s plan is considered affordable (i.e. their employee contribution towards the employer sponsored health plan for single coverage is less than 9.5% of their income) and the employer offers a plan that meets the minimum value standard, they will not be eligible for any tax credits or cost sharing reductions for any months that they continue to be enrolled in an individual qualified plan. However, if their employee contribution towards the employer sponsored health plan is considered unaffordable (i.e. greater than 9.5% of their income for single coverage) or does not meet the minimum value standard, they may be eligible for tax credits and cost sharing reductions (depending on their household income) for any months they continue to be enrolled in the individual exchange. They will be required to reconcile their advanced premium tax credits on their plan year tax filing. The employee may also terminate their individual coverage and join their employer-sponsored plan. The employee should alert Maryland Health Connection that they would like to terminate their individual coverage. The individual is not responsible for paying back any subsidies received while employer-sponsored coverage was not available to the employee and their dependents. An employee who is eligible for employer-sponsored coverage through their spouse and/or parent s plan, as applicable, or through a public plan, including Medicare, Medicaid and CHAMPUS, may elect to keep that coverage and not enroll in their newly-offered employer-sponsored plan. marylandhealthconnection.gov 2014 Maryland Health Benefit Exchange MHC
8 17. Is there a minimum participation requirement for SHOP direct enrollment? For the direct enrollment process in the SHOP, there are no minimum participation requirements. Because SHOP plans were not available for purchase from November 15, 2013 through December 15, 2013, no minimum participation may be enforced for plans with effective dates in Does an employee need to submit an eligibility application? No, an employee does not need to submit a SHOP eligibility application during direct enrollment. An employee should follow the enrollment steps provided by the carrier/employer. An employee s eligibility will be confirmed by comparing the insurance carrier s enrollment file for the employer against the employer s roster submitted in the employer s SHOP eligibility application. If an employee does not appear on the employer s roster, a representative from SHOP will contact the employer to ascertain whether the employee was left off the roster inadvertently. If so, the employer may provide MHC an updated roster. MHC will provide all employees that enroll in coverage a notice of eligibility determination. Employers must offer SHOP coverage to all full-time employees and may elect to offer coverage to part-time employees and dependents of any employee. 19. How do I calculate my full-time equivalent (FTE) employees? You should refer to the MHC SHOP FTE calculator to determine your number of FTEs. You may also find information about FTEs through the IRS website at irs.gov/uac/small-business-health-care-tax-credit-questions-and-answers:-determining- FTEs-and-Average-Annual-Wages. 20. Who counts as an employee in the FTE calculation? A FTE is a full-time equivalent employee. In general, all employees of the eligible small employer are taken into account when determining FTEs and average annual FTE wages, including employees who terminated employment during the tax year, employees covered under a collective bargaining agreement, and employees who are not enrolled in health care coverage. The following individuals are not considered employees for purposes of SHOP eligibility and the tax credit: owners of the small business, such as sole proprietors, partners, shareholders owning more than 2% of an S corporation or more than 5% of a C corporation; spouses of these owners; and family members of these owners, which include a child, grandchild, sibling or step-sibling, parent or ancestor of a parent, a step-parent, niece or nephew, aunt or uncle, son-in-law or daughter-in-law, father-in-law, mother-in-law, brother-in-law or sister-in-law. A spouse of any of these family members should also not be counted as an employee. marylandhealthconnection.gov 2014 Maryland Health Benefit Exchange MHC
9 Seasonal workers are workers who perform labor or services on a seasonal basis, including retail workers employed exclusively during holiday seasons. Seasonal workers are not employees for purposes of SHOP eligibility and the tax credit unless the seasonal worker provides services to the employer on more than 120 days during the taxable year, however, premiums paid on behalf of a seasonal worker are counted in determining the amount of the tax credit. Part-time workers are counted in FTEs and average annual wages. If an employee works part-time throughout most of the year, he or she is not a seasonal worker and the employer must count the employee s hours of service during the year in its FTE for SHOP eligibility and tax credit and average annual wage calculation for the tax credit. Leased employees are counted in the FTE for SHOP eligibility and the tax credit and average annual wage calculation for the tax credit. A leased employee is a person who is not an employee of the service recipient and who provides services to the service recipient pursuant to an agreement with the leasing organization. You may find more information at the IRS website on FTEs at irs.gov/uac/small-business Health-Care-Tax-Credit-Questions-and-Answers:-Determining-FTEs-and-Average-Annual-Wages. marylandhealthconnection.gov 2014 Maryland Health Benefit Exchange MHC
10 SHOP DIRECT ENROLLMENT PROGRAM Maryland Shop Direct Enrollment Policy & Procedures Policy Small employers who are eligible to purchase a SHOP plan can purchase a Maryland Health Benefit Exchange certified Qualified Health Plan (QHP) and/or Qualified Dental Plan (QDP) through a SHOP-authorized producer beginning April 1, 2014 and ending December 31, Eligible employers who purchase a SHOP plan through the direct enrollment process may access tax credits afforded to them under the Affordable Care Act (ACA). Steps (High Level): a. Plan information is requested on behalf of an employer by a SHOP-authorized producer b. Maryland Health Connection SHOP Employer Application is completed and submitted to MHC to determine group eligibility (can happen simultaneously with steps below) c. The employer selects a plan or plans to offer to employees and informs employees about their options d. Employees and dependents enroll in the plan of their choice e. The employer makes their initial payment to the carrier and coverage begins f. Carriers submit to MHC a monthly audit file of those employees and dependents who are enrolled in their SHOP-certified plans Procedure Step 1: Employer requests information about SHOP from a SHOP-authorized producer or a SHOP-authorized producer contacts an employer about plans available in Maryland s small group market, including SHOP-certified QHPs and QDPs. Step 2: The carrier identifies to the SHOP-authorized producer which plans have been certified by MHBE as QHPs for sale on the SHOP exchange. Step 3: The employer completes the MHC SHOP Employer Paper Application by himself or with the assistance of a SHOP-authorized producer. Using the information on this application, the SHOP-authorized producer can complete an initial screening to determine if the group is likely to be eligible to purchase a SHOP plan based on the number of full time equivalent employees (FTEs), location of the business, and whether or not the employer will offer coverage to all full-time employees. marylandhealthconnection.gov
11 Step 4: When the MHC SHOP Employer Paper Application is complete, the employer or SHOP-authorized producer sends the application to MHC for a SHOP eligibility determination. Step 4a: If the employer is determined to be eligible to participate in the SHOP Exchange, Maryland Health Connection will notify the employer with a mailed notice of eligibility. Step 4b: If the employer is determined to be ineligible to participate in the SHOP Exchange, Maryland Health Connection will notify the employer and provide information about the appeals process. Coverage under the plan may continue, but, unless the eligibility determination is reversed on appeal, the employer will not be eligible for federal tax credits. * Please note that completion of the SHOP Employer Paper Application may occur concurrently with plan selection. A SHOP Employer Paper Application does not need to be completed and formal eligibility does not need to have been determined in order for a group to shop and enroll with a carrier. Step 5: The employer provides information to employees about its SHOP open enrollment. Step 6: The carrier has the employer and its employees complete a carrier-specific enrollment process. Step 7: The carrier provides the employer with an exact premium quote. Step 8: The employer makes the initial premium payment directly to the carrier or third party administrator (TPA). Step 9: The carrier notifies the employer and employees of successful enrollment in a QHP. Step 10: SHOP-eligible employers or their SHOP-authorized producer make any necessary coverage changes with issuers throughout the plan year. Life Events: Employee should alert employer to life event. Employer will determine if employee and/or eligible dependents are eligible for special enrollment period. Employer will work with SHOP-authorized producer and/or carrier, as applicable for that employer, to provide special enrollment period. marylandhealthconnection.gov 2014 Maryland Health Benefit Exchange MHC
12 Step 12: The carrier submits a monthly snap shot membership file to MHC that contains the following data elements: Business Name of qualified employer (eligible for SHOP) Business EIN of qualified employer (eligible for SHOP) Name, DOB, SSN of qualified employees (those on employee roster) Name, DOB, SSN of qualified employees who actually enroll in a QHP or QDP Name, DOB, SSN of dependents who actually enroll in a QHP or QDP Total Premium Amount per enrollee (by employer and employee contribution, if available) Dates enrollees have coverage QHP/QDP Issuer Name QHP/QDP Issuer ID QHP/QDP Plan Name QHP/QDP Plan ID *The first report from medical carriers will be due on July 15, *Dental carriers offering Stand Alone Dental Plans need only to submit a one-time enrollment report to MHBE. That report will be due by January 15, Step 13: MHBE staff matches the employee enrollment data in the monthly file against the employer s roster in the application and determines eligibility for each employee. This includes newly added employees due to special enrollment period. If an employee is eligible, they will receive a notice of eligibility from MHBE If an employee is ineligible, MHBE staff will contact the employer regarding the inconsistency. If the employer does not confirm that the employee was inadvertently left off of the roster or the monthly file (new hire or special enrollment), the employee will receive a notice of ineligibility from MHBE and information on how to appeal. Step 14: In January 2015, MHBE notifies the IRS of businesses and employees enrolled in QHPs and QDPs for tax year marylandhealthconnection.gov 2014 Maryland Health Benefit Exchange MHC
13 MHBE Certified SHOP Medical and Dental Plans (by Carrier) IMPORTANT: This list contains all the plans certified by MHBE for the 2014 plan year. The carriers may or may not offer each of these plans for sale. Check with the carrier to find out whether a plan in this list is being offered for sale. Medical Plans CareFirst Plan ID Plan Marketing Name 28137MD BlueChoice HMO Referral HSA/HRA $ MD BlueChoice HMO HSA/HRA $ MD BlueChoice HMO $ MD BlueChoice Advantage 90%/70% 45532MD BluePreferred PPO HSA/HRA $ MD BluePreferred PPO100% / 80% 45532MD MD BlueCross BlueShield Preferred 1000, A Multi State Plan BlueCross BlueShield Preferred 2000, A Multi State Plan 94084MD BluePreferred PPO HSA/HRA $ MD BluePreferred PPO 100% / 80% 94084MD MD BlueCross BlueShield Preferred 1000, A Multi State Plan BlueCross BlueShield Preferred 2000, A Multi State Plan Coventry Plan ID 14468MD MD MD MD MD Plan Marketing Name Gold $0 Copay HMO Silver $10 Copay HMO Bronze $10 Copay HMO Gold $0 Copay PPO Silver $10 Copay PPO
14 68541MD Bronze Deductible Only PPO HSA Eligible Evergreen Plan ID 72564MD MD MD MD MD MD MD MD MD Plan Marketing Name Evergreen Health Care Small Group Gold Plus Plan Evergreen Health Care Small Group Gold Plan Evergreen Health Care Small Group Silver Plus Plan Evergreen Health Care Small Group Silver Plan Evergreen Health Insurance Small Group Gold Plus Plan Evergreen Health Insurance Small Group Gold Plan Evergreen Health Insurance Silver Plus Plan Evergreen Health Insurance Small Group Silver Plan Evergreen Health Insurance Small Group Bronze Plan Kaiser Permanente Plan ID 90296MD MD MD MD MD MD MD MD MD MD Plan Marketing Name KP MD Platinum 0/20/Dental KP MD Gold 0/30/Dental KP MD Platinum 500/20/Dental KP MD Gold 1000/30/Dental KP MD Silver 1250/35/Dental KP MD Silver 2500/35/Dental KP MD Bronze 3550/50/Dental KP MD Platinum 1250/10/HSA/Dental KP MD Gold 1250/0%/HSA/Dental KP MD Gold 1500/30/HSA/HRA/Dental
15 90296MD MD MD MD MD KP MD Silver 1500/30/HSA/Dental KP MD Silver 2000/30/HSA/HRA/Dental KP MD Bronze 3150/20%/HSA/Dental KP MD Bronze 2900/20/HSA/Dental KP MD Bronze 3550/50/POS/Dental United Healthcare Plan ID 65635MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD Plan Marketing Name HSA KV Z EPO with Rx YM HSA KV 4 EPO with Rx YM HSA KW Y EPO with Rx YM HSA KW 8 EPO with Rx YM HSA KX M EPO with Rx YM HSA KX S EPO with Rx YM Choice Direct OCI EDGE POST LD 5 EPO with Rx ZS Choice Plus Direct OCI EDGE POST LG 6 POS with Rx ZR Choice Direct OCI EDGE POST LC 6 EPO with Rx ZV Choice Direct OCI EDGE POST LG 8 EPO with Rx ZU Choice Direct OCI EDGE POST LD S EPO with Rx YM Choice Direct OCI EDGE POST LG 2 EPO with Rx YM Choice Direct OCI EDGE POST LF G EPO with Rx ZT Choice Direct OCI EDGE POST LF 3 EPO with Rx ZT HSA KV 1 HMO with Rx YM HSA KV 2 HMO with Rx ZX HSA KV 6 HMO with Rx YM HSA KW 6 HMO with Rx YM HSA KX Q HMO with Rx YM
16 72375MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD MD HSA KX U HMO with Rx YM OCI Direct OCI EDGE POST LG 7 HMO with Rx ZR OCI Direct OCI EDGE POST LD R HMO with Rx ZU OCI Direct OCI EDGE POST LH P HMO with Rx Z OCI Direct OCI EDGE POST LE J HMO with Rx ZS OCI Direct OCI EDGE POST LD 3 HMO with Rx YM OCI Direct OCI EDGE POST LE 7 HMO with Rx YM OCI Direct OCI EDGE POST LG 4 HMO with Rx YM OCI Direct OCI EDGE POST LF 1 HMO with Rx D0 OCI Direct OCI EDGE POST LF 7 HMO with Rx ZT HSA KV V POS with Rx YM HSA KW 2 POS with Rx YM HSA KX K POS with Rx YM HSA KX O POS with Rx YM HSA KX W POS with Rx YM HSA KU 6 POS with Rx YM Traditional with Deductible MT M POS with Rx ZV Choice Plus Direct EDGE POST LD 7 POS with Rx ZS Choice Plus Direct EDGE POST LC 7 POS with Rx ZV Choice Plus Direct EDGE POST LG 9 POS with Rx ZU Choice Plus Direct EDGE POST LD U POS with Rx YM Choice Plus Direct EDGE POST LG 3 POS with Rx YM Choice Plus Direct EDGE POST LF 5 POS with Rx ZT HSA KX Y HMO with Rx YM HSA KV 3 HMO with Rx ZX HSA KV 5 HMO with Rx ZX Traditional with Deductible MT K HMO with Rx ZV
17 31112MD MD MD MD MD MD MD MD Choice Direct EDGE POST LF 9 HMO with Rx ZT Choice Direct EDGE POST LG 5 HMO with Rx ZR Choice Direct EDGE POST LC 9 HMO with Rx ZU Choice Plus Direct EDGE POST LD A POS with Rx ZU Choice Direct EDGE POST LE 3 HMO with Rx YM Choice Plus Direct EDGE POST LE 5 POS with Rx YM Choice Direct EDGE POST LE 9 HMO with Rx YM Choice Plus Direct EDGE POST LF C POS with Rx YM Dental Plans BestLife Plan ID 34137MD MD MD MD MD MD Plan Marketing Name BEST Life Child Dental Plus BEST Life Child Dental BEST Dental Advantage Gold BEST Dental Basic Gold BEST Dental Advantage Silver BEST Dental Basic Silver Coventry Plan ID 68541MD MD MD Plan Marketing Name Bronze Comprehensive PPO Gold Pediatric PPO Bronze Pediatric Pediatric PPO DentaQuest Plan ID Plan Marketing Name
18 49014MD MD MD MD Pediatric High Pediatric Low Family High Family Low Dominion Plan ID 88078MD MD MD MD Plan Marketing Name Select Plan Kids Access PPO Kids Select Plan Access PPO Guardian Plan ID 85008MD MD Plan Marketing Name Guardian Pediatric Advantage Guardian Family Advantage Plus United Concordia Plan ID 98514MD MD MD MD MD MD Plan Marketing Name Smile for Health Child C60A60 Smile for Health Family C60A60 Smile for Health Family C60A50 Smile for Health Family C80A80 Smile for Health Child DHMO Smile for Health Family DHMO
19 SHOP DIRECT ENROLLMENT PROGRAM SHOP Eligibility Calculation Employers must perform this specific calculation annually to determine whether they are eligible to participate in the SHOP Exchange as a small business employer for the following calendar year: Step 1: For each of the 12 calendar months in the preceding calendar year, an employer must determine how many employees (including seasonal employees) averaged at least 30 hours of service a week over the month, or 130 hours or more of service in a calendar month. That will be the number of full-time employees you employed during that calendar month. Note the number of full-time employees for each calendar month. Step 2: Add the hours of service of all other non-full-time employees (including part-time seasonal employees), but do not count more than 120 hours per person per calendar month. Step 3: Divide the total hours of service for each calendar month for non-full-time employees by 120. That determines a full-time-equivalent number for non-full-time employees. Step 4: Next, add the number of full-time employees (Step 1) to the number of equivalents (Step 3), to get the total number of full-time-equivalent employees for that calendar month. Repeat the process for each of the remaining 11 months. Step 5: Add each of the 12 numbers together. Step 6: Divide by 12 for the average annual full-time-employee-equivalent number. That is the number employers must use to determine whether they are considered Small Business. If the total number of full-time-equivalent employees in the previous calendar year is equal/below 50, the employer is considered a small employer under the health care law for the current calendar year and is eligible to participate in SHOP Exchange. If the total number of full-time-equivalent employees in the previous calendar year is over 50, the employer is not considered a small employer the current calendar year and is not eligible to participate in SHOP Exchange. marylandhealthconnection.gov
20 Definitions Full-time: The health care law defines full-time as any employee who averages at least 30 hours of service a week over a calendar month (or at least 130 hours in a calendar month). Seasonal employee: Until further guidance is issued, employers may apply a reasonable, good-faith interpretation of the statutory definition of seasonal worker, the Treasury Department says. For further details, see January 2, 2013, Treasury/IRS proposed regulations. Hours of service: Includes hours worked and also hours for which the employee is paid or entitled to payment even when no work is performed (vacation, holiday, illness, incapacity (including disability), layoff, jury duty, military duty or leave of absence.) Part-time: The health care law defines part-time as an employee who averages less than 30 hours of service a week over a calendar month, or fewer than 130 hours in a calendar month. (Note: Include no more than 120 hours for any one part-time employee in the above equation.) SHOP FTE Calculation Worksheet JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC 1. Enter total number of full-time employees (including seasonal full-time employees) 2. Enter total monthly hours of service for all part-time employees (including seasonal part-time employees) 3. Divide Line 2 by 120 to calculate full-time equivalent (FTE) number for part-time employees 4. Add Line 1 & 3 for total FTEs 5. Add total for Line 4 to calculate total FTEs/Year 6. Divide Line 5 by 12 to calculate average FTEs SHOP Eligibility If Average FTEs is = < 50, your Small Business is eligible to participate in SHOP Exchange, if Average FTEs > 50, your Small Business is not. marylandhealthconnection.gov 2014 Maryland Health Benefit Exchange MHC
21 Small Business Health Options Program (SHOP) Health coverage application for employers Maryland Health Connection s Small Business Health Options Program (SHOP) is open to all eligible small business owners. It should take about 15 minutes to complete this application for eligibility. Is my business eligible for the SHOP? Your business or organization must: Have a primary business address within Maryland, Have at least one common-law employee, Have 50 or fewer full-time equivalent (FTE) employees, and Offer coverage through the SHOP to all full-time employees THINGS TO KNOW Get help Online: MarylandHealthConnection.gov. Phone: Call our consumer support center at TTY users should call En Español: Llame a nuestro centro de asistencia al consumidor al Los usuarios de TTY deben llamar al Contact a broker. What happens next? You ll send this form to the address on page 3. We ll let you know if you re eligible to buy insurance for your small business and give you the information you need to compare cost and coverage options, select a plan, and complete the enrollment process. You may also contact an insurance agent or broker or an insurance company with SHOP plans to begin the application and enrollment process. To see which companies offer SHOP plans in your area, go to MarylandHealthConnection.gov. Your information is private. We ll keep your information private as required by law. Your answers on this form will only be used to see if your business or organization is eligible for the SHOP and, if eligible, to facilitate enrollment. You can learn more about how we handle your information at MarylandHealthConnection.gov. MHC
22 STEP 1 Tell us about the employer offering coverage. Employers must be located within Maryland and must offer coverage to all full-time employees (those working on average 30+ hours per week). 1. Marketplace User ID (optional) (Administrative use only) 2. Employer name* 3. Federal Employer Identification Number (EIN)* 4. Doing business as 5. Employer type* Private sector (profit & non-profit) Church /church affiliated State/local government Foreign government Tribal government and tribally-owned or sponsored organizations and businesses 6. Primary business address* 7. City* 8. State* 9. Zip Code* 10. To be eligible to participate in the SHOP, your business must: Have a primary business address within Maryland; Have at least one common-law employee; Have 50 or fewer Full Time Equivalent (FTE) employees; and Offer coverage through the SHOP to all full-time employees. I agree that all of the above apply to my business.* STEP 2 Tell us who to contact about this application. Primary contact 1. First name* Middle name Last name* Suffix 2. Title* 3. Mailing address* (if different from primary business address above) 4. City* 5. State* 6. Zip Code* 7. Phone number* Work Home Cell 8. Second phone number* Work Home Cell 9. Fax number 10. address* Re-enter address* 11. Preferred language (if not English) 12. Note: Notices and monthly invoices will be sent by the carrier. Secondary contact (optional) 13. First name* Middle name Last name* Suffix 14. Title* 15. Mailing address* (if different from primary business address above) 16. City* 17. State* 18. Zip Code* 19. Phone number* Work Home Cell 20. Second phone number* Work Home Cell 21. Fax number 22. address* Re-enter address* NEED HELP WITH YOUR APPLICATION? Contact a broker with questions, visit MarylandHealthConnection.gov or call us at TTY users should call * Required Field Page 1 of 3 MHC
23 STEP 3 For certified application counselors, navigators, agents, and brokers only. Complete this section if you re a certified application counselor, navigator, agent, or broker filling out this application for somebody else. 1. First name Middle name Last name Suffix 2. Organization name (if applicable) 3. ID number, if applicable (NPN for brokers) 4. Phone number Work Home Cell 5. Second phone number Work Home Cell 6. Fax number 7. address Re-enter address STEP 4 List all employees who ll get an offer of coverage even if they may not enroll. Include owners and business partners. You must include all full-time employees (30+ hours)* Employee first name* Middle name Last name* Suffix Date of birth (mm/dd/yyyy)* (If available) Social Security/ Tax ID Number* (If available) Employment status* Date of hire (mm/dd/yyyy) Average weekly hours if not full time Attach more sheets as necessary. You may attach your own spreadsheet with the information requested in Step 4 instead of using this document to provide that information. * Required Field Page 2 of 3 MHC
24 STEP 5 Read & sign this application. I m signing this application under penalty of perjury, which means I ve provided true answers to all of the questions to the best of my knowledge. I know that I may be subject to penalties under state and federal law if I intentionally provide false or untrue information. I know that my information on this form will only be used to determine eligibility for health coverage and will be kept private as required by law. If my business or organization is eligible, this information will be used to facilitate enrollment. I know that I must tell the SHOP if anything changes (and is different than) what I wrote on this application. I can visit MarylandHealthConnection.gov or call (TTY users: ) to report changes. I have consent from everyone I ll list on the application to include their personally identifiable information, like dates of birth, Social Security numbers, addresses, and phone numbers. I know that under state and federal law, discrimination isn t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. I can file a complaint of discrimination by visiting or Name of person signing* Signature* Date(mm/dd/yyyy)* * Required Field STEP 6 Mail the completed application. Mail your completed application to: Maryland Health Connection P.O. Box 857 Lanham, MD We ll let you know if you re eligible to buy insurance for your small business and give you the information you need to compare cost and coverage options, select a plan, and complete the enrollment process. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is The time required to complete this information collection is estimated to average minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C , Baltimore, Maryland Need help? If you have questions about this application or need help completing it, contact a broker, or call TTY users should call Page 3 of 3 MHC
25 Special Notes on the SHOP Employer Application Form Producers, please take note of the following: Under Step 1 on page 2, there is a checkbox that says I agree that all of the above apply to my business. This is where the business attests to their having 50 or fewer FTEs. MHBE does not need to see an entire list of all the group s employees in order to make the eligibility determination. The business simply must attest to having 50 or fewer FTEs. The business is assumed to have used the FTE calculation tools to determine that they have 50 or fewer FTEs. The employee roster under Step 4 is where MHBE will look to determine whether a particular person is qualified to be a member of a SHOP group. This is not intended to be an entire list of all employees just a list of those employees who will be offered coverage.
26 Privacy Statement In addition to collecting business information on the Maryland Health Connection Small Business Health Options Program (SHOP) Employer Application form, we are authorized, under the Patient Protection and Affordable Care Act (Public Law No ), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law No ), to collect personally identifiable information and any supporting documentation that might be required for processing this application, including the name and contact information ( address, home address, home phone number, date of birth and Social Security number) for a primary and secondary employer contact, and the names, Social Security numbers and dates of birth of all full-time employees. We need the information provided by you about primary and secondary employer contacts and the full-time employees listed on this form to determine whether you are a qualified employer and your employees are qualified employees to facilitate enrollment in a qualified health plan (QHP) through the SHOP. As part of that process, we will verify the information provided on the form, communicate with your primary and/or secondary employer contacts and any Agent, Broker or other SHOP assister that may have assisted you with your SHOP application, and eventually provide the information to the health plan selected so that qualified employees can enroll in a (QHP). We will also use the information provided as part of the ongoing operation of the SHOP, including activities such as verifying continued eligibility, reporting on and managing enrollment for qualified employees, performing oversight and quality control activities, combatting fraud, and responding to any concerns about the security or confidentiality of the information. While providing the requested information (including Social Security numbers) is voluntary, failing to provide it may delay or prevent your ability to obtain health coverage through the SHOP. If an individual does not maintain qualifying health coverage for three months or longer during the year, that individual may be subject to a penalty. If you don t provide correct information on this form or knowingly and willfully provide false or fraudulent information, you may be subject to a penalty and other law enforcement action. In order to verify and process application forms, determine whether you are a qualified employer and if your employees are eligible to participate, and to operate the SHOP, we may need to share selected information that we receive from you on the Maryland Health Connection SHOP Employer Application form outside of Maryland Health Connection, including with: 1. Federal agencies, (i.e., the Internal Revenue Service) to report eligibility for health insurance coverage through the SHOP, 2. Maryland Health Connection contractors engaged to perform a function for the SHOP and other contractors engaged to perform verification including those conducting verification of the employer s primary and secondary contacts identity and other consumer reporting agencies, 3. Agents, Brokers and other SHOP assisters, and issuers of QHPs as applicable, who have been engaged to assist with eligibility determinations and enrollment in QHPs, and 4. Anyone else as required by law. You can learn more about how we handle your information at
27 Maryland Health Connection P.O. Box 857 Lanham, MD <Applicant_name> <Applicant_address> or Notice date: <Notice_date> Application date: <application_date> Maryland Health Connection SHOP ID : <HIX#> <applicant name> In care of <authorized representative name> <Authorized Representative_address> Good news for <applicant name>! You qualify to purchase coverage through the Maryland Health Connection s SHOP Exchange. What s next? If you have not done so already, you will need to select the type of coverage you want to offer your employees and complete a carrier-specific enrollment process. If you need assistance with the enrollment process, you may contact a SHOP-authorized broker about SHOP-certified qualified health plans and qualified dental plans. Additional resources may be found at You may be eligible for a small business tax credit if you contribute at least 50% towards your employees premium costs, employ fewer than 25 full-time equivalent (FTE) employees, and pay an average annual salary of less than $50,000 per FTE. The small business tax credit is administered by the Internal Revenue Service through Form You may find more information about the tax credit by visiting and Small-Employers. Sincerely, Maryland Health Connection SHOP We will keep your information secure and private. Your Secure User Account Maryland Health Connection keeps all important information about your application and your health coverage. Go to to access your account. If you have not yet created an account, click on Account Setup for instructions. Language services are available to assist you. If you need assistance call (855) (TTY: (855) ). Servicios de traductor están disponibles para asistirles. Si usted necesita ayuda llame al (855) (TTY: (855) ).
28 A Service of the Maryland Health Benefit Exchange <Applicant_name> <Applicant_address> or Maryland Health Connection SHOP P.O. Box 857 Lanham, MD Notice Date: <Notice_date> Application Date: <application_date> Maryland Health Connection SHOP ID: <HIX ID> <applicant name> In care of <authorized representative name> <Authorized Representative_address> Important Information for <employer_name> Based on the information provided, you are not qualified to provide coverage to your employees through the Maryland Small Business Health Options Program (SHOP) for the following reason(s): denialcode1 denialcode2 denialcode3 How to Appeal You can request a desk review of your denial of eligibility as a qualified employer in the Maryland Health Connection SHOP by mail, or phone as discussed in the appeals information provided below. The Reviewing Officer will consider your request, along with the information the Maryland Health Connection SHOP used to determine your eligibility. You can submit any other relevant information to the Maryland Health Connection SHOP to be considered as part of your appeal. You may submit additional information to the Reviewing Officer by: Mail: Fax: Sincerely, Maryland Health Connection SHOP We will keep your information secure and private. Your Secure User Account Maryland Health Connection keeps all important information about your application and your health coverage. Go to to access your account. If you have not yet created an account, click on Account Setup for instructions. Language services are available to assist you. If you need assistance call (855) (TTY: (855) ). Servicios de traductor están disponibles para asistirles. Si usted necesita ayuda llame all (855) (TTY: (855) ).
29 Maryland Health Connection SHOP P.O. Box 857 Lanham, MD IF YOU THINK WE MADE A MISTAKE You may appeal the decision by the Maryland Health Connection Small Business Health Options Health Program (SHOP) that you are not eligible to be a SHOP Exchange qualified employer. You may also file an appeal if the SHOP did not make a timely decision regarding your application for eligibility as a SHOP qualified employer. You have 90 days from the date of this notice to a file a request for review of our decision or failure to make a timely decision. To file a request for review: By Mail: Write a request for review and mail it to: Maryland Health Connection SHOP P.O. Box 857 Lanham, MD By Write a request for review, scan the document and attach it in an or write an to: By Phone: Call the Maryland Health Connection SHOP at: (855) (TTY: (855) ). *Please include your Maryland Health Connection SHOP ID# on all requests. If you disagree with our decision and want to speak to someone about it, or if you need help filing an appeal, call (855) (TTY: (855) ). If you file an appeal, a reviewing officer at the Maryland Health Benefit Exchange will review your request along with the Maryland Health Connection SHOP information used to determine your denial of eligibility as a SHOP qualified employer. You may submit additional relevant documents for the reviewing officer to consider by sending them to the mail or addresses listed above. The reviewing officer will issue a written decision after reviewing your request, our decision and any additional documents provided by you. You may review our documents regarding your eligibility at any time.
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