The future of the Small Business Health Options Program (SHOP) in Maryland. Presentation to the MHBE Stakeholder Advisory Committee December 10, 2015

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1 The future of the Small Business Health Options Program (SHOP) in Maryland Presentation to the MHBE Stakeholder Advisory Committee December 10, 2015

2 Historical support for small business Senate Bill 6, The Working Families and Small Business Health Coverage Act created the Maryland Health Insurance Partnership effective July 1, 2008 Subsidies provided to small, low-to-moderate wage firms with less than ten employees Administered by the Maryland Health Care Commission (MHCC) Program phased out effective June 1, 2015 Small employers encouraged to transition to the SHOP Exchange for coverage and access to Federal two-year subsidy Dec-08 Dec-09 Dec-10 Dec-11 Dec-12 Dec-13 Dec-14 # Employers # Employees # Covered persons Average group size 4.3 full-time employees

3 ACA introduces SHOP Regulation 45 CFR 155 subpart H An Exchange must provide for the establishment of a SHOP A SHOP must perform the following functions Provide online plan comparison, premium calculator and enrollment tool Certification of issuers to participate in the SHOP program Certification of SHOP Qualified Health Plans (QHPs) Authorization of producers to sell SHOP products Determination of Employer and Employee Eligibility to purchase SHOP QHPs Process employee applications and facilitate the enrollment of employees in QHPs Process Eligibility and renewal notice distribution Performance of Premium Aggregation, Billing and Collections The SHOP program must be offered to small business with up to 50 employees (to increase to 100 at a later date)

4 Maryland creates State Regulations The Maryland Health Benefit Exchange Act of 2012 (HB 443/SB 238) established a distinct Small Business Health Options Program (SHOP); limited enrollment to employers with less than 50 employees increasing to 100 employees in 2016 (delayed per MIA bulletin 15-27, October 8, 2015); and allowed for employee choice as defined by the ACA as well as the existing market model of employer choice. (MIA bulletin The Maryland Health Progress Act of 2013 (HB 228/ SB 274) further defined SHOP rules for employer premium contributions. Percent contribution In this method, the employer pays a fixed percentage of the premium of the reference plan based on the coverage level selected by the member and the member s job classification Employees pay the same amount In this method, the employer uses the employer selected reference plan to determine a set amount that employees will pay towards their total monthly premium based on designated employee tiers. Each employee within a tier pays the same monthly dollar amount. The employer pays the balance premium

5 What does SHOP provide that the Existing small group market can t A small business health insurance tax credit of up to 50% of the premium paid by the employer beginning with the 2014 tax year, and applies to group plans purchased through the Small Business Health Options Programs (SHOP). The tax credit is available to eligible employers for two consecutive taxable years. The ability to offer employees more than one health plan choice. Through the Employee Choice model available only through the SHOP marketplace, a small employer can select one metal level (currently) and allow employees the option to choose any plan from any insurance company in that category. Aggregated billing and payment to multiple carriers and the producer for the employee choice option More than 3 health plans from a single insurance carrier under Employer choice. Health insurers generally limit number of plans to three

6 The Maryland SHOP Marketplace 2014 Technical challenges required focus to be solely on the individual market deferring the build of an online SHOP marketplace. SHOP opening delayed to April 1, 214 For the 2014 plan year, Maryland received federal authorization to operate its SHOP Marketplace through a direct enrollment process with SHOP authorized carriers Through a direct enrollment process small employers utilized the services of a SHOP authorized broker for assistance in purchasing a SHOP certified plan from a SHOP authorized carrier Only the Employer Choice model was available for small employers in 2014 SHOP eligibility determinations and notice distribution was completed by Maryland Health Connection internal staff 2014 Enrollment Participating Employers 45 Participating Members 257 (employees & dependents)

7 The Maryland SHOP Marketplace 2015 As required by Federal regulation, Maryland introduced the Employee Choice model to the SHOP Marketplace on January 1, 2015 for plans with effective dates commencing March 1, Based on need to rebuild MHC platform and cost to build a SHOP online marketplace, the MHBE contracted with three Third Party Administrators (TPAs) to provide SHOP administration services and use of their existing systems for the purchase of SHOP plans. (existing contracts end June 30, 2016) Conflict with authorized carriers over payment to TPAs for enrollment functions required the MHBE to continue to operate the employee choice model through a direct enrollment process with SHOP carriers. SHOP eligibility determinations, notice distribution and billing completed by SHOP Administrators 2015 Enrollment (to date) Participating Employers 114 Participating Members 981 (employees & dependents)

8 The Maryland SHOP Marketplace 2016 and beyond What does Maryland want the SHOP Marketplace to be in the future? How do we get there?

9 Small Business landscape in MD According to a 2015 SBA report 104,603 small businesses in Maryland with employees Eighteen percent had 1-19 employees (18,828) In 2014, 87% of SHOP applicants had fewer than 10 employees Robert Wood Johnson Foundation in September 2015 reported In 2014 nearly 25% of full-time employees and 35% of part-time employees worked for small employers in the US workforce The national percentage of private-sector establishments that offer health insurance among firms with less than 50 employees 32% Based on the above statistics, the potential market of small employers in Maryland is significant (estimate 71,130) Focus group reveled small employers unaware of options or rely on insurance agent to provide guidance and selection

10 Post ACA trends in Health Coverage For small businesses Robert Wood Johnson Foundation and Urban Institute Report September 2015 A single risk pool for small group business may actually increase premiums for some small employers with young and healthy workers Member-level rating may increase premium of owners Multiple choices for coverage Grandfathered plans - indefinite with no significant change (benefit/cost sharing) Transitional plans can remain in effect through 2017 Self-funded plans No mandate for employers with less than 50 employees lack of incentive Small group employees in lower wage scale can obtain federal tax credits through individual market

11 Post ACA trends in Health Coverage For small businesses (con t) Robert Wood Johnson Foundation and Urban Institute Report September 2015 Brokers and insurers are not embracing the SHOP Membership across the country is low Montana 835 enrollees New Mexico 800 enrollees Maryland 935 enrollees Feeling that SHOP does not add value to the existing small group markets Complexity of employer choice Complexity of federal tax credit, limited applicability and short duration Perception that SHOP offers too much or too little choice

12 Feedback from the field Small employers are not aware that the SHOP program exists Composite rating is needed for multiple plans to even out high/low premium variance Having employee choice across metal levels would incent owners who want and can afford more robust, higher premium plans, while young employees want less expensive plans The SHOP program should complement the existing small group market and not compete with it Brokers need to better understand the SHOP program The value-add of the SHOP program must be emphasized

13 Key considerations small business Health coverage through SHOP Financial incentive for small employers Should Maryland or the State Based Marketplace Network advocate at the Federal level for an extension to the Federal Tax Credit? Should Maryland reinstate a State subsidy program for small, low to moderate wage firms? Amount of choice in health plan selection Should MHBE restrict the number of plans a carrier can offer on the SHOP Marketplace to limit complexity for employees? Should Maryland advocate for Federal regulation change to allow for selection of multiple plans within a metal tier instead of all plans within a metal tier? Allow alternate choice models (i.e., contiguous metal tiers) Consider if a composite rating methodology would be possible under the employee choice model Enact composite rating for multiple plans under employer choice model

14 Discussion Topics What are the thoughts of the Standing Advisory Committee regarding providing a robust, affordable, competitive small business health insurance marketplace for Maryland? minimal effort to be in compliance with Federal law keep market to 50 employees increase market to 100 employees (delayed per MIA bulletin 15-27, October 8, 2015) combine small group with individual How should Maryland administer the SHOP Marketplace? Should Maryland continue to contract out the SHOP Administrator function? Cost and time to build SHOP online marketplace into existing MHC online system How does Maryland further develop the SHOP Marketplace so that it is the best it can be for small employers and affordable to the State? Tax credit continuation Expand Plan choice models Composite rating models Marketing efforts

15 Next Steps 1. Draft continuation / RFP for Administrative Services 2. Board recommendations for Legislative items 3. Board recommendations for regulatory items (MIA) 4. Other?

16 Questions? If not now, feel free to contact: Michele Eberle Chief Operating Officer MHBE

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