EXPLORING NEW YORK S SHOP MARKETPLACE. An Overview for Small Groups

EXPLORING NEW YORK S SHOP MARKETPLACE An Overview for Small Groups

TABLE OF CONTENTS Why SHOP... 1 Who Can Enroll...2 How to Enroll...3 Choosing Plans...4 Our SHOP Offerings...5 SHOP Plan Comparison...6-7 EmblemHealth s Select Care Network...8-9 Employee Health Benefits...10 Help With Costs...11 Enrollment Assistance... 12 Key Terms...13-14

Under the Affordable Care Act (also known as Obamacare), small businesses may qualify for tax credits to help them pay the costs of their group health coverage. This assistance is available through the Small Business Health Options Program, better known as SHOP. Each state has a SHOP marketplace. In New York it s known as the Small Business Marketplace, and it s available at nystateofhealth.ny.gov/employer. This kit can help you understand New York s SHOP who qualifies, how to enroll and how to access the available tax credits. Use the Key Terms section at the back to get important definitions. WHY SHOP SHOP is an online marketplace where small businesses can choose plans to offer their employees and get government help funding the costs of coverage. In fact, it s the only place businesses can get this financial help. Within the NY State of Health marketplace (NYSOH), SHOP is called the Small Business Marketplace. Some advantages of getting health coverage through SHOP are: Tax benefits: If your group qualifies, you can get tax credits that return up to 50 percent of your contribution to employee premiums. This credit is only available through SHOP. Use our Cost Calculator at emblemhealthreform.com to see if you may qualify. Defined contribution: You, as the employer, choose whether to offer a fixed amount or a percentage of the employee s monthly individual or family premium as well as the amount or percentage to contribute. However, if you qualify for a tax credit you must contribute at least 50 percent of the premium cost of the lowestpriced self-only plan you choose to offer on SHOP. Easy enrollment and administration: Simply start an online account and choose your plans, and then your employees enroll on their own. You ll pay a monthly bill to SHOP, but NYSOH takes care of most other administrative responsibilities. Guaranteed coverage: Insurers must accept every group that applies for coverage, with very few exceptions. No participation requirements: On SHOP, health insurers cannot deny groups coverage based on the number of employees who enroll in a plan. Outside SHOP, however, minimum participation rules may still apply. More choices for you and your employees: SHOP offers a variety of medical and dental plans at different price points. You pick the plans that work best for your group and then your employees choose which of those plans works best for them. *The information in this kit is current as of October 2014 and may not reflect changes made after publication. It is not meant to provide tax or legal advice. For specific questions, please speak with your legal counsel, tax professional or broker. 1

WHO CAN ENROLL SHOP is open to small businesses only, so you first need to determine whether your business qualifies. To enroll in SHOP, you must be a small business with: Under 50 eligible employees A primary business address in New York State At least one common-law employee You cannot enroll through SHOP in 2015 if you are: A business with more than 50 eligible employees A sole proprietor A business consisting of just you and your spouse, or you and your child HOW TO ENROLL If you re eligible for SHOP and decide to enroll, you, as the employer, take the first step by registering your group. Then it s up to each eligible employee to enroll in coverage through the Employees section of NYSOH. To register your group, follow these five steps: 1. Visit NYSOH online to start an account. Before you do this, you can choose to explore the SHOP marketplace anonymously to see your plan options. When you re ready to start your account, simply: a. Visit the NY State of Health website at nystateofhealth.ny.gov. b. Select Employers. c. Follow the instructions to Register as an Employer, where you ll upload information about your small business such as a roster of your employees. 2. Choose SHOP plans for your group. You can choose to offer your employees: a. All plans: You can offer all metal plans from all health insurers. Your employees can then choose any plan that s available in the county where they live. b. All plans at one metal level: For example, you can offer all Silver plans from all insurers. c. All plans from one insurer: For example, you can offer all of EmblemHealth s metal plans. d. Select metal plans from multiple insurers: For example, you can offer only Platinum and Silver plans from both EmblemHealth and another insurer of your choice. 3. Select your preferred method of premium contribution. You can choose to offer either: a. A fixed dollar amount (you choose the amount) OR b. A percentage of your employees premium (you choose the percentage) However, if you qualify for a tax credit you must contribute at least 50 percent of the premium cost of the lowest-priced self-only plan you choose on SHOP. Note: As a SHOP enrollee, you must offer SHOP coverage to all of your eligible employees without exception. 4. Select a coverage effective date. This is the first day your employees will be covered under the health plan they choose. 5. Expect notification from SHOP. In the month before the plan s effective date, SHOP will notify your employees via email to tell them they can shop for coverage and how to do so. Want help enrolling? You can work with a New York State-certified broker or agent, or a New York State-certified Navigator, to get help enrolling on SHOP. See our Enrollment Assistance section on page 12 for more information. 2 3

CHOOSING PLANS Not sure which SHOP health plans are right for your group and employees? Here are some things to keep in mind. SHOP offers both standard and nonstandard small group health plans, including: Four types of standard metal plans (Platinum, Gold, Silver and Bronze): Each type of metal plan covers the same health benefits, but at different costs both premiums and out-of-pocket costs. All four plan types are offered by all health insurers participating on NYSOH. Each plan type has the standardized cost-sharing required by NYSOH. Various nonstandard plans: Nonstandard plans cover the same health benefits as the standard plans. But, unlike the standard plans, they do not have to conform to the cost-sharing required by New York State, and health insurers can choose whether to offer them. The metal plans carry a tradeoff between premiums and out-of-pocket costs. In general: Platinum and Gold plans have higher premiums, but lower out-of-pocket costs. So, if your employees visit the doctor often, they may want to consider one of these plans. Silver and Bronze plans have lower premiums, but higher out-of-pocket costs. So, if your employees don t visit the doctor often and want lower monthly costs, these plans may be better for them. Here are some things to consider when choosing a selection of plans for your employees: Employee needs: If your employees vary greatly in age, health status and how often they see the doctor, you may want to offer them a variety of metal plans so they can choose the plan that best suits their health needs. Where your employees live: Employees can sign up only for plans offered in their home county. But they can see any network provider, in any county, participating in their plan. So, if your employees live in several different counties, you may want to offer plans with a larger service area so they can see doctors close to home. EmblemHealth s Select Care network provides service in 28 New York counties including the five boroughs of New York City and its surrounding counties, plus upstate regions that stretch north of Albany. Your contribution: To contain costs, consider contributing a fixed dollar amount and offering plans at different metal levels. This way your employees can buy up and, in doing so, purchase plans at lower out-of-pocket costs. OUR SHOP OFFERINGS On SHOP, EmblemHealth offers four standard and three nonstandard small group plans. Each covers the same health benefits, but at different costs both premiums and out-of-pocket costs. Off SHOP, we have more plans for your small business. To learn more, contact us at emblemhealth.com/contact-us/sales.aspx. Or call us at 1-877-347-0440, from 8 am to 8 pm, seven days a week (excluding major holidays). If you have a hearing or speech impairment and use a TTY/TDD, please call 711. EmblemHealth s standard metal plans on SHOP are: Select Care Platinum S: Highest premium, lowest out-of-pocket costs Select Care Gold S: Second-highest premium, second-lowest out-of-pocket costs Select Care Silver S: Second-lowest premium, second-highest out-of-pocket costs Select Care Bronze S: Lowest premium, highest out-of-pocket costs EmblemHealth s standard plans have the standardized cost-sharing required by New York State. EmblemHealth s nonstandard plans on SHOP are: EmblemHealth HMO 40/60 S: Highest premium, lowest out-of-pocket costs (similar to standard Gold plan) EmblemHealth HMO 35/55 S: Medium premium, medium out-of-pocket costs (similar to standard Silver plan) EmblemHealth HMO HD6300 S: Lowest premium, highest out-of-pocket costs (similar to standard Bronze plan) EmblemHealth designs the nonstandard plans itself. Unlike the standard plans, these plans do not have to conform to the standardized cost-sharing required by New York State. 4 5

SHOP PLAN COMPARISON Below you can compare the out-of-pocket costs your employees will need to pay to see a doctor, get medicine or use your other health benefits. All of EmblemHealth s SHOP plans are HMO plans. Members have in-network coverage, choose a primary care physician (PCP) and must get referrals to see specialists. Select Care Platinum S Select Care Gold S Select Care Silver S Select Care Bronze S EmblemHealth HMO 40/60 S (Gold) EmblemHealth HMO 35/55 S (Silver) EmblemHealth HMO HD6300 S (Bronze) Plan Type Standard Standard Standard Standard Nonstandard Nonstandard Nonstandard Deductible Individual Family Copay Primary Care Physician Specialist Emergency Room Out-of-Pocket Maximum Individual Family $0 $0 $15 $35 $100 $2,000 $4,000 $600 $1,200 $25 $40 $150 $4,000 $8,000 $2,000 $4,000 $30 $50 $150 $5,500 $11,000 $3,000 $6,000 $0 $0 None $40 $60 $200 $6,350 $12,700 Coinsurance Select services* Select services* Select services* 50% coinsurance after deductible * Applies after deducible to benefits such as DME (durable medical equipment), hearing aids and pediatric eyewear $4,000 $8,000 $2,000 $4,000 $35 $55 $200 $6,000 $12,000 $6,300 $12,600 None $6,300 $12,600 Select services* Select services** None ** Applies after deductible to inpatient and outpatient facility and surgeon services, and applies before deductible to DME (durable medical equipment), hearing aids and pediatric eyewear Please refer to HIP policy form number 155-23-SGONHIXCONTRACT(04-14), et al. 6 7

EMBLEMHEALTH S SELECT CARE NETWORK EmblemHealth s SHOP plans use the Select Care network a portion of our larger network. It includes leading hospitals and more than 34,000 primary care doctors and specialists. The Select Care network is a carefully chosen group of health care professionals who: Together cover primary care needs and all major medical specialties, such as cardiology and dermatology Provide care in 28 New York counties including the five boroughs of New York City and its surrounding counties, plus upstate regions that stretch north of Albany Include AdvantageCare Physicians, one of the largest multispecialty physician practices in the New York metro area To find Select Care doctors, hospitals and other health care providers, or to choose a new doctor, your employees should: 1. Use our online Find a Doctor tool at emblemhealth.com. 2. Click on any small business health plan they all use the Select Care network. 3. Search by provider type, location, doctor name or medical specialty to get a list of doctors who match their search. AdvantageCare Physicians has 36 locations in and around New York City, giving your employees convenient access to: A team of doctors who track their health and coordinate their care A full range of health services in one place: primary care, pediatrics, cardiology, OB/GYN, gastrointestinal care, lab and pharmacy services, X-rays and more Urgent care or extended hours in most locations Coordinated care across 36 locations and electronic health records that allow your information to travel with you Learn more at acpny.com. All Select Care plans are HMO plans. This means your employees and any dependents covered under their plan must: Get services from doctors in the Select Care network for their care to be covered (except for emergency care which is covered at any hospital nationwide) Choose a primary care physician (PCP), their first contact for medical care Get a referral from their PCP in order to see specialists Looking for an AdvantageCare Physicians doctor? In our Find a Doctor tool, the icon tells you the doctor is part of AdvantageCare Physicians. 8 9

EMPLOYEE HEALTH BENEFITS Health care reform ensures that all plans provide quality coverage for common health needs. That s why all small group plans cover the same health benefits. What makes them different is their costs both premiums and out-of-pocket costs. All group health plans cover: Preventive care at no added cost. Your employees will have 100% coverage for services like regular checkups, immunizations (shots) and screenings such as a colonoscopy, prostate exam, cervical screening and mammogram. They won t pay anything out of pocket for these services. 10 categories of essential health benefits. The specific benefits within these categories vary by state, so your employees would have the coverage offered in New York State. The 10 categories are: 1. Routine doctor visits 6. Prescription drugs 2. Emergency room visits 7. Habilitative and rehabilitative services 3. Hospital care 8. Laboratory services 4. Mental health and substance-use 9. Preventive and wellness services and treatment chronic disease management 5. Maternity and newborn care 10. Pediatric services, including vision care Gym membership reimbursement. Your employees can get up to $200 for the subscriber and up to $100 for the subscriber s spouse OR the actual cost of the membership per six-month period whichever is less. To be eligible, an employee must join or be a member of a participating health club or fitness center (not including tennis clubs, weight-loss clinics, spas or other similar places) and complete at least 50 visits within six months. Note: For some of the essential health benefits, your employees may need to meet the cost of their deductible before the health insurer starts paying, and they may need to get a referral from their primary care physician before getting the care. Health and wellness programs. Your employees can join programs to help them stay healthy, get well and live better. Learn more at emblemhealth.com/healthandwellness. Telehealth. Talk to doctors anytime, day or night, using a computer, mobile device or phone. Learn more at emblemhealth.com/telehealth. HELP WITH COSTS Qualifying employers may be eligible for a small business tax credit, which the employer gets back upon filing their taxes. This tax credit is only available through SHOP. Use our Cost Calculator at emblemhealthreform.com to see if your business might qualify for tax credits. Small business tax credits offset the costs of employee health coverage: For-profit businesses: You may get a tax credit worth up to 50 percent of your contribution to employee premiums. Non-profit organizations: You may get a tax credit worth up to 35 percent of your contribution to employee premiums. You may be eligible for small business tax credits if: Your business has fewer than 25 employees (use our Cost Calculator at emblemhealthreform.com to see which employees count) Your employees make less than $50,000 a year on average All eligible employees are offered health coverage through SHOP You, as the employer, contribute at least 50 percent of the premium cost of the lowest-priced self-only plan you choose to offer on SHOP To get the tax credits, your business will need to claim them during tax time: For-profit businesses: Complete and attach to your tax return Form 8941 (Credit for Small Employer Health Insurance Premiums) Non-profit organizations: Complete and attach to your tax return Form 990-T (Exempt Organization Business Income Tax Return) Note: The tax credit is limited to the amount the employer would have received if all their eligible employees had enrolled in a plan with the average premium for that service area. Use our Cost Calculator at emblemhealthreform.com to see what you might qualify for. 10 11

ENROLLMENT ASSISTANCE New York State offers help registering your group on SHOP. Here are three key ways to get enrollment assistance: Talk to a broker or agent. Brokers and agents are licensed by New York State to sell insurance. Health insurers pay them commissions. To work with a broker or agent affiliated with EmblemHealth plans, please visit nystateofhealth.ny.gov/employer. Then click Get Assistance, go to the Brokers page, and select EmblemHealth from the Issuers Affiliations drop-down window. Talk to a Navigator. Navigators are nonpartisan organizations paid by New York State to enroll small businesses in coverage through the NY State of Health marketplace. Visit nystateofhealth.ny.gov/employer to find Navigators in your area. Call NY State of Health. Call 1-855-355-5777, Monday through Friday, from 8 am to 8 pm, and Saturday, from 9 am to 1 pm. If you have a hearing or speech impairment and use a TTY/TDD, call 711. You can talk to someone in one of 13 languages. KEY TERMS Actuarial value: The percentage the health insurer pays for total health care costs versus what the member pays. Affordable Care Act (ACA): The bill President Obama signed into law in 2010 to reform the US health care system. It s also known as Obamacare. Coinsurance: A percentage of the cost an insured person pays for a covered health service, often once they meet their deductible, if they have one. Copay: The fixed dollar amount an insured person pays to a health care professional for covered services, typically at the time of the office visit. Cost-sharing: A payment arrangement whereby patients pay a portion of covered health services not covered by the health insurer. Deductible: The fixed dollar amount an insured person pays toward covered health services each year before a health insurer starts paying for covered health services. Defined contribution: The amount you choose to contribute to your employees plan premium each month. It can be a fixed amount or a percentage of the premium cost. Dependent: A spouse, child or other eligible family member covered under a subscriber s health insurance policy. Eligible employee: As defined by SHOP, any full-time employee working over 20 hours per week. Essential health benefits: Ten categories of medical services covered under all small group health plans. Exchange: A word commonly used to describe a health insurance marketplace a website where you can choose from a variety of insurers and enroll in quality, affordable coverage. Full-time employee: As defined by the ACA, an employee who works an average of 30 or more hours per week. Full-time equivalent: As defined by the ACA, either a full-time employee or multiple part-time employees whose hours together add up to those of a full-time employee. Grandfathered plans: Plans that have been permitted to keep most of their pre-obamacare health benefits subject to certain conditions. To qualify, the plan must have been effective on or before March 23, 2010 the date of the ACA s enactment and cannot be modified in a way that would cause a loss of grandfathered status. HMO (Health Maintenance Organization): A type of health plan that provides care to members through a network of doctors, hospitals and other health care providers. 12 13

Metal plans: Four plan types (Platinum, Gold, Silver and Bronze) that meet the respective actuarial values required for small group health plans under the ACA. All four types are offered by all health insurers offering individual and small group coverage on the NY State of Health marketplace. Minimum essential coverage: Health insurance that meets the national standards for health coverage that all lawfully present US residents must obtain starting in 2014, if they want to avoid paying the individual penalty. Navigator: A nonpartisan organization chosen by New York State to help individuals and small businesses enroll in coverage through the state-based health insurance marketplaces. Network: The group of doctors, hospitals and other health care providers with whom a health insurer or self-funded plan contracts in order to deliver medical services to plan members. NY State of Health marketplace (NYSOH): An online marketplace where New Yorkers can shop for and enroll in a health plan. They must buy their plan here to get government help with the costs, if they qualify. Non-grandfathered plans: Plans that do not qualify as grandfathered plans and/or plans that became effective after March 23, 2010 the date of the ACA s enactment. Non-grandfathered plans must meet all pertinent ACA requirements. Out-of-pocket costs: Costs that plan members pay as part of their health coverage. This includes copays, coinsurance and deductibles. Out-of-pocket maximum: The annual maximum dollar amount an insured person will have to pay in out-of-pocket costs for covered essential health benefits received in network. Pre-existing condition: A health condition someone had before their coverage start date. Premium: The amount an insured group and/or individual pays to their health insurer each month for their health coverage. Preventive care: A type of medical care focused on health and wellness. It includes services like checkups, immunizations (shots) and screenings. Primary care physician (PCP): A family physician family practitioner, general practitioner, internist or pediatrician who delivers or coordinates care. SHOP: The Small Business Health Options Program an online marketplace for small businesses to obtain health coverage for their employees. Small group employers who qualify for a government-funded tax credit to offer coverage must choose plans here to receive the credit. Sole proprietor: An individual who owns an unincorporated business. Specialist: A doctor trained in a specific area of medicine, such as cardiology or dermatology. Subscriber: A person who holds a health insurance policy. 14

55 Water Street, New York, New York 10041-8190 www.emblemhealth.com Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies. 50-8277 10/14