Affordable Care Act | SBA | Entrepreneur Road Map

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The SBA spoke at the WDCEP's Entrepreneur Road Map's Business Insurance seminar held at Venable (7/16/14). The topic of the presentation was focused on the Affordable Care Act.

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  • Credit works on a sliding scale, i.e., for each FTE above 10 and average annual wages above $25,000, the credit is reduced
  • Non-profit employers are also eligible for the tax credit. For 2010 – 2013, it’s a credit of up to 25% for eligible non-profit employers. Starting in 2014, the credit rises to 35% for non-profits who are otherwise eligible and purchase coverage through SHOP.
  • As a small employer, you now have access to a new program designed to help you offer health insurance to your employees.

    The Small Business Health Options Program, or the SHOP, is open to employers with 50 or fewer employees in 2014—including non-profit and religious organizations.

    The SHOP is part of the new Health Insurance Marketplace—sometimes called an Exchange—available in each state. Some states are running their own SHOP Marketplaces, while others are participating in the Federally-facilitated SHOP Marketplace.

    The SHOP offers employers a choice of health and dental plans, and tools to help you make informed purchasing decisions. You and your employees can enroll in SHOP coverage at any time throughout the year.

    In addition, if you offer your employees coverage through the SHOP, and meet other eligibility requirements, you may be able to claim a Small Business Health Care Tax Credit worth up to 50% percent of your premium contributions.

    Together, new insurance reforms and the SHOP will help curb premium growth, and spur competition based on price and quality.

    If you have fewer than 50 full-time-equivalent employees, you’re not required to offer you employees health insurance, and there’s no penalty if you choose not to.

    If you want to offer your employees a SHOP Qualified Health Plan this year, and you’re located in a state with a Federally-facilitated SHOP Marketplace, you’ll use the “Direct Enrollment” process and enroll by working directly with an agent, broker or insurance company offering plans certified by the SHOP.

    You can’t currently purchase SHOP coverage online through HealthCare.gov, but we expect that you’ll be able to do so in the fall of 2014, for coverage beginning in 2015.







  • The SHOP is open to small employers with 50 or fewer employees (FTEs)

    Full-time equivalent employees generally include those who work at least 30 hours per week.

    Part-time workers, whose combined hours total at least 30 hours per week, are also included when determining SHOP eligibility.

    You must have at least one common-law employee, who is not your spouse, on payroll to be eligible for SHOP coverage.

    In the Federally-facilitated SHOP you must offer coverage to all of your full-time employees who work an average of 30 or more hours per week.

    You’ll also need to make sure you meet any “minimum participation” requirement that your state has set. In many states that are using the Federally-facilitated SHOP, at least 70% of your employees who are offered coverage must accept the offer before you can enroll.

    HealthCare.gov now offers an online tool, the SHOP FTE Calculator, that can help you count how many full-time equivalent employees you have, to determine whether you might be eligible for the Federally-facilitated SHOP.

    You can find this calculator using the web address listed on this slide, or by visiting HealthCare.gov, clicking on the Small Businesses tab, then clicking “See if you qualify to use the SHOP Marketplace” under the heading “Take Action” on the right-hand side of the screen.

    The Federally-facilitated SHOP Marketplace uses a specific full-time-equivalent counting method to determine SHOP eligibility. Until 2016, states running their own state-based SHOP may use their traditional methods to count employees. Employers in a state with a state-based SHOP may not be able to rely on this calculator, but should contact the SHOP in their state to learn more.

  • If you’re a sole proprietor or shareholder of more than 2% of an S corporation that has no common law employees, you can’t buy insurance through the SHOP.

    However, you—and your spouse—may qualify to buy insurance through the Health Insurance Marketplace, which sells health insurance for individuals and families.

    Depending on your level of income, as individuals, you may qualify for premium assistance through the Health Insurance Marketplace.

    While small employers and their employees can enroll in SHOP coverage at any time during the year, individuals using the Health Insurance Marketplace generally must enroll during the Open Enrollment Period.

    For 2014 coverage, the Open Enrollment period for individuals and families in the Health Insurance Marketplace ended on March 31. For 2015 coverage, Open Enrollment for individuals and families will begin again on November 15, 2014 and will continue until February 15, 2015.

    However, as an individual or family you may be eligible for a Special Enrollment Period to enroll in health coverage outside of Open Enrollment if you have a change in your life, known as a “qualifying life event” and other limited circumstances. Examples of qualifying life events include: moving to a new state, certain changes in your income, and changes in your family size like, if you marry, divorce, or have a baby.

    Visit HealthCare.gov for more information on premium assistance, enrollment, and qualifying life events.
  • Small employers in states using the Federally-facilitated SHOP can’t apply for SHOP coverage online this year, and must use “Direct Enrollment”, but they may still qualify for the Small Business Health Care Tax Credit when they enroll in coverage through the SHOP.

    If you’re considering using the SHOP to take advantage of the Small Business Health Care Tax Credit, you can now visit HealthCare.gov to use the SHOP Tax Credit Estimator. This tool can help employers and the agents and brokers assisting them learn if they might be eligible for the tax credit and how much of a tax credit they could receive.

    To claim the credit, generally, you must offer your employees coverage in a SHOP Qualified Health Plan (and a SHOP Qualified Dental Plan, if applicable)—so if you’re working with an agent, broker or insurance company, make sure that’s what you’re getting.

    In tax year 2014, if you’re in a state using the Federally-facilitated SHOP, the SHOP must determine that you’re eligible to participate in the SHOP before you can claim the credit.

    To be determined as eligible for the Federally-facilitated SHOP, you must have submitted an application and have been found by the SHOP to meet the requirements to purchase SHOP coverage.

    For 2014, you can choose not to wait for an eligibility determination from the SHOP Marketplace before purchasing a SHOP Qualified Health Plan. This may allow you to get coverage for your employees more quickly, and to get the full advantage of the tax credit sooner.

    You do need to get the SHOP eligibility determination sometime before the end of 2014. We suggest that you mail in your application within a week of enrolling your employees in SHOP coverage, but no later than December 1, 2014.

    This timing is important, because if you’re found eligible, the SHOP will also send your employee enrollment information to the IRS to ensure that, if you meet all the other requirements, you can claim the tax credit for tax year 2014.

    If the SHOP Marketplace determines that you aren’t eligible to participate in the SHOP after you’ve already enrolled in SHOP coverage, you would not be able to claim the Small Business Health Care Tax Credit, but you may be able to continue your coverage.

  • You can offer your employees health coverage through a SHOP now, or at any time during the year.

    Unlike the Health Insurance Marketplace for sole-proprietors, individuals and families, the SHOP Marketplace accepts initial group enrollments all year long.

    In the FF-SHOP, if your initial group enrollment is completed between the 1st and 15th day of the month, your group coverage could begin as soon as the first day of the next month. For example, if your initial group enrollment is completed on July 10, 2014, your group coverage could begin as soon as August 1, 2014.

    In the FF-SHOP, for initial group enrollments completed after the 15th of the month, coverage could begin as soon as the first day of the second following month. So, if the initial group enrollment is completed on July 18, your group coverage could begin as soon as on September 1.

    If you’re seeking SHOP coverage for your employees in the Federally Facilitated SHOP Marketplace in 2014, you’ll need to purchase that coverage directly from an agent, broker or insurance company that offers a SHOP Qualified Health Plan. This process is referred to as “direct enrollment.”

    Online enrollment is not available in the Federally-facilitated SHOP in 2014, but is expected to be available for coverage taking effect in 2015.

    Direct enrollment in a Federally-facilitated SHOP plan in 2014 is pretty similar to how many small employers enroll in coverage today.

    You can start by learning about the SHOP plans available in your area from an agent, broker, an insurance company with plans certified by the SHOP, or by using the premium estimation tool on HealthCare.gov.

    After you’ve selected a plan, the agent, broker or SHOP insurance company can give you an exact price quote.

    If you decide to take this plan, you’ll offer it to your employees. Those that accept will enroll with the help of the insurance company, agent or broker.

    After your employees enroll, you’ll pay the insurance company directly, or with the help of an agent or broker.

    A state that runs its own SHOP Marketplace may have a different enrollment process. The SHOP in many of these states already offers online enrollment.


  • Only employers may file applications for Federally-facilitated SHOP eligibility, not employees.

    The SHOP will verify employee eligibility based on information sent by the insurance company.

    In the Federally-facilitated SHOP Marketplace, an agent, broker, or insurer can help you get, fill out and mail in the paper application. A Marketplace Navigator or other assister can also help.

    Or you can fill out and download the paper application from HealthCare.gov. The website has instructions for completing the form and the mailing address, which is also listed on application.

    Finally, you can complete the application by phone through the SHOP Employer Call Center.

    The Federally-facilitated SHOP Marketplace will notify you of your eligibility to participate in the SHOP by phone and e-mail, as well as by mail, if requested..

    You should get a SHOP eligibility determination 3-5 days after the SHOP Marketplace receives your fully completed application. Plan to keep your eligibility determination notice for your tax records.

    The Federally-facilitated SHOP can only determine whether you’re eligible to participate in the SHOP, and not whether you can receive the tax credit. The IRS will ultimately determine if you meet the requirements for the Small Business Health Care Tax Credit after you file your tax returns.
  • On July 2, 2013, Treasury issued transitional relief to employers covered by these rules indicating that the employer shared responsibility provisions will not take effect until 2015, and no shared responsibility payments will apply until 2015.
  • Link to MV Calculator: http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/mv-calculator-final-4-11-2013.xlsm
  • The penalties listed in this slide are per adult. The amount per child is 47.50, 162.50, and 347.50, respectively. The penalties go up to $285, $975, and $2,085 per family.
  • Affordable Care Act | SBA | Entrepreneur Road Map

    1. 1. Affordable Care Act 101: What The Health Care Law Means for Small Businesses These materials are provided for informational purposes only and are not intended as legal or tax advice. Readers should consult their legal or tax professionals to discuss how these matters relate to their individual business circumstances.
    2. 2. Small Business and Health Care 2 For years, small businesses have reported that their NUMBER ONE concern has been access to AFFORDABLE HEALTH CARE.
    3. 3. ACA Reduces Premium Cost Growth and Increases Access to Affordable Care Before ACA, Small Employers Faced Many Obstacles to Covering Workers Under the ACA, insurance companies: • Face limits on administrative spending. Most insurers must now spend at least 80 percent of consumers’ premium dollars on actual medical care • Must disclose and justify proposed rate hikes of 10% or more, which states, or the federal government, may review 3 • Too few choices • Higher premiums and unpredictable rate increases • Higher rates for groups with women, older workers & those with chronic health concerns or high-cost illnesses, in most states • Waiting periods or no coverage for individuals with Pre-Existing Conditions • Can’t charge higher rates or deny coverage because of a chronic or pre-existing condition • Can’t charge higher rates for women, and face limits on charging additional premiums for older employees • Must pool risks across small groups creating larger pools like large businesses • Must not have annual dollar limits on coverage • Must offer plans that provide a core package of “Essential Health Benefits” equal to typical employer plans in the state May 7, 2014
    4. 4. ACA Reduces Premium Cost Growth and Increases Access to Affordable Care 4 The Affordable Care Act increases access to affordable, quality health care for the self-employed and small businesses • For 2010 thru 2013, worth up to 35 percent of their premium contributions (25% for tax- exempt employers) for their employees’ health insurance. For 2014 and beyond, eligible small businesses can get a tax credit worth up to 50 percent (35% for tax-exempts) for health coverage offered to employees through the SHOP. • Better options through new Health Insurance Marketplaces: Starting January 1, 2014, the self-employed and small businesses will have access to a range of affordable health care options no matter where they are located.
    5. 5. How Will ACA Impact Small Businesses? It often depends on the size of the business. How many employees does the business have? 5 Number of Full-Time Equivalent (FTE) Employees 24 or fewer Up to 50 50 and above
    6. 6. Affordable Care Act 6 Small Business Health Care Tax Credit
    7. 7. Businesses with 24 or Fewer FTE Employees • If these smaller businesses provide coverage, they may qualify for the Small Business Health Care Tax Credit to help offset costs: – Must have average annual wages below $50,000; and – Contribute 50% or more toward employees’ self-only premium costs Note: The maximum tax credit is available to employers with 10 or fewer full-time equivalent employees and average annual wages of less than $25,000 7 Number of FTE Employees 24 or fewer Up to 50 50 and above
    8. 8. Small Business Health Care Tax Credit • In 2010 - 2013, up to 35% of a for-profit employer’s premium contribution – Employers can still deduct remainder of contribution – Credit can be claimed through 2013 • Starting in 2014, the credit goes up to 50% – To take advantage of the credit, business must buy coverage through one of the new small business health insurance Marketplaces known as SHOP – Credit can be claimed for any 2 consecutive taxable years beginning in 2014 (or beginning in a later year) through the SHOP • Note that this is a Federal credit, and that some states may also have additional tax credits available 8
    9. 9. Businesses with Up to 50 FTE Employees • Starting January 2014, if a small business of this size chooses to offer coverage, there is a new way to do so: Small Business Health Options Program (SHOP) Marketplace • Enhanced SB Health Care Tax Credits available for eligible employers participating in SHOP 9 Number of FTE Employees 24 or fewer Up to 50 50 and above
    10. 10. Affordable Care Act 10 January 1, 2014: Health Insurance Marketplaces
    11. 11. What is the SHOP Marketplace? SHOP = Small Business Health Options Program • Part of the Health Insurance Marketplace created by the Affordable Care Act (ACA) • Offers employers a choice of health insurance plans and dental plans and tools for making informed choices • Offers qualified small employers access to the enhanced Small Business Health Care Tax Credit—now worth up to 50% of employer’s premium contributions • Works with new insurance reforms to spur competition based on price and quality Note: If you have fewer than 50 full-time-equivalent employees, you’re not required to offer health insurance, and there’s no penalty if you choose not to. 11May 7, 2014
    12. 12. Who Can Purchase FF-SHOP Coverage? Small employers who: • Have 50 or fewer employees in 2014 • Have at least one common law employee • Offer coverage to all of their full-time employees o In the Federally-facilitated SHOP this means employees working on average 30 or more hours per week • Can be for-profit or tax-exempt • Meet minimum participation rates o In many states using Federally Facilitated SHOP Marketplace, at least 70% of full-time employees must accept your offer of insurance Visit the SHOP FTE Calculator HealthCare.gov/fte-calculator/ 12May 7, 2014
    13. 13. Options for the Self-Employed Use Health Insurance Marketplace for individuals, families • Sole proprietors and shareholders > 2% S corp. with no employees • Owners, co-owners and their spouses Important features of the individual Marketplace • Premium assistance may be available, depending on income • Individuals generally must enroll during Open Enrollment Period o Next Open Enrollment November 15, 2014 - February 15, 2015 • Special enrollment periods for those with “qualifying life events” and other limited circumstances o Including marriage, divorce, or having a baby 13May 7, 2014
    14. 14. Using the SHOP to Qualify for the Tax Credit in 2014 Find Out How Much the Tax Credit Might Be Worth to Your Business: To Qualify for the Tax Credit in 2014 employers must: • Have employees enrolled in a SHOP Qualified Health Plan • Meet other requirements for the credit, and • Receive an “eligibility determination” from the SHOP Marketplace An eligibility determination from the Federally Facilitated SHOP • Means the SHOP Marketplace finds you meet the requirements to use the SHOP • Is not required before buying SHOP coverage • Is required to claim the Small Business Health Care Tax Credit o Must get determination before the end of 2014 o Should send application within a week of enrollment; no later than December 1 If you’re found not to be eligible after buying SHOP coverage • You can’t claim the tax credit, but • Your insurance company need not end your coverage 14 The SHOP Tax Credit Estimator HealthCare.gov/small-business- tax-credit-calculator May 7, 2014
    15. 15. Buying SHOP Coverage: When & How? When can you offer a SHOP Qualified Health Plan? • Get started now, or offer anytime during the year • Unlike Marketplace for individuals, no limited Open Enrollment period for the SHOP How do you buy a SHOP Qualified Health Plan? • For Federally Facilitated SHOP, in 2014 only—must use Direct Enrollment o Work directly with an agent, broker or insurance company o Similar to how small businesses have gotten coverage in the past o Use the same process for buying a SHOP Qualified Dental Plan • With Direct Enrollment you’ll: o Select a SHOP Qualified Health Plan to offer employees (and a SHOP Qualified Dental Plan, if applicable.) o Submit a hard copy employer application to the FF-SHOP o Have the agent, broker, or insurer help enroll those employees who accept o Pay the insurance company, directly or with the help of an agent or broker • In states running their own SHOP Marketplace o Enrollment processes may differ o Many offer online enrollment 15May 7, 2014
    16. 16. Federally Facilitated SHOP Eligibility: How to Apply To apply to the Federally-facilitated SHOP Marketplace, you can: • Ask an agent, broker or insurance company for help • Get help from a Marketplace-approved Navigator or assister • Get the paper application and instructions from HealthCare.gov • Apply by phone through the SHOP Employer Call Center The SHOP Marketplace will notify you: • By phone and e-mail • By regular mail, if you request this • Within 3-5 days of receipt Role of the SHOP Marketplace : • Determines whether you’re eligible to participate in the SHOP o This determination is a requirement for receiving the tax credit • Does not determine whether you’re eligible to receive the tax credit. o This is an IRS matter 16May 7, 2014
    17. 17. Affordable Care Act 17 2015: Employer Shared Responsibility for Employee Health Insurance Coverage
    18. 18. Businesses with 50 or More FTE Employees 18 Employer Shared Responsibility Provisions Number of FTE Employees 24 or fewer Up to 50 50* and above *In 2015 there are two types of transition relief: (1) for businesses with 50 to 99 full-time equivalent employees; and (2) for businesses with 100 and above full- time equivalent employees
    19. 19. Nearly All Small Firms Are Exempt from Employer Shared Responsibility • ACA exempts all firms that have fewer than 50 employees – nearly 96 percent of all firms in the United States or 5.8 million out of 6 million total firms – from any employer shared responsibility requirements. These 5.8 million firms employ nearly 34 million workers. • Many firms that do not currently offer coverage will be better able to do so because of lower costs and wider choices in the SHOP Marketplaces. 19
    20. 20. Employer Shared Responsibility Provisions: Key Definitions • Full-Time Employee: an employee who is employed on average 30 hours or more per week (or at least 130 hours of service in a given month). • Full-Time Equivalent (FTE) Employee: a combination of employees, each of whom individually is not a full-time employee because they are not employed at least 30 hours per week, but who, in combination, are counted as the equivalent of a full-time employee. – For example, two employees each of whom works 15 hours/week are added together to equal one full-time employee. • Controlled Group Employers: employers with common owners or who are otherwise related are aggregated together to determine whether they meet the threshold number of 50 or more FTE employees. 20
    21. 21. Employer Shared Responsibility Provisions 21 If employer meets 50 (100 for 2015) full-time/FTE employee threshold, two scenarios for potential shared responsibility payment • EITHER (1) An employer does not offer coverage to at least 95%* of its full-time employees (and their dependents), OR (2) The coverage offered to employer’s full-time employees is not “affordable” or does not provide “minimum value” • AND At least one full-time employee receives a premium tax credit in the individual Marketplace *For 2015, replace 95% with 70%
    22. 22. Employer Shared Responsibility: Insurance Coverage Standards Coverage Provides Minimum Value • Plan must cover, on average, at least 60% of the plan’s total cost of incurred benefits • HHS and IRS have an online calculator employers can use to input their plan details and determine if it meets the 60% value threshold. Coverage is Affordable • Coverage is unaffordable if the full-time employee’s share of self-only coverage costs more than 9.5% of his/her annual household income • Affordability safe harbor: If the cost to the employee of a self- only plan is not more than 9.5% of his/her wages as reported on Box 1 of the W-2, it’s deemed affordable for purposes of Employer Shared Responsibility 22
    23. 23. Summary of Employer Shared Responsibility Transition Relief in 2015 • 50 – 99 Full-time Equivalent Employees: Not subject to the ESRP rules • 100 or more Full-time Equivalent Employees: Must offer coverage to 70% (instead of 95%) of its full-time employees and their dependents to avoid the ESR payment • Certification Requirement: • Maintain FTEs throughout the year between 50 and 99 • Did not reduce # of employees or employees’ hours in order to qualify for the transition relief • Employer maintained previously offered health coverage to its employees 23
    24. 24. Employer Shared Responsibility Payments: Two Scenarios If Coverage Not Offered to At Least 95% (70% in 2015) of Full-Time Employees, Then • Payment applies if any full-time employee receives a premium tax credit in the individual Marketplace • Payment owed: $2K/year times number of full-time employee (minus 30) (minus 80 in 2015) • Payment calculated separately for each month for which coverage not offered ($166.67/month) • Payment based on employer’s number of full-time employees for that month (minus the first 30) If Coverage Offered to Full- Time Employees, But Either Not Affordable or Does Not Meet Minimum Value, Then • Payment owed: $3K/year per full- time employee who receives a premium tax credit in Marketplace • Payment calculated on monthly basis = $250/month • This payment can’t exceed payment described in Scenario # 1 (left hand column) 24
    25. 25. Advanced Premium Tax Credit 25SBA Washington Metropolitan Area District Office Purchase Insurance on the Individual Marketplace Income between 100% and 400% of federal poverty level (Based on Modified Adjusted Gross Income: AGI + various non-taxable income) Not eligible for Government Sponsored Program
    26. 26. Employer Shared Responsibility Provisions 26 Other Key Points • No employer payment is owed for non-coverage of part-time employees even if they receive a premium tax credit in the Marketplace • If employer offers affordable coverage that provides minimum value to a full-time employee who declines it, no employer payment is owed for that employee • No payment is owed if an employee obtains coverage through means other than the individual Marketplace (e.g., spouse’s family coverage) • To avoid a payment, employers that offer coverage to full-time employees must also offer coverage to the dependents of those full-time employees who are children under age 26 (coverage need not be offered to spouses)
    27. 27. Small Business Resources 27 www.Business.USA.gov www.sba.gov/healthcare www.healthcare.gov

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