Who can use the Marketplace?
There are really two marketplaces, one for businesses and one for individuals.
Maine’s Health Insurance Marketplace (HealthCare.gov) offers a Small Business Health Options program, or “SHOP,” that gives small business owners and their employees options for comprehensive health plan coverage.
HealthCare.gov also offers coverage for people looking for individual or family coverage. Employees and their families with insurance coverage provided through their jobs are not likely to buy health plans on the Marketplace. If coverage that meets certain requirements is available at work, the individual and their family would not be eligible for financial assistance on the individual marketplace. Maine’s marketplace is mostly for people who don't have access to coverage at work.
Do I have to provide health insurance for my employees? If I don’t will I have to pay a penalty?
Small businesses with fewer than 50 full-time (or full time equivalents, such as having 2 employees working 50% time equals 1 FTE) employees will not be required to provide health insurance. They also will not have to pay a penalty for not providing coverage. Some small businesses may qualify for a tax credit if they choose to provide coverage.
Under the Affordable Care Act, businesses with 50 or more full-time employees will be charged a fee if they do not provide quality health insurance to their employees and one or more of their employees takes a federal tax credit or subsidy. This penalty for employers with 50-99 employees begins in 2016.
My wife and I own our own business and are the only employees. Should we shop for a health plan as a family or as a small business?
Federal regulation does not permit sole proprietors to purchase small group coverage so you will not be shopping as a small business. You would purchase insurance as an individual or family through the Health Insurance Marketplace. If you do, you may be eligible for financial assistance that can lower your out of pocket premium payments and provide assistance with cost-sharing to help you cover the cost of care.
How can I find and compare health plans?
The best way to compare plans is to go directly to the Marketplace at HealthCare.gov where you can compare available health plans offered. The Marketplace also provides dental plan options. You can get help applying from free, certified assisters in your local community or from certified insurance agents or brokers. Use the “Find Help” ZIP code locator to locate people near your home or business who can provide free assistance.
How can I get help when using the online Marketplace?
Here's how you can get help when using the Health Insurance Marketplace:
- We encourage you to work with your current insurance agent or broker to help you enroll. If you don’t have a local agent or broker, you can find professionals in your area who are familiar with SHOP plans by using the “Find Help” ZIP code locator.
- Call the Marketplace toll-free telephone number 1-800-318-2596 to get help.
What kinds of insurance plans are available on the Marketplace?
All health insurance plans offered on the Marketplace are qualified health plans that cover all essential health benefits required by law. Plans are categorized into four different types: bronze, silver, gold and platinum (currently no platinum plans are available in Maine). All plans offer the same set of essential health benefits. The different levels do not reflect the quality or amount of care the plans cover. The metal categories (bronze, silver, gold) are based on how much the premium costs each month and the total amount of out-of-pocket costs you’ll have.
As with all health insurance, the amount of premium a company charges will depend on that company’s claims experiences. Because of this, costs for each plan in each tier level will vary. The following is a general guideline for how to select coverage:
- In general, plans with lower premiums will have higher out-of-pocket costs. The bronze level plans tend to have the lowest premiums but higher out-of-pocket costs. Plans like this may be good for people who are relatively healthy and do not need a lot of medical care or prescription drugs.
- Plans with higher premiums generally have lower out-of-pocket costs. Gold is usually higher than Silver and Silver is usually higher than Bronze. Maine’s Individual Marketplace also offers a catastrophic plan for people under the age of 30 or for those who are exempt from the requirement to purchase insurance. Catastrophic plans have a lower premium cost, and still offer no cost preventive care, but generally they require you to pay all of your medical costs out-of-pocket up to a certain amount - usually several thousand dollars. These plans are intended to protect from major injuries or illnesses, not for everyday doctor visits. Individuals buying catastrophic plans are not eligible to get tax credits or subsidies to help pay for this coverage.
What kind of tax credits are available to small businesses that provide employee health insurance?
The health reform law (Affordable Care Act) set in place many health care and health insurance reforms. One of these reforms is a tax credit, available to small businesses with fewer than 25 full-time (or equivalent) employees and average salary of $50,000 or less who provide health insurance to those employees. To qualify for the tax credit, the employer’s health plan must be purchased through SHOP.
Who is eligible to receive the tax credits?
In order to be eligible for the tax credit, all of the following must be true:
- You are a small business owner with fewer than 25 full-time employees.
- You pay at least 50% of the health insurance premium cost for your employees.
- Your employees, on average, make less than $50,000 per year.
- The plan must be purchased through SHOP.
Are non-profit or tax-exempt organizations eligible to receive the tax credits?
Yes, but the amount of the tax credit is lower, and some special rules may apply.
How much is the tax credit?
The tax credit is highest for companies with fewer than 10 employees who are paid an average of $25,000 or less. The smaller the business, the bigger the credit. For companies with more than 10 employees there is a sliding scale of up to 50% of the employer’s premium expense.
Non-profit and tax-exempt organizations are eligible for tax credits as well, but the amount is lower and some special rules may apply.
Are seasonal employees counted toward the total number of full-time employees?
Generally, any employee who works fewer than 120 days each year does not need to be counted in the employee number.
How is the tax credit claimed?
The credit is claimed on the business or organization’s annual tax return by filling out Form 8941. The amount taken for the tax credit must be subtracted from any deductions claimed on the tax return.
Where can I get more information?
Additional information can be found at Healthcare.gov.