In addition to collecting business information on the Small Business Health Options Program Federally-facilitated Marketplace (FF-SHOP) Employer Application form, we are authorized, under the Patient Protection and Affordable Care Act (Public Law No. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law No. 111-152), to collect personally identifiable information and any supporting documentation that might be required for processing this application, including the name and contact information (email 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 through the FF-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 Marketplace assister that may have assisted you with your FF-SHOP application, and eventually provide the information to the health plan selected so that qualified employees can enroll in a qualified health plan. We will also use the information provided as part of the ongoing operation of the Marketplace, 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 FF-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 Marketplace, we will need to share selected information that we receive from you on the FF-SHOP Employer application form outside of CMS, including to:
Other federal agencies, (i.e. the Internal Revenue Service) to report eligibility for health insurance coverage through a FF-SHOP
CMS contractors engaged to perform a function for the FF-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
Agents, Brokers and other Marketplace assisters, and issuers of Qualified Health Plans (QHPs), as applicable, have been engaged to assist with eligibility determinations and enrollment in QHPs
Anyone else as required by law or allowed under the Privacy Act System of Records Notice associated with this collection (CMS Health Insurance Exchanges System (HIX), CMS System No. 09-70-0560, as amended, 78 Federal Register, 8538, March 6, 2013, and 78 Federal Register, 32256, May 29, 2013)
This statement provides the notice required by the Privacy Act of 1974 (5 U.S.C. § 552a(e)(3)).
Effective October 1, 2013