HHS Issues Guidelines For The Small Business Health Options Program (SHOP)

In the August 17 Federal Register, the U.S. Department of Health and Human Services (HHS) has published a proposed rule for provisions in the Patient Protection and Affordable Care Act (ACA) governing the American Health Benefit Exchange eligibility and employer standards.

The specific Exchange functions in the HHS proposed rule include eligibility determinations for Exchange participation and insurance affordability programs and standards for employer participation in the Small Business Health Options Program (SHOP).


Under the ACA, by Jan. 1, 2014, each state must establish an American Health Benefit Exchange for that state that would facilitate the purchase of qualified health plans. Each state also is required establish a SHOP Exchange. A SHOP Exchange is designed to assist qualified small employers (those with 100 or fewer employees) in the state in enrolling their employees in qualified health plans (QHPs) in the state’s small group market.

A state may elect to provide for only one state Exchange that would provide both American Health Benefit Exchange services and SHOP Exchange services to both qualified individuals and qualified small employers.

According to the August 17 preamble, the proposed rule to a significant extent “mirrors and complements” Exchange rules proposed in July.

Employer SHOP Participation

Among other provisions, the August 17 proposed rule would do the following regarding employer participation in SHOP:

A qualified employer participating in SHOP shall disseminate information to its employees about the methods for selecting and enrolling in a QHP. The information should include at least the timeframes for enrollment, instructions for how to access the SHOP website and other tools to compare QHPs, and the SHOP toll-free hotline. The SHOP may assist qualified employers, for example by providing an easy-to-use toolkit explaining the key pieces of information to disseminate to its employees.

Qualified employers will provide the SHOP with information about individuals or employees whose eligibility to purchase coverage through the employer has changed. This notice include both newly eligible employees and dependents, as well as those no longer eligible for coverage. It includes a COBRA qualifying event. The SHOP may in turn notify the QHP to process the change in enrollment.

The employer retains all notice responsibilities under federal and state law. The HHS suggests that SHOPs direct employers to provide such notices within 30 days of the change in eligibility.

A qualified employer must adhere to the annual employer election period to change program participation for the next plan year. An employer may begin participating in the SHOP at any time. However, once an employer begins participating, it will adhere to an annual employer election period during which it may change employee offerings.

If an employer remains eligible for coverage and does not take action during the annual employer election period, such employers would continue to offer the same plan, coverage level, or plans selected the previous year for the next plan year unless the QHP or QHPs are no longer available.

Comments on the proposed rule are due 75 days after publication in the Federal Register (refer to file code CMS-9974) and should be sent via the Federal eRulemaking Portal at http://www.regulations.gov; or by regular mail to CMS, Department of Health and Human Services, Attention: CMS-9974-P, P.O. Box 8010, Baltimore, MD 21244-8010.

For more information, contact Laurie McWright at (301) 492-4372, for general information matters; Alissa DeBoy at (301) 492-4428, for general information and matters related to Exchange establishment standards and other related standards; Michelle Strollo at (301) 492-4429, for matters related to eligibility; or Naomi Senkeeto at (301) 492-4419, for matters related to employer interactions with Exchanges and SHOP participation.

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