The Centers for Medicare and Medicaid Services (CMS) issued a final rule on May 31, 2013, effective July 31, 2013, regarding the Small Business Health Options Program (SHOP) under the Affordable Care Act (ACA).
The ACA permits individuals and small businesses to purchase private health insurance through Health Insurance Marketplaces; section 1311(b)(1)(B) of the ACA provides that each state will have a SHOP to assist qualified employers in providing insurance options for employees. This final rule outlines standards for administering SHOP exchanges. The final rule amends existing regulations related to triggering events and enrollment periods for qualified employees and their dependents, implementing a transitional policy regarding employees’ choice of health plans in the SHOP.
The Exchange Establishment Rule set standards for special enrollment periods for people enrolled in an individual market exchange provided that a special enrollment period is 60 days from the date of the triggering event. These provisions were also applicable to SHOPs. This final rule amends the special enrollment period for the SHOP to 30 days for most triggering events. This aligns with the enrollment periods for the group market established by HIPAA. The SHOP provisions are also aligned with HIPAA by creating a triggering event when employees or dependents who become eligible for premium assistance under Medicaid or the Children’s Health Insurance Program (CHIP) or lose eligibility for Medicaid or CHIP. The employee or dependent would have a 60 day special enrollment period to select a qualified health provider.
The rule also instructs that, for plans beginning between January 1, 2014 and January 1, 2015, a SHOP will not be required to permit qualified employers to offer their qualified employees a choice of qualified health providers (QHP) at a single level of courage. But employers will have the option of doing so. This option will not apply to federally-facilitated SHOPs, which instead will allow employers to choose a single QHP from the choices available in the federally-facilitated SHOP to offer their qualified employees. This transitional policy is meant to provide more time to prepare for an employee choice model.
The full text of the rule can be read here.