On August 9, 2013, the Centers for Medicare and Medicaid Services (CMS) released guidance on State Alternative Applications for Health Coverage through the Small Business Health Options Program (SHOP). Beginning October 1, 2013, the new SHOP marketplaces will use applications to determining eligibility for participation in SHOP and enrollment in qualified health plans through the SHOP. In May 2013, CMS released model applications for shop coverage, but state-based SHOPs may also use an alternative SHOP application as approved by CMS. This guidance provides background on the development process, review, and approval of alternative SHOP applications.
States may submit SHOP applications for approval, and the alternative applications must meet the general principles of the model applications by adhering to regulations implementing the Affordable Care Act. Some aspects of the application will require formal approval. But there are also a number of ways a state can adopt the model applications without formal approval as an alternative application. For example, states can add state SHOP program names and contact information to the application, change the visuals of the application for proper branding, add language to the privacy statement, or remove questions about text messaging. Moreover, no approval is required for some modifications that minimize consumer burden.
If the state application differs from the model application such that it requires approval, CMS will review the changes to ensure the application is consistent with the relevant statute and regulations. States’ Marketplace Blueprint must indicate whether the state will use a model or an alternative application. Proposed alternative applications should submit a full copy of the alternative form and an analysis describing the key differences from the model form.
CMS may offer an expedited approval process for states and CMS will allow for conditional approval of an alternative application for 2014. The guidance explains the steps to attaining conditional approval as well as those needed to obtain full approval, which includes a demonstration that all applicable regulatory requirements are being met. States seeking to use alternative applications for 2014 can begin requesting conditional approval from CMS as of the release of this guidance.
The full text of the guidance can be found here.