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CCIIO posts SHOP forms and SHOP guidance

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The Center for Consumer Information & Insurance Oversight (CCIIO) today posted versions of the employer and employee applications forms for the Patient Protection and Affordable Care Act (PPACA) small-group exchanges.

CCIIO, an arm of the U.S. Department of Health and Human Services (HHS), also a batch of small-group exchange regulations – Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified  Health Plans; Small Business Health Options Program (CMS-9964-F2) (RIN 0938-AR76) – and guidance for issuers of indemnity insurance policies.

Opponents of PPACA are still trying to repeal the law and block or delay implementation of parts or all of the law.

If the law takes effect and works as drafters expect, it will require the U.S. Department of Health and Human Services (HHS) and state agencies to make exchanges, or Web-based health insurance supermarkets, available to individuals and small groups in all 50 states and the District of Columbia.

The carriers that sell “qualified health plans” (QHPs) through the exchanges are supposed to offer four different “metal levels” of coverage, includes bare-bones bronze plans, silver plans, gold plans and platinum plans.

The small-group exchange program — the Small Business Health Options Program (SHOP) — can make health insurance purchase tax credit subsidies available to workers at employers with 50 or fewer modestly paid, full-time equivalent employees. In some states, SHOP exchanges may be open to employers with as many as 100 employees.

The employer application form on the Web includes a cover sheet and three other pages. The employee form includes a cover sheet and two other pages.

The cover sheet for the employee application tells workers that those who find that the cost of employee-only coverage exceeds 9.5 percent of household income may be able to get help with buying coverage through the PPACA individual exchange system.

Getting notices sent electronically is the default option, but workers check a box to get paper notices sent by traditional mail.

An optional race selection form includes options such as Samoan, Native Hawaiian, and Gaumananian or Chamorro along with options such as White and Black.

A worker must sign to indicate that the worker has seen a statement explaining that, “I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability.”

The employer application posted is a paper version of the Web-based application process. The paper application is designed for “employers who cannot apply online” and “employers not working with a broker,” according to the form.

To complete the employer SHOP application, an employer must provide the name, date of birth, Social Security number, e-mail address, employment status and date of hire for each employee who works for the employer 30 hours or more per week. Employment status options could include full-time, part-time, owner/partner, spouse of owner, COBRA or retired.

According to the form, SHOP exchange managers will reply within two weeks after receiving the form.

“Note,” the form says, “if you’re using a broker, you must apply online.”

The SHOP final rule covers technical aspects of SHOP exchange administration, such as details concerning when employees and dependents can sign up for coverage.

In the final rule, officials at HHS, CCIIO’s parent department, also talk about the status of a PPACA multi-plan option requirement.

PPACA requires each SHOP exchange to offer an employer the ability to set up a menu-based health plan.

An employer could simply choose to provide one, two or several of the health plans available through a SHOP exchange.

An employer that wanted to give workers more choices would be able to buy a menu plan option that would give workers access to all coverage choices available at a given “metal level.” The employer could, for example, provide a plan menu that included all silver-level plans, or all gold-level plans.

HHS announced earlier that it intended to put off requiring exchanges to offer the menu-based plan option until 2015. The “federally facilitated exchanges” (FFEs) that HHS is running will not offer the menu-based option until 2015, officials said.

Some commenters wanted HHS to requiring SHOP exchanges to offer the menu-based option in 2014, and others wanted the department of postpone imposing the mandate for five years or more, but HHS decided to stick with postponing enforcement of the requirement for a year, officials said.

Meanwhile, the batch of guidance, HHS dealt with administrative questions affecting insurers that sell indemnity health insurance plans that pay benefits whehn a specific event, such as a hospitalization, occurs, rather than a fixed amount for a specific period of time.

PPACA exempts indemnity plans from new minimum medical loss ratio (MLR) requirements and other requirements that apply to medical insurance plans.

Federal regulators stated earlier this year that what an insurer may have called an “indemnity policy” is not an indemnity policy for purposes of PPACA if it does not pay a fixed amount for a specific period of time, rather than an amount based on the delivery of a health care service.

Although federal regulators believe that a policy that pays a set amount per service delivered is not an indemnity policy, a health insurer that discovered that an indemnity policy is not an indemnity policy in the eyes of federal regulators need not report the claims experience for such a policy through the PPACA MLR reporting system for the 2012 MLR reporting year, officials said.

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