Summary
This
final rule implements provisions of the Patient Protection and Affordable
Care Act and the Health Care and Education Reconciliation Act of 2010
(collectively referred to as the Affordable Care Act) related to the Small
Business Health Options Program (SHOP). Specifically, this final rule amends
existing regulations regarding triggering events and special enrollment
periods for qualified employees and their dependents and implements a
transitional policy regarding employees' choice of qualified health plans
(QHPs) in the SHOP.
Dates
These
regulations are effective on July 1, 2013.
For
Further Information Contact
Leigha
Basini at (301) 492-4307.
Supplementary
Information
I.
Executive Summary
Beginning
in 2014, individuals and small businesses will be able to purchase private
health insurance through competitive marketplaces, called Affordable
Insurance Exchanges or “Exchanges” (also called Health Insurance
Marketplaces). Section 1311(b)(1)(B) of the Affordable Care Act contemplates
that in each State there will be a SHOP that assists qualified employers in
providing health insurance options for their employees. The final rule,
Patient Protection and Affordable Care Act; Establishment of Exchanges and
Qualified Health Plans; Exchange Standards for Employers (Exchange
Establishment Rule), (1) as modified by the Notice of
Benefit and Payment Parameters for 2014, (2) sets forth
standards for the administration of SHOP Exchanges. In this rule, we finalize
provisions proposed in the Establishment of Exchanges and Qualified Health
Plans; Small Business Health Options Program Notice of Proposed Rule Making, (3) which
amends some of the standards established in the Exchange Establishment Rule.
In
the Exchange Establishment Rule, we established standards for special
enrollment periods for people enrolled through an individual market Exchange,
and provided that, in most instances, a special enrollment period is 60 days
from the date of the triggering event. See 45 CFR 155.420.
We also made these provisions applicable to SHOPs, at § 155.725(a)(3). In the
proposed rule we proposed and this final rule amends, the special enrollment
period for the SHOP to 30 days for most applicable triggering events, so that
it aligns with the special enrollment periods for the group market
established by the Health Insurance Portability and Accountability Act of
1996 (HIPAA). (4) To further align the SHOP provisions
with HIPAA, we also proposed that if an employee or dependent becomes
eligible for premium assistance under Medicaid or the Children's Health
Insurance Program (CHIP) or loses eligibility for Medicaid or CHIP, this
would be a triggering event, and the employee or dependent would have a
60-day special enrollment period to select a QHP. This triggering event had
previously been inadvertently omitted from the regulations because it applies
only to group health plans and health insurance coverage in the group market.
We also proposed to make a conforming change to § 156.285(b)(2), so that this
section references the SHOP special enrollment periods in a way that is
consistent with our proposed changes to § 155.725.
In
the Exchange Establishment Rule, we also set forth the minimum functions of a
SHOP, including that the SHOP must allow employers the option to offer
employees all QHPs at a level of coverage chosen by the employer, and that
the SHOP may allow employers to offer one or more QHPs to qualified employees
by other methods. We proposed and are now finalizing the following
transitional policy. For plan years beginning on or after January 1, 2014 and
before January 1, 2015, a SHOP will not be required to permit qualified
employers to offer their qualified employees a choice of QHPs at a single
level of coverage, but will have the option of doing so.
Federally-facilitated SHOPs (FF-SHOPs) will not exercise this option, but
will instead allow employers to choose a single QHP from the choices available
in FF-SHOP to offer their qualified employees. This transitional policy is
intended to provide additional time to prepare for an employee choice model
and to increase the stability of the small group market while providing small
groups with the benefits of SHOP in 2014 (such as a choice among competing
QHPs and access for qualifying small employers to the small business health
care tax credit). We also proposed changes to the effective date of the SHOP
premium aggregation function set forth at § 155.705(b)(4) in the Exchange
Establishment Rule consistent with this transitional policy, which we are
finalizing in this rule.
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For
the reasons set forth in the preamble, the Department of Health and Human
Services amends 45 CFR parts 155 and 156 as set forth below:
Regulatory
Text
Part
155 Exchange Establishment Standards and Other Related Standards Under the
Affordable Care Act
1.
The authority citation for part 155 continues to read as follows:
Authority:
Title
I of the Affordable Care Act, sections 1301, 1302, 1303, 1304, 1311, 1312,
1313, 1321, 1322, 1331, 1334, 1402, 1411, 1412, 1413.
2.
Section 155.705 is amended by revising paragraphs (b)(2) through (4) to read
as follows:
§
155.705 Functions of a SHOP.
*
* * * *
(b)
* * *
(2) Employer
choice requirements. With regard to QHPs offered through the SHOP
for plan years beginning on or after January 1, 2015, the SHOP must allow a qualified
employer to select a level of coverage as described in section 1302(d)(1) of
the Affordable Care Act, in which all QHPs within that level are made
available to the qualified employees of the employer.
(3) SHOP
options with respect to employer choice requirements. (i) For plan
years beginning before January 1, 2015, a SHOP may allow a qualified employer
to make one or more QHPs available to qualified employees:
(A)
By the method described in paragraph (b)(2) of this section, or
(B)
By a method other than the method described in paragraph (b)(2) of this
section.
(ii)
For plan years beginning on or after January 1, 2015, a SHOP:
(A)
Must allow an employer to make available to qualified employees all QHPs at
the level of coverage selected by the employer as described in paragraph
(b)(2) of this section, and
(B)
May allow an employer to make one or more QHPs available to qualified
employees by a method other than the method described in paragraph (b)(2) of
this section.
(iii)
For plan years beginning before January 1, 2015, a Federally-facilitated SHOP
will provide a qualified employer the choice to make available to qualified
employees a single QHP.
(iv)
For plan years beginning on or after January 1, 2015, a Federally-facilitated
SHOP will provide a qualified employer a choice of two methods to make QHPs
available to qualified employees:
(A)
The employer may choose a level of coverage as described in paragraph (b)(2)
of this section, or
(B)
The employer may choose a single QHP.
(4)(i) Premium
aggregation. Consistent with the effective dates set forth in
paragraph (b)(4)(ii) of this section, the SHOP must perform the following
functions related to premium payment administration:
(A)
Provide each qualified employer with a bill on a monthly basis that identifies
the employer contribution, the employee contribution, and the total amount
that is due to the QHP issuers from the qualified employer;
(B)
Collect from each employer the total amount due and make payments to QHP
issuers in the SHOP for all enrollees; and
(C)
Maintain books, records, documents, and other evidence of accounting
procedures and practices of the premium aggregation program for each benefit
year for at least 10 years.
(ii) Effective
dates. (A) A State-based SHOP may elect to perform these functions
for plan years beginning before January 1, 2015, but need not do so.
(B)
A Federally-facilitated SHOP will perform these functions only in plan years
beginning on or after January 1, 2015.
*
* * * *
3.
Section 155.725 is amended by:
A.
Amending paragraph (a)(1) by adding “and” at the end of the paragraph.
B.
Amending paragraph (a)(2) by removing “; and” and by adding a period in its
place at the end of the paragraph.
C.
Removing paragraph (a)(3), and
D.
Adding paragraph (j).
The
addition reads as follows:
§
155.725 Enrollment periods under SHOP.
*
* * * *
(j)(1) Special
enrollment periods. The SHOP must provide special enrollment periods
consistent with this section, during which certain qualified employees or a
dependent of a qualified employee may enroll in QHPs and enrollees may change
QHPs.
(2)
The SHOP must provide a special enrollment period for a qualified employee or
dependent of a qualified employee who:
(i)
Experiences an event described in § 155.420(d)(1), (2), (4), (5), (7), (8),
or (9);
(ii)
Loses eligibility for coverage under a Medicaid plan under title XIX of the
Social Security Act or a State child health plan under title XXI of the
Social Security Act; or
(iii)
Becomes eligible for assistance, with respect to coverage under a SHOP, under
such Medicaid plan or a State child health plan (including any waiver or
demonstration project conducted under or in relation to such a plan).
(3)
A qualified employee or dependent of a qualified employee who experiences a
qualifying event described in paragraph (j)(2) of this section has:
(i)
Thirty (30) days from the date of a triggering event described in paragraph
(j)(2)(i) of this section to select a QHP through the SHOP; and
(ii)
Sixty (60) days from the date of a triggering event described in paragraph
(j)(2)(ii) or (iii) of this section to select a QHP through the SHOP;
(4)
A dependent of a qualified employee is not eligible for a special election
period if the employer does not extend the offer of coverage to dependents.
(5)
The effective dates of coverage are determined using the provisions of §
155.420(b).
(6)
Loss of minimum essential coverage is determined using the provisions of §
155.420(e).
Part
156 Health Insurance Issuer Standards Under the Affordable Care Act Including
Standards Related to Exchanges
4.
The authority citation for part 156 continues to read as follows:
Authority:
Title
I of the Affordable Care Act, sections 1301-1304, 1311-1312, 1321, 1322,
1324, 1334, 1341-1343, and 1401-1402, Pub l. 111-148, 124 Stat. 119 (42
U.S.C. 18042).
5.
Section 156.285 is amended by revising paragraph (b)(2) to read as follows:
§
156.285 Additional standards specific to SHOP.
*
* * * *
(b)
* * *
(2)
Provide special enrollment periods as described in § 155.725(j);
*
* * * *
Dated:
May 13, 2013.
Marilyn
Tavenner,
Administrator,
Centers for Medicare & Medicaid Services.
Approved:
May 15, 2013
Kathleen
Sebelius,
Secretary,
Department of Health and Human Services.
[FR
Doc. 2013-13149 Filed 5-31-13; 11:15 am]
BILLING
CODE 4120-01-P
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