CMS offers enrollment guidance, including SHOP instructions for employers

Qualified individuals (QIs) who wish to purchase coverage in a qualified health program (QHP) must enroll either during the open enrollment period or qualify for a special enrollment period. The effective date for coverage depends on when the plan is selected: plans selected before December 15, 2015, will go into effect January 1, 2016, while plans selected later in the open enrollment period go into effect either February 1 or March 1, 2016. In light of the upcoming open enrollment period, CMS’ Center for Consumer Information & Insurance Oversight (CCIIO) has provided guidance for enrollment activities related to federally-facilitated marketplaces (FFMs) and federally-facilitated small business health option programs (FF-SHOPs) established under the Patient Protection and Affordable Care Act (ACA).

Enrollment transactions. All marketplaces must use HHS standards adopted under the ACA and the Health Insurance Portability and Accountability Act (HIPAA) for transmitting electronic information QHP issuers. CMS has provided guidance for using certain data elements. The agency acknowledges that in certain circumstances, information must be transferred in a non-electronic data interchange (EDI) format that does not conform with data content rules. In these events, CMS will work with issuers to determine appropriate alternatives for transmitting this data.

Information changes. Regulations require both taxpayers and enrollees to update changes to application information within 30 days of the change by phone or internet. Some changes may have an effect on the enrollee’s eligibility for coverage or assistance, which may result in the enrollee becoming liable for repaying some advanced premium tax credits (APTCs). The manual contains step-by-step instructions for reporting changes, as well as a list of reportable changes, that issuers should pass on to enrollees.

FF-SHOP enrollment. Employers can complete FF-SHOP initial group enrollment throughout the year. Employers, employees, and former employees offered coverage who which to purchase FF-SHOP coverage must submit applications to CMS, which will then determine applicant eligibility. Qualified employers may offer all plans within a metal level in some states. Employers may also offer coverage to former employees, including retirees, and set one premium contribution percentage for qualified employees in the enrollment group. Employers may also offer Consolidated Omnibus Budget Reconciliation Act (COBRA) continuation coverage through an FF-SHOP.

SOURCE: CCIIO Manual, October 1, 2015.

Visit our News Library to read more news stories.