45 CFR 156.285 - Additional standards specific to SHOP.

§ 156.285 Additional standards specific to SHOP.
(a) SHOP rating and premium payment requirements. QHP issuers offering a QHP through a SHOP must:
(1) Accept payment from the SHOP on behalf of a qualified employer or an enrollee in accordance with§ 155.705(b)(4) of this subchapter;
(2) Adhere to the SHOP timeline for rate setting as established in§ 155.705(b)(6) of this subchapter; and
(3) Charge the same contract rate for a plan year.
(4)
(i) Adhere to the premium rating standards described in§ 147.102 of this subchapter regardless of whether the QHP being sold through the SHOP is sold in the small group market or the large group market; and
(ii) Effective in plan years beginning on or after January 1, 2015, a QHP issuer in a Federally-facilitated SHOP may not offer to an employer premiums that are based on average enrollee premium amounts under§ 147.102(c)(3) of this subchapter, if the employer elects to offer coverage to its employees under § 155.705(b)(3)(iv)(A) of this subchapter. This paragraph (a)(4)(ii) also applies to stand-alone dental plans in a Federally-facilitated SHOP, if the employer elects to offer coverage to its employees under § 155.705(b)(3)(v)(B) of this subchapter.
(b) Enrollment periods for the SHOP. QHP issuers offering a QHP through the SHOP must:
(1) Enroll a qualified employee in accordance with the qualified employer's annual employee open enrollment period described in§ 155.725 of this subchapter;
(2) Provide special enrollment periods as described in§ 155.725(j);
(3) Provide an enrollment period for an employee who becomes a qualified employee outside of the initial or annual open enrollment period as described in§ 155.725(g) of this subchapter; and
(4) Adhere to effective dates of coverage in accordance with§ 156.260 and those established through § 155.720 of this subchapter.
(c) Enrollment process for the SHOP. A QHP issuer offering a QHP through the SHOP must:
(1) Adhere to the enrollment timeline and process for the SHOP as described in§ 155.720(b) of this subchapter;
(2) Receive enrollment information in an electronic format, in accordance with the requirements in§§ 155.260 and 155.270 of this subchapter, from the SHOP as described in § 155.720(c);
(3) Provide new enrollees with the enrollment information package as described in§ 156.265(e);
(4) Reconcile enrollment files with the SHOP at least monthly;
(5) Acknowledge receipt of enrollment information in accordance with SHOP standards; and
(6) Enroll all qualified employees consistent with the plan year of the applicable qualified employer.
(7) A QHP issuer must enroll a qualified employee only if the SHOP—
(i) Notifies the QHP issuer that the employee is a qualified employee;
(ii) Transmits information to the QHP issuer as provided in§ 155.400(a) of this subchapter; and
(iii) Effective for QHPs offered through a Federally-facilitated SHOP in plan years beginning on or after January 1, 2015, does not send a cancellation notice to the QHP issuer prior to the effective date of coverage.
(d) Termination of coverage in the SHOP. QHP issuers offering a QHP through the SHOP must:
(1) Comply with the following requirements with respect to coverage termination of enrollees in the SHOP:
(i)
(A) Effective in plan years beginning on or after January 1, 2015, requirements regarding termination of coverage established in§ 155.735 of this subchapter, if applicable to the coverage being terminated; otherwise
(B) General requirements regarding termination of coverage established in§ 156.270(a) of this subchapter.
(ii) Requirements for notices to be provided to enrollees and qualified employers in§ 156.270(b) and § 156.290(b); and
(iii)
(A) Effective in plan years beginning on or after January 1, 2015, requirements regarding termination of coverage effective dates as set forth in§ 155.735 of this subchapter, if applicable to the coverage being terminated; otherwise
(B) Requirements regarding termination of coverage effective dates as set forth in§ 156.270(i).
(e) Participation rules. QHP issuers offering a QHP through the SHOP may impose group participation rules for the offering of health insurance coverage in connection with a QHP only if and to the extent authorized by the SHOP in accordance with § 155.705 of this subchapter.
[77 FR 18469, Mar. 27, 2012, as amended at 78 FR 15535, Mar. 11, 2013; 78 FR 33240, June 4, 2013; 78 FR 54143, Aug. 30, 2013; 79 FR 13840, Mar. 11, 2014]
Beta! The text on the eCFR tab represents the unofficial eCFR text at ecfr.gov.
§ 156.285 Additional standards specific to SHOP.

(a) SHOP rating and premium payment requirements. QHP issuers offering a QHP through a SHOP must:

(1) Accept payment from the SHOP on behalf of a qualified employer or an enrollee in accordance with § 155.705(b)(4) of this subchapter;

(2) Adhere to the SHOP timeline for rate setting as established in § 155.705(b)(6) of this subchapter; and

(3) Charge the same contract rate for a plan year.

(4)

(i) Adhere to the premium rating standards described in § 147.102 of this subchapter regardless of whether the QHP being sold through the SHOP is sold in the small group market or the large group market; and

(ii) Effective in plan years beginning on or after January 1, 2015, a QHP issuer in a Federally-facilitated SHOP may not offer to an employer premiums that are based on average enrollee premium amounts under § 147.102(c)(3) of this subchapter, if the employer elects to offer coverage to its employees under § 155.705(b)(3)(iv)(A) of this subchapter. This paragraph (a)(4)(ii) also applies to stand-alone dental plans in a Federally-facilitated SHOP, if the employer elects to offer coverage to its employees under § 155.705(b)(3)(v)(B) of this subchapter.

(b) Enrollment periods for the SHOP. QHP issuers offering a QHP through the SHOP must:

(1) Enroll a qualified employee in accordance with the qualified employer's initial and annual employee open enrollment periods described in § 155.725 of this subchapter;

(2) Provide special enrollment periods as described in § 155.725(j);

(3) Provide an enrollment period for an employee who becomes a qualified employee outside of the initial or annual open enrollment period as described in § 155.725(g) of this subchapter; and

(4) Adhere to effective dates of coverage established in accordance with § 155.725 of this subchapter.

(c) Enrollment process for the SHOP. A QHP issuer offering a QHP through the SHOP must:

(1) Adhere to the enrollment timeline and process for the SHOP as described in § 155.720(b) of this subchapter;

(2) Receive enrollment information in an electronic format, in accordance with the requirements in §§ 155.260 and 155.270 of this subchapter, from the SHOP as described in § 155.720(c);

(3) Notify new enrollees of their effective date of coverage consistent with § 155.720(e) of this subchapter.

(4) Provide new enrollees with the enrollment information package as described in § 156.265(e);

(5) Reconcile enrollment files with the SHOP at least monthly;

(6) Acknowledge receipt of enrollment information in accordance with SHOP standards; and

(7) Enroll all qualified employees consistent with the plan year of the applicable qualified employer.

(8) A QHP issuer must enroll a qualified employee only if the SHOP -

(i) Notifies the QHP issuer that the employee is a qualified employee;

(ii) Transmits information to the QHP issuer as provided in § 155.400(a) of this subchapter; and

(iii) Effective for QHPs offered through a Federally-facilitated SHOP in plan years beginning on or after January 1, 2015, does not send a cancellation notice to the QHP issuer prior to the effective date of coverage.

(d) Termination of coverage or enrollment in the SHOP. QHP issuers offering a QHP through the SHOP must:

(1) Comply with the following requirements with respect to termination of enrollees in the SHOP:

(i)

(A) Effective in plan years beginning on or after January 1, 2015, requirements regarding termination of coverage or enrollment established in § 155.735 of this subchapter, if applicable to the coverage or enrollment being terminated; otherwise

(B) General requirements regarding termination of coverage or enrollment established in § 156.270(a).

(ii) If a QHP issuer terminates an enrollee's coverage or enrollment through the SHOP in accordance with § 155.735(d)(1)(iii) or (v) of this subchapter, the QHP issuer must notify the qualified employer and the enrollee of the termination. Such notice must include the termination effective date and reason for termination, and must be sent within 3 business days if an electronic notice is sent, and within 5 business days if a mailed hard copy notice is sent. When a primary subscriber and his or her dependents live at the same address, a separate termination notice need not be sent to each dependent at that address, provided that the notice sent to each primary subscriber at that address contains all required information about the termination for the primary subscriber and his or her dependents at that address.

(iii)

(A) Effective in plan years beginning on or after January 1, 2015, requirements regarding termination of coverage or enrollment effective dates as set forth in § 155.735 of this subchapter, if applicable to the coverage or enrollment being terminated; otherwise

(B) Requirements regarding termination of coverage or enrollment effective dates as set forth in § 156.270(i).

(2) If a qualified employer chooses to withdraw from participation in the SHOP, the QHP issuer must terminate coverage for all enrollees of the withdrawing qualified employer.

(e) Participation rules. QHP issuers offering a QHP through the SHOP may impose group participation rules for the offering of health insurance coverage in connection with a QHP only if and to the extent authorized by the SHOP in accordance with § 155.705 of this subchapter.

[77 FR 18469, Mar. 27, 2012, as amended at 78 FR 15535, Mar. 11, 2013; 78 FR 33240, June 4, 2013; 78 FR 54143, Aug. 30, 2013; 79 FR 13840, Mar. 11, 2014; 80 FR 10874, Feb. 27, 2015; 80 FR 10875, Feb. 27, 2015]

This is a list of United States Code sections, Statutes at Large, Public Laws, and Presidential Documents, which provide rulemaking authority for this CFR Part.

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United States Code

Title 45 published on 2015-10-01

The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 45 CFR Part 156 after this date.

  • 2015-12-02; vol. 80 # 231 - Wednesday, December 2, 2015
    1. 80 FR 75488 - Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017
      GPO FDSys XML | Text
      DEPARTMENT OF HEALTH AND HUMAN SERVICES, HHS, Centers for Medicare & Medicaid Services (CMS)
      Proposed rule.
      To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on December 21, 2015.
      45 CFR Parts 144, 146, 147, 153, 154, 155, 156, and 158