Small Business Health Options Program (SHOP) FAQ
Guidance for FAQ regarding Premium Calculations and Other
Program Area: Small Business Health Options Program (SHOP)
Question: When will subscriber rates be calculated? Will they be based on the age of an enrollee using the group's original effective date or will they be based on the age of a subscriber when they actually enroll? For example: One subscriber has a Date of Birth of July 18, 1967, and enrolls when the group initially enrolls on May 1st, 2013. For billing submitted to this subscriber on September 1, 2013, the subscriber would remain 45-years-old until May 1, 2014. Another subscriber has a Date of Birth of July 18, 1967 in the same SHOP group with an original effective date of coverage of August 1, 2013. For billing submitted to this subscriber on September 1, 2013, is the subscriber's age 45 or 46 until May 1, 2014?
Answer: Subscriber rates in the FF-SHOPs are calculated at the time of initial enrollment and upon renewal based on the coverage effective dates. Thus in the example above, the subscriber with an effective date of August 1, 2013 will be billed using the per-member rate for a 46-year-old.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: August 28, 2013
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