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Small Business Health Options Program (SHOP) FAQ

Guidance for FAQ regarding Issuer Participation Requirements and Participation Tying Provision

Program Area: Small Business Health Options Program (SHOP)

Question: Does the FF-SHOP participation provision at 45 C.F.R. 156.200(g) apply to stand-alone dental issuers wanting to participate in the individual market FFEs?

Answer: the FF-SHOP participation provision as applying to stand-alone dental plans seeking certification to participate in the FF-SHOPs. First, the FF-SHOP participation provision provides that issuers are subject to it based on small group market share, which is determined based on earned premium data submitted annually to HHS by medical plan issuers pursuant to 45 C.F.R. 158.110. Stand-alone dental issuers are not subject to the reporting requirement at 158.110, and therefore HHS would generally not have the data it would require to determine whether they are subject to the participation provision. Second, the FF-SHOP participation provision requires issuers subject to it to offer both a silver QHP and a gold QHP in the FF-SHOP. The terms "silver" and "gold" refer to comprehensive medical plans subject to the metal tier actuarial value requirements. Generally speaking, issuers of stand-alone dental plans, which are subject to different actuarial value level requirements and are permitted to issue stand-alone dental plans at only one level, would not be able to meet this requirement. We note that 45 C.F.R. 155.1065(a)(3) requires stand-alone dental plans being offered through an Exchange to meet all qualified health plan (QHP) certification standards, except for any certification requirement that cannot be met by a stand-alone dental plan. We believe that the exception at 155.1065(a)(3) applies to the FF-SHOP participation provision.

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: June 28, 2013

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