Form CMS-10439 Appendix 1 SHOP Employer Questions

Appendix A – SHOP Application Employer Form

OMB Control # 0938-1193
Expiration Date: xx/xx/2022

Image One: SHOP Eligibility Determination Form Landing Page

Accessible Text for Image One:
Screenshot of https://forms.cms.gov/shop-eligibility-determination-form. Page
Title: SHOP Eligibility Determination Form.
Content:
Get a SHOP eligibility determination here. To be eligible to enroll in health insurance through the Small
Business Health Options Program (SHOP), your small business or non-profit organization must:
• Have a primary business address in the state where you’re buying coverage.
• Have at least one employee enrolling in coverage who isn’t the owner, business partner, or
spouse of the owner or business partner.
• Have from 1 to 50 [Link] full-time equivalent (FTE) employees.
• Offer SHOP coverage to all full-time employees. This form will determine your eligibility for
SHOP.
QUESTIONS? [Link] https://www.healthcare.gov/contact-us.
[Linked button labeled “Start” sends user to Main Page.] [Link]

View a previous submission or resume a draft.
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average 9 minutes per response, including the time to review instructions, search existing data resources, gather the data
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questions or concerns regarding where to submit your documents, please contact Elliot Klein at
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Image Two: SHOP Eligibility Determination Form Main Page (1)

Accessible Text for Image Two:
First screenshot of https://forms.cms.gov/shop-eligibility-determination-form/responses/new. Page
Title: SHOP Eligibility Determination Form – New Submission.
Content:
[Link] Finish this later.
[Form with three fields]:
All fields marked with an asterisk (*) are required.
Business Name: * [Text field].
Business Email: [Text field]; Don’t use a personal email address unless it’s the one you also use for your
business.
Business Phone Number: * [Text field, phone number placeholder text].
Image Three: SHOP Eligibility Determination Form Main Page (2)

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Accessible Text for Image Three:
Second screenshot of https://forms.cms.gov/shop-eligibility-determination-form/responses/new.
Content:
Business Phone Number: * [Repeated from previous image].
Business Address: * Address [Text field]; City [Text field]; State [Select option field]; ZIP Code [Text field];
Country [Text field, default value “United States”].
Employer Identification Number (EIN): * [Text field]; Must be a nine-digit number.
Date current SHOP plan year began, or will begin: * [Three separate text fields for Month, Day, and Year
with forward slashes in between them].
Image Four: SHOP Eligibility Determination Form Main Page (3)

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Accessible Text for Image Four:
Third screenshot of https://forms.cms.gov/shop-eligibility-determination-form/responses/new.
Content:
To be eligible to enroll in SHOP insurance, you must indicate that your small business or non-profit
organization meets all the following qualifications. Answer “Yes” or “No” to the following questions. This
business has from 1 to 50 full-time equivalent (FTE) employees or participated in SHOP last year. * [Two
radio buttons for Yes and No].
[Link] Learn how to count FTE employees.
Click “Preview” to review the information you entered prior to clicking “Submit” on the eligibility form
on the next page.
Retain your eligibility determination for your records. Your eligibility determination will be sent to the
email address you provided. If you didn’t provide an email address, please be sure to print or save your
responses on the next page.
[Linked button labeled Preview].
Image Five: SHOP Eligibility Determination Form Main Page (Contingent Questions 1)
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Accessible Text for Image Five:
Fourth screenshot of https://forms.cms.gov/shop-eligibility-determination-form/responses/new
showing questions that will appear based on user input.
Content:
To be eligible to enroll in SHOP insurance, you must indicate that your small business or non-profit
organization meets all the following qualifications. Answer “Yes” or “No” to the following questions. This
business has from 1 to 50 full-time equivalent (FTE) employees or participated in SHOP last year. * [Two
radio buttons for Yes and No; Yes is selected].
[Link] Learn how to count FTE employees.
This business has a primary business address in the state where I’m applying for this SHOP coverage. *
[Two radio buttons for Yes and No; Yes is selected].
All full-time employees of my business will be offered SHOP coverage. * [Two radio buttons for Yes and
No; Yes is selected].
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This business has at least one employee enrolling in coverage who isn’t an owner or business partner, or
the spouse of the owner or business partner. * [Two radio buttons for Yes and No; Yes is selected].

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Image Six: SHOP Eligibility Determination Form Main Page (Contingent Questions 2)

Accessible Text for Image Six:
Fifth screenshot of https://forms.cms.gov/shop-eligibility-determination-form/responses/new showing
questions that will appear based on user input.
Content:
To be eligible to enroll in SHOP insurance, you must indicate that your small business or non-profit
organization meets all the following qualifications. Answer “Yes” or “No” to the following questions. This
business has from 1 to 50 full-time equivalent (FTE) employees or participated in SHOP last year. * [Two
radio buttons for Yes and No; No is selected].
[Link] Learn how to count FTE employees.
IMPORTANT: Your business is NOT ELIGIBLE to enroll in SHOP coverage. If you don’t agree you can file
an appeal or re-apply. Please confirm the information in your business’ eligibility determination below.
[Checkbox] I confirm this business is NOT currently eligible for SHOP coverage and understand this
decision can be appealed. *
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Click “Preview” to review the information you entered prior to clicking “Submit” on the eligibility form
on the next page.
Retain your eligibility determination for your records. Your eligibility determination will be sent to the
email address you provided. If you didn’t provide an email address, please be sure to print or save your
responses on the next page.
Image Seven: SHOP Eligibility Determination Form Submission Page

Accessible Text for Image Seven:
Screenshot of user input review page with sample text input. Page
Title: SHOP Eligibility Determination Form – Preview.
Content:
[Link] Edit submission. [Link] Finish this later.
Business Name: X;
Business Email: [email protected];
Business Phone Number: (123) 456-7890;
Business Address: XX; XX, Illinois 00000; US; Employer
Identification Number (EIN): 123456789.
[Linked button labeled Submit].

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