CMS-10439 - SHOP Application - Crosswalk of Changes

REDLINE CHANGES TO THE CURRENTLY APPROVED SHOP APPLICATION TO REFLECT THE 2019 REVISIONS

Appendix A:

List of Questions in the Small Business Health Options Program (SHOP) Eligibility Determination Form

C ontents

Appendix A: 1

List of Questions in the Small Business Health Options Program (SHOP) Eligibility Determination Form for Employers 1

A. Verify eligibility 1

B. SHOP Eligibility Determination Form Questions 1

A. Verify eligibility

(Display this item for all applicants.)

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 full-time equivalent (FTE) employees

• Offer SHOP coverage to full-time employees

B. SHOP Eligibility Determination Form Questions

(Display these items for all applicants.)

1. Business Name:

2. Business Email:

3. Business Phone Number:

4. Business Address

   1. Address

   2. City

   3. State

   4. Zip Code

   5. Country

5. Employer Identification Number (EIN)

6. Date current SHOP plan year began, or will begin

7. 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.

   1. This business has from 1 to 50 full-time equivalent (FTE) employees or participated in SHOP last year.

      1. Yes or No

   2. This business has a primary business address in the state where I’m applying for this SHOP coverage.

      1. Yes or No

   3. All full-time employees of my business will be offered SHOP coverage.

      1. Yes or No

   4. 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.

      1. Yes or No

   5. This business has from 1 to 50 full-time equivalent (FYE) employees or participated in SHOP last year.

      1. Yes or No