Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) A small employer who is eligible to purchase
coverage from a Qualified Health Plan (QHP) Issuer for its eligible employees
through the Small Business Health Options Program (SHOP) pursuant to Section
6522, may apply to participate in the
SHOP by submitting the following information to the SHOP:
(1) General employer information: business legal
name and whether the employer is doing business under a fictitious name, Federal
Employer Identification Number, State Employer Identification Number, organization
type (private, nonprofit, government, church/church affiliated), Standard Industry
Classification (SIC) code, principal business address, and mailing
address;
(2) The number of eligible
employees being offered enrollment in SHOP and the total number of full-time
equivalent (FTE) employees employed by the qualified employer, as calculated in
accordance with Health and Safety Code Section
1357.500(k)(3)
and Insurance Code Section
10753(q)(3);
(3) Whether you have employed 20 or more employees
for 20 or more weeks in the current or preceding calendar year;
(4) Whether the qualified employer is offering
dependent health coverage or dental coverage for spouses, registered or
non-registered domestic partners and/or dependent children;
(5) The qualified employer's desired health
coverage or dental coverage effective date;
(6) Whether the qualified employer is subject to
COBRA or Cal-COBRA continuation coverage regulations;
(7) Whether the qualified employer is currently
offering health coverage or dental coverage, and if so, through which
issuer;
(8) Whether the qualified
employer intends to claim the Small Business Health Care Tax Credit with the
IRS;
(9) The name, primary phone number,
and email address for the primary contact and business owner/authorized company
officer for the qualified employer and the preferred method of
communication;
(10) Whether the
qualified employer used an insurance agent and if so, the agent's name, general
agency name (if applicable), CA insurance license number, the agency Federal
Employer Identification Number if applicable, and whether the agent is an insurance
agent certified by Covered California. If the qualified employer uses an insurance
agent, the qualified employer must have that agent certify that he or she
understands he or she may be subject to a civil penalty for providing false
information under Health and Safety Code Section
1389.8
and Insurance Code Section
10119.3.
(11) Information about the qualified employer's
qualified employees, in the employee application in subdivision (d);
(12) The employer's offer of health coverage or
dental coverage, and the reference plan or dental reference plan which includes:
(A) The employer's contribution rate to each of
its qualified employee's health plan premiums pursuant to Section
6522(a)(5)(A);
(B) The employer's health plan premium
contribution rate for spouse or non-registered domestic partner, or dependent
children health coverage, if applicable; and
(C) The employer's selection for one, two
contiguous, three contiguous, or four contiguous tiers of health coverage, pursuant
to 45 CFR Section
156.140(b) (bronze, silver, gold,
or platinum) (February 25, 2013), hereby incorporated by reference;
(D) Whether the qualified employer wishes to
include infertility benefits to qualified employees;
(E) Effective August 1, 2021, if the qualified
employer is offering dental coverage to qualified employees, the employer must
select a dental reference plan. The qualified employer must indicate its
contribution rate for qualified employees' QDP premiums pursuant to Section
6522(h)(3). The
qualified employer must indicate its QDP premium contribution rate for spouse's or
non-registered domestic partner's, or dependent children's coverage, if
applicable;
(13) New qualified
employer application submissions are due five days prior to the requested effective
date. Completed submissions received after this date will carry an effective date no
earlier than the first of the following month unless the qualified employer submits
a signed CCSB New Business Late Submission Acknowledgement Form (Rev. 3/18), hereby
incorporated by reference. Exceptions for exceptional circumstances will be
considered on a case-by-case basis.
(b) To participate in the SHOP, an employer must
attest to the following:
(1) That the business has
100 or fewer full-time or FTE employees and has a principal business address in
California;
(2) That all eligible
full-time employees of this business will be offered SHOP coverage;
(3) That the business has at least one employee
who is not the owner or business partner, or the spouse of the owner or business
partner;
(4) That the employer is
signing the application under penalty of perjury, which means all information
contained in the qualified employer application is true and correct to the best of
the qualified employer's knowledge;
(5)
That the employer knows that he or she may be subject to penalties under federal law
if he or she intentionally provides false or untrue information pursuant to
45 CFR Section
155.285 (September 6, 2016), hereby incorporated
by reference;
(6) That the employer
knows that the information will only be used to determine eligibility and facilitate
enrollment health coverage or dental coverage and will otherwise be kept private as
required by federal and state law;
(7)
That any waiting period established by the qualified employer complies with
42 U.S.C. Section
300gg-7,
45 CFR Section
155.725 (April 18, 2017), hereby incorporated by
reference, and applicable state law, and all qualified employees have complied with
the qualified employer's waiting period;
(8) That the employer has the consent from every
qualified employee listed on the application to include their personally
identifiable information such as dates of birth, addresses, social security numbers
or tax identification numbers, phone numbers, and email addresses;
(9) That the employer understands that
discrimination is prohibited on the basis of race, color, national origin, religion,
sex, age, sexual orientation, marital status, gender identity, veteran status,
disability, or any other type of discrimination prohibited in the Health and Safety
Code and Insurance Code;
(10) That the
qualified employer understands that the SHOP will not consider the qualified
employer approved for health coverage or dental coverage until the SHOP has received
the qualified employer's first month's total premium payment;
(11) That the qualified employer agrees to
continue to make the total required monthly premium payment by the due date to
maintain eligibility for coverage in the SHOP;
(12) That the qualified employer agrees to inform
its eligible employees of the availability of health coverage and dental coverage
and that those declining coverage must wait until the next open enrollment period,
pursuant to Section
6528, to sign up for coverage, unless
that employee experiences an event that would entitle him or her to a special
enrollment period pursuant to Section
6530;
(13) That the qualified employer understands that
once coverage in a QHP is approved by the SHOP, changes to the coverage cannot be
implemented until the qualified employer's annual election of coverage period
pursuant to Section
6526, except to the extent the
qualified employer exercises the right to change coverage with the same QHP issuer
within the first 30 days of the effective date of coverage pursuant to Section
6528(f),
Health and Safety Code 1357.504(d), and Insurance Code Section
10753.06.5(d);
(14) That the qualified employer understands that
health coverage and dental coverage through the SHOP is subject to the applicable
terms and conditions of the QHP issuer contract or policy and applicable state law,
which will determine the procedures, exclusions and limitations relating to the
coverage and will govern in the event of any conflict with SHOP or QHP issuer
benefits comparison, summary or other description of the coverage;
(15) That the qualified employer understands that
once employer and employee information is transmitted to the selected QHP Issuers,
the qualified employer's coverage effective date cannot be changed nor can the
qualified employer terminate coverage until after the first month of
coverage;
(16) That the qualified
employer agrees to inform its qualified employees of the availability of child and
family dental plans and that qualified employees may choose to enroll only in a QDP
even if the qualified employee does not choose to enroll in a health plan;
(17) That the qualified employer understands that
the attestations in this section are subject to audit by the SHOP at any time;
and
(18) That the qualified employer
agrees to maintain compliance with the attestations in this section in order to
continue eligibility for coverage through the SHOP.
(c) A qualified employer must provide the SHOP
with its most recent Quarterly Contribution Return and Report of Wages (Form DE-9C),
as filed with the California Employment Development Division, on which the qualified
employer must identify on the face of the form whether each employee listed on the
DE-9C is a full-time employee, part-time eligible employee, ineligible employee and
whether the employee is still employed by the qualified employer. If there is not
sufficient space on the face of the Form DE-9C for the qualified employer to add the
required information, the qualified employer may attach additional sheets of paper
to the Form DE-9C as necessary. A qualified employer must provide the SHOP with
additional or other documents in the following circumstances:
(1) For a qualified employer who is a sole
proprietor in business less than three (3) months, a California business license or
Fictitious Business Name Filing and a DE-9C or payroll records for 30
days;
(2) For a qualified employer who
is a sole proprietor who is in business three (3) months or more, a DE-9C. If the
owner is not listed as earning wages on the DE-9C and wishes to enroll for coverage,
a current IRS Form 1040 Schedule C Profit or Loss From Business (Sole
Proprietorship) or, if a Form 1040 Schedule C is not available, a California
business license or Fictitious Business Name filing may be substituted;
(3) For a qualified employer who is a corporation
in business less than three (3) months, Articles of Incorporation, filed and stamped
by the Secretary of State, and a Statement of Information or corporate meeting
minutes listing all officers' names and a DE-9C or payroll records for 30
days;
(4) For a qualified employer who
is a corporation in business three (3) months or more, a DE-9C, and, if officers who
are not listed on DE-9C enroll for coverage, a Statement of Information;
(5) For a qualified employer who is a partnership
in business less than three (3) months, a Partnership Agreement, a Federal Tax
Identification appointment letter, and a DE-9C or payroll records for 30
days;
(6) For a qualified employer who
is a partnership in business three (3) months or more, a DE-9C and a current IRS
Form 1065 Schedule K-1, if the partners are not listed on DE-9C and want to enroll
for coverage. If an IRS Form 1065 Schedule K-1 is not yet available, the Partnership
Agreement and the Federal Tax Identification appointment letter can be
substituted;
(7) For a qualified
employer who is a limited partnership in business less than three (3) months, a
Partnership Agreement, a Federal Tax Identification appointment letter, and a DE-9C
or payroll records for 30 days;
(8) For
a qualified employer who is a limited partnership in business three (3) months or
more, a DE-9C. If general partners are not listed on DE-9C and wish to enroll in
coverage, then a current IRS Form 1065 Schedule K-1. If an IRS Form 1065 Schedule
K-1 is not available, the Partnership Agreement and a Federal Tax Identification
appointment letter can be substituted. Limited partners are not eligible for
coverage unless they appear on a DE-9C;
(9) For a qualified employer who is a limited
liability partnership in business less than three (3) months, a Partnership
Agreement or a Federal Tax Identification appointment letter, and a DE-9C or payroll
records for 30 days;
(10) For a
qualified employer who is a limited liability partnership in business three (3)
months or more, a DE-9C. If partners are not listed on the DE-9C and wish to enroll
in coverage, then a current IRS Form 1065 Schedule K-1. If the IRS Form 1065
Schedule K-1 is not yet available, the Partnership Agreement and the Federal Tax
Identification appointment letter can be substituted;
(11) For a qualified employer who is a limited
liability company in business less than three (3) months, Articles of Organization
with the Operating Agreement or the Statement of Information and a DE-9C or payroll
records for 30 days;
(12) For a
qualified employer who is a limited liability company in business three (3) months
or more, a DE-9C. If managing members are not listed as earning wages on the DE-9C
and wish to enroll for coverage, a current IRS Form 1065 Schedule K-1 for a
partnership or IRS Form 1040 Schedule C for a sole proprietorship. If an IRS Form
1065 Schedule K-1 is not yet available, a Statement of Information or Articles of
Organization with the Operating Agreement may be substituted; and
(13) For a qualified employer who was previously
insured outside of the SHOP, the SHOP may waive or alter any additional
documentation submission requirements in Section
6520(c)(1) - (12), if
as determined by the SHOP on a case-by-case basis, the proof of coverage is
sufficient to satisfy these requirements.
(d) To participate in the SHOP, a qualified
employee must submit the following information to the SHOP five days prior to the
requested effective date:
(1) The employer's
business name and business phone number;
(2) The qualified employee's first and last name,
SSN or Taxpayer Identification Number, date of birth, home address, mailing address
(if different from home address), telephone number, email address, and if the
employee is newly hired;
(3) Whether the
employee is applying for Cal-COBRA or COBRA continuation coverage pursuant to the
following conditions:
(A) The COBRA coverage is
currently in effect under the qualified employer's health plan; or
(B) The employee has had a qualifying event that
renders the employee eligible for continuation of coverage and is applying for that
coverage; and,
(C) If applicable, the
effective date of coverage, the qualifying event that triggered that coverage, and
the date of the qualifying event;
(4) If the qualified employer is offering coverage
for dependents and the employee elects to offer his or her dependents coverage, the
marital or domestic partnership status of the qualified employee;
(5) If the qualified employer is offering coverage
for spouses, registered domestic partners, or non-registered domestic partners,
and/or dependent children, and the employee elects to offer his or her dependents
coverage, then information about the qualified employee's spouse, registered
domestic partner, or non-registered partner, and/or dependent children, which
includes:
(A) The first and last name of each
spouse, registered domestic partner, or non-registered domestic partner, and/or each
dependent child, their relationship to the qualified employee, SSN or taxpayer
identification number, date of birth, age, gender, home address, and mailing address
(if different from home address); and
(B) Whether the qualified employee would like to
enroll a dependent who is a disabled child pursuant to Section
of Title
2599.500 of Title 2 of the California Code of
Regulations;
(6) The names of
the health plans and dental plans, if applicable, selected by the qualified employee
and dependents.
(e) To
participate in the SHOP, a qualified employee must do all of the following:
(1) Agree to mandatory arbitration if the QHP
Issuer selected by the employee requires arbitration, which would require the
employee and his or her dependents to arbitrate all claims relating to his or her
QHP;
(2) Disclose whether the employee
used an insurance agent and, if so, the agent's name, general agency name (if
applicable), and whether the agent is an insurance agent certified by Covered
California. If the employee uses an insurance agent, the employee must have that
agent certify that he or she understands he or she may be subject to a civil penalty
for providing false information under Health and Safety Code Section
1389.8
and Insurance Code Section
10119.3.
(3) Sign the application under penalty of perjury,
that all information contained in the employee application is true and correct to
the best of the employee's knowledge.
(4) Acknowledge that the employee understands that
he or she may be subject to penalties under federal law if he or she intentionally
provides false or untrue information pursuant to
45 CFR Section
155.285 (September 6, 2016), hereby incorporated
by reference.
(f) If a
qualified employee declines coverage, the employee must sign the declination of
coverage, which is part of the application, and state other sources of coverage, if
any.
(g) The SHOP must keep all
information received pursuant to this section private in accordance with applicable
federal and state privacy and security laws pursuant to
45 CFR Section
155.260 (September 6, 2016), hereby incorporated
by reference, and the Information Practices Act of 1977 (Cal. Civ. Code, commencing
with Section 1798). The SHOP may not provide to the
qualified employer any information collected on the employee application with
respect to the qualified employees or dependents of qualified employees, other than
the name, address, birth date, and health plan or dental plan selection of the
spouse or dependent. The SHOP may only share information from an employee
application with the QHP Issuer or employer that is strictly necessary for the
purposes of eligibility and enrollment. Information obtained by the SHOP pursuant to
this section may not be used for purposes other than eligibility determinations and
enrollment in health or dental coverage through the SHOP.
1. New article 6
(sections 6520-6538) and section filed 9-30-2013 as a deemed emergency pursuant to
Government Code section
100504(a)(6);
operative 9-30-2013 (Register 2013, No. 40). A Certificate of Compliance must be
transmitted to OAL by 4-1-2014 or emergency language will be repealed by operation
of law on the following day.
2. New article 6 (sections 6520-6538) and
section, including amendment of subsection (d)(3), refiled 4-1-2014 as a deemed
emergency pursuant to Government Code section
100504(a)(6);
operative 4-1-2014 (Register 2014, No. 14). A Certificate of Compliance must be
transmitted to OAL by 6-30-2014 or emergency language will be repealed by operation
of law on the following day.
3. Refiling of 4-1-2014 action on 6-30-2014,
including amendment of subsection (a)(10)(B), as a deemed emergency pursuant to
Government Code section
100504,
subdivision (a)(6), as modified by Senate Bill 857 (Stats. 2014, c. 31); operative
6-30-2014 (Register 2014, No. 27). A Certificate of Compliance must be transmitted
to OAL by 9-30-2015 pursuant to Government Code section
100504 or
emergency language will be repealed by operation of law on the following
day.
4. Refiling of 6-30-2014 order, including further amendment of
section, on 10-2-2014 as a deemed emergency pursuant to Government Code section
100504
subdivision (a)(6), as modified by Senate Bill 857 (Stats. 2014, c. 31); operative
10-2-2014 (Register 2014, No. 40). A Certificate of Compliance must be transmitted
to OAL by 9-30-2015 pursuant to Government Code section
100504 or
emergency language will be repealed by operation of law on the following
day.
5. Editorial correction of HISTORY 3 and HISTORY 4 (Register 2014,
No. 45).
6. Senate Bill 75 (Stats. 2015, Ch. 18) modified Government Code
section
100504(a)(6)
to change the date upon which a Certificate of Compliance must be transmitted to
OAL. Pursuant to Government Code section
100504(a)(6),
as modified by Senate Bill 75 (Stats. 2015, Ch. 18), a Certificate of Compliance
must be transmitted to OAL by 9-30-2016 or the language in the emergency order of
10-2-2014 will be repealed by operation of law on the following day (Register 2015,
No. 38).
7. Senate Bill 833 (Stats. 2016, c. 30) modified Government Code
section
100504(a)(6)
to extend the date upon which a Certificate of Compliance must be transmitted to
OAL. Refiling of 10-2-2014 order on 9-30-2016 as a deemed emergency pursuant to
Government Code section
100504(a)(6);
operative 9-30-2016 (Register 2016, No. 40). A Certificate of Compliance must be
transmitted to OAL by 10-1-2018 pursuant to Government Code section
100504(a)(6)
or emergency language will be repealed by operation of law on the following
day.
8. Refiling of 9-30-2016 order, including further amendment of
section, on 11-28-2016 as a deemed emergency pursuant to Government Code section
100504(a)(6),
as modified by Senate Bill 833 (Stats. 2016, c. 30); operative 11-28-2016 (Register
2016, No. 49). A Certificate of Compliance must be transmitted to OAL by 10-1-2018
pursuant to Government Code section
100504 or
emergency language will be repealed by operation of law on the following
day.
9. Refiling of 11-28-2016 order, including further amendment of
section, on 4-17-2017 as a deemed emergency pursuant to Government Code section
100504(a)(6),
as modified by Senate Bill 833 (Stats. 2016, c. 30); operative 4-17-2017 (Register
2017, No. 16). A Certificate of Compliance must be transmitted to OAL by 10-1-2018
pursuant to Government Code section
100504 or
emergency language will be repealed by operation of law on the following
day.
10. Refiling of 4-17-2017 order, including further amendment of
section, filed 4-20-2018 as a deemed emergency pursuant to Government Code section
100504(a)(6),
as modified by Senate Bill 833 (Stats. 2016, c.30); operative 4-20-2018 (Register
2018, No. 16). A Certificate of Compliance must be transmitted to OAL by 10-1-2018
pursuant to Government Code section
100504 or
emergency language will be repealed by operation of law on the following
day.
11. Certificate of Compliance as to 4-20-2018 order, including
amendment of subsections (a) and (a)(12)(B), repealer of subsection (a)(12)(D),
subsection relettering, amendment of subsections (b)(2), (b)(7), (b)(12) and (g)(4)
and amendment of NOTE, transmitted to OAL 8-3-2018 and filed 9-17-2018; amendments
effective 9-17-2018 pursuant to Government Code section
11343.4(b)(3)
(Register 2018, No. 38).
12. Amendment filed 9-7-2021 as an emergency;
operative 9-7-2021 (Register 2021, No. 37). Pursuant to Government Code section
100504(a)(6)(A),
a Certificate of Compliance must be transmitted to OAL by 9-7-2026 or emergency
language will be repealed by operation of law on the following
day.
Note: Authority cited: Section
100504,
Government Code. Reference: Sections
100502 and
100503,
Government Code; and 45 CFR
Sections 155.260,
155.705,
155.715,
155.725,
155.730,
156.140 and
156.285.
