The final exchange rule clarifies that claims after the first 30 days will be pended and that the issuer will have to notify the provider, as you mention. The examples and description here https://www.federalregister.gov/articles/2012/03/27/2012-6125/patient-pr... indicate that HHS believes there are "technology-based approaches" to provide this notification.

To the second part of your question, if the member does not ever pay the premium but receives a service after the first 30 days, it seems the member would be liable for that claim. Timothy Jost at Health Affairs wrote a blog that mentions this issue: http://healthaffairs.org/blog/2012/03/13/implementing-health-reform-a-fi...

OK, so here's my conclusion based on what you've said. In case it's helpful to anyone else!

1) In general, (both inside and outside the Exchange) the rule in 147.104 says that issuers may only limit coverage to employers with employees that live/reside or work in the service area. It is only in the individual market that the issuer can limit individuals to those who live or reside in the service area. So, if Employer Y applies for eligibility for small group coverage where its employees WORK (out of state), rather than where they RESIDE (in state), and if Issuer X’s (out of state) service area doesn’t expand across state lines (to employees living in state), then the employees of Employer Y who live in state but work out of state would simply be forced to choose a provider in the State in which they work, instead of the State where they reside.

2) For SHOPs, specifically, section 155.710 states that an employer is eligible for SHOP if (1) its principle place of business is in the Exchange service area and offers coverage to all FTEs through that SHOP or (2) the employer offers coverage to each eligible employee through the SHOP serving that employee’s primary work site. Employees are eligible by virtue of the offer of coverage by the employer. Therefore, if there are some employees that work in one service area, and others that work in another, the employer may participate in multiple SHOPs, where employees can enroll in the SHOP plan offered where their primary work site is. Selection of a multi-state plan could be another possible solution.

Hi Joyce- One group you could reach out to is Small Business Majority- they are very active in the exchange discussions and they may have some testimony: http://www.smallbusinessmajority.org/about-small-business-majority/
Others, please chime in if you have testimony to share!

Thank you for your question, Mike. In § 155.710 (d), the proposed rule on SHOP exchanges states that “the SHOP must treat a qualified employer which ceases to be a small employer solely by reason of an increase in the number of employees of such employer as a qualified employer until the qualified employer otherwise fails to meet the eligibility criteria of this section or elects to no longer purchase coverage for qualified employees through the SHOP.” As stated in the final rule's preamble, because of the range of comments CMS received in response to the proposed rule and because the method of counting employees has implications that extend beyond the operation of the SHOP, at this time, they are not finalizing a rule for determining employer size. They are considering future rulemaking to address the method of determining employer size for purposes of deciding whether an employer is a small employer or a large employer. So the final rule adopts the language set forth in the proposed rule. You can see the final rule here: https://federalregister.gov/a/2012-6125.

Employer's file quarterly payroll reports with the IRS and state authorities on payroll and payroll deductions for federal and state programs. This provides a standard and easy method to determine number of employees, pay etc. By using this existing report employers would not have to generate a new report, learn new terms or methods of calculating employees etc.