This is the accessible text file for GAO report number GAO-15-58 
entitled 'Small Business Health Insurance Exchanges: Low Initial 
Enrollment Likely due to Multiple, Evolving Factors' which was 
released on November 13, 2014. 

This text file was formatted by the U.S. Government Accountability 
Office (GAO) to be accessible to users with visual impairments, as 
part of a longer term project to improve GAO products' accessibility. 
Every attempt has been made to maintain the structural and data 
integrity of the original printed product. Accessibility features, 
such as text descriptions of tables, consecutively numbered footnotes 
placed at the end of the file, and the text of agency comment letters, 
are provided but may not exactly duplicate the presentation or format 
of the printed version. The portable document format (PDF) file is an 
exact electronic replica of the printed version. We welcome your 
feedback. Please E-mail your comments regarding the contents or 
accessibility features of this document to Webmaster@gao.gov. 

This is a work of the U.S. government and is not subject to copyright 
protection in the United States. It may be reproduced and distributed 
in its entirety without further permission from GAO. Because this work 
may contain copyrighted images or other material, permission from the 
copyright holder may be necessary if you wish to reproduce this 
material separately. 

United States Government Accountability Office: 
GAO: 

Report to the Chairman, Committee on Small Business, House of 
Representatives: 

November 2014: 

Small Business Health Insurance Exchanges: 

Low Initial Enrollment Likely due to Multiple, Evolving Factors: 

GAO-15-58: 

GAO Highlights: 

Highlights of GAO-15-58, a report to the Chairman, Committee on Small 
Business, House of Representatives. 

Why GAO Did This Study: 

The Patient Protection and Affordable Care Act required SHOPs—-
exchanges or marketplaces where small employers can shop for health 
coverage for their employees—-to be established in all states. States 
may elect to establish and operate SHOPs themselves or allow CMS to do 
so within the state. Enrollment in SHOPs was to begin in October 2013, 
with coverage effective January 2014. GAO was asked to examine the 
early implementation experiences of the SHOPs. 

In this report GAO describes (1) SHOP functionality, enrollment, plan 
availability, and premiums and (2) stakeholders' views on key factors 
that have affected current SHOP enrollment or may affect future 
enrollment growth. GAO reviewed relevant information from CMS and 
states, including data on employer and employee enrollment, plan 
availability, and premiums generally through June 1, 2014. GAO also 
interviewed representatives of key stakeholders that operate SHOPs 
(CMS and states), offer coverage in SHOPs (health insurance issuers), 
obtain coverage through SHOPs (small employers), or assist in 
obtaining coverage through SHOPs (agents and brokers) on a national 
basis and, for certain stakeholders, in five states—California, 
Illinois, Kentucky, Rhode Island, and Texas. The five states were 
selected based on factors including varied issuer participation levels 
and SHOP functionality. The experiences of these stakeholders cannot 
be generalized to other states or stakeholders. 

We incorporated HHS comments on a draft of this report as appropriate. 

What GAO Found: 

Though all of the Small Business Health Options Programs (SHOPs) 
required by the Patient Protection and Affordable Care Act were 
operational, many features were not yet available and enrollment was 
low as of June 2014. According to the Centers for Medicare & Medicaid 
Services (CMS), the agency that oversees the SHOPs, all 33 of the 
SHOPs run by CMS (federally facilitated, or FF-SHOPs) and 14 of the 18 
SHOPs run by states (state-based, or SB-SHOPs) were accepting 
enrollment applications as of the October 1, 2013, deadline. The 
remaining 4 SB-SHOPs became operational by the following May. Websites 
where employers could review plan information such as premiums and 
benefits were available on October 1, 2013, for all FF-SHOPs and most 
SB-SHOPs. Other key SHOP features—-online enrollment and employee 
choice, the ability for employees to choose among multiple plans—-were 
delayed for all FF-SHOPs, but available for most of the SB-SHOPs. CMS 
is currently preparing to implement online enrollment for all FF-SHOPs 
and employee choice for many of the FF-SHOPs for 2015. Based on 
official estimates and stakeholders' expectations, enrollment for the 
SB-SHOPs has been significantly lower than expected. The 18 SB-SHOPs 
had enrolled about 76,000 individuals—-including employees, their 
spouses, and dependent children-—in plans purchased through nearly 
12,000 small employers, as of June 1, 2014, for most states. Enrollment 
data for the FF-SHOPs was not yet available, although CMS was in the 
process of collecting the data from issuers and expected to have 
complete data by early 2015. However, CMS officials said they do not 
expect major differences in enrollment trends for 2014 between SB-
SHOPs and FF-SHOPs. Finally, most SHOPs had multiple plans available 
in each county, although a small number of states had counties with no 
plans available. Premiums for SHOP plans varied across states and 
were generally comparable to premiums for other small group plans 
offered within a state but outside of the SHOP. 

Stakeholders identified several factors that may have led to current 
low SHOP enrollment and that may affect future enrollment growth. Many 
stakeholders reported that the primary incentive for employers to use 
the SHOPs has been the small business tax credit available to certain 
eligible employers who offer coverage through a SHOP, although some 
noted that the credit may be too small and administratively complex to 
motivate many employers to enroll. Other factors identified that may 
have hindered current enrollment include the ability of employers to 
renew plans that existed before the SHOPs-—which, depending on state 
requirements, is permitted until October 1, 2016—-and employer 
misconceptions about SHOP availability. Stakeholders also described 
factors that may help stimulate or detract from future SHOP enrollment 
growth. For example, the phase-out of existing pre-SHOP plans, the 
implementation of employee choice by an increasing number of SHOPs, 
improved coordination with agents and brokers, and increased marketing 
to small employers may help stimulate enrollment growth. Conversely, 
other factors, such as the 2-year limit on the availability of the 
small business tax credit and the likelihood, according to 
stakeholders, that SHOP premiums will not be lower than non-SHOP 
premiums, may hinder future enrollment growth. The evolving and 
localized nature of these factors suggests that a determination of the 
SHOPs' long-term impact remains premature at this time. 

View [hyperlink, http://www.gao.gov/products/GAO-15-58]. For more 
information, contact John Dicken at (202) 512-7114 or dickenj@gao.gov. 

Contents: 

Letter: 

Background: 

SHOPs Were Operational in All States, Although Many Expected Features 
Were Not Yet Available and Enrollment Was Low as of June 2014: 

Stakeholders Identified Several Factors That May Have Led to Current 
Low SHOP Enrollment and That May Affect Future Enrollment Growth: 

Concluding Observations: 

Agency Comments: 

Appendix I: Small Business Health Options Program (SHOP) Features as 
of June 1, 2014: 

Appendix II: State-Based Small Business Health Options Program (SB-
SHOP) Enrollment Generally as of June 1, 2014: 

Appendix III: Small Business Health Options Program (SHOP) 2014 
Average Monthly Premiums for Silver-Tier Plans: 

Appendix IV: Small Business Health Options Program (SHOP) Silver-Tier 
Plan Availability: 

Appendix V: Comments from the Department of Health and Human Services: 

Appendix VI: GAO Contact and Staff Acknowledgments: 

Figure: 

Figure 1: Total Enrollment in the State-Based Small Business Health 
Options Programs (SB-SHOPs) Generally As of June 1, 2014: 

Abbreviations: 

CBO: Congressional Budget Office: 

CMS: Centers for Medicare & Medicaid Services: 

FF-SHOP: federally facilitated Small Business Health Options Program: 

HHS: Department of Health and Human Services: 

PPACA: Patient Protection and Affordable Care Act: 

QHP: qualified health plan: 

SB-SHOP: state-based Small Business Health Options Program: 

SHOP: Small Business Health Options Program: 

[End of section] 

United States Government Accountability Office: 
GAO:
441 G St. N.W. 
Washington, DC 20548: 

November 13, 2014: 

The Honorable Sam Graves: 
Chairman: 
Committee on Small Business: 
House of Representatives: 

Dear Mr. Chairman: 

The Patient Protection and Affordable Care Act (PPACA) required the 
creation in all states of Small Business Health Options Programs 
(SHOPs)[Footnote 1]--exchanges, or marketplaces, where small employers 
can shop for and purchase health coverage for their employees. 
[Footnote 2] SHOPs were required to begin accepting enrollment 
applications for 2014 coverage by October 1, 2013, with coverage 
starting as early as January 1, 2014.[Footnote 3] A state may elect to 
establish and operate a SHOP itself (through a state-based, or SB-
SHOP) or allow the Department of Health and Human Services' (HHS) 
Centers for Medicare & Medicaid Services (CMS) to establish and 
operate a federally facilitated SHOP (FF-SHOP) within that state. 
[Footnote 4] In June 2013, we reported on the status of federal and 
state efforts to establish the SHOPs. At that time, we found that both 
CMS and states had made progress in establishing SHOPs, although many 
activities remained to be completed and some were behind schedule. 
[Footnote 5] 

As the first year of SHOP operations nears its end, members of 
Congress have raised questions about the challenges that SHOPs may 
face in achieving long-term success. Such questions include whether 
SHOPs have been able to provide online enrollment tools and other 
expected functionalities, and in general whether SHOPs will offer 
sufficient value to small employers to motivate them to enroll. You 
asked that we examine the early implementation experiences of the 
SHOPs. In this report, we describe: 

1. SHOP functionality, enrollment, plan availability, and premiums; 
and: 

2. stakeholders' views on key factors that have affected current SHOP 
enrollment or may affect future enrollment growth. 

To describe early indicators of SHOP functionality, enrollment, plan 
availability, and premiums, we requested information from CMS and 
states and interviewed relevant officials. Specifically, to describe 
SHOP functionality, including when SHOPs became operational, whether 
SHOPs had a website that allowed employers to browse plan options and 
enroll online, and whether SHOPs offered employers the ability to 
offer their employees a choice among multiple plans, we requested 
information from CMS and interviewed CMS officials. We analyzed CMS 
and SB-SHOP data on plan availability and premiums in 2014, and we 
analyzed SB-SHOP data on employer and employee enrollment for 
timeframes ending between May and September 2014, with most ending on 
June 1, 2014. To assess the reliability of the data we received from 
CMS and states, we performed manual and electronic tests of the data 
to identify any outliers or anomalies and followed up with officials 
as necessary and incorporated the corrections we received. We 
determined that the data were sufficiently reliable for the purposes 
of our analysis. We also reviewed other information sources, including 
published literature and state SHOP websites, and identified federal 
requirements related to the SHOPs by interviewing CMS officials and 
reviewing relevant laws and regulations. 

To describe stakeholders' views on key factors that have affected 
current SHOP enrollment or may affect future enrollment growth, we 
interviewed national-level representatives of key stakeholders that 
operate, offer coverage in, obtain coverage through, or assist in 
obtaining coverage through SHOPs. Specifically, we interviewed 
officials from CMS's Center for Consumer Information and Insurance 
Oversight (CCIIO) who oversee the operation of SHOPs, as well as 
national organizations representing issuers of health coverage, 
insurance commissioners, small employers, and health insurance agents 
and brokers.[Footnote 6] In addition, we selected five states in which 
to interview state-level representatives of the SHOPs, small 
employers, and agents and brokers.[Footnote 7] To ensure that we 
captured a range of SHOP-related experiences and perspectives, we 
selected states that varied in terms of state population, geographic 
location, SHOP type (FF-SHOP or SB-SHOP), SHOP website functionality, 
including the availability of employee choice, and issuer 
participation in the SHOP. We selected Kentucky, Rhode Island, 
California, Illinois, and Texas for our study.[Footnote 8] For the SB-
SHOP states--Kentucky, Rhode Island, and California--we interviewed 
state exchange officials. For the FF-SHOP states--Texas and Illinois--
we interviewed CMS officials involved with the establishment and 
operation of the FF-SHOPs.[Footnote 9] Our work was limited to 
reviewing illustrative examples of stakeholders' experiences with and 
perspectives on the SHOPs. The findings from our interviews therefore 
cannot be generalized to the perspectives and experiences of all 
issuers, insurance commissioners, employers, agents and brokers, or 
state exchange officials. 

We conducted this performance audit from February 2014 to November 
2014 in accordance with generally accepted government auditing 
standards. Those standards require that we plan and perform the audit 
to obtain sufficient, appropriate evidence to provide a reasonable 
basis for our findings and conclusions based on our audit objectives. 
We believe that the evidence obtained provides a reasonable basis for 
our findings and conclusions based on our audit objectives. 

Background: 

PPACA included a number of provisions that changed requirements for 
small group health plans.[Footnote 10] For example, PPACA required 
that, beginning January 1, 2014, plans offer a set of minimum 
essential health benefits. PPACA also set standards for the percentage 
of total average costs that plans must cover for such benefits. The 
average costs covered by each plan are reflected in different plan 
levels, or tiers, and each tier is designated as bronze, silver, gold, 
or platinum.[Footnote 11] In addition, beginning on January 1, 2014, 
issuers are no longer able to consider the average health status of a 
particular group when setting premium rates and can only adjust 
premiums based on enrollment type (individual or family enrollment), 
geographic area, age, and tobacco use.[Footnote 12] Plans meeting 
these and other federal requirements, as well as other standards set 
by states, may be certified to be offered in an exchange; these plans 
are referred to as qualified health plans (QHPs). 

PPACA required all small group health plans to comply with these 
requirements as of January 1, 2014.[Footnote 13] However, in response 
to concerns regarding some issuers terminating plans that did not 
comply with PPACA requirements, CMS announced in November 2013 that it 
would provide transitional relief under which states could elect to 
permit issuers in their states to offer renewals of their noncompliant 
plans for a plan year beginning between January 1, 2014, and October 
1, 2014, provided the plans met certain conditions.[Footnote 14] In 
March 2014, CMS extended this transitional policy through October 1, 
2016, and noted that the agency may grant an additional 1 year 
extension, if necessary.[Footnote 15] 

PPACA also mandated the establishment of SHOPs in each state to allow 
small employers to compare available health insurance options in their 
states and facilitate the enrollment of their employees in coverage. 
Until 2016, states have the option to define small employers either as 
employers with 100 or fewer employees or employers with 50 or fewer 
employees.[Footnote 16] To be eligible for SHOP coverage, a small 
employer must offer coverage to all full-time employees in a QHP 
through a SHOP. To be eligible to enroll in a QHP through a SHOP, an 
individual must have been offered health insurance coverage by a 
qualified employer through a SHOP. 

The SHOPs are required to have certain functionalities to facilitate 
the health plan comparison and enrollment process. For example, each 
SHOP must provide access to the SHOP to employers and employees 
through a website, toll-free call centers, and in person. Each SHOP 
must present the QHPs approved by the SHOP for the small-employer 
market in the state by the participating issuers of health coverage. 
[Footnote 17] In addition, the benefits, cost-sharing features, and 
premiums of each QHP must be presented in a manner that facilitates 
comparison shopping of plans by small employers and their employees. 
Each SHOP must accept employer and employee applications through the 
SHOP website and may also accept applications over the phone, in 
person, or by mail. This application should collect the information 
necessary to screen an employer's eligibility for SHOP participation 
and identify employees eligible to enroll in a QHP. Employers and 
employees may receive assistance to compare coverage options and 
complete applications through a qualified insurance agent or broker. 
[Footnote 18] 

In addition, SHOPs will implement requirements related to employee 
choice--that is, the ability of employees to choose a plan among 
multiple plans offered to them by their employer.[Footnote 19] Employee 
choice may be offered in different ways. In general, a SHOP must allow 
a qualified employer to offer its employees a choice among all QHPs 
available within a specific metal tier of coverage, but may allow an 
employer to offer broader employee choices among multiple plans across 
different tiers.[Footnote 20] According to CMS, employee choice is 
intended to be a fundamental new benefit of SHOPs, in that small 
employers would be able to offer multiple plans from more than one 
issuer of health coverage, whereas traditionally most small employers 
have offered only one or a few plans from a single issuer. SHOPs were 
initially required to have the capacity to allow employers to provide 
employee choice beginning in 2014. However, under a final rules issued 
in June 2013, the requirement that SHOPs offer employee choice was first 
postponed to 2015, although SB-SHOPsretained the option of providing 
employee choice in 2014. The requirement was further postponed under a 
May 2014 final rule to 2016 in states that could demonstrate to CMS that 
postponing employee choice would be in the best interest of small 
employers and their employees and dependents, given the likelihood 
that implementing employee choice could cause issuers to price their 
products and plans higher than they would otherwise due to issuers' 
beliefs about adverse selection.[Footnote 21] 

To provide an incentive for small employers to provide health 
insurance, and to make insurance more affordable, PPACA established a 
small business tax credit for certain eligible small employers 
offering coverage to their employees.[Footnote 22] The tax credit was 
available beginning in 2010, prior to the establishment of SHOPs. 
However, beginning in 2014, employers must offer coverage to their 
employees through the SHOP to be eligible for the credit.[Footnote 23] 
Beginning in 2014, employers are eligible for the credit for a maximum 
of 2 years.[Footnote 24] 

PPACA directed states to establish SHOPs by January 1, 2014.[Footnote 
25] In states electing not to establish and operate an SB-SHOP, PPACA 
required the federal government to establish and operate an FF-SHOP in 
the state.[Footnote 26] For 2014, 18 states chose to operate SB-SHOPs 
while 33 states opted for an FF-SHOP.[Footnote 27] CMS's and states' 
roles in operating SHOPs and individual exchanges may change in future 
years. CMS officials stated that as of September 2014, Nevada was 
planning to begin using the FF-SHOP platform, while Idaho was planning 
to begin using its own state-based platform, in 2015. 

SHOPs Were Operational in All States, Although Many Expected Features 
Were Not Yet Available and Enrollment Was Low as of June 2014: 

Though SHOPs were operational in all states as of June 1, 2014, many 
expected features were not yet available for a number of SHOPs. 
Enrollment for the SB-SHOPs, as of June 1, 2014 for most states, has 
been lower than expected, and CMS officials said they do not expect 
the enrollment trends for the FF-SHOPs to be significantly different, 
although they are still in the process of collecting enrollment data. 
Most SHOPs had multiple plans available in each county, though in some 
states there were a few counties with no plans available. Premiums 
varied across states, though were generally comparable to premiums for 
small group plans within the same state offered outside of the SHOPs. 

SHOPs Were Operational in All States, Although Many Expected Features 
Were Not Yet Available, Particularly for the Federally Facilitated 
SHOPs: 

All of the FF-SHOPs and most of the SB-SHOPs were operational as 
required--that is, accepting enrollment applications--as of October 1, 
2013. According to CMS, four of the SB-SHOPs--Hawaii, Maryland, 
Mississippi, and Oregon--were not operational as of the October 1, 
2013, deadline, although all have since become operational. Hawaii 
became operational on October 15, 2013, Maryland became operational on 
April 1, 2014, and Oregon and Mississippi became operational on May 1, 
2014. 

Websites where employers could review plan information, including 
premiums and benefits, were available on October 1, 2013, for all FF-
SHOPs and most SB-SHOPs. This information allows employers and 
employees to make meaningful comparisons about available SHOP plans in 
their state. Plan information for the FF-SHOPs was provided by CMS 
through its website. According to CMS, on October 1, 2013, the SB-
SHOPs in Maryland, Oregon, and Mississippi lacked websites where 
employers could review plan and premium information. Mississippi has 
since added plan and premium information to its websites. Oregon and 
Maryland have directed employers to contact agents and brokers or 
issuers to review plan options. 

According to CMS, most SB-SHOPs created online enrollment portals by 
October 1, 2013, though a handful of states--Maryland, Oregon, 
California, and Mississippi--did not have online enrollment portals 
available or had to take them offline, requiring employers to enroll 
directly through issuers. For example, the California SHOP initially 
offered online enrollment but took its enrollment portal down in 
February 2014 due to technical challenges, leaving small businesses in 
California able to enroll in SHOP plans only through direct 
enrollment. Online enrollment for the Mississippi SHOP began when it 
became operational in May 2014, while Maryland and Oregon have yet to 
implement online enrollment for their SHOPs. 

CMS did not implement online enrollment in the FF-SHOPs in 2014. As a 
result, employers enrolling in any of the FF-SHOPs, starting in 
October 2013, had to enroll in SHOP coverage either through agents and 
brokers or directly through issuers.[Footnote 28] CMS is currently 
preparing to implement online enrollment for the FF-SHOPs for 2015, 
and expects to launch online enrollment fully in all FF-SHOPs by 
November 15, 2014, when SHOP enrollment begins for 2015.[Footnote 29] 
The online enrollment system will allow, among other functions, 
enhanced features for agents and brokers, notification to employees of 
their employers' annual open enrollment period, online employer 
payments, transmitting of enrollment and payment transactions to 
issuers, and the processing of coverage changes.[Footnote 30] 

According to CMS, fifteen SB-SHOPs offered employee choice in 2014 
through a variety of approaches, though employee choice was delayed 
for the FF-SHOPs until 2015. These approaches included enabling 
employers to offer a choice of plans across all metal tiers and all 
issuers; a choice of plans across one metal tier but for multiple 
issuers; or a choice of plans from one issuer but across multiple 
metal tiers. Some states allowed the employer to choose which employee 
choice model to use, while other states only offered one approach. 
Four states, including California, required that employers offer their 
employees a choice of plans, while others, including Rhode Island and 
Kentucky, gave employers the option of choosing one plan or offering 
wider plan choice to their employees. 

The majority of enrolled employers in SB-SHOP states where data was 
available took advantage of the employee choice feature. For example, 
exchange officials in Kentucky and Rhode Island said that 
approximately 65 and 61 percent of enrolled employers, respectively, 
decided to offer their employees a choice of plans.[Footnote 31] In 
Rhode Island, in cases where employers offered the choice of any plans 
through the SHOP, just over 50 percent of their employees chose the 
reference plan the employer had selected, 14 percent selected a 
different plan within the same tier, 13 percent purchased a lower 
metal tier--or less expensive--plan than the reference plan, and 21 
percent purchased a higher metal tier--or more expensive--plan than 
the reference plan. CMS officials said that two additional SB-SHOPs, 
Colorado and New York, reported that a majority of employers decided 
to offer their employees a choice of plans. However, three SB-SHOPs 
did not offer employee choice in 2014: Maryland, Massachusetts, and 
Oregon. Massachusetts was unable to offer employee choice because its 
online system for employee choice is still in development, according 
to CMS officials. Maryland and Oregon were unable to offer employee 
choice because SHOP enrollment was only available through direct 
enrollment, according to CMS and state officials, respectively. 

CMS did not offer employee choice in the FF-SHOPs in 2014 but plans to 
do so for many FF-SHOPs for 2015. However, CMS offered state insurance 
commissioners the chance to recommend whether or not employee choice 
should be implemented in their state for 2015 or delayed until 2016, 
if the commissioners could adequately explain that this would be in 
the best interest of small employers and their employees and 
dependents.[Footnote 32] Fourteen FF-SHOP states chose to allow CMS to 
implement employee choice for 2015 while 18 FF-SHOP states chose to 
delay employee choice until 2016.[Footnote 33] (See appendix I for 
additional details on SHOP functionality as of June 1, 2014.) 

State-Based SHOP Enrollment Was Significantly Lower than Anticipated, 
While Enrollment Data for Federally Facilitated SHOPs Were Not Yet 
Available: 

SB-SHOP plans had enrolled approximately 76,000 individuals--including 
employees, spouses, and dependent children--into plans purchased 
through 11,742 small employers, as of June 1, 2014 for most states, 
with end dates ranging from May to September 2014. Enrollment varied 
widely among the 18 states with SB-SHOPS, from 33,696 individuals 
(purchased through 3,580 small employers) in Vermont,[Footnote 34] to 
1 individual (purchased through 1 small employer) in 
Mississippi.[Footnote 35] (See figure 1.) 

Figure 1: Total Enrollment in the State-Based Small Business Health 
Options Programs (SB-SHOPs) Generally As of June 1, 2014: 

[Refer to PDF for image: vertical bar graph] 

Vermont[A]: 33,696; 
Utah[B]: 10,900; 
New York: 10,023;
California[C]: 9,563; 
Massachusetts: 3,324; 
Colorado: 2,135
Rhode Island: 1,489; 
Minnesota: 1,178; 
Hawaii[D]: 851; 
District of Columbia[E]: 714; 
New Mexico: 602; 
Connecticut: 548; 
Kentucky: 442; 
Oregon[F]: 329; 
Maryland[G]: 76; 
Nevada: 43; 
Washington: 42; 
Mississippi[H]: 1. 

Sources: SB-SHOPs. GAO-15-58. 

Notes: Figure indicates the total number of individuals (including the 
employees, spouses, and any dependent children) covered by SB-SHOP 
plans. 

[A] Vermont required that all small group plans in the state be 
offered only through the SHOP. Vermont provided data as of June 13, 
2014. 

[B] Utah had an operational exchange for small employers prior to the 
enactment of the Patient Protection and Affordable Care Act. 

[C] California provided data as of May 22, 2014. 

[D] The number for Hawaii only reflects the number of employees 
covered, as total enrollment was not available. 

[E] The number for the District of Columbia does not include 
Congressional employees who are required to obtain coverage through 
the District of Columbia's SB-SHOP in order to receive a government 
contribution toward their health insurance premiums under the Federal 
Employees Health Benefits Program. 

[F] The number for Oregon only reflects the number of employees 
covered, as total enrollment was not available. 

[G] Maryland provided data as of September 15, 2014. 

[H] Mississippi provided data as of July 1, 2014. 

[End of figure] 

Based on the average number of employees who enrolled in each state 
per small employer, it appears that the employer groups that enrolled 
in the SHOPs generally had few employees, particularly given that 
states allowed employers with as many as 50 employees to enroll in the 
SHOPs in 2014. Overall, the average number of employees per employer 
was 3.7, although the average number of employees enrolled per 
employer in each state varied. Employers that enrolled in Utah had the 
largest average number of employees enrolled per employer, 8.3, while 
New York had the smallest average number of employees enrolled per 
employer, 1.6.[Footnote 36] (See app. II for additional details on SB-
SHOP enrollment.) 

Based on official estimates and stakeholders' expectations, SB-SHOP 
enrollment--as of June 1, 2014 for most states, with end dates ranging 
from May to September 2014--was significantly lower than anticipated 
and, at its current pace, is unlikely to reach expectations by the end 
of 2014.[Footnote 37] In April 2014, the Congressional Budget Office 
(CBO) estimated that 2 million employees would enroll in coverage 
through the SB-SHOPs and FF-SHOPs in 2014, with the number of 
enrollees rising to 3 million in 2015 and leveling off at 4 million 
enrollees by 2017.[Footnote 38] In general, stakeholders we spoke with 
said that SHOP enrollment has been low, often lower than anticipated. 
For example, officials from the three SB-SHOPs we spoke to all said 
that enrollment has been low, with officials from two of the states 
indicating enrollment was lower than expected. Officials from the 
third state said challenges related to implementation and the lack of 
resources for marketing the SHOP had already lowered their 
expectations for enrollment, though they acknowledged that enrollment 
was generally low. Further, other stakeholders, including issuer, 
employer, and agent and broker representatives, also said that 
enrollment to date has been lower than anticipated. 

Enrollment data for the FF-SHOPs was not yet available, though CMS 
officials reported that the agency was in the process of collecting 
the data from issuers. According to officials, because CMS was not 
ultimately prepared to implement online enrollment it has had to 
require each issuer involved in an FF-SHOP to manually report 
enrollment data. This data reporting role for issuers had not 
originally been anticipated, and so CMS has had to work with issuers 
to develop protocols to submit the data. CMS officials said that they 
are working on a system through which issuers can report their 2014 
SHOP enrollment data, and that they expect to have initial data by 
fall of 2014 but will not have complete data for 2014 until early 
2015.[Footnote 39] However, CMS officials said they do not have reason 
to expect major differences in enrollment trends for 2014 between the 
SB-SHOPs and the FF-SHOPs. Beginning in 2015, CMS officials said they 
plan to have online enrollment that will likely facilitate the more 
timely and accurate collection of enrollment data.[Footnote 40] 

Most SHOPs Have Multiple Plans Available in Each County, and Plan 
Premiums Varied Across States and Were Generally Comparable to Similar 
Plans Outside the SHOPs: 

In nearly all states, multiple issuers offered multiple plans in the 
SHOPs in 2014. The total number of participating issuers and plans in 
each state varied widely from 1 to 13 issuers and 3 to 320 plans. 
[Footnote 41] Forty-five states had more than one issuer participating 
in their SHOP and 31 states had 3 or more participating issuers and 
each issuer offered, on average, 12 plans in each rating area. 
[Footnote 42] 

In looking at silver-tier plans specifically, we found that most 
states had at least one silver-tier plan available in each county, 
though New York, Washington, and Wisconsin had counties where no 
silver-tier plans were available.[Footnote 43] Further, most states 
had at least two silver-tier plans available in each county. When 
looking at the total number of silver-tier plans, Washington, D.C., 
offered the most, with 89, while Arkansas, New Hampshire, and West 
Virginia each only had one silver-tier plan available. Regarding 
issuer participation in the SHOPs, we found that just over half of 
states offered silver-tier plans from two or more issuers in each 
county. Maryland had the most issuers offering silver-tier plans in 
its SHOP, with 13, though six states--Arkansas, Mississippi, New 
Hampshire, North Carolina, Washington, and West Virginia--had only one 
issuer offering silver-tier plans. 

The type of plan with the highest enrollment also varied across SB-
SHOP states, as did the proportion of employees enrolling in these 
plans.[Footnote 44] The highest enrollment plans in each state were 
most often gold-tier. The plan with the highest enrollment was a gold-
tier plan in seven states, a silver-tier plan in 5 states, and a 
platinum-tier plan in five states.[Footnote 45] The proportion of 
individuals enrolled in the highest enrollment plan ranged from 
approximately one-fourth of enrollees in California, Connecticut, 
Kentucky, and Vermont to less than 10 percent in Minnesota, New Mexico, 
New York, and Utah. [Footnote 46] (See appendix II for additional 
details on the highest enrollment SB-SHOP plans.) 

Premiums for silver-tier plans varied within and across states, 
[Footnote 47] though no clear patterns emerged. Monthly silver-tier 
plan premiums for enrollees aged 21 ranged widely from $138 for the 
least expensive Hawaii plan to $523 for the most expensive Alaska 
plan, with the median plan costing $262.[Footnote 48] For enrollees 
aged 40, the monthly premiums varied from $176 for the least expensive 
Hawaii plan to $669 for the most expensive Alaska plan, with the 
median plan costing $335. Finally, for enrollees aged 60, the monthly 
premiums varied from $375 for the least expensive Hawaii plan to $1421 
for the most expensive Alaska plan, with the median plan costing $711. 
The differences between the premiums of the most expensive and least 
expensive silver-tier plans within a given state also varied widely. 
Arizona had the largest difference, with the most expensive plan 
costing almost three times as much as the lowest-cost plan.[Footnote 
49] North Carolina had the least disparate silver-tier plan premiums, 
with the most expensive plan costing only approximately five percent 
more than the least expensive plan.[Footnote 50] (See app. III for 
additional details about SHOP premium variation across states.): 

In the three states where we compared SHOP premiums to non-SHOP small 
group market premiums in the state, we found that premiums for silver-
tier plans were generally comparable.[Footnote 51] PPACA requires that 
prices for identical plans within a given state be the same, 
regardless of whether plans are offered on or off the SHOP.[Footnote 
52] Many stakeholders we spoke to said that SHOP premiums were 
generally comparable to premiums for plans outside of the SHOPs. As 
previously noted, PPACA requires that small group plans meet a number 
of requirements. These requirements limit the overall variability 
between PPACA-compliant plans offered within or outside of the SHOPs, 
including variation in premiums. 

Stakeholders Identified Several Factors That May Have Led to Current 
Low SHOP Enrollment and That May Affect Future Enrollment Growth: 

Stakeholders we interviewed reported that the primary incentive for 
employers to use the SHOPs has been the small business tax credit. 
However, stakeholders identified several factors that may have 
hindered enrollment, thus leading to current low SHOP enrollment. 
Stakeholders also described factors that may help stimulate or detract 
from SHOP enrollment in the future. 

Stakeholders Reported that the Small Business Tax Credit Has Been the 
Primary Motivator for Employers to Enroll in SHOPs: 

Many stakeholders, including issuer, employer, and agent and broker 
representatives we interviewed, reported that the primary incentive 
for employers to use SHOPs has been the small business tax credit. 
[Footnote 53] Employers must generally purchase coverage through a 
SHOP and meet certain other criteria, including having fewer than 25 
employees, to be eligible for the credit, which they may receive for a 
maximum of two years beginning in 2014. Most employer group 
representatives reported that those small employers that were 
interested in and taking steps to enroll in the SHOPs were largely 
doing so in order to be eligible for the tax credit. Exchange 
officials in Kentucky also reported that the tax credit has likely 
been an important incentive for small employers enrolling in the 
state's SHOP, and that most employers that had enrolled as of April 
2014 had less than 25 employees, indicating that they may have been 
pursuing the credit.[Footnote 54] Similarly, as discussed previously, 
we found that the average number of enrolled employees in SB-SHOPs 
ranged from 1.6 to 8.3 employees,[Footnote 55] suggesting that many 
enrolled employers may have been eligible for the credit. 

However, several stakeholders noted that the tax credit is too small 
and administratively complex to motivate many small employers to 
enroll. CMS officials and one employer group representative noted that 
the temporary nature of the tax credit--that is, the fact that 
employers may receive the credit for only 2 years beginning in 2014--
may deter some employers from offering coverage for the first time 
through the SHOP to obtain the credit. This is consistent with our 
prior work, which revealed low use of the credit even prior to the 
establishment of the SHOPs. In 2012, we reported that the take-up of 
the small business tax credit in tax year 2010, the first year the 
credit was offered, was much lower than the estimated number of 
eligible employers. According to tax preparers and other stakeholders 
we interviewed for that work, small employers likely did not view the 
credit as a sufficient incentive to begin offering health insurance, 
particularly given the complexity of, and time required to claim, the 
credit.[Footnote 56] 

Stakeholders Identified Several Factors That May Have Hindered Current 
SHOP Enrollment: 

Although the small business tax credit may have led some employers to 
enroll in the SHOPs, stakeholders identified several other factors 
that may have hindered enrollment, thus leading to current low SHOP 
enrollment. 

* Delays in key SHOP features. Stakeholders, including representatives 
of national employer, agent and broker, and insurance commissioner 
groups, said that the delays in implementation of online enrollment 
and employee choice in the FF-SHOPs may have hindered SHOP enrollment. 
These key features, which have also been delayed in certain SB-SHOPs, 
are not typically available to small employers purchasing coverage 
through other means. According to stakeholders, until these key 
features are implemented, employers may not have as much incentive to 
enroll in coverage through the SHOP. 

* Limited awareness of and misconceptions about SHOP availability. 
Many stakeholders, including state exchange officials and national-and 
state-level agent, broker, and employer representatives, reported a 
lack of employer awareness of the ability to enroll in SHOP plans 
beginning October 1, 2013, largely due to misconceptions about whether 
the SHOPs were open for enrollment and a lack of outreach by states 
and CMS. Stakeholders said that media reports announcing delays in 
certain SHOP features--in particular, the delays in FF-SHOP online 
enrollment and employee choice--led many employers to assume that the 
overall implementation of SHOPs was delayed and that enrolling in 
plans was not yet possible. In addition, stakeholders said that low 
awareness stemmed from a federal and state emphasis on highlighting 
the availability of the individual exchanges. For example, exchange 
officials from one SB-SHOP state noted that employer awareness of the 
SHOP remained low in part because the state initially focused outreach 
and marketing efforts on the individual exchange. However, exchange 
officials from this and another SB-SHOP state reported that with the 
end of their individual exchanges' open enrollment periods, the states 
are now focusing outreach and marketing efforts on their SHOPs, which 
must provide for rolling enrollment.[Footnote 57] 

* Renewal of existing, noncompliant plans. The majority of 
stakeholders--including national-level groups as well as stakeholders 
representing four of the five states included in our study--said that 
the ability for employers to renew their existing, non-PPACA compliant 
plans may have limited SHOP enrollment.[Footnote 58] National-level 
employer and agent and broker groups we interviewed said that most 
small employers chose to renew their existing plans in states where 
this was permitted, in part due to a general preference for the status 
quo, as well as other factors, such as concerns about potential 
premium increases associated with new plans.[Footnote 59] Kentucky, 
California, and Illinois exchange officials, as well as CMS officials 
who participated in the implementation of the SHOP in Illinois and 
Texas, said that the renewal of these plans may have limited SHOP 
enrollment in these states. 

* Technical challenges and administrative burden. Some stakeholders 
said that the ongoing technical challenges and administrative burden 
associated with many of the SHOPs have served as a barrier to entry 
for employers, in part by discouraging some agents and brokers from 
recommending the SHOP to employers. National-and state-level employer 
group representatives reported hearing from small employers that they 
have avoided SHOPs due to technical challenges with SHOP websites, as 
well as administrative burdens, such as difficulty reaching customer 
service and, in some cases, the need to send application paperwork by 
mail. State exchange officials reported that they worked closely with 
agents and brokers to establish their SB-SHOPs, particularly given 
that most small employers have traditionally relied on agents and 
brokers when purchasing coverage for their employees. However, state 
exchange officials and other stakeholders, including CMS officials, 
noted that agents and brokers still faced challenges associated with 
using SHOPs. These challenges included, in some cases, poor or 
inaccessible customer service for brokers; poor training for brokers 
on SHOP requirements; the extra time required to explain SHOP 
requirements to clients; challenges receiving compensation; and the 
lack of a dedicated broker "portal" on some SHOP websites that would 
allow brokers to set up and help manage accounts for their 
clients.[Footnote 60] Agent and broker representatives from one state 
noted that challenges such as these have led some agents and brokers 
to avoid recommending that their small employer clients use the SHOP. 

Stakeholders Identified Various Factors That Have the Potential to 
Contribute to or Detract from Future SHOP Enrollment Growth: 

Despite the various factors that may have restrained SHOP enrollment 
to date, many stakeholders noted that certain other factors suggest 
that the SHOPs have the potential to experience future enrollment 
growth. According to some stakeholders, central to enrollment growth 
will be the phasing out of noncompliant plans, the resolution of the 
technical challenges and reduction of the administrative burden cited 
as hampering current enrollment, and the demonstration of a "value 
proposition" that gives employers a reason for preferring SHOP-based 
coverage to coverage available outside the SHOP. Stakeholders 
suggested several additional factors that could help stimulate future 
SHOP enrollment growth. 

* Improved coordination with agents and brokers. Stakeholders, 
including CMS officials, state exchange officials, and issuer, 
employer, and agent and broker representatives, emphasized the 
importance of coordinating with and providing improved web-or phone-
based tools to agents and brokers in order to facilitate SHOP 
enrollment. States and CMS reported taking steps to resolve certain 
challenges faced by agents and brokers when using the SHOP. For 
example, Kentucky exchange officials said that they are working to 
develop a tool that will allow agents and brokers to easily provide 
price quotes across multiple SHOP plans to their clients, and are 
considering allowing SHOP-certified agents and brokers to initiate 
applications on behalf of employers. Illinois exchange officials 
reported developing a dedicated section for agents and brokers on the 
state's SHOP website through which agents and brokers can obtain 
updated information on the SHOP, in response to feedback from agent 
and broker community leaders. CMS officials said that establishing a 
broker portal for the FF-SHOPs is a key agency priority, and that the 
agency plans to have a broker portal in place when FF-SHOP online 
enrollment becomes available in fall 2014. According to CMS officials, 
the portal will, among other functions, allow agents and brokers to 
search for and communicate with employer clients; monitor employees' 
enrollment progress; make changes to employee rosters; and receive 
messages regarding employers' monthly invoices, including any late 
payment warnings.[Footnote 61] 

* Availability of employee choice. Some stakeholders stated that the 
employee choice feature, when fully implemented in all states, will be 
a key value proposition for the SHOPs. For instance, CMS officials 
said that employers will likely value being able to offer employees a 
choice from among multiple plan and issuer options--an ability that 
small employers typically have not been able to offer. Employer group 
representatives reported that their members consider employee choice 
to be an important benefit of the SHOPs, as employees will be able to 
decide on their own the coverage that best suits their needs and, if 
necessary, will have the option to spend more to purchase more 
comprehensive plans. Evidence from Kentucky and Rhode Island, whose 
SHOPs offer, but do not require, the use of employee choice, further 
suggests that employers may value this feature. As discussed 
previously, according to state exchange officials, the majority of 
employers in Kentucky and Rhode Island that enrolled in the SHOPs 
chose to offer their employees the choice of multiple plans.[Footnote 
62] 

However, some issuer representatives and other stakeholders were 
uncertain about the value of employee choice, noting that it is 
challenging for issuers to implement and that too many choices may be 
overwhelming for employers and employees. Representatives from 
national issuer and insurance commissioner groups reported that it is 
time consuming and expensive for issuers to build the information 
technology systems required for premium aggregation and other issuer-
specific functions necessary for employee choice. In addition, issuers 
and other stakeholders have reported concerns regarding whether 
employee choice would lead to adverse selection among plans in the 
SHOP--a concern that has, in part, led some states to delay their 
implementation of employee choice until 2016. 

* Increased marketing to employers. Some stakeholders said that states 
need to better market the SHOP to small employers to increase SHOP 
awareness. Some employer group representatives said states need to 
improve outreach by more aggressively targeting small employers and 
highlighting the value of the SHOPs in their marketing. Exchange 
officials in one state emphasized the importance of marketing the 
SHOPs to small employers as a product that offers value, rather than 
performing traditional outreach, which is more characteristic of 
public programs. The officials also noted that marketing must be 
conducted continuously throughout the year, given that employers renew 
their coverage at different points in the year. 

* Robust issuer participation. Although stakeholders representing four 
of the five states included in our study reported that issuer 
participation has not been a challenge, CMS officials said that robust 
issuer participation will be important in ensuring the SHOPs' long-
term viability. Issuer representatives noted that, due to the 
requirement that certain issuers must participate in a state's FF-SHOP 
if they wish to participate in its federally facilitated individual 
exchange, some issuers will be required to participate in the 
SHOPs.[Footnote 63] However, according to the representatives, other 
issuers may be hesitant to participate given factors such as 
uncertainties regarding delays in SHOP functionality and technical 
readiness; potential new requirements, such as those related to the 
adequacy of provider networks; the expense and complexity of 
implementing employee choice and other SHOP features; and the ability 
for employers to renew noncompliant plans. CMS officials said that 
although some issuers may be reluctant to participate in the FF-SHOPs 
in the early years of implementation, once information technology 
systems have been fully developed and refined, issuers may be more 
eager to participate. 

* Expansion of the SHOPs to larger employers. Exchange officials in 
one state noted that as eligibility for SHOP enrollment expands to 
employers with up to 100 employees--which must occur no later than 
January 1, 2016--and, eventually, to larger employers in some states, 
additional employers may consider the SHOP as an option for purchasing 
coverage.[Footnote 64] However, based on the small average number of 
employees per employer enrolled in SB-SHOPs, it remains to be seen 
whether larger employers will enroll when given the opportunity. 

* Financial sustainability of the SHOPs. Exchange officials in one 
state noted that an essential element of SHOP viability will be 
ensuring the SHOPs are financially sustainable.[Footnote 65] They and 
other SB-SHOP exchange officials we interviewed said that their states 
have proposed or finalized funding mechanisms in place. In two of the 
states, these funding mechanisms will draw from either all exchange 
plans--both individual and SHOP--or all health plans in the state; 
therefore, low initial SHOP enrollment is not likely to significantly 
affect SHOP operating revenues in those states.[Footnote 66] However, 
one stakeholder expressed concern regarding whether SHOPs will be 
sustainable in the long run if enrollment remains low, particularly 
given the expense required to maintain the SHOPs' information 
technology systems. 

Stakeholders also described factors whose future effects on SHOP 
enrollment are more uncertain or have the potential to detract from 
SHOP enrollment growth in the long term. 

* Loss of the tax credit. As noted previously, stakeholders and our 
analysis of SB-SHOP enrollment data suggested that many employers 
currently enrolling in the SHOP may be eligible for the tax credit. 
However, employers may only receive the tax credit for a maximum of 2 
years. It therefore remains to be seen whether employers will continue 
to purchase coverage through the SHOP once they have exhausted their 
ability to receive the tax credit, and how this will affect overall 
SHOP enrollment. One employer representative suggested that an 
extension of the credit, or a re-design of the credit such that larger 
businesses are eligible, will help ensure SHOP enrollment growth 
moving forward. 

* Comparability of prices on and off the SHOP. Issuer representatives 
and other stakeholders noted that prices for SHOP plans are likely to 
remain similar to prices for non-SHOP small group plans, which may 
limit the incentive for small employers to enroll in coverage through 
the SHOP. According to stakeholders, small employers' coverage 
decisions are largely driven by price. However, as we noted 
previously, premiums are currently similar for plans offered on and 
off the SHOP in part due to the requirement that prices for identical 
plans in a given state be the same, regardless of whether they are 
offered on or off the SHOP. In order for issuers to offer more 
competitive prices through the SHOPs, they must offer unique, SHOP-
only plans that are lower in price when compared to non-SHOP options. 
However, according to issuer representatives, there are limited 
mechanisms by which issuers could do so. As PPACA requires that all 
plans offer a set of minimum essential health benefits, issuers are 
limited in the extent to which they can lower prices by restricting 
the benefits they offer in SHOP plans. In addition, though issuers 
could lower prices for SHOP plans by offering narrower provider 
networks, issuer representatives cite the high administrative costs of 
creating and maintaining new networks as a deterrent. 

* Competition with private exchanges. Some stakeholders, including 
issuer, agent, and broker representatives, as well as exchange 
officials from one state, reported that private exchanges for small 
group coverage--or online health coverage marketplaces managed by 
private companies, such as issuers or benefits consulting firms--are 
becoming more prevalent and may compete with SHOPs for employer 
enrollment. According to some agent and broker representatives, 
private exchanges may appeal to employers because, in some cases, they 
offer employee choice--a key value proposition of the SHOP that has 
not yet been implemented in all states--without many of the 
requirements associated with the SHOP. Exchange officials from one 
state said that recently created private exchanges in that state have 
been able to spend more on advertising, which has made it difficult 
for the SHOP to compete. However, the officials noted that the SHOPs 
provide increased value in that they offer full transparency and 
choice of SHOP plans--whereas some private exchanges, despite claiming 
to offer full choice of plans, simply offer plans from the carrier 
operating the exchange. 

* Possibility of sending employees to the individual exchanges. 
Exchange officials from two states and some agent and broker 
representatives reported that some small employers have chosen, or may 
choose in upcoming years, to drop coverage for their employees 
altogether, particularly in light of the availability of premium and 
cost-sharing assistance for eligible low-and moderate-income 
individuals obtaining coverage through an individual exchange. CMS 
officials said they have heard anecdotal information that this may be 
occurring, but have no data. Several recent employer surveys have 
found that, while the majority of surveyed small employers were not 
considering dropping coverage for their employees, a minority were 
intending to or considering whether to drop coverage and, in some 
cases, direct their employees to the individual exchanges in 2014 or 
2015.[Footnote 67] 

* Potential for adverse selection. If it were to occur, adverse 
selection between SHOP and non-SHOP plans could lead to increased SHOP 
premiums and thus inhibit SHOP enrollment in the long term. However, 
issuer representatives said that the similarity in premiums seen thus 
far has diminished concerns about such adverse selection. The issuer 
representatives said a greater concern is the risk for adverse 
selection between PPACA-compliant plans--that is, both the SHOP and 
non-SHOP plans that comply with PPACA's insurance reforms--and the 
existing, noncompliant plans that have been renewed. This risk may be 
temporary, as CMS's current transitional relief policy, under which 
noncompliant plans may continue to be offered, permits issuers of such 
plans to offer renewals of these plans only for plan years beginning 
on or before October 1, 2016.[Footnote 68] In addition, PPACA 
established mechanisms to mitigate adverse selection if it does occur 
among PPACA-compliant plans, and stakeholders said it will be at least 
1 year, if not several years, before it becomes clear if adverse 
selection is occurring in the SHOPs, as well as how well these 
mechanisms will mitigate its effect.[Footnote 69] 

Concluding Observations: 

The SHOPs are an important element of PPACA, intended to provide a new 
mechanism by which small employers can shop for and purchase health 
insurance coverage for their employees and to offer features not 
typically available to the employees of small employers, such as the 
ability to choose among multiple health plans. While much progress has 
been made by CMS and states to ensure all SHOPs are now operational, 
early evidence suggests enrollment is significantly lower than 
anticipated amid the delayed availability of key functions among many 
SHOPs and misconceptions by employers about the availability of SHOPs. 
CMS officials and other stakeholders point to structural factors to 
help explain the current low enrollment--such as the temporary ability 
for employers in many states to renew their existing plans even if 
they do not comply with PPACA insurance reforms--and suggest reasons 
for optimism about future SHOP enrollment trends. They point to such 
factors as the phase-out of the noncompliant plans, the expected 
availability of online enrollment and employee choice functions in 
many more SHOPs, and intended CMS or state efforts to improve SHOP 
awareness and coordination with agents and brokers. Nevertheless, 
other factors may temper such optimism, such as the loss of the small 
business tax credit for some employers, the potential for adverse 
selection, and the challenge SHOPs may face in competing with plans 
offered to small employers outside of the SHOPs. These collective 
factors will vary across states and continue to evolve, suggesting 
that a determination of the long-term impact of the SHOPs remains 
premature at this time. 

Agency Comments: 

We received comments from HHS on a draft of this report (see appendix V). 
HHS described steps it is taking to improve the SHOP program based on 
lessons learned from the first year of operation and emphasized the 
future role SHOPs could play to produce more competition in the small 
group health insurance markets as the SHOPs improve and mature. HHS 
also provided technical comments, which we incorporated as appropriate. 

We are sending copies of this report to the Secretary of Health and 
Human Services and other interested parties. In addition, the report is 
available at no charge on the GAO website at http://www.gao.gov]. 

If you or your staff have any questions about this report, please 
contact John E. Dicken at (202) 512-7114 or dickenj@gao.gov. Contact 
points for our Offices of Congressional Relations and Public Affairs 
may be found on the last page of this report. GAO staff who made key 
contributions to this report are listed in appendix VI. 

Sincerely yours, 

Signed by: 

John E. Dicken: 
Director, Health Care: 

[End of section] 

Appendix I: Small Business Health Options Program (SHOP) Features as 
of June 1, 2014: 

State-based SHOPS: 

SHOP: California; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No[A]; 
SHOP offers employee choice: Yes. 

SHOP: Colorado; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: Yes; 
SHOP offers employee choice: Yes. 

SHOP: Connecticut; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: Yes; 
SHOP offers employee choice: Yes. 

SHOP: District of Columbia; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: Yes; 
SHOP offers employee choice: Yes. 

SHOP: Hawaii; 
Date SHOP enrollment began: 10/15/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: Yes; 
SHOP offers employee choice: Yes. 

SHOP: Kentucky; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: Yes; 
SHOP offers employee choice: Yes. 

SHOP: Maryland; 
Date SHOP enrollment began: 4/1/2014; 
SHOP website allows browsing for plans and premiums: No; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Massachusetts; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: Yes; 
SHOP offers employee choice: No. 

SHOP: Minnesota; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: Yes; 
SHOP offers employee choice: Yes. 

SHOP: Mississippi; 
Date SHOP enrollment began: 5/1/2014; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: Yes; 
SHOP offers employee choice: Yes. 

SHOP: Nevada; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: Yes; 
SHOP offers employee choice: Yes. 

SHOP: New Mexico; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: Yes; 
SHOP offers employee choice: Yes. 

SHOP: New York; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: Yes; 
SHOP offers employee choice: Yes. 

SHOP: Oregon; 
Date SHOP enrollment began: 5/1/2014; 
SHOP website allows browsing for plans and premiums: No; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Rhode Island; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: Yes; 
SHOP offers employee choice: Yes. 

SHOP: Utah; 
Date SHOP enrollment began: 10/1/2013[B]; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: Yes; 
SHOP offers employee choice: Yes. 

SHOP: Vermont; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: Yes; 
SHOP offers employee choice: Yes. 

SHOP: Washington; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: Yes; 
SHOP offers employee choice: Yes. 

Federally facilitated SHOPs: 

SHOP: Alabama; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Alaska; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Arizona; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Arkansas; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Delaware; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Florida; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Georgia; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Idaho[C]; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Illinois; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Indiana; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Iowa; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Kansas; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Louisiana; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Maine; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Michigan; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Missouri; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Montana; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Nebraska; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: New Hampshire; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: New Jersey; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: North Carolina; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: North Dakota; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Ohio; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Oklahoma; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Pennsylvania; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: South Carolina; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: South Dakota; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Tennessee; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Texas; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Virginia; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: West Virginia; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Wisconsin; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

SHOP: Wyoming; 
Date SHOP enrollment began: 10/1/2013; 
SHOP website allows browsing for plans and premiums: Yes; 
SHOP allows employers to enroll online: No; 
SHOP offers employee choice: No. 

Sources: Centers for Medicare & Medicaid Services. GAO-15-58. 

[A] In November 2013, California launched online enrollment for the 
SHOP. However, the system was taken down in February 2014 and now 
California is only using direct enrollment. 

[B] Utah had an operational exchange for small employers prior to the 
enactment of the Patient Protection and Affordable Care Act. 

[C] Idaho originally planned to establish an SB-SHOP, but ultimately 
elected to use the FF-SHOP platform. We therefore consider Idaho as 
having an FF-SHOP in 2014 for the purposes of our report. 

[End of table] 

[End of section] 

Appendix II: State-Based Small Business Health Options Program (SB-
SHOP) Enrollment Generally as of June 1, 2014: 

State: California[A]; 
Employer enrollment: 1,360; 
Employee enrollment: 6,667; 
Total enrollment: 9,563; 
Average employees enrolled per employer: 4.9; 
Highest enrollment plan: 
Metal tier: Silver; 
Employee enrollment: 1,749; 
Total enrollment: 2,499. 

State: Colorado; 
Employer enrollment: 258; 
Employee enrollment: 1,499; 
Total enrollment: 2,135; 
Average employees enrolled per employer: 5.8; 
Highest enrollment plan: 
Metal tier: Silver; 
Employee enrollment: 171; 
Total enrollment: 247. 

State: Connecticut; 
Employer enrollment: 92; 
Employee enrollment: 344; 
Total enrollment: 548; 
Average employees enrolled per employer: 3.7; 
Highest enrollment plan: 
Metal tier: Silver; 
Employee enrollment: 95; 
Total enrollment: 150. 

State: District of Columbia; 
Employer enrollment: 211; 
Employee enrollment: 525; 
Total enrollment: 714; 
Average employees enrolled per employer: 2.5; 
Highest enrollment plan: 
Metal tier: Platinum; 
Employee enrollment: 66; 
Total enrollment: 79. 

State: Hawaii[B]; 
Employer enrollment: 398; 
Employee enrollment: 851; 
Total enrollment: [Empty]; 
Average employees enrolled per employer: 2.1; 
Highest enrollment plan: 
Metal tier: 7A[C]; 
Employee enrollment: 228; 
Total enrollment: [Empty]. 

State: Kentucky; 
Employer enrollment: 58; 
Employee enrollment: 341; 
Total enrollment: 442; 
Average employees enrolled per employer: 5.9; 
Highest enrollment plan: 
Metal tier: Gold; 
Employee enrollment: 92; 
Total enrollment: 124. 

State: Maryland[D]; 
Employer enrollment: 15; 
Employee enrollment: 65; 
Total enrollment: 76; 
Average employees enrolled per employer: 4.3; 
Highest enrollment plan: 
Metal tier: Gold; 
Employee enrollment: 6; 
Total enrollment: 13. 

State: Massachusetts; 
Employer enrollment: 729; 
Employee enrollment: 1,840; 
Total enrollment: 3,324; 
Average employees enrolled per employer: 2.5; 
Highest enrollment plan: 
Metal tier: Platinum; 
Employee enrollment: 240; 
Total enrollment: 409. 

State: Minnesota; 
Employer enrollment: 159; 
Employee enrollment: 790; 
Total enrollment: 1178; 
Average employees enrolled per employer: 5.0; 
Highest enrollment plan: 
Metal tier: Gold; 
Employee enrollment: 57; 
Total enrollment: 87. 

State: Mississippi[E]; 
Employer enrollment: 1; 
Employee enrollment: 1; 
Total enrollment: 1; 
Average employees enrolled per employer: 1; 
Highest enrollment plan: 
Metal tier: Gold; 
Employee enrollment: 1; 
Total enrollment: 1. 

State: Nevada; 
Employer enrollment: 16; 
Employee enrollment: 41; 
Total enrollment: 43; 
Average employees enrolled per employer: 2.6; 
Highest enrollment plan: 
Metal tier: Gold; 
Employee enrollment: 10; 
Total enrollment: 10. 

State: New Mexico; 
Employer enrollment: 129; 
Employee enrollment: 408; 
Total enrollment: 602; 
Average employees enrolled per employer: 3.2; 
Highest enrollment plan: 
Metal tier: Gold; 
Employee enrollment: 41; 
Total enrollment: 57. 

State: New York[F]; 
Employer enrollment: 3,964; 
Employee enrollment: 6,390; 
Total enrollment: 10,023; 
Average employees enrolled per employer: 1.6; 
Highest enrollment plan: 
Metal tier: Platinum; 
Employee enrollment: [Empty]; 
Total enrollment: 637. 

State: Oregon[G]; 
Employer enrollment: 57; 
Employee enrollment: 329; 
Total enrollment: [Empty]; 
Average employees enrolled per employer: 5.8; 
Highest enrollment plan: 
Metal tier: Silver; 
Employee enrollment: 41; 
Total enrollment: [Empty]. 

State: Rhode Island; 
Employer enrollment: 229; 
Employee enrollment: 884; 
Total enrollment: 1489; 
Average employees enrolled per employer: 3.9; 
Highest enrollment plan: 
Metal tier: Gold; 
Employee enrollment: 171; 
Total enrollment: 286. 

State: Utah; 
Employer enrollment: 478; 
Employee enrollment: 3,977; 
Total enrollment: 10,900; 
Average employees enrolled per employer: 8.3; 
Highest enrollment plan: 
Metal tier: Gold; 
Employee enrollment: 303; 
Total enrollment: 757. 

State: Vermont[H]; 
Employer enrollment: 3,580; 
Employee enrollment: 18,706; 
Total enrollment: 33,696; 
Average employees enrolled per employer: 5.2; 
Highest enrollment plan: 
Metal tier: Platinum; 
Employee enrollment: 4,535; 
Total enrollment: 8,436. 

State: Washington[I]; 
Employer enrollment: 8; 
Employee enrollment: 25; 
Total enrollment: 42; 
Average employees enrolled per employer: 3.1; 
Highest enrollment plan: 
Metal tier: Silver; 
Employee enrollment: 9; 
Total enrollment: [Empty]. 

Sources: SB-SHOPs. GAO-15-58. 

Notes: Total enrollment reflects the total number of individuals 
(including the employees, spouses, and any dependent children) covered 
by SB-SHOP plans. 

[A] California provided data as of May 22, 2014. 

[B] Hawaii was not able to provide total enrollment. 

[C] In Hawaii, group plans are designated as "7a" or "7b", which are 
the equivalent of platinum-and gold-tier plans, respectively. 

[D] Maryland provided the number of employers enrolled as of September 
2, 2014, and the number of enrollees, including the plan with the 
highest enrollment, as of September 15, 2014. Maryland had two plans 
with 13 total enrollees; both plans were gold-tier. 

[E] Mississippi provided data as of July 1, 2014. 

[F] New York was not able to provide the number of employees enrolled 
for the highest enrollment plan. 

[G] Oregon was not able to provide total enrollment. 

[H] Vermont provided data as of June 13, 2014: 

[I] Washington was unable to provide total enrollment for the highest 
enrollment plan. 

[End of table] 

[End of section] 

Appendix III: Small Business Health Options Program (SHOP) 2014 
Average Monthly Premiums for Silver-Tier Plans: 

State: Alabama; 
Silver-tier SHOP plan average monthly premiums age 21: 
Low: $213; 
Median: $262; 
High: $279; 
Silver-tier SHOP plan average monthly premiums age 40: 
Low: $272; 
Median: $335; 
High: $357; 
Silver-tier SHOP plan average monthly premiums age 60: 
Low: $579; 
Median: $711; 
High: $757. 

State: Alaska; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $480; 
Median: $491; 
High: $523; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $613; 
Median: $627; 
High: $669; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $1,302; 
Median: $1,332; 
High: $1,421. 

State: Arizona; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $165; 
Median: $217; 
High: $449; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $211; 
Median: $278; 
High: $574; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $448; 
Median: $590; 
High: $1,220. 

State: Arkansas[A]; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $236; 
Median: $236; 
High: $236; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $302; 
Median: $302; 
High: $302; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $641; 
Median: $641; 
High: $641. 

State: California; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $180; 
Median: $247; 
High: $355; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $230; 
Median: $316; 
High: $453; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $488; 
Median: $670; 
High: $963. 

State: Colorado; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $251; 
Median: $296; 
High: $382; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $321; 
Median: $378; 
High: $489; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $681; 
Median: $804; 
High: $1,038. 

State: Connecticut; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $339; 
Median: $352; 
High: $359; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $429; 
Median: $449; 
High: $459; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $911; 
Median: $954; 
High: $974. 

State: Delaware; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $277; 
Median: $293; 
High: $303; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $354; 
Median: $374; 
High: $388; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $753; 
Median: $795; 
High: $823. 

State: District of Columbia; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $186; 
Median: $231; 
High: $304; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $249; 
Median: $310; 
High: $408; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $536; 
Median: $666; 
High: $879. 

State: Florida; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $230; 
Median: $257; 
High: $303; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $295; 
Median: $329; 
High: $387; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $625; 
Median: $698; 
High: $821. 

State: Georgia; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $214; 
Median: $252; 
High: $316; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $273; 
Median: $322; 
High: $404; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $580; 
Median: $684; 
High: $857. 

State: Hawaii; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $138; 
Median: $192; 
High: $208; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $176; 
Median: $245; 
High: $266; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $375; 
Median: $521; 
High: $565. 

State: Idaho; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $199; 
Median: $256; 
High: $313; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $255; 
Median: $327; 
High: $400; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $541; 
Median: $695; 
High: $849. 

State: Illinois; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $203; 
Median: $295; 
High: $335; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $259; 
Median: $377; 
High: $428; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $550; 
Median: $802; 
High: $909. 

State: Indiana; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $281; 
Median: $306; 
High: $330; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $359; 
Median: $391; 
High: $421; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $762; 
Median: $830; 
High: $894. 

State: Iowa; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $185; 
Median: $272; 
High: $356; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $236; 
Median: $347; 
High: $455; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $502; 
Median: $738; 
High: $966. 

State: Kansas; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $204; 
Median: $216; 
High: $326; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $261; 
Median: $276; 
High: $417; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $554; 
Median: $586; 
High: $886. 

State: Kentucky; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $213; 
Median: $233; 
High: $302; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $273; 
Median: $295; 
High: $365; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $579; 
Median: $626; 
High: $775. 

State: Louisiana; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $234; 
Median: $264; 
High: $293; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $299; 
Median: $337; 
High: $374; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $635; 
Median: $717; 
High: $795. 

State: Maine; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $264; 
Median: $280; 
High: $324; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $338; 
Median: $358; 
High: $414; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $718; 
Median: $759; 
High: $878. 

State: Maryland; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $183; 
Median: $271; 
High: $354; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $233; 
Median: $346; 
High: $453; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $495; 
Median: $735; 
High: $961. 

State: Massachusetts; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $215; 
Median: $262; 
High: $371; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $253; 
Median: $308; 
High: $437; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $429; 
Median: $523; 
High: $743. 

State: Michigan; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $151; 
Median: $280; 
High: $346; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $193; 
Median: $358; 
High: $442; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $410; 
Median: $761; 
High: $939. 

State: Minnesota; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $193; 
Median: $251; 
High: $309; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $247; 
Median: $321; 
High: $400; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $524; 
Median: $681; 
High: $861. 

State: Mississippi; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $243; 
Median: $246; 
High: $264; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $310; 
Median: $314; 
High: $337; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $658; 
Median: $667; 
High: $715. 

State: Missouri[B]; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $251; 
Median: $278; 
High: $304; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $321; 
Median: $355; 
High: $389; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $681; 
Median: $754; 
High: $826. 

State: Montana; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $241; 
Median: $256; 
High: $268; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $308; 
Median: $327; 
High: $343; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $654; 
Median: $694; 
High: $728. 

State: Nebraska; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $189; 
Median: $262; 
High: $325; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $241; 
Median: $335; 
High: $416; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $513; 
Median: $711; 
High: $882. 

State: Nevada; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $199; 
Median: $226; 
High: $356; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $255; 
Median: $289; 
High: $456; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $541; 
Median: $614; 
High: $967. 

State: New Hampshire[C]; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $284; 
Median: $284; 
High: $284; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $363; 
Median: $363; 
High: $363; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $771; 
Median: $771; 
High: $771. 

State: New Jersey; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $280; 
Median: $382; 
High: $411; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $312; 
Median: $425; 
High: $458; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $511; 
Median: $696; 
High: $750. 

State: New Mexico; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $224; 
Median: $270; 
High: $312; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $287; 
Median: $345; 
High: $399; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $609; 
Median: $732; 
High: $847. 

State: New York[D]; 
Silver-tier shop plan average monthly premiums age 21: 
Low: [Empty]; 
Median: [Empty]; 
High: [Empty]; 
Silver-tier shop plan average monthly premiums age 40: 
Low: [Empty]; 
Median: [Empty]; 
High: [Empty]; 
Silver-tier shop plan average monthly premiums age 60: 
Low: [Empty]; 
Median: [Empty]; 
High: [Empty]. 

State: North Carolina; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $309; 
Median: $317; 
High: $323; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $395; 
Median: $405; 
High: $413; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $838; 
Median: $859; 
High: $878. 

State: North Dakota; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $244; 
Median: $253; 
High: $263; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $312; 
Median: $323; 
High: $336; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $663; 
Median: $686; 
High: $713. 

State: Ohio; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $228; 
Median: $278; 
High: $330; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $292; 
Median: $355; 
High: $421; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $620; 
Median: $755; 
High: $895. 

State: Oklahoma; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $166; 
Median: $220; 
High: $268; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $212; 
Median: $281; 
High: $342; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $451; 
Median: $598; 
High: $727. 

State: Oregon; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $197; 
Median: $283; 
High: $347; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $252; 
Median: $361; 
High: $443; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $535; 
Median: $768; 
High: $941. 

State: Pennsylvania; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $186; 
Median: $240; 
High: $306; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $238; 
Median: $306; 
High: $391; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $506; 
Median: $651; 
High: $830. 

State: Rhode Island; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $211; 
Median: $245; 
High: $257; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $269; 
Median: $313; 
High: $328; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $572; 
Median: $665; 
High: $697. 

State: South Carolina; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $283; 
Median: $297; 
High: $303; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $361; 
Median: $379; 
High: $387; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $767; 
Median: $806; 
High: $822. 

State: South Dakota; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $239; 
Median: $263; 
High: $273; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $305; 
Median: $336; 
High: $349; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $649; 
Median: $713; 
High: $741. 

State: Tennessee; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $225; 
Median: $243; 
High: $310; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $287; 
Median: $311; 
High: $396; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $609; 
Median: $660; 
High: $840. 

State: Texas; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $207; 
Median: $259; 
High: $282; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $264; 
Median: $331; 
High: $360; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $562; 
Median: $703; 
High: $765. 

State: Utah[E]; 
Silver-tier shop plan average monthly premiums age 21: 
Low: [Empty]; 
Median: [Empty]; 
High: [Empty]; 
Silver-tier shop plan average monthly premiums age 40: 
Low: [Empty]; 
Median: [Empty]; 
High: [Empty]; 
Silver-tier shop plan average monthly premiums age 60: 
Low: [Empty]; 
Median: [Empty]; 
High: [Empty]. 

State: Vermont[F]; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $395; 
Median: $422; 
High: $429; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $395; 
Median: $422; 
High: $429; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $395; 
Median: $422; 
High: $429. 

State: Virginia; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $195; 
Median: $260; 
High: $359; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $249; 
Median: $333; 
High: $459; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $527; 
Median: $706; 
High: $975. 

State: Washington; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $268; 
Median: $278; 
High: $294; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $342; 
Median: $355; 
High: $376; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $727; 
Median: $753; 
High: $799. 

State: West Virginia[G]; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $296; 
Median: $296; 
High: $296; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $378; 
Median: $378; 
High: $378; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $803; 
Median: $803; 
High: $803. 

State: Wisconsin; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $224; 
Median: $282; 
High: $450; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $286; 
Median: $361; 
High: $576; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $608; 
Median: $766; 
High: $1222. 

State: Wyoming; 
Silver-tier shop plan average monthly premiums age 21: 
Low: $337; 
Median: $355; 
High: $383; 
Silver-tier shop plan average monthly premiums age 40: 
Low: $431; 
Median: $454; 
High: $490; 
Silver-tier shop plan average monthly premiums age 60: 
Low: $915; 
Median: $964; 
High: $1040. 

Sources: GAO analysis of Centers for Medicare & Medicaid Services and 
state-based SHOP data. GAO-15-58. 

Notes: All premiums have been rounded to the nearest dollar. 

[A] The Arkansas SHOP only had one plan available. 

[B] The Missouri SHOP only had two plans available. 

[C] The New Hampshire SHOP had only one plan available. 

[D] Premium data from New York was not available. 

[E] Vermont does not allow variation in plan premiums based on age. 

[F] The West Virginia SHOP had only one plan available. 

[End of table] 

[End of section] 

Appendix IV: Small Business Health Options Program (SHOP) Silver-Tier 
Plan Availability: 

State: Alabama; 
Total silver plans: 5; 
Issuers offering silver plans: 2; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Alaska; 
Total silver plans: 8; 
Issuers offering silver plans: 2; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Arizona; 
Total silver plans: 44; 
Issuers offering silver plans: 5; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Arkansas; 
Total silver plans: 1; 
Issuers offering silver plans: 1; 
Plans available in all counties: Yes; 
At least two plans in each county: No; 
At least two issuers in each county: No. 

State: California; 
Total silver plans: 11; 
Issuers offering silver plans: 6; 
Plans available in all counties: Yes; 
At least two plans in each county: No; 
At least two issuers in each county: No. 

State: Colorado; 
Total silver plans: 31; 
Issuers offering silver plans: 7; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Connecticut; 
Total silver plans: 3; 
Issuers offering silver plans: 3; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Delaware; 
Total silver plans: 4; 
Issuers offering silver plans: 2; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: District of Columbia; 
Total silver plans: 89; 
Issuers offering silver plans: 7; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Florida; 
Total silver plans: 17; 
Issuers offering silver plans: 5; 
Plans available in all counties: Yes; 
At least two plans in each county: No; 
At least two issuers in each county: No. 

State: Georgia; 
Total silver plans: 7; 
Issuers offering silver plans: 3; 
Plans available in all counties: Yes; 
At least two plans in each county: No; 
At least two issuers in each county: No. 

State: Hawaii; 
Total silver plans: 13; 
Issuers offering silver plans: 2; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Idaho; 
Total silver plans: 17; 
Issuers offering silver plans: 3; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Illinois; 
Total silver plans: 20; 
Issuers offering silver plans: 3; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Indiana; 
Total silver plans: 58; 
Issuers offering silver plans: 2; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: No. 

State: Iowa; 
Total silver plans: 28; 
Issuers offering silver plans: 5; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: No. 

State: Kansas; 
Total silver plans: 3; 
Issuers offering silver plans: 2; 
Plans available in all counties: Yes; 
At least two plans in each county: No; 
At least two issuers in each county: No. 

State: Kentucky; 
Total silver plans: 8; 
Issuers offering silver plans: 4; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Louisiana; 
Total silver plans: 12; 
Issuers offering silver plans: 4; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Maine; 
Total silver plans: 4; 
Issuers offering silver plans: 2; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Maryland; 
Total silver plans: 29; 
Issuers offering silver plans: 13; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Massachusetts; 
Total silver plans: 19; 
Issuers offering silver plans: 10; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Michigan; 
Total silver plans: 21; 
Issuers offering silver plans: 8; 
Plans available in all counties: Yes; 
At least two plans in each county: No; 
At least two issuers in each county: No. 

State: Minnesota; 
Total silver plans: 22; 
Issuers offering silver plans: 3; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: No. 

State: Mississippi; 
Total silver plans: 3; 
Issuers offering silver plans: 1; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: No. 

State: Missouri; 
Total silver plans: 2; 
Issuers offering silver plans: 2; 
Plans available in all counties: Yes; 
At least two plans in each county: No; 
At least two issuers in each county: No. 

State: Montana; 
Total silver plans: 10; 
Issuers offering silver plans: 3; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Nebraska; 
Total silver plans: 14; 
Issuers offering silver plans: 4; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Nevada; 
Total silver plans: 6; 
Issuers offering silver plans: 2; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: No. 

State: New Hampshire; 
Total silver plans: 1; 
Issuers offering silver plans: 1; 
Plans available in all counties: Yes; 
At least two plans in each county: No; 
At least two issuers in each county: No. 

State: New Jersey; 
Total silver plans: 11; 
Issuers offering silver plans: 3; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: New Mexico; 
Total silver plans: 21; 
Issuers offering silver plans: 5; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: New York[A]; 
Total silver plans: [Empty]; 
Issuers offering silver plans: [Empty]; 
Plans available in all counties: No; 
At least two plans in each county: No; 
At least two issuers in each county: No. 

State: North Carolina; 
Total silver plans: 4; 
Issuers offering silver plans: 1; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: No. 

State: North Dakota; 
Total silver plans: 6; 
Issuers offering silver plans: 3; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Ohio; 
Total silver plans: 39; 
Issuers offering silver plans: 6; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Oklahoma; 
Total silver plans: 22; 
Issuers offering silver plans: 3; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: No. 

State: Oregon; 
Total silver plans: 28; 
Issuers offering silver plans: 8; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Pennsylvania; 
Total silver plans: 44; 
Issuers offering silver plans: 9; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: No. 

State: Rhode Island; 
Total silver plans: 5; 
Issuers offering silver plans: 3; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: South Carolina; 
Total silver plans: 5; 
Issuers offering silver plans: 3; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: South Dakota; 
Total silver plans: 7; 
Issuers offering silver plans: 3; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Tennessee; 
Total silver plans: 4; 
Issuers offering silver plans: 2; 
Plans available in all counties: Yes; 
At least two plans in each county: No; 
At least two issuers in each county: No. 

State: Texas; 
Total silver plans: 9; 
Issuers offering silver plans: 2; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: No. 

State: Utah; 
Total silver plans: 33; 
Issuers offering silver plans: 3; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Vermont; 
Total silver plans: 6; 
Issuers offering silver plans: 2; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

State: Virginia; 
Total silver plans: 13; 
Issuers offering silver plans: 5; 
Plans available in all counties: Yes; 
At least two plans in each county: No; 
At least two issuers in each county: No. 

State: Washington; 
Total silver plans: 3; 
Issuers offering silver plans: 1; 
Plans available in all counties: No; 
At least two plans in each county: No; 
At least two issuers in each county: No. 

State: West Virginia; 
Total silver plans: 1; 
Issuers offering silver plans: 1; 
Plans available in all counties: Yes; 
At least two plans in each county: No; 
At least two issuers in each county: No. 

State: Wisconsin; 
Total silver plans: 59; 
Issuers offering silver plans: 9; 
Plans available in all counties: No; 
At least two plans in each county: No; 
At least two issuers in each county: No. 

State: Wyoming; 
Total silver plans: 5; 
Issuers offering silver plans: 2; 
Plans available in all counties: Yes; 
At least two plans in each county: Yes; 
At least two issuers in each county: Yes. 

Sources: GAO analysis of Centers for Medicare & Medicaid Services and 
state-based SHOP data. GAO-15-58. 

[A] Data on the total number of silver plans and the number of issuers 
offering silver plans was not available for New York. 

[End of table] 

[End of section] 

Appendix V: Comments from the Department of Health and Human Services: 

Department of Health & Human Services: 
Office of The Secretary: 
Assistant Secretary for Legislation: 
Washington, DC 20201: 

October 24, 2014: 

John E. Dicken: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street NW: 
Washington, DC 20548: 

Dear Mr. Dicken: 

Attached are comments on the U.S. Government Accountability Office's 
(GAO) report entitled, "Small Business Health Insurance Exchanges: Low 
Initial Enrollment Likely due to Multiple, Evolving Factors" (GAO 15-
58). 

The Department appreciates the opportunity to review this report prior 
to publication. 

Sincerely, 

Signed by: 

Jim R. Esquea: 
Assistant Secretary for Legislation: 

Attachment: 

General Comments Of The Department Of Health And Human Services (HHS) 
On The Government Accountability Office's Draft Report Entitled: Small 
Business Health Insurance Exchanges: Low Initial Enrollment Due To 
Multiple, Evolving Factors (GAO-15-581): 

The Department of Health & Human Services (HHS) appreciates the 
opportunity to review and comment on this draft report. 

HHS is committed to improving the Small Business Health Options 
Program (SHOP), by acting on lessons learned from the first year of 
operation. HHS has worked to continually improve the SHOP experience 
to increase ease and reduce administrative burden for employers. For 
example, in order to help small employers determine if they qualify 
for the tax credit and for how much, the Centers for Medicare & 
Medicaid Services launched a SHOP Small Business Healthcare Tax Credit 
Estimator in English and Spanish in early 2014. Importantly, on 
November 15, 2014, employers will be able to access a seamless online 
Federally-facilitated SHOP experience including key new features such 
as a choice of health plans for employees in many states, premium 
aggregation services, and a dedicated online system for licensed 
agents and brokers to assist their SHOP clients. Prior to November 15, 
2014, this new online experience will have been tested in five states 
through targeted consumer testing with small businesses, agents, 
brokers, and assisters. 

Small business owners have struggled to keep up with the ever-rising 
cost of providing health insurance for their employees. Historically, 
small businesses have been charged 10 to 18 percent more for the same 
benefits compared to large employers.[Footnote 1] There has been 
limited competition in the small group health insurance market, as 
shown by the Government Accountability Office in its 2008 
report.[Footnote 2] The SHOP, as it improves and matures, may produce 
more competition in the small group markets, potentially benefiting 
small employers and their employees. HHS, through the SHOP, new 
insurance reforms, and tax credits, has worked to improve the 
insurance market for small employers, making it easier for them to 
find and purchase employee health coverage. 

Footnotes: 

[1] [hyperlink, http://www.commonwealthfund.org]. 

[2] [hyperlink, http://www.gao.gov/assets10095991.pdf] 

[End of section] 

Appendix VI: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

John E. Dicken, (202) 512-7114 or dickenj@gao.gov: 

Staff Acknowledgments: 

In addition to the contact name above, Randy DiRosa, Assistant 
Director; Priyanka Sethi Bansal; Sandra George; Eagan Kemp; Laurie 
Pachter; and Kate Tussey made key contributions to this report. 

[End of section] 

Footnotes: 

[1] Pub. L. No. 111-148, §§ 1311(b), 1321(c),124 Stat. 119, 173, 186 
(Mar. 23, 2010) (codified at 42 U.S.C. §§ 18031(b), 18041(c)) 
(hereafter, "PPACA"), as amended by the Health Care and Education 
Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (Mar. 
30, 2010) (hereafter, "HCERA"). In this report, references to PPACA 
include any amendments made by HCERA. 

In this report, the term "state" includes the District of Columbia. 

[2] PPACA also required the establishment of individual exchanges in 
each state where eligible individuals can compare and select private 
insurance coverage from among participating health insurance plans. 
The SHOPs and individual exchanges are intended to provide single 
points of access to enroll employees of small businesses and 
individuals into private health plans. Individual exchanges are also 
the access point to determine eligibility for income-based premium 
subsidies and assess eligibility for other health coverage programs 
such as Medicaid. 

[3] PPACA, § 1311(b)(1), 124 Stat. at 173 (codified at 42 U.S.C. § 
13031(b)(1)); 45 C.F.R. § 155.410(b)-(c). 

[4] CMS has invited states to assist with certain FF-SHOP operations. 

[5] GAO, Patient Protection and Affordable Care Act: Status of Federal 
and State Efforts to Establish Health Insurance Exchanges for Small 
Businesses, [hyperlink, http://www.gao.gov/products/GAO-13-614] 
(Washington, D.C.: June 19, 2013). 

[6] We interviewed representatives from the following national 
organizations: the Blue Cross and Blue Shield Association, America's 
Health Insurance Plans, the National Association of Insurance 
Commissioners, the National Federation of Independent Business, and 
the National Association of Health Underwriters. 

[7] The employer and agent and broker organizations for which we 
interviewed state-level representatives were, respectively, the 
National Federation of Independent Business and the National 
Association of Health Underwriters. We refer to state-level officials 
who have participated in the establishment and operation of SHOPs as 
state exchange officials. 

[8] We interviewed agent and broker representatives in Kentucky, 
California, Illinois, and Texas, and employer representatives in 
California, Rhode Island, and Illinois. The agent and broker 
representative we contacted in Rhode Island and the employer 
representatives we contacted in Kentucky and Texas elected not to 
participate in an interview. 

[9] We also interviewed state exchange officials in Illinois, who are 
assisting CMS in operating the FF-SHOP in that state. 

[10] These requirements apply to small group health plans whether they 
are sold inside or outside of the SHOPs. 

[11] For a bronze-tier plan, on average, an employee would be 
responsible for 40 percent of the costs of all covered benefits; for a 
silver-tier plan, on average, an employee would be responsible for 30 
percent; for a gold-tier plan, on average, an employee would be 
responsible for 20 percent; and for a platinum-tier plan, on average, 
an employee would be responsible for 10 percent of the costs of all 
covered benefits. PPACA requires that issuers participating in an 
exchange offer, at a minimum, plans at both the silver and gold levels 
of coverage. 

[12] There are further restrictions in the amount issuers can vary 
premiums based on the ages and tobacco use of employees within a small 
group. 

[13] PPACA provided a narrow exception from these requirements for 
"grandfathered plans"--health plans in which an individual was 
enrolled on March 23, 2010. 

[14] Conditions included that the coverage was in effect on October 1, 
2013 and that appropriate notices were provided to individuals and 
small employers. See Department of Health and Human Services, Centers 
for Medicare & Medicaid Services, Centers for Consumer Information & 
Insurance Oversight, Letter to Insurance Commissioners on Market 
Transitional Policy, November 14, 2013, accessed September 8, 2014, 
[hyperlink, 
http://www.cms.gov/CCIIO/Resources/Letters/Downloads/commissioner-
letter-11-14-2013.PDF]. According to CMS, 39 states adopted the 
transitional policy for 2014, while 12 states did not. 

[15] See Department of Health and Human Services, Centers for Medicare 
& Medicaid Services, Extension of Transitional Policy through October 
1, 2016, (Washington, D.C.: Mar. 5, 2014). Under this policy, 
depending on state requirements, some small employers may choose to 
remain enrolled in noncompliant plans through the end of plan years 
beginning on or before October 1, 2016. 

[16] Under PPACA, beginning in 2016, small employers will be defined 
in all states as those with 100 or fewer full-time equivalent 
employees. Beginning in 2017, states may allow issuers of health 
insurance coverage in the large group market--issuers offering 
coverage to groups of 101 or more full-time equivalent employees--to 
offer QHPs through the SHOP and, in turn, will allow large employers 
to obtain coverage through the SHOP. 

[17] All issuers or members of the same issuer group with a market 
share of greater than 20 percent in the state's small group health 
insurance market must participate in a state's FF-SHOP if they wish to 
participate in its federally facilitated individual exchange. For 
other issuers, participation is generally voluntary. States with SB-
SHOPs may also impose requirements related to issuer participation--
for example, Maryland required issuers to participate in its SB-SHOP 
if the issuers' reported total annual earned premiums were $20 million 
or more in the small group market outside the exchange. 

[18] Small employers and employees may also receive assistance from 
Navigators, who are individuals and entities, such as community and 
consumer-focused nonprofit groups, which receive grants from exchanges 
and provide information and services in a fair and impartial manner to 
enrollees or potential enrollees. However, CMS has noted that 
Navigators have focused largely on the individual exchanges, and that 
brokers have played a much more central role in the SHOPs--as they 
have traditionally done in the small-group health coverage market--
providing service at the time of plan selection and enrollment and 
customer service throughout the plan year. 

[19] In general, when offering coverage though a SHOP, employers select 
a plan, which becomes the employer's reference plan. Employers also 
decide the percentage they will contribute to the premiums for 
employees who select that plan, referred to as a defined contribution. 
Employees who have been offered a choice of plans are typically able 
to use the amount of the defined contribution for the reference plan 
when paying their premiums for a different SHOP plan. 

[20] To make it more administratively efficient for employers to 
provide their employees a choice of QHP, CMS also required SHOPs to 
perform premium aggregation--that is, to aggregate the QHP premiums 
for multiple employees enrolling in SHOP coverage, provide the 
relevant employer with a single bill identifying the total amount that 
is due to the one or more QHPs in which the employer's employees are 
enrolled, collect the appropriate amount from each employer, and pay 
the issuers of the QHPs directly. 

[21] 21See 79 Fed. Reg. 30240, 30349-50 (May 27, 2014) (to be codified 
at 45 C.F.R. § 155.705(b)(2)-(3)). Adverse selection refers to the 
potential for consumers with fewer health concerns to select certain 
plans—particularly those with lower premiums—and for consumers with 
greater health concerns to select other, more comprehensive plans. 
Applications for consideration of delaying employee choice until 2016 
were due to CMS by June 2, 2014 for FF-SHOPs. According to CMS, the 
agency remains committed to implementing employee choice in all SHOPs 
by 2016.

[22] PPACA, §§ 1421, 10105(e), 124 Stat. at 237, 906 (codified at 26 
U.S.C. § 45R). 

To be eligible, an employer must: (1) have fewer than the equivalent 
of 25 full-time employees, (2) have an average annual employee wage 
below $50,000, and (3) cover at least 50 percent of the cost of health 
insurance coverage for employees. 

[23] The Internal Revenue Service has stated that in 2014, small 
employers in certain counties in Wisconsin and Washington where SHOP 
plans are not offered may be eligible for the tax credit if they offer 
coverage that would have qualified for the credit prior to January 1, 
2014. See Internal Revenue Service, Section 45R - Transition Relief 
with Respect to the Tax Credit for Employee Health Insurance Expenses 
of Certain Small Employers, Internal Revenue Bulletin: 2014-2 
(Washington, D.C.: January 6, 2014). 

[24] The tax credit offered to eligible small employers from 2010 
through 2013 was smaller than the credit offered beginning in 2014, 
but had no restrictions on the number of years employers could receive 
the credit. From 2010 through 2013, for-profit employers were eligible 
for a credit of up to 35 percent of the employers' share of the 
employees' premiums, and nonprofit employers were eligible for a 
credit of up to 25 percent. Beginning in 2014, eligible for-profit 
employers may receive a credit of up to 50 percent of the employers' 
share of the employees' premiums, and nonprofit employers meeting the 
eligibility criteria may receive a credit of up to 35 percent. The 
maximum credit is available to employers with 10 or fewer employees 
and with an average annual employee wage of $25,000 or less, and the 
size of the credit employers are eligible for decreases as employer 
size and average employee wage increase. 

[25] PPACA, § 1311(b)(1), 124 Stat. at 173 (codified at 42 U.S.C. § 
13031(b)(1)). 

[26] PPACA, § 1321(c), 124 Stat. at 186 (codified at 42 U.S.C. § 
18041(c)). 

[27] The 18 states that had SB-SHOPs in 2014 were California, 
Colorado, Connecticut, Hawaii, Kentucky, Maryland, Massachusetts, 
Minnesota, Mississippi, Nevada, New Mexico, New York, Oregon, Rhode 
Island, Utah, Vermont, Washington, and the District of Columbia. 

CMS officials noted that Idaho, although initially approved as an SB-
SHOP state, used the FF-SHOP platform in 2014. We therefore refer to 
Idaho as having an FF-SHOP in 2014 for the purposes of our report. 
Including Idaho, the 33 states that had FF-SHOPs in 2014 were Alabama, 
Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Idaho, 
Illinois, Indiana, Iowa, Kansas, Louisiana, Maine, Michigan, Missouri, 
Montana, Nebraska, New Hampshire, New Jersey, North Carolina, North 
Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, 
Tennessee, Texas, Virginia, West Virginia, Wisconsin, and Wyoming. 
Some states were approved by CMS to assist with certain FF-SHOP 
functions associated with consumer assistance and plan management. 

These states differ from the SB-SHOP and FF-SHOP states presented in 
our June 2013 report [hyperlink, 
http://www.gao.gov/products/GAO-13-614] because Idaho had an FF-SHOP 
according to our definition, while Mississippi operated an SB-SHOP, in 
2014. 

[28] CMS and other stakeholders we interviewed noted that small 
employers have traditionally used direct enrollment methods, such as 
working with agents and brokers, to apply for small group coverage. 

[29] In preparation for launching online enrollment, CMS planned to 
partially launch online enrollment early in five FF-SHOP states 
(Delaware, Illinois, Missouri, New Jersey, and Ohio) in October 2014. 
Employers were to be able to log in, create an account, and complete 
the eligibility application, or authorize an agent or broker to assist 
with signing up for SHOP coverage. 

[30] CMS plans to add functionality to support its online system in 
early 2015, including enhanced call center access to assist employers, 
employees, and agent and brokers; integration with the other exchange 
systems to facilitate IRS reporting and data analytics; and the 
handling of coverage terminations and delinquent payments. 

[31] The remaining employers offered their employees one SHOP plan. 
All employers offering coverage through California's SHOP offered 
employee choice, as this was a requirement for participating in the 
state's SHOP. 

[32] 79 Fed. Reg. 30240, 30349-50 (May 27, 2014) (to be codified at 45 
C.F.R. § 155.705(b)(2)-(3)). 

[33] CMS required that FF-SHOP states notify the agency of their 
preference and justification for delaying employee choice until 2016. 
CMS approved the delay of employee choice until 2016 for 18 FF-SHOPs: 
Alabama, Alaska, Arizona, Delaware, Illinois, Kansas, Louisiana, 
Maine, Michigan, Montana, New Hampshire, New Jersey, North Carolina, 
Oklahoma, Pennsylvania, South Carolina, South Dakota, and West 
Virginia. In addition, Nevada, an SB-SHOP in 2014, will use the FF-
SHOP platform in 2015 and will not offer employee choice. The 14 
FF-SHOP states that chose to allow CMS to implement employee choice for 
2015 were Arkansas, Florida, Georgia, Indiana, Iowa, Missouri, Nebraska, 
North Dakota, Ohio, Tennessee, Texas, Virginia, Wisconsin, and Wyoming. 

[34] Vermont required that all small group plans in the state be 
offered only through the SHOP. 

[35] Mississippi provided enrollment information as of July 1, 2014. 
Mississippi's SHOP did not come online until May, which limited the 
time that small employers have had to enroll. 

[36] Mississippi is a unique situation in that only one employer 
enrolled and so was not included in this calculation. 

[37] CMS officials cautioned against inferring future enrollment 
trends from the partial-year enrollment data for 2014. Officials said 
that employers may enroll in the SHOPs at any point in the year, 
unlike individuals pursuing coverage in the individual exchanges, 
which have limited open enrollment periods. According to the 
officials, more employers will likely become eligible for SHOP 
coverage in later months, when their existing non-SHOP plans end. 

[38] See Congressional Budget Office, Updated Estimates of the Effects 
of the Insurance Coverage Provisions of the Affordable Care Act 
(Washington, D.C.: April 2014). 

[39] CMS officials noted that some issuers have reported to CMS that 
they are unable to accurately report complete enrollment data for 
2014, which could underestimate actual enrollment numbers ultimately 
reported to CMS later in 2014. 

[40] While enrollment data is not available for FF-SHOPs, employers 
that are interested in applying for the small business tax credit in 
2014 must submit paper applications to CMS to obtain an official SHOP 
eligibility determination. CMS reported that it had received 12,376 
paper applications from employers for FF-SHOPs as of September 8, 
2014. According to CMS officials, employers that are interested in the 
tax credit have up to one year after enrolling in the SHOP to submit 
their paperwork to CMS. As a result, the number of paper applications 
for the SHOP tax credit as of September 8, 2014 likely differs from 
the actual number of employers that plan to apply for the tax credit 
in 2014. In addition, as some enrollees in the SHOP may not be 
eligible for or interested in applying for the tax credit, the number 
of paper applications likely differs from actual employer enrollment 
in the FF-SHOPs. 

[41] For additional details on issuer participation in both the 
individual and small business exchanges beginning in 2014, as well as 
how this compares with issuer participation in the individual and 
small group markets prior to the exchanges, see GAO, Patient 
Protection and Affordable Care Act: Largest Issuers of Health Coverage 
Participated in Most Exchanges, and Number of Plans Available Varied, 
[hyperlink, http://www.gao.gov/products/GAO-14-657] (Washington D.C.: 
August 29, 2014) 

[42] PPACA required each state to establish geographical rating areas 
that all issuers in the state must use as part of their rate setting. 
In some states these rating areas are based on counties, while in 
others they are based on Metropolitan Statistical Areas. 

[43] As noted previously, PPACA requires that issuers participating in 
the SHOP offer, at a minimum, plans at both the silver and gold levels 
of coverage.CMS officials said that they expect SHOP plans to be 
offered in these counties in plan year 2015. 

[44] Enrollment data for the FF-SHOPs was not yet available, though 
CMS officials reported that the agency was in the process of 
collecting the data from issuers. 

[45] Mississippi was excluded from this summary because it only had 
one enrollee as of July 1, 2014. 

[46] Mississippi was excluded from this analysis because it only had 
one enrollee as of July 1, 2014. Hawaii and Oregon were excluded 
because they were unable to provide total enrollment, and Washington 
was excluded because it was unable to provide total enrollment for the 
highest enrollment plan. 

[47] We focused our analysis of plan premiums on silver-tier plans. 

[48] Vermont does not allow variation in plan premiums based on age 
and so was not included in these comparisons. 

[49] As would be expected, this difference was consistent across 
Arizona plans for all three age groups that we reviewed. 

[50] Similar to Arizona, this difference was consistent across North 
Carolina plans for all three age groups that we reviewed. 

[51] For California, the prices for non-SHOP plans were somewhat 
higher than the prices for SHOP plans, with the lowest priced, the 
median priced, and the highest priced plan in the non-SHOP market 
being somewhat higher than the lowest priced, the median priced, and 
the highest priced plan in the California SHOP. For Illinois, the 
highest priced plan in the non-SHOP market was somewhat more expensive 
than the highest priced plan in the Illinois SHOP. 

We requested data from the five states that we selected to interview 
state-level stakeholders, California, Illinois, Kentucky, Rhode 
Island, and Texas. The necessary data were not available within our 
timeframes from Kentucky and Texas. 

[52] PPACA, § 1301(a)(1)(C)(iii) (codified at 42 U.S.C. 
18021(a)(1)(C)(iii)). 

[53] The Internal Revenue Service has stated that in 2014, small 
employers in certain counties in Wisconsin and Washington where SHOP 
plans are not offered may be eligible for the tax credit if they offer 
coverage that would have qualified for the credit prior to January 1, 
2014. 

[54] Kentucky exchange officials noted that they cannot determine how 
many employers have applied for or received the tax credit because the 
federal government, rather than the state, handles tax credit 
applications. 

[55] Mississippi is a unique situation in that only one employer 
enrolled and so was not included in this calculation. 

[56] See GAO, Small Employer Health Tax Credit: Factors Contributing 
to Low Use and Complexity, [hyperlink, 
http://www.gao.gov/products/GAO-12-549] (Washington, D.C.: May 14, 
2012). CMS officials noted that the agency launched a SHOP Small 
Business Health Care Tax Credit Estimator, available at the federal 
exchange website, in early 2014 to ease administrative burden and help 
employers better understand the tax credit. According to the 
officials, this tool is intended to make it easier for employers to 
determine if they qualify for the tax credit as well as the size of 
the credit they might receive. 

[57] The open enrollment period refers to the limited time frame when 
individuals are eligible to enroll in QHPs through an individual 
exchange. Individuals may be eligible to enroll in QHPs outside of the 
open enrollment period if they experience certain qualifying life 
events. 

[58] Rhode Island exchange officials indicated that this factor was 
not applicable in Rhode Island as it did not permit the renewal of non-
PPACA-compliant plans in 2014. 

[59] In addition, press reports have suggested that some issuers may 
have encouraged their customers to renew their noncompliant plans 
early, before SHOP enrollment and pricing became available. 

[60] The FF-SHOPs offered customer service phone lines, but not broker 
portals; however, CMS officials indicated that FF-SHOPs will offer 
broker portals when online enrollment begins in November 2014. 

[61] Employee rosters contain information, such as names and dates of 
birth, for each employee to whom SHOP coverage is offered. 

[62] According to CMS officials, data reported to CMS by two 
additional SB-SHOP states--Colorado and New York--indicate that the 
majority of employers using the SHOP in those states have chosen to 
offer employee choice. 

[63] 78 Fed. Reg. 15410, 15535 (Mar. 11, 2013) (to be codified at 45 
C.F.R. § 156.200(g)). In addition, some SB-SHOPs require that issuers 
meeting certain requirements participate in the state's SHOP. 

[64] CMS officials said that as of September 2014 they were not aware 
of any states that were planning to expand the SHOP to employers with 
51 to100 employees in 2015. 

Beginning in 2015, employers with 100 or more employees that do not 
offer affordable health coverage to 70 percent or more of their 
employees may be subject to a penalty if at least one employee 
receives subsidized coverage through an exchange. Beginning in 2016, 
employers with 50 or more employees that do not offer affordable 
health coverage to their full-time employees may be subject to this 
penalty if at least one employee receives subsidized coverage through 
an exchange. PPACA, § 1513(a). 124 Stat. at 253 (codified at 26 U.S.C. 
§ 4980H); 79 Fed. Reg. 8544, 8575, 8597-8601 (Feb. 12, 2014) (to be 
codified at 26 C.F.R. §§ 54.4980H-4, 54.4980H-5). Therefore, as SHOP 
eligibility expands to larger employers and these penalties take 
effect, more employers may be likely to participate in the SHOP. 

[65] States operating SB-SHOPs are required to ensure that the SHOPs 
are self-sustaining by January 1, 2015, meaning that states must 
ensure their SHOPs have sufficient funding to support ongoing 
operations, as federal grants awarded to establish exchanges will no 
longer be available. SHOPs may generate funding for SHOP operations in 
certain ways, including requiring issuers to pay user fees, or a 
percentage of premiums charged by the issuer. HHS requires that 
issuers participating in the FF-SHOPs pay a monthly user fee to fund 
FF-SHOP operations; in 2014, this fee is equal to 3.5 percent of the 
monthly premium charged by the issuer. HHS requires that this user fee 
be spread across all of an issuer's small group plans, regardless of 
whether the plans are offered in a SHOP. 

[66] Exchange officials in the remaining SB-SHOP state noted that they 
have proposed various options for SHOP funding, but that they expect 
that operating revenues and expenditures for the state's individual 
exchange and SHOP will be combined. 

[67] For example, one survey found that 67 percent of respondents said 
they would continue to offer health coverage in 2014, while 6 percent 
said they would definitely stop offering coverage and 27 percent said 
they would consider discontinuing coverage under certain 
circumstances. See eHealth ®, Small Employer Health Insurance Survey: 
March 2013, accessed August 21, 2014, [hyperlink, 
http://news.ehealthinsurance.com/_gallery/get_file/?file_id=514a002dfc96
aa2799001afe&file_ext=.pdf]. Another survey found that 23 percent of 
respondents were considering dropping coverage and giving money 
directly to employees to purchase coverage through the individual 
exchange in late 2013 or 2014. See National Small Business 
Association, 2014 Small Business Health Care Survey, accessed August 
21, 2014, [hyperlink, http://www.nsba.biz/wp-
content/uploads/2014/02/Health-Care-Survey-2014.pdf]. An additional 
survey found that the majority, or approximately 85 percent, of small 
employer respondents were very or definitely likely to continue 
coverage for their full-time employees in 2015, and another 
approximately 9 percent said that they were somewhat likely to 
continue coverage. The remaining 7 percent said they were more likely 
to direct employees to the individual exchanges in 2015. See 
International Foundation of Employee Benefit Plans, 2014 Employer-
Sponsored Health Care: ACA's Impact (Brookfield, Wis.: 2014). 

[68] CMS has noted, however, that it may consider extending this 
transitional policy for an additional year. See Department of Health 
and Human Services, Centers for Medicare & Medicaid Services, 
Extension of Transitional Policy through October 1, 2016, (Washington, 
D.C.: Mar. 15, 2014). 

[69] These provisions, or risk mitigation mechanisms, are designed to 
mitigate the potential effects of adverse selection and provide 
stability for health insurance issuers in the individual and small 
group markets. All issuers in the small group market are eligible to 
participate in the risk adjustment programs. Issuers of small group 
plans offered through a SHOP are also eligible to participate in the 
temporary risk corridors program in effect in 2014, 2015, and 2016. 
According to issuer representatives, of these two mechanisms, risk 
adjustment likely has the more significant ability to help stabilize 
SHOP premiums. GAO is separately examining early experiences with these 
risk mitigation programs. 

[End of section] 

GAO's Mission: 

The Government Accountability Office, the audit, evaluation, and 
investigative arm of Congress, exists to support Congress in meeting 
its constitutional responsibilities and to help improve the 
performance and accountability of the federal government for the 
American people. GAO examines the use of public funds; evaluates 
federal programs and policies; and provides analyses, recommendations, 
and other assistance to help Congress make informed oversight, policy, 
and funding decisions. GAO's commitment to good government is 
reflected in its core values of accountability, integrity, and 
reliability. 

Obtaining Copies of GAO Reports and Testimony: 

The fastest and easiest way to obtain copies of GAO documents at no 
cost is through GAO's website [hyperlink, http://www.gao.gov]. Each 
weekday afternoon, GAO posts on its website newly released reports, 
testimony, and correspondence. To have GAO e-mail you a list of newly 
posted products, go to [hyperlink, http://www.gao.gov] and select 
"E-mail Updates." 

Order by Phone: 

The price of each GAO publication reflects GAO's actual cost of 
production and distribution and depends on the number of pages in the 
publication and whether the publication is printed in color or black 
and white. Pricing and ordering information is posted on GAO's 
website, [hyperlink, http://www.gao.gov/ordering.htm]. 

Place orders by calling (202) 512-6000, toll free (866) 801-7077, or 
TDD (202) 512-2537. 

Orders may be paid for using American Express, Discover Card, 
MasterCard, Visa, check, or money order. Call for additional 
information. 

Connect with GAO: 

Connect with GAO on facebook, flickr, twitter, and YouTube.
Subscribe to our RSS Feeds or E mail Updates. Listen to our Podcasts.
Visit GAO on the web at [hyperlink, http://www.gao.gov]. 

To Report Fraud, Waste, and Abuse in Federal Programs: 

Contact: 
Website: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]; 
E-mail: fraudnet@gao.gov; 
Automated answering system: (800) 424-5454 or (202) 512-7470. 

Congressional Relations: 

Katherine Siggerud, Managing Director, siggerudk@gao.gov: 
(202) 512-4400: 
U.S. Government Accountability Office: 
441 G Street NW, Room 7125: 
Washington, DC 20548. 

Public Affairs: 

Chuck Young, Managing Director, youngc1@gao.gov: 
(202) 512-4800: 
U.S. Government Accountability Office: 
441 G Street NW, Room 7149: 
Washington, DC 20548. 

[End of document]