CMS-10526 CSR Reconciliation Supporting_Statement (09-15-14 clean)

Supporting Statement For Paperwork Reduction Act Submissions:
Cost Sharing Reduction Reconciliation Data Template

CMS-10526 (OCN: 0938-New)
A. Background
The Patient Protection and Affordable Care Act, Public Law 111-148, enacted on March 23,
2010, and the Health Care and Education Reconciliation Act, Public Law 111-152, enacted on
March 30, 2010 (collectively, the “Affordable Care Act”), provides for reduced cost sharing for
eligible individuals who purchase health insurance from a qualified health plan (QHP) through a
Marketplace.1
Under this law, cost-sharing reductions (CSRs) are paid by issuers to health care providers to
lower the out-of-pocket cost to enrollees at the time of service. The goal is to make health care
more accessible by reducing its cost. HHS advances dollar amounts for cost-sharing reductions to
issuers. In 45 CFR 156.430(c), issuers must report to HHS the amount of cost-sharing reductions
provided during the benefit year. In 45 CFR 156.430(d), HHS will reconcile the amount of
advance payments for cost-sharing reductions against the actual amount of cost-sharing reductions
issuers made to health care providers on behalf of enrollees.
The 2014 Notice of Payment and Benefit Parameters rule (the “Payment Notice”) published
March 11, 2013, detailed a plan in which HHS would advance monthly payments to issuers for
estimated CSRs and then reconcile the advanced amounts against actual CSRs provided by issuers
to eligible enrollees during the benefit year. The Payment Notice detailed a methodology for
issuers to use when calculating and submitting to HHS the actual CSR amounts provided enrollees
in a benefit year. In response to comments on the proposed rule that the “standard methodology”
to identify actual CSRs was too complex for timely implementation, HHS in the final Payment
Notice said it would provide a second, optional method for estimating CSRs provided by issuers.
An interim final rule with comment, “Amendment to the HHS Notice of Benefit and Payment
Parameters for 2014,” published concurrently with the final 2014 Payment Notice described in
detail a second “simplified methodology.” As a result, QHP issuers may elect to use a simplified
formula during the first three years of the program, from 2014 through 2016, to estimate cost
sharing reductions provided to enrollees.
In 45 CFR 156.430(c)(1), we established the standard methodology for QHP issuers to submit
data to HHS showing the amount of cost sharing paid by enrollees in each plan variation, as well
as the amount of cost sharing the enrollees would have paid under the standard plan. The value of
the cost sharing provided is the difference between those two amounts.
To calculate what the enrollees would have paid under the standard plan, QHP issuers using the
standard methodology detailed in 45 CFR 156.430(c)(2) are required to apply the actual cost
sharing amount for the standard plan to the total allowed costs for essential health benefits (EHB)
for each plan variation policy. Essentially, the issuer first processes a claim using standard cost
sharing, and then re-processes the claim, applying the reduced cost sharing to establish the CSR
amount.
The simplified methodology provided in 45 CFR 156.430(c)(4) does not require complex readjudication of claims. Instead, issuers are required to calculate the amount enrollees would have
paid under the standard plan by applying four cost-sharing parameters for the standard plan to the
total allowed costs paid for EHB under the policy with cost sharing reductions. The four cost-

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Supporting Statement For Paperwork Reduction Act Submissions:
Cost Sharing Reduction Reconciliation Data Template
sharing parameters are: the effective deductible, the effective pre-deductible coinsurance rate, the
effective post-deductible coinsurance rate, and the effective claims ceiling.
QHP issuers will have already notified HHS of their selection of methodology as required
under 45 CFR 156.430(c)(3) prior to the benefit year. A QHP that selected the simplified
methodology must apply the methodology to all plan variations it offers on the Exchange for the
benefit year under 45 CFR 156.430(c)(3)(ii).
[In the previous 60-day comment period to this collection] we proposed to collect the
necessary data elements for both methodologies using an HHS created CSR Reconciliation Data
Template. For efficiency in transmitting the necessary volume of data for this collection, and to
more closely resemble other data collections that issuers currently participate in with the
Marketplace, we are changing the method of collection from a template to a standard electronic
file format. HHS will release additional information on the file structure and transfer protocols
through separate technical guidance at a later date.
The reporting and data collection provisions described here apply to issuers of QHPs inside an
Exchange. (Cost-sharing reductions are only available through Exchange-based products.) All
such QHP issuers would be required to report the data elements contained in the Issuer Summary
Report described in Part I. Depending on whether they selected the standard or simplified CSR
reconciliation methodology, QHP issuers then would be required to report elements from the
following additional sections of the CSR reconciliation reports:
 Issuers using the standard CSR reconciliation methodology would be required to report
the elements in the Plan and Policy Report (Part II).
 Issuers using the simplified CSR reconciliation methodology with at least 12,000
member months per year in the associated standard plan would be required to report the
elements in the Effective Parameters Report and a Plan and Policy Report (Parts III and
IV.)
 Issuers using the simplified CSR reconciliation methodology with fewer than 12,000
member months per year in the associated standard plan would be required to report the
elements in the Simplified Actuarial Value Methodology Plan and Policy Report (Part
V).
The data elements required for these reports are described at length below.
This information collection allows HHS to collect data necessary to reconcile dollar amounts
advanced to QHP issuers by HHS with dollar amounts paid by the issuer on behalf of an enrollee,
and recoup or remit the balance.

B. Justification
1.

Circumstances Making the Collection of Information Necessary

Section 1402 of the Affordable Care Act provides cost-sharing reductions for certain eligible
individuals to help them afford out-of-pocket expenses associated with health care purchased
through QHPs offered on Exchanges. Sections 1402 and 1412 of the Affordable Care Act provide
for reductions in cost sharing on EHB for low and moderate income enrollees in silver level health
plans sold on individual market Exchanges. Section 1402(c)(3) of the law directs QHP issuers to
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Supporting Statement For Paperwork Reduction Act Submissions:
Cost Sharing Reduction Reconciliation Data Template
notify the Secretary of Health and Human Services of cost-sharing reductions made under the
statute for qualified individuals, and directs the Secretary to make periodic and timely payments to
the QHP issuer equal to the value of those reductions. Further, the law permits advance payment
of the cost-sharing reduction amounts to QHP issuers based upon amounts specified by the
Secretary.
To ensure the appropriate use of federal funds, HHS needs to compare and reconcile the
estimated monthly payments it advanced to a QHP issuer with actual cost sharing reductions made
by the issuer for medical services for each eligible enrollee in a benefit year.
2.

Purpose and Use of Information

The data collection and reporting requirements described below will enable HHS to review
actual medical costs incurred by enrollees for EHB and CSRs provided by issuers on behalf of
these enrollees for these services, and to compare this information to the dollar amount of
estimated payments HHS advanced to issuers. This comparison will allow HHS to determine
whether the HHS advance payment to the issuer was greater or less than the CSR amounts
provided on behalf of enrollees. Using this data, HHS will calculate the difference between the
advanced CSR payments and the amount actually provided during the benefit year, and either
make a payment to an issuer or invoice the issuer for amounts not spent on behalf of the enrollee.
For benefit year 2014, issuers must submit CSR data to HHS by April 30, 2015.
3.

Use of Information Technology

Information gathered through this collection will be submitted electronically. HHS staff will
communicate with States and the District of Columbia using standardized reporting, e-mail or
telephone.
4.

Duplication of Efforts
This information collection does not duplicate any other Federal effort.

5.

Small Businesses
This information collection will not have a significant impact on small businesses.

6.

Less Frequent Collection

Reconciliation of advance payments of cost-sharing reductions is an annual process. A less
frequent collection could result in a loss of funds to the U.S. Treasury from uncollected
receivables and interest. Failure to reimburse issuers for cost-sharing reduction amounts in excess
of the amount advanced by HHS at least once yearly could result in cash flow difficulties for
issuers.
7.

Special Circumstances

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Supporting Statement For Paperwork Reduction Act Submissions:
Cost Sharing Reduction Reconciliation Data Template
There are no special circumstances associated with this collection.
8.

Federal Register/Outside Consultation

This collection of information will be available for comment for 30 days. We have consulted
with contractors, States, and industry on the feasibility of this information collection. We have
based many of the requirements in this information collection on those consultations.
Additionally, CMS requested comment on this collection on June 27, 2014 (see 79 FR 36516
CMS-10526). We received comments from two health insurance organizations and we address
these in Appendix A.

9.

Payments/Gifts to Respondents
No payments or gifts will be provided to respondents.

10. Confidentiality
We will maintain respondent privacy with respect to the information collected to the extent
required by applicable law and HHS policies.
11. Sensitive Questions
There are no sensitive questions included in this information collection effort.
12. Burden Estimates (Hours & Wages)
Below is a summary of the information collection requirements established in the 2014
Payment Notice (45 CFR 78 FR 15409), and the final Program Integrity rule (45 CFR 78 FR
65046) with regard to reconciliation of advanced payments for CSRs.
Our estimate of paperwork burden for issuers is based on responses from 295 issuers and
whether they elected the standard or simplified method for calculating amounts of CSRs provided.
Additionally, issuers electing the simplified method must use the simplified actuarial value
methodology for determining the value of CSRs provided for enrollees when calculating cost
sharing for standard plans with fewer than 12,000 member months in a benefit year.
A number of assumptions are made regarding the wages of personnel needed to accomplish the
proposed collection of information. Wage rates are based on the Employer Costs for Employee
Compensation report by U.S. Bureau of Labor Statistics and represent a national average. Some
States or employers may face higher or lower wage burdens. Wage rates estimates include a 35%
increase to account for employee fringe benefits.

I. Issuer Summary Report
Within Part 156, subpart E we described Health Insurance Issuer responsibilities with respect
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Cost Sharing Reduction Reconciliation Data Template
to advance payments of CSRs.
Under 45 CFR 156.430(c)(1), each QHP each year must submit to HHS for every plan
variation it sells on the Exchange the total allowed costs for EHB provided for the policy for the
benefit year, broken down by the amount the issuer paid, the amount the enrollee(s) paid, and the
amount the issuer would have paid under the standard plan without cost-sharing reductions.
In this collection, HHS proposes to require each issuer to submit the data elements contained
in the Issuer Summary Report, which includes the total number of policies paying cost-sharing
reductions and the total amount of actual CSRs provided under those policies. All QHP issuers
offering individual market plans in the Exchange are subject to this annual data collection
requirement and would be required to complete this report.
This report also requires issuers to attest that the actual CSR amounts paid were paid only for
EHB, not including certain benefits for which Federal funds may not be used, as described in
Section 1301 of the ACA. Additionally, as required under 45 CFR 156.430(c)(4)(iii)(E), issuers
that elect the simplified methodology must submit a memorandum and actuarial attestation to the
method of calculation for each effective cost sharing parameter for each applicable subgroup in the
standard plan. This signed memo would be submitted electronically concurrent with the CSR cost
report.
Approximately 295 QHP issuers on Exchanges are subject to this data collection. Additionally,
as described under 45 CFR 156.430(c)(iv), in the case of a merger or acquisition, an issuer may be
required to file reports under both standard and simplified methodologies. Assuming on average
that one issuer would need to complete two Issuer Summary Report reports in any given year, we
estimate 296 reports would be filed each year.
We previously estimated the cost of establishing information technology to use this
methodology in the Information Collection associated with the 2014 Payment Notice and the final
Program Integrity rule. We assume these reports will be automatically generated on a regular basis
as a normal part of business, and below we estimate capital costs for all data extraction for this file
transfer. Therefore, our estimate here is limited to performing the extraction and reviewing data in
this file. We estimate that on average, for each issuer, it will take an operations analyst 30 minutes
(at a wage rate of $55 an hour) and a senior manager (at $79.08 an hour) 15 minutes to oversee
and review the Issuer Summary Report section of this file, for a total estimated burden of 222
hours per year. The average cost estimate for each issuer is $47.28 and the estimated aggregated
cost burden is $13,994.88.
II. Standard Methodology Plan and Policy Report
Only issuers using the standard methodology would be required to report this section of the
reports. As required under §156.430(c)(2), QHP issuers in this section must calculate the value of
the amount the enrollee would have paid under the standard plan without cost-sharing reductions
by applying actual cost-sharing requirements for the standard plan to the allowed costs for EHB
under the enrollee’s policy for the benefit year. The Plan and Policy Report includes identifying
numbers for each policy, total allowed costs for EHB, amounts the issuer and enrollee paid, and
the amounts the enrollee(s) would have paid under the standard plan. It also includes memberlevel data such as name, date of birth, and amount of CSR paid by the issuer for that member.
As noted above, we separately estimate capital costs related to data extraction required to
complete all sections of the file submission, and we assume an automated information system.
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Supporting Statement For Paperwork Reduction Act Submissions:
Cost Sharing Reduction Reconciliation Data Template
Therefore our estimate here is limited to performing the extraction and reviewing the data in the
file.
In the aggregate, we estimate that 295 issuers will report reconciliation data for approximately
4 million policies in various sections of this template. A review of HHS data shows that 104 QHP
issuers, or approximately 35 percent of QHP issuers required to report CSR data, selected the
standard methodology and would submit data for this section of the report.
Assuming 35 percent of policies (or 1,400,000 policies) also fall under the standard
methodology, each issuer completing this section of the report would submit data for
approximately 13,461 policies. To submit and review this data collection, we estimate on average
for each issuer it would take an operations analyst 10 hours (at an average wage rate of $55 an
hour) and a senior manager five hours (at $79.08 an hour) to meet these requirements. Therefore
we estimate on average each issuer would need 15 hours to complete this section, for an estimated
aggregate burden of 1,560 hours. We estimate the average cost to each issuer would be $945.40,
for an aggregated estimated cost burden of $98,321.60.
We anticipate that more issuers will use this method in future years. Assuming that the number
of policies reported under this section in the first year would double in subsequent years, the
estimated aggregate hourly burden and cost in benefit years 2015 and 2016 would also double.
III. Simplified Methodology Effective Parameters Report
IV. Simplified Methodology Plan and Policy Report
Only QHP issuers that selected the simplified methodology and whose associated standard
plan meets the credibility standard established in §156.430(c)(4)(iv) are required to complete
Sections III and IV of the CSR Reconciliation Data Reports. The simplified methodology may be
used for benefit years 2014, 2015, and 2016, and only by issuers that selected it beginning in the
initial year.
The simplified methodology requires QHP issuers to estimate cost sharing for the standard plan
associated with each plan variation in part by developing a set of parameters from the claims
population for that standard plan for the year. For these calculations to be meaningful, the standard
plan would need to have at least 12,000 member months each year, in and out of the Exchange.
Section III of this report would require issuers to submit formulas in accord with 45 CFR
156.430(c)(4)(iii)(A)-(D) for four cost sharing parameters: the effective deductible, the effective
pre-deductible coinsurance rate, the effective post-deductible coinsurance rate, and the effective
claims ceiling, for each standard plan, for both self-only coverage and other than self-only
coverage. Section III also requires issuers to provide plan variation level information that
describes whether the plan has separate cost-sharing parameters for self only and other than self,
and for medical and pharmaceutical services. Issuers also must provide this information for HMOlike plans where 80 percent or more of the total allowed costs for EHB under a standard plan are
not subject to the deductible, since these require a separate set of effective cost sharing parameters.
In Section IV, QHP issuers would be required to report the amount of cost sharing the enrollee
would have paid under the standard plan, as calculated by applying summary cost sharing
parameters in Section III to plan variation policy claims data. Issuers would report Level 3
subsections depending on whether the policy is self only or other than self only, and whether it
falls under formulas A, B, or C.

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Cost Sharing Reduction Reconciliation Data Template
As noted above, we separately estimate capital costs related to data extraction required to
complete all sections of the file submission, and we assume an automated information system.
Therefore our estimate here is limited to performing the extraction and reviewing the data in the
file. Approximately 65 percent or 191 QHP issuers selected the simplified methodology.
However, according to HHS data, of the 2,234 standard plans offered by issuers that chose to
report using the simplified methodology, only 222 plans or about 10 percent meet the credibility
standard required to estimate parameters under this section. Therefore we estimate that each issuer
would submit data on, at most, one standard plan and associated plan variation under Section III.
Assuming calculations for 10 percent of the remaining 2.6 million policies would be reported
under Section IV, we estimate that for Sections III and IV, issuers would submit data for a total of
222 standard plans, 222 plan variations, and 260,142 policies. On average, for each issuer with
one standard plan, one associated plan variation, and an estimated 1,362 policies, we estimate it
will take an actuary 10 hours (at $69.93 an hour), an operations analyst 10 hours (at an average
wage rate of $55 an hour) and a senior manager 5 hours (at $79.08 an hour) to oversee the data
submissions required in this section, for an average per issuer cost of $1,644.70. For 191 issuers,
the aggregate hourly burden is 4,775 hours and the aggregate wage burden is $314,137.7.
We anticipate that fewer issuers will use this method in future years. Assuming that only half
of all plan variations reported under this section in the first year would be reported here in
subsequent years, we estimate the aggregate cost burden in benefit years 2015 and 2016 would
decline by half.
V. Simplified Actuarial Value Methodology Plan and Policy Report
This section of the report must be completed by QHP issuers that selected the simplified
methodology to calculate CSRs but that enrolled fewer than 12,000 member months for a benefit
year in an associated standard plan.
Under CFR 156.430(c)(4)(v), issuers whose standard plans lack sufficient enrollment to
provide a credible estimate of average claims data must use the standard plan actuarial value from
the AV calculator to estimate cost sharing under the standard plan. This is calculated as the lesser
of the annual limit on cost sharing for the standard plan, or the product of (x) one minus the
standard plan’s actuarial value, as calculated under 45 CFR 156.135, and (y) the total allowed cost
for EHB.
HHS estimates that 90 percent or 2,012 standard plans offered by issuers selecting the
simplified methodology do not meet the threshold required for the simplified method and,
therefore, to calculate CSR for policies associated with these plans, these issuers must use the
simplified actuarial value methodology.
Assuming 90 percent of the 2.6 million policies to be reconciled under the simplified
methodology will use the actuarial value methodology and complete this section, we estimate on
average that each issuer would submit data for 12,251 policies. On average, we estimate it will
take an operations analyst 1 hour (at an average wage rate of $55 an hour) and a senior manager 1
hour (at $79.08 an hour) to oversee the data submissions required in this section. The total burden
for 191 QHP issuers is therefore 382 hours and the aggregated cost burden would be $25,609.20.
We anticipate that fewer issuers will use this method in future years. Assuming that only half
of all plan variations reported under this section in the first year would be reported here in
subsequent years, we estimate the aggregate cost burden in benefit years 2015 and 2016 would
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Supporting Statement For Paperwork Reduction Act Submissions:
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decline by half.
Aggregate burden
As noted above, each QHP issuer must complete only two reports: the Issuer Summary Report
(Section I) and the report that corresponds to their methodology. The aggregate burden for issuers
completing this file is as follows:
12A. Estimated Annualized Burden Hours
Information
Type of
Frequency
Collection
Respondent
and
Requirement
Duration
Issuer Summary
Report
Standard
Methodology
Plan and Policy
Report
Simplified
Methodology
Effective
Parameters and
Plan and Policy
Reports
Simplified
Actuarial Value
Plan and Policy
Report
Total

Number of
Respondents

Number of
Responses
per
Respondent

Average
Burden
Hours per
Response

Total
Burden
Hours

Issuer

Annually,
Permanent

296

1

.75

222

Issuer

Annually,
Permanent

104

13,461

0.0011

1,560

Issuer

Annually,
2014,2015,
2016 only

191

1,362

0.0183

4,775

Issuer

Annually,
2014,2015,
2016 only

191

12,251

0.0001

382
6,939

12B. Cost Estimate for All Respondents Completing each Form
Hourly Labor
Total
Average
Total Labor Costs
Number of
Cost of
Burden Labor Cost
(All
Respondents
Reporting ($) Hours per Response
Respondents)
Issuer Summary Report
296
$8,140
Operations Analyst
$55.00
.50
$27.50
296
$5,854.88
Senior Manager
$79.09
.25
$19.78
Total
.75
$47.28
$13,994.88
Type of
Respondent

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Supporting Statement For Paperwork Reduction Act Submissions:
Cost Sharing Reduction Reconciliation Data Template

Type of
Respondent

Hourly Labor Total
Average
Number of Total Labor Costs
Cost of
Burden Labor Cost Respondents (All Respondents)
Reporting ($) Hours per Response
Standard Methodology Plan and Policy Report
104
10
$550.00
$57.200
Operations Analyst
$55.00
104
5
$395.40
$41,121.6
Senior manager
$79.08
$945.40
$98,321.6
Total
Simplified Methodology Effective Parameters Report and Plan and Policy Report
191
10
$699.3
$133,566.30
Actuary
$69.93
191
10
$550.00
$105,050.00
Operations Analyst
$55.00
191
75,521.404
5
$394. 40
Senior Manager
$79.08
$314,137.70
$1,644.70
Total
Simplified Actuarial Value Methodology Report
1
Operations Analyst
$55.00
1
Senior Manager
$79.08
Total

$55.00
$79.08
$134.08

191
191

$10,505
$15,104.28
$25,609.28

13. Capital Costs
In the 2014 HHS Notice of Benefit and Payment Parameters, we estimated that the information
technology associated with implementing the standard methodology would be developed by three
vendors at a cost of approximately $6 million per vendor, for total costs of approximately $18
million. We also estimated each issuer would need to spend approximately $100,000 to customize
the vendor solution technology and modify their claims system to extract data. Our estimate for
total administrative costs was $138 million. We revised our estimate in the Program Integrity Rule
on the assumption that half of an estimated 1,200 issuers would use the simplified methodology.
We included in that estimate 42 hours of work by an actuary and 22 hours of work by an insurance
manager to develop and calculate cost-sharing parameters for the simplified method. We are
revising our estimate further to reflect current HHS expectations that 90 percent of 295 issuers will
use one of the simplified methods. The new estimate is $47.5 million and includes systems
development for all methodologies.
Here we estimate the burden of extracting and reporting data from the information technology
accounted for above, as well as maintenance. For an issuer using the standard methodology, we
estimate on average it would take each QHP using automated systems 10 hours a year to provide
the information required in these reports. Therefore for all issuers using this methodology, we
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Supporting Statement For Paperwork Reduction Act Submissions:
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estimate it would take 1,040 hours to produce summary data for 1.4 million policies. The cost of
this capital requirement is approximately $1,500 per issuer, including maintenance and
depreciation, for a total estimated burden of $156,000.
The time required to produce reports using the simplified methodology is expected to be
slightly greater than that required for the standard methodology. We estimate each issuer using
this method would take two hours to provide data for 1,171 policies once a year. Therefore the
estimated aggregate annual burden to submit data for 260,142 policies is 382 hours. The cost of
this capital requirement is approximately $300 per issuer, for a total estimated burden of $57,300.
Issuers using the simplified actuarial value methodology would require slightly less time than
those reporting under the standard methodology to calculate parameters and produce reports.
Using previously gathered information and an automated information system, we estimate it
would take each QHP issuer on average one hour to complete this report for 12,251 policies once a
year. Therefore, for 2.3 million policies the estimated aggregate annual time burden for issuers
completing this section would be 183.5 hours. The cost of this capital requirement is
approximately $150 per issuer, for a total estimated burden of $28,650.

14. Cost to Federal Government
The initial burden to the Federal Government for the establishment of the CSR Reconciliation
program is $14,552.64. The calculations for CCIIO employees’ hourly salary was obtained from
the OPM website: http://www.opm.gov/oca/10tables/html/dcb_h.asp.
Task
Development of HHS CSR reconciliation template
3 GS-13: 3 x $42.66 x 30 hours
Collection of HHS CSR reconciliation data
5 GS-13: 5 x $42.66 x 40 hours

Estimated Cost
$3,839.40

$8,532

Technical Assistance to Issuers
5 GS-13: 5 x $42.66 x 8 hours

$1706.40

Managerial Review and Oversight
2 GS-15: 2 x $59.30 x 4 hours

$474.40

Total Costs to Government

$14,552.22

15. Explanation for Program Changes or Adjustments
There are no changes to the burden. This is a new data collection.
16. Publication/Tabulation Dates
Not applicable.
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17. Expiration Date
Not applicable.
18. Certification Statement
There is no exception to the certification statement identified in Item 19, "Certification for
Paperwork Reduction Act Submissions," of OMB Form 83-I.

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QHP issuers must reduce cost sharing for individuals with household incomes between 100 percent and 250 percent of the federal poverty level
(FPL) who are enrolled in a silver level QHP in the individual market on an Exchange. In addition, issuers must eliminate cost sharing for Indians
with household incomes under 300 percent of FPL who are enrolled in a QHP in the individual market on an Exchange. Finally, issuers must
eliminate cost sharing for Indians enrolled in a QHP in the individual market on the Exchange, regardless of income, when services are provided by
the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization, or through referral under contract health services.

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