Form CMS-10526 CSR Reconciliation Data Elements

CSR Reconciliation Data Elements

1. Issuer Summary Report

Information in this report would be collected from all QHP issuers offering coverage through the individual market on the Marketplace (both FFMs and SBMs). This does not include stand-alone dental plan issuers.

Data Element	Description/Notes
Level 1: Issuer Summary Information
Record Code	Record code at the issuer level is always 01
Trading Partner ID
Tenant ID	Issuer’s state code
HIOS ID	Enter the five-digit Health Insurance Oversight System (HIOS)–generated Issuer ID number
Issuer extract date	Date information extracted by issuer
Issuer extract time	Time Information extracted by issuer
Benefit year
Total benefit year CSR variant plans under this QHP ID	Total count of all plan variations for the QHP issuers under this HIOS ID
Total actual CSR amount	Total CSR amount provided by this QHP issuer to enrollees in all plan variations
CSR Amount advanced to the issuer	Amount the issuer shows received for the benefit year January 1 to December 31. Issuers should include retroactive adjustments to advance payments for the applicable benefit year that were made after the close of the benefit year but before or by April 30, 2016.
Level 1:Issuer Summary Information (Continued)
Reconciliation methodology (standard or simplified)	In the case of a merger with or acquisition of an issuer that used a different methodology, the QHP issuer must submit two sets of reports using the applicable standard and simplified methodology for each issuer.
Acquisition	Has the issuer HIOS ID filing this reconciliation report been acquired by another issuer in the applicable benefit year? Enter Y or N
Acquiring issuer	HIOS ID of the acquiring issuer
Acquisition effective date	Date the acquisition was final
Data Element	Description/Notes
Merger	Has the issuer HIOS ID filing this reconciliation report merged with another issuer in the applicable benefit year? Enter Y or N
Merger party	HIOS ID of the other issuer(s) party in the merger
Merger effective date	Date the merger was final
Technical point of contact first name
Technical point of contact last name
Technical point of contact email address
Technical point of contact organization
Technical point of contact phone number
Business point of contact first name
Business point of contact last name
Business point of contact email address
Business point of contact organization
Business point of contact phone number
Issuer attestation	Attestation that CSR amounts represent only EHB cost-sharing amounts for which Federal reimbursement is permitted (in the case of fee-for-service providers, these amounts must have been passed through by the issuer to such providers, pursuant to 45 CFR 156.430(c)(5).) If the issuer has estimated total allowed essential health benefits as allowed under 45 CFR 156.430(c)(2)(i)(A)-(B), this includes attestation that the issuer has met the standards required to estimate EHB. If the issuer has selected the simplified methodology, this includes the actuarial attestation that describes how the issuer calculated the effective cost-sharing parameters for each applicable subgroup in the standard plan. If the issuer submitted a certified estimate for cost-sharing reductions provided for the purpose of risk corridors and medical loss reporting, this includes a description of the estimate and attestation by the issuer’s chief financial officer and chief actuary that the estimate is the issuer’s best estimate.

2. Standard Methodology Plan and Policy Report: Information from this report would be collected only from QHP Issuers who selected the standard CSR reconciliation methodology.

Data Element	Description/Notes
Level 1: Plan Information
Record Code	Record Code at the plan level is always 02
16 digit QHP ID	Enter the 16-digit HIOS-generated qualified health plan identification number. This includes the 14-digit standard plan ID plus the 2-digit variant ID.
Total Annual Premium
Total Number of Exchange Subscribers in this plan	Enter the total count of unique Exchange subscriber IDs in this plan variation for the benefit year
Total Allowed Costs for EHB
Total Actual Amount the Issuer paid for EHB
Total Actual Amount Paid for EHB by Enrollees
Total Actual Amount for EHB Enrollees would have paid in the Standard Plan
Total Actual Value of CSR Provided
Total Actual CSR Advanced to issuer (optional)
Level 2: Policy Information
Record Code	Record code at the policy level is always 03
QHP Plan ID	Enter the 16-digit HIOS-generated qualified health plan identification number. This includes the 14-digit standard plan ID plus the 2-digit variant ID.
Exchange Assigned Subscriber ID
Plan Benefit Start Date
Plan Benefit End Date
Total Monthly Premium for this policy	If the policy changed to self-only or other than self-only during the benefit year, or if the monthly premium amount changed during the benefit period as the result of other changes in circumstance, enter the average monthly premium for this policy over the months in which it was in effect. Issuers should include retroactive adjustments to premium for the applicable benefit year that are made after the close of the applicable benefit year but before or by April 30, 2016
Total Allowed Costs for EHB	Enter the amount of claims for essential health benefits incurred by the enrollee(s) on this policy.
Data Elements	Description/ Notes
Amount the Issuer Paid for EHB	Enter the total dollar amount the issuer paid to providers for all EHB services to enrollees on this policy. This includes cost-sharing reduction reimbursement amounts to fee-for-service providers to the extent the issuer reimbursed fee-for-service providers. Issuers of partially or fully capitated plans should enter all amounts paid by the issuer for those services. This value does not include enrollee liability.
Amount the Enrollee(s) Paid for EHB	Enter the amount all enrollees on this policy paid (or are liable for) in cost sharing for all EHB services. .
Amount the Enrollee(s) Would Have Paid for EHB Under the Standard Plan
CSR Amount	This field would auto-populate (amount enrollees would have paid, minus amount enrollees paid)
CSR Amount advanced to the issuer (optional)

III. Simplified Methodology: Effective Parameters Report

Information in this report would be collected only from QHP Issuers that selected the simplified CSR reconciliation methodology with ≥12,000 member months in the associated standard plan (in and out of Exchange). Effective parameters are only submitted under Level 2, if the conditions in that level are met.

Data Element	Description/Notes
Level 1: Plan Variation Level Information
16 digit QHP ID
Plan metal level
Separate cost-sharing parameters for self-only coverage and other than self-only coverage	Yes or No
Separate cost-sharing parameters for medical services and pharmaceutical services	Yes or No
>80% of total allowed costs for EHB for benefit year under standard plan not subject to a deductible	Yes or No for self-only coverage (submission fields grey out depending on answer)
>80% of total allowed costs for EHB for benefit year under standard plan not subject to a deductible	Yes or No for other than self-only coverage (submission fields grey out depending)
>80% of total allowed costs for EHB for benefit year under standard plan not subject to a deductible	Yes or No for medical (submission fields grey out depending on answer)
>80% of total allowed costs for EHB for benefit year under standard plan not subject to a deductible	Yes or No for pharmaceutical (grey out depending on answer)
Data Elements	Description/Notes
Level 2A: +80% Self-only Combined Effective Parameters Collected only if >80% of total allowed costs for EHB for self-only coverage under the standard plan are not subject to the deductible, and combined parameters for medical and pharmaceutical services.
Average deductible	Automatically equal to zero
Effective deductible	Automatically equal to zero
Effective pre-deductible coinsurance rate
Effective post-deductible coinsurance rate	Automatically equals pre-deductible coinsurance rate
Effective non-deductible cost-sharing	Automatically equal to zero
Effective claims ceiling
Effective pre-deductible coinsurance rate
Level 2B: +80% Other than Self-only Combined Effective Parameters Collected only if >80% of total allowed costs for EHB for other than self-only coverage under the standard plan are not subject to the deductible, and the plan has separate parameters for self-only and other than self-only coverage, and combined parameters for medical and pharmaceutical services.
Average deductible	Automatically equal to zero
Effective deductible	Automatically equal to zero
Effective pre-deductible coinsurance rate
Effective post-deductible coinsurance rate	Automatically equals pre-deductible coinsurance rate
Effective non-deductible cost-sharing	Automatically equal to zero
Effective claims ceiling
Effective pre-deductible coinsurance rate
Level 2C: +80% Self-only Medical Effective Parameters Collected only if >80% of total allowed costs for medical EHB services for self-only coverage under the standard plan are not subject to the deductible, and the plan has separate effective parameters for medical and pharmaceutical services.
Average deductible	Automatically equal to zero
Effective deductible	Automatically equal to zero
Effective pre-deductible coinsurance rate
Effective post-deductible coinsurance rate	Automatically equals pre-deductible coinsurance rate
Effective non-deductible cost-sharing	Automatically equal to zero
Effective claims ceiling
Effective pre-deductible coinsurance rate
Level 2D: +80% Self-only Pharmaceutical Effective Parameters Collected only if >80% of total allowed costs for pharmaceutical EHB services for self-only coverage under the standard plan are not subject to the deductible, and the plan has separate effective parameters for medical and pharmaceutical services.
Average deductible	Automatically equal to zero
Effective deductible	Automatically equal to zero
Effective pre-deductible coinsurance rate
Effective post-deductible coinsurance rate	Automatically equals pre-deductible coinsurance rate
Effective non-deductible cost-sharing	Automatically equal to zero
Effective claims ceiling
Data Element	Description/Notes
Level 2E: +80% Other than Self-only Medical Effective Parameters Collected only if >80% of total allowed costs for medical EHB services for other than self-only coverage under the standard plan are not subject to the deductible, the plan has separate parameters for self-only and other than self-only coverage, and separate effective parameters for medical and pharmaceutical services.
Average deductible	Automatically equal to zero
Effective deductible	Automatically equal to zero
Effective pre-deductible coinsurance rate
Effective post-deductible coinsurance rate	Automatically equals pre-deductible coinsurance rate
Effective non-deductible cost-sharing	Automatically equal to zero
Effective claims ceiling
Level 2F: +80% Other than Self-only Pharmaceutical Effective Parameters Collected only if >80% of total allowed costs for pharmaceutical EHB services for other than self-only coverage under the standard plan are not subject to the deductible, the plan has separate effective parameters for self-only and other than self-only coverage, and separate effective parameters for medical and pharmaceutical services.
Average deductible	Automatically equal to zero
Effective deductible	Automatically equal to zero
Effective pre-deductible coinsurance rate
Effective post-deductible coinsurance rate	Equals pre-deductible coinsurance rate
Effective non-deductible cost-sharing	Automatically equal to zero
Effective claims ceiling
Level 2G: Self-only Combined Effective Parameters Collected only if ≤ 80% of total allowed costs for EHB for self-only coverage under the standard plan are not subject to the deductible, and combined effective parameters medical and pharmaceutical services.
Average deductible
Effective deductible
Effective pre-deductible coinsurance rate
Effective post-deductible coinsurance rate
Effective non-deductible cost-sharing
Effective claims ceiling
Level 2H: Other than Self-only Combined Effective Parameters Collected only if ≤ 80% of total allowed costs for EHB for other than self-only coverage under the standard plan are not subject to the deductible, and the plan has separate parameters for self-only and other than self-only coverage, and combined effective parameters for medical and pharmaceutical services.
Average deductible
Effective deductible
Effective pre-deductible coinsurance rate
Effective post-deductible coinsurance rate
Effective non-deductible cost-sharing
Effective claims ceiling
Data Element	Description/Notes
Level 2I: Self-only Medical Effective Parameters Collected only if ≤ 80% of total allowed costs for medical EHB services for self-only coverage under the standard plan are not subject to the deductible, and the plan has separate effective parameters for medical and pharmaceutical services.
Average deductible
Effective deductible
Effective pre-deductible coinsurance rate
Effective post-deductible coinsurance rate
Effective non-deductible cost-sharing
Effective claims ceiling
Level 2J: Self-only Pharmaceutical Effective Parameters Collected only if ≤ 80% of total allowed costs for pharmaceutical EHB services for self-only coverage under the standard plan are not subject to the deductible, and the plan has separate effective parameters for medical and pharmaceutical services.
Average deductible
Effective deductible
Effective pre-deductible coinsurance rate
Effective post-deductible coinsurance rate
Effective non-deductible cost-sharing
Effective claims ceiling
Level 2K: Other than Self-only Medical Effective Parameters Collected only if ≤ 80% of total allowed costs for medical EHB services for self-only coverage under the standard plan are not subject to the deductible, and the plan has separate parameters for self-only and other than self-only coverage, and separate effective parameters for medical and pharmaceutical services.
Average deductible
Effective deductible
Effective pre-deductible coinsurance rate
Effective post-deductible coinsurance rate
Effective non-deductible cost-sharing
Effective claims ceiling
Level 2L: Other than Self-only Pharmaceutical Effective Parameters Collected only if ≤ 80% of total allowed costs for pharmaceutical EHB services for other than self-only coverage under the standard plan are not subject to the deductible, and the plan has separate effective parameters for self-only and other than self-only coverage, and separate effective parameters for medical and pharmaceutical services.
Average deductible
Effective deductible
Effective pre-deductible coinsurance rate
Effective post-deductible coinsurance rate
Effective non-deductible cost-sharing
Effective claims ceiling

IV. Simplified Methodology: Plan and Policy Report

Information in this report would be collected only from QHP Issuers who selected the simplified CSR reconciliation methodology with ≥12,000 member months in the associated standard plan (in and out of Exchange).

Level 3 elements are collected only if the issuer has submitted effective parameters for the QHP Plan under the “Simplified Methodology: Effective Parameters Report” such that:

• If effective parameters were submitted for only self-only coverage, the QHP issuer should submit information for Levels 3A-3C, as applicable.

• If effective parameters were submitted for only self-only and other than self-only coverage, the QHP issuer should submit information for Levels 3A-3F, as applicable.

• If effective medical and pharmaceutical parameters were submitted for only self-only coverage, the QHP issuer should submit information for Levels 3G-3L, as applicable.

• If effective medical and pharmaceutical parameters were submitted for self-only coverage and other than self-only coverage, the QHP issuer should submit information for Levels 3G-3R, as applicable.

Data Element	Description/Notes
Level 1: Plan Information
16 digit QHP ID
Total Annual Premium
Total Allowed Costs for EHB
Total Actual Amount the Issuer paid for EHB
Total Actual Amount Paid for EHB by Enrollees
Total Actual Amount for EHB Enrollees would have paid in the Standard Plan
Total Actual Value of CSR Provided
Total Actual CSR Advanced to issuer (optional)
Level 2: Policy Information
Exchange Assigned Subscriber ID
Plan Benefit Start Date
Plan Benefit End Date
Total Monthly Premium for this Policy
Is policy self-only coverage or other than self-only coverage?	Self-only or other than self-only (Other submission field will grey out depending on response.)
Does policy fall into formula A, B, or C?	A, B, or C. (Other submission fields will grey out depending on response.)
Data Element	Description/Notes
Total CSR provided for this policy	For the simplified methodology, CSR provided is the sum of actual CSR amounts provided for all subgroups on this policy; for example, if a policy has separate medical and pharmaceutical parameters, actual CSR provided must be calculated separately and added together.
Level 3A: Formula A Total Self-only Actual CSR Amounts If total allowed costs for EHB for the policy ≤ the effective deductible.
Total allowed cost for EHB by policy
Total cost-sharing subscriber would have paid under the standard plan
Total subscriber cost sharing for the benefit year
Total actual CSR amounts
Level 3B: Formula B Total Self-only Actual CSR Amounts If total allowed costs for EHB for the policy > effective deductible and in-network costs less than the effective claims ceiling.
Total allowed EHB costs, subject to a deductible for policy
Total cost-sharing subscriber would have paid under the standard plan
Total subscriber cost sharing for the benefit year
Total actual CSR amounts
Level 3C: Formula C Total Self-only Actual CSR Amounts If total allowed costs for EHB for the policy > the effective claims ceiling. (Note issuer may choose to use the annual limitation on cost-sharing or standard methodology to calculate cost-sharing under the standard plan.)
Annual limitation on cost sharing for the standard plan ­
Total allowed costs for EHB
Total cost-sharing subscriber would have paid under the standard plan
Total subscriber cost sharing for the benefit year
Total actual CSR amounts
Level 3D: Formula A Total Other than Self-only Actual CSR Amounts If total allowed costs for EHB for the policy ≤ the effective deductible, plan has separate effective parameters for self-only and other than self-only coverage.
Total allowed cost for EHB by policy
Total cost-sharing subscriber would have paid under the standard plan
Total subscriber cost sharing for the benefit year
Total actual CSR amounts
Data Elements	Description/ Notes
Level 3E: Formula B Total Other than Self-only Actual CSR Amounts If total allowed costs for EHB for the policy > effective deductible and in-network costs less than the effective claims ceiling, plan has separate parameters for self-only and other than self-only coverage.
Total allowed EHB costs, subject to a deductible for policy
Total cost-sharing subscriber would have paid under the standard plan
Total subscriber cost sharing for the benefit year
Total actual CSR amounts
Level 3F: Formula C Total Other than Self-only Actual CSR Amounts If total allowed costs for EHB for the policy > the effective claims ceiling, and plan has separate parameters from self and other than self-only. (Note issuer may choose to use the annual limitation on cost-sharing or standard methodology to calculate cost-sharing under the standard plan.)
Annual limitation on cost sharing for the standard plan ­
Total allowed costs for EHB
Total cost-sharing subscriber would have paid under the standard plan
Total subscriber cost sharing for the benefit year
Total actual CSR amounts
Level 3G: Formula A Total Self-only Actual Medical CSR Amounts If total allowed costs for medical EHB services for the policy ≤ the effective deductible, and the plan has separate effective parameters for medical and pharmaceutical services.
Total allowed cost for medical EHB by policy
Total cost-sharing subscriber would have paid under the standard plan
Total subscriber cost sharing for the benefit year
Total actual CSR amounts
Level 3H: Formula B Total Self-only Actual Medical CSR Amounts If total allowed costs for medical EHB services for the policy > effective deductible and in-network costs less than the effective claims ceiling, and the plan has separate effective parameters for medical and pharmaceutical services.
Total allowed medical EHB costs, subject to a deductible for each policy
Total cost-sharing subscriber would have paid under the standard plan
Total subscriber cost sharing for the benefit year
Total actual CSR amounts
Level 3I: Formula C Total Self-only Actual Medical CSR Amounts If total allowed costs for medical EHB services for the policy > the effective claims ceiling, and plan has separate effective parameters for medical and pharmaceutical services. (Note issuer may choose to use the annual limitation on cost-sharing or standard methodology to calculate cost-sharing under the standard plan.)
Annual limitation on cost sharing for the standard plan ­
Total allowed costs for medical EHB
Data Elements	Description/Notes
Total cost-sharing subscriber would have paid under the standard plan
Total subscriber cost sharing for the benefit year
Total actual CSR amounts
Level 3J: Formula A Total Self-only Actual Pharmaceutical CSR Amounts If total allowed costs for pharmaceutical EHB services for the policy ≤ the effective deductible, and the plan has separate effective parameters for medical and pharmaceutical services.
Total allowed cost for pharmaceutical EHB by policy
Total cost-sharing subscriber would have paid under the standard plan
Total subscriber cost sharing for the benefit year
Total actual CSR amounts
Level 3K: Formula B Total Self-only Actual Pharmaceutical CSR Amounts If total allowed costs for pharmaceutical EHB services for the policy > effective deductible and in-network costs less than the effective claims ceiling, and the plan has separate effective parameters for medical and pharmaceutical services.
Total allowed pharmaceutical EHB costs, subject to a deductible for each policy
Total cost-sharing subscriber would have paid under the standard plan
Total member cost sharing for the benefit year
Total actual CSR amounts
Level 3L: Formula C Total Self-only Actual Pharmaceutical CSR Amounts If total allowed costs for pharmaceutical EHB services > the effective claims ceiling, and plan has separate effective parameters for medical and pharmaceutical. (Note issuer may choose to use the annual limitation on cost-sharing or standard methodology to calculate cost-sharing under the standard plan.)
Other than self-only annual limitation on cost sharing for the standard plan ­
Total allowed costs for pharmaceutical EHB
Total cost-sharing subscriber would have paid under the standard plan
Total member cost sharing for the benefit year
Total actual CSR amounts
Level 3M: Formula A Total Other than Self-only Actual Medical CSR Amounts If total allowed costs for medical EHB services for the policy ≤ the effective deductible, and the plan has separate parameters for self-only and other than self-only coverage, and separate effective parameters for medical and pharmaceutical services.
Total allowed cost for pharmaceutical EHB by policy
Total cost-sharing subscriber would have paid under the standard plan
Total subscriber cost sharing for the benefit year
Total actual CSR amounts
Data Element	Description/Notes
Level 3N: Formula B Total Other than Self-only Actual Medical CSR Amounts If total allowed costs for medical EHB services for the policy > effective deductible and in-network costs less than the effective claims ceiling, the plan has separate parameters for self-only and other than self-only coverage, and separate effective parameters for medical and pharmaceutical services.
Total allowed medical EHB costs, subject to a deductible for each policy
Total cost-sharing subscriber would have paid under the standard plan
Total subscriber cost sharing for the benefit year
Total actual CSR amounts
Level 3O: Formula C Total Other than Self-only Actual Medical CSR Amounts If total allowed costs for medical EHB services for the policy > the effective claims ceiling and plan has separate parameters for self-only and other than self-only, the plan has separate parameters for self-only and other than self-only, and separate effective parameters for medical and pharmaceutical services. (Note issuer may choose to use the annual limitation on cost-sharing or standard methodology to calculate cost-sharing under the standard plan.)
Annual limitation on cost sharing for the standard plan ­
Total allowed costs for medical EHB
Total cost-sharing subscriber would have paid under the standard plan
Total subscriber cost sharing for the benefit year
Total actual CSR amounts
Level 3P: Formula A Total Other than Self-only Actual Pharmaceutical CSR Amounts If total allowed costs for pharmaceutical EHB services for the policy ≤ the effective deductible, the plan has separate parameters for self-only and other than self-only coverage, and separate effective parameters for medical and pharmaceutical services.
Total allowed cost for medical EHB by policy
Total cost-sharing subscriber would have paid under the standard plan
Total subscriber cost sharing for the benefit year
Total actual CSR amounts
Level 3Q: Formula B Total Other than Self-only Actual Pharmaceutical CSR Amounts If total allowed costs for pharmaceutical EHB services for the policy > effective deductible and in-network costs less than the effective claims ceiling, the plan has separate parameters for self-only and other than self-only coverage, and separate effective parameters for medical and pharmaceutical services.
Total allowed pharmaceutical EHB costs, subject to a deductible for each policy
Total cost-sharing subscriber would have paid under the standard plan
Total subscriber cost sharing for the benefit year
Total actual CSR amounts
Data Element	Description/Notes
Level 3R: Formula C Total Other than Self-only Actual Pharmaceutical CSR Amounts If total allowed costs for pharmaceutical EHB services > the effective claims ceiling, the plan has separate parameters for self-only and other than self-only coverage, and separate effective parameters for medical and pharmaceutical services. (Note issuer may choose to use the annual limitation on cost-sharing or standard methodology to calculate cost-sharing under the standard plan.)
Other than self-only annual limitation on cost sharing for the standard plan ­
Total allowed costs for pharmaceutical EHB
Total cost-sharing subscriber would have paid under the standard plan
Total member cost sharing for the benefit year
Total actual CSR amounts

V. Simplified AV Methodology Plan and Policy Report

Information in this report would be collected only from QHP Issuers who selected the simplified CSR reconciliation methodology with <12,000 member months in the associated standard plan.

Data Element	Description/Notes
Level 2: Plan Information
16 digit QHP ID
Total Annual Premium
Total Allowed Costs for EHB
Total Actual Amount the Issuer paid for EHB
Total Actual Amount Paid for EHB by Enrollees
Total Actual Amount for EHB Enrollees would have paid in the Standard Plan
Total Actual Value of CSR Provided
Total Actual CSR Advanced to issuer (optional)
Level 2: Policy Information
Exchange Assigned Subscriber ID
Plan Benefit Start Date
Plan Benefit End Date
Total Monthly Premium
Annual limitation on cost-sharing for the standard plan
Total allowed costs for EHB
Actuarial value amount of standard plan
Total subscriber cost sharing for the benefit year
Total actual CSR amounts	The lesser of the annual limitation 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 costs for EHB
Total CSR amount advanced to the issuer (optional)

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