Form CMS-10488 Data Collection Instructions

Dear [Issuer],

On February 20, 2015, HHS published a final rule “Final HHS Notice of Benefit and Payment Parameters for 2016” (CMS-9954-F, 80 Fed Reg 10750). HHS also published an information collection summary in accordance with the Paperwork Reduction Act of 1995 (CMS-10448).

This rule and information collection summary authorize collection of data from certain issuers in order to establish State-specific Essential Health Benefits (EHB) benchmark plans. Specifically, we are collecting data from the largest plan in the three largest health insurance products in each State, based on enrollment data as of March 31, 2014.  The information collected will allow us to determine which benefits are covered if your plan is identified as the default benchmark plan and [State] does not select their own benchmark plan. 

Based on our analysis of enrollment data, we have identified the following product(s) as one of the three largest products in the small group market in [State].  If you believe this determination is in error, please notify the Centers for Medicare & Medicaid Services (CMS) immediately at [email protected]. 

Product ID	[insert ID #]
Product Name	[insert name]
Product Type	[insert type]

Pursuant to 45 CFR 156.120, we are requesting information about the largest plan within the product(s) identified above, as of March 31, 2014. Please provide the following information:

       Plan Name;

       Plan ID;

       Certificate of coverage and any other plan documents that describe covered services, exclusions, limitations, cost sharing and all other terms and conditions of plan benefits; and

       List of RxCUIs. If you have previously provided CMS with a prescription drug template listing your covered drugs by RxCUI, you may send that plan’s prescription drug template again to fulfill this request for drug coverage. If you have not provided the complete list of prescription drugs covered by the plan, please submit an Excel file listing RxCUIs.  We have attached a spreadsheet for your convenience. 

Please submit this information via email to [email protected] no later than [due date].  We intend to support you in this data collection effort as much as possible.  Please email us with any questions or concerns.

Sincerely,

Lourdes Grindal-Miller

Director, Exchanges Policy and Operations Group