Response to comment

No.	Method	Commenter Name	Commenter Organization	Comment	CMS Response	Recommendation for Next Steps
1	Email -informal feedback	Simon, Myra	AHIP	“Individual Responsibility Payment” is still in the updated list of anchors even though it’s gone from the glossary	Agree. “Individual Responsibility Payment” should be removed from the list of anchors.	CMS has submitted updated materials to OMB.
2	Email -informal feedback	Simon, Myra	AHIP	I’m working on my memo to members and in the SBC templates and completed examples you sent me I don’t see the “not applicable” option under the minimum value question. I do see the option noted in the Individual Instructions. I just want to make sure these are the right template attachments for me to send out. If they are, should we assume that the individual instructions are the guidance that issuers can rely on for any compliance reviews or enforcement activity if they put “not applicable” for that question?	Agree. CMS will update documents to include "Not Applicable" in the SBC templates and SBC sample completed templates.	CMS has submitted updated materials to OMB.
3	Email -informal feedback	Simon, Myra	AHIP	So it sounds like for the maternity example the option to work from a maternity bundle is going away. Is that right? Assuming that’s right, many plans pay maternity by bundle so SBCs maternity examples being always calculated by service might lead to significant inaccuracies in what people would really pay. I know this is probably too late for you to deal with in this round but just wanted to flag. They only brought it to me on Tuesday. And I do hope to have more details next week on how much estimates would likely be off for plans that do bundles if they can’t go that route in the SBC. Hope that helps.	Disagree. The bundle for professional obstetric care is still included in the updated calculator. The inpatient maternity bundle was separated into individual services in the updated calculator. The normal newborn service has been removed from the maternity service timeline based on feedback that it would not typically be included as a maternity service for the mother. The 2 remaining services (anesth/analgvag delivery and vaginal delivery w/o complicating diagnoses) that were previously included in the bundle have been separated and assigned different benefit categories to allow for non-bundled designs. The user may re-create the maternity bundle by assigning these two services to the same benefit category in the Maternity line item tab. This will apply the same cost sharing to both services.	No changes made to documents.
4	[email protected] - formal	Heard, Sarah	BCBSA	1. General Comments regarding changes in total allowed amounts include: • Maternity total slightly down from ~$12,800 to ~$12,600 (removal of birthing class(es), initial office visit service line items), • Diabetes total slightly down form ~$7,400 to ~$5,600 (appears due to slightly less prescription drug service line items, which comprised a vast number of items on the previous diabetes timeline), and • Fracture total slightly up from ~$1,900 to ~$2,800 (addition of generic prescription drug service line items, increase in emergency/outpatient/ambulance costs).	Disagree. • Maternity: the total cost has decreased from $12,731 to $12,687. • The diabetes and foot fracture cost changes are confirmed.	No changes made to documents.
5	[email protected] - formal	Heard, Sarah	BCBSA	2. An additional, detailed example of an issue that needs confirmation by CMS is shown in Appendix I. It illustrates an example of the problems related to radiologic examination. BCBSA is asking that this issue be confirmed as valid and not a duplicate. CMS note: In Appendix I, BCBA identified some service lines in the coverage example guides for the calculator for both the foot fracture and diabetes examples. They request us to confirm the identified items are not duplicative of each other.	Based on Acumen's review, an update to the Managing Type 2 Diabetes Guide to fix incorrect service costs has been made. 1. Fracture calculator: Acumen confirmed the new foot fracture service for 6/9 under radiologic examination is not a duplicate. The updated foot fracture narrative specifies that x-rays are ordered on the day of the injury on 6/2 and during the first follow-up visit on 6/9. 2. Fracture calculator: Acumen confirmed the line items for the date of service of 8/11 are correct. After consulting with a clinician the consensus was that the patient would receive physical therapy for a 30 minute period on 8/11. Each service line is for 15 minutes. We have included 2 service lines on 8/11 to equal 30 minutes of physical therapy. 3. Diabetes calculator: Acumen confirm the issue identified is an error and will make the correction. Specifically, Acumen indicated that the costs do appear to be mixed for a few services in the Type 2 Diabetes guide. We will update the type 2 diabetes scenario guide to include the correct costs for these services. These costs are correctly entered in the calculator.	CMS has made an update to the Managing Type 2 Diabetes Guide to fix incorrect service costs and has submitted the update to OMB.
6	[email protected] - formal	Heard, Sarah	BCBSA	3. Many of plans have an office visit cost share type that could be described as “$X Copay for the first 3 visits, then X% Coinsurance after deductible”. However, the new coverage calculator does not allow users to enter these type of benefit designs. That is, a plan cannot specifically enter a benefit cost share that has both a copay and coinsurance amount. Below are the only combinations that are possible with the way the logic is currently built. -Covered in full for x number of visits, then a copay -Covered in full for x number of visits, then a coinsurance -Covered in full for x number of visits, then deductible/copay -Covered in full for x number of visits, then deductible/coinsurance -Copay for x number of visits, then deductible/copay -Coinsurance for x number of visits, then deductible/coinsurance -While the feature to have PCP cost sharing after a set number of visits is available, it assumes that the set number of visits is either covered in full and post that the cost sharing starts.	No changes needed. Previous versions of calculator have not included the option to enter dual cost sharing - copay and coinsurance for the same benefit category. This option is not available for the 2021 Calculator updates, but we will keep in mind for future updates.	No changes made to documents.
7	[email protected] - formal	Heard, Sarah	BCBSA	4. There is no rounding logic on the element: “Total Patient Pays” amount.	The rounding rules are accurately captured in the calculator instructions. In the most recent Calculator version, the Total Patient Pays amount is rounded. Lack of rounding on that element was present in a previous version of the calculator but has been fixed.	No changes made to documents.
8	[email protected] - formal	Heard, Sarah	BCBSA	5. The Calculator still does not allow the user to enter benefit shares that have both copay and coinsurance.	Previous versions of calculator have not included the option to enter dual cost sharing - copay and coinsurance for the same benefit category. Implementing this type of benefit structure in the calculator is very complex. Acumen previously recommended against implementing this update in the calculator.	No changes made to documents.
9	[email protected] - formal	Heard, Sarah	BCBSA	6. The total coverage example costs provided to us are not matching with the CMS objections we received last year. For example, the foot fracture is still showing as $2,800, but we received an objection from CMS that it should be $1,900.	CMS is confirming the costs in the 2021 calculator have been updated to $2,800.	No changes made to documents.
10	[email protected] - formal	Heard, Sarah	BCBSA	7. There seems to be a problem with the “Single Plan Mode” option. Sometimes it works and sometimes it gives an error option. Every time it gives an error, the user must go in to “Multi-plan Mode”, calculate the amounts, and then again return to “Single Plan Mode”. Plans are not certain if that’s a problem on the plan’s end or if there is a problem with the Excel macro code.	Agree. CMS has been able to replicate this error in certain cases where the user switches between modes after entering inputs but without running the calculator.	The Calculator is now updated to address this issue. CMS has submitted updated materials to OMB. An issue with the load button on the benefit_design worksheet that prevented the button from working has also been fixed.