Form CMS-10526 CSR Reconciliation Data Elements

OMB control number: 0938-1266
Expiration date: XX/XXXX
CSR Reconciliation Data Elements

I.

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 Total count of all plan variations for the QHP
ID
issuers under this HIOS ID
Total number of Subscriber IDs for this issuer
Total actual CSR amount
Total CSR amount provided by this QHP issuer
to enrollees in all plan variations
In the case of a merger with or acquisition of
Reconciliation methodology (standard)
an issuer,The QHP issuer must submit two
sets of reports using the standard and
methodology for each issuer.

Acquisition

Acquiring issuer
Acquisition effective date

Has the issuer HIOS ID filing this
reconciliation report been acquired by another
issuer in the applicable benefit year? Enter Y
or N
HIOS ID of the acquiring issuer
Date the acquisition was final

According to the Paperwork Reduction Act of 1995, no persons are required to respond to collection information unless such
collection displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1266.
The time required to complete this information collection is estimated to average 0.0911 seconds per response, including the
time to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form,
please write to: CMS. 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-2605, Baltimore, Maryland,
21244-1850.

Data Element
1

Description/Notes

OMB control number: 0938-1266
Expiration date: XX/XXXX
CSR Reconciliation Data Elements

Merger

Merger party
Merger effective date
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

2

Has the issuer HIOS ID filing this
reconciliation report merged with another
issuer in the applicable benefit year? Enter Y
or N
HIOS ID of the other issuer(s) party in the
merger
Date the merger was final

OMB control number: 0938-1266
Expiration date: XX/XXXX
CSR Reconciliation Data Elements

Issuer attestation

Attestation that CSR amounts represent only
EHB cost-sharing amounts for which Federal
reimbursement is permitted (in the case of feefor-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 submitted a certified estimate for
cost-sharing reductions provided for 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.

I. Standard Methodology Plan and Policy Report:.
Data Element
Level 1: Plan Information (Optional)
Record Code
16 digit QHP ID

Total Annual Premium
Total Number of Exchange Subscribers in this plan

Total Allowed Costs for EHB
Total Actual Amount the Issuer paid for EHB
3

Description/Notes
Record Code at the plan level is always 02
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.
Enter the total count of unique Exchange
subscriber IDs in this plan variation for the
benefit year

Commented [AO1]: Risk corridors program no longer
exists

OMB control number: 0938-1266
Expiration date: XX/XXXX
CSR Reconciliation Data Elements

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
Level 2: Policy Information
Record Code
Record code at the policy level is always 03
16-digit 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
Exchange Assigned Policy ID
Optional ]
Policy Start Date
Optional
Policy End Date
Optional
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 of the applicable year.

Data Elements
Total Allowed Costs for EHB

Amount the Issuer Paid for EHB

4

Description/Notes
Enter the amount of claims for essential health
benefits incurred by the enrollee(s) on this
policy.
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.

OMB control number: 0938-1266
Expiration date: XX/XXXX
CSR Reconciliation Data Elements

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)

5