Form CMS-10526 CSR Reconciliation Data Elements

Cost-Sharing Reduction Reconciliation (CMS-10526)

CMS-10526 CSR Recon PRA_Collection Elementsx

Standard Methodology Plan and Policy Report

OMB: 0938-1266

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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 ID

Total count of all plan variations for the QHP 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

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.

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

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

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.

I. 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 (Optional)

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

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 for 2016

Policy Start Date

Optional for 2016

Policy End Date

Optional for 2016

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

Data Elements

Description/Notes

Total Allowed Costs for EHB

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

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-forservice 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 Element

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 selfonly 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

Data Element

Description/Notes

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 selfonly 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 (Optional)


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

Exchange Assigned Policy ID

Optional for 2016

Policy Start Date

Optional for 2016

Policy End Date

Optional for 2016

16 digit QHP 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

I f total allowed costs for EHB for the policy ≤ the effective deductible, plan has separate effective -only coverage.


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 A

ctual CSR Amounts

If total allowed costs for EHB for the policy > effectiv

e 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 A

ctual CSR Amounts

If total allowed costs for EHB for the policy > the effe

ctive claims ceiling, and plan has separate

parameters from self and other than self-only. (Note is

suer 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 Medic

al 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 pha

rmaceutical 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 Medic

al CSR Amounts


If total allowed costs for medical EHB services for the

policy > effective deductible an

d in-network

costs less than the effective claims ceiling, and the pla and pharmaceutical services.

n has separate effective paramet

ers for medical

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 Medica

l CSR Amounts


If total allowed costs for medical EHB services for the

policy > the effective claims cei

ling, and plan

has separate effective parameters for medical and pha

rmaceutical services. (Note issu

er may choose

to use the annual limitation on cost-sharing or standar the standard plan.)

d methodology to calculate cost

Shape1 sharing under



Data Elements

Description/Notes

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 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 innetwork 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 innetwork 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 (Optional)

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

Exchange Assigned Policy ID

Optional for 2016

Policy Start Date

Optional for 2016

Policy End Date

Optional for 2016

16 digit QHP 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

Data Elements

Description/Notes

Total actual CSR amounts

The lesser of the annual limitation on costsharing 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)

20

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleCMS-10526 CSR Recon PRA_Collection Elements revision 2 (02 08 2017).pdf
SubjectCMS-10526 CSR Recon PRA_Collection Elements revision 2 (02 08 2017).pdf
AuthorARIEL NOVICK
File Modified0000-00-00
File Created2021-01-12

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