Form CMS-10878 Non-Standardized Plan Option Limit Exceptions

OMB Control Number: 0938-NEW
Expiration Date: XX/XX/20XX

Non-Standardized Plan Option Limit Exception Justification Form
Background
In the Notice of Benefit and Payment Parameters (NBPP) for 2025 Proposed Rule, CMS
proposed an exceptions process at new §§ 156.202(d) and (e) that would permit issuers
offering Qualified Health Plans (QHPs) through the Federally-facilitated Exchanges (FFEs) and
State-based Exchanges on the Federal Platform (SBE-FPs) to offer more than two nonstandardized plan options per product network type, metal level, inclusion of dental and/or
vision benefit coverage, and service area for PY 2025 and subsequent plan years, if issuers
demonstrate that these additional non-standardized plan options beyond the limit at §
156.202(b) have specific design features that would substantially benefit consumers with
chronic and high-cost conditions.
Specifically, pursuant to proposed § 156.202(d), FFE and SBE-FP issuers would be permitted
to offer more than two non-standardized plan options if these additional plans’ cost sharing for
benefits pertaining to the treatment of chronic and high-cost conditions (including benefits in
the form of prescription drugs, if pertaining to the treatment of the condition(s)) is at least 25
percent lower, as applied without restriction in scope throughout the plan year, than the cost
sharing for the same corresponding benefits in an issuer’s other non-standardized plan option
offerings in the same product network type, metal level, and service area.
Additionally, as part of this proposed exceptions process, at proposed § 156.202(e), issuers
would be required to submit a written justification in a form and manner and at a time
prescribed by CMS that provides additional details and explains how the particular plan design
the issuer desires to offer above the non-standardized plan option limit of two satisfies the
proposed standards for receiving an exception to this limit – namely, how the particular plan
design would substantially benefit consumers with chronic and high-cost conditions.
Instructions for Submitting a Non-Standardized Plan Option Limit Exception
Justification Form
First, provide the information requested below in order to identify the non-standardized plan
option(s) you desire to have excepted from the non-standardized plan option limit at 45 C.F.R.
156.202(b), in accordance with proposed §§ 156.202(d) and (e).
Next, respond to each of the three questions below, ensuring to thoroughly substantiate each
response. You must respond completely to each of the three questions; otherwise your request
may be denied. After completing this form, combine it, along with any supplementary evidence
you are providing to substantiate your responses, into a single PDF file.
Name the combined file using the following convention:
[Issuer ID]_[State]_non-standardized_plan_option_limit_exception_justification_form, such as:
“12345_MD_non-standardized_plan_option_limit_exception_justification_form.pdf.” A separate
justification form must be submitted for each non-standardized plan option you desire to have
excepted from the non-standardized plan option limit.
After completing, combining, and naming the file, upload the combined file, along with your
completed Plans and Benefits Template, in the Plans and Benefits section of the Marketplace
Plan Management System (MPMS).
PRA DISCLOSURE: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938-NEW, expiration date is XX/XX/20XX. The time
required to complete this information collection is estimated to take 850 hours annually for all FFE and SBE-FP issuers. If you have 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 C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records
or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the
information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you
have questions or concerns regarding where to submit your documents, please contact Nikolas Berkobien at [email protected].

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Clear Form

Provide the following information in order to identify the non-standardized option you desire to
have excepted from the non-standardized plan option limit:
Health Insurance Oversight System (HIOS) Issuer ID:
Issuer State:
HIOS Plan ID:
Plan Marketing Name:
HIOS Product ID:
Network ID:
Service Area ID:
Formulary ID:
New/Existing Plan:
Plan Type:
Level of Coverage:

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Question 1: Identify the specific chronic and high-cost condition(s) that this additional nonstandardized plan option is intended for.

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Question 2: Explain which benefit(s) within the Plans and Benefits Template would have
reduced annual enrollee cost sharing (as opposed to reduced cost sharing for a limited number
of visits) for the treatment of the specified condition(s) by 25 percent or more relative to the cost
sharing for the same corresponding benefits in your other non-standardized plan offerings in
the same product network type, metal level, and service area.

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Question 3: Explain how the reduced cost sharing for these services pertains to clinically
indicated guidelines for treatment of the specified chronic and high-cost condition(s). Include
any relevant studies, guidelines, or supplementary documents, as applicable.

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