CMS-10878 Non-Standardized Plan Option Limit Exceptions

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

Non-Standardized Plan Option Limit Exceptions Justification Form
and Actuarial Memorandum
For each non-standardized plan option found above limit per product network type, metal level,
service area, and inclusion of dental and/or vision coverage, please complete the following
justification form and actuarial memorandum.

Justification Form:

Please answer the following questions.

1. Identify the specific chronic and high-cost condition that the additional nonstandardized plan option is designed to offer substantially reduced cost sharing for.
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2. Identify which specific benefits (as well as these benefits’ interaction with deductibles
and maximum out-of-pocket limits) in the Plans and Benefits Template are discounted to
provide reduced treatment-specific cost sharing for individuals with the specified chronic
and high-cost condition. These discounts must be relative to the treatment-specific 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.
For the purposes of this standard, “treatment specific cost sharing” are the costs for obtaining
services that pertain to the treatment of a particular chronic and high-cost disease – but not the
costs for obtaining services that do not pertain to the treatment of the relevant condition. The
issuer must identify all services for which the benefits substantially reduce cost sharing in the
Plans and Benefits Template. Note that these benefits must encompass a complete list of
relevant services pertaining to the treatment of the relevant condition. For example, if you intend
to offer a plan that is targeted to treatment of diabetes, list only the benefits pertaining to the
treatment of diabetes.

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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. The purpose of this information collection is to provide the
authority for CMS to collect issuer requests to be excepted from the non-standardized plan option limit in accordance with 45 C.F.R. 156.202. The time
required to complete this information collection is estimated to average 17 hours per response, including the time to review instructions, search existing
data resources, gather the data needed, to review and complete the information collection. This information collection will allow issuers to request to be
excepted from the non-standardized plan option limit so they are able to offer additional health plans that substantially benefit consumers with chronic
and high-cost conditions. Responses to this collection are required for issuers to be excepted from the non-standardized plan option limit at 45 C.F.R.
156.202. All information collected will be kept private in accordance with regulations at 45 C.F.R. 155.260, Privacy and Security of Personally Identifiable
Information. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850, Attention: Information Collections Clearance Officer, or email Nikolas
Berkobien at [email protected].

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2025 QHP Application Instructions

3. Explain how the reduced cost sharing for these services pertains to clinically indicated
guidelines and a representative treatment scenario for treatment of the specified chronic
and high-cost condition. Include any relevant studies, guidelines, or supplementary
documents to support your application.
For the purposes of this standard, a representative treatment scenario is an annual course of
treatment for a chronic and high-cost condition. For example, if you listed benefits/services
pertaining to the treatment of diabetes in the previous question, explain, or provide external
reference to, a clinically indicated treatment scenario/guideline that recommends the use of
those services in treatment of diabetes.
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2025 QHP Application Instructions

Actuarial Memorandum Form:
Section 1. General Identification Section
Company Identifying Information: Click or tap here to enter text.
Company Contact Information: Click or tap here to enter text.
Market for which the plans will be offered (i.e., Individual, Small Group, or both):
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Section 2. Plan Identification
Confirm the plan IDs for which the following justification is suitable.
Correctly identify the plan ID for which the reduced cost sharing is being
demonstrated.
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Correctly identify the plan ID that will establish the baseline for the cost sharing
comparison.
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Section 3. Demonstrating Reduced Cost Sharing
Demonstrate how the out-of-pocket costs of services specifically referenced in Question
2 of the Justification are at least 25% lower for an enrollee seeking treatment for this
condition under the exception plan compared to at least one of the identified in-limit
offerings in the same product network type, metal level, inclusion of dental and/or vision
coverage, and service area combination. Provide this demonstration specifically in
reference to the specific population that would be seeking treatment for that chronic and
high-cost condition and not the general population.
For example, if seeking to justify this plan for the population of individuals with diabetes,
demonstrate that the out-of-pocket costs of diabetes-related treatment services are at least 25%
lower over the course of the year for an enrollee in this plan compared to an in-limit offering.

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2025 QHP Application Instructions

Section 4. Actuarial Opinion & Signature
In my expert opinion as a certified actuary and member of the American Academy of
Actuaries, this analysis was prepared in accordance with the appropriate Actuarial
Standards of Practice (ASOPs) and the profession’s Code of Professional Conduct. While
other ASOPs apply, particular emphasis is placed on:
•
•
•

ASOP No. 8, Regulatory Filings for Health Benefits, Accident and Health
Insurance, and Entities Providing Health Benefits
ASOP No. 23, Data Quality
ASOP No. 41, Actuarial Communications

Name and Identifying Contact Information: Click or tap here to enter text.
Date: Click or tap here to enter text.

Signature:

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 0938-1461. This information collection is to
provide the authority for CMS to collect issuer requests to be excepted from the non-standardized plan option limit in accordance with 45 C.F.R.
156.202. This collection will allow issuers to request to be excepted from the non-standardized plan option limit so they are able to offer additional
health plans that substantially benefit consumers with chronic and high-cost conditions. The time required to complete this information collection is
estimated to average less than 17 hours per response, including the time to review instructions, search existing data resources, gather the data needed,
to review and complete the information collection. This information collection is required for issuers to be excepted from the non-standardized plan
option limit at 45 C.F.R. 156.202. All information collected will be kept private in accordance with regulations at 45 C.F.R. 155.260, Privacy and Security
of Personally Identifiable Information. Pursuant to this regulation, Marketplaces may only use or disclose personally identifiable information to the
extent that such information is necessary to carry out their statutorily and regulatorily mandated functions. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: MS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850 or [email address], Attention: Information Collections Clearance Officer.

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2025 QHP Application Instructions