Form CMS-10526 CSR Reconciliation Data Elements

OMB control number: 0938-1266

Expiration date: XX/XXXX

CSR Data Submission Elements

I. Issuer Summary Report

Information in this report would be collected from all QHP issuers offering coverage through the individual market on the Exchanges (Federally-facilitated Exchanges (FFEs), State-based Exchanges on the Federal platform (SBE-FPs), and State-based Exchanges (SBEs). 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
Reconciliation methodology (standard)	In the case of a merger with or acquisition of an issuer, the QHP issuer must submit two sets of reports using the standard methodology for each issuer.
Acquisition	Has the issuer HIOS ID filing this data submission 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 a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1266. This information collection may be used, but is not required to be used, by qualified health plan (QHP) issuers through the individual market on the Exchanges to understand the data collection and reporting requirements related to the calculation of reconciled cost-sharing reduction (CSR) amounts. This form aims to simplify the process for QHP issuers submitting CSR data particularly in the consideration of settlement and judgment amounts in litigation brought by issuers against HHS related to the lack of advance CSR payments. The time required to complete this information collection is estimated to average 15.75 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. The use of this information collection is voluntary per CMS regulations at 45 CFR
156.430(d). 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.

Data Element	Description/Notes
Merger	Has the issuer HIOS ID filing this data submission 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 (EHB) 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. . .

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
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	Description/Notes
Total Allowed Costs for EHB	Enter the amount of claims for EHBs 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-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.
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)

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