Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: March 11, 2016

Program Area: CSR Reconciliation (CSR)

Question: Can you please clarify what we should be using to calculate the allowed amount, since CMS has said both that the coordination of benefit (COB) should be included in a claim and also, in the CSR Reconciliation Issuer to MIDAS Inbound Specification document, that the amount the enrollee(s) paid is the difference between the total allowed costs for EHB and the amount the issuer paid.

Answer: Issuers should reflect adjustments for COB claims when reporting total allowed costs. However, the amount paid by the issuer or by the enrollee would be reduced, as applicable, in both the standard plan and the plan variation by any amounts that have been paid by a third party. For example, if a claim costs $500, and the auto insurer pays the issuer $250, the total allowed cost for the claim is $250 in both the standard plan and the CSR plan. If the auto issuer also pays the enrollee's $10 cost sharing, the total allowed cost remains the same at $250, of which the issuer pays $240 and the (auto insurer on behalf of the) enrollee paid $10.

HHS is committed to making its websites and documents accessible to the widest possible audience, including individuals with disabilities. We are in the process of retroactively making some documents accessible. If you need assistance accessing an accessible version of this document, please reach out to the guidance@hhs.gov.

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.