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

Issue Date: March 11, 2016

Program Area: CSR Reconciliation (CSR)

Question: Does the total amount the issuer paid for Essential Health Benefits (EHB) include per-member-per-month payments (PMPM) by issuers for capitated arrangements, e.g. full medical, pediatric, dental, and vision benefits) and that issuers using such arrangements may estimate reasonable allowed amounts for associated encounters using their internal pricing methodology for such encounters.

Answer: Yes, the total amount the issuer paid for EHB may include a PMPM payment, if applicable. Issuers may use their internal pricing methodology to establish a cost of a medical service in a capitated pay arrangement.

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