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

Issue Date: March 11, 2016

Program Area: CSR Reconciliation (CSR)

Question: What is CMS' stance on plans' inability to re-adjudicate capitated claims for the purpose of creating the base shadow claim? Is it acceptable to exclude capitated services from the reconciliation?

Answer: No. How the issuer pays for services does not affect whether or not cost-sharing reductions were provided. Services that the issuer pays for in a capitated manner should be included in cost-sharing reduction reconciliation by measuring what the enrollee paid in cost sharing for the service under the plan variation against what the enrollee would have paid for the service under the standard plan.

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