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

Issue Date: March 11, 2016

Program Area: CSR Reconciliation (CSR)

Question: Both the Plan Summary Record and the Policy Summary Record include claims information in the form of allowed costs and amount the issuer paid for EHB, etc. Should the claim amounts include both in and out of network claims? Should the claims amounts include or exclude certain fees such as pooling charges, access fees, HCRA surcharges, prompt pay interest, and provider incentive payments?

Answer: Out-of -network claims are generally not eligible for cost-sharing reductions and do not need to be included. However, if the plan variation provides cost-sharing reductions on out-of-network services, they should be included (for example, with the zero cost-sharing plan variation, cost-sharing reductions are required because the enrollee pays no cost sharing for essential health benefits (EHBs), in-network or out-of-network, as long as the associated standard plan also covers EHB out of network).. If the standard plan does not cover EHB out of network, then CMS will not reimburse issuers for any cost sharing reduction provided to an enrollee for such non covered services. Total allowed costs for essential health benefits do not include fees, charges, interest or any other administrative costs for the issuer.

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