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

Issue Date: March 21, 2016

Program Area: CSR Reconciliation (CSR)

Question: Do Cost-sharing Reduction (CSR) subsidies only apply to in-network Essential Health Benefits (EHB)?

Answer: Plans are permitted to provide cost-sharing reductions on covered out-of-network EHB benefits, for example to simplify plan design. In such cases, the issuer is permitted to include these out-of-network EHB claims when calculating cost-sharing reductions provided. Additionally, in the zero cost-sharing plan for American Indians/Alaska Natives, enrollees pay no cost sharing for 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. See 78 FR 15481 (March 11, 2013) for discussion of 156.130(c), under which a plan is not required to count out-of-network cost sharing toward the annual limitation or reduced annual limitation on cost sharing.

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.