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

Issue Date: January 30, 2019

Program Area: CSR Reconciliation (CSR)

Question: If a member changes variant throughout the year, how do we report this? For instance, member was in same product the entire year but moved from Variant 04 (73 Actuarial Value) to 05 (87 Actuarial Value) halfway through the year. On the CSR submission, do we report the member aggregated as being Variant 05 1/1 to 12/31? Or, do we report the member twice, once in Variant 04 from 1/1 to 5/31 and once in Variant 05 from 6/1 to 12/31? Does the same rule apply when a member goes from Silver 70 to Silver 94 and vice versa?

Answer: You report the subscriber twice. Since these are two (2) different plan variations, whether or not they have one (1) or more Subscriber IDs, the issuer needs to adjudicate, re-adjudicate separately, and file two (2) separate Policy Detail records, whether or not the issuer also is required to carry over accumulators. When the subscriber moves from the standard Silver Plan 70 (no CSRs) to the Silver 94 and then back to Silver 70, there would be one (1) Policy Detail record, for the Silver 94, since that is the only CSR plan. However, accumulators must transfer if there is no gap, or, if there is a gap, accumulators may transfer depending on issuer policy.

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