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

Issue Date: April 13, 2016

Program Area: CSR Reconciliation (CSR)

Question: If a member enrolled in a Cost-sharing Reduction (CSR) plan for the 2014 benefit year goes into the hospital in December 2014 but is not discharged until January 2015, in which benefit year reconciliation cycle should the issuer report the claim and CSR paid? Is this a CSR provided in 2014, or in 2015?

Answer: For a hospital stay that crosses benefit years, the issuer should adjudicate CSRs based on the year for which accumulators for the CSRs applied, regardless of when the claim is presented for payment. For example, if cost sharing (co-pays, deductibles, coinsurance) for part of the hospital stay was incurred in 2014, that cost sharing and associated cost-sharing reductions should be adjudicated against 2014 benefit year plan designs, re-adjudicated with other 2014 benefit year claims, and reported as part of CSR reconciliation data for the 2014 benefit year, regardless of whether further related services for the stay were provided in 2015. However, for example, if the enrollee's entire cost for hospital coinsurance related to the stay is not incurred until 2015, such claims and associated cost-sharing reductions should be adjudicated against 2015 benefit year plan designs, re-adjudicated with other 2015 benefit year claims, and reported as part of CSR reconciliation data for the 2015 benefit year. The issuer must apply accumulators consistently for all enrollees in the standard plan and plan variations. The EDGE server data submission rules regarding discharge dates for claims that cross benefit years do not apply to the CSR reconciliation data submission.

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