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

Issue Date: April 13, 2016

Program Area: CSR Reconciliation (CSR)

Question: If a member in a Cost-sharing Reduction (CSR) plan is admitted to the hospital prior to a grace period, and is discharged after the 30-day grace period date, how should issuers handle these claims?

Answer: The issuer should pay, adjudicate, and re-adjudicate the portion of claims with cost sharing incurred during the period the enrollee was covered, regardless of when the claim is presented for payment. The Centers for Medicare & Medicaid Services (CMS) will not reimburse issuers for cost-sharing reductions provided during the second and third months of a 90-day grace period after which the enrollee is retroactively terminated. See also REGTAP FAQ 15103.

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