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

Issue Date: April 19, 2016

Program Area: CSR Reconciliation (CSR)

Question: Should we include actual claims from the standard plan when an enrollee moves from the standard plan to a plan variation and accumulators must be transferred to the plan variation? Do the Centers for Medicare & Medicaid (CMS) want to see the claims?

Answer: For Cost-sharing Reductions (CSR) reconciliation, issuers should not include claims adjudicated under a standard plan when an enrollee switches to a plan variation of that standard plan and the accumulators must be transferred; however, when an enrollee moves to a plan variation of the same Qualified Health Plan (QHP) plan, issuers must carry over cost sharing amounts paid by the enrollee that accumulated to the Maximum Out of Pocket (MOOP) of the standard plan. This means the accumulator amount in the new CSR plan would be reduced by the amount that had accumulated to the standard plan MOOP from cost sharing paid by the enrollee on claims in the standard plan. The claims themselves are not carried over or reported. As discussed in REGTAP FAQ 14892, prior to re-adjudication of claims for the purpose of cost-sharing reduction reconciliation, if the issuer has reduced the plan variation MOOP amount by the amount accumulated from a previous standard plan or plan variation, the issuer must also reduce the associated standard plan's maximum out of pocket amount by the same amount, to accurately determine what the enrollee would have paid in the standard plan.

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