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

Issue Date: May 03, 2016

Program Area: CSR Reconciliation (CSR)

Question: In the case of capitated services, what the issuer paid and what the enrollee paid does not always sum to the total allowed cost, since the issuer paid a capitated or discounted amount for the encounter. Will the Centers for Medicare & Medicaid (CMS) reject the file if these amounts do not add up?

Answer: No, files will not be rejected if the enrollee share and the amount paid by the issuer for a service do not equal the allowed cost. Issuers must use an internal pricing mechanism to determine the allowed cost of the capitated service as well as the cost of the member's share in both the Cost-sharing Reduction (CSR) plan and the standard plan.

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