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

Issue Date: January 30, 2019

Program Area: CSR Reconciliation (CSR)

Question: Related to excluding claims that are 100% covered (e.g. preventive care) from total allowed costs, does this guidance apply only to the Standard Methodology or does it also apply to the Simplified Actuarial Value (AV) Methodology? The AV reflects preventive care covered at 100% and excluding these claims from the total allowed creates a disconnect between the AV and our understanding of the Simplified AV Methodology.

Answer: Issuers using the Simplified AV Methodology should include claims that are 100% covered in total allowed costs for Essential Health Benefits (EHB) when determining standard plan cost, since the actuarial value of a plan is calculated based on cost sharing for all services.

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