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

Issue Date: January 30, 2019

Program Area: CSR Reconciliation (CSR)

Question: Do the Centers for Medicare & Medicaid Services (CMS) have guidance as to how the following claim amounts should be factored into the allowed amount for the Simplified Methodology? - Capitation, i.e. prepaid amounts - Coordination of Benefits (COB) - Write-off amounts - Network discounts for in-network providers

Answer: For prepaid amounts, issuers should estimate a reasonable cost in the standard plan that is consistent with the way they calculated Simplified Methodology parameters (See REGTAP FAQ ID 15573). For COB, issuers must reduce total allowed costs and reduce what the issuer paid in both the plan variation and standard plan by the amount of the COB (FAQ ID 15101 and FAQ ID 15106). Issuers should treat write-off amounts and network discounts for in-network providers consistent with the way they treat write-off amounts and network discounts when calculating simplified methodology parameters (See REGTAP FAQ 15573).

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