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

Issue Date: January 30, 2019

Program Area: CSR Reconciliation (CSR)

Question: How will the Centers for Medicare & Medicaid Services (CMS) validate Cost-sharing Reduction (CSR) data submitted for the purpose of reconciling the cost-sharing reduction portion of advance payments for 2014 and 2015 benefit years?

Answer: CMS performs certain technical validations, for example to ensure file transfer, and that the issuer used the applicable methodology and submitted applicable attestations, prior to accepting data files for reconciliation of the cost-sharing reduction portion of advance payments for the 2014 and 2015 benefit years. In order to help ensure the integrity of the data submitted, CMS also compares the actual CSR provided, as reported by the issuer as part of its reconciliation data submission for the applicable benefit year, to Risk Adjustment (RA) risk scores for the corresponding benefit year. CMS' identification of outliers takes into account member-month differences, as reported by the issuer when it requested Advance Payments of the Premium Tax Credit (APTC) for cost-sharing plan variations, and state-level differences in advance payments and actual CSR provided. CMS contacted issuers identified as outliers to request explanations for significant differences between actual CSR provided and RA risk scores, and to request that issuers review their data submissions to identify any reporting errors. Issuers that have identified errors should contact CSRreconquestions@cms.hhs.gov as soon as possible. Issuers that are unresolved outliers and that are owed an additional payment from the Federal government, as calculated based on the issuer's most recent submitted data file for cost-sharing reduction reconciliation for the 2014 and 2015 benefit years, will not receive a report of reconciled cost-sharing reduction amounts on June 30, 2016, and will not receive payment in August 2016. Additional cost-sharing reduction payments for these issuers will be withheld until the outlier issue is resolved. CMS will begin netting charges that result from cost-sharing reduction reconciliation from all issuers, including those that have been identified as outliers, in August 2016.* Any additional charges that the issuer may owe based on resubmissions to correct data errors will be collected in subsequent payment cycles. Additionally, an unresolved outlier may trigger a CMS audit under 45 CFR 156.480(c). * As set forth at 45 CFR 156.1215(b), CMS will net any cost-sharing reduction reconciliation charges owed by a QHP issuer to the Federal government from payments due to that issuer and its affiliates under the same taxpayer identification number in the applicable monthly payment cycle.

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