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

Issue Date: January 30, 2019

Program Area: CSR Reconciliation (CSR)

Question: Should issuers submit additional 2015 claims data that becomes available after the cost-sharing reductions portion of advance payments have been reconciled for the 2015 benefit year as part of the discrepancy reporting process in the summer of 2016? If additional claims data is available for 2014 benefit year claims, or the value of 2014 claims has changed due to re-adjudication, should issuers use the discrepancy reporting process in the summer of 2016 to submit additional 2014 benefit year claims data?

Answer: Pursuant to the Manual for Reconciliation of the Cost-sharing Reduction (CSR) Component of Advanced Payments for Benefit Years 2014 and 2015, issuers may submit additional 2015 data that becomes available after the cost-sharing reductions portion of advance payments have been reconciled for the 2015 Benefit Year, during the 2016 cost-sharing reduction reconciliation reporting year cycle, in the spring of 2017. Issuers should not use the discrepancy reporting process to submit newly settled 2015 claims. Instead, issuers should submit these new or revised claims amounts in the 2016 cost-sharing reduction reconciliation cycle. Issuers that have additional or revised 2014 benefit year claims should use the discrepancy reporting process to re-adjudicate and submit policies with those new claims. CMS will not permit issuers to submit additional 2014 data during the 2016 cost-sharing reduction reconciliation reporting cycle, except in very limited circumstances. CMS will issue guidance on the data submission for the reconciliation of the cost-sharing reduction portion of advance payments for the 2016 benefit year at a later date.

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