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

Issue Date: January 30, 2019

Program Area: CSR Reconciliation (CSR)

Question: In REGTAP FAQ 11651 (August 22, 2015),[1] CMS expects that all claims from the 2014 benefit year will be included in 2014 benefit year data submitted for cost-sharing reduction reconciliation on April 30, 2016. If an issuer is unable to re-adjudicate and submit 2014 claims by April 30, 2016 because of appeals or other complex circumstances may the issuer submit these claims during the 2017 cost-sharing reduction reconciliation cycle?

Answer: Yes. Although CMS expects most claims from the 2014 benefit year to be included in 2014 benefit year data submitted for cost-sharing reduction reconciliation on April 30, 2016, we recognize there may be delays caused by appeals and unusual circumstances. Issuers may continue to re-adjudicate and submit claims from 2014 during the 2017 reconciliation cycle. For any 2014 claims submitted in 2017, the issuer must recalculate and restate all claims for the associated policy against the standard plan as necessary prior to a final re-adjudication of such claims for reconciliation. Such claims may not be re-adjudicated outside the associated policy or added to 2015 benefit year claims. CMS intends to provide additional guidance on the restatement of claims for a prior benefit year.

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