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

Issue Date: February 05, 2020

Program Area: Payment Policy and Financial Management Group External Audits (PPFMG EA)

Question: For the policy level documentation (documentation request no. 4), should proof of payment for every month of enrollment be submitted?

Answer: For documentation request no. 4a, issuers should submit de-identified policy level documentation that supports the premium and APTC amounts for each month of enrollment during the benefit year. This could include screenshots from the enrollment system, actual monthly invoices that are sent to the subscriber, or any other documentation that includes, at a minimum, information about the period of coverage and the corresponding premium and APTC amounts. For documentation request no. 4b, issuers should submit de-identified documentation that shows that the enrollment for the subscriber was actually effectuated (i.e., that the subscriber paid the full amount of the total premium for which they were responsible during the first month of enrollment). This could include documentation such as a payment receipt, paid invoice, screenshot of a check, billing statement, etc. Proof of payment for the first month of enrollment only is required. Documentation submitted to fulfill request 4a may be sufficient to fulfill request 4b so long as it includes information that substantiates the receipt of the initial, full premium payment.

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