CSR Reconciliation (CSR) FAQ

Guidance for FAQ regarding Cost Sharing Reduction (CSR) Reconciliation Methodology and Simplified Methodology

Program Area: CSR Reconciliation (CSR)

Question: Do Qualified Health Plan (QHP) issuers that select the Cost-sharing Reduction (CSR) reconciliation simplified methodology, as described in the Amendments to the HHS Notice of Benefit and Payment Parameters for 2014 Final Rule, available at http://www.gpo.gov/fdsys/pkg/FR-2013-10-30/pdf/2013-25326.pdf, permitted to count both on and off-Marketplace members in a standard plan for purposes of determining whether the plan meets the credibility standard described in 45 CFR 156.430(c)(4)(v)?

Answer: Qualified Health Plan (QHP) issuers that select the simplified methodology must count both on and off-Marketplace members of a standard plan (enrollees in the standard plan that purchase the plan through the Marketplace or directly from the QHP issuer) when determining whether the standard plan meets the criteria in any of subparagraphs (A)-(D) of 45 CFR 156.430(c)(4)(v). If the standard plan meets the criteria in any of the subparagraphs (it does not meet the minimum credibility standard), then the QHP issuer must calculate the amount that the enrollees in the plan variation would have paid under the standard plan without cost-sharing reductions using the actuarial value methodology, described in section 156.430(c)(4)(v).