Reinsurance (RP) FAQ
Guidance for FAQ regarding Payment and Calculation / Reconciliation
Program Area: Reinsurance (RP)
Question: With regard to the Cost-Sharing Reduction (CSR) Maximum Out-of-Pocket (MOOP) adjustment for a family plan and the Detailed Reinsurance Report, if an issuer takes the individual MOOP, and adjusts that number by the standard cost-sharing silver level, would this be the accurate amount for adjusting the CSR MOOP?
Answer: A family's CSR MOOP adjustment is calculated by subtracting the MOOP of the CSR plan variant from the MOOP of the corresponding standard plan, pro-rated by the number of days in the family policy. The result is then allocated across all enrollees of that plan by each enrollee's proportion of the family's total paid claims during the policy period. For more information, issuers should refer to the Reinsurance Calculation Guide posted in the REGTAP Library under the Reinsurance program area.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: April 01, 2015
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