Plans and Benefits

All issuers are required to provide the following data on their health plans:
  • Plan identifiers
  • Plan attributes
  • URLs
  • Covered benefits and their limits
  • Cost-sharing information
Issuers enter this plan data in the Plans and Benefits Template, which consists of two worksheets: the benefits package worksheet and the cost share variances worksheet.

Issuers must also indicate essential health benefit (EHB) benchmark plan coverage requirements. To reflect these requirements, the Plans and Benefits Add-in file populates state- and market-specific EHB benchmark data in the benefits package worksheet.

Key Changes for PY20:

  • The EHB benchmark, which is populated through the Refresh EHB button in the Plans & Benefits Add-In, has been updated to reflect plan year changes.
  • Catastrophic plans will be required to have a “Child-Only Offering” value of “Allows Adult and Child-Only” to validate.
  • After running the Actuarial Value Calculator (AVC), if AVC screenshots are saved, they will each be on an Excel tab named with the plan variant ID, as opposed to a generic “Output” name.
  • Issuers offering SADPs will be required to certify the “Issuer Actuarial Value” of each SADP’s coverage of pediatric dental EHB for PY2020. Issuers may offer the pediatric dental EHB at any actuarial value (AV).

Tips for the Plans & Benefits Section

  • Download the most recent versions of the 2020 Plans & Benefits Template, Plans & Benefits Add-In file, and AVC.
  • Save the Plans & Benefits Add-In file in the same folder as the Plans & Benefits Template for the macros to run properly.
  • All data elements that CMS anticipates displaying to individual market consumers on Plan Compare are identified by a number sign (#) next to the field name.
  • Data fields required for all issuers are identified by an asterisk (*)  in the Plans & Benefits Template. Data fields required for SADP issuers are identified by an asterisk (*) next to the field name in the Plans & Benefits Instructions document posted below. 
  • All data fields used by the AVC are identified by a caret (^) next to the field name. See Appendix A for additional AVC instructions.
  • Issuers should complete the Network, Service Area, and Prescription Drug Templates (QHPs only) and save the templates before filling out the Plans & Benefits Template. The Plans & Benefits Template requires issuers to assign a network, service area, and formulary ID to each plan based on the IDs already created in these three templates.
  • Complete a separate Benefits Package worksheet for each unique benefits package the issuer wishes to offer. To create additional benefits packages, click the Create New Benefits Package button on the menu bar under the Plans & Benefits ribbon. The HIOS Issuer ID, Issuer State, Market Coverage, Dental Only Plan, and Taxpayer Identification Number (TIN) fields are auto-populated.
  • Complete a row in the associated Cost Share Variances worksheet for each plan and associated cost-sharing reduction (CSR) plan variation the issuer wishes to offer.
  • The cost sharing entered in the Plans & Benefits Template must reflect what the consumer pays. See Appendix A for how these values relate to AV.
  • When a cell is grayed out, it is locked and cannot be edited. HIOS will not process data entered into the cell before it was grayed out.
Application Resources