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 (except for URLs, which are submitted through the Supplemental Submission Module, or SSM) 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 PY2022: 
  • The EHB percent of total premium for SHOP market QHPs is no longer collected in this template. 
  • The EHB percent of total premium calculation should be the multiplicative inverse of the Unified Rate Review Template (URRT) field titled “Benefits in Addition to EHB” when rounded to the fourth decimal point (e.g., 1 divided by Benefits in Addition to EHB).
  • Explanation is added of how individual market QHP issuers should address defrayal requirements for the portion of premium related to state required benefits in addition to the EHB.
  • The EHB apportionment for pediatric dental for SHOP market SADPs is no longer collected in this template. 

Tips for the Plans & Benefits Section

  • Download the most recent versions of the 2022 Plans & Benefits Template, Plans & Benefits Add-In file, and AVC from the QHP certification website. 
  • Save the Plans & Benefits Add-In file in the same folder as the Plans & Benefits Template so the macros will 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 in the instructions below. 
  • All data fields required for SADP issuers are identified by an asterisk (*) next to the field name in the instructions below. Follow the instructions below for details relating to the Benefits Package worksheet. For the Cost Share Variances worksheet, see sections 4.11, 4.20–4.22, 4.24, and 4.25 in this chapter.
  • All data fields used by the AVC are identified by a caret (^) next to the field name in the instructions below. See Appendix A for additional AVC instructions. 
  • Complete and save the Network, Service Area, and Prescription Drug (QHPs only) Templates before filling out the Plans & Benefits Template. The Plans & Benefits Template requires you to assign a network, service area, and formulary ID (QHPs only) to each plan based on the IDs created in these three templates.
  • Complete a separate Benefits Package worksheet for each unique benefits package you wish to offer. To create additional benefits packages, click Create New Benefits Package under the Plans & Benefits Add-In. HIOS Issuer ID, Issuer State, Market Coverage, and Dental Only Plan will auto-populate.
  • 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

SBC Instructions and Template 

Authorized for use for plan or policy years that begin on or after January 1, 2021.

Issuers offering health insurance coverage on the Exchange must provide applicants, enrollees, and policyholders with an accurate Summary of Benefits and Coverage (SBC). Issuers are required to provide the SBC in a manner compliant with the standards set forth in 45 CFR 147.200, which implements section 2715 of the Public Health Service Act, as added by the Patient Protection and Affordable Care Act (PPACA). Specifically, issuers must fully comply with the requirements of § 147.200(a)(3), which requires issuers to “provide an SBC in the form, and in accordance with the instructions for completing the SBC, that are specified by the Secretary in guidance.” Instructions for completing the SBC are below.
Please refer to the Summary of Benefits and Coverage and Uniform Glossary section of the CCIIO website for additional information, including the approved SBC Template for issuers to use when completing their SBCs. Additional regulatory guidance related to SBCs can be found in the 2022 Letter to Issuers.