Plans and Benefits FAQs

Template Use

Q1: What should an issuer do if their cost-sharing structure does not fit well within the templates?

If a plan’s cost-sharing structure does not fit the Plans & Benefits Template, issuers are advised to contact CMS through their Account Manager to determine the specific characteristics of the cost-sharing design that they believe would not be sufficiently captured by the Plans & Benefits Template.

If the plan’s cost-sharing structure does not fit the Plans & Benefits Template, the plan design may not be supported by the Actuarial Value (AV) Calculator, or the AV obtained using the integrated version of the calculator in the Plans & Benefits Template may not fall within the de minimis range for the plan’s metal tier. Review Section 4.1 "Unique Plan Design" of Appendix A of the QHP Application Instructions for details about how to correctly enter the AV for the plan in the Plans & Benefits Template. The plan design may also not display appropriately on HealthCare.gov. Review Section 5.10 “Plan Compare Cost-Sharing Display Rules” of Section 2G of the QHP Application Instructions for details.

Finally, for more information on how to enter cost-sharing information for a benefit with a different cost-sharing amount for telehealth, please see the Plans & Benefits FAQ Q11, also located under Template Use.

Q2: Should the Plans & Benefits Template include on-Exchange and off-Exchange stand-alone dental plans (SADPs)?

All issuers should submit the Plans & Benefits Template for SADPs for which they are seeking QHP certification, both for on-Exchange as well as for off-Exchange. CMS will review off-Exchange SADPs for QHP certification if submitted by issuers to be offered in states with a Federally-facilitated Exchange (FFE). Issuers are not required to submit to CMS off-Exchange SADPs for which they are not seeking QHP certification.

Q3: Do separate Plans & Benefits Templates need to be completed for the SHOP and Individual Markets if the issuer is submitting for both markets?

Yes, each application requires a separate Plans & Benefits Template for the SHOP and Individual Market plans. To use the same add-in file for multiple Plans & Benefits Templates, the issuer must store the add-in file in the same folder as all of the templates. CMS also recommends that the issuer not have more than one Plans & Benefits Template open at once.

Q4: Can issuers submit multiple plans in a single benefits package (for example, 3 silver plans), using the Plans & Benefits Template?

Yes, issuers can submit multiple plans (e.g., silver, bronze) in a single benefits package in the Plans & Benefits Template. All plans defined within a benefits package cover the same benefits and have the same benefit limits, but the plans may differ in cost sharing. To offer a different set of benefits and limits, issuers will need to create a new benefits package.

Q5: In the Plans & Benefits Template, how will plan variations for American Indians and Alaska Natives with household incomes above 300% of the federal poverty level (FPL), the limited cost sharing plans, be distinguished in the certification materials?

Plans are certified at the Standard Component ID level. All cost sharing plan variations, including the Zero Cost Sharing and Limited Cost Sharing plan variations, must meet the QHP certification standards to be certified. On the Cost Sharing Variance worksheet of the Plans & Benefits Template, the plan variations are distinguished by adding a code to the Standard Component Plan ID as follows:

- 00 = off-exchange variant
- 01 = on-exchange variant, or standard plan
- 02 = Zero Cost Sharing Plan Variation
- 03 = Limited Cost Sharing Plan Variation
- 04 = 73% AV Level Silver Plan Cost Sharing Reduction (CSR) plan variant
- 05 = 87% AV Level Silver Plan CSR
- 06 = 94% AV Level Silver Plan CSR

American Indians and Alaska Natives with household incomes above 300% of the FPL qualify for the Limited Cost Sharing Plan Variation (-03). The plan variation will auto-populate in the template for all plans that are required to offer it.

Q6: Are issuers required to provide coverage for all of the items and services on the Plans & Benefits Template?

No. For each State, the Plans & Benefits Template Add-in File allows issuers to easily prepopulate the Plans & Benefits Template with items and services that are EHB in a specific State. Despite this prepopulated data, issuers remain responsible for providing items and services as EHB in accordance with 45 CFR 156.115 and describing those EHB accurately on the Plans & Benefits Template. Issuers should review the relevant State’s EHB-benchmark plan to understand the items and services that are EHB. 45 CFR 156.115(b) also permits issuers to substitute certain items and services as EHB in particular circumstances. Issuers that substitute benefits in this manner are required to make corresponding changes to the Plans & Benefits Template to reflect any changes in items and services covered as EHB. The Plans & Benefits Template is designed for use by issuers in any State and without regard to any State’s EHB. Thus, there may be items and services on the Plans & Benefits template that are not EHB. In all circumstances, issuers are prohibited from providing coverage of routine non-pediatric eye exam services; long-term/custodial nursing home care; and non-medically necessary orthodontia as EHB. This is true even if the applicable State’s EHB-benchmark plan describes such items and services as covered benefits.

Q7: How do the service area ID, network ID, and formulary ID relate to the Plans & Benefits Template?

The Plans & Benefits Template includes macros that allow users to import IDs from other templates including the Service Area, Network ID, and Prescription Drug Templates. These macros populate the drop-down menus so users can select the correct IDs specific to each health plan.

Issuers must select a single service area ID, network ID, and formulary ID for each QHP in the Plans & Benefits Template. Stand-alone dental plans (SADPs) do not require a formulary ID, so SADP issuers only need to select a service area ID and network ID for each SADP.

The service area ID includes the entire service area for the plan; the network ID includes a link for consumers to get information on covered providers; and the formulary ID includes a link for consumers to get information on the formulary.

Q8: How do issuers enter coinsurance values in the Plans & Benefits Template and the Actuarial Value (AV) Calculator?

While the coinsurance values in the Plans & Benefits Template represent the percentage of costs that the enrollee pays for a given service, the coinsurance values in the AV Calculator represent the percentage of costs the issuer pays. Thus, the coinsurance values entered into the AV Calculator must be set equal to 1-X%, where X% is the coinsurance value entered in the Plans & Benefits Template. For example, if enrollees pay 10% of Specialist Visit costs, the coinsurance in the Plans & Benefits Template would be equal to 10%. The Specialist Visit coinsurance in the AV Calculator would be equal to 90% to represent the 90% of costs incurred by the issuer.

Q9: How does an Issuer enter an HSA-compatible plan at one metal level, but not at any of the other metal levels?

HSA-eligibility is designated at the plan variation level in the Cost Share Variances worksheet of the Plans & Benefits Template. One benefits package is allowed to have different HSA-eligibility designations for its included plan variations.

Q10: Are medical copay amounts considered when using the Actuarial Value (AV) Calculator macro?

Yes, medical copay amounts are considered when calculating the plan’s AV. Both the stand-alone AV Calculator and the macro "Check AV Calc" button within the Plans & Benefits Template include medical copay and coinsurance amounts in their AV calculations.

For more information on how the fields in Plans & Benefits Template map to data inputs in the stand-alone AV Calculator, please review the AV Calculator Instructions found on the QHP certification website.

Q11: How should issuers enter benefit-level cost sharing that differs based on in-person vs. virtual/telehealth settings?

If cost sharing differs based on whether the benefit is provided in-person or virtually through telehealth services, fill out the copay and/or coinsurance for the most common in-person setting for provision of that benefit. In the Benefit Explanations field, issuers should explain the cost sharing for any other settings, including for the virtual version of the benefit if applicable. Please see the Plans & Benefits webpage for more information.

Essential Health Benefit (EHB) Percent of Total Premium

Q1: Are issuers required to enter a value in the Essential Health Benefit (EHB) Percent of Total Premium field in the Plans and Benefits Template for Small Business Health Options Program (SHOP) plans?

No, issuers are not required to enter a value in the EHB Percent of Total Premium field for each SHOP market plan offered. Both the “EHB Percent of Total Premium” and “EHB Apportionment for Pediatric Dental” fields are disabled and no longer collected for SHOP plans.

Geographic and Network Coverage

Q1: What is the definition of "National Network" and how would an issuer complete this section in the Plans & Benefits Template?

Plans with a national provider network allow consumers to use providers nationwide at an in-network rate. Issuers that enter "Yes" in the National Network field should enter "Yes" in the Out of Service Area Coverage field. If an issuer has a network of providers nationwide, but does not offer in-network rates for care received from providers in the national network outside the plan's service area, then the issuer should enter "No" in the National Network field.

Q2: Can an issuer enter “Yes” in the National Network field, and enter “No” in the Out of Service Area Coverage field?

No, if a plan offers a national network, the issuer must enter “Yes” in the Out of Service Area Coverage field because the plan has in-network coverage nationwide.

Q3: How can issuers ensure that the appropriate plan type is selected when considering the plan’s network coverage?

When completing the Plans & Benefits Template, issuers must select a plan type (e.g., Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), etc.) for each plan offered. Issuers must select the plan type that matches with their state's form filings, in accordance with their state's definitions and requirements for plan type. In addition, the plan type listed in the Plans & Benefits Template must match the product type listed in the Health Insurance Oversight System (HIOS).

Q4: If an issuer contracts with a company that provides contract-based access to a national PPO network, to provide consumers in certain plans with access to a nationwide provider network outside of the primary service area, should the issuer indicate that those plans have national network coverage in the Plans & Benefits Template?

Yes, issuers that have contracts with a national provider network, either as a primary or tiered network, that allows enrollees to obtain care nationally at an in-network rate, should select "Yes" for the national network field, indicating that those plans have national network coverage.