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 an issuer's cost-sharing structure does not fit within a template, the Centers for Medicare & Medicaid Services (CMS) recommends that the issuer fill out the copay and/or coinsurance that is typical for most enrollees (i.e., highest utilization).

In the Benefit Explanation field of the Plans & Benefits Template, issuers should add appropriate and brief detail describing the cost sharing in other scenarios outside of the most common one already entered on the Cost Share Variances worksheet. Issuers should also ensure that the cost-sharing differences are clear in the Plan Brochure and Summary of Benefits and Coverage document, which consumers can access via the URLs that issuers submit.

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.

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

All issuers should submit templates 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 and 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 and Benefits Template for the SHOP and Individual market plans. To use the same add-in file for multiple Plans and Benefits Templates, the issuer must store the add-in file in the same folder as all of the templates. We also recommend that the issuer not have more than one Plans and Benefits Template open at once.

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

Yes, issuers can submit multiple plans (e.g., silver, bronze) in a single Benefits Package in the Plans and 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, you will need to create a new Benefits Package.

Q5: In the Plans and Benefits Template, how will plan variations for American Indians 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 and 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 Federal Poverty Level (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 the services outlined in 45 CFR 156.115(d), even if they are on the Plans & Benefits Template marked as EHB?

Issuers are not required to provide routine non-pediatric dental; routine, non-pediatric eye exam services; long-term/custodial nursing home care; and non-medically necessary orthodontia, which are listed at 45 CFR 156.115(d) as not being EHB. . This is true even if the applicable EHB-benchmark plan covers these services. Information on the state-specific EHB benchmark benefits is provided on the Centers for Medicare & Medicaid Services website.

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 and Benefits template and the Actuarial Value (AV) Calculator?

While the coinsurance values in the Plans and 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 and Benefits template. For example, if enrollees pay 10% of Specialist Visit costs, the coinsurance in the Plans and 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 tab of the Plans and 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 varies on the basis of place of service or provider type?

If cost sharing varies on the basis of place of service or provider type, ensure that no benefit already specifically applies to the place of service or provider type. If none of the available fields fit the desired benefit, fill out the highest copay and/or coinsurance a consumer could encounter accessing this benefit. In the Benefit Explanations field, issuers should briefly communicate the range of cost sharing (from lowest to highest) and any reasons for the variation. Please see the QHP Application Instructions 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 and 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 and 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 and 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 and 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.