How to Use the Cost Sharing Tool
Did you know that CMS provides review tools that issuers and states can use to prepare for the QHP Application process?
These review tools allow you to check for errors within your QHP Application that
would result in corrections after submission. Issuers are encouraged to use these tools
to identify and correct data errors prior to submitting application data,
in order to reduce the number of required corrections identified during CMS’s reviews.
States are encouraged to use these tools during their reviews to identify potential
errors in their issuers’ application data that would require issuers to make corrections.
The Cost Sharing Tool runs five different reviews to help ensure that health plans
satisfy the cost sharing standards for QHP certification.
These five reviews include: The Maximum Out of Pocket Review,
The Cost Sharing Reduction Plan Variation Review, The Standardized Plan Options Review,
The Catastrophic Plan Review, and The Expanded Bronze Plan Review.
The tool gives you the option to run each review separately, or all at once.
To use the Cost Sharing Tool, you will need a populated Master Review Tool, with data from:
the Plans & Benefits Template,
the Service Area Template, and the Prescription Drug Template.
To download the Cost Sharing Tool, visit the Review Tools webpage of the
QHP certification website and click on the Automated Review Tools link.
A .zip file will be downloaded to your computer. Within this .zip file,
you’ll see several of the stand-alone review tools, including the Cost Sharing Tool.
Open the tool in Excel, and enable macros. Read the “Instructions” tab carefully before beginning.
In Step 2 on the “Instructions” tab, click on the “Import Cost Sharing Data” button, and select the
Master Review Tool workbook you are using. Step 3 asks if you want to run the reviews
for on-Exchange plans, off-Exchange plans, or plans offered both on- and off-Exchange.
Select the appropriate option from the drop-down menu so the results will be accurate.
You can run each analysis individually and review the corresponding tab for the results,
or you can run all the analyses together at the end.
The first review in the Cost Sharing Tool is the Maximum Out of Pocket, or MOOP review.
The MOOP review ensures that the plans’ MOOP values are within the allowable limits.
The MOOP limits are market-wide standards that apply to all plans.
The MOOP review only checks standard plans—not plan variations. You will be able to check the
MOOP for plan variations during the Cost Sharing Reduction Plan Variation review.
In Step 4a, the MOOP values have been pre-populated based on CMS guidelines,
but you may update the MOOP limits based on state-specific standards.
Note that the MOOP limits shown in this video are examples, and do not necessarily reflect
the MOOP limits for the upcoming plan year. After you’ve confirmed the MOOP values,
click the “Run MOOP Analysis” button in Step 4a to run this analysis now. When you run the MOOP review,
results will populate on the “Maximum Out of Pocket” tab.
The second review in this tool is the Cost Sharing Reduction, or CSR, Plan Variation Review. This
review ensures that each plan offers the required plan variations in compliance with defined MOOP
deductible limits, among other requirements. The CSR Plan Variation Review also checks that
successive cost sharing requirements are met. This review ensures that, when comparing two plans,
the plan with the higher actuarial value, or AV, has equal or lower cost-sharing. As the AV
of a plan variation increases, its cost sharing values must decrease.
For more information on successive cost sharing requirements,
reference the “Successive Cost Sharing” tab. The CSR Plan Variation Review is only applicable
to Individual plans on the Exchange. CSR requirements do not apply to Catastrophic plans.
To run the analysis now, click the “Run CSR Analysis” button in Step 4b.
The “Cost Sharing Reduction” tab outlines the specific requirements each plan variation must
meet in order to pass the CSR Plan Variation Review. Once you run the review, plan data
will populate the relevant fields on this tab. When you run the CSR Plan Variation Review,
the results will populate on the “Detailed CSR Results” tab.
The third review in this tool is the Standardized Plan Options Review.
This analysis checks every plan that is listed as using a standardized plan option
in the “Design Type” field of the Plans & Benefits Template conforms with the
cost sharing values designated for that state and metal level’s standardized plan.
To run the analysis now, click the “Run Standardized Plan Options Review” button. When you
run the Standardized Options review, the results will populate on the “Std. Options Results” tab.
The fourth review in this tool is the Catastrophic Plan Review.
This analysis checks that each catastrophic plan meets CMS guidelines.
The Catastrophic Plan Review is not performed for stand-alone dental plans.
In Step 4d, the MOOP and deductible values for catastrophic plans have been pre-populated based
on CMS guidelines, but you may update the values based on state-specific standards.
Note that the MOOP and deductible limits shown in this video are examples, and do not necessarily
reflect the limits for the upcoming plan year. To run the analysis now, click the
"Run Catastrophic Analysis” button in Step 4d. The “Catastrophic” tab outlines the specific
requirements a catastrophic plan must meet in order to pass the review.
Once you run the review, catastrophic plan data will populate the relevant fields on this tab.
Catastrophic Plan review results will populate on the “Detailed Catastrophic Results” tab.
The fifth and final review in the Cost Sharing Tool is the Expanded Bronze Plan Review.
This analysis checks that each Expanded Bronze plan meets CMS guidelines.
Expanded bronze plans must either: Meet the requirements to be a high
deductible health plan, OR
Pay for a major service before the deductible with a reasonable cost sharing structure.
The list of major services is provided in Step 4e.
The major services are: Primary Care Visits,
Specialist Visits, Emergency Room Services,
Inpatient Hospital Services, Generic Drugs,
Preferred Brand Drugs, and Specialty Drugs.
Reasonable cost sharing is defined as a coinsurance less than or equal to 50%,
or an equivalent copay. Default cost sharing values
are pre-populated in Step 4e, but can be updated according to state-specific standards.
To run the analysis now, click the “Run Expanded Bronze Plan Review” button in Step 4e. You will
receive a warning message reminding you to return to step 4e to update the default copay parameters,
if you have not already. Note that if you do not update these values, the review will not run
properly. When you run the Expanded Bronze Plan review, the results will populate on
the “Expanded Bronze Plan Results” tab. If you ran each analysis individually,
review the appropriate tabs to determine the corrections that need to be made.
To run all four reviews simultaneously, proceed to Step 5 and click the
"Run Cost Sharing Analysis” button. Running the tool could take several minutes.
You may receive a message notifying you that no plans were reviewed during one or more of
the four analyses. For instance, if there are no catastrophic plans in the Master Review Tool
that was uploaded, you will receive this message. This is not an error message—it
is just a notification to indicate not all reviews in the tool were relevant to the imported data.
Once the tool finishes running, you will see the “Cost Sharing Review Summary” tab,
which displays a summary of the results for each individual review. Use columns G
through K to identify which plans did not meet which reviews, and navigate to the appropriate
individual review results tab for more detail. Once the problem is identified, issuers will
need to make necessary corrections within one or more templates. Use caution, though,
and carefully consider how these changes would impact other certification requirements.
Once an issuer decides which action to take, they will need to correct the error by opening
the relevant template, making the appropriate changes, and validating and saving it.
The updated template will need to then be reimported into the Master Review Tool.
Then, reimport the Master Review Tool into the Cost Sharing Tool, rerun the tool, and repeat
the review process until all plans meet the cost sharing requirements for each individual review,
indicated in Columns G through K of the “Cost Sharing Review Summary” tab.
Now let’s review examples of corrections users may receive when using the tool,
and how issuers can resolve them. After importing the relevant data and
running the tool, the “Cost Sharing Reduction” tab shows two plans that did not pass the CSR Review.
The first plan listed does not meet two requirements listed on the Cost Sharing Reduction tab.
The first correction occurs within the Zero Cost Sharing Plan Variation section. The criteria
not met reads: Cost sharing for EHBs in the zero cost sharing plan variation must be $0 or 0%.
The first plan’s other correction occurs within the Limited Cost Sharing Plan Variation section.
The criteria not met reads: MOOP for limited cost sharing plan variation
must be the same as standard plan. The second plan listed on the Cost
Sharing Reduction tab does not meet one cost sharing requirement, which occurs in the
Silver Plan Variations section. The criteria not met reads: Cost sharing for all EHBs
must follow the successive cost sharing rule. Now that we generally know which criteria the
plans did not meet, we can view more detailed information on the Detailed CSR Results tab.
For each correction, the tab shows the HIOS Plan ID Standard Component,
the plan variation type, the requirement that was not met, the benefit/field affected,
and a detailed description of the correction. The detailed descriptions are linked within
the tool to the cells that contain errors. Example 1: Clicking on the first correction’s
description navigates to the cell that contains the total In Network Individual MOOP value
of the affected plan in the Data Input tab. The value in this cell is “$7,150.” The total
In Network Individual MOOP of the standard variation of the same plan is “$7,350.”
To meet the criteria, the standard plan and the limited cost sharing plan variation’s cost
sharing structures must be the same. Therefore, one of the values in question must be changed.
In this example, we will adjust the limited cost sharing plan variation’s total In Network
Individual MOOP to be equal to the standard variation’s total In Network Individual MOOP.
To make this correction, open the Plans & Benefits template and navigate to the appropriate
“Cost Share Variances” worksheet, where the plan’s cost sharing information was entered.
Locate the limited cost sharing plan variation of the plan and its total
In Network Individual MOOP field. Since the standard plan and limited cost sharing plan
variation must have the same cost sharing values, correct this value to be $7,350.
Once the correction is made, save the template and navigate back to the Detailed CSR Results
tab in the Cost Sharing Tool to continue reviewing corrections.
Example 2: The next row on the Detailed CSR Results tab shows
that a zero cost sharing plan variation’s cost sharing values are not compliant.
Zero cost sharing plan variations cannot have non-zero cost sharing values for EHBs that are
covered by the standard plan variation. That is, if the standard plan covers the benefit,
the cost sharing value must be $0 or 0% for the zero cost sharing plan variation.
In this scenario, the copay for a Specialist Visit In Network (Tier 1) is $10, when it should be $0.
Clicking on the issue description navigates to the affected cell in the Data Input tab.
Review the details here, and then reopen the same Plans & Benefits Template that was previously corrected.
Navigate to the Cost Share Variances worksheet where this plan’s cost sharing information is stored.
Locate the correct Plan ID and its Specialist Visit In Network (Tier 1)
cost sharing section, and change the copay from $10
to $0. Save the template, and return to the Detailed CSR Results tab of the Cost Sharing Tool.
Example 3: The final two rows on the Detailed CSR Results tab show that successive cost sharing
standards were not followed for two different essential health benefits for one of the plans.
In the first scenario, successive cost sharing is not followed between the standard silver plan
and the 73% AV silver plan variation for the In Network (Tier 1) copay for Generic Drugs.
In the second scenario, successive cost sharing is not followed between the same two
silver plan variations for the In Network (Tier 1) coinsurance for Urgent Care Centers or Facilities.
Clicking on each of these issue descriptions navigates to the affected cell in the Data Input tab.
For both scenarios, make sure you’re looking at values for both the standard silver plan,
and the 73% AV silver plan variation.
The successive cost sharing rule tells us that when comparing two plans, the plan with the higher
AV should always be an equal or lesser value to the consumer than the plan with the lower AV.
For the first scenario, the standard silver plan’s copay for the In Network (Tier 1)
Generic Drugs is $20, and the 73% AV silver plan variation’s copay for the same benefit
is $30. The 73% AV plan variation’s copay must be equal to or less than the standard silver
plan’s copay, and needs to be corrected. The successive cost sharing rule also
tells us that the cost sharing structure for each benefit must be consistent throughout
plan variations. This means that if the standard plan requires a copay for a benefit,
all plan variations of that plan must also require a copay for that benefit, rather than coinsurance.
For the second scenario, the standard silver plan’s In Network (Tier 1) Urgent Care Centers
or Facilities cost sharing structure requires a co-pay of $100, and the 73%
AV plan variation’s cost sharing structure for the same benefit requires coinsurance of 20%.
Note that the 87 and 94% AV plan variations also require coinsurance of 20%.
For all plan variations to follow the same cost sharing structure,
either the standard silver plan and limited cost sharing plan variation need to use a coinsurance
structure (like the AV silver plan variations), or the AV silver plan variations need to use a
copay structure. In this example, we will choose to have all plan variations use a copay structure,
and adjust the values for the 73%, 87% and 94% AV silver plan variations.
Reopen the same Plans & Benefits Template that was previously corrected, and navigate to the Cost
Share Variances worksheet where this plan’s cost sharing information is stored. First, locate the
73% AV silver plan variation’s Generic Drugs In Network (Tier 1) cost sharing section. Change the
copay to be equal to or less than the standard silver plan’s $20 copay for the same benefit.
Next, locate the same plan’s Urgent Care Centers or Facilities In Network (Tier 1) cost sharing section.
Change the coinsurance values to “Not Applicable” for the 73%, 87%, and 94%
AV silver plan variations. Then, enter values for this benefit’s In Network (Tier 1) copays.
Remember: the values must be equal to or less than $100, and decrease as the AV increases.
Save the Plans & Benefits template, and return to the Cost Sharing Tool.
Review all results tabs to ensure all errors found by the tool were corrected.
Then, reimport the corrected Plans & Benefits Template into the Master Review Tool.
Save and reimport the Master Review Tool into the Cost Sharing Tool.
In step 5 on the Instructions tab, click “Clear Summary Data” to clear all of the data from the
Summary tab and “Clear Data from Section Analysis” to clear the data from the individual review tabs.
Then, click the “Run Cost Sharing Analysis” button.
The Cost Sharing Review Summary tab now shows that
all plans meet the Overall Cost Sharing Compliance Standards.
If you have questions regarding the QHP Application Review Tools,
please contact the Marketplace Service Desk at CMS_FEPS@cms.hhs.gov, or 855-CMS-1515.
For more information about the QHP Certification Process, visit www.qhpcertification.cms.gov.