How to Use the Non-Discrimination Cost Sharing Review 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 a 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’ 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 Non-Discrimination Cost Sharing Review Tool performs an outlier analysis
and determines if any plans could potentially be discriminatory based on cost sharing values.
Note that the Non-Discrimination Cost Sharing Review Tool is only effective when loaded with
the data from all issuers in a state. Therefore, the tool will not yield meaningful results if run
without all issuers’ data. For that reason, it is not recommended that issuers use the
Non-Discrimination Cost Sharing Review Tool to determine compliance with the
review. This tool is provided to issuers to give transparency into how the review is conducted.
The Non-Discrimination Cost Sharing Review Tool is not applicable to:
Off-Exchange plans,
Catastrophic plans, or Stand-alone dental plans.
To use the Non-Discrimination Cost Sharing Review Tool,
you will need a populated Master Review Tool, with data from all relevant Plans and Benefits Templates.
To download the Non-Discrimination Cost Sharing Review 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 Non-Discrimination Cost Sharing Review Tool.
Open the tool in Excel, and enable macros. Read the “Instructions” tab carefully before beginning.
In Step 1 on the Instructions tab, click the “Populate input tabs using data from
“Master Review Tool”” button, and select the Master Review Tool you are using.
Once the data is imported, navigate to the “Input” tab to ensure all data has been imported properly.
Then return to the “Instructions” tab.
Step 3 asks you to enter the outlier multiplier you want to use for the state level outlier
calculations. The default and recommended outlier multiplier has been pre-populated to 1.5,
but you can change this value depending on state-specific standards. Please note that if
you choose to use a larger number than 1.5, the test will be easier for an issuer to pass, and
if you choose to use a lower number than 1.5, the test will be more difficult for issuers to pass.
You will then be asked if you would like to apply the more lenient standard for
benefits that are not subject to the deductible. Generally, a benefit’s cost sharing structure
is more generous to a consumer when it is not subject to a plan’s deductible.
For example, a plan which sets primary care visit cost sharing at a $35 copay not subject
to the deductible would require the enrollee to pay only $35 for a primary care visit.
Conversely, a plan which sets primary care cost sharing at a $35 copay subject to a deductible of
$1,500 would require an enrollee to pay the entire cost of their primary care visit until $1,500 is
spent on qualifying medical services, and then afterward pay only $35 per primary care visit.
For that reason, the tool gives you the option of providing some
leniency for plan benefits that are not subject to the deductible.
If you select “Yes” in step 4, and a benefit is not subject to the deductible, its copay value can
be up to two times greater than the corresponding outlier threshold before it is identified as an
outlier, and its coinsurance value can be up to 90 percent before they are identified as an outlier.
If you select “No” in step 4, a benefit’s cost sharing values cannot
exceed the outlier threshold, whether it’s subject to the deductible or not.
Step 5 asks if you would like to compare the plans in the Input tab to the national
outlier thresholds, in addition to your state-level thresholds. If you choose to
use national thresholds, the national threshold will be provided to states
once all plans are received from issuers following the initial submission deadline.
States can choose to use or ignore the national outlier threshold. Given that the national
threshold takes into account a larger number of plans and encompasses plans throughout diverse
geographic regions and markets, the national threshold is less likely to be influenced by
the cost sharing structure of a single large regional issuer than a state threshold, and may
be particularly useful in markets where the number of plans offered by the issuers in the state is
more variable or in states where there are not enough plans to calculate a state threshold.
Step 6 asks if you would like to calculate the state outlier threshold. For the tool to yield
the most accurate results, it’s recommended that states only calculate the state threshold
after data from every issuer in that state has been imported into the tool, and only calculate
the state threshold one time during the review process so that issuers are not subjected to a
moving standard during certification. This could create new corrections in plans that previously
passed the requirements, as issuers lower their cost sharing in order to meet the standard.
To calculate the state threshold, after all issuer data in that state has been uploaded,
select “yes” during this step. If you are running the tool in response to issuers’ corrections,
select “no” during this step so that new plans do not become outliers in response
to the updated data as described previously. Once you’ve finished answering all questions
on the Instructions tab, scroll to the bottom and click the “Run Tool” button.
Running the tool could take several minutes. If there are any data errors in the input tab,
an Errors tab will generate, identifying where the error is located and describing the error.
If there are no data errors, you will either be taken to the “Output_ST” or “Summary” tab. The
tab you are taken to depends on whether you incorporate the national outlier thresholds.
Both tabs utilize the same columns to display information so the following
instructions apply regardless of whether you incorporate the national thresholds.
If all plans meet the non-discrimination requirements, the “Any Issue?” column,
column E, will contain only values of “Met.” You may see a value of “Incomplete” in
column E. This means that there was not enough data for that plan to determine whether it
meets the non-discrimination requirements. And if the tool determined that there were
any plans that did not meet the non-discrimination requirements, you will see a value of “Not Met”
for those plans in column E. These plans will also be listed on the “Plans with Outliers” tab.
For the plans that do not meet the non-discrimination requirements,
or have a value of “Incomplete” in column E, you can use columns F through AL
to determine which benefits’ cost sharing values are causing the plan to be out of compliance.
For Incomplete plans, there will be a value of “Bad Data” under the benefit that’s missing data.
For plans that did not meet the non-discrimination requirement, there
will be a value of “Outlier” under the benefit that’s causing that plan to fail the review.
Review each incomplete plan and each plan that does not meet the
non-discrimination requirements carefully, and determine the corrections needed.
If corrections or updates to the data are required, once states receive updated
templates from their issuers, they should reimport them into the Master Review Tool.
Reimport the Master Review Tool into the Non-Discrimination Cost Sharing Review Tool.
Navigate to step 6, and change the “Yes” to “No,” to ensure the tool
does not recalculate the state threshold. Rerun the tool and repeat the review process
until all plans meet the non-discrimination requirements. The easiest way to determine
whether all plans have met the requirements is to reference the “Plans with Outliers” tab.
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.