Form CMS-10515 SBM Isser Payment Report

---

Overview

Enrollment and Payment Data
Template Instructions

---

Sheet 1: Enrollment and Payment Data

Enrollment and Payment Data Template

Submission Date:

Payment Month:

January-14

Submission Status

Test

State

9 Digit Issuer TIN

5 Digit HIOS Issuer ID

16 Digit QHP ID

Total Premium amount by QHP ID for effectuated enrollments

Total APTC amount by QHP ID for effectuated enrollments

Total CSR amount by QHP ID for effectuated enrollments

Total User Fee amount by QHP ID

Total # of effectuated enrollment groups by QHP ID

Total # of effectuated enrollment groups receiving APTC by QHP ID

Total # of effectuated enrollment groups receiving CSR by QHP ID

Total # of effectuated members by QHP ID

Total # of effectuated members receiving APTC by QHP ID

Total # of effectuated members receiving CSR by QHP ID

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

$-

---

Sheet 2: Template Instructions

Enrollment and Payment Data Template Instructions
Data Template Objective:	To document the total premium, APTC, CSR advance payment, and user fee amounts for all effectuated enrollment groups by Qualified Health Plan (QHP) ID. User fees do not apply to SBMs.
Submissions Guidelines:	1.)	During each data submission window, submitters will be allowed to submit multiple versions of the Enrollment and Payment Data Template (the "Template"). Based on data validation checks, CMS may require submitters to submit updated versions of the Template during each data collection window.
	2.)	Submitters will email the Template to the Marketplacepayments@cms.hhs.gov mailbox. Submitters will be instructed to send the Templates as a ‘reply’ to an email that they get from CMS. Please ensure that the email subject line retains the issuer's 5-digit HIOS ID, as well as the applicable reporting period - test or production. Additionally, email submissions should include the following information in the body of the email:
		- Whether this is a resubmission, and reason for the resubmission where necessary		- Enrollment and Payment Data Template attachment		- Certification of data accuracy
Data Collection Timelines:	1.)	Submission Window for Enrollment and Payment Data Template testing : 12/04/13 – 12/10/13
	2.)	Submission Window for Production Enrollment and Payment Data Template: 12/16/13 - 12/20/13
	3.)	Submission Window for February Enrollment and Payment Data Template: TBD
Payment Reporting Completion Information:	1.)	In the FFM, data should be submitted for issuers in both the individual and small group markets. For small group market issuers in the FFM, all APTC and CSR enrollment and payment fields on the Template should be listed as zero since SHOP plans do not receive APTC or CSR payments. FFM SHOP plans must be included in the Template as these plans are subject to user fees.
	2.)	In the SBM, data should be submitted for both the individual and small group markets. User fee amounts will automatically populate to zero if the issuer is participating in an SBM.
	3.)	If the submitter is an issuer, all information for an issuer should be documented in a single Enrollment and Payment Data Template. Issuers will be identified by the 5 digit HIOS ID.
	4.)	If the submitter is an SBM, data for all issuers in the SBM in a single Enrollment and Payment Data Template. Data should be documented in numerical order by issuer ID. For example, if an SBM has four participating individual market issuers with enrollment data, data for all four issuers will be included within the same tab in a single Enrollment and Payment Data Template file submission.
	5.)	CMS will replace any previously submitted files with the resubmission file. As a result, when submitters send resubmission files, the file must include the most current data for all issuers. For example, if during the initial submission, CMS determined that three of the four QHP ID's data required modification, when the submitter sends the corrected data for its three QHP IDs, it must also submit the original data for the fourth QHP ID in the same file.
	6.)	Blank fields will be treated as zero values in the payment calculations. Submitters are encouraged to enter zero values instead of leaving fields blank.
	7.)	Data should be submitted at the 16-digit QHP ID level (14 digit standard component ID plus 2 digit variant ID, otherwise known as the HIOS Plan ID). There should be no spaces between the 14 digit standard component ID and the 2 digit variant ID and no special characters.
	8.)	Data submitted should be for QHPs certified by the Marketplace that have at least one enrollee. Submitters do not have to submit plans in the Template that do not have any enrollment as these plans would have $0 total premium, $0 advance APTC or CSR payments, and $0 user fees.
File Name Requirements			FFM submitters must use the following naming convention for their Template submissions: Characters 1-3: FFM Characters 4-8: 5 Digit issuer ID (e.g. 56789) Characters 9-14: Date in MMDDYY format (e.g. 120113) Characters 15-18: Test or Production file as TEST or PROD (all caps) Characters 19-20: Submission Version of test or prod file in VXX formate, (e.g. V01) Sample file name: FFM56789120113testV01 SBMs submitting on behalf of issuers must use the following naming convention for their Template submissions: Characters 1-3: SBM Characters 4-5: State abbreviation (e.g., CT) Characters 6-11: Date in MMDDYY format (e.g. 120113) Characters 12-15: Test or Production file as TEST or PROD (all caps) Characters 16-18: Submission Version of test or prod file in VXX format, (e.g. V01) Sample file name: SBMCT122013prodV02 SBM issuers submitting on their own behalf must use the following naming convention for their Template submissions: Characters 1-3: SBM Characters 4-8: 5 Digit issuer ID (e.g. 56789) Characters 9-14: Date in MMDDYY format (e.g. 120113) Characters 15-18: Test or Production file as TEST or PROD (all caps) Characters 19-20: Submission Version of test or prod file in VXX format, (e.g. V01) Sample file name: SBM56789120113testV02
Enrollment and Payment Data Template Completion Instructions:		This section lists each data element that will required for the current payment cycle, a definition of each data type, and detailed instructions on how to populate each data field in the Template.
		Column Name (Column / Cell #)		Definition		Instructions
	1.)	Submission Date (B2):		Date of Enrollment and Payment Data Template Submission.		Enter the date that the Enrollment and Payment Data Template is being submitted to CMS, using a MM/DD/YYYY format.
	2.)	Payment Month (E2):		Month in which submitted data will be paid to issuers (January is the first month).		Enter the month that follows the submission month (e.g. December submission will be paid in January).
	3.)	Submission Status (H2):		Indicates whether Template submission is a test or production file.		Choose TEST or PROD from the dropdown menu. Only PROD will be used for payment.
	4.)	State Code (A):		2 letter state code in caps (e.g. TX, WA, FL).		Choose the appropriate state code from the drop-down menu.
	5.)	Issuer TIN (B):		Issuer's 9 digit taxpayer identification number assigned by the IRS.		Enter the issuer's 9 digit taxpayer identification number for each QHP identified. All issuers should be documented on the same table.
	6.)	5 Digit HIOS Issuer ID (C):		5 digit issuer identifier assigned by HIOS.		Enter the issuer's 5 digit HIOS identification number.
	7.)	16 Digit QHP ID (D):		16 digit unique QHP identifier. Includes 14 digit standard component ID, plus the 2 digit variant ID and is otherwise known as the HIOS Plan ID.		For each QHP offered, document the 16 digit unique QHP identifier without the use of spaces or non-numeric characters. Each 16 digit QHP identifier should only be used once throughout the entire table.
	8.)	Total Premium amount for effectuated enrollments by QHP ID (E):		The total premium amount by 16 digit QHP ID for all effectuated enrollments within a qualified health plan. If following the CMS 834 Companion Guide, this amount is the REF02 value for PRE AMT TOT in the 2750 loop of the 834 transaction summed for all effectuated enrollment groups within a QHP ID.		Sum the total premium amounts for all effectuated enrollment groups and enter this amount for each QHP ID listed.
	9.)	Total APTC amount for effectuated enrollments by QHP ID (F):		The total APTC amount the issuer can expect to receive as the amount of actual APTC toward the total premium amount for effectuated enrollments within a 16 digit QHP ID. If following the CMS 834 Companion Guide, this amount is the REF02 value for APTC AMT in the 2750 loop of the 834 transaction summed for all effectuated enrollment groups within a QHP ID.		Total the actual APTC amount that is expected for all effectuated enrollment groups within each QHP ID, and document it in this column.
	10.)	Total CSR amount for effectuated enrollments by QHP ID (G):		The total monthly advance CSR payment amount the issuer can expect to receive for all effectuated enrollments within a 16 digit QHP ID. If following the CMS 834 Companion Guide, this amount is the REF02 value for CSR AMT in the 2750 loop of the 834 transaction summed for all effectuated enrollment groups within a QHP ID.		Total the CSR amount that is expected for all effectuated enrollment groups within each QHP ID, and document it in this column.
	11.)	Total User Fee amount by QHP ID (H)		The total user fee amount the issuer can expect to incur for participation in the FFM.		This amount will display automatically once the premium amount is inserted in Column E. User fees are calculated as 3.5% of total premium collected. This amount does not apply to SBM issuers.
	12.)	Total # of effectuated enrollment groups by QHP ID (I):		Total number of effectuated enrollment groups associated with a QHP ID.		Sum the number of effectuated enrollment groups associated with each QHP and enter the number in this column.
	13.)	Total # of effectuated enrollment groups receiving APTC by QHP ID (J):		Total number effectuated enrollment groups associated with a QHP ID that will receive APTC payments.		Sum the number of effectuated enrollment groups associated with each QHP, that will receive APTC payments, and enter the number in this column.
	14.)	Total # of effectuated enrollment groups receiving CSR by QHP ID (K):		Total number effectuated enrollment groups associated with a QHP ID that will receive CSR payments.		Sum the number of effectuated enrollment groups associated with each QHP, that will receive CSR payments, and enter the number in this column.
	15.)	Total # of effectuated members by QHP ID (L):		Total number of members by QHP ID within effectuated enrollment groups.		Sum the total number of members within effectuated enrollment groups associated with each QHP ID and enter the number in this column.
	16.)	Total # of effectuated members receiving APTC by QHP ID (M):		Total number of members by QHP ID within effectuated enrollment groups who receive APTC.		Sum the total number of members who will receive APTC within effectuated enrollment groups associated with each QHP and enter the number in this column.
	17.)	Total # of effectuated members receiving CSR by QHP ID (N):		Total number of members by QHP ID within effectuated enrollment groups who receive CSR.		Sum the total number of members who will receive CSR within effectuated enrollment groups associated with each QHP and enter the number in this column.
	1.)	submitter:		A submitter is defined as the entity submitting the Enrollment and Payment Data Template. This could include an FFM issuer, an SBM issuer, or an SBM submitting on behalf of their issuers.
Definitions:	2.)	enrollment group:		Enrollment group is defined as all members enrolled in a QHP who receive coverage and are linked by the Exchange Assigned Policy ID.
	3.)	effectuated enrollment group:		Effectuated enrollment group is defined as any enrollment in which the amount the enrollment group is responsible to pay toward the total premium amount has been paid in full by the enrollment group. If following the CMS 834 Companion Guide, this is the REF02 value for TOT RES AMT as listed in the 2750 loop.
PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this information collection is estimated to average [Insert Time (hours or minutes)] per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact CMS via email at marketplacepayments@cms.hhs.gov.