Form CMS-10515 CMS Enrollment Payment Data Template

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Overview

January Restatement
February Restatement
March Restatement
April Restatement
May Template
Template Instructions

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Sheet 1: January Restatement

Enrollment and Payment Data Template

Submission Date:

Change in Enrollment from Prior January Submission? (Y/N)

Yes (populate this sheet with updated enrollment data)

Enrollment Month:

January-14

Submission Status

Initial Submission

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

Reasons for Validation Failures

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Sheet 2: February Restatement

Enrollment and Payment Data Template

Submission Date:

Change in Enrollment from Prior February Submission? (Y/N)

Yes (populate this sheet with updated enrollment data)

Enrollment Month:

February-14

Submission Status

Initial Submission

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

Reasons for Validation Failures

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Sheet 3: March Restatement

Enrollment and Payment Data Template

Submission Date:

Change in Enrollment from Prior March Submission? (Y/N)

Yes (populate this sheet with updated enrollment data)

Enrollment Month:

March-14

Submission Status

Initial Submission

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

Reasons for Validation Failures

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Sheet 4: April Restatement

Enrollment and Payment Data Template

Submission Date:

Change in Enrollment from Prior March Submission? (Y/N)

Yes (populate this sheet with updated enrollment data)

Enrollment Month:

April-14

Submission Status

Initial Submission

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

Reasons for Validation Failures

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Sheet 5: May Template

Enrollment and Payment Data Template

Submission Date:

Enrollment Month:

May-14

Submission Status

Initial Submission

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

Reasons for Validation Failures

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Sheet 6: 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.
	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.
Submissions Guidelines:	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. 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
	1.) Submission Window for May payment initial submission of the Production Enrollment and Payment Data Templates: 4/16/14 - 4/21/14
Data Collection Timelines:	2) Submission Window for resubmission of the May Production Enrollment and Payment Data Templates: 4/23/14 -4/25/14
	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 the individual market. User fee amounts will automatically populate to zero if the issuer is participating in an SBM.
	3.) Any stand alone dental issuer expecting to receive no APTC payments for the current collection month is not required to submit an Enrollment and Payment Data workbook. Such stand alone dental issuers must state that they expect to receive no APTC on the submission certification form.
	4) Enrollment and Payment Data workbooks should not be submitted for issuers with zero enrollments as these plans would have $0 total premium, $0 advance APTC or CSR payments, and $0 user fees. If the submitter is an issuer, the submitter must identify that issuer ID as having no enrollments on the submission certification form. If the submitter is an SBM, the submitter must omit that issuer ID from the Enrollment and Payment Data workbook and identify that issuer ID as having no enrollments on the submission certification form.
	5.) 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.
Payment Reporting Completion Information:	6.) If the submitter is an SBM, data for all issuers in the SBM should be included 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.
	7.) 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.
	8.) Blank fields will be treated as zero values in the payment calculations. Submitters are encouraged to enter zero values instead of leaving fields blank.
	9.) 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.
	10.) Data submitted should be for QHPs certified by the Marketplace that have at least one enrollee.
	11.) For the May payment month, submitters must send one excel file which includes five worksheets. The first four worksheets include the restatements of enrollment and payment data through April, and the fifth worksheet includes effectuated enrollment and payment data effective May 1 as of April 15, 2014.
	ISSUER SUBMITTERS ONLY (NOT APPLICABLE FOR SBM SUBMITTERS) 12.) For each of the prior months, issuer submitters must either (1) restate enrollment data to ensure that any retroactive enrollment data or enrollments effectuated after March 15, 2014 are captured or (2) indicate that there have been no changes to the data since the last submission cycle in March. To restate prior months' data: For each of the restatement templates, the issuer submitter must select "Yes" from the drop down menu in cell D2 to indicate changes in enrollment since the prior submission. Next, the issuer submitter must fill out each of the restatement tabs with current enrollment and payment data for every applicable plan The issuer submitter must also complete the "May Template" tab, which contains May enrollment and payment data. To indicate that there have been no changes in data since the last submission cycle: For each of the selected restatement templates, the issuer submitter would select "No" from the drop down menu in cell D2 to indicate that there have been no changes in enrollment since the prior submission. The issuer submitter must not populate the restatement template(s). The issuer submitter must complete the "May Template" tab, which contains May enrollment and payment data.
File Name Requirements	FFM submitters must use the following naming convention for their Excel file submission: Characters 1-3: FFM Characters 4-8: 5 Digit issuer ID (e.g. 56789) Characters 9-14: Date in MMDDYY format (e.g. 041614) Characters 15-18: PROD (all caps) Characters 19-21: Submission Version of prod file in VXX formate, (e.g. V01) Sample file name: FFM56789041614PRODV01 SBMs submitting on behalf of issuers must use the following naming convention for their Excel file submission: Characters 1-3: SBM Characters 4-5: State abbreviation (e.g., CT) Characters 6-11: Date in MMDDYY format (e.g. 041614) Characters 12-15: PROD (all caps) Characters 16-18: Submission Version of prod file in VXX format, (e.g. V01) Sample file name: SBMCT041614PRODV01 SBM issuers submitting on their own behalf must use the following naming convention for the Excel file submission: Characters 1-3: SBM Characters 4-8: 5 Digit issuer ID (e.g. 56789) Characters 9-14: Date in MMDDYY format (e.g. 041614) Characters 15-18: PROD (all caps) Characters 19-21: Submission Version of prod file in VXX format, (e.g. V01) Sample file name: SBM56789041614PRODV01
	This section lists each data element that will be 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.
	ISSUER SUBMITTERS ONLY (NOT APPLICABLE FOR SBM SUBMITTERS) 2.) Enrollment Data Changes (D2)	Change in Enrollment from Prior Month Submission (Y/N)		This field is relevant for issuer submitters only. This field only applies to the three restatment tabs. Issuer submitters will indicate whether there have been any changes to enrollment data since the prior month submission by selecting either "Yes" or "No". When "Yes" is selected, the issuer submitter must populate the data template. When "No" is selected, the issuer submitter must not populate the data template.
	2.) Enrollment Month (E2):	Month in which enrollment is effective (January is the first month). A January enrollment month includes all enrollments effective in the month of January. A February enrollment month includes all enrollments effective in the month of February, etc. For the payment month, this should also include enrollments that were effectuated in the prior months and that continue into the payment month.		The submission month is pre-selected for each submitter. Please use the appropriate worksheet for reporting enrollment and payment data.
	3.) Submission Status (H2):	Indicates whether Template submission is an initial submission or a resubmission of data. All data sent will be production data.		Choose "initial submission, "resubmission 1," "resubmission 2," or "resubmission 3."
	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.
Enrollment and Payment Data Template Completion Instructions:	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.
Validate Template Data Instructions	1) Validate Template Data (O)	Tool that will automatically perform validation testing on data populated on the template.		Populate the data template. Click the button "validate template data". Repeat this process on each tab of the workbook.
	2) Clear Validation Results (O)	Function used to clear the current validation results.		To re-run a validation test, click the clear current validation results button.
	3) Reasons for Validation Failures (P)	Provides an explanation of submissions that fail validation testing.		Review the reasons for validation failures and make updates to the template, addressing these failures. Revalidate the template data as needed until all results pass.
	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 for the first month of coverage. If following the CMS 834 Companion Guide, this is the REF02 value for TOT RES AMT as listed in the 2750 loop. An enrollment group is considered effectuated after it has made it's first monthly payment toward the first monthly total premium amount.