How to Complete the Plans & Benefits Template
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How to Complete the Plans & Benefits Template


How to Complete the Plans & Benefits Template Issuers seeking to offer qualified health plans (or QHPs), including stand-alone dental plans (or SADPs) on the Federally-facilitated Exchange must submit a completed QHP Application per CMS guidelines. As part of the QHP certification process,
issuers are asked to fill out several templates with issuer- and plan-level data. These templates, along with any supporting documentation submitted, comprise an issuer’s QHP Application. Among these templates is the Plans & Benefits
Template. The Plans & Benefits Template collects health
insurance plan information, including plan identifiers, plan attributes, geographic coverage,
relevant website links, benefit coverage, and cost sharing information. Before filling out the Plans & Benefits Template,
you’ll need to complete the Network ID Template, the Service Area Template, and the Prescription
Drug Template. You’ll also need to download and save the
Plans & Benefits Add-in file to your computer in the same location as the Plans & Benefits
Template. The add-in file uses state-specific benchmark
information to auto-populate the template based on information entered in the template. Opening this file along with the Plans & Benefits
Template adds another tab to the ribbon across the top of the template. Additionally, you’ll need to download and save the Actuarial Value Calculator to your computer. The AV Calculator, or AVC, helps determine
levels of coverage by calculating the actuarial value for all standard, non-catastrophic medical
plans, all silver plan CSR variations, and all limited cost-sharing plans. The AVC will be used before validating your
template. To download the Plans & Benefits Template,
Add-in file, AV Calculator and applicable instructions, visit www.qhpcertification.cms.gov,
click on “Application Materials,” and click on “Plans and Benefits” in the left
navigation bar. This webpage contains more information about the plans and benefits section of the QHP Application, including tips and additional resources. Before filling out the Plans & Benefits Template,
download and read the instructions from the Application Resources section. Once you’re ready to complete the Plans
& Benefits Template, download the template, add-in file, and AV Calculator from the Application
Resources section, save them to the same folder on your computer, open the template and add-in
file, and enable macros in the template. The Plans & Benefits template is divided into
two portions: the Benefits Package worksheet, and the Cost Share Variances Worksheet. There will be a Cost Share Variances Worksheet for each Benefits Package worksheet that you complete. The Benefits Package worksheet itself is divided
into two sections: the top section collects basic information about the issuer and type of plans that will be offered, while the bottom section collects more information on each benefit. Each Benefits Package worksheet can collect
data on up to fifty plans. If you need to provide more than fifty plans,
create a new Benefits Package worksheet with an identical Benefits Package structure. When filling out templates in the QHP Application,
it’s important to start in the top left corner, and fill out fields moving down and
to the right until all required fields are completed. Now let’s walk through filling out the Plans
& Benefits Template with sample data. Before you begin, look through the data elements
required to ensure you have the necessary plan information to successfully complete
this template. To start, navigate to the Plans & Benefits
tab in the ribbon across the top and import the Service Area, Network ID, and Prescription
Drug Templates by selecting the appropriate buttons and following the prompts in the dialogue
boxes. Note that you will not import the Prescription
Drug Template into the Plans & Benefits Template for stand-alone dental plans (or SADPs). Once you’ve imported the necessary templates,
enter the 5-digit HIOS Issuer ID you received when you registered in the Health Insurance
Oversight System (or HIOS) and the state where the applicable plans will be offered. Next, use the dropdown menu to select the
Market Coverage type for the products you’re offering. You’ll choose either Individual or SHOP;
SHOP stands for Small Business Health Options Program, and is designated for products offered
in the small group market. Issuers offering both individual and small
group products will need to fill out separate Plans & Benefits Templates for each market. If this applies to you, you can navigate to
the Plans & Benefits tab in the ribbon and select “New Plans and Benefits Template.” Follow the prompts to create an additional
Plans & Benefits Template. The next data element asks you to determine
whether this template is for dental only plans. If you select “yes,” some data elements
will be grayed out; these do not apply to SADPs. You will need separate templates if you offer
both QHPs and SADPs. Required fields are marked with an asterisk. Next, fill in your 9-digit Federal Taxpayer
Identification Number (or TIN). Moving to the Plan Identifiers section, enter
the 14-character alphanumeric HIOS Plan ID that identifies the plan associated with the
information you’ll fill in this row. Plan IDs should be unique for each plan, including
across market types. Next, enter the Plan Marketing name for the standard plan level; this name will be displayed to the consumer. Then enter the 10-character HIOS Product ID associated with each proposed plan you wish to offer on the Exchange. The next data element, the HPID, is optional. This is a 10-character identifier that you
received when registering in HIOS. Then, select the Network ID, Service Area
ID, and Formulary ID associated to this plan. In the Plan Attributes section, use the dropdown
menu to select whether this plan is new for the current plan year or existed in the previous
plan year’s QHP Application submission. Issuers should also select “New” if the
plan was offered last year, but the plan design exceeds the uniform modification of coverage
standards. All existing plans should use the same HIOS
Plan ID that was used for the previous plan year. Next, select the plan type. This must be consistent with your state form-filing
submissions. Then select the level of coverage, identifying
the metal level of the plan based on its actuarial value (or AV). The next field says to select the Design Type
from the dropdown menu. “Not Applicable” is auto-populated for
this field, since Simple Choice plans are no longer offered. The template then asks if this plan design
is unique, meaning the plan would not use the standard AV Calculator. Refer to the AV Calculator (or AVC) section
of the QHP Application Instructions to determine if a plan is truly unique. Select “Yes” if the unique plan design
features cause the use of the AVC to yield an AV result that materially differs from
that of the other approved methods. If you select “Yes” for this reason, upload
the Unique Plan Design Supporting Documentation and Justification. Next, indicate if the plan will be offered
on the Exchange, off the Exchange, or both. Plans offered both on- and off-Exchange must
have the same premium, provider network, cost sharing structure, service area, and benefits. Selecting this option creates two separate
plan variations in the Cost Share Variance worksheet. Indicate in the next column whether the plan
requires the issuer to be notified by a doctor before pregnancy benefits are covered. Similarly in the next element, indicate whether
a referral is required to see a specialist. If you select “Yes,” enter the types of
specialists that require a referral in the next column. The next element, “Plan Level Exclusions,”
is an optional field issuers can use to enter any exclusions that may apply to the plan. The following field, “Limited Cost Sharing
Plan Variation Estimated Advanced Payment,” is also optional; the Exchange will calculate
the advance payment amounts for cost sharing reductions (or CSRs) for limited cost sharing
plan variations, so you can leave this field blank. The next data element, “Does this plan offer
composite rating?” will pre-populate as “No.” Next, complete the “Child-Only Offering”
field by indicating whether the plan is offered at a child-only rate or has a corresponding
child-only plan. Note that selecting “Allows Adult-Only”
does not mean that only adults can enroll in the plan. Rather, this plan requires an adult to be
the primary subscriber. An adult-only plan requires a corresponding
child-only plan ID. Note that FF-SHOP does not accommodate child-only
plans. If you select “Allows Adult Only” and
the coverage level is not Catastrophic, the next data element is required. Enter the 14-character Plan ID that corresponds
to the child-only plan. If the coverage level of the plan is Catastrophic,
the “Child-Only Offering” field auto-populates as “Allows Adult and Child-Only”. Catastrophic plans are available to any enrollment
group of consumers under the age of 30. In the next column, indicate whether the plan
offers a wellness program designed to prevent or reduce tobacco use. The “Disease Management Programs Offered”
field is optional, available for you to indicate whether the plan offers programs for one or
more of the following: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Lower Back Pain, Pain Management, Pregnancy, or Weight Loss Programs. In the next column, enter the percentage of
the total premium that is associated with the essential health benefit (or EHB) services
in each plan (including administrative expenses and associated profits). This data element is required for all plans
on the individual market other than catastrophic plans. The EHB percent of total premium is used to
calculate advanced premium tax credits. The next section is only required for SADPs. In the first data element, enter the percentage
of the portion of monthly premium allocable to the pediatric dental EHB. In the next column, select “Guaranteed”
if you wish to charge the premium shown to the consumers on the website or “estimated”
if you wish to have the enrollee contact you to determine the final rate. The next section, titled “Plan Dates”
collects information regarding the effective and expiration date for each plan. In the first element, enter the effective
date for this plan using the format shown on the screen. The effective date must be January 1st of
the plan year for all plans that will be offered through the Federally-facilitated Exchange
or FF-SHOP. Using the same format, complete the Plan Expiration
Date field. This date must be December 31st of the plan
year for the individual market. In the Geographic Coverage section, first
complete the Out of Country Coverage field to indicate whether the plan will cover care
obtained outside of the country. If you select “Yes,” enter a short description
of the care that is covered in the next field. Next, indicate whether the plan covers care
obtained outside of the service area. Again, if you select yes, enter a brief description
of the care that is covered in the next field. The final data element in this section asks
you to indicate whether a national network is available for this plan. The last section in this part of the Benefits
Package worksheet asks you to enter the website location for enrollment payment information. URLs must start with either http:// or https://. Finish filling in information for additional
plan IDs you want to add to this template. Now, let’s walk through the benefits section
of the Benefits Package worksheet. All of the data elements in the benefits section
must be completed for all benefits offered, which are shown on the left side. Navigate to the Plans & Benefits tab in the
ribbon and click “Refresh EHB Data.” If the benefits package has multi-state plans
using an alternate benchmark, click “Yes” in the dialogue box that displays. Otherwise, click “No.” The data in the “Benefit Information”
section auto-populates based on the state. Review that the auto-populated information
is accurate according to your state’s benchmark plan. Refer to the CCIIO website to determine if
a benefit needs to be covered for your state. To add additional benefits, select “Add
benefit” from the Plans & Benefits tab and follow the dialogue box’s prompts. To delete a benefit, navigate to column D, select “Not Covered,” and click the “Refresh EHB Data” button. This removes any added benefit that is not
covered. Note that if you select “Refresh EHB Data,”
any data that has been manually entered or changed in other fields in this section will
also be removed, and you may need to re-input data you had already entered. The first data element in the “General Information”
section asks if the benefit is covered by the plan. For benefits that are identified as an EHB,
the field auto-populates as “Covered.” If you change this to “Not Covered,” you
must substitute another benefit in its place and provide the EHB Supporting Documentation
and Justification. If you entered “Covered,” the “Quantitative
Limit on Service” field is required, and is auto-populated based on the designated
EHBs (some fields are left blank). If you change this field, you must provide an EHB variance reason and associated supporting documents. For any benefit not identified as an EHB,
indicate whether the benefit has quantitative limits. If “Yes” was entered on the previous element, complete the “Limit Quantity” and “Limit Unit” fields to show the quantitative limits
placed on this benefit. A dialogue box will appear, prompting users
to select the quantitative limit units per interval. In the “Exclusions” field, enter any benefit-level
exclusions for particular services for diagnoses that are covered under some circumstances
but not others. Next, enter any benefit explanations, which
may include additional quantitative limits, links to additional plan documents, child-specific
maximum out of pocket or deductible limits, or alternate cost-sharing structures. If changes have been made in the previous
four columns, select the EHB Variance Reason. In the “Out of Pocket Exceptions” section,
indicate whether each benefit is excluded from the maximum out of pocket, or MOOP. All plans in a benefits package must have
the same MOOP structure and exclude the same benefits from the MOOP. If you have plans that offer a different MOOP
structure, create a new benefits package from the Plans & Benefits tab in the ribbon. If your plans do not offer different MOOP
structures, then indicate if the benefit is excluded from In-Network MOOP. The final data element in the Benefits Package
worksheet is “Excluded from Out-of-Network MOOP.” In this field, similar to the last data element, indicate whether this benefit is excluded from the out-of-network MOOP. We’ve completed entering data for the Benefits
Package worksheet. Now, let’s move to creating and completing
the Cost Share Variances worksheet. As mentioned earlier, each Benefits Package worksheet needs to be accompanied by a Cost Share Variances worksheet. To create a Cost Share Variances worksheet,
navigate to the Plans & Benefits tab in the ribbon across the top of the template and
select “Create Cost Share Variances.” Read the dialogue box’s questions, select
OK, and read the reminder that displays. Select “OK” again. The template will then ask if you have deductible
subgroups. Deductible subgroups are used to identify benefits or groups of benefits that have their own deductibles. These deductibles are not outside of maximums allowed, and still contribute to the overall MOOP limits. If you select “Yes,” you’ll be asked to enter the number of subgroups, and uniquely name each one. Once you’ve completed the deductible subgroup
prompts, the Cost Share Variances worksheet will be created based on the data entered
in the Benefits Package worksheet. Each Benefits Package/Cost Share Variances
worksheet pair will be labeled with the same number. The Cost Share Variances worksheet will contain
the necessary plan variations for each standard plan entered in the Benefits Package worksheet. Review the QHP Application Instructions for
additional details on plan variations. The first four fields in the “Plan Cost
Sharing Attributes” section have been auto-populated from the Benefits Package worksheet. Note that the same Plan Variant Marketing
Name appears for all variants of a standard plan. Feel free to change this field if you want
unique marketing names to display to customers. The Level of Coverage and the CSR Variation
Type fields cannot be edited. Note that the HIOS Plan ID field contains plan IDs with a dash and two digits following the standard plan ID. The CSR Variation Type field gives a description
of the cost sharing structure for each plan variant, related to the two-digit variant. For example, all “dash 02” plan variants
are Zero Cost Sharing Plan Variants. To learn more about the plan variants, see
the QHP Application Instructions. If you labeled a plan as having a Unique Plan Design, the “Issuer Actuarial Value” field is required; enter the issuer-calculated AV here. For all non-unique QHP plan designs, the next data element, the “AV Calculator Output Number,” is required. Complete this field after all other cost-sharing
information has been filled out. For SADPs, issuers have the option to input a value in the “Issuer Actuarial Value” field of the template. While this field is optional, if the issuer
chooses to enter the AV level of coverage into the template, the SADP’s AV must fall
within the previous requirements of the High or Low AV coverage. The next two columns only display for QHPs. In the next column, indicate whether the medical and drug deductibles are integrated for this plan. The deductible is integrated when both medical and drug costs will accrue towards a single deductible. The deductible is separate when medical and drug costs accrue towards their own, respective deductibles. Your selection for the standard plan will
populate for all its plan variations, since all plan variations are required to have the
same plan structure. Similarly, in the next field, indicate whether the medical and drug maximum out of pocket values are integrated. In the “multiple in-network tiers” field,
select whether this plan includes multiple tiers in its network, thereby applying different
levels of in-network cost sharing depending on the tier of the provider or facility. This data is used for the AV calculation for
non-unique plan designs. The next two columns allow you to specify the percentage of the anticipated cost of claims utilized within each tier. If you do not have multiple in-network tiers,
these fields auto-populate. If you do have multiple in-network tiers,
enter the value for the 1st tier utilization, and the 2nd tier utilization field will auto-populate. The fields in the SBC Scenario section are
required for medical plans and can be accessed through HealthCare.gov’s Plan Compare. Cost-sharing information for each SBC scenario is required for the data elements within each subsection: “Having a Baby,” “Having Diabetes,” and
“Treatment of a Simple Fracture.” The next several sections collect MOOP and
deductible information for each plan. There are subsection headers, including “In-Network,”
“In-Network (Tier 2),” “Out-of-Network,” and “Combined In/Out-of-Network.” Beneath each header are data elements for
both Individual and Family plans. Depending on whether the medical and drug
deductibles and MOOP values are integrated, some of the fields will be greyed out and
cannot be edited. For this example, the test data shows a plan
that has an integrated medical and drug MOOP. Therefore, the sections “Maximum Out of
Pocket for Medical EHB Benefits” and “Maximum Out of Pocket for Drug EHB Benefits” are
greyed out and cannot be edited. Under the “Maximum Out of Pocket for Medical
and Drug EHB Benefits (Total)” section, issuers can enter separate in-network and
out-of-network MOOP limits, or enter a combined MOOP limit that accounts for both in- and
out-of-network costs. In this example, we will enter separate MOOP
values for In- and Out-of-Network. In the “In-Network Individual MOOP,” select $X from the dropdown and enter the individual MOOP limit. This number cannot exceed the annual limitation
on cost sharing. Note that the three silver plan variations have different MOOP limitations than those set for a standard plan. Next, enter the “In-Network Family” values
in the dialogue box that displays, noting that the “per-person” value applies to
a single person in a family. The per-group value applies to the family
as a unit. Continue completing the “In-Network (Tier
2)” and “Out-of-Network” fields in the same way you completed the “In-Network”
fields. Because this example does not use a combined
MOOP, select “Not Applicable” for the applicable fields. The next two sections, called the “Medical
EHB Deductible” and “Drug EHB Deductible” are similar to the Medical EHB MOOP and Drug
EHB MOOP sections. The values here should be completed if the Medical and Drug Deductibles are not integrated, as in this example. These fields are similar to the fields in the MOOP section, with the addition of the default coinsurance field. This field is used to calculate the AV when
running the AV Calculator. Complete these fields similar to how you completed
the previous section. The data elements in the “Combined Medical
and Drug EHB Deductible section” should be completed if the medical and drug deductibles
are integrated. Since this example does not have an integrated
deductible, this section is not editable. Next, complete the “Other Deductible” section if you indicated you have deductible subgroups. The HSA/HRA Detail section collects information pertaining to health savings accounts or health reimbursement arrangements. In the first column, indicate whether the
plan meets all of the requirements to be a health savings account, or HSA. Then, for small group plans, fill in the “HSA/HRA
Employer Contribution” to indicate whether an employer contributes to a health reimbursement
arrangement. If you selected “Yes,” enter the whole dollar amount the employer contributes in the next column. For the first data element in the “Plan
Variant Level URLs” section, enter the website URL for the summary of benefits and coverage,
or SBC. This URL is required by the final QHP Application
submission deadline. URLs must begin with http:// or https:// to
work properly for consumers. Please ensure each URL, when active for Open
Enrollment and Special Enrollment Periods, links directly to the plan variant’s unique
and up-to-date information. The next data element, “Plan Brochure,” is optional. The “AV Calculator Additional Benefit Design”
section is used for inputs for the AVC, and is not required to complete the worksheet. The first data element, “Maximum Coinsurance
for Specialty Drugs” collects the maximum coinsurance allowed for specialty prescription
drugs. In the next column, enter the maximum number of days allowed for charging an inpatient copay. Then, in the next field, enter the maximum
number of visits that a visit is fully covered before primary care cost-sharing begins. Finally, enter the maximum number of copay
visits that can occur before the visit becomes subject to the deductible and/or coinsurance. The rest of the worksheet collects cost-sharing
information for covered benefits. A section has been created for each benefit that was labeled “covered” on the Benefits Package worksheet. Each benefit has two sections: Copay and Coinsurance. Within each section, you can enter cost sharing
for “In-Network (Tier 1),” “In-Network (Tier 2)” if you have multiple tiers, and
“Out-of-Network.” For all copay fields, there is a dropdown
with six cost-sharing options. Please refer to the QHP Application Instructions
for more details on each cost-sharing structure. Note that the “Not Applicable” option
should be used in cases when you intend to charge only a copay or only a coinsurance
for In-Network Coverage. For this example, we’ll complete the cost
sharing section for Primary Care. We’ve decided to designate the in-network
copay at $30 with the deductible. With a copay with deductible, a consumer first
pays the copay, and any net remaining allowed charges accrue to the deductible. From the dropdown under “In-Network (Tier 1),” select the “$X copay with deductible” and enter “30.” Then select “Not applicable” for the coinsurance
value. If we had tiers, Tier 2 might be a network
of more expensive providers, so if we want to charge a higher copay but use the same
structure, we would select the “$X copay with deductible” and enter a value of 40. Then we would select a coinsurance of “Not
Applicable.” In this example, there will be no Out-of-Network
coverage. To represent this, select a copay of “Not
Applicable” and for the coinsurance, select “X%” and enter “100.” This indicates the consumer will pay 100%
of the service. Note that you should not indicate that both
the copay and coinsurance are “Not Applicable” for tier 1 or Out-of-Network cost sharing. However, it’s appropriate for both copay
and coinsurance to be labeled as “Not Applicable” for tier 2 if the specific benefit does not
have two tiers of cost sharing. Continue filling out the benefit cost sharing
sections until complete. Then, calculate the actuarial value for the plans by returning to the “AV Calculator Output Number” column. To do this, ensure you have saved the AV Calculator
to your computer and select “Check AV Calc” in the Plans & Benefits tab in the ribbon
across the top of your template. Follow the prompts to open your saved AV Calculator
and determine whether you want to save screenshots of the AVC calculations. The AV Calculator Output Number column will populate with the values determined by the AVC. Note that if you make any changes to your
cost sharing after running the AVC, you will be required to run it again before you can
validate the template. Running the AVC will also run validation checks
for your template. Any data issues in your template that need
to be resolved will be displayed. In this case, we have five data errors; the
majority are related to the AVC calculations. Make the necessary corrections to the template
and run the AVC again. Continue to add Benefits Package and Cost Share Variances worksheets until all your data has been entered. Now, let’s validate and finalize the template. Once you have completed the template, click
the “Validate” button at the top of the worksheet. Any data issues in your template that need
to be resolved will be displayed; correct these and click the Validate button again. Continue this process until all errors have
been resolved. Once the template is valid, click the “Finalize”
button to create an XML that will be automatically saved in the same folder as the template. The XML extract is the file you will submit
as part of your QHP Application. If you have questions regarding your QHP Application,
please contact the Marketplace Service Desk at [email protected] or 855-CMS-1515. For more information about the QHP certification
process, visit https://www.qhpcertification.cms.gov.

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