Form CMS-10392 Reporting Templates

Consumer Operated and Oriented Plan [CO-OP] Program

CMS-10392.CO-OP Reporting Template

Enhanced Reporting (Before Loan Repayment) - Start-up/Solvency Loan Recipients

OMB: 0938-1139

Document [docx]
Download: docx | pdf

Consumer Operated and Oriented Plan (CO-OP) Program Report Templates




Submission Date:


Organization:


Reporting Period:


Example: Quarter 3 (07/01/2012 - 09/30/2012)


CMS Project Officer:


Project Director (name and title):


Email:


Phone:


Alternate Contact (name and title):


Email:


Phone:



Loans Received, Award Date, Date of Initial Drawdown:

Example:

Start-up Loan (Award: 08/15/2012, Drawdown: 09/01/2012)

Reporting Period Timeframe for Delivery)

I. Financial Reporting

Quarter 1: January 1st through March 31st April 30th

Quarter 2: April 1st through June 30th July 30th

Quarter 3: July 1st through September 30th October 31st

Quarter 4: October 1st through December 31st January 31st



II. Deeming for Exchange Certification

Bi-annual: 24 months Within 30 days following

the end of the reporting period

III. Progress Report

Prior to Repayment in Full

Semi-annual 1: January 1st through June 30th July 30th

Semi-annual 2: July 1st through December 31st January 31st


After Repayment in Full

Annual: January 1st through December 31st January 31st



Section 1322 of the Patient Protection and Affordable Care Act (ACA) requires the Secretary to award federal loans to foster the creation of consumer-governed nonprofit health insurance issuers (CO-OPs) to compete in the Exchanges. Under the CO-OP program, CMS provides Start-up Loans to assist with start-up costs and Solvency Loans1 to assist with State solvency requirements. The statute requires loan recipients to repay the Start-up Loans within 5 years and Solvency Loans within 15 years, taking into consideration State reserve requirements, solvency regulations, and requisite surplus note arrangements (collectively referred to as “solvency requirements”).


Recipients of Start-up Loans and Solvency Loans are required to submit financial documents to CMS on a quarterly basis starting with the quarter in which loan funds are first disbursed and ending with the quarter in which the loan recipient completes repayment of all loans awarded under the CO-OP program. If a loan recipient seeks to be deemed certified for an Affordable Insurance Exchange, the organization must submit the documentation requested in Part II of this document demonstrating that it has met the requirements for being a qualified health plan pursuant to Section 1311 of the Affordable Care Act, once every two years for as long as the loan recipient seeks to be deemed.


Progress reports must be submitted to CMS semi-annually starting with the reporting period in which loan funds are first disbursed and ending ten years following the date on which the loan recipient completes repayment of all loans awarded under the CO-OP program. The progress report describes significant advances towards the loan recipient’s goal of becoming a viable and sustainable CO-OP. CMS will use the information provided on the progress report and the financial report to monitor the CO-OP’s performance, ensure the appropriate use of federal funds, and verify that the loan recipient is conforming to the requirements in its loan agreement.


The following reporting guidelines are intended as a framework and can be modified when agreed upon by the CMS project officer and the loan recipient. If any of the requested information is readily available to CMS through another source (from example, an Exchange), CMS may choose not to collect the information from the loan recipient directly. A complete progress report must detail how loan funds were utilized; describe program progress and challenges; and provide an update on the measurable objectives of the CO-OP program.




PART I: FINANCIAL REPORTING [QUARTERLY SUBMISSIONS]

Provide a statement that the loan recipient is in compliance with all relevant State licensure requirements appropriate for its stage of Start-up or an explanation of any deficiencies, warnings, additional oversight, or any other adverse action or determination by State insurance regulators received by the loan recipient since the last-filed quarterly report. If the loan recipient is experiencing compliance issues with State regulators, describe the steps being taken to resolve those issues.

Provide financial statements (audited financial statements when available) including balance sheets, income statements, and statements of cash flow. In addition, provide a statement of total enrollment for each month in the quarter and the revenue received from enrollment. Identify by title any attachments along with a brief description of what information the document contains.


Provide an attestation signed by an officer of your organization’s Board of Directors, the chief executive officer (CEO), the chief financial officer (CFO), or an individual delegated the authority to sign on behalf of one of these officers, and who reports directly to such officer certifying the accuracy, completeness, and truthfulness of any information submitted in Part I- Financial Reporting.


PART II: DEEMING for EXCHANGE CERTIFICATION [BI-ANNUAL SUBMISSIONS]

If your organization would like to be deemed as certified to participate in the Exchanges, provide evidence that your organization meets the standards for qualified health plans pursuant to section 1311 of the Affordable Care Act and the applicable State-specific standards for qualified health plans established by the Exchanges in which your organization seeks to be deemed as certified. This information is required once every two years during the time period that your organization seeks to be deemed as certified. Identify by title any attachments along with a brief description of what information the document contains.

Provide an attestation signed by an officer of your organization’s Board of Directors, the chief executive officer (CEO), the chief financial officer (CFO), or an individual delegated the authority to sign on behalf of one of these officers, and who reports directly to such officer certifying the accuracy, completeness, and truthfulness of any information submitted for consideration.


PART III: PROGRESS REPORT [SEMI-ANNUAL SUBMISSIONS]

Identify by title any attachments along with a brief description of what information the document contains.


A. Narrative

Only items 4 and 5 are required after all loans awarded under the CO-OP program have been repaid in full.


1. Introduction

Provide a brief overview of your organization and your updated business plan for developing a CO-OP describing the goals, objectives, and milestones. Updates should be based on the business plan submitted and approved with the loan application.


2. CO-OP Planning and Development Status

Include a detailed discussion of the following:


  1. Accomplishments

Describe achieved milestones, loan disbursement associated with the milestones, and outcomes during the reporting period, including progress towards 1) each milestone in the business plan and loan agreement, 2) State licensure, and 3) meeting the requirements to become a CO-OP in 45 CFR part 156 subpart F and in the FOA. Please feel free to use charts and graphs to highlight progress;


  1. Challenges and Responses

Provide a detailed description of any challenges, issues, or problems encountered during the reporting period in developing and operating your CO-OP and offering qualified health plans. Also provide a detailed description of your response to such challenges and the outcome.


  1. Variations from Business Plan

Describe any required variations from the original business plan, the rationale for the variation, and the objectives served. What, if any activities proposed in the business plan were not completed during the reporting period? Describe future plans to complete the activities and milestones originally proposed for the reporting period.


3. Significant Activities Undertaken and Planned

Discuss activities that occurred during the reporting period, or anticipated to occur in the near future, that affect the planning, development, and establishment of your CO-OP. Please also describe any products developed, offered, or acquired or materials produced during the reporting period, for example by-laws for your organization, IT systems, benefit packages or plans, or materials for member development and community outreach.


4. Activities Related to Consumer Control

Summarize activities and promising practices undertaken during the reporting period to promote consumer governance such as inclusion of consumers in the development process, Board of Directors elections, member education, and development and training of management and employees to promote member governance and consumer-focused services. Provide documentation of such activities. Identify any activities or practices undertaken during the reporting period that potentially dilute consumer control and actions taken by your organization to mitigate the effects on member governance. Provide documentation of such actions.

5. Quality Improvement System

Describe activities undertaken during the reporting period to develop and implement your organization’s quality improvement plan. If the quality improvement plan has been implemented, provide evidence that the quality improvement system has been fully operational during the reporting period.



6. Collaborative Efforts with States

Describe any communication or collaboration during the reporting period with the States in which your organization operates or intends to operate (for example, any communication with Exchanges or State insurance departments).


7. Other Collaborative efforts/Partnerships

Describe any new partnerships or collaborative efforts initiated during the reporting period with other entities such as sponsors, investors, or providers. Indicate the name of the partner or organization with your organization is collaborating, the type of organization, and the nature of the partnership or collaboration.


8. Lessons Learned

Provide additional information on any lessons learned during the reporting period that may inform your development or administration of the CO-OP or be helpful to share with other loan recipients or CO-OPs as well as any recommendations you may have to improve the operation of the CO-OP program.


9. Technical Assistance

Please describe in detail any technical assistance your organization needs at this time and your plans for securing such assistance. Please be as specific as possible about any assistance you would like to request from CMS.


10. Additional Funding

Please describe in detail any additional funding that your organization would like to request from CMS under the CO-OP program including the type of funding, the purpose of the funding, and when such funding would be needed.



B. Documentation

Only item 3 is required after all loans awarded under the CO-OP program have been repaid in full.


1. Updated Budget and Expenditures Table

Attach an updated detailed budget for the next reporting period. The budget must reflect all activities funded using the loans awarded under the CO-OP program and the organization’s revenues, if any.


In addition, provide a table comparing projected expenses and actual expenses for the current reporting period. This expenditures table should include a detailed account of expenditures to date indicating the portion of expenditures funded using loan awarded under the CO-OP program, any unused loan funds originally allocated for the expenditure (indicating amounts to be returned to CMS), the portion of expenditures funded by other sponsors or organizations, and the portion of expenditures funded by your organization through revenues. The expenditures table must reflect all activities funded using the loans awarded under the CO-OP program and the organization’s revenues, if any. Describe whether the current allocation of funds follows the progression of the detailed budget provided in your business plan and loan agreement. Also provide any unforeseen expenses and a brief description of the event that led to its occurrence. See Table 7 in section D for a sample format for the requested expenditures table.


2. Updated Business Plan, Work Plan, Financial Pro Forma, and Timeline

Provide an updated business plan, work plan, and timeline to reflect the events of the reporting period. Highlight any completed milestones as well as any additional milestones or time frames that were not included in your original business plan. Annually, provide updated three-year pro forma financial statements including balance sheet, income statement, enrollment projections, and statement of cash flows.


3. Attestation

Provide an attestation signed by an officer of your organization’s Board of Directors, the chief executive officer (CEO), the chief financial officer (CFO), or an individual delegated the authority to sign on behalf of one of these officers, and who reports directly to such officer certifying the accuracy, completeness, and truthfulness of any information submitted in this progress report.


C. Summary Data Statistics

Please fill in the data below as available for all activity occurring during the reporting period. Only items 5, 7, 8, 9, and 10 are required after all loans awarded under the CO-OP program have been repaid in full.



  1. Total Funds Expended to date (CO-OP Loan Funds): (Insert Number)

  2. Total Funds Expended to date (All): (Insert Number)

  3. Total Staff Hired (new during reporting period and hired to date with CO-OP loan funds): (Insert Number)

  4. Total Contracts and Policies in Place (new during reporting period and established to date): (Insert Number)

  5. Enrollments (Current): (Insert number)

    • Total enrollment in the small group market: (Insert Number)

    • Total enrollment in the large group market: (Insert Number)

    • Number of enrollment requests rejected and reason: (Insert Number)

  6. Disenrollments: (Insert number)

    • Total enrollment in the small group market: (Insert Number)

    • Total enrollment in the large group market: (Insert Number)

  7. Enrollment projections in the next twelve months: (Insert number)

    • Total enrollment in the small group market: (Insert Number)

    • Total enrollment in the large group market: (Insert Number)

    • Number of disenrollment: (Insert number)

  8. Total number of grievances: (Insert Number)

    • Quarter One: (Insert Number)

    • Quarter Two: (Insert Number)

    • Quarter Three: (Insert Number)

    • Quarter Four: (Insert Number)

  9. Total number of complaints (formal and informal): (Insert Number)

  • Quarter One (Insert Number)

    • Quarter Two: (Insert Number)

    • Quarter Three: (Insert Number)

Quarter Four: (Insert Number)

  1. Total number of coverage redeterminations made in reporting period: (Insert Number)



D. CO-OP Data Reports

Tables 7 and 8 are not required after all loans awarded under the CO-OP program have been repaid in full.



Table 1. Actual Enrollment as of End of Reporting Period by State

Reporting (Curt Estimate)

Enrollment Reporting (Current)


Market

In the Exchange

Outside of the Exchange


Number of Member Months by State

Number of Contracts and Policies by State

Number of Member Months by State

Number of Contracts and Policies by State

Small Group





Individual





Large Group





Medicaid





Other







Table 2. Projected Enrollments by State for One Year Following End of Reporting Period


Enrollment Projections through the next 12 Months


Market

In the Exchange

Outside of the Exchange


Number of Member Months by State

Number of Policies by State

Number of Member Months by State

Number of Policies by State

Small Group





Individual





Large Group





Medicaid





Other








Table 3. Actual Disenrollments as of End of Reporting Period by State


Disenrollment Reporting


Market

In the Exchange

Outside of the Exchange


Number of Member Months by State

Number of Contracts and Policies by State

Number of Member Months by State

Number of Contracts and Policies by State

Small Group





Individual





Large Group





Medicaid





Other







Table 4. Grievances Received during Reporting Period by Qualified Health Plan


Grievances Reporting & Notification


Type

(Related To)

Total Number of Grievances

Total Number of Grievances to which the CO-OP Provided Timely Notification of its Decision

Consumer Governance



Customer Service



Coverage Determinations/Exceptions and Appeals Process



Enrollment, Plan Benefits, or Provider Access



Quality of care



Other



Total Number of Greivances Received









Table 5. Complaints Received during Reporting Period by Qualified Health Plan


Complaints* Reporting & Notification


Type

(related to)

Total Number of Complaints

Total Number of Complaints to which the CO-OP Responded within 30 days

Consumer Governance



Customer Service



Coverage Determinations/Exceptions and Appeals Process



Enrollment, Plan Benefits, or Provider Access



Quality of care



Other



Total Number of Complaints Received



*Includes all complaints received either formally or informally.



Table 6. Membership Involvement


Membership Involvement


Measure

Amount


Percentage of membership representation on the BOD


Percentage of membership that voted in the most recent BOD election


Percentage of membership that has participated in advisory committees


Percentage of membership that has participated in membership development activities






Table 7. Use of Federal Funds


Use of Federal Funds


Required Measure

(Amounts)

Quarter One

Quarter Two

Quarter Three

Quarter Four

Annual Total

Total






Staffing







Management







Quality of Care/Care Coordination






Provider Services






Operating Space (Clinical and Administrative)






Systems Development






Outreach







Other



























Table 8. Sample Expenditures Table for B1


Expenditures During Reporting Period


Type of Expenditure


Total Expenditures

Originally Budgeted Expenditures

Difference Between Budgeted and Actual Expenditures

Explanation of Difference

Total





Staffing






Management






Actuarial Services





Accounting/Legal Services





Enrollment and Cost-sharing Administrative Systems





Claims Processing System Development





Customer Service Call Center Development





Provider Service

Call Center Development





Clinical IT System Development





Provider Payment





Reserves for Solvency Requirements





Marketing





Quality Improvement/Care Coordination





Member Education and Development






Other









Expenditures During Reporting Period


Type of Expenditure


Total Loan Funds Used

Originally Budgeted Loan Funds

Difference Between Budgeted and Actual Expenditures

Explanation of Difference

Unused Loan Funds to Be Returned to CMS

Total






Staffing







Management







Actuarial Services






Accounting/Legal Services






Enrollment and Cost-sharing Administrative Systems






Claims Processing System Development






Customer Service Call Center Development






Provider Service

Call Center Development






Clinical IT System Development






Provider Payment






Reserves for Solvency Requirements






Marketing






Quality Improvement/Care Coordination






Member Education and Development







Other












Expenditures During Reporting Period


Type of Expenditure


Expenditures Funded by Organization’s Revenues

Expenditures Funded by Sponsors or Other Sources

Sponsor or Other Source of Funding

Total




Staffing





Management





Actuarial Services




Accounting/Legal Services




Enrollment and Cost-sharing Administrative Systems




Claims Processing System Development




Customer Service Call Center Development




Provider Service

Call Center Development




Clinical IT System Development




Provider Payment




Reserves for Solvency Requirements




Marketing




Quality Improvement/Care Coordination




Member Education and Development





Other







1 Although Section 1322 of the Affordable Care Act refers to Solvency Loans as “grants” to assist with meeting State solvency requirements, they are loans because they must be repaid. Therefore, Solvency Loans are referred to as “loans” throughout this document.

1


INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:

This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleHealth Insurance Rate Review Grant Program Cycle I Quarterly Report Template
AuthorCMS
File Modified0000-00-00
File Created2021-01-31

© 2024 OMB.report | Privacy Policy