CMS-10401 - 3Rs Supporting_Statement 2015 PN Oct 17

Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals
A. Background
The Patient Protection and Affordable Care Act, Public Law 111-148, enacted on March 23,
2010, and the Health Care and Education Reconciliation Act, Public Law 111-152, enacted on
March 30, 2010 (collectively, the “Affordable Care Act”), provides for three premium stabilization
programs – a reinsurance program, a risk corridors program, and a risk adjustment program – to
mitigate the negative impacts of adverse selection and market uncertainty. On March 23, 2012,
The Centers for Medicare & Medicaid Services (CMS) published the Premium Stabilization Rule
(77 FR 17220) to implement and set standards for these premium stabilization programs. On
March 11, 2013, CMS published the final Notice of Benefit and Payment Parameters for 2014
(“2014 Payment Notice”) (78 FR 15410), to implement requirements for various programs
established by the Affordable Care Act, establish standards for the cost-sharing reduction program
and the premium tax credit program, to provide for the collection of user fees from issuers to fund
operations of the Federally-facilitated Exchange and the risk adjustment program in States where
HHS operates risk adjustment, and to expand on standards set forth in the Premium Stabilization
Rule. CMS published a proposed Notice of Benefit and Payment Parameters for 2015 (“2015
Payment Notice”) on December 02, 2013, to expand upon, modify, and clarify the provisions of
the Premium Stabilization Rule, the 2014 Payment Notice, and the first and second final Program
Integrity Rules (78 FR 54070 and 78 FR 65046).
The transitional reinsurance program and the temporary risk corridors program are
designed to provide issuers with greater payment stability as insurance market reforms begin. The
reinsurance program serves to reduce the uncertainty of insurance risk in the individual market in
each State by making payments for high-cost enrollees. The HHS-administered risk corridors
program serves to protect against rate-setting uncertainty with respect to qualified health plans by
limiting the extent of issuer losses (and gains). The permanent risk adjustment program is
intended to protect health insurance issuers that attract a disproportionate number of higher risk
enrollees (e.g., those with chronic conditions). These programs will support the effective
functioning of the American Health Benefit Exchanges (“Exchanges”), which will become
operational by January 1, 2014. The Exchanges are individual and small group health insurance
marketplaces designed to enhance competition in the health insurance market and to expand access
to affordable health insurance for millions of Americans. Individuals who enroll in qualified health
plans (QHPs) through individual market Exchanges may receive premium tax credits to make
health insurance more affordable and financial assistance to reduce cost sharing for health care
services. The reporting and data collection provisions described below apply to States and health
plans both inside and outside of an Exchange.

B. Justification
1.

Need and Legal Basis

Section 1341 of the Affordable Care Act provides that each State must establish a transitional
reinsurance program to help stabilize premiums for coverage in the individual market during the
first three years of Exchange operation. Section 1342 provides for the establishment of a
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Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals
temporary risk corridors program that will apply to qualified health plans in the individual and
small group markets for the first three years of Exchange operation. Section 1343 provides for a
program of risk adjustment for all non-grandfathered plans in the individual and small group
market both inside and outside of the Exchange. Sections 1402 and 1412 of the Affordable Care
Act establish a program for reducing cost sharing for individuals with lower household income and
Indians. Sections 1401 and 1411 of the Affordable Care Act provide for advance payments of the
premium tax credit for low- and moderate-income enrollees in a QHP through an Exchange.
Section 1321(a) also provides broad authority for the Secretary to establish standards and
regulations to implement the statutory requirements related to Exchanges, reinsurance, risk
adjustment, and other components of title I of the Affordable Care Act. These risk-spreading and
insurance affordability programs, which will be implemented by HHS and/or States, are designed
to mitigate adverse selection, to provide stability for health insurance issuers in the individual and
small group markets as market reforms and Exchanges are implemented, and to make health
insurance more affordable and accessible to millions of Americans who currently do not have
affordable options available to them.
2.

Information Users

The data collection and reporting requirements described below will enable States and/or
HHS to implement these programs, which will mitigate the impact of adverse selection in the
individual and small group markets both inside and outside the Exchange.
3.

Use of Information Technology

Information collected for this rule will be submitted electronically. HHS staff will
communicate with States and the District of Columbia using standardized reporting, e-mail or
telephone.
4.

Duplication of Efforts
This information collection does not duplicate any other Federal effort.

5.

Small Businesses
This information collection will not have a significant impact on small businesses.

6.

Less Frequent Collection

The anticipated flows of funds for these programs require the collection of information as
indicated. A less frequent collection could result in cash flow difficulties for issuers and logistical
difficulties for issuers and the entities operating premium stabilization programs.
7.

Special Circumstances
In order for payments to be made in a timely manner for these premium stabilization
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Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals
programs, it is necessary to collect information according to timeframes established by the State or
HHS on behalf of the State.
8.

Federal Register/Outside Consultation

CMS published the draft 2015 Payment Notice in the Federal Register on December 02, 2013
and requested comments on the proposed information collections related to the proposed rule.
CMS provided a 60-day notice for this information collection in the Federal Register published as
part of the proposed Notice of Benefit and Payment Parameters for 2015 (78 FR 72322). We have
consulted with contractors, academia, States, and industry on the feasibility of this information
collection, and have based many of the requirements in this information collection on those
consultations.
9.

Payments/Gifts to Respondents
No payments or gifts will be provided to respondents.

10. Confidentiality
We will maintain respondent privacy with respect to the information collected to the extent
required by applicable law and HHS policies.
11. Sensitive Questions
There are no sensitive questions included in this information collection effort.
12. Burden Estimates (Hours & Wages)
Below is a summary of the information collection requirements set forth in the final rule.
Throughout this summary, the frequency of data collection is assumed to be the frequency
discussed in the preamble to the rule.
A number of assumptions are made regarding the wages of personnel needed to accomplish the
proposed collection of information. Wage rates are based on the Employer Costs for Employee
Compensation report by U.S Bureau of Labor Statistics and represent a national average. Some
States or employers may face higher or lower wage burdens. Wage rates estimates include a 35%
fringe benefit estimate for State employees and a 30% fringe benefit estimate for private sector
employees. We present an annualized estimate of the burden associated with these information
collection requirements below.

I. Health Insurance Issuer Standards Related to the Transitional Reinsurance Program
(§153.400-§153.420)
Within Part 153, subpart E we discussed reporting requirements for health insurance issuers
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Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals
related to the transitional reinsurance program. Based on data from the healthcare.gov website, we
estimate there are approximately 2,400 issuers in the individual and small group markets. Based on
2012 data from the Department of Labor, we estimate that 22,900 entities (including self-insured
and partially insured entities) will make reinsurance contributions.
Calculation of Reinsurance Contributions (§153.405)
As described in §153.400(b) all contributing entities both inside and outside of the
Exchange will be required to provide enrollment data (covered lives and member months) to HHS
to calculate contribution amounts. As described in §153.405, we require contributing entities to
provide annual counts of their enrollment and reinsurance contributions to HHS based on
modified counting methods used for Patient-Centered Outcome Trust Fund (PCORTF) reporting.
The burden associated with this requirement is the time and effort required by an issuer or selfinsured group health plan to derive an annual enrollment count. Because issuers and self-insured
group health plans will already be under an obligation to determine a count of covered lives using
a PCORTF method, the burden associated with this requirement is the additional burden of
conducting these counts using the slightly modified counting methods specified in the final
Payment Notice. On average, we estimate it will take each issuer 1 hour to reconcile and submit
final enrollment counts to HHS. Assuming an hourly wage rate of $55 for an operations analyst,
we estimate an aggregate burden of $1,259,500 for 22,900 reinsurance contributing entities subject
to this requirement. In §153.405(i), we propose that HHS or its designee would have the authority
to audit reinsurance contributing entities to assess compliance with the requirements of subparts E,
G and H of Part 153, as applicable. For contributing entities, we estimate that or approximately 37
hours at a cost of approximately $1,989 for each contributing entity. Because we have not
finalized the audit protocols, it is difficult to accurately estimate an audit rate. However, we
estimate that approximately 1 percent of contributing entities would be audited, representing 226
contributing entities. Therefore, we estimate an aggregate burden of 8,362 hours, or $449,514, as
a result of this proposed requirement.
All health insurance issuers, group health plans, and third party administrators are required
to register in a Federal system in order to access the module or form for the reinsurance
contributions process. The “Initial Plan Data Collection to Support QHP Certification and other
Financial Management and Exchange Operations” (OMB Control No. 0938-1187) details data
submission required when an entity is remitting payment for an invoice or receiving a payment
from HHS. The data elements that will be requested through the reinsurance contribution module
or form are detailed in Appendix C.
Request for Reinsurance Payments (§153.410)
As described in §153.410(a), health insurance issuers of reinsurance-eligible plans seeking
reinsurance payment must make a request for payment in accordance with the requirements in the
HHS notice of benefit and payment parameters or the State notice of benefit and payment
parameters, as applicable. To the greatest extent possible, we wish to minimize burden for issuers.
The data collected, and the manner in which that data will be collected, will be identical for both
the reinsurance and risk adjustment programs. HHS has determined that issuers will need to
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Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals
maintain data elements identified in Appendix A in order to make reinsurance payment requests.
A subset of issuers (specifically, issuers operating reinsurance-eligible plans in the individual
market) subject to the risk adjustment data collection requirements are eligible to make
reinsurance payment requests. As such, we anticipate minimal burden associated with this
provision; the burden associated with this provision is described in Part III of this section.
As described in §153.420(a), to be eligible for reinsurance payments, an issuer must submit or
make accessible all required reinsurance data in accordance with the reinsurance data collection
approach established by the State or HHS on behalf of the State. As described in 153.420(b) the
submission deadline is April 30 of the year following the applicable benefit year.
In §153.410(d), we propose that HHS or its designee would have the authority to audit
issuers of risk adjustment covered plans or reinsurance-eligible plans to assess compliance with
the requirements of subparts E, G and H of Part 153, as applicable. For issuers of reinsuranceeligible plans, these provisions would result in a third party disclosure requirement for issuers to
prepare and compile the financial and programmatic information necessary to comply with the
audit. Because we are conducting an audit of risk adjustment covered issuers that would include
issuers of reinsurance-eligible plans, we discuss the audit burden for reinsurance-eligible plans
along with the audit burden for risk adjustment covered plans in section III of this supporting
statement. As discussed in section III of this supporting statement, we estimate it will take 145
hours at a cost of approximately $7,794 for each issuer to make information available to HHS for
an onsite review.

II. Health Insurance Issuer Standards Related to the Temporary Risk Corridors
Program (§153.520-§153.530)
Within Part 153, subpart F we discussed reporting and recordkeeping requirements for QHP
issuers related to the risk corridors program. As described in §153.520(e), QHP issuers will be
required to maintain data and supporting information used to make the required allocations and
attributions of revenues and expenses, and to determine that the methods and bases detailed in the
report described below were accurately implemented. As described in §153.520(c), we will
require all QHP issuers to submit to HHS a detailed description of the methods and specific bases
used to attribute revenues and expenses in allowable costs and target amount to each QHP and
across plans. Under §153.530, we will also require all QHP issuers to submit data on premiums
earned, allowable costs, and allowable administrative costs. For the 2014 benefit year, we propose
to collect risk corridors data by using the same form as is used for MLR data collection, at the
same time (July 31st of the year following the applicable benefit year). We intend to modify the
MLR collection form for benefit year 2015, approved under OMB control number 0938-1164, to
add reporting elements (for example, QHP-specific premium amounts) that are required under the
risk corridors data submission requirements under §153.530. We intend to include these data
elements in an amendment to the information collection approved under OMB control number
0938-1164 for MLR data submission that we will publish for public comment and advance for
OMB approval in the future.
In §§153.530 and 153.540 we propose a data validation process for risk corridors data
submissions. Because the MLR program and the risk corridors program will require similar data,
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Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals
we estimate that submitting the data elements required for the risk corridors program will impose
limited additional burden on issuers. We estimate that it will take each QHP issuer approximately
1.5 hours, representing 1 hour for an insurance analyst (at an hourly wage rate of $38.49) and 30
minutes for a senior manager (at an hourly wage rate of $77), to input and review data that is
specific to the risk corridors program in the MLR and risk corridors reporting form for benefit year
2015. We estimate that 1,200 QHP issuers will submit risk corridors data for the 2014 benefit year
in the 2015 risk corridors and MLR reporting cycle. Therefore, we estimate an aggregate burden
of 1,800 hours (at a total cost of approximately $92,388) for QHP issuers as a result of this
requirement.
In §153.540(a), we propose that HHS or its designee would have the authority to audit
QHP issuers to assess compliance with the requirements of subpart F of Part 153. We intend to
align the risk corridors audit process with the audits conducted for the MLR program. Therefore,
we believe that the burden on QHP issuers associated with the risk corridors audit proposed in
§153.540(a) is already accounted for as part of the Supporting Statement for the MLR program
approved under OMB control number 0938-1164.
For the 2014 benefit year, we are considering adjustments to the premium stabilization
programs that would help to further mitigate unexpected losses for QHP issuers with plans that are
affected by the transitional policy. To effectuate potential adjustments, we must estimate the
State-specific effect on average claims costs. This submission would occur in 2015 prior to the
risk corridors July 31, 2015 data submission deadline. HHS would analyze that enrollment data,
and publish the State-specific adjustments that issuers would use in the risk corridors calculations
for the 2014 benefit year. We estimate that there will be approximately 2,400 issuers in the
individual and small group market in the 2014 benefit year, and that it would take an insurance
analyst approximately 30 minutes (at an hourly wage rate of $38.49) to estimate enrollment in
transitional plans and non-transitional plans and submit this information to HHS. Therefore, we
estimate a cost of approximately $19.25 for each issuer, and an aggregate cost of $46,200 for all
individual and small group market issuers (though this cost may be lower depending upon the data
collection method we adopt). To reduce the burden on issuers, we are considering coordinating
this data collection with other data collections for the premium stabilization programs. Because
we anticipate collecting this information in 2015, and because we expect to issue additional
clarifying guidance on this proposed policy, will seek OMB approval and solicit public comment
on this information collection requirement at a future date.
III. Health Insurance Issuer Standards for the Risk Adjustment Program (§153.610§153.630; and §153.700-730)
Within Part 153, subpart G, we described reporting requirements for health insurance
issuers related to the risk adjustment program.
Distributed Data and Risk Adjustment Data Submission Requirements (§153.610, §153.700(a),
and §153.720)
As described in §153.610, health insurance issuers will be required to maintain risk
adjustment data in order for HHS to operate risk adjustment on behalf of the State. HHS has
determined that issuers will need to maintain data elements identified in Appendix A. HHS intends
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Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals
to employ a distributed data approach when running risk adjustment on behalf of a State and will
also use this data for the purpose of determining the risk adjustment user fee for each issuer.
Under §153.610(f), we establish a user fee to support Federal operation of risk adjustment.
This per capita monthly fee will be charged to issuers of risk adjustment covered plans based on
enrollment estimates provided to HHS in the distributed data environment. HHS will calculate
user fees owed, and issuers will remit the fee owed only once, in June of the year following the
benefit year, in connection with processing of payments and charges for risk adjustment.
We estimate that 2,400 issuers will be required to pay risk adjustment user fees, and the
additional cost associated with this requirement is the time and effort for an issuer to provide
monthly enrollment data and remit fees. Because HHS will utilize existing data collection and
payments and charges processing, we do not anticipate that this provision will alter the collection
cost.
Under a distributed data approach, the required data is accessed and stored separately from
other issuer data pursuant to formats specified by HHS. In §153.700(a), we require that an issuer
of a risk adjustment covered plan or a reinsurance-eligible plan in a State where HHS is operating
the risk adjustment or reinsurance program on behalf of the State, as applicable, must provide
HHS, through the dedicated data environment, access to enrollee-level plan enrollment data,
enrollee claims data, and enrollee encounter data as specified by HHS. We estimate that this data
submission requirement will affect 2,400 issuers, and will cost each issuer approximately
$342,086 in total labor costs. This cost estimate reflects the wages of 3 full-time equivalent
employees (5,760 hours per year) at an average hourly rate of $59.39 per hour for a technical
employee. We anticipate that 400 data processing servers will be established across the market in
2014 (at an average cost of $15,000) and issuers will process approximately 9 billion claims and
enrollment files in 2014. Therefore, we estimate an aggregate burden, including labor and capital
costs (as described in section 13 below), of $821,006,400 for all issuers as a result of these
requirements. We are proposing to clarify the timeframe for this data submission by proposing
that an issuer must make good faith efforts to make complete, current enrollment and claims files
accessible through its dedicated distributed data environments no less frequently than quarterly,
once the issuer’s dedicated distributed data environment is established. This proposed clarification
will not affect the burden associated with this information collection requirement.
HHS has issued guidance indicating that we will provide issuers with the option of
uploading supplemental diagnoses to the dedicated distributed data environment in addition to the
other enrollee, claims, and medical data elements (see Appendix A) that are required for the risk
adjustment program. If an issuer chooses to submit supplemental diagnosis information, HHS has
determined that issuers will need to maintain data elements identified in Appendix B. The burden
associated with this requirement will be the additional effort for an issuer to gather and submit
supplemental diagnoses to HHS. We estimate that all 2,400 issuers of risk adjustment covered
plans will submit this information for 30% of their enrollees. In the 2014 Payment Notice, we
estimated the time and effort associated with submitting risk adjustment and reinsurance data
through the distributed data environment. Because issuers will only submit supplemental
diagnoses for 30% of their enrollees, we believe that the time and effort associated with this
process will be approximately 30% of the time and effort associated with uploading information to
the distributed data environment. We estimate that it will take 3 full-time equivalent employees
(at an average hourly wage rate of $59.39 for a technical employee) approximately 1,728 hours per
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Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals
year to submit supplemental diagnoses to HHS. For 2,400 issuers, we estimate an aggregate
burden of 4,147,200 hours and $246,302,208 associated with this option.
As described in §153.720(a), an issuer of a risk adjustment covered plan or reinsuranceeligible plan in a State in which HHS operates risk adjustment or reinsurance, as applicable, must
establish a unique masked enrollee identification number for each enrollee, in accordance with
HHS-defined requirements, and maintain the same masked enrollee identification number for an
enrollee across enrollments or plans within the issuer, within the State, during a benefit year.
Under §153.720(b), an issuer of a risk adjustment covered plan or reinsurance-eligible plan in a
State in which HHS is operating the risk adjustment or reinsurance program, as applicable, may
not include an enrollee’s personally identifiable information in the masked enrollee identification
number or use the same masked enrollee identification number for different enrollees enrolled
with the issuer. As discussed in OMB Memorandum M-07-16, the term “personally identifiable
information” is a broadly used term across Federal agencies, and has been defined in the Office of
Management and Budget Memorandum M-07-16 (May 22, 2007).1
We estimate that 2,400 issuers will be affected by the requirement to maintain a masked
enrollee identification number for each enrollee. The cost of setting up a masked identity for each
enrollee would be the time and effort required to assign an identification number to each enrollee
and remove other identifying factors from the enrollee’s profile or claims information as submitted
to HHS. We estimate it would cost each issuer approximately $178 per year, based on three hours
of work by a technical analyst at $59.39 per hour. Therefore, we estimate an aggregate cost of
$427,200 for all issuers to maintain a masked enrollee identification number.
We propose in §153.710(d) that within 30 calendar days of the date of an interim dedicated
distributed data environment report from HHS, an issuer of a reinsurance-eligible or risk
adjustment covered plan must either confirm to HHS that the information in the interim reports for
the risk adjustment and reinsurance programs accurately reflect the data to which the issuer has
provided access to HHS through its dedicated distributed data environment in accordance with
§153.700(a) for the timeframe specified in the report, or describe to HHS any inaccuracy it
identifies in the interim report. Similar to the interim report process, we propose in §153.710(e)
that the issuer either confirm to HHS that the information in the final dedicated distributed data
environment report accurately reflects the data to which the issuer has provided access to HHS
through its dedicated distributed data environment in accordance with §153.700(a) for the benefit
year specified in the report, or describe to HHS any inaccuracy it identifies in the final dedicated
distributed data environment report within 15 calendar days of the date of the report.
We estimate that 2,400 issuers of risk adjustment covered plans and reinsurance-eligible
plans will be subject to this requirement, and that issuers will compare enrollee condition codes
with risk scores and analyze claims costs to confirm information in the interim and final dedicated
distributed data environment reports. On average, we estimate that it will take an insurance
operations analyst (at an hourly wage rate of $38.49) approximately 2 hours to respond to an
interim report and 6 hours to respond to the final dedicated distributed data environment report.
Therefore, we estimate an aggregate burden of 19,200 hours and $739,008 for 2,400 issuers as a
result of this requirement.

1

Available at: http://www.whitehouse.gov/sites/default/files/omb/memoranda/fy2007/m07-16.pdf.

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Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals
Data Validation Requirements when HHS Operates Risk Adjustment (§153.630)
As described in §153.630, we will require health insurance issuers to comply with data
validation activities as specified by HHS or States. The burden associated with this requirement is
the issuer’s time and effort to provide HHS with source claims, records, and enrollment
information to validate enrollee demographic information for initial and second validation audits,
and the issuer’s cost to employ an independent auditor to perform the initial validation audit on a
statistically valid sample of enrollees. We estimate that each issuer sample will consist of
approximately 300 enrollees, with approximately two-thirds of the sample consisting of enrollees
with HCCs. We also anticipate that this audit burden will affect about 2,400 issuers. Based on
Truven Health Analytics 2010 MarketScan® data, we have determined that for enrollees with
HCCs, the average number of HCCs to be reviewed by an auditor per enrollee is approximately
two. Additionally, based on HHS audit experience, we estimate that it may cost approximately
$180 ($90 per hour for 2 hours) for an auditor to review the medical record documentation for one
enrollee with roughly two HCCs. We expect that it may cost approximately $30 per enrollee ($90
per hour for 20 minutes) to validate demographic information for all enrollees in the audit sample,
totaling approximately $210 per enrollee with HCCs and $30 per enrollee with no HCCs. We
assume that an initial validation audit will be performed on 180,000 enrollees without HCCs, and
360,000 enrollees with HCCs. For 2,400 issuers, we anticipate that the total burden of conducting
initial validation audits will be approximately $115.3 million.
In §153.630(b)(1), we propose that an issuer of a risk adjustment covered plan must engage
one or more independent auditors to perform an initial validation audit of a sample of its risk
adjustment data selected by HHS. This provision also proposes that the issuer provide HHS with
the identity of the initial validation auditor, and attest to the absence of conflicts of interest
between the initial validation auditor (or the members of its audit team, owners, directors, officers,
or employees) and the issuer (or its owners, directors, officers, or employees), in a timeframe and
manner to be specified by HHS. The additional burden associated with this proposed reporting
requirement is the time and effort necessary to report the auditor’s identity to HHS. We estimate it
will take an insurance operations analyst (at an hourly wage rate of $38.49) and a senior manager
(at an hourly wage rate of $77) each approximately 15 minutes to prepare and send an electronic
report to HHS. Therefore, for 2,400 risk adjustment covered issuers, the aggregate burden
associated with this requirement is 1,200 hours, at an approximate cost of $69,300.
In §153.630(b)(8), we propose that the initial validation auditor measure and report to the
issuer and HHS, in a manner and timeframe specified by HHS, its inter-rater reliability rates
among its reviewers. Also in this provision, we propose that the initial validation auditor to
achieve a minimum consistency measure of 95 percent for demographic, enrollment, and health
status review outcomes. We believe establishing inter-rater reliability among reviewers is standard
practice in the industry and will not result in extra cost for the initial validation auditor. Therefore,
the burden associated with this reporting requirement is the time and effort for the initial validation
auditor to report the inter-rater reliability rate to the issuer and to HHS. We estimate it will take an
insurance operations analyst (at an hourly wage rate $38.49) and a senior manager (at an hourly
wage rate of $77) each approximately 15 minutes to report the inter-rater reliability rate to the
issuer and to HHS. Therefore, for 2,400 issuers risk adjustment covered issuers, the aggregate
burden associated with this requirement is 1,200 hours, at an approximate cost of $69,300.
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Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals
Table 1 - Burden Estimates for Risk Adjustment Data Collection and Data Validation

Forms
Type of Frequency Number of
Number of
Average
(if necessary) Respondent
and
Respondents Responses per Burden
Duration
Respondent Hours per
Response
Risk adjustment
and reinsurance
distributed data
collection

Issuer

Supplemental
Diagnoses

Issuer

Masked enrollee
information

Issuer

Risk adjustment
data validation
Initial Validation
Audit
Identification
and Inter-rater
Reliability
Report
Confirmation of
Interim Reports
Total

Annually,
Permanent
Annually,
Permanent

Annually,
Permanent

Total
Burden
Hours

2,400

1

5,760

13,824,000

2,400

1,500,000

0.001

4,147,200

2,400

1

3

7,200

Issuer

Annually,
Permanent

2,400

300

1.78

1,281,600

Issuer

Annually,
Permanent

2,400

2

0.50

2,400

Issuer

Annually,
Permanent

2,400

1

8

19,200

2,400

19,281,600

Table 2 - Burden Estimates for Risk Adjustment Data Collection and Data Validation by Labor
Category

Type of
Respondent

Hourly Labor
Cost of
Reporting ($)

Total
Burden
Hours

Average
Labor Cost
per
Response

Insurance
Operations
Analyst

$38.49

1,200

$19.25

Technical Analyst

$59.39

16,154,400

Senior Manager

$77.00

Auditor

$90.00

Total

Number of Total Labor Costs
Respondents (All Respondents)

2,400

$46,188

$178

7,200

$1,067,735,808

1,200

$38.50

2,400

$92,400

1,281,600

$160

2,400

$115,344,000

2,400

$1,183,218,396

13,291,200

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Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals

Administrative Burden Related to Audits of the Risk Adjustment Covered Issuers (§153.410(d);
§153.620(c))
We propose that HHS or its designee would have the authority to audit issuers of risk
adjustment covered plans or reinsurance-eligible plans to assess compliance with the requirements
of subparts G and H of Part 153, as applicable. For issuers of risk adjustment covered plans and
issuers of reinsurance-eligible plans, these provisions would result in a third party disclosure
requirement for issuers to prepare and compile the financial and programmatic information
necessary to comply with the audit. For each onsite review we estimate that it will take an average
of 40 hours for administrative work to assemble the requested information, 19.5 hours to review
the information for completeness, and 30 minutes to submit the information to HHS in preparation
for an onsite review. We estimate that an onsite review would require an additional 2 hours to
schedule the onsite activities with the compliance reviewer (at an hourly wage rate of $53.75), 4
hours for introductory meeting, 8 hours to tour reviewers onsite, 10 hours of interview time, 2
hours to walk through processes with the reviewer, and 4 hours for concluding meetings, resulting
in a total of approximately 60 hours of preparation time and an additional 30 hours for onsite time
for each issuer. We estimate it will take 90 hours at a cost of approximately $4,838 for each issuer
to make information available to HHS for an onsite review. Although it is difficult to accurately
estimate an audit rate because we have not finalized out audit protocols, we believe that it would
be reasonable to assume that approximately 120 issuers, representing roughly 5 percent of issuers
of risk adjustment covered plans or reinsurance-eligible plans would be audited. Therefore, we
estimate an aggregate burden of 10,800 hours and $580,500 for issuers as a result of this
requirement.

IV.
Administrative Appeals for Premium Stabilization Programs, Federal
Exchange User Fees, Premium Tax Credits, and Cost-sharing Reductions (§156.1220)
In §156.1220, we propose an administrative appeals process to address unresolved
discrepancies for advance payment of the premium tax credit, advance payment and reconciliation
of cost-sharing reductions, FFE user fees, and the premium stabilization programs, as well as any
assessment under §153.740(b) of a default risk adjustment charge. In §156.1220(a), we propose
that an issuer may file a request for reconsideration to contest an incorrect loading or use of data,
an incorrect application of the relevant methodology, or a mathematical error for the amount of:
(1) advance payment of the premium tax credit, advance payment of cost-sharing reductions or
Federally-facilitated user fees charge for a particular month; (2) risk adjustment payments or
charges for a benefit year, including an assessment of risk adjustment user fees; (3) reinsurance
payments for a benefit year; (4) a risk adjustment default charge for a benefit year; (5) a
reconciliation payment or charge for cost-sharing reductions for a benefit year; or (6) risk corridors
payments or charges for a benefit year. While the hours involved in a request for reconsideration
may vary, for the purpose of this burden estimate we estimate that it will take an insurance
operations analyst 1 hour (at an hourly wage rate of $38.49) to make the comparison and submit a
request for reconsideration to HHS. We estimate that 24 issuers, representing approximately 1
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Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals
percent of all issuers that may be eligible for reinsurance payments, risk adjustment payments or
charges (including any assessment of risk adjustment user fees or a default risk adjustment
charge), advance payment and reconciliation of cost-sharing reductions, advance payment of the
premium tax credit, and FFE user fees, will submit a request for reconsideration for a total
aggregate burden of approximately $924.
We note that, in some circumstances, reinsurance contributing entities may receive two
invoices, and would be required to remit payments associated with each invoice received.
However, we do not believe that responding to these invoices will impose an additional burden on
contributing entities, because this process is already accounted for as part of their standard
business practices. Additionally, in §156.1220(b), we propose that an issuer dissatisfied with the
reconsideration decision regarding: (1) risk adjustment payments and charges, including an
assessment of risk adjustment user fees, (2) reinsurance payments, (3) default risk adjustment
charge, (4) reconciled cost-sharing reduction amounts, (5) risk corridors payments or charges,
provided under paragraph (a) of §156.1220, is entitled to an informal hearing before a CMS
hearing officer, if a request is made in writing within 15 calendar days of the date the issuer
receives the reconsideration decision. Further review is available from the CMS Administrator.
However, because we believe these processes will occur extremely infrequently, we are not
estimating the burden related to this requirement.
13. Capital Costs
Regardless of the data format and specifications for the reinsurance and risk adjustment
programs, issuers will need to extract and, for purposes of audit, store the necessary data elements
separately from data used during the normal course of business. We anticipate that approximately
400 data processing servers will be established across the market in 2014 to process the required
data elements at an average one-time cost of $15,000 each. Therefore, we estimate a total capital
burden of $6,000,000 for all issuers subject to this requirement. This estimate does not include the
labor costs associated with data and server maintenance, which are estimated separately.
14. Cost to Federal Government
The initial burden to the Federal Government for the establishment of the risk-related
programs is $274,936. The calculations for CCIIO employees’ hourly salary was obtained from the
OPM website: http://www.opm.gov/oca/10tables/html/dcb_h.asp.

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Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals
Table 3 – Administrative Burden Costs for the Federal Government Associated with the
Reinsurance, Risk Adjustment, and Risk Corridors Programs

Task

Estimated Cost

Development of HHS notice of benefit and payment parameters
15 GS-13: 15 x $42.66 x 160 hours

$102,384

Technical Assistance to States
15 GS-13: 15 x $42.66 x 240 hours

$153,576

Managerial Review and Oversight
2 GS-15: 2 x $59.30 x 160 hours

$18,976

Cost of Contracts for HHS-operated Reinsurance and Risk
Adjustment
Total Costs to Government

$27,300,000
$27,574,936

15. Explanation for Program Changes or Adjustments
As detailed above, certain burden estimates for information collection requirements associated
with the reinsurance, risk adjustment, risk corridors, premium tax credit, cost-sharing
reduction, and user fee programs would change from what was previously estimated in the
Premium Stabilization Rule and 2014 Payment Notice due to the proposed policy changes in
the proposed HHS notice of benefit and payment parameters for 2015. We have also updated
burden to reflect our most current estimates of program operations, including increasing our
estimate of the number of risk adjustment covered issuers in the individual and small group
insurance market.
16. Publication/Tabulation Dates
The following information described in part 12 of this document will be published annually in
the HHS notice of benefit and payment parameters:




Approved State alternate risk adjustment methodologies (as described in §153.330).
States publishing a State notice of benefit and payment parameters described in §153.100110 will include the following annually in that notice, as applicable. The risk adjustment
methodology that will be used if the State is operating the risk adjustment program.
The data validation standards, as described in §153.350, that will be used when operating
the risk adjustment program.

Finally, States will publish information about their risk adjustment program in an annual summary
report to be submitted to HHS. HHS intends that these reports will be made public soon after they
are submitted.2

2 For 2014, two states have elected to operate reinsurance and only one state, Massachusetts, will operate risk

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Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals
17. Expiration Date
Not applicable.
18. Certification Statement
There is no exception to the certification statement identified in Item 19, "Certification for
Paperwork Reduction Act Submissions," of OMB Form 83-I.

adjustment. The number does not reach the required threshold of nine or more entities affected and, therefore, we are
not submitting a PRA package. We will seek OMB approval in subsequent years if nine or more states decide to
operate risk adjustment programs.

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Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals

Appendix A
Data Elements for Risk Adjustment and Reinsurance
Data Category
Geographic Data

Market Level Data

Enrollee level data

Data Elements
 Metal level
 Actuarial value
 Benefit year
 Individual versus small-group
 State average actuarial risk (HHS-sourced)
 State Rating Curve
Includes header, issuer, and enrollee data elements:
 File ID
 Execution Zone
 Run Date
 Report Type
 Total Number of Enrollee Records
 Total Number of Enrollment Periods
 Record ID
 Issuer ID
 De-Identified (Masked) Enrollee ID
 Enrollee DOB
 Enrollee Gender
 Enrollment Period Activity
 Subscriber Indicator
 Subscriber ID
 Plan ID
 Enrollment start date
 Enrollment end date
 Premium Amount
 Geographic Rating area
 Interface Control Release Number

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Submitting
Entity
State

State

Issuers

Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals
Data Category

Pharmacy Claims

Data Elements
Includes header, issuer, plan and claim data elements:
 File ID
 Execution Zone
 Run Date
 Report Type
 Total Claims
 Total Plan Paid Amount
 Issuer ID
 Record ID
 Plan ID
 De-Identified (Masked) Enrollee ID
 Claim ID
 Claim Processed Date/Time
 Fill Date
 Paid Date
 Prescription/Service Reference Number
 Product/Service ID
 Dispensing Provider Service ID Qualifier
 Dispensing Provider Service ID
 Fill Number
 Dispensing Status
 Void/Replace Indicator
 Total Allowed Cost
 Derived Amount Indicator
 Interface Control Release Number
 Plan Paid Amount

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Submitting
Entity

Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals
Data Category

Medical Claims

Data Elements
Includes header, issuer, plan and claim header and claim
line data elements:
 File ID
 Execution Zone
 Run Date
 Report Type
 Total Claims
 Total Claim Lines
 Total Plan Paid Amount
 Record ID
 Issuer ID
 Plan ID
 De-Identified (Masked) Enrollee ID
 Interface Control Release Number
Claim Header Level Data Elements
 Form Type
 Claim ID
 Original Claim ID
 Claim Processed Date/Time
 Bill type
 Date Paid
 Void/Replace Indicator
 Discharge Status Code
 Statement Covers From
 Statement Covers Through
 Billing Provider ID Qualifier
 Billing Provider ID
 Total Amount Allowed
 Total Amount Paid
 Derived Amount Indicator
 Diagnosis Code Qualifier
 Diagnosis Code

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Submitting
Entity

Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals
Data Category

Medical Claims (continued)

Data Elements
Claim Line Level Data Elements
 Record ID
 Claim Line Sequence Number
 Date of Service - From
 Date of Service - To
 Revenue Code
 Service Code Qualifier
 Service Code
 Service Code Modifier
 Place of Service
 Rendering Provider ID Qualifier
 Rendering Provider ID
 Amount Allowed
 Amount Paid
 Derived Amount Indicator

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Submitting
Entity

Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals

Appendix B
Supplemental Diagnoses for HHS Operated Risk Adjustment
Data Elements

Submitting Entity

Includes header, issuer, plan and claim header and claim line data
elements:
 File ID
 Execution Zone
 Run Date
 Report Type
 Total Claims
 Total Claim Lines
 Total Plan Paid Amount
 Record ID
 Issuer ID
 Plan ID
 De-Identified (Masked) Enrollee ID
 Interface Control Release Number
Claim Header Level Data Elements
 Form Type
 Claim ID
 Original Claim ID
 Claim Processed Date/Time
 Bill type
 Date Paid
 Void/Replace Indicator
 Discharge Status Code
 Statement Covers From
 Statement Covers Through
 Billing Provider ID Qualifier
 Billing Provider ID
 Total Amount Allowed
 Total Amount Paid
 Derived Amount Indicator
 Diagnosis Code Qualifier
 Diagnosis Code

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Issuer

Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals

Appendix C
Data Elements for Reinsurance Contributions Reporting
The transitional reinsurance program requires that health insurance issuers, self-insured group
health plans (including a group health plan that is partially self-insured and partially insured) or
third party administrators on behalf of them submit to HHS an annual enrollment count no later
than November 15 of calendar year 2014, 2015 and 2016 respectively. The annual enrollment
count submission will be used to calculate the applicable benefit year’s annual reinsurance
contribution.
All health insurance issuers, group health plans, and third party administrators are required to
register in a Federal system in order to access the module or form for the reinsurance contributions
process. The “Initial Plan Data Collection to Support QHP Certification and other Financial
Management and Exchange Operations” (OMB Control No. 0938-1187) details data submission
required when an entity is remitting payment for an invoice or receiving a payment from HHS.
This PRA details the data elements that will be requested through the reinsurance contribution
module or form.
General
1.
HIOS ID
2.
Benefit Year applicable to the reported Gross Annual Enrollment Count (2014, 2015,
2016)
3.
Are you a contributing entity?
a. Yes. If yes and using Third Party Administrator (TPA) or parent company to complete the
reinsurance contributions process, please provide the TPA’s or parent company’s HIOS ID.
b. No (Excepted). If no, please select:

Not major medical

Self-insured, self-administered

Other. If other, please explain.
Entity Information (to be completed by contributing entity or Third Party Administrator/Parent
Company on behalf of issuer or group health plan)
1.
HIOS ID (submitter of enrollment information)
2.
Legal Business Name (submitter of enrollment information)
3.
Federal TIN (submitter of enrollment information)
4.
Address (submitter of enrollment information)
a.
Address Line 1, Address Line 2, City, State, Zip Code+4, State
5.
Contact 1, Contact 2, Contact 3 (submitter of enrollment information)
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Supporting Statement For Paperwork Reduction Act Submissions:
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and Payment Appeals
6.
7.

8.
9.

b.
c.
d.
e.

a.
First Name, Last Name, Title, E-mail, Phone Number, Phone Number Extension
Authorizing Official for Acknowledgment (submitter of enrollment information)
a.
First Name, Last Name, Title, E-mail, Phone Number, Phone Number Extension
Is submitting entity a Third Party Administrator or Parent Company on behalf of issuer(s)
or group health plan(s) pursuant to the definition of “contributing entity” at 45 CFR
153.20?
Gross Annual Enrollment Count
Provide for the following for each contributing entity represented in the ‘Gross Annual
Enrollment Count’ (repeat many times, select one for each entity):
a.
Select Type of Entity :
 Health insurance issuer (§153.405(d));
 Self-insured group health plan (including a group health plan with a selfinsured coverage option and fully insured coverage option) (§153.405(e));
 Group health plans with a self-insured coverage option and an insured
coverage option (§153.405(f))
o NOTE: Pursuant to §153.405(f)(2), a plan with multiple coverage
options may use any of the counting methods specified for health insurance
issuers or self-insured group health plans, as applicable to each coverage
option, if it determines the number of covered lives under each coverage
option separately as if each coverage option provided major medical
coverage
 Multiple group health plans maintained by the same plan sponsor, that
collectively provide major medical coverage for the same covered lives
simultaneously, which are treated as a single group health plan including an
insured plan (§153.405(g)(4)(i)); or
 Multiple group health plans maintained by the same plan sponsor, that
collectively provide major medical coverage for the same covered lives
simultaneously, which are treated as a single group health plan NOT
including an insured plan (§153.405(g)(4)(ii)).
o NOTE: Pursuant to §153.405(g)(1), if there are multiple group health
plans maintained by the same plan sponsor, the plan sponsor may treat the
multiple plans as separate group health plans if the plan sponsor determines
the number of covered lives under each separate group health plan as if the
separate group health plan provided major medical coverage (i.e. is its own
plan for which reinsurance contributions are required).
Entity HIOS ID
Entity Legal Business Name
Entity Federal Tax Identification Number
Entity Address
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Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals
o Address Line 1, Address Line 2, City, State, Zip Code+4, State
f. For each entity being reported, please complete the applicable section below based on the
‘Entity Type’ selected above.

Health Insurance Issuer
1.
Annual enrollment count
a. Total Count
 Net to exclude any excepted coverage types/plans/enrollees (count to be used for assessing
reinsurance contributions due for the reporting benefit year)
 Number of policy holders represented in the net enrollment count
 Number of employer groups represented in the net enrollment count
b. Count for each Group Health Plan:
 Not Applicable (select when issuer does not provide plans/coverage in the group health
market)
 Yes, issuer provides coverage in the individual market. If yes, complete the following for
each Group Health Plan:

Name of Plan

Gross enrollment count to include all coverage types

Net enrollment count to exclude any excepted coverage types/plans/enrollees

Provide information for the excepted coverage types/plans/enrollees
c. Count for Individual Market:
 Not Applicable (select when issuer does not provide plans/coverage in the individual
market)
 Yes, issuer provides coverage in the individual market. If yes, complete the following:

Gross enrollment count to include all coverage types

Net enrollment count to exclude any excepted coverage types/plans/enrollees

Provide information for the excepted coverage types/plans/enrollees
2.
Select method used for calculation of enrollment count
a. Actual Count
 Dates used to add up total of covered lives
b. Snapshot Count
 Specific date or date(s) were used for each quarter
 Number of enrollees on the specific date or date(s) that were used for each quarter
c. Member Months or State Form
 Date of the NAIC Supplemental Health Care Exhibit or from the most recent form filed
with the issuer’s State of domicile
 Upload form
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Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals
Self-Insured Group Health Plan
1.
Annual enrollment count
a. Total Count
 Net enrollment count to exclude any excepted coverage types/plans/enrollees (count to be
used for assessing reinsurance contributions due for the reporting benefit year)
b. Count by Coverage Type:
 Not Applicable (select when self-insured group health plan provides all coverage through
major medical plan)
 Coverage Type

Gross enrollment count to include all coverage types

Net enrollment count to exclude any excepted coverage types/plans/enrollees

Provide information for the excepted coverage types/plans/enrollees
2.
Select method used for calculation of enrollment count
a. Actual Count
 Dates used to add up total of covered lives
b. Snapshot Count
 Specific date or date(s) were used for each quarter
 Number of enrollees on the specific date or date(s) that were used for each quarter
c. Snapshot Factor
 Specific date or date(s) were used for each quarter
 Number of enrollees on the specific date or date(s) that were used for each quarter
d. Form 5500 Schedule A
 Date of the Form 5500 Schedule A
 Number of total participants covered at the beginning and end of the benefit year as
reported on the Form 5500 Schedule A
 Upload form
Group Health Plan with a Self-insured Coverage Option and Fully Insured Coverage Option
[45 CFR 153.405(f)(1)]
1.
Are you combining coverage options for reporting of annual enrollment count under 45
CFR 153.405(f)(1)?
a. Yes. If Yes, complete the below as applicable.
b. No. If No [45 CFR 153.405(f)(2)], treat each plan as providing major medical coverage
with contributing entity completing the ‘Health Insurance Issuer’ and ‘Self-insured Group
Health Plan’ section as applicable.
2.
Annual enrollment count
a. Total Count
 Gross enrollment count to include all coverage types/plans
3.
Net enrollment count to exclude any excepted coverage types/plans (count to be used for
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Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals
assessing reinsurance contributions due for the reporting benefit year)Select method used for
calculation of annual enrollment count
a. Actual Count
 Dates used to add up total of covered lives
b. Snapshot Count
 Specific date or date(s) were used for each quarter
 Number of enrollees on the specific date or date(s) that were used for each quarter
4.
If combining, provide for all plans and/or options (insured and self-insured) for purposes of
calculating the annual enrollment count (repeated for each option):
a. Name of issuer or self-insured group health plan
b. HIOS ID (situational)
c. Gross enrollment count for option
d. Net enrollment count for option
e. Provide information for enrollment under excepted coverage option
Multiple Group Health Plans Maintained by the Same Plan Sponsor [45 CFR 153.405(g)]
(One or more group health plans under the same plan sponsor)
1.
a.

b.

2.
a.

3.
a.
b.

c.

Are you aggregating multiple group health plans under 45 CFR 153.405(g)?
Yes. If Yes, which entity type are you for purposes of reporting?
 Self-insured. If selected, complete the below as applicable.
 Fully-insured. If selected, complete the below as applicable.
 Mixed. If selected, complete the below as applicable.
No. If No, treat each plan as providing major medical coverage with contributing entity
completing the ‘Health Insurance Issuer’ and ‘Self-insured Group Health Plan’ section as
applicable.
Annual enrollment count
Total Count
 Gross enrollment count to include all coverage types/plans
 Net enrollment count to exclude any excepted coverage types/plans (count to be used for
assessing reinsurance contributions due for the reporting benefit year)
Select method used for calculation of enrollment count
Actual Count
 Dates used to add up total of covered lives
Snapshot Count
 Specific date or date(s) were used for each quarter
 Number of enrollees on the specific date or date(s) that were used for each quarter
Snapshot Factor
 Specific date or date(s) were used for each quarter
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Supporting Statement For Paperwork Reduction Act Submissions:
Standards Related to Reinsurance, Risk Corridors, Risk Adjustment,
and Payment Appeals
 Number of enrollees on the specific date or date(s) that were used for each quarter
d. Form 5500
 Date of the Form 5500
 Number of total participants covered at the beginning and end of the benefit year as
reported on the Form 5500
 Upload form
e. Member Months or State Form
 Date of the NAIC Supplemental Health Care Exhibit or from the most recent form filed
with the issuer’s State of domicile
 Upload form
4.
If aggregating, provide for the plans being treated as a single group health plan for
purposes of calculating the annual enrollment count (repeated for each plan):
a. Name of group health plan
b. HIOS ID (situational)
c. Gross enrollment count for group health plan
d. Net enrollment count for group health plan
e. Provide information for enrollment under excepted coverage
Attestation
The following attestation must be signed by a certifying official of the contributing entity that has
the authority to submit the enrollment count and related data:
I attest that the data provided for the Reinsurance Contributions Process for the current reporting
year is accurate to the best of my knowledge.

Acknowledgement
1. Yes or No. The gross annual enrollment count entered in this form matches the aggregate
enrollment count by entity in the supporting documentation.
2. Yes or No. I acknowledge that the data provided in this form is accurate to the best of my
knowledge and that I have the authority to submit such data on behalf of the contributing entity
which I represent. I acknowledge that the provisions of the Affordable Care Act specifically
make payments made by or in connection with an Exchange subject to the False Claims Act if
those payments include any Federal funds. This includes, but is not limited to, the transitional
reinsurance program established under Section 1341 of the Affordable Care Act.

25