Form CMS-10380 Cycle I - Quarterly Report

Health Insurance Rate Review Grant Program
Cycle I Quarterly Report Template

Submission Date:
State:
Project Title:
Project Quarter Reporting Period:
Example: Quarter 1 (08/09/2010-12/31/2010)
Grant Project Director (name and title):
Email:
Phone:
Grant Authorizing Representative:
Email:
Phone:

1
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-1121. The time required to complete this information collection is estimated to average 24 hours per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Health Insurance Rate Review Grant Program
Cycle I Quarterly Report Template

Grant Performance Period-Cycle I: August 9, 2010 to September 30, 2011

Reporting Period:
Quarterly Report 1:
Quarterly Report 2:
Quarterly Report 3:
Quarterly Report 4:
Timeframe for Delivery:

August 9, 2010 through December 31, 2010
January 1, 2011 through March 31, 2011
April 1, 2011 through June 30, 2011
July 1, 2011 through September 30, 2011
January 31, 2011-February, 28, 2011
April 30, 2011-TBD
July 31, 2011-TBD
October 31, 2011-TBD

Section 1003 of the Affordable Care Act requires the Secretary of the Department of Health and
Human Services (HHS), in conjunction with the States, to establish a process for the annual
review of health insurance premiums to protect consumers from unreasonable, unjustified and/or
excessive rate increases. Section 2974 of the Public Health Service Act (PPACA Section 1003)
provides for a program of grants that enable states to improve the health insurance rate review
and reporting processes.
States are required to submit quarterly progress reports to OCIIO. The quarterly progress report
describes significant advancements towards the State’s goal of improving its current health
insurance rate review and reporting process beginning from the time of approval through
completion of the grant period.
The first quarterly report must be submitted between January 31, 2011 and February 28, 2011
and must be submitted electronically through the Health Insurance Oversight System (HIOS).
Each state will be trained individually on the use of this system in January, 2011.
The following reporting guidelines are intended as a framework and can be modified when
agreed upon by the OCIIO grant project officer and the State. A complete quarterly progress
report must detail how grants funds were utilized; describe program progress, barriers and
provide an update on the measurable objectives of the grant program.

2
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-1121. The time required to complete this information collection is estimated to average 24 hours per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Health Insurance Rate Review Grant Program
Cycle I Quarterly Report Template
PART I: NARRATIVE REPORT FORMAT
Introduction:
Provide a brief overview of the project describing the proposed rate review enhancements and
clearly articulating the goals, measurable objectives, and milestones for each proposed
enhancement. Provide updates to the original grant proposal where necessary.

Program Implementation Status: As relevant to your project, include a discussion and update
on progress towards:
1. Accomplishments to Date: implementation milestones, early outcomes, include progress
toward stated goals, objectives and milestones;
2. Challenges and Responses: provide a detailed description of any encountered challenges
in implementing your program, the response and the outcome; and
3. Describe any required variations from the original timeline.
Significant Activities: Undertaken and Planned
Discuss activities that occurred during the quarter, or anticipated to occur in the near future, that
affect the progression of comprehensive rate review for your state. For States proposing
legislative enhancements to expand the scope of rate review activities, please provide a detailed
status update on the progress of all proposed grant activities undertaken in support of new
legislation.
Operational/Policy Developments/Issues
Identify all significant program developments/issues/problems that have occurred in the current
quarter, including legislative activity and proposed ways to rectify the barriers.
Public Access Activities
Summarize activities and/or promising practices undertaken during the previous quarter working
towards increased public access to rate review information for your state. Identify all barriers
associated with increasing public access to rates and rate filing information and proposed ways to
rectify the barriers.
Collaborative efforts
Describe any collaborative efforts in place that that are advancing the objectives of the Rate
Review Program in your state.

3
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-1121. The time required to complete this information collection is estimated to average 24 hours per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Health Insurance Rate Review Grant Program
Cycle I Quarterly Report Template
Lessons Learned
Provide additional information on lessons learned and any initial promising practices.
Updated Budget
Provide a detailed account of expenditures to date and describe whether the current allocation of
funds follows the progression of the detailed budget provided in your original application. Also
provide any unforeseen expenses and a brief description of the event that led to its occurrence.
Attach an updated detailed budget with the State’s quarterly report submission.
Updated Work Plan and Timeline
Provide an updated work plan and timeline to reflect the events of the previous quarter. Highlight
any additional time frames or items that were not included on the State’s original submission as
well as completion of milestones.
Enclosures/Attachments
Identify by title any attachments along with a brief description of what information the document
contains.

4
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-1121. The time required to complete this information collection is estimated to average 24 hours per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Health Insurance Rate Review Grant Program
Cycle I Quarterly Report Template

PART II: HEALTH INSURANCE RATE DATA COLLECTION
The data for Tables A-E (provided below) and the Rate Filing Detailed Data Elements will be
submitted through the Health Insurance Oversight System (HIOS). The rate filing data can
either be downloaded through the SERFF system or uploaded directly by the States (for states
not working with SERFF) into the HIOS system. States do not need to also input the data into
the programmatic narrative report template displayed here.
If using SERFF to import your data into the HIOS System, please discuss any discrepancies
between the imported data and State records.

Tables A-E: Rate Volume Tables
Table A. Rate Review Volume
State
Quarter 1

Quarter 2

Quarter 3

Quarter 4

Annual
Total

Number of
submitted rate
filings
Number of
policy rate
filings
requesting
increase in
premiums
Number of
filings reviewed
for
approval/denial,
acceptance etc.
Number of
filings
approved
Number of
filings denied
Number of
filings deferred
5
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-1121. The time required to complete this information collection is estimated to average 24 hours per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Health Insurance Rate Review Grant Program
Cycle I Quarterly Report Template
Table B. Number and Percentage of Rate Filings Reviewed – Individual Group
State
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Annual Total
Number of
covered lives
affected
Table C. Number and Percentage of Rate Filings Reviewed – Small Group
State
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Number of
covered lives
affected
Table D. Number and Percentage of Rate Filings Reviewed – Large Group
State
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Number of
covered lives
affected

Annual Total

Annual Total

Table E. (SERFF Users): Number and Percentage of Rate Filings Reviewed –Combined
State
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Annual Total
Number of
covered lives
affected
Rate Filing Detailed Data Elements: Please refer to the Enclosure for the updated Rate Filing
Detailed Data Elements (originally Attachment C the “Data Dictionary”).

6
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-1121. The time required to complete this information collection is estimated to average 24 hours per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.