Department of Health and Human Services | |||||||||||
2014 Transitional Adjustment Reporting Form | |||||||||||
Member Months by State and Market | |||||||||||
Company Name: | |||||||||||
Contact Name: | |||||||||||
Contact Email: | |||||||||||
Contact Phone: | Federal EIN : | ||||||||||
Refer to Instructions for important information about completing this form. |
Member Months in 2014 | ||||||||||
Individual Market | Small Group | ||||||||||
Business State | Issuer ID(s) | Transitional Policies | All Other Non-grandfathered, ACA-compliant Policies | Transitional Policies | All Other Non-grandfathered, ACA-compliant Policies | ||||||
1 | 2 | 3 | 4 | ||||||||
Alabama | |||||||||||
Alaska | |||||||||||
Arizona | |||||||||||
Arkansas | |||||||||||
California | |||||||||||
Colorado | |||||||||||
Connecticut | |||||||||||
Delaware | |||||||||||
District of Columbia | |||||||||||
Florida | |||||||||||
Georgia | |||||||||||
Hawaii | |||||||||||
Idaho | |||||||||||
Illinois | |||||||||||
Indiana | |||||||||||
Iowa | |||||||||||
Kansas | |||||||||||
Kentucky | |||||||||||
Louisiana | |||||||||||
Maine | |||||||||||
Maryland | |||||||||||
Massachusetts | |||||||||||
Michigan | |||||||||||
Minnesota | |||||||||||
Mississippi | |||||||||||
Missouri | |||||||||||
Montana | |||||||||||
Nebraska | |||||||||||
Nevada | |||||||||||
New Hampshire | |||||||||||
New Jersey | |||||||||||
New Mexico | |||||||||||
New York | |||||||||||
North Carolina | |||||||||||
North Dakota | |||||||||||
Ohio | |||||||||||
Oklahoma | |||||||||||
Oregon | |||||||||||
Pennsylvania | |||||||||||
Rhode Island | |||||||||||
South Carolina | |||||||||||
South Dakota | |||||||||||
Tennessee | |||||||||||
Texas | |||||||||||
Utah | |||||||||||
Vermont | |||||||||||
Virginia | |||||||||||
Washington | |||||||||||
West Virginia | |||||||||||
Wisconsin | |||||||||||
Wyoming | |||||||||||
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 XXXXXXX. The time required to complete this information collection is estimated to average 3 hours, or 180 minutes per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. Completed forms should be submitted to [email protected] from February 9, 2015 through February 13, 2015. 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. |
Department of Health and Human Services | ||||||||||
2014 Transitional Adjustment Reporting Form | ||||||||||
The officer of the company signed below, being duly sworn, attests that he/she is the described officer of the reporting company, and that this Reporting Form includes full and true statements of all the elements included therein for the benefit year stated above, and that the Reporting Form has been completed in accordance with the Department of Health and Human Services’ reporting instructions, according to the best of his/her information, knowledge and belief. Furthermore, the scope of this attestation by the described officer includes any related electronic filings and postings for the Benefit Year stated above and which are required by Department of Health and Human Services under section 45 CFR 153.530(e). | ||||||||||
____________________________ | ||||||||||
Chief Financial Officer (or direct desingee) |
Reference Tables | ||||||
Table 3 | Table 4 | Table 5 | ||||
State Names | Benefit Years | Yes/No | ||||
Alabama | 2011 | Yes | ||||
Alaska | 2012 | No | ||||
Arizona | 2014 | |||||
Arkansas | 2015 | |||||
California | 2016 | |||||
Colorado | 2018 | |||||
Connecticut | 2019 | |||||
Delaware | 2020 | |||||
District of Columbia | 2021 | |||||
Florida | 2022 | |||||
Georgia | 2023 | |||||
Hawaii | 2025 | |||||
Idaho | 2026 | |||||
Illinois | 2027 | |||||
Indiana | 2028 | |||||
Iowa | 2029 | |||||
Kansas | 2030 | |||||
Kentucky | 2031 | |||||
Louisiana | 2032 | |||||
Maine | 2033 | |||||
Maryland | 2034 | |||||
Massachusetts | 2035 | |||||
Michigan | 2036 | |||||
Minnesota | 2037 | |||||
Mississippi | 2038 | |||||
Missouri | 2039 | |||||
Montana | 2040 | |||||
Nebraska | 2041 | |||||
Nevada | 2042 | |||||
New Hampshire | 2043 | |||||
New Jersey | 2044 | |||||
New Mexico | 2045 | |||||
New York | 2046 | |||||
North Carolina | 2047 | |||||
North Dakota | 2048 | |||||
Ohio | 2050 | |||||
Oklahoma | 2051 | |||||
Oregon | 2052 | |||||
Pennsylvania | 2054 | |||||
Rhode Island | 2056 | |||||
South Carolina | 2057 | |||||
South Dakota | 2058 | |||||
Tennessee | 2059 | |||||
Texas | 2060 | |||||
Utah | ||||||
Vermont | ||||||
Virginia | ||||||
Washington | ||||||
West Virginia | ||||||
Wisconsin | ||||||
Wyoming | ||||||
Grand Total |
File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |