Form CMS-10532 Transitional Policy Reporting Form

Risk Corridors Transitional Policy (CMS-10532)

CMS-10532 Copy of 30 day transitional reporting form_Jan clean v2.xlsx

Risk Corridors Transitional Policy

OMB: 0938-1267

Document [xlsx]
Download: xlsx | pdf

Overview

Member Months
Attestation
Tables


Sheet 1: Member Months

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.

Sheet 2: Attestation

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)

Sheet 3: Tables

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 Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

© 2024 OMB.report | Privacy Policy