Form CMS-10532 Transitional Policy Reporting Form

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Overview

Member Months
Attestation
Tables

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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.

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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)

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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