Form CMS-10392 Reporting Templates

Consumer Operated and Oriented Plan (CO-OP) Program Report Templates

Submission Date:

Organization:

Reporting Period:

Example: Quarter 3 (07/01/2012 - 09/30/2012)

CMS Project Officer:

Project Director (name and title):

Email:

Phone:

Alternate Contact (name and title):

Email:

Phone:

Loans Received, Award Date, Date of Initial Drawdown:

Example:

Start-up Loan (Award: 08/15/2012, Drawdown: 09/01/2012)

Reporting Period Timeframe for Delivery)

I. Financial Reporting

Quarter 1: January 1^st through March 31st April 30^th

Quarter 2: April 1^st through June 30^th July 30^th

Quarter 3: July 1^st through September 30^th October 31^st

Quarter 4: October 1^st through December 31^st January 31^st

II. Deeming for Exchange Certification

Bi-annual: 24 months Within 30 days following

the end of the reporting period

III. Progress Report

Prior to Repayment in Full

Semi-annual 1: January 1^st through June 30^th July 30th

Semi-annual 2: July 1^st through December 31^st January 31^st

After Repayment in Full

Annual: January 1^st through December 31^st January 31^st

Section 1322 of the Patient Protection and Affordable Care Act (ACA) requires the Secretary to award federal loans to foster the creation of consumer-governed nonprofit health insurance issuers (CO-OPs) to compete in the Exchanges. Under the CO-OP program, CMS provides Start-up Loans to assist with start-up costs and Solvency Loans¹ to assist with State solvency requirements. The statute requires loan recipients to repay the Start-up Loans within 5 years and Solvency Loans within 15 years, taking into consideration State reserve requirements, solvency regulations, and requisite surplus note arrangements (collectively referred to as “solvency requirements”).

Recipients of Start-up Loans and Solvency Loans are required to submit financial documents to CMS on a quarterly basis starting with the quarter in which loan funds are first disbursed and ending with the quarter in which the loan recipient completes repayment of all loans awarded under the CO-OP program. If a loan recipient seeks to be deemed certified for an Affordable Insurance Exchange, the organization must submit the documentation requested in Part II of this document demonstrating that it has met the requirements for being a qualified health plan pursuant to Section 1311 of the Affordable Care Act, once every two years for as long as the loan recipient seeks to be deemed.

Progress reports must be submitted to CMS semi-annually starting with the reporting period in which loan funds are first disbursed and ending ten years following the date on which the loan recipient completes repayment of all loans awarded under the CO-OP program. The progress report describes significant advances towards the loan recipient’s goal of becoming a viable and sustainable CO-OP. CMS will use the information provided on the progress report and the financial report to monitor the CO-OP’s performance, ensure the appropriate use of federal funds, and verify that the loan recipient is conforming to the requirements in its loan agreement.

The following reporting guidelines are intended as a framework and can be modified when agreed upon by the CMS project officer and the loan recipient. If any of the requested information is readily available to CMS through another source (from example, an Exchange), CMS may choose not to collect the information from the loan recipient directly. A complete progress report must detail how loan funds were utilized; describe program progress and challenges; and provide an update on the measurable objectives of the CO-OP program.

PART I: FINANCIAL REPORTING [QUARTERLY SUBMISSIONS]

Provide a statement that the loan recipient is in compliance with all relevant State licensure requirements appropriate for its stage of Start-up or an explanation of any deficiencies, warnings, additional oversight, or any other adverse action or determination by State insurance regulators received by the loan recipient since the last-filed quarterly report. If the loan recipient is experiencing compliance issues with State regulators, describe the steps being taken to resolve those issues.

Provide financial statements (audited financial statements when available) including balance sheets, income statements, and statements of cash flow. In addition, provide a statement of total enrollment for each month in the quarter and the revenue received from enrollment. Identify by title any attachments along with a brief description of what information the document contains.

Provide an attestation signed by an officer of your organization’s Board of Directors, the chief executive officer (CEO), the chief financial officer (CFO), or an individual delegated the authority to sign on behalf of one of these officers, and who reports directly to such officer certifying the accuracy, completeness, and truthfulness of any information submitted in Part I- Financial Reporting.

PART II: DEEMING for EXCHANGE CERTIFICATION [BI-ANNUAL SUBMISSIONS]

If your organization would like to be deemed as certified to participate in the Exchanges, provide evidence that your organization meets the standards for qualified health plans pursuant to section 1311 of the Affordable Care Act and the applicable State-specific standards for qualified health plans established by the Exchanges in which your organization seeks to be deemed as certified. This information is required once every two years during the time period that your organization seeks to be deemed as certified. Identify by title any attachments along with a brief description of what information the document contains.

Provide an attestation signed by an officer of your organization’s Board of Directors, the chief executive officer (CEO), the chief financial officer (CFO), or an individual delegated the authority to sign on behalf of one of these officers, and who reports directly to such officer certifying the accuracy, completeness, and truthfulness of any information submitted for consideration.

PART III: PROGRESS REPORT [SEMI-ANNUAL SUBMISSIONS]

Identify by title any attachments along with a brief description of what information the document contains.

A. Narrative

Only items 4 and 5 are required after all loans awarded under the CO-OP program have been repaid in full.

1. Introduction

Provide a brief overview of your organization and your updated business plan for developing a CO-OP describing the goals, objectives, and milestones. Updates should be based on the business plan submitted and approved with the loan application.

2. CO-OP Planning and Development Status

Include a detailed discussion of the following:

1. Accomplishments

Describe achieved milestones, loan disbursement associated with the milestones, and outcomes during the reporting period, including progress towards 1) each milestone in the business plan and loan agreement, 2) State licensure, and 3) meeting the requirements to become a CO-OP in 45 CFR part 156 subpart F and in the FOA. Please feel free to use charts and graphs to highlight progress;

2. Challenges and Responses

Provide a detailed description of any challenges, issues, or problems encountered during the reporting period in developing and operating your CO-OP and offering qualified health plans. Also provide a detailed description of your response to such challenges and the outcome.

3. Variations from Business Plan

Describe any required variations from the original business plan, the rationale for the variation, and the objectives served. What, if any activities proposed in the business plan were not completed during the reporting period? Describe future plans to complete the activities and milestones originally proposed for the reporting period.

3. Significant Activities Undertaken and Planned

Discuss activities that occurred during the reporting period, or anticipated to occur in the near future, that affect the planning, development, and establishment of your CO-OP. Please also describe any products developed, offered, or acquired or materials produced during the reporting period, for example by-laws for your organization, IT systems, benefit packages or plans, or materials for member development and community outreach.

4. Activities Related to Consumer Control

Summarize activities and promising practices undertaken during the reporting period to promote consumer governance such as inclusion of consumers in the development process, Board of Directors elections, member education, and development and training of management and employees to promote member governance and consumer-focused services. Provide documentation of such activities. Identify any activities or practices undertaken during the reporting period that potentially dilute consumer control and actions taken by your organization to mitigate the effects on member governance. Provide documentation of such actions.

5. Quality Improvement System

Describe activities undertaken during the reporting period to develop and implement your organization’s quality improvement plan. If the quality improvement plan has been implemented, provide evidence that the quality improvement system has been fully operational during the reporting period.

6. Collaborative Efforts with States

Describe any communication or collaboration during the reporting period with the States in which your organization operates or intends to operate (for example, any communication with Exchanges or State insurance departments).

7. Other Collaborative efforts/Partnerships

Describe any new partnerships or collaborative efforts initiated during the reporting period with other entities such as sponsors, investors, or providers. Indicate the name of the partner or organization with your organization is collaborating, the type of organization, and the nature of the partnership or collaboration.

8. Lessons Learned

Provide additional information on any lessons learned during the reporting period that may inform your development or administration of the CO-OP or be helpful to share with other loan recipients or CO-OPs as well as any recommendations you may have to improve the operation of the CO-OP program.

9. Technical Assistance

Please describe in detail any technical assistance your organization needs at this time and your plans for securing such assistance. Please be as specific as possible about any assistance you would like to request from CMS.

10. Additional Funding

Please describe in detail any additional funding that your organization would like to request from CMS under the CO-OP program including the type of funding, the purpose of the funding, and when such funding would be needed.

B. Documentation

Only item 3 is required after all loans awarded under the CO-OP program have been repaid in full.

1. Updated Budget and Expenditures Table

Attach an updated detailed budget for the next reporting period. The budget must reflect all activities funded using the loans awarded under the CO-OP program and the organization’s revenues, if any.

In addition, provide a table comparing projected expenses and actual expenses for the current reporting period. This expenditures table should include a detailed account of expenditures to date indicating the portion of expenditures funded using loan awarded under the CO-OP program, any unused loan funds originally allocated for the expenditure (indicating amounts to be returned to CMS), the portion of expenditures funded by other sponsors or organizations, and the portion of expenditures funded by your organization through revenues. The expenditures table must reflect all activities funded using the loans awarded under the CO-OP program and the organization’s revenues, if any. Describe whether the current allocation of funds follows the progression of the detailed budget provided in your business plan and loan agreement. Also provide any unforeseen expenses and a brief description of the event that led to its occurrence. See Table 7 in section D for a sample format for the requested expenditures table.

2. Updated Business Plan, Work Plan, Financial Pro Forma, and Timeline

Provide an updated business plan, work plan, and timeline to reflect the events of the reporting period. Highlight any completed milestones as well as any additional milestones or time frames that were not included in your original business plan. Annually, provide updated three-year pro forma financial statements including balance sheet, income statement, enrollment projections, and statement of cash flows.

3. Attestation

Provide an attestation signed by an officer of your organization’s Board of Directors, the chief executive officer (CEO), the chief financial officer (CFO), or an individual delegated the authority to sign on behalf of one of these officers, and who reports directly to such officer certifying the accuracy, completeness, and truthfulness of any information submitted in this progress report.

C. Summary Data Statistics

Please fill in the data below as available for all activity occurring during the reporting period. Only items 5, 7, 8, 9, and 10 are required after all loans awarded under the CO-OP program have been repaid in full.

1. Total Funds Expended to date (CO-OP Loan Funds): (Insert Number)

2. Total Funds Expended to date (All): (Insert Number)

3. Total Staff Hired (new during reporting period and hired to date with CO-OP loan funds): (Insert Number)

4. Total Contracts and Policies in Place (new during reporting period and established to date): (Insert Number)

5. Enrollments (Current): (Insert number)

   • Total enrollment in the small group market: (Insert Number)

   • Total enrollment in the large group market: (Insert Number)

   • Number of enrollment requests rejected and reason: (Insert Number)

6. Disenrollments: (Insert number)

   • Total enrollment in the small group market: (Insert Number)

   • Total enrollment in the large group market: (Insert Number)

7. Enrollment projections in the next twelve months: (Insert number)

   • Total enrollment in the small group market: (Insert Number)

   • Total enrollment in the large group market: (Insert Number)

   • Number of disenrollment: (Insert number)

8. Total number of grievances: (Insert Number)

   • Quarter One: (Insert Number)

   • Quarter Two: (Insert Number)

   • Quarter Three: (Insert Number)

   • Quarter Four: (Insert Number)

9. Total number of complaints (formal and informal): (Insert Number)

• Quarter One (Insert Number)

• Quarter Two: (Insert Number)

• Quarter Three: (Insert Number)

Quarter Four: (Insert Number)

10. Total number of coverage redeterminations made in reporting period: (Insert Number)

D. CO-OP Data Reports

Tables 7 and 8 are not required after all loans awarded under the CO-OP program have been repaid in full.

Table 1. Actual Enrollment as of End of Reporting Period by State

Reporting (Curt Estimate)

Enrollment Reporting (Current)
Market	In the Exchange		Outside of the Exchange
	Number of Member Months by State	Number of Contracts and Policies by State	Number of Member Months by State	Number of Contracts and Policies by State
Small Group
Individual
Large Group
Medicaid
Other

Table 2. Projected Enrollments by State for One Year Following End of Reporting Period

Enrollment Projections through the next 12 Months
Market	In the Exchange		Outside of the Exchange
	Number of Member Months by State	Number of Policies by State	Number of Member Months by State	Number of Policies by State
Small Group
Individual
Large Group
Medicaid
Other

Table 3. Actual Disenrollments as of End of Reporting Period by State

Disenrollment Reporting
Market	In the Exchange		Outside of the Exchange
	Number of Member Months by State	Number of Contracts and Policies by State	Number of Member Months by State	Number of Contracts and Policies by State
Small Group
Individual
Large Group
Medicaid
Other

Table 4. Grievances Received during Reporting Period by Qualified Health Plan

Grievances Reporting & Notification
Type (Related To)	Total Number of Grievances	Total Number of Grievances to which the CO-OP Provided Timely Notification of its Decision
Consumer Governance
Customer Service
Coverage Determinations/Exceptions and Appeals Process
Enrollment, Plan Benefits, or Provider Access
Quality of care
Other
Total Number of Greivances Received

Table 5. Complaints Received during Reporting Period by Qualified Health Plan

Complaints* Reporting & Notification
Type (related to)	Total Number of Complaints	Total Number of Complaints to which the CO-OP Responded within 30 days
Consumer Governance
Customer Service
Coverage Determinations/Exceptions and Appeals Process
Enrollment, Plan Benefits, or Provider Access
Quality of care
Other
Total Number of Complaints Received

*Includes all complaints received either formally or informally.

Table 6. Membership Involvement

Membership Involvement
Measure	Amount
Percentage of membership representation on the BOD
Percentage of membership that voted in the most recent BOD election
Percentage of membership that has participated in advisory committees
Percentage of membership that has participated in membership development activities

Table 7. Use of Federal Funds

Use of Federal Funds
Required Measure (Amounts)	Quarter One	Quarter Two	Quarter Three	Quarter Four	Annual Total
Total
Staffing
Management
Quality of Care/Care Coordination
Provider Services
Operating Space (Clinical and Administrative)
Systems Development
Outreach
Other

Table 8. Sample Expenditures Table for B1

Expenditures During Reporting Period
Type of Expenditure	Total Expenditures	Originally Budgeted Expenditures	Difference Between Budgeted and Actual Expenditures	Explanation of Difference
Total
Staffing
Management
Actuarial Services
Accounting/Legal Services
Enrollment and Cost-sharing Administrative Systems
Claims Processing System Development
Customer Service Call Center Development
Provider Service Call Center Development
Clinical IT System Development
Provider Payment
Reserves for Solvency Requirements
Marketing
Quality Improvement/Care Coordination
Member Education and Development
Other

Expenditures During Reporting Period
Type of Expenditure	Total Loan Funds Used	Originally Budgeted Loan Funds	Difference Between Budgeted and Actual Expenditures	Explanation of Difference	Unused Loan Funds to Be Returned to CMS
Total
Staffing
Management
Actuarial Services
Accounting/Legal Services
Enrollment and Cost-sharing Administrative Systems
Claims Processing System Development
Customer Service Call Center Development
Provider Service Call Center Development
Clinical IT System Development
Provider Payment
Reserves for Solvency Requirements
Marketing
Quality Improvement/Care Coordination
Member Education and Development
Other

Expenditures During Reporting Period
Type of Expenditure	Expenditures Funded by Organization’s Revenues	Expenditures Funded by Sponsors or Other Sources	Sponsor or Other Source of Funding
Total
Staffing
Management
Actuarial Services
Accounting/Legal Services
Enrollment and Cost-sharing Administrative Systems
Claims Processing System Development
Customer Service Call Center Development
Provider Service Call Center Development
Clinical IT System Development
Provider Payment
Reserves for Solvency Requirements
Marketing
Quality Improvement/Care Coordination
Member Education and Development
Other

1 Although Section 1322 of the Affordable Care Act refers to Solvency Loans as “grants” to assist with meeting State solvency requirements, they are loans because they must be repaid. Therefore, Solvency Loans are referred to as “loans” throughout this document.

1

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:

This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.