CMS-10392 Monthly Reporting Guidance

Department of Health & Human Services
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201
INSURANCE PROGRAMS GROUP
CO-OP PROGRAM DIVISION

Date:
To:
From:
Subject:

May 15, 2015
CO-OP Project Officers
Kelly O’Brien, Director
CO-OP Program
Additional Guidance Re: New Monthly Reporting Requirements

This memo sets forth additional guidance and clarifications regarding the new monthly reporting
requirements for CO-OP loan recipients. Pursuant to Sections 10 and 11 of the Loan Agreement, COOP loan recipients must submit reports and other data required by CMS to monitor the performance
of CO-OP loan recipients. To provide a timely snapshot of each CO-OP loan recipient’s capital
position and risk profile, CMS requests that each CO-OP submit a few pieces of key data to CMS on
a monthly basis. The current requirements for the CO-OP monthly reporting include the following:

1. Active enrolled members – on the individual Marketplace – total and broken down by age:
a. Age 0-20
b. Age 21-34
c. Age 35-44
d. Age 45-54
e. Age 55-64
f. Age 65+
2. Total disenrollment – on the individual Marketplace
3. Active enrolled members – off the individual Marketplace – total and broken down by age:
a. Age 0-20
b. Age 21-34
c. Age 35-44
d. Age 45-54
e. Age 55-64
f. Age 65+
4. Total disenrollment – off the Individual Marketplace
5. Total active enrollment – Small Group
a. Small Group enrollment – on the Marketplace

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 fullest extent of the law.

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b. Small Group enrollment – off the Marketplace
Total active enrollment – Large Group
Total active members enrolled in QHPs (Individual and SHOP)
Total active members enrolled in non-QHPs (Off exchange: Individual, Small and large group)
Total overall active enrollment
Total overall disenrollment
Total projected enrollment for next reporting period
Total active enrollment as a % of previously projected (prior month)
Total written premiums (gross)
Total uncollected premiums and agents’ balances in course of collection
Total claims incurred (gross)
Total claims unpaid
Total cash/cash equivalents on-hand
Total bonds/other solvency investments
Investment Income Receivables
Healthcare Receivables
Premium Deficiency Reserve (PDR)
Capital and Surplus
Federal Reinsurance Premiums
Commercial Federal Reinsurance Premiums
Federal Reinsurance Recoveries
Commercial Reinsurance Recoveries
Total G&A Expenses
Claims Adjustment Expenses
Net Investment Income (Loss)
Other Income (Loss)
Net Income (Loss)
DOI Financial Reports

As of February 2014, CO-OP loan recipients were required to begin submitting select enrollment and
financial data by the last day of the month. This data should cover the YTD balance as of the last
day of the prior month. Specifically, active enrollment data should reflect the number of enrollees
with coverage in effect as of the last day of the current reporting period. Additionally, financial data
reported should be current and cumulative YTD as of the last day of the reporting period. In
addition, all CO-OPs presently providing data to their State Department of Insurance (DOI) on a
monthly basis should provide CMS with a copy of their full submission. Please note that all financial
data provided on a monthly basis will be verified against NAIC report submissions to help assess the
accuracy and validity of the data being provided to CMS. Thus, CO-OPs should ensure the amounts
reported in the monthly reports agree with their reporting to state DOI.
Please note that additional changes have been made to the guidance below for clarification provided
on definitions in the February 3, 2015 memo. To assist in providing clarification regarding the new

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 fullest extent of the law.

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monthly data reporting requirement, the following clarification notes are provided along with an
updated Data Dictionary.
•

“Active Enrolled Members” should solely reflect members presently being provided with
coverage. (Note: ASO business should be included in the figures provided.)

•

“Age” should be provided for all subcategory ranges provided. If a CO-OP has no members
presently within a given age range, please enter a zero (0) within the monthly report template.
o Please ensure that your data submission is not coded with a dash (-) or other null
figure as this will result in inaccurate data being recorded for your CO-OP.

•

“Total active members enrolled in QHPs” should be the total of SHOP and individual
members enrolled with Qualified Health plans: # 1 and #5a.

•

“Total active members enrolled in non-QHPs” should be the total of small group,
individual and large group members enrolled with non-Qualified Health plans.

•

“Total overall active enrollment” should be the total of active enrollments across all
markets: # 1, #3, # 5, and #6. Also, this field should equal the total of fields, #7 and #8.

•

“Total overall disenrollment” should be the total of all disenrollments across all markets:
Individual, small group (including SHOP) and large group.

•

“Total Uncollected Premiums and Agents’ Balances in Course of Collection” should not
be provided as a negative (-) figure. For the purposes of analysis, providing a negative figure
will result in inaccurate data being assessed for your CO-OP.

•

“Total Claims Incurred” should be a cumulative amount for claims incurred (paid and
unpaid) during the current year only, consistent with the calculation methodology used for
the Statement of Revenue and Expense, Line 16 – Subtotal of hospital and medical from the
regulatory filing. This amount should not include reinsurance recoveries from federal and
commercial reinsurance programs.

•

“Total Claims Unpaid” should also not be provided as a negative (-) figure within the
monthly report template. For the purposes of analysis, providing a negative figure will result
in inaccurate data being assessed for your CO-OP.

•

“Total administrative expenses incurred” should not include claims adjustment expenses.
Calculation methodology used should be consistent with the methodology used to report the
Statement of Revenue and Expense, Line 21 - General administrative expenses on the
regulatory filings. Refer to SSAP No.70 for accounting guidance.

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 fullest extent of the law.

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•

“Total Cash/Cash Equivalents On-hand” amount reported on the monthly report should
equal to amount reported on Assets Statement, Line 5 - Cash, cash equivalents, and shortterm investments of the regulatory filing.

•

“Total Bonds/Stocks/Other Investments” – amount reported on the monthly report should
equal to sum of amounts reported on Asset Statement, Lines 1 (Bonds) and 2 (Stocks preferred and common) of the regulatory filing.

Attachments (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 fullest extent of the law.

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DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight
200 Independence Avenue SW
Washington, DC 20201
INSURANCE PROGRAMS GROUP
CO-OP PROGRAM DIVISION
March XX, 2015
Purpose:
This document provides further clarification regarding the specifications of the monthly report measures now required by CMS for all COOPs that are offering products. Effective February 2014, CO-OP loan recipients must report the following information for current year-todate. Please refer to NAIC definitions and reporting standards for additional clarification if needed.
Data Dictionary:
Measure:
Age
On the Marketplace
Off the Marketplace
Active Enrolled Members
- INDIVIDUAL

Instructions:
To determine the appropriate age category of an enrollee, use the age of the enrolled individual at the time of
application.
Report data from qualified health plans sold through the Exchange.
Report data from plans not sold through the Exchange.
Report the number of Individual Market enrolled members with coverage in effect as of the last day of the
reporting period. All individuals counted in this column should have paid their first month’s premium.

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 fullest extent of the law.

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Active Enrolled Members
– SMALL GROUP
Active Enrolled Members
– LARGE GROUP
Active Enrolled Members
- TOTAL
Disenrollment

Total Premiums Written

Total Uncollected
Premiums and Agents’
Balances in Course of
Collection
Total Claims Incurred
(Gross)

Report the number of Small Group Market enrolled members with coverage in effect as of the last day of the
reporting period. All individuals counted in this column should have paid their first month’s premium.
Report the number of Large Group Market enrolled members with coverage in effect as of the last day of the
reporting period. All individuals counted in this column should have paid their first month’s premium.
Report the number of enrolled members with coverage in effect as of the last day of the reporting period. All
individuals counted in this column should have paid their first month’s premium.
Report the number of members who have since disenrolled from coverage in effect as of the last day of the
reporting period.
Report the sum amount of all premiums written during the current year, including: amounts for premium
transactions conducted directly with insured; amounts due from agents resulting from various insurance
transactions; and premiums receivable from government-insured plans. Refer to SSAP No 6; SSAP No. 61R
for accounting guidance.
Written premium is the contractually determined amount charged to the policy holder for the effective period
of the contract. For health contracts without fixed contract periods, premium written will equal the amount
collected during the reporting period plus uncollected premiums at the end of period less uncollected premium
at the beginning of the period.
The amount reported on monthly should equal to the cumulative YTD total premium written during the
current year and should not be adjusted for reinsurance ceded or receivables/payables from risk adjustment
and risk corridors. Ceded reinsurance should be reported separately.
Report the sum amount for all uncollected premiums and agents’ balances in course of collection, including:
amounts for direct and group billed uncollected premiums; amounts collected but not yet remitted to the home
office; and accident and health premiums due and unpaid.
The amount reported monthly should equal to the cumulative YTD total claims incurred during the current
year consistent with the amount reported on Line 16 of the Statement of Revenue and Expenses of the
Regulatory Filing, and should not be adjusted for reinsurance recoveries.

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 fullest extent of the law.

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Report the sum of all amounts incurred for member health services and benefits including: hospital and
medical benefits; other professional services; outside referrals; emergency room and out-of-area; prescription
drugs; and aggregate write-ins for other hospital and medical; and incentive pool, withhold adjustments and
bonus amounts.
The amount reported monthly should be consistent with the amount reported on Statement of Liabilities,
Capital and Surplus, Line 1 – Claims Unpaid, of the Regulatory Filing.
Total Claims Unpaid

Report the sum of all amounts for unpaid claims, including: those that have been reported and are in the
process of adjustment; percentage withholds from payments made to contracted providers; incurred but not
reported losses; recoverable for anticipated coordination of benefits and subrogation. Refer to SSAP No. 55
for accounting guidance.
The amount reported monthly should be consistent with the amount reported on Statement of Assets, Line 5 –
Cash, cash equivalents, and short-term investments, of the Regulatory Filing.

Total Cash/Cash
Equivalents And Shortterm Investments

Report the sum amount reflecting all cash, including petty cash, other un-deposited funds, certificates of
deposit in banks or other similar financial institutions with maturity dates of one year or less from the
acquisition date and other instruments defined as cash and cash equivalents in accordance with SSAP No. 2,
Cash, Drafts, and Short-term Investments.
Bonds - amount reported on the monthly report should equal to sum of amounts reported on Asset Statement,
Line 1 - Bonds of the regulatory filing.

Total Bonds/Stocks/Other
Investments

Report the sum amount reflecting all bonds with maturity dates greater than one year from the acquisition date.
Bonds are valued and reported in accordance with guidance set forth in SSAP No. 26, Bonds, excluding Loanbacked and Structured Securities; and SSAP No. 43R, Loan-backed and Structured Securities. Record bond
acquisitions or disposals on the trade date, not the settlement date. Record private placements on the funding
date. Exclude: Interest due and accrued. (Include definition of stocks, and other investments applicable.)
Stocks - amount reported on the monthly report should equal to sum of amounts reported on Asset Statement,

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 fullest extent of the law.

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Line 2.1 – Preferred Stocks and 2.2 – Common Stocks of the regulatory filing
Report the amount reported for common stocks and preferred stocks in the value in accordance with guidance
set forth in SSAP No. 30, SSAP No. 32, and SSAP No. 97.
Investment Income
Receivables

Amount reported on monthly report should be consistent with amount reported on Statement of Assets, Line
14 of the Regulatory Filing.
Report the cumulative YTD income earned on investments but not yet received.

Healthcare Receivables

The amount reported monthly should be consistent with the amount reported Statement of Assets, Line 24 of
the Regulatory Filing.
Report the cumulative YTD receivables including pharmaceutical rebate receivable, claim overpayment
receivables, loans and advances to providers, capitation arrangement receivables and risk sharing receivables
from affiliated and non-affiliated entities.

Premium Deficiency
Reserve (PDR)

The amount reported monthly should be consistent with the amount reported on Statement of Liabilities,
Capital and Surplus, Line 4 of the Regulatory Filing.
Report the YTD balance of reserves including aggregate reserves for accident and health policies and
excluding reserves relating to uninsured plans and the uninsured portion of partially insured plans.

Capital and Surplus

The amount reported monthly basis should be consistent with the amount reported on Statement of
Liabilities, Capital and Surplus, Line 14 of the Regulatory Filing;
Report total of capital and surplus available at the end of reporting period.

Federal Reinsurance
Premiums

The amount reported monthly should be consistent with the amount reported on Schedule S and ACA notes
of Regulatory Filing.

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 fullest extent of the law.

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Report the cumulative YTD ceded reinsurance premium payable to the ACA transitional Federal reinsurance
program.
Commercial Reinsurance
Premiums

The amount reported monthly should be consistent with the amount reported in Schedule S of the Regulatory
Filing.
Report the cumulative YTD ceded reinsurance premium paid and payable to the private reinsurance program.

Federal Reinsurance
Recoveries

The amount reported monthly should be consistent with the amount reported on Schedule S and ACA notes
of the Regulatory Filing.
Report the cumulative YTD amount recoverable from transitional ACA reinsurance program for claims paid
and unpaid.

Commercial Reinsurance
Recoveries

The amount reported monthly should be consistent with the amount reported in Schedule S of the Regulatory
Filing.
Report the cumulative YTD amounts recovered and recoverable from private reinsurance on paid claims.

Total G&A Expenses

The amount reported monthly should be consistent with the amount reported in Statement of Revenue and
Expenses, Line 21 of the Regulatory Filing.
Report the cumulative YTD total of all general and administrative expenses incurred excluding all expenses
relating to cost containment activities.

Claims Adjustment
Expenses

The amount reported monthly should be consistent with the amount reported on the Statement of Revenue
and Expenses, Line 20 of the Regulatory Filing.
Report the cumulative YTD total of all expenses incurred in connection with the recording, adjustment and

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 fullest extent of the law.

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settlement of claims.
Net Investment Income
(Loss)

The amount reported monthly should be consistent with the amount reported on Statement of Revenue and
Expenses, Line 25 of the Regulatory Filing.
Report the cumulative total YTD investment income earned from all forms of investments, including
investment fees earned relating to uninsured plans. Include dividend from subsidiary controlled and affiliated
entities, joint ventures, partnership, and limited liability companies less investment expenses, taxes (excluding
federal income taxes), licenses, fees, depreciation on real estate and other invested assets. Additionally,
include investment incomes credited to uninsured plans, and interest on borrowed money. Exclude capital
gains and losses on investment.

Other Income (Loss)

The amount reported monthly should be consistent with the amount reported on Statement of Revenue and
Expenses, Line 29 of the Regulatory Filing.
Report the cumulative YTD total of write-ins listed in schedule details of Write-ins for other income or
expenses.

Net Income (Loss)

The amount reported monthly should be consistent with the amount reported on Statement of Revenue and
Expenses, Line 32 of the Regulatory Filing.
Report YTD balance of excess or deficiency of total revenue over total expenses adjusted for extraordinary
items and less federal taxes as of the end of the reporting period.

DOI Financial Reports

Provide copies of any monthly financial reporting submitted to the state DOI.

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 fullest extent of the law.

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