CMS-10392 Monthly Reporting Template

CO-OP Program Division
CO-OP Program Monthly Reporting
CO-OP Name:

State

Year

1. Active Enrolled Members
On the Marketplace

Month

Age 0-20

Age 21-34

Age 35-44

Age 45-54

Age 55-64

Age 65+

Total

Age 0-20

-

4. Total
Disenrollment
Off the Individual
Marketplace

3. Active Enrolled - Individual Members
Off the Individual Marketplace

2. Total Disenrollment
On the Individual Marketplace

Age 21-34

Age 35-44

Age 45-54

Age 55-64

Age 65+

5. Total Active Enrollment Small Group

6. Total Active
7.Total Active
8. Total Active
Enrollment - Large Members Enrolled in Members Enrolled in
Group
QHPs
non-QHPs

9. Total Overall
Active Enrollment

10. Total Overall
Disenrollment

On the Marketplace Off the Marketplace

Total

12. Total Active
11. Total Projected
Enrollment as a % of
Enrollment for Next
Previously Projected
Reporting Period
(Prior Month)

13. Total Written
Premiums (Gross)

14. Total
Uncollected
Premiums and
Agents' Balances in
the Course of
Collection

15. Total Clams
Incurred (Gross)

16. Total
Claims
Unpaid

17. Total
Cash/Cash
Equivalent OnHand

18. Total
Bonds/Other
Solvency
Investments

19.
Investment
Income
Receivable

20. Healthcare
Receivables

21. Premium
Deficiency
Reserves
(PDR)

22. Capital and
Surplus

23. Federal
Reinsurance
Premiums

24. Commercial
Federal
Reinsurance
Premiums

25. Federal
Reinsurance
26. Commerical
Recoveries
27. Total G&A
Reinsurance
(Estimate on
Expenses
Recoveries
paid and
unpaid claims)

28. Claims
Adjustment
Expenses

29. Net
Investment
Income (Loss)

30. Other
Income
(Loss)

31. Net
Income
(Loss)

-

Copy of Monthly reporting template UPDATED clean 033015.xlsx

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