CMS-10320 Appendix C - Insurance Issuer and Product Level Data

Appendix C - Insurance Issuer and Product Level Data
Issuer Requirements for Individual Market or Small Group Market
This section covers requests for information from issuers with offerings of health insurance coverage on
an individual or small group basis. The Patient Protection and Affordable Care Act (ACA), Section
1103(a)(2) “Connecting to Affordable Coverage” (as modified by section 10102) requires the Secretary to
“provide ways for residents of, and small businesses in, any state to receive information regarding their
health insurance options, including “health insurance coverage offered by health insurance issuers” under
sub-section (A). As a result the Secretary is requiring that each issuer report on individual and small
group health insurance plans, both the package of benefits and a specific cost sharing option for that
product.
While some of the required information is already gathered by the states, most states do not require
detailed specification of benefits and pricing necessary for informed consumer decisions. The variance
between state collection standards also makes aggregating the data in a single place for comparisons
impossible. As a result, the Secretary is requiring a new data submission.
As this information is already compiled by issuers, minimal difficulties are anticipated in meeting these
reporting requirements. The primary burden will likely be transforming the data into a standardized
reporting format. Nevertheless, the emergence of a standard for reporting will allow for commonalities to
emerge which will reduce the burden of meeting current data requirements utilizing a variety of standards
from the states and federal government.
The following criteria were used in selecting reporting requirements:
1) Utility for citizen discovery and differentiation of available health insurance options in their area of
residence;
2) Minimal administrative burden on issuers;
3) Legislative and regulatory authority;
4) Rapid availability of valid, reliable data elements.
To reduce the ultimate burden on issuers, the Secretary first undertook to contract with a vendor with
significant coverage of information in these two markets. An initial data collection from issuers and States
was required to provide minimal information used to define the universe of plans in an area. This data
was also used to verify that all issuers are ultimately represented, and that information gathered is
correct. This information was required by May 21, 2010 in order to define from whom additional
information was needed. The elements collected from these issuers have been collected periodically for
updates regarding corporate details as well as information on available products.

Issuer Corporate and Contact Information
One requirement for connecting citizens to affordable coverage is the name of the issuers from whom
they can purchase coverage and the contact information of those parties.
A. Issuer Name: Issuer name shall be provided as the legal name of the entity registered to provide the
plan within the coverage area.
B. Marketing Name: The primary name under which issuers identify themselves for consumers. To the
extent an issuer believes they have created a brand identity for communication with issuers that is useful
to maintain, we ask that they include these marketing names.
C. IRS Federal Employer Identification Number (EIN): Issuers are required to provide the employer
identification number under which they pay taxes to the IRS. This element is obtained solely to allow for
unique identification of the entities, and required verification of information.
D. NAIC Company Code Number: Issuers are required to provide the NAIC Company Code number if
they have one.
E. NAIC Group Code: If a company has an NAIC Group code, we ask that this be provided for
administrative tracking.

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F. Issuer Address: The Issuer Address is the official street address used to receive information requests
from the public via the US Postal Service or commercial postal firms.
G. Rating: The issuer should report whether or not they have been rated by one or more independent
companies, the source of those ratings, and the actual most recent ratings.
H. Customer Service Phone Number – Toll-Free: This element should be provided if a toll free number is
available for specific consumer requests for plan information.
I. Customer Service Phone Number – Local: This element represents a local phone number within the
area of coverage retained by the issuer for receiving requests for information from the public.
J. Customer Service Phone Number – TTY: This element represents a phone number for receiving
information from the deaf.
K. Customer service email: For reaching corporate customer service.
L. Website address – link to Issuer: The universal resource locator of the issuer which contains general
information on the company.
M. Contact Information – Contact names, phone numbers and email addresses will be collected for a
primary and backup contact for individual and small group markets allowing for different information to be
entered for data submission and data validation contacts.
a. Data Submission Contact and backup (Phone Number & E-mail Address): Essential for
reaching primary person responsible for the initial data entry.
b. Data Validation Contact and backup (Phone Number & E-mail Address): Person who will
review and approve the submitted information on the website before it goes live.
N. Company Overview - A brief description of the company appropriate for consumers will be provided.
This may include separate data components for year of founding, the number of employees, subsidiaries
and affiliates, corporate awards, description of the coverage area, membership and the provider network.
O. Grievance and appeals contact: Issuers will submit the phone number and or URL for customers to
contact them with grievances or appeals.
P. State: The state of the product offering. Given that health insurance regulation is managed primarily at
the state level, issuers’ data will be recorded at the state level within the database.

Product administrative information
While future implementation of Section 1103 of the ACA may ask for additional administrative information
necessary for consumers to be able to evaluate plans, in order to minimize the burden on issuers we will
not focus on those details for this data request. Other elements that will not be covered in this request are
to be collected under 2718 of the PHSA (specifically the medical loss ratio requirements which went into
effect in 2011), and are the subject of a different information collection requirement. We do require
enrollment information. Our intent at this time is to gather a minimum amount of information necessary to
prioritize the presentation of information and coordinate plan and product level data.
A. Product enrollment: Number of individual enrollments for the last date of the reference quarter.
B. Number of applications received: The number of applications which were submitted for enrollment
under the product during the reference quarter.
C. Number applications denied for product enrollment (individual market only): In order to inform
consumers about the relative risk that they will be unable to obtain this insurance, issuers will report the
number of applications which were denied for enrollment or pended for healthcare intervention (for
example until after surgery) or not accepted at terms applied for but offered a counteroffer (for example
offered a policy under a much higher deductible, or with a rider that limits coverage for a condition or body
part) during the reference quarter.
D. Number up-rated offers: Actual premiums may vary widely for most products. Issuers are required to
report the number of offers issued for a product which were “up-rated,” such that the under-writing
process has resulted in a premium quote higher than the base rate for the reference quarter.
Reference Quarters for Reporting on Applications refer to the actions occurred during prior quarter, and
issuers will be required to report the most recent prior quarter starting in the third month of the current
quarter. Enrollment will be collected as of the last day of the prior quarter starting in the third month of the
current quarter.
E. Product Status: Indicates the current offering status of the product as regards to its inclusion on the
website. Statuses include withdrawn from market, pending approval by the state, approved but not open
to new enrollees, active but only during an annual enrollment period, and may identify other types based

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on additional issuer feedback. Additional types of insurance product statuses will also be included, such
as association product status and whether a product has been grandfathered.
F. Standard Policy Period: The time period for which a policy is issued (e.g., six months, one year, two
years, other). Where an issuer chooses “other,” a free-text field will capture the appropriate answer. This
will be a required field, as all plans have a policy period.
G. Required Renewal Date: Yes or No field intended to capture information on plans that have a policy
year beginning on a consistent specified date (normally the first day of a particular month) other than the
standard policy period. If yes, the date will be reported.
H. Open enrollment: Some products are limited to a specified period during which individuals may enroll.
Issuers will be required to identify if that is the case for a particular product, to identify the actual period by
start and end day within the year, and will indicate whether they wish the product to be referenced on the
site outside of that enrollment period.
I. System for Electronic and Rate Form Filing (SERFF) number –The SERFF number by which many
states accept applications for product level form filings will be added to product level records.

Product contact and detail information
This section references the specific fields necessary to identify the product, and for consumers to obtain
specific plan level information.
A. Product name: The legal name under which the product is marketed to consumers. It should be
substantively similar to product name reported in Part II Section 1(a) of IRS Form 5500.
B. Product number: In cases where a product has an assigned three digit product number equivalent to
the product number/Enrollment Code used for filing IRS Form 5500, that information shall be provided.
C. Market type: In order to appropriately direct consumers, issuers will indicate whether the product
specified is an individual or small group offering.
D. Product type (e.g., indemnity/HMO/PPO): Product type is the most common means of identifying
general limits on provision of services. To provide the consumer with a basic understanding of the plan, it
is essential to gather the type of product. These types will be defined in correspondence with the “health
care plans and systems” defined by the Interdepartmental Committee on Employment-based Health
Insurance Surveys (Indemnity Plan, HMO, PPO, etc.).
E. Website address –brochure: If available, the URL link to the specific product brochure from the issuer.
F. Website address –Formulary: If available, a URL link to a list of prescription drugs, both generic and
brand name that are available through the health product.
G. System for Electronic and Rate Form Filing (SERFF) number – At the request of states, the SERFF
number by which many states accept applications for product level form filings will be added to product
records for update starting in September 2010. This unique identifier will be extremely helpful for tracking
and matching product level data to plan information and administrative records.

Provider network information
Insurance products are generally characterized by three different types of health care provider
arrangements: exclusive providers, any providers, and mixed where particular incentives are offered for
using certain providers. These mixed and exclusive arrangements are generally identified as “provider
networks.” In pertinent cases, we require that a link to that information on the web be provided. This is a
necessary requirement to inform consumers as to the ability of a product to pay within their existing health
care relationships, and is essential information on how to obtain an appropriate physician once a plan has
been chosen.
A. Provider Network: Issuers will be asked to indicate whether the product utilizes a specific network of
providers.
B. Website address – Provider Network: If available, a URL link to a listing of exclusive or preferred care
providers.

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