Form CMS-10380 Grant Program Data Dictionary

Rate Review Grant Program Detailed Rate Filing Data "Data Dictionary"
DATA ELEMENT
SERFF Tracking Number/Rate
Filing ID

REQUIRED
Yes

SERFF Rate Filing Mode

Yes

HIOS Product ID
Product Name

Yes

Type of Insurance

Yes

OMB control no: 0938-1121
Expiration date: XX/XX/XXXX

DESCRIPTION
The tracking number assigned by the NAIC SERFF system or the Rate Filing ID assigned to the
Filing by another state system.
The Filing Mode as used in the NAIC SERFF system; values include “Review & Approval”, “File
and & Use” “Informational”, “Combination” and “Other”, the same allowable values may be
used for Non-SERFF states.
The product level tracking number assigned by the HIOS system
Product name.
Type of insurance. (For an example, see Item 8, "Type of Insurance", on the Uniform Life,
Accident& Health, Annuity, Credit Transmittal Document of the NAIC SERFF system).

Standard Component ID (Plan ID)

Optional

The plan level tracking number assigned by the HIOS system

Plan Name
HIOS Submission ID

Optional
Yes

Plan name.
A submission specific tracking number assigned by the HIOS system
Insurance Company Information
The unique identifier as assigned by the HHS HIOS system to the state specific issuer entity.
The company identifier assigned by the NAIC system to identify the insurer.
The name of the insurance company.
Rate Review Disposition
The type of rate change expected: Increase, Decrease, Neutral, or New Product.
Values include “Not Reviewed”, “Review – no Actuary” or “Review with Actuary”
demonstrating the level of review by the State. This value will be “Not Reviewed” for States
that collect information but do not currently review rates or for States that “deem” rates
approved.

Issuer ID
NAIC Company ID Number
Insurance Company Name

Yes
Yes
Yes

Rate Change Type

Yes

State Review

Yes

% Change Requested

Change Period for Requested
Rate

Conditional

The Percent Change requested field represents the overall percentage of the rate change
requested or sought in the rate filing. This can be a positive or negative number. This number
is demonstrated as range of three different values: min, max and a weighted average.
The specified timeframe applying to the proposed rate change. Allowable values include:
"Annual", "Semi-annual", "Quarterly" and "Other." If upon renewal, select from either:
"Annual", "Semi-annual", "Quarterly" and select "Other" if there are multiple change periods
for products within a filing.

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Rate Review Grant Program Detailed Rate Filing Data "Data Dictionary"

Disposition of Rate Review

Yes

% Change Approved

Conditional

Proposed Rate Effective Date
Approved Rate Effective Date

Yes
Conditional

Change Period for Approved Rate

Yes

Market Segment

Yes

Number of Covered Lives
Included

Conditional

Annualized Prior Rate (PMPM)

Conditional

Annualized PMPM $ for New
Rate

Yes

The HHS Disposition of the rate review, e.g., "Approved", "Denied", "Deemed", "Withdrawn".
Filings will not be reported with a Disposition of "Deferred" or "Not Reported".
The Percent Approved field represents the overall percentage of the rate changes approved in
the rate filing. This can be a positive or negative number. This number is demonstrated as
range of three different values: min, max and a weighted average representing all products in
the rate filing.
Rate Change Details
Date that the rate is proposed to be effective for policyholders.
Date that the rate is effective for the policyholders.
The specified timeframe in which the rate change is effective. Allowable values include:
"Annual", "Semi-annual", "Quarterly" and "Other." If upon renewal, select from either:
"Annual", "Semi-annual", "Quarterly" and select "Other" if there are multiple change periods
for products within a filing.
Product/Market Information
Allowable values for the market segment include: "Large Group", "Small Group", "Small and
Large Group" and "Individual."
Comprehensive Major Medical Product Type
The total number of enrolled individuals included in the rate change requested in this filing.
This may be null for States that only collect policy holder counts.
Prior Year Information
The PMPM of the dollar amount of the Prior Rate, the frame of reference is the effective date
of the new rate.
New Rate
The PMPM of the dollar amount of the new annual rate demonstrated as a weighted average.

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 0938-1121. The time required to
complete this information collection is estimated to average 30 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. 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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Rate Review Grant Program Detailed Rate Filing Data "Data Dictionary"

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