CMS-10418 Risk Corridors Plan Level Form

Medical Loss Ratio Annual Reports, MLR Notices, and Recordkeeping Requirements (CMS-10418)

CMS-10418 - 2016-Risk-Corridors-Plan-Level-Form-x.xlsx

OMB: 0938-1164

Document [xlsx]
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Overview

Company Information
1- RC Plan Level Data - Ind
2 - RC Plan Level Data-Sm Group
3 - RC Payment or Charge Calc
Attestation


Sheet 1: Company Information

Company Information


Line Description Value
Company Name:
Group Affiliation:
Federal EIN:
A.M. Best Number:
NAIC Group Code:
NAIC Company Code:
DBA / Marketing Name:
HIOS Issuer ID:
Business in the State of:
Domiciliary State:
Address:
Federal Tax Exempt:
Not-For-Profit:
Benefit Year:




Cell Keys for Parts 1 - 3:
White cells accept input from the issuer
Grey cells require no data input – input will result in an upload failure
Green cells require no data input – fields will be auto-calculated for the user
Asterisk (*) denotes a field that will be auto-populated for the user



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 0938-1164. The time required to complete this information collection is estimated to average 6 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.

Sheet 2: 1- RC Plan Level Data - Ind


Risk Corridors Plan Level Data - Individual
























1.Non-Grandfathered ACA-compliant plans











Line Description Blank Column A.
Individual
Total Premium Earned
B.
Individual Proportion of Market Premium









All non-Grandfathered ACA-compliant plans

100.0%





















2. Exchange QHPs


3. Off-Exchange QHPs


4. Plans Substantially The Same As Exchange QHPs


# Exchange QHP
C.
Plan Name*
Exchange QHP
D.
HIOS Plan ID*

E.
Individual
Total Premium Earned
Exchange QHP
F.
Individual Proportion of Market Premium in Table 1
Off Exchange QHP
G.
Plan Name*
Off Exchange QHP
H.
HIOS Plan ID*

I.
Individual
Total Premium Earned
Off Exchange QHP
J.
Individual Proportion of Market Premium in Table 1
Substantially The Same As Exchange QHP
K.
Plan Name
Substantially The Same As Exchange QHP
L.
HIOS Plan ID

M.
Individual
Total Premium Earned
Substantially The Same As Exchange QHP
N.
Individual Proportion of Market Premium in Table 1
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Sheet 3: 2 - RC Plan Level Data-Sm Group


Risk Corridors Plan Level Data - Small Group
























1.Non-Grandfathered ACA-compliant plans











Line Description Blank Column A.
Small Group
Total Premium Earned
B.
Small Group Proportion of Market Premium









All non-Grandfathered ACA-compliant plans

100.0%





















2. Exchange QHPs


3. Off-Exchange QHPs


4. Plans Substantially The Same As Exchange QHPs


# Exchange QHP
C.
Plan Name*
Exchange QHP
D.
HIOS Plan ID*
Exchange QHP
E.
Small Group
Total Premium Earned
Exchange QHP
F.
Small Group Proportion of Market Premium in Table 1
Off Exchange QHP
G.
Plan Name*
Off Exchange QHP
H.
HIOS Plan ID*
Off Exchange QHP
I.
Small Group
Total Premium Earned
Off Exchange QHP
J.
Small Group Proportion of Market Premium in Table 1
Substantially The Same As Exchange QHP
K.
Plan Name
Substantially The Same As Exchange QHP
L.
HIOS Plan ID
Substantially The Same As Exchange QHP
M.
Small Group
Total Premium Earned
Substantially The Same As Exchange QHP
N.
Small Group Proportion of Market Premium in Table 1
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Sheet 4: 3 - RC Payment or Charge Calc


Risk Corridors Payment or Charge Calculation








Line Description A. Individual B. Small Group
1 1 - Total percentage of market premium in QHPs
For Ind (Tab 1, Column F + Column J + Column N), or
For SmGrp (Tab 2, Column F + Column J + Column N)
0.0% 0.0%
2 2 - Risk corridors allowable costs
(MLR Reporting Form, Part 3, Line 3.1)



3 3 - Risk corridors target amount
(MLR Reporting Form, Part 3, Line 3.5)



4 4 - Risk corridors ratio
(Line 2 / Line 3)



5 5 - Risk corridors aggregate payment or charge calculation by market $0 $0
6 6 - Risk corridors payment expected from HHS or charge payable to HHS
(Line 1 x Line 5)
$0 $0
















Reference Table








Risk corridors ratio: allowable costs/target amount Base % of target amount Variable % of excess Excess cutoff % of target amount

92% -2.5% 80.0% 92%

97% 0.0% 50.0% 97%

100% 0.0% 0.0% 100%

103% 0.0% 50.0% 103%

108% 2.5% 80.0% 108%

Sheet 5: Attestation

Attestation Statement

The party submitting this form attests as follows: (1) he or she is a duly authorized officer of the reporting issuer, and (2) this Risk Corridors Plan-level Data form, the Company/Issuer Associations, and any supplemental submission or related filings for the Risk Corridors benefit year are true, complete, and accurate statements, to the best of his or her knowledge, information and belief, of all the elements therein.

____________________________ 
Chief Executive Officer/President

____________________________  
Chief Financial Officer
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