CMS-10418 Risk Corridors Plan Level Form

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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

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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.

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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%

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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.

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Chief Executive Officer/President

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Chief Financial Officer