| 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 0938-1218. The time required to complete this information collection is estimated to average 22 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. |
| BHP State Report for Health Insurance Exchange Premiums - Instructions |
| 1. A complete submission will include the following tables completed according to the instructions described below: the State Information table; and either the Silver Plan and Bronze Plan Data Tables A (for states that use age as a rating factor for premiums) or Tables B (for states that do not use age as a rating factor for premiums). |
| 2. For the purpose of this report, the enrollee is defined as an individual policyholder (except for categories specified in Tables B for states that use family tier ratios for rate setting). |
| 3. Include in the name of the return Excel file the following: a) state, b) date sent, c) BHP State Report for Exchange Premiums |
| 4. Following review of the information in this report by the state official responsible for its completeness, accuracy and compliance with the instructions provided herein, have the state official: a) sign an attestation indicating that the data has been reviewed and is complete, accurate and in compliance with the instructions; b) direct the attestation to the attention of the Director of the Center for Medicaid and CHIP Services; and c) copy the signed attestation into a PDF file. |
| 5. Send completed Excel file and signed attestation in pdf file to [email protected]. Include in the subject line, 'BHP State Report for Exchange Premiums'. |
| 6. For technical assistance, notify Christopher Truffer at [email protected] |
1. State Information - Questionnaire Questions |
| 1. State: Select the appropriate two-letter state abbreviation from the drop-down menu in cell B10. |
| 2. State official attesting to the data's completeness, accuracy, and compliance with CMS specification. Provide the appropriate information for the state official attesting to the information provided in this report. |
| 3. State staff responsible for answering technical questions concerning the data submission. Provide the appropriate information for the state employee to contact for questions about the information provided in this report. |
| 4. Date: Enter the date that the information in this report was certified and submitted to CMS. |
2. Silver Plan Data Table A Use this table if the state uses age as a rating factor for the Health Insurance Exchange premiums. Enter the information for each county or county equivalent entity in the state. Enter the information for each county or county-equivalent entity by row. For counties or county-equivalent entities where, in different portions of the county, either (a) different silver level qualified health plans charge the second lowest cost premium in different portions of the county or county-equivalent entity, or (b) different bronze level qualified health plans charge the lowest premium in different portions of the county or county-equivalent entity, provide the information for the portion of the county or county-equivalent entity that contains the greatest number of residents in the county or county-equivalent entity and for the specified plan operating in that area. |
| 1. County: Enter the name of the county or county-equivalent entity. |
| 2. County ID: Enter each county's or county-equivalent entity's 3-digit ANSI code. For a list of ANSI codes, see: http://www.census.gov/geo/reference/codes/cou.html . |
| 3. Second Lowest Cost Silver Plan Name: Enter the name of the second lowest cost silver level qualified health plan operating in the county or county-equivalent entity. For the purposes of this report, the second lowest cost silver level qualified health plan is defined as the silver level qualified health plan that charges the second lowest monthly premium among all silver level qualified health plans that are offering coverage to any county residents who are qualified to purchase coverage on the Health Insurance Exchange. The plan name is defined as the Plan Marketing Name in Table 2 of CCIIO's Plan Management Benefits & Service Area User Guide, Version 3.0; Last Modified: May 20, 2013. |
| 4. Second Lowest Cost Silver Plan Issuer: Enter the name of the issuer of the second lowest cost silver level qualified health plan operating in the county or county-equivalent entity. The Issuer Legal Name is described as “Issuer Legal Name” in Table 2 in the CCIIO document, “Plan Management (PM), Issuer Module User Guide, Version: 9.0, Last Modified: May 20, 2013.” (The Issuer Legal Name may be different from the Issuer Marketing Name.) |
| 5. Second Lowest Cost Silver Plan ID: Enter the plan ID for second lowest cost silver level qualified health plan operating in the county or county-equivalent entity. The plan's 14-digit Plan ID is described in Table 1 in the CCIIO document, “Plan Management (PM), Rating Module User Guide, Version: 4.0, Last Modified: May 15, 2013.” The Plan ID consists of a 5-digit, numerical issuer ID; a two-letter state postal code; a 3-digit Product ID number; and a 4-digit Plan Unique Identifier Number. For example, 12345FL1234567 is a Plan ID number that includes an issuer ID (12345), a state postal code (FL), a Product ID number (123), and a Plan Unique Identifier number (4567). |
| 6. Second Lowest Cost Silver Plan Coverage: If a single silver level qualified health plan charges the second lowest cost premium through the entire county or county-equivalent entity, enter or select "1". If there is not a single silver level qualified health plan that charges the second lowest cost premium throughout the entire county or county-equivalent entity, enter or select "2". |
| 7. Monthly premium for 10-year-old enrollee: Enter the monthly premium charged for a 10-year-old enrollee by the second lowest cost silver level qualified health plan. |
| 8. Monthly premium for 21-year-old non-tobacco user enrollee: Enter the monthly premium charged for a 21-year-old non-tobacco user enrollee by the second lowest cost silver level qualified health plan. If the state does not allow tobacco use as a rating factor, enter the monthly premium charged for a 21-year-old enrollee. |
| 9. Monthly premium for 21-year-old tobacco user enrollee: Enter the monthly premium charged for a 21-year-old tobacco user enrollee by the second lowest cost silver level qualified health plan. If the state does not allow tobacco use as a rating factor, leave this field blank. |
| 10. Monthly premium for 45-year-old non-tobacco user enrollee: Enter the monthly premium charged for a 45-year-old non-tobacco user enrollee by the second lowest cost silver level qualified health plan. If the state does not allow tobacco use as a rating factor, enter the monthly premium charged for a 45-year-old enrollee. |
| 11. Monthly premium for 45-year-old tobacco user enrollee: Enter the monthly premium charged for a 45-year-old tobacco user enrollee by the second lowest cost silver level qualified health plan. If the state does not allow tobacco use as a rating factor, leave this field blank. |
| 12. Monthly premium for 55-year-old non-tobacco user enrollee: Enter the monthly premium charged for a 55-year-old non-tobacco user enrollee by the second lowest cost silver level qualified health plan. If the state does not allow tobacco use as a rating factor, enter the monthly premium charged for a 55-year-old enrollee. |
| 13. Monthly premium for 55-year-old tobacco user enrollee: Enter the monthly premium charged for a 55-year-old tobacco user enrollee by the second lowest cost silver level qualified health plan. If the state does not allow tobacco use as a rating factor, leave this field blank. |
3. Bronze Plan Data Table A Use this table if the state uses age as a rating factor for the Health Insurance Exchange premiums. Enter the information for each county or county equivalent entity in the state. Enter the information for each county or county-equivalent entity by row. For counties or county-equivalent entities where, in different portions of the county, either (a) different silver level qualified health plans charge the second lowest cost premium in different portions of the county or county-equivalent entity, or (b) different bronze level qualified health plans charge the lowest premium in different portions of the county or county-equivalent entity, provide the information for the portion of the county or county-equivalent entity that contains the greatest number of residents in the county or county-equivalent entity and for the specified plan operating in that area. |
| 1. County: Enter the name of the county or county-equivalent entity. |
| 2. County ID: Enter each county's or county-equivalent entity's 3-digit ANSI code. For a list of ANSI codes, see: http://www.census.gov/geo/reference/codes/cou.html. |
| 3. Lowest Cost Bronze Plan Name: Enter the name of the lowest cost bronze level qualified health plan operating in the county or county-equivalent entity. For the purposes of this report, the lowest cost bronze level qualified health plan is defined as the bronze level qualified health plan that charges the lowest monthly premium among all bronze level qualified health plans that are offering coverage to any county residents who are qualified to purchase coverage on the Health Insurance Exchange. The plan name is defined as the Plan Marketing Name in Table 2 of CCIIO's Plan Management Benefits & Service Area User Guide, Version 3.0; Last Modified: May 20, 2013. |
| 4. Lowest Cost Bronze Plan Issuer: Enter the name of the issuer of the lowest cost bronze level qualified health plan operating in the county or county-equivalent entity. The Issuer Legal Name is described as “Issuer Legal Name” in Table 2 in the CCIIO document, “Plan Management (PM), Issuer Module User Guide, Version: 9.0, Last Modified: May 20, 2013.” (The Issuer Legal Name may be different from the Issuer Marketing Name.) |
| 5. Lowest Cost Bronze Plan ID: Enter the plan ID for lowest cost bronze level qualified health plan operating in the county or county-equivalent entity. The plan's 14-digit Plan ID is described in Table 1 in the CCIIO document, “Plan Management (PM), Rating Module User Guide, Version: 4.0, Last Modified: May 15, 2013.” The Plan ID consists of a 5-digit, numerical issuer ID; a two-letter state postal code; a 3-digit Product ID number; and a 4-digit Plan Unique Identifier Number. For example, 12345FL1234567 is a Plan ID number that includes an issuer ID (12345), a state postal code (FL), a Product ID number (123), and a Plan Unique Identifier number (4567). |
| 6. Lowest Cost Bronze Plan Coverage: If a single bronze level qualified health plan charges the lowest cost premium through the entire county or county-equivalent entity, enter or select "1". If there is not a single bronze level qualified health plan that charges the lowest cost premium throughout the entire county or county-equivalent entity, enter or select "2". |
| 7. Monthly premium for 10-year-old enrollee: Enter the monthly premium charged for a 10-year-old enrollee by the lowest cost bronze level qualified health plan. |
| 8. Monthly premium for 21-year-old non-tobacco user enrollee: Enter the monthly premium charged for a 21-year-old non-tobacco user enrollee by the lowest cost bronze level qualified health plan. If the state does not allow tobacco use as a rating factor, enter the monthly premium charged for a 21-year-old enrollee. |
| 9. Monthly premium for 21-year-old tobacco user enrollee: Enter the monthly premium charged for a 21-year-old tobacco user enrollee by the lowest cost bronze level qualified health plan. If the state does not allow tobacco use as a rating factor, leave this field blank. |
| 10. Monthly premium for 45-year-old non-tobacco user enrollee: Please provide the monthly premium charged for a 45-year-old non-tobacco user enrollee by the lowest cost bronze level qualified health plan. If the state does not allow tobacco use as a rating factor, enter the monthly premium charged for a 45-year-old enrollee. |
| 11. Monthly premium for 45-year-old tobacco user enrollee: Enter the monthly premium charged for a 45-year-old tobacco user enrollee by the lowest cost bronze level qualified health plan. If the state does not allow tobacco use as a rating factor, leave this field blank. |
| 12. Monthly premium for 55-year-old non-tobacco user enrollee: Enter the monthly premium charged for a 55-year-old non-tobacco user enrollee by the lowest cost bronze level qualified health plan. If the state does not allow tobacco use as a rating factor, enter the monthly premium charged for a 55-year-old enrollee. |
| 13. Monthly premium for 55-year-old tobacco user enrollee: Enter the monthly premium charged for a 55-year-old tobacco user enrollee by the lowest cost bronze level qualified health plan. If the state does not allow tobacco use as a rating factor, leave this field blank. |
4. Silver Plan Data Table B Use this table if the state does not use age as a rating factor for the Health Insurance Exchange premiums. Enter the information for each county or county equivalent entity in the state. Enter the information for each county or county-equivalent entity by row. For counties or county-equivalent entities where, in different portions of the county, either (a) different silver level qualified health plans charge the second lowest cost premium in different portions of the county or county-equivalent entity, or (b) different bronze level qualified health plans charge the lowest premium in different portions of the county or county-equivalent entity, provide the information for the portion of the county or county-equivalent entity that contains the greatest number of residents in the county or county-equivalent entity and for the specified plan operating in that area. |
| 1. County: Enter the name of the county or county-equivalent entity. |
| 2. County ID: Enter each county's or county-equivalent entity's 3-digit ANSI code. For a list of ANSI codes, see: http://www.census.gov/geo/reference/codes/cou.html. |
| 3. Second Lowest Cost Silver Plan Name: Enter the name of the second lowest cost silver level qualified health plan operating in the county or county-equivalent entity. For the purposes of this report, the second lowest cost silver level qualified health plan is defined as the silver level qualified health plan that charges the second lowest monthly premium among all silver level qualified health plans that are offering coverage to any county residents who are qualified to purchase coverage on the Health Insurance Exchange. The plan name is defined as the Plan Marketing Name in Table 2 of CCIIO's Plan Management Benefits & Service Area User Guide, Version 3.0; Last Modified: May 20, 2013. |
| 4. Second Lowest Cost Silver Plan Issuer: Enter the name of the issuer of the second lowest cost silver level qualified health plan operating in the county or county-equivalent entity. The Issuer Legal Name is described as “Issuer Legal Name” in Table 2 in the CCIIO document, “Plan Management (PM), Issuer Module User Guide, Version: 9.0, Last Modified: May 20, 2013.” (The Issuer Legal Name may be different from the Issuer Marketing Name.) |
| 5. Second Lowest Cost Silver Plan ID: Enter the plan ID for second lowest cost silver level qualified health plan operating in the county or county-equivalent entity. The plan's 14-digit Plan ID is described in Table 1 in the CCIIO document, “Plan Management (PM), Rating Module User Guide, Version: 4.0, Last Modified: May 15, 2013.” The Plan ID consists of a 5-digit, numerical issuer ID; a two-letter state postal code; a 3-digit Product ID number; and a 4-digit Plan Unique Identifier Number. For example, 12345FL1234567 is a Plan ID number that includes an issuer ID (12345), a state postal code (FL), a Product ID number (123), and a Plan Unique Identifier number (4567). |
| 6. Second Lowest Cost Silver Plan Coverage: If a single silver level qualified health plan charges the second lowest cost premium through the entire county or county-equivalent entity, enter or select "1". If there is not a single silver level qualified health plan that charges the second lowest cost premium throughout the entire county or county-equivalent entity, enter or select "2". |
| 7. Monthly premium for 1 adult enrollee: Enter the monthly premium charged for a 1 adult enrollee by the second lowest cost silver level qualified health plan. |
| 8. Monthly premium for 2 adult enrollees: Enter the total monthly premium charged for 2 adult enrollees by the second lowest cost silver level qualified health plan. |
| 9. Monthly premium for 1 adult and 1 or more child enrollees: Enter the total monthly premium charged for 1 adult and 1 or more child enrollees by the second lowest cost silver level qualified health plan. |
| 10. Monthly premium for 2 adult and 1 or more child enrollees: Enter the total monthly premium charged for 2 adult and 1 or more child enrollees by the second lowest cost silver level qualified health plan. |
5. Bronze Plan Data Table B Use this table if the state does not use age as a rating factor for the Health Insurance Exchange premiums. Enter the information for each county or county equivalent entity in the state. Enter the information for each county or county-equivalent entity by row. For counties or county-equivalent entities where, in different portions of the county, either (a) different silver level qualified health plans charge the second lowest cost premium in different portions of the county or county-equivalent entity, or (b) different bronze level qualified health plans charge the lowest premium in different portions of the county or county-equivalent entity, provide the information for the portion of the county or county-equivalent entity that contains the greatest number of residents in the county or county-equivalent entity and for the specified plan operating in that area. |
| 1. County: Enter the name of the county or county-equivalent entity. |
| 2. County ID: Enter each county's or county-equivalent entity's 3-digit ANSI code. For a list of ANSI codes, see: http://www.census.gov/geo/reference/codes/cou.html. |
| 3. Lowest Cost Bronze Plan Name: Enter the name of the lowest cost bronze level qualified health plan operating in the county or county-equivalent entity. For the purposes of this report, the lowest cost bronze level qualified health plan is defined as the bronze level qualified health plan that charges the lowest monthly premium among all bronze level qualified health plans that are offering coverage to any county residents who are qualified to purchase coverage on the Health Insurance Exchange. The plan name is defined as the Plan Marketing Name in Table 2 of CCIIO's Plan Management Benefits & Service Area User Guide, Version 3.0; Last Modified: May 20, 2013. |
| 4. Lowest Cost Bronze Plan Issuer: Enter the name of the issuer of the lowest cost bronze level qualified health plan operating in the county or county-equivalent entity. The Issuer Legal Name is described as “Issuer Legal Name” in Table 2 in the CCIIO document, “Plan Management (PM), Issuer Module User Guide, Version: 9.0, Last Modified: May 20, 2013.” (The Issuer Legal Name may be different from the Issuer Marketing Name.) |
| 5. Lowest Cost Bronze Plan ID: Enter the plan ID for lowest cost bronze level qualified health plan operating in the county or county-equivalent entity. The plan's 14-digit Plan ID is described in Table 1 in the CCIIO document, “Plan Management (PM), Rating Module User Guide, Version: 4.0, Last Modified: May 15, 2013.” The Plan ID consists of a 5-digit, numerical issuer ID; a two-letter state postal code; a 3-digit Product ID number; and a 4-digit Plan Unique Identifier Number. For example, 12345FL1234567 is a Plan ID number that includes an issuer ID (12345), a state postal code (FL), a Product ID number (123), and a Plan Unique Identifier number (4567). |
| 6. Lowest Cost Bronze Plan Coverage: If a single bronze level qualified health plan charges the lowest cost premium through the entire county or county-equivalent entity, enter or select "1". If there is not a single bronze level qualified health plan that charges the lowest cost premium throughout the entire county or county-equivalent entity, enter or select "2". |
| 7. Monthly premium for 1 adult enrollee: Enter the monthly premium charged for a 1 adult enrollee by the lowest cost bronze level qualified health plan. |
| 8. Monthly premium for 2 adult enrollees: Enter the total monthly premium charged for 2 adult enrollees by the lowest cost bronze level qualified health plan. |
| 9. Monthly premium for 1 adult and 1 or more child enrollees: Enter the total monthly premium charged for 1 adult and 1 or more child enrollees by the lowest cost bronze level qualified health plan. |
| 10. Monthly premium for 2 adult and 1 or more child enrollees: Enter the total monthly premium charged for 2 adult and 1 or more child enrollees by the lowest cost bronze level qualified health plan. |
| State Information | |||||
| 1. State | |||||
| Reporting State | |||||
| 2. State official attesting to the data's completeness, accuracy, and compliance with CMS specifications | |||||
| Name | Title | Agency | Email address | Phone | Mailing address |
| 3. State staff responsible for answering technical questions concerning the data submission | |||||
| Name | Title | Agency | Email address | Phone | Mailing address |
| Date submitted |
| Health Insurance Exchange Silver Plan Data - Table A | ||||||||||||||
| See "Instructions" for information on how to enter data into the table. | ||||||||||||||
| Notes | ||||||||||||||
| 1. Only enter data in Table A if the state uses age as a rating factor for premiums. Do not enter data in Table A if the state does not | ||||||||||||||
| use age as a rating factor for premiums. | ||||||||||||||
| 2. Only enter premiums for tobacco users if the state uses tobacco use as a rating factor for premiums. | ||||||||||||||
| 3. All premium data should reflect monthly premiums. | ||||||||||||||
| State | 0 | |||||||||||||
| County Name | County ID | Second Lowest Cost Silver Plan Name | Second Lowest Cost Silver Plan Issuer | Second Lowest Cost Silver Plan ID | Second Lowest Cost Silver Plan Coverage | Monthly Premium for 10-year-old enrollee | Monthly Premium for 21-year-old non-tobacco user enrollee | Monthly Premium for 21-year-old tobacco user enrollee | Monthly Premium for 35-year-old non-tobacco user enrollee | Monthly Premium for 35-year-old tobacco user enrollee | Monthly Premium for 45-year-old non-tobacco user enrollee | Monthly Premium for 45-year-old tobacco user enrollee | Monthly Premium for 55-year-old non-tobacco user enrollee | Monthly Premium for 55-year-old tobacco user enrollee |
| Health Insurance Exchange Bronze Plan Data - Table A | ||||||||||||||
| See "Instructions" for information on how to enter data into the table. | ||||||||||||||
| Notes | ||||||||||||||
| 1. Only enter data in Table A if the state uses age as a rating factor for premiums. Do not enter data in Table A if the state does not | ||||||||||||||
| use age as a rating factor for premiums. | ||||||||||||||
| 2. Only enter premiums for tobacco users if the state uses tobacco use as a rating factor for premiums. | ||||||||||||||
| 3. All premium data should reflect monthly premiums. | ||||||||||||||
| State | 0 | |||||||||||||
| County Name | County ID | Lowest Cost Bronze Plan Name | Lowest Cost Bronze Plan Issuer | Lowest Cost Bronze Plan ID | Lowest Cost Bronze Plan Coverage | Monthly Premium for 10-year-old enrollee | Monthly Premium for 21-year-old non-tobacco user enrollee | Monthly Premium for 21-year-old tobacco user enrollee | Monthly Premium for 35-year-old non-tobacco user enrollee | Monthly Premium for 35-year-old tobacco user enrollee | Monthly Premium for 45-year-old non-tobacco user enrollee | Monthly Premium for 45-year-old tobacco user enrollee | Monthly Premium for 55-year-old non-tobacco user enrollee | Monthly Premium for 55-year-old tobacco user enrollee |
| Health Insurance Exchange Silver Plan Data - Table B | |||||||||
| See "Instructions" for information on how to enter data into the table. | |||||||||
| Notes | |||||||||
| 1. Only enter data in Table B if the state does not use age as a rating factor for premiums. Do not enter data in Table B if the state does use age as a rating factor. | |||||||||
| use age as a rating factor for premiums. | |||||||||
| 2. All premium data should reflect monthly premiums. | |||||||||
| State | 0 | ||||||||
| County Name | County ID | Second Lowest Cost Silver Plan Name | Second Lowest Cost Silver Plan Issuer | Second Lowest Cost Silver Plan ID | Second Lowest Cost Silver Plan Coverage | Monthly Premium for 1 Adult | Monthly Premium for 2 Adults | Monthly Premium for 1 Adult and 1 or More Children | Monthly Premium for 2 Adults and 1 or More Children |
| Health Insurance Exchange Bronze Plan Data - Table B | |||||||||
| See "Instructions" for information on how to enter data into the table. | |||||||||
| Notes | |||||||||
| 1. Only enter data in Table B if the state does not use age as a rating factor for premiums. Do not enter data in Table B if the state does use age as a rating factor. | |||||||||
| use age as a rating factor for premiums. | |||||||||
| 2. All premium data should reflect monthly premiums. | |||||||||
| State | 0 | ||||||||
| County Name | County ID | Lowest Cost Bronze Plan Name | Lowest Cost Bronze Plan Issuer | Lowest Cost Bronze Plan ID | Lowest Cost Bronze Plan Coverage | Monthly Premium for 1 Adult | Monthly Premium for 2 Adults | Monthly Premium for 1 Adult and 1 or More Children | Monthly Premium for 2 Adults and 1 or More Children |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |