Texas Consumer Choice Health Plan Reporting (Figure 2)

Form CCP 2

All fields marked with * are required and must be filled.

Company/Issuer name*

NAIC number*

TDI number

Reporting Year*

Choose the year that represents the data being entered. It most cases, it is the previous calendar year.

The following information, related to fully-insured Consumer Choice health benefit plans issued by health carriers in this state, is required to be provided no later than June 1 of each calendar year, under 28 Texas Administrative Code 21.3544.

Please note that for each market plan type listed, the total number of renewed plans reported in a calendar year generally should not exceed the total number of plans (newly issued and renewed combined) reported in the previous year. Likewise, the number of lives covered under renewed plans as reported should generally not exceed the total number of lives covered as reported in the previous year. For example, if a company reports a total of 4,500 newly issued and renewed Consumer Choice individual plans in one year, the total number of renewed plans reported in the subsequent year should not exceed 4,500. An exception would be if a company assumed a new block of business from another company, thus increasing the number of plans renewed in a subsequent year beyond the total reported for the previous year. If that has occurred, please indicate the assumed company's name and detailed information in item 5, the Additional Information field.

Please note that throughout this data form, "number of lives" includes all covered individuals, including members/employees, spouses, and dependents. Do not report only the number of certificate holders or employees.

If reporting more than one insurer or HMO, a separate form is required for each licensed entity.

For additional information, visit https://www.tdi.texas.gov/health/consumerchoice.html.

1. Report the total number of consumer choice plans newly issued and renewed covering Texas lives

Rows	Number of Consumer Choice Plans Newly Issued	Number of Consumer Choice Plans Renewed
A. Individual Accident and Health
B. Group Association (Non-Bona Fide)
C. Group Association (Bona Fide)
D. Group Blanket Accident and Health
E. Small Employer Accident and Health
F. Large Employer Accident and Health
G. Individual HMO
H. Group Association HMO (Non-Bona Fide)
I. Group Association HMO (Bona Fide)
J. Group Blanket HMO
K. Small Employer HMO
L. Large Employer HMO

2. Report the total number of lives (including members/employees, spouses, and dependents) covered under newly issued and renewed consumer choice plans.

Rows	Number of Insured Lives - Newly Issued Plans	Number of Insured Lives - Renewed Plans
A. Individual Accident and Health
B. Group Association (Non-Bona Fide)
C. Group Association (Bona Fide)
D. Group Blanket Accident and Health
E. Small Employer Accident and Health
F. Large Employer Accident and Health
G. Individual HMO
H. Group Association HMO (Non-Bona Fide)
I. Group Association HMO (Bona Fide)
J. Group Blanket HMO
K. Small Employer HMO
L. Large Employer HMO

3. Report gross premiums received for newly issued and renewed consumer choice health benefit plans covering Texas lives.

Rows	Consumer Choice Gross Premiums - Newly Issued	Consumer Choice Gross Premiums - Renewed
A. Individual Accident and Health
B. Group Association (Non-Bona Fide)
C. Group Association (Bona Fide)
D. Group Blanket Accident and Health
E. Small Employer Accident and Health
F. Large Employer Accident and Health
G. Individual HMO
H. Group Association HMO (Non-Bona Fide)
I. Group Association HMO (Bona Fide)
J. Group Blanket HMO
K. Small Employer HMO
L. Large Employer HMO

4. Report the average premium index rates for consumer choice health benefit plans and state-mandated plans.

Rows	Average Index Rate for State-Mandated Plans	Average Index Rate for Consumer Choice Plans
A. Individual Accident and Health
B. Group Association (Non-Bona Fide)
C. Group Association (Bona Fide)
D. Group Blanket Accident and Health
E. Small Employer Accident and Health
F. Large Employer Accident and Health
G. Individual HMO
H. Group Association HMO (Non-Bona Fide)
I. Group Association HMO (Bona Fide)
J. Group Blanket HMO
K. Small Employer HMO
L. Large Employer HMO

5. Additional Information

In accordance with the instructions provided to the best of my information, knowledge, and belief,*

By checking this box, I attest that all information contained in this form is a full and true statement.

Name*

Title*

Email Address*

example@example.com

Phone Number

Optional: Provide a phone number

Figure 2 - Consumer Choice Health Benefit Plan Data Certification

Data Certification