Figure 48 - Texas Small Employer Data

Figure 48 - Annual small employer health benefit plan report

LAH335 | 0126
Form Number 1212 CERT DATA

Texas Insurance Code Chapter 1501 and 28 TAC §26.20

All fields marked with * are required and must be filled.
Company/Issuer Name*
NAIC Number*
Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Person

First NameLast Name
Reporting Year*
Choose the year that represents the data being entered. It most cases, it is the previous calendar year.
Applicability: This issuer has small employer business to report for this reporting period.*

YesNo

1. Total Health Benefit Plans

Rows	Small Employers Newly Issued	Small Employers Renewed	Lives Covered Newly Issued	Lives Covered Renewed
Health Benefit Plans in Previous Calendar Year

2. Consumer Choice Health Benefit Plans (CCHBP) - Insurer

Rows	Small Employers Newly Issued	Small Employers Renewed	Lives Covered Newly Issued	Lives Covered Renewed
A) Group Size Under 2
B) Group Size 2-9
C) Group Size 10-20
D) Group Size 21-35
E) Group Size 36-50
F) Group Size 51+

2. Consumer Choice Health Benefit Plans (CCHBP) - HMO

Rows	Small Employers Newly Issued	Small Employers Renewed	Lives Covered Newly Issued	Lives Covered Renewed
G) Group Size Under 2
H) Group Size 2-9
I) Group Size 10-20
J) Group Size 21-35
K) Group Size 36-50
L) Group Size 51+

3. Fully-Mandated Health Benefit Plans (HBP) - Insurer

Rows	Small Employers Newly Issued	Small Employers Renewed	Lives Covered Newly Issued	Lives Covered Renewed
A) Group Size Under 2
B) Group Size 2-9
C) Group Size 10-20
D) Group Size 21-35
E) Group Size 36-50
F) Group Size 51+

3. Fully-Mandated Health Benefit Plans (HBP) - HMO

Rows	Small Employers Newly Issued	Small Employers Renewed	Lives Covered Newly Issued	Lives Covered Renewed
G) Group Size Under 2
H) Group Size 2-9
I) Group Size 10-20
J) Group Size 21-35
K) Group Size 36-50
L) Group Size 51+

4. Coalitions and Cooperatives (Isolate from responses 1-3)

Rows	Coalitions and Cooperatives Newly Issued	Coalitions and Cooperatives Renewed	Lives Covered Newly Issued	Lives Covered Renewed
A) Insurer CCHBP
B) HMO CCHBP
C) State-Mandated Insurer HBP
D) State-Mandated HMO HBP
E) Small Health Group Cooperative Plan Issued under TAC §26.409

5. Small Employer Health Benefit Plans voluntarily not renewed by small employer
6. Small Employer Health Benefit Plans terminated or nonrenewed
7. The Number of plans issued to small employers that were uninsured for at least two months prior to issue
8. Gross Premiums for Small Employer Health Benefit Plans
9. Did the issuer assume any small employer business?*

YesNo
Provide the name and NAIC information of the carrier(s) for which business was assumed.

10. Small Employer Health Benefit Plans - List the number of small employers and lives covered by the first three digits of the ZIP code of the employer's principal place of business.

Rows	Number of Small Employers	Number of Covered Lives
733
739
750
751
752
753
754
755
756
757
758
759
760
761
762
763
764
765
766
767
768
769
770
772
773
774
775
776
777
778
779
780
781
782
783
784
785
786
787
788
789
790
791
792
793
794
795
796
797
798
799
885
Other

11. Additional Information
12. Data Certification*

I attest that all information provided on this form is complete and true base on my best information, knowledge, and belief.
Name*

First NameLast Name
Title
Email*
example@example.com
May TDI release this email address?*

YesNo
Phone Number
Optional: Provide a phone number
Should be Empty:

Figure 48 - Annual small employer health benefit plan report