{"text_format":"1","workbook":"xlsx","n_sheets":3,"sheets":["Attestation C Signature Page","Attestation C Parameters","Attestation C for AV Plans"],"not_rendered":{"charts":0,"images":1,"macros":1,"external_links":0,"defined_names":0,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Attestation C Signature Page","index":0,"n_rows":59,"n_cols":13,"rows_kept":59,"cut":false,"hidden":false,"merged":[[9,2,11,12],[12,2,17,12],[49,4,49,5],[49,6,49,11],[19,2,22,12],[24,2,24,3],[26,2,26,3],[39,2,40,12],[43,2,43,5],[43,6,43,11],[45,6,45,11],[47,4,47,5],[47,6,47,11],[34,11,34,12],[51,4,51,5],[51,6,51,11],[53,4,53,5],[53,6,53,11],[55,4,55,5],[55,6,55,7]]}
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[null,null,null,null,null,null,"Department of Health and Human Services "]
[null,null,null,null,null,null,"Centers for Medicare & Medicaid Services "]
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[null,null,"ATTESTATION FORM C (2015): Simplified Methodology Attestation Signature "]
[null,null,"Issuers using the simplified methodology must submit data for each standard plan with claims in the corresponding plan variation and attest to the accuracy of the effective cost-sharing parameters calculated for each standard plan and formulas used in establishing cost-sharing reductions provided. "]
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[null,null,"Actuarial attestation must include a written description by a member of the American Academy of Actuaries in accordance with generally accepted actuarial principles and methodologies of how the issuer calculated the effective parameters for each applicable subgroup of a standard plan, for all plan variations with claims sets for which the issuer provided cost-sharing reductions. (Issuers should provide descriptions of individual standard plan calculations on “Simplified Method Effective Parameters” forms accompanying this attestation signature page.)  "]
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[null,null,"Instructions:  Issuer must upload a signed copy of this form along with effective parameters reports for each standard plan to an EFT folder by June 2, 2017.  Signatures may simply be typed in this form. Please submit a separate attestation and effective parameters forms for each benefit year cost-sharing reduction payments were received. "]
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[null,null,"Benefit year: ",null,2015]
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[null,null,"HIOS Issuer ID [1] "]
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[null,null,"I certify in my capacity as actuary (or authorized delegate of actuary) of [(Issuer Name)] as indicated below: "]
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[null,null,"I have reviewed the information on each Simplified Methodology Effective Parameters Report submitted to the Centers for Medicare & Medicaid "]
[null,null,"Services (CMS) for each standard plan with claims in the corresponding plan variation. I further certify that to the best of my knowledge, information, and"]
[null,null,"belief, the information provided is accurate and that the effective parameters listed for each standard plan are calculated according to the methodology "]
[null,null,"provided at 45 CFR 156.430. I certify that effective parameters have been calculated for all subgroups in each standard plan associated with plan "]
[null,null,"variation subgroups for which this issuer has provided cost-sharing reductions.  I certify that for each policy in each plan variation,  ",null,null,null,null,null,null,null,null,"(insert issuer name)"]
[null,null,"has selected the CMS formula (A, B, and C) appropriate to each policy subgroup claims set and applied the appropriate effective parameters to calculate"]
[null,null,"cost-sharing reductions provided for that policy. "]
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[null,null,"I understand the information included in this submission is the basis for calculating cost-sharing reduction amounts provided by my organization to eligible enrollees. "]
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[null,null,"Name of the Person Completing this form:"]
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[null,null,null,null,null,"Title:"]
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[null,null,null,null,"Organization:"]
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[null,null,null,null,"Telephone: "]
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[null,null,null,null,"Email Address:"]
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[null,null,null,null,"Signature: ",null,null,null,null,null,null,null,"(type)"]
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[null,null,null,null,"Date Signed: ",null,null,null,"example: MM/DD/YYYY"]
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[null,null,"[1] The five-digit Health Insurance Oversight System (HIOS)-generated issuer ID number"]

{"sheet":"Attestation C Parameters","index":1,"n_rows":202,"n_cols":17,"rows_kept":202,"cut":false,"hidden":false,"merged":[[15,2,17,8],[13,2,14,8],[25,2,26,12],[28,3,44,11],[48,2,50,8],[48,10,49,11],[68,8,68,10],[69,8,69,10],[64,2,67,6],[64,8,64,10],[19,2,19,3],[21,2,21,3],[23,6,23,7],[21,5,21,6],[108,8,108,10],[119,8,119,10],[92,8,92,10],[93,8,93,10],[130,2,130,12],[57,4,57,9],[58,4,58,9],[59,4,59,9],[60,4,60,9],[84,8,84,10],[90,8,90,10],[102,8,102,10],[103,8,103,10],[104,8,104,10],[105,8,105,10],[106,8,106,10],[112,8,112,10],[91,8,91,10],[81,8,81,10],[82,8,82,10],[83,8,83,10],[70,8,70,10],[71,8,71,10],[72,8,72,10],[73,8,73,10],[79,8,79,10],[80,8,80,10],[75,8,75,10],[94,8,94,10],[95,8,95,10],[101,8,101,10],[86,8,86,10],[97,8,97,10],[124,8,124,10],[125,8,125,10],[126,8,126,10],[127,8,127,10],[119,2,122,6],[190,8,190,10],[192,2,195,6],[196,8,196,10],[197,8,197,10],[166,8,166,10],[168,2,171,6],[172,8,172,10],[173,8,173,10],[174,8,174,10],[151,8,151,10],[155,8,155,10],[156,8,156,10],[157,8,157,10],[160,2,163,6],[164,8,164,10],[160,8,160,10],[168,8,168,10],[198,8,198,10],[192,8,192,10],[176,2,179,6],[180,8,180,10],[181,8,181,10],[182,8,182,10],[184,2,187,6],[188,8,188,10],[176,8,176,10],[184,8,184,10],[189,8,189,10],[9,2,11,12],[135,2,137,6],[135,8,136,9],[135,10,136,11],[145,4,145,9],[146,4,146,9],[147,4,147,9],[148,4,148,9],[165,8,165,10],[153,8,153,10],[154,8,154,10],[132,2,133,12],[151,2,154,6],[123,8,123,10],[128,8,128,10],[113,8,113,10],[114,8,114,10],[115,8,115,10],[116,8,116,10],[117,8,117,10],[75,2,78,6],[86,2,89,6],[97,2,100,6],[108,2,111,6]]}
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[null,null,null,null,null,null,"Department of Health and Human Services "]
[null,null,null,null,null,null,"Centers for Medicare & Medicaid Services "]
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[null,null,"ATTESTATION FORM C (2015): Simplified Methodology Effective Parameters Report "]
[null,null,"Complete one form for each standard plan with claims in the associated plan variation.  All issuers must provide a written description and list all subgroups. Fully capitated plans and fee-for-service plans with some capitated pay arrangements for certain subgroups, such as medical other than self-only,  should provide parameters in the section of this form that applies to “HMO-like plans or plans with HMO-like payment arrangements.”"]
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[null,null,"For additional QHP reports, please click \"Create Another Sheet\" "]
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[null,null,"When creating a form to report each subsequent plan variation, please check that the new form is blank before filling it out to avoid including data from previous plan variations. "]
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[null,null,"Benefit year: ",null,2015]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[null,null,"HIOS Issuer ID[1]: "]
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[null,null,"Qualified Health Plan ID [2]:"]
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[null,null,"For each standard plan, provide written description here: (Describe the subgroups and how the issuer calculated effective parameters). "]
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[null,null,"For each standard plan, report all subgroups: "]
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[null,null,"PLAN SUBGROUPS with claims sets =<80% of total allowed costs for essential health benefits under the standard plan are not subject to the deductible",null,null,null,null,null,null,null,"Check  Yes for all that apply "]
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[null,null,null,"Individual Medical "]
[null,null,null,"Individual Pharmacy"]
[null,null,null,"Individual Medical Pharmacy combined"]
[null,null,null,"Enrollment Group Medical"]
[null,null,null,"Enrollment Group Pharmacy"]
[null,null,null,"Enrollment Group Medical Pharmacy combined"]
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[null,null,"For each standard plan, list Effective Parameters for each subgroup with claims sets in the corresponding Plan Variation. "]
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[null,null,"PLAN SUBGROUP 1: Individual Medical =<80% of total allowed costs for medical essential health benefits under the standard plan are not subject to the deductible",null,null,null,null,null,"EFFECTIVE PARAMETERS"]
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[]
[null,null,null,"Average Deductible:"]
[null,null,null,"Effective Deductible:"]
[null,null,null,"Effective Pre-deductible Coinsurance Rate:  "]
[null,null,null,"Effective Post-deductible Coinsurance Rate:   "]
[null,null,null,"Effective non-deductible cost-sharing: "]
[null,null,null,"Effective claims ceiling: "]
[]
[null,null,"PLAN SUBGROUP 2: Individual Pharmacy =<80% of total allowed costs for pharmacy essential health benefits under the standard plan are not subject to the deductible",null,null,null,null,null,"EFFECTIVE PARAMETERS"]
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[]
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[null,null,null,"Average Deductible:"]
[null,null,null,"Effective Deductible:"]
[null,null,null,"Effective Pre-deductible Coinsurance Rate:  "]
[null,null,null,"Effective Post-deductible Coinsurance Rate:   "]
[null,null,null,"Effective non-deductible cost-sharing: "]
[null,null,null,"Effective claims ceiling: "]
[]
[null,null,"PLAN SUBGROUP 3: Individual Medical & Pharmacy Combined =<80% of total allowed costs for combined essential health benefits under the standard plan are not subject to the deductible",null,null,null,null,null,"EFFECTIVE PARAMETERS"]
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[]
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[null,null,null,"Average Deductible:"]
[null,null,null,"Effective Deductible:"]
[null,null,null,"Effective Pre-deductible Coinsurance Rate:  "]
[null,null,null,"Effective Post-deductible Coinsurance Rate:   "]
[null,null,null,"Effective non-deductible cost-sharing: "]
[null,null,null,"Effective claims ceiling: "]
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[null,null,"PLAN SUBGROUP 4: Enrollment Group Medical =<80% of total allowed costs for medical essential health benefits under the standard plan are not subject to the deductible",null,null,null,null,null,"EFFECTIVE PARAMETERS"]
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[null,null,null,"Average Deductible:"]
[null,null,null,"Effective Deductible:"]
[null,null,null,"Effective Pre-deductible Coinsurance Rate:  "]
[null,null,null,"Effective Post-deductible Coinsurance Rate:   "]
[null,null,null,"Effective non-deductible cost-sharing: "]
[null,null,null,"Effective claims ceiling: "]
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[null,null,"PLAN SUBGROUP 5: Enrollment Group Pharmacy =<80% of total allowed costs for pharmacy essential health benefits under the standard plan are not subject to the deductible",null,null,null,null,null,"EFFECTIVE PARAMETERS"]
[]
[]
[]
[null,null,null,"Average Deductible:"]
[null,null,null,"Effective Deductible:"]
[null,null,null,"Effective Pre-deductible Coinsurance Rate:  "]
[null,null,null,"Effective Post-deductible Coinsurance Rate:   "]
[null,null,null,"Effective non-deductible cost-sharing: "]
[null,null,null,"Effective claims ceiling: "]
[]
[null,null,"PLAN SUBGROUP 6: Enrollment Group Medical & Pharmacy Combined =<80% of total allowed costs for combined essential health benefits under the standard plan are not subject to the deductible",null,null,null,null,null,"EFFECTIVE PARAMETERS"]
[]
[]
[]
[null,null,null,"Average Deductible:"]
[null,null,null,"Effective Deductible:"]
[null,null,null,"Effective Pre-deductible Coinsurance Rate:  "]
[null,null,null,"Effective Post-deductible Coinsurance Rate:   "]
[null,null,null,"Effective non-deductible cost-sharing: "]
[null,null,null,"Effective claims ceiling: "]
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[null,null,"HMO-like plans or plans with HMO-like payment arrangements "]
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[null,null,"Fully capitated plans or plans with some HMO-like payment arrangements list subgroups and report Effective Parameters for each subgroup with claims sets in the corresponding Plan Variation here, as applicable. "]
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[null,null,"PLAN SUBGROUPS with claims sets >80% of total allowed costs for essential health benefits under the standard plan are not subject to the deductible",null,null,null,null,null,null,null,"Check  Yes for all that apply "]
[]
[]
[]
[null,null,null,"Individual Medical "]
[null,null,null,"Individual Pharmacy"]
[null,null,null,"Individual Medical Pharmacy combined"]
[null,null,null,"Enrollment Group Medical"]
[null,null,null,"Enrollment Group Pharmacy"]
[null,null,null,"Enrollment Group Medical Pharmacy combined"]
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[]
[]
[]
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[null,null,"PLAN SUBGROUP 1: Individual Medical >80% of total allowed costs for medical essential health benefits under the standard plan are not subject to the deductible",null,null,null,null,null,"EFFECTIVE PARAMETERS"]
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[]
[]
[null,null,null,"Effective Pre-deductible Coinsurance Rate *:  "]
[null,null,null,"Effective Post-deductible Coinsurance Rate:   "]
[null,null,null,"Effective claims ceiling: "]
[null,null,null,"*Pre and post-deductible coinsurance rates are equal"]
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[null,null,"PLAN SUBGROUP 2: Individual Pharmacy >80% of total allowed costs for pharmacy essential health benefits under the standard plan are not subject to the deductible",null,null,null,null,null,"EFFECTIVE PARAMETERS"]
[]
[]
[]
[null,null,null,"Effective Pre-deductible Coinsurance Rate :  "]
[null,null,null,"Effective Post-deductible Coinsurance Rate:   "]
[null,null,null,"Effective claims ceiling: "]
[]
[null,null,"PLAN SUBGROUP 3: Individual Medical & Pharmacy combined  >80% of total allowed costs for combined essential health benefits under the standard plan are not subject to the deductible",null,null,null,null,null,"EFFECTIVE PARAMETERS"]
[]
[]
[]
[null,null,null,"Effective Pre-deductible Coinsurance Rate :  "]
[null,null,null,"Effective Post-deductible Coinsurance Rate:   "]
[null,null,null,"Effective claims ceiling: "]
[]
[null,null,"PLAN SUBGROUP 4: Enrollment Group Medical >80% of total allowed costs for medical essential health benefits under the standard plan are not subject to the deductible",null,null,null,null,null,"EFFECTIVE PARAMETERS"]
[]
[]
[]
[null,null,null,"Effective Pre-deductible Coinsurance Rate :  "]
[null,null,null,"Effective Post-deductible Coinsurance Rate:   "]
[null,null,null,"Effective claims ceiling: "]
[]
[null,null,"PLAN SUBGROUP 5: Enrollment Group Pharmacy >80% of total allowed costs for pharmacy essential health benefits under the standard plan are not subject to the deductible",null,null,null,null,null,"EFFECTIVE PARAMETERS"]
[]
[]
[]
[null,null,null,"Effective Pre-deductible Coinsurance Rate :  "]
[null,null,null,"Effective Post-deductible Coinsurance Rate:   "]
[null,null,null,"Effective claims ceiling: "]
[]
[null,null,"PLAN SUBGROUP 6: Enrollment Group Medical & Pharmacy combined  >80% of total allowed costs for combined essential health benefits under the standard plan are not subject to the deductible",null,null,null,null,null,"EFFECTIVE PARAMETERS"]
[]
[]
[]
[null,null,null,"Effective Pre-deductible Coinsurance Rate :  "]
[null,null,null,"Effective Post-deductible Coinsurance Rate:   "]
[null,null,null,"Effective claims ceiling: "]
[]
[null,null,"[1] The five-digit Health Insurance Oversight System (HIOS)-generated issuer ID number"]
[null,null,"[2] The 16-digit HIOS-generated qualified health plan identification number"]

{"sheet":"Attestation C for AV Plans","index":2,"n_rows":24,"n_cols":7,"rows_kept":24,"cut":false,"hidden":false,"merged":[[19,2,19,3],[21,2,21,3],[21,5,21,6],[9,2,11,12],[23,6,23,10]]}
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[null,null,null,null,null,null,"Department of Health and Human Services "]
[null,null,null,null,null,null,"Centers for Medicare & Medicaid Services "]
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[null,null,"ATTESTATION FORM C (2015): Simplified Methodology (Simplified Actuarial Value Plans ONLY) "]
[null,null,"Please list all QHPs under this HIOS ID for which the issuer calculated CSRs using the simplified actuarial value methodology.  Issuers are not required to submit effective parameters or subgroups for plans which use the Actuarial Value Methodology."]
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[null,null,"Benefit year: ",null,2015]
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[null,null,"HIOS Issuer ID[1]: "]
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[null,null,"Qualified Health Plan ID (separate each by a semi-colon) [2]:"]