Colorado: DORA : Agency Name

Colorado.gov

Colorado Small Group Activity Survey 2012

Carrier Name:

NAIC Number:

Street Address:

Address (cont)

City:

State

Zip:

First Name:

Last Name:

Phone:

Extension:

Email:

Toll Free Marketing Number

Figures should reflect 2012 Colorado small group health business only.

1.Colorado Total Small Group Written Premium for calendar year 2012:

2.Colorado Total Small Group Earned Premium for calendar year 2012:

Please be aware that the numbers reported for each plan type below should be mutually exclusive and there should be no double counting. Please use information as of 12/31/2012.

If you are reporting for a group of companies that allow their small group members to choose multiple small group product options offered by different companies within the group, please report the information for those groups for a single company in the available "multi-option" plan fields.

Please indicate which companies are included in the "multi-option" plan reporting in question 18, within the additional questions section, at the end of the survey.

3. Number of groups and covered lives in the following categories as of December 31, 2012:

	Number of Groups	Number of Lives
a) BG1s
b) 2 - 5
c) 6 - 10
d) 11 - 15
e) 16 - 25
f) 26 >

4. Please explain any variances of 5% or more (increase or decrease) from the number of groups reported in question 3 to the number of groups your company had as of December 31, 2011:

5. Number of employer groups that have received rating adjustments due to:

a) being self-insured or insured through a non-small group plan in the 12 months prior to applying for coverage with your company:
b) having been previously discontinued for non-payment of premium:

6.Number of individuls in small group plans issued in 2012 who were uninsured for more than 90 days prior to coverage:

7.Number of small group plans terminated during 2012 for non-payment of premiums:

8. Please check the rating factors being used for small group rating:

Tobacco Use
Smoking Cessation/ Non-Smoker Discount
Standard Industrial Classification

9. Do you offer any products in the small group market that qualify for a federal Health Savings Account other than one of the Basic HSA-qualified plans?

Yes
No

Number of plan types

10. Do you offer:

	Yes	No
Basic HSA Health Benefit Plan
Basic Limited Mandate Health Benefit Plan
Basic HSA Limited Mandate Health Benefit Plan

11. Basic Health Benefit Plans	Indemnity	PPO	HMO	Multi Option
Number of Small Employer Groups
Number of Employees
Number of Dependents
Total Number of Ind. Covered

12. Standard Health Benefit Plans	Indemnity	PPO	HMO	Multi Option
Number of Small Employer Groups
Number of Employees
Number of Dependents
Total Number of Ind. Covered

13. HSA-Qualified Health Benefit Plan	Indemnity	PPO	HMO	Multi Option
Number of Small Employer Groups
Number of Employees
Number of Dependents
Total Number of Ind. Covered

14. All Other Small Group Plans	Indemnity	PPO	HMO	Multi Option
Number of Small Employer Groups
Number of Employees
Number of Dependents
Total Number of Ind. Covered

15.	Indemnity	PPO	HMO	Multi Option
Grand Total: Number of Small Groups
Grand Total: Number of Individuals Covered

Is your company currently writing new small employer group business?

Yes
No

If you answered "no" to question 16, please provide the date your company withdrew from the small employer group market.

17. Is your company offering an accredited wellness program, in compliance with CRS 10-16-136(3.5)?

Yes
No

Please provide any clarifying comments you may have regarding this survey and its process, and list all companies included in multi-option plan numbers.