Group Data Collection Survey for CY 2012 & 2013

 
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Federal law, the Patient Protection and Affordable Care Act (PPACA), requires Blue Cross & Blue Shield of Rhode Island (BCBSRI) to collect certain information regarding your company's average number of employees, as defined under a specific federal definition, for the purpose of measuring Medical Loss Ratios (MLR). This will be used to determine whether you and your enrollees are entitled to rebates in 2013.

In order to ensure compliance with PPACA, it is important that you complete this brief online survey. The survey should be completed by an authorized employee who is knowledgeable about employer information, such as the group administrator or benefits coordinator.

Providing this information does not impact eligibility or participation requirements and does not change your coverage - but it will help determine if you are eligible for any rebate required to be issued.

Thank you for your assistance in complying with this federal law.

Please contact your BCBSRI sales or account executive for more information; you should also consult your plan counsel for any legal questions.

Note: BCBSRI is committed to honoring your privacy. This survey is provided by a secure website.
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1. What is your Group Name?
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2. What is your Employer Group Number?
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3. Please enter the last 4 digits of your Employer Identification Number (EIN).
4. Please enter your Rating Segment (included in your letter).
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5. Calendar Year 2012

How many employees did your company (including your affiliates) employ on average during calendar year 2012? If your company was not in existence in 2012, then you should answer based on the average number of employees you reasonably expect to employ for 2013.

(Please note: Include part-time and seasonal employees regardless of their eligibility for benefits or enrollment in the health plan.)
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6. Was your company wholly owned by you and/or your spouse in 2012?
7. If yes to Question 6, then were you and/or your spouse the only employee(s) enrolled in the health plan in 2012?
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8. Calendar Year 2013

How many employees did your company (including your affiliates) employ on average during calendar year 2013? If your company was not in existence in 2013, then you should answer based on the average number of employees you reasonably expect to employ for 2014.

(Please note: Include part-time and seasonal employees regardless of their eligibility for benefits or enrollment in the health plan.)
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9. Was your company wholly owned by you and/or your spouse in 2013?
10. If yes to Question 9, then were you and/or your spouse the only employee(s) enrolled in the health plan in 2013?
Providing your name, title and today’s date will serve as your authorized signature and confirmation that the information provided above is correct.
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11. Name:
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12. Title:
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13. Please enter today's date.
14. Please enter your email address.
Thank you for taking the time for filling in this survey.
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