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Client Name - Transitional Reinsurance Fee Worksheet - page 2
Method 3 - Snapshot Factor Method
A.
Jan-16 1st of the month
Number of subscribers with self only-coverage (a)
356
Number of subscribers with other than self-only coverage (b)
532
Number of lives (a+(b*2.35))
1606.20
B.
Apr-16 1st of the month
Number of subscribers with self only-coverage (a)
355
Number of subscribers with other than self-only coverage (b)
539
Number of lives (a+(b*2.35))
1621.65
C.
Jul-16 1st of the month
Number of subscribers with self only-coverage (a)
316
Number of subscribers with other than self-only coverage (b)
507
Number of lives (a+(b*2.35))
1507.45
E.
Sum of all 3 quarters
4735.30
F.
Number of counts
3
G.
Average lives (E/F)
1578.43
H.
2016 Fee
$27.00
I.
Total Fee Due (amount remitted via Pay.gov)
$42,617.70
● Submit form and schedule full payment by November 15, 2016
● No later than January 17, 2017, pay full amount due (single payment)
● Submit form and schedule payment for first collection contribution and duplicate the form and schedule payment of
second collection.
● No later than January 17, 2017, pay first contribution amount ($21.60)
● No later than November 15, 2017, pay second contribution amount ($5.40)
1.
Calculate the number of covered lives in their major medical plans.
2.
Register on Pay.gov or confirm your password if you registered for the previous benefit years of the program.
3.
Access the
2016 ACA Transitional Reinsurance Program Annual Enrollment and Contributions Submission Form.
4.
Complete the Form (which includes providing Contributing Entity information when reporting for three or fewer
Contributing Entities and entering your annual enrollment count).
5.
Upload Supporting Documentation only when reporting for four or more Contributing Entities.
6.
Schedule your payment date for calculated contributions on the payment page.
OR
2016 Key Deadlines
How to Make a Reinsurance Contribution