Anthem Hcr Survey PDF Details

"If you are interested in improving the health of your organization, please take this Anthem HCR Survey. The results will help us to better understand how we can work with our clients to improve their employee satisfaction and organizational performance." Blog post intro paragraph: "The survey asks questions about things like your company's culture, leadership style, communication practices and other key areas that affect both employees' well-being and productivity.

You could find it useful to know how much time you will need to fill out this anthem hcr survey and how lengthy the document is.

Form NameAnthem Hcr Survey
Form Length2 pages
Fillable fields32
Avg. time to fill out6 min 58 sec
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Form Preview Example

<John Q. Employer>

Please respond by

<Business Name>

September 30, 2011

<1234 Street Address>


<Extra Address Line>


<City, ST 12345-6789>


Dear <John Q. Employer>,

As we put the health care reform law into action, we do our best to keep you posted on our progress. And, from time to time, we need your help. This is one of those times.

We simply need to know how to categorize your group based on the number of employees you had, on average, in 2010. To help you answer this question, we've provided a worksheet on the back of this page. Please do not return the worksheet to us.

Here’s why we need you to answer the survey question:

The health care reform law’s medical loss ratio (MLR) rules say we need to categorize groups as small or large based on number of employees.

We have data about how many are enrolled in your health plan, but we don’t know how many employees you have.

Issuers have to meet different MLR thresholds for small and large groups. So if the MLR requirement results in rebates, the way you’re categorized could have an impact on your rebate amount.

We’ll use your survey response only to categorize your group for 2011 calendar year MLR reporting.

Please respond by September 30, 2011 in the way that’s most convenient for you:

Online: Go to

By mail: Check one of the boxes on the survey below and return it in the enclosed envelope.

Be sure to include your email address so we can provide you with timely information about this and other requirements of health care reform.

If you do not reply to this survey, we will categorize your group as small or large for

2011 MLR reporting based on the number of enrollees in our health plan and applicable state-specific laws and regulations.

We’re committed to making health care reform work for you and your employees. Over the next few months, you will receive more information from us about the MLR requirement. If you have questions about this survey, call us at 866-214-6623, or refer to the FAQs at For all other questions, contact your broker or account manager.

Thank you,

<Anthem Blue Cross and Blue Shield> Compliance Department


JMedical loss ratio (MLR)—The portion of premium (less federal and state taxes and licensing or regulatory fees) spent on medical care and quality programs for the members covered under your plan.

JFull-time equivalency —A way of counting part-time and seasonal workers by adding their total hours and dividing by a number. For example, two employees who work 20 hours a week would count as 1.33 full-time equivalents based on a 30-hour work week.

2011 Health Care Reform Compliance Survey

To ensure our records are accurate and to help comply with requirements of the Affordable Care Act (ACA), please complete and return this form by September 30, 2011.

<John Q. Employer>

<Business Name>

<1234 Street Address>

<Extra Address Line>

<City, ST 12345-6789>

In 2010, my company had on average:

MBetween 1 and 50 employees

MBetween 51 and 100 employees

M101 or more employees

I am a duly authorized representative of <Business Name> and certify that the above information is true, correct and complete to the best of my knowledge.


COMPANY NAME _____________________________________________


TITLE___________________________________ DATE ____________

* Please provide us with your email address for future business communications.

Return in the enclosed envelope to: PO Box 509130, San Diego, CA 92150-9055

Health Care Reform Compliance Survey Worksheet

This worksheet is for your use only. Do not return this worksheet to us.

1.Enter the number of full-time employees at the end of the month in COLUMN 1.

2.Enter the full-time equivalency for part-time and seasonal employees at the end of the month in COLUMN 2. To figure out full-time equivalency, add the total number of hours these employees worked during the month and divide by 120.

3.Add Column 1 to Column 2 for each month and enter the total in COLUMN 3.

4.Add all the numbers in Column 3 and then enter the total in BOX 1.

5.Divide the number in Box 1 by 12 and then enter the result in BOX 2.


Full-time employees

COLUMN 2 Full-time equivalency

for part-time and seasonal employees


Total employees at the end of each month













If you are treated as a single employer under Section 414 of the Internal Revenue Code, you must report to us the total number for the single employer group.












































































Box 1






This is your average


Box 2

number of employees



Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO

Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In

Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

<Form number>

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Note the appropriate information in January, February, March, April, May, June, July, August, September, October, November, December, Box, This, is, your, average and number, of, employees, Box area.

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