2009 ANNUAL REPORT SUPPLEMENT and INSTRUCTIONS
HEALTH INSURERS and HEALTH MAINTENANCE ORGANIZATIONS WITH AT LEAST $2,000,000 of DIRECT WRITTEN HEALTH INSURANCE PREMIUM IN MAINE (See Section 5 of this Rule.)
1. Reports shall not include data for accidental injury, specified disease, hospital indemnity, dental, vision, disability income, long-term care, Medicare supplement, or other limited benefit health insurance as defined in Rule 755, Section 9. The filing requirements do apply to employee benefit excess (stop-loss) insurance as defined in 24-A M.R.S.A. §707(1) (C-1) with respect to health benefit plans. The filing requirements also apply coverage issued under the Federal Employees Health Benefits Program and to short-term medical coverage as defined in 24-A M.R.S.A. §2849-B(1).2. The reporting entity shall report the information (hereinafter referred to as "line items") indicated on the attached reporting forms. Statewide data is to be reported on Part 1. One copy of Part 2 of the form must be completed for each region, as defined in item 3 below, in which the entity has health business. The majority of the line items listed correspond to line items from the Statement of Revenue and Expenses, the Underwriting and Investment Exhibit, Part 3 - Analysis of Expenses and the Exhibit of Premiums, Enrollment and Utilization, which are contained in the health annual statutory financial statements. For insurers completing life and accident and health (Life) or property and casualty (P&C) annual statutory financial statements, a portion of the information required is contained within Schedule H - Accident and Health Exhibit-of those annual statutory financial statements. Some line items may not tie directly to any exhibits in the Life or P&C statements. For these items, the reporting entity may look to the instructions for the health statement for guidance. a. Member and Contract Information. The reporting entity shall report the indicated information on member months and on contracts in-force and covered lives as of December 31.b. Revenue and Expense Information. The reporting entity shall report the indicated information on revenues and expenses and shall use the definitions and guidance found in the National Association of Insurance Commissioner's Annual Statement Instructions and Accounting Practices and Procedures Manual or their successor publications. i. Total cost containment expenses should be reported in the cost containment expense line item and should be equivalent to information contained in line 20 of the Statement of Revenue and Expenses if the insurer files a health annual statutory financial statement.ii. Other claims adjustment expenses should be reported in total only and should be equivalent to information contained in line 20 of the Statement of Revenue and Expenses if the insurer files a health annual statutory financial statement.iii. All other general and administrative expenses should be reported in the appropriate line items and should, in total, be equivalent to line 21 of the Statement of Revenue and Expenses if the insurer files a health annual statutory financial statement.iv. Lobbying expenses are expenditures in connection with matters before legislative bodies or governmental officers or agencies, including general legislative lobbying and direct lobbying of pending and proposed statutes or regulations. (A) All lobbying expenses should be included, whether paid directly by the reporting entity or paid by a parent, affiliate, or holding company on behalf of the reporting entity.(B) Lobbying expenses paid by a parent, affiliate, or holding company on behalf of multiple entities within the corporate structure should be included in an amount reflective of an appropriate allocation to the reporting entity.v. Investment expenses should not be included in any of the expense line items.c. Utilization Statistics. The reporting entity shall report the indicated information on utilization and shall use the definitions and guidance found in the National Association of Insurance Commissioner's Annual Statement Instructions and Accounting Practices and Procedures Manual or their successor publications.d. The following definitions and guidance apply to items not found in the NAIC health annual statutory financial statements. Line 2: "Number of contracts 12/31" means the number of individual or group policies in force at the end of the reporting year. A single group policy counts as one contract regardless of the number of certificate holders.
Line 2a: "Number of contracts included in line 2 that were issued during the year" means the number of individual or group policies issued during the year and still in force at the end of the year.
Line 2b: "Number of contracts included in line 2a covering policyholders that were uninsured for the prior 90 days" means the number of individual policies issued to previously uninsured individuals and the number issued to small groups that did not have a previous health plan in the prior 90 days.
Drafting Note: This information should be available from applications since it is needed to administer continuity rights provided by 24-A M.R.S.A. §§2849 and 2849-B.
Line 3: "Number of subscribers covered as individuals (non-family) under group or individual contracts 12/31" means the number of individual policyholders or group certificate holders who have no covered dependents as of the end of the reporting year. For stop-loss coverage, this refers to the underlying employee benefit plan.
Line 4: "Number of families covered (individual + spouse, individual + dependent, individual + family) 12/31" means the number of individual policyholders or group certificate holders who have covered dependents as of the end of the reporting year. For stop-loss coverage, this refers to the underlying employee benefit plan.
Line 5: "Number of dependents 12/31" means the number of covered members other than policyholders and certificate holders. The total of lines 3, 4, and 5 must equal the number of covered persons as of the end of the reporting year. For stop-loss coverage, this refers to the underlying employee benefit plan.
Line 33: "Dirigo savings offset payments" are payments required by the Board of Directors of Dirigo Health pursuant to 24-A M.R.S.A. §6913(2).
Line 33a: "Dirigo access payments" are payments required pursuant to 24-A M.R.S.A. §6917.
3. Except as provided in item 4 regarding small cells, the reporting entity shall report the information required in Item 2 by geographic region and category of policyholder within the State of Maine. The five geographic regions are:(a) Zip codes beginning with 039, 040, and 041(b) Zip codes beginning with 042(c) Zip codes beginning with 043, 045, 046, 048, and 049(d) Zip codes beginning with 044(e) Zip codes beginning with 047 The six categories of policyholders are:
(a) Fully insured large groups, meaning all group and blanket policies, including Federal Employees Health Benefits Program, other than small groups and Dirigo groups(b) Fully insured small groups (1-50 employees) as defined by 24-A M.R.S.A. §2808-B, excluding Dirigo groups(c) Fully insured individuals, including short-term coverage and excluding Medicare Advantage plans and Dirigo individuals(d) Dirigo groups (issued pursuant to 24-A M.R.S.A. Chapter 87)(e) Dirigo individuals (issued pursuant to 24-A M.R.S.A. Chapter 87)(f) Stop-loss (employee benefit excess insurance as defined in 24-A M.R.S.A. §707(1) (C-1)) The reporting entity shall report the information according to the geographic region as follows:
a. Information pertaining to individual policies shall be included in the geographic region in which the individual contract holder resides.b. Information pertaining to employer groups and labor union groups shall be included in the geographic region in which the employer is located unless the employer is not located in Maine. If the employer is not located in Maine, information shall be included in the geographic region in which the majority of the Maine employees work. Information pertaining to coverage of employees working in Maine under group policies issued in another state should be included if it is reported on the Maine state page of the insurer's annual statutory financial statement.c. For other types of groups, including but not limited to association groups and trustee groups, information shall be reported as follows: i. If coverage relates to employment, for example a policy issued to a multiple employer trust or to an association of employers to cover their employees, then information shall be included in the geographic region in which the employer is located unless the employer is not located in Maine. If the employer is not located in Maine, information shall be included in the geographic region in which the majority of the Maine employees work.ii. If coverage does not relate to employment, for example a policy issued to an association of individuals that does not provide coverage to employees of members, then information shall be included in the geographic region in which the certificate holder resides.4. If the segmentation by category of policy and geographic region required in item 2 would disclose claims data or utilization data relating to a very small number of individuals or employer groups such that confidentiality might be sacrificed, the data must be combined with a larger cell as follows: a. Data for a small cell, as defined below, must be combined with the corresponding cell for the geographic area reflecting experience for the largest number of individuals. The reporting entity shall describe clearly which cells were combined.b. A "cell" means data for one policy category in one geographic region,c. A "small cell" means a cell reflecting the experience of fewer than 25 individuals or fewer than two employer groups.d. If the reporting entity has fewer than 25 individual policies or two group policies in a policy category statewide, data for that category must be combined with a larger category. The reporting entity shall describe clearly which categories were combined.5. The reporting entity shall distinguish reported amounts representing actual revenues and expenses from reported amounts representing an allocation of revenues and expenses for each line item on Part 3 of the reporting form. If a revenue or expense line item is a combination of actual amounts and allocated amounts, the reporting entity shall so indicate. The reporting entity shall provide an explanation of the basis used when allocating revenues or expenses. As an example, rent expense may be allocated across all reporting categories. In this case, the reporting entity would indicate that rent expense is allocated along with the method used to allocate the expense. Actual amounts must be reported for lines 6-13, 15-24, 26-28, 30, and 33 to the extent feasible. An exception to this requirement is that allocation by region is acceptable if the insurer has fewer then 1,200 member months in the region. Otherwise, if allocation is used for any of these lines, the reporting entity must provide an explanation of why it is not feasible to report actual amounts. MAINE ANNUAL REPORT SUPPLEMENT for Year ____
This form is for companies with at least $2 million of premium - see Rule 945, section 5.
PART 1: Statewide Data
Company ______________________________________________________ NAIC Code _____
Name of person completing this form _______________________________
Telephone Number ____________ Email ____________________________________
| Large Groups | Small Groups | Individ-uals | Dirigo Groups | Dirigo Individ-uals | Stop-loss | TOTAL |
| Member and Contract Information |
| 1 | Member months during year |
| 2 | Number of contracts 12/31 |
| 2a | Number of contracts included in line 2 that were issued during the year |
| 2b | Number of contracts included in line 2a covering policyholders that were uninsured for the prior 90 days | XXX | XXX | XXX |
| 3 | Number of subscribers covered as individuals (non-family) under group or individual contracts 12/31 |
| 4 | Number of families covered (individual + spouse, individual + dependent, individual + family) 12/31 |
| 5 | Number of dependents 12/31 |
| 5a | Covered lives 12/31 (lines 3-5) |
| Revenue Information |
| 6 | Direct premiums written |
| 7 | Direct premiums earned |
| 8 | Net premium income |
| 9 | Change in unearned premium reserves and reserve for rate credits |
| 10 | Fee-for-service | XXX |
| 11 | Risk revenue | XXX |
| 13 | Aggregate write-ins for other health care related revenues |
| 14 | Total revenues (lines 8-13) |
| Expense Information |
| 15 | Hospital benefits (not including emergency room) - inpatient only | XXX |
| 16 | Hospital benefits (not including emergency room) - outpatient only | XXX |
| 17 | Medical benefits (excluding hospital inpatient and outpatient above) | XXX |
| 18 | Other professional services | XXX |
| 19 | Outside referrals | XXX |
| 20 | Emergency room and out-of-area | XXX |
| 21 | Prescription drugs | XXX |
| 22 | Aggregate write-ins for other medical and hospital | XXX |
| 23 | Incentive pool and withhold adjustments and bonus amounts | XXX |
| 24 | Net reinsurance recoveries |
| 25 | Total medical and hospital expenses (lines 15-23 less line 24) (For stop-loss, just enter total) |
| 26 | Increase in reserves |
| 27 | Cost containment expenses |
| 28 | Other claims adjustment expenses |
| 29 | Salaries, wages and other benefits excluding cost containment expenses and other claims adjustment expenses |
| 30 | Commissions |
| 31 | Marketing and advertising |
| 32 | Taxes, licenses and fees, , excluding Dirigo savings offset payments and Dirigo access payments |
| 33 | Dirigo savings offset payments |
| 33a | Dirigo access payments |
| 34 | Charitable contributions |
| 35 | Lobbying expenses |
| 36 | All other expenses |
| 37 | Total claims adjustment and administrative expenses (lines 27-36) |
| 38 | Net underwriting gain or (loss) (line 14 less line 25 less line 26 less line 37) |
| Utilization Statistics |
| 39 | Hospital days (not including emergency room) - inpatient only | XXX |
| 40 | Physician encounters | XXX |
| 41 | Other professional encounters | XXX |
| 42 | Number of emergency room visits | XXX |
MAINE ANNUAL REPORT SUPPLEMENT for Year ____
This form is for companies with at least $2 million of premium - see Rule 945, section 5.
PART 2: Regional Data
Company ______________________________________________________ NAIC Code _____
Name of person completing this form _______________________________
Telephone Number ____________ Email ____________________________________
This report is for the following zip code areas (Check one):
[] 039, 040, and 041, [] 042, [] 043, 045, 046, 048, and 049, [] 044, [] 047
| Large Groups | Small Groups | Individ-uals | Dirigo Groups | Dirigo Individ-uals | Stop-loss | TOTAL |
| Member and Contract Information |
| 1 | Member months during year |
| 2 | Number of contracts 12/31 |
| 3 | Number of subscribers covered as individuals (non-family) under group or individual contracts 12/31 |
| 4 | Number of families covered (individual + spouse, individual + dependent, individual + family) 12/31 |
| 5 | Number of dependents 12/31 |
| Revenue Information |
| 6 | Direct premiums written |
| 7 | Direct premiums earned |
| 10 | Fee-for-service | XXX |
| 11 | Risk revenue | XXX |
| Expense Information |
| 15 | Hospital benefits (not including emergency room) - inpatient only | XXX |
| 16 | Hospital benefits (not including emergency room) - outpatient only | XXX |
| 17 | Medical benefits (excluding hospital inpatient and outpatient above) | XXX |
| 18 | Other professional services | XXX |
| 19 | Outside referrals | XXX |
| 20 | Emergency room and out-of-area | XXX |
| 21 | Prescription drugs | XXX |
| Utilization Statistics |
| 39 | Hospital days (not including emergency room) - inpatient only | XXX |
| 40 | Physician encounters | XXX |
| 41 | Other professional encounters | XXX |
| 42 | Number of emergency room visits | XXX |
MAINE ANNUAL REPORT SUPPLEMENT for Year ____
This form is for companies with at least $2 million of premium - see Rule 945, section 5.
PART 3: Allocation Method
Company ______________________________________________________ NAIC Code _____
Check appropriate boxes. Attach explanation regarding line items indicated as "Allocated" or "Combination."
| Allocation by Region | Allocation by Category of Policyholder |
| Actual | Allocat-ed | Combin-ation | Actual | Allocat-ed | Combin-ation |
| Revenue Information |
| 6 | Direct premiums written |
| 7 | Direct premiums earned |
| 8 | Net premium income | XXX | XXX | XXX |
| 9 | Change in unearned premium reserves and reserve for rate credits | XXX | XXX | XXX |
| 10 | Fee-for-service |
| 11 | Risk revenue |
| 13 | Aggregate write-ins for other health care related revenues | XXX | XXX | XXX |
| Expense Information |
| 15 | Hospital benefits (not including emergency room) - inpatient only |
| 16 | Hospital benefits (not including emergency room) - outpatient only |
| 17 | Medical benefits (excluding hospital inpatient and outpatient above) |
| 18 | Other professional services |
| 19 | Outside referrals |
| 20 | Emergency room and out-of-area |
| 21 | Prescription drugs |
| 22 | Aggregate write-ins for other medical and hospital | XXX | XXX | XXX |
| 23 | Incentive pool and withhold adjustments and bonus amounts | XXX | XXX | XXX |
| 24 | Net reinsurance recoveries | XXX | XXX | XXX |
| 26 | Increase in reserves | XXX | XXX | XXX |
| 27 | Cost containment expenses | XXX | XXX | XXX |
| 28 | Other claims adjustment expenses | XXX | XXX | XXX |
| 29 | Salaries, wages and other benefits | XXX | XXX | XXX |
| 30 | Commissions | XXX | XXX | XXX |
| 31 | Marketing and advertising | XXX | XXX | XXX |
| 32 | Taxes, licenses and fees, excluding Dirigo savings offset payments and Dirigo access payments | XXX | XXX | XXX |
| 33 | Dirigo savings offset payments | XXX | XXX | XXX |
| 33a | Dirigo access payments | XXX | XXX | XXX |
| 34 | Charitable contributions | XXX | XXX | XXX |
| 35 | Lobbying expenses | XXX | XXX | XXX |
| 36 | All other expenses | XXX | XXX | XXX |
C.M.R. 02, 031, ch. 945, app 031-945-A