C.M.R. 02, 031, ch. 945, app 031-945-B

Current through 2024-46, November 13, 2024

Appendix 031-945-B

2009 ANNUAL REPORT SUPPLEMENT and INSTRUCTIONS HEALTH INSURERS and HEALTH MAINTENANCE ORGANIZATIONS WITH LESS THAN $2,000,000 of DIRECT WRITTEN HEALTH INSURANCE PREMIUM IN MAINE (See Section 5 of this Rule.)

Reports must 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).

The reporting entity shall report the information (hereinafter referred to as "line items") indicated on the attached reporting form on a statewide basis. The reporting entity shall report the indicated information using 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. The information should be on a basis consistent with the annual statement line indicated in the following table:

Health Blank:	Life Blank or P&C Blank
Source Exhibit:	Statement of Revenue and Expenses	Schedule H Part 1
1	Net premium income	Line 2	Line 2
2	Total revenues	Line 8	Line 2
3	Total medical and hospital expenses	Line 18	Line 3
4	Total claims adjustment and administrative expenses	Lines 20+21	Lines 4+7+8+9+10+11
5	Increase in reserves	Line 22	Line 6
6	Net underwriting gain or (loss) (line 2 less line 3 less line 4 less line(5)	Line 24	Line 12

Since all of the items on this "short form" are net of reinsurance ceded, companies having less than $2,000,000 of direct written health insurance premium in Maine and having 100% of the business reinsured should file blank reports providing only their contact information.

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))

MAINE ANNUAL REPORT SUPPLEMENT for Year ____

This form is for companies with less than $2 million of premium - see Rule 945, section 5.

Statewide Data

Company ______________________________________________________ NAIC Code _____

Name of person completing this form _______________________________

Telephone Number ____________ Email ____________________________________

Large Groups	Small Groups	Individuals	Dirigo Groups	Dirigo Individuals	Stop-loss	TOTAL
1	Net premium income
2	Total revenues
3	Total medical and hospital expenses
4	Total claims adjustment and administrative expenses
5	Increase in reserves
6	Net underwriting gain or (loss) (line 2 less line 3 less line 4 less line(5)

C.M.R. 02, 031, ch. 945, app 031-945-B