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Maine.gov > PFR Home > Insurance Regulation > Company Services > Annual Statement Filing > Checklists

Health Entities

Click here for a printable table form of the checklist for Health Entities in Word or Adobe PDF format.

Company Name:_______________________   NAIC Company Code: _________
Contact:_____________________________   Telephone: _________________
REQUIRED FILINGS IN THE STATE OF: Maine   Filings Made During the Year 2012
(1)

Check-list

(2)

Line #

(3)

REQUIRED FILINGS FOR THE ABOVE STATE

 (4)

NUMBER OF COPIES*

(5)

DUE DATE
Postmarked

(6)

FORM SOURCE**

 (7)

APPLICABLE
NOTES

Domestic Foreign
State NAIC State
    I. NAIC FINANCIAL STATEMENTS            
  1 Annual Statement (8 ½"x14") 3 EO 2 3/1 NAIC I
  1.1 Printed Investment Schedule detail (Pages E01-E27) 2 EO XXX 3/1 NAIC  
  2 Quarterly Financial Statement (8 ½" x 14") 2 EO 1 5/15, 8/15, 11/15 NAIC I
    II. NAIC SUPPLEMENTS            
  10 Accident & Health Policy Experience Exhibit 1 EO 1 4/1 NAIC  
  11 Actuarial Opinion 1 EO 1 3/1 Company  
  12 Health Care Exhibit (Parts 1, 2 and 3) Supplement 1 EO 1 4/1 NAIC  
  13 Health Care Exhibit’s Allocation Report Supplement 1 EO 1 4/1 NAIC  
  14 Investment Risk Interrogatories 1 EO 1 4/1 NAIC  
  15 Life Supplemental Data due March 1 0 EO 0 3/1 NAIC  
  16 Life Supp Statement non-guaranteed elements –Exh 5, Int. #3 0 EO 0 3/1 Company  
  17 Life Supp Statement on par/non-par policies – Exh 5 Int. 1&2 0 EO 0 3/1 Company  
  18 Life Supplemental Data due April 1 0 EO 0 4/1 NAIC  
  19 Long-term Care Experience Reporting Forms 1 EO XXX 4/1 NAIC  
  20 Management Discussion & Analysis 1 EO 1 4/1 Company  
  21 Medicare Supplement Insurance Experience Exhibit 1 EO XXX 3/1 NAIC  
  22 Medicare Part D Coverage Supplement 1 EO 1 3/1, 5/15, 8/15, 11/15 NAIC  
  23 Property/Casualty Supplement due March 1 0 EO 0 3/1 NAIC  
  24 Property/Casualty Supplement due April 1 0 EO 0 4/1 NAIC  
  25 Risk-Based Capital Report 1 EO 1 3/1 NAIC  
  26 Schedule SIS 1 N/A N/A 3/1 NAIC  
  27 Supplemental Compensation Exhibit 1 N/A N/A 3/1 NAIC P
    III. ELECTRONIC FILING REQUIREMENTS            
  50 Annual Statement Electronic Filing XXX 1 XXX 3/1 NAIC  
  51 March .PDF Filing XXX 1 XXX 3/1 NAIC  
  52 Risk-Based Capital Electronic Filing XXX 1 N/A 3/1 NAIC  
  53 Risk-Based Capital PDF Filing XXX 1 N/A 3/1 NAIC  
  54 Supplemental Electronic Filing XXX 1 XXX 4/1 NAIC  
  55 Supplemental .PDF Filing XXX 1 XXX 4/1 NAIC  
  56 Quarterly Statement Electronic Filing XXX 1 XXX 5/15, 8/15, 11/15 NAIC  
  57 Quarterly PDF Filing XXX 1 XXX 5/15, 8/15, 11/15 NAIC  
  58 June .PDF Filing XXX 1 XXX 6/1 NAIC  
    IV. AUDIT/INTERNAL CONTROL RELATED REPORTS            
  71 Accountants Letter of Qualifications 1 EO N/A 6/1 Company  
  72 Audited Financial Reports 1 EO N/A 6/1 Company  
  73 Audited Financial Reports Exemption Affidavit 1 N/A N/A   Company  
  74 Communication of Internal Control Related Matters Noted in Audit 1 N/A N/A 8/1 Company  
  75 Independent CPA (change) 1 N/A N/A   Company  
  76 Management’s Report of Internal Control Over Financial Reporting 1 N/A N/A 8/1 Company  
  77 Notification of Adverse Financial Condition 1 N/A N/A   Company  
  78 Request for Exemption to File 1 N/A N/A   Company  
  79 Relief from the five-year rotation requirement for lead audit partner 1 EO N/A 3/1 Company  
  80 Relief from the one-year cooling off period for independent CPA 1 EO N/A 3/1 Company  
  81 Relief from the Requirements for Audit Committees 1 EO N/A 3/1 Company  
    V. STATE REQUIRED FILINGS            
  101 Advertising Certificate 1 0 1 3/1 Company P
  102 Affidavit of Filing 0 0 0 3/1 State  
  103 Annual Report Supplement (Rule 945) 1 0 1 3/1 State P
  104 Carrier Reporting Form 1 0 1 2/1 State P
  105 Certificate of Compliance 1 0 1 3/1 State  
  106 Certificate of Deposit 1 0 1 3/1 State P
  107 Consumer Complaint Contact Update 1 0 1 3/1 State P
  108 Downstream Risk Arrangement Disclosure 1 0 1 4/1 Company P
  109 Exam Assessment Fee 1 0 XXX 3/1 State C
  110 Filings Checklist (with Column 1 completed) 1 0 1 3/1 State  
  111 Form B Holding Company Registration Statement 1 0 XXX 5/1 Company H, J
  112 Health Insurance Annual Data Report (Rule 940) 1 0 1 4/30 State P
  113 Health Report Card Survey 1 0 1 3/1 State P
  114 Maine Fraud and Abuse Annual Report 1 0 1 3/1 State P
  115 Managing General Agent Report 1 0 1 3/1 State P
  116 Mandated Benefit Experience Report (Bulletin 292) 1 0 1 4/30 State P
  117 Premium Tax 1 0 1 3/15 State E
  118 See Additional HMO Requirements on our website 1 0 1 3/1 State  
  119 Signed Jurat Page 1 0 XXX 3/1, 5/15, 8/15, 11/15 NAIC  
  120 State Filing Fees 1 0 1 8/10 State C,P
  121 State Page for Maine 1 0 1 3/1 Company  
  122 State Specific Enrollment Data for Maine-HMO Only 1 0 1 3/1 NAIC  
  123 Supplement Health Insurance Report (Bulletin 286A) 1 0 1 4/1 State P
  124 Tick Borne Disease Report 1 0 1 2/1 State P

 

*If XXX appears in this column, this state does not require this filing, if hard copy is filed with the state of domicile and if the data is filed electronically with the NAIC. If N/A appears in this column, the filing is required with the domiciliary state.  EO (electronic only filing).

**If Form Source is NAIC, the form should be obtained from the appropriate vendor.

State of Maine
Additional HMO Filing Requirements

The following requirements are in addition to the information requested by the Financial Analysis Division. Please note the contact person assigned to each report.

The HMO law includes the following reporting requirements:

  1. 4204(2A)(M) - "The HMO must make an annual report to the superintendent regarding the plan [for providing services for rural and underserved populations and for developing relationships with essential community providers]" - Please forward this report and direct any questions to Joanne Rawlings-Sekunda in our Consumer Health Care Division. Ms. Rawlings-Sekunda can be reached at the following phone number and Email address: 207-624-8472 or Joanne.Rawlings-Sekunda@maine.gov
  2. 4204(8) - "If the HMO has a net loss of 5 or more primary care physicians in any county in any 30-day period, the HMO shall notify the Bureau in writing within 10 days of acquiring knowledge of that loss." - Please forward this report and direct any questions to Joanne Rawlings-Sekunda in our Consumer Health Care Division. Ms. Rawlings-Sekunda can be reached at the following phone number and Email address: 207-624-8472 or Joanne.Rawlings-Sekunda@maine.gov
  3. 4207-A(3) - an HMO with a POS product must in its quarterly financial report demonstrate that it is not expending more than 20% of its total annual health care expenditures for out-of plan covered services. The quarterly financial reports are filed with the Financial Analysis Division.
  4. 4211(2) - "Each HMO shall submit to the superintendent and [DHS] an annual report...which shall include:
    1. a description of the procedures of such complaint system
    2. the total number and disposition of complaints handled through the complaint system and a compilation of causes underlying the complaints filed. Complaints concerning access to chiropractic providers and the results of those complaints must be separately identified; and
    3. the number, amount and disposition of malpractice claims settled during the year by the HMO." Please forward the above report and direct any questions to Joanne Rawlings-Sekunda in our Consumer Health Care Division. Ms. Rawlings-Sekunda can be reached at the following phone number and Email address: 207-624-8472 or Joanne.Rawlings-Sekunda@maine.gov
  5. 4228(1) - Report on utilization review experience - "On or before April 1st of each year, each HMO which issues a program of contract in this State that contains a provision whereby in nonemergency cases the insured is required to be prospectively evaluated through a prehospital admission certification, preinpatient service eligibility program or any similar preutilization review or screening procedure prior to the delivery of contemplated hospitalization, inpatient or outpatient health care or medical services which are prescribed or ordered by a duly licensed physician shall file a report on the results of that evaluation for the preceding year with the superintendent which shall contain the following...". Please forward this information and direct any questions to Patty Woods in our Consumer Health Care Division. Ms. Woods can be reached at the following phone number and Email address: (207) 624-8459 or Patricia.A.Woods@.maine.gov.
  6. Section 4302 (4) requires the following:

    4. Claims data. By February 1st of each year, a carrier that provides only administrative services for a plan sponsor shall annually file with the superintendent for the most recent complete calendar year for all covered individuals in the State the total number of claims paid for each plan sponsor and the total dollar amount of claims paid for each plan sponsor. [2001, c. 457, §23 (new).] Please forward this information and direct any questions to Glenn Griswold in the Consumer Health Care Division. Mr. Griswold can be reached at 207-624-8494 or glenn.j.griswold@maine.gov.

  7. Section 4234-A(10) requires HMOs to report their experience under the section, which establishes a mental health coverage mandate. The report is due by April 30th and must address the HMO's experience for the immediately preceding calendar year. The report must include the amount of claims paid in Maine for the services required by the section, and the total amount of claims paid in Maine for individual and group health care contracts, both separated according to those paid for inpatient, day treatment and outpatient services. The reporting forms are attached. Please direct these forms and any questions to:

    Marti Hooper
    Life & Health Actuarial Division
    Maine Bureau of Insurance
    34 State House Station
    Augusta, ME 04333-0034
    Mary.M.Hooper@maine.gov

 

NOTES AND INSTRUCTIONS (A-K APPLY TO ALL FILINGS)

GENERAL INSTRUCTIONS FOR COMPANIES TO USE CHECKLIST

 

Last Updated: September 27, 2010