NAIC BLANKS (E) WORKING GROUP
Blanks Agenda Item Submission Form
DATE: 10/07/2014CONTACT PERSON:
TELEPHONE:
EMAIL ADDRESS:
ON BEHALF OF:
NAME: Debbie Doggett
TITLE: Chief Financial Analyst
AFFILIATION: Missouri Department of Insurance
ADDRESS: Harry S. Truman State Office Bldg, Rm 530
301 West High
Jefferson City, MO 65102 / FOR NAIC USE ONLY
Agenda Item # 2014-19BWG
Year 2015
Changes to Existing Reporting [ X ]
New Reporting Requirement [ ]
REVIEWED FOR ACCOUNTING PRACTICES AND PROCEDURES IMPACT
No Impact [ X ]
Modifies Required Disclosure [ ]
DISPOSITION
[ ] Rejected For Public Comment
[ ] Referred To Another NAIC Group
[ ] Received For Public Comment
[ ] Adopted Date
[ ] Rejected Date
[ ] Deferred Date
[ ] Other (Specify)
BLANK(S) TO WHICH PROPOSAL APPLIES
[ X ] ANNUAL STATEMENT [ ] QUARTERLY STATEMENT
[ X ] INSTRUCTIONS [ X ] CROSSCHECKS [ X ] BLANK
[ ] Life and Accident & Health [ ] Property/Casualty [ X ] Health
[ ] Separate Accounts [ ] Fraternal [ ] Title
[ ] Other Specify
Anticipated Effective Date: Annual 2015
IDENTIFICATION OF ITEM(S) TO CHANGE
Change the reference for Line 11 of the General Interrogatories, Part 2 from “minimum net worth” to “statutory minimum capital and surplus.” Modify the description for Line 3 of the Five Year Historical Data page to match reference in Line 11 of the General Interrogatories, Part 2.
REASON, JUSTIFICATION FOR AND/OR BENEFIT OF CHANGE**
The purpose of this proposal is to clarify what is reported on Line 3 of the Five Year Historical Data page and Line 11 of the General Interrogatories, Part 2 by using the same language for both lines. Some companies are interpreting the description for the Five Year Historical Line 3 to be the same amount asked to be reported on Line 4. This either generates questions or results in companies failing the crosscheck. This does not change the intent of what previously should have been reported but clarifies that the amount on the Five Year Historical Data page and the General Interrogatories, Part 2 should be the same.
NAIC STAFF COMMENTS
Comment on Effective Reporting Date:
Other Comments:
** This section must be completed on all forms. Revised 6/13/2009
ANNUAL STATEMENT INSTRUCTIONS - HEALTH
PART 2 – HEALTH INTERROGATORIES
Detail Eliminated To Conserve Space
11. If the Plans’ statutory minimum capital and surplus minimum net worth requirement is based upon a contingency reserve for statutory minimum capital and surplus Minimum Net Worth that is other than a flat dollar amount, the calculation must be shown. An example of the disclosure of a calculation based upon 2% of the net capitation revenue from risk contracts is:
Net earned subscription revenue / $ 33,103,9062%
Addition to Reserve / 662,078
Reserve Balance Beginning of Year / 353,689
Reserve Balance End of Year / 1,025,767
Item 11.4 should equal Column 1, Line 3 of the Five Year History Page.
Detail Eliminated To Conserve Space
FIVE-YEAR HISTORICAL DATA
Detail Eliminated To Conserve Space
Balance Sheet (Pages 2 and 3)
Line 1 – Total Admitted Assets
All years Page 2, Line 28
Line 2 – Total Liabilities
All years Page 3, Line 24
Line 3 – Statutory Minimum Capital and Surplus Requirement
Report the statutory minimum capital and surplus (net worth) required under applicable state law. If statutory minimum capital and surplus required is the result of a calculation or calculations, report the result here and report the current year calculation in General Interrogatories – Part 2 – Health Interrogatory 11.6.
Should equal Line 11.4, Column 1 of the General Interrogatories Part 2
Line 4 – Total Capital and Surplus
All years Page 3, Line 33
Detail Eliminated To Conserve Space
ANNUAL STATEMENT BLANK - HEALTH
GENERAL INTERROGATORIES
PART 2 – HEALTH INTERROGATORIES
11.1 Is the reporting entity organized as:11.12 A Medical Group/Staff Model,
11.13 An Individual Practice Association (IPA), or,
11.14 A Mixed Model (combination of above)? / Yes [ ] No [ ]
Yes [ ] No [ ]
Yes [ ] No [ ]
11.2 Is the reporting entity subject to Statutory Minimum Capital and Surplus Minimum Net Worth Requirements? / Yes [ ] No [ ]
11.3 If yes, show the name of the state requiring such minimum capital and surplusnet worth.
11.4 If yes, show the amount required. / $
11.5 Is this amount included as part of a contingency reserve in stockholder’s equity? / Yes [ ] No [ ]
11.6 If the amount is calculated, show the calculation
Detail Eliminated To Conserve Space
FIVE–YEAR HISTORICAL DATA
12015 / 2
2014 / 3
2013 / 4
2012 / 5
2011
Balance Sheet (Pages 2 and 3)
1. Total admitted assets (Page 2, Line 28)
2. Total liabilities (Page 3, Line 24)
3. Statutory minimum capital and surplus requirement
4. Total capital and surplus (Page 3, Line 33)
Income Statement (Page 4)
5. Total revenues (Line 8)
6. Total medical and hospital expenses (Line 18)
7. Claims adjustment expenses (Line 20)
8. Total administrative expenses (Line 21)
9. Net underwriting gain (loss) (Line 24)
10. Net investment gain (loss) (Line 27)
11. Total other income (Lines 28 plus 29)
12. Net income or (loss) (Line 32)
Cash Flow (Page 6)
13. Net cash from operations (Line 11)
Detail Eliminated To Conserve Space
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