NAIC & New York State Department of Financial Services

Annual Statement Filing Checklist and Instructions 

HEALTH MAINTENANCE ORGANIZATIONS

COMPANY NAME:                                                                                    NAIC Company Code:                    
Contact:                                                                                                        Telephone:                                        
REQUIRED FILINGS IN THE STATE OF NEW YORK                      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
 

(6)
FORM SOURCE**
 

(7)
APPLICABLE NOTES
 

Domestic 

Foreign 

   

State 

NAIC 

State 

   
  

I. NAIC FINANCIAL STATEMENTS 

      
 1 Annual Statement (8 1/2" X 14") 

1 

EO 

 4/1 NAIC  
 1.1 Printed Investment Schedule detail (Pages E01-E27) 

1 

EO 

 4/1 NAIC  
 2 Quarterly Financial Statement (8 1/2" x 14") 

1 

EO 

 5/15, 8/15, 11/15 NAIC  
         
  

II. NAIC SUPPLEMENTS 

      
 10 Accident & Health Policy Experience Exhibit 

1 

EO 

 4/1 NAIC  
 11 Actuarial Opinion 

1 

EO 

 4/1 Company  
 12Health Care Exhibit (Parts 1, 2 and 3) Supplement 

1 

EO 

 4/1 NAIC  
 13Health Care Exhibit's Allocation Report Supplement 

1 

EO 

 4/1 NAIC  
 14Investment Risk Interrogatories 

1 

EO 

 4/1 NAIC  
 15Life Supplement 

1 

EO 

 4/1 NAIC  
 16Long-term Care Experience Reporting Forms 

1 

EO 

 4/1 NAIC  
 17Management Discussion & Analysis 

1 

EO 

 4/1 Company  
 18Medicare Supplement Insurance Experience Exhibit 

1 

EO 

 4/1 NAIC  
 19Medicare Part D Coverage Supplement 

1 

EO 

 4/1, 5/15, 8/15, 11/15 NAIC  
 20Risk-Based Capital Report 

1 

EO 

 4/1 NAIC  
 21Supplemental Compensation Exhibit 

1 

N/A 

 4/1 NAIC  
         
   

III. ELECTRONIC FILING REQUIREMENTS 

       
 30 Annual Statement Electronic Filing 

xxx 

1 

 4/1 NAIC  
 31 March .PDF Filing 

xxx 

1 

 4/1 NAIC  
 32 Risk-Based Capital Electronic Filing 

xxx 

1 

 4/1 NAIC  
 33 Supplemental Electronic Filing 

xxx 

1 

 4/1 NAIC  
 34 Supplemental .PDF Filing 

xxx 

1 

 4/1 NAIC  
 35 June .PDF Filing 

xxx 

1 

 5/31 NAIC  
  36 Quarterly Electronic Filing 

xxx 

1 

 5/15, 8/15, 11/15 NAIC Health Statement Filing 
  37 Quarterly .PDF Filing 

xxx 

1 

 5/15, 8/15, 11/15 NAIC  
         
  

IV. AUDITED FINANCIAL STATEMENTS 

      
 51 Accountants Letter of Qualifications 

1 

N/A

  Company  
 52 Audited Financial Statements 

1 

EO 

 4/1 Company  
 53 Audited Financial Statements Exemption Affidavit 

xxx 

N/A 

  Company  
 54 Communication of Internal Control Related Matters Noted in Audit

1 

N/A 

 5/31Company  
 55 Independent CPA (change) 

1 

N/A 

 4/1 Company  
 56Management's Report of Internal Control Over Financial Reporting 

1 

N/A 

 5/31Company  
 57Notification of Adverse Financial Condition 

1 

N/A 

 4/1 Company  
 58Report of Significant Deficiencies in Internal Controls 

1 

N/A 

 4/1 Company  
 59Request for Exemption to File 

1 

N/A 

  Company Call for instructions 
         
  

V. STATE REQUIRED FILINGS 

      
 101 New York Annual Data Requirement 

1 

N/A 

 4/1 State  
 102 New York Quarterly Data Requirement 

1

N/A 

 5/15, 8/15, 11/15 State  
 103 New York Annual Data Requirement Electronic Filing 

1 

N/A 

 4/1 State  
 104 New York Quarterly Supplement Electronic Filing 

1 

N/A 

 5/15, 8/15, 11/15 State  
 105 Filings Checklist (with Column 1 completed) 

1 

0 

  State  

*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.

  Notes and Instructions (A-O Apply to All Filings)

 A Required Filings Contact Person:

 

Mr. Michael Scharff, Health Bureau
New York State Department of Financial Services
25 Beaver Street
New York, NY 10004
(212) 480-5060

E-mail: Michael.Scharff@dfs.ny.gov
When answering by e-mail, please include telephone number.
 

 B Mailing Address:

 

Annual Statement and New York Supplement, and related items (hard copies):

Mr. Daniel Sheridan, Health Bureau
New York State Department of Financial Services
25 Beaver Street
New York, NY 10004

Audited Annual Statements:

Mr. Daniel Sheridan, Health Bureau
New York State Department of Financial Services
25 Beaver Street
New York, NY 10004

Quarterly Statement and New York Quarterly Supplement (hard copies):

Mr. Daniel Sheridan, Health Bureau
New York State Department of Financial Services
25 Beaver Street
New York, NY 10004

Diskettes (See Note O):

Ms. Nora Dixon
Insurance Regulatory Systems Bureau
New York State Department of Financial Services
25 Beaver Street
New York, NY 10004

 

 C Mailing Address for Health Department:

 

In addition, two copies of both the annual and quarterly NAIC statements and the annual and quarterly Data Requirements should be filed with the Department of Health, one each to the following:

Susan Barth, Assistant Director
Bureau of Managed Care Financing
New York State Department of Health
Empire State Plaza
Tower Building – Room 1970
Albany, New York 12237

Patrick Roohan, Director
Bureau of Quality Management and Outcomes Research
New York State Department of Health
Empire State Plaza
Tower Building – Room 1938
Albany, New York 12237

 D Mailing Address for Premium Tax Payments:  N/A 
 E Delivery Instructions:

 

All Department of Financial Services filings must be physically received at the appropriate address as indicated in NOTE B no later than the indicated due date. Companies should file ONLY ONE COMPANY per package.

The NAIC Statement and Supplement must be bound at the left side in sequential order and it must have a "COVER" page that indicates New York Supplement to the Annual Statement, the FULL Company Name and the Year. Diskettes should be labeled. 

 F Late Filings:

 

Failure to timely file any component of an annual, quarterly or NY supplement filing subjects insurer to penalties set forth in NY Insurance Law Section 307 and 308. 
 G Original Signatures:  Actual live signatures required. 
 H Signature/Notarization/Certification:  Appropriate notarization required 
 I Amended Filings:

 

Only accepted in accordance with the Department’s prior instructions.

All amendments to your Annual and Quarterly Statement and/or New York Supplement must be provided in hard copy as well as an amended ELECTRONIC filing. 

Note: For Amended New York Supplement filings, the entire electronic filing is required.

 J Exceptions from normal filings:  Only accepted in accordance with the Department’s prior instructions. 
 K Bar Codes (State or NAIC)

 

The NAIC Annual Statement and New York Supplement require the use of bar codes on the jurat page and certain other pages and forms. General Bar Coding instructions and a full listing of New York required bar coded forms are included on the web site. 
 L NONE Filings: All parts of the Annual Statement except those schedules identified by the use of "xxx" on the checklist and all parts of the New York Data Requirements must be accounted for. If there is nothing to report, you may complete the NAIC Annual Statement page entitled "Supplemental Exhibits and Schedules Interrogatories" INSTEAD OF filing duplicate reports marked "None". 
 M Investment Schedules:  Investment Schedules required for all filings. 
 N Filings new, discontinued or modified materially since last year:  None 
 O Internet Filing Instructions concerning internet filing alternative to filing diskette with New York for New York Supplement are set forth in the Department's Circular Letter No. 4 (2001).

All companies are strongly encouraged to file national form filings (as identified in items 30, 31, 32, 33, 34, 35, 36, and 37 in the checklist) with the NAIC preferably via the Internet. By filing over the Internet or via diskette with the NAIC an insurer will have fulfilled its electronic filing requirement for national forms with New York and therefore should not file a diskette with the Department 

 

General Instructions
For Companies to Use Checklist

Please Note:

This state’s instructions for companies to file with the NAIC are included in this Checklist. The NAIC will not be sending their own checklist this year.

Electronic Filing is intended to include filing via the Internet or filing via diskette with the NAIC. Companies that file with the NAIC via the Internet are not required to submit diskettes to the NAIC. Companies are not required to file hard copy filings with the NAIC.


Column (1) (Checklist)
Companies may use the checklist to submit to a state, if the state requests it. Companies should copy the checklist and place an "x" in this column when mailing information to the state.

Column (2) (Line #)
Line # refers to a standard filing number used for easy reference. This line number may change from year to year.

Column (3) (Required Filings)
Name of item or form to be filed.

The Annual Statement Electronic Filing includes the annual statement data and all supplements due March 1, per the Annual Statement Instructions. This includes all detail investment schedules and other supplements for which the Annual Statement Instructions exempt printed detail.

The March .PDF Filing is the .pdf file for annual statement data, detail for investment schedules and supplements due March 1.

The Risk-Based Capital Electronic Filing includes all risk-based capital data.

The Supplemental Electronic Filing includes all supplements due April 1, per the Annual Statement Instructions.

The Supplemental .PDF Filing is the .pdf file for all supplemental schedules and exhibits due April 1.

The Quarterly Electronic Filing includes the complete quarterly filing and the PDF files for all quarterly data.

The Quarterly .PDF Filing is the .pdf file for quarterly statement data.

The June .PDF Filing is the .pdf file for the Audited Financial Statements.

Column (4) (Number of Copies)
Indicates the number of copies that each foreign or domestic company is required to file for each type of form. The Blanks (E) Task Force modified the 1999 Annual Statement Instructions to waive paper filings of certain NAIC supplements and certain investment schedule detail, if such investment schedule data is available to the states via the NAIC database. The checklists reflect this action taken by the Blanks (EX4) Task Force. XXX appears in the "Number of Copies" "Foreign" column for the appropriate schedules and exhibits. Some states have chosen to waive printed quarterly and annual statements from their foreign insurers and have chosen to rely upon the NAIC database for these filings. This waiver could include supplemental annual statement filings. The XXX in this column might signify that the state has waived the paper filing of the annual statement and all supplements.

Column (5) (Due Date)
Indicates the date on which the company must file the form.

Column (6) (Form Source)
This column contains one of three words: "NAIC," "State," or "Company," If this column contains "NAIC," the company must obtain the forms from the appropriate vendor. If this column contains "State," the state will provide the forms with the filing instructions (generally, on the state web site). If this column contains "Company," the company, or its representative (e.g., its CPA firm), is expected to provide the form based upon the appropriate state instructions or the NAIC Annual Statement Instructions.

Column (7) (Applicable Notes)
This column contains references to the Notes to the Instructions that apply to each item listed on the checklist. The company should carefully read these notes before submitting a filing.

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