2012 ANNUAL STATEMENT and NEW YORK SUPPLEMENT
Health Maintenance Organization - General Filing Instructions

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IMPORTANT FILING REMINDER:

Schedule G is to be submitted in its own PDF file, separate from the New York Data Requirements PDF file. This follows the practice of recent years. Both pdf files MUST be contained in one zip file. If Schedule G is included in the New York Data Requirements PDF, the filing will be rejected.

Please note that you must mail your NAIC Quarterly Statement and New York Quarterly Data Requirements Hard Copies to:

Mr. Daniel Sheridan, Health Bureau, 2nd Floor
New York State Department of Financial Services
25 Beaver Street
New York, New York 10004          DO NOT MAIL TO ALBANY 

You must file Diskettes to:

Mr. Daniel Sheridan, Health Bureau, 2nd Floor
New York State Department of Financial Services
25 Beaver Street
New York, New York 10004          DO NOT MAIL TO ALBANY 

Instructions concerning internet filing alternatives to filing a diskette with New York for New York Data Requirements are set forth in the Department's Circular Letter No. 4 (2001).

All companies are strongly encouraged to file national form filings 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.

We are providing for your use the Health Maintenance Organization Annual Statement Checklist & Instructions. This checklist provides filing requirements for submission to the NAIC and the New York State Department of Financial Services. This Web site also provides specific instructions for filing the New York Data Requirements and supplemental forms with our Department. Copies of the New York Data Requirements and supplemental forms are available in the Download section of this Web site.

Health maintenance organizations subject to these filing requirements are strongly encouraged to submit copies of all annual and quarterly statement filings electronically with the NAIC. The following electronic submissions to the NAIC will fulfill the electronic filing requirements of New York:

• National Form Annual Statement via the internet or diskette.
• National Form Quarterly Statement via the internet or diskette.
• New York Data Requirements via the internet.

Any statements not filed as above will require the filing of a diskette with New York.

In all cases, hard copies must still be filed in accordance with the Health Maintenance Organization Annual Statement Checklist & Instructions.

Health Maintenance Organization - Specific Filing Information

The HMO Filing INSTRUCTIONS AND FORMS PACKET is a self-extracting zipped file; after downloading file, run EXE to obtain the following PDF (Acrobat) and Excel files. You will need the Adobe Acrobat Reader to view or print PDF files. When printing the blanks, be sure to use legal size paper (8 1/2"X14"). Each of the Blanks is bookmarked with a full table of contents for on-line viewing.

FORMS included for Download and/or Print:

• NEW YORK STATE HMO DATA REQUIREMENTS 2012
• HMO DATA REQUIREMENTS QUARTERLY 2013
• NAIC Health Maintenance Organization Annual Checklist & Instructions
• Annual Electronic Filing Requirement Letter
• BAR CODE INSTRUCTIONS

To view full instructions for unzipping compressed files, please select this link.

The NEW YORK STATE HMO DATA REQUIREMENTS 2012 (in PDF Format) is also available from the SUPPLEMENT BLANKS PAGE.

Special Instructions For Filing Schedule G

For-profit HMOs are now required to complete Schedule G for ALL personnel described in the instructions at the top of the schedule. No longer should you leave Column 2 blank for employees other than directors, trustees or senior officers.

DUE DATE & MAILING:
Please refer to the Health Maintenance Organization Annual Statement Checklist & Instructions.

For NAIC Numbers and Company Names:
To view the company listing for this blank type, select Health Maintenance Organization List.

PROBLEMS AND QUESTIONS:
If you need help filling out your forms, call: Health Bureau, Mr. Michael Scharff, New York City (212) 480-5060. For diskette related questions, contact Information Systems & Technology Bureau, Albany (518) 473-3775.

MAILING INSTRUCTIONS:
Please see the Health Maintenance Organization Annual Statement Checklist & Instructions due dates and other related information.