NAIC and DFS Annual Statement Checklist and Instructions

Health Maintenance Organizations 2021-2022

COMPANY NAME: NAIC Company Code:
Contact: Telephone:
REQUIRED FILINGS IN THE STATE OF: NEW YORK Filings Made During the Year 2022
(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 ½”X14”)

1

EO

 

4/1

NAIC

Notes B, C, U

 

1.1

Printed Investment Schedule detail (Pages E01-E29)

1

EO

 

4/1

NAIC

Notes B, C, U

 

2

Quarterly Financial Statement (8 ½” x 14”)

1

EO

 

5/15, 8/15,
11/15

NAIC

Notes B, C, U

 

 

 

 

 

 

 

 

 

 

 

II. NAIC SUPPLEMENTS

 

 

 

 

 

 

 

11

Accident & Health Policy Experience Exhibit

1

EO

 

4/1

NAIC

 

 

12

Actuarial Opinion

1

EO

 

4/1

Company

 

 

18

Long-term Care Experience Reporting Forms

1

EO

 

4/1

NAIC

 

 

19

Management Discussion & Analysis

1

EO

 

4/1

Company

 

 

20

Medicare Part D Coverage Supplement

1

EO

 

4/1, 5/15, 8/15,
11/15

NAIC

 

 

21

Medicare Supplement Insurance Experience Exhibit

1

EO

 

4/1

NAIC

 

 

22

Risk-Based Capital Report

1

EO

 

4/1

NAIC

 

 

23

Schedule SIS

1

N/A

 

4/1

NAIC

 

 

24

Supplemental Compensation Exhibit

1

N/A

 

4/1

NAIC

 

 

25

Supplemental Health Care Exhibit (Parts 1, 2 and 3)

1

EO

 

4/1

NAIC

 

 

26

Supplemental Health Care Exhibit's Allocation Report

1

EO

 

4/1

NAIC

 

 

27

Supplemental Investment Risk Interrogatories

1

EO

 

4/1

NAIC

 

 

 

 

 

 

 

 

 

 

 

 

III. ELECTRONIC FILING REQUIREMENTS

 

 

 

 

 

 

 

61

Annual Statement Electronic Filing

xxx

EO

 

4/1

NAIC

 

 

62

March .PDF Filing

xxx

EO

 

4/1

NAIC

 

 

63

Risk-Based Capital Electronic Filing

xxx

EO

 

4/1

NAIC

 

 

64

Risk-Based Capital .PDF Filing

xxx

EO

 

4/1

NAIC

 

 

65

Supplemental Electronic Filing

xxx

EO

 

4/1

NAIC

 

 

66

Supplemental .PDF Filing

xxx

EO

 

4/1

NAIC

 

 

67

Quarterly Electronic Filing

xxx

EO

 

5/15, 8/15,
11/15

NAIC

 

 

68

Quarterly .PDF Filing

xxx

EO

 

5/15, 8/15,
11/15

NAIC

 

 

69

June .PDF Filing

xxx

EO

 

5/31

NAIC

 

 

 

 

 

 

 

 

 

 

 

 

IV. AUDIT/INTERNAL CONTROL RELATED REPORTS

 

 

 

 

 

 

 

81

Accountants Letter of Qualifications

1

EO

 

4/1

Company

 

 

82

Audited Financial Reports

1

EO

 

4/1

Company

Notes B, C, U

 

83

Audited Financial Reports Exemption Affidavit

1

N/A

 

4/1

Company

 

 

84

Communication of Internal Control Related Matters
Noted in Audit

1

EO

 

4/1

Company

 

 

85

Independent CPA (Change)

1

N/A

 

Within 60 days
of any change

Company

 

 

86

Management's Report of Internal Control Over
Financial Reporting

1

N/A

 

4/1

Company

 

 

87

Notification of Adverse Financial Condition

1

N/A

 

Within 5 days of
any change

Company

Note S

 

88

Relief from the five-year rotation requirement for
lead audit partner

1

EO

 

At least 30 days
prior to 12/31

Company

Note T

 

89

Relief from the one-year cooling off period for
independent CPA

1

EO

 

At least 30 days
prior to 12/31

Company

Note T

 

90

Relief from the Requirements for Audit Committees

1

EO

 

4/1

Company

 

 

91

Hardship Exemption

1

N/A

 

4/1

Company

Note O

 

 

 

 

 

 

 

 

 

 

 

V. STATE REQUIRED FILINGS

 

 

 

 

 

 

 

101

New York Annual Supplement

1

N/A

 

4/1

State

Notes B, C, U

 

102

New York Quarterly Supplement

1

N/A

 

5/15, 8/15,
11/15

State

Notes B, C, U

 

103

New York Annual Supplement 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

Certificate of Compliance

1

0

 

4/1

State

 

 

106

Filings Checklist (with Column 1 completed)

1

0

 

4/1

State

 

 

107

Form HC-1

1

0

 

4/30

State

Note P

 

108

Form IR

1

0

 

5/1

State

Note P

 

109

Qualifications of CPA – Insurance Regulation No. 118 Section 89.5(e)(2). (11 NYCRR 89.5(e)(2))

1

0

 

4/1

Company

Note Q

 

110

Change in Actuary

1

0

 

Within 5 days of
any change

Company

Note R

 

111

Managed Care Operations Report

EO

N/A

 

4/1, 5/15, 8/15,
11/15

State

Note V

 

112

Attestation on Segregation of Funds – Circular Letter #7 (2013) 1 0   4/1 Company Note W

*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.


A

Required Filings Contact Person:

Mrs. Darlene Pettit, Health Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004
(212) 480-6298

E-mail:  [email protected]

When answering by E-mail, please include telephone number.

B

Mailing Address:

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

Mr. Thomas Dudek, Health Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004

Audited Annual Statements:
Mr. Thomas Dudek, Health Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004

Quarterly Statement and New York Quarterly Supplement (hard copies):
Mr. Thomas Dudek, Health Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004

CDs (See Note N):

Ms. Nikki Brate
Information Technology Bureau
New York State Department of Financial Services
One State Street
New York, NY 10004

C

Email Address for Health Department:

In addition, an electronic copy of both the annual and quarterly NAIC statements and the annual and quarterly New York Supplements should be filed with the New York State Department of Health at the following email address:

[email protected]

D

Mailing Address for Premium Tax Payments:

N/A

E

Delivery Instructions:

All Department 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 an orange "COVER" page that indicates New York Supplement to the Annual Statement, the FULL Company Name and the Year. CDs should be labeled.

F

Late Filings:

Failure to timely file any component of an annual, quarterly or NY supplement filing would subject insurer to penalties set forth in NY Insurance Law Section 308.

G

Original Signatures:

Actual live signatures required.

H

Signature/Notarization/Certification:

Appropriate notarization required.

I

Amended Filings:

Only accepted in accordance with 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 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

Filings new, discontinued or modified materially since last year:

None

N

Internet Filing

Instructions concerning internet filing alternative to filing CD with  New York for New York Supplement are set forth in Insurance Circular Letter No. 4 (2001).

All companies are strongly encouraged to file national form filings (as identified in items 61, 62, 63, 64, 65, 66, 67, 68 and 69 in the checklist) with the NAIC preferably via the Internet. By filing over the Internet or via CD with the NAIC, an insurer will have fulfilled its electronic filing requirement for national forms with New York and therefore should not file a CD with the Department.

O

Hardship Exemption

Application for exemption to file must be filed with the Superintendent prior to the event or period for which the exemption is being requested. The company shall file, with its annual statement filing, both its request for relief and the approval   of that request with the New York State Department of Financial Services and the NAIC.

P

Form HC-1 and Form IR Electronic Filings*

Pursuant to New York State Department of Health Regulation Part 98 (10 NYCRR 98-1.16(e), submit the annual holding company information report electronically through the Department’s Holding Company and Parent Corporation Filing Portal Application via the link below:

https://www.dfs.ny.gov/apps_and_licensing/insurance_companies/insco_fratbenesoc_filings

These forms should also be filed with the New York State Department of Health at the address in Note C.

Q

Qualifications of CPA – (A statement from  the company stating that the CPA does not function in the role of management, does not audit his or her own work, and does not serve in an advocacy role for the company.)

Pursuant to Insurance Regulation No. 118 Section 89.5(e)(2) (11 NYCRR 89.5(e)(2)), attach the required statement to the audited annual financial statement.

R

Change in Actuary

If there is a change in actuary, the HMO shall notify the New York State Department of Financial Services within five business days of the event in accordance with the NAIC Annual Statement Instructions. The notification should be addressed to the individual in Note B above. The written notification should also be filed with the annual statement filings.

S

Notification of Adverse Financial Condition

Pursuant to Insurance Regulation No. 118 Section 89.8 (11 NYCRR 89.8), CPA should submit written notification to the individual in Note B above. The written notification should also be filed with the
annual statement filings.

T

Relief from the Five-Year Rotation Requirement for Lead Audit Partner

Relief from the One-Year Cooling Off Period for Independent CPA

Applications should be made pursuant to Insurance Regulation No. 118 Section 89.5(c) (11 NYCRR 89.5(c)) and Section 89.5(j) (11 NYCRR 89.5(j)). Approvals of applications should be filed with the annual statement filings.

U

Current Guidance Regarding Electronic Signatures, Transactions, and Filings with DFS

COVID-19 pandemic guidance regarding electronic signatures, transactions, and filings with DFS

https://www.dfs.ny.gov/industry_guidance/electronic_signatures_transactions_filings

V

Managed Care Operations Report

HMOs, who are required to file Managed Care Operations Reports with the New York State Department of Health, should also submit an electronic copy of the required Managed Care Operations Report to the following email address:

[email protected]

W

Other

Attestation to Segregation of Funds

Circular Letter No. 7 (2013): Segregation of Funds for Certain Abortion Services on the Exchange for Enrollees who Receive Federal Funds | Department of Financial Services.

Under the United States Department of Health and Human Services (“HHS”) regulation a Qualified Health Plan (“QHP”) issuer must file an annual assurance with the Superintendent attesting that the QHP issuer has complied with 42 USC §18023 and all applicable regulations.

The company may file through the Department’s Filings Portal described in Note P or email a copy to Health Bureau mailbox at [email protected] if the company has no access to the portal.


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 CD with the NAIC. Companies that file with the NAIC via the Internet are not required to submit CDs 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 Risk-Based Capital .PDF Filing is the .pdf file for 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.