Code of Maine Rules
02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION
031 - BUREAU OF INSURANCE
Chapter 945 - ANNUAL REPORT SUPPLEMENT FOR HEALTH INSURERS
Appendix 031-945-A

1. Reports shall not include data for accidental injury, specified disease, hospital indemnity, dental, vision, disability income, long-term care, Medicare supplement, or other limited benefit health insurance as defined in Rule 755, Section 9. The filing requirements do apply to employee benefit excess (stop-loss) insurance as defined in 24-A M.R.S.A. §707(1) (C-1) with respect to health benefit plans. The filing requirements also apply coverage issued under the Federal Employees Health Benefits Program and to short-term medical coverage as defined in 24-A M.R.S.A. §2849-B(1).

2. The reporting entity shall report the information (hereinafter referred to as "line items") indicated on the attached reporting forms. Statewide data is to be reported on Part 1. One copy of Part 2 of the form must be completed for each region, as defined in item 3 below, in which the entity has health business. The majority of the line items listed correspond to line items from the Statement of Revenue and Expenses, the Underwriting and Investment Exhibit, Part 3 - Analysis of Expenses and the Exhibit of Premiums, Enrollment and Utilization, which are contained in the health annual statutory financial statements. For insurers completing life and accident and health (Life) or property and casualty (P&C) annual statutory financial statements, a portion of the information required is contained within Schedule H - Accident and Health Exhibit-of those annual statutory financial statements. Some line items may not tie directly to any exhibits in the Life or P&C statements. For these items, the reporting entity may look to the instructions for the health statement for guidance.

3. Except as provided in item 4 regarding small cells, the reporting entity shall report the information required in Item 2 by geographic region and category of policyholder within the State of Maine. The five geographic regions are:

4. If the segmentation by category of policy and geographic region required in item 2 would disclose claims data or utilization data relating to a very small number of individuals or employer groups such that confidentiality might be sacrificed, the data must be combined with a larger cell as follows:

5. The reporting entity shall distinguish reported amounts representing actual revenues and expenses from reported amounts representing an allocation of revenues and expenses for each line item on Part 3 of the reporting form. If a revenue or expense line item is a combination of actual amounts and allocated amounts, the reporting entity shall so indicate. The reporting entity shall provide an explanation of the basis used when allocating revenues or expenses. As an example, rent expense may be allocated across all reporting categories. In this case, the reporting entity would indicate that rent expense is allocated along with the method used to allocate the expense. Actual amounts must be reported for lines 6-13, 15-24, 26-28, 30, and 33 to the extent feasible. An exception to this requirement is that allocation by region is acceptable if the insurer has fewer then 1,200 member months in the region. Otherwise, if allocation is used for any of these lines, the reporting entity must provide an explanation of why it is not feasible to report actual amounts.

MAINE ANNUAL REPORT SUPPLEMENT for Year ____

This form is for companies with at least $2 million of premium - see Rule 945, section 5.

PART 1: Statewide Data

Company ______________________________________________________ NAIC Code _____

Name of person completing this form _______________________________

Telephone Number ____________ Email ____________________________________

MAINE ANNUAL REPORT SUPPLEMENT for Year ____

This form is for companies with at least $2 million of premium - see Rule 945, section 5.

PART 2: Regional Data

Company ______________________________________________________ NAIC Code _____

Name of person completing this form _______________________________

Telephone Number ____________ Email ____________________________________

This report is for the following zip code areas (Check one):

[] 039, 040, and 041, [] 042, [] 043, 045, 046, 048, and 049, [] 044, [] 047

MAINE ANNUAL REPORT SUPPLEMENT for Year ____

This form is for companies with at least $2 million of premium - see Rule 945, section 5.

PART 3: Allocation Method

Company ______________________________________________________ NAIC Code _____