(3) The Annual
Comprehensive Financial Statement shall report the following information for
each Market group size defined in
211
CMR 156.07(1) and each line
of business defined in
211
CMR 156.07(2):
(b) Income Statement Information.
1. Premiums, including earned premiums
(premium earned during the calendar year) and net earned premiums (direct
premiums earned, plus premium assumed, and less reinsurance ceded).
2. Incurred Claims, including direct claims
paid during the calendar year on services rendered during the calendar year,
unpaid claims reserves on service rendered or claims incurred during the
calendar year, changes in contract reserves, the claims-related portion of
reserves for contingent benefits and lawsuits, and experience rating refunds
paid or received and reserves for experience rating refunds with negative
adjustment for Dental Care receivables and for reinsurance
recoverables.
3. Actual Dental Loss
Ratio, as defined in accordance with
211
CMR 156.03.
4. Investment gains and losses:
a. Investment income, including that part of
a Carrier's income that stems from the interest and dividends earned on the
stocks and bonds it owns or the return on any other invested funds;
and
b. Net Realized capital gains
and losses, including the difference between the amount received from the sale
or disposal of an asset and its carrying value.
5. Financial administration expenses,
including all costs associated with underwriting, auditing, actuarial,
financial analysis, investment-related expenses (not included elsewhere),
treasury, reinsurance, and outside benefit consultants.
6. Marketing and sales expenses:
a. Billing and Member enrollment, including
all costs associated with group and individual billing, Member enrollment,
premium collection, and reconciliation functions;
b. Customer services and Member relations,
including all costs associated with individual, group or provider support
relating to membership, enrollment, grievance resolution, specialized phone
services and equipment, consumer services, and consumer information;
c. Product management, marketing and sales,
including all costs associated with the management and marketing of current
products, including product promotion and advertising, marketing materials,
changes or additions to current products, sales, pricing, and enrollee
education regarding coverage prior to the sale; and
d. Product Development, including all costs
associated with product design and development for new products not currently
offered, major systems development associated with the new products, and
integrated system network development.
7. Distribution expenses, including all costs
associated with the distribution and sale of products, including commissions,
insurance producer and benefit consultant fees, intermediary fees, commission
processing, and account reporting to insurance producers.
8. Claims operations expenses, including all
costs associated with claims adjudication and adjustment of claims, appeals,
claims settlement, coordination of benefits processing, maintenance of the
claims system, printing of claims forms, claim audit function, electronic data
interchange expenses associated with claims processing, and fraud
investigation.
9. Dental
administration expenses:
a. Quality assurance
and cost containment, including all costs associated with dental and disease
management and wellness initiatives (other than for education), Dental Care
quality assurance, appeals, case management, network access fees, fraud
detection and prevention, utilization review, practice protocol development,
peer review, outcomes analysis related to existing products, nurse triage,
dental management, and other Dental Care evaluation activities;
b. Wellness and dental education, including
all costs associated with wellness and dental promotion, disease prevention,
Member education and materials, and education and outreach services;
and
c. Dental research, including
all costs associated with outcomes research, dental research programs and
development of new dental management programs not currently offered, major
systems development, and integrated system network
development.
10. Network
operational expenses, including all costs associated with provider contracting
negotiation and preparation, monitoring of provider compliance, field training
with providers, provider communication materials and bulletins, administration
of provider capitation and settlements, dental policy procedures, dentist
relations, dental policy procedures, network access fees, and
credentialing.
11. Charitable
expenses, including all costs associated with contributions to foundations,
charities that are not related to the company business enterprises, and
community benefits.
12. Taxes,
Assessments and Fines Paid to Federal, State or Local Government:
a. Taxes (premium, real estate, other
non-payroll) paid, including all costs associated with state premium taxes,
state and local insurance taxes, federal taxes, except taxes on capital gains,
state income tax, state sales tax, and other sales taxes not included with the
cost of goods purchased;
b.
Assessments, fees and other amounts paid to government agencies, including all
assessments, fees or other amounts paid to state or local government, but
excluding any taxes or fines or penalties paid to any government agency;
and
c. Fines and penalties paid to
government agencies, including all costs associated with penalties and fines
paid to government agencies.
13. General Administration:
a. Payroll administration expenses and
payroll taxes, including all costs associated with salaries, benefits, and
payroll taxes (not allocated elsewhere);
b. Real estate expenses, including all costs
associated with company building and other taxes and expenses of owned real
estate, excluding home office employee expenses, and rent (not allocated
elsewhere) and insurance on real estate;
c. Regulatory compliance and government
relations, including all costs associated with Federal and State reporting,
rate filing, state and federal audits, tax accounting, lobbying, licensing and
filing fees, preparation and filing of financial, utilization, statistical, and
quality reports, and administration of government programs;
d. Board, bureau and association fees,
including all board of directors, bureau, and association fees paid or expensed
during the calendar year;
e. Other
administration, including all costs associated with information technology,
senior management, outsourcing (not allocated elsewhere), insurance except on
real estate, equipment rental, travel (not allocated elsewhere), certification
and accreditation fees, legal fees and expenses before administrative and legal
bodies, and other general administrative expenses;
f. Reimbursement from uninsured plans,
representing a negative adjustment that would include all revenue receipts from
uninsured plans (including excess pharmaceutical rebates and administrative
fees net of expenses) and reimbursements from fiscal intermediaries (including
administrative fees net of expenses from the government); and
g. Number of employees on the Carrier's
payroll on December 31st of the preceding year,
including the number of full-time employees whose normal work week is 30 or
more hours, but not including any employee who works on a part-time, temporary,
or substitute basis.
14.
Detailed miscellaneous expenses including, but not limited to, all collection
and bank service charges, printing and office supplies not allocated elsewhere,
postage, and telephone not allocated elsewhere.
15. Capital Expenses and Depreciation:
a. Depreciation, including all costs
associated with depreciation for electronic data processing, equipment,
software, and occupancy;
b. Capital
acquisitions, including all expenditures for the acquisition of capital assets,
including lease payments that were paid or incurred during the calendar
year;
c. Capital costs on behalf of
a clinic, including all expenditures for capital and lease payments incurred or
paid during the calendar year on behalf of a clinic (or part of a partnership,
joint venture, integration, or affiliation agreement); and
d. Other capital costs, including
expenditures for other costs that are directly associated with the incurring of
capital costs, such as legal or administrative costs, incurred or paid during
the calendar year.
16.
Net income, which equals direct premiums earned, less direct claims incurred,
less expenses, plus investment gains and losses.
(c) Balance Sheet
1. Accumulated surplus, including common
stock, preferred stock, gross paid in and contributed surplus, surplus notes,
unassigned funds, and other capital or surplus items.
2. Accumulated reserves, including all
reserves, including claim reserves, premium reserves, and contract
reserves.
3. Risk based capital
ratio in accordance with 211 CMR 25.00: Risk-based Capital (RBC) for
Health Organizations.