| Department of Health and Human Services, Centers for Medicare and Medicaid Services | ||||||||||||
| Medical Loss Ratio Quarterly Reporting Form - "Mini-Med" Plans | ||||||||||||
| Part 1 | ||||||||||||
| Report for: - Corporation - (Fill in below) | ||||||||||||
| NAIC Group Code: | ||||||||||||
| Location: - (Select from the drop-down menu below) | Business in the State of: | |||||||||||
| NAIC Company Code: | ||||||||||||
| Corporation Contact Information | ||||||||||||
| Please provide contact information for the issuer regarding this filing | Quarter: | |||||||||||
| Name: | ||||||||||||
| Year: | ||||||||||||
| Telephone: | ||||||||||||
| Email: | ||||||||||||
| Mailing Address: | ||||||||||||
| "Mini-Med" | ||||||||||||
| NAIC SHCE Cross Reference | 1 Individual |
2 Small Group Employer |
3 Large Group Employer |
4 Total Mini-Med 1 + 2 + 3 |
||||||||
| 1. | Adjusted premium: | |||||||||||
| 1.1 | Direct premium earned | $- | $- | $- | $- | |||||||
| 1.2 | Federal high risk pools | Pt 1, Ln 1.2 | $- | |||||||||
| 1.3 | State high risk pools | Pt 1, Ln 1.3 | $- | |||||||||
| 1.4 | Federal taxes and federal assessments | Pt 1, Ln 1.5 | $- | |||||||||
| 1.5 | State insurance, premium and other taxes | Pt 1, Ln 1.6 | $- | |||||||||
| 1.6 | Regulatory authority licenses and fees | Pt 1, Ln 1.7 | $- | |||||||||
| 1.7 | Adjusted premium (Lines 1.1 + 1.2 + 1.3 – 1.4 – 1.5 – 1.6) | $- | $- | $- | $- | |||||||
| 2. | Claims | |||||||||||
| 2.1 | Incurred claims excluding presecription drugs | Pt 1, Ln 2.1 | $- | |||||||||
| 2.2 | Prescription drugs | Pt 1, Ln 2.2 | $- | |||||||||
| 2.3 | Pharmaceutical rebates | Pt 1, Ln 2.3 | $- | |||||||||
| 2.4 | State stop loss, market stabilization and claim/census based assessments | Pt 1, Ln 2.4 | $- | |||||||||
| 3. | Incurred medical incentive pools and bonues | Pt 1, Ln 3 | $- | $- | $- | $- | ||||||
| 4. | Deductible Fraud and Abuse Recoveries. | Pt 1, Ln 4 | $- | $- | $- | $- | ||||||
| 5. | Total Incurred Claims (Lines 2.1 + 2.2 – 2.3 – 2.4 + 3) (Should equal Part 2, Line 2.16) | $- | $- | $- | $- | |||||||
| 6. | Improving Health Care Quality Expenses Incurred: | |||||||||||
| 6.1 | Type A. Expenses for health improvements other than Health Information Technology | Pt 1, Ln 6.1 | $- | |||||||||
| 6.2 | Type B. Health Information Technology expenses related to health improvement | Pt 1, Ln 6.2 | $- | |||||||||
| 6.3 | Total of defined expenses incurred for improving health care quality (Lines 6.1 + 6.2) | Pt 1, Ln 6.3 | $- | $- | $- | $- | ||||||
| 7. | Preliminary MLR (Lines 4 + 5 + 6.3 divided by Line 1.7) | #DIV/0! | #DIV/0! | #DIV/0! | XXX | |||||||
| 8. | Non-Claims Costs: | |||||||||||
| 8.1 | Cost Containment expenses not included in quality of care expenses in Line 6.3 | Pt 1, Ln 8.1 | $- | |||||||||
| 8.2 | All other claims adjustment expenses | Pt 1, Ln 8.2 | $- | |||||||||
| 8.3 | Direct sales salaries and benefits | Pt 1, Ln 10.1 | $- | |||||||||
| 8.4 | Agents and brokers fees and commissions | Pt 1, Ln 10.2 | $- | |||||||||
| 8.5 | Other taxes | Pt 1, Ln 10.3 | $- | |||||||||
| 8.6 | Other general and administrative expenses | Pt 1, Ln 10.4 | $- | |||||||||
| 8.7 | Total non-claims expense (Lines 8.1 + 8.2 + 8.3 + 8.4 + 8.5 + 8.6) | $- | $- | $- | $- | |||||||
| 8.8 | ICD-10 Implementation expenses (informational only) | Pt 1, Ln 16 | $- | |||||||||
| 9. | Underwriting gain/(loss) (Lines 1.7 – 5 – 6.3 – 8.7) | Pt 1, Ln 11 | $- | $- | $- | $- | ||||||
| Other Indicators: | ||||||||||||
| 1. | Number of certificates/policies | Pt 1 Other, Ln 1 | - | |||||||||
| 2. | Number of covered lives | Pt 1 Other, Ln 2 | - | |||||||||
| 3. | Number of groups | Pt 1 Other, Ln 3 | XX | - | ||||||||
| 4. | Member Months | Pt 1 Other, Ln 4 | - | |||||||||
| See instructions provided in accompanying document. | ||||||||||||
| Department of Health and Human Services, Centers for Medicare and Medicaid Services | |||||||
| Medical Loss Ratio Quarterly Reporting Form - "Mini-Med" Plans | |||||||
| Part 2 | |||||||
| "Mini-Med" | |||||||
| NAIC SHCE Cross Reference | 1 Individual |
2 Small Group Employer |
3 Large Group Employer |
4 Total Mini-Med 1 + 2 + 3 |
|||
| 1. | Premium | ||||||
| 1.1 | Direct premium written | Pt 2, Ln 1.1 | $- | ||||
| 1.2 | Unearned premium, as of end of prior year | Pt 2, Ln 1.2 | $- | ||||
| 1.3 | Unearned premium, as of end of current quarter | Pt 2, Ln 1.3 | $- | ||||
| 1.4 | Premium write-offs | incl. in Pt 2, Ln 1.8 | $- | ||||
| 1.5 | Group conversion charges | incl. in Supp Form, Ln 2 | $- | ||||
| 1.6 | Adjusted direct premiums earned (Lines 1.1 + 1.2 – 1.3 – 1.4 + 1.5) | $- | $- | $- | $- | ||
| 2. | Claims | ||||||
| 2.1 | Paid claims | Pt 2, Ln 2.1 | $- | ||||
| 2.2 | Direct claim liability, as of end of current quarter | Pt 2, Ln 2.2 | $- | ||||
| 2.3 | Direct claim liability, as of end of prior year | Pt 2, Ln 2.3 | $- | ||||
| 2.4 | Direct claim reserves, as of end of current quarter | Pt 2, Ln 2.4 | $- | ||||
| 2.5 | Direct claim reserves, as of end of prior year | Pt.2, Ln 2.5 | $- | ||||
| 2.6 | Direct contract reserves, as of end of current quarter | Pt 2, Ln 2.6 | $- | ||||
| 2.7 | Direct contract reserves, as of end of prior year | Pt.2, Ln 2.7 | $- | ||||
| 2.8 | Paid rate credits | Supp Form, Ln 7 | $- | ||||
| 2.9 | Reserve for rate credits, as of end of current quarter | Supp Form, Ln 7 | $- | ||||
| 2.10 | Reserve for rate credits, as of end of prior year | Supp Form, Ln 7 | $- | ||||
| 2.11 | Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b – 2.11c) | Pt 2, Ln 2.8 | $- | $- | $- | $- | |
| 2.11a. Paid medical incentive pools and bonuses as of end of current quarter | Pt 2, Ln 2.8a | $- | |||||
| 2.11b. Accrued medical incentive pools and bonuses, as of end of current quarter | Pt 2, Ln 2.8b | $- | |||||
| 2.11c. Accrued medical incentive pools and bonuses, as of end of prior year | Pt 2, Ln 2.8c | $- | |||||
| 2.12 | Healthcare receivables (Lines 2.12a – 2.12b) | Pt 2, Ln 2.9 | $- | $- | $- | $- | |
| 2.12a. Healthcare receivables, as of end of current quarter | Pt 2, Ln 2.9a | $- | |||||
| 2.12b. Healthcare receivables, as of end of prior year | Pt 2, Ln 2.9b | $- | |||||
| 2.13 | Contingent Benefit and Lawsuit reserves, as of end of current quarter | Supp Form, Ln 9 | $- | ||||
| 2.14 | Group conversion charges | incl. in Supp Form, Ln 5 | $- | ||||
| 2.15 | Multi-option coverage blended rate adjustment | incl. in Supp Form, Ln 5 | $- | ||||
| 2.16 | Total incurred claims (Lines 2.1 + 2.2 – 2.3 + 2.4 – 2.5 + 2.6 – 2.7 + 2.8 + 2.9 – 2.10 + 2.11 – 2.12 + 2.13 + 2.14 + 2.15) |
$- | $- | $- | $- | ||
| 3. | Deductible Fraud and Abuse recovery expense | ||||||
| 3.1 | Total Fraud and Abuse recoveries expense (informational only) | Pt 3, Col 7, Ln x.11 | $- | ||||
| 3.2 | Total Fraud and Abuse recoveries of paid claims (informational only) | $- | |||||
| 3.3 | Deductible Fraud and Abuse recovery expense (the lesser of Line 3.1 or 3.2) | Pt 1, Ln 4 | $- | $- | $- | $- | |
| See instructions provided in accompanying document. | |||||||
| Department of Health and Human Services, Centers for Medicare and Medicaid Services | ||||||||||||
| Medical Loss Ratio Quarterly Reporting Form - Expatriate Plans | ||||||||||||
| Part 1 | ||||||||||||
| Report for: - Corporation - (Fill in below) | ||||||||||||
| NAIC Group Code: | ||||||||||||
| Location: - (Select from the drop-down menu below) | Business in the State of: (List All) | |||||||||||
| NAIC Company Code: | ||||||||||||
| Corporation Contact Information | ||||||||||||
| Please provide contact information for the issuer regarding this filing | Quarter: | |||||||||||
| Name: | ||||||||||||
| Year: | ||||||||||||
| Telephone: | ||||||||||||
| Email: | ||||||||||||
| Mailing Address: | ||||||||||||
| Expatriate | ||||||||||||
| NAIC SHCE Cross Reference | 1 Small Group National Aggregation |
2 Large Group National Aggregation |
3 Total Expatriate 1 + 2 |
|||||||||
| 1. | Adjusted premium: | |||||||||||
| 1.1 | Direct premium earned | $- | $- | $- | ||||||||
| 1.2 | Federal high risk pools | Pt 1, Ln 1.2 | $- | |||||||||
| 1.3 | State high risk pools | Pt 1, Ln 1.3 | $- | |||||||||
| 1.4 | Federal taxes and federal assessments | Pt 1, Ln 1.5 | $- | |||||||||
| 1.5 | State insurance, premium and other taxes | Pt 1, Ln 1.6 | $- | |||||||||
| 1.6 | Regulatory authority licenses and fees | Pt 1, Ln 1.7 | $- | |||||||||
| 1.7 | Adjusted premium (Lines 1.1 + 1.2 + 1.3 – 1.4 – 1.5 – 1.6) | $- | $- | $- | ||||||||
| 2. | Claims | |||||||||||
| 2.1 | Incurred claims excluding presecription drugs | Pt 1, Ln 2.1 | $- | |||||||||
| 2.2 | Prescription drugs | Pt 1, Ln 2.2 | $- | |||||||||
| 2.3 | Pharmaceutical rebates | Pt 1, Ln 2.3 | $- | |||||||||
| 2.4 | State stop loss, market stabilization and claim/census based assessments | Pt 1, Ln 2.4 | $- | |||||||||
| 3. | Incurred medical incentive pools and bonues | Pt 1, Ln 3 | $- | $- | $- | |||||||
| 4. | Deductible Fraud and Abuse Recoveries. | Pt 1, Ln 4 | $- | $- | $- | |||||||
| 5. | Total Incurred Claims (Lines 2.1 + 2.2 – 2.3 – 2.4 + 3) (Should equal Part 2, Line 2.16) | $- | $- | $- | ||||||||
| 6. | Improving Health Care Quality Expenses Incurred: | |||||||||||
| 6.1 | Type A. Expenses for health improvements other than Health Information Technology | Pt 1, Ln 6.1 | $- | |||||||||
| 6.2 | Type B. Health Information Technology expenses related to health improvement | Pt 1, Ln 6.2 | $- | |||||||||
| 6.3 | Total of defined expenses incurred for improving health care quality (Lines 6.1 + 6.2) | Pt 1, Ln 6.3 | $- | $- | $- | |||||||
| 7. | Preliminary MLR (Lines 4 + 5 + 6.3 divided by Line 1.7) | #DIV/0! | #DIV/0! | XXX | ||||||||
| 8. | Non-Claims Costs: | |||||||||||
| 8.1 | Cost Containment expenses not included in quality of care expenses in Line 6.3 | Pt 1, Ln 8.1 | $- | |||||||||
| 8.2 | All other claims adjustment expenses | Pt 1, Ln 8.2 | $- | |||||||||
| 8.3 | Direct sales salaries and benefits | Pt 1, Ln 10.1 | $- | |||||||||
| 8.4 | Agents and brokers fees and commissions | Pt 1, Ln 10.2 | $- | |||||||||
| 8.5 | Other taxes | Pt 1, Ln 10.3 | $- | |||||||||
| 8.6 | Other general and administrative expenses | Pt 1, Ln 10.4 | $- | |||||||||
| 8.7 | Total non-claims expense (Lines 8.1 + 8.2 + 8.3 + 8.4 + 8.5 + 8.6) | $- | $- | $- | ||||||||
| 8.8 | ICD-10 Implementation expenses (informational only) | Pt 1, Ln 16 | $- | |||||||||
| 9. | Underwriting gain/(loss) (Lines 1.7 – 5 – 6.3 – 8.7) | Pt 1, Ln 11 | $- | $- | $- | |||||||
| Other Indicators: | ||||||||||||
| 1. | Number of certificates/policies | Pt 1 Other, Ln 1 | - | |||||||||
| 2. | Number of covered lives | Pt 1 Other, Ln 2 | - | |||||||||
| 3. | Number of groups | Pt 1 Other, Ln 3 | - | |||||||||
| 4. | Member Months | Pt 1 Other, Ln 4 | - | |||||||||
| See instructions provided in accompanying document. | ||||||||||||
| Department of Health and Human Services, Centers for Medicare and Medicaid Services | ||||||
| Medical Loss Ratio Quarterly Reporting Form - Expatriate Plans | ||||||
| Part 2 | ||||||
| Expatriate | ||||||
| NAIC SHCE Cross Reference | 1 Small Group National Aggregation |
2 Large Group National Aggregation |
3 Total Expatriate 1 + 2 |
|||
| 1. | Premium | |||||
| 1.1 | Direct premium written | Pt 2, Ln 1.1 | $- | |||
| 1.2 | Unearned premium, as of end of prior year | Pt 2, Ln 1.2 | $- | |||
| 1.3 | Unearned premium, as of end of current quarter | Pt 2, Ln 1.3 | $- | |||
| 1.4 | Premium write-offs | incl. in Pt 2, Ln 1.8 | $- | |||
| 1.5 | Group conversion charges | incl. in Supp Form, Ln 2 | $- | |||
| 1.6 | Adjusted direct premiums earned (Lines 1.1 + 1.2 – 1.3 – 1.4 + 1.5) | $- | $- | $- | ||
| 2. | Claims | |||||
| 2.1 | Paid claims | Pt 2, Ln 2.1 | $- | |||
| 2.2 | Direct claim liability, as of end of current quarter | Pt 2, Ln 2.2 | $- | |||
| 2.3 | Direct claim liability, as of end of prior year | Pt 2, Ln 2.3 | $- | |||
| 2.4 | Direct claim reserves, as of end of current quarter | Pt 2, Ln 2.4 | $- | |||
| 2.5 | Direct claim reserves, as of end of prior year | Pt.2, Ln 2.5 | $- | |||
| 2.6 | Direct contract reserves, as of end of current quarter | Pt 2, Ln 2.6 | $- | |||
| 2.7 | Direct contract reserves, as of end of prior year | Pt.2, Ln 2.7 | $- | |||
| 2.8 | Paid rate credits | Supp Form, Ln 7 | $- | |||
| 2.9 | Reserve for rate credits, as of end of current quarter | Supp Form, Ln 7 | $- | |||
| 2.10 | Reserve for rate credits, as of end of prior year | Supp Form, Ln 7 | $- | |||
| 2.11 | Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b – 2.11c) | Pt 2, Ln 2.8 | $- | $- | $- | |
| 2.11a. Paid medical incentive pools and bonuses as of end of current quarter | Pt 2, Ln 2.8a | $- | ||||
| 2.11b. Accrued medical incentive pools and bonuses, as of end of current quarter | Pt 2, Ln 2.8b | $- | ||||
| 2.11c. Accrued medical incentive pools and bonuses, as of end of prior year | Pt 2, Ln 2.8c | $- | ||||
| 2.12 | Healthcare receivables (Lines 2.12a – 2.12b) | Pt 2, Ln 2.9 | $- | $- | $- | |
| 2.12a. Healthcare receivables, as of end of current quarter | Pt 2, Ln 2.9a | $- | ||||
| 2.12b. Healthcare receivables, as of end of prior year | Pt 2, Ln 2.9b | $- | ||||
| 2.13 | Contingent Benefit and Lawsuit reserves, as of end of current quarter | Supp Form, Ln 9 | $- | |||
| 2.14 | Group conversion charges | incl. in Supp Form, Ln 5 | $- | |||
| 2.15 | Multi-option coverage blended rate adjustment | incl. in Supp Form, Ln 5 | $- | |||
| 2.16 | Total incurred claims (Lines 2.1 + 2.2 – 2.3 + 2.4 – 2.5 + 2.6 – 2.7 + 2.8 + 2.9 – 2.10 + 2.11 – 2.12 + 2.13 + 2.14 + 2.15) |
$- | $- | $- | ||
| 3. | Deductible Fraud and Abuse recovery expense | |||||
| 3.1 | Total Fraud and Abuse recoveries expense (informational only) | Pt 3, Col 7, Ln x.11 | $- | |||
| 3.2 | Total Fraud and Abuse recoveries of paid claims (informational only) | $- | ||||
| 3.3 | Deductible Fraud and Abuse recovery expense (the lesser of Line 3.1 or 3.2) | Pt 1, Ln 4 | $- | $- | $- | |
| See instructions provided in accompanying document. | ||||||
| File Type | application/vnd.ms-excel |
| Author | DHHS |
| Last Modified By | WNPIII |
| File Modified | 2011-05-10 |
| File Created | 2010-12-13 |