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Health Entities

Click here for a printable table form of the checklist for Health Entities in Word or Adobe PDF format.

Company Name:_______________________   NAIC Company Code: _________
Contact:_____________________________   Telephone: _________________
REQUIRED FILINGS IN THE STATE OF: Maine   Filings Made During the Year 2009
(1)

Check-list

(2)

Line
#

(3)

REQUIRED FILINGS FOR THE ABOVE STATE

 (4)

NUMBER OF COPIES*

(5)

DUE DATE
Postmarked

(6)

FORM SOURCE**

 (7)

APPLICABLE
NOTES

Domestic Foreign
State NAIC State
    I. NAIC FINANCIAL STATEMENTS            
  1 Annual Statement (8 ½"x14") 3 EO 2 3/1 NAIC  
  1.1 Printed Investment Schedule detail (Pages E01-E27) 2 EO XXX 3/1 NAIC  
  2 Quarterly Financial Statement (8 ½" x 14") 2 EO 1 5/15, 8/15, 11/15 NAIC  
    II. NAIC SUPPLEMENTS            
  10 Accident & Health Policy Experience Exhibit 2 EO 2 4/1 NAIC  
  11 Actuarial Opinion 1 EO 1 3/1 Company  
  12 Investment Risk Interrogatories 1 EO 1 4/1 NAIC  
  13 Life Supplemental Data due March 1 0 EO 0 3/1 NAIC  
  14 Life Supp Statement non-guaranteed elements –Exh 5, Int. #3 1 EO 1 3/1 Company  
  15 Life Supp Statement on par/non-par policies – Exh 5 Int. 1.1 1 EO 1 3/1 Company  
  16 Life Supplemental Data due April 1 0 EO 0 4/1 NAIC  
  17 Long-term Care Experience Reporting Forms 1 EO XXX 4/1 NAIC  
  18 Management Discussion & Analysis 1 EO 2 4/1 Company  
  19 Medicare Supplement Insurance Experience Exhibit 1 EO XXX 3/1 NAIC  
  20 Medicare Part D Coverage Supplement 1 EO 1 3/1, 5/15, 8/15, 11/15 NAIC  
  21 Property/Casualty Supplement due March 1 0 EO 0 3/1 NAIC  
  22 Property/Casualty Supplement due April 1 0 EO 0 4/1 NAIC  
  23 Risk-Based Capital Report 1 EO 1 3/1 NAIC  
  24 Schedule SIS 1 N/A N/A 3/1 NAIC  
  25 Supplemental Compensation Exhibit 1 N/A N/A 3/1 NAIC O
    III. ELECTRONIC FILING REQUIREMENTS            
  40 Annual Statement Electronic Filing XXX 1 XXX 3/1 NAIC  
  41 March .PDF Filing XXX 1 XXX 3/1 NAIC  
  42 Risk-Based Capital Electronic Filing XXX 1 N/A 3/1 NAIC  
  43 Risk-Based Capital PDF Filing XXX 1 N/A 3/1 NAIC  
  44 Supplemental Electronic Filing XXX 1 XXX 4/1 NAIC  
  45 Supplemental .PDF Filing XXX 1 XXX 4/1 NAIC  
  46 June .PDF Filing XXX 1 XXX 6/1 NAIC  
  47 Quarterly Electronic Filing XXX 1 XXX 5/15, 8/15, 11/15 NAIC  
  48 Quarterly .PDF Filing XXX 1 XXX 5/15, 8/15, 11/15 NAIC  
    IV. AUDITED FINANCIAL STATEMENTS            
  61 Accountants Letter of Qualifications 1 N/A N/A 6/1 Company  
  62 Audited Financial Statements 1 EO N/A 6/1 Company  
  63 Audited Financial Statements Exemption Affidavit 1 N/A N/A 6/1 Company  
  64 Independent CPA 1 N/A N/A 6/1 Company  
  65 Notification of Adverse Financial Condition 1 N/A N/A 6/1 Company  
  66 Report of Significant Deficiencies in Internal Controls 1 N/A N/A 6/1 Company  
  67 Request for Exemption to File 1 N/A N/A 5/1 Company  
    V. STATE REQUIRED FILINGS            
  101 Advertising Certificate 1 0 1 3/1 Company O
  102 Affidavit of Filing 0 0 0 3/1 State  
  103 Annual Report Supplement (Rule 945) 1 0 1 3/1 State O
  104 Carrier Reporting Form 1 0 1 2/1 State O
  105 Certificate of Compliance 1 0 1 3/1 State  
  106 Certificate of Deposit 1 0 1 3/1 State  
  107 Consumer Complaint Contact Update 1 0 1 3/1 State N
  108 Downstream Risk Arrangement Disclosure 1 0 1 4/1 Company O
  109 Exam Assessment Fee 1 0 XXX 3/1 State C
  110 Filings Checklist (with Column 1 completed) 1 0 1 3/1 State  
  111 Form B Holding Company Registration Statement 1 0 XXX 5/1 Company I
  112 Health Insurance Annual Data Report (Rule 940) 1 0 1 4/30 State O
  113 Health Report Card Survey 1 0 1 3/1 State O
  114 Maine Fraud and Abuse Annual Report 1 0 1 3/1 State O
  115 Mandated Benefit Experience Report (Bulletin 292) 1 0 1 4/30 State O
  116 Premium Tax 1 0 1 3/15 State D
  117 See Add’l HMO Requirements on our website 1 0 1 3/1 State  
  118 Signed Jurat 1 0 XXX 3/1, 5/15, 8/15, 11/15 NAIC  
  119 State Filing Fees 1 0 1 8/10 State C, O
  120 State Page for Maine 1 0 1 3/1 Company  
  121 State Specific Enrollment Data for Maine-HMO Only 1 0 1 3/1 NAIC  
  122 Supplement Health Insurance Report (Bulletin 286A) 1 0 1 4/1 State O

 

*If XXX appears in this column, this state does not require this filing, if the data is filed electronically with the NAIC and in accordance to the guidelines of the domiciliary state. 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.

State of Maine
Additional HMO Filing Requirements

The following requirements are in addition to the information requested by the Financial Analysis Division. Please note the contact person assigned to each report.

The HMO law includes the following reporting requirements:

  1. 4204(2A)(M) - "The HMO must make an annual report to the superintendent regarding the plan [for providing services for rural and underserved populations and for developing relationships with essential community providers]" - Please forward this report and direct any questions to Joanne Rawlings-Sekunda in our Consumer Health Care Division. Ms. Rawlings-Sekunda can be reached at the following phone number and Email address: (207) 624-8472 or joanne.rawlings-sekunda@maine.gov
  2. 4204(8) - "If the HMO has a net loss of 5 or more primary care physicians in any county in any 30-day period, the HMO shall notify the Bureau in writing within 10 days of acquiring knowledge of that loss." - Please forward this report and direct any questions to Joanne Rawlings-Sekunda in our Consumer Health Care Division. Ms. Rawlings-Sekunda can be reached at the following phone number and Email address: (207) 624-8472 or joanne.rawlings-sekunda@maine.gov
  3. 4207-A(3) - an HMO with a POS product must in its quarterly financial report demonstrate that it is not expending more than 20% of its total annual health care expenditures for out-of plan covered services. The quarterly financial reports are filed with the Financial Analysis Division.
  4. 4211(2) - "Each HMO shall submit to the superintendent and [DHS] an annual report...which shall include:
    1. a description of the procedures of such complaint system
    2. the total number and disposition of complaints handled through the complaint system and a compilation of causes underlying the complaints filed. Complaints concerning access to chiropractic providers and the results of those complaints must be separately identified; and
    3. the number, amount and disposition of malpractice claims settled during the year by the HMO." Please forward the above report and direct any questions to Joanne Rawlings-Sekunda in our Consumer Health Care Division. Ms. Rawlings-Sekunda can be reached at the following phone number and Email address: (207) 624-8472 or joanne.rawlings-sekunda@maine.gov
  5. 4228(1) - Report on utilization review experience - "On or before April 1st of each year, each HMO which issues a program of contract in this State that contains a provision whereby in nonemergency cases the insured is required to be prospectively evaluated through a prehospital admission certification, preinpatient service eligibility program or any similar preutilization review or screening procedure prior to the delivery of contemplated hospitalization, inpatient or outpatient health care or medical services which are prescribed or ordered by a duly licensed physician shall file a report on the results of that evaluation for the preceding year with the superintendent which shall contain the following...". Please forward this information and direct any questions to Patty Woods in our Consumer Health Care Division. Ms. Woods can be reached at the following phone number and Email address: (207) 624-8459 or patricia.a.woods@.maine.gov.
  6. Section 4302 (4) requires the following:

    4. Claims data. By February 1st of each year, a carrier that provides only administrative services for a plan sponsor shall annually file with the superintendent for the most recent complete calendar year for all covered individuals in the State the total number of claims paid for each plan sponsor and the total dollar amount of claims paid for each plan sponsor. [2001, c. 457, §23 (new).] Please forward this information and direct any questions to Glenn Griswold in the Consumer Health Care Division. Mr. Griswold can be reached at 207-624-8494 or glenn.j.griswold@maine.gov.

  7. Section 4234-A(10) requires HMOs to report their experience under the section, which establishes a mental health coverage mandate. The report is due by April 30th and must address the HMO's experience for the immediately preceding calendar year. The report must include the amount of claims paid in Maine for the services required by the section, and the total amount of claims paid in Maine for individual and group health care contracts, both separated according to those paid for inpatient, day treatment and outpatient services. The reporting forms are attached. Please direct these forms and any questions to:

    Marti Hooper
    Life & Health Actuarial Division
    Maine Bureau of Insurance
    34 State House Station
    Augusta, ME 04333-0034
    Mary.M.Hooper@maine.gov

 

NOTES AND INSTRUCTIONS (A-K APPLY TO ALL FILINGS)
A Required Filings Contact Person: Annual and Quarterly Statements: Lauri Cooper (207) 624-8464 Laurelyn.S.Cooper@maine.gov
B Mailing Address: Regular Mail:
Maine Bureau of Insurance
Financial Analysis Division
#34 State House Station
Augusta, ME 04333-0034		 Courier:
Maine Bureau of Insurance
Financial Analysis Division
76 Northern Avenue
Gardiner, ME 04345
C Mailing Address for Filing Fees: Annual Statement filing fees will be billed on or before July 1 of each year. DO NOT send fees at this time.
If the domestic company has elected to pay examination assessment fees based on Title 24-A, M.R.S.A., § 228 (3), please include your payment with the filing of your annual statement. If you have any questions with regards to the exam fees, please contact Stuart Turney (207) 624-8468 or Email stuart.e.turney@maine.gov
D Mailing Address & Contact for Premium Tax Payments, Questions & Forms: Maine Revenue Services, PO Box 9120, Augusta, ME 04333-9120, Phone: Carlotta Larrabee (207) 624-9753.
http://www.maine.gov/revenue/forms/insurance/2009.htm
E Delivery Instructions: All filings must be postmarked no later than the indicated due date. If the due date falls on a weekend or holiday, then the deadline is extended to the next business day.
F Late Filings: Foreign companies must supply a written copy of any exemption or extension received by its state of domicile at least 10 days prior to the filing due date to receive such from Maine. Domestic companies should apply at least 30 days prior to the due date.
G Original Signatures: Original signatures required on all filings from Domestic Companies. Foreign companies should follow the instructions in the NAIC Annual Statement instructions.
H Signature/Notarization/Certification: The following officers are required to sign the annual statement: CEO, President, & Treasurer for domestic companies.
I Amended Filings: The following items must be filed within 10 days of their amendment, along with an explanation of the amendments.
*Bylaws (certified) $25.00 filing fee, *Articles $25.00 filing fee, *Biographical Affidavits(domestics only)
Domestic Form B Statements are Due 5/1. Form B Holding Company Registration Statement amendments are due on the 15th of the month following the change.

CHECK PAYABLE TO TREASURER STATE OF MAINE

*As changes occur.
J Exceptions from normal filings:
  • Foreign companies must supply a written copy of any exemption or extension received by its state of domicile at least 10 days prior to the filing due date to receive such from Maine. Domestic companies should apply at least 30 days prior to the due date.
  • Foreign or alien insurers are only required to file an Annual Statement at the request of the Superintendent of Insurance.
K Bar Codes (State or NAIC) Not Used
L Signed Jurat Signed Jurat pages are NOT required for foreign or alien insurers. They are required for domestic insurers.
M NONE Filings: Supplemental exhibits & schedules as listed in the annual statement interrogatories are not required to be filed if your response in the supplemental exhibits & schedules interrogatories is a "NONE" report.
N Filings new, discontinued, modified since last year: None
O Required by the State of Maine
Should be filed separately from the annual statement
 
  • Advertising Certification required under Maine Rule 140 §11(B): Tracy Cunningham, (207) 624-8436, electronically to tracy.a.cunningham@maine.gov. Applies to all companies writing Health.

    http://www.maine.gov/sos/cec/rules/02/031/031c140.doc

  • Annual Report Supplement (Rule 945) : David Stetson (207) 624-8435, electronically to david.g.stetson@maine.gov Applies to all companies writing or renewing medical or stop loss health insurance. NULL reports need not be submitted. Due Date is March 1st.
    The Bureau is planning to collect data for these reports directly through a new web-based data entry program. The new program has not been finalized at this time. Please check our website before completing this report for updated instructions or check with the listed contact person. The following links are provided as an example of the data required to be filed.

    Rule 945 Reporting Forms:
    http://www.maine.gov/pfr/insurance/forms/excel/Rule945.xls - for companies with $2 million or more in premium
    http://www.maine.gov/pfr/insurance/forms/excel/Rule945_short.xls - for companies with less than $2 million in premium

  • Carrier Reporting Form (formally the Administrative Services Only Claims Report) {24-A M.R.S.A. § 4302(4)}: William Bremer (207) 624-8476, william.a.bremer@maine.gov.
    All insurance carriers with a HEALTH authority must file with the Superintendent of the Maine Bureau of Insurance by February 1st.
    The Bureau is collecting data for these reports directly through a new web-based data entry program. Please click on the following link to access the online reporting system.

    Online Reporting Form

  • Consumer Complaint Contact Update

    For Life/Accident/Health/Annuity/Credit Insurance, contact Lisa Lewis at (207)624-8417 or by email at lisa.a.lewis@maine.gov
    For Property/Casualty Insurer, contact Cynthia Willey at (207)624-8423 or by email at cynthia.l.willey@maine.gov
    Applies to all Property/Casualty, Life, Accident, Health, Annuity and Credit Insurers.
    http://www.maine.gov/pfr/insurance/forms/word/CompanyComplaintContact.doc (Word)
    http://www.maine.gov/pfr/insurance/forms/pdf/CompanyComplaintContact.pdf (PDF)

  • Downstream Risk Arrangement Disclosure required under §4336 B(2): Kendra L. Godbout, (207) 684-8495, electronically at kendra.l.godbout@maine.gov Applies to Health Maintenance Organizations.

  • Filing Fees: Ingrid Garand (207) 624-8465 ingrid.e.garand@maine.gov
    Fees will be billed on or before July 1 of each year. DO NOT send fees at this time

  • Health Insurance Annual Data Report (Rule 940): David Stetson (207) 624-8435, electronically to david.g.stetson@maine.gov Applies to all companies writing or renewing small group or individual Medical Insurance. Null reports need not be submitted. Due Date is April 30th.
    The Bureau is planning to collect data for these reports directly through a new web-based data entry program. The new program has not been finalized at this time. Please check our website before completing this report for updated instructions or check with the listed contact person. The following links are provided as an example of the data required to be filed.

    Rule 940 Reporting Form: http://www.maine.gov/pfr/insurance/forms/excel/Rule940Report.xls
    Rule 940: http://www.maine.gov/sos/cec/rules/02/031/031c940.doc

  • Health Report Card Survey: Joanne Rawlings-Sekunda, (207) 624-8472, electronically to joanne.rawlings-sekunda@maine.gov Applies to all companies with enrollees in health insurance at any point during 2008.

    Health Report Card Survey Form: http://www.maine.gov/pfr/insurance/forms/word/report_card_survey_form.doc (Word) http://www.maine.gov/pfr/insurance/forms/pdf/report_card_survey_form.pdf (PDF)

  • Liquor Liability Report: Thomas Michaud (207) 624-8440, thomas.r.michaud@maine.gov.
    Applies to all Property and Casualty companies.
    The Bureau is collecting data for these reports directly through a new web-based data entry program. Please click on the following link to access the online reporting system.

    Online Reporting Form

  • Maine Fraud and Abuse Annual Report: Kelly E. Rogers (207) 624-8438, kelly.e.rogers@maine.gov.
    Applies to all companies and Electronic Submissions are Encouraged.
    The Bureau is collecting data for these reports directly through a new web-based data entry program. Please click on the following link to access the online reporting system.

    Online Reporting Form

  • Managing General Agent Report: Barbra Garboski (207) 624-8489, electronically to barbra.l.garboski@maine.gov
    Applies to only those companies utilizing an MGA.
    Managing General Agent Reporting Form:
    http://www.maine.gov/pfr/insurance/producer/word/AnnualMGAReportingForm.doc (Word)
    http://www.maine.gov/pfr/insurance/producer/pdf/AnnualMGAReportingForm.pdf (PDF)

  • Mandated Benefit Experience Report: David Stetson (207) 624-8435, electronically to david.g.stetson@maine.gov Applies to all companies writing or renewing Health. NULL reports need not be submitted. Due Date is April 30th.
    The Bureau is planning to collect data for these reports directly through a new web-based data entry program. The new program has not been finalized at this time. Please check our website before completing this report for updated instructions or check with the listed contact person. The following links are provided as an example of the data required to be filed.

    Mandated Benefit Experience Reporting Form:
    http://www.maine.gov/pfr/insurance/forms/excel/mandated_benefits.xls
    Mandated Benefit Experience Bulletin: http://www.maine.gov/pfr/insurance/bulletins/292.htm

  • Reasonableness of Assumptions Certification

    Reasonableness & Consistency of Assumptions Certification
    For the above, contact Kendra Godbout at (207)-624-8495 or electronically to kendra.l.godbout@maine.gov
    Actuarial certifications required for equity indexed annuities as found in Actuarial Guideline XXXV, Appendix C of the Accounting Practices and Procedures Manual

  • Reasonableness of Assumptions Certifications for Implied Guaranteed Rate Method

    Reasonableness & Consistency of Assumptions Certification (Updated Average Market Value)

    Reasonableness & Consistency of Assumptions Certification (Updated Market Value)
    For all of the above, contact Kendra Godbout at (207)-624-8495 or electronically to kendra.l.godbout@maine.gov
    Actuarial certifications required for equity indexed life insurance policies as found in Actuarial Guideline XXXVI, Appendix C of the Accounting Practices and Procedures Manual.

  • Supplemental Compensation Exhibit: Lauri Cooper (207) 624-8464, electronically to laurelyn.s.cooper@maine.gov
    Due March 1st. Forms can be sent with the Annual Statement or separately.

  • Supplemental Health Insurance Report: Marti Hooper (207) 624-8449, electronically to mary.m.hooper@maine.gov Applies to all companies writing or renewing Health. NULL reports need not be submitted. Due Date is April 1st.
    The Bureau is planning to collect data for these reports directly through a new web-based data entry program. The new program has not been finalized at this time. Please check our website before completing this report for updated instructions or check with the listed contact person. The following links are provided as an example of the data required to be filed.

    Supplemental Health Reporting Form:
    http://www.maine.gov/pfr/insurance/forms/excel/SuppHealthPremiumForm.xls
    Supplemental Health Bulletin: http://www.maine.gov/pfr/insurance/bulletins/286a.htm

  • Tick Borne Disease Report: Diane Williams (207) 624-8453, diane.m.williams@maine.gov.
    Applies to all companies. Due Date is February 1st.
    The Bureau is collecting data for these reports directly through a new web-based data entry program. Please click on the following link to access the online reporting system.

    Online Reporting Form

  • Workers Compensation Benefits Report: Thomas Michaud (207) 624-8440, thomas.r.michaud@maine.gov.
    Applies to all companies writing workers' compensation.
    The Bureau is collecting data for these reports directly through a new web-based data entry program. Please click on the following link to access the online reporting system.

    Online Reporting Form

 

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 diskette with the NAIC. Companies that file with the NAIC via the Internet are not required to submit diskettes 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 investments 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 its 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.

Last Updated: September 2, 2009