memo

STATE OF HAW All INSURANCE DIVISION • P. 0. BOX 3614, HONOLULU, HI 96811-3614 250 S. KING STR., 5TH FLOOR, HONOLULU, HI 96813 ATTN: DANIEL CHEUNG HEAL TH ENTITIES (LICENSED IN HAWAII) • Memorandum 2002-13H December 10, 2002 COMPANY NAME: _____________________ NAIC Company Code: ---------- Contact: Telephone:-------------- REQUIRED FILINGS IN THE STATE OF: HAWAII Filings Made During the Year 2003 (1) (2) (3) (4) (5) (6) (7) Check- Line NUMBER OF FORM APPLICABLE list # REQUIRED FILINGS FOR THE ABOVE STATE COPIES DUE DATE(S) SOURCE* NOTES State NAIC (A·L aooly to all filings) I. NAIC FINANCIAL STATEMENTS 1 2002 Annual Statement (8 %" x 14") 2 1 3/1 NAIC N 1.1 Printed Investment Schedule (pages E01-E25) 2 1 3/1 NAIC N 2 Quarterly Financial Statement (8 %" x 14") for 2 1 5/15, 8/15, NAIC Quarters ending 3/31/03, 6/30/03 and 9/30/03 11/15 II. NAIC SUPPLEMENTS 10 Actuarial Certification 2 1 3/1 Company N 11 Investment Risk Interrogatories 2 1 4/1 NAIC N 12 Long Term Care Experience Reporting Forms 2 1 4/1 NAIC N 13 Manaaement Discussion & Analysis 2 1 4/1 Company N 14 Medicare Supplement Insurance Experience 2 1 3/1 NAIC N Exhibit 15 Risk-Based Capital Report N/A N/A N/A NAIC 16 Supplemental Compensation Exhibit 2 N/A 3/1 NAIC N 17 SVO Compliance Certification 2 1 3/1, 5/15, NAIC N 8/15, 11/15 Ill. NAIC ELECTRONIC FILINGS 30 Annual Statement Electronic Filing N/A 1 3/1 NAIC N,O 31 March .PDF Filing N/A 1 3/1 NAIC N,O 32 Risk-Based Capital Electronic Filing N/A N/A N/A NAIC 33 Suoolemental Electronic Filing N/A 1 4/1 NAIC N,O 34 Suoolemental .PDF Filing N/A 1 4/1 NAIC N,O 35 June .PDF Filing N/A 1 6/1 NAIC 0 36 Quarterly Electronic Filing N/A 1 5/15, 8/15, NAIC 0 11/15 37 Quarterly .PDF Filing N/A 1 5/15, 8/15, NAIC 0 11/15 " • HEAL TH ENTITIES (LICENSED IN HAWAII) • HAWAII Memorandum 2002-13H December 10, 2002 COMPANY NAME: _____________________ NAIC Company Code: ---------- Contact: Telephone:-------------- REQUIRED FILINGS IN THE STATE OF: HAWAII Filings Made During the Year 2003 (1) (2) (3) (4) (5) (6) (7) Check- Line NUMBER OF FORM APPLICABLE list # REQUIRED FILINGS FOR THE ABOVE STATE COPIES DUE DATE(S) SOURCE* NOTES State NAIC (A-L apply to all filings) IV. AUDITED FINANCIAL STATEMENTS 51 Accountants Letter of Qualifications 2 N/A 6/1 Company 52 Audited Financial Statements 2 1 6/1 Company 54 Independent CPA-Annual Notification of 1 N/A Prior to the Company Accountant/Accounting Firm beginning of audit 55 Notification of Adverse Financial Condition 1 N/A 6/1 - If Company aoolicable 56 Report of Significant Deficiencies in Internal 1 N/A 6/1 - If Company Controls applicable V. STATE FILINGS 101 Filings Checklist (with Column 1 completed) 1 1 Checklist to State accompany every filing 102 Compliance Resolution Fund Assessment 1 0 7/1 State (formerly known as Insurance Regulation Fund Assessment) - Assessment Notice will be sent to insurers 103 Computation of Net Worth (Separate 2 0 3/1 State worksheets for MBS and HMO attached) 104 Grievance Procedures, number of grievances 1 0 3/1 Company handled, causes underlying those grievances, and a summary of disposition of grievances 105 Quarterly Net Solvency Report 2 0 2/14, 5/15, Company (for mutual benefit societies under HRS 8/14, 11/14 §432:1-407(g) and HMO under §432D-8(g) 106 4m Quarter (10/1-12/31) Financial Statement 1 0 2/14 NAIC (8 %" x 14") 107 Minutes 1 0 Within 60 Company days of the board meeting 108 Amendments to Charter or Articles of 1 0 Within 60 Company Incorporation, Constitution and Bylaws days after enactment VI. FILINGS FOR HMO INSURERS ONLY 109 List of Providers 1 0 3/1 Company 110 Renewal of Certificate of Authority 1 0 8/16 State *If Form Source is NAIC, the form should be obtained from the appropriate vendor. DOCUMENTS SUBMITTED TO THE HAWAII INSURANCE DIVISION WHICH ARE NOT REQUIRED TO BE FILED (NOT ON OUR L/S1) WILL BE DESTROYED WITHOUT REVIEW. 2 R R N N N N N N N p ,. • • NOTES AND INSTRUCTIONS (A-L APPLY TO ALL FILINGS) [HEAL TH ENTITIES] A Required Filings Contact Person: Compliance Resolution Fund Assessment (Line #102) Gordon Nishiki: (808) 586-0985 E-mail: gnishiki@dcca.state.hi.us Renewal of Certificate of Authority (Line #110) [HMO Insurers ONLY] Licensing Branch: (808) 586-2788 E-mail: inslic@dcca.state.hi.us Annual Statement and all other filings: Daniel Cheung: (808) 587-6735 Fax: (808) 587-5379 E-mail: dcheung@dcca.state.hi.us B Mailing Address: P. 0. Box 3614 Honolulu, HI 96811-3614 ATTN: DANIEL CHEUNG OR 250 S. King Street, 5th Fir. Honolulu, HI 96813 ATTN: DANIEL CHEUNG c Mailing Address for Filing Fees: Not applicable D Mailing Address for Premium Tax Payments: Not applicable E Delivery Instructions: For filings to be considered as delivered on time, the Insurance Division must receive all filings on or before the indicated due date. If the due date falls on a weekend or holiday, then the next business day becomes the due date. F Late Filings: Failure or refusal to submit the filings on time are punishable by law including fines, suspension or revocation of the Certificate of Authority. G Original Signatures: The Annual and Quarterly Statement Jurat pages, and the Quarterly Net Solvency Report, shall bear original signatures of at least two of the reporting entity's principal officers. Financial statement attestations and actuarial certification shall also bear the original signature(s) of the attestant(s). H Signature/Notarization/Certification: Original signatures of the Annual and Quarterly Statement Jurat pages (Note "G") shall be notarized. I Amended Filings: An explanation of the individual amendments shall accompany each amended filing. If there are signature requirements for the original filing, the same should be followed for any amended filing. 3 • • NOTES AND INSTRUCTIONS (A-L APPLY TO ALL FILINGS) rHEAL TH ENTITIESl J Exceptions from normal filings: Insurer may request an extension of filing due date from March 1 to April 30, 2003 for its filings of: 1. 2002 Annual Statement (Line #1), 2. Grievance related filings (Line #104), and 3. Listing of providers (Line #109) The request for extension, in writing, must reach the Insurance Division on or before Februa!Y 151 2003 and must be accom~anied by a guarterly financial statement {NAIC format} for the ~receding fourth guarter that ended on December 31 1 2002. (Please note that the filing of fourth quarter 2002 financial statement is not required for insurers who meet the regular 2002 Annual Statements filing due date of March 1, 2003.) K Bar Codes (State or NAIC): Not applicable L Affidavit of Filing and Financial Statement Not applicable (foreign insurers are required to submit Attestation: filings in hard copies with the Insurance Division) M NONE Filings: See NAIC Annual Statement Instructions. Exceptions to these instructions are noted on the form. N Filings new, discontinued or modified materially New Filings: since last year: 1. Supplemental Compensation Exhibit (Line #16) 2. Checklist to accompany every filing (Line #101) 3. Computation of Net Worth Worksheet for Mutual Benefit Societies (Line #103) 4. Quarterly Net Solvency Report (Line #105) 5. Minutes (Line #107) Modified Filings: New due dates for various NAIC filings (i.e. NAIC annual statement, NAIC supplements, NAIC electronic filings) and grievance related filings (Line #104). 0 Electronic Filing: Electronic filing with the NAIC includes filing via the Internet or filing via diskette. Companies that file with the NAIC via the Internet are not required to submit diskettes to the NAIC. Please review General Instructions for Companies to Use Checklist. Effective 2003, insurer is no longer required to submit the original or amended filings in diskette to the Insurance Division. p Certificate of Authority: The Insurance Division will notify HMO insurers of the license renewal before August 16 each year. (HMO Insurers ONLY) QUESTIONS - CONT ACT THE LICENSING BRANCH @ (808) 586-2788. E-mail: inslic@dcca.state.hi.us 4 • • NOTES AND INSTRUCTIONS (A·L APPLY TO ALL FILINGS) [HEAL TH ENTITIES] Q Checks/payments: Checks should be made payable to "DEPARTMENT OF COMMERCE AND CONSUMER AFFAIRS, STATE OF HAWAII" unless otherwise noted on the form. A service charge of $15 will be assessed for each dishonored check. Your cancelled check is your receipt; an official receipt will be issued only upon written request. R Accountants Letter of Qualifications Originals required for filing. Audited Financial Statements Audit shall be prepared in accordance with the NAIC Annual Statement Instructions, following the practices and procedures prescribed by the NAIC Accounting Practices and Procedures Manual. s Websites: Please visit the following websites for additional information: www .naic.org/1 filing www.state.hi.us/dcca/ins 5 • • STATE OF HAWAII Health Entities - 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 send mailing labels and other information to all companies but will not be sending their own checklist this year. Column (1) Electronic filing with the NAIC is intended to include filing via the Internet or via diskette. Companies that file with the NAIC via the Internet are not required to submit diskettes to the NAIC. (Checklist) Companies should copy the checklist and place an "K' in this column when mailing ALL 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, Officers and Directors Information and supplements due March 1. The Risk-Based Capital Electronic Filing includes all risk-based capital data. (This filing is N/A.) 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 Health Insurer is required to file for each type of form. 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 either with the filing instructions OR will be mailed to the insurer at a later date. 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. Also, phone inquiries should be directed to the proper contact person (See NOTE A). 6 •.' The greater of: • Mutual Benefit Societies Computation of Net Worth • HRS §432:1-407 Protection Against Insolvency Filing Requirement #103 1. $2,000,000 .{fil 2. The sum of 2% of the first $150,000,000 annual premium revenues and 1 % of annual premium revenues in excess of $150,000,000, as reported on the most recent Annual Statement. Annual premiums: x Up to $150,000,000 2% In excess of $150,000,000 1% Total ____ (b) 3. An amount equal to 8% of the sum of annual health care expenditures and operating expenses as reported on the most recent Annual Statement. Annual health care expenditures $ Annual operating expenses Total $ Multiplied by 8% Total $ (c) Minimum Net Worth: Greater of (a, b, or c) ACTUAL NET WORTH: Excess I (Deficiency) Prepared By: Signature Date Name: Title: (Revised 12/02)