NH Insurance Department Bulletin INS 21-019-AB
Supplemental Data Request
The State of New Hampshire
Insurance Department
21 South Fruit Street, Suite 14
Concord, NH 03301
(603) 271-2261 Fax (603) 271-1406
TDD Access: Relay NH 1-800-735-2964
Christopher R. Nicolopoulos
Commissioner
BULLETIN
Docket No.: INS No. 21-019-AB
David J. Bettencourt
Deputy Connnissioner
TO:
All New Hampshire Licensed Health Insurance Companies, Health
Maintenance Organizations, Fraternal Benefit Societies and
Third Party Administrators
FROM:
ChristopherNicolopoulos
Insurance Commissioner
C,R,N.
DATE:
April 2, 2021
RE:
Supplemental Data Request
Table of Contents
Background ........................................................................................................................... 2
Changes in Requirements ..................................................................................................... 2
Purpose of Changes .............................................................................................................. 3
Definitions ............................................................................................................................ 3
Applicability ......................................................................................................................... 7
Exemptions ........................................................................................................................... 7
De Minimis Exemption ......................................................................................................... 7
Creditable Coverage ............................................................................................................. 7
DueDate ............................................................................................................................... 8
Fines ...................................................................................................................................... 8
Tabulation Methods and Issues ............................................................................................ 8
Tabulation oflnformation ..................................................................................................... 9
Tabulation Issues - Multiple Carriers ................................................................................. 10
Tabulation Issues - Geographic Location ........................................................................... 10
Acceptable Methods for Estimating Data ........................................................................... 11
Acceptable Methods for Submission ................................................................................... 11
Data Reconciliation ............................................................................................................. 12
Confidentiality .................................................................................................................... 12
Attachment A Supplemental Data Request Specifications .................................................. 13
Transmittal ...................................................................................................................................................... 13
Main Data Collection ...................................................................................................................................... 14
Limited Data Collection .................................................................................................................................. 26
Stop Loss Data Collection ............................................................................................................................... 29
Data Checks .................................................................................................................................................... 33
Data Reconciliation ......................................................................................................................................... 3 5
Summary Tables ............................................................................................................................................. 35
Attachment B-1 ................................................................................................................... 36
Attachment B-2 ................................................................................................................... 37
Attachment C ...................................................................................................................... 38
Attachment D ...................................................................................................................... 40
Attachment E ...................................................................................................................... 41
Attachment F ...................................................................................................................... 45
Background
Pursuant to RSA 400-A:36 and other provisions of Title XXXVII, the Insurance Commissioner
has the authority to prescribe the format and content of financial and other reports filed by
licensed insurers in New Hampshire. The reports submitted by licensed carriers and other
entities are required to evaluate the financial solvency of carriers operating in New Hampshire
(NH) as well as to understand the characteristics of New Hampshire's insurance markets.
In 2002, the Commissioner implemented an annual statement supplemental reporting
requirement with respect to health insurance coverage.
The New Hampshire General Court, during its 2003 general session, adopted Senate Bill 110,
now codified at RSA 420-G: 14-a, which placed further health insurance data collection
responsibilities on the Department. On March 22, 2006, the approval of Senate Bill 369
amended RSA 420-G: 14-a and broadened the authority of the Commissioner to collect
information related to the supplemental report.
This bulletin is issued to update the information requested by the Department. The
requirements for submitting data for the supplemental data request are very similar to the
requirements for submitting claims data according to INS 4000. Carriers should confirm
that they have applied the same reporting criteria to both submissions. If the same
reporting criteria are not applied, the carrier/Third Party Administrator shall identify and
explain the differences.
This bulletin repeals and replaces INS No. 19-003-AB.
Changes in Requirements
The following is a high-level description of changes made to this bulletin from the previous
bulletin and other important notes. Do not rely on this list exclusively; read the entire bulletin to
ensure compliance with reporting requirements.
•
A column (M) has been added to the data reconciliation page requesting carriers to
include "Code used to extract member month data from the Comprehensive Health Care
Information System (CHIS) database (for example, SQL code)"
•
A section was added to the Transmittal Worksheet for the insurer to confirm that they
have responded to the request in the Data Reconciliation Worksheet
2
Submission Details
•
The completed Excel template must be delivered to the NHID using the State of NH
Online Forms website (https://onlineforms.nh.gov/). This website requires a registration
to deliver the completed Excel template or to request a de minimus exemption. Under
the dropdown menu named "Select Organization", select "New Hampshire Insurance
Department", and then "Healthcare Data Collection". Under the Forms section, select
"Current Year Supplemental Data Request". Alternatively, the Supplemental Data
Request nF orm can be found using this link:
https://onlineforms.nh.gov/?FormTag=frm-nhid-sdr
•
The NH Online Forms website is unable to accept an Excel file with macros. After you
have completed the template, run the data validation and data reconciliation checks and
create the summary tables; please save the file as a non-macro enabled Excel file. Do
this in Excel by selecting "File", "Save As", and then use the dropdown menu to select
"Excel Workbook(* .xlsx).
•
The due date for the submission of data is June 30.
•
The primary point of contact for questions related to this submission is Don Gorman at
Gorman Actuarial, Inc. (Email: Actuary@GormanActuarial.com)
Purpose of Changes
•
The minor change this year is intended to improve the transparency of the data
submission and provide more detail to explain variation between the data submitted to
CHIS and the data submitted to the supplemental data request.
•
The requirements for submitdng data for the supplemental data request are very
similar to the requirements for submitdng claims data according to INS 4000.
Carriers should confirm that they have applied the same reporting criteria to both
submissions.
Deflnitions
(a)
"Actuarial Value" - For the purposes of this report, the Actuarial Value will be
the Minimum Value measure as outlined in Section 1302 (d)(2)(C) of the
Affordable Care Act. Beginning in 2014, insurers and employers or unions with
self-insured plans must report information to the IRS for each individual covered
under a health insurance plan that provides minimum coverage. This information
will be used by the IRS to determine whether individuals who purchase insurance
on the exchanges will be eligible for a premium tax credit. The minimum value is
defined as the percentage of the total allowed costs of benefits provided under a
group health plan or health insurance coverage. In accordance with the HHS
regulations there are several options for determining the Minimum Value:
•
Determine Minimum Value figure using the most recent version of the
publicly available Minimum Value Calculator Excel model tool that can be
downloaded from the Centers for Medicare & Medicaid Services (CMS)
3
website1. The Department of Health and Human Services has published
guidance titled "Minimum Value Calculator Methodology'' which is also
available on the website. This guidance provides a detailed description of the
data underlying the MV Calculator and the calculator's methodology.
•
Determine Minimum Value figure through any safe harbor
established by HHS and IRS.
•
If the plan design is incompatible with the Minimum Value Calculator or
Safe Harbor Plan, the Minimum Value figure may be determined through
an actuarial certification from a member of the American Academy of
Actuaries.
For each set of reported coverage options, e.g. each benefit plan, the carrier shall
include the Minimum Value figure calculated in accordance to one of the three
options mentioned above. The Minimum Value Calculator can be used for a wide
variety of health plan designs; however, it is possible some benefit plan designs
may not fit into the calculator. In circumstances where this is the case, and the
minimum value from the safe harbor or actuarial certification is not readily
available, a reasonable estimate based on comparison to similar plan designs may
be reported if the carrier receives prior approval from the Department. If a carrier
used a method other than the Minimum Value Calculator, the alternate method
that was used must be disclosed and described in the notes section of the report
submittal form along with documentation of prior approval, if applicable.
Please do not provide figures based on the Actuarial Value Calculator. The
Actuarial Value Calculator uses different population base and different
continuance tables than the Minimum Value Calculator. The results from the
two calculators will be slightly different. For the purposes of this report and
stable comparison across coverage segments and carriers, the Minimum Value
Calculator must be used.
This minimum value as described above is the "actuarial value."
(b)
"Blanket health insurance" is as defined under RSA 415: 18, I-a and means that
form of accident and health insurance that is not "health coverage" under RSA
420-G:2, IX, that does not require individual applications from covered persons,
and that does not require a carrier to furnish each person with a certificate of
coverage.
( c)
"Certificate holder" shall have its standard language meaning for insurance
writers and their written coverage. For employer-sponsored group coverage, the
employee or subscriber shall be the certificate holder. For individual coverage,
the policyholder shall be the certificate holder. For other types of group
coverage, the certificate holder shall mean the person who is the principal
1 Currently at this link: http://www.cms.gov/cciio/resources/regulations-and-guidance/index.html
4
insured.
( d)
"Claims Incurred" shall reflect total medical expense for services received by the
covered members in the reporting class during the calendar year for which the
data are being reported. Note that total claims are based on an accrual basis for
calendar year, and are equal to the sum of (i) claims incurred and paid, (ii)
claims incurred and unpaid, and (iii) other payments and credits (see Attachment
A for definitions of these sub-components). All claims with a date of service
during the reporting year are to be included as claims paid in this field. If
necessary, actuarial completion factors should be used to estimate incurred
claims and should be based on when the carrier extracts the data for the
Supplemental Data Request. Incurred claims should be consistent with what is
reported in Part 1, Line 5 of the NAIC Supplemental Health Care Exhibit,
allowing for variances due to any restatement of unpaid claims with additional
paid claim runout. Additional detail regarding how to report Claims Incurred can
be found in Attachment A.
(e)
"Covered lives" or "members" shall include all individuals, employees and
dependents for which the health carrier or third-party administrator has an
obligation to adjudicate, pay or disburse claim payments. Data submission
requirements apply to all members who receive services under a policy sold to a
New Hampshire employer with a business location in New Hampshire, or to a
resident of New Hampshire who receives services under a policy issued by the
carrier or services by the third party administrator. For employer-sponsored
group coverage, covered lives would include certificate holders and their
dependents.
(t)
"Creditable coverage" shall have the same meaning as defined in RSA 420-G:2,
m.
(g)
"Data" means factual information used as a basis for calculation or
measurement.
(h)
"Database" means a collection of data organized especially for search and
retrieval.
(i)
"Eligible Employee" shall have the same meaning as defined in INS 4100,
specifically INS 4103.03 (g) for the Small Group market, INS 4104.03 (i) for
the Large Group market, and 4105.03 (h) for the Stop Loss market.
(j)
"Health carrier" shall mean any licensed insurance company with a Paragraph 4
authorization on its New Hampshire license. Licensed entities include Life
Insurance Companies, Property & Casualty Insurance Companies, Health
Maintenance Organizations, Fraternal Benefit Societies and Nonprofit Health
Service Corporations. Health carrier shall also include Third Party
5
Administrators (TPAs).
(k)
"Policy'' shall have its standard language meaning for insurance writers. For
employer-sponsored group coverage, where the coverage is written directly for
the employer's benefit plan, the employer shall be considered the policyholder.
A policy that is issued in New Hampshire shall include any policy that provides
coverage to the employees of a New Hampshire employer that has a business
location in New Hampshire. An employer's branch location in New Hampshire
shall be considered a New Hampshire employer, and the carrier/TP A shall
submit data for all members who are employed at that branch location. For
employer-sponsored group coverage, issued to a qualified association trust, each
member employer shall be considered a separate policyholder. For all
association business, each member employer shall be considered as a separate
policyholder. TP As shall report policyholders in a like manner.
(1)
"Premium" shall be calculated as "earned" premium, or the total amount of
premium from policyholders to provide insurance coverage during the reporting
year. Earned premium = premiums collected + change in due and uncollected
premium - change in unearned and advance premium. This should include
advance payments of the premium tax credit. If premium is collected prior to
January 1, to provide insurance coverage during the reported calendar year, then
it must be included in this column. The Commissioner may approve the use of a
reasonable proxy upon the carrier's provision of documentation demonstrating
that the use of the same does not materially distort the carrier's data submission.
For TPAs, premium shall mean the funds collected from contracted accounts to
provide for all claims and expenses associated with the administration of the
employer's benefit plan. Additional detail regarding how to report Premium can
be found in Attachment A.
(m)
"Situs" of a policy shall be defined as the jurisdiction in which the policy is
issued or delivered as stated in the policy. For employer business issued through
a qualified association trust, the situs shall be based on the location of each
member employer. The intent of this definition is to be consistent with the
instructions for the NAIC Supplemental Health Care Exhibit. Carriers should
apply the same consideration when determining situs for this report as they do for
the Supplemental Health Care Exhibit. TP As shall determine situs of their
contracts in a like manner.
(n)
"Subcontractor" shall be defined as a vendor or contractor who manages carved
out categories of services such as mental health services or pharmacy services.
Since the subcontractor may be required by the carrier/TP A to satisfy state
reporting requirements for the subcontracted services, the Department needs to
understand what carriers or TP As are including in their data from a subcontractor
in order to avoid double counting multiple submissions. The carrier/TP A is
ultimately responsible for a complete submission without duplicate data, and is
6
most often better served by submitting one filing rather than relying on the
subcontractor to fulfill the carrier/TPA's obligations.
Applicability
All carriers licensed to write accident and health insurance in the state of New Hampshire and
meeting minimum thresholds must submit Supplemental Data Request data. A carrier is
licensed to write accident and health insurance if it has a Paragraph 4 authorization on its New
Hampshire license. A licensed or registered Third Party Administrator (TPA) must submit
Supplemental Data Request data only if it exceeds the de minimis exemption criteria described
below. Covered lives/members are individual members eligible to have claims paid for them,
not accounts. Membership is determined based on the definition of covered lives as defined
herein, and will include New Hampshire residents with an account that is located out of state.
Exemptions
All carriers and TP As must submit Supplemental Data Request data unless they meet the de
minimis exemption described below.
De Minimis Exemption
Carriers and third-party administrators are not required to submit data if they meet the following
criteria:
For carriers that do not offer any products on the health insurance exchange for
residents of New Hampshire, and that did not cover more than 9,999 members in New
Hampshire at any point in any coverage class (medical or pharmacy) during the
immediately preceding calendar year; or
For third-party administrators that did not cover more than 9,999 members in New
Hampshire at any point in any coverage class (medical or pharmacy) during the
immediately preceding calendar year.
Carriers and third-party administrators shall perform the de minimis calculation at the entity
level, i.e., the level at which major governance decisions are made under a senior leadership
team, regardless of the number of companies operating under separate corporate divisions.
Creditable Coverage
A carrier writes creditable coverage when it issues a policy for coverage that meets the definition
of creditable coverage in RSA 420- G:2, III. A TP A administers creditable coverage when it
provides administrative services to either an insurer or an employer that has assumed the risk for
an employer-sponsored or other sponsored plan that provides creditable coverage. In addition,
carriers writing stop- loss or group excess loss insurance to employers whose self-insured plans
meet the definition of creditable coverage must submit data. Throughout this bulletin,
references to writing carriers shall include all of the activities referenced in this paragraph. All
of these carriers and TP As must submit the policy data tabulated as prescribed.
7
Stop loss and group excess coverage shall be reported, both by carriers issuing standalone stop loss coverage and carriers issuing stop loss coverage to the employer groups
for which they administer the self-insured health benefits.
Due Date
Carriers and TPAs must submit data summarizing the carrier's business from the immediately
preceding calendar year. The data submission due June 30 shall summarize the carrier's
business for the preceding calendar year, ending on December 31. This annual reporting
requirement shall continue in perpetuity unless and until explicit revocation by the
Department.
Data submissions must be made using the State of NH Online Forms website
(https://onlineforms.nh.govQ. The Supplemental Data Request nForm can be found using this
link: https://onlineforms.nh.gov/?FormTag=frm-nhid-sdr.
Please note that the NH Online Forms website is unable to accept an Excel file with macros.
After you have completed the template, run the data validation and data reconciliation checks
and create the summary tables; please save the file as a non-macro enabled Excel file. Do this
in Excel by selecting "File", "Save As", and then use the dropdown menu to select "Excel
Workbook (*.xlsx).
The submission will be reviewed for completeness. Insurance carriers and TP As are required to
submit a filing which satisfies NHID standards for completeness and compliance by June 30.
Incomplete or non-compliant filings on June 30 will be subject to an administrative fine.
Fines
Fines will be assessed for failure to meet the submission deadline of June 30, for filing an
incomplete template, or for filing data that is inaccurate. Fines shall accrue on a daily basis.
There will be no grace period to achieve compliance. All reports are expected to be complete
and accurate submissions on the date of submission.
Tabulation Methods and Issues
Data shall be tabulated in three separate, mutually exclusive data collections: (1) the Main Data
collection, (2) the Limited Data collection, and (3) the Stop Loss Data collection. The Main Data
collection shall include data for all members who receive services under a policy (whether
individual or employer-sponsored) with a New Hampshire situs or through a contract with a New
Hampshire situs issued by a third party administrator. The Limited Data collection shall include
data for all New Hampshire residents, or members who have a work location in New Hampshire
(e.g. an out-of-state employer with a branch location in New Hampshire), with a policy that does
not have a New Hampshire situs. The carrier/TPA shall submit data for all members who are
employed at the New Hampshire branch location. The following chart provides a visual
description of the Main and Limited data collections:
8
Breakdown of Data Collection Population
M: Main data collection, L : Limited do ta collection
Member
Residence
Member
work Location•
Policy/Contract Situs
NH
Non-NH
NH
NH
I
M
L
NH
Non~NH
M
L
Non-NH
NH
M
L
Non-NH
Non-NH
I
M
--
• only COfl!i~r«J tor ~mplO/tN{JOf'ISOttll cov,~
The Stop Loss Data collection shall include data for all policies with Coverage Type Code =
"STL" (as defined in Attachment B-1). No policies with Coverage Type Code
= "STL" should be included in either the Main Data collection or the Limited Data collection.
The tabulation of information and issues below should be considered separately within each of
the three data collections.
Tabulation of Information
A reporting record shall include unique combinations of the coverage category, market type
(market category code), and benefit structure. Any difference in benefit structure due to
covered benefits specified as "exception variables," member liabilities (i.e. copay, deductible,
and coinsurance) or any other variable listed in this report, means that data needs to be reported
on a separate row.
Carriers shall submit one record for each type of coverage and benefit structure. For example,
if a carrier provides multiple employers with only two types of HMO policies, one an HMO
with a low deductible and another with a high deductible, the carrier shall submit two separate
records with the corresponding member months, premium, and claims.
Carriers issuing stop loss coverage to the employer groups for which they also administer the
self-insured health benefits shall submit one record for each type of coverage: the self-insured
health coverage and the stop loss coverage.
The information described below shall be submitted in the format prescribed in Attachment A.
Please note that there are a series of Exception Variables (EV) listed in Attachment A and in the
report template. When the insurance policy covers the indicated service, leave the field blank in
the report submission. When the insurance policy does not offer coverage for the indicated
service at all, submit "NC" in the appropriate field for that policy. If the insurance policy
generally covers the indicated service but the coverage does not meet the coverage definition
provided in Attachment A, submit "DM" in the appropriate field for that policy. Do NOT
substitute field requirements with "Y", "N", "NA", or anything not specified in the reporting
requirement. Do not change column headings. Do not insert or delete columns.
9
Tabulation Issues - Multiple Carriers
The Department recognizes that there may be instances where more than one carrier is
involved in administrating policies for a common employer in conjunction with that
employer's health insurance benefits. For self-insured plans, both the carrier administering the
plan and the carrier writing the stop loss coverage shall submit a supplemental report.
The following guidelines clarify, in those instances when more than one carrier is involved
with providing coverage to a single employer, which carrier has the responsibility to include
the coverage in its tabulation.
•
Data on reinsurance policies, insurance policies written by a carrier to another
carrier, shall not be tabulated and shall not be included with the required
supplemental report.
•
Stop-loss insurance, or group excess loss insurance issued to an employer or other
group, shall be reported by the writing carrier. It is considered direct insurance and
carriers writing such coverage shall be responsible for submitting information on
their written policies.
•
In the event that the entity administering coverage is different than the carrier writing
coverage, the writing carrier shall be responsible for submitting the required
information. Carriers writing risks shall be responsible for submitting information on
policies covering the underwritten risks. Entities responsible only for policy
administration shall not be responsible for tabulating data on policies that they
administer when such coverage is written on another carrier's paper and reported by
that carrier.
•
TP As or carriers administering an employer-sponsored health insurance benefit
plan shall submit records for all self-insured plans that they administer. TP As
must file a supplemental report for this type of activity regardless of whether a
stop-loss writer is filing information for the same employer.
•
Similarly, a stop loss carrier must file the information prescribed in this section
regardless of whether a TPA, or some other carrier, is filing a supplemental
report for the same employer.
Tabulation Issues - Geographic Location
The policy geographic location code shall be based on the specific business location of the
policyholders; where the policy is sitused (refer to "Situs" in the Definitions section of this
bulletin). For NH residents working at a branch location in NH, the policyholder location may
be out of state. All codes are specified in Attachment D.
All policies included in the Main Data collection should be NH sitused policies with a
geographic location of the policy holder. All policies included in the Limited Data collection
should be non-NH sitused policies with a geographic location code of 'Y'. Policies included
in the Stop Loss Data collection should use the appropriate code from Attachment D, whether
'Y' or another value.
IO
Carriers shall use a county code of' Z' to identify NH locations for which there is no county
code mapped to the NH zip code that is stored by the carrier. Whenever a code of' Z' is used,
the carrier shall include a note record specifying the NH zip code for which there is no county
code match.
Acceptable Methods for Estimating Data
fu certain instances, a carrier may not have the information it needs to tabulate data as
prescribed. For example, a carrier writing stop loss, or group excess insurance may not know
who the employer's employees are. Carriers and TPAs shall provide data at the most detailed
level at which the carrier or TPA keeps the data. For this example, the number of certificate
holders, e.g. employees, and the number of covered lives shall be estimated based on data used
by the carrier to price the business.
Where carriers use estimation methods, the carrier shall include, as part of its data submission,
an explanation in the notes section to explain why estimation methods were necessary and the
methods used to generate the estimates. The Department reserves the right to approve or
disapprove the method of estimation.
Acceptable Methods for Submission
All data submissions will be processed electronically. Carriers are required to submit the
supplemental data in an MS Excel Workbook format provided by the Department. The
Department created a template that is distributed to carriers that were required to provide data in
the previous year.
The template is the Excel file called Supplemental Data Request Template20xx.xlsm. This file
shall be used as a template for creating new spreadsheets. After downloading this file to a local
directory in Windows Explorer, right click on the downloaded file, and select New. This will
create a new workbook file based on the downloaded template. Do not change the worksheet
names or column headings in the template.
All carriers shall create a workbook using the Supplemental Data Request Excel Template.
Carriers shall name the workbook SIR<cocode> SDR 20:xx.xlsx
-
-
based on the carrier NAIC
code. The naming is important for processing purposes.
After data has been input into the worksheet, please use the button on the "Transmittal" sheet
to check that data fields are formatted correctly and only valid codes have been reported. Any
possibly invalid entries will be highlighted and should be reviewed and, if necessary, corrected
prior to submission. Note that macros must be enabled in order to run the validity check.
Data submissions must be made using the State of NH Online Forms website
(https://onlineforms.nh.gov/). The Supplemental Data Request nForm can be found using this
link: https://onlineforms.nh.gov/?FormTag=frm-nhid-sdr.
Please note that the NH Online Forms website is unable to accept an Excel file with macros.
After you have completed the template, run the data validation and data reconciliation checks
11
and create the summary tables; please save the file as a non-macro enabled Excel file. Do this
in Excel by selecting "File", "Save As", and then use the dropdown menu to select "Excel
Workbook (*.xlsx).
Data Reconciliation
To assist carriers in ensuring consistent reporting practices and that the data submission is
reasonable in relation to the reporting requirements, we have included additional data
reconciliation checks. These data checks compare the data in this submission to data the carrier
reported to the NH Comprehensive Health Information System (CHIS). Instructions and a
template for the data reconciliations can be found on the "Data Reconciliation" sheet in the
Supplemental Report Excel Template. These reconciliations should be performed prior to the
template being submitted to the Department. While the data submission is not required to
reconcile exactly to the other data sources, explanations of differences must be provided. Please
note that comparisons are made only on the data that overlap between the reports and should
reconcile.
If the CHIS data are not available for use in the comparison, the reason must be provided on the
"Notes" sheet in the Supplemental Data Request Excel Template.
Confidentiality
Each company or person from whom information is sought shall provide the required
information to the Commissioner. The Supplemental Data Request data filed by each health
carrier shall be maintained as a confidential document, but shall not be deemed to limit the
Commissioner's authority to use or disclose such information which the Commissioner in
the exercise of his/her duty may deem appropriate, pursuant to RSA 400-A:25.
Any questions on the Supplemental Data Request should be directed to Don Gorman at Gorman
Actuarial, Inc. at Actuary@GormanActuarial.com.
12
Attachment A Supplemental Data Request Specifications
Transmittal
There shall be one worksheet in the workbook named 'Transmittal." The worksheet shall contain
the following information.
Field Name
Description
Company Code
Please be sure to enter as text, e.g. for 01234, type
'01234 in the cell.
Company Name
Reporting Year
Four-digit years for the calendar year from which
this report is based.
Fiscal Year End Date
Use MMDD format.
will be 1231.
For most companies, this
Contact Person First Name
Contact Person Last Name
Contact Person Mailing Address Line
One
Contact Person Mailing Address
Line Two
Contact Person Mailing City
Contact Person Mailing 2-Letter State
Abbreviation
Contact Person Mailing Zip Code
Enter as text (see Company Code above).
Contact Person Direct Voice Phone
Number
If there is an extension, use the character 'x' to
separate the phone number from the extension.
Contact Person e-mail address
Identify all subcontractors and the
services that are subcontracted.
List all subcontractors and the services that are
subcontracted ( e.g. prescription drugs, mental
health/substance abuse).
Are all claims for subcontracted services
included in the submitted data?
Input "Y" for yes, "N" for no. If "N" please
explain what has been included and/or
excluded.
13
Main Data Collection
The main data collection worksheet shall be called "'Main Data" and shall include data for
policies with a NH situs with the exception of those with coverage type "STL". The first row of
the Main Data worksheet shall contain the labels listed in the Variable column below.
Subsequent rows shall contain the data prescribed. The data must be provided at the most
specific level in order to accurately recognize the health plan product characteristics and benefit
differences, including those based on member/patient liabilities.
All numeric data, such as member months and dollar totals must be reported on an accrual basis
in a number format. Dates of coverage, premium collected, claims paid, and all determinations
are based on a calendar year. Since determinations are made based on the calendar year, the data
will include any changes in enrolled membership, premiums, and claims, such as when a group
renews mid-year. Data specific to individual groups will be summarized and combined with all
other groups with similar benefit characteristics (as determined by the variables listed below).
Variable
Description
Coverage Type
Three-digit character code for coverage type: UND, ASW, ASO,
STN, or MCD as fully described in Attachment B-1.
Plan Type
Three-digit character code for plan type: HMO, POS, PPO, EPO, or
FFS as fully described in Attachment B-2.
Market Category Code
Three or four-digit character code for identifying employer size,
student insurance policies, or blanket insurance. Employer size is
based on the number of eligible employees2 in the group. For
qualified association trusts, assign the group size applicable to each
subgroup within the association. Codes are in Attachment C.
Policyholder Geographic
Location
One-digit county codes assigned based on the location of the
policyholder (not member). Codes are in Attachment D.
State, Federal or
Municipal Account
Are the data for the state of NH, federal or municipal account?
Input "S" for State, "F" for federal, "M" for municipal or "O" for
all other accounts.
Note that this field does not refer to whether the policy is sold on
the Exchange. It identifies employer groups that are government
entities.
Qualified Association
Trust
Are the data for a Qualified Association Trust?
"N" for no.
Input "Y" for yes,
2 "Eligible Employee" shall have the same meaning as defined in INS 4100, specifically INS 4103 .03 (g) for the
Small Group market, INS 4104.03 (i) for the Large Group market, and 4105.03 (h) for the Stop Loss market.
14
Professional Employer
Organization
Are the data for a Professional Employer Organization? Input "Y"
for yes, "N" for no.
HealthFirst
This field is obsolete, and may be left blank.
Calendar Year
Calendar year the data are reported for.
Number of Policyholder
Months
Total number of covered months for the policyholder (usually
employer for group policies, or individual for non-group policies).
One policyholder covered for one full year would be equal to 12.
Policy months may not be additive. If an account has two rows
because of the purchase of multiple products, the policy months will
be the same.
Number of Subscriber
Months
Total number of covered months for the subscriber ( employee or
individual). One employee covered for one full year would be equal
to 12.
Number of Member
Months
Includes both the total number of covered life months for the
subscriber and for any covered spouses and dependents.
Total Premium
"Premium" shall be calculated as "earned" premium, or the total
amount of premium from policyholders to provide insurance
coverage during the reporting year. Earned premium = premiums
collected + change in due and uncollected - change in unearned and
advance premium. This should include advance payments of the
premium tax credit. If premium is collected prior to January 1, to
provide insurance coverage during the reported calendar year, than
it must be included in this column. The Commissioner may approve
the use of a reasonable proxy upon the carrier's provision of
documentation demonstrating that the use of the same does not
materially distort the carrier's data submission.
For self-insured business, TPAs and carriers shall calculate earned
premium by aggregating the total funds collected from contracted
accounts to provide for all claims and expenses associat¥d with the
administration of the employer's benefit plan. These funds include
provisions for claims (net of stop-loss recoveries), administration,
premium for stop-loss coverage (for policies with Coverage Type of
"ASW"), profit margins, commissions, wellness programs, network
fees, and disease management programs.
Total Claims
Total claims incurred on behalf of the covered members in the
reporting class during the calendar year for which the
supplemental report is being made. Note that total claims are
15
Claims Incurred and
Paid
reported on an accrual basis for calendar year. All claims with a
date of service during the reporting year are to be included as
claims paid in this field. If necessary, actuarial completion
factors should be used to estimate incurred claims and should be
based on when the carrier extracts the data for the Supplemental
Report.
Incurred claims shall include:
•
claims incurred during the reporting period and paid prior
to the report date
•
claims incurred and reported during the reporting
period but unpaid prior to the report date
•
claims incurred but not reported during the reporting
period.
•
other payments such as capitation and incentive
payments, and net of credits, such as prescription drug
rebates, etc.
Do not include member responsibility in this field.
For insured business, incurred claims should be consistent with
what is reported in Part 1, Line 5 of the NAIC Supplemental Health
Care Exhibit, allowing for variances due to any restatement of
unpaid claims with additional paid claim runout.
For self-insured business, TP As and carriers shall calculate incurred
claims on a similar basis with the following additions:
•
incurred claims shall be net of any stop-loss
recoveries.
•
include amounts paid for stop-loss coverage.
The amount reported in this field should be the sum of the
following three fields: (1) Claims Incurred and Paid, (2)
Claims Incurred and Unpaid, and (3) Other Payments and
Credits.
l:J;lcludes claims incurred during the reporting period and paid prior
to when the carrier extracts the data for the Supplemental Report.
Do not include member responsibility in this field.
16
Claims Incurred and
Unpaid
Claims incurred during the reporting period and unpaid (payable) as
of the data extract including both (1) claims reported but still
payable (sometimes referred to as in course of settlement) and (2)
claims not reported and payable (sometimes referred to as incurred
but not reported).
Do not include member responsibility in this field.
Other Payments and
Credits
Includes other payments made such as capitation, incentive
payments, etc. and is net of credits received such as prescription
drug rebates which are included in medical expense as reported for
the carrier's Statement of Revenue and Expenses, or its equivalent,
which is a required component of the annual statement filing. For
policies with Coverage Type= "ASW", TPAs and carriers should
report any stop-loss recoveries and stop-loss premiums in this field.
Do not include member responsibility in this field.
Member Responsibility
For the claims included in the "Total Claims" field, report the total
known amount (that is, those associated with incurred and paid
claims) of deductibles, coinsurance amounts, and copayments or
any balance-billing for which the member is responsible. This field
should not include amounts for denied claims or claims covered by
another payer due to coordination of benefits.
Plan ID
This is the 17 character HIOS Plan ID (Standard component plus
Variant). This field may not be available for all market
segments; input ''NI A" where not available.
Plan Code
This identifier should be the same Plan Code or Name used in
the NH Individual and Small Group rate filings, which is
described in the Requirements for Accident and Health
Insurance Rate Submissions User Manual (found on the NHID
website3). This field may not be available for all market
segments; input "NIA" where not available.
3 h1rp://www.nh.gov/insurance/legal/documents/user w ide-v5.pdf or updated version, if available
17
Policy Form Number
Policy Form Number associated with this health plan coverage.
Exchange and Network
Indicator
Describe the network4 and whether the coverage is On Exchange or
Off Exchange. Please choose one of the following four choices:
On Exchange, Standard Network (ES)
Off Exchange, Standard Network (NS)
On Exchange, Limited Network (EL)
Off Exchange, Limited Network (NL)
Grandfathered or
Transitional Policy
Indicator
Is this health coverage plan Grandfathered per the ACA definition
or considered a Grandmother/Transitional policy? Input "G" for
Grandfathered plans, "T" for Transitional/Grandmothered
policies, or "N" for plans that are neither Grandfathered nor
Transitional.
HDHP
Does the policy meet the IRS definition of a HDHP? Input "Y" for
yes, ''N" for no.
Is this health coverage
plan open?
Is this health coverage plan open or closed? Input "Y" if open, ''N"
for closed.
In closed blocks, only existing contracts are allowed to renew.
Benefit options in closed blocks are not marketed or being sold to
new customers. If at any time in the reporting year a block
becomes closed, it should be considered closed for the purpose of
this report.
Is this a new health
coverage plan?
Was this health coverage plan new in the calendar year for which
the supplemental report is being made? Input "Y" for yes, "N" for
no.
A new health coverage plan is a benefit design that is being
offered/marketed for the first time in this reporting year.
Does Deductible apply
to all Medical Services?
Input "Y" for yes, "N" for no, or "N/ A" if there is no medical
deductible.
Since many plans will be covering preventative office visits at
100%, consider only other types of medical services when
responding to this question.
4 Standard network refers to a broad, full or non-limited provider network, which should include all 26 acute care
hospitals in New Hampshire. Limited Network, or select network, refers to a provider network where less than 26 of
the acute care hospitals in New Hampshire are considered in-network.
18
Is there an integrated
Medical and Pharmacy
Deductible?
Input "Y" for yes, ''N" for no, or "NI A" if there is no medical
deductible.
Are Preventive Services
Covered 100%?
Input "Y" for yes, "N" for no.
Preventive Services refers to the preventive services as defined and
required in the Affordable Care Act as of the reporting year.
Does this health
coverage plan provide
coverage for MHISA?
Input "Y" for yes, ''N" for no.
Does this health
coverage plan have a
Tiered Network
component?
Input "Y" for yes, "N" for no.
A Tiered Network is defined as varying levels of cost sharing based
on different networks of providers set up to cover a broad range of
services that are considered in-network. An arrangement that is
specific to a limited number of services, such as gastric bypass or
transplants, would not be considered a Tiered Network for the
purposes of this report.
PCP Office Visit Copay
Dollar amount of the PCP office visit copay for services within
network. If this service has no cost sharing, input O (zero). If this
service does not have a copay but is subject to the deductible and/or
coinsurance, input "DIC". For Tiered Network HMO products,
provide cost sharing for most utilized tier.
Specialist Office Visit
Copay
Dollar amount of the Specialist office visit copay for services within
network. If this service has no cost sharing, input 0
(zero). If this service does not have a copay but is subject to the
deductible and/or coinsurance, input "DIC". For Tiered Network
HMO products, provide cost sharing for most utilized tier.
ED Copay
Dollar amount of the Emergency Department copay for services
within network. If this service has no cost sharing, input O (zero). If
this service does not have a copay but is subject to the deductible
and/or coinsurance, input "DIC". For Tiered Network HMO
products, provide cost sharing for most utilized tier.
19
Outpatient Surgery
Copay
Dollar amount of the Outpatient Surgery copay for services within
network. If this service has no cost sharing, input O (zero). If this
service does not have a copay but is subject to the deductible and/or
coinsurance, input "DIC". For Tiered Network HMO products,
provide cost sharing for most utilized tier.
Inpatient Copay
Dollar amount of the Inpatient copay for services within network. If
this service has no cost sharing, input O (zero). If this service does
not have a copay but is subject to the deductible and/or coinsurance,
input "DIC". For Tiered Network HMO products, provide cost
sharing for most utilized tier.
In-Network Single
Deductible
Dollar amount of the in-network, single tier type policy deductible.
For Tiered Network HMO products, provide cost sharing for most
utilized tier. For FFS products, provide the overall cost sharing
information.
This is the Medical deductible for policies with a Medical only
deductible, and the integrated Medical and Pharmacy deductible for
policies that have an integrated Medical and Pharmacy deductible
as reported in the data field "Is there an integrated Medical and
Pharmacy Deductible?"
In-Network Coinsurance
Percentage figure of total plan and patient liability that the member
is responsible for paying. For example, if the insurer pays 80% and
the member pays 20%, a value of 0.20 should be reported. If the
plan has more than one co-insurance, use the highest level for
services within network. For Tiered Network HMO products,
provide cost sharing for most utilized tier. For FFS products,
provide the overall cost sharing information. This value shall be in
numeric decimal format with a value between O and 1.
In-Network Single OOP
Max
Dollar amount of the maximum out of pocket expenses for services
within network for a single tier type policy. The out of pocket
maximum should include any deductibles, where applicable. For
Tiered Network HMO products, provide cost sharing for most
utilized tier. For FFS products, provide the overall cost sharing
information. If there is no maximum, enter: 9,999,999.
20
Retail Phannacy Single
Deductible Generic
Dollar amount of the single tier type policy deductible for generic
prescriptions dispensed at an in-network retail phannacy. If there is
no deductible, input O (zero). For polices with an integrated
Medical and Phannacy deductible, input O (zero) in this field,
report the integrated deductible in the "In-Network Single
Deductible" field, and input "Y" in the "Is there an integrated
Medical and Phannacy Deductible?" field.
Retail Phannacy Single
Deductible Brand
Formulary
Dollar amount of the single tier type policy deductible for brand
prescriptions on the formulary dispensed at an in- network retail
phannacy. lfthere is no deductible, input O (zero). For polices
with an integrated Medical and Phannacy deductible, input 0
(zero) in this field, report the integrated deductible in the "In-
Network Single Deductible" field, and input "Y" in the "Is there
an integrated Medical and Phannacy Deductible?" field.
Retail Phannacy Single
Deductible Brand Non-
Formulary
Dollar amount of the single tier type policy deductible for brand
prescriptions not on the formulary dispensed at an in- network retail
phannacy. If there is no deductible, input O (zero). For polices with
an integrated Medical and Phannacy deductible, input O (zero) in
this field, report the integrated deductible in the "In-Network
Single Deductible" field, and input "Y" in the "Is there an
integrated Medical and Phannacy Deductible?" field.
Retail Pharmacy Single
Deductible Specialty
Dollar amount of the single tier type policy deductible for specialty
prescriptions dispensed at an in-network retail phannacy. If there is
no deductible, input O (zero). For polices with an integrated
Medical and Pharmacy deductible, input O (zero) in this field,
report the integrated deductible in the "In-Network Single
Deductible" field, and input "Y" in the "Is there an integrated
Medical and Pharmacy Deductible?" field.
Retail Pharmacy
Copay/Coinsurance
Generic
Dollar amount of the copay for 30-day supply generic prescriptions
dispensed at an in-network retail pharmacy. If this service does not
have a copay, input O (zero). For cases where there is pharmacy
coinsurance cost sharing instead of copays, please enter the
coinsurance percentage for the member's responsibility as a decimal
with a value between O and 1.
21
Retail Pharmacy
Copay/Coinsurance
Brand F ormulary
Dollar amount of the copay for 30-day supply brand prescriptions
on the formulary dispensed at an in-network retail pharmacy. If this
service does not have a copay, input 0 (zero). For cases where
there is pharmacy coinsurance cost sharing instead of copays,
please enter the coinsurance percentage for the member's
responsibility as a decimal with a value between 0 and 1.
Retail Pharmacy
Copay/Coinsurance
Brand Non-Formulary
Dollar amount of the copay for 30-day supply brand prescriptions
not on the formulary dispensed at an in- network retail pharmacy. If
this service does not have a copay, input 0 (zero). For cases where
there is pharmacy coinsurance cost sharing instead of copays,
please enter the coinsurance percentage for the member's
responsibility as a decimal with a value between 0 and 1.
Retail Pharmacy
Copay/Coinsurance
Specialty
Dollar amount of the copay for 30-day supply specialty prescriptions
dispensed at an in-network retail pharmacy. If this service does not
have a copay, input 0 (zero). For cases where there is pharmacy
coinsurance cost sharing instead of copays, please enter the
coinsurance percentage for the member's responsibility as a
decimal with a value between 0 and 1.
Actuarial Value
"Actuarial Value" -For the purposes of this report, the Actuarial
Value will be the Minimum Value measure as outlined in Section
1302 (d)(2)(C) of the Affordable Care Act. Beginning in 2014,
insurers and employers or unions with self-insured plans must report
information to the IRS for each individual covered under a health
insurance plan that provides minimum coverage. This information
will be used by the IRS to determine whether individuals who
purchase insurance on the exchanges will be eligible for a premium
tax credit. The minimum value is defined as the percentage of the
total allowed costs of benefits provided under a group health plan or
health insurance coverage. In accordance with the HHS regulations
there are several options for determining the Minimum Value:
• Determine Minimum Value figure using publicly available
Minimum Value Calculator excel model tool which can be
downloaded from the following website:
h!:!Q://www.cms.gov/cciio/resources/regulations- andguidance/index.html . The Department of Health and Human
Services has published guidance titled "Minimum Value
Calculator Methodology" which is also available on the
website. This guidance provides a detailed description of the
data underlying the MV Calculator and the calculator's
methodology
Determine Minimum Value figure through any safe harbor
established by HHS and IRS.
•
22
• If the plan design is incompatible with the Minimum Value
Calculator or Safe Harbor Plan, the Minimum Value figure
may be determined through an actuarial certification from a
member of the American Academy of Actuaries.
For each set ofreported coverage options, e.g. each benefit plan,
the carrier shall include on the Supplemental Report the Minimum
Value figure calculated in accordance to one of the three options
mentioned above. The Minimum Value Calculator can be used for
a wide variety of health plan designs; however, it is possible some
benefit plan designs may not fit into the calculator. In circumstances
where this is the case, and the minimum value from the safe harbor
or actuarial certification is not readily available, it is recommended
that a reasonable estimate based on comparison to similar plan
designs be reported in the Supplemental Report. If a method other
than the Minimum Value Calculator is used, the alternate method
that was used must be disclosed and described in the notes section
of the report submittal form.
Please do not provide figures based on the Actuarial Value
Calculator. The Actuarial Value Calculator uses different
population base and different continuance tables than the Minimum
Value Calculator. The results from the two calculators will be
slightly different. For the purposes of this report and stable
comparison across coverage segments and carriers, the Minimum
Value Calculator must be used.
This minimum value as described above is the "actuarial value."
The remaining variables are Exception Variables (EV). Enter
"NC" if the policy does not cover this service. Enter "DM" if the
policy generally covers this service, but does not meet the exact
service description. Leave blank if this is a covered item.
Ambulance Service
EV
Audiology Screening for
N ewboms
EV - Includes: covered for one screening and one confirming
screening.
Blood and Blood
Products
EV - Includes: fees associated with the collection or donation of
blood or blood products, all cost recovery expenses for blood, blood
derivatives, components, biologics, and serums to include
autologous services and albumin.
23
Case Management
Program
EV - Includes: available for medically complex and costly services.
Chiropractic Services
EV
Durable Medical
Equipment (DME)
EV - Includes: nebulizers, peak flow meters, and diabetes glucose
monitoring equipment.
Emergency Room
EV
Family Planning
Services
EV - full range of services including: counseling services and
patient education; examination and treatment by medical
professionals; laboratory examinations and tests; and medically
approved methods, procedures, pharmaceutical supplies and devices
to prevent conception. This category does not include infertility
services; these services are covered under a separate benefit
category.
Habilitative Services
EV - Includes: coverage for children 0-19 years of age for treatment
of congenital and genetic birth defects.
Hearing Aids
EV - Includes: coverage and services as defined by NH State Law;
including hearing aid for each hearing-impaired ear every 60
months.
Home Health Care
EV - Includes: coverage as an alternative to otherwise covered
services in a hospital or other related institution.
Hospice
EV - Includes: coverage same as Medicare, including nursing care,
medical social services, physicians' services, counseling services,
short-term inpatient care, medical appliances and supplies, home
health aide services, physical therapy, occupational therapy,
speech-language pathology, and other items and services.
Hospitalization
EV - Includes: unlimited (includes detoxification)
24
Infertility Services
EV - Includes: coverage for services obtained after diagnosis of
infertility including all non-experimental infertility procedures
including, but not limited to, artificial insemination and intrauterine
insemination, in vitro fertilization and embryo transfer, gamete
intrafallopian transfer, sperm and/or egg procurement and
processing, intracytoplasmic sperm injection, zygote intrafallopian
transfer, assisted hatching, cryopreservation of eggs, and infertilityrelated drugs.
Does not include any experimental infertility procedure, surrogacy, or
reversal of voluntary sterilization.
Medical Food
EV - Includes: for persons with metabolic disorders when ordered
by a health care practitioner qualified to provide diagnosis or
treatment in the field of metabolic disorders
Mental Health and
Substance Abuse
EV - Includes: when delivered through a managed care system for
60 inpatient days with partial hospitalization traded on a 2 to 1 basis
and unlimited outpatient visits
Nutritional Services
EV - Includes: six visits per year for cardiovascular disease,
diabetes, malnutrition, cancer, cerebral vascular disease, or kidney
disease.
Outpatient Hospital
Services & Surgery
EV
Outpatient Laboratory &
Diagnostic Services
EV
Outpatient Short- Term
Rehabilitative Services
EV - Includes: physical therapy, speech therapy, and occupational
therapy
Pediatric Dental Services
EV - Includes: coverage for diagnostic, preventative services
minor and major restorative services, implants and orthodontia.
Minor restorative services include but aren't limited to filings,
crowns and oral surgery for impacted teeth. Major restorative
services include inlays, root canals and fixed prosthesis.
Leave blank when covered under the medical policy. Input "NC" if
the medical policy does not cover these services.
25
Pediatric Vision
Services
EV - Includes: but is not limited to, diagnostic services, frames &
prescription lenses or contract lenses.
Leave blank when covered under the medical policy. Input "NC" if
the medical policy does not cover these services.
Pregnancy and Maternity
EV
Prescription Drugs (Rx)
EV - Includes: prescriptions available on an open formulary with
coverage of at least the generic drug equivalent amount when the
brand name drug is prescribed.
Preventive Services
EV - Includes: preventive services as defined and required in the
Affordable Care Act as of the reporting year.
Skilled Nursing Facility
EV - Includes: 100 days as an alternative to otherwise covered care
in a hospital or other related institution.
Transplants
EV - Includes: for bone marrow, cornea, kidney, liver, lung, heart,
pancreas, and pancreas/kidney transplants.
Well Child&
Immunization Benefits
EV - Includes: for children 0 - 13 years of age.
Limited Data Collection
The limited data collection worksheet shall be called "'Limited Data" and shall include data for
policies with a non-NH situs with the exception of those with coverage type "STL". The first
row of the Limited Data worksheet shall contain the labels listed in the Variable column below.
Subsequent rows shall contain the data prescribed. The data must be provided at the most
specific level in order to accurately recognize the health plan product characteristics.
All numeric data, such as member months and dollar totals must be reported on an accrual basis
in a number format. Dates of coverage, claims paid, and all determinations are based on a
calendar year. Since determinations are made based on the calendar year, the data will include
any changes in enrolled membership, premiums, and claims, such as when a group renews midyear. Data specific to individual groups will be summarized and combined with all other groups
with similar characteristics (as determined by the variables listed below).
Variable
Description
Coverage Type
Three-digit character code for coverage type: UND, ASW, ASO,
STN, or MCD as fully described in Attachment B-1.
26
Plan Type
Three-digit character code for plan type: HMO, POS, PPO, EPO, or
FFS as fully described in Attachment B-2.
Market Category Code
Three or four-digit character code for identifying employer size,
student insurance policies, or blanket insurance. Employer size is
based on the number of eligible employees5 in the group. For qualified
association trusts, assign the group size applicable to each subgroup
within the association. Codes are in Attachment C.
Policyholder
Geographic Location
One-digit county codes assigned based on the location of the
policyholder (not member). Codes are in Attachment D. Only
policies with a Policyholder Geographic Location code of"Y" (a
non-NH sitused policy) should be reported on the "Limited Data" tab.
Qualified Association
Trust
Are the data for a Qualified Association Trust? Input "Y" for yes, ''N"
for no.
Professional Employer
Organization
Are the data for a Professional Employer Organization? Input "Y" for
yes, ''N" for no.
HealthFirst
This field is obsolete, and may be left blank.
State, Federal or
Municipal Account
Are the data for the state of NH, federal or municipal account? Input
"S" for State, "F" for federal, "M" for municipal or "O" for all other
accounts.
Note that this field does not refer to whether the policy is sold on the
Exchange. It identifies employer groups that are government entities.
Number of
Policyholder Months
Total number of covered months for the policyholder (usually
employer for group policies, or individual for non-group policies).
One policyholder covered for one full year would be equal to 12.
Policy months may not be additive. If an account has two rows
because of the purchase of multiple products, the policy months will be
the same.
Number of Subscriber
Months
Total number of covered months for the subscriber ( employee or
individual). One employee covered for one full year would be equal to
12.
Number of Member
Months
Includes both the total number of covered life months for the
subscriber and for any covered spouses and dependents.
5 "Eligible Employee" shall have the same meaning as defined in INS 4100, specifically INS 4103 .03 (g) for the
Small Group market, INS 4104.03 (i) for the Large Group market, and 4105.03 (h) for the Stop Loss market.
27
Calendar Year
Calendar year the data are reported for.
Total Claims
Total claims incurred on behalf of the covered members in the
reporting class during the calendar year for which the supplemental
report is being made. Note that total claims are reported on an accrual
basis for calendar year. All claims with a date of service during the
reporting year are to be included as claims paid in this field. If
necessary, actuarial completion factors should be used to estimate
incurred claims and should be based on when the carrier extracts the
data for the Supplemental Report.
Incurred claims shall include:
claims incurred during the reporting period and paid prior to
the report date
claims incurred and reported during the reporting period
but unpaid prior to the report date
claims incurred but not reported during the reporting period.
other payments such as capitation and incentive payments,
and net of credits, such as prescription drug rebates, etc.
Do not include member responsibility in this field.
For self-insured business, TPAs and carriers shall calculate incurred
claims on a similar basis with the following additions:
incurred claim§l shall be net of any stop-loss
recovenes.
include amounts paid for stop-loss coverage
The amount reported in this field should be the sum of the following
three fields: (1) Claims Incurred and Paid, (2) Claims Incurred and
Unpaid, and (3) Other Payments and Credits.
Claims Incurred and
Paid
Includes claims incurred during the reporting period and paid prior to
when the carrier extracts the data for the Supplemental Report.
Do not include member responsibility in this field.
Claims Incurred and
Unpaid
•
•
•
•
•
•
Claims incurred during the reporting period and unpaid (payable) as of
the data extract including both (1) claims reported but still payable
(sometimes referred to as in course of settlement) and (2) claims not
reported and payable (sometimes referred to as incurred but not
reported).
Do not include member responsibility in this field.
28
Other Payments and
Credits
Includes other payments made such as capitation, incentive payments,
etc. and is net of credits received such as prescription drug rebates
which are included in medical expense as reported for the carrier's
Statement of Revenue and Expenses, or its equivalent, which is a
required component of the annual statement filing. For policies with
Coverage Type= "ASW", TPAs and carriers should report any stoploss recoveries and stop-loss premiums in this field.
Do not include member responsibility in this field.
Member Responsibility For the claims included in the ''Total Claims" field, report the total
known amount (that is, those associated with incurred and paid claims)
of deductibles, coinsurance amounts, and copayments or any balancebilling for which the member is responsible. This field should not
include amounts for denied claims or claims covered by another payer
due to coordination of benefits.
Stop Loss Data Collection
The stop loss data collection worksheet shall be called "Stop Loss Data" and shall include all
data related to "STL" coverage type (both NH and non-NH situs). The first row of the Stop Loss
Data worksheet shall contain the labels listed in the Variable column below. Subsequent rows
shall contain the data prescribed. The data must be provided at the most specific level in order
to accurately recognize the product characteristics.
All numeric data, such as member months and dollar totals must be reported on an accrual basis
in a number format. Dates of coverage, claims paid, and all determinations are based on a
calendar year. Since determinations are made based on the calendar year, the data will include
any changes in enrolled membership, premiums, and claims, such as when a group renews midyear. Data specific to individual groups will be summarized and combined with all other groups
with similar characteristics (as determined by the variables listed below).
Variable
Description
Coverage Type
Three-digit character code for coverage type as fully described in
Attachment B-1. All policies in the Stop Loss Data collection
should have coverage type = "STL".
Plan Type
Three-digit character code for plan type of the underlying health plan:
HMO, POS, PPO, EPO, or FFS as fully described in Attachment B-2.
If plan type of the underlying health plan is not available, input "NI A".
29
Market Category Code
Three or four-digit character code for identifying employer size, student
insurance policies, or blanket insurance. Employer size is based on the
number of eligible employees6 in the group. For qualified association
trusts, assign the group size applicable to each subgroup within the
association. Codes are in Attachment C.
Policyholder
Geographic Location
One-digit county codes assigned based on the location of the
policyholder (not member). Codes are in Attachment D.
Qualified Association
Trust
Are the data for a Qualified Association Trust? Input "Y" for yes, "N"
for no.
Professional Employer
Organization
Are the data for a Professional Employer Organization? Input "Y" for
yes, ''N" for no.
State, Federal or
Municipal Account
Are the data for the state of NH, federal or municipal account? Input
"S" for State, "F" for federal, "M" for municipal or "O" for all other
accounts.
Note that this field does not refer to whether the policy is sold on the
Exchange. It identifies employer groups that are government entities.
Number of
Policyholder Months
Total number of covered months for the policyholder (usually
employer for group policies, or individual for non-group policies).
One policyholder covered for one full year would be equal to 12.
Policy months may not be additive. If an account has two rows
because of the purchase of multiple products, the policy months will be
the same.
Number of Subscriber
Months
Total number of covered months for the subscriber ( employee or
individual). One employee covered for one full year would be equal to
12.
Number of Member
Months
Includes both the total number of covered life months for the
subscriber and for any covered spouses and dependents.
Calendar Year
Calendar year the data are reported for.
6 "Eligible Employee" shall have the same meaning as defined in INS 4100, specifically INS 4103.03 (g) for the
Small Group market, INS 4104.03 (i) for the Large Group market, and 4105.03 (h) for the Stop Loss market.
30
Specific Premium
Specific Claims
Specific Attachment
Point
Specific%
Reimbursable
Specific
Reimbursement
Maximum
Premium for specific stop loss coverage provided in the reported
calendar year.
"Premium" shall be calculated as "earned" premium, or the total
amount of premium from policyholders to provide insurance coverage
during the reporting year. Earned premium = premiums collected +
change in due and uncollected - change in unearned and advance
premium. This should include advance payments of the premium tax
credit. If premium is collected prior to January 1, to provide insurance
coverage during the reported calendar year, then it must be included in
this column. The Commissioner may approve the use of a reasonable
proxy upon the carrier's provision of documentation demonstrating
that the use of the same does not materially distort the carrier's data
submission.
Total specific stop loss claims incurred during the calendar year for
which the supplemental report is being made. Note that claims are
reported on an accrual basis for calendar year. If necessary, actuarial
completion factors should be used to estimate incurred claims and
should be based on when the carrier extracts the data for the
Supplemental Report.
Incurred claims shall include:
•
claims incurred during the reporting period and paid prior to
the report date
•
claims incurred and reported during the reporting period
but unpaid prior to the report date
•
claims incurred but not reported during the reporting period.
Dollar amount of claim threshold level for an individual at which
specific stop loss coverage begins.
Portion of the claims above the attachment point to be reimbursed by
the specific stop loss coverage. This value shall be in numeric decimal
format with a value between 0 and 1. For example, if 80% of claims
over the attachment point are covered by stop loss insurance, enter
0.80.
Dollar amount of the maximum amount reimbursable for a specific stop
loss claim. If there is no maximum, enter: 9,999,999.
31
Aggregate Premium
Aggregate Claims
Aggregate
Attachment Point
Aggregate%
Reimbursable
Aggregate
Reimbursement
Maximum
Premium for aggregate stop loss coverage provided in the reported
calendar year.
"Premium" shall be calculated as "earned" premium, or the total
amount of premium from policyholders to provide insurance coverage
during the reporting year. Earned premium = premiums collected+
change in due and uncollected - change in unearned and advance
premium. This should include advance payments of the premium tax
credit. If premium is collected prior to January 1, to provide insurance
coverage during the reported calendar year, then it must be included in
this column. The Commissioner may approve the use of a reasonable
proxy upon the carrier's provision of documentation demonstrating
that the use of the same does not materially distort the carrier's data
submission.
Total aggregate stop loss claims incurred during the calendar year for
which the supplemental report is being made. Note that claims are
reported on an accrual basis for calendar year. If necessary, actuarial
completion factors should be used to estimate incurred claims and
should be based on when the carrier extracts the data for the
Supplemental Report.
Incurred claims shall include:
•
claims incurred during the reporting period and paid prior to
the report date
•
claims incurred and reported during the reporting period
but unpaid prior to the report date
•
claims incurred but not reported during the reporting period.
Multiple of expected claims at which aggregate stop loss coverage
begins. This value shall be in numeric decimal format with a value
greater than 1. For example, if the attachment point is 110% of
expected claims, input 1.10.
Portion of the claims above the attachment point to be reimbursed
by the aggregate stop loss coverage. This value shall be in numeric
decimal format with a value between 0 and 1. For example, if 80%
of claims over the attachment point are covered by stop loss
insurance, enter 0.80.
Dollar amount of the maximum amount reimbursable under aggregate
coverage. If there is no maximum, enter: 9,999,999.
32
Medical
Do Medical claims apply toward the stop loss limit? Input "Y" if yes,
"N" ifno.
Pharmacy
Do Pharmacy claims apply toward the stop loss limit? Input "Y" if yes,
''N" if no.
Dental
Do Dental claims apply toward the stop loss limit? Input "Y'' if yes,
"N" ifno.
Vision
Do Vision claims apply toward the stop loss limit? Input "Y" if yes,
''N" ifno.
Disability
Do Disability claims apply toward the stop loss limit? Input "Y" if
yes, "N" if no.
Data Checks
The carrier/TP A shall perform the validation check provided within the Supplemental Data
Request Template prior to submitting the data to the New Hampshire Insurance Department.
The template contains an automated process, or data validation tool, for checking the validity of
some, but not all data on the 'Main Data', 'Limited Data' and 'Stop Loss Data' tabs. The data
validation tool checks specific columns for specific values and should not be substituted for an
extensive data review using the provided instructional information. This process is only a tool to
facilitate the overall data validation process.
The 'Transmittal' tab contains a button labeled 'Click to Run Data Validation Checks' in the
C19:G21 cell range. This button is provided to facilitate the verification process of data input
into the 'Main Data', 'Limited Data' and 'Stop Loss Data' tabs. Please note that the data
validation process can be run multiple times.
When pressed, the workbook will scan the 'Main Data', 'Limited Data' and 'Stop Loss Data'
tabs and provide a brief summary on the 'Transmittal' tab of invalid and potentially invalid data.
Additionally, the scan will highlight invalid or potentially invalid fields within the data tabs
themselves. Finally, pressing the button scans the 'Main Data' and 'Limited Data' tabs and
populates the Supplemental Report data in the exhibits on the 'Data Reconciliation' tab. To
assist the carriers in populating the fields correctly, instructions for all reported fields have been
included in tabs within the Supplemental Report Template. If there are any discrepancies
between the instructions in the template and this bulletin, the bulletin instructions supersede the
template.
The 'Transmittal' tab contains several reports on invalid or potentially invalid data arranged in
several blocks. Column C displays counts for the 'Main Data', column I displays counts for the
'Limited Data' and column O displays counts for the 'Stop Loss Data'.
The first set of blocks below the validation button displays an overview of potential errors:
33
•
Row 25 reports a count of'Null', or empty, cells where null cells are not
expected.
•
Row 26 reports a count of potentially invalid data, not including nulls.
The second set of blocks contains specifics on potential issues involving Coverage Type,
Plan Type, and Market Category Code:
•
Rows 31, 32 and 33 contain a count of invalid Coverage Type, Plan Type and Market
Category Codes for both data tabs. These should be counted as invalid and fixed
according to the respective tabs in the instruction section of the workbook.
The third set of blocks contains additional specifics on potential issues relating to the remaining
data fields:
•
Row 35 checks that appropriate rules are followed regarding the 'Policyholder
Geographic Location' column of the two data tabs. Any possible inconsistencies are
highlighted in yellow on the respective data tabs.
•
Rows 37, 39, 41 and 43 are specific to the 'Main Data' tab.
•
Row 37 checks for an appropriate ill-Network Coinsurance level. A cell highlighted
in yellow may potentially be acceptable, but the 'Coinsurance' illStruction tab should
be referenced to make sure the meaning is fully understood.
•
Row 39 checks for an appropriate Actuarial Value. A number higher than 1.0 will be
highlighted in yellow as it is unexpected and should be double checked.
•
Row 41 checks for an ill-Network Deductible inconsistency based on IRS rules for
High Deductible Health Plans. Please see the 'Deductible' illStruction tab for more
details.
•
Row 43 checks for an ill-Network Out of Pocket Maximum inconsistency based on
IRS rules for High Deductible Health Plans. Please see the 'OOP Max' illStruction
tab for more details.
•
Each of the checks in Rows 35 through 43 has additional notes provided at the
bottom of the 'Transmittal' tab.
Please note that while the data validation tool can provide the user with potential errors, it is
possible that not all errors or warnings are invalid, and it is also possible that the tool overlooks
actual errors. The tool should be used in addition to a reasonable data validation process, and
not as the only method of validating data.
For technical issues you may encounter when performing the validation step, please refer to the
'Technical Troubleshooting' tab in the workbook.
34
Data Reconciliation
The "Data Reconciliation" sheet compares the data reported in the Supplemental Data Request to
data submitted for the NH Comprehensive Health Information System (CHIS). The data from
the Supplemental Data Request is pulled from both the "Main Data" collection and the "Limited
Data" collection worksheets. Carriers/TP As shall populate the highlighted cells with the
requested data as submitted to NH CHIS. Any differences greater than the percentage shown in
the template must be explained in the space provided.
Values from the Supplemental Data Request data submission will be populated by pressing
the button on the "Transmittal" tab. There is also a button labeled "Click to Populate Report
Exhibits Below" located on the "Data Reconciliation" tab in cells E3 and E4. Clicking this
button will recalculate the values from the Supplemental Data Request data in both sections of
the report on the "Data Reconciliation" tab.
If the CHIS data are not available for use in the comparison, the reason must be provided on the
''Notes" sheet in the Supplemental Data Request Excel Template.
Summary Tables
The Worksheet "Summary Tables" contains a summary table for each of the three data submittal
Worksheets: Main Data, Limited Data and Stop Loss Data. The carrier must review the total
amounts for Member Months, Premium, Claims, Member Responsibility and subsequent per
member per month (PMPM) amounts. These amounts are broken out by Coverage Type and
Market Category Code. The carrier must check these summary amounts for accuracy prior to
submitting the data.
35
Attachment B-1
Coverage Type Codes
All coverage type character codes are exactly three characters. Carriers shall use the codes listed
herein.
For self-funded plans that are administered by a third-party administrator, where the employer has
purchased stop-loss, or group excess, insurance coverage, carriers shall use a code of ASW.
For self-funded plans that are administered by a third-party administrator, where the employer has not
purchased stop-loss, or group excess insurance coverage, carriers shall use a code of ASO.
For stop-loss, or group excess loss insurance, carriers shall use STL.
For short-term non-renewable health insurance, as defined per RSA 415:5 III, carriers shall use a code
ofSTN.
Insurance sold to protect the health of Medicaid eligible individuals, generally purchased by state
governments, shall not be considered major medical expense. Carriers shall report such business as
other than major medical expense coverage and use the Medicaid related insurance code ofMCD.
For plans underwritten by the carrier and not referenced above, use code UND.
For any other plan, use 0TH. Carriers using this code shall provide an explanation on the Notes
worksheet.
36
Attachment B-2
Plan Type Codes
All plan type character codes are exactly three characters. Carriers shall use the codes listed
herein, and the codes should reflect how plans are licensed.
For indemnity-type plans, with no managed care features, carriers shall use a code ofFFS, (Fee-for-
Service).
For Preferred Provider Organization type plans, carriers shall use a code of PPO.
For Exclusive Provider Organization type plans, carriers shall use a code ofEPO.
For Point of Service type plans, carriers shall use a code of POS.
For Health Maintenance Organizations managed care plans, carriers shall use a code of HMO.
37
Attachment C
Market Category Codes
All market category character codes are described below. Carriers shall use the codes listed
herein. For policies sold and issued through a qualified association trust, carriers shall assign
the code based on the employee count of the employer sub-group.
"Eligible Employee" shall have the same meaning as defined in INS 4100, specifically INS
4103.03 (g) for the Small Group market, INS 4104.03 (i) for the Large Group market, and
4105.03 (h) for the Stop Loss market.
For policies sold and issued directly to individuals, other than those sold on a franchise basis, as
defined per RSA 415:19, or as group conversion policies, previously required per RSA 415:18,
VIl (a), carriers shall use a code of IND.
For policies sold and issued directly to individuals on a franchise basis, as defined per RSA
415:19, carriers shall use a code ofFCH.
For policies sold and issued directly to individuals as group conversion policies, as previously
required per RSA 415:18, VII (a), carriers shall use a code ofGCV.
For policies sold and issued directly to employers having exactly one eligible employee,
carriers shall use a code of GS 1.
For policies sold and issued directly to employers having between two and nine eligible
employees, carriers shall use a code of GS2.
For policies sold and issued directly to employers having between 10 and 25 eligible employees,
carriers shall use a code of GS3.
For policies sold and issued directly to employers having between 26 and 50 eligible employees,
carriers shall use a code ofGS4.
For policies sold and issued directly to employers having between 51 and 99 eligible employees,
carriers shall use a code of GLG 1.
For policies sold and issued directly to employers having 100 or more eligible employees, carriers
shall use a code of GLG2.
For policies sold and issued as blanket health insurance policies to a common carrier, carriers shall
use a code of BLC.
38
For policies sold and issued as blanket health insurance policies to an employer, carriers shall
use a code ofBLE.
For policies sold and issued as blanket health insurance policies to a volunteer fire department,
first aid, or other such volunteer group, carriers shall use a code ofBLV.
For policies sold and issued as blanket health insurance policies to a sports team or a camp,
carriers shall use a code ofBLS.
For policies sold and issued as blanket health insurance policies to a travel agency, or other
organization that provides travel-related services, carriers shall use a code of BLT.
For policies sold and issued as blanket health insurance policies to a university or college,
carriers shall use a code ofBLU.
For policies sold and issued as student major medical expense large group coverage to enrolled
students at an accredited college, university, or other educational institution, carriers shall use a
codeofSLG.
For policies sold and issued as group short term student health insurance, carriers shall use a code
ofSTS.
For policies sold and issued as student major medical group health insurance, carriers shall use
codeSMG.
For policies sold and issued as student group health insurance that is not major medical
coverage, carriers shall use a code of SNM.
For policies sold and issued as student individual major medical health insurance, carriers shall
use a code of SIM.
For policies sold and issued as student individual health insurance that is not major medical
coverage, carriers shall use a code of SIN.
For policies sold to other types of entities, carriers shall use a code of 01H. Carriers using this
market code shall provide an explanation on the Notes worksheet.
39
Attachment D
Policyholder Geographic Location
County
County Code
Belknap
B
Carroll
L
Cheshire
E
Coos
s
Grafton
G
Hillsboroul!h
H
Merrimack
M
Rockingham
R
Strafford
D
Sullivan
N
Non-NH
y
NH; unable to
match zip code to
county code 7
z
Note: The above codes should be assigned based on the location of the policyholder (not the
member). Non-NH policyholder data (with County Code of"Y") shall be reported on the
Limited Data tab and all other data shall be reported on the Main Data tab.
7 Zip code(s) must be provided to the NHID.
40
Attachment E
Translation Table - Zip Codes to NH County Codes
From
Through
County
03031
Hillsborough
03032
Rockingham
03033
Hillsboroul!h
03034
03042
Rockingham
03043
Hillsborough
03044
Rockingham
03045
Hillsboromili
03046
Merrimack
03047
03052
Hillsboroul!h
03053
Rockingham
03054
03071
Hillsboromili
03073
Rockingham
03076
Hillsborough
03077
03079
Rockingham
03082
03086
Hillsboroul!h
03087
Rockingham
03101
03105
Hillsborou.e;b
03106
Merrimack
03107
03111
Hillsborou2h
03215
Grafton
03216
Merrimack
03217
Grafton
03218
03220
Belknap
03221
Merrimack
03222
03223
Grafton
03224
Merrimack
03225
03226
Belknap
03227
Carroll
03229
03231
Merrimack
03232
Grafton
03233
03235
Merrimack
03237
Belknap
03238
03241
Grafton
03242
03243
Merrimack
03244
Hillsborough
03245
Grafton
41
Attachment E
Translation Table - Zip Codes to NH County Codes
From
Through
County
0303 1
Hillsborough
03032
Rockingham
03033
Hillsboroueh
03034
03042
Rockingham
03043
Hillsborough
03044
Rockimmam
03045
Hillsboroucll
03046
Merrimack
03047
03052
Hillsboroul!h
03053
Rockingham
03054
03071
Hillsborourn
03073
Rockingham
03076
Hillsborough
03077
03079
Rockingham
03082
03086
Hillsboroul!h
03087
Rockingham
03101
03105
Hillsborou,gb
03106
Merrimack
03107
031 1 1
Hillsboroul!h
03215
Grafton
03216
Merrimack
03217
Grafton
03218
03220
Belknap
03221
Merrimack
03222
03223
Grafton
03224
Merrimack
03225
03226
Belknap
03227
Carroll
03229
0323 1
Merrimack
03232
Grafton
03233
03235
Merrimack
03237
Belknap
03238
03241
Grafton
03242
03243
Merrimack
03244
Hillsborough
03245
Grafton
41
From
Through
County
03246
03249
Belknap
03251
Grafton
03252
03253
Belknap
03254
Carroll
03255
Merrimack
03256
Belknap
03257
03258
Merrimack
03259
Carroll
03260
Merrimack
03261
Rockin!!ham
03262
Grafton
03263
Merrimack
03264
03266
Grafton
03268
Merrimack
03269
Belknap
03272
03273
Merrimack
03274
Grafton
03275
Merrimack
03276
Belknap
03278
Merrimack
03279
Grafton
03280
Sullivan
03281
Hillsboromm
03282
Grafton
03284
Sullivan
03287
Merrimack
03289
Belknap
03290
03291
Rockimiliam
03293
Grafton
03298
03299
Belknap
03301
03307
Merrimack
03431
03435
Cheshire
03440
Hillsborough
03441
Cheshire
03442
Hillsborou!!h
03443
03448
Cheshire
03449
Hillsborough
03450
03457
Cheshire
03458
Hillsborou!!h
03461
03467
Cheshire
03468
Hillsborough
42
From
Throumi
County
03246
03249
Belknap
03251
Grafton
03252
03253
Belknap
03254
Carroll
03255
Merrimack
03256
Belknap
03257
03258
Merrimack
03259
Carroll
03260
Merrimack
03261
Rockingham
03262
Grafton
03263
Merrimack
03264
03266
Grafton
03268
Merrimack
03269
Belknap
03272
03273
Merrimack
03274
Grafton
03275
Merrimack
03276
Belknap
03278
Merrimack
03279
Grafton
03280
Sullivan
03281
Hillsboroueh
03282
Grafton
03284
Sullivan
03287
Merrimack
03289
Belknap
03290
03291
Rockingham
03293
Grafton
03298
03299
Belknap
03301
03307
Merrimack
03431
03435
Cheshire
03440
Hillsborough
03441
Cheshire
03442
Hillsborough
03443
03448
Cheshire
03449
Hillsborough
03450
03457
Cheshire
03458
Hillsboroul?h
03461
03467
Cheshire
03468
Hillsborough
42
From
Through
County
03469
03470
Cheshire
03561
Grafton
03570
Coos
03574
Grafton
03575
03579
Coos
03580
Grafton
03581
03584
Coos
03585
Grafton
03587
03598
Coos
03601
Sullivan
03602
Cheshire
03603
Sullivan
03604
Cheshire
03605
03607
Sullivan
03608
03609
Cheshire
03740
03741
Grafton
03743
03746
Sullivan
03748
03750
Grafton
03751
03754
Sullivan
03755
03769
Grafton
03770
Sullivan
03771
Grafton
03772
03773
Sullivan
03774
03780
Grafton
03781
03782
Sullivan
03784
03785
Grafton
03801
03804
Rockingham
03805
Strafford
03809
03810
Belknap
03811
Rockingham
03812
03814
Carroll
03815
Strafford
03816
03818
Carroll
03819
Rockingham
03820
03825
Strafford
03826
03827
Rockimrllam
03830
03832
Carroll
03833
Rockingham
03835
Strafford
03836
Carroll
03837
Belknap
43
From
Through
Countv
03469
03470
Cheshire
03561
Grafton
03570
Coos
03574
Grafton
03575
03579
Coos
03580
Grafton
03581
03584
Coos
03585
Grafton
03587
03598
Coos
03601
Sullivan
03602
Cheshire
03603
Sullivan
03604
Cheshire
03605
03607
Sullivan
03608
03609
Cheshire
03740
03741
Grafton
03743
03746
Sullivan
03748
03750
Grafton
03751
03754
Sullivan
03755
03769
Grafton
03770
Sullivan
03771
Grafton
03772
03773
Sullivan
03774
03780
Grafton
03781
03782
Sullivan
03784
03785
Grafton
03801
03804
Rockimiham
03805
Strafford
03809
03810
Belknap
0381 1
Rockinl!b.am
03812
03814
Carroll
03815
Strafford
03816
0381 8
Carroll
03819
Rockingham
03820
03825
Strafford
03826
03827
RockinQ"ham
03830
03832
Carroll
03833
Rockinru:iam
03835
Strafford
03836
Carroll
03837
Belknap
43
From
Through
County
03838
Carroll
03839
Strafford
03840
03844
Rockimiliam
03845
03847
Carroll
03848
Rockingham
03849
03850
Carroll
03851
03852
Strafford
03853
Carroll
03854
Rockingham
03855
Strafford
03856
03859
Rockingham
03860
Carroll
03862
Rockingham
03864
Carroll
03865
Rockimiliam
03866
03869
Strafford
03870
03871
Rockingham
03872
Carroll
03873
03874
Rockingham
03875
Carroll
03878
Strafford
03882
03883
Carroll
03884
Strafford
03885
Rockingham
03886
Carroll
03887
Carroll
03890
03897
Carroll
44
From
Through
County
03838
Carroll
03839
Strafford
03840
03844
Rockingham
03845
03847
Carroll
03848
Rockingham
03849
03850
Carroll
03851
03852
Strafford
03853
Carroll
03854
Rockingham
03855
Strafford
03856
03859
Rockingham
03860
Carroll
03862
Rockini!ham
03864
Carroll
03865
Rockingham
03866
03869
Strafford
03870
03871
Rockingham
03872
Carroll
03873
03874
Rockinl?ham
03875
Carroll
03878
Strafford
03882
03883
Carroll
03884
Strafford
03885
Rockingham
03886
Carroll
03887
Carroll
03890
03897
Carroll
44
Attachment F
Notes -Explanations as required in Instructions
Included in the Excel workbook is a worksheet for carriers/TP As to include notes on any
explanations as required in the instructions. For example, if data are submitted with Coverage
Type Code of"OTH" an explanation of what this represents should be included on the "Notes"
sheet in the data submission file. Another example is if a carrier/TP A used a method other than
the Minimum Value Calculator for the "actuarial value," the reason and method used must be
described in the notes section.
Carriers/TP As should include notes on any membership not included in the report submission,
and the approximate total membership on December 31 of the calendar year included in the
report filing. These may include covered lives for additional lines of business that do not meet
the supplemental report criteria but that are covered as risks in some form by the carrier/TP A.
Examples include dental insurance, Medicare supplemental insurance, or pharmacy benefit
management services when not provided in conjunction with health insurance benefits.
The notes section of the submission template can also be used to include additional information
relevant to the report submission.
45