Supplemental Data Request

The State of New Hampshire Insurance Department 21 South Fruit Street, Suite 14 Concord, NH 03301 David J. Bettencourt Keith E. Nyhan Commissioner Deputy Commissioner BULLETIN Docket #INS 25-033-AB TO: All New Hampshire Licensed Health and Dental Insurers FROM: Commissioner David J. Bettencourt DATE: April 22, 2025 RE: Supplemental Data Request 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. RSA 420-G:14-a, placed further health insurance data collection responsibilities on the Department 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. 21-019-AB. Telephone 603-271-2261 • Fax 603-271-1406 • TDD Access: Relay NH 1-800-735-2964 nh.gov/insurance Table of Contents Background ................................................................................. 1 Changes in Requirements ............................................................... 3 Submission Details ........................................................................ 3 Definitions.................................................................................... 3 Applicability.................................................................................. 7 Exemptions .................................................................................. 7 De Minimis Exemption.................................................................... 7 Creditable Coverage ...................................................................... 8 Due Date ..................................................................................... 8 Fines........................................................................................... 8 Tabulation Methods and Issues........................................................ 9 Tabulation of Information ............................................................... 9 Tabulation Issues - Multiple Carriers................................................10 Tabulation Issues - Geographic Location ..........................................11 Acceptable Methods for Estimating Data...........................................11 XVI. Acceptable Methods for Submission ..........................................12 Data Reconciliation.......................................................................12 Confidentiality .............................................................................13 Attachment A ..............................................................................13 Supplemental Data Request Specifications Transmittal.....................13 Main Data Collection ...............................................................14 Limited Data Collection .........................................................31 Stop Loss Data Collection......................................................36 Data Checks...........................................................................44 Data Reconciliation ...............................................................48 Summary Tables....................................................................48 Attachment B-1 ..........................................................................49 Attachment B-2 ..........................................................................50 Attachment C .............................................................................51 Attachment D .............................................................................54 Attachment E...............................................................................55 Attachment F..............................................................................59 Page 2 of 59 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. • NHID will now be using the BOX application for data submissions. For directions on using BOX, see the Submission Details section below. Instructions can also be found on the Supplemental Data Template Tabulation Methods & Issues sheet. • The definition of ‘Situs’ has been updated. See the Definitions, Section (m), below. Submission Details • The completed Excel template must be delivered to the NHID using the BOX submission form. A link to this form will be provided to submitters in an email. [Note: Entities NOT required to provide SDR data to the NHID are still required to submit the nonsubmitter attestation—included in the contact e-mail.] • BOX does not require an account to be able to submit data. Fill out all applicable questions on the BOX submission form. Each type of data submission will have its own BOX submission form with a unique link. [Note, if you are an entity submitting both an Annual Hearing Report and a Supplemental Data Request Report, you will have to submit the reports separately by using the distinct BOX links for each submission type.] • More detailed instructions on the use of BOX can be found on the Supplemental Data Template Tabulation Methods & Issues sheet. • The due date for the submission of data is the last Friday in June. • The primary point of contact for questions related to this submission is the contracting vendor. Their contact information can be found on the Introduction tab on the template. Questions can also be sent to the NHID Data Analytics Unit at:healthcareanalytics@ins.nh.gov. Definitions (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 Page 3 of 59 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)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." 1 http://www.cms.gov/cciio/resources/regulations-and-guidance/index.html Page 4 of 59 (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 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 persons" 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. (f) "Creditable coverage" shall have the same meaning as defined in RSA 420-G:2, III. (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. Page 5 of 59 (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 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/TPA shall submit data for all members who are employed at that branch location. For employersponsored 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. TPAs shall report policyholders in a like manner. (l) "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 with respect to health insurance and the jurisdiction of New Hampshire state insurance laws governing health insurance, New Hampshire jurisdiction is based on the residence of the risk and not the situs of the contract. (See, Metropolitan Life Insurance V. Whaland, 119 N.H. 894 (1979).) For individual policies, all information Page 6 of 59 should be based on covered persons who are New Hampshire residents. For group policies, all information should be based on New Hampshire residents who work in New Hampshire and regardless of where the master contract was entered into. (See, New Hampshire Insurance Department Bulletin INS No. 08-014-AB, dated March 4, 2008.) Information should exclude Stop Loss that meets the standards in RSA 415-H, Medicare Supplement, Vision, Dental, FEHBP, Medicare and Medicaid lines of business. Each of the separate tabs will further specify the exact population to be included in the response or any additional required segments to report. (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/TPA to satisfy state reporting requirements for the subcontracted services, the Department needs to understand what carriers or TPAs are including in their data from a subcontractor in order to avoid double counting multiple submissions. The carrier/TPA is ultimately responsible for a complete submission without duplicate data, and is 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 TPAs 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 Page 7 of 59 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 TPA 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 TPAs must submit the policy data tabulated as prescribed. Due Date Carriers and TPAs must submit data summarizing the carrier's business from the immediately preceding calendar year. The data submission due on the last Friday in June 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 BOX submission form. BOX is able to accept Excel files with macros enabled. The submission will be reviewed for completeness. Insurance carriers and TPAs are required to submit a filing which satisfies NHID standards for completeness and compliance by the last Friday in June. Incomplete or non-compliant filings on the last Friday in June will be subject to an administrative fine. Fines Fines will be assessed for failure to meet the submission deadline of the last Friday in June, for filing an incomplete template, or for filing data that is inaccurate. Fines shall accrue on a daily basis. There will be no Page 8 of 59 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 covered persons 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 covered persons who reside in New Hampshire, or covered persons 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 covered persons who are employed at the New Hampshire branch location. The following chart provides a visual description of the Main and Limited data collections: Breakdown of Data Collection Population M=Main data collection, L=Limited data collection Covered Person’s Covered Person’s Work Location* Policy/Contract Situs Residence NH Non-NH NH NH M L NH Non-NH M L Non-NH NH M L Non-NH Non-NH M --­ *only considered for employer-sponsored coverage 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 Page 9 of 59 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. 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 selfinsured 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 Page 10 of 59 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. • TPAs or carriers administering an employer-sponsored health insurance benefit plan shall submit records for all self-insured plans that they administer. TPAs 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 covered persons residing in NH, and 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. 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 In 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 Page 11 of 59 the estimates. The Department reserves the right to approve or disapprove the method of estimation. XVI. 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- 20xx.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 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. Page 12 of 59 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 the contracting vendor. Their contact information can be found on the Introduction sheet on the template. Questions can also be sent to the NHID Data Analytics Unit at healthcareanalytics@ins.nh.gov 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 Page 13 of 59 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. For most companies, this will be 1231. 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. Main Data Collection The main data collection worksheet shall be called "'Main Data" and shall include data for policies with a NH situs except for 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 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 Page 14 of 59 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? 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. Calendar Year Calendar year the data are reported for. 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. Page 15 of 59 Number of Policyholder Months Total number of covered months for the policyholder (usually employer for group policies, or individual for nongroup 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 associated 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. Page 16 of 59 Total Claims Total claims incurred on behalf of the covered persons 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 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, TPAs 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. Page 17 of 59 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. 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 Includes other payments made such as capitation, and Credits 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 For the claims included in the "Total Claims" field, Responsibility 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 covered person 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 ''N/A" where not available. Page 18 of 59 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 New Hampshire Individual and Small Group Rate Filing User Guide (found on the NHID website3). This field may not be available for all market segments; input "NI A" where not available. 3 https://mm.nh.gov/files/uploads/nhid/documents/userguide-v6final.pdf or updated version, if available 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 Is this health coverage plan Grandfathered per the or Transitional ACA definition or considered a Policy Indicator 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 Is this health coverage plan open or closed? Input "Y" coverage plan if open, ''N" for closed. open? 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. Page 19 of 59 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 "NI 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. Is there an integrated Medical and Pharmacy Deductible? Input "Y" for yes, ''N" for no, or "N/A" if there is no medical deductible. Are Preventive Input "Y" for yes, "N" for no. Services Covered 100%? 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 MH/SA? Input "Y" for yes, ''N" for no. Does this health Input "Y" for yes, "N" for no. coverage plan have a Tiered A Tiered Network is defined as varying levels of cost Network sharing based on different networks of providers set component? 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. Page 20 of 59 PCP Office Visit Dollar amount of the PCP office visit copay for services Copay 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 Dollar amount of the Specialist office visit copay for Visit Copay 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. 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. Page 21 of 59 In-Network Single Dollar amount of the in-network, single tier type Deductible 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 Percentage figure of total plan and patient liability Coinsurance that the covered person is responsible for paying. For example, if the insurer pays 80% and the covered person 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. Retail Pharmacy Dollar amount of the single tier type policy deductible Single Deductible for generic prescriptions dispensed at an in-network Generic retail pharmacy. 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 "ls there an integrated Medical and Pharmacy Deductible?" field. Page 22 of 59 Retail Pharmacy Dollar amount of the single tier type policy Single Deductible deductible for brand prescriptions on the formulary Brand Formulary dispensed at an in- network retail pharmacy. If there is no deductible, input O (zero). For polices with an integrated Medical and Pharmacy deductible, input 0 (zero) in this field, report the integrated deductible in the "In- Network Single Deductible" field, and input "Y" in the "ls there an integrated Medical and Pharmacy Deductible?" field. Retail Pharmacy Dollar amount of the single tier type policy deductible Single Deductible for brand prescriptions not on the formulary dispensed Brand Nonat an in- network retail pharmacy. If there is no Formulary 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 Dollar amount of the single tier type policy deductible Single Deductible for specialty prescriptions dispensed at an in-network Specialty retail pharmacy. 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 covered person's responsibility as a decimal with a value between O and 1. Page 23 of 59 Retail Pharmacy Dollar amount of the copay for 30-day supply brand Copay/Coinsurance prescriptions on the formulary dispensed at an in- Brand Formulary 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 covered person‘ s responsibility as a decimal with a value between O 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 innetwork 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 covered person's responsibility as a decimal with a value between O and 1. Retail Pharmacy Dollar amount of the copay for 30-day supply Copay/Coinsuranc specialty prescriptions dispensed at an in-network e Specialty 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 covered person's responsibility as a decimal with a value between O 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: Page 24 of 59 • Determine Minimum Value figure using publicly available Minimum Value Calculator excel model tool which can be downloaded from the following website: https://view.officeapps.live.com/op/view.aspx?src =https%3A%2F%2Fwww.cms.gov%2Fcciio%2Fres ources%2Fregulations-and­ guidance%2Fdownloads%2Fmv-calculator-final-4­ 11-2013.xlsm&wdOrigin=BROWSELINK 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. Page 25 of 59 • 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 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 Page 26 of 59 this service, but does not meet the exact service description. Leave blank if this is a covered item. Ambulance Service EV Audiology Screening for Newborns 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. Page 27 of 59 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 hearingimpaired 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) Page 28 of 59 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 Page 29 of 59 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 Page 30 of 59 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 mid- year. Data specific to individual groups will be summarized and Page 31 of 59 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. 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 One-digit county codes assigned based on the Geographic location of the policyholder (not covered person). Location 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. State, Federal or Are the data for the state of NH, federal or municipal Municipal Account 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. Page 32 of 59 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. Page 33 of 59 Calendar Year Calendar year the data are reported for. Total Claims Total claims incurred on behalf of the covered persons 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 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. Claims Incurred Includes claims incurred during the reporting period and Paid and paid prior to when the carrier extracts the data for the Supplemental Report. Do not include member responsibility in this field. Page 34 of 59 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 Page 35 of 59 Other Payments Includes other payments made such as capitation, and Credits 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 For the claims included in the ''Total Claims" field, Responsibility 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 covered person 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 mid- year. 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 Page 36 of 59 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". Page 37 of 59 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 covered person). 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 Are the data for the state of NH, federal or municipal Municipal Account 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 Total number of covered months for the policyholder Policyholder (usually employer for group policies, or individual for Months 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. Page 38 of 59 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. Page 39 of 59 Specific Premium 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. Specific Claims 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. Specific Attachment Point Dollar amount of claim threshold level for an individual at which specific stop loss coverage begins. Specific% Portion of the claims above the attachment point to be Reimbursable reimbursed by the specific stop loss coverage. This value shall be in numeric decimal format with a value between O and 1. For example, if 80% of claims over Page 40 of 59 the attachment point are covered by stop loss insurance, enter 0.80. Specific Reimbursement Maximum Dollar amount of the maximum amount reimbursable for a specific stop loss claim. If there is no maximum, enter: 9,999,999. 31 Page 41 of 59 Aggregate Premium 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. Aggregate Claims 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. Aggregate Multiple of expected claims at which aggregate stop Attachment loss coverage begins. This value shall be in numeric Point decimal format with a value greater than 1. For example, if the attachment point is 110% of expected claims, input 1.10. Page 42 of 59 Aggregate% Reimbursable 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. Aggregate Reimbursement Maximum Dollar amount of the maximum amount reimbursable under aggregate coverage. If there is no maximum, enter: 9,999,999. Page 43 of 59 Medical Do Medical claims apply toward the stop loss limit? Input "Y" if yes, ''N" if no. 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" if no. Vision Do Vision claims apply toward the stop loss limit? Input "Y" if yes, ''N" if no. Disability Do Disability claims apply toward the stop loss limit? Input "Y" if yes, "N" if no. Data Checks The carrier/TPA 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. Page 44 of 59 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: Page 45 of 59 • 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 In-Network Coinsurance level. A cell highlighted in yellow may potentially be acceptable, but the 'Coinsurance' Instruction 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 In-Network Deductible inconsistency based on IRS rules for High Deductible Health Plans. Please see the 'Deductible' Instruction tab for more details. • Row 43 checks for an In-Network Out of Pocket Maximum inconsistency based on IRS rules for High Deductible Health Plans. Please see the 'OOP Max' Instruction 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. Page 46 of 59 For technical issues you may encounter when performing the validation step, please refer to the 'Technical Troubleshooting' tab in the workbook. Page 47 of 59 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/TPAs 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. Page 48 of 59 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 Ill, carriers shall use a code of STN. 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 of MCD. 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. Page 49 of 59 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 of FFS, (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 of EPO. 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. Page 50 of 59 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, VII (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 of FCH. 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 of GCV. For policies sold and issued directly to employers having exactly one eligible employee, carriers shall use a code of GS1. 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 of GS4. For policies sold and issued directly to employers having between 51 and 99 eligible employees, carriers shall use a code of GLG1. Page 51 of 59 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. For policies sold and issued as blanket health insurance policies to an employer, carriers shall use a code of BLE. 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 of BLV. For policies sold and issued as blanket health insurance policies to a sports team or a camp, carriers shall use a code of BLS. For policies sold and issued as blanket health insurance policies to a travel agency, or other organization that provides travelrelated 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 of BLU. 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 code of SLG. For policies sold and issued as group short term student health insurance, carriers shall use a code of STS. For policies sold and issued as student major medical group health insurance, carriers shall use code SMG. 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. Page 52 of 59 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 0TH. Carriers using this market code shall provide an explanation on the Notes worksheet. Page 53 of 59 Attachment D Policyholder Geographic Location County County Code Belknap B Carroll L Cheshire E Coos S Grafton G Hillsborough H Merrimack M Rockingham R Strafford D Sullivan N Non-NH Y NH; unable to match zip code to Z county code7 Note: The above codes should be assigned based on the location of the policyholder (not the covered person). 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. Page 54 of 59 Attachment E Translation Table - Zip Codes to NH County Codes From Through County 03031 Hillsborough 03032 Rockingham 03033 Hillsborough 03034 03042 Rockingham 03043 Hillsborough 03044 Rockingham 03045 Hillsborough 03046 Merrimack 03047 03052 Hillsborough 03053 Rockingham 03054 03071 Hillsborough 03073 Rockingham 03076 Hillsborough 03077 03079 Rockingham 03082 03086 Hillsborough 03087 Rockingham 03101 03105 Hillsborough 03106 Merrimack 03107 03111 Hillsborough 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 From Through County Page 55 of 59 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 Hillsborough 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 Hillsborough 03461 03467 Cheshire 03468 Hillsborough From Through County 03469 03470 Cheshire Page 56 of 59 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 Rockingham 03830 03832 Carroll 03833 Rockingham 03835 Strafford 03836 Carroll 03837 Belknap From Through County 03838 Carroll 03839 Strafford Page 57 of 59 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 Rockingham 03864 Carroll 03865 Rockingham 03866 03869 Strafford 03870 03871 Rockingham 03872 Carroll 03873 03874 Rockin2ham 03875 Carroll 03878 Strafford 03882 03883 Carroll 03884 Strafford 03885 Rockingham 03886 Carroll 03887 Carroll 03890 03897 Carroll Page 58 of 59 Attachment F Notes - Explanations as required in Instructions Included in the Excel workbook is a worksheet for carriers/TPAs 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/TPA 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/TPAs 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/TPA. 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. Page 59 of 59