NAIC and DFS Annual Statement Checklist and Instructions
Health Maintenance Organizations 2023-2024
| COMPANY NAME: | NAIC Company Code: |
| Contact: | Telephone: |
| REQUIRED FILINGS IN THE STATE OF: NEW YORK | Filings Made During the Year 2024 |
| (1) Check -list | (2) Line # | (3) REQUIRED FILINGS FOR THE ABOVE STATE | (4) NUMBER OF COPIES* | (5) DUE DATE | (6) FORM SOURCE** | (7) APPLICABLE NOTES | ||
|---|---|---|---|---|---|---|---|---|
| Domestic | Foreign | |||||||
| State | NAIC | State | ||||||
| I. NAIC FINANCIAL STATEMENTS | ||||||||
| 1 | Annual Statement (8 ½”X14”) | EF*** | EO | 4/1 | NAIC | Notes C,E | ||
| 1.1 | Printed Investment Schedule detail (Pages E01-E29) | EF*** | EO | 4/1 | NAIC | Notes C,E | ||
| 2 | Quarterly Financial Statement (8 ½” x 14”) | EF*** | EO | 5/15, 8/15, 11/15 | NAIC | Notes C,E | ||
| II. NAIC SUPPLEMENTS | ||||||||
| 11 | Accident & Health Policy Experience Exhibit | EF*** | EO | 4/1 | NAIC | |||
| 12 | Actuarial Opinion | EF*** | EO | 4/1 | Company | |||
| 18 | Long-term Care Experience Reporting Forms | EF*** | EO | 4/1 | NAIC | |||
| 19 | Management Discussion & Analysis | EF*** | EO | 4/1 | Company | |||
| 20 |
Medicare Part D Coverage Supplement | EF*** | EO | 4/1, 5/15, 8/15, 11/15 |
NAIC | |||
| 21 | Medicare Supplement Insurance Experience Exhibit | EF*** | EO | 4/1 | NAIC | |||
| 22 | Risk-Based Capital Report | EF*** | EO | 4/1 | NAIC | |||
| 23 | Schedule SIS | EF*** | N/A | 4/1 | NAIC | |||
| 24 | Supplemental Compensation Exhibit | 1 | N/A | 4/1 | NAIC | Notes C, E | ||
| 26 | Supplemental Health Care Exhibit (Parts 1 and 2) | EF*** | EO | 4/1 | NAIC | |||
| 27 | Supplemental Investment Risk Interrogatories | EF*** | EO | 4/1 | NAIC | |||
| III. ELECTRONIC FILING REQUIREMENTS | ||||||||
| 61 | Annual Statement Electronic Filing | xxx | EO | 4/1 | NAIC | |||
| 62 | March .PDF Filing | xxx | EO | 4/1 | NAIC | |||
| 63 | Risk-Based Capital Electronic Filing | xxx | EO | 4/1 | NAIC | |||
| 64 | Risk-Based Capital .PDF Filing | xxx | EO | 4/1 | NAIC | |||
| 65 | Supplemental Electronic Filing | xxx | EO | 4/1 | NAIC | |||
| 66 | Supplemental .PDF Filing | xxx | EO | 4/1 | NAIC | |||
| 67 |
Quarterly Electronic Filing | xxx | EO | 5/15, 8/15, 11/15 |
NAIC | |||
| 68 |
Quarterly .PDF Filing | xxx | EO | 5/15, 8/15, 11/15 |
NAIC | |||
| 69 | June .PDF Filing | xxx | EO | 5/31 | NAIC | |||
| IV. AUDIT/INTERNAL CONTROL RELATED REPORTS | ||||||||
| 81 | Accountants Letter of Qualifications (10 NYCRR 98-3.11) (11 NYCRR 89.10) | 1 | EO | 4/1 | Company | |||
| 82 | Audited Financial Reports | 1 | EO | 4/1 | Company | Notes C,E | ||
| 83 | Audited Financial Reports Exemption Affidavit | 1 | N/A | 4/1 | Company | |||
| 84 | Communication of Internal Control Related Matters Noted in Audit (10 NYCRR 98-3.10) (11 NYCRR 89.9) | 1 | EO | 4/1 |
Company | |||
| 85 |
Independent CPA (Change) (10 NYCRR 98-3.5) (11 NYCRR 89.4) | 1 | N/A | Within 60 days of any change |
Company | |||
| 86 | Management's Report of Internal Control Over Financial Reporting (10 NYCRR 98-3.15) (11 NYCRR 89.14) | 1 | N/A | 4/1 |
Company | |||
| 87 | Notification of Adverse Financial Condition (10 NYCRR 98-3.9) (11 NYCRR 89.8) | 1 | N/A | Within 5 days of any change |
Company | Note T | ||
| 88 | Relief from the five-year rotation requirement for lead audit partner (10 NYCRR 98-3.6(c)) (11 NYCRR89.5(c) | 1 | EO | At least 30 days prior to 12/31 |
Company | Note U | ||
| 89 | Relief from the one-year cooling off period for independent CPA (10 NYCRR 98-3.6(j)) (11 NYCRR 89.5(j)) | 1 | EO | At least 30 days prior to 12/31 |
Company | Note U | ||
| 90 | Relief from the Requirements for Audit Committees | 1 | EO | 4/1 | Company | |||
| 91 | Hardship Exemption | 1 | N/A | 4/1 | Company | Note P | ||
| 92 | Change in membership of the Audit Committee (10 NYCRR 98-3.13(e)) (11 NYCRR 89.12(e)) | 1 | N/A | Company | ||||
| V. STATE REQUIRED FILINGS | ||||||||
| 101 | New York Annual Supplement | 1 | N/A | 4/1 | State | Notes C, E | ||
| 102 |
New York Quarterly Supplement | 1 | N/A | 5/15, 8/15, 11/15 |
State | Notes C, E | ||
| 103 (a) | Signed and Notarized Jurat Page (Annual NAIC Blank) | 1 | N/A | 4/1 | NAIC | Notes G, H, L | ||
| 103 (b) | Signed and Notarized Jurat Page (Annual New York Supplement) | 1 | N/A | 4/1 | State | Notes G, H, L | ||
| 103 (c) | Signed and Notarized Jurat Page (Quarterly NAIC Blank) | 1 | N/A | 5/15, 8/15, 11/15 | NAIC | Notes G, H, L | ||
| 103 (d) | Signed and Notarized Jurat Page (Quarterly New York Supplement) | 1 | N/A | 5/15, 8/15, 11/15 | State | Note L | ||
| 104 | Certificate of Compliance | 1 | 0 | 4/15 | State | Notes G, H, L | ||
| 105 | Filings Checklist (with Column 1 completed) | 1 | 0 | 4/1 | State | |||
| 108 | Form HC-1 | 1 | 0 | 4/30 | State | Note Q | ||
| 109 | Form IR | 1 | 0 | 5/1 | State | Note Q | ||
| 110 | Qualifications of CPA (10 NYCRR 98-3.6(e)(2)) (11 NYCRR 89.5(e)(2)) | 1 | 0 | 4/1 | Company | Note R | ||
| 111 | Change in Actuary | 1 | 0 | Within 5 days of any change | Company | Note S | ||
| 111 | Managed Care Operations Report | EO | N/A | 4/1, 5/15, 8/15, 11/15 | State | Note V | ||
| 113 | Attestation on Segregation of Funds – Circular Letter No. 7 (2013) | 1 | 0 | 4/1 | Company | Note W | ||
*If XXX appears in this column, this state does not require this filing, providing the data is filed electronically with the NAIC. If N/A appears in this column, the filing is required with the domiciliary state. EO (electronic only filing).
**If Form Source is NAIC, the form should be obtained from the appropriate vendor.
***If EF appears in this column, electronic filings (“EF”) to the NAIC are equivalent to filing with DFS.
NOTES AND INSTRUCTIONS (A-P apply to all filings)
| A | Required Filings Contact Person: | Darlene Pettit, Health Bureau New York State Department of Financial Services One State Street New York, NY 10004 (212) 480-6298 E-mail: [email protected] When answering by E-mail, please include telephone number. |
| B | Mail Address: | N/A |
| C | Email Address for Health Department: | Electronic copies of both the annual and quarterly NAIC statements and the annual and quarterly New York Supplements should also be filed with the New York State Department of Health at the following email address: |
| D | Mailing Address for Premium Tax Payments: | N/A |
| E | Delivery Instructions: | All Department filings must be filed electronically no later than the indicated due date. Insurers are not required to submit a hard copy of the electronic filing unless requested by the Department. In addition to electronic filing to the NAIC, all HMO’s are also required to file pdf copies of the fully executed Jurat pages and Certifications of Compliance etc. of the Annual and Quarterly filings directly with this Department via the Department’s insurance entity filings portal: If the due date falls on a weekend or a legal holiday, then the filing must be submitted by the end of the next business day. |
| F | Late Filings: | Failure to timely file any component of an annual, quarterly or NY supplement filing would subject insurer to penalties set forth in NY Insurance Law Section 308. |
| G | Original Signatures: | “Wet” or electronic signatures are required. See Note L for further instructions. |
| H | Notarization: | Appropriate notarization required on the actual document. See Note L for further instructions. |
| I | Amended Filings: | Insurers must obtain the Department’s prior approval before submitting any amended statements. All amendments to your Annual and Quarterly Statement and/or New York Supplement are required to be filed electronically with the NAIC. Note: For Amended New York Supplement filings, the entire electronic filing is required to be filed with the NAIC. |
| J | Exceptions from normal filings: | Only accepted in accordance with Department’s prior approval. |
| K | Bar Codes (State or NAIC) | The NAIC Annual Statement and New York Supplement require the use of bar codes on the Jurat page and certain other pages and forms. General Bar Coding instructions and a full listing of New York required bar coded forms are included on the web site. |
| L | Signed and Notarized Jurat pages and Certificate of Compliance Filing: | Insurers are required to file a PDF copy of the fully executed and notarized Jurat pages and Certificates of Compliance etc. of the Annual and Quarterly filings, specifically lines 103(a), 103(b), 103(c), 103(d), 104 and 105 of the checklist above, directly with this Department via the Department’s insurance entity filings portal: https://www.dfs.ny.gov/apps_and_licensing/insurance_companies/insco_fratbenesoc_filings under the appropriate category. |
| M | NONE Filings: | All parts of the Annual Statement except those schedules identified by the use of "xxx" on the checklist and all parts of the New York Data Requirements must be accounted for. If there is nothing to report, you may complete the NAIC Annual Statement page entitled "Supplemental Exhibits and Schedules Interrogatories" INSTEAD OF filing duplicate reports marked "None." |
| N | Filings new, discontinued or modified materially since last year: | None |
| O | Internet Filing | Instructions concerning internet filing alternative to filing CD with New York for the New York Supplement are set forth in Insurance Circular Letter No. 4 (2001). All companies must file national form filings (as identified in items 61, 62, 63, 64, 65, 66, 67, 68 and 69 in the checklist) with the NAIC, preferably via the Internet. By filing over the Internet or via CD with the NAIC, an insurer will have fulfilled its electronic filing requirement for national forms with New York. |
| P | Hardship Exemption | Application for exemption to file must be filed with the Superintendent prior to the event or period for which the exemption is being requested. The company shall file, with its annual statement filing, both its request for relief and the approval of that request with the New York State Department of Financial Services and the NAIC. |
| Q | Form HC-1 and Form IR Electronic Filings* | Pursuant to New York State Department of Health Regulation Part 98 (10 NYCRR 98-1.16(e), submit the annual holding company information report electronically through the Department’s insurance entity portal filing application via the link below: https://www.dfs.ny.gov/apps_and_licensing/insurance_companies/insco_fratbenesoc_filings These forms should also be filed with the New York State Department of Health at the address in Note C. |
R | Qualifications of CPA – (A statement from the company stating that the CPA does not function in the role of management, does not audit his or her own work, and does not serve in an advocacy role for the company.) | Pursuant to Insurance Regulation No. 118 Section 89.5(e)(2) (11 NYCRR 89.5(e)(2)), attach the required statement to the audited annual financial statement. |
| S | Change in Actuary | If there is a change in actuary, the HMO shall notify the New York State Department of Financial Services within five business days of the event in accordance with the NAIC Annual Statement Instructions. A pdf copy of the written notification should be filed through the Department’s insurance entity filing portal. The written notification should also be filed electronically with the annual statement filings. |
| T | Notification of Adverse Financial Condition | Pursuant to Insurance Regulation No. 118 Section 89.8 (11 NYCRR 89.8), CPA should submit a pdf copy of written notification through the Department’s insurance entity filing portal. The written notification should also be filed with the annual statement filings. |
| U | Relief from the Five-Year Rotation Requirement for Lead Audit Partner Relief from the One-Year Cooling Off Period for Independent CPA | Applications should be made pursuant to Insurance Regulation No. 118 Section 89.5(c) (11 NYCRR 89.5(c)) and Section 89.5(j) (11 NYCRR 89.5(j)). Approvals of applications should be filed with the annual statement filings. |
| V | Managed Care Operations Report | HMOs, who are required to file Managed Care Operations Reports with the New York State Department of Health, should also submit an electronic copy of the required Managed Care Operations Report to the following email address: |
| W | Other | Attestation to Segregation of Funds Under the United States Department of Health and Human Services (“HHS”) regulation a Qualified Health Plan (“QHP”) issuer must file an annual assurance with the Superintendent attesting that the QHP issuer has complied with 42 USC §18023 and all applicable regulations. The company may file through the Department’s Filings Portal described in Note Q or email a copy to Health Bureau mailbox at [email protected] if the company has no access to the portal. |
General Instructions
For Companies to Use Checklist
Please Note:
This state’s instructions for companies to file with the NAIC are included in this Checklist. The NAIC will not be sending their own checklist this year.
Electronic Filing is intended to include filing via the Internet or filing via CD with the NAIC. Companies that file with the NAIC via the Internet are not required to submit CDs to the NAIC. Companies are not required to file hardcopy filings with the NAIC.
Column (1) (Checklist)
Companies may use the checklist to submit to a state, if the state requests it. Companies should copy the checklist and place an “x” in this column when mailing information to the state.
Column (2) (Line #)
Line # refers to a standard filing number used for easy reference. This line number may change from year to year.
Column (3) (Required Filings)
Name of item or form to be filed.
The Annual Statement Electronic Filing includes the annual statement data and all supplements due March 1, per the Annual Statement Instructions. This includes all detail investment schedules and other supplements for which the Annual Statement Instructions exempt printed detail.
The March .PDF Filing is the .pdf file for annual statement data, detail for investment schedules and supplements due March 1. The Risk-Based Capital Electronic Filing includes all risk-based capital data.
The Risk-Based Capital .PDF Filing is the .pdf file for risk-based capital data.
The Supplemental Electronic Filing includes all supplements due April 1, per the Annual Statement Instructions.
The Supplemental .PDF Filing is the .pdf file for all supplemental schedules and exhibits due April 1.
The Quarterly Electronic Filing includes the complete quarterly filing and the PDF files for all quarterly data.
The Quarterly .PDF Filing is the .pdf file for quarterly statement data.
The June .PDF Filing is the .pdf file for the Audited Financial Statements.
Column (4) (Number of Copies)
Indicates the number of copies that each foreign or domestic company is required to file for each type of form. The Blanks (E) Task Force modified the 1999 Annual Statement Instructions to waive paper filings of certain NAIC supplements and certain investment schedule detail, if such investment schedule data is available to the states via the NAIC database. The checklists reflect this action taken by the Blanks (EX4) Task Force. XXX appears in the “Number of Copies” “Foreign” column for the appropriate schedules and exhibits. Some states have chosen to waive printed quarterly and annual statements from their foreign insurers and have chosen to rely upon the NAIC database for these filings. This waiver could include supplemental annual statement filings. The XXX in this column might signify that the state has waived the paper filing of the annual statement and all supplements.
Column (5) (Due Date)
Indicates the date on which the company must file the form.
Column (6) (Form Source)
This column contains one of three words: “NAIC,” “State,” or “Company,” If this column contains “NAIC,” the company must obtain the forms from the appropriate vendor. If this column contains “State,” the state will provide the forms with the filing instructions (generally, on the state web site). If this column contains “Company,” the company, or its representative (e.g., its CPA firm), is expected to provide the form based upon the appropriate state instructions or the NAIC Annual Statement Instructions.
Column (7) (Applicable Notes)
This column contains references to the Notes to the Instructions that apply to each item listed on the checklist. The company should carefully read these notes before submitting a filing.