ANNUAL STATEMENT For the Year Ending DECEMBER 31, 2016 OF THE CONDITION AND AFFAIRS OF THE Neighborhood Health Plan of Rhode Island

Transcription

1 Document Code: 201 ANNUAL STATEMENT For the Year Ending DECEMBER 31, 2016 OF THE CONDITION AND AFFAIRS OF THE Neighborhood Health Plan of Rhode Island NAIC Group Code 0000, 0000 NAIC Company Code Employer's ID Number (Current Period) (Prior Period) Organized under the Laws of Rhode Island, State of Domicile or Port of Entry RI Country of Domicile United States of America Licensed as business type: Life, Accident & Health[ ] Property/Casualty[ ] Hospital, Medical & Dental Service or Indemnity[ ] Dental Service Corporation[ ] Vision Service Corporation[ ] Health Maintenance Organization[X] Other[ ] Is HMO Federally Qualified? Yes[ ] No[X] N/A[ ] Incorporated/Organized 12/09/1993 Commenced Business 12/01/1994 Statutory Home Office 910 Douglas Pike, Smithfield, RI, US (Street and Number) (City or Town, State, Country and Zip Code) Main Administrative Office 910 Douglas Pike (Street and Number) Smithfield, RI, US (401) (City or Town, State, Country and Zip Code) (Area Code) (Telephone Number) Mail Address 910 Douglas Pike, Smithfield, RI, US (Street and Number or P.O. Box) (City or Town, State, Country and Zip Code) Primary Location of Books and Records 910 Douglas Pike (Street and Number) Smithfield, RI, US (401) (City or Town, State, Country and Zip Code) (Area Code) (Telephone Number) Internet Website Address Statutory Statement Contact Joanne Roux (401) (Name) (Area Code)(Telephone Number)(Extension) jroux@nhpri.org (401) ( Address) (Fax Number) OFFICERS Peter Bancroft, Chairman Brenda Dowlatshahi, Secretary Name Peter Marino Frank Meaney Francisco Trilla MD Shantha Diaz Title Chief Executive Officer Chief Financial Officer Chief Medical Officer Chief Operating Officer OTHERS Jane Hayward, Vice Chairman Peter Walsh, Treasurer DIRECTORS OR TRUSTEES Merrill Thomas Brenda Dowlatshahi Raymond Joseph Lavoie Jr. Christopher Little Esq. Pablo Rodriguez MD Jane Hayward Peter Bancroft CPA Doris De Los Santos Peter Walsh Charles Jones William Hochstrasser-Walsh Dennis Roy Michael Lichtenstein Patricia Martinez Richard Besdine MD Peter Marino State of Rhode Island County of Providence ss The officers of this reporting entity being duly sworn, each depose and say that they are the described officers of the said reporting entity, and that on the reporting period stated above, all of the herein described assets were the absolute property of the said reporting entity, free and clear from any liens or claims thereon, except as herein stated, and that this statement, together with related exhibits, schedules and explanations therein contained, annexed or referred to, is a full and true statement of all the assets and liabilities and of the condition and affairs of the said reporting entity as of the reporting period stated above, and of its income and deductions therefrom for the period ended, and have been completed in accordance with the NAIC Annual Statement Instructions and Accounting Practices and Procedures manual except to the extent that: (1) state law may differ; or, (2) that state rules or regulations require differences in reporting not related to accounting practices and procedures, according to the best of their information, knowledge and belief, respectively. Furthermore, the scope of this attestation by the described officers also includes the related corresponding electronic filing with the NAIC, when required, that is an exact copy (except for formatting differences due to electronic filing) of the enclosed statement. The electronic filing may be requested by various regulators in lieu of or in addition to the enclosed statement. (Signature) (Signature) (Signature) Peter Marino Frank Meaney Francisco Trilla, MD (Printed Name) (Printed Name) (Printed Name) Chief Executive Officer Chief Financial Officer Chief Medical Officer (Title) (Title) (Title) Subscribed and sworn to before me this a. Is this an original filing? Yes[X] No[ ] day of, 2017 b. If no, 1. State the amendment number 2. Date filed 3. Number of pages attached (Notary Public Signature)

2 EXHIBIT 2 - ACCIDENT AND HEALTH PREMIUMS DUE AND UNPAID Name of Debtor 1-30 Days Days Days Over 90 Days Nonadmitted Admitted TOTAL Individuals Premiums due and unpaid not individually listed , , , ,894, TOTAL Group , , , ,894, Premiums due and unpaid from Medicare entities Premiums due and unpaid from Medicaid entities ,767, ,832, ,398, , ,811, Accident and health premiums due and unpaid (Page 2, Line 15) ,343, ,466, ,083, , ,705,901 18

3 EXHIBIT 3 - HEALTH CARE RECEIVABLES Name of Debtor 1-30 Days Days Days Over 90 Days Nonadmitted Admitted Pharmaceutical Rebate Receivables - Not Individually Listed , , , , , ,050, Subtotal - Pharmaceutical Rebate Receivables , , , , , ,050, Claim Overpayment Receivables - Not Individually Listed Subtotal - Claim Overpayment Receivables Loans and Advances to Providers - Not Individually Listed , , , , Subtotal - Loans and Advances to Providers , , , , Capitation Arrangement Receivables - Not Individually Listed Subtotal - Capitation Arrangement Receivables Risk Sharing Receivables - Not Individually Listed Subtotal - Risk Sharing Receivables Other Receivables Stop Loss A/R from EOHHS ,624, ,975, ,452, ,057, ,110, Other Receivables - Not Individually Listed Subtotal - Other Receivables ,624, ,975, ,452, ,057, ,110, Gross health care receivables ,105, ,325, ,802, ,825, , ,199,574 19

4 EXHIBIT 3A - ANALYSIS OF HEALTH CARE RECEIVABLES COLLECTED AND ACCRUED Health Care Receivables Collected Health Care Receivables Accrued 5 6 During the Year as of December 31 of Current Year Estimated Health Care On Amounts On Amounts Health Care Receivables Accrued Prior On Amounts Accrued On Amounts Receivables Accrued as of to January 1 of Accrued During December 31 of Accrued During in Prior Years December 31 of Type of Health Care Receivable Current Year the Year Prior Year the Year (Columns 1 + 3) Prior Year 1. Pharmaceutical rebate receivables ,001, ,723, ,459, ,001, ,983, Claim overpayment receivables Loans and advances to providers ,311, , , ,529, ,529, Capitation arrangement receivables Risk sharing receivables Other health care receivables ,760, ,649, , ,022, ,848, ,217, TOTALS (Lines 1 through 6) ,073, ,373, , ,752, ,379, ,731,688 Note that the accrued amounts in Columns 3, 4, and 6 are the total health care receivables, not just the admitted portion. 20

5 EXHIBIT 4 - CLAIMS UNPAID AND INCENTIVE POOL, WITHHOLD AND BONUS (Reported and Unreported) Aging Analysis of Unpaid Claims Account 1-30 Days Days Days Days Over 120 Days Total Aggregate Accounts Not Individually Listed - Uncovered Aggregate Accounts Not Individually Listed - Covered ,091, ,091, Subtotals ,091, ,091, Unreported claims and other claim reserves ,843, TOTAL Amounts Withheld TOTAL Claims Unpaid ,935, Accrued Medical Incentive Pool and Bonus Amounts ,017,508 21

6 22 Exhibit 5 - Amounts Due From Parent NONE 23 Exhibit 6 - Amounts Due to Parent NONE 22-23

7 EXHIBIT 7 - PART 1 - SUMMARY OF TRANSACTIONS WITH PROVIDERS Column 1 Column 1 Direct Medical Column 1 Total Column 3 Expenses Paid Expenses Paid Payment Expense as a % Members as a % to Affiliated to Non-Affiliated Method Payment of Total Payments Covered of Total Members Providers Providers Capitation Payments: 1. Medical groups ,723, , ,723, Intermediaries All other providers TOTAL Capitation Payments ,723, , ,723,702 Other Payments: 5. Fee-for-service X X X X X X Contractual fee payments ,560, X X X X X X ,560, Bonus/withhold arrangements - fee-for-service X X X X X X Bonus/withhold arrangements - contractual fee payments ,392, X X X X X X ,392, Non-contingent salaries X X X X X X Aggregate cost arrangements X X X X X X All other payments X X X X X X TOTAL Other Payments ,952, X X X X X X ,952, TOTAL (Line 4 plus Line 12) ,676, X X X X X X ,676,270 EXHIBIT 7 - PART 2 - SUMMARY OF TRANSACTIONS WITH INTERMEDIARIES Intermediary's Intermediary's NAIC Name of Capitation Average Monthly Total Adjusted Authorized Control Code Intermediary Paid Capitation Capital Level RBC N O N E TOTALS X X X X X X X X X

8 EXHIBIT 8 - FURNITURE, EQUIPMENT AND SUPPLIES OWNED Book Value Assets Net Accumulated Less Not Admitted Description Cost Improvements Depreciation Encumbrances Admitted Assets 1. Administrative furniture and equipment ,022, , ,254, , , Medical furniture, equipment and fixtures Pharmaceuticals and surgical supplies Durable medical equipment Other property and equipment ,099, , , , TOTAL ,121, , ,160, ,127, ,127,

9 30 Rhode Island EXHIBIT OF PREMIUMS, ENROLLMENT AND UTILIZATION (a) Document Code: 430 REPORT FOR: 1. CORPORATION: 2. LOCATION: NAIC Group Code 0000 BUSINESS IN THE STATE OF RHODE ISLAND DURING THE YEAR NAIC Company Code Comprehensive (Hospital & Medical) Federal Employees Medicare Vision Dental Health Benefits Title XVIII Title XIX Total Individual Group Supplement Only Only Plan Medicare Medicaid Other TOTAL Members at end of: 1. Prior Year , , , First Quarter , , , Second Quarter , , , Third Quarter , , , Current Year , , , Current Year Member Months ,231, , , ,033, TOTAL Member Ambulatory Encounters for Year: 7. Physician ,348, , , ,114, Non-Physician , , , , TOTAL ,138, , , ,861, Hospital Patient Days Incurred ,306, , ,303, Number of Inpatient Admissions , , Health Premiums Written (b) ,122,948, ,267, ,048, ,069,632, Life Premiums Direct Property/Casualty Premiums Written Health Premiums Earned ,122,948, ,267, ,048, ,069,632, Property/Casualty Premiums Earned Amount Paid for Provision of Health Care Services ,225, ,573, , ,960, Amount Incurred for Provision of Health Care Services ,557, ,168, , ,652, (a) For health business: number of persons insured under PPO managed care products...0 and number of persons insured under indemnity only products...0. (b) For health premiums written: amount of Medicare Title XVIII exempt from state taxes or fees $...0

10 30 Grand Total EXHIBIT OF PREMIUMS, ENROLLMENT AND UTILIZATION (a) Document Code: 430 REPORT FOR: 1. CORPORATION: 2. LOCATION: NAIC Group Code 0000 BUSINESS IN THE STATE OF GRAND TOTAL DURING THE YEAR NAIC Company Code Comprehensive (Hospital & Medical) Federal Employees Medicare Vision Dental Health Benefits Title XVIII Title XIX Total Individual Group Supplement Only Only Plan Medicare Medicaid Other TOTAL Members at end of: 1. Prior Year , , , First Quarter , , , Second Quarter , , , Third Quarter , , , Current Year , , , Current Year Member Months ,231, , , ,033, TOTAL Member Ambulatory Encounters for Year: 7. Physician ,348, , , ,114, Non-Physician , , , , TOTAL ,138, , , ,861, Hospital Patient Days Incurred ,306, , ,303, Number of Inpatient Admissions , , Health Premiums Written (b) ,122,948, ,267, ,048, ,069,632, Life Premiums Direct Property/Casualty Premiums Written Health Premiums Earned ,122,948, ,267, ,048, ,069,632, Property/Casualty Premiums Earned Amount Paid for Provision of Health Care Services ,225, ,573, , ,960, Amount Incurred for Provision of Health Care Services ,557, ,168, , ,652, (a) For health business: number of persons insured under PPO managed care products...0 and number of persons insured under indemnity only products...0. (b) For health premiums written: amount of Medicare Title XVIII exempt from state taxes or fees $...0

11 SCHEDULE S - PART 1 - SECTION 2 Reinsurance Assumed Accident and Health Insurance Listed by Reinsured Company as of December 31, Current Year Reserve Liability Reinsurance Funds NAIC Type of Other Than Payable on Modified Withheld Company ID Effective Domiciliary Reinsurance Unearned for Unearned Paid and Coinsurance Under Code Number Date Name of Reinsured Jurisdiction Assumed Premiums Premiums Premiums Unpaid Losses Reserve Coinsurance N O N E Total (Sum of and )

12 SCHEDULE S - PART 2 Reinsurance Recoverable on Paid and Unpaid Losses Listed by Reinsuring Company as of December 31, Current Year NAIC Company ID Effective Domiciliary Code Number Date Name of Company Jurisdiction Paid Losses Unpaid Losses Total - Life and Annuity Accident and Health - Non-Affiliates - U.S. Non-Affiliates AA /01/2016 US Dept of Hlth & Human Serv DC , /01/2016 ZURICH AMER INS CO OF IL IL , Subtotal - Accident and Health - Non-Affiliates - U.S. Non-Affiliates ,292, Total - Accident and Health - Non-Affiliates ,292, Total - Accident and Health ,292, Total U.S. (Sum of , , and ) ,292, Total Non-U.S. (Sum of , , and ) Total (Sum of and ) ,292,

13 33 ANNUAL STATEMENT FOR THE YEAR OF THE 2016 Neighborhood Health Plan of Rhode Island SCHEDULE S - PART 3 - SECTION 2 Reinsurance Ceded Accident and Health Insurance Listed by Reinsuring Company as of December 31, Current Year Outstanding Surplus Relief Reserve Credit Taken Funds NAIC Type of Type of Unearned Other than for Modified Withheld Company ID Effective Domiciliary Reinsurance Business Premiums Unearned Current Prior Coinsurance Under Code Number Date Name of Company Jurisdiction Ceded Ceded Premiums (Estimated) Premiums Year Year Reserve Coinsurance /01/2016 ZURICH AMER INS CO OF IL IL SSL/A/I CMM,MC ,977, AA /01/2016 US Dept of Hlth & Human Serv DC SSL/A/I CMM , Subtotal - General Account - Authorized - Non-Affiliates - U.S. Non-Affiliates ,288, Total - General Account - Authorized - Non-Affiliates ,288, Total - General Account Authorized ,288, Subtotal - General Account - Unauthorized - Affiliates - U.S. - Total Total - General Account - Unauthorized Subtotal - General Account - Certified - Affiliates - U.S. - Total Total - General Account - Certified Total - General Account - Authorized, Unauthorized and Certified ,288, Subtotal - Separate Accounts - Authorized - Affiliates - U.S. - Total Total - Separate Accounts - Authorized Subtotal - Separate Accounts - Unauthorized - Affiliates - U.S. - Total Total - Separate Accounts - Unauthorized Subtotal - Separate Accounts - Certified - Affiliates - U.S. - Total Total - Separate Accounts - Certified - Non-Affiliates Total - Separate Accounts - Certified Total - Separate Accounts - Authorized, Unauthorized and Certified Total U.S. (Sum of , , , , , , , , , , and ) ,288, Total Non-U.S. (Sum of , , , , , , , , , , and ) Total (Sum of and ) ,288, General Account - Authorized - Non-Affiliates - U.S. Non-Affiliates

14 34 Schedule S - Part NONE 35 Schedule S - Part NONE 34-35

15 SCHEDULE S - PART 6 Five-Year Exhibit of Reinsurance Ceded Business (000 Omitted) A. OPERATIONS ITEMS 1. Premiums , Title XVIII-Medicare Title XIX - Medicaid , , , , , Commissions and reinsurance expense allowance TOTAL Hospital and Medical Expenses , , , , B. BALANCE SHEET ITEMS 6. Premiums receivable Claims payable Reinsurance recoverable on paid losses , , Experience rating refunds due or unpaid Commissions and reinsurance expense allowances due Unauthorized reinsurance offset Offset for reinsurance with Certified Reinsurers C. UNAUTHORIZED REINSURANCE (DEPOSITS BY AND FUNDS WITHHELD FROM) 13. Funds deposited by and withheld from (F) Letters of credit (L) Trust agreements (T) Other (O) D. REINSURANCE WITH CERTIFIED REINSURERS (DEPOSITS BY AND FUNDS WITHHELD FROM) 17. Multiple Beneficiary Trust Funds deposited by and withheld from (F) Letters of credit (L) Trust agreements (T) Other (O)

16 SCHEDULE S - PART 7 Restatement of Balance Sheet to Identify Net Credit For Ceded Reinsurance As Reported Restatement Restated (net of ceded) Adjustments (gross of ceded) ASSETS (Page 2, Col. 3) 1. Cash and invested assets (Line 12) ,821, ,821, Accident and health premiums due and unpaid (Line 15) ,705, ,705, Amounts recoverable from reinsurers (Line 16.1) ,292, (1,292,994) Net credit for ceded reinsurance X X X ,292, ,292, All other admitted assets (Balance) ,005, ,005, TOTAL Assets (Line 28) ,826, ,826,417 LIABILITIES, CAPITAL AND SURPLUS (Page 3) 7. Claims unpaid (Line 1) ,484, ,484, Accrued medical incentive pool and bonus payments (Line 2) ,017, ,017, Premiums received in advance (Line 8) ,649, ,649, Funds held under reinsurance treaties with authorized and unauthorized reinsurers (Line 19, first inset amount plus second inset amount) Reinsurance in unauthorized companies (Line 20 minus inset amount) Reinsurance with Certified Reinsurers (Line 20 inset amount) Funds held under reinsurance treaties with Certified Reinsurers (Line 19 third inset amount) All other liabilities (Balance) ,971, ,971, TOTAL Liabilities (Line 24) ,123, ,123, TOTAL Capital and Surplus (Line 33) ,702, X X X ,702, TOTAL Liabilities, Capital and Surplus (Line 34) ,826, ,826,417 NET CREDIT FOR CEDED REINSURANCE 18. Claims unpaid Accrued medical incentive pool Premiums received in advance Reinsurance recoverable on paid losses ,292, Other ceded reinsurance recoverables TOTAL Ceded Reinsurance Recoverables ,292, Premiums receivable Funds held under reinsurance treaties with authorized and unauthorized reinsurers Unauthorized reinsurance Reinsurance with Certified Reinsurers Funds held under reinsurance treaties with Certified Reinsurers Other ceded reinsurance payables/offsets TOTAL Ceded Reinsurance Payables/Offsets TOTAL Net Credit for Ceded Reinsurance ,292,994 37

17 39 Schedule T - Part 2 - Interstate Compact - Exhibit of Premiums Written NONE 40 Schedule Y - Part NONE 41 Schedule Y - Part 1A NONE 42 Schedule Y - Part NONE 39-42

18 SUPPLEMENTAL EXHIBITS AND SCHEDULES INTERROGATORIES The following supplemental reports are required to be filed as part of your statement filing unless specifically waived by the domiciliary state. However, in the event that your domiciliary state waives the filing requirement, your response of WAIVED to the specific interrogatory will be accepted in lieu of filing a "NONE" report and a bar code will be printed below. If the supplement is required of your company but is not being filed for whatever reason, enter SEE EXPLANATION and provide an explanation following the interrogatory questions. Response MARCH FILING 1. Will the Supplemental Compensation Exhibit be filed with the state of domicile by March 1? Yes 2. Will an actuarial opinion be filed by March 1? Yes 3. Will the confidential Risk-based Capital Report be filed with the NAIC by March 1? Yes 4. Will the confidential Risk-based Capital Report be filed with the state of domicile, if required by March 1? Yes APRIL FILING 5. Will Management's Discussion and Analysis be filed by April 1? Yes 6. Will the Supplemental Investment Risks Interrogatories be filed by April 1? Yes 7. Will the Accident and Health Policy Experience Exhibit be filed by April 1? Yes JUNE FILING 8. Will an audited financial report be filed by June 1? Yes 9. Will Accountants Letter of Qualifications be filed with the state of domicile and electronically with the NAIC by June 1? Yes AUGUST FILING 10. Will the regulator-only (non-public) Communication of Internal Control Related Matters Noted in Audit be filed with the state of domicile and electronically with the NAIC (as a regulator-only non-public document) by August 1? Yes The following supplemental reports are required to be filed as part of your statement filing. However, in the event that your company does not transact the type of business for which the special report must be filed, your response of NO to the specific interrogatory will be accepted in lieu of filing a "NONE" report and a bar code will be printed below. If the supplement is required of your company but it is not being filed for whatever reason enter SEE EXPLANATION and provide an explanation following the interrogatory questions. MARCH FILING 11. Will the Medicare Supplement Insurance Experience Exhibit be filed with the state of domicile and the NAIC by March 1? No 12. Will the Supplemental Life data due March 1 be filed with the state of domicile and the NAIC? No 13. Will the Supplemental Property/Casualty data due March 1 be filed with the state of domicile and the NAIC? No 14. Will Schedule SIS (Stockholder Information Supplement) be filed with the state of domicile by March 1? No 15. Will the actuarial opinion on participating and non-participating policies as required in Interrogatories 1 and 2 on Exhibit 5 to Life Supplement be filed with the state of domicile and electronically with the NAIC by March 1? No 16. Will the actuarial opinion on non-guaranteed elements as required in Interrogatory 3 to Exhibit 5 to Life Supplement be filed with the state of domicile and electronically with the NAIC by March 1? No 17. Will the Medicare Part D Coverage Supplement be filed with the state of domicile and the NAIC by March 1? No 18. Will an approval from the reporting entity's state of domicile for relief related to the five-year rotation requirement for lead audit partner be file electronically with the NAIC by March 1? No 19. Will an approval from the reporting entity's state of domicile for relief related to the one-year cooling off period for independent CPA be filed electronically with the NAIC by March 1? No 20. Will an approval from the reporting entity's state of domicile for relief related to the Requirements for Audit Committees be filed electronically with the NAIC by March 1? No APRIL FILING 21. Will the Long-Term Care Experience Reporting Forms be filed with the state of domicile and the NAIC by April 1? No 22. Will the Supplemental Life data due April 1 be filed with the state of domicile and the NAIC? No 23. Will the Supplemental Property/Casualty Insurance Expense Exhibit due April 1 be filed with any state that requires it, and, if so, the NAIC? No 24. Will the Supplemental Health Care Exhibit (Parts 1, 2 and 3) be filed with the state of domicile and the NAIC by April 1? Yes 25. Will the regulator only (non-public) Supplemental Health Care Exhibit's Allocation Report be filed with the state of domicile and the NAIC by April 1? Yes AUGUST FILING 26. Will Management's Report of Internal Control Over Financial Reporting be filed with the state of domicile by August 1? Yes Explanation: Bar Code: Medicare Supplement Insurance Experience Exhibit Health Life Supplement Document Code: 360 Health Property / Casualty Supplement Document Code: 205 Schedule SIS Document Code: 207 Actuarial Opinion on Participating and Non-Participating Policies Document Code: 420 Statement of Non-Guaranteed Elements for Exhibit Document Code: 371 Medicare Part D Coverage Supplement Document Code: 370 Approval for Relief related to five-year rotation for lead Audit Partner Document Code: Document Code: