OFFICERS Name Title Name Title 1. Orlando Gonzalez President 2. Jose Mercado VP of Finance OTHER
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- Reynold Bradford
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1 * * ANNUAL STATEMENT For the Year Ended December 31, 2010 of the Condition and Affairs of the NAIC Group Code..., NAIC Company Code Employer's ID Number (Current Period) (Prior Period) Organized under the Laws of Puerto Rico State of Domicile or Port of Entry Puerto Rico Country of Domicile US Licensed as Business Type...Health Mainteinance Organization Is HMO Federally Qualified? Yes [ X ] No [ ] Incorporated/Organized... January 10, 2001 Commenced Business... August 1, 2004 Statutory Home Office 350 Chardón Avenue.. San Juan... PR (Street and Number) (City or Town, State and Zip Code) Main Administrative Office 350 Chardón Avenue.. San Juan... PR (Street and Number) (City or Town, State and Zip Code) (Area Code) (Telephone Number) Mail Address P.O. Box San Juan... PR (Street and Number or P. O. Box) (City or Town, State and Zip Code) Primary Location of Books and Records 350 Chardón Avenue.. San Juan... PR (Street and Number) (City or Town, State and Zip Code) (Area Code) (Telephone Number) Internet Web Site Address N/A Statutory Statement Contact Sonia Nieves (Name) (Area Code) (Telephone Number) (Extension) sonia.nieves@mmmhc.com ( Address) (Fax Number) OFFICERS Name Title Name Title 1. Orlando Gonzalez President 2. Jose Mercado VP of Finance OTHER DIRECTORS OR TRUSTEES Richard Shinto MD Orlando Gonzalez Doug Malton Robert Torricelli Claude Chevance State of... County of... The officers of this reporting entity being duly sworn, each depose and say that they are the described officers of 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) Orlando Gonzalez Jose Mercado 1. (Printed Name) 2. (Printed Name) 3. (Printed Name) President VP of Finance (Title) (Title) (Title) Subscribed and sworn to before me a. Is this an original filing? Yes [ X ] No [ ] This day of 2011 b. If no 1. State the amendment number 2. Date filed 3. Number of pages attached
2 ASSETS Current Year Prior Year Net Admitted Nonadmitted Assets Net Assets Assets (Cols. 1-2) Admitted Assets 1. Bonds (Schedule D) ,211, ,211, ,719, Stocks (Schedule D): 2.1 Preferred stocks Common stocks , , , Mortgage loans on real estate (Schedule B): 3.1 First liens Other than first liens Real estate (Schedule A): 4.1 Properties occupied by the company (less $...0 encumbrances) Properties held for the production of income (less $...0 encumbrances) Properties held for sale (less $...0 encumbrances) Cash ($...3,394,773, Sch. E-Part 1), cash equivalents ($...0, Sch. E-Part 2) and short-term investments ($...2,022,551, Sch. DA) ,417, ,417, ,588, Contract loans (including $...0 premium notes) Derivatives Other invested assets (Schedule BA) Receivables for securities , , Securities lending reinvested collateral assets Aggregate write-ins for invested assets , , , Subtotals, cash and invested assets (Lines 1 to 11) ,256, ,256, ,911, Title plants less $...0 charged off (for Title insurers only) Investment income due and accrued , , , Premiums and considerations: 15.1 Uncollected premiums and agents' balances in course of collection ,421, , ,219, ,203, Deferred premiums, agents' balances and installments booked but deferred and not yet due (including $...0 earned but unbilled premiums) Accrued retrospective premiums Reinsurance: 16.1 Amounts recoverable from reinsurers Funds held by or deposited with reinsured companies Other amounts receivable under reinsurance contracts Amounts receivable relating to uninsured plans Current federal and foreign income tax recoverable and interest thereon Net deferred tax asset , , , , Guaranty funds receivable or on deposit Electronic data processing equipment and software Furniture and equipment, including health care delivery assets ($...0) Net adjustment in assets and liabilities due to foreign exchange rates Receivables from parent, subsidiaries and affiliates Health care ($...2,825,539) and other amounts receivable ,825, ,825, ,525, Aggregate write-ins for other than invested assets ,372, , , , Total assets excluding Separate Accounts, Segregated Accounts and Protected Cell Accounts (Lines 12 to 25) ,725, , ,890, ,723, From Separate Accounts, Segregated Accounts and Protected Cell Accounts TOTALS (Lines 26 and 27) ,725, , ,890, ,723,447 DETAILS OF WRITE-INS Statutory Deposit with The Insurance Commissioner , , , Summary of remaining write-ins for Line 11 from overflow page Totals (Lines 1101 thru 1103 plus 1198) (Line 11 above) , , , Plan to Plan Receivable , , , Other Receivable , , , Prepaid Expenses , , , Summary of remaining write-ins for Line 25 from overflow page , , Totals (Lines 2501 thru 2503 plus 2598) (Line 25 above) ,372, , , ,200 2
3 LIABILITIES, CAPITAL AND SURPLUS Current Period Prior Year Covered Uncovered Total Total 1. Claims unpaid (less $...0 reinsurance ceded) ,997, ,997, ,734, Accrued medical incentive pool and bonus amounts ,407, ,407, ,984, Unpaid claims adjustment expenses , , , Aggregate health policy reserves ,800, ,800, ,978, Aggregate life policy reserves Property/casualty unearned premium reserve Aggregate health claim reserves Premiums received in advance General expenses due or accrued , , Current federal and foreign income tax payable and interest thereon (including $...0 on realized capital gains (losses)) ,473, Net deferred tax liability Ceded reinsurance premiums payable Amounts withheld or retained for the account of others , , , Remittances and items not allocated Borrowed money (including $...0 current) and interest thereon $...0 (including $...0 current) Amounts due to parent, subsidiaries and affiliates ,929, ,929, ,155, Derivatives Payable for securities Payable for securities lending Funds held under reinsurance treaties with ($...0 authorized reinsurers and $...0 unauthorized reinsurers) Reinsurance in unauthorized companies Net adjustments in assets and liabilities due to foreign exchange rates Liability for amounts held under uninsured plans , , ,563, Aggregate write-ins for other liabilities (including $...0 current) ,641, ,641, , Total liabilities (Lines 1 to 23) ,199, ,199, ,757, Aggregate write-ins for special surplus funds......xxx......xxx Common capital stock......xxx......xxx , , Preferred capital stock......xxx......xxx Gross paid in and contributed surplus......xxx......xxx ,988, ,988, Surplus notes......xxx......xxx Aggregate write-ins for other than special surplus funds......xxx......xxx Unassigned funds (surplus)......xxx......xxx ,692, ,968, Less treasury stock at cost: shares common (value included in Line 26 $...0)......XXX......XXX shares preferred (value included in Line 27 $...0)......XXX......XXX Total capital and surplus (Lines 25 to 31 minus Line 32)......XXX......XXX ,690, ,966, Total liabilities, capital and surplus (Lines 24 and 33)......XXX......XXX ,890, ,723,447 DETAILS OF WRITE-INS Statutory Deposit with The Insurance Commissioner , , , Plan To Plan Payable Other ,041, ,041, Summary of remaining write-ins for Line 23 from overflow page Totals (Lines 2301 thru 2303 plus 2398) (Line 23 above) ,641, ,641, , XXX......XXX XXX......XXX XXX......XXX Summary of remaining write-ins for Line 25 from overflow page......xxx......xxx Totals (Lines 2501 thru 2503 plus 2598) (Line 25 above)......xxx......xxx XXX......XXX XXX......XXX XXX......XXX Summary of remaining write-ins for Line 30 from overflow page......xxx......xxx Totals (Lines 3001 thru 3003 plus 3098) (Line 30 above)......xxx......xxx
4 STATEMENT OF REVENUE AND EXPENSES Current Year Prior Year Uncovered Total Total 1. Member months......xxx , , Net premium income (including $...0 non-health premium income)......xxx ,399, ,051, Change in unearned premium reserves and reserve for rate credits......xxx Fee-for-service (net of $...0 medical expenses)......xxx Risk revenue......xxx Aggregate write-ins for other health care related revenues......xxx Aggregate write-ins for other non-health revenues......xxx Total revenues (Lines 2 to 7)......XXX ,399, ,051,017 Hospital and Medical: 9. Hospital/medical benefits ,200, ,574, Other professional services ,637, ,863, Outside referrals Emergency room and out-of-area ,379, ,317, Prescription drugs ,168, ,556, Aggregate write-ins for other hospital and medical Incentive pool, withhold adjustments and bonus amounts ,227, ,963, Subtotal (Lines 9 to 15) ,613, ,275,332 Less: 17. Net reinsurance recoveries Total hospital and medical (Lines 16 minus 17) ,613, ,275, Non-health claims (net) Claims adjustment expenses, including $...0 cost containment expenses General administrative expenses ,683, ,170, Increase in reserves for life and accident and health contracts including $...0 increase in reserves for life only) Total underwriting deductions (Lines 18 through 22) ,297, ,445, Net underwriting gain or (loss) (Lines 8 minus 23)......XXX ,102, ,605, Net investment income earned (Exhibit of Net Investment Income, Line 17) ,934, ,114, Net realized capital gains or (losses) less capital gains tax of $...151, (380) 27. Net investment gains or (losses) (Lines 25 plus 26) ,934, ,114, Net gain or (loss) from agents' or premium balances charged off [(amount recovered $...0) (amount charged off $...0)] Aggregate write-ins for other income or expenses , Net income or (loss) after capital gains tax and before all other federal income taxes (Lines 24 plus 27 plus 28 plus 29)......XXX ,037, ,987, Federal and foreign income taxes incurred......xxx ,543, ,444, Net income (loss) (Lines 30 minus 31)......XXX ,493, ,542,281 DETAILS OF WRITE-INS XXX XXX XXX Summary of remaining write-ins for Line 6 from overflow page......xxx Totals (Lines 0601 thru 0603 plus 0698) (Line 6 above)......xxx XXX XXX XXX Summary of remaining write-ins for Line 7 from overflow page......xxx Totals (Lines 0701 thru 0703 plus 0798) (Line 7 above)......xxx Summary of remaining write-ins for Line 14 from overflow page Totals (Lines 1401 thru 1403 plus 1498) (Line 14 above) Other income , Summary of remaining write-ins for Line 29 from overflow page Totals (Lines 2901 thru 2903 plus 2998) (Line 29 above) ,582 4
5 STATEMENT OF REVENUE AND EXPENSES (Continued) 1 2 CAPITAL AND SURPLUS ACCOUNT Current Year Prior Year 33. Capital and surplus prior reporting period ,966, ,695, Net income or (loss) from Line ,493, ,542, Change in valuation basis of aggregate policy and claim reserves Change in net unrealized capital gains and (losses) less capital gains tax of $ Change in net unrealized foreign exchange capital gain or (loss) Change in net deferred income tax ,820...(140,803) 39. Change in nonadmitted assets......(270,964)...334, Change in unauthorized reinsurance Change in treasury stock (20,001,735) 42. Change in surplus notes Cumulative effect of changes in accounting principles Capital changes: 44.1 Paid in Transferred from surplus (Stock Dividend) Transferred to surplus Surplus adjustments: 45.1 Paid in Transferred to capital (Stock Dividend) Transferred from capital Dividends to stockholders......(23,540,000)...(41,494,265) 47. Aggregate write-ins for gains or (losses) in surplus......(25,008)...30, Net change in capital and surplus (Lines 34 to 47) ,798...(19,729,033) 49. Capital and surplus end of reporting period (Line 33 plus 48) ,690, ,966,319 DETAILS OF WRITE-INS Other surplus adjustments......(25,008)...30, Summary of remaining write-ins for Line 47 from overflow page Totals (Lines 4701 thru 4703 plus 4798) (Line 47 above)......(25,008)...30,101 5
6 CASH FROM OPERATIONS CASH FLOW 1 2 Current Year Prior Year 1. Premiums collected net of reinsurance ,982, ,342, Net investment income ,713, , Miscellaneous income Total (Lines 1 through 3) ,695, ,240, Benefit and loss related payments ,053, ,690, Net transfers to Separate Accounts, Segregated Accounts and Protected Cell Accounts Commissions, expenses paid and aggregate write-ins for deductions ,160, ,379, Dividends paid to policyholders Federal and foreign income taxes paid (recovered) net of $...0 tax on capital gains (losses) ,663, ,266, Total (Lines 5 through 9) ,877, ,336, Net cash from operations (Line 4 minus Line 10) ,818, ,903,789 CASH FROM INVESTMENTS 12. Proceeds from investments sold, matured or repaid: 12.1 Bonds ,620, ,850, Stocks Mortgage loans Real estate Other invested assets Net gains or (losses) on cash, cash equivalents and short-term investments Miscellaneous proceeds ,000, Total investment proceeds (Lines 12.1 to 12.7) ,620, ,850, Cost of investments acquired (long-term only): 13.1 Bonds ,810, ,701, Stocks , Mortgage loans Real estate Other invested assets Miscellaneous applications Total investments acquired (Lines 13.1 to 13.6) ,810, ,704, Net increase (decrease) in contract loans and premium notes Net cash from investments (Line 12.8 minus Lines 13.7 minus Line 14)......(1,189,294)...(83,853,930) 16. Cash provided (applied): CASH FROM FINANCING AND MISCELLANEOUS SOURCES 16.1 Surplus notes, capital notes Capital and paid in surplus, less treasury stock (20,001,734) 16.3 Borrowed funds Net deposits on deposit-type contracts and other insurance liabilities Dividends to stockholders ,740, ,494, Other cash provided (applied)......(2,059,675)...3,972, Net cash from financing and miscellaneous sources (Lines 16.1 to 16.4 minus Line 16.5 plus Line 16.6)......(16,799,675)...(57,523,985) RECONCILIATION OF CASH, CASH EQUIVALENTS AND SHORT-TERM INVESTMENTS 18. Net change in cash, cash equivalents and short-term investments (Line 11 plus Line 15 plus Line 17)......(10,170,722)...(78,474,126) 19. Cash, cash equivalents and short-term investments: 19.1 Beginning of year ,588, ,062, End of year (Line 18 plus Line 19.1) ,417, ,588,046 Note: Supplemental disclosures of cash flow information for non-cash transactions: Dividend Payable ,800,
7 7 Statement as of December 31, 2010 of the ANALYSIS OF OPERATION BY LINES OF BUSINESS Federal Comprehensive Employees Title Title (Hospital Medicare Dental Vision Health XVIII XIX Other Other Total and Medical) Supplement Only Only Benefit Plans Medicare Medicaid Health Non-Health 1. Net premium income ,399, ,399, Change in unearned premium reserves and reserve for rate credit Fee-for-service (net of $...0 medical expenses) xxx Risk revenue xxx Aggregate write-ins for other health care related revenues xxx Aggregate write-ins for other non-health care related revenues xxx......xxx......xxx......xxx......xxx......xxx......xxx......xxx Total revenues (Lines 1 to 6) ,399, ,399, Hospital/medical benefits ,200, ,200, xxx Other professional services ,637, ,637, xxx Outside referrals xxx Emergency room and out-of-area ,379, ,379, xxx Prescription drugs ,168, ,168, xxx Aggregate write-ins for other hospital and medical xxx Incentive pool, withhold adjustments and bonus amounts ,227, ,227, xxx Subtotal (Lines 8 to 14) ,613, ,613, XXX Net reinsurance recoveries xxx Total hospital and medical (Lines 15 minus 16) ,613, ,613, XXX Non-health claims (net) xxx......xxx......xxx......xxx......xxx......xxx......xxx......xxx Claims adjustment expenses including $...0 cost containment expenses General administrative expenses ,683, ,683, Increase in reserves for accident and health contracts xxx Increase in reserve for life contracts xxx......xxx......xxx......xxx......xxx......xxx......xxx......xxx Total underwriting deductions (Lines 17 to 22) ,297, ,297, Net underwriting gain or (loss) (Line 7 minus Line 23) ,102, ,102, DETAILS OF WRITE-INS XXX XXX XXX Summary of remaining write-ins for Line 5 from overflow page xxx Total (Lines 0501 thru 0503 plus 0598) (Line 5 above) xxx XXX......XXX......XXX......XXX......XXX......XXX......XXX......XXX XXX......XXX......XXX......XXX......XXX......XXX......XXX......XXX XXX......XXX......XXX......XXX......XXX......XXX......XXX......XXX Summary of remaining write-ins for Line 6 from overflow page xxx......xxx......xxx......xxx......xxx......xxx......xxx......xxx Total (Lines 0601 thru 0603 plus 0698) (Line 6 above) xxx......xxx......xxx......xxx......xxx......xxx......xxx......xxx XXX XXX XXX Summary of remaining write-ins for Line 13 from overflow page xxx Total (Lines 1301 thru 1303 plus 1398) (Line 13 above) xxx...
8 UNDERWRITING AND INVESTMENT EXHIBIT PART 1 - PREMIUMS Net Premium Direct Reinsurance Reinsurance Income Line of Business Business Assumed Ceded (Cols ) 1. Comprehensive (hospital and medical) Medicare supplement Dental only Vision only Federal employees health benefits plan Title XVIII - Medicare ,399, ,399, Title XIX - Medicaid Other health Health subtotal (Lines 1 through 8) ,399, ,399, Life Property/casualty Totals (Lines 9 to 11) ,399, ,399,812
9 9 Statement as of December 31, 2010 of the 1. Payments during the year: UNDERWRITING AND INVESTMENT EXHIBIT PART 2 - CLAIMS INCURRED DURING THE YEAR Federal Comprehensive Employees Title Title (Hospital Medicare Dental Vision Health XVIII XIX Other Other Total and Medical) Supplement Only Only Benefits Plan Medicare Medicaid Health Non-Health 1.1 Direct ,110, ,110, Reinsurance assumed Reinsurance ceded Net ,110, ,110, Paid medical incentive pools and bonuses ,805, ,805, Claim liability December 31, current year from Part 2A: 3.1 Direct ,997, ,997, Reinsurance assumed Reinsurance ceded Net ,997, ,997, Claim reserve December 31, current year from Part 2D: 4.1 Direct Reinsurance assumed Reinsurance ceded Net Accrued medical incentive pools and bonuses, current year ,407, ,407, Net healthcare receivables (a) ,988, ,988, Amounts recoverable from reinsurers December 31, current year Claim liability December 31, prior year from Part 2A: 8.1 Direct ,734, ,734, Reinsurance assumed Reinsurance ceded Net ,734, ,734, Claim reserve December 31, prior year from Part 2D: 9.1 Direct Reinsurance assumed Reinsurance ceded Net Accrued medical incentive pools and bonuses, prior year ,984, ,984, Amounts recoverable from reinsurers December 31, prior year Incurred benefits: 12.1 Direct ,385, ,385, Reinsurance assumed Reinsurance ceded Net ,385, ,385, Incurred medical incentive pools and bonuses ,227, ,227, (a) Excludes $...0 loans or advances to providers not yet expensed.
10 1. Reported in process of adjustment: UNDERWRITING AND INVESTMENT EXHIBIT PART 2A - CLAIMS LIABILITY END OF CURRENT YEAR Federal Comprehensive Employees Title Title (Medical Medicare Dental Vision Health XVIII XIX Other Other Total and Hospital) Supplement Only Only Benefits Plan Medicare Medicaid Health Non-Health 1.1 Direct Reinsurance assumed Reinsurance ceded Net Incurred but unreported: 2.1 Direct ,997, ,997, Reinsurance assumed Reinsurance ceded Net ,997, ,997, Amounts withheld from paid claims and capitations: 3.1 Direct Reinsurance assumed Reinsurance ceded Net Totals: 4.1 Direct ,997, ,997, Reinsurance assumed Reinsurance ceded Net ,997, ,997,
11 UNDERWRITING AND INVESTMENT EXHIBIT PART 2B - ANALYSIS OF CLAIMS UNPAID - PRIOR YEAR - NET OF REINSURANCE Claims Paid Claim Reserve and Claim Liability 5 6 During the Year December 31 of Current Year Estimated Claim Reserve and On Claims Incurred On Claims On Claims Unpaid On Claims Claims Incurred Claim Liability Prior to January 1 Incurred During December 31 of Incurred During in Prior Years December 31 of Line of Business of Current Year the Year Prior Year the Year (Columns 1 + 3) Prior Year 1. Comprehensive (hospital and medical) Medicare supplement Dental only Vision only Federal employees health benefits plan Title XVIII - Medicare ,408, ,713, ,414, ,583, ,822, ,734, Title XIX - Medicaid Other health Health subtotal (Lines 1 to 8) ,408, ,713, ,414, ,583, ,822, ,734, Healthcare receivables (a) Other non-health Medical incentive pools and bonus amounts ,570, ,234, ,354, ,052, ,925, ,984, Totals (Lines ) ,979, ,948, ,769, ,635, ,748, ,718,962 (a) Excludes $...0 loans or advances to providers not yet expensed.
12 UNDERWRITING AND INVESTMENT EXHIBIT PART 2C - DEVELOPMENT OF PAID AND INCURRED CLAIMS (000 Omitted) SECTION A - PAID HEALTH CLAIMS - GRAND TOTAL Cumulative Net Amounts Paid Year in Which Losses Were Incurred Prior XXX XXX......XXX XXX......XXX......XXX XXX......XXX......XXX......XXX GT SECTION B - INCURRED HEALTH CLAIMS - GRAND TOTAL Sum of Cumulative Net Amount Paid and Claim Liability, Claim Reserve and Medical Incentive Pool and Bonuses Outstanding at End of Year Year in Which Losses Were Incurred Prior XXX XXX......XXX XXX......XXX......XXX XXX......XXX......XXX......XXX SECTION C - INCURRED YEAR HEALTH CLAIM AND CLAIM ADJUSTMENT EXPENSE RATIO - GRAND TOTAL Claim and Claim Total Claims and Years in Which Adjustment Unpaid Claim Claims Adjustment Premiums were Earned and Premiums Claim Claim Adjustment Percent Expense Payments Percent Claims Adjustment Expense Incurred Percent Claims were Incurred Earned Payments Expense Payments (Col. 3/2) (Col ) (Col. 5/1) Unpaid Expense (Col ) (Col. 9/1) , , , , , , , , , , , , , , , , , , , , ,
13 UNDERWRITING AND INVESTMENT EXHIBIT PART 2C - DEVELOPMENT OF PAID AND INCURRED CLAIMS (000 Omitted) SECTION A - PAID HEALTH CLAIMS - HOSPITAL AND MEDICAL Cumulative Net Amounts Paid Year in Which Losses Were Incurred Prior XXX XXX......XXX XXX......XXX......XXX XXX......XXX......XXX......XXX HM SECTION B - INCURRED HEALTH CLAIMS - HOSPITAL AND MEDICAL Sum of Cumulative Net Amount Paid and Claim Liability, Claim Reserve and Medical Incentive Pool and Bonuses Outstanding at End of Year Year in Which Losses Were Incurred Prior XXX XXX......XXX XXX......XXX......XXX XXX......XXX......XXX......XXX SECTION C - INCURRED YEAR HEALTH CLAIM AND CLAIM ADJUSTMENT EXPENSE RATIO - HOSPITAL AND MEDICAL Claim and Claim Total Claims and Years in Which Adjustment Unpaid Claim Claims Adjustment Premiums were Earned and Premiums Claim Claim Adjustment Percent Expense Payments Percent Claims Adjustment Expense Incurred Percent Claims were Incurred Earned Payments Expense Payments (Col. 3/2) (Col ) (Col. 5/1) Unpaid Expenses (Col ) (Col. 9/1) , , , , , , , , , , , , , , , , , , , , , ,
14 UNDERWRITING AND INVESTMENT EXHIBIT PART 2C - DEVELOPMENT OF PAID AND INCURRED CLAIMS (000 Omitted) SECTION A - PAID HEALTH CLAIMS - MEDICARE SUPPLEMENT Cumulative Net Amounts Paid Year in Which Losses Were Incurred Prior XXX XXX......XXX XXX......XXX......XXX XXX......XXX......XXX......XXX MS SECTION B - INCURRED HEALTH CLAIMS - MEDICARE SUPPLEMENT Sum of Cumulative Net Amount Paid and Claim Liability, Claim Reserve and Medical Incentive Pool and Bonuses Outstanding at End of Year Year in Which Losses Were Incurred Prior XXX XXX......XXX XXX......XXX......XXX XXX......XXX......XXX......XXX SECTION C - INCURRED YEAR HEALTH CLAIM AND CLAIM ADJUSTMENT EXPENSE RATIO - MEDICARE SUPPLEMENT Claim and Claim Total Claims and Years in Which Adjustment Unpaid Claim Claims Adjustment Premiums were Earned and Premiums Claim Claim Adjustment Percent Expense Payments Percent Claims Adjustment Expense Incurred Percent Claims were Incurred Earned Payments Expense Payments (Col. 3/2) (Col ) (Col. 5/1) Unpaid Expenses (Col ) (Col. 9/1)
15 UNDERWRITING AND INVESTMENT EXHIBIT PART 2C - DEVELOPMENT OF PAID AND INCURRED CLAIMS (000 Omitted) SECTION A - PAID HEALTH CLAIMS - DENTAL ONLY Cumulative Net Amounts Paid Year in Which Losses Were Incurred Prior XXX XXX......XXX XXX......XXX......XXX XXX......XXX......XXX......XXX DO SECTION B - INCURRED HEALTH CLAIMS - DENTAL ONLY Sum of Cumulative Net Amount Paid and Claim Liability, Claim Reserve and Medical Incentive Pool and Bonuses Outstanding at End of Year Year in Which Losses Were Incurred Prior XXX XXX......XXX XXX......XXX......XXX XXX......XXX......XXX......XXX SECTION C - INCURRED YEAR HEALTH CLAIM AND CLAIM ADJUSTMENT EXPENSE RATIO - DENTAL ONLY Claim and Claim Total Claims and Years in Which Adjustment Unpaid Claim Claims Adjustment Premiums were Earned and Premiums Claim Claim Adjustment Percent Expense Payments Percent Claims Adjustment Expense Incurred Percent Claims were Incurred Earned Payments Expense Payments (Col. 3/2) (Col ) (Col. 5/1) Unpaid Expenses (Col ) (Col. 9/1)
16 UNDERWRITING AND INVESTMENT EXHIBIT PART 2C - DEVELOPMENT OF PAID AND INCURRED CLAIMS (000 Omitted) SECTION A - PAID HEALTH CLAIMS - VISION ONLY Cumulative Net Amounts Paid Year in Which Losses Were Incurred Prior XXX XXX......XXX XXX......XXX......XXX XXX......XXX......XXX......XXX VO SECTION B - INCURRED HEALTH CLAIMS - VISION ONLY Sum of Cumulative Net Amount Paid and Claim Liability, Claim Reserve and Medical Incentive Pool and Bonuses Outstanding at End of Year Year in Which Losses Were Incurred Prior XXX XXX......XXX XXX......XXX......XXX XXX......XXX......XXX......XXX SECTION C - INCURRED YEAR HEALTH CLAIM AND CLAIM ADJUSTMENT EXPENSE RATIO - VISION ONLY Claim and Claim Total Claims and Years in Which Adjustment Unpaid Claim Claims Adjustment Premiums were Earned and Premiums Claim Claim Adjustment Percent Expense Payments Percent Claims Adjustment Expense Incurred Percent Claims were Incurred Earned Payments Expense Payments (Col. 3/2) (Col ) (Col. 5/1) Unpaid Expenses (Col ) (Col. 9/1)
17 UNDERWRITING AND INVESTMENT EXHIBIT PART 2C - DEVELOPMENT OF PAID AND INCURRED CLAIMS (000 Omitted) SECTION A - PAID HEALTH CLAIMS - FEDERAL EMPLOYEES HEALTH BENEFITS PLAN PREMIUM Cumulative Net Amounts Paid Year in Which Losses Were Incurred Prior XXX XXX......XXX XXX......XXX......XXX XXX......XXX......XXX......XXX FE SECTION B - INCURRED HEALTH CLAIMS - FEDERAL EMPLOYEES HEALTH BENEFITS PLAN PREMIUM Sum of Cumulative Net Amount Paid and Claim Liability, Claim Reserve and Medical Incentive Pool and Bonuses Outstanding at End of Year Year in Which Losses Were Incurred Prior XXX XXX......XXX XXX......XXX......XXX XXX......XXX......XXX......XXX SECTION C - INCURRED YEAR HEALTH CLAIM AND CLAIM ADJUSTMENT EXPENSE RATIO - FEDERAL EMPLOYEES HEALTH BENEFITS PLAN PREMIUM Claim and Claim Total Claims and Years in Which Adjustment Unpaid Claim Claims Adjustment Premiums were Earned and Premiums Claim Claim Adjustment Percent Expense Payments Percent Claims Adjustment Expense Incurred Percent Claims were Incurred Earned Payments Expense Payments (Col. 3/2) (Col ) (Col. 5/1) Unpaid Expenses (Col ) (Col. 9/1)
18 UNDERWRITING AND INVESTMENT EXHIBIT PART 2C - DEVELOPMENT OF PAID AND INCURRED CLAIMS (000 Omitted) SECTION A - PAID HEALTH CLAIMS - TITLE XVIII - MEDICARE Cumulative Net Amounts Paid Year in Which Losses Were Incurred Prior XXX XXX......XXX XXX......XXX......XXX XXX......XXX......XXX......XXX XV SECTION B - INCURRED HEALTH CLAIMS - TITLE XVIII - MEDICARE Sum of Cumulative Net Amount Paid and Claim Liability, Claim Reserve and Medical Incentive Pool and Bonuses Outstanding at End of Year Year in Which Losses Were Incurred Prior XXX XXX......XXX XXX......XXX......XXX XXX......XXX......XXX......XXX SECTION C - INCURRED YEAR HEALTH CLAIM AND CLAIM ADJUSTMENT EXPENSE RATIO - TITLE XVIII - MEDICARE Claim and Claim Total Claims and Years in Which Adjustment Unpaid Claim Claims Adjustment Premiums were Earned and Premiums Claim Claim Adjustment Percent Expense Payments Percent Claims Adjustment Expense Incurred Percent Claims were Incurred Earned Payments Expense Payments (Col. 3/2) (Col ) (Col. 5/1) Unpaid Expenses (Col ) (Col. 9/1)
19 UNDERWRITING AND INVESTMENT EXHIBIT PART 2C - DEVELOPMENT OF PAID AND INCURRED CLAIMS (000 Omitted) SECTION A - PAID HEALTH CLAIMS - TITLE XIX - MEDICAID Cumulative Net Amounts Paid Year in Which Losses Were Incurred Prior XXX XXX......XXX XXX......XXX......XXX XXX......XXX......XXX......XXX XI SECTION B - INCURRED HEALTH CLAIMS - TITLE XIX - MEDICAID Sum of Cumulative Net Amount Paid and Claim Liability, Claim Reserve and Medical Incentive Pool and Bonuses Outstanding at End of Year Year in Which Losses Were Incurred Prior XXX XXX......XXX XXX......XXX......XXX XXX......XXX......XXX......XXX SECTION C - INCURRED YEAR HEALTH CLAIM AND CLAIM ADJUSTMENT EXPENSE RATIO - TITLE XIX - MEDICAID Claim and Claim Total Claims and Years in Which Adjustment Unpaid Claim Claims Adjustment Premiums were Earned and Premiums Claim Claim Adjustment Percent Expense Payments Percent Claims Adjustment Expense Incurred Percent Claims were Incurred Earned Payments Expense Payments (Col. 3/2) (Col ) (Col. 5/1) Unpaid Expenses (Col ) (Col. 9/1)
20 UNDERWRITING AND INVESTMENT EXHIBIT PART 2C - DEVELOPMENT OF PAID AND INCURRED CLAIMS (000 Omitted) SECTION A - PAID HEALTH CLAIMS - OTHER Cumulative Net Amounts Paid Year in Which Losses Were Incurred Prior XXX XXX......XXX XXX......XXX......XXX XXX......XXX......XXX......XXX OT SECTION B - INCURRED HEALTH CLAIMS - OTHER Sum of Cumulative Net Amount Paid and Claim Liability, Claim Reserve and Medical Incentive Pool and Bonuses Outstanding at End of Year Year in Which Losses Were Incurred Prior XXX XXX......XXX XXX......XXX......XXX XXX......XXX......XXX......XXX SECTION C - INCURRED YEAR HEALTH CLAIM AND CLAIM ADJUSTMENT EXPENSE RATIO - OTHER Claim and Claim Total Claims and Years in Which Adjustment Unpaid Claim Claims Adjustment Premiums were Earned and Premiums Claim Claim Adjustment Percent Expense Payments Percent Claims Adjustment Expense Incurred Percent Claims were Incurred Earned Payments Expense Payments (Col. 3/2) (Col ) (Col. 5/1) Unpaid Expenses (Col ) (Col. 9/1)
21 13 Statement as of December 31, 2010 of the UNDERWRITING AND INVESTMENT EXHIBIT PART 2D - AGGREGATE RESERVE FOR ACCIDENT AND HEALTH CONTRACTS ONLY Federal Comprehensive Employees Title Title (Hospital Medicare Dental Vision Health XVIII XIX Total and Medical) Supplement Only Only Benefit Plan Medicare Medicaid Other POLICY RESERVE 1. Unearned premium reserves Additional policy reserves (a) Reserve for future contingent benefits Reserve for rate credits or experience rating refunds (including $...0) for investment income Aggregate write-ins for other policy reserves ,800, ,800, Totals (gross) ,800, ,800, Reinsurance ceded Totals (net) (Page 3, Line 4) ,800, ,800, CLAIM RESERVE 9. Present value of amounts not yet due on claims Reserve for future contingent benefits Aggregate write-ins for other claim reserves Totals (gross) Reinsurance ceded Totals (net) (Page 3, Line 7) DETAILS OF WRITE-INS Risk Sharing Payable ,800, ,800, Summary of remaining write-ins for Line 5 from overflow page Totals (Lines 0501 thru 0503 plus 0598) (Line 5 above) ,800, ,800, Summary of remaining write-ins for Line 11 from overflow page Totals (Lines 1101 thru 1103 plus 1198) (Line 11 above) (a) Includes $...0 premium deficiency reserve.
22 UNDERWRITING AND INVESTMENT EXHIBIT PART 3 - ANALYSIS OF EXPENSES Claim Adjustment Expenses Cost Other Claim General Containment Adjustment Administrative Investment Expenses Expenses Expenses Expenses Total 1. Rent ($...0 for occupancy of own building) ,305, ,305, Salaries, wages and other benefits ,200, ,200, Commissions (less $...0 ceded plus $...0 assumed) ,718, ,718, Legal fees and expenses , , Certifications and accreditation fees , , Auditing, actuarial and other consulting services ,428, ,428, Traveling expenses , , Marketing and advertising ,486, ,486, Postage, express and telephone , , Printing and office supplies ,848, ,848, Occupancy, depreciation and amortization ,698, ,698, Equipment , , Cost or depreciation of EDP equipment and software Outsourced services including EDP, claims, and other services Boards, bureaus and association fees Insurance, except on real estate , , Collection and bank service charges Group service and administration fees Reimbursements by uninsured plans Reimbursements from fiscal intermediaries Real estate expenses Real estate taxes Taxes, licenses and fees: 23.1 State and local insurance taxes State premium taxes Regulatory authority licenses and fees Payroll taxes Other (excluding federal income and real estate taxes) , , Investment expenses not included elsewhere Aggregate write-ins for expenses ,378, ,378, Total expenses incurred (Lines 1 to 25) ,683, (a)...58,683, Less expenses unpaid December 31, current year , , , Add expenses unpaid December 31, prior year , , Amounts receivable relating to uninsured plans, prior year Amounts receivable relating to uninsured plans, current year Total expenses paid (Lines 26 minus 27 plus 28 minus 29 plus 30) (37,109)...58,633, ,596,561 DETAILS OF WRITE-INS Data Process ,655, ,655, Public Relations , , Provider Relations , , Summary of remaining write-ins for Line 25 from overflow page ,019, ,019, TOTALS (Lines 2501 thru 2503 plus 2598) (Line 25 above) ,378, ,378,638 (a) Includes management fees of $...57,121,006 to affiliates and $...0 to non-affiliates. 14
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