Wis. Admin. Code Office of the Commissioner of Insurance Ins 9.08 - Other reporting requirements
(1) ANNUAL STATEMENT. All
insurers authorized to write health maintenance organization business and insurers licensed to write only
limited service health organization business shall file with the commissioner by March 1 of each year an
annual statement for the preceding year. A health maintenance organization insurer and limited service health
organization insurer shall use the current health annual statement blank prepared by the national association
of insurance commissioners.
(a) A health maintenance organization insurer
shall include with its annual statement a statement of covered expenses, and a special procedures opinion
from a certified public accountant, in the form prescribed by the commissioner as appendix A.
(b) A health maintenance organization insurer shall file a quarterly
report, including a report concerning covered expenses, in a form prescribed by the commissioner within 45
days after the close of each of the first 3 calendar quarters of the year unless the commissioner has
notified the insurer that another reporting schedule is appropriate.
(c) A health maintenance organization insurer shall include with its annual
audit financial reports filed under s. Ins 50.05 a statement of covered expenses and an audit opinion
concerning the statement. Both the statement and opinion shall be in the form prescribed by the commissioner
as appendix B and are due no later than May 1 of each year.
(1m) MEDICARE AND MEDICAID HEALTH MAINTENANCE ORGANIZATIONS. A health
maintenance organization insurer that writes 100 % of its business to Medicare or Medicaid recipients, or a
combination of the 2, is not required to include a special procedures opinion from a certified public
accountant as required by sub. (1) (a) or an audit opinion concerning the statement of covered expenses as
required by sub. (1) (c).
(2) QUARTERLY REPORT. An insurer
writing health maintenance organization business, other than a health maintenance organization insurer, shall
file a quarterly report in a form prescribed by the commissioner within 45 days after the close of each of
the first 3 calendar quarters of the year unless the commissioner notifies the insurer that another reporting
schedule is appropriate.
(3) PRESUMPTIONS.
(a) If a health maintenance organization insurer fails to file a statement
or opinion required under subs. (1) to (3) by the time required, it is presumed, in any action brought by the
office within one year of the due date, that the health maintenance organization insurer is in financially
hazardous condition and that the percentage of its liabilities for health care costs which are covered
liabilities is and continues to be less than 65% for the purpose of s. 609.95, Stats.
(b) It is presumed that the percentage of liabilities that are covered
liabilities of a health maintenance organization insurer is and continues to be not greater than the
percentage of covered expenses stated in the report or statement filed under subs. (1) to (3) for the most
recent period.
(c) The health maintenance organization insurer
has the burden of refuting a presumption under par. (a) or (b).
Notes
The form described in sub. (1) may be obtained from the Office of the Commissioner of Insurance, P. O. Box 7873, Madison, WI 53707-7873.
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