Annual Statement Supplement Report (ASSR) Definitions
For the Year Ending: December 31, 2012 (Report Due: March 1, 2013 or May 1, 2013 for HMO only)
Vermont law requires all Insurance Carriers, including Health Service Corporations and Fraternal companies, to submit an annual accurate and complete report of their business. Industry analysts, policy makers and researchers use this data to understand more about Vermont’s health insurance market.
- No Subsitute Forms Will Be Accepted
- Forms must be submitted even if there has been no activity.
- All amounts must be reported in whole dollars.
Definitions for Column Headings:
Column A - Lists the type of accident and health lines of insurance business on which to report for Vermont residents.
Column B – For each respective section (i.e. Vermont Situs vs. Non-Vermont Situs policies and Individual vs. Group), insurers must report the number of policies or certificates in force as of December 31, 2012 for ALL Vermont residents. This is the number of individual policies or group certificates issued to Vermont residents in force as of December 31, 2012. It is not the number of persons covered under individual policies or group certificates.
Column C - For each respective section (i.e. Vermont Situs vs. Non-Vermont Situs policies and Individual vs. Group), insurers must report the total number of Vermont lives insured, including dependents, under individual policies and group certificates as of December 31, 2012.
Column D - For each respective section (i.e. Vermont Situs vs. Non-Vermont Situs policies and Individual vs. Group), insurers must report member months, which is the sum of total number of lives insured on a pre-specified day of each month in 2012 (total member months are the cumulative total of member months for the calendar year 2012).
Column E - For each respective section (i.e. Vermont Situs vs. Non-Vermont Situs policies and Individual vs. Group), insurers must report Direct Premium/Premium Equivalent Earned, which is the total premium or premium equivalent collected in 2012 for Vermont residents that are insured under an individual policy or group certificate. Include any premiums/premium equivalents paid in 2010 for 2012, but do not include premiums/premium equivalents paid in 2012 for the year 2013.
Column F - For each respective section (i.e. Vermont Situs vs. Non-Vermont Situs policies and Individual vs. Group), insurers must report Direct Claims Incurred/Claim Payments, which is the total claims incurred or claim payments made during or after 2012 for Vermont residents that are insured under an individual or group policy.
Column G – New category!: For each respective section (i.e. Vermont Situs vs. Non-Vermont Situs policies and Individual vs. Group), insurers must report Lapsed Policies or Certificates, which is the number of Vermont residents whose insurance coverage was terminated due to non-payment of premium in 2012.
Definitions for Selected Row Headings:
Accident Only or AD&D: Polices that provide coverage, for accidental death, dismemberment, disability, or hospital and medical care caused by or necessitated as a result of accident or specified kinds of accidents. Types of coverage include student accident, sports accident, travel accident, blanket accident, specific accident or accidental death and dismemberment (AD&D).
Catamount Health Insurance: An individual (non-group) health insurance product for uninsured Vermonters who do not have access to employer (group) insurance and do not quality for other state subsidized health programs.
Comprehensive Major Medical: These policies include but are not limited to policies that provide indemnity, HMO, PPO, POS or expense based coverage including coverage for hospital, medical and surgical expenses. This category excludes limited benefit plans such as Short Term Medical Insurance, hospital only, medical only, hospital confinement indemnity, surgical, outpatient indemnity, specified disease, intensive care, and organ and tissue transplant coverage as well as any other coverage described in the other categories of this exhibit.
Dental: Policies providing only dental treatment benefits such as routine dental examinations, preventative dental work, and dental procedures needed to treat tooth decay and diseases of the teeth and jaw. If dental benefits are part of a comprehensive medical plan, this data should be included under comprehensive/major medical category.
Disability (Long-Term): Policies that provide a weekly or monthly income benefit for more than five years for individual coverage and more than one year for group coverage for full or partial disability arising from accident and/or sickness. Include policies that provide Overhead Expense Benefits. This does not include credit disability.
Disability (Short-Term): Policies that provide a weekly or monthly income benefit for up to five years for individual coverage and up to one year for group coverage for full or partial disability arising from accident and/or sickness. Include policies that provide Overhead Expense Benefits. This does not include credit disability.
Discretionary Groups (Group Only): This line pertains to groups that do not meet the statutory requirements of employer groups, associations or trusts, and have received discretionary approval by the Department of Banking, Insurance, Securities and Health Care Administration. The totals in the columns should be calculated in such a manner that includes the total number covered lives in each discretionary group.
High Deductible Health Plan (HDHP): Defined in the Medicare Modernization and Prescription Drug Act of 2003.
Non-Exempt Associations (Group Only): Subject to the statewide community rate. The totals in each of the columns should be calculated in a such a manner that includes the number of covered lives in each association.
Exempt Associations (Group Only): Applied and received exemption from the Vermont Department of Banking, Insurance, Securities and Health Care Administration. Exempt associations are community rated within the association. The totals in each of the columns should be calculated in such a manner that includes the number of lives covered in each association.
Federal Employees (Group Only): Coverage provided to Federal employees, retirees and their survivors, and administered by the Office of Personnel Management under the FEHBP (Federal Employees Health Benefit Program).
Limited Benefit: Policies that provide coverage that is designed to provide specified health benefits in certain limited and clearly specified circumstances. Only include policies that are not requested elsewhere in the submission form. For example include Hospital Confinement only, Vision Care only and Short Term Major Medical, etc. (Do not include Dental Only , Specified Disease and Accident Only & Accidental Death and Dismemberment because these policies are listed elsewhere on the submission form).
Long-Term Care (Tax Qualified): Policies that provide coverage for not less than one year for diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services provided in a setting other than an acute care unit of a hospital including policies that provide benefits for cognitive impairment, or loss of functional capacity. This includes policies providing nursing home care plus home health care and/or community based care. This coverage meets the federal IRS requirements to qualify for a tax deduction.
Long-Term Care (Non Qualified): Policies that provide coverage for not less than one year for diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services provided in a setting other than an acute care unit of a hospital including policies that provide benefits for cognitive impairment, or loss of functional capacity. This includes policies providing nursing home care plus home health care and/or community based care. This coverage does NOT meet the federal IRS requirements to qualify for a tax deduction.
Medicare Part C (Individual Only): Refers to private managed care plans that offer Parts A and B services together. Also known as Medicare Advantage program, which offers the option of enrolling in a managed care plan to receive Medicare benefits (both medical and drug coverage). Types of plans authorized under The Federal Balanced Budget Act of 1997 include preferred provider organizations (PPO’s), provider-sponsored organizations (PSO’s), private fee-for-service (PFFS) plans and high deductible plans linked to Medical Savings Accounts (MSA’s), and as of 2003, Special Needs Plans (SNP’s) for dual eligibles and other vulnerable populations.
Medicare Part D (Individual Only): Created under the Medicare Modernization Act of 2003 (MMA), it is a voluntary outpatient prescription drug benefit for Medicare Beneficiaries that began in 2006. Medicare Part D does not need to be Licensed by the state of Vermont as it is Licensed by Centers for Medicare and Medicaid Services (CMS).
Medicare Supplement (MEDIGAP): Standardized Plans are policies sold by insurance companies to fill “gaps” in a policyholder’s Medicare coverage. These policies were issued after July 1, 1992.
Medicare Supplement (MEDIGAP): Pre-Standardized Plans are policies sold by insurance companies to fill “gaps” in a policyholder’s Medicare coverage. These policies were issued before July 1, 1992.
Other Medical (Non Comprehensive): This includes policies such as hospital only, hospital confinement, surgical, outpatient indemnity, intensive care, mental health/substance abuse, and organ and tissue transplant (including scheduled type policies). Expense reimbursement and indemnity plans should be included. This category does not include TRICARE/CHAMPUS supplement, Medicare supplement, or Federal Employee Health Benefit Program coverage, comprehensive major medical or limited benefit coverage.
Other are plans not fitting in the categories listed in this document, which must be identified:
Specified or Named Disease: This includes policies that provide benefits only for the diagnosis and/or treatment of a specifically named disease or diseases. Benefits can be paid as expense incurred, per diem, or as a principle sum.
Stop Loss/Excess Loss (Group Only): This insurance or other risk-transfer arrangement that is purchased by a group health plan or by the sponsor or trustee of such plan to limit the exposure of such person against losses sustained by such plan.
Student Policies: This includes policies that cover students for both accident and health benefits while they are enrolled and attending school or college. These can be either individual policies or group policies sponsored by the school or college.
Third Party Administrator (TPA) And Administrative Services Only (ASO) (Group Only): This means an entity or person contracting to provide any combination of services in administering health benefits for a health insurer or other entity such as self-insured employer plans, to include claims processing, underwriting, premium collection, case management, authorizations and customer service.
Trusts (Group Only): This line pertains to the total number of policies issued to a trust, or to one or more trustees of a fund established or adopted by two or more employers or one or more labor unions or similar employee organizations. The total number of policies includes the number of trusts not the number of groups within the trust. The total number of lives includes all the members/employees and all dependents of all the groups that belong to every trust.
**NOTE: Under Group Business for Comprehensive Major Medical only, each market segment has two different reporting items. The first row EXCLUDES “High Deductible Health Plans” (HDHP) and is Non-“HDHP” business ONLY. The second row is only the “HDHP” portion of the business.