Section 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).Wis. Admin. Code Office of the Commissioner of Insurance Ins 9.08
Cr. Register, February, 2000, No. 530, eff. 3-1-00.Amended by, CR 22-070: am. (1) (intro.), cr. (1m), r. (4) Register June 2023 No. 810, eff. 7-1-23; correction in (1m) made under s. 35.17, Stats., Register June 2023 No. 810, eff. 7/1/2023The form described in sub. (1) may be obtained from the Office of the Commissioner of Insurance, P. O. Box 7873, Madison, WI 53707-7873.