Section 3: Annual comprehensive financial statement; contents; appendix; failure to file; public hearing for excessive risk-based capital ratio; waivers
[Text of section applicable to all dental benefit plans issued, made effective, delivered or renewed on or after January 1, 2024. See 2022, 287, Sec. 4.]
Section 3. (a) Each carrier shall submit an annual comprehensive financial statement to the division detailing carrier costs from the previous calendar year. The annual comprehensive financial statement shall include all of the information in this section and shall be itemized, where applicable, by:
(i) market group size, including individual; small groups of 1 to 5, 6 to 10, 11 to 25, and 26 to 50; large groups of 50 to 100, 101 to 500, 501 to 1000 and greater than 1000; and
(ii) line of business, including any stand-alone dental plan that covers oral surgical care, dental services, dental procedures or benefits covered by any individual, general, blanket or group policy of health, accident and sickness insurance issued by an insurer licensed or otherwise authorized to transact accident and health insurance under chapter 175; any oral surgical care, dental services, dental procedures or benefits covered by a stand-alone individual or group dental medical service plan issued by a non-profit medical service corporation under chapter 176B; any oral surgical care, dental services, dental procedures or benefits covered by a stand-alone individual or group dental service plan issued by a dental service corporation organized under chapter 176E; any oral surgical care, dental services, dental procedures or benefits covered by a stand-alone individual or group dental health maintenance contract issued by a health maintenance organization organized under chapter 176G; any oral surgical care, dental services, dental procedures or benefits covered by a stand-alone individual or group preferred provider dental plan issued by a preferred provider arrangement organized under chapter 176I; and stand-alone dental group health insurance plans issued by the commission under chapter 32A.
(b) The financial statement shall include, but shall not be limited to, the following information: (i) direct premiums earned, as defined in chapter 176J; direct claims incurred, as defined in said chapter 176J; (ii) medical loss ratio; (iii) number of members; (iv) number of distinct groups covered; (v) number of lives covered; (vi) realized capital gains and losses; (vii) net income; (viii) accumulated surplus; (ix) accumulated reserves; (x) risk-based capital ratio, based on a formula developed by the National Association of Insurance Commissioners; (xi) financial administration expenses, including underwriting, auditing, actuarial, financial analysis, treasury and investment expenses; (xii) marketing and sales expenses, including advertising, member relations, member enrollment expenses; (xiii) distribution expenses, including commissions, producers, broker and benefit consultant expenses; (xiv) claims operations expenses, including adjudication, appeals, settlements and expenses associated with paying claims; (xv) dental administration expenses, including disease management, utilization review and dental management expenses; (xvi) network operational expenses, including contracting, dentist relations and dental policy procedures; (xvii) charitable expenses, including any contributions to tax-exempt foundations and community benefits; (xviii) board, bureau or association fees; (xix) any miscellaneous expenses described in detail by expense, including an expense not included in (i) to (xviii), inclusive; (xx) payroll expenses and the number of employees on the carrier's payroll; (xxi) taxes, if any, paid by the carrier to the federal government or to the commonwealth; and (xxii) any other information deemed necessary by the commissioner.
(c) Any carrier required to report under this section, which provides administrative services to 1 or more self-insured groups shall include, as an appendix to such report, the following information: (i) the number of the carrier's self-insured customers; (ii) the aggregate number of members, as defined in section 1 of chapter 176J, in all of the carrier's self-insured customers; (iii) the aggregate number of lives covered in all of the carrier's self-insured customers; (iv) the aggregate value of direct premiums earned, as defined in said chapter 176J, for all of the carrier's self-insured customers; (v) the aggregate medical loss ratio, as defined in said chapter 176J, for all of the carrier's self-insured customers; (vi) net income; (vii) accumulated surplus; (viii) accumulated reserves; (ix) the percentage of the carrier's self-insured customers that include each of the benefits mandated for health benefit plans under chapters 175, 176A, 176B and 176G; (x) administrative service fees paid by each of the carrier's self-insured customers; and (xi) any other information deemed necessary by the commissioner.
(d) A carrier who fails to file this report on or before April 1 shall be assessed a late penalty not to exceed $100 per day. The division shall make public all of the information collected under this section. The division shall issue an annual summary report to the joint committee on financial services, the joint committee on health care financing and the house and senate committees on ways and means of the annual comprehensive financial statements by May 15. The information shall be exchanged with the center for health information and analysis for use under section 10 of chapter 12C. The division shall, from time to time, require payers to submit the underlying data used in their calculations for audit.
The commissioner shall adopt rules to carry out this subsection, including standards and procedures requiring the registration of persons or entities not otherwise licensed or registered by the commissioner, such as third-party administrators, and criteria for the standardized reporting and uniform allocation methodologies among carriers. The division shall, before adopting regulations under this section, consult with other agencies of the commonwealth and the federal government and affected carriers to ensure that the reporting requirements imposed under the regulations are not duplicative.
(e) If, in any year, a carrier reports a risk-based capital ratio on a combined entity basis under subsection (a) that exceeds 700 percent, the division shall hold a public hearing within 60 days. The carrier shall submit testimony on its overall financial condition and the continued need for additional surplus. The carrier shall also submit testimony on how, and in what proportion to the total surplus accumulated, the carrier will dedicate any additional surplus to reducing the cost of dental benefit plans or for dental care quality improvement, patient safety, or dental cost containment activities not conducted in previous years. The division shall review such testimony and issue a final report on the results of the hearing.
(f) The commissioner may waive specific reporting requirements in this section for classes of carriers for which the commissioner deems such reporting requirements to be inapplicable; provided, however, that the commissioner shall provide written notice of any such waiver to the joint committee on health care financing and the house and senate committees on ways and means.