2013 NAIC ANNUAL STATEMENT INSTRUCTIONS HEALTH DEC 2013 REVISIONS

2013 NAIC ANNUAL STATEMENT INSTRUCTIONS HEALTH DEC 2013 REVISIONS PAGE 45: LIABILITIES, CAPITAL AND SURPLUS Revision: Modify instruction for Details of Write-ins Aggregated at Line 23 for Liablities Reason: Correct the name reference for SSAP No. 104 PAGE 118: Revision: Reason: NOTES TO FINANCIAL STATEMENTS Modify the instruction for Note 5D(3) SAPWG modified the disclosure language PAGE 189 & 189.1: NOTES TO FINANCIAL STATEMENTS Revision: Add disclosure Note 21for Joint and Several Liability Arrangements Reason: SAPWG adopted new disclosure for SSAP No. 5R in November 2013. PAGE 329 & 330: Revision: Reason: SCHEDULE BA GENERAL INSTRUCTIONS Correct reference to Mortgage Obligations in the category line definitions Mortgage Loans now have their own lines. EDITOR S NOTE: The above changes are highlighted within the attached instructions that follow this page. Recent Blanks Working Group Agenda Items (Exposure Drafts) may be viewed in detail at the following web site: http://www.naic.org/committees_e_app_blanks.htm. 2013 National Association of Insurance Commissioners 1

This page intentionally left blank.

Detail of Write-ins Aggregated at Line 23 for Other Liabilities List separately each category of liabilities for which there is no pre-printed line on Page 3. Uncashed drafts and checks that are pending escheatment to a state. Details of Write-ins Aggregated at Line 25 for Special Surplus Funds Interest paid in advance on mortgage loans, rents paid in advance and retroactive reinsurance amounts, if any. Servicing liabilities as described in SSAP No. 103, Accounting for Transfers and Servicing of Financial Assets and Extinguishments of Liabilities. Unearned compensation for employee stock ownership plan stock options issued and stock purchase and award plans. Refer to SSAP No. 12, Employee Stock Ownership Plans and SSAP No. 104, Share-Based Payments, for accounting guidance. Amount recorded as required by the additional minimum liability calculation with a description of additional pension liability. See SSAP No. 102, Accounting for Pensions, A Replacement of SSAP No. 89, for guidance. Voluntary and general contingency reserves and subscriber accounts that represent individual subscriber contributions. Details of Write-ins Aggregated at Line 30 for Other-Than-Special Surplus Funds Enter separately by category the amount of guaranty fund notes, contribution certificates, statutory deposits of alien insurers, or similar funds other than capital stock, with appropriate description. List separately the aggregate amount of all surplus notes required, or those that are a prerequisite for purchasing an insurance policy and that are held by the policyholder. 2000 2013 National Association of Insurance Commissioners 45 Revised 12/2013 Health 2013

STATEMENT OF REVENUE AND EXPENSES Report fully accrued revenue and expenses as defined below, for the period. Report uncovered expenses appropriately for medical, hospital and administration. Lines 9 through 13 should be reported gross of withholds and net of applicable coordination of benefits, deductibles, co-payments, risk share, and provider discounts. Column 1 Uncovered Expenses Line 1 Member Months Costs discussed previously in defining uncovered liabilities. Column 2 should equal Exhibit 1, Enrollment by Product Type, Line 7, Column 6. Line 2 Net Premium Income (including $ non-health premium income) Should equal the total premiums reported in the Underwriting and Investment Exhibit, Part 1, Line 12, Column 4, direct written premiums plus reinsurance assumed less reinsurance ceded. Written premium is defined as the contractually determined amount charged by the reporting entity to the policyholder for the effective period of the contract based on the expectation of risk, policy benefits, and expenses associated with the coverage provided by the terms of the insurance contract. For health contracts without fixed contract periods, premiums written will be equal to the amount collected during the reporting period plus uncollected premiums at the end of the period less uncollected premiums at the beginning of the period. Line 3 Change in Unearned Premium Reserves and Reserve for Rate Credits Exclude: Reserves relating to uninsured plans and the uninsured portion of partially insured plans. Line 4 Fee-for-Service (net of $ medical expenses) Revenue recognized by the reporting entity for provision of health services to non-members by reporting entity providers and to members through provision of health services excluded from their prepaid benefit packages. Include in the inside amount, the medical expenses associated with fee-for-service business. Line 5 Risk Revenue Amounts charged by the reporting entity as a provider or intermediary for specified medical services (e.g., full professional, dental, radiology, etc.) provided to the policyholders or members of another insurer or reporting entity. Line 6 Aggregate Write-ins for Other Health Care Related Revenues Unlike premiums that are collected from an employer group or individual member, risk revenue is the prepaid (usually on a capitated basis) payment, made by another insurer or reporting entity to the reporting entity in exchange for services to be provided or offered by such organization. Enter the total of the write-ins listed in schedule Details of Write-ins Aggregated at Line 6 for Other Health Care Related Revenues. Line 7 Aggregate Write-ins for Other Non-health Revenues Enter the total of the write-ins in schedule Details of Write-ins Aggregate at Line 7 for Other Non-health Revenues. 2000 2013 National Association of Insurance Commissioners 46 Health 2013

(6) For impaired loans disclose the amounts, aggregated by type (Farm, Residential Insured, Residential All Other, Commercial Insured, Commercial All Other, Mezzanine), related to the following: Average recorded investment Interest income recognized Recorded investments on nonaccrual status pursuant to SSAP No. 34, Investment Income Due and Accrued Unless not practicable, the amount of interest income recognized using a cash-basis method of accounting during the time within that period that the loans were impaired. (7) For each period for which results of operations are presented, the activity in the allowance for credit losses account, including: a. The balance in the allowance for credit losses account at the beginning of each period. b. Additions charged to operations. c. Direct write-downs charged against the allowance. d. Recoveries of amounts previously charged off. e. The balance in the allowance for credit losses account at the end of each period. (8) The policy for recognizing interest income on impaired loans, including the method for recording cash receipts. B. Debt Restructuring For restructured debt in which the reporting entity is a creditor, disclose the following: (1) The recorded investment in the loans for which impairment has been recognized in accordance with SSAP No. 36, Troubled Debt Restructuring. (2) The related realized capital loss. (3) The amount of commitments, if any, to lend additional funds to debtors owing receivables whose terms have been modified in troubled debt restructuring. (4) The creditor s income recognition policy for interest income on an impaired loan. C. Reverse Mortgages For reverse mortgages, disclose the following: (1) A description of the reporting entity s accounting policies and methods, including the statistical methods and assumptions used in calculating the reserve. (2) General information regarding the reporting entity s commitment under the agreement. (3) The reserve amount that is netted against the asset. (4) Investment income or loss recognized in the period as a result of the re-estimated cash flows. 2000 2013 National Association of Insurance Commissioners 117 Health 2013

D. Loan-Backed Securities For loan-backed securities, disclose the following: (1) Descriptions of sources used to determine prepayment assumptions. (2) All securities within the scope of this statement with a recognized other-than-temporary impairment, disclosed in the aggregate, classified on the basis for the other-than-temporary impairment: Intent to sell. Inability or lack of intent to retain the investment in the security for a period of time sufficient to recover the amortized cost basis. (3) For each security, by CUSIP, with an other-than-temporary impairment, recognized in the current reporting period by the reporting entity, as the present value of cash flows expected to be collected is less than the amortized cost basis of the securities: The amortized cost basis, prior to any current-period other-than-temporary impairment. The other-than-temporary impairment recognized in earnings as a realized loss. The fair value of the security. The amortized cost basis after the current-period other-than-temporary impairment. (4) All impaired securities (fair value is less than cost or amortized cost) for which an other-than-temporary impairment has not been recognized in earnings as a realized loss (including securities with a recognized other-than-temporary impairment for non-interest related declines when a non-recognized interest related impairment remains): a. The aggregate amount of unrealized losses (that is, the amount by which cost or amortized cost exceeds fair value); and b. The aggregate related fair value of securities with unrealized losses. The disclosures in (a) and (b) above should be segregated by those securities that have been in a continuous unrealized loss position for less than 12 months and those that have been in a continuous unrealized loss position for 12 months or longer using fair values determined in accordance with SSAP No. 27, Disclosure of Information about Financial Instruments with Off-Balance-Sheet Risk and Financial Instruments with Concentration of Credit Risk. (5) Additional information should be included describing the general categories of information that the investor considered in reaching the conclusion that the impairments are not other-thantemporary. 2000 2013 National Association of Insurance Commissioners 118 Revised 12/2013 Health 2013

(2) Number and balance of retained asset accounts in force at the end of the current year and prior year segregated within aging categories of up to 12 months, 13 to 24 months, 25 to 36 months, 37 to 48 months, 49 to 60 months, over 60 months. (3) Disclose the following segregated between individual and group contracts: Number and balance of retained asset accounts in force at the beginning of the year; Number and amount of retained asset accounts issued during the year; Investment earnings credited to retained asset accounts; Fees and other charges assessed to retained asset accounts during the year; Number and amount of retained asset accounts transferred to state unclaimed property funds; Number and amount of retained asset accounts closed/withdrawn during the year; and Number and balance of retained asset accounts in force at the end of the year. H. Offsetting and Netting of Assets and Liabilities The following quantitative information shall be disclosed (separately for assets and liabilities) when derivative, repurchase and reverse repurchase, and securities borrowing and securities lending assets and liabilities are offset and reported net in accordance with a valid right to offset per SSAP No. 64, Offsetting and Netting of Assets and Liabilities: The gross amounts of recognized assets and recognized liabilities The amounts offset in accordance with a valid right to offset per SSAP No. 64, Offsetting and Netting of Assets and Liabilities The net amounts presented in the statement of financial positions. Assets and liabilities that have a valid right to offset, but are not netted as they are prohibited under SSAP No. 64, Offsetting and Netting of Assets and Liabilities, are not required to be captured in the disclosures. I. Joint and Several Liabilities Disclose the following information for each joint and several liability arrangements accounted for under SSAP No. 5R, Liabilities, Contingencies and Impairment of Assets. If co-obligors are related parties, disclosure requirements in SSAP No. 25, Accounting for and Disclosures about Transactions with Affiliates and Other Related Parties also apply. The nature of the arrangement including: How the liability arose. The relationship with co-obligors. The terms and conditions of the arrangements. The total outstanding amount under the arrangement, which shall not be reduced by the effect of any amounts that may be recoverable from other entities. The carrying amount, if any, of the entity s liability and the carrying amount of a receivable recognized, if any. The nature of any recourse provisions that would enable recovery from other entities of the amounts paid, including any limitations on the amounts that might be recovered. In the period the liability is initially recognized and measured or in a period the measurement changes significantly: The corresponding entry. Where the entry was recorded in the financial statements. 2000 2013 National Association of Insurance Commissioners 189 Revised 12/2013 Health 2013

Illustration: A. Extraordinary Items On November, 20, the Company prepaid the holders of its % senior notes. Accordingly, the Company recorded a loss of $ related to the early retirement of debt. The loss comprised a $ million prepayment penalty and a write off of premium associated with the debt. This loss is reflected in Line of the Income Statement. B. Troubled Debt Restructuring (1) The Company has one mortgage loan payable with restructured terms. The principal changes in terms include the modification of terms from years to years and an increase in the interest rate from % to %. (2) The aggregate gain on restructuring the payable and the related income tax effect were $ and $, respectively. (3) The aggregate gain on the transfer of assets during 20 was $. (4) As of December 31, 20, the Company has $ that is considered contingently payable on the restructured loan, of which $ is included in the loan s carrying amount. The Company will be required to pay the contingent amount if its financial condition improves to the degree specified in the loan agreements. C. Other Disclosures and Unusual Items The following amounts were not represented in the financial statements as of December 31, 20X1 as they represent segregated funds held for others: Cash deposits of $ were not reported in the financial statements as of December 31, 20X1, as these deposits represented funds held in an escrow account. This is an increase of $ from the prior year December 31, 20X1 financial statements. NOTE The above is just an example of disclosing one item. The reporting entity could have more than one item to disclose. 2000 2013 National Association of Insurance Commissioners 189.1 Revised 12/2013 Health 2013

This page intentionally left blank. 2000 2013 National Association of Insurance Commissioners 189.2 Revised 12/2013 Health 2013

D. The company received $ and $ in 20 and 20, respectively, in business interruption insurance recoveries related to flooding that occurred at the company s main administrative office in August 20. The recoveries were reported within the line item xxx on the Summary of Operations. E. State Transferable and Non-transferable Tax Credits THIS EXACT FORMAT MUST BE USED IN THE PREPARATION OF THIS NOTE FOR THE TABLE BELOW. REPORTING ENTITIES ARE NOT PRECLUDED FROM PROVIDING CLARIFYING DISCLOSURE BEFORE OR AFTER THIS ILLUSTRATION. (1) Carrying Value of Transferable and Non-transferable State Tax Credits Gross of any Related Tax Liabilities and Total Unused Transferable and Non-transferable State Tax Credits by State and in Total Description of State Transferable and Non-transferable Tax Credits State Carrying Value Unused Amount Total (2) Method of Estimating Utilization of Remaining Transferable and Non-transferable State Tax Credits The Company estimated the utilization of the remaining transferable and non-transferable state tax credits by projecting future premium taking into account policy growth and rate changes, projecting future tax liability based on projected premium, tax rates and tax credits, and comparing projected future tax liability to the availability of remaining transferable and non-transferable state tax credits. (3) Impairment Loss The Company recognized an impairment loss of $ related to the write-down as a result of impairment analysis of the carrying amount for state transferable and non-transferable tax credits. THIS EXACT FORMAT MUST BE USED IN THE PREPARATION OF THIS NOTE FOR THE TABLE BELOW. REPORTING ENTITIES ARE NOT PRECLUDED FROM PROVIDING CLARIFYING DISCLOSURE BEFORE OR AFTER THIS ILLUSTRATION. (4) State Tax Credits Admitted and Nonadmitted Total Admitted Total Nonadmitted a. Transferable b. Non-transferable 2000 2013 National Association of Insurance Commissioners 190 Health 2013

Mineral Rights Investments in extractive materials. Timber Deeds. Fixed or Variable Interest Rate Investments that Have the Underlying Characteristics of a Bond, Mortgage Loan or Other Fixed Income Instrument Fixed income instruments that are not corporate or governmental unit obligations (Schedule D) or secured by real property (Schedule B). For Life and Fraternal Insurers: Any investments deemed by the reporting entity to possess the underlying characteristics of a bond or other fixed income instrument which qualify for Filing Exemption or that have been reviewed and approved by the Securities Valuation Office (SVO) within this category. Exclude: For Life and Fraternal Insurers: Any investments deemed by the reporting entity to possess the underlying characteristics of a bond or other fixed income investment, but for which the Securities Valuation Office (SVO) has not yet affirmed that the specific BA investment (identified by CUSIP) fits in this category (as identified in the Valuation of Securities product). Until affirmed by the SVO, report these BA investments in the category for Any Other Class of Assets. Joint Ventures or Partnership Interests for Which the Primary Underlying Investments are Considered to Be: Fixed Income Instruments Leveraged Buy-out Fund. A fund investing in the Z strip of Collateralized Mortgage Obligations. For Life and Fraternal Insurers: Any investments deemed by the reporting entity to possess the underlying characteristics of fixed income instruments which qualify for Filing Exemption or that have been reviewed and approved by the Securities Valuation Office (SVO) within this category. Exclude: For Life and Fraternal Insurers: Any investments deemed by the reporting entity to possess the underlying characteristics of fixed income instruments, but for which the Securities Valuation Office (SVO) has not affirmed that the specific BA investment (identified by CUSIP) fits in this subcategory. Until affirmed by the SVO, report these BA investments in the Other subcategory of this category. 2000 2013 National Association of Insurance Commissioners 329 Revised 12/2013 Investments 2013

Common Stocks Venture Capital Funds. Real Estate Real estate development interest. Mortgage Loans Mortgage Obligations. Other Limited partnership interests in oil and gas production. Forest product partnerships. Investments within the Joint Venture and Partnership Interests category that do not qualify for inclusion in the Fixed Income Instruments, Common Stocks, Real Estate or Mortgage Loans subcategories. For Life and Fraternal Insurers: This includes investments believed by the reporting entity to have the underlying characteristics of Fixed Income Instruments but which do not qualify for Filing Exemption and have not been reviewed by the SVO, as well as those that have been reviewed by the SVO and were determined to have the underlying characteristics of Other instruments. Surplus Debentures, etc. That portion of any subordinated indebtedness, surplus debenture, surplus note, debenture note, premium income note, bond, or other contingent evidence of indebtedness that is reported in the surplus of the issuer. Collateral Loans Refer to SSAP No. 21, Other Admitted Assets, for a definition of collateral loans. In the description column, the name of the actual borrower and state if the borrower is a parent, subsidiary, affiliate, officer or director. Also include the type of collateral held. Non-collateral Loans For purposes of this section, non-collateral loans are considered the unpaid portion of loans previously made to another organization or individual in which the reporting entity has a right to receive money for the loan, but for which the reporting entity has not obtained collateral to secure the loan. Non-collateral loans shall not include those instruments that meet the definition of a bond, per SSAP No. 26, Bonds, excluding, Loan-backed and Structured Securities, a mortgage loan per SSAP No. 37, Mortgage Loans, loan-backed or structured securities per SSAP No. 43R, Loan-backed and Structured Securities, or a policy or contract loan per SSAP No. 49, Policy Loans. In the description column, the name of the actual borrower. For affiliated entities, state if the borrower is a parent, subsidiary, affiliate, officer or director. Refer to SSAP No. 20, Nonadmitted Assets and SSAP No. 25, Accounting for and Disclosures about Transactions with Affiliates and Other Related Parties, for accounting guidance. 2000 2013 National Association of Insurance Commissioners 330 Revised 12/2013 Investments 2013