"Comprehensive Health Insurance Pool" - Nebraska

Comprehensive Health Insurance Pool is a legal document that was released by the Nebraska Department of Insurance - a government authority operating within Nebraska.

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STATE OF NEBRASKA
DEPARTMENT OF INSURANCE
P. O. Box 82089
Lincoln, NE 68501-2089
COMPREHENSIVE HEALTH INSURANCE POOL
Only insurers that write health insurance need to file this form. Insurers that write ONLY property and
casualty insurance do not need to file this form.
Nebraska adopted the Comprehensive Health Insurance Pool Act (NE CHIP) in 1985. The purpose of
CHIP is to provide a mechanism to ensure the availability and affordability of health insurance to Nebraska
residents unable to purchase such insurance as a result of preexisting medical conditions.
NE CHIP is funded directly through premium taxes paid by insurers writing health insurance in Nebraska.
Insurer means any insurance company as defined by Neb. Rev. Stat. § 44-103, or a Health Maintenance
Organization as defined by §44-32,105, authorized to transact health insurance business in Nebraska. The
Department requires companies that write health insurance to submit the attached form by April 1 following the
tax year.
If there is any discrepancy between premium amounts reported on paragraph two of these forms
and the direct business page, please explain. This form also requests the amount of individual health insurance
premiums received in Nebraska. The form shall be filled out completely, correctly and filed with the Department
on time. Failure to do so may result in an administrative action against your company. This information is needed
to identify the insurers that received the largest amount of premiums in order to establish the standard risk rate
and to calculate the NE CHIP premium. The form also asks whether or not your company sells association group
insurance that is individually underwritten and, if so, how much premium is earned from that product. If you have
any questions, please contact Martin Swanson at (402) 471-4648.
STATE OF NEBRASKA
DEPARTMENT OF INSURANCE
P. O. Box 82089
Lincoln, NE 68501-2089
COMPREHENSIVE HEALTH INSURANCE POOL
Only insurers that write health insurance need to file this form. Insurers that write ONLY property and
casualty insurance do not need to file this form.
Nebraska adopted the Comprehensive Health Insurance Pool Act (NE CHIP) in 1985. The purpose of
CHIP is to provide a mechanism to ensure the availability and affordability of health insurance to Nebraska
residents unable to purchase such insurance as a result of preexisting medical conditions.
NE CHIP is funded directly through premium taxes paid by insurers writing health insurance in Nebraska.
Insurer means any insurance company as defined by Neb. Rev. Stat. § 44-103, or a Health Maintenance
Organization as defined by §44-32,105, authorized to transact health insurance business in Nebraska. The
Department requires companies that write health insurance to submit the attached form by April 1 following the
tax year.
If there is any discrepancy between premium amounts reported on paragraph two of these forms
and the direct business page, please explain. This form also requests the amount of individual health insurance
premiums received in Nebraska. The form shall be filled out completely, correctly and filed with the Department
on time. Failure to do so may result in an administrative action against your company. This information is needed
to identify the insurers that received the largest amount of premiums in order to establish the standard risk rate
and to calculate the NE CHIP premium. The form also asks whether or not your company sells association group
insurance that is individually underwritten and, if so, how much premium is earned from that product. If you have
any questions, please contact Martin Swanson at (402) 471-4648.
COMPREHENSIVE HEALTH INSURANCE POOL
(Neb. Rev. Stat. § 44-4201 et seq.)
For Year Ending December 31, _______
Return completed form to Nebraska Department of Insurance, P. O. Box 82089, Lincoln, NE 68501-2089
*Fraternal benefit societies are not required to file this Comprehensive Health Insurance Pool form.
+Insurers that write only property and casualty insurance do not need to file this form.
Nebraska Co. S.B.S. No.
Contact Person
NAIC No.
Telephone Number
Email Address:
Company Name
Address
City
State
Nine Digit Zip Code
1.
Total Nebraska Accident and Health Insurance Premiums (As reported in the 2019 Annual Statement)
Life & Health Insurance Companies (direct business page 24, line 26, less line 24.1); Property & Casualty Companies and
Reciprocal Insurers (page 19, lines 13 through 15.6); Health Maintenance Organizations (premiums written or renewed – cash
basis); Assessment Companies (premiums written or renewed – cash basis).
Do not include Federal employee health benefits program premiums
$
*
2.
Less, Nebraska Premiums Not Considered “Health Insurance” Under NE CHIP
“Health Insurance” shall mean any hospital, surgical, or medical expense incurred policy, or health insurance organization
contract. “Health Insurance” shall not include (1) accident only, disability income, hospital confinement indemnity, dental, or
credit insurance, (2) coverage issued as a supplement to liability insurance, (3) Medicare or insurance provided as a supplement
to Medicare, (4) insurance arising from workers’ compensation provisions, (5) automobile medical payment insurance, (6) any
other specific limited coverage, or (7) insurance under which benefits are payable with or without regard to fault and which is
statutorily required to be contained in any liability insurance policy. (Neb. Rev. Stat. § 44-4209).
(-)
$
3.
Total Group and Individual “Health Insurance” Premiums in Nebraska.
=
$
From Line 3, 2019 total, indicate the portion for individual premiums.
4.
$
5.
If your company sells group association business that is individually underwritten,
indicate the amount of premium for this product.
$
6.
Please provide your most commonly used trend number for individual major
medical health insurance policies throughout this reporting year.
$
SIGNATURE OF OFFICER OF COMPANY
State of
)
)ss
County of
)
I,
being duly sworn on oath say that I am
,
officer of the
Insurance Company of
and that the statement of NE CHIP “Health Insurance” is correctly computed in accordance with the foregoing instructions.
(Signature)
Subscribed and sworn to before me, a Notary Public, this
day of
20
(Notary Public)
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