ALABAMA GROUP MENTAL HEALTH ("MH") PARITY COST REPORT DUE APRIL 30
CALENDAR YEAR
Company Name:
NAIC #:
Company Address:
Company Contact:
Contact E-mail:
Contact Phone
I certify as follows with respect to the Company indicated above (check all that apply):
The company does not issue group health benefit plans to which the requirements of ALA. CODE Chapter 27-54 apply. (If checked, proceed to signature line.)
The Company issues policies subject to and is in compliance with the parity in mental health benefit requirements of ALA. CODE Chapter 27-54. The total annual
mental health benefit costs and total health benefit costs for the Calendar Year shown above were as follows:
(a)
Avg # of Groups Covered
(b)
Avg # of Certificateholders
(c)
Total Claims Paid for Certificateholders
(d)
Avg Claims Paid Per Certificate
Groups without
MH Benefits
Groups with MH
Benefits
Groups Without
MH Benefits
Groups With MH
Benefits
Total Claims Paid
Without MH Benefits
Total Claims Paid
with MH Benefits
Groups Without
MH Benefits
Groups with MH
Benefits
Notes: For "Groups With MH Benefits" category, use only groups of more than 50 lives with MH benefit coverage.
For "Groups Without MH Benefits" category, use only groups of more than 50 lives without MH benefit coverage.
(a) AVG # of Groups Covered = (# of Groups in Force Beginning of Year + # of Groups in Force at End of Year)
2
(b) AVG # of Certificateholders = (# of Certificateholders in Force Beginning of Year + # of Certificateholders in Force End of Year)
2
(d) Avg Claims Paid Per Certificateholder = Total Claims Paid During Year for Groups Without MH Benefits Total Claims Paid During Year for Groups With MH Benefits
AVG # of Certificateholders Group Without MN Benefits AVG # of Certificateholders Groups With MH Benefits
Date
Signature of Company Officer
Print Officer Name
