STATE OF ARIZONA
DEPARTMENT OF INSURANCE
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) REPORTS
FOR CALENDAR YEAR - __________
A.R.S. §20-1382 ESTABLISHED REPORTING REQUIREMENTS TO BE FOLLOWED BY
HEALTH CARE INSURERS (AS DEFINED IN A.R.S. §20-1379(U)(7)). IF YOU ARE A HEALTH
CARE INSURER, YOU MUST PROVIDE THE DEPARTMENT WITH THE DATA REQUESTED
BELOW.
A. Health Care Insurer name: ______________________________________________________________
______________________________________________________________________________________________
NAIC number: __________________
B. Health Care Insurer address: _____________________________________________________________
_______________________________________________________________________________________________
C. Using Exhibit I, please list all products that you offer in the individual market, including
the product form number and a summary of the product, including the date it was placed
in use.
D. Please provide the following data;
1. Number of eligible individuals (as defined in A.R.S. §20-1379(P)) covered by policies
written in the individual market during the calendar year: _____________
2. Earned premium for policies included in 1.above: ______________________________________
3. Number of individuals covered by policies issued in the individual market to other
than eligible individuals: during the calendar year: _____________
4. Earned premium for policies included in 3. above: ______________________________________
5. Total number of eligible individuals covered by policies as of the end of the calendar
year: _____________
E. If you elected the option provided in A.R.S. §20-1379(C)(2)(a), i.e., the policy forms with the
Largest and next to the largest earned premium volume of all policy forms offered, please
use Exhibit II to provide the following data for calendar year : __________
1. The earned premium volumes for each of the policy forms you offer in the individual
market.
2. The number of individuals who are covered under each of the policy forms you offer in
The individual market.
F. If you elected the option provided in A.R.S. §20-1379(C)(2)(b), i.e., the choice of two plans
With representative coverage consisting of a lower level of coverage policy form and a
higher level of coverage policy form, please attach an exhibit providing the data,
assumptions and methods used to calculate the actuarial values of the two representative
policy forms.
G. Please provide an explanation as to how you are complying with A.R.S. §20-1379, A.R.S.
