COMPANY NAME
NAIC NO.
PART A – ARIZONA HEALTH BUSINESS
IMPORTANT - Attach copies of the ARIZONA State Page 30 and Schedule T from your Health Annual Statement to this page.
COMPREHENSIVE MEDICAL
MEDICARE
A
B
C
D
E
F
G
H
I
J
GRAND TOTAL
Federal
Title XVIII
AHP Small
Medicare
All Other
Vision
Dental
Sum of Columns
Employees
Medicare
Individual
Group Only
Supplement
Other
Group
Only
Only
B through J
Health
*Arizona Premium
Written (Annual
1.
Statement Page 30,
0.00
line 12)
[FE Gross]
[
[
]
]
AH Gross]
SG Gross]
[GAH Gross
[MCX Gross
2. Exempt Premiums
0.00
0.00
0.00
(See Below)
Taxable Premium
]
]
[FE Tax = 0]
[MCX Tax=0]
GE Tax =0]
GE Tax = 0]
[SG Tax = 0
[GE Tax = 0
3.
(line 1 minus line
0.00
0.00
0.00
0.00
0.00
0.00
0.00
xxxxxxxxxxxx
xxxxxxxxxxx
2)
xxxxxxxxxxxx
[AH Tax]
[GAH Tax]
4. Tax Rate
2 %
Gross Tax Amount
5.
[AHT]
0.00
(line 3 x line 4)
Carry to Page 3, line 1
* Refer to the applicable statute for the basis of premiums to be reported and provide a reconciliation schedule if the amounts reported on line 12, 13
and 14 on Page 30 of your Annual Statement differ from the amounts reported in Line 1, Page 2 of this report. Health Care Services Organizations
see ARS § 20-1060, Prepaid Dental Plan Organizations see ARS § 20-1010, and Hospital, Medical, Dental and Optometric Services Corporations see
ARS § 20-837.
LINE 2 EXEMPTIONS:
HOSPITAL, MEDICAL, DENTAL AND OPTOMETRIC SERVICE CORPORATIONS ONLY – ARS § 20-837, “the tax shall not apply with respect to any coverage
concerning which the corporation’s relationship is as administrative or fiscal agent for national, state or municipal government or any political subdivision or body thereof,
and such tax shall not apply with respect to any premiums received from funds of national, state or municipal government or any political subdivision or body thereof.”
Complete Form E-HEALTHORG.HMDO and enter the exempt amounts in the appropriate Columns on line 2, including Column A.
COLUMN C, LINES 1 AND 2 – AHP SMALL GROUP ONLY:
This Column should only be completed if the organization is an approved Accountable Health Plan (“AHP”) that issued “Health Benefit Plans” to “Small Employers” as
defined in ARS § 20-2301. THE ORGANIZATION MUST COMPLETE AND ATTACH FORM E-AHP TO SUPPORT THE CLAIMED EXEMPT PREMIUMS.
COLUMN F, FEDERAL EMPLOYEE HEALTH BENEFIT PLAN premiums are pre-empted from state tax under federal law. Enter your total FEHBP premiums on both
lines 1 and 2 of Column F and include it in lines 1 and 2 of Column A.
COLUMN G, Title XVIII MEDICARE funds are pre-empted from state tax under federal law. Attach a copy of the approval letter issued by CMS as a Medicare
Advantage Organization for this calendar year.
E-HEALTHORG (R
. 12/07)
ARIZONA DEPARTMENT OF INSURANCE
P
2
3
EV
AGE
OF