I l llllllllllJ llllJ llll !llll lllll Jllll lllll J lll lJllll Jllll lllll jllll lllll lllll jllll lll ll Jlll 1 111 QUARTERLY STATEMENT AS OF SEPTEMBER 30, 201 6 OF THE CONDITI ON AND AFFAI RS OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST NAIC Group Code 0601 0601 NAIC Company Code ___ 9_ 554 _0 __ Employer's ID Number __ 9_3-0 _7_ 98 _0_3_9 __ (Prior Period) (Cunent Period) Organized under the laws of State of Domicile or Port of Enb'y Oregon Counb'y of Domicile Licensed as business type: Life, Accident & Health [ ) Dental Service Corporation [ Other I J United States Property/Casualty [ ) Vision Service Corporation [ Hospital, Medical & Dental Service or Indemnity [ Health Maintenance Organization [ X ) Incorporated/Organized Statutory Home Office 10 / 19/ 1981 Commenced Business Is HMO Federally Qualified? Yes [ ) No [ X) 05/ 01 /1942 500 N.E. Multnomah Street, Suite 100 Portland, OR, US 97232-2099 (Sbeel and N- ) (City or Town. S tate. Ctuiby and Zip Code) Main Admi nistrative Office __ -= 5 -= 00 "-'- N "'. E "' . '"' M ""u "' l "' tn "' o"" m"" a"" h'"' S °' tr °' e '"' e"' t, '"' S °' u "' it "' e_1 -= 0 -= 0-- Portland, OR, US 97232-2099 503-81 3-2800 <Street and Nt.mber) (C;,y or Town. State. Counl1y and :Z., Code ) (Area Code) (Telephone Number ) Mail Address 500 N.E. Multnomah Steel, Suite 100 Portland, OR, US 97232-2099 (Street aod Nt.mberorP.O. Box) (City or Town. S tate, Cot.ntry and Zip Code) Pri mary Location of Books and Records 500 N.E. Multnomah Street. Suite 100 Portland, OR US 97232-2099 503-813-2502 {StrfftandNumbe<) Internet Web Site Address Statutory Statement Contact Rachell e Anne Qui nn (Name) Rachelle.A.Qu[email protected](E-Mail Address) (City or TONO. State. Ctuiby and Zip Code) (Area Code) (Telephone Number) www. kp.org 503-813-2502 (Area Code) (Telephone Numbe<) (Extension) 503-813-4408 (FAX N..,,ber) OFFICERS Name Trtle Andrew Raymond McCulloch Regional President Jenny Smith # Interim CFO and Executive Director Name William Netherton Wiechmann Bernard James Tyson Title Assistant Secretary - V.P. & Regional Counsel Director, Chairman, CEO and President OTHER OFFICERS Kathryn Lee Lancaster Gregory Adams Donald HoY1 Orndoff Mark Steven Zemelman Ex. V.P. & Chief Financial Officer Executive Vice President & Group President Senior V.P. - National Faci lities Services Senior Vice President, General Counsel & Secretary Arthur Milton Southam MD Thomas Ralph Meier Monse L Upshaw Ex. V.P. - Health Plan Operations SeniorV.P. & Treasurer Seni or V.P. - Corp. Controller & CAO DIRECTORS OR TRUSTEES Margaret Effie Porfido JD Edward Ying Wah Pei Judith Ann Johansen JD Cynthia Ann Telles PhD Jeffrey Emanuel Epstein Richard Patrick Shannon MD Regina Marcia Benjamin MD Ramon Francis Baez State of _·········--······· Oregon ...... --······-- SS County of _·········-···Multnomah _________ _ Arnold Eugene Washington MD Ki m John Kaiser David Frank Hoffmeister Bernard James Tyson Philip Albert Marineau Leslie Stone Heisz The officers of this reporting entity bei ng duly sworn, each depose and say that they are the descri>ed offi c ers of said reporting entity, and that on the reporting period stated above, all of the herein descri>ed assets were the absolute property of the said reporti ng entity, free and clear from any liens or claims thereon, except as herein stated, and that this statement, t ogether with rel ated exhibits, schedules and explanations therei n contai ned, annexed or referred to, is a full and true statement of all the assets and l iabilities and of the condition and affairs of the said reporting entity as of the reporting period stated above, and of its income and deductions therefrom for the period ended, and have been completed in accordance with the NAIC Annual Statement Instruct ions and Accounting Practices and Procedures manual except to the extent that (1 ) state law may di ffer; or, (2) that state rul es or regul ations requi"e differenc es in reporting not related to ac counting prac tices and procedures, accor ding to the best of their information, knowledge and bei ef, respectivety. Furthermore, the scope of this attestation by the described officers also i ncl udes the related correspondi ng el ectronic fili ng wi th the NAIC, when required, that is an exact copy (except for formatting differences due to electronic filing) of the enclosed statement The electronic filing may be requested by various regulators in lieu of or in addition to the enclosed statement Andrew Raymond McCulloch Regional President Subscribed and sworn to before me this ______ day of Jenny Smith William Netherton Wiechmann Assistant Secretary- V.P. & Regional Counsel Interim CFO and Executive Dir ector a. Is this an original filing? Yesl XJ No l b. l fno : 1. State the amendment number 2. Date filed 3. Number of pages attached
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KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST NAIC Group Code 0601 0601 NAIC Company Code ___ 9_554_ 0 __ Employer's ID Number __ 9_3-0_ 7_98_0_3_9 __
(Prior Period) (Cunent Period)
Organized under the laws of --------=0-'-reg"""'o""n'------~ State of Domicile or Port of Enb'y Oregon
Counb'y of Domicile
Licensed as business type: Life, Accident & Health [ ) Dental Service Corporation [
Other I J
United States
Property/Casualty [ ) Vision Service Corporation [
Hospital, Medical & Dental Service or Indemnity [ Health Maintenance Organization [ X )
Incorporated/Organized Statutory Home Office
10/19/1981 Commenced Business Is HMO Federally Qualified? Yes [ ) No [ X )
05/01 /1942 500 N.E. Multnomah Street, Suite 100 Portland, OR, US 97232-2099
(Sbeel and N-) (City or Town. S tate. Ctuiby and Zip Code)
Main Administrative Office __ -=5-=00"-'-N"'.E"'.'"'M""u"'l"'tn"'o""m""a""h'"'S°'tr°'e'"'e"'t,'"'S°'u"'it"'e_1-=0-=0- Portland, OR, US 97232-2099 503-813-2800 <Street and Nt.mber) (C;,y or Town. State. Counl1y and :Z., Code) (Area Code) (Telephone Number)
Mail Address 500 N.E. Multnomah Steel, Suite 100 Portland, OR, US 97232-2099 (Street aod Nt.mberorP.O. Box) (City or Town. S tate, Cot.ntry and Zip Code)
Primary Location of Books and Records 500 N.E. Multnomah Street. Suite 100 Portland, OR US 97232-2099 503-813-2502 {StrfftandNumbe<)
Internet Web Site Address
Statutory Statement Contact Rachelle Anne Quinn (Name)
DIRECTORS OR TRUSTEES Margaret Effie Porfido JD Edward Ying Wah Pei Judith Ann Johansen JD Cynthia Ann Telles PhD Jeffrey Emanuel Epstein Richard Patrick Shannon MD
Regina Marcia Benjamin MD Ramon Francis Baez
State of _·········--·······Oregon ...... --······--SS
County of _·········-···Multnomah _________ _
Arnold Eugene Washington MD Kim John Kaiser
David Frank Hoffmeister
Bernard James Tyson Philip Albert Marineau
Leslie Stone Heisz
The officers of this reporting entity being duly sworn, each depose and say that they are the descri>ed officers of said reporting entity, and that on the reporting period stated above, all of the herein descri>ed assets were the absolute property of the said reporting entity, free and clear from any liens or claims thereon, except as herein stated, and that this statement, together with related exhibits, schedules and explanations therein contained, annexed or referred to, is a full and true statement of all the assets and liabilities and of the condition and affairs of the said reporting entity as of the reporting period stated above, and of its income and deductions therefrom for the period ended, and have been completed in accordance with the NAIC Annual Statement Instructions and Accounting Practices and Procedures manual except to the extent that (1 ) state law may differ; or, (2) that state rules or regulations requi"e differences in reporting not related to accounting practices and procedures, according to the best of their information, knowledge and bei ef, respectivety. Furthermore, the scope of this attestation by the described officers also includes the related corresponding electronic filing with the NAIC, when required, that is an exact copy (except for formatting differences due to electronic filing) of the enclosed statement The electronic filing may be requested by various regulators in lieu of or in addition to the enclosed statement
Andrew Raymond McCulloch Regional President
Subscribed and sworn to before me this ______ day of
Jenny Smith William Netherton Wiechmann Assistant Secretary- V.P. & Regional Counsel Interim CFO and Executive Director
a. Is this an original filing? Yes l XJ No l
b. lfno:
1. State the amendment number 2. Date filed 3. Number of pages attached
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
ASSETS Current Statement Date
2 3 December31
Net Admitted Assets Prior Year Net Assets Nonadmitted Assets ICols. 1 - 2\ Admitted Assets
3.1 Flrstliens .... --··········--··········--·········--··········--··········- -······--······- ······--······-- ····--······____o ·--······--··D 3.2 Other than first liens _··········--··········--·········--··········--······-······--······- ······--······-- ····--······___J) ·--······--··D
4. Real estate:
4 .1 Properties occupied by the company {less
$ -······-7,447 ,457 encumbrances)·--······--······--······-······--213,431,527 ······--······-- .... -----213,431,527 ·--·209 ,126,637 4.2 Properties held for the production of ilcome
(less$ -··········--·····.1 ,768 encumbrances) ...... ·--··········--········· -······--4,536,277 ······--······-- ····--···4,536,277 ·--·····4,233,502 4.3 Properties held tor sale (less
13. Title plants less$ -·········--··········- charged off {for TJUe insurers
onlyL·····--··········--·········--··········--··········--·········--·········· -······--······- ······--······-- ····--······___J) ·--······--··D 14. Investment income due and accrued ··--··········--·········--··········- -······--4,589,595 ······--······-- ····--···4,589,595 ·--·····4,253,785 15. Premiums and con~derations:
15.1 Uncollected premiums and agents• balances il the course of
collection _··········--··········--·········--··········--··········--·········- -······-15,394 ,796 ······--····491,239 ····--·14,903,557 ·--···28 ,332,034 15.2 Deferred premiums, agents' balances and installments booked but
deferred and not yet due {including$ ···--······--····earned
but unbiled premium•>--······--······--······--······--······ -······--······__JJ ······--······-- ····--······___J) ·--······--··D 15.3 Accrued retrospective premiums {$ -··········--·········--· ) and
16.2 Funds held by or deposited with reinsured companies __ ······--······--······- ······--······-- ····--······_____!) ·--······--··D 16.3 Other amounts receivable under reilsurance contracts ···········--······-······--······- ······--······-- ····--······___J) ·--······--··D
17. Amounts receivable relating to uninsured plans _······--······--······ -······--······- ······--······-- ····--······___J) ·--······--··D 18.1 Current federal and foreign income tax recoverable and interest thereon -···-······--······- ······--······-- ····--······___J) ·--······--··D 182Netdeferred tax asseL_······--······--······--······--······- -······--······- ······--······-- ····--······_____!) ·--······--··D 19. Guaranty funds receivable or on deposit ·······--··········--·········--······ -······--······- ······--······-- ····--······___J) ·--······--··D 20. Electronic data processing equipment and software __ ······--······- -······--1,263,232 ······--····589,224 ····--·······674,008 ·--······-899,804 21 . Furniture and equipment, including heatth care delivery assets
($ ····-····.76 ,566,688 >······--······--······--······--······ -······-77 , 191,825 ······--····625, 137 .... __ .76 ,566,688 ·--··.73 ,929,746 22. Net adjustment in assets and liabilities due to foreign exchange rates .......... -······--······__j) ······--······___j) ····--······___J) ·--······--··D 23. Receivables from parent, subsidiaries and affi liates __ ······--······- -······-65,569,784 ······--······___j) ····--·65 ,569,784 ·--···34 ,337 ,882 24. Healthcare($ -······--12,433 ,966 )andother amounts receivable __ ...... _ 15,640 ,131 ...... __ 3,206,165 ····--·12,433,966 ·--···19,294,543
25. Aggregate write-ins for other-than-invested assets _··········--··········- -······--7 ,261,998 ······--7 ,261,998 ····--······___J) ·--······--··D 26. Total assets excluding Separate Accounts, Segregated Accounts and
Protected Cell Accounts (Lines 12 to 25~···--·········--··········--··········1---1......,466.-....-763...,.883=+---1-2..,1 ... 1 .... 3,..7 ... 63.._. __ _.1 .. 454-.....,590--..._1.-20-+---1._4 ... 77""""5"'52.....,11"'3"-i 27. From Separate Accounts, Segregated Accounts and Protected
9. General expenses due or accrued-······--······--······--······ -··········-105,987 ,094 ··········--··········-- ·······--105 ,987 ,094 ·····--···23 ,447, 731 10.1 c ....... t federal and foreign income tax payable and interest thereon (including
$ ······--·········--· oorealizedgains(losses))_ ..... ·--······--······-··········--·········- ··········--··········-- ·······--··········___{) ·····--·········--··!) 10.2 Net deferred tax liabii1Y-······--······--······--······--······- -··········--·········- ··········--··········-- ·······--··········___{) ·····--·········--··D 11. Ceded reinsurance premiums payable _······--······--······--·· -··········--.754 ,001 ··········--··········-- ·······--······.754,001 ·····--········.762,993 12. Amounts withheld or retained for the account of others ....... ·--··········- -··········-1,429 ,477 ··········--··········-- ·······--···1,429,477 ·····--··.78 ,513,855
13. Remittances and items not allocated-·········--··········--··········--·· -··········--·········- ··········--··········-- ·······--··········____j) ·····--·········--··!) 14. Borrowed money {including S -·········--········· current) and
18. Payable for securities lending ··········--·········--··········--··········--·· -··········--·········- ··········--··········-- ·······--··········_____!} ·····--·········--··D 19. Funds held under reinsurance treaties {with S ····--··········--········
and S -··········--········· certified reinsurersL·-········--··········--······ -···---··- -···--··········-- ·······--··········____j) ·····--·········--··D 20. Reinsurance in unauthorized and certified {$ ·······--·········-- )
companies ········--··········--·········--··········--··········--·········--··········--·········- ··········--··········-- ·······--··········____j) ·····--·········--··!) 21. Net adjustments il assets and liabilities due to foreign exchange rates _ -··········--·········- ··········--··········-- ·······--··········_____!} ·····--·········--··D 22. Liability for amounts held under uninsured plans ········--·········--·········· -··········--·········- ··········--··········-- ·······--··········____j) ·····--·········--··D 23. Aggregate write-ins for other liabii ties (including $ -··········-9, 938 , 499
3003. -··········--··········--·········--··········--··········--·········--··········- -··········-XXX. ....... _ .......... _ XXX. .... __ ·······--··········--··· ·····--·········--··!) 3098. Summary of remaililg write-ins for Line 30 from overflow page ···--···-··········-XXX. ....... _ .......... _ XXX. .... __ ·······--··········_____!} ·····--·········--··D 3099. Totals llines 3001 throuah 3003 alus 3098\ ILine 30 above\ XXX XXX 0 0
3
STATEMENT A S OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
STATEMENT OF REVENUE AND EXPENSES
Current Year To Date
Uncovered
1. Member Month._······--······--······--······--······--······--······ ...... _xxx... ..... . 2. Net premium income (including$ non-health premium income
3. Change in unearned premium reserves and reserve for rate credits -·········--··········
expenses_··········--··········--·········--··········--··········--·········--·········· 21. General administrative expenses_······--······--······--······--······
22. Increase in reserves for life and accident and health contracts (including
$ ····--·········--········· increase in reserves for life onty)·······--······--······
23. Total underwriting deductions (Lines 18 through 22) __ ······--······--······
24. Net underwriting gain or (loss) (Lines 8 minus 23) ·········--··········--·········--··········
25. Net ilvestment income earned -·········--··········--··········--·········--··········--···
26. Net realized capital gains {losses) less capital gains tax of$ ...... ·--······--·········
27. Net ilvestment gains (losses) (Lines 25 plus 26) --·········--··········--··········--·· 28. Net gain or {k>ss) from agents• or premium balances charged off [{amount recovered
29. Aggregate write-ins for other income or expenses ·········--··········--·········--··········
30. Net iloome or {loss) after capital gains tax and before all other federal income taxes (Liles 24 plus 27 plus 28 plus 29) ······--·········--··········--··········--·········
31. Federal and foreign income taxes incurred--······--······--······--······ 32. Net ilcome (loss) (Lines 30 minus 31)
DETAILS OF WRITE-INS
...... _xxx... ..... .
...... _xxx... ..... .
...... _xxx... ..... .
...... _xxx... ..... .
...... _xxx... ..... .
...... _xxx... ..... .
...... _xxx... ..... .
······--······-0
······--······...J)
······--······-0
······--······-0 ...... _xxx... ..... .
······--······...J)
······--······-0
...... _xxx... ..... .
...... _xxx... ..... . xxx
0601. Other Health Care Revenue.__·········--··········--··········--·········--··········--··· ...... _xxx... ..... . 0602. Meaiingfu t Use Grant Revenue...._·········--··········--··········--·········--·········· ...... _xxx... ..... . 0603. -··········--··········--·········--··········--··········--·········--··········--·········· ...... _xxx... ..... . 0698. Summary of remaililg write-ins for Line 6 from overflow page -··········--··········--·· ...... _ XX><-..... .
0699. Totals (Lines 0601 through 0603 plus 0698) (Line 6 above) XXX
0701 .
0702.
0703.
0798. Summary of remaililg write-ins for Line 7 from overflow page -··········--··········--·· 0799. Totals Lines 0701 throu h 0703 lus 0798 Line 7 above
1401 . Medica l Off ice ~rat ions_·········--··········--··········--·········--··········--··· 1402. Publ ic & Professional Liabi t i ty_······--······--······--······--······ 1403.
1498. Summary of remailing write-ins for Line 14 from overflow page ·--······--······
1499. Totals Lines 1401 throu h 1403 lus 1498 Line 14 above
2901 . Other Revenue .. ·--··········--·········--··········--··········--·········--··········--···
2998. Summary of remailing write-ins for Line 29 from overflow page ·--······--······
2999. Totals Lines 2901 throu h 2903 lus 2998 Line 29 above
4
...... _xxx... ..... .
...... _xxx... ..... .
...... _xxx... ..... . xxx
······--······...J)
······--······-0
2 Total
...... _48, 169,876
...... 115,024,780
...... -3.310,306
······--······o .2 ,650.108,627
.. 1, 148,400,093
.... .274 ,265,749
...... 119, 175,879
...... J0,773,434
..... 296 ,866,806
...... 516,682,476
······--······o .2 ,426, 164,437
...... --1>.577 ,218
.2 ,420,587 ,219
······--······o ...... ..31,581,017
..... .168 , 160,285
······--·····J) .2 ,620,328,521
...... ..29.780, 106
...... _16, 107 ,079
...... -6.091,270
...... .22.198,349
...... _(1,960,469)
...... _ 1,414,874
...... .51,432,860
······--·····J) 51,432,860
...... -3,280,481
. ..... _ 29,825
······--······o 3,310,306
······--·····J)
...... _13,838,095
······--·····J) 516 682 476
······--······o 1 414 874
Prior Year Ended Prior Year To Date December 31
3 4
1, 116,426,233
... 256 ,426,592
... .108 ,988,230
...... 65 ,353,191
.... 301,647 ,!i'.>2
.... 481,458,494
······--····o ,330 ,300,242
...... ..9 ,533, 142
,320,767, 100
······--····o ..... .$6,713,405
... .171,792, 111
······--···J) ,529 ,272,616
.... (23 ,003, 123)
. ..... 11,919,252
...... _ (914,858)
...... 11,004,394
...... (2,999,013)
...... _1,271, 157
.... (13,726,585)
······--···J) (13,726,585)
...... -2 ,941,146
...... _1, 196,473
······--····o
······--···J) ······--···J) ······--···J)
...... 12 ,289,235
······--····o ······--···J)
481 458 494
······--····o ······--····o
1 271 157
Total
.... 5 ,668,454
,167 ,470,248
······--··o . . .55 ,881,275
.127 ,308,216
.... .6 ,840, 151
······--··o ,357 ,499,890
1,485 ,668,786
.345 ' 688 ,508
.146 ,359,984
.. 90 .218,448
.404 ,482,847
.652 ,051,294
······--··o , 124 ,469,867
.. .13,074, 155
, 111,395,712
······--··o ... 46 ,949,398
224 ,451,058
······--··o ,382 ,796, 168
.(25 ,296,278)
... 17 ,354, 143
.. .(2 ,862,513)
... 14,491,630
... (4,374,312)
.... .1 ,680,445
.(13,498,515)
······--··o (13,498,515)
.... 3 ,822,841
. ... 3 ,017,310
······--··o 6,840, 151
······--··o ······--··o ······--··o ······--··o
0
.635 ,697,205
... 16 ,354,089
······--··o ······--··o 652 051 294
..... 1,680,445
······--··o ······--··o ······--··o
1 680 445
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
STATEMENT OF REVENUE AND EXPENSES Continued)
CAPITAL & SURPLUS ACCOUNT
Current Year To Date
2
Prior Year To Date
3
Prior Year Ended
Oecember31
33. Capital and surplus prior reporting year ....... ·--··········--·········--··········--··········--········· ··--····~19,324,870 .......... ---203, 154 ,414 ........ ---203 , 154,414
34. Net income or (loss) from Line 32 ··--······--······--······--······--······--· ··--······51,432,860 .......... ___j 13, 726,585) ........ __{13 ,498,515)
35. Change in valuation bas.is of aggregate policy and claim reserves ·······--·········--··········--·· ··--··········--········ ··········--·········___D ········--··········----1)
36. Change in net unrealized capital gains (losses) less capital gains tax of$ ······--··········--····· ··--··········--········ ··········--·········___!) ········--··········___j)
37. Change in net unrealized fore;gn exchange capital gain or (loss) ·--······--······--······ ··--··········--········ ··········--·········___!) ········--··········___j)
38. Change in net deferred income tax ···········--·········--··········--··········--·········--··········- ··--··········--········ ··········--·········__J) ········--··········___j)
45.2 Transferred to capital (Stock Dividend)---····--······--······--······--······- ··--··········--···.!) ··········--·········__JJ ········--··········__J)
45.3 Transferred from capital _ ..... ·--······--······--······--······--······- ··--··········--········ ··········--·········__JJ ········--··········__J)
46. Dividends to stockholders ····--·········--··········--··········--·········--··········--··········- ··--··········--········ ··········--·········__J) ········--··········___j)
47. Aggregate wrtte-ins for gains or (losses) in surplus······--······--······--······--····· ··--······22 , 704,984 .......... ---429 ,464, 736) ········--50 ,537 ,632
48. Net change in capttal and surplus (Lines 34 to47l ---·····--······--······--······- ··--·····.75 ,825,147 .......... _ 57 ,784 ,350 ........ ---216 ,170,456
49. Capital and surplus end of reporlilg period (Line 33 plus 48) 495, 150,017 260,938 ,764 419 ,324,870
4702. Post Reti rement Benef i t SSAP 92. ... ·--·········--··········--··········--·········--··········--·· ··--········9 ,436,602 .......... ___j49,015,978) ........ __ 14,873,648
4798. Summary of remaining write-ins for Line 47 from overflow page ···········--·········--··········--·· ··--··········--····D ··········-·········__JJ ········-··········__J)
4799. Totals llines 4701 throuah 4703 olus 4798\ l line 47 abovel 22 ,704,984 (29,464,736) 50 ,537,632
5
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
CASH FLOW
Cash from Operations
Current Year To Date
2 Prior Year To Date
3 Prior Year Ended
Oecember31
1. Premiums collected net of reinsurance. ..... ·--······--······--······--······--······- ...... --2,573 , 148,958 _____ 2,352, 107 ,249 ......... ....3. 134,733,981 2. Net investment income ·······--·········--··········--··········--·········--··········--··········--····· ······--14,874,566 ····---26,660 , 138 ......... _ 36,633,363 3. Miscellaneous income ....... ·--··········--·········--··········--··········--·········--··········--····· 174 058 019 156 812 084 206 857 190 4. Total (Lines 1 to 3) ···--······--······--······--······--······--······--······ 2,762 ,081,543 2,535,579 ,471 3,378,224,534 5. Benefit and loss related payments ···--·········--··········--··········--·········--··········--········· ...... --2,415,973, 162 .... - 2,326,965 ,596 ......... ....3. 102,682,389 6. Net transfers to Separate Ac.counts, Segregated Ac.counts and Protected Cell Acoounts_··········- ······--······-- ····--······--0 ·········--··········__j) 7. Commissions, expenses paid and aggregate write-ils fe<deduction•--······--······--····· ...... __ 115,869,045 .... -----210,473 ,931 ......... --269,724,025 8. Dividends paid to policyholders __ ·····--······--······--······--······--······--····· ······--······-- ····--······--0 ·········--··········_j) 9. Federal and foreign income taxes paid (recovered) net of $ --··········--··········-tax on capital
gains (losse•l---······--······--······--······--······--······--······--·····1--.....,....,..,-..,..,.,....,.,,oo+--,....,,,,,,.-=....,.,,;..+--..,...=---'o'"-l 10. Total (Lines 5 through 9) _·········--··········--··········--·········--··········--··········--·········-i---=-2'-', 53~1!.!·~84~2'-",20~7+---2~.e!_53~7_,_,43~9'-', 5~27!..+---'3!.!.· ~37c:2_.:,406~.~4.!:14!...j 11. Net cash from operations (Line 4 minus Line 1 0) --·····--······--······--······--······-i---~2~30~23~9~336~1----.1,;' 1~860~056~!1----.i!5.J8!_!12,8 ._!1~20!!_l
Cash from Investments 12. Proceeds from investments sold, matured or repaid:
14. Net increase (or decrease) in contract loans and premium notes_······--······--······--·1------.....::0"+------"-0+------.....:0'"-l 15. Net cash from investments (Line 12.8 minus Line 13.7 and Line 14l---·····--······--·······;.----'47'-'''-"800=•.::;52:..:8+---'(-'133=,8=-1'-'4-",2:..:4"'2)'1----"(2:..:1.::6'-',59=3,"'557"'-4)
Cash from Financing and Miscellaneous Sources 16. Cash provided (applied):
16.1 Surplus notes, capital notes--······--······--······--······--······--······- ······--······___JJ ····--······--0 ·········--··········_j) 162Capitalandpaidinsurplus, lesstreasurystock ... --······--······--······--······- ······--······___JJ .... __ 100,000 ,000 ......... _ 175,000,000 16.3 Borrowed funds .. ·--······--······--······--······--······--······--······- ······--······___JJ ····--······--0 ·········--··········___!) 16.4 Net deposits on deposit-type contracts and other insurance liabilities ··--······--······- ······--······-- ····--······--0 ·········--··········__j)
17. Net cash from financing and miscellaneous sources (Line 16.1 through line 16.4 minus Line 16.5 plus Line 16.6L ..... ·--······--······--······--······--······--······--······ (265 , 113,764) 110,284 , 103 183,903,857
RECONCILIATION OF CASH, CASH EQUIVALENTS AND SHORT-TERM INVESTMENTS 18. Net change in cash, cash equivalents and short-term investments (Line 11, plus Lines 15 and 17) _ ······--12,926, 100 ····--(25,390 , 195) ......... __(26,871,580) 19. Cash, cash equivalents and short-term investments:
19.1 Beginning of year.--······--······--······--······--······--······--······- ...... __ 6,510,605 _______ 33,382 , 185 ......... _ 33,382, 185 192 End of period (Line 18 plus Line 19.1) 19,436,705 7 ,991,990 6,510,605
6
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLA N OF THE NORTHWEST
18. Amount Incurred for Provision of Health Care Services 2 4~ 164 437 115 922 992 1 221 361 802 0 0 94 331 080 86 140 435 750 172 397 295 117 157 940 614
(a) For health premiums written: amount o f Medicare TitleXVlll e>C8111>t from state ta>C8s or fees$ 732,261,353
OErltal mentlers are cOtll ted as Medical mentlers .
The membe rsh ip roove does not i ncluded the COO (Canmmi ty Care Orgooization) and self- funded mentlers . Menber mon ths for the CCO and sel f- fmded groops are 395,539 ood 109,971 , respectively .
co
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
CLAIMS UNPAID AND INCENTIVE POOL, WITHHOLD AND BONUS (Reported and Unreported) Aaing Analyoio of Unpaid Clalmo
1 I 2 I 3 I 4 I s I 6 i>«:count 1 - 30 Davs 31 - 60 Davs 61 - 90 Davs 91 - 120 Davs Oller 120 Davs
0499999 Subtotals I (1, 105,315!1 @6,:<.:il 1474 ,037! I (555,289!1 (4 , 124 ,019! I (7, 155,0031 0599999 Unreoortedclaimsandotherclaim reserves I XXX I XXX xxx I xxx I xxx I 34 .118 ,277 0699999Total amountswithheld I XXX I XXX xxx I xxx I xxx I 21 ,607 ,053 0799999 Total claims urc>aid I XXX I XXX xxx I xxx I xxx I 48,570 ,327 0899999 l'<x:rued medical incentive pool and bonus amounts I XXX I XXX xxx I xxx I xxx
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
UNDERWRITING AND INVESTMENT EXHIBIT ANALYSIS OF CLAIMS UNPAID-PRIOR YEAR-NET OF REINSURANCE
Claims Liability Paid Year to Date End of Current Quarter 5 6
2 3 4 Estimated Claim
On I On Reserve and Claim Claims Incurred Prior On Claims Urc>aid On Claims Incurred Liability
to January 1 of Claims Incurred Dec. 31 Claims Incurred in Prior Years Dec. 31 of Current Year Ourill!l the Year of Prior Year During the Year (Columns 1 + 3) Prior Year Line of Business
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
NOTES TO FINANCIAL STATEMENTS
1) Summary of Significant Accom1ting Policies
A. Accounting Practices
The statutory financial statements of Kaiser Foundation Health Plan of the Northwest (Health Plan) have been prepared in conformity with the National Association of Insm·ance Commissioners' (NAIC) Accounting Practices and Procedm·es Manual (NAIC SAP), the NAIC Annual Statement Instructions, and other accom1ting practices, as prescribed or permitted by the Oregon Department of Constuner and Business Services Division of Financial Regulation (State of Oregon). For the qua1ter ended September 30, 2016 and year ended December 31, 2015, there were no differences between the NAIC SAP and the practices prescribed by or pemiitted by the State of Oregon that impacted Health Plan's statutory net income or capital and smplus. As noted in the schedule below (in thousands):
State of FIS Domicile SSAP#
NET INCOME FIS Pase line# 2016
(1) Health Plan state basis (Page 4, Line 32, Columns 2 & 4) Oregon $ 51,433 $
(2) State Prescribed Practices that increase/(decrease) NAIC SAP Oregon
(3) State Permitted Practices that increase/( decrease) NAIC SAP Oregon (4) NAIC SAP(1-2-3=4) Oregon 51,433 SURPLUS (5) Health Plan state basis (Page 3, Line 33, Columns 3 & 4) Oregon 495,150
(6) State Prescribed Practices that increase/(decrease) NAIC SAP Oregon
(7) State Permitted Practices that increase/( decrease) NAIC SAP Oregon Statutory Surplus. NAIC SAP (5~7=8) Oregon $ 495,150 s
B. Use of Estiniates in the Preparation of the Financial Statements
No significant changes from the 2015 annual statement.
C. Accom1ting Policies
New Accotu1ting Pronouncements
In June 2015, the NAIC adopted revisions to Statement of Statutory Accounting Principles (SSAP) 54, Individual and Group Accident and Health Contracts and SSAP 84, Amollllts Receivable Under Government Insured Plans. The guidance was adopted prospectively by Health Plan in 2015. The revisions clarify repo1ting requirements for Medicare risk adjustment receivables and payables. Management reclassified certain Medicare receivables from health care receivables - net to premituns receivable - net and certain Medicare payables from other liabilities to aggregate health policy reserves during 2015.
In August 2016, the NAIC adopted revisions to SSAP 55 , Unpaid Claims, Losses and Loss Adjustment Expenses. The guidance was adopted prospectively by Health Plan for the period ended September 30, 2016. The revisions clarify accotu1ting treatment of costs associated with salvage and subrogation. Health Plan recognized $0.9 million of estimated collection costs at September 30, 2016.
Loan-Backed Stiucttu·ed Securities
Health Plan does have investinents in loan-backed and/or structured sectu1ties and collateralized m01tgage obligations. These secm1ties are stated on the amottized cost basis and adjustinents are made prospectively.
2) Accotmting Changes and Co!1'ections ofEffors
For the qua1ter ended September 30, 2016, Health Plan reclassified ce1tain accounts within assets and liabilities between lines of the financial statements. The changes continue to comply with statutory accollllting guidance, align the Health Plan w1th other Kaiser Health Plans, and bimg consistency across the prograni. The changes did not have a mate11al or negative impact on capital and stuplus.
3) Business Combinations and Goodwill
No significant changes from the 2015 annual statement.
4) Discontinued Operations
No significant changes from the 2015 annual statement.
10
2015
(13,499)
j13,499J
419,325
419,325
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
NOTES TO FINANCIAL STATEMENTS
5) Investments
A - C.
Health Plan has no investments in mortgage loans, restructtU'ed debt or reverse mo1tgages.
D. Loan-Backed Secm-ities
(1) Health Plan does have investments in loan-backed and/or stmctllred sectu-ities and collateralized m01tgage obligations. Prepayment asstunptions are obtained from a third party vendor data source.
(2) Dtumg thenine months ended September 30, 2016, the aggregate other-than-temporary impainnent (OTII) recognized for certain loan-backed and/or structtu·ed secmities was as follows (in thousands):
(1) (2) (3) Amortized C os t Other-than- Fafr Value (1) -(2)
B as is B e fore Other- T e mp or:u y than-Temporary Impairme n t
Impairment R e cognized in Loss
om recognized 1st Quarter a . Intent to sell $ - $ - $
b . Inability or lack of intent to retain the
inve stment in the security for a period of 38,861 222 38,639
time sufficient to recover the amortized
cost bas is
c . Total 1st Quarter $ 38,861 $ 222 $ 38,639
om recognized 2nd Quarter d Intent to sell $ - $ - $
e . Inability or lack of intent to retain the
inve stment in the security for a period of 11,621 53 11,568
time sufficient to recover the amortized
cost bas is
f. Total 2nd Quart.er $ 11,621 $ 53 $ 11,568
om recognized 3rd Quarter
g. Intent to sell $ - $ - $
h. Inability or lack of intent to retain the
inve stment in the security for a period of 31,392 67 31,325
time sufficient to recover the amortized
cost bas is
i Tota13rd Quarter $ 31,392 $ 67 $ 31,325
10.1
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
NOTES TO FINANCIAL STATEMENTS
(3) Each impainnent of loan-backed and/or structtu·ed sectu1ties recognized dm1ng the nine months ended September 30, 2016 was as follows (in thousands):
(1) (2) (3) (4) (5) (6) (7) Book/Adjusted Amo1·tized Cos t Date of
Ca1·11ing Value Recognized Afte1· O the1·- Financial Amo1·tized Cost Present Value Othe1·-Than- Than- Statement Befor e Cur r ent of Pr ojected Te1J¥t"at1' Temporn1-y Fair Value at When
For the nine months ended September 30, 2016, there were no impaired loan-backed secm1ties for which an other-than-tempora1y impaitment has not been recognized it1 eamings as a realized loss.
E-G.
For the nit1e months ended September 30, 2016 and the year ended December 31, 2015, Health Plan had no illvestments ill repurchase agreements and/or secm1ties lendillg transactions, real estate or low-illcome housit1g tax credits.
10.2
STATEM ENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
NOTES TO FINANCIAL STATEMENTS H. Restricted Assets
(1) Restricted assets (including pledged) as of September 30, 2016 were as follows (in thousands):
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
NOTES TO FINANCIAL STATEMENTS
9) Income Taxes
No significant changes from the 2015 annual statement.
10) Infonnation Conceming Parent, Subsidiaries and Affiliates
No significant changes from the 2015 annual statement.
11) Debt
As of September 30, 2016 and December 31 , 2015 Health Plan has no bo1Towings.
12) Retirement Plans, Defe1Ted Compensation, Postemployment Benefits and Compensated Absences and other Postretirement Benefit Plans
( 4) Components of net period benefit cost:
Pension:
Health Plan pa1ticipates with affiliated organizations in a defined benefit pension plan covering substantially all its employees. Benefits are based on age at retirement, years of credited service, and average compensation for a specified period prior to retirement. Contributions are intended to prnvide not only for benefits attributed to service to date but also for those expected to be earned in the fottu·e.
The pension plan is administered by KFHP. Plan assets for Health Plan are not segregated and, accordingly, are not disclosed below. However, KFHP separately accounts for Health Plan liability and expense, and KFHP allocates pension expense and related prepaid or accmed benefit costs to Health Plan based on pa1ticipant demographics and plan prnvisions.
Health Plan Allocations
The accrued pension plan liability allocated to Health Plan at December 31, 2015 and the change tlu·ough September 30, 2016 are as follows (in thousands):
Allocated pension plan liability at December 31, 2015
Recognized transition liability
Provision Contributions
Allocated pension plan liability at September 30, 2016
Unrecognized transition liability
GAAP provision adjustment
Allocated GAAP basis pension obligation at September 30, 2016
$ 375,966
42,680 (98,636)
320,010
(2,429)
$ ===31=7=,5=8=1 =
For the nine months ended September 30, pension expense allocated to Health Plan was as follows (in thousands):
2016
Service cost $ 41,867 Interest cost 32,846 Expected return on plan assets (32,033) Amortization of net actuarial loss 11,847 Amortization of prior service cost 1,422
Net pension expense 55,949
Other changes in plan assets and benefit obligations recognized in capital and surplus:
Amortization of net actuarial loss (11,847) Amortization of prior service cost ~l ,422~
Total recognized in surplus {13,269~
Total recognized in net periodic benefit cost and surplus $ 42,680
10.4
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
NOTES TO FINANCIAL STATEMENTS Plan assets and actuarial assmnptions are materially consistent v.rith the 2015 annual statement.
Postretirement:
Certain employees may become eligible for postretirement health care and life insurance benefits while working for Health Plan. Benefits available to retirees, through both affiliated and unaffiliated provider networks, vary by employee group. Postretirement health care benefits available to retirees include subsidized Medicare premimns, medical and prescription dmg benefits, dental benefits, and vision benefits.
The accrued liability for postretirement benefits at December 31, 2015 and the change through September 30, 2016 are as follows (in thousands):
Accrued benefit liability at December 31, 2015
before liability transfer to KFHP $ 379,677
Liability transferred to KFHP ~83 ,064~
Accrued benefit liability at December 31, 2015 296,613 Provision 15,141
Contributions (91 ,747) Benefits paid or provided ~11 ,978~
Accrued benefit liability at September 30, 2016 208,029
Unrecognized transition liability
GAAP provision adjustment (207)
GAAP basis accumulated postretirement obligation at September 30, 2016 $ 207,822
For the nine months ended September 30, postreti.rement benefits expense was as follows (in thousands):
Service cost
Interes t cost
Expected return on plan assets
Amortizat ion of prior service cos t Amortizat ion of net actuarial loss
Postretire1nent benefits expense
Other changes in plan ass ets and benefit obligations
recognized in capital and stuph.1S: Arnortization of prior service cos t
Arnortization of net actuarial los s
Total recognized in stuph.lS
Total recognized in net periodic benefit cost and
stuph.lS
$ 201 6
5,452 16,265 (6 ,576) 8,491
946 24,578
(8,491) (946)
(9 ,437)
$ ___ 1 .. 5, ... 14_1_
Actuarial assumptions are consistent with the 2015 annual statement asstunptions.
13) Capital and Surplus, Shareholders' Dividend Restrictions and Quasi-Reorganizations
No significant changes from the 2015 annual statement.
14) Contingencies
No significant changes from the 2015 annual statement.
15) Leases
No significant changes from the 2015 annual statement.
16) Information about Financial Instnunents with Off-Balance Sheet Risk and Financial Instnunents with Concentrations of Credit Risk.
No significant changes from the 2015 annual statement.
10.5
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
NOTES TO FINANCIAL STATEMENTS
17) Sale, Transfer and Servicing of Financial Assets and Extinguishments of Liabilities
A - B. Transfer of Receivables Repo1ted as Sales & Transfer and Servicing of Financial Assets
Health Plan has no transaction subject to the disclosure requirements of this footnote during the reporting period.
C. Wash Sales
SSAP No. 103 Accounting for Transfers and Servicing of Financial Assets and Extinguishment of Liabilities (SSAP No. 103), paragraph 28 requires a repo1ting entity to disclose any wash sales involving securities with a NAIC designation of 3 or below. Although the Health Plan's investment strategy does not include purchasing any securities with a NAIC designation of3 or below, four sectu-ities were held at September 30, 2016 with a NAIC designation of 3. Dtu-ing 2016 and 2015, Health Plan did not participate in any wash sale as defined by SSAP No. 103.
18) Gain or Loss to the Reporting Entity from Uninsured A&H Plans and the Uninstu·ed Portion of Pa1tially Insured Plans
No significant changes from the 2015 annual statement.
19) Direct Premium Written/Produced by Managing General Agentsffhird Pa1ty Administrators
No significant changes from the 2015 annual statement.
20) Fair Value Measurements
A - B.
Health Plan has no assets or liabilities that are measured and reported at fair value in the statement of financial position after initial recognition.
c.
Investments are repo1ted at lower of amortized cost or fair value, with impairment recorded if amortized cost is greater than fair value. The fair values of investments are based on quoted market pi-ices, if available, or estiniated using quoted market pi-ices for similar investments. If listed prices or quotes are not available, fair value is based upon other observable inputs or models that p1-imarily use market based or independently sourced market parameters as inputs. In addition to market information, models also incorporate transaction details such as maturity. Fair value adjustments, including credit, liquidity, and other factors, are included, as apprnpriate, to arrive at a fair value measurement.
Health Plan utilizes a three level valuation hierarchy for fair value measurements. An instrument's categorization within the hierarchy is based upon the lowest level of input that is significant to the fair value measurement. For instnunents classified in level 1 of the hierarchy, valuation inputs are quoted prices for identical instrtunents in active markets at the measm·ement date. For instrtunents classified in level 2 of the hierarchy, valuation inputs are directly observable but do not qualify as level 1 inputs. Examples oflevel 2 inputs include: quoted pi-ices for similar instnunents in active markets; quoted prices for identical or similar instnunents in inactive markets; other obse1vable inputs such as interest rates and yield ctuves observable at commonly quoted intervals, volatilities, prepayment speeds, loss seve1-ities, Cl·edit risks, and default rates; and market co!l'elated inputs that are de1-ived principally from or co!l'oborated by obse1vable market data. For instnunents classified in level 3 of the hierarchy, valuation inputs are unobse1vable inputs for the instnunent. Level 3 inputs incorporate asstunptions about the factors that market pa1t icipants would use in pi-icing the instnunent.
10.6
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
NOTES TO FINANCIAL STATEMENTS
At September 30, 2016, bonds and short-term investments at statement value and estimated fair value, derived using level 2 inputs, were as follows (in thousands):
Bonds and other invested assets: U .S. Treaswy and gove.m.ment-sponsored
agencies 278,508 278,314 278,508 All other govemment bonds 11,823 11,823 11,823 U.S. states, tenitories and possessions 985 984 985 U.S. special revenue bonds 382 379 382 loan-backed and/or sbucttued securities 221,356 220,872 221,356 Industrialandniscellaneous bonds 539.560 537 808 539 560
Total bonds and other invested assets 1.052,614 1050 180 I 052.614
Total investments 1.063,600 $ J,0613166 $ $ 1,063.600 $ $
D.
There were no investments at September 30, 2016 for which it was not practicable to estimate fair value.
21) Other Items
Health Plan had no other items for the reporting periods;
22) Events Subsequent
No significant changes from the 2015 annual statement.
23) Reinsurance
No significant changes from the 2015 annual statement.
24) Retrospectively Rated Contracts and Contract Subject to Redetennination
E. Risk Sharing Provisions of the Affordable Care Act
(1) Health Plan wrote health insurance pre1nium which is subject to the Affordable Care Act risk sharing provisions.
10.7
Not P'racti<'able !Carni5 Value}
Not P'racti<'able !Carni5 Value}
STATEM ENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
NOTES TO FINANCIAL STATEMENTS
(2) Risk sharing provisions relating to the Affordable Care Act (ACA) were as follows :
a . Pennanent ACA Risk Adjustment Program
~ 1. Premiumadjustments receivable due to ACA Risk Adjustment
Liabilities 2. Risk adju.stment user fees payable for ACA Risk Adjustment
3. Premium adjustments payable due to ACA Risk Adjustment Ooerations !Revenue & Pa>ense)
4. Reported as revenue in premium for accident and heahh contracts (written/collected) due to ACA Risk Adju.stment
5. Reported in e11penses as ACA risk adjustment user fees (incurred/paid)
b . TransitionalACA Reinsurance Program and OTRP
~
$
1. Amounts recoverable for claims paid due to ACA Reinsurance and OTRP $
2. Amounts recoverable for claims unpaid due to ACA Reinsurance (Contra Liability)
3. Amounts receivable relating to uninsured plans for contnbutions for ACA Reinsurance
Liabilities
4. Liabilities for contributions payable due to ACA Reinsurance - not reported as ceded premium
5. Ceded reinsurance premiums payable due to ACA Reinsurance 6. Liabilities for amounts held under uninsured plans contributions for ACA
Reinsurance Opggtiogs (Revgpne & . Rnensfil
7. Ceded reinsurance premiums due to ACA Reinsurance 8. Reinsurance recoveries (income statement) due to ACA Reinsurance and
OTRP payments or eiq:i ected payments 9. ACA Reinsurance contributions - not reported as ceded premium
c. TeJlllorary ACA Risk Corridors Program
~ 1. Accrued retrospective premium due to ACA Risk Corridors
Liabilities
2. Reserve for rate credits or policy eiq:ierience rating refunds due to ACA Risk Corridors
0peratiogs CRevenne &.Emegs el
3. Effect of ACA Risk Corridors on net premium income (paid/received)
4. Effect of ACA Risk Corridors on change in reserves for rate credits
$
September 30, 2016
14,249,665
65,023 4,500,000
933,057
64,979
6,103,717
871,949
11,478,047
754,001
563,252
5,577,218
7,446,907
1,376,717
4,623,283
(3) Roll-forward of prior year ACA risk-sharing provisions for the following asset (gross of any nonadmisstion) and Liability balances, along with the reasons for adjustments to prior year balance:
20.193.682 20.417.401 n SJ.n 1 3.H 5,S95 - B Uil.170 1.682.170 (1.612.170) - B
39.908.401 3).817,263 4 .031.140
I 666 201 1 47S 455 190 74S
2U7U52 41.SJ.4.606 20.417.401 37.Hl.718 l .39"1.449 4.221.818 l .67l,42S
9.167.746 3.867,746 6 .000.000 (5,323.28.3) C
9.167.746 3.867,746 6 .000.000 f5,323.28J d. Total forACAJWk ProvUiom s SS,846.124 s Sl .4~.290 s 4&.631.267 s 41.134,402 s I0.21S.OS7 uo.22uas s <39l,Sl8 s S,323.283
Expi..tioo. of AdjwtlDAGb A CMS~fiml 2015 R.A~&:ipon 00- 061l0/2016 B. CMS~ lizla.12015111-hpon 00- 06!3012016 (•vly p.,_at f9C.9n-.d03116. 25% Com.-b• tiud.aiamdlita 'll.b:aittad02/0l/16). C. 2015Rclc~U'laapasof06/3M6~~oaly)
10.8
6,749.60
l.071.8"74
l.071.8"74
' 9,121.539 '
4.031.140
190 741
4.221.8!8
676.717
676.717 4.898,60S
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
NOTES TO FINANCIAL STATEMENTS
(4) Roll-Forward of Risk Con-idors Asset and Liability Balances by Program Benefit Year:
Attrued as of December 31 R.ec:ei\--ed or Paid as of the of the prior year reporting Cane.at Period on Business
year Written For the Risk
Unsettled B.i..c.s as of the Reporring Date
Coiridors Program Year Less Accrued Less Cumulatn·e Cumulatn·e
B.i..c.s B.W.:. SW..:. r•6' Corridors Program Year.
Explanation of Adjusnnents A. 2015 Risk Corridor true up as of06/30/16 (recorded payables only)
3 867746
(5) ACA Risk Con-idors Receivable as ofRepo1ting Date:
Estimated Amount to be Non-Accrued Amounts for Risk Corridors Filed or Final Amount J.mpallment or Other Amounts received from
6,000,000 (5,323,283) A 676,717
15 323183' 676 717
Asset Balance (Gross of Non-
Program Year. Filed with CMS Reasons CMS admissions) Non-admitted Amount Net Admitted Asset
2014 s s $ $ $ s
2015 s 9,821,230 s 9,821,230 $ $ $ s
2016 s 15,554,588 s 15,554,588 $ $ $ s
Total s 25,375,818 s 25,375,818 $ $ $ s
25) Change in Incurred Claims and Claim Adjustment Expenses
Unpaid claims and claims adjustment expense includes both repo1ted and unreported medical claims, which have been pattially reduced by estimated recoverables for salvage and subrogation and estimated reinsurance recoveries tu1der the PPACA. Unpaid claims inctm·ed but not report.ed represent an estimate of claims incurred for or on behalf of Health Plan's members that had not yet been repo1ted to the Health Plan in the statutory statements of admitted assets, liabilities, capital, and stuplus. Unpaid claims are based on a number of factors including hospital admission data and p11or claims experience, as well as claims processing pattems; adjustments, if necessa1y, are made to medical expense in the pe1-iod the actual claims costs are ultiniately detennined. The estiniated salvage and subrogation included as a reduction to tu1paid claims and claims adjustment expense was $7.2 million and $8.8 million at September 30, 2016 and December 31 , 2015, respectively. At September 30, 2016 and December 31, 2015, the estimated rei.t1sm·ance recoveries under the PPACA included as a reduction to reserves for unpaid clai.tns and clai.tns adjustment expense was $0.9 and $1 . 7 million, respectively.
Claims adjustment expense represents costs incm1·ed related to the claim settlement process such as costs to record, process, and adjust claims. These expenses are calculated using a percentage of current medical costs, which is based on historical cost experience.
10.9
-
-
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
NOTES TO FINANCIAL STATEMENTS
Activity in the reserves for unpaid claims and claims adjustment expense was smrunarized as follows (in thousands):
9/30/2016 12/3112015 Balances at Janua1y 1 $ 59,278 $ 52,837
Incull'ed related to Cm1·ent year $ 2,418,864 $ 3,117,839 Prior years $ 1,723 $ (6,3 17)
Total incull'ed $ 2,420,587 $ 3,111 ,522
Paid related to Cm1·ent year $ 2,370,891 $ 3,060,080 Prior years $ 59,954 $ 45,001
Total paid $ 2,430,845 $ 3,105,081
Balance at end of period $ 49,020 $ 59,278
Amounts incurred related to prior years vary from previously estimated liabilities as the claims are ultimately adjudicated and paid. Liabilities are reviewed and revised as infonnation regarding actual claims payments becomes known. Positive (negative) amounts repo1ted for incurred related to prior years result from claims being adjudicated and paid for amounts more (less) than originally estimated.
26) Intercompany Pooling Arrangements
No significant changes from the 2015 annual statement.
27) Stmctured Settlements
Not applicable for Health Entities.
28) Health Care Receivables
No significant changes from the 2015 annual statement.
29) Participating Policies
No significant changes from the 2015 annual statement.
30) Premium Deficiency Reserves
No significant changes from the 2015 annual statement.
31) Anticipated Salvage and Subrogation
No significant changes from the 2015 annual statement.
10.10
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
GENERAL INTERROGATORIES
PART 1 · COMMON INTERROGATORIES GENERAL
1.1 Did the reporting entity experience any material transactions requiring the filing of Oisck>sure of Material Transactions with the State of
Domicile, as required by the Model Act? -·········--··········--··········--·········--··········--··········--·········--··········--··········-
1.2 If yes, has the report been fi led with the domiciliary state? -··········--··········--·········--··········--··········--·········--··········--····
2.1 Has any change been made during the year of this statement in the charter, by-laws, articles of incorporation, or deed of settlement of the
2.2 If yes, date of change: __ ······--······--······--······--······--······--······--······--······--······--··--··········--·····03/03/2016
3.1 Is the reporting entity a member of an Insurance Holding Company System consisting of two or more affii ated persons, one or more of
which is an insurer? _······--······--······--······--······--······--······--······--······--······--······--If yes, complete Schedule Y, Parts 1 and 1A.
3.2 Have there been any substantial changes in the organizational chart since the prior quarter end? -·········--··········--··········--·········-
3.3 If the response to 3.2 is yes, provide a brief desc~tion of those changes.
4.1 Has the reportilg entity been a party to a merger or consolidation during the period covered by this statement? -······--······--·······
4.2 If yes, provide the name of entity, NAIC Company Code, and state of domicile (use two letter state abbreviation) for any entity that has ceased to exist as a result of the merger or consolidation.
Name of Entity NAIC Company Code State of Domicile
5. If the reporting entity is subject to a management agreement, including third.party administrator{s). managing general agent{s), attomey-in-
Yes (XJ No f J
Yes f J No (XJ
Yes f J No (XJ
fact, or similar agreement, have there been any significant changes regardilg the terms of the agreement or principals involved? ·--···· Yes ( ] No fXJ NA f J If yes, attach an explanation.
6.1 State as of what date the latest financial examination of the reporting entity was made or is being made. ·······--······--······--··--··········--·····.12/ 31 / 2013
6.2 State the as of date that the latest financial examination report became avai able from either the state of domicile or the reporting entity. This date should be the date of the examined balance sheet and not the date the report was completed or released. -······--······----··········--·····.12/ 31 / 2013
6.3 State as of what date the latest financial examination report became avai able to other states or the public from either the state of domicile or the reporting entity. This is the release date or completion date of the examination report and not the date of the examination {balance
sheet date>· --······--······--······--······--······--······--······--······--······--······--······--···--··········--·····03/24/2015 6.4 By what department or departments?
State of Oregon Department of Consumer & Bus iness Services_·········--··········--··········--·········--··········--··········--·········-
6.5 Have all financial statement adjustments within the latest financial examination report been accounted for in a subsequent m ancial statement filed witll Departments?-······--······--······--······--······--······--······--······--······--······- res [ I No ( J NA (XJ
6.6 Have all of the recommendations within the latest financial examination report been complied with? ·······--··········--··········--·········- Yes ( ] No f J NA (XJ
7.1 Has this reportilg entity had any Certificates of Authority, licenses or registrations (ilcluding corporate registration, if applicable) suspended or revoked by any governmental entity during the reporting period? __ ······--······--······--······--······-- Yes ( ] No (X]
7 .2 If yes, give ful information:
8.1 Is the company a subsidiary of a bank holding company regulated by the Federal Reserve Board? ......... ·--··········--··········--·········-
8.2 If response to 8.1 is yes, please identify the name of the bank holding company.
8.3 Is the company affiiated with one or more banks, thrifts or securities firms? __ ······--······--······--······--······--······-
8.4 If response to 8.3 is yes, please provide below the names and location (city and state of the main office) of any affiiates regulated by a federal regulatory services agency [i.e. the Federal Reserve Board (FRB), the Office of the Comptroller of the Currency (OCC), the Federal Deposit Insurance Corporation (FDIC) and the Securities Exchange Commission (SEC)] and identify the affiliate's primary federal regulator.)
Affiiate Name
2 Location
c· State
11
3
FRB DCC FDIC
Yes f J No (XJ
Yes f J No (XJ
6
SEC
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
GENERAL INTERROGATORIES 9.1 Are the senior officers (principal executive officer, principal financial officer, principal acoounting officer or controller, or persons performing
similar functions) of the reporting entity subject to a oode of ethics, which includes the following standards? ·········--··········--·········--
{a) Honest and ethical conduct, including the ethical handling of actual or apparent conflicts of in terest between personal and professional relationsh~s;
{b) Full, fair, accurate, timely and understandable disck>sure in the periodic reports requi"ed to be filed by the reporting entity;
{c) Compliance with applicable governmental laws, rules and regulations;
{d) The prompt internal reporting of violations to an appropriate person or persons identified in the code; and
{e) Acoountability for adherence to the code.
9.11 If the response to 9.1 is No, please explain:
9.2 Has the oode of ethics for senior managers been amended? ···--······--······--······--······--······--······--·······
9.21 If the response to 9.2 is Yes, provide information related to amendment(s).
9.3 Have any provisions of the code of ethics been waived for any of the specified officers? -·········--··········--··········--·········--········
9.31 If the response to 9.3 is Yes, provide the nature of anywaiver(s).
FINANCIAL 10.1 Does the reporting entity report any amounts due from parent, subsidiaries or affiiates on Page 2 of this statement?_··········--··········-
Yes (XJ No ( I
Yes ( I No (XJ
Yes ( I No (XJ
Yes (XJ No ( I
102 If yes, indicate any amounts receivable from parent included in the Page 2 amount:_·········--··········--··········--·········--··········-$ -······--······--·D
INVESTMENT 11.1 Were any of the stocks, bonds, or other assets of the reporting entity loaned, placed under option agreement, or otherwise made available
for use by another person? (Exclude securities under securities lending agreements.>--······--······--······--······--·······
112 If yes, give ful and complete information relating thereto:
Yes ( I No (XJ
12. Amount of real estate and mortgages held in other invested assets in Schedule BA: -······--······--······--······--······~ -······--······--······
13. Amount of real estate and mortgages held in short-temi investments: ·······--·········--··········--··········--·········--··········--······$ -······--······--······
14.1 Does the reporting entity have any investments in parent, subsidiaries and affi liates? -··········--·········--··········--··········--·········-
142 If yes, please complete the following:
14.21 Bonds ·····--··········--·········--··········--··········--14.22 Preferred Stock ········--·········--··········--··········--14.23 Common Stock ·--······--······--······--···· 14.24 Short-Term lnvestments __ ······--······--······-14.25 Mortgage Loans on Real Estate ··--··········--··········-14.26 All Other·····--······--······--······--······-14.27 Total Investment in Parent, Subsidiaries and Affiliates
(Subtotal Lines 1421 to14.26)-...... --······--······-14.28 Total Investment in Parent included in Lines 1421 to14.26
15.1 Has the reportilg entity entered into any hedging transactions reported on Schedule OB? ······--······--······--······--······-
152 If yes, has a comprehensive description of the hedging program been made available to the domiciiary state? ····--······--······--
If no, attach a description with this statement
11 .1
Yes I J No [XJ
Yes ( I No (XJ
Yes f I No f I
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
GENERAL INTERROGATORIES
16 For the reporting entity's security lending program, state the amount of the fol owing as of the current statement date:
16.1 Total fair value of reinvested collateral assets reported on Schedule OL, Parts 1 and 2 $ ..... ·--······--······-16.2 Total book adjusted/carryilg value of rei w ested co l a teral assets reported on Schedule Ol, Parts 1 and 2 $ ...... --······--······-16.3 Total payable for securities lendilg reported on the liabi ity page $ ..... ·--······--······-
17. Excluding items in Schedule E - Part 3 - Special Deposits, real estate, mortgage loans and investments held physicalty in the reporting entity's offices, vaults or safety deposit boxes, were all stocks, bonds and other securities, owned throughout the current year held pursuant to a custodial agreement with a quai fied bank or trust company in accordance with Section 1, Ill - General Examilation Considerations, F. outsourcing of Critical Functions, Custodial or Safekeeping Agreements of the NAIC Financial Condition Examiners
17 .1 For all agreements that comply with the requirements of the NAIC Financial Condition Examiners Handbook, complete the followilg:
1 2 Name of Custodianls) Custodian Address
U.S. Bank Nat ional Association__ ......... --··········- !ll(JU Nico l let Mat I , Minneapol is , !fl 55402-70200 __ .. State Street Bank and Trust COOl)any .... ·--··········- 2 Ave de Lafayet te, Boston, MA 02111-.. ... ·--······-
17 2 For all agreements that do not comply with the requirements of the NA IC Financial Condition Examiners Handbook, provide the name, location and a complete explanation:
3 Name(sJ Location(s) Complete ExP'anation(s)
17.3 Have there been any changes, including name changes, in the custodian(s) identified il 17.1 during the current quarter? -······--······-
17.4 If yes, give ful and complete information relating thereto:
Old Custodian New Custodian 3
Date of Chan e 4
Reason
17.5 Identify al investment advisors, broker/dealers or individuals actilg on behalf of broker/dealers that have access to the investment accounts, handle securities and have authority to make investments on behalf of the reporting entity:
2 3 Central Reaistration Oeoositorv Name-ts\ Address
525 Market Street , 10th f Joor . San 104973_······--······--······ We l ls Gap i ta l Managemeot.. __ .. f ranc isco, CA 94510_·········--··········--···· 10716Q_······--······--······ Payden & Rygel_······--······- 333 S. Grand, Los Ange les , CA 9007L-....
18.1 Have all the fiing requirements of the Purposes and Procedures Manual of the NAIC Investment Analysis OfflCe been fol owed? -··········-18.2 If no, list exceptions:
11 .2
Yes (XJ No ( J
Yes ( I No (XJ
Yes [XJ No ( I
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
2.1 Oo you act aa a custocfian tor healh aavings accounts?·- - - -··--- ··········-······------··········-·- ·- ········
2.2 II yea, please provide the amooot ol custodial funds held as of lhe repor&>g dale--······--······--······--······--······-
2.3 Oo you act aa an admilistrator for heat1h savings accounts? ..... --······- -······--······--······--······--······--···
2.4 II yea, please provide the balance of the funds admilislered as of the reporting date- .......... - .......... - ......... - .......... - ··········-
12
96 .1 'l
0.6 'l
7.4 'l
Yes I I It> [XI
$
Yes I I It> (X)
2
Co1
w
3
Effectiw Date
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KA ISER FOUNDATION HEALTH PLA N OF THE NORTHWEST
SCHEDULE S - CEDED REINSURANCE
NameofReinsurer
Showlna All New Relnsuran .. Treatlee -Current Year to Date 5
. Line 58 from overflow page ...... ·--+--""X. .... . . ........ __JJ ······--·D ···-·········D ··--······D .......... ---1J ·-··········.D ······--D ····-········D 8999 Totals (Lines 58001 through 58003
. plus 58998) (Line 58 above) xxx 0 0 (l) Lioensed or Oiartered - Lioensed Insurance Carrier or Domiciled RRG: (R) Registered - Non«imicied RRGs; (Q) Ouarifi.ed - Qualified oc Aocredited Reinsorer: (E) Eligible - Reporting Entities eligble or approved to write Surplus Lines in the state; (N) None of the abcNe - Not allowed io write business in the state. (a) klsert the nU11"tlerof L responses except for Canada and other Aien.
14
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST SCHEDULE Y - INFORMATION CONCERNING ACTIVITIES OF INSURER MEMBERS OF A HOLDING COMPANY GROUP
PART 1 -ORGANIZATION CHART
Kaiser Foundation Health Plan of the Northwest
Rainbow Dialysis, LLC
KAISER FOUNDATION HEALTH PLAN, INC. AND KAISER FOUNDATION HOSPITALS SUBSIDIARIES AND AFFILIATED CORPORATIONS
As of September 30, 2016
Kaiser Foundation Health Plan, Inc.
Northern California Region
Kaiser Foundation Health Plan of Georgia, Inc.
Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.
Kaiser Permanente Insurance Company
Camp Bowie Service Center
1800 Harrison Foundation
Kaiser Foundation Health Plan of Washington
KP Cal, LLC
Kaiser Health Alternatives
Southern California Region
Hawaii Region
15
Kaiser Foundation Health Plan of Colorado
Kaiser Health Plan Asset Management, Inc.
Lokahi Assurance, Ltd.
Ordway International, Ltd.
Kaiser Colorado Holdings
Kaiser Properties Services, Inc.
Oak Tree Assurance, Ltd.
OrdWay Indemnity, Ltd.
Kaiser Foundation Hospitals
..... O>
Gr0'4) Code
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
SCHEDULE Y PART 1A- DETAIL OF INSURANCE HOLDING COMPANY SYSTEM
2 3 5 6 7 Name of Serurities
Exchange if
8
Company ID Federal Traded (U.S. or Parent Stbsidiaries NAIC I I I I Ptblidy I Name of
Gro14> Name I Code Ni.mber RSSD CIK International) or Affiliates Kaiser 001datioo ttial th Ian, Kaiser ounda tioo Heal th Ian
......... _, lnc(l(FH')_ .......... -.......... _......... 93-0954562......_ .. ____________________ --------------· Kai se r Hea l th Al ternat iveL ....... _ OR ...... ___ .NIA.. ....... KFHP .... _ .......... -......... Owne rsh ip_ .... _ ...... J 00.0 KFH'._.......... ____ O Kaise r f001datioo tbspi tal s
......... _, ("KFH')_ .... ______ .... __ .... _......... 94-3245176-.. --·----.... _ ...... __ .... ____ .... ___ Kaiser Permaiente lnterna t iooal _ CA ...... __ . .NIA.. ....... KffL ...... ____ .... __ ...... Ownership__ .... _ ...... .JOO.O KFK ...... --...... ____ o Kaise r F001datioo tbspi tals Kai se r Hospi tal Asse t
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
SCHEDULE Y PART 1A- DETAIL OF INSURANCE HOLDING COMPANY SYSTEM
2 3 5 6 7 Name of Serurities
Exchange if
8
Company ID Federal Traded (U.S. or Parent Stbsidiaries NAIC I I I I Ptblidy I Name of
Gro14> Name I Code Ni.mber RSSD CIK International) or Affiliates Kaiser 001datioo tbspi tals Kaiser erm<11ente Ventu res , LL
9
Domiciliary Location
10
Relationshi> to Reporting
Entitv
11
Directly Controlled by (Name of Entity/Personl
12 T)l)e of Control
(Ownershi>, Board,
Management, Attorney-ir>-Fact I nftuence, Otherl
13
If Control is ONnership
Provide Percentage
14
Ultinate Controlling Entity(iesY Person(s)
15
·········-• ( "l(FH")_______________________________ 47-1874300_ _____________ -······--····--······--· - Series D .. ·--······--······ ___DE_ _________ .NIA.... ...... KFIL ..... ·--······--······ MMagemeoL ....... -···········0.0 KFtL _______________ O Kai se r F001datioo tila l th Plan ,
·········-• l rc (l<FH')_ ......... ·-·········· -········· 27-04737'!1 ____ ···--······ -······-- ····--······--· Ra irlJow Dialys is, LLC ....... ·-··· ___DE. ...... ___ .NIA ......... KFHP ... ·-··········-········· O·rne rsh ip_ .... _ ...... .JOO.O KFH'·-·········· ____ O Kai se r F001datioo tl:>spi tal s Kai se r Hospi tal Ass i starce
·········-• ("l(FH') _____________________ -········· 31-1779500_ .. ···--······ -······-- ····--······--· C.Orporat i(ll________________ _ CA ...... ___ .NIA.... ...... KFIL ..... ·--······--······ Ownership_ .... -······J OO.O KHL ... --······ ____ Q Kai se r F001datioo tl:>spi tal s Kai se r Hospi tal Ass i starce I -
·········-• ("l(FH')_ ..... ·--······--···· -········· ·········-··········- ···--······ -······-- ····--······--· uc__ ____ ··--······--······ _ CA... ... ___ .NIA ......... KFIL ..... ·--······--······ Ownership_ .... _ ...... .JOO.O KFK ..... ·--······ ____ 5 Kai se r F001datioo tl:>spi tal s llXT Capi tal Senior loan Fund 1,
········--• ("l(FH')_______________________________ 37 -1 651297 ______________ -······-- ····--······--· uc__ ______________________ ___DE_ _________ .NIA.... ...... KFIL ..... ·--······--······ O·rnersh ip_ .... -········.75.1 KFK ..... ·--········--6 Kaiser F001dat ioo tsal th Plan, Kaiser Founda t ion Heal th Plan
·········-• l rc(l<FH')--·········-·········· -········· g3.(J43)a__ __ ···--······ -······-- ····--······--· of lashi rg too .... ·-·········-···· _ IA ...... ___ .NIA ......... KFHP ... ·-··········-········· Owne rsh ip_ .... _ ...... .JOO.O KFH'·-·········· ____ 7 Kaiser F001dat ioo tsal th Plan,
·········-• l rc (l<FH')_ ......... ·-·········· -········· ·········-··········- ···--······ -······-- ····--······--· Kai se r Colorado Holdings. ..... __ CO ....... ___ .NIA ......... KFH' of C.Ol°'ado_......... O·rne rsh ip_ .... _ ...... .JOO.O KFH'·-·········· ____ 8 Kai se r F001datioo tl:>spi tal s Mau i Hea l th System, A Kai ser
·········-• ( "l(FH") _____________________ -········· 81-15$375..__ __ ···--······ -······--····--······--· Foundation tl:>spi tal s LLC ...... ___ Jll ....... ___ .NIA ......... KFIL ..... ·--······--······ Owne rsh ip _____ -······J OO.O KFK ..... ·--······ ____ O Kai se r F001datioo tl:>spi tal s Kai se r PermMente School of ("l(FH')_ ...... --······--···· -········· 814053028..__ .. ···--······ -······-- ····--······--· Medicine, l nc ..... . CA... ... _, . .NIA ........ .JKFIL ..... . . ..... -10wnershin_ . ..... .JOO.O IKFK ..... . 0
100% of pre ferred stock owned by KFttP , ~of voti ng stock owned by KFHP and 00% owned by Perm<11ente Medical Groups__ _________ ·····--······--······--······--······--······--······--······--······--······--······--······--······-Relat ion to repor ting mti ty - holdi ng caupany - _holds 1()(g _of the sha res of Ordway l nde1111 i ty, Ltd . Thi s enti ty i s a_f(){eign corporation . _I t does not Ojlerate i n the Uni ted States and the ref°'e no US tax identif ica t ion nunter required ...... ·--······--~MI C.Ol(){ado, LLC 1s not a stand -alone oorpora t 1on and 1t 1s a disregarded ent i ty w1th1n Hlllll , tl'e re f(){e , no US tax 1dm t 1f 1cat 1on nunter 1s required ..... ·--······--······--······--······--······--······--······--······--······--······-Kaiser Hospi tal Assist<11ce M LC is not a stand -alone oorporat ion and i t is a disregarded ent i ty, tl'e refore , no US tax ident i f icat ioo nunter is required·-··········--··········--·········--··········--··········--·········--··········--··········--·········--··········--······· KFH and the Kaise r Permanm te Group Trus t are the Par ticipation menbers of this LLC, aid KFH owns 75.1% and Kai se r Permmente Groop Trus t owns 24 .g%. Kaiser Foondation Heal th Plan, Inc. i s t l'e fiduciary of Kai se r Permanen te Gr<J14> Trust. llXT Capi tal
Relation to repor ting mti ty - captive i nsurarce c~any oon trolled by KFHP·--······--······--······--······--······--······--······--······--······--······--······--······--······--······--······--······--······--·····-~
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
SUPPLEMENTAL EXHIBITS AND SCHEDULES INTERROGATORIES The folk>wing supplemental reports are required to be filed as part of your statement filing. However, in the event that your company does not transact the type of business for which the special report must be filed, your response of NO to the specific interrogatory will be accepted il lieu of ftilg a •NONE• report and a bar code will be printed below. If the supplement is required of your company but is not being fi led for whatever reason enter SEE EXPLANATION and provide an explanation following the in terrogatory questions.
RESPONSE
1. Will the Medicare Part 0 Coverage Supplement be filed with the state of domicile and the NAIC with this statement? -······____NQ ________ _
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
OVERFLOW PAGE FOR WRITE-INS
M0003 Additional Aggregate l ines for Page 03 l ine 23. 'LIAB
1 2 3 Covered Uncovered Total
2304. Other Liabi l i ty .. ·-··········-··········-·········-··········-··········- ......... - 18,251,068 ·······-·········-···· ····-····18,251,068 2305. Se l f Insurance_ ..... ·--······--······--······--······--······ ·········-·5,256 ,616 ·······-·········-···· ····-······5 ,256,616 2306. ··········-·········-··········-··········-·········-··········-··········- ·········-··········-· ·······-·········-···· ····-··········-·.!) 2397. Summarv of remainina write-ins for l ine 23 from Paae 03 23,507,684 0 23 ,507 ,684
STATEMENT AS OF SEPTEMBER 30, 201 6 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
SCHEDULE A - VERIFICATION Real Estate
Year To Date
2 Prior Year Ended
Oecember31
1. Book/adjusted carrying value, December 31 of prior year-······--······--······--······--······- -······------216, 193 ,095 --······---209, 100 ,999 2. Cost of acquired:
2.1 Actual cost at time of acquisffion ... --··········--·········--··········--··········--·········--··········--·· -······--······--·O --······--······___j) 2.2 Additional investment made after acquisition --··········--·········--··········--··········--·········--··· -······--··19.758,312 --······----25 ,595,950
3. Current year change in encumbrances ···--·········--··········--··········--·········--··········--··········- -······--····· (312,620) --······--·999, 197 4. Total gain Qoss) on disposals········--··········--··········--·········--··········--··········--·········--·········· -······--···;J,943 ,605 --······--·388,712 5. Deduct amounts received on disposals ······--·········--··········--··········--·········--··········--··········- -······--···6,663 ,964 --······--·484,737 6. Total foreign exchange change in bookladjusted carrying value-..... ·--······--······--······--·· -······--······--·O --······--······___j) 7. Deduct current year's other-than-temporary impaiment recognized--·········--··········--··········--········· -······--······--·O --······--······_JJ 8. Deduct current year's depreciation ...... ·--······--······--······--······--······--······- -······----14,950,625 --······--19,407 ,026 9. Book/adjusted carrying value attheend of current period (Lines 1•2•3•4-5•6-7-8)...__ ...... --······- -······------217,961 ,803 --······---216, 193,095
10. Deduct total nonadmitted amounts _··········--··········--·········--··········--··········--·········--·········· -······--······--·O --······--······___j) 11. Statement value at end of current oeriod Cline 9 minus Line 10) 217 9fi1 803 216 193 095
SCHEDULE B - VERIFICATION Mort a e Loans
Year To Date
2 Prior Year Ended
December31
1. Book value/recorded investment excluding accrued interest, December 31 of prior year.--······--······ ······--······--D --······--······_JJ 2. Cost of acquired:
2.1 Actual cost at time of acquisition ······--·········--··········--··········--·········--··········--·········· 2.2 Additional investment made after acquisition --··········--·········--··········--··········--·········--···
3. Capitalized deferred interest and other ... ·--·········--~·· .... ......... ...... . .... . .... . 4. Accrual of disoount_.·········--·········--··········--······ .... .. .... .... ... ·········--··· 5. Unrealized valuation increase (decrease>-······--······ ... .... ... --··· 6. Total gain (loss) on disposals········--··········--·········· ... .......... ..... ······--·········· 7. Deduct amounts received on disposats..___······--·· ...... ...... ... . 8. Deduct amortization of premium and mortgage ilterest points and oommitment fees····--······--······ 9. Total foreign exchange change in book value/recorded investment excludilg accrued interest ······--······
10. Deduct current year's other-than-temporary impaiment recognized __ ·········--··········--··········--········· 11. Book value/recorded investment excluding accrued interest at end of current period (Liles 1 +2+3+4+5+6-7-
8•9-10)--·····--······--······--······--······--······--······--······--······-12. Total vaktation allowance_·········--··········--··········--·········--··········--··········--·········--··········-13. Subtotal (Line 11 plus Line 12l----···--······--······--······--······--······--······--··· 14. Deduct total nonadmitted amounts_·········--··········--··········--·········--··········--··········--········· 15. Statement value atend of current riod Line 13 minus Line 14
1. Book/adjusted carrying vakte, December 31 of prior year ......... ·--··········--·········--··········--·········· ······--······--D --······--······_JJ 2. Cost of acquired:
2.1 Actual cost at time of acquisition ······--·········--··········--··········--·········--··········--·········· 2.2 Additional investment made after acquisition __ ······N····e· .. ENE.. .... ... ··--···
3. Capitalized deferred interest and other ... ·--·········--··· . ... ... ... . .... . ........ .
~: ~~~~~~ d~~~~~~~~~~~ (d;~~~~se)_::::::==:::::: ::: :··· .. . . ... ::::::~::: 6. Total gain (loss) on disposals ....... ·--··········--··········--·········--··········--··········--·········--·········· 7. Deduct amounts received on disposats..___······--······--······--······--······--······ 8. Deduct amortization of premium and depreciation_······--······--······--······--······--······ 9. Total foreign exchange change in bookladjusted carrying value-..... ·--······--······--······--··
10. Deduct current year's other-than-temporary impaiment recognized __ ·········--··········--··········--········· 11. Book/adjusted carrying value at end of current period (Lines 1 +2+3+4+5+6-7-8+9-10) ......... --··········--······ 12. Deduct total nonadmitted amounts_·········--··········--··········--·········--··········--··········--········· 13. Statement value at end of current riod Line 11 minus Line 12
1. Book/adjusted carrying value of bonds and stocks, December 31 of prior year-··········--··········--········· -······--1,050, 179 , 771 2. Cost of bonds and stocks acquired ··--······--······--······--······--······--······--··· _ ...... ----510,900 ,277 3. Accrual of discount __ ······--······--······--······--······--······--······--······- -······----.2, 174 ,073 4. Unrealized valuation increase (decrease>-······--······--······--······--······--······--··· -······--······--D 5. Total gain Qoss) on disposals········--··········--··········--·········--··········--··········--·········--·········· -······--··.2,756 ,692 6. Deduct consideration for bonds and stocks disposed of_··········--·········--··········--··········--·········- _ ...... ----570,910 ,564 7. Deduct amortization of premiurn ......... ·--··········--·········--··········--··········--·········--··········--·· -······--····1,305 ,278 8. Total foreign exchange change in bookladjusted carrying value_······--······--······--······--·· -······--······--D 9. Deduct current year's other-than-temporary impaiment recognized--·········--··········--··········--········· -······--·······612 ,521
10. Book/adjusted carrying value at end of current period (Lines 1+2+3+4+5-6-7+8-9). __ ·········--··········--·· _ ...... ---993.182 ,450 11. Deduct total nonadmitted amounts_·········--··········--··········--·········--··········--··········--·········- -······--······--D 12. Statement value at end of current oeriod Cline 10 minus Line 11) 993, 182 ,450
:: §~ •••••••••• •••••••••• ••••••••• •••••••••• •••••••••• •••••••• ••••••••• l •••••••••• ~ [ •••••• l •••••• ~ E •••••• L ••••••••• l E ··········~ ••••••••• ••••••••• l :: :~...;;;;::~ ==-=-===-1 ..... ~J ~ ... J ••. ~ .. '. I
(a) Book/Aqusted Carrying Value column for the end of the OJrrent reporting period includes the following amount of n0r>-rated short-term and cash equivalent bonds by NAIC designation: NAIC 1 $ _ .......... _ 10,550,000 ; NAIC 2 $ ........ --..... 988,549
10. Book/adjusted call)'ing value at end of current period (Lines 1 •2•3•4•5-6-7•8-9~ ....... --.. ········--......... _ ·····--.......... -26 ,017,436 f-......... --...... ..10,985 ,320
11. Deduct total nonadmitted amounts .. ·--··········--·········--··········--··········--·········--··········--······ ·····--··········--··········..!) -·········--··········--·····D 12. Statement value at end of current oeriod rune 10 minus Line 11) 26 ,017,436 10,985 ,320
SI03
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
Schedule DB - Part A - Verification
NONE Schedule DB - Part B - Verification
NONE Schedule DB - Part C - Section 1
NONE Schedule DB - Part C - Section 2
NONE Schedule DB - Verification
NONE
8104, SIDS, 8106, 8107
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
SCHEDULE E ·VERIFICATION (Cash Equivalents)
Year To Date
2 Prior Year
Ended December 31
1. Bookladjusted carrying value, December 31 of prior year_·········--··········--··········--·········--·········· ·····--··········--··········_!} ~-········--··········--·····.1
2. Cost of cash equivalents acquired_······--······--······--······--······--······--······- ·····--··········-11,969, 181 -·········--········.2,999 ,543
3. Accrual of discount ...... --······--······--······--······--······--······--······--······ ·····--··········--········765 -·········--··········--·212
5. Total gain (loss) on disposal•-··········--·········--··········--··········--·········--··········--··········--·· ·····--··········--········(18) >-·········--··········--··129
6. Deduct consideration received on disposal•--······--······--······--······--······--······- ·····--··········-11,969 ,928 -·········--·········2 ,999 ,885
7. Deduct amortization of premium··--······--······--······--······--······--······--······ ·····--··········--··········j) ~-········--··········--·····D
8. Total fore;gn exchange change in book/adjusted carrying value ··--······--······--······--······- ·····--··········--··········_!} ~-········--··········--······O
9. Deduct current year's other than temporary impairment recognized ······--··········--··········--·········--··· ·····--··········--··········j) -·········--··········--·····D
10. Book/adjusted carryilg value at end of current period (Lines 1+2+3+4+5-6-7+8-9) ........... --·········--·········· ·····--··········--··········_!} -·········--··········--······O
11. Deduct total nonadmitted amounts ······--·········--··········--··········--·········--··········--··········--·· ·····--··········--··········_!} ~-········--··········--······O 12. Statement value at end of current period (Line 10 minus Line 11) 0
SI08
m 0 .....
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KA ISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
.... o ___ 1.587.19• ......... _o .......... ___o ·······--··D L ...... ...D •.......• ___o ·······--·····o L ... .3.'93.m ......... _o .. _l .939 .955 ...... - 1.989.955 --·········_J ..... 10.231 OIOClfm • Prcper ty d isposOO 13,411 ::rn o I 2,776,743 I ZT,fl:M I o I 2,383 I <25.21111 o I o I 6,663,954 I o I 3,9'3,ros I 3,943,0'.15 I o I 65,472
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
Schedule B - Part 2
NONE Schedule B - Part 3
NONE Schedule BA - Part 2
NONE Schedule BA - Part 3
NONE
E02, E03
m ~
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLA N OF THE NORTHWEST
CUSIP Identification
Bonds - U.S. Go"9rM18nts
~ ..... 91'828-lf-L_. us TllfASOO Ml ..... 91'828-N2-2.__. us TllfASOO Ml ..... 91'828·P9·L-. US TllfASl.ltY Ml ..... 91'828·R8·L-. US TllfASl.ltY Ml ..... 91'828·119·3,__. US TllfASl.ltY Ml ..... 91'828-S2-7 __ us TllfASOO Ml ..... 91'828-56-a.__. us TllfASOO Ml ..... 91'828-S7 -&.___. US TllfASOO Ml
2 3
Oesaiptjon Foreign
SCHEDULE D - PART 3 Show Ml Lona-Term Bonds and Sk>ckAcquired Durina the CurTent Quarter
~··•••••••• r•••••••••••••••••••••••••••••••••••••••••••••••:E :••••••••••••••••••••••••••••••••••••••• @••••••••• L @•••••••••••••••••••••••••••I•• 9999999 Totals 156,960,498 xxx 149,031 xxx (a) For all 0011111on stoci< bearing the NAIC mar1<et indicator "l!' provide: the runber of such issues -··········--·········J
m 0 (JI
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KA ISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
SCHEDULE D - PART 4 Show All Long-Tenn Bonds and Stock Sold, Redeemed or Otherwise Disposed of Du~ng the Current Quarter
CUSIP ldeni-
8 I 9 I 10 I I Change in ~ook/Adus.ted c ,-n!ng Value
PricrYear Bod</Acju•"d!
11 12
lklrealzed Valuation CuTentYear'$
13
CUnentYeafs Of'lerThan Terrcxuary
14
18
15
17 18 19 20
Bond Fcreign
E>Change Ga in Realzed Gain
21 22
MAIC Des;g-nation
Stated « conracl\lal Ma11<e1
fleaticrl I De!ffi:Alon Clis!loool
Date Named P\Jttnaset
Nt.mberof Slaresof
St>ct< Consldetallonl Par llalue ActJalCo&t Conyi'lg
Value lnaeoS&' (Nnortimion)/
I Demase Accntticrl '""'*ment Recoooiz~
Tctal Charge inl B./A.C.V.
111 +1~13)
Total Fcreign Exeharge Charge i"I B/A&,V.
Book/ Adj.1$ted
ConyirgValue at
Disoosal Date (l.oos) on (l.oss) on nt&N'lgal 0 Ml
Tolal Gain (Lo• ) on f'krlogal
lnEresVStodt CJMcjend$ ReceNed
Duma Year Maturiy Indicator
Date a 8Md$ - U.S. Govemnents
OOl'E>li Blf l~TIOW. 3837•V-H7 -7 .. l l HGN'JE ~RIES all /01/ a'.116- Payd:lwn...__...... ·········-- .83,937
OOl'E>l• Ba HATIOW. 383758-'11·9 •• l l HGN'JE A BIES 20 00/01/ a'.116_ Pa)'OOwtL__...... ·········-- 70,19'
<581X0-8'1' -9 .. J t . t :!!l'i 0011511 ......... ....J.F.L00/2712016_! HAl'RIS IESBITI CIRP. 1,001,5ro l .... J .000 .000 L .... .t .002.200 L .t .002.200 ~ ~351 ~ & 35111 .,,__p 1,000,8'9 ~ .711 .,,__Jlt . .11 ,656 L oo11512011 .. 1~ 1099999 - Bonda- AIClher Govemmenta 1.001.5ro I 1 000 ooo I 1.002.200 I 1.002.200 1.35111 1.35111 1.000.849 711 711 11 .656 I m m
Bonds • U.S. Soec:ial Reverue aid Seed• Anessment and a l Non-Guaranteed Otjgations d enciet aid Authorities o f Go.-errmenlS aid Their Poff cal SubdMsions flUC GCUI POCl J19~
3 l4l6X-!f-O .. 0110112L-.......... 101/allL Payctown____ ....... CIJJO SI HOO FIN IC! llTGE
611l007-l6-0 .. 1£'Etl 0.4!0I......... 107/allL Cllase Soair ltles. ... CIJJO SI HOO FIN /li'I llTGE
611l007<6-0.. 1£'Etl O.<&'.lll........ 101/allL llo<1>1>tiai 100.0003. ... I 3199999 · Bonds · U.S. Special Re""1ue •nd Special A"°"""'nt ond .. Non-Quwonteed
Ct>ligatm• ot Agencies ond ...,,,,.._ ot Governments ond The~ Political SubdMsiom
Bonds • Indus.trial aid Misc:elaneous /CINA llC l.900I
...... .21 051 ...... __,'} I 057 __ .. .9 600 OSI 151201&. lfL ..
m 0 ~ w
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KA ISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
SCHEDULE D - PART 4 Show All Long-Tenn Bonds and Stock Sold, Redeemed or Otherwise Disposed of Du~ng the Current Quarter
8 I 9 I 10 I I Change in ~ook/Adus.ted c ,-n!ng Value 18
11 12 13 14 15
17 18 19 20 21 22
MAIC Des;g-
CUnent Yeafs Bend nation PricrYear lklrealzed Of'lerThan Fcreign lnEresVStoCk «
CUSIP i Nt.mberof BodVA<t.Jsed Valuation Terrcxuary Tctal Change in E>ChangeGain Tolal Gain 0Mdend$ Market ldeni- Clis!loool Sl,..sof Conyi'lg lnaeow '°"'*menl B./A.C.V. (l.oos)on (Lo• ) on ReoeM>d Indicator ftcaticrl Date Named P\utnaset Stlek Consideration Pat value Act.Jal Cost Value Dec:tease Reco ized 11+12·13 · Ml · osal o i.m Yeat
9-UIE AOO llfl' llBJ.ICl OA 82'81L·M ·7 •• ~~=~ ICM.S iE .. f . OO/al/all6_ BIY/&lnlrust C~ilaL.. 04,9'6
88167A·.IC-6.. 2.20'.l'i 0712112.... .F. 09102/aJIL Var lw '---...
..... ~.ooo t ...... ..fl'.M ,510 .......... _o 1·--...... ..P t ...... __p t ...... __ .. o 1--...... ..P t ...... __p l ...... _ ro•.5101--...... ..P t ...... _ oi l ...... __ <l61--...... __p oo12312019.. 2fL ..
.. . ..3375 .ooo .... 3.374.111 ., ........ _o ·--...... .JJ ...... __J ...... __ .. o __ ...... J ...... __p ...... _ 3374.178 __ ...... .JJ ...... _ 408 ...... __ <08 __ .. ~<D 0712112021.. 2fL .. 3899999 - Bond• - lnduarial and Miscelaneouo (llnalliiated) I lU 16,223 ro .sso .oai I ro ,310 ,ro6 I 65,383,698 I o I 66,81' I 2.69 11 64 .123 I o I 16.«1 1,570 I o I 35',656 I 35<.656 I 999 ,998 I xxx I xxx 8399997 - Sutt"111• - BondS- Part 4 I 163.485.083 163.012 .968 I 162.785.376 I 1os.<38.90ll I o I 6.1911 I 5.998 I aio I o I 162.856.698 I o I 628.169 I 628.189 I u 12.1n I xxx I xxx 8399999 - Suttctals - Bondo I 163.<85,083 163.012 ,968 I 162,785,376 I 1os.•38,90ll I o I 6.198 I 5,998 I aio I o I 162,856,998 I o I 628.199 I 628.189 I 1 ,512. m I xxx I xxx ........ _.l_ ...... - ...... m ......... ~ .... -.......... -...... ~ ......... -~ ...... ~ ..... -...... ~ ...... -~ .......... ~.-...... I ...... ~ ...... - .... 1_ ...... I ...... ~ ...... - .... 1_ ...... I ...... ~ ...... - .... 1-...... I ...... i ...... ~ ········-·-······-······ ......... ····-··········-······ ·········- ...... ·····-······ ······- .......... ·-······ ...... ······-····-······ ...... ······-····-······ ...... ······-····-······ ...... . .... .
9999999 rcu1s I 163.•85,083 I xxx I 162,785,376 I 1os.•38,90ll 6c198 5c998 aJO 162,856,998 628c199 628c189 1 ,filh11:1 xxx xxx (a} For al COtrVnCr'I &i:X:k beaMg the NA.IC mnet lndicatcr "LI" p-<Nide: the nunat d kld'I ts.sue& -······--······___tt
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
Schedule DB - Part A - Section 1
NONE Schedule DB - Part B - Section 1
NONE Schedule DB - Part D - Section 1
NONE Schedule DB - Part D - Section 2
NONE Schedule DL - Part 1
NONE Schedule DL - Part 2
NONE
E06, E07, E08, E09, E10, E11
STATEMENT AS OF SEPTEMBER 30, 2016 OF THE KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
SCHEDULEE-PART1-CASH
D silo De si tor ies
lell s Fargo· ~rating A<xxlunt_ __________ _for t land, OIL ____________ _ lell s Fargo· PharL ______________________ _for t land, OIL ____________ _ lell s Fargo· rire&...._ _____________________ __f'or t land, OIL ____________ _ lell s Fargo· ~l/Oent_ ____________________ _for t land, OIL ____________ _
Cit ibalk · Disbursement EML--·········~ Casile, CE·--········· Cit ibalk • Disbursement CSSQ__ .......... __Hew Casile, CE·--········· Cit ibalk · Disbursement T~l r)' ........... _New Casile, OC·--········· State St reet BanlL__ ........ ·--··········-Boston , ~.\.·······--········· 0199398 Depos its in -······--·······O depositor ies that do
m l exceed the alfCM'able I i1i t in any one depos itory (See Instruct ions) • ~ Oeposi tor ies
0199399 Total Open Depos i tor i es
0399999 Total tash m it 0499999 C3sll in ·s Off ice 0599999Toal
Month End Depository Balances 2 3 4
Rate of
Code Interest
Amount of Interest
Received During Current Quarter
s
Amount o f Interest
Accrued at Current
Statement Date
.000 -··········-0 ·······--·········o
xxx xxx
E12
Book Balance at End of Each Month Ourin Current Quarter