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Currency [0]/Explanatory TextG5Explanatory Text %0 : Followed Hyperlink 1Good;Good  a%2 Heading 1G Heading 1 I}%O3 Heading 2G Heading 2 I}%?4 Heading 3G Heading 3 I}%235 Heading 49 Heading 4 I}%6( Hyperlink 7InputuInput ̙ ??v% 8 Linked CellK Linked Cell }% 9NeutralANeutral  e%"Normal :Noteb Note   ;OutputwOutput  ???%????????? ???<$Percent =Title1Title I}% >TotalMTotal %OO? Warning Text? Warning Text %XTableStyleMedium2PivotStyleLight16` fCover c1 2 3 S 4 H15 U6 7 8 2  ;5  ;  ;  ;'  ;  ;%  ;0  ;5"____ PPO _____Direct Contract # Family # Single # Employee & Spouse # Employee & Child Subscribers* End of YearContact Person: __________________________, ______________________________________ (Name) (Area code & Telephone Number)____________________________________, __________________________________________ (E-mail) (Fax)SexyySCA ANNUAL REPORT SCA ANNUAL REPORTName of CarrierA. ADMINISTRATIVE INFORMATION CERTIFICATION BY OFFICER  (Name) (Area Code & Telephone Number)#SCA Annual Report Name of Carrier MEMBERSHIP BY RATING STATUS YEAR ENDING SINGLE EES * EE & SPOUSE * EE & CHILD *FAMILY *(Number of Employer Contracts by Products Year EndingHospital/ Medical* PrescriptionVisionDentalF* Indicate the number of employees that are enrolled in each category. "SCA ANNUAL SUPPLEMENTPLAN EXPERIENCECalendar YearPremiumIncurred Claims In Network$Incurred Claims Out of Network# Of Claims In Network# Of Claims Out of NetworkSCA ANNUAL Report Total EmployeesTOTAL Employees EnrolledB. NETWORK INFORMATIONat SubscriberTotalAverageMembersPer SubscribersActual(a)(b)$A. Group Contracts (Non-Government) 3. Large GroupB. Individual ContractsC. Government Plans 1. FEHBPNotes:TDate Carrier Incorporated or Organized: ____________________________________________PDate Carrier Commenced Business: _______________________________________________TDate Carrier Certified as a SCA: ___________________________________________________III Vision: ____________________________________________________________________ (Name of network) hAs an Officer of the carrier, I certify that for the reporting period stated above, all information and Name President Signaturea* Subscriber means, in the case of a group contract, an individual whose employment or othero cost contracts or risk contracts with the Social Security Administration. Excludes Medicare eligible in_________________ other categories.AtlanticBergen BurlingtonCamden CumberlandEssex GloucesterHudsonMercer MiddlesexMonmouthMorrisOceanPassaicSalemSomersetSussexUnionWarren Out of StateUnknownTOTAL#Department of Banking and Insurance 2 Other/Localf status, except family status, is the basis for eligibility for enrollment or, in the case of anM individual contract, the person in whose name the contract is issued. C. Membership .1. Please provide Membership by Rating Status  O2. Please complete the table for the number of employer contracts by products:.5. Subscribers and members by type of payment Type of PaymentSTATE OF NEW JERSEY Year EndingH(Dec. 31 current year minus Dec. 31 prior year membership divided by 12)Total Members**Year Endat (c)Cape May HunterdonA____ Certified ODS ______Licensed ODS _____Direct Contract ONAIC #: _________________________ TAX ID #: _____________________IStatutory Home Office: _________________________ _____________________KMain Administrative Office: __________________________ ___________________FContact Person: ______________________________ ______________________W ______________________________ _______________________ (Street) (City, State & Zip Code) (Street) (City, State & Zip Code) =** Total Member means the total number of covered persons. 4. Student*** D. Medicare****E. Other (Specify)V COBRA extension, small group extensions, etc. not reported in other categories.i**** Medicare relates only to members enrolled in programs complementary to Title XVIII, or under direct ? If yes, please identify the market and date of withdrawal.E*** Student means anyone who is covered under a Student Health Plan.O_____________________________________________________________ (Name of Network)>D. Vendor OversightK ______________________________________________________________________ 4. Please provide Membership by County or by zip code (first three digits only) for the previous calendar year. (Complete a separate table for each PPO/HMO)$a. Total member months for the year:b. Average monthly change: ] _______________________________________________________________________________________gPlease identify the network used in the Selective Contracting Arrangement. If there is no SCA, please mark N/A. Designate whether the network is provided through an ODS, PPO in the case of a Prescription Drug Benefit, or through a direct contract with providers. Identify the principal contact person, if different from the person identified in Section A. IV Prescription Drug Benefit: ____________________________________________ (Name of network)II Dental: ___________________________________________________________ (Name of network) astatements made in this Annual Report are true, complete and current to the best of my knowledge and belief.U6. Has the carrier withdrawn from any market in which it was previously approved?  A7. Identify any affiliated companies associated with the SCA.   ? Q* Which may include prescription, vision and or dental on a non-stand alone basisVI Other: __________________________________________________________ (Name of network) I Hospital/Medical: __________________________________________ (Name of Network)   j Name of SCA The use of twenty (20) three digit zip codes can be used as an alternative to counties. # Indicate the number of Employees that are enrolled in each category. s|eV Behavioral Health (Mental Health and Substance Abuse): :Q evaluated the quality of care and services provided to covered persons. I (E-Mail)  (FAX) / 1. SEH Standard Group Plans (1-50 Employees)) 2. Non-Standard Plans (1-50 Employees)December 31, 20230This report may be submitted to the Department by mail or electronically. Please submit a completed report by May 1, 2025 to the address below: Danielle Cifelli Insurance Analyst New Jersey State Department of Banking and Insurance Office of Managed Care P. O. Box 329 20 West State Street, 9th Floor Trenton, New Jersey 08625-0329 Fax: 609-777-0508 Email: officeofmanagedcare@dobi.nj.gov /3. Please complete the Plan Experience table for the SCA Line of Business for 2023 and 2024 calendar years. If any products are stand-alone, complete a separate table.,Membership by County as of December 31, 2024OPlease submit a copy of the 2024 vendor performance reports upon which carriers G aHaJJ~K~#L#L*M*dOdP P 4Q4 R dSd 3T3 !W! 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