**FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM**

**EXPERIENCE-RATED CARRIERS**

**ESTIMATED SUMMARY STATEMENT**

**As of September 30, 2001**

**[(Due to OPM by Oct 26, 2001)]{.underline}**

**Instructions for Preparing**

### *ESTIMATED* SUMMARY STATEMENT OF FEHBP FINANCIAL OPERATIONS

Round all amounts to the nearest whole dollar and ensure they add to the
totals.

1.  **[PROGRAM INCOME:]{.underline}**

> Enclosure A of the covering letter lists Letter-of-
>
> Credit (LOC) authorizations recorded by OPM for your plan during the
> period October 1, 2000 through September 30, 2001. Please compare the
> information provided to your records and immediately notify Zaff
> Shafi, of our Benefits Accounting Branch on (202) 606-4189 of any
> differences.
>
> [Carrier Interest Income:]{.underline} Your contract states that all
> funds in excess of those needed to promptly discharge the obligations
> of the contract should be invested. Report all interest earned on
> these funds on line 1e. [Do not]{.underline} report interest earned on
> your Letter-of-Credit account on this line.

**2. [ESTIMATED HEALTH BENEFITS CHARGES:]{.underline}**

a.  [Paid:]{.underline} Show the amount of cash payments for health
    benefit charges from October 1, 2000 through September 30, 2001.

b.  [Accrued but Unpaid:]{.underline}

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1)  [Beginning:]{.underline} Line 2 of Enclosure A of the cover letter
    shows the ending health benefits accrual reported on your September
    30, 2000 fiscal year accounting statement. This figure is to be used
    on line 2b(1) of this year\'s ESTIMATED SUMMARY STATEMENT.

2)  [Ending:]{.underline} Show the charges incurred but unpaid as of
    September 30, 2001.

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c.  [Total:]{.underline} Line 2a minus line 2b(1) plus line 2b(2).

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3.  **[ESTIMATED ADMINISTRATIVE EXPENSES:]{.underline}** If your plan
    has high and standard options, show the basis and amounts used for
    prorating administrative expenses between the two options. You may
    charge a maximum of 25% of the 2000 administrative expenses plus 75%
    of the 2001 contract limitation.

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a.  [Paid:]{.underline} The estimated cash payments for administrative
    expenses during fiscal year 2001.

**Instructions for Preparing**

### *ESTIMATED* SUMMARY STATEMENT OF FEHBP FINANCIAL OPERATIONS continued:

b.  [Accrued but Unpaid:]{.underline}

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1)  [Beginning:]{.underline} Show on line 3b(1) the amount of the
    accrued administrative expenses as shown on your prior fiscal year
    accounting statement.

2)  [Ending:]{.underline} Show on line 3b(2) the estimated amount of
    accrued administrative expenses as of September 30, 2001.

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c.  [Total:]{.underline} Line 3a minus line 3b(1) plus line 3b(2).

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4.  **[ESTIMATED OTHER EXPENSES AND RETENTIONS:]{.underline}**

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a.  [State Statutory Reserve:]{.underline} Report the amount necessary
    to satisfy state requirements for mandatory statutory reserves for
    the period October 1, 2000 through September 30, 2001.

b.  [Reinsurance Expenses:]{.underline} List the amount paid for
    reinsurance expenses (if applicable) for the period October 1, 2000
    through September 30, 2001.

c.  [Service Charge:]{.underline} Show on Line 4c, 25 percent of the
    formula derived contract limitation for calendar year 2000 plus 75
    percent of the allowable 2001 service charge.

d.  [Other:]{.underline} Other expenses not previously stated.

e.  [Total:]{.underline} The sum of lines 4a through 4d.

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5.  **[ESTIMATED CHANGES TO SPECIAL RESERVE:]{.underline}**

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a.  [Special Reserve, 09/30/00:]{.underline} The amount of the prior
    fiscal year accounting statement ending Special Reserve (line 3, of
    Enclosure A).

b.  [Gain (Loss) on Operations:]{.underline} This is calculated as
    follows: (Line 1f)-(line 2c)-(line 3c)-(line 4e).

c.  [Prior Period Adjustments:]{.underline} All adjustments made to the
    current fiscal year report as a result of prior OPM audits or due to
    any other reasons.

    **Instructions for Preparing**

### *ESTIMATED* SUMMARY STATEMENT OF FEHBP FINANCIAL OPERATIONS continued: {#estimated-summary-statement-of-fehbp-financial-operations-continued-1 .unnumbered}

d.  [Contingency Reserve Payments:]{.underline} Show the amount
    transferred from the contingency reserve to your LOC account during
    the period October 1, 2000 through September 30, 2001.(Line 4d(1) of
    Enclosure A.)

e.  [Return of Excess Reserves:]{.underline} Show the amount of excess
    reserves withdrawn from your LOC account and transferred to the
    contingency reserve from October 1, 2000 through September 30, 2001
    (Line 4d(2)of Enclosure A).

f.  [Other:]{.underline} Show on line 5f any transfers or other
    additions or subtractions to the special reserve during fiscal 2000.

g.  [Special Reserve, Ending:]{.underline} The total of lines 5a, 5b,
    5c, 5d, 5e, and 5f.

**FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM**

**EXPERIENCE-RATED CARRIERS**

**SUMMARY STATEMENT**

**As of September 30, 2001**

**[(Due to OPM by December 14, 2001]{.underline})**

**Instructions for Preparing**

### SUMMARY STATEMENT OF FEHBP FINANCIAL OPERATIONS

Round all amounts to the nearest whole dollar and ensure they add to the
totals. Carriers participating in the Department of Defense (DOD)
Project should state this activity separately on the Summary Statement
and related schedules.

1.  **[PROGRAM INCOME:]{.underline}** Enclosure A of the covering letter
    lists

> Letter-of-Credit (LOC) authorizations recorded by OPM for your plan
> during the period October 1, 2000 through September 30, 2001. Please
> compare the information provided to your records and immediately
> notify Zaff Shafi of our Benefits Accounting Branch on (202) 606-4189
> of any differences.

**[Carrier Interest Income:]{.underline}** Your contract states that all
funds in excess of those needed to promptly discharge the obligations of
the contract should be invested. Report all interest earned on these
funds on line 1e. [Do not]{.underline} report interest earned on your
Letter-of-Credit account on this line.

2.  **[HEALTH BENEFITS CHARGES:]{.underline}**

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a.  [Paid:]{.underline} Should agree with the \"TOTAL\" in Part D of the
    "**Health Benefits Charges Paid\"** Schedule 1.

b.  [Accrued but Unpaid:]{.underline}

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1)  [Beginning:]{.underline} Line 2 of Enclosure A of the cover letter
    shows the ending health benefits accrual reported on your September
    30, 2000 fiscal year accounting statement. This figure is to be used
    on Line 2b(1) of this year\'s SUMMARY STATEMENT. Attach a schedule
    showing the monthly liquidation of the September 30, 2000 accrual.

2)  [Ending:]{.underline} Show the charges incurred but unpaid as of
    September 30, 2001. Attach a schedule showing the development of the
    unreported health benefit charges. All assumptions, judgment factors
    and estimates should be supported and all sources of data
    identified.

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c.  [Total:]{.underline} Line 2a minus line 2b(1) plus line 2b(2).

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3.  **[ADMINISTRATIVE EXPENSES:]{.underline}** If your plan has high and
    standard options, show the basis and amounts used for prorating
    administrative expenses between the two options. You may charge a
    maximum of 25% of the 2000 administrative expenses plus 75% of the
    2001 contract limitation.

**Instructions for Preparing**

**SUMMARY STATEMENT OF FEHBP FINANCIAL OPERATIONS** continued:

a.  [Paid:]{.underline} Should agree with the amount stated on the
    Statement of Cash Flows.

b.  [Accrued but Unpaid]{.underline}:

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1)  [Beginning:]{.underline} Show on Line 3b(1) the amount of the
    accrued administrative expenses as shown on your prior fiscal year
    accounting statement.

2)  [Ending:]{.underline} Show on line 3b(2) the amount of accrued
    administrative expenses as of September 30, 2001.

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c.  [Total:]{.underline} Line 3a minus line 3b(1) plus line 3b(2).

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4.  **[OTHER EXPENSES AND RETENTIONS:]{.underline}**

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a.  [State Statutory Reserve:]{.underline} Report the amount necessary
    to satisfy state requirements for mandatory statutory reserves for
    the period October 1, 2000 through September 30, 2001. Attach a
    schedule showing in detail the development of the charges or credits
    for this retention.

b.  [Reinsurance Expenses:]{.underline} List the amount paid for
    reinsurance expenses (if applicable) for the period October 1, 2000
    through September 30, 2001.

c.  [Service Charge:]{.underline} Show on Line 4c, 25 percent of the
    formula derived contract limitation for calendar year 2000 plus 75
    percent of the allowable 2001 service charge.

d.  [Other:]{.underline} Other expenses not previously stated.

e.  [Total:]{.underline} The sum of Lines 4a through 4d.

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5.  **[CHANGES TO SPECIAL RESERVE:]{.underline}**

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a.  [Special Reserve, 09/30/00:]{.underline} The amount of the prior
    fiscal year accounting statement ending Special Reserve (Line 3 of
    Enclosure A).

b.  [Gain (Loss) on Operations:]{.underline} This is calculated as
    follows: (Line 1f)-(line 2c)-(line 3c)-(line 4e).

c.  [Prior Period Adjustments:]{.underline} All adjustments made to the
    current fiscal year report as a result of prior OPM audits or due to
    any other reasons. These adjustments should also be included in your
    annual accounting statement of December 31, 2001.

    **Instructions for Preparing**

    **SUMMARY STATEMENT OF FEHBP FINANCIAL OPERATIONS** continued

d.  [Contingency Reserve Payments:]{.underline} Show the amount
    transferred from the contingency reserve to your LOC account during
    the period October 1, 2000 through September 30, 2001.(Line 4d(1)of
    Enclosure A)

e.  [Return of Excess Reserves:]{.underline} Show the amount of excess
    reserves withdrawn from your LOC account and transferred to the
    contingency reserve during the period October 1, 2000 through
    September 30, 2001. (Line 4d(2) of Enclosure A)

f.  [Other:]{.underline} Show on line 5f any transfers or other
    additions or subtractions to the special reserve during fiscal 2001.

g.  [Special Reserve, Ending:]{.underline} The total of lines 5a, 5b,
    5c, 5d, 5e, and 5f.