Minnesota Insurance Premium Tax Return for HMOs

Insurance Premium Tax Return for HMOs
2023 M11H, Insurance Premium Tax Return for HMOs
*226281*

2023 M11H, Insurance Premium Tax Return for HMOs
Due March
1, 2024
			

Check if: 	

Premiums

Print or Type

Name of Provider	
Mailing Address	

Check if New Address

City	

State	

ZIP Code	

Email Address	

Website Address		

Amended Return 	

No Activity Return

FEIN			

Minnesota Tax ID (required)

NAIC Number		

State/Country of Incorporation

Contact Person		

Daytime Phone

Fax Number			

	1	 Total gross written premiums (total from NAIC, Schedule T; attach a copy)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 1	
	2	 a	 Federal employees health benefits  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 2a	
b	 Nontaxable Medicare  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 2b	
c	 Other nontaxable premiums (attach separate itemized schedule)  .  .  .  .  . 2c	
Total nontaxable premiums (add lines 2a, 2b and 2c)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 2	
	3	 Subtract line 2 from line 1  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 3	
	4	 Other adjustments (attach separate itemized schedule)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 4	
	5	 Total taxable premiums (add line 3 and line 4) .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 5	
	6 	 Premium tax percentage rate (1%)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 6	
	7	 Premium tax liability (multiply line 5 by line 6)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 7	
	8	Minnesota Guaranty Fund Association offset (see instructions) .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 8	
	9	Short Line Railroad Transfer Credit (attach credit certificate) .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 9	
	10	 Film Production Credit (attach credit certificate) .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 10	

1%

Amount Due/
Overpaid

Premium Tax and Payments

	11	 Minnesota Housing Tax Credit .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 11	
		
Enter the credit certificate number from Minnesota Housing: SHTC 	12	 Tax liability (subtract lines 8-11 from line 7) .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 12	
	13	 Premium tax prepayments
a	 Prior year‘s overpayment  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 13a	
b	 Estimated payment March 15  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 13b	
c	 Estimated payment June 15  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 13c	
d	 Estimated payment Sept. 15  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 13d	
e	 Estimated payment Dec. 15  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 13e	
Total payments (add lines 13a through 13e)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . . . . . . . . . . . . . . . . . . . . . . 13	
	14	 Subtract line 13 from line 12  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . . . . . . . . . . . . . . . . . . . . . . 14	
	15	 a	 Additional charge for underpaying estimated tax
(determine from worksheet in the instructions)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 15a	
b	 Penalty (see instructions)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 15b	
c	 Interest (see instructions)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 15c	
		Total (add lines 15a through 15c)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 15	
	16	 TOTAL AMOUNT DUE (or overpaid) (add lines 14 and 15)  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 16	
		
If you owe additional tax:
		
Payment method:
Enter amount paid

Electronic payment

Check (payable to Minnesota Revenue; write MN tax ID number on check; attach voucher)

Date paid

(If amount paid is different from amount due on line 16, attach an explanation.)

If you overpaid:
Amount on line 16 to be credited to next year‘s estimated tax  .  .  .  .  .  .  .  .  .  .  .  .  .  .
		 Amount on line 16 to be refunded  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

Sign Here

I declare that this return is correct and complete to the best of my knowledge and belief.
Authorized Signature	

Title	

Date	

Daytime Phone

Signature of Preparer	

Print Name of Preparer	

Date	

Daytime Phone

Mail to: Minnesota Department of Revenue, Mail Station 1780, 600 N. Robert St., St. Paul, MN 55146-1780

I authorize the Minnesota
Department of Revenue to
discuss this tax return with
the preparer.

2023 Form M11H, Insurance Premium Tax Return for HMOs Instructions
For insurance tax laws, see Minnesota Statutes, Chapter 297I at www.leg.state.mn.us.

What’s New

Guaranty Fund Assessment

If you were assessed and made a payment to the Guaranty Fund Assessment (GFA), you may be able to claim a credit on line 8. See line 8
instructions.

Before You File

You Need a Minnesota Tax ID

Your Minnesota tax ID is the seven-digit number you are assigned when you register with the Department of Revenue. You must include your
Minnesota tax ID on your return so that your filing and any payments you make are properly credited to your account.
If you do not have a Minnesota tax ID, apply online at www.revenue.state.mn.us or call 651‑282-5225 or 1-800-657-3605.
It is also important to enter your federal ID number and NAIC number on your return, but not in place of your Minnesota tax ID number.

Filing Requirements

Any health care provider organized as a nonprofit health plan corporation, health maintenance organization, accountable provider networks
(APN) or community integrated service network that writes premiums in Minnesota must file Form M11H, Insurance Premium Tax Return for
HMOs. (M.S. 297I.05)

Due Date

File Form M11H with all required attachments and pay any tax due by March 1. Payment extensions are not allowed.
The U.S. postmark date, or date recorded or marked by a designated delivery service, is considered the filing date (private postage meter marks
are not valid). When the due date falls on a Saturday, Sunday or legal holiday, returns and payments electronically made or postmarked the next
business day are considered timely. When a return or payment is late, the date it is received at the Department of Revenue is treated as the date
filed or paid.
Extension for Filing Return. If good cause exists, you may request a filing extension.

Check Boxes

At the top of the form, check if the return is:
an Amended Return: Check only if you’re amending a previously filed return for the same period. Include all original and corrected premiums
on the amended return.
a No Activity Return: Check only if you did not have any tax activity during the year. Note: If no amount is due or if you pay electronically, do
not send in a voucher.

Line Instructions

Round amounts to the nearest dollar. Decrease any amount less than 50 cents and increase any amount that is 50 cents or more to the next higher
dollar.
If the reported premiums are different from the premiums on the state page or Schedule T, attach a schedule reconciling the difference.

Line 1
Total Premiums

Enter total gross written premiums from NAIC, Schedule T.

Line 2
Non-Taxable Premiums

2a. Enter all premiums from Federal employees health benefits.
2b. Enter all nontaxable Medicare premiums.
2c. Enter all other nontaxable premiums. Attach a separate itemized schedule.

Line 4
Other Additions

Enter other adjustments to the premiums include risk adjustment payments, broker fees, finance and service charges. Attach a separate itemized
schedule.

Lines 8 through 11
Non-Refundable Credits

If assessments and credits are more than your tax before refundable credits (positive amount on line 7), use only the amount necessary to reduce
your tax to zero; the remaining amount may be deducted in future tax years.

Line 8

Guaranty Fund Assessment. Twenty percent of assessments (less any refunds) made and paid to the Minnesota Life and Health Guaranty
Association or the Minnesota Insurance Guaranty Association are allowable offsets against the tax liability for the five years following the
payment of the assessment.
1
Continued

2023 Form M11H Instructions (Continued)
If you receive a refund for an assessment from the association, the refund must be subtracted from the paid assessment amount. If a refund is more
than the assessment, the excess must be paid to Minnesota.

Line 9

Short Line Railroad Transfer Credit. Enter the credit amount indicated on the Short Line Railroad Infrastructure Certificate. If the amount
exceeds liability, the excess is a carryforward to each of the five succeeding taxable years.

Line 10

Film Production Credit. Enter the credit amount indicated on the Film production credit certificate statement. If the amount of the credit exceeds
liability, the excess is a credit carryforward to each of the five succeeding taxable years.

Line 11

Minnesota Housing Tax Credit. Enter 85 percent of the contribution amount indicated on the Minnesota Housing Tax Credit certificate. The
credit must be claimed for the taxable year in which the contribution payment is received by the account. If the amount of the credit exceeds
liability, the excess is a credit carryforward to each of the ten succeeding taxable years.

Estimated Tax Payments

If your estimated premium tax is more than $500, you must make estimated payments based on the entire estimated amount. To avoid an
additional charge for underpaying the tax, your payments must be made on time and be at least one-fourth of the prior year’s total annual tax
liability, or one-fourth of 80% of the current year’s total annual tax liability.
Estimated payments are due quarterly on March 15, June 15, Sept. 15 and Dec. 15. When the due date falls on a weekend or legal holiday,
payments made electronically or postmarked on the next business day are considered timely.

Payments

Electronic Payments

If your total insurance taxes and surcharges for the last 12-month period ending June 30 is $10,000 or more, you’re required to pay your tax
electronically in all subsequent years.
You must also pay electronically if you’re required to pay any Minnesota business tax electronically, such as sales or withholding tax.
To pay electronically, go to the department’s website at www.revenue.state.mn.us and log in to e-Services. You’ll need your user name, password
and bank routing and account numbers. You cannot use a foreign bank account.
If you use other electronic payment methods, such as Automated Clearing House (ACH) credit method or Fed Wire, instructions are available on
our website or by calling Business Registration Office at 651-282-5225 or 1-800-657-3605.
Submit separate payments for each return.

Check or Money Order

If you are not required to pay electronically and you choose to pay by check, you must mail a personalized payment voucher along with your
estimated tax payment to help ensure the payment is credited correctly. Go to www.revenue.state.mn.us and select Make a Payment. Select
Check or Money Order. Use the Payment Voucher System to create a voucher.
When you pay by check, your check authorizes us to make a one-time electronic fund transfer from your account. You will not receive your
canceled check.
Note: If no amount is due or if you pay electronically, do not send in a voucher.

Penalties and Interest

Late Payment. If you do not pay all the tax due by the due date, a late payment penalty is due. The penalty is 5% of the unpaid tax for any part of
the first 30 days the payment is late, and 5% for each additional 30-day period, up to a maximum of 15%.
Late Filing. Add a late filing penalty to the late payment penalty if your return is not filed by the due date. The penalty is 5% of the unpaid tax.
When added to the late payment penalty, the maximum combined penalty is 20%.
Payment Method. If you’re required to pay electronically and do not, an additional 5% penalty applies to payments not made electronically, even
if a paper check is sent on time.
Interest. You must pay interest on the unpaid tax plus penalty from the due date until the total is paid. The interest rate for calendar year 2024 is
8%. The rate may change for future years.
To figure how much interest you owe, use the following formula with the appropriate interest rate:

Interest = (tax + penalty) × # of days late × interest rate ÷ 365

Mailing Your Return

Mail your return and all required attachments to:
Minnesota Department of Revenue
For express deliveries, use our street address:
Mail Station 1780
Minnesota Department of Revenue
600 N. Robert St.
600 N. Robert St.
St. Paul, MN 55146-1780
St. Paul, MN 55101

Continued

2

2023 Form M11H Instructions (Continued)
Business Information Changes

Be sure to let us know within 30 days if you change mailing addresses, phone numbers, or any other business information. To do so, to go
our website, log in to e-Services and update your profile information. By notifying us, we will be able to let you know of any changes in
Minnesota tax laws and filing requirements.

Information and Assistance
Website:	www.revenue.state.mn.us
Email: 	 [email protected]
Phone:	 651-556‑3024

This material is available in other formats.
For questions about licensing and regulations, contact the Minnesota Department of Health:
Website:	www.health.state.mn.us/facilities/insurance/managedcare/index.html
Email:	 [email protected]
Phone:	 651-201-5100 or 1-800-657-3916
Fax:	
651-201-5186

Worksheet Instructions
Step 5

Payments of estimated tax are applied against any underpayments of required estimated payments in the order that the estimated payments
were due.
For example, if your first estimated payment is underpaid by $100 and you deposit $200 for your second estimated payment, $100 of your
second payment is applied to the first estimated payment. The additional charge for the first estimated payment is computed from the first
estimated payment’s due date to the date the second payment is made.
Also, the second estimated payment will then be underpaid by $100 (assuming that the second payment is $200) until sufficient repayments
are received to eliminate the underpayment.
If more than one payment has been made for a required estimated payment, attach a separate computation for each payment.
Credit the excess of any overpayment for a period on step 5 of the next payment period.

Step 10

If there is no underpayment on step 7, enter “none” on step 10 for that period.

Worksheet: Additional Charge for Underpaying Estimated Tax
	 1	 Enter 80% of the total annual tax liability from line 7 of your 2023 Form M11H.
		 If your tax liability was $500 or less, you do not owe an additional charge.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 1	
	2	 Enter the amount from line 7 of your 2022 Form M11H. If you were not required to file a 2022
		 return, you do not owe an additional charge.  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 2	
			
Due Dates
	
March 15	
June 15	
Sept. 15	
	3	 Enter one-fourth of step 1 or step 2 (whichever is less)
		 in each column  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 3	

	

	

	

	4	 Amounts paid on or before the due date for each period. Include
		 credits applied, such as prior year’s overpayment  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 4	

	

	

	

	 5	 Overpayment of previous installment (see worksheet instructions)  .  .  .  . 5	

	

	

	

	6	 Add steps 4 and 5 .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 6	

	

	

	

	7	 Underpayment (or overpayment). Subtract step 6 from step 3  .  .  .  .  .  .  .  . 7	

	

	

	

	 8	 Date underpayment is paid or March 1, 2024, whichever is earlier .  .  .  .  .  . 8	

	

	

	

	 9	 Number of days from the due date to the date on step 8  .  .  .  .  .  .  .  .  .  .  .  . 9	

	

	

	

	10	 Additional charge (step 9 ÷ 365 × interest (see below) × step 7)  .  .  .  .  . 10	

	

	

	

Dec. 15

	 1	 TOTAL. Add amounts in each column on step 10.
1
		 Enter the result here and on Form M11H, line 10a  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 11	
If step 11 is zero, keep this worksheet for your records. Do not send it with your return.
If it is more than zero, attach a copy of the worksheet to your Form M11H.
Interest: 2023 = 5% (0.05); 2024 = 8% (0.08)
3