Medical Loss Ratio. In calendar year 2017, the MLR shall be calculated as follows: On an annual basis the Contractor shall calculate and submit to FSSA its Medical Loss Ratio (MLR), based on standards and forms established by the National Association of Insurance Commissioners (NAIC). A separate MLR shall be calculated for the Contractor’s Hoosier Healthwise line of business. The MLR calculations shall be exclusive of any taxes. In addition, the State provides the following clarifications: The MLR calculation shall be performed separately for each MLR reporting year. The MLR calculation shall be performed separately for each program. The MLR for the Hoosier Healthwise program shall be calculated separately from other managed care programs. The Contractor shall maintain, at minimum, a MLR of eighty-five percent (85%) for its Hoosier Healthwise line of business. The MLR will be calculated exclusive of reimbursement for the health insurance providers’ fee (see Section 2.6.7). The Contractor is required to submit MLR reporting as described in the MCE Reporting Manual for Hoosier Healthwise. FSSA shall recoup excess capitation paid to the Contractor in the event that the Contractor’s MLR, as calculated by FSSA on an annual basis, is less than eighty- five percent (85%) for the Hoosier Healthwise line of business. Beginning in calendar year 2018, the MLR shall be calculated as follows: The Contractor shall calculate and submit to FSSA its Medical Loss Ratio (MLR). The calculation must fully comply with 42 CFR 438.8. In addition, the State provides the following clarifications: The MLR calculation shall be performed separately for each MLR reporting year. The MLR calculation shall be performed separately for each program. The MLR for the Hoosier Healthwise program shall be calculated separately from other managed care programs. For each MLR reporting year, a preliminary calculation will be performed with six months of incurred claims run-out, and a final calculation will be performed with 18 months of incurred claims run-out. Incurred claims reported in the MLR should relate only to members who were enrolled with the MCE on the date of service, based on data and information available on the reporting date. (Claims for members who were retroactively disenrolled should be recouped from providers and excluded from MLR reporting). Under Contract arrangements, the MCE may only include amounts actually paid to providers for covered services and supplies as incurred claims. T...
Medical Loss Ratio. 1. To provide to the Department a completed MLR Reporting Template, including the MCO attestation and any additional documentation supporting the MLR reporting template (Appendix G), in accordance with 42 CFR 438.8, by November 15th of the calendar year following the MLR reporting year.
Medical Loss Ratio. The MLR shall be calculated as follows: Each reporting year, consistent with MLR standards as required in 42 CFR 438.8, t he Contractor shall calculate, attest to the accuracy, and submit to FSSA its Medical Loss Ratio (MLR). For the HIP line of business, POWER Account expenditures may be included in both the numerator and denominator of the MLR calculation. The calculation must fully comply with 42 CFR 438.8(d)-(f) which specifies that the MLR calculation is the ratio of the numerator (as defined in accordance with 42 CFR 438.8(e)) to the denominator (as defined in accordance with 42 CFR 438.8(f)). In accordance with 42 CFR 438.604(a)(3), 42 CFR 438.606, and 42 CFR 438.8, the Contractor is required to submit data on the basis of which the State determines the compliance with MLR requirements. In addition, the State provides the following clarifications: ▪ The MLR calculation shall be performed separately for each MLR reporting year per 42 CFR 438.8(a). EXHIBIT 1
Medical Loss Ratio. In calendar year 2017, the MLR shall be calculated as follows: On an annual basis the Contractor shall calculate and submit to FSSA its Medical Loss Ratio (MLR), based on standards and forms established by the National Association of Insurance Commissioners (NAIC). A separate MLR shall be calculated for the Contractor’s HIP line of business. For the HIP line of business, POWER Account expenditures may be included in both the numerator and denominator of the MLR calculation. The MLR calculations shall be exclusive of any taxes. In addition, the State provides the following clarifications: The MLR calculation shall be performed separately for each MLR reporting year. The MLR calculation shall be performed separately for each program. The MLR for the HIP program shall be calculated separately from other managed care programs. The Contractor shall maintain, at minimum, a MLR of eighty-seven percent (87%) for its HIP line of business. The MLR will be calculated exclusive of reimbursement for the health insurance providers’ fee (see Section 2.6.7). The Contractor is required to submit MLR reporting as described in the MCE Reporting Manual for HIP. FSSA shall recoup excess capitation paid to the Contractor in the event that the Contractor’s MLR, as calculated by FSSA on an annual basis, is less than eighty- seven percent (87%) for the HIP line of business. Beginning in calendar year 2018, the MLR shall be calculated as follows:
Medical Loss Ratio. Description ODM’s provider agreement indicates that ODM will perform medical loss ratio (MLR) calculations for the MMC program. This includes the ABD, CFC, AFK, and Extension populations. Financial consequences There are no financial consequences associated with MLR requirements.
Medical Loss Ratio. Description ODM’s provider agreement indicates that ODM will perform medical loss ratio (MLR) calculations for the MMC program. This includes the ABD, CFC, AFK, and Extension populations. The capitation rates were developed such that the MCPs are reasonably expected to achieve a medical loss ratio greater than 85 percent, which includes provisions for non-benefit costs that are appropriate and attainable. ODM’s provider agreement indicates that ODM will perform medical loss ratio (MLR) calculations for the MMC program. Financial consequences ODM has implemented a minimum MLR requirement of 86% for the MMC program. ODM will require remittance in the event a MCP reports a MLR below 86%.
Medical Loss Ratio. The minimum medical loss ratio (MLR) for each rating period is eighty-five percent (85%). Likewise, the maximum non-benefit premium component for each rating period shall not exceed fifteen percent (15%). Insurer shall identify what components and subcomponents have been included in its non-benefit expenses, as required by FHKC. The MLR shall be calculated in accordance with 42 CFR 457.1203, which incorporates 42 CFR 438.8. FHKC may issue additional written guidance on the definition of medical expense or non-benefit expense to Insurer. Federal and state regulations impacting the calculation of MLRs or non- benefit expense requirements may also be applicable. To the extent permissible by law, FHKC may choose to adopt such regulations early or adopt such regulations that would not otherwise be applicable. Should such guidelines be applied, FHKC shall notify Insurer in writing. In the event Insurer achieves an MLR less than eighty-five percent (85%) for the rating period, Insurer shall return one hundred percent (100%) of the difference between the actual MLR and the minimum MLR to FHKC. Insurer’s MLR rebate shall include both Insurer’s Title XXI Enrollees and Insurer’s Full-pay Enrollees in the Service Area; however, Insurer shall report the portion of the rebate attributable to the Title XXI Enrollees and the Full-pay Enrollees based on the respective proportion of Enrollee member months for the rating period.
Medical Loss Ratio. The CONTRACTOR shall spend no less than ninety percent (90%) of net Medicaid line of business Net Capitation Revenue on direct medical expenses on an annual basis. HCA reserves the right, in accordance with and subject to the terms of this Agreement, to reduce or increase the minimum allowable for direct medical services over the term of this Agreement provided that any such change: (i) shall only apply prospectively; (ii) shall exclude any retroactive increase to allowable direct medical services; and (iii) shall comply with State and federal law. The MLR calculation and definitions for its calculation are separate from the underwriting gain limitation outlined in Sections 7.2.1 through7.2.2.4 of this Agreement. For the purposes of this requirement, the MLR calculation standards shall be consistent with 42 C.F.R. § 438.8. The CONTRACTOR shall submit annually to HCA a MLR report in the specified format, as required by HCA. This report shall be consistent with the requirements in 42 C.F.R. § 438.8(k) and will include, for each reporting year, taxes, licensing, and regulatory fees, and a comparison of the information reported with the CONTRACTOR’s audited financial reports, specific to this Agreement. Key components of the MLR calculation are outlined below: Numerator: Sum of the CONTRACTOR’s incurred Claims, activities that improve health care quality and fraud prevention activities. The expenditures for fraud prevention activities shall be consistent with regulations adopted for the private market at 45 C.F.R. part 158 and not include expenses for fraud reduction efforts. Denominator: The adjusted premium revenue, which is premium revenue less the CONTRACTOR’s federal, State, local taxes, and licensing and regulatory fees.
Medical Loss Ratio. The three-way contract between CMS, ODM, and the MCOPs indicates that ODM and CMS will perform medical loss ratio (MLR) calculations for the MyCare Opt-In program, and the minimum MLR requirement is 88% for demonstration year 8 (DY8). Details of the MLR remittance calculation can be found in the three-way contract between CMS, ODM, and the MCOPs.
Medical Loss Ratio. 22.2.1 The Contractor shall report a Medical Loss Ratio and related data, including the data on the basis of which ASES will determine the compliance of the Contractor with the Medical Loss Ratio Requirement, as required under 42 CFR 438.8(k) for each rating period. Such reporting shall be provided to ASES no later than March 31st of the following year.
