Common use of Medical Loss Ratio Clause in Contracts

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. 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: