Common use of Medical Loss Ratio Clause in Contracts

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 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 HSD 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 Section 7.2.1-7.2.2.4 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 HSD a MLR report in the specified format, as required by HCAHSD. 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.