Filing Instructions For The 2015 Mlr Reporting Year - Centers For Medicare & Medicaid Services (Cms) Page 12
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57Exclude:
Policies reported in other columns. Also exclude amounts paid to a provider for
services that do not represent reimbursement for covered services provided to an
enrollee and are directly covered by a student administrative health fee.
Column 40
Government Program Plans (Not Subject to Section 2718 of the PHSA)
Include:
Government sponsored programs that are not subject to section 2718 of the PHSA,
such as Medicaid (Title XIX), State Children’s Health Insurance Program (SCHIP)
(Title XXI), and other Federal or State government-sponsored coverage (other than
the Federal Employees Health Benefits Program or State government sponsored
coverage for State employees or retirees).
Report the experience of the issuer’s government program plans for the MLR
reporting year as of December 31, as reported to the regulatory authority in the
issuer’s State of domicile or as filed on the NAIC SHCE filing for the MLR
reporting year.
Exclude:
Medicare Advantage Part C and Medicare Part D stand-alone plans subject to the
Medicare MLR requirements pursuant to section 1857(e) of the Social Security
Act, reported in Column 42
Column 41
Other Health Business (Not Subject to Section 2718 of the PHSA)
Information reported here is similar to that reported in the SHCE Part 1, Columns 9 and 10.
Report health plan arrangements that are not group or individual health insurance coverage
provided by a health insurance issuer. Report all other health care business that is not reported in
Columns 1–39, including stand-alone dental and vision coverage, long-term care, disability
income, etc.
Include:
Short-term, limited-duration insurance (as defined under 45 CFR §144.103);
supplemental coverage if offered as a separate policy, certificate, or contract of
insurance (45 CFR §146.145), including Medicare supplemental health insurance
(as defined under section 1882(g)(1) of the Social Security Act), coverage
supplemental to the coverage provided under chapter 55 of title 10, United States
Code, and similar supplemental coverage provided under a group health plan;
hospital or other fixed indemnity insurance, and specified disease or illness
coverage if offered under a separate policy, certificate, or contract of insurance (45
CFR §146.145), and other “excepted benefits” as specified by regulations
promulgated by HHS (45 CFR §146.145). The experience for pharmacy,
chiropractic, or mental health coverage, whether sold as a stand-alone product or in
conjunction with any other health insurance coverage, should be reported with the
health insurance coverage for the applicable market if the coverage does not meet
the definition of “excepted benefits” under the PHSA.
Report the experience of the issuer’s Other Business for the MLR reporting year as
of December 31, as reported to the regulatory authority in the issuer’s State of
domicile or as filed on the NAIC SHCE filing for the MLR reporting year.
Column 42
Medicare MLR Business
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