Filing Instructions For The 2015 Mlr Reporting Year - Centers For Medicare & Medicaid Services (Cms) Page 15
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57Line 1.6 – Risk revenue
Include:
Amounts charged by the reporting entity as a provider or intermediary for specified
medical services (e.g., full professional, dental, radiology, etc.) provided to the
policyholders or members of another issuer or reporting entity.
Unlike premiums that are collected from an employer group or individual member, risk
revenue is the prepaid (usually on a capitated basis) payment, made by another insurer or
reporting entity to the reporting issuer in exchange for services to be provided or offered by
such organization.
Section 2 – Claims
Line 2.1 – Total incurred claims
Part 2, Line 2.16.
Line 2.2 – Prescription drugs (informational only)
Include:
Expenses for prescription drugs and other pharmacy benefits covered by the
reporting entity.
Exclude: Prescription drug charges that are included in a hospital billing which should be
classified as Hospital/Medical Benefits.
Line 2.3 – Pharmaceutical rebates (informational only)
Line 2.4 – State stop loss, market stabilization, and claim/census based assessments (informational only)
Adjustments that must be included in incurred claims:
• Market stabilization payments or receipts by issuers that are directly tied to claims
incurred and other claims-based or census-based assessments
• State subsidies based on a stop-loss payment methodology
Adjustments that must be either included in or deducted from incurred claims:
• Payment to and from unsubsidized State programs designed to address distribution of
health risks across issuers via charges to low risk issuers that are distributed to high
risk issuers must be included in or deducted from incurred claims, as applicable
Line 2.5 – Net assumed less ceded claims incurred
Assumed reinsurance claims paid; plus the change in the assumed reinsurance claims liability
and aggregate assumed reinsurance claims reserve; less the ceded reinsurance claims paid; plus
the change in the ceded reinsurance claims liability and aggregate ceded reinsurance claims
reserve; less the change in claims related reinsurance recoverable.
Line 2.6 – Other adjustments due to MLR calculation – claims incurred
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