Filing Instructions For The 2015 Mlr Reporting Year - Centers For Medicare & Medicaid Services (Cms) Page 2
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57Instructions for the 2015 MLR Reporting Year
These are the filing instructions for the report to the Secretary required by section 2718 of the Public
Health Service Act (PHSA), which includes elements that make up the medical loss ratio (MLR) and the
calculation and provision of rebates to enrollees. The data included in the MLR Annual Reporting Form
(MLR Form) are the exact data that will be used to calculate an issuer’s MLR and rebates, if any, under
section 2718 of the PHSA and the implementing regulation, codified at 45 CFR Part 158. The data
included in the MLR Form will also be used to calculate an issuer’s payments or receipts related to the
risk corridors (RC) program established by section 1342 of the Patient Protection and Affordable Care
Act (ACA) and the implementing regulation, codified at 45 CFR Part 153.
The MLR implementing regulations can be found at:
Loss
Ratio.
The implementing regulations for the risk corridors program can be found at:
Stabilization
Programs.
These MLR Form Filing Instructions only apply to the 2015 MLR reporting year and its reporting
requirements. These Filing Instructions will be revised to reflect changes that apply to the filing years
subsequent to 2015. Filing requires a one-time registration by the issuer through the secured CMS
Enterprise Portal for the Health Insurance Oversight System (HIOS) to submit its report to the Secretary.
If an issuer registered for a previous MLR reporting year, it does not need to reregister, but will need to
confirm or update its issuer associations. The CMS Enterprise Portal can be accessed at
https://portal.cms.gov/wps/portal/unauthportal/home/.
For information regarding HIOS, including user roles, company/issuer associations, downloading and
submitting MLR Form templates, and attestation, please refer to the HIOS User Manual, which will be
posted on the CCIIO MLR Training webpage,
https://
Resources/index.html#Medical Loss
Ratio.
Risk corridors information reported through this reporting form should only include data for plans that
were compliant with the market reforms of the Affordable Care Act during the 2015 calendar year. The
Affordable Care Act market reforms are set forth in sections 2701 through 2707 of the Public Health
Service Act (P.L. 410), and the implementing regulations in Title 45 of the Code of Federal Regulations.
References are made in these instructions to the National Association of Insurance Commissioners
(NAIC) Statements of Statutory Accounting Principles (SSAP) and Supplemental Health Care Exhibit
(SHCE) (as filed by many issuers with the NAIC) in effect for the MLR reporting year. These references
are solely for the convenience of the filer in identifying the information needed for this MLR Form.
These Filing Instructions are to be used in completing the MLR Form by all health insurance issuers
(issuers) offering health insurance coverage subject to section 2718 of the PHSA and the MLR
implementing regulations. All terms used in these Filing Instructions that are not defined here have the
meaning used in 45 CFR Part 158, 45 CFR Part 153 (as it pertains to the risk corridors program), and the
PHSA.
The term “health insurance coverage” means benefits consisting of medical care (provided directly,
through insurance or reimbursement, or otherwise and including items and services paid for as medical
care) under any hospital or medical service policy or certificate, hospital or medical service plan contract,
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