Filing Instructions For The 2015 Mlr Reporting Year - Centers For Medicare & Medicaid Services (Cms) Page 31

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Include:
If Tab 3, Line 10 of the Risk Corridors Plan-Level Data Form is a charge, report that
charge amount on this line. If Tab 3, Line 10 is a payment, report $0 on this line.
Line 1.12 – Premium ceded under 100% reinsurance (informational only; excluded from Line 1.1)
Include:
• Premium ceded under a 100% assumption reinsurance agreement (with a novation)
• Premium ceded under a 100% indemnity reinsurance and administrative agreement,
limited to only those agreements both entered into and also effective prior to March 23,
2010, where the assuming entity is responsible for 100% of the ceding entity’s financial
risk and takes on all of the administration of the block of business
Line 1.13 – Premium assumed under 100% reinsurance agreement (informational only; included in Line
1.1)
Include:
• Premium assumed under a 100% assumption reinsurance agreement (with a novation)
• Premium assumed under a 100% indemnity reinsurance and administrative agreement,
limited to only those agreements both entered into and also effective prior to March 23,
2010, where the assuming entity is responsible for 100% of the ceding entity’s financial
risk and takes on all of the administration of the block of business
Line 1.14 – Advance Payments of the Premium Tax Credit Received from HHS (informational only;
included in Lines 1.1-1.11)
Include:
Amount of advance premium tax credit received from HHS for the applicable benefit
year (MLR reporting year).
Section 2 – Claims
Amounts reported in Section 2 must include direct claims paid to or received by physicians and other non-
physician clinical providers, including under capitation contracts with those providers, whose services are
covered by the policy for clinical services or supplies covered by the policy. Non-physician clinical
providers must be licensed, accredited, or certified to perform clinical health services, consistent with
State law, and engaged in the delivery of medical services to enrollees.
Reimbursement for clinical services to enrollees is also referred to as incurred claims.
Line 2.1 – Claims paid
2.1a – 12/31 Column – claims paid during the MLR reporting year regardless of incurred date.
2.1b – 3/31 Column – claims incurred only during the MLR reporting year, paid from 1/01 of the
MLR reporting year through 3/31 of the following year. Do not reduce paid claims by the
amount of federal transitional reinsurance receipts. Reinsurance receipts are subtracted
from incurred claims in Part 3.
PLEASE NOTE: This methodology differs from the NAIC SHCE methodology used in the
12/31 Column.
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