Filing Instructions For The 2015 Mlr Reporting Year - Centers For Medicare & Medicaid Services (Cms) Page 32
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57Include:
• Report payments net of risk share amount collected or paid
• Any overpayment that has not yet been recovered should be included in paid claims and
included in health care receivables
• Market stabilization payments by issuers that are directly tied to claims incurred and other
claims based or census based assessments
• Claims assumed under a 100% assumption reinsurance agreement (with a novation) must
be reported by the assuming issuer for the entire MLR reporting year during which the
policies are assumed and must not be reported by the ceding issuer
• Claims assumed under a 100% indemnity reinsurance and administrative agreement,
limited to only those agreements both entered into an 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
• Payment to 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 incurred claims
• Payment by a group health insurance issuer for contraceptive services for participants and
beneficiaries of its insured health plans under the accommodations for eligible
organizations
• In the 3/31 columns, include all payments by a QHP issuer to enrollees in all plan
variations, and do not reduce these payments by the amount of cost-sharing reductions
(CSR) received by the issuer for the applicable benefit year (MLR reporting year). CSRs
are subtracted from incurred claims in Part 3.
Exclude:
• Claims ceded under a 100% assumption reinsurance agreement (with a novation) must be
reported by the assuming issuer for the entire MLR reporting year during which the
policies are assumed and must not be reported by the ceding issuer
• Claims ceded under a 100% indemnity reinsurance and administrative agreement, limited
to only those agreements both entered into an 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
• Amounts paid to third party vendors for secondary network savings
• Amounts paid to third party vendors for network development, administrative fees and
profit, claims processing, and concurrent or post-service utilization management or any
other issuer function
• Amounts paid, including amounts paid to a provider, for professional or administrative
services that do not represent compensation or reimbursement for covered services
provided to an enrollee
• Incentive and bonus payments made to providers (to be reported in Line 2.11)
Deduct:
• State subsidies based on a stop-loss payment methodology, including receipts from certain
2
state reinsurance programs
2
For example, receipts from the Oregon Transitional Reinsurance Pool.
31
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