Filing Instructions For The 2015 Mlr Reporting Year - Centers For Medicare & Medicaid Services (Cms) Page 36
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57related party hospitals, established as prepaid assets that are not expensed until the related claims
have been received from the provider.
Line 2.13 – Contingent benefit and lawsuit reserves for claims incurred in the MLR reporting year
12/31 Column – reserves as of 12/31 of the MLR reporting year.
If not separately reported in annual financial filings to the issuer’s regulatory authority, the
issuer does not need to separately report this element in this column.
3/31 Column – reserves related to claims incurred during the MLR reporting year and unpaid as of
3/31 of the following year.
Issuer must separately report this data element in the 3/31 column as provided in 45 CFR
Part 158 and as noted in the General Instructions.
Include:
The claims-related portion of reserves for contingent benefits and lawsuits.
Exclude: Reserves related to costs associated with claims lawsuits within Line 2.13; e.g., legal
fees, court costs, pain and suffering damages, punitive damages, etc.
Line 2.14 – Group conversion charges
If there are any group conversion charges for a health plan, the conversion charges must be
subtracted from the incurred claims for the aggregation that includes the conversion policies and
this same amount must be added to the incurred claims for the aggregation that provides coverage
that is intended to be replaced by the conversion policies.
If an issuer transfers portions of earned premium associated with group conversion privileges
between group and individual lines of business in its annual statement accounting, these amounts
must be added to or subtracted from incurred claims.
Line 2.15 – Blended rate adjustment
Affiliated issuers that offer group coverage at a blended rate may choose whether to make an
adjustment to each affiliate’s incurred claims and activities to improve health care quality, to
reflect the experience of the issuer with respect to the employer as a whole, according to an
objective formula the issuer defined prior to the beginning of the MLR reporting year, so as to
result in each affiliate having the same ratio of incurred claims to earned premium for that
employer group for the MLR reporting year as the ratio of incurred claims to earned premium
calculated for the employer group in the aggregate. From the date an issuer chooses to use such
an adjustment, it must be used for a minimum of three consecutive MLR reporting years.
Affiliated issuers that choose to make such an adjustment must do so for all policies with blended
rates in the applicable State market.
Line 2.16 Total incurred claims
12/31 Column – Part 2, Lines 2.1a + 2.2a – 2.3 + 2.4a – 2.5 + 2.6a – 2.7 + 2.8a + 2.9a – 2.10 +
2.11a + 2.11b – 2.11c – 2.12a + 2.12b + 2.13 + 2.14 + 2.15
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