Filing Instructions For The 2015 Mlr Reporting Year - Centers For Medicare & Medicaid Services (Cms) Page 47
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57calculations on Lines 3.1 through 3.10 in the RC Columns for both markets (individual market in
column 4A and small group market in column 8A). Please note that MLR numerator, denominator,
and life-years to determine credibility, and RC calculated fields are the only fields on the MLR
Form where experience for the two markets may be combined.
Section 4 – Credibility Adjustment
Line 4.1 – Life-years
PY2 and PY1 Columns – 2013 and 2014 MLR Forms, respectively, Part 1, Line 7.5, Columns
3/31 + Deferred PY1 – Deferred CY
CY Column – Part 1, Line 7.5, Columns 3/31 + Deferred PY1 – Deferred CY
RC Column – Part 1, Line 7.5, Column [RC] 3/31
For Health Insurance Coverage and Mini-med plans respectively, issuers with experience in both
the individual and small group markets who merge their markets in accordance with state law
(such as in Massachusetts, Vermont, and the District of Columbia), should combine Line 4.1 for
both markets and enter the combined amounts on Line 4.1 in the PY2, PY1, CY, and Total
Columns for both markets (Columns 1-8 for health insurance coverage, Columns 13-20 for Mini-
med plans). Please note that MLR numerator, denominator, and life-years to determine
credibility, and RC calculated fields are the only fields on the MLR Form where experience for the
two markets may be combined.
Line 4.2 – Base credibility factor
Non-credible experience: An issuer with aggregated life-years of less than 1,000 as reported in
Line 4.1, Total Column for the relevant market is presumed to meet or exceed the applicable MLR
standard and does not receive a credibility adjustment.
Fully credible experience: An issuer with 75,000 or more aggregated life-years as reported in Line
4.1, Total Column for the relevant market does not receive a credibility adjustment. Enter zero
(0%) or leave blank.
Partially credible experience: An issuer with at least 1,000 but fewer than 75,000 aggregated life-
years as reported in Line 4.1, Total Column for the relevant market may receive a base credibility
factor calculated as follows:
Beginning with the 2013 reporting year, the credibility adjustment for an MLR based on partially
credible experience is zero if both of the following conditions are met:
(1) The current MLR reporting year and each of the two previous MLR reporting years
included experience of at least 1,000 life-years; and
(2) Without applying any credibility adjustment, the issuer’s MLR for the current MLR
reporting year and each of the two previous MLR reporting years were below the
applicable MLR standard for each year.
Specifically, the base credibility factor is zero if all of the following conditions are met:
• Line 4.1, PY2 Column is at least 1,000; and
46
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