Filing Instructions For The 2015 Mlr Reporting Year - Centers For Medicare & Medicaid Services (Cms) Page 55
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57Instructions for MLR Annual Reporting Form
Part 5
–
(Additional Responses)
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.
Line 1 – If the issuer reported amounts in Part 1, Line 3.2c, Community Benefit Expenditures, provide the
state premium tax rate that was used in determining the reported amount. Complete on each
State template and not on the GT template.
Line 2 – If the issuer reported amounts in Part 2, Line 2.15, Blended rate adjustment, provide the
affiliate(s)’ name(s) for which blended rate adjustments were made.
Line 3 – If the issuer reported amounts in the 3/31 Columns related to dual contract options with affiliates
providing out-of-network coverage, provide the affiliate(s)’ name(s) for which experience is
being reported.
Line 4 – If the issuer entered into any 100% assumption reinsurance agreements (with a novation) during
the MLR reporting year provide the name(s) of the entity(ies) with which the agreement was
(were) made and the effective date of the novation. Report only those agreements that are
applicable to “health insurance coverage” as defined at the beginning of these Filing
Instructions.
Line 5 – If the issuer novated any business in the MLR reporting year, and that novation was effective
during the MLR reporting year, provide the name(s) of the entity(ies) to which the business was
sold and the date of the sale or transfer.
Line 6 – If the issuer has any 100% indemnity reinsurance and administrative agreements effective prior
to March 23, 2010, for which the assuming entity is responsible for 100 percent of the ceding
entity’s financial risk and takes on all of the administration of the block of business, provide
name(s) of the entity(ies) that is (are) reporting the experience related to such business. Report
only those agreements that are applicable to “health insurance coverage” as defined at the
beginning of these Filing Instructions.
54
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