Filing Instructions For The 2015 Mlr Reporting Year - Centers For Medicare & Medicaid Services (Cms) Page 6
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57If a reinsurance arrangement does not meet the exact criteria specified in the two preceding
paragraphs, the experience under that reinsurance arrangement must be reported by the ceding
issuer and not by the assuming issuer.
Closed Blocks of Business
All health insurance issuers offering health insurance coverage subject to Section 2718 of the
PHSA must submit an MLR report. CMS will use its enforcement discretion and will not initiate
an enforcement action against an issuer of group or individual health insurance coverage who fails
to submit a full MLR report if the issuer’s only health insurance coverage consists of
grandfathered plans in closed blocks of business. To qualify, the issuer must provide and the
issuer’s CFO and CEO must attest to the following information regarding the applicable MLR
reporting year:
1. The issuer has ceased offering health insurance coverage, as defined by §2791(b)(1) of the PHSA,
in the small group, large group, and individual health insurance markets in every State in which it
is licensed to offer health insurance coverage;
2. The issuer has only grandfathered health plans (as defined in 45 CFR §147.140(a)) in closed
blocks of business that are in run-off;
3. The issuer did not submit a Supplemental Health Care Exhibit (SHCE) or other similar State filing
for business during the applicable MLR reporting year, has been exempted from filing a SHCE or
similar State filing by the State in which it is domiciled, and submits to CMS evidence of this
exemption on State letterhead. If the issuer is not subject to a SHCE or similar State filing
requirement, this criterion is not applicable;
4. The issuer has less than 1,000 life-years nationwide (combined for all health insurance coverage)
for the MLR reporting year; and
5. The issuer has non-credible experience in each State market in which it provides coverage. The
issuer must report the number of life-years in each State market for each MLR reporting year that
is aggregated to determine whether the issuer has non-credible
experience.
Like all issuers that are subject to the MLR reporting requirements, a company that meets all of
the criteria described above must register with the MLR module of HIOS, and complete, update,
or confirm the “company issuer association” form in HIOS. A company that meets all of the
above criteria may select “yes” in the “small closed blocks of business” box on the HIOS company
issuer association confirmation. When a company that selects “yes” in the “small closed blocks of
business” box downloads the MLR reporting form from HIOS, it may complete only Part 3, Line
4.1 of the MLR reporting form for every State and market in which it has health insurance
coverage. The company should use HIOS’ “upload supplemental material” function to submit an
attestation statement that affirms the criteria described above. The company should also upload
any State Supplemental Health Care Exhibit (or other similar State required filing) exemption it
has received from its State of domicile. The company should then complete the HIOS process.
Issuers satisfying the above criteria may instead choose to complete the full MLR form for their
grandfathered plans in closed blocks of business. The option described in this closed block of
business policy is intended to reduce MLR reporting burden.
If CMS determines that an issuer does not satisfy the criteria described above, CMS will notify the
issuer that it must complete the full MLR reporting form as specified in 45 CFR Part 158.
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