Filing Instructions For The 2015 Mlr Reporting Year - Centers For Medicare & Medicaid Services (Cms) Page 8
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57For employer business issued through a group trust, the issuer shall include the experience in the
State report for the State where the employer has its principal place of business. For employer
business issued through a multiple employer welfare association (MEWA), the issuer shall include
the experience in the State report for the State where the MEWA has its principal place of business
(if the MEWA is the policyholder). For employer business issued through a non-MEWA
association, experience with respect to each employer shall be reported as large group or small
group based on the size of each employer and be reported in each State based upon the
aggregation rules for employer based insurance.
Definition of Small Group and Large Group:
The large group and small group markets are defined as those where health insurance coverage is
obtained by a large or small employer, respectively. Large employer and small employer are
defined by the number of employees employed; a small employer has 1 to 50 employees, but if a
State elects to use “100” employees as the upper limit for a small employer, then “100” must be
substituted for “50” employees.
• For the purposes of the MLR program, a sole proprietor or a sole proprietor’s spouse is not
considered a group of one. An employer’s number of employees is determined by
averaging the total number of all employees employed on business days during the
preceding calendar year. This includes each full-time, part-time, and seasonal employee.
• For the purposes of the RC program, the definition of employer size and the employee
counting method applicable under State law will determine whether a plan is considered to
be offered in the small group market.
Non-Affiliate Business:
An issuer must report on this MLR Form only the business issued by the reporting entity. Business
that is written by an unaffiliated entity as part of a package provided to the enrollee (e.g., inpatient
coverage written by the reporting entity, outpatient coverage written by an unaffiliated separate
entity) must not be included in this MLR Form.
Merged Markets:
Issuers of health insurance coverage in the individual and small group markets that merge their
markets in accordance with state law (such as in Massachusetts, Vermont, and the District of
Columbia) should report all experience separately for the individual and small group markets, and
combine it only in MLR numerator, denominator, and credibility life-years fields and RC
calculation fields (Part 3, Lines 1.8, 1.9, 2.3, 3.1-3.10, and 4.1).
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