Filing Instructions For The 2015 Mlr Reporting Year - Centers For Medicare & Medicaid Services (Cms) Page 9
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57Column Definitions for MLR Annual Reporting Form − Parts 1 and 2
Health insurance coverage, Columns 1 through 15, includes policies that provide medical coverage,
including office visits, hospital, surgical, and major medical (illness and injury). Include risk contracts
and the Federal Employees Health Benefit Plan (FEHBP). Exclude from Columns 1–15 mini-med plans,
since they are reported separately in Columns 16–24 of each State MLR Form, and exclude expatriate
plans and student health plans reported in Columns 25–39 on the GT template. Exclude from Columns
2A and 7A grandfathered plans and non-grandfathered plans that are not ACA-compliant.
Do not include in Columns 1–39 business specifically included in Columns 40–43 (e.g., uninsured or self-
funded business, Medicare (Title XVIII, including Medicare Advantage), Medicaid (Title XIX), vision
only, dental only, State Children’s Health Insurance Program (SCHIP) (Title XXI), other Federal or State
government-sponsored coverage (other than the Federal Employees Health Benefits Program or State
government sponsored coverage for State employees or retirees), and short-term, limited duration
insurance as further defined in the PHSA). The experience for pharmacy, chiropractic, or mental health
coverage, whether sold as a stand-alone product or in conjunction with any other health insurance
coverage, should be reported with the health insurance coverage for the applicable market if the coverage
does not meet the definition of “excepted benefits” under the PHSA.
The experience of stop loss or excess of loss coverage for self-funded groups should be reported in Parts 1
and 2, Column 41 – Other Health Business Plans (business excluded by statute). Column 41 includes
information reported in Column 11 of the SHCE.
For any data element that is not separately reported in the financial statement filings to the issuer’s
regulatory authority, an issuer does not need to separately report that element in the 12/31 column of the
MLR Form. However, an issuer must separately report that data element in the 3/31 column as required
by 45 CFR Part 158 and as instructed in the MLR Form instructions. For example, an issuer may not
need to report the amount of contingent benefit and lawsuit reserves in Part 2, Line 2.13 in the 12/31
column, but must report such amounts in the 3/31 column. An issuer must still report, in the detail
provided by the MLR Form, the amounts for premiums and unearned premium reserves, taxes and fees,
claims and claims-related reserves, quality improving activities, and non-claims costs, in both the 12/31
and the 3/31 columns, to the extent the issuer reports such amounts to the issuer’s regulatory authority.
Columns 1, 6, 11, 16, 19, 22, 25, 30, 35, 40, 41, 42, 43 – Business as of 12/31 of the MLR reporting
year
Financial information reported for the 12/31 columns should generally equal the exact amounts
that were reported directly to the State regulatory authority of the issuer, including amounts that
may have been amended in the SHCE the issuer submitted to the NAIC prior to filing the 2015
MLR Form.
Include:
Experience of policies in each of the relevant markets for the MLR reporting year,
as reported as of December 31, to the regulatory authority in the issuer’s State of
domicile or as filed on the NAIC SHCE filing for the MLR reporting year
regardless of incurred date.
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