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Crosswalk for Changes to MLR Annual Reporting Form, MLR Rebate Notices, MLR
Information Notice, and Instructions CMS 10418

A.

Table of Contents
Introduction ...................................................................................................................... 1

B.

Changes to MLR Reporting Form and Accompanying Instructions................................ 1

C.
Changes to MLR Rebate Notices, MLR Information Notice, and Accompanying
Instructions ................................................................................................................................ 15

A. Introduction
CMS received 27 public comments regarding the Medical Loss Ratio (MLR) PRA package
published in the Federal Register on December 16, 2012 (76 FR 78265), and amended on
February 16, 2012 (77 FR 9931). The original comment period closed on February 14, 2012, but
on February 16 was reopened until March 2, 2012 to accommodate comments on amendments to
the PRA package.
The PRA package contained two different collections of information: the MLR Annual
Reporting Form that issuers must file with CMS each year on June 1, beginning June 1, 2012;
and Notices of rebates that issuers must send to subscribers and policyholders each year no later
than August 1, beginning August 1, 2012. In addition, the PRA package contained a sample
notice and instructions for what a notice might contain if CMS were to issue a rule requiring
notice of MLR information when an issuer meets or exceeds the MLR standard. CMS notes that
this sample notice is not currently required.
The following charts document the changes made to the MLR Annual Reporting Form, the MLR
Rebate Notices and MLR Information Notice, and the accompanying instructions for each of
these documents.
B. Changes to MLR Reporting Form and Accompanying Instructions
The following chart contains the list of changes made to the MLR Reporting Form and the
accompanying Instructions. These changes were made in response to internal comments and in
response to comments received following the 60-day public comment period. Additional minor
changes were made to correct excel cell references, typographical errors, and technical errors.

1

Crosswalk for Changes to MLR Annual Reporting Form, MLR Rebate Notices, MLR
Information Notice, and Instructions CMS 10418
Document

Instruction

Section Edited

Entire
Document

Instruction

Entire
Document

Instruction

Entire
Document

Instruction

Entire
Document

Reporting
Form

Domiciliary
State

Revision (Red indicates added language)

Rationale

Instruction Update:
INSTRUCTIONS FOR THE 2011 MLR REPORTING
YEAR ONLY

The instructions are
clarified throughout to
indicate that they are
specific to 2011 and that
guidance for future MLR
reporting years will be
issued in the future.

The annual MLR reporting form filing Instructions only
apply to the 2011 MLR Reporting Year and its
reporting requirements. The Filing Instructions will be
revised for subsequent reporting years to reflect
changes made since publication of the MLR Interim
Final Rule.

The Instructions were revised to replace all references
to the term "current MLR reporting year" with "MLR
reporting year."

The Instructions were
revised to clarify the time
period for which the data is
sought.

The Instructions were revised to replace all references
to “prior MLR reporting year” and “prior year” with “the
year preceding the MLR reporting year”

The Instructions were
revised to clarify the time
period for which the data is
sought.

The Instructions were revised to replace the term
“grand total filing” with “grand total page.”

This instruction was
revised to correct a
technical error.

Form Update:
I12 Domiciliary State - Drop Down List should be
adjusted to include only States and territories

This item has been revised
to ensure all States are
available from the dropdown list.

CCIIO agrees to remove "Canada" and "Other
Territories" from drop down menu.

Instruction Page 1 Update:
Instruction

Page 1

(Note: The experience of expatriate plans is
aggregated on a national basis and should be reported
on the “Grand Total” MLR Form for each issuer, along
with the aggregated lines of business on that form.)

2

This item has been revised
to conform to the
regulation and properly
capture the data.

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Instruction

Section Edited

Introduction

Revision (Red indicates added language)

Rationale

Instruction Update:
Note: The MLR Form is an excel workbook that
contains many calculated fields based on the
information inputted into the data fields by the issuer.
Calculated cells or cells not requiring any data input
have been shaded and a key provided on each tab
within the workbook for further clarification. This
workbook includes calculations for any credibility
adjustment based on an issuer’s life-years and
average deductible.

The Instructions were
revised to clarify how data
is to be entered in the
Excel spreadsheet.

The various “Parts” of the MLR Form contain
calculated fields, which will assist in reducing data
input for the various elements required in the reporting
form. Many of the fields within Part 1 of the MLR Form
copy over calculated information from data that is
entered into Part 2 and Part 3. (Recommendation:
Begin inputting data into Part 2 and Part 3, prior to
completing Part 1.) Once the information has been
inputted into the cells not shaded in Part 2, Part 3, Part
1 and Part 5, the MLR and Rebate Calculation – Part 5
will automatically calculate the issuer’s MLR and
rebate for each market in each State.

Instruction Update:
These Filing Instructions are to be used in completing
the MLR Form by all issuers offering health insurance
coverage. All terms used in these Filing Instructions
that are not defined here have the meaning used in 45
CFR Part 158 and further defined within the PHS Act.

Instruction

Introduction

The term “health insurance coverage” means benefits
consisting of medical care (provided directly, through
insurance or reimbursement, or otherwise and
including items and services paid for as medical care)
under any hospital or medical service policy or
certificate, hospital or medical service plan contract, or
health maintenance organization contract offered by a
health insurance issuer. The definition includes any
insurance product, such as drug, chiropractic, and
mental health coverage, whether sold as a stand-alone
product or in conjunction with any other health
insurance coverage, unless specifically identified as
“excepted” by Federal law.

3

The Instructions are being
revised to clarify that all
issuers offering health
insurance coverage are
required to file the MLR
Form.

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Instruction

Instruction

Instruction

Section Edited

Introduction Reinsurance

Introduction –
Allocation of
Expenses

Introduction Aggregation Dual Contract

Revision (Red indicates added language)

Rationale

Addition to Instructions:
Experience under a 100% assumption reinsurance
agreement (treated as novation) must be reported by
the assuming issuer for the entire MLR reporting year
during which the policies are assumed and must not be
reported by the ceding issuer.

This section was revised to
clarify the treatment of
100% assumptive
reinsurance.

Reporting of 100% indemnity reinsurance and
administrative agreements is limited to only those
agreements both entered into and also effective prior
to March 23, 2010, where the assuming entity is
responsible for 100% of the ceding entity’s financial
risk and takes on all of the administration of the block
of business. Experience under those indemnity
reinsurance and administrative agreements must be
reported by the assuming issuer and must not be
reported by the ceding issuer.

Addition to Instructions:
Allocation of Expenses
Each expense must be reported under only one type of
expense, unless a portion of the expense fits under the
definition of or criteria for one type of expense and the
remainder fits into a different type of expense, in which
case the expense must be pro-rated between the two
(or more) types of expenses. Expenditures that benefit
more than one affiliate may be allocated between the
affiliates that benefit from these expenditures on a pro
rata basis. Expenditures that benefit all lines of
business or products, including but not limited to those
that are for or benefit self-funded plans, must be
reported on a pro rata basis.

Instruction Update:
Dual-Contract Group Health Coverage:
If an issuer has a group health plan which provides
coverage for in-network coverage only and an affiliate
issuer provides only out-of-network coverage solely for
the purpose of providing a group health plan that offers
both in-network and out-of-network benefits, the issuer
may choose to treat the out-of-network experience of
the affiliate that provides the out-of-network coverage
as if it were related to the contract providing the innetwork coverage. If an issuer chooses this method of
aggregation, it must do so for a minimum of three
consecutive reporting years and the affiliate that
provides the out-of-network coverage must not report
this experience. After an issuer applies this method for
the initial three consecutive reporting years, the issuer
may either continue to apply this method for any
number of additional consecutive reporting years, or
may choose to discontinue applying this method.
Affiliated issuers that choose to make such an

4

The instruction is being
revised to clarify that an
entity may allocate
administrative costs to only
those affiliated entities that
benefit from the allocated
expenses

The instruction is being
revised to clarify that an
issuer may discontinue this
method after three
consecutive years.

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Rationale

adjustment must do so for all policies with blended
rates in the applicable State market.

Instruction

Page 4 –
Health
Insurance
Coverage

Instruction Update:
Health Insurance Coverage:
Do not include health insurance coverage specifically
not subject to section 2718 of the PHS Act, such as
government-sponsored programs, (e.g., Medicare
(Title XVIII, including Medicare Advantage), Medicaid
(Title XIX), State Children’s Health Insurance Program
(SCHIP) (Title XXI), and other Federal or State
government-sponsored coverage (other than the
Federal Employee Health Benefits Program or State
government sponsored coverage for State employees
or retirees), or uninsured business. Stop (or excess)
loss coverage for self insured groups should be
reported in Parts 1 and 2 – Other Health Business
(business excluded by statute).
Instruction Update:
Page 4
Columns 1, 6, 11, 16, 18, 20, 22, 27, 32, 33, 34, and
35 – Business as of 12/31 of the MLR reporting year

Instruction

Business as of
12/31 of
Current
Reporting Year

Include: Experience of policies in each of the relevant
markets (individual market, small group market, large
group market, mini-med individual market, mini-med
small group market, mini-med large group market,
expatriate small group market, or expatriate large
group market) for the MLR reporting year, as reported
as of December 31, to the department of insurance in
the issuer’s State of domicile or as filed on the NAIC
SHCE filing for the MLR reporting year regardless of
incurred date.

Part 2
Line 2.1 – Claims paid
2.1a – 12/31 Column – Claims paid during the MLR
reporting year regardless of incurred date.
Report payments net of risk share amount collected.

5

The instruction was
revised to consistently
refer to "health insurance
coverage" throughout.
This eliminated the use of
duplicative and ambiguous
terms.

The instruction was
clarified to specify the time
period for which premiums
are to be reported.

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Rationale

Instruction Update:
Page 4

The instruction for this item
is being revised to specify
which actuarial elements
are being referenced.

Columns 2, 7, 12, 17, 19, 21, 23, and 28 – Business as
of 3/31 of subsequent MLR reporting year

Instruction

Instruction

Instruction

Business of
Subsequent
Reporting Year

Include: Experience for policies for each market,
incurred, paid or received relevant only to the MLR
reporting year, reported as of March 31 of the
subsequent MLR reporting year.
For purposes of actuarial claims elements, the 3/31
column items should generally follow the structure of
amounts incurred in the prior year settled through 3/31
of the following year (traditionally described as incurred
12 paid 15), plus any provision remaining as of 3/31 for
items properly allocable to the prior period but not yet
paid as of 3/31.

Part 1 – Fee for
Service and
Co-pay
revenue - Line
2.10

Instruction Update:
Include: Revenue recognized by the issuer for
collection of co-payments from members and revenue
derived from health services rendered by reporting
entity providers that are not included in member
policies (generally applicable to only staff-model
HMOs).

This item has been
clarified to add specificity
to avoid confusion.

Part 1 - Taxes
and Regulatory
Fees - Lines
3.1 - 3.3

Instruction Update:
Line 3.1 – Federal taxes and assessments incurred by
the reporting issuer
Line 3.2 – State insurance, premium and other taxes
incurred by the reporting issuer
Line 3.3 – Regulatory authority licenses and fees
incurred by the reporting issuer

The phrase "owed and
paid by" was replaced with
the phrase "incurred by" to
clarify the meaning.

6

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Information Notice, and Instructions CMS 10418
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Instruction

Instruction

Section Edited

Revision (Red indicates added language)

Rationale

The instructions are
clarified for this item to
indicate that they are
specific to 2011 and that
guidance for future MLR
reporting years will be
issued in the future.

Part 1 Community
Benefit
Expenditures Line 3.2c

Instruction Update:
For the 2011 MLR Reporting Year ONLY–Not-for-profit
health plans report one of the following types of
payments:
• Payments by a not-for-profit issuer to a State of
premium tax exemption values in lieu of State premium
taxes. limited to the State premium tax rate applicable
to for-profit entities subject to premium tax multiplied by
the allocated premiums earned for individual, small
group and large group;
• Payments by a not-for-profit issuer for community
benefit expenditures** (described below in these Filing
Instructions) if made pursuant to a State-based
requirement, limited to the State premium tax rate
applicable to for-profit entities subject to premium tax
multiplied by the allocated premiums earned for
individual, small group, and large group;
• Payments by an issuer exempt from Federal income
tax for community benefit expenditures** (described
below in these Filing Instructions), limited to the State
premium tax rate applicable to for-profit entities subject
to premium tax multiplied by the allocated premiums
earned for individual, small group, and large group.

Instruction Update:
Line 3.4 – Total Federal and State taxes and fees to be
excluded from Premium

This instruction was
revised to make a
technical correction.

Part 1 – Total
Federal Taxes
and Fees to be
excluded from
Premium – Line
3.4

Instruction

Part 1 - ICD-10
- Line 5.9

Reporting
Form

Part 1 Underwriting
Gain / Loss Line 6

This is necessary here as
the MLR Final Rule,
published December 7,
2011, provides a different
rule for 2012 and beyond.
Additional changes are
made to this section to
conform to the controlling
regulation.

(Lines 3.1 + 3.2a + Max(3.2b or 3.2c) + 3.3)

Instruction Update:
Part 1 Line 5.9 – ICD-10 Implementation expenses
(already included in line 5.6; informational for 2011)

The instruction for this item
is being revised to note
that it is being collected for
informational purposes
only for the 2011 MLR
experience.

Form Update:
Pre-tax underwriting gain / (loss) (Lines 1.8 – 2.11 –
4.6 – 5.8 + 5.5a + 5.5b - Part 2 Line 2.16)
Formula change:
=F$27-F$40-F$57-F$69+F$65+F$66-F$149

This item has been revised
to avoid double counting
for fraud expenses and to
conform to the regulation

7

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Section Edited

Instruction

Instruction

Revision (Red indicates added language)

Rationale

Part 1 Underwriting
Gain / Loss Line 6

Instruction Update:
Line 6 – Pre-tax underwriting gain/(loss) as of
12/31/XX (Lines 1.8 – 2.11 – 4.6 – 5.7 + 5.5a + 5.5b –
Part 2 Line 2.16)

This item has been revised
to avoid double counting
for fraud expenses and to
conform to the regulation

Part 2 Premium - Line
1.1

Addition to Instructions:
Include:
Premium assumed under a 100% assumption
reinsurance agreement (treated as a novation) must be
reported by the assuming issuer for the entire MLR
reporting year during which the policies are assumed
and must not be reported by the ceding issuer.

The instruction was
revised to clarify the
reference to 100%
assumptive and indemnity
reinsurance in the
instruction for determining
premium.

Premium assumed under a 100% indemnity
reinsurance and administrative agreements, limited to
only those agreements both entered into and also
effective prior to March 23, 2010, where the assuming
entity is responsible for 100% of the ceding entity’s
financial risk and takes on all of the administration of
the block of business.
Exclude:
Premium ceded under a 100% assumption reinsurance
agreement (treated as a novation) must be reported by
the assuming issuer for the entire MLR reporting year
during which the policies are assumed and must not be
reported by the ceding issuer.
Premium ceded under a 100% indemnity reinsurance
and administrative agreements, limited to only those
agreements both entered into and also effective prior
to March 23, 2010, where the assuming entity is
responsible for 100% of the ceding entity’s financial
risk and takes on all of the administration of the block
of business.

Instruction

Part 2 unearned
premium (prior
year) - Line 1.2

Instruction

Part 2 -Reserve
for Experience
Rating Refunds
- Line 1.6

Instruction Update:
Line 1.2 - Unearned premium (year preceding the MLR
reporting year)
Report reserves established to account for the portion
of the premium paid in the prior MLR reporting year
that was intended to provide coverage during the MLR
reporting year.

The instruction for this item
was revised to specify that
unearned premium for the
year preceding the MLR
reporting year is to be
reported.

Instruction Update:
Line 1.6 – Reserve for experience rating refunds (rate
credits) (MLR reporting year) unpaid or received

This section was revised to
correct the instruction and
conform to the regulation.
In addition, the instruction
is being revised to clarify
treatment of “amounts
receivable under
retrospectively rated

12/31 Columns – Unpaid as of 12/31 of the MLR
reporting year.
3/31 Columns – Incurred only in the reporting year and

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Instruction

Instruction

Section Edited

Part 2 –
Premium ceded
under 100%
reinsurance –
Line 1.12

Part 2 –
Premium
assumed under
100%
reinsurance –
Line 1.13

Revision (Red indicates added language)

Rationale

unpaid in the reporting year and through 3/31 of the
following year
…
Deduct: Amounts receivable under retrospectively
rated funding arrangements.

funding arrangements.”

Instruction Update:
Include:
• Premium ceded under a 100% assumption
reinsurance agreement (treated as a novation) .
• Premium ceded under a 100% indemnity
reinsurance and administrative agreement, limited to
only those agreements both entered into and
effective prior to March 23, 2010, where the
assuming entity is responsible for 100% of the
ceding entity’s financial risk and takes on all of the
administration of the block of business.
Instruction Update:
Include:
•
Premium assumed under a 100% assumption
reinsurance agreement (treated as a novation).
•
Premium assumed under a 100% indemnity
reinsurance and administrative agreement, limited
to only those agreements both entered into, and
effective prior to March 23, 2010, where the
assuming entity is responsible for 100% of the
ceding entity’s financial risk and takes on all of the
administration of the block of business.
Instruction Update:
Ex gratia payments have been removed from the
instructions.

The section was revised to
clarify what is to be
included in the reporting of
this data.

The section was revised to
clarify what is to be
included in the reporting of
this data.

The instruction is being
clarified to specify
treatment of certain
expenditures.

Deduct:

Instruction

Part 2 - Claims
Paid - Line 2.1

Instruction

Part 2 - Claims
Paid - Line 2.1

• Any overpayment that has already been received
from providers should not be reported as a paid claim;
• Prescription drug rebates, refunds, incentive
payments, bonuses, discounts charge backs, coupons,
grants, direct or indirect subsidies, direct or indirect
remuneration, upfront payments, goods in kinds or
similar benefits received by the issuer; •
• Payment from unsubsidized State programs designed
to address distribution of health risks across issuers via
charges to low risk issuers that are distributed to high
risk issuers must be deducted from incurred claims

Instruction Update:
Removed incentive and bonus payments to providers
from Line 2.1. The instruction for line is only for Line

9

The instruction is being
revised to indicate the
proper treatment of
incentive payments to

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Instruction

Section Edited

Part 2 - Claims
- Line 2.1

Revision (Red indicates added language)

Rationale

2.11

conform to the regulation,
and to clarify that incentive
and bonus payments to
providers should only be
included in Line 2.11.

Addition to Instructions:
Include:
Claims assumed under a 100% assumption
reinsurance agreement (treated as a novation) must be
reported by the assuming issuer for the entire MLR
reporting year during which the policies are assumed
and must not be reported by the ceding issuer.

The instruction was
revised to clarify that
“claims assumed and
ceded under 100%
assumptive and indemnity
reinsurance agreements,”
are to be reported.

Claims assumed under a 100% indemnity reinsurance
and administrative agreements, limited to only those
agreements both entered into an also effective prior to
March 23, 2010, where the assuming entity is
responsible for 100% of the ceding entity’s financial
risk and takes on all of the administration of the block
of business.
Deduct:
Claims ceded under a 100% assumption reinsurance
agreement (treated as a novation) must be reported by
the assuming issuer for the entire MLR reporting year
during which the policies are assumed and must not be
reported by the ceding issuer.
Claims ceded under a 100% indemnity reinsurance
and administrative agreements, limited to only those
agreements both entered into an also effective prior to
March 23, 2010, where the assuming entity is
responsible for 100% of the ceding entity’s financial
risk and takes on all of the administration of the block
of business.

Instruction Update:
The instruction for this item was revised to state:

Instruction

Part 2, Line
2.6, Contract
Reserves

For policies issued prior to 2011, contract reserves
may only be used in the MLR calculation if such
reserves were held prior to 2011, and may include
reserves used for the purpose of leveling policy
duration-based variation in claims experience only if
durational contract reserves were held for such policies
prior to 2011. Reported contract reserves may not
exceed contract reserves calculated using the
applicable product pricing assumptions.

10

This item was revised to
clarify elements that could
be included in contract
reserves.

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Instruction

Part 2 Experience
Rated Refunds
Paid - Line 2.8

Instruction Update:
Experience rating refunds associated with premium
earned during the MLR reporting year, including State
premium refunds paid during the MLR reporting year.
Experience rating refund is the return of a portion of
premium pursuant to a retrospectively rated funding
arrangement when the sum of incurred losses,
retention and margin are less than earned premium.

This item has been revised
to conform to the
regulation and properly
capture the data.

Instruction

Part 2 –
Reserve for
Experience
Rated Refunds
(rate credits) –
Line 2.9

Instruction Update:
Subtract: Amounts receivable under retrospectively
rated funding arrangements.

This item has been revised
to clarify the treatment of
“amounts receivable under
retrospectively rated
funding arrangements.”

Instruction

Part 2 - Net
Healthcare
Receivables line 2.12

Instruction Update:
3/31 Column – receivables incurred during the MLR
reporting year and that remain outstanding as of 3/31
following the MLR reporting year.

The instruction for this item
was revised to specify
"receivables" that are to be
reported

Instruction

Part 2 –
Contingent
benefit and
lawsuit
reserves – Line
2.13

Instruction Update:
Exclude: Reserves related to costs associates with
claims lawsuits within Line 2.13; i.e. legal fees, court
costs, pain and suffering damages, punitive damages,
etc.

This item was revised to
clarify treatment of
contingent benefit and
lawsuit reserves.

Instruction

Part 2 Blended Rate
Adjustment Line 2.15

Instruction

Part 2 - Fraud Line 2.16

Instruction Update:
Affiliated issuers that offer group coverage at a
blended rate may choose whether to make an
adjustment to each affiliate’s incurred claims and
activities to improve health care quality, to reflect the
experience of the issuer with respect to the employer
as a whole, according to an objective formula the
issuer defined prior to January 1, 2011, so as to result
in each affiliate having the same ratio of incurred
claims to earned premium for that employer group for
the MLR reporting year as the ratio of incurred claims
to earned premium calculated for the employer group
in the aggregate. From the date an issuer chooses to
use such an adjustment, it must be used for a
minimum of three consecutive MLR reporting years.
Affiliated issuers that choose to make such an
adjustment must do so for all policies with blended
rates in the applicable State market.
Instruction Update:
Line 2.16a – Total Fraud Reduction expense:
Line 2.16b – Total Fraud Reduction Recoveries that
Reduced PAID claims.

11

The instruction was
clarified to conform to the
regulation.

This item has been revised
to indicate that the data is
used the MLR calculation
and to conform to the

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Revision (Red indicates added language)

Rationale

(Removed reference to informational only)

regulation

Reporting
Form

Formula
change within
Part 2 Line
2.17

Form Update:
Formula change within Part 2 Line 2.17
=SUM(K$126+K$128-K$129+K$130-K$131+K$132K$133+K$135+K$137-K$138+K$140+K$141-K$142K$144+K$145+K$146+K$147+K$148+K$149)

This item was revised to
correct a typographical
error

Instruction

Part 3 Improving
Health care
outcomes Column 1

Instruction Update:
• Effective case management, care coordination, and
chronic disease management, including through the
use of the medical homes model as defined in section
3606 of the Affordable Care Act.”

This section was revised to
include a list of items
mistakenly omitted from
the prior version.

Instruction

Part 3 Column
4 Wellness and
Health
Promotion
Activities

Instruction Update:
• Actual rewards/incentives/bonuses/reductions in copays, etc. (not administration of these programs) that
are not already reflected in premiums or claims should
be allowed as QI for the group market to the extent
permitted by section 2705 of the PHS Act.

This item was revised to
clarify the classification of
"wellness" activities in
conformity with the
regulation

Part 4 Acceptable
Bases for
Allocation of
Expenses Instruction

Instruction Update:
Any basis adopted to apportion expenses must be that
which is expected to yield the most accurate results
and may result from special studies of employee
activities, salary ratios, premium ratios or similar
analyses. Expenses that relate to a specific entity or
sub-set of entities, such as personnel costs associated
with the adjusting and paying of claims, must be borne
solely by that specific entity or subset of entities and
must not be apportioned to other entities within a
group.

The instruction regarding
"acceptable bases of
allocation" is clarified to
more accurately express
CMS policy. A comment
suggests that the
instruction was vague.

Instruction Update:

This section was revised to
indicate that this data input
is not required for the 2011
MLR reporting. The data
field indicates that an
issuer is to provide the
preceding year's MLR and
since 2010 is not an MLR
reporting year, the data is
not required.

Instruction

Instruction

Section Edited

Part 5 Instruction

The annual MLR reporting form Filing Instructions only
apply to the 2011 MLR Reporting Year and its
reporting requirements. These Filing Instructions will
be revised to reflect changes that apply to the filing
years subsequent to 2011. Part 5 of each State filing is
self calculating based on other data elements entered
into the other associated tabs. No data information is
needed to be completed in any of the shaded cells
within the filing.

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Crosswalk for Changes to MLR Annual Reporting Form, MLR Rebate Notices, MLR
Information Notice, and Instructions CMS 10418
Document

Section Edited

Revision (Red indicates added language)

Rationale

Instruction Update:
Line 1.4 – MLR rebates paid based on experience for
the two immediately preceding MLR reporting years.
(Not applicable to the 2011 MLR Reporting Year).

This item has been revised
to conform to the
regulation and properly
capture the data.

Instruction

Part 5 Rebates paid
based on
experience for
the two
immediately
preceding MLR
reporting years
- Line 1.4

The Instructions are being revised to clarify that the
Instructions apply only to the reporting of 2011 MLR
experience. Guidance on this comment is required
only for future MLR reporting years. Instructions for
2012 and beyond will be issued at a later date.

This section was revised to
clarify that instructions
apply for 2011 only.

Instruction

Part 5 - MiniMed - Line 1.6

Instruction Update:
Line 1.6 – Mini-Med / Expatriate numerator after
adjustment factor (Line 1.5 x adjustment factor)
For the 2011 MLR reporting year, the adjustment factor
for mini-med plans and expatriate plans is 2.

Reporting
Form

Part 5 - Federal
& State high
risk programs Line 2.1

Instruction

Part 5 Average
Deductible Line 3.3

Reporting
Form

Part 5 Deductible
factor - Line 3.4

Instruction

Part 5 Credibilityadjusted MLR -

Form Update:
Formula change;
='Pt 1 and 2'!$G$20,$K$20, $O$20, etc should be
changed to reference row 23

The formula was edited to
correct the calculation and
conform to the regulation.

Instruction Update:
The per person deductible for a policy that covers a
subscriber and the subscriber’s dependents shall be
calculated as follows:

The calculation instruction
is being clarified, as
suggested by commenters.

The lesser of the deductible applicable to each of the
individual family members or the overall family
deductible for the subscriber and subscriber’s family
divided by two (regardless of the total number of
individuals covered through the subscriber).

Excel – Part 5, Line 3.4: The cell reference was
corrected to properly refer to deductibility factors.
Additionally, the formula was modified to correctly
interpolate for deductible levels under $2,500 rather
than reporting a factor of 1.000.

Instruction Update:
Line 4.4 – MLR including credibility adjustment if

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This item has been revised
to conform to the
regulation and properly
capture the data.

This item was revised to
correct a typographical

Crosswalk for Changes to MLR Annual Reporting Form, MLR Rebate Notices, MLR
Information Notice, and Instructions CMS 10418
Document

Section Edited
Line 4.4

Instruction

Part 5 - MLR
Standard - Line
5.1

Reporting
Form

Part 5 - MLR
Standard - Line
5.1

Instruction

Part 5 Credibilityadjusted MLR Line 5.2

Instruction

Part 6 Number of
policyholders/
subscribers
owed rebates Line 3

Revision (Red indicates added language)

Rationale

applicable (Lines 4.2a or 4.2b + 4.3)

error

Instruction Update:
INSTRUCTIONS FOR THE 2011 MLR REPORTING
YEAR ONLY

The instructions are
clarified throughout to
indicate that they are
specific to 2011 and that
guidance for future MLR
reporting years will be
issued in the future.

The annual MLR reporting form filing Instructions only
apply to the 2011 MLR Reporting Year and its
reporting requirements. The Filing Instructions will be
revised for subsequent reporting years to reflect
changes made since publication of the MLR Interim
Final Rule.

The State-specific MLR standard will be 'pre-coded' in
the form.

The State-specific MLR
standard will be 'precoded' in the form. This
will increase data integrity

Instruction Update:
Line 5.2 – Credibility-adjusted MLR (MLR Form, Part 5,
Line 4.4)
(Not applicable to Grand Total page)

This item was revised to
correct a typographical
error and to clarify that it
does not apply to the
Grand Total page.

Instruction Update:

This section was revised to
replace references to the
term "owed" with the term
"being paid", as a
clarification.

Line 1 – Is a rebate being paid?
This cell is automatically populated with a “Yes” if Part
5 Line 5.4 is greater than 0, otherwise it will populate
with “No”.
If no rebate is being paid, do not complete Lines 2
through 5.
Line 3 - Number of policyholders/subscribers being
paid rebates
Line 3.a – Number of group policyholders who are
being paid a rebate
Include: All group policies within the respective group
markets that are due a rebate
Exclude: Rebates being paid in the individual market
for individual policies.
Line 3.b – Number of subscribers who are being paid
a rebate.

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Crosswalk for Changes to MLR Annual Reporting Form, MLR Rebate Notices, MLR
Information Notice, and Instructions CMS 10418
C. Changes to MLR Rebate Notices, MLR Information Notice, and Accompanying
Instructions
The following chart contains the list of changes made to the MLR Rebate Notices, the MLR
Information Notice, and the accompanying Instructions. These changes were made in response
to comments received following the 60-day public comment period. Additional minor changes
were made to correct typographical errors.
Document

Notices &
Instructions

Item Edited

All throughout
Notices and
Instructions

Type of Revision

Rationale

Change language to match
language in Public Health
Service Act.

CMS is revising the language in the Notices and
Instructions from “refund” to “rebate” to
correspond with the language in the statute and
regulation.

Since non-credible issuers are presumed to
meet or exceed the MLR standard, they do not
pay rebates. CMS has clarified the Instructions
to reflect that Notices #1 - #3 do not apply to
non-credible issuers.

Instructions

Notices #1-3

Add clarification for whether
non-credible plans are required
to send out notices.

Notices

Notices #1-4

Add examples of administrative
costs to notices.

CMS is adding language to the Notices by
including the example “sales” to reflect
additional administrative costs.

Notices

Notices #1-3

In addition to phone #s,
website/email should be
provided.

CMS is revising the language of the Notices to
add a website or email address of the issuer for
consumers to contact with questions.

Instructions

Instruction When Notice
of Rebate
Must be
Provided

Add clarification that notices
may be sent prior to or after
payment of rebates so long as
notice is provided by Aug 1.

CMS is clarifying the Instructions to note that
Notices may be sent prior to or after payment of
rebates as long as the notice is provided by
August 1, as stated in the regulation (§158.250).

Add language to notice
regarding de minimis
thresholds.

The regulations require that notices be sent to
each enrollee who receives a rebate. If a rebate
is de minimis, the enrollee would not be
receiving a rebate and therefore would not be
receiving a notice.

Notices

Instructions

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Information Notice, and Instructions CMS 10418
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Item Edited

Type of Revision

Rationale

Re-write the sentence for those
States with higher MLR
standards.

The sentence that previously stated “The
Affordable Care Act allows States to require
health insurers to meet a higher ratio” will now
read “States may require health insurers to meet
a higher standard”. This will ease confusion for
consumers.

Clarify language regarding for
which notices an eligibility
report should be run.

CMS is updating the Instructions to clarify that
an eligibility report may be run for all Notices.

Notice #2

Clarify that Notice 2 is
applicable to both group
policyholders and subscribers
in group plans that will receive
a rebates.

CMS is revising Notice 2 to clarify that the
rebate is being sent to the employer or group
policyholder.

CMS is revising the notices to address rebates
that are paid by premium credit.

Notices

Notices #1-2

Clarify that the premium
rebates should be applied to
the next premium payment due
on or after August 1st following
the MLR reporting year.

Notices

Notices #1-4,
Opening

Change to generic salutation.

Modifying notices to delete the Mr., Ms., Dr.,
etc., salutation to ease the burden for issuers.

Notices

Notices #1-4,
Signature

Allow latitude for executives in
addition to the Company
President to sign the letter.

CMS will be revising the language to allow an
authorized executive to sign for the Notices to
allow more flexibility.

Notices &
Instructions

Notices #1-4
Instructions within each
applicable field

Allow plans to specify the State
for which the notice pertains.

CMS is clarifying the Instructions to allow
issuers to specify the State in which they reside,
or to use the words “your State”, to allow
flexibility.

Correct acronym for ERISA.

Notices

Notice #2,
Ways in Which
an Employer
Can Distribute
the Rebate

CMS is revising the sentence in the Notice to
correctly reference ERISA as “Employee
Retirement Income Security Act of 1974”.

Notices

Notices #1-3

Instructions

Instructions Who Must be
Provided
Notice of
Rebate

Notices

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Crosswalk for Changes to MLR Annual Reporting Form, MLR Rebate Notices, MLR
Information Notice, and Instructions CMS 10418
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Notices

Item Edited

Type of Revision

Rationale

Notices #1-4

Change "wellness program" as
the example of activities to
improve health care quality.
Use “efforts to improve patient
safety” as an example of quality
improving activities.

CMS is revising the language in the Notices to
reflect the variations in “wellness programs”
among issuers. Instead, CMS will be using the
phrase “efforts to improve patient safety”.

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