| Department of Health and Human Services | ||||||||||||||||||||||||||||||||||||||||
| Medical Loss Ratio Reporting Form | ||||||||||||||||||||||||||||||||||||||||
| Parts 1 and 2 - Data Development | ||||||||||||||||||||||||||||||||||||||||
| Holding Company | Federal EIN : | |||||||||||||||||||||||||||||||||||||||
| Company Name | AmBest Number: | Issuer ID: | Merge Markets - Ind/SmGrp (MA Only) | |||||||||||||||||||||||||||||||||||||
| DBA / Marketing Name: | NAIC Group Code: | Business in the State of: | Not-For-Profit | |||||||||||||||||||||||||||||||||||||
| Yes | ||||||||||||||||||||||||||||||||||||||||
| Address: | NAIC Company Code: | Domiciliary State: | MLR Reporting Year: | |||||||||||||||||||||||||||||||||||||
| Health Insurance Coverage | "Mini-Med" | Expatriate | Government Program Plans | Other Health Business | Aggregate 2% Rule | Uninsured Plans | Grand Total as of 12/31/XX | |||||||||||||||||||||||||||||||||
| Individual | Small Group | Large Group | Individual | Small Group | Large Group | Small Group | Large Group | |||||||||||||||||||||||||||||||||
| Part 1 | NAIC Supp. Health Care Exhibit Line | Total as of 12/31/XX | 3/31/YY | Deferred PY (Add) | Deferred CY (Subtract) | Total as of 3/31/YY | Total as of 12/31/XX | 3/31/YY | Deferred PY (Add) | Deferred CY (Subtract) | Total as of 3/31/YY | Total as of 12/31/XX | 3/31/YY | Deferred PY (Add) | Deferred CY (Subtract) | Total as of 3/31/YY | Total as of 12/31/XX | Total as of 3/31/YY | Total as of 12/31/XX | Total as of 3/31/YY | Total as of 12/31/XX | Total as of 3/31/YY | Total as of 12/31/XX | 3/31/YY | Deferred PY (Add) | Deferred CY (Subtract) | Total as of 3/31/YY | Total as of 12/31/XX | 3/31/YY | Deferred PY (Add) | Deferred CY (Subtract) | Total as of 3/31/YY | Total as of 12/31/XX | Total as of 12/31/XX | Total as of 12/31/XX | Total as of 12/31/XX | ||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 | 32 | 33 | 34 | 35 | 36 | |||||
| 1. | Premium | |||||||||||||||||||||||||||||||||||||||
| 1.1 | Total direct premium earned (from Part 2, Line 1.11 respectively) | Pt 1, Ln 1.1 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | XXX | $- | ||
| 1.2 | Federal high risk pools | Pt 1, Ln 1.2 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | XXX | $- | |||||||||||||||||||||||
| 1.3 | State high risk pools | Pt 1, Ln 1.3 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | XXX | $- | |||||||||||||||||||||||
| 1.4 | Premium earned including federal and state high risk programs (Lines 1.1 + 1.2 + 1.3) | Pt 1, Ln 1.4 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | XXX | $- | ||
| 1.5 | Net assumed less ceded reinsurance premium earned (exclude amts reported already included in Line 1.1) |
Pt 1, Ln 1.9 | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | |||||||||||||
| 1.6 | Other adjustments due to MLR calculations Premium | Pt 1, Ln 1.10 | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | |||||||||||||
| 1.7 | Risk revenue | Pt 1, Ln 1.11 | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | |||||||||||||
| 1.8 | Premium earned including federal and state high risk programs net of reinsurance (Lines 1.4 + 1.5 + 1.6 + 1.7) |
$- | XXX | XXX | XXX | XXX | $- | XXX | XXX | XXX | XXX | $- | XXX | XXX | XXX | XXX | $- | XXX | $- | XXX | $- | XXX | $- | XXX | XXX | XXX | XXX | $- | XXX | XXX | XXX | XXX | $- | $- | $- | XXX | $- | |||
| 2. | Claims | |||||||||||||||||||||||||||||||||||||||
| 2.1 | Adjusted Incurred Claims (from Part 2, Line 2.17 & 2.18 respectively) | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | XXX | $- | |||
| 2.2 | Prescription drugs (informational only; already included in adjusted incurred claims above) |
Pt 1, Ln 2.2 | XXX | XXX | $- | XXX | XXX | $- | XXX | XXX | $- | XXX | XXX | $- | XXX | XXX | $- | XXX | $- | |||||||||||||||||||||
| 2.3 | Pharmaceutical rebates (informational only; already excluded from adjusted incurred claims above) |
Pt 1, Ln 2.3 | XXX | XXX | $- | XXX | XXX | $- | XXX | XXX | $- | XXX | XXX | $- | XXX | XXX | $- | XXX | $- | |||||||||||||||||||||
| 2.4 | State stop loss, market stabilization and claim/census based assessments (informational only; already excluded from adjusted incurred claims above) |
Pt 1, Ln 2.4 | XXX | XXX | $- | XXX | XXX | $- | XXX | XXX | $- | XXX | XXX | $- | XXX | XXX | $- | XXX | $- | |||||||||||||||||||||
| 2.5 | Net assumed less ceded claims incurred (exclude amounts reported already included in Line 2.1) |
Pt 1, Ln 5.1 | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | |||||||||||||
| 2.6 | Other adjustments due to MLR calculation – claims incurred | Pt 1, Ln 5.2 | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | |||||||||||||
| 2.7 | Rebates paid | Pt 1, Ln 5.3 | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | |||||||||||||
| 2.8 | Estimated rebates unpaid at the end of the prior MLR reporting year | Pt 1, Ln 5.4 | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | |||||||||||||
| 2.9 | Estimated rebates unpaid at the end of the current MLR reporting year | Pt 1, Ln 5.5 | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | |||||||||||||
| 2.10 | Fee-for-service and co-pay revenue (net of expenses) | Pt 1, Ln 5.6 | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | |||||||||||||
| 2.11 | Net incurred claims after reinsurance (Line 2.1 + 2.5 + 2.6 + 2.7 – 2.8 + 2.9 – 2.10) | $- | XXX | XXX | XXX | XXX | $- | XXX | XXX | XXX | XXX | $- | XXX | XXX | XXX | XXX | $- | XXX | $- | XXX | $- | XXX | $- | XXX | XXX | XXX | XXX | $- | XXX | XXX | XXX | XXX | $- | $- | $- | XXX | $- | |||
| 3. | Federal and State Taxes and Licensing or Regulatory Fees | |||||||||||||||||||||||||||||||||||||||
| 3.1 | Federal taxes and assessments | Pt 1, Ln 1.5 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||
| 3.2 | State insurance, premium and other taxes | |||||||||||||||||||||||||||||||||||||||
| 3.2 a State income, excise, business, and other taxes excluded from premium | Pt 1, Ln 1.6 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||||
| 3.2 b State premium taxes | Pt 1, Ln 1.6 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||||
| 3.2 c Community Benefit Expenditures | Pt 1, Ln 1.6 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||||
| 3.3 | Regulatory authority licenses and fees | Pt 1, Ln 1.7 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||
| 3.4 | Total Federal and State taxes and fees to be excluded from Premium (Lines 3.1 + 3.2a + Max(3.2b or 3.2c ) + 3.3) |
$- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||
| 4. | Improving Health Care Quality Expenses Incurred: | |||||||||||||||||||||||||||||||||||||||
| 4.1 | Improve health outcomes | Pt 1, Ln 6.1 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||
| 4.2 | Activites to prevent hospital readmission | Pt 1, Ln 6.2 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||
| 4.3 | Improve patient safety and reduce medical errors | Pt 1, Ln 6.3 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||
| 4.4 | Wellness and health promotion activities | Pt 1, Ln 6.4 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||
| 4.5 | Health information technology expenses related to health improvement | Pt 1, Ln 6.5 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||
| 4.6 | Total of defined expenses incurred for improving health care quality (Lines 4.1 + 4.2 + 4.3 + 4.4 + 4.5) | Pt 1, Ln 6.6 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||
| 5. | Non-Claims Costs: | |||||||||||||||||||||||||||||||||||||||
| 5.1 | Cost containment expenses not included in quality improvement expenses on Line 4.6 | Pt 1, Ln 8.1 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||
| 5.2 | All other claims adjustment expenses | Pt 1, Ln 8.2 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||
| 5.3 | Direct sales salaries and benefits | Pt 1, Ln 10.1 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||
| 5.4 | Agents and brokers fees and commissions | Pt 1, Ln 10.2 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||
| 5.5 | Other taxes | |||||||||||||||||||||||||||||||||||||||
| 5.5a State taxes and assessments not excluded from premium (not reported in Line 3.2a) | Pt 1, Ln 10.3 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||||
| 5.5b Fines and penalties of regulatory authorities (not reported in Line 3.3) | Pt 1, Ln 10.3 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||||
| 5.6 | Other general and administrative expenses | Pt 1, Ln 10.4 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||||||||||||||||||||||||
| 5.7 | Community benefit expenditures (exclude amounts reported already in Line 3.2c) | $- | $- | |||||||||||||||||||||||||||||||||||||
| 5.8 | Total non-claims costs (Lines 5.1 + 5.2 + 5.3 + 5.4 + 5.5a + 5.5b + 5.6 + 5.7) | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||
| 5.9 | ICD-10 implementation expenses (informational only) | Pt 1, Ln 16 | $- | XXX | XXX | $- | $- | XXX | XXX | $- | $- | XXX | XXX | $- | $- | $- | $- | $- | XXX | XXX | $- | $- | XXX | XXX | $- | $- | ||||||||||||||
| 6. | Pre-tax underwriting gain / (loss) (Lines 1.8 – 2.11 – 4.6 – 5.8 + 5.5a + 5.5b - Part 2 Line 2.16) | $- | XXX | XXX | XXX | XXX | $- | XXX | XXX | XXX | XXX | $- | XXX | XXX | XXX | XXX | $- | XXX | $- | XXX | $- | XXX | $- | XXX | XXX | XXX | XXX | $- | XXX | XXX | XXX | XXX | $- | $- | $- | XXX | $- | |||
| 7. | Income from fees of uninsured plans | Pt 1, Ln 12 | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | |||
| 8. | Net investment and other gain / (loss) | Pt 1, Ln 13 | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | |||
| 9. | Federal income taxes (excluding taxes on Line 3.1 above) | Pt 1, Ln 14 | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | |||
| 10. | After-tax net gain / (loss) (Lines 1.8 – 2.11 – 3.4 – 4.6 – 5.8 + 7 + 8 – 9) | Pt 1, Ln 15 | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | ||
| 11. | Other Indicators or information: | |||||||||||||||||||||||||||||||||||||||
| 11.1 | Number of policies/certificates | Pt 1 Other, Ln 1 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | ||||||||||||||||||||||||
| 11.2 | Number of covered lives | Pt 1 Other, Ln 2 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | ||||||||||||||||||||||||
| 11.3 | Number of groups | Pt 1 Other, Ln 3 | XXX | XXX | XXX | XXX | XXX | - | - | - | - | XXX | XXX | - | - | - | - | - | - | - | ||||||||||||||||||||
| 11.4 | Member months | Pt 1 Other, Ln 4 | - | - | - | - | - | - | - | - | - | - | - | - | - | - | ||||||||||||||||||||||||
| 11.5 | Number of life-years | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |||
| Cell Keys: | ||||||||||||||||||||||||||||||||||||||||
| Blank cells require input from issuer | ||||||||||||||||||||||||||||||||||||||||
| Grey cells denote calculated cells or no input required - locked down | ||||||||||||||||||||||||||||||||||||||||
| Pink "XXX" cells require no data input - locked down | ||||||||||||||||||||||||||||||||||||||||
| Green cells - not pertinent to 2011 MLR - locked down | ||||||||||||||||||||||||||||||||||||||||
| Health Insurance Coverage | "Mini-Med" | Expatriate | Government Program Plans | Other Health Business | Aggregate 2% Rule | Uninsured Plans | Grand Total as of 12/31/XX | |||||||||||||||||||||||||||||||||
| Individual | Small Group | Large Group | Individual | Small Group | Large Group | Small Group | Large Group | |||||||||||||||||||||||||||||||||
| Part 2 | NAIC Supp. Health Care Exhibit Line | Total as of 12/31/XX | 3/31/YY | Deferred PY (Add) | Deferred CY (Subtract) | Total as of 3/31/YY | Total as of 12/31/XX | 3/31/YY | Deferred PY (Add) | Deferred CY (Subtract) | Total as of 3/31/YY | Total as of 12/31/XX | 3/31/YY | Deferred PY (Add) | Deferred CY (Subtract) | Total as of 3/31/YY | Total as of 12/31/XX | Total as of 3/31/YY | Total as of 12/31/XX | Total as of 3/31/YY | Total as of 12/31/XX | Total as of 3/31/YY | Total as of 12/31/XX | 3/31/YY | Deferred PY (Add) | Deferred CY (Subtract) | Total as of 3/31/YY | Total as of 12/31/XX | 3/31/YY | Deferred PY (Add) | Deferred CY (Subtract) | Total as of 3/31/YY | Total as of 12/31/XX | Total as of 12/31/XX | Total as of 12/31/XX | Total as of 12/31/XX | ||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 | 32 | 33 | 34 | 35 | 36 | |||||
| 1. | Premium: | |||||||||||||||||||||||||||||||||||||||
| 1.1 | Direct premium written | Pt 2, Ln 1.1 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | XXX | $- | |||||||||||||||||||||||
| 1.2 | Unearned premium prior year | Pt 2, Ln 1.2 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | XXX | $- | |||||||||||||||||||||||
| 1.3 | Unearned premium current year | Pt 2, Ln 1.3 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | XXX | $- | |||||||||||||||||||||||
| 1.4 | Change in unearned premium (Lines 1.2 – 1.3) | Pt 2, Ln 1.4 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | XXX | $- | ||
| 1.5 | Experience rating refunds (rate credits) paid | $- | ||||||||||||||||||||||||||||||||||||||
| 1.5a Experience rating refunds with all incurral dates that were paid in the reporting year | Pt 2, Ln 1.5 | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | ||||||||||||||
| 1.5b Experience rating refunds incurred only in the reporting year and paid in the reporting year and through 3/31 of the following year | XXX | $- | XXX | $- | XXX | $- | XXX | XXX | XXX | XXX | $- | XXX | $- | XXX | XXX | XXX | XXX | |||||||||||||||||||||||
| 1.6 | Reserve for experience rating refunds (rate credits) current year | Pt 2, Ln 1.6 | $- | $- | $- | $- | $- | XXX | $- | |||||||||||||||||||||||||||||||
| 1.7 | Reserve for experience rating refunds (rate credits) prior year | Pt 2, Ln 1.7 | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | |||||||||||||
| 1.8 | Change in reserve for experience rating refunds (Lines 1.6 – 1.7) | Pt 2, Ln 1.8 | $- | XXX | XXX | XXX | XXX | $- | XXX | XXX | XXX | XXX | $- | XXX | XXX | XXX | XXX | $- | XXX | $- | XXX | $- | XXX | $- | XXX | XXX | XXX | XXX | $- | XXX | XXX | XXX | XXX | $- | $- | $- | XXX | $- | ||
| 1.9 | Premium balances written off | Pt 2, Ln 1.9 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | XXX | $- | |||||||||||||||||||||||
| 1.10 | Group conversion charges | Pt 2, Ln 1.10 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | XXX | $- | |||||||||||||||||||||||
| 1.11 | Total direct premium earned (Lines 1.1 + 1.4 – 1.9 + 1.10) | Pt 2, Ln 1.11 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | XXX | $- | ||
| 1.12 | Premium ceded under 100% reinsurance (informational only; excluded from Line 1.1) | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | XXX | $- | ||||||||||||||||||||||||
| 1.13 | Premium assumed under 100% reinsurance (informational only; already included in Line 1.1) | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | XXX | $- | ||||||||||||||||||||||||
| 2. | Claims: | |||||||||||||||||||||||||||||||||||||||
| 2.1 | Claims paid | |||||||||||||||||||||||||||||||||||||||
| 2.1a Claims with all incurral dates that were paid in the reporting year | Pt 2, Ln 2.1 | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | ||||||||||||||
| 2.1b Claims incurred only in the reporting year, and paid in the reporting year and through 3/31 of the following year | XXX | $- | XXX | $- | XXX | $- | XXX | XXX | XXX | XXX | $- | XXX | $- | XXX | XXX | XXX | XXX | |||||||||||||||||||||||
| 2.2 | Direct claim liability current year | Pt 2, Ln 2.2 | $- | $- | $- | $- | $- | XXX | $- | |||||||||||||||||||||||||||||||
| 2.3 | Direct claim liability prior year | Pt 2, Ln 2.3 | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | |||||||||||||
| 2.4 | Direct claim reserves current year | Pt 2, Ln 2.4 | $- | $- | $- | $- | $- | XXX | $- | |||||||||||||||||||||||||||||||
| 2.5 | Direct claim reserves prior year | Pt 2, Ln 2.5 | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | |||||||||||||
| 2.6 | Direct contract reserves current year | Pt 2, Ln 2.6 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | XXX | $- | |||||||||||||||||||||||
| 2.7 | Direct contract reserves prior year | Pt 2, Ln 2.7 | $- | XXX | XXX | $- | $- | XXX | XXX | $- | $- | XXX | XXX | $- | $- | $- | $- | $- | XXX | XXX | $- | $- | XXX | XXX | $- | XXX | $- | |||||||||||||
| 2.8 | Experience rating refunds (rate credits) paid | $- | ||||||||||||||||||||||||||||||||||||||
| 2.8a Experience rating refunds with all incurral dates that were paid in the reporting year | Pt 2, Ln 2.8 | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | ||||||||||||||
| 2.8b Experience rating refunds incurred only in the reporting year and paid in the reporting year and through 3/31 of the following year | XXX | $- | XXX | $- | XXX | $- | XXX | XXX | XXX | XXX | $- | XXX | $- | XXX | XXX | XXX | XXX | |||||||||||||||||||||||
| 2.9 | Reserve for experience rating refunds (rate credits) current year | Pt 2, Ln 2.9 | $- | $- | $- | $- | $- | XXX | $- | |||||||||||||||||||||||||||||||
| 2.10 | Reserve for experience rating refunds (rate credits) prior year | Pt 2, Ln 2.10 | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | |||||||||||||
| 2.11 | Incurred medical incentive pool and bonuses | $- | ||||||||||||||||||||||||||||||||||||||
| 2.11a Paid medical incentive pools and bonuses current year | Pt 2, Ln 2.11a | $- | $- | $- | $- | $- | XXX | |||||||||||||||||||||||||||||||||
| 2.11b Accrued medical incentive pools and bonuses current year | Pt 2, Ln 2.11b | $- | $- | $- | $- | $- | XXX | $- | ||||||||||||||||||||||||||||||||
| 2.11c Accrued medical incentive pools and bonuses prior year | Pt 2, Ln 2.11c | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | ||||||||||||||
| 2.12 | Net healthcare receivables | $- | ||||||||||||||||||||||||||||||||||||||
| 2.12a Healthcare receivables current year | Pt 2, Ln 2.12a | $- | $- | $- | $- | $- | XXX | $- | ||||||||||||||||||||||||||||||||
| 2.12b Healthcare receivables prior year | Pt 2, Ln 2.12b | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | ||||||||||||||
| 2.13 | Contingent benefit and lawsuit reserves | $- | $- | $- | $- | $- | XXX | $- | ||||||||||||||||||||||||||||||||
| 2.14 | Group conversion charges | Pt 2, Ln 2.13 | $- | $- | $- | $- | $- | XXX | $- | |||||||||||||||||||||||||||||||
| 2.15 | Blended rate adjustment | Pt 2, Ln 2.14 | $- | $- | $- | $- | $- | XXX | $- | |||||||||||||||||||||||||||||||
| 2.16 | Allowable fraud reduction expense (the smaller of Lines 2.16a or 2.16b) | Pt 1, Ln 4 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | XXX | $- | ||
| 2.16a Total fraud reduction expense | Pt 3, Col 7, Ln 1.11/ 2.11/3.11/5.11/6.11 | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||||||||||||
| 2.16b Total fraud recoveries that reduced paid claims | Pt 2, Ln 3 | $- | $- | $- | $- | $- | $- | |||||||||||||||||||||||||||||||||
| 2.17 | Total adjusted incurred claims as of 12/31 (Lines 2.1a + 2.2 – 2.3 + 2.4 – 2.5 + 2.6 – 2.7 + 2.8a + 2.9 - 2.10+ 2.11a + 2.11b – 2.11c - 2.12a + 2.12b + 2.13 + 2.14 + 2.15 + 2.16) | $- | XXX | XXX | XXX | XXX | $- | XXX | XXX | XXX | XXX | $- | XXX | XXX | XXX | XXX | $- | XXX | $- | XXX | $- | XXX | $- | XXX | XXX | XXX | XXX | $- | XXX | XXX | XXX | XXX | $- | $- | $- | XXX | $- | |||
| 2.18 | Total adjusted incurred claims as of 3/31 (Lines 2.1b + 2.2 + 2.4 + 2.6 – 2.7 + 2.8b + 2.9 + 2.11a + 2.11b – 2.12a + 2.13 + 2.14 + 2.15 + 2.16) | XXX | $- | $- | $- | $- | XXX | $- | $- | $- | $- | XXX | $- | $- | $- | $- | XXX | $- | XXX | $- | XXX | $- | XXX | $- | $- | $- | $- | XXX | $- | $- | $- | $- | XXX | XXX | XXX | XXX | ||||
| Cell Keys: | ||||||||||||||||||||||||||||||||||||||||
| Blank cells require input from issuer | ||||||||||||||||||||||||||||||||||||||||
| Grey cells denote calculated cells or no input required - locked down | ||||||||||||||||||||||||||||||||||||||||
| Pink "XXX" cells require no data input - locked down | ||||||||||||||||||||||||||||||||||||||||
| Green cells - not pertinent to 2011 MLR - locked down | ||||||||||||||||||||||||||||||||||||||||
| Department of Health and Human Services | Federal EIN : | DBA/Marketing Name: | ||||||||||
| Medical Loss Ratio Reporting Form | ||||||||||||
| Part 3 - Expense Allocation Report | AmBest Number: | Issuer ID: | Merge Markets - Ind/SmGrp (MA Only) | |||||||||
| Holding Company | NAIC Group Code: | Business in the State of: | Not-For-Profit | |||||||||
| Company Name: | NAIC Company Code: | Domiciliary State: | MLR Reporting Year: | |||||||||
| Address: | ||||||||||||
| Improving Health Care Quality Expenses | Claims Adjustment Expenses | General Administrative Expenses | Total Expenses |
|||||||||
| Description of Expense Element (by Type) | Improve Health Outcomes | Activites to prevent hospital readmission | Improve patient safety and reduce medical errors | Wellness and health promotion activities | HIT Expenses | Cost Containment Expenses | Other Claims Adjustment Expenses | |||||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | ||||
| 1. | Health Insurance Coverage | |||||||||||
| 1.1a | Individual | $- | ||||||||||
| 1.1b | Deferred (PY) | $- | ||||||||||
| 1.1c | Deferred (CY) | $- | ||||||||||
| 1.1d | Total | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||
| 1.2a | Small group | $- | ||||||||||
| 1.2b | Deferred (PY) | $- | ||||||||||
| 1.2c | Deferred (CY) | $- | ||||||||||
| 1.2d | Total | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||
| 1.3a | Large group | $- | ||||||||||
| 1.3b | Deferred (PY) | $- | ||||||||||
| 1.3c | Deferred (CY) | $- | ||||||||||
| 1.3d | Total | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||
| 2. | "Mini-Med" | |||||||||||
| 2.1 | Individual | $- | ||||||||||
| 2.2 | Small group | $- | ||||||||||
| 2.3 | Large group | $- | ||||||||||
| 3. | Expatriate | |||||||||||
| 3.1a | Small group | $- | ||||||||||
| 3.1b | Deferred (PY) | $- | ||||||||||
| 3.1c | Deferred (CY) | $- | ||||||||||
| 3.1d | Total | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||
| 3.2a | Large group | $- | ||||||||||
| 3.2b | Deferred (PY) | $- | ||||||||||
| 3.2c | Deferred (CY) | $- | ||||||||||
| 3.2d | Total | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||
| 4. | Other Business | |||||||||||
| 4.1 | Government program plans | $- | ||||||||||
| 4.2 | Other health business | $- | ||||||||||
| 4.3 | Aggregate 2% rule | $- | ||||||||||
| 4.4 | Uninsured / Self-funded plans | $- | ||||||||||
| 5. | Total | $- | $- | $- | $- | $- | $- | $- | $- | $- | ||
| Cell Keys: | ||||||||||||
| Blank cells require input from issuer | ||||||||||||
| Grey cells denote calculated cells or no input required - locked down | ||||||||||||
| Pink "XXX" cells require no data input - locked down | ||||||||||||
| Green cells - not pertinent to 2011 MLR - locked down | ||||||||||||
| Department of Health and Human Services | Federal EIN : | DBA/Marketing Name: | ||||||||
| Medical Loss Ratio Reporting Form | ||||||||||
| Part 4 - Expense Allocation Methodology Report | AmBest Number: | Issuer ID: | Merge Markets - Ind/SmGrp (MA Only) | |||||||
| Holding Company | NAIC Group Code: | Business in the State of: | Not-For-Profit | |||||||
| Company Name: | NAIC Company Code: | Domiciliary State: | MLR Reporting Year: | |||||||
| Description of Expense Element (by Type) | NEW | Detailed Description of Expense Allocation Methods | ||||||||
| 1 | 2 | 3 | ||||||||
| 1. Incurred Claims | ||||||||||
| 2. Federal and State Taxes and Licensing or Regulatory Fees | ||||||||||
| Federal taxes and assessments | ||||||||||
| State insurance, premium and other taxes | ||||||||||
| Community Benefit Expenditures (Not for Profit Entities) | ||||||||||
| Regulatory authority licenses and fees | ||||||||||
| 3. Quality Improvement Expenses | ||||||||||
| Improve Health Outcomes | ||||||||||
| Activites to prevent hospital readmission | ||||||||||
| Improve patient safety and reduce medical errors | ||||||||||
| Wellness and health promotion activities | ||||||||||
| Health Information Technology expenses related to health improvement | ||||||||||
| 4. Non-Claims costs | ||||||||||
| Cost containment expenses not included in quality improvement expenses | ||||||||||
| All other claims adjustment expenses | ||||||||||
| Direct sales salaries and benefits | ||||||||||
| Agents and brokers fees and commissions | ||||||||||
| Other taxes | ||||||||||
| Community Benefit Expenditures | ||||||||||
| Other general and administrative expenses | ||||||||||
| Cell Keys: | ||||||||||
| Blank cells require input from issuer | ||||||||||
| Grey cells denote calculated cells or no input required - locked down | ||||||||||
| Pink "XXX" cells require no data input - locked down | ||||||||||
| Green cells - not pertinent to 2011 MLR - locked down | ||||||||||
| Department of Health and Human Services | Federal EIN : | DBA/Marketing Name: | ||||||||||||||||||||||||||||||||
| Medical Loss Ratio Reporting Form | ||||||||||||||||||||||||||||||||||
| Part 5 - MLR and Rebate Calculation | AmBest Number: | Issuer ID: | Merge Markets - Ind/SmGrp (MA Only) | |||||||||||||||||||||||||||||||
| Holding Company | NAIC Group Code: | Business in the State of: | Not-For-Profit | |||||||||||||||||||||||||||||||
| Company Name: | NAIC Company Code: | Domiciliary State: | MLR Reporting Year: | |||||||||||||||||||||||||||||||
| Health Insurance Coverage | "Mini-Med" | Expatriate | ||||||||||||||||||||||||||||||||
| Individual | Small Group | Large Group | Individual | Small Group | Large Group | Small Group | Large Group | |||||||||||||||||||||||||||
| PY2 | PY1 | CY | Total | PY2 | PY1 | CY | Total | PY2 | PY1 | CY | Total | PY2 | PY1 | CY | Total | PY2 | PY1 | CY | Total | PY2 | PY1 | CY | Total | PY2 | PY1 | CY | Total | PY2 | PY1 | CY | Total | |||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 | 32 | |||
| 1. | Medical Loss Ratio Numerator | |||||||||||||||||||||||||||||||||
| 1.1 | Adjusted incurred claims (from Part 1, Line 2.1) as of 12/31 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||
| 1.2 | Adjusted incurred claims for prior year restated as of March 31 following the current MLR reporting year | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||
| 1.3 | Quality improvement expenses (from Part 1, Line 4.6) | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||
| 1.4 | MLR rebates paid based on 2011 or 2012 experience | XXX | $- | XXX | $- | XXX | $- | XXX | $- | XXX | $- | XXX | $- | XXX | $- | XXX | $- | |||||||||||||||||
| 1.5 | MLR numerator (Lines 1.2 + 1.3 + 1.4) | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |
| 1.6 | MLR numerator: "Mini-Med" & Expatriate (Line 1.5 x adjustment factor) |
XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | $- | $- | $- | $- | $- | ||||||||||||||||
| 2. | Medical Loss Ratio Denominator | |||||||||||||||||||||||||||||||||
| 2.1 | Premium earned including federal and state high risk programs (from Part 1, Line 1.4) | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||
| 2.2 | Federal and State taxes and licensing or regulatory fees (from Part 1, Line 3.4) |
$- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |||||||||||||||||
| 2.3 | MLR denominator (Lines 2.1 – 2.2) | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | |
| 3. | Credibility Adjustment | |||||||||||||||||||||||||||||||||
| 3.1 | Life years to determine credibility (from Part 1, Line 11.5) | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | - | |||||||||||||||||
| 3.2 | Base credibility factor | XXX | XXX | XXX | 0.0% | XXX | XXX | XXX | 0.0% | XXX | XXX | XXX | 0.0% | XXX | XXX | XXX | 0.0% | XXX | XXX | XXX | 0.0% | XXX | XXX | XXX | 0.0% | XXX | XXX | XXX | 0.0% | XXX | XXX | XXX | 0.0% | |
| 3.3 | Average deductible | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | ||||||||||||
| 3.4 | Deductible factor | XXX | XXX | XXX | 1.000 | XXX | XXX | XXX | 1.000 | XXX | XXX | XXX | 1.000 | XXX | XXX | XXX | #N/A | XXX | XXX | XXX | 1.000 | XXX | XXX | XXX | 1.000 | XXX | XXX | XXX | 1.000 | XXX | XXX | XXX | 1.000 | |
| 3.5 | Credibility adjustment factor (Lines 3.2 x 3.4) | XXX | XXX | XXX | N/A | XXX | XXX | XXX | N/A | XXX | XXX | XXX | N/A | XXX | XXX | XXX | N/A | XXX | XXX | XXX | N/A | XXX | XXX | XXX | N/A | XXX | XXX | XXX | N/A | XXX | XXX | XXX | N/A | |
| 4. | MLR Calculation | |||||||||||||||||||||||||||||||||
| 4.1 | Is experience credible? | XXX | XXX | XXX | No | XXX | XXX | XXX | No | XXX | XXX | XXX | No | XXX | XXX | XXX | No | XXX | XXX | XXX | No | XXX | XXX | XXX | No | XXX | XXX | XXX | No | XXX | XXX | XXX | No | |
| 4.2 | Preliminary MLR | |||||||||||||||||||||||||||||||||
| 4.2a Preliminary MLR (Lines 1.5 / 2.3, as calculated in the Total column of this Part on the MLR Form submitted for the relevant MLR reporting year) | XXX | 80.0% | XXX | 80.0% | XXX | XXX | XXX | 85.0% | XXX | XXX | XXX | 80.0% | XXX | XXX | XXX | 80.0% | XXX | XXX | XXX | 85.0% | XXX | XXX | XXX | 80.0% | XXX | XXX | XXX | 85.0% | ||||||
| 4.2b Preliminary MLR: "Mini-Med" & Expatriate (Lines 1.6 / 2.3, as calculated in the Total column of this Part on the MLR Form submitted for the relevant MLR reporting year) | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | XXX | 80.0% | XXX | 80.0% | XXX | 85.0% | XXX | 80.0% | XXX | 85.0% | ||||||||||||||
| 4.3 | Credibility adjustment factor (Line 3.5) | XXX | XXX | XXX | N/A | XXX | XXX | XXX | N/A | XXX | XXX | XXX | N/A | XXX | XXX | XXX | N/A | XXX | XXX | XXX | N/A | XXX | XXX | XXX | N/A | XXX | XXX | XXX | N/A | XXX | XXX | XXX | N/A | |
| 4.4 | Credibility-adjusted MLR (Lines 4.2a or 4.2b + 4.3) | XXX | XXX | XXX | 80.0% | XXX | XXX | XXX | 80.0% | XXX | XXX | XXX | 85.0% | XXX | XXX | XXX | 80.0% | XXX | XXX | XXX | 80.0% | XXX | XXX | XXX | 85.0% | XXX | XXX | XXX | 80.0% | XXX | XXX | XXX | 85.0% | |
| 5. | Rebate Calculation | |||||||||||||||||||||||||||||||||
| 5.1 | MLR standard | XXX | XXX | XXX | 80.0% | XXX | XXX | XXX | 80.0% | XXX | XXX | XXX | 85.0% | XXX | XXX | XXX | 80.0% | XXX | XXX | XXX | 80.0% | XXX | XXX | XXX | 85.0% | XXX | XXX | XXX | 80.0% | XXX | XXX | XXX | 85.0% | |
| 5.2 | Credibility-adjusted MLR (Line 4.4) | XXX | XXX | XXX | 80.0% | XXX | XXX | XXX | 80.0% | XXX | XXX | XXX | 85.0% | XXX | XXX | XXX | 80.0% | XXX | XXX | XXX | 80.0% | XXX | XXX | XXX | 85.0% | XXX | XXX | XXX | 80.0% | XXX | XXX | XXX | 85.0% | |
| 5.3 | Adjusted earned premium less Federal and State taxes and licensing or regulatory fees (Line 2.3 CY) | XXX | XXX | XXX | $- | XXX | XXX | XXX | $- | XXX | XXX | XXX | $- | XXX | XXX | XXX | $- | XXX | XXX | XXX | $- | XXX | XXX | XXX | $- | XXX | XXX | XXX | $- | XXX | XXX | XXX | $- | |
| 5.4 | Rebate amount if credibility-adjusted MLR is less than MLR standard (Lines (5.1 – 5.2) x 5.3) | XXX | XXX | XXX | $- | XXX | XXX | XXX | $- | XXX | XXX | XXX | $- | XXX | XXX | XXX | $- | XXX | XXX | XXX | $- | XXX | XXX | XXX | $- | XXX | XXX | XXX | $- | XXX | XXX | XXX | $- | |
| Cell Keys: | ||||||||||||||||||||||||||||||||||
| Blank cells require input from issuer | ||||||||||||||||||||||||||||||||||
| Grey cells denote calculated cells or no input required - locked down | ||||||||||||||||||||||||||||||||||
| Pink "XXX" cells require no data input - locked down | ||||||||||||||||||||||||||||||||||
| Green cells - not pertinent to 2011 MLR - locked down | ||||||||||||||||||||||||||||||||||
| Department of Health and Human Services | Federal EIN : | DBA/Marketing Name: | ||||||||
| Medical Loss Ratio Reporting Form | ||||||||||
| Part 6 - Rebate Disbursement Report | AmBest Number: | Issuer ID: | Merge Markets - Ind/SmGrp (MA Only) | |||||||
| Holding Company | NAIC Group Code: | Business in the State of: | Not-For-Profit | |||||||
| Company Name: | NAIC Company Code: | Domiciliary State: | MLR Reporting Year: | |||||||
| Health Insurance Coverage | "Mini-Med" | Expatriate | ||||||||
| Individual | Small Group | Large Group | Individual | Small Group | Large Group | Small Group | Large Group | |||
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | |||
| 1. | Is rebate being paid? | No | No | No | No | No | No | No | No | |
| 2. | Number of policies / certificates (from Part 1 Line 11.1) | - | - | - | - | - | - | - | - | |
| 3. | Number of policyholders/subscribers owed rebates | |||||||||
| 3.a Number of policyholders being paid a rebate | XXX | XXX | ||||||||
| 3.b. Number of subscribers being paid a rebate | ||||||||||
| 3.c Number of policyholders whose rebate would be de minimis | XXX | XXX | ||||||||
| 3.d Number of subscribers whose rebate would be de minimis | ||||||||||
| 4. | Total amount of rebates | |||||||||
| 4.a Total amount of rebates (from Part 5, Line 5.4) | $- | $- | $- | $- | $- | $- | $- | $- | ||
| 4.b Amount of de minimis rebates | ||||||||||
| 4.c Amount of rebates being paid by premium credit | ||||||||||
| 4.d Amount of rebates being paid by lump-sum reimbursement | ||||||||||
| 5. | Amount of unclaimed rebates from prior MLR reporting year | |||||||||
| 5.a Description of methods used to locate policyholders/subscribers for prior MLR reporting year's unclaimed rebates: | ||||||||||
| 5.b Describe disbursement of prior MLR reporting year's unclaimed rebates: | ||||||||||
| Cell Keys: | ||||||||||
| Blank cells require input from issuer | ||||||||||
| Grey cells denote calculated cells or no input required - locked down | ||||||||||
| Pink "XXX" cells require no data input - locked down | ||||||||||
| Green cells - not pertinent to 2011 MLR - locked down | ||||||||||
| Department of Health and Human Services | |||||||||||||
| Medical Loss Ratio Attestation | Federal EIN : | DBA/Marketing Name: | |||||||||||
| AmBest Number: | Issuer ID: | Merge Markets - Ind/SmGrp (MA Only) | |||||||||||
| Holding Company | NAIC Group Code: | Business in the State of: | Not-for-Profit | ||||||||||
| Company Name: | NAIC Company Code: | Domiciliary State: | MLR Reporting Year: | ||||||||||
| Address: | |||||||||||||
| Attestation Statement | |||||||||||||
| The officers of this reporting issuer being duly sworn, each attest that he/she is the described officer of the reporting issuer, and that this MLR Reporting Form is a full and true statement of all the elements related to the health insurance coverage issued for the MLR reporting year stated above, and that the MLR Reporting Form has been completed in accordance with the Department of Health and Human Services reporting instructions, according to the best of his/her information, knowledge and belief. Furthermore, the scope of this attestation by the described officer includes any related electronic filings and postings for the MLR reporting year stated above, that are required by Department of Health and Human Services under section 2718 of the Public Health Service Act and implementing regulations. | |||||||||||||
| ____________________________ | |||||||||||||
| Chief Executive Officer/President | |||||||||||||
| ____________________________ | |||||||||||||
| Chief Financial Officer | |||||||||||||
| Table 1 | Table 3 | Table 4 | Table 5 | |||||
| Base Credibility Adjustment Factors | State and Territory Names | Reporting Years | Yes/No | |||||
| Life Years | Base credibility factor | Alaska | 2011 | Yes | ||||
| - | 0.0% | Alabama | 2012 | No | ||||
| 1,000 | 8.3% | Arkansas | 2013 | |||||
| 2,500 | 5.2% | American Samoa | 2014 | |||||
| 5,000 | 3.7% | Arizona | 2015 | |||||
| 10,000 | 2.6% | California | 2016 | |||||
| 25,000 | 1.6% | Colorado | 2017 | |||||
| 50,000 | 1.2% | Connecticut | 2018 | |||||
| 75,000 | 0.0% | District of Columbia | 2019 | |||||
| Delaware | 2020 | |||||||
| Florida | 2021 | |||||||
| Table 2 | Georgia | 2022 | ||||||
| Deductible Factors | Grand Total | 2023 | ||||||
| Average Health Plan Deductible | Deductible factor | Average Health Plan Deductible | Guam | 2024 | ||||
| <$2,500 | 1.000 | <$2,500 | Hawaii | 2025 | ||||
| $2,500 | 1.164 | >=$2,500 - <$5,000 | Iowa | 2026 | ||||
| $5,000 | 1.402 | >=$5,000 - <$10,000 | Idaho | 2027 | ||||
| $10,000 | 1.736 | >= $10,000 | Illinois | 2028 | ||||
| Indiana | 2029 | |||||||
| Kansas | 2030 | |||||||
| Kentucky | 2031 | |||||||
| Louisiana | 2032 | |||||||
| Massachusetts | 2033 | |||||||
| Maryland | 2034 | |||||||
| Maine | 2035 | |||||||
| Michigan | 2036 | |||||||
| Minnesota | 2037 | |||||||
| Missouri | 2038 | |||||||
| Mississippi | 2039 | |||||||
| Montana | 2040 | |||||||
| Northern Mariana Islands | 2041 | |||||||
| North Carolina | 2042 | |||||||
| North Dakota | 2043 | |||||||
| Nebraska | 2044 | |||||||
| New Hampshire | 2045 | |||||||
| New Jersey | 2046 | |||||||
| New Mexico | 2047 | |||||||
| Nevada | 2048 | |||||||
| New York | 2049 | |||||||
| Ohio | 2050 | |||||||
| Oklahoma | 2051 | |||||||
| Oregon | 2052 | |||||||
| Pennsylvania | 2053 | |||||||
| Puerto Rico | 2054 | |||||||
| Rhode Island | 2055 | |||||||
| South Carolina | 2056 | |||||||
| South Dakota | 2057 | |||||||
| Tennessee | 2058 | |||||||
| Texas | 2059 | |||||||
| Utah | 2060 | |||||||
| Virginia | ||||||||
| United States Virgin Islands | ||||||||
| Vermont | ||||||||
| Washington | ||||||||
| Wisconsin | ||||||||
| West Virginia | ||||||||
| Wyoming | ||||||||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |