Crosswalk of changes to MLR Form

Crosswalk for Changes to the 2013 MLR Annual Reporting Form and Instructions
(CMS 10418) Following the 30 Day Comment Period
Table of Contents
A. Introduction……………………………………………………………………………..1
B. Changes to the MLR Reporting Form and Accompanying Instructions……….………..1
C. 2013 MLR Reporting Form and Instructions Changes………………….……………….2

A. Introduction
CMS received 2 public comments regarding the notice of the revised Medical Loss Ratio (MLR)
PRA package published in the Federal Register on November 22, 2013 (78 FR 70059). The 60
day comment period closed on January 21, 2014. CMS received 2 public comments regarding
the notice of the revised MLR PRA package published in the Federal Register on January 31st
(79 FR 5417). The 30 day comment period closed on March 5, 2014. The PRA package contains
the MLR Annual Reporting Form for the 2013 MLR reporting year, which health insurance
issuers must file with CMS by June 1, 2014, and the instructions for completing the form. It
modifies the MLR Annual Reporting Form for the 2012 MLR reporting year, approved by OMB
on May 3, 2013, OCN 0938-1164.
B. Changes to MLR Reporting Form and Accompanying Instructions
The following chart lists the changes made to the 2013 MLR Reporting Form and the
accompanying Instructions, as a result of internal review and in response to comments received
following the 60-day and 30-day public comment periods. Most of the comments addressed
clarifying the instructions, updates for recent guidance issuance, treatment of Student Health
Plans, treatment of ACA fees, experience aggregation of the individual markets with adjusted
MLR standards, annual Mini-med multipliers for credibility determination, reporting for both
QIA and non-claims costs and reporting requirements for businesses in run-off. We have taken
into consideration all of the comments and have made changes to the 2013 MLR Annual
Reporting Form and Instructions.
C. 2013 MLR Reporting Form and Instructions Changes
No. Section Edited
1
Instructions for
MLR Annual
Reporting Form Part 2 - (Premiums
and Claims)
Section 1 - Health
Premiums Earned

Revision
Revised line 1.1- Direct Premium
written, to read “3/31 Column
(premium for coverage in MLR
reporting year only) – report premium
collected from 1/01 of the MLR
reporting year through 3/31 of the year
following the MLR reporting year for

Rationale
In response to comments
received, this language was
revised to provide
consistency with prior
year’s instructions and
clarity regarding MLR data
through 3/31.
1

No. Section Edited

2

Instructions for
MLR Annual
Reporting Form Part 2 - (Premiums
and Claims)
Section 1 - Health
Premiums Earned

Revision
coverage in the MLR reporting year
only, plus uncollected (due and
unpaid) premium for coverage in the
MLR reporting year only as of 3/31 of
the year following the MLR reporting
year. Premium should reflect
retroactive eligibility adjustments
related to coverage in the MLR
reporting year. PLEASE NOTE that
this methodology differs from NAIC
SHCE methodology. However, issuers
may choose to report amounts on the
same basis as in the 12/31 columns.
Premium should include all amounts
collected toward ACA fees, regardless
of whether the fees were included in
premium or billed as a separate line
item.”
Revised line 1.2-Unearned Premiums
(Year preceding the MLR reporting
year to read “3/31 Column (premium
for coverage in the MLR reporting
year only) – report premium for
coverage in the MLR reporting year
only, collected in the immediately
preceding MLR reporting year. Report
amounts as of 12/31 of the year
preceding the MLR reporting year.
PLEASE NOTE that this methodology
differs from NAIC SHCE
methodology. However, if the issuer
chose to report written premium on
the same basis as in the 12/31 column,
the issuer should report unearned
premium reserves consistently with
how it reports written premium.”

Rationale

In response to comments
received, this language was
revised to provide
consistency with prior
year’s instructions and
clarity regarding MLR data
through 3/31.

Revised line 1.3-Unearned Premiums
Unearned premium (MLR reporting
year) to read “3/31 Column – report
zero (note that if collected and due and
unpaid premium is reported correctly
in Line 1.1 above, Line 1.1 should not
include amounts that would constitute
unearned premium for coverage in
years subsequent to the MLR reporting
year. (PLEASE NOTE that this
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No. Section Edited

3

MLR Annual
Reporting Form
and Instructions Part 4 – (MLR
Rebate and
Calculation)
Section 6 Optional Temp
Adj.

Revision
methodology differs from the NAIC
SHCE methodology. However, if the
issuer chose to report written premium
on the same basis as in the 12/31
column, the issuer should report
unearned premium reserves
consistently with how it reports written
premium. Do not include any amounts
collected during 2013 for 2014 ACA
fees as unearned premium.”
Added language to instructions and
changed form to accommodate issued
guidance:

Rationale

This language was revised
to reflect guidance issued
on December 30, 2013.

Section 6 – Optional Temporary
Adjustments
For the 2013 MLR reporting year,
issuers may defer including in their
MLR and rebate calculations the
portion of 2013 premiums collected
for 2014 ACA assessments or fees on
non-calendar year policies. If issuers
elect to defer this portion of premium
in the 2013 MLR and rebate
calculations, they must disclose the
deferred amount for each respective
state and market. In addition, issuers
must disclose and reduce the MLR tax
adjustment to premium by the amount
of federal and state taxes and fees
associated with the deferred portion of
premium. (Note: The optional
premium and tax adjustments will be
added back into the MLR calculation
in the 2014 MLR reporting year.)
6.1a Disclose the deferred portion
of premium for each respective
State and market. This amount may
be excluded from Line 2.1, CY
column but must be included in Part
1, Line 1.1.
6.1b Disclose the total Federal and
State taxes paid on the associated
premium revenue. If the issuer
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No. Section Edited

4

MLR Annual
Reporting Form –
Part 4 Section 6

5

Instructions for
MLR Annual
Reporting Form Part 4 – (MLR
Rebate and
Calculation) Line
1.5 for other
market columns

6

7

Instructions for
MLR Annual
Reporting Form Part 4 – (MLR
Rebate and
Calculation) Line
1.6 for Mini-med
columns.

MLR Annual
Reporting Form –
Part 4 Lines 1.5 &
1.6

Revision
choses to exclude the premium in
Line 6.1a from Line 2.1, CY
column, the issuer must also
exclude the taxes and fees in Line
6.1b from Line 2.2, CY column.
Note that the amount of taxes and
fees in Line 6.1b must be included
in Part 1, Section 3.
Added Section 6 within Part 4 of MLR
Form to allow for reporting of optional
deferment of prefunded 2014 ACA
fees. Also inserted rows that are
reserved for future use.
Added language to reflect annual
numerator

Rationale

The MLR form was revised
to reflect instructions from
guidance issued on
December 30, 2013 and to
reserve rows for future use.
In response to comments
received and to reflect
guidance issued on April 5,
Line 1.5 – MLR numerator
2013, this language was
PY2 Column – Lines 1.2 + 1.3 revised to clarify the
PY1 Column – Lines 1.2 + 1.3 methodology for calculating
CY Column – Lines 1.2 + 1.3
the MLR numerator for
Total Column – Lines 1.2 + 1.3 determining credibility
+ 1.4
adjustment.
Added instructions for
calculating the optional
scaling adjustment for issuers
with changing MLR standards.
Added language to reflect annual
multiplier adjustment.
PY2 Column – enter the results of the
following calculation:
Mini-Med: 2.0 x (Lines 1.2 + 1.3)

In response to comments
received, this language was
revised to clarify the
methodology for calculating
the MLR numerator for
determining credibility
adjustment.

PY1 Column – enter the results of the
following calculation:
Mini-Med: 1.75 x (Lines 1.2 + 1.3)
CY Column – enter the results of the
following calculation:
Mini-Med: 1.50 x (Lines 1.2 + 1.3)
Correctly titled lines due to updated
instructions.
1.5 MLR numerator
1.6 MLR numerator Mini-Med and
Student Health
(using adjustment factor).

This was retitled to provide
calculation clarity of the
line item.

4

No. Section Edited
8
MLR Annual
Reporting Form –
Part 4 Line 3.3
9
Instructions for
MLR Annual
Reporting Form –
Column
Definitions for
Parts 1 and 2

Revision
Removed blue shading.

Revised definition for items to be
included in Column 41 – Other Health
Business, to read “Short-term, limitedduration insurance (as defined under
45 CFR §144.103); supplemental
coverage if offered as a separate
policy, certificate, or contract of
insurance (45 CFR §146.145),
including Medicare supplemental
health insurance (as defined under
section 1882(g)(1) of the Social
Security Act), coverage supplemental
to the coverage provided under chapter
55 of title 10, United States Code, and
similar supplemental coverage
provided under a group health plan;
hospital or other fixed indemnity
insurance, and specified disease or
illness coverage if offered under a
separate policy, certificate, or contract
of insurance (45 CFR §146.145), and
other “excepted benefits” as specified
by regulations promulgated by HHS
(45 CFR §146.145). For the 2013
MLR reporting year, issuers may
include the experience of policies that
the issuer had categorized as “fixed
indemnity” policies and that were filed
and approved as such by the state
regulatory authority, but which in fact
fail to satisfy the criteria for fixed
indemnity policies described in the
Affordable Care Act Implementation
FAQs, Set 11, Question and Answer
#7 (January 24, 2013) in this Column,
in lieu of reporting such experience in
Columns 1–39. 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, as these are not

Rationale
Shading corrected to
improve shading
consistency within Part 4.
In response to comments
received, this language was
revised to provide
transitional accommodation
for certain fixed indemnity
policies.

5

No. Section Edited
10

MLR Annual
Reporting Form –
Columns 26 -29
for Parts 1 & 2,
and columns 25-32
in Part 4.

Revision
“excepted benefits” under the PHSA.”
Shaded Expatriate columns grey to
indicate that data entry is not required.

Rationale
Revised to reflect guidance
issued on March 8, 2013.

6