Form CMS-10418 MLR Reporting Form

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Overview

Company Information
Pt 1 Summary of Data
Pt 2 Premium and Claims
Pt 3 MLR and Rebate Calculation
Pt 4 Rebate Disbursement
Pt 5 Additional Responses
Pt 6 Expense Allocation
Attestation
Reference Tables

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Sheet 1: Company Information

Company Information
Line Description	Value
Company Name:
Group Affiliation:
Federal EIN:
A.M. Best Number:
NAIC Group Code:
NAIC Company Code:
DBA / Marketing Name:
HIOS Issuer ID:
Business in the State of:
Domiciliary State:
Address:
Federal Tax Exempt:
Merge Markets - Ind/SmGrp:
Not-For-Profit:
MLR Reporting Year:
Cell Keys for Parts 1 - 6:
White cells accept input from the issuer
Grey cells require no data input – input will result in an upload failure
Green cells require a calculation by the issuer
	PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1164. The time required to complete this information collection is estimated to average 64 hours or 3,840 minutes per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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Sheet 2: Pt 1 Summary of Data

Part 1 Summary of Data

Line Description

SHCE

1 Health Insurance INDIVIDUAL Total as of 12/31/14

2 Health Insurance INDIVIDUAL Total as of 3/31/15

3 Health Insurance INDIVIDUAL Dual Contracts (Included in Total as of 3/31/15)

4 Health Insurance INDIVIDUAL Deferred PY1 (Add)

5 Health Insurance INDIVIDUAL Deferred CY (Subtract)

2A Health Insurance INDIVIDUAL [Risk Corridors] Total as of 3/31/15

6 Health Insurance SMALL GROUP Total as of 12/31/14

7 Health Insurance SMALL GROUP Total as of 3/31/15

8 Health Insurance SMALL GROUP Dual Contracts (Included in Total as of 3/31/15)

9 Health Insurance SMALL GROUP Deferred PY1 (Add)

10 Health Insurance SMALL GROUP Deferred CY (Subtract)

7A Health Insurance SMALL GROUP [Risk Corridors] Total as of 3/31/15

11 Health Insurance LARGE GROUP Total as of 12/31/14

12 Health Insurance LARGE GROUP Total as of 3/31/15

13 Health Insurance LARGE GROUP Dual Contracts (Included in Total as of 3/31/15)

14 Health Insurance LARGE GROUP Deferred PY1 (Add)

15 Health Insurance LARGE GROUP Deferred CY (Subtract)

16 Mini-Med INDIVIDUAL Total as of 12/31/14

17 Mini-Med INDIVIDUAL Total as of 3/31/15

18 Mini-Med INDIVIDUAL Dual Contracts (Included in Total as of 3/31/15)

19 Mini-Med SMALL GROUP Total as of 12/31/14

20 Mini-Med SMALL GROUP Total as of 3/31/15

21 Mini-Med SMALL GROUP Dual Contracts (Included in Total as of 3/31/15)

22 Mini-Med LARGE GROUP Total as of 12/31/14

23 Mini-Med LARGE GROUP Total as of 3/31/15

24 Mini-Med LARGE GROUP Dual Contracts (Included in Total as of 3/31/15)

25 Expat SMALL GROUP Total as of 12/31/14

26 Expat SMALL GROUP Total as of 3/31/15

27 Expat SMALL GROUP Dual Contracts (Included in Total as of 3/31/15)

28 Expat SMALL GROUP Deferred PY1 (Add)

29 Expat SMALL GROUP Deferred CY (Subtract)

30 Expat LARGE GROUP Total as of 12/31/14

31 Expat LARGE GROUP Total as of 3/31/15

32 Expat LARGE GROUP Dual Contracts (Included in Total as of 3/31/15)

33 Expat LARGE GROUP Deferred PY1 (Add)

34 Expat LARGE GROUP Deferred CY (Subtract)

35 Student Health INDIVIDUAL Total as of 12/31/14

36 Student Health INDIVIDUAL Total as of 3/31/15

37 Student Health INDIVIDUAL Dual Contracts (Included in Total as of 3/31/15)

38 Student Health INDIVIDUAL Deferred PY1 (Add)

39 Student Health INDIVIDUAL Deferred CY (Subtract)

40 Government Program Plans Total as of 12/31/14

41 Other Health Business Total as of 12/31/14

42 Aggregate 2% Rule Total as of 12/31/14

43 Uninsured Plans Total as of 12/31/14

44 Grand Total Total as of 12/31/14

1. Premium

1.1 Total direct premium earned

1.2 Federal high risk pools

Pt 1, Ln 1.2

1.3 State high risk pools

Pt 1, Ln 1.3

1.4 Net assumed less ceded reinsurance premium earned (exclude amounts already reported in Line 1.1)

Pt 1, Ln 1.9

1.5 Other adjustments due to MLR calculations - premium

Pt 1, Ln 1.10

1.6 Risk revenue

Pt 1, Ln 1.11

2. Claims

2.1 Total incurred claims (MLR Form Part 2, Line 2.16)

2.2 Prescription drugs (informational only; already included in total incurred claims above)

Pt 1, Ln 2.2

2.3 Pharmaceutical rebates (informational only; already excluded from total incurred claims above)

Pt 1, Ln 2.3

2.4 State stop loss, market stabilization and claim/census based assessments (informational only; already excluded from total incurred claims above)

Pt 1, Ln 2.4

2.5 Net assumed less ceded claims incurred (exclude amounts already reported in Line 2.1)

Pt 1, Ln 5.1

2.6 Other adjustments due to MLR calculations – claims incurred

Pt 1, Ln 5.2

2.7 Rebates paid

Pt 1, Ln 5.3

2.8 Estimated rebates unpaid at the end of the previous MLR reporting year

Pt 1, Ln 5.4

2.9 Estimated rebates unpaid at the end of the MLR reporting year

Pt 1, Ln 5.5

2.10 Fee-for-service and co-pay revenue (net of expenses)

Pt 1, Ln 5.6

2.11 Allowable fraud reduction expenses (MLR Form Part 2, Line 2.17)

Pt 1, Ln 4

3. Federal and State Taxes and Licensing or Regulatory Fees

3.1 Federal taxes and assessments incurred by the reporting issuer during the MLR reporting year

Pt 1, Ln 1.5

3.1a Federal income taxes deductible from premium in MLR calculations

3.1b Patient Centered Outcomes Research Institute (PCORI) Fee

3.1c Affordable Care Act section 9010 Fee

3.1d Other Federal Taxes and assessments deductible from premium

3.2 State insurance, premium and other taxes incurred by the reporting issuer during the MLR reporting year (deductible from premium in MLR calculation)

Pt 1, Ln 1.6

3.2a State income, excise, business, and other taxes

3.2b State premium taxes

3.2c Community benefit expenditures deductible from premium in MLR calculations

Pt 1, Ln 1.6a

3.3 Regulatory authority licenses and fees

Pt 1, Ln 1.7

3.3a Federal Transitional Reinsurance Program contributions

3.3b Other Federal and State regulatory authority licenses and fees

4. Health Care Quality Improvement Expenses Incurred

4.1 Improve health outcomes

Pt 1, Ln 6.1

4.2 Activities 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 improving health care quality

Pt 1, Ln 6.5

4.6 Allowable Implementation ICD-10 expenses (not to exceed 0.3% of premium)

Pt 1, Ln 16a

5. Non-Claims Costs

5.1 Cost containment expenses not included in quality improvement expenses in Section 4

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 Taxes and assessments (exclude amounts reported in Section 3 or Line 9)

5.5b Fines and penalties of regulatory authorities (exclude amounts reported in Line 3.3)

5.6 Other general and administrative expenses

5.7 Community benefit expenditures (informational only; include amounts reported in Lines 3.2c and 5.6)

Pt 1, Ln 10.4a

5.8 ICD-10 implementation expenses (informational only; include amounts reported in Lines 4.6 and 5.6)

Pt 1, Ln 16

6. Income from fees of uninsured plans

Pt 1, Ln 12

7. Other Indicators or information

7.1 Number of policies/certificates

Pt 1 Other, Ln 1

7.2 Number of covered lives

Pt 1 Other, Ln 2

7.3 Number of groups

Pt 1 Other, Ln 3

7.4 Member months

Pt 1 Other, Ln 4

7.5 Number of life-years

8. Net investment income and other gain / (loss)

Pt 1, Ln 13

9. Other Federal income taxes (exclude taxes on Lines 3.1a-d)

Pt 1, Ln 14

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Sheet 3: Pt 2 Premium and Claims

Part 2 Premium and Claims

Line Description

SHCE

1 Health Insurance INDIVIDUAL Total as of 12/31/14

2 Health Insurance INDIVIDUAL Total as of 3/31/15

3 Health Insurance INDIVIDUAL Dual Contracts (Included in Total as of 3/31/15)

4 Health Insurance INDIVIDUAL Deferred PY1 (Add)

5 Health Insurance INDIVIDUAL Deferred CY (Subtract)

2A Health Insurance INDIVIDUAL [Risk Corridors] Total as of 3/31/15

6 Health Insurance SMALL GROUP Total as of 12/31/14

7 Health Insurance SMALL GROUP Total as of 3/31/15

8 Health Insurance SMALL GROUP Dual Contracts (Included in Total as of 3/31/15)

9 Health Insurance SMALL GROUP Deferred PY1 (Add)

10 Health Insurance SMALL GROUP Deferred CY (Subtract)

7A Health Insurance SMALL GROUP [Risk Corridors] Total as of 3/31/15

11 Health Insurance LARGE GROUP Total as of 12/31/14

12 Health Insurance LARGE GROUP Total as of 3/31/15

13 Health Insurance LARGE GROUP Dual Contracts (Included in Total as of 3/31/15)

14 Health Insurance LARGE GROUP Deferred PY1 (Add)

15 Health Insurance LARGE GROUP Deferred CY (Subtract)

16 Mini-Med INDIVIDUAL Total as of 12/31/14

17 Mini-Med INDIVIDUAL Total as of 3/31/15

18 Mini-Med INDIVIDUAL Dual Contracts (Included in Total as of 3/31/15)

19 Mini-Med SMALL GROUP Total as of 12/31/14

20 Mini-Med SMALL GROUP Total as of 3/31/15

21 Mini-Med SMALL GROUP Dual Contracts (Included in Total as of 3/31/15)

22 Mini-Med LARGE GROUP Total as of 12/31/14

23 Mini-Med LARGE GROUP Total as of 3/31/15

24 Mini-Med LARGE GROUP Dual Contracts (Included in Total as of 3/31/15)

25 Expat SMALL GROUP Total as of 12/31/14

26 Expat SMALL GROUP Total as of 3/31/15

27 Expat SMALL GROUP Dual Contracts (Included in Total as of 3/31/15)

28 Expat SMALL GROUP Deferred PY1 (Add)

29 Expat SMALL GROUP Deferred CY (Subtract)

30 Expat LARGE GROUP Total as of 12/31/14

31 Expat LARGE GROUP Total as of 3/31/15

32 Expat LARGE GROUP Dual Contracts (Included in Total as of 3/31/15)

33 Expat LARGE GROUP Deferred PY1 (Add)

34 Expat LARGE GROUP Deferred CY (Subtract)

35 Student Health INDIVIDUAL Total as of 12/31/14

36 Student Health INDIVIDUAL Total as of 3/31/15

37 Student Health INDIVIDUAL Dual Contracts (Included in Total as of 3/31/15)

38 Student Health INDIVIDUAL Deferred PY1 (Add)

39 Student Health INDIVIDUAL Deferred CY (Subtract)

40 Government Program Plans Total as of 12/31/14

41 Other Health Business Total as of 12/31/14

42 Aggregate 2% Rule Total as of 12/31/14

43 Uninsured Plans Total as of 12/31/14

44 Grand Total Total as of 12/31/14

1. Premium

1.1 Direct premium written

1.2 Unearned premium prior year

Pt 2, Ln 1.2

1.3 Unearned premium MLR Reporting year

Pt 2, Ln 1.3

1.4 Experience rating refunds (rate credits) paid

1.4a Experience rating refunds, with all incurred dates, paid in the MLR reporting year

Pt 2, Ln 1.5

1.4b Experience rating refunds associated with premium earned only in the reporting year and paid through 3/31 of the following year

1.5 Reserve for experience rating refunds (rate credits) MLR Reporting year

Pt 2, Ln 1.6

1.6 Reserve for experience rating refunds (rate credits) prior year

Pt 2, Ln 1.7

1.7 Premium balances written off

Pt 2, Ln 1.9

1.8 Group conversion charges

Pt 2, Ln 1.10

1.9 Federal Transitional Reinsurance Program payments expected from HHS (as indicated by HHS as of 6/30)

1.10 Federal Risk Adjustment Program net payments expected from HHS / (charges payable to HHS) (as indicated by HHS as of 6/30)

1.11 Federal Risk Corridors Program net payments / (charges)

1.12 Premium ceded under 100% reinsurance (informational only; already excluded from Lines 1.1-1.11)

1.13 Premium assumed under 100% reinsurance (informational only; already included in Lines 1.1-1.11)

1.14 Advance payments of the premium tax credit received from HHS (informational only; already included in Lines 1.1-1.11)

2. Claims

2.1 Claims Paid

2.1a Claims paid during the MLR reporting year regardless of incurred date

2.1b Claims incurred only during the MLR reporting year, paid through 3/31 of the following year

2.2 Direct claim liability

2.2a Liability as of 12/31 of MLR reporting year for all claims regardless of incurred date

Pt 2, Ln 2.2

2.2b Liability for claims incurred only during the MLR reporting year, calculated as of 3/31 of the following year

2.3 Direct claim liability prior year

Pt 2, Ln 2.3

2.4 Direct claim reserves

2.4a Reserves as of 12/31 of MLR reporting year for all claims regardless of incurred date

Pt 2, Ln 2.4

2.4b Reserves for claims incurred only during the MLR reporting year, calculated as of 3/31 of the following year

2.5 Direct claim reserves prior year

Pt 2, Ln 2.5

2.6 Direct contract reserves

2.6a Direct contract reserves 12/31 column

Pt 2, Ln 2.6

2.6b Direct contract reserves 3/31, dual contract, deferred columns

2.7 Direct contract reserves prior year

Pt 2, Ln 2.7

2.8 Experience rating refunds (rate credits) paid

2.8a Experience rating refunds, with all incurred dates, paid in the MLR reporting year

Pt 2, Ln 2.8

2.8b Experience rating refunds associated with premium earned only in the reporting year and paid through 3/31 of the following year

2.9 Reserve for experience rating refunds (rate credits)

2.9a Reserved in MLR reporting year regardless of incurred date

Pt 2, Ln 2.9

2.9b Reserves specific to the MLR reporting year through 3/31 of the following year

2.10 Reserve for experience rating refunds (rate credits) prior year

Pt 2, Ln 2.10

2.11 Incurred medical incentive pool and bonuses

2.11a Paid medical incentive pools and bonuses MLR Reporting year

Pt 2, Ln 2.11a

2.11b Accrued medical incentive pools and bonuses MLR Reporting year

Pt 2, Ln 2.11b

2.11c Accrued medical incentive pools and bonuses prior year

Pt 2, Ln 2.11c

2.12 Net healthcare receivables

2.12a Healthcare receivables MLR Reporting year

Pt 2, Ln 2.12a

2.12b Healthcare receivables prior year

Pt 2, Ln 2.12b

2.13 Contingent benefit and lawsuit reserves

2.14 Group conversion charges

Pt 2, Ln 2.13

2.15 Blended rate adjustment

Pt 2, Ln 2.14

2.16 Total incurred claims

Pt 2, Ln 2.15

2.17 Allowable fraud reduction expense (the smaller of Lines 2.17a or 2.17b)

Pt 1, Ln 4

2.17a Total fraud reduction expense

Pt 3, Col 7, Ln 1.11/2.11/3.11/5.11/6.11

2.17b Total fraud recoveries that reduced paid claims in Line 2.1

Pt 2, Ln 3

2.18 Advance payments of cost-sharing reductions

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Sheet 4: Pt 3 MLR and Rebate Calculation

Part 3 MLR and Rebate Calculation

Line Description

1 Health Insurance Coverage INDIVIDUAL PY2

2 Health Insurance Coverage INDIVIDUAL PY1

3 Health Insurance Coverage INDIVIDUAL CY

4 Health Insurance Coverage INDIVIDUAL Total

4A Health Insurance Coverage INDIVIDUAL RC

5 Health Insurance Coverage SMALL GROUP PY2

6 Health Insurance Coverage SMALL GROUP PY1

7 Health Insurance Coverage SMALL GROUP CY

8 Health Insurance Coverage SMALL GROUP Total

8A Health Insurance Coverage SMALL GROUP RC

9 Health Insurance Coverage LARGE GROUP PY2

10 Health Insurance Coverage LARGE GROUP PY1

11 Health Insurance Coverage LARGE GROUP CY

12 Health Insurance Coverage LARGE GROUP Total

13 Mini-Med Plans INDIVIDUAL PY2

14 Mini-Med Plans INDIVIDUAL PY1

15 Mini-Med Plans INDIVIDUAL CY

16 Mini-Med Plans INDIVIDUAL Total

17 Mini-Med Plans SMALL GROUP PY2

18 Mini-Med Plans SMALL GROUP PY1

19 Mini-Med Plans SMALL GROUP CY

20 Mini-Med Plans SMALL GROUP Total

21 Mini-Med Plans LARGE GROUP PY2

22 Mini-Med Plans LARGE GROUP PY1

23 Mini-Med Plans LARGE GROUP CY

24 Mini-Med Plans LARGE GROUP Total

25 Expatriate Plans SMALL GROUP PY2

26 Expatriate Plans SMALL GROUP PY1

27 Expatriate Plans SMALL GROUP CY

28 Expatriate Plans SMALL GROUP Total

29 Expatriate Plans LARGE GROUP PY2

30 Expatriate Plans LARGE GROUP PY1

31 Expatriate Plans LARGE GROUP CY

32 Expatriate Plans LARGE GROUP Total

33 Student Health Plans INDIVIDUAL PY2

34 Student Health Plans INDIVIDUAL PY1

35 Student Health Plans INDIVIDUAL CY

36 Student Health Plans INDIVIDUAL Total

1. Medical Loss Ratio Numerator

1.1 Adjusted incurred claims as reported on MLR Form for prior year(s)

1.2 Adjusted incurred claims as of 3/31 of the year following the MLR reporting year

1.3 Improving Health Care Quality Expenses

1.4 Advance payments of cost-sharing reductions

1.5 Federal Transitional Reinsurance Program payments expected from HHS (as indicated by HHS as of 6/30)

1.6 Federal Risk Adjustment Program net payments expected from HHS / (charges payable to HHS) (as indicated by HHS as of 6/30)

1.7 Federal Risk Corridors Program net payments / (charges)

1.8 MLR numerator

1.9 MLR numerator Mini-Med and Student Health (using adjustment factor)

2. Medical Loss Ratio Denominator

2.1 Premium earned including Federal and State high risk programs and adjusted for net premium stabilization program payments / (charges)

2.2 Federal and State taxes and licensing or regulatory fees

2.3 MLR Denominator (Lines 2.1 - 2.2)

3. Risk Corridors Calculation

3.1 Allowable costs (Lines 1.2 + 1.3 - 1.4 - 1.5 - 1.6)

3.2 Administrative costs excluding taxes (MLR Form Part 1 Lines 5.1 + 5.2 + 5.3 + 5.4 + 5.5a + 5.5b + 5.6)

3.3 Ratio of allowable costs to after-tax premium (Lines 3.1 / (2.1 - 2.2))

3.4 Transitional Adjustment Percentage (if Line 3.3 ≥ 80%)

3.5 Profit for risk corridors calculation (the greater of Lines 3.5a or 3.5b)

3.5a Earned profit (Lines 2.1 - 3.1 - 2.2 - 3.2)

3.5b Capped profit ((3% + Line 3.4) x (Lines 2.1 - 2.2))

3.6 Allowable administrative costs (the lesser of Lines 3.6a or 3.6b)

3.6a Profit and administrative costs excluding taxes (Lines 3.2 + 3.5)

3.6b Capped administrative costs ((20% + Line 3.4) x (Lines 2.1 - 2.2) + Line 2.2)

3.6c Capped administrative costs without adjustment (20% x (Lines 2.1 - 2.2) + Line 2.2)

3.7 Risk corridors adjusted target amount (Lines 2.1 - 3.6)

3.8 Allowable administrative costs without adjustment (the lesser of Lines 3.6a or 3.6c)

3.9 Risk corridors unadjusted target amount (Lines 2.1 - 3.8)

3.10 Unadjusted risk corridors ratio (Lines 3.1 / 3.9)

3.11 Risk corridors aggregate amount by market without adjustment (from Risk Corridors Plan Data Form, Part 3 Line 9)

3.12 Risk corridors total payment or charge amount used for MLR calculation (from Risk Corridors Plan Data Form, Part 3 Line 10)

4. Credibility Adjustment

4.1 Life-years

4.2 Base credibility factor

4.3 Average deductible

4.4 Deductible factor

4.5 Credibility adjustment (Lines 4.2 x 4.4 (do not round))

5. MLR Calculation (for issuers with at least 1,000 life years in the Total column of Line 4.1)

5.1 Preliminary MLR

5.1a Preliminary MLR (Lines 1.8 / 2.3)

5.1b Preliminary MLR: Mini-Med and Student Health (Lines 1.9 / 2.3)

5.2 Credibility adjustment (Line 4.5, if applicable)

5.3 Credibility-adjusted MLR (Lines 5.1a or 5.1b + 5.2)

6. Rebate Calculation

6.1 MLR standard

6.2 Credibility-adjusted MLR (Line 5.3)

6.3 Adjusted earned premium (Lines 2.1 - 2.2 CY)

6.4 Rebate amount if credibility-adjusted MLR is less than MLR standard (Lines (6.1 - 6.2) x 6.3)

7. Optional temporary adjustments

7.1 ACA assessments on non-calendar year policies (2013 only)

7.1a Deferred portion of 2013 premium collected for 2014 ACA assessments or fees.

7.1b Total Federal and State taxes associated with the deferred premium on Line 7.1a.

7.2 Reserved for future use

7.2a Reserved for future use

7.2b Reserved for future use

7.2c Reserved for future use

7.2d Reserved for future use

7.2e Reserved for future use

7.2f Reserved for future use

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Sheet 5: Pt 4 Rebate Disbursement

Part 4 Rebate Disbursement
Line Description	1 Health Insurance Coverage INDIVIDUAL	2 Health Insurance Coverage SMALL GROUP	3 Health Insurance Coverage LARGE GROUP	4 Mini-Med Plans INDIVIDUAL	5 Mini-Med Plans SMALL GROUP	6 Mini-Med Plans LARGE GROUP	7 Expatriate Plans SMALL GROUP	8 Expatriate Plans LARGE GROUP	9 Student Health Plans INDIVIDUAL
1. Number of policies / certificates (from Part 1, Line 7.1)
2. Number of policyholders/subscribers owed rebates
2.a Number of group policyholders being paid a rebate
2.b Number of subscribers being paid a rebate
2.c Number of group policyholders whose rebate is de minimis
2.d Number of subscribers whose rebate is de minimis
3. Total amount of rebates
3.a Total amount of rebates (from Part 3, Line 6.4)
3.b Amount of de minimis rebates
3.c Amount of rebates being paid by premium credit
3.d Amount of rebates being paid by lump-sum reimbursement
4. Prior MLR year rebates
4.a Total amount of rebates paid for the previous MLR reporting year
4.b Total amount of rebates still owed for the previous MLR reporting year
4.c Percentage of notices sent timely to individual policy subscribers or group policyholders owed a rebate
4.d Percentage of notices sent timely to subscribers of group policies owed a rebate
4.e Percentage of rebates paid timely to individual policy subscribers or group policyholders owed a rebate
4.f Percentage of rebates paid timely to subscribers of group policies owed a rebate
4.g Amount of unclaimed rebates from prior MLR reporting years
4.h Describe methods used to locate policyholders/subscribers for prior MLR reporting year's unclaimed rebates:
4.i Describe disbursement of prior MLR reporting year's unclaimed rebates:

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Sheet 6: Pt 5 Additional Responses

Part 5 Additional Responses
Line Description	Tax Rate
1. If an amount is reported in Part 1 Line 3.2c, Community benefit expenditures, provide the state premium tax rate used to determine the reported amount:
2. If the issuer reported amounts in Part 2 Line 2.15 Blended rate adjustment provide the affiliate(s) name(s) with whom blended rate adjustments were made.
Name of Affiliate
3. If the issuer reported amounts in the Dual Contract 3/31 Columns provide the affiliate(s) name(s) with whom experience is being reported.
Name of Affiliate
4. If the issuer entered into any 100% assumptive reinsurance agreements with a novation during the MLR reporting year, provide the name(s) of the entity(ies) with whom the agreement was (were) made and the effective date of the novation.
Name of Entity with whom Agreement was made	Effective Date of Novation
5. If the Issuer novated any business in the MLR reporting year effective during the reporting year provide the name of the entity to whom the business was sold or transferred and the date of the sale or transfer.
Name of Entity to whom business was sold or transferred	Effective Date of sale or transfer
6. If the issuer has any 100% indemnity reinsurance and administrative agreements effective prior to March 23, 2010, for which the assuming entity is responsible for 100% of the ceding entity's financial risk and takes on all of the administration of the block, report the name(s) of the entity(ies) that is (are) reporting the experience related to such business.

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Sheet 7: Pt 6 Expense Allocation

Part 6 Expense Allocation
1 Description of Expense Element (by Type)	2 NEW	3 Detailed Description of Expense Allocation Methods
1. Incurred Claims
2. Federal and State Taxes and Licensing or Regulatory Fees
2.a Federal taxes and assessments
2.b State insurance, premium and other taxes
2.c Community benefit expenditures
2.d Regulatory authority licenses and fees
3. Quality Improvement Expenses
3.a Improve health outcomes
3.b Activities to prevent hospital readmission
3.c Improve patient safety and reduce medical errors
3.d Wellness and health promotion activities
3.e Health Information Technology expenses related to healthcare quality
3.f Allowable ICD-10 Expenses
4. Non-Claims costs
4.a Cost containment expenses not included in quality improvement expenses
4.b All other claims adjustment expenses
4.c Direct sales salaries and benefits
4.d Agents and brokers fees and commissions
4.e Other taxes
4.f Other general and administrative expenses
4.g Community benefit expenditures
4.h ICD-10 implementation expenses

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Sheet 8: Attestation

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, the Company/Issuer Associations, and any supplemental submission that the issuer includes are full and true statements of all the elements included therein 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 and which are required by Department of Health and Human Services under section 2718 of the Public Health Service Act and implementing regulation.

____________________________ 

Chief Executive Officer/President

____________________________  

Chief Financial Officer

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Sheet 9: Reference Tables

Table 1 - Base Credibility Adjustment Factors			Table 3 - State and Territory Names		Table 4 - Reporting Years		Table 5 - 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%		Canada		2017
50,000	1.2%		Colorado		2018
75,000	0.0%		Connecticut		2019
			District of Columbia		2020
			Delaware		2021
			Florida		2022
Table 2 - Deductible Factors			Georgia		2023
Average Health Plan Deductible	Deductible factor		Guam		2024
$0	1.000		Hawaii		2025
$2,500	1.164		Iowa		2026
$5,000	1.402		Idaho		2027
$10,000	1.736		Illinois		2028
			Indiana		2029
			Kansas		2030
			Kentucky		2031
			Louisiana		2032
			Massachusetts		2033
			Maryland		2034
			Maine		2035
			Michigan		2036
			Minnesota		2037
			Missouri		2038
			MP		2039
			Mississippi		2040
			Montana		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
			Other Territories		2053
			Pennsylvania		2054
			Puerto Rico		2055
			Rhode Island		2056
			South Carolina		2057
			South Dakota		2058
			Tennessee		2059
			Texas		2060
			Utah
			Virginia
			Virgin Islands
			Vermont
			Washington
			Wisconsin
			West Virginia
			Wyoming
			Grand Total