CMS-10476 MLR Report

MLR Report for Contract Year 2015
Worksheet 1

MLR-2015.1
OMB Approved # 0938-1232
CMS-10476 (OMB exp date 04/30/2017)

Section 1: General Information
1. Contract Year
2015
2. Contract Number
3. Organization Name
4. Date MLR Report finalized
5. Contact Information for any questions from CMS regarding this report:
Contact #1
Name, Position
Phone Number
E-mail Address
Contact #2
Name, Position
Phone Number
E-mail Address
Section 2: Data Collection
1. Revenue
1.0a
1.0b
1.1a
1.1b
1.2

1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
2.

Total $
MA Sequestration Adjustment (enter as negative amount)
Part D Sequestration Adjustment (enter as negative amount)
MA Beneficiary Premium (Basic + Mandatory Supplemental + Optional Supplemental)
Part D Beneficiary Premium (Basic + Supplemental)
MA plan payments (based on A/B bid), using final risk scores, including:
MA Rebate for Cost Sharing Reduction
MA Rebate for Other Mandatory Supplemental Benefits
MA Rebate for Part D Supplemental Benefits
MA Rebate for Part B Premium Reduction (note: included as revenue)
MA Rebate for Part D Basic Premium Reduction
MSA Enrollee Deposit (note: included as revenue)
Part D direct subsidy, using final risk scores
Part D federal reinsurance subsidy (prospective and reconciliation adjustments)
Part D Low Income Premium Subsidy Amount (LIPSA)
Part D risk corridor payments
Total

$
$

$

PMPM
-

-

$
$
$
$
$

-

$
$
$
$
$
$
$
$

-

$
$

-

$
$
$
$
$
$
$
$
$
$
$

-

$
$

-

$
$
$
$
$

N/A
-

$
$
$
$
$
$
$

-

$
$
$
$

-

$
$
$
$
$
$

-

Claims
2.1 Claims incurred only during CY 2015, paid through 9/30/2016
2.2 Liability and reserves for claims incurred only during CY 2015, calc'd as of 9/30/2016
2.3 Incurred medical incentive pool and bonuses
2.3a Paid medical incentive pools and bonuses MLR Reporting year
2.3b Accrued medical incentive pools and bonuses MLR Reporting year
2.4 Contingent benefit and lawsuit reserves
2.5 MA Rebate for Part B Premium Reduction
2.6 MSA Enrollee Deposit
2.7 Allowable fraud reduction expense (the smaller of Lines 2.7a or 2.7b)
2.7a Total fraud reduction expense
2.7b Total fraud recoveries that reduced paid claims in Line 2.1
2.8 Total
2.8a Part D (informational only; already included in Line 2.8)

$
$
$

-

$

-

2.8b Direct and Indirect Remuneration (DIR) (informational only; already excluded from Line 2.8)
3.

4.

5

Federal and State Taxes and Licensing or Regulatory Fees
3.1 Federal taxes and assessments, incurred in CY 2015, deductible from revenue in MLR calculation
3.1a Federal income taxes
3.1b Other Federal Taxes (other than income tax) and assessments
3.2 State insurance, premium and other taxes, incurred in CY 2015, deductible from revenue in MLR calculation
3.2a State income, excise, business, and other taxes
3.2b State premium taxes
3.2c Community benefit expenditures
3.3 Regulatory authority licenses and fees
3.4 Total
3.4a Affordable Care Act section 9010 Fee (informational only; already included in Line 3.1)
Health Care Quality Improvement (QI) Expenses Incurred
4.1 Improve health outcomes
4.2 Activities to prevent hospital readmission
4.3 Improve patient safety and reduce medical errors
4.4 Wellness and health promotion activities
4.5 Health information technology expenses related to improving healthcare quality
4.6 Allowable ICD-10 expenses
4.7 Total
Non-Claims Costs
5.1 Cost containment expenses not included in QI expenses in Section 4
5.2 All other claims adjustment expenses
5.3 Direct sales salaries and benefits
5.4 Agents and brokers fees and commissions
5.5 Other taxes
5.5a Taxes and assessments not excl. from revenue (not reported in Section 3)
5.5b Fines and penalties of regulatory authorities (not reported in Line 3.3)
5.6 Other general and administrative expenses
5.7 Total
5.8 Community benefit expend. (informational only; incl. amts. reported in 3 & 5)
5.9 ICD-10 implementation exp. (informational only; incl. amts. reported in 4 & 5)

N/A

$

$

$

-

-

-

6. Methodology for determining the Medicare-funded portion of the contract for EGWP plans
6.1 Option 1 "Actual EGWP costs", or Option 2 "Allocated based on revenue"
6.2 Enter percentage used to allocate EGWP costs (i.e., Medicare % of total revenue)
7. Total Member months

-

MLR Report for Contract Year 2015
Worksheet 1 (continued)

Section 2: Data Collection (continued)
8. Plan-Specific Data
(a)

(b)

Enter the list of plans offered
under contract in CY 2015,
using
Plan ID format: Hxxxx-xxx-xx
Plan1
Plan2
Plan3
Plan4
Plan5
Plan6
Plan7
Plan8
Plan9
Plan10

(c)

(d)

CY2015
Member
Months

Is plan a Dual-Eligible
Special Needs Plan
(ie, D-SNP)?
(Yes/No)

(e)
Does the plan's
defined service
area include
territories?
(Yes/No)

(f)

(g)

(h)

(i)

(j)

(k)

(l)

(m)

(n)

Medicaid Claims Cost
Is the plan a DSNP in a
territory?
Dual-Eligible Member Months in
(Yes/No)
territories
No
No
No
No
No
No
No
No
No
No

Medicaid Revenue PMPM

Medicaid Non-Claims Cost
PMPM

Medicaid Cost PMPM
$
$
$
$
$
$
$
$
$
$

-

Medical: Cost Sharing
Reduction PMPM

Medical: Other Benefits PMPM

Pharmacy PMPM

Medicaid Gain/(Loss) PMPM
$
$
$
$
$
$
$
$
$
$
-

MLR Report for Contract Year 2015
Worksheet 2
Contract Year: 2015
Contract Number:
Org Name:
Date MLR Report finalized:
Section 1: Medicare MLR and Remittance Calculation
1. Medical Loss Ratio Numerator
1.1 Claims
1.2 Improving health care quality expenses
1.3 MLR numerator

$
$
$

-

2. Medical Loss Ratio Denominator
2.1 Revenue
2.2 Federal and State taxes and licensing or regulatory fees
2.3 MLR denominator

$
$
$

-

3. Credibility Adjustment
3.1 Member Months to determine credibility
3.2 MLR Credibility adjustments table
3.3 Credibility adjustment

0
PD adjustments
N/A

4. MLR Calculation
4.1 Unadjusted MLR
4.2 Credibility adjustment
4.3 Adjusted MLR

0.0%
N/A
N/A

5. Remittance Calculation
5.1 Is contract either partially-credible or fully-credible? (Yes/No)
5.2 MLR standard
5.3 Adjusted MLR
5.4 MLR denominator
5.5 Remittance amount due to CMS for CY 2015 experience
5.5a Allocated to Parts A&B (for CMS system purposes only)
5.5b Allocated to Part D (for CMS system purposes only)

$
$
$
$

No
85.0%
N/A
-

Section 2: MLR Credibility Adjustments Table
MA contracts
member
credibility
months adjustment
< 2,400
non-cred
2,400
8.4%
6,000
5.3%
12,000
3.7%
24,000
2.6%
60,000
1.7%
120,000
1.2%
180,000
1.0%
> 180,000
fully cred

PD stand-alone contracts
member
credibility
months
adjustment
< 4,800
non-cred
4,800
8.4%
12,000
5.3%
24,000
3.7%
48,000
2.6%
120,000
1.7%
240,000
1.2%
360,000
1.0%
> 360,000
fully cred

MLR Report for Contract Year 2015
Worksheet 3
Contract Year: 2015
Contract Number:
Org Name:
Date MLR Report finalized:
Section 1: Description of Expense Allocation Methods
1. 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. Health Care 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

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 0938-1232. The time required to complete this
information collection is estimated to average 47 hours 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.