CMS-10476 MLR Report

MLR Report for Contract Year 2023
Worksheet 1

MLR-2023.1
OMB Approved # 0938-1232
CMS-10476 (OMB exp date pending)

Section 1: General Information
1. Contract Year
2023
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

Total $

1.0 Sequestration Adjustments
1.0a MA Sequestration Adjustment (enter as negative amount)
1.0b Part D Sequestration Adjustment (enter as negative amount)
1.1 Beneficiary Premiums
1.1a MA Beneficiary Premium (Basic + Mandatory Supplemental + Optional Supplemental)
1.1b Part D Beneficiary Premium (Basic + Supplemental)
1.2 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
Part D risk corridor payments
1.10 Total

$
$

PMPM

-

1.3
1.4
1.5
1.6
1.7
1.8
1.9

2.

$

-

$

-

$
$

-

$
$
$

-

$
$
$
$
$
$
$
$

-

$

-

Claims
2.1 Claims incurred only during CY 2023, paid through 9/30/2024
2.1a Claims incurred for benefits covered under Parts A & B (incl.
supp. benefits that extend or reduce cost sharing for A/B benefits)
2.1b Claims incurred for MA supplemental benefits (excl. supp.
benefits that extend or reduce cost sharing for A/B benefits)
$
2.1b.1 Dental
2.1b.2 Vision
2.1b.3 Hearing

2.2
2.3

2.4
2.5
2.6
2.7

2.1b.4 Transportation
2.1b.5 Fitness Benefit
2.1b.6 Worldwide Coverage / Visitor Travel
2.1b.7 Over the Counter (OTC) Items
2.1b.8 Remote Access Technologies
2.1b.9 Meals
2.1b.10 Routine Foot Care
2.1b.11 Acupuncture Treatments
2.1b.12 Chiropractic Care
  2.1b.13 Personal Emergency Response System (PERS)
2.1b.14 Health Education
2.1b.15 Smoking and Tobacco Cessation Counseling
2.1b.16 All Other Primarily Health Related Supplemental Benefits
2.1b.17 Non-Primarily Health Related SSBCI
2.1b.18 Out-of-network Services (informational only; amount already incl. in Lines 2.1a through 2.1b.1-2.1b.17)
2.1c Claims incurred for Part D prescription drugs
Liability and reserves for claims incurred only during CY 2023, calc'd as of 9/30/2024
Incurred medical incentive pool and bonuses
2.3 a Paid medical incentive pools and bonuses MLR Reporting year
2.3b Accrued medical incentive pools and bonuses MLR Reporting year
Contingent benefit and lawsuit reserves
MA Rebate for Part B Premium Reduction
MSA Enrollee Deposit
Total
2.7a Low Income Cost Sharing Subsidy Amount (informational only; amount must be excl. from Line 2.1c)
2.7b Direct and Indirect Remuneration (DIR) (informational only; amount must be excl. from Line 2.1c)

3.

Federal and State Taxes and Licensing or Regulatory Fees
3.1 Federal taxes and assessments, incurred in CY 2023, 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 2023, deductible from revenue in MLR calculation
3.2a State income, excise, business, and other taxes

$
$
$

Benefit offered
under only 1
plan?

-

-

$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

-

$
$
$
$
$
$
$
$

-

$
$

-

$

-

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)
4.

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 Medication Therapy Management program expenses
4.8 Fraud reduction activities
4.9 Total

5

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 Line 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

-

8. Plan-Specific Data
(a)

(b)

Enter the list
of plans
offered under
contract in CY
2023, using
Plan ID
format: Hxxxxxxx-xx
Plan1
Plan2
Plan3
Plan4
Plan5
Plan6
Plan7
Plan8
Plan9
Plan10

(c)

(d)

CY 2023
Member
Months

For MA Medical
Savings
Account (MSA)
contracts only:
MSA Plan
Deductible

N/A
$
$
$
$

-

$
$
$
$
$
$

-

$
$

-

$
$
$
$

-

$
$
$
$
$
$

-

MLR Report for Contract Year 2023

Worksheet 2

Contract Year: 2023
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 Base credibility adjustment factor
3.4 MSA deductible factor

N/A
N/A

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

$

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 CY2023
5.5a Allocated to Parts A&B (for CMS system purposes only)
5.5b Allocated to Part D (for CMS system purposes only)

$
$
$
$

Yes
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
Section 3: MSA Deductible Factors
weighted
average deductible
deductible
factor
< $2,500
$2,500
$5,000
≥ $10,000

1.000
1.164
1.402
1.736

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 2023

Worksheet 3

Contract Year: 2023
Contract Number:
Org Name:
Date MLR Report finalized:
Section 1: Description of Expense Allocation Methods
1. Claims
1.a Claims incurred for benefits covered under Parts A & B (Worksheet 1 Line 2.1a)
1.b Claims incurred for MA supplemental benefits (Worksheet 1 Lines 2.1b.1 through
2.1b.17)
1.c Claims incurred for Part D presciption drugs (Worksheet 1 Line 2.1c)
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
3.g Medicare Therapy Management program expenses
3.h Fraud reduction activities
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

PRA Disclosure Statement: This information is being collected to assist the Centers for Medicare & Medicaid Services
(CMS) with the ongoing management of Medicare programs and policies. This required information collection will be used to
meet the statutory requirements at sections 1857(e)(4) and 1860D-12 of the Social Security Act to determine the medical
loss ratio for each contract year and to apply remittances and sanctions. Under the Privacy Act of 1974 any personally
identifying information obtained will be kept private to the extent of the law.
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it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1232 (CMS10476). The time required to complete this information collection is estimated to average 61.1 hours per response, including
the time to review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to: CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.