CMS-10108 MLR Reporting Tool

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Purpose of Medical Loss Ratio (MLR) Reporting Template
As described at 42 CFR 438.74, states are required to report summary Medical Loss Ratio (MLR) reports to the Centers for Medicare and Medicaid Services (CMS). Beginning on [DATE] this template will support standardized data submission by state Medicaid and CHIP programs to CMS. The
data reported using this template will support state Medicaid and CHIP programs along with the CMS mandate to promote the transparency of Medicaid and CHIP managed care plan financial reporting.

Submission and Communications
- Completed forms should be submitted to [INSERT INSTRUCTIONS RE: HOW TO SUBMIT FORM].
- Questions about this form may be directed to [email protected]

MLR Reporting Template Organization
Consistent with 42 CFR 438.74, this template provides space for states to report on the following reporting requirements: (1) the amount of the MLR numerator, (2) the amount of the MLR denominator, (3) the MLR percentage achieved, (4) the number of member months, (5) any remittances owed
by each MCO, PIHP, or PAHP for the MLR reporting year, and (6) a description of the methodology used to determine the State and Federal share of remittances owed.
Within this template, states will find data elements with specific drop downs that CMS has pre-selected to standardize data across states, as well as places with instructions for states to report numerical values or free text. States shall report all data in the BEIGE COLORED CELLS. Tabs are
organized as follows:
Tab topic:
Reporting instructions
Primary contact & program reporting structure information
Medicaid medical loss ratio (MLR) reporting & remittance calculations
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Tab name:
Instructions
Program Information
MLR Reporting

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Reporting Instructions

Consistent with 42 CFR 438.74, this template allows states to report on the five (5) required MLR summary components: (1) the amount of the MLR numerator, (2) the amount of the MLR denominator, (3) the MLR percentage achieved, (4) the number of member months, and (5) any remittances owed by
each MCO, PIHP, or PAHP for the MLR reporting year. In addition to the 5 required requirements, fields marked as "Optional" are included to allow states to report additional MLR data that states currently collect from MCOs, PIHPs, or PAHPs.
Integrated plans (such as DSNPs and MMPs) are considered both Medicaid and Medicare managed care plans and are not exempt from Medicaid MLR reporting requirements at 42 CFR 438.74. Therefore, unless the state has authority to require their plans to calculate the MLR differently than as is
required under 42 CFR 438.8, such as under a financial alignment demonstration approved under Section 1115A, the plan must calculate and report their MLR experience for Medicaid only.

MLR Reporting Template Organization
The data entry portion of the template is split between two (2) tabs, the "Program Information" tab and the "MLR Reporting" tab. States must first complete the "Program Information" tab before moving to the "MLR Reporting" tab. Data entered in the "Program Information" tab will be used to populate the
reporting columns for the "MLR Reporting" tab. For both tabs, the reporting detail is by Program by MCO, PIHP, or PAHP, as detailed further below.
Additional details related to the structure and purpose of these data entry tabs are provided below
"Program Information" tab
Progress Indicators
Progress Indicators at the top of the worksheet note when all required information for each section is complete. When a requisite cell is blank, the indicator will say INCOMPLETE; when a requisite cell has been populated, the indicator will say COMPLETE. Indicators are provided for the following
sections: Contract Information, Version Control, Program Reporting Structure, Eligibility Group Reporting Structure, MCO Name Reporting Structure, Reporting Period Reporting Structure. Data files with INCOMPLETE progress indicators should not be submitted to CMS.
Information for Primary Contact
A-D: States must enter the Name, Phone Number, Email Address, and Title of the Primary Contact related to this template. Follow-up communications related to this template will be made with the primary contact.
E-F: States must select the relevant state or territory name from the drop down for the name of the state/territory agency that is submitting this report.
G: States must indicate if this file is an updated version of an MLR Report--covering the same time period--that was previously submitted. States must select either Yes or No using the dropdown.
H: Free text response field that states must complete only if "Yes" was selected in section G (MLR resubmission). States should describe the differences between a previously submitted template, and the current version.
Program Reporting Information
States must provide summary MLR report data at the plan level. The summary reports are based on the plans’ annual MLR reports to the state under 42 CFR 438.8(k). States have the option of reporting these data for each plan by program, statewide, or at another level of aggregation (e.g.,
eligibility groups). Program is defined by a specified set of benefits and eligibility criteria that are articulated in a contract between the state and managed care plans. Generally, MLR data should not be aggregated across multiple plans or across multiple programs; however, there is an exception
if a managed care plan has more than one contract with the state—the state can report results for each contract separately or combine results for each plan. Further, if a state combines the reporting for plans with multiple contracts, the report must use a consistent MLR reporting year.
States must report credible and non-credible MLRs for all MCOs, PIHPs, and PAHPs. Under 42 CFR 438.8(l) a state may exclude a plan that is newly contracted with the state from this reporting for the first year of the plan’s operation. These “new experience” plans must report MLRs during the
next MLR reporting year in which the plan is in business with the state, even if the first year was not a full 12 months.
States can submit multiple MLR summary reporting forms (e.g., one per program) to CMS.
In this section of the report, states must describe the aggregation level used and any applicable program information. If a plan’s data reflect all populations served across the state or all populations in a geographic region, a state should indicate “Statewide” or “Region” in the Program Name. If the
state is reporting the MLR separately for specific eligibility group(s), the state must indicate this information in the “Eligibility Group” column. The MLR reporting period should be a period of 12 months consistent with the rating period. The MLR reporting period must not exceed 12 months. Note:
The remittance reporting period may differ from the MLR reporting period. The remittance reporting period is the period of time used when determining the remittance amounts. If the remittance reporting period differs from the MLR reporting period, the remittance period should be entered
separately on the MLR Reporting worksheet.
The information included in this section will be used to develop appropriate reporting columns for the "MLR Reporting" tab.
Data Element

Data Format

Instructions and Definition

I. Program Name

Free text
(32,767 character limit)

Enter the name of the program(s) for which the state is reporting MLR data. A program is defined generally by a specified set of benefits and eligibility criteria that is articulated in a contract between the
state and a managed care plan. If a state reports a plan’s data on a statewide or regional basis, describe the Program Name as “Statewide ” or “Region” and the state may provide additional details and
descriptions in the Miscellaneous Notes field, such as the counties included. Leave unused fields blank.

J. Program Type

Set values (drop down)

K. Eligibility Group

Set values (drop down)

Select from the drop down list the program type definition that best describes the program entered in the Program Name column.
1.
For States that intend to report MLRs for separate CHIP only programs, the state should select “CHIP only” from the drop down list in this column. These separate child health assistance programs are
defined in 42 CFR 457.10. A state has the option to report the MLR for all populations (to include Medicaid and separate CHIP populations) served under the contract for the specified plan/program
being reported, and in this case, the state should select “All Populations” as described in Option 4 below.
2.
States that intend to qualify for the SUPPORT Act Section 4001 MLR provision must provide an MLR for the eligibility group described in section 1902(a)(10)(A)(i)(VIII) (referred to here as “the
Expansion Group”). Indicate that an expansion-only MLR is being reported by using the drop-down list in this column to indicate Group VIII expansion only adult population.
3.
For States that intend to report separate MLRs for eligibility groups that are served under the same program, select "Other" from the drop-down list in this column. Please see instructions in Data
Element L for further instructions.
4.
If neither 1, 2, nor 3 apply, select "All Populations", indicating that all Medicaid eligibility groups (and CHIP eligibility groups as applicable) covered under the contract for the specified plan/program
are being reported.
If "Other" was selected in Data Element K (Eligibility Group), states must specify the eligibility group(s) reported in Data Element L. For example, a State may report separate MLRs for each eligibility
group that is included in their "Comprehensive" program: Children <19 years; Aged, Blind, Disabled; Pregnant Women.

L. If Other, Describe Eligibility Group

Free text
(32,767 character limit)

M. MCO, PIHP, or PAHP Name

Free text
(32,767 character limit)

N. MLR Reporting Period
Start Date

Date (MM/DD/YYYY)

States must input the start date of the MLR Reporting Period as MM/DD/YYYY

O. MLR Reporting Period
End Date

Date (MM/DD/YYYY)

States must input the end date of the MLR Reporting Period as MM/DD/YYYY

P. Explanation of Reporting Period
Discrepancy

Free text
(32,767 character limit)

For (A) Reporting Periods that are less than a 12-month period, or (B) for MCO/PIHP/PAHPs that have a different reporting period than other MCO/PIHP/PAHPs within the same program, include a
qualitative response in this column. Examples include (but are not limited to) a new plan entering the market or state is re-aligning the reporting period from a state fiscal year to a calendar year.
Responses may expand beyond the cell column widths.

Q. Misc. Notes

Free text
(32,767 character limit)

Include any other notes/responses that the State wishes to report. Responses may expand beyond the cell column widths.

Enter the full name of each plan for which the state is reporting MLR data. Do not abbreviate plan names. All MCOs/PIHPs/PAHPs contracted in a specific program should be reported, including noncredible plans with small enrollment. Plan names should reflect those used in the Medicaid enrollment report: "Managed Care Enrollment by Program and Plan"
(https://www.medicaid.gov/medicaid/managed-care/enrollment-report/index.html)
Leave unused fields blank. MLR data should not be aggregated across more than one plan and generally should not be aggregated across multiple programs unless states use the exception above.

"MLR Reporting" tab
Based on the data entered in the "Program Information" tab, column K and onwards in the "MLR Reporting" tab will be populated with (an) appropriate reporting column(s) representing each Program-Plan combination. States must report the five required MLR summary elements. Note that the cells
in this worksheet do not automatically calculate the MLR numerator, denominator, or MLR percentage. Each element must be entered manually. The applicable regulations for each element are provided in Column H.
Progress Indicators
Progress Indicators at the top of the worksheet note when all required information for each section is complete. When a requisite cell is blank, the indicator will say INCOMPLETE; when a requisite cell has been populated, the indicator will say COMPLETE. Indicators are provided for the following
sections: MLR Numerator, MLR Denominator, Member Months, Adjusted MLR, Remittance (if applicable).
Note: States that are reporting non-credible plans should enter member month values in section 3.1 as described below. States should report all other required MLR reporting elements (sections 1.3, 2.3, 3.4) with the value 0, and answer "No" for section 4.1 when reporting non-credible plan
information. Reporting in this way will ensure that the Progress Indicators result in a COMPLETE status.
Section

Data Format

Instructions and Definition

1.1 - 1.3 Medical Loss Ratio Numer

Dollar

- States may enter one or more of the optional MLR Numerator subcomponents in sections 1.1 - 1.2 Note: if the optional subcomponents are reported, states must still report the total MLR
Numerator (i.e., subcomponents will not automatically sum to Numerator). Optional elements include: Incurred Claims and Activities that improve health care quality.
- Enter the required MLR Numerator dollar value in section 1.3

1.4 Non-Claims Costs

Dollar

- States may enter the optional non-claims costs value in section 1.4. This amount is not included in the MLR Numerator

2. Medical Loss Ratio Denominato

Dollar

- States may enter one or more of the optional MLR Denominator subcomponents in sections 2.1 - 2.2. Note: if the optional subcomponents are reported, states must still report the total MLR
Denominator (i.e., subcomponents will not automatically calculate Denominator). Optional elements include: Premium Revenue; Federal, State, and local taxes and licensing; and regulatory fees
- Enter the required MLR Denominator dollar value in section 2.3

3.1 MLR Calculation:
Member Months

Count

- Enter the required Member Months value in section 3.1

3.2 - 3.4 MLR Calculation:
Adjusted MLR Value

Percentage
(enter exactly as the
percentage should appear;
i.e. entering '1' will result in
1% instead of 100%)

- Enter the required Adjusted MLR value in section 3.4
- States may enter one or more of the optional subcomponents in sections 3.2 - 3.3. Note: if the optional subcomponents are reported, states must still report the total Adjusted MLR value (i.e.,
subcomponents will not automatically calculate Adjusted MLR). Optional elements include: Unadjusted MLR and Credibility adjustment. State may enter 0% if no credibility adjustment is needed.
- For non-credible plans, the credibility adjustment should be rounded to the nearest tenth and entered up to 100%. For fully credible plans, the credibility adjustment should be entered as 0%.
Complete the series of questions related to MLR Remittances via drop-downs and free form entry fields. Based on the state responses, cells may appear beige, indicating a response is required or
"gray", indicating that a response is not required. States must answer these questions for each MLR reporting column.

4. Remittance

4.1:
Does the contract
include a
remittance/payment
requirement for being
below/above a specified
4.6.1:
Remittance dollar
amount owed for MLR
reporting period
4.6.2:
Payment dollar amount
due to plan for MLR
reporting period
4.9:
Remittance
Methodology Qualitative
Response

Enter amounts for either line 4.6.1 or 4.6.2; do not enter values in both lines. All amounts should be reported as absolute values.
The following sections are required:

Set values (drop down)

- Select one of the following: Yes or No. This element indicates if a remittance to the state or a payment to a plan is required in an MCO/PIHP/PAHP contract if a specific minimum MLR is not
met.

Dollar

- Report the amount of remittances owed by each MCO/PIHP/PAHP in section 4.6.1. States should enter a zero (0) value if no remittance was owed by a plan. States should enter a positive
value if a remittance was collected by the state. If states answered "No" in section 4.1, section 4.6.1 will appear "gray", indicating that a response is not required.

Dollar

- Report the amount of the payment due to each MCO/PIHP/PAHP in section 4.6.2 as a positive value, where applicable. This payment is specific to losses reimbursed under a minimum MLR
arrangement; do not report the results of other risk corridors, reinsurance or other risk mitigation arrangements. If states answered "No" in section 4.1, section 4.6.2 will appear "gray", indicating
that a response is not required. If states answered “Yes” in section 4.1, but do not make payments to plans for losses under a minimum MLR arrangement, states may enter $0.

Free text
(32,767 character limit)

- Describe the methodology used to determine the State and Federal share of the remittance in the free entry text field in section 4.9.
- States that intend to qualify for the SUPPORT Act Section 4001 MLR provision must provide a description of the methodology used to determine the State and Federal share of the remittance
for the eligibility group described in section 1902(a)(10)(A)(i)(VIII).

Error Warnings
In sections 1, 2, 3 & 4 of the MLR Reporting tab, error warnings may appear indicating that data entered may have been entered incorrectly. The table below outlines the error warnings and their description. These messages are only warnings, and the MLR data may be submitted even if one or more
of the warnings appear.
Section

Error Warning

Description

1. Medical Loss Ratio Numerator

Warning: Numerator ≠
Subcomponents

If the optional MLR numerator subcomponents were reported by a state, this error warning will appear when the sum of the optional numerator subcomponents do not equal the total reported MLR
numerator amount in section 1.3.

2. Medical Loss Ratio Denominato

Warning: Denominator ≠
Difference of
Subcomponents

If the optional MLR denominator subcomponents were reported by a state, this error warning will appear when the reported Premium Revenue less the reported Federal, State, and local taxes and
licensing and regulatory fees does not equal the total reported MLR denominator amount in section 2.3.

3. MLR Calculation

Warning: MLR is Outside of
Typical Range

This error warning will appear if the adjusted MLR reported by a state in section 3.4 is greater than 110% or less than 70%.

3. MLR Calculation

Warning: Unadj. MLR ≠
Numerator ÷ Denominator

This error warning will appear if the Unadjusted MLR reported by a state in section 3.2 does not equal the ratio of the reported MLR numerator over the reported MLR denominator (as reported in
sections 1.3 and 2.3 of the template)

3. MLR Calculation

Warning: Adj. MLR ≠ Unadj.
MLR + Credibility Adj.

If the optional MLR calculation subcomponents were reported by a state (i.e. Unadjusted MLR & Credibility Adjustment ) this error warning will appear when the sum of the optional MLR calculation
subcomponents do not equal the reported adjusted MLR in section 3.4.

4. Remittance

Warning: Enter amounts
either in line 4.6.1 or 4.6.2;
do not enter values in both
lines

This error warning will appear if a state has reported dollar amounts in both sections 4.6.1 and 4.6.2. Dollar amounts should be entered in one line or the other, not both lines.

Optional: Explanation of
reporting errors
END OF WORKSHEET

N/A

Free text fields are present for each reporting error flag. These fields allow states to explain why an error is present or to describe limitations the state may have had when reporting in the template.
Responses may expand beyond the cell column widths and all responses are optional.

Primary Contact Information & Program Reporting Information
Progress Indicators
INCOMPLETE
INCOMPLETE

Contact Information (A-F):
Version Control Information (G-H):

Program Reporting Structure (I-J):
Eligibility Group Reporting Structure (K-L):

INCOMPLETE
INCOMPLETE

MCO Name Reporting Structure (M):
Reporting Period Reporting Structure (N-P):

INCOMPLETE
INCOMPLETE

Information for Primary Contact (Regarding Information Reported in this Template)
Item
A
B
C
D
E
F

Data Format
Enter free text

Contact Name:
Contact Phone:
Contact Email:
Contact Title:
State:
State Agency Name:

Response

Enter number as ###-###-####
Enter email address
Enter free text
Select from set values (drop down)
Enter free text

Version Control:
G Is this template an updated version of a previously submitted summary MLR
report covering the same time period?
Version Control Description:
If "Yes" to question G above, please provide a description of the changes
H
between this version and the prior version of the annual summary MLR
Reporting template.

Select from set values (drop down)

Enter free text

Program Reporting Information
Reporting Structure:
Per 42 CFR 438.8(k)(xii) states must describe how MCO, PIHP, or PAHP data will be aggregated for Medicaid eligibility groups covered under the contract with the state. This section of the template allows states to describe the method by which data will be aggregated
when reporting MLRs. The information included in the reporting structure table below will be used to develop appropriate reporting columns for the "MLR Reporting" tab.
I

J

K

L

M

Program Name

Program Type

Eligibility Group

If Other, Describe
Eligibility Group

MCO, PIHP, or PAHP
Name

Enter free text

Select from set values (drop down)

Select from set values (drop down)

Free text for "other" response

Free text

END OF WORKSHEET

N
MLR Reporting
Period
Start Date
Date (MM/DD/YYYY)

O

P

Q

MLR Reporting
Period End Date

Explanation of Reporting
Period Discrepancy

Misc. Notes

Date (MM/DD/YYYY)

Free text

Free text, optional

Medicaid Medical Loss Ratio (MLR) & Remittance Calculations
Progress Indicators
MLR State Reporting Requirements per 42 CFR 438.74

Are required elements
completed?

Are reporting errors
present?

COMPLETE
COMPLETE
COMPLETE
COMPLETE
COMPLETE

NO ERRORS
NO ERRORS
N/A
NO ERRORS
NO ERRORS

1.3 MLR numerator
2.3 MLR denominator
3.1 Member Months
3.4 Adjusted MLR
4.1, 4.6.1 & 4.9 Remittance (if applicable)

Medicaid MLR and Remittance Calculations

Regulatory Definitions (42 CFR)

Optional: Explanation of reporting errors

Data Format
0

1. Medical Loss Ratio Numerator

Optional
Optional
Required

1.1
1.2
1.3

Incurred Claims
Activities that improve health care quality
MLR numerator

Optional

1.4

Non-Claims costs (not included in numerator)

2. Medical Loss Ratio Denominator

Optional
Optional
Required

§ 438.8(e)(2)
§ 438.8(e)(3)
§ 438.8(e)(1)

Dollar
Dollar
Dollar

§ 438.8(e)(2)(v)(A)

Dollar

2.1
2.2

Premium Revenue
Federal, State, and local taxes and licensing and regulatory fees

§ 438.8(f)(2)
§ 438.8(f)(3)

Dollar
Dollar

2.3

MLR denominator

§ 438.8(f)(1)

Dollar

3. MLR Calculation

Required

3.1

Member Months

Optional

3.2

Unadjusted MLR

Optional

3.3

Credibility adjustment

§ 438.8(h)

Required

3.4

Adjusted MLR

§ 438.8(h)

§ 438.8(b)

Count
Percentage
(rounded to nearest tenth)
Percentage
(rounded to nearest tenth)
Percentage

4. Remittance
Required

4.1

Does the contract include a remittance/payment requirement for being below/above a
specified MLR?

Optional

4.2

If yes, what is the state minimum MLR requirement?

Optional

4.3

Does the state remittance MLR calculation align with the required components and methodology
outlined in 438.8(c)?

Optional

4.4

If no, please describe

Optional

4.5

Calculated MLR for remittance purposes (please enter as a percentage)

Required

4.6.1

Remittance dollar amount owed for MLR reporting period

Optional

4.6.2

Payment dollar amount due to plan for MLR reporting period
MLR reporting period (autopopulated based on response in "Program Information" tab)
Is the remittance period the same as the MLR reporting period?

Optional

4.7

Optional

4.8.1

If no, please include remittance period start date

Optional

4.8.2

If no, please include remittance period end date

Required

O

4.9

O

S

Remittance Methodology Qualitative Response
- Per 42 CFR 438.74(b)(2), if a remittance is owed, the state must describe the methodology
used to determine the State and Federal share of the remittance. Please include in the text field
to the right.
- States that intend to qualify for the SUPPORT Act Section 4001 MLR provision must provide a
description of the methodology used to determine the State and Federal share of the remittance
for the eligibility group described in section 1902(a)(10)(A)(i)(VIII).

Set values (drop down)
Percentage
Set values (drop down)
Free text for "No" response
Percentage
Dollar
Dollar
Autopopulated
Set values (drop down)
MM/DD/YYYY for "No"
response
MM/DD/YYYY for "No"
response

Free text

0

0

0