Track Change: MLR Report Workbook

^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			Total $	PMPM
1.	Revenue
	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		$ -
	1.3	MA Rebate for Part B Premium Reduction (note: included as revenue)		$ -
	1.4	MA Rebate for Part D Basic Premium Reduction		$ -
	1.5	MSA Enrollee Deposit (note: included as revenue)		$ -
	1.6	Part D direct subsidy, using final risk scores		$ -
	1.7	Part D federal reinsurance subsidy (prospective and reconciliation adjustments)		$ -
	1.8	Part D Low Income Premium Subsidy Amount		$ -
	1.9	Part D risk corridor payments		$ -
	1.10	Total	$ -	$ -

2. Claims

   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

2.1b.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 Non-Primarily Health Related Items – Other

2.1b.19 Out-of-network Services (informational only; amount already incl. in Lines 2.1a through 2.1b.1-2.1b.18)

2.1c Claims incurred for Part D prescription drugs

2. Liability and reserves for claims incurred only during CY 2023, calc'd as of 9/30/2024

3. 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

4. Contingent benefit and lawsuit reserves

5. ^{MA Rebate for Part B Premium Reduction $}

6. ^{MSA Enrollee Deposit $}

7. ^{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)

N/A

$ -

^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)

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)

$ -

$ -

$ -

$ -

$ -

$ -

7.	Total Member Months

-

8.	Plan-Specific Data

(a)	(b)	(c)	(d)
	Enter the list of plans offered under contract in CY 2023, using Plan ID format: Hxxxx- xxx-xx	CY 2023 Member Months	For MA Medical Savings Account (MSA) contracts only: MSA Plan Deductible
Plan1
Plan2
Plan3
Plan4
Plan5
Plan6
Plan7
Plan8
Plan9
Plan10

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	N/A
	3.4	MSA deductible factor	N/A

4.	MLR Calculation
	4.1	Unadjusted MLR	$ -
	4.2	Credibility adjustment	N/A
	4.3	Adjusted MLR	N/A

5.	Remittance Calculation
	5.1	Is contract either partially-credible or fully-credible? (Yes/No)	Yes
	5.2	MLR standard	85.0%
	5.3	Adjusted MLR	N/A
	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)	$ -

Section 2: MLR Credibility Adjustments Table

MA contracts		PD stand-alone contracts
member months	credibility adjustment	member months	credibility adjustment
< 2,400	non-cred	< 4,800	non-cred
2,400	8.4%	4,800	8.4%
6,000	5.3%	12,000	5.3%
12,000	3.7%	24,000	3.7%
24,000	2.6%	48,000	2.6%
60,000	1.7%	120,000	1.7%
120,000	1.2%	240,000	1.2%
180,000	1.0%	360,000	1.0%
> 180,000	fully cred	> 360,000	fully cred

Section 3: MSA Deductible Factors

weighted average deductible	deductible factor
< $2,500	1.000
$2,500	1.164
$5,000	1.402
≥ $10,000	1.736

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.

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 (CMS- 10476). 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.