CMS-10418 MLR Reporting Form

Medical Loss Ratio Annual Reports, MLR Notices, and Recordkeeping Requirements (CMS-10418)

2022-MLR-Reporting-Form-PRA.xlsx

OMB: 0938-1164

Document [xlsx]
Download: xlsx | pdf

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


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:
Marketplace:
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 63 hours or 3,804 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.
Last updated: 4/27/23

Sheet 2: Pt 1 Summary of Data

Part 1 Summary of Data


























































































Line Description SHCE 1
Health Insurance
INDIVIDUAL
Total as of 12/31/22
2
Health Insurance
INDIVIDUAL
Total as of 3/31/23
3
Health Insurance
INDIVIDUAL
Dual Contracts
(Included in Total as of 3/31/23)
4
Health Insurance
INDIVIDUAL
Deferred PY1
(Add)
5
Health Insurance
INDIVIDUAL
Deferred CY
(Subtract)
6
Health Insurance
SMALL GROUP
Total as of 12/31/22
7
Health Insurance
SMALL GROUP
Total as of 3/31/23
8
Health Insurance
SMALL GROUP
Dual Contracts
(Included in Total as of 3/31/23)
9
Health Insurance
SMALL GROUP
Deferred PY1
(Add)
10
Health Insurance
SMALL GROUP
Deferred CY
(Subtract)
11
Health Insurance
LARGE GROUP
Total as of 12/31/22
12
Health Insurance
LARGE GROUP
Total as of 3/31/23
13
Health Insurance
LARGE GROUP
Dual Contracts
(Included in Total as of 3/31/23)
14
Health Insurance
LARGE GROUP
Deferred PY1
(Add)
15
Health Insurance
LARGE GROUP
Deferred CY
(Subtract)
16
Mini-Med
INDIVIDUAL
Total as of 12/31/22
17
Mini-Med
INDIVIDUAL
Total as of 3/31/23
18
Mini-Med
INDIVIDUAL
Dual Contracts
(Included in Total as of 3/31/23)
19
Mini-Med
SMALL GROUP
Total as of 12/31/22
20
Mini-Med
SMALL GROUP
Total as of 3/31/23
21
Mini-Med
SMALL GROUP
Dual Contracts
(Included in Total as of 3/31/23)
22
Mini-Med
LARGE GROUP
Total as of 12/31/22
23
Mini-Med
LARGE GROUP
Total as of 3/31/23
24
Mini-Med
LARGE GROUP
Dual Contracts
(Included in Total as of 3/31/23)
25
Expat
SMALL GROUP
Total as of 12/31/22
26
Expat
SMALL GROUP
Total as of 3/31/23
27
Expat
SMALL GROUP
Dual Contracts
(Included in Total as of 3/31/23)
28
Expat
SMALL GROUP
Deferred PY1
(Add)
29
Expat
SMALL GROUP
Deferred CY
(Subtract)
30
Expat
LARGE GROUP
Total as of 12/31/22
31
Expat
LARGE GROUP
Total as of 3/31/23
32
Expat
LARGE GROUP
Dual Contracts
(Included in Total as of 3/31/23)
33
Expat
LARGE GROUP
Deferred PY1
(Add)
34
Expat
LARGE GROUP
Deferred CY
(Subtract)
35
Student Health
INDIVIDUAL
Total as of 12/31/22
36
Student Health
INDIVIDUAL
Total as of 3/31/23
37
Student Health
INDIVIDUAL
Dual Contracts
(Included in Total as of 3/31/23)
38
Student Health
INDIVIDUAL
Deferred PY1
(Add)
39
Student Health
INDIVIDUAL
Deferred CY
(Subtract)
40
Government Program Plans
Total as of 12/31/22
41
Other Health Business
Total as of 12/31/22
42
Medicare MLR Business
Total as of 12/31/22
43
Uninsured Plans
Total as of 12/31/22
44
Grand Total
Total as of 12/31/22
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 2.17)












































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 claims recovered through fraud reduction efforts (MLR Form Part 2, Line 2.18) 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 Reserved












































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 Total allowable quality improvement expenses












































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 Lines 5.5c or 9)












































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












































5.5c Federal and State employment taxes and assessments












































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











































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












































Sheet 3: Pt 2 Premium and Claims

Part 2 Premium and Claims


























































































Line Description SHCE 1
Health Insurance
INDIVIDUAL
Total as of 12/31/22
2
Health Insurance
INDIVIDUAL
Total as of 3/31/23
3
Health Insurance
INDIVIDUAL
Dual Contracts
(Included in Total as of 3/31/23)
4
Health Insurance
INDIVIDUAL
Deferred PY1
(Add)
5
Health Insurance
INDIVIDUAL
Deferred CY
(Subtract)
6
Health Insurance
SMALL GROUP
Total as of 12/31/22
7
Health Insurance
SMALL GROUP
Total as of 3/31/23
8
Health Insurance
SMALL GROUP
Dual Contracts
(Included in Total as of 3/31/23)
9
Health Insurance
SMALL GROUP
Deferred PY1
(Add)
10
Health Insurance
SMALL GROUP
Deferred CY
(Subtract)
11
Health Insurance
LARGE GROUP
Total as of 12/31/22
12
Health Insurance
LARGE GROUP
Total as of 3/31/23
13
Health Insurance
LARGE GROUP
Dual Contracts
(Included in Total as of 3/31/23)
14
Health Insurance
LARGE GROUP
Deferred PY1
(Add)
15
Health Insurance
LARGE GROUP
Deferred CY
(Subtract)
16
Mini-Med
INDIVIDUAL
Total as of 12/31/22
17
Mini-Med
INDIVIDUAL
Total as of 3/31/23
18
Mini-Med
INDIVIDUAL
Dual Contracts
(Included in Total as of 3/31/23)
19
Mini-Med
SMALL GROUP
Total as of 12/31/22
20
Mini-Med
SMALL GROUP
Total as of 3/31/23
21
Mini-Med
SMALL GROUP
Dual Contracts
(Included in Total as of 3/31/23)
22
Mini-Med
LARGE GROUP
Total as of 12/31/22
23
Mini-Med
LARGE GROUP
Total as of 3/31/23
24
Mini-Med
LARGE GROUP
Dual Contracts
(Included in Total as of 3/31/23)
25
Expat
SMALL GROUP
Total as of 12/31/22
26
Expat
SMALL GROUP
Total as of 3/31/23
27
Expat
SMALL GROUP
Dual Contracts
(Included in Total as of 3/31/23)
28
Expat
SMALL GROUP
Deferred PY1
(Add)
29
Expat
SMALL GROUP
Deferred CY
(Subtract)
30
Expat
LARGE GROUP
Total as of 12/31/22
31
Expat
LARGE GROUP
Total as of 3/31/23
32
Expat
LARGE GROUP
Dual Contracts
(Included in Total as of 3/31/23)
33
Expat
LARGE GROUP
Deferred PY1
(Add)
34
Expat
LARGE GROUP
Deferred CY
(Subtract)
35
Student Health
INDIVIDUAL
Total as of 12/31/22
36
Student Health
INDIVIDUAL
Total as of 3/31/23
37
Student Health
INDIVIDUAL
Dual Contracts
(Included in Total as of 3/31/23)
38
Student Health
INDIVIDUAL
Deferred PY1
(Add)
39
Student Health
INDIVIDUAL
Deferred CY
(Subtract)
40
Government Program Plans
Total as of 12/31/22
41
Other Health Business
Total as of 12/31/22
42
Medicare MLR Business
Total as of 12/31/22
43
Uninsured Plans
Total as of 12/31/22
44
Grand Total
Total as of 12/31/22
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












































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 Reserved












































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 State Reinsurance Program payments












































2.17 Total incurred claims Pt 2, Ln 2.15











































2.18 Allowable claims recovered through fraud reduction efforts (the smaller of Lines 2.18a or 2.18b) Pt 1, Ln 4











































2.18a Total fraud reduction expense Pt 3, Col 7, Ln 1.11/2.11/3.11/5.11/6.11











































2.18b Total fraud recoveries that reduced paid claims in Line 2.1 Pt 2, Ln 3











































2.19 Reconciled payments of cost-sharing reductions













































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
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
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 Reconciled payments of cost-sharing reductions



































1.5 Federal Transitional Reinsurance Program payments from HHS



































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 Reserved



































1.8 Shared Savings payments to enrollees



































1.9 MLR numerator



































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. Credibility Adjustment



































3.1 Life-years



































3.2 Base credibility factor



































3.3 Average deductible



































3.4 Deductible factor



































3.5 Credibility adjustment (Lines 3.2 x 3.4 (do not round))



































4. MLR Calculation (for issuers with at least 1,000 life years in the Total column of Line 3.1)



































4.1 Preliminary MLR (Lines 1.9 / 2.3)



































4.2 Credibility adjustment (Line 3.5, if applicable)



































4.3 Credibility-adjusted MLR (Lines 4.1 + 4.2)



































5. Rebate Calculation



































5.1 MLR standard



































5.2 Credibility-adjusted MLR (Line 4.3)



































5.3 Adjusted earned premium (Lines 2.1 - 2.2 CY)



































5.4 Rebate amount if credibility-adjusted MLR is less than MLR standard (Lines (5.1 - 5.2) x 5.3)



































5.5 Optional: single-year rebate liability (Line 2.3 x [Line 5.1 - (Lines 4.1 + 4.2)])



































5.6 Optional: paid rebate liability (see instructions)



































5.7 Optional: unpaid rebate liability (Lines 5.5 - 5.6)



































5.8 Limited payable rebate amount (see instructions)



































6. Temporary Adjustments



































6.1 Reserved for future use



































6.1a Reserved for future use



































6.1b Reserved for future use



































6.2 Reserved for future use



































6.2a Reserved for future use



































6.2b Reserved for future use



































6.2c Reserved for future use



































6.2d Reserved for future use



































6.2e Reserved for future use



































6.2f Reserved for future use




































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 5.4 or 5.8)








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








3.e Amount of rebates prepaid in advance of filing the MLR Form








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:









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 sold any business in the MLR reporting year, and the novation was effective during the MLR reporting year, provide the name(s) of the entity(ies) to which the business was sold 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.











Sheet 7: Pt 6 Expense Allocation

Part 6 Expense Allocation






1. Incurred Claims


Incurred Claims
1
Description of Expense Element (by Type)
Incurred Claims
2
NEW
Incurred Claims
3
Detailed Description of Expense Allocation Methods





















































































2.a Federal taxes and assessments


Federal taxes and assessments
1
Description of Expense Element (by Type)
Federal taxes and assessments
2
NEW
Federal taxes and assessments
3
Detailed Description of Expense Allocation Methods





























2.b State insurance, premium and other taxes


State insurance, premium and other taxes
1
Description of Expense Element (by Type)
State insurance, premium and other taxes
2
NEW
State insurance, premium and other taxes
3
Detailed Description of Expense Allocation Methods





























2.c Community benefit expenditures


Community benefit expenditures
1
Description of Expense Element (by Type)
Community benefit expenditures
2
NEW
Community benefit expenditures
3
Detailed Description of Expense Allocation Methods





























2.d Regulatory authority licenses and fees


Regulatory authority licenses and fees
1
Description of Expense Element (by Type)
Regulatory authority licenses and fees
2
NEW
Regulatory authority licenses and fees
3
Detailed Description of Expense Allocation Methods





























3.a Improve health outcomes


Improve health outcomes
1
Description of Expense Element (by Type)
Improve health outcomes
2
NEW
Improve health outcomes
3
Detailed Description of Expense Allocation Methods













































3.b Activities to prevent hospital readmission


Activities to prevent hospital readmission
1
Description of Expense Element (by Type)
Activities to prevent hospital readmission
2
NEW
Activities to prevent hospital readmission
3
Detailed Description of Expense Allocation Methods













































3.c Improve patient safety and reduce medical errors


Improve patient safety and reduce medical errors
1
Description of Expense Element (by Type)
Improve patient safety and reduce medical errors
2
NEW
Improve patient safety and reduce medical errors
3
Detailed Description of Expense Allocation Methods













































3.d Wellness and health promotion activities


Wellness and health promotion activities
1
Description of Expense Element (by Type)
Wellness and health promotion activities
2
NEW
Wellness and health promotion activities
3
Detailed Description of Expense Allocation Methods













































3.e Health Information Technology expenses related to healthcare quality


Health Information Technology expenses related to healthcare quality
1
Description of Expense Element (by Type)
Health Information Technology expenses related to healthcare quality
2
NEW
Health Information Technology expenses related to healthcare quality
3
Detailed Description of Expense Allocation Methods













































4.a Cost containment expenses not included in quality improvement expenses


Cost containment expenses not included in quality improvement expenses
1
Description of Expense Element (by Type)
Cost containment expenses not included in quality improvement expenses
2
NEW
Cost containment expenses not included in quality improvement expenses
3
Detailed Description of Expense Allocation Methods













































4.b All other claims adjustment expenses


All other claims adjustment expenses
1
Description of Expense Element (by Type)
All other claims adjustment expenses
2
NEW
All other claims adjustment expenses
3
Detailed Description of Expense Allocation Methods













































4.c Direct sales salaries and benefits


Direct sales salaries and benefits
1
Description of Expense Element (by Type)
Direct sales salaries and benefits
2
NEW
Direct sales salaries and benefits
3
Detailed Description of Expense Allocation Methods













































4.d Agents and brokers fees and commissions


Agents and brokers fees and commissions
1
Description of Expense Element (by Type)
Agents and brokers fees and commissions
2
NEW
Agents and brokers fees and commissions
3
Detailed Description of Expense Allocation Methods













































4.e Other taxes


Other taxes
1
Description of Expense Element (by Type)
Other taxes
2
NEW
Other taxes
3
Detailed Description of Expense Allocation Methods













































4.f Other general and administrative expenses


Other general and administrative expenses
1
Description of Expense Element (by Type)
Other general and administrative expenses
2
NEW
Other general and administrative expenses
3
Detailed Description of Expense Allocation Methods













































4.g Community benefit expenditures


Community benefit expenditures
1
Description of Expense Element (by Type)
Community benefit expenditures
2
NEW
Community benefit expenditures
3
Detailed Description of Expense Allocation Methods










































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, 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 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

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



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