CMS-10418 - 2016-Risk-Corridor-Plan-Level-Instructions-x

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

CMS-10418 - 2016-Risk-Corridor-Plan-Level-Instructions-x

OMB: 0938-1164

Document [pdf]

Download: pdf | pdf

OMB Control Number: 0938-1164
Expiration Date: XX/XXXX

Centers for Medicare & Medicaid Services (CMS) Risk Corridors Plan-level Data
Form Filing Instructions for the 2016 Benefit Year
Table of Contents
PURPOSE

GENERAL DEFINITIONS

GENERAL INSTRUCTIONS

Tab 1 - Risk Corridors Plan Level Data – Individual

Table 1 - Non-Grandfathered ACA-Compliant Plans: Row Definitions and Instructions
Tab 1 - Risk Corridors Plan Level Data – Individual

5
6

Table 1 - Non-Grandfathered ACA-Compliant Plans: Column Definitions and Instructions
Tab 1 - Risk Corridors Plan Level Data – Individual

6
7

Table 2 - Exchange QHPs: Column Definitions and Instructions
Tab 1 - Risk Corridors Plan Level Data – Individual

7
8

Table 3 - Off-Exchange QHPs: Column Definitions and Instructions
Tab 1 - Risk Corridors Plan Level Data – Individual

8
9

Table 4 - Plans Substantially the Same as Exchange QHPs: Column Definitions and Instructions
Tab 2 - Risk Corridors Plan Level Data – Small Group

9
10

Table 1 - Non-Grandfathered ACA-Compliant Plans: Column Definitions and Instructions
Tab 2 - Risk Corridors Plan Level Data – Small Group

10
11

Table 2 - Exchange QHPs: Column Definitions and Instructions
Tab 2 - Risk Corridors Plan Level Data – Small Group

11
12

Table 3 - Off-Exchange QHPs: Column Definitions and Instructions
Tab 2 - Risk Corridors Plan Level Data – Small Group

12
13

Table 4 - Plans Substantially the Same as Exchange QHPs: Column Definitions and Instructions
Tab 3: Risk Corridors Payment or Charge Calculation

13
14

Column Instructions

Tab 3: Risk Corridors Payment or Charge Calculation

APPENDIX A: Calculation References

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 6 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.

PURPOSE

The Patient Protection and Affordable Care Act, Public Law 111-148, enacted on March 23, 2010 (the “Affordable Care
Act”), provides for three premium stabilization programs to mitigate the negative impacts of adverse selection and
market uncertainty. Section 1342 of the Affordable Care Act establishes a temporary risk corridors program that is
designed to provide qualified health plans (QHPs) in the individual and small group markets with greater payment
stability during the first three years of Marketplace operation. CMS has issued implementing regulations for the risk
corridors program at 45 CFR Part 153. The implementing regulations for the risk corridors program can be found at:
http://www.cms.gov/cciio/Resources/Regulations-and-Guidance/index.html#Premium Stabilization Programs.
These are the filing instructions for the Risk Corridors Plan-level Data Form for the 2016 benefit year. Section 153.530 of
45 CFR Part 153 sets forth the data requirements for this report. Each company with at least one health insurance issuer
that offered a certified QHP through the Federal or State-based Marketplace during the 2016 benefit year will submit
the Risk Corridors Plan Level Data Form with plan-specific premium data for each of its QHP issuers in the individual or
small group markets. This form is only required to be submitted by companies with at least one issuer with at least one
plan that is certified and offered through either the Federal or State-based Marketplace. The data included in the Risk
Corridors Plan-level Data Form will be used to calculate risk corridors payments and charges as defined in 45 CFR
§153.500. CMS will calculate risk corridors payments and charges only based on the plan-specific premium information
of plans that are Exchange QHPs, off-Exchange offerings that are the same as an Exchange QHP, and plans offered
outside of the Exchange that are substantially the same as an Exchange QHP (as defined below in these filing
instructions, and at 45 CFR §153.500).
Health insurance issuers that participate in the risk corridors program must comply with other data submission
requirements that are not covered in the Risk Corridors Plan-level Data Form or these filing instructions. Under
§153.530, CMS will also require all QHP issuers to submit data on premiums earned, allowable costs, and allowable
administrative costs for purposes of the risk corridors calculation. As described in §153.520, all QHP issuers must submit
to CMS information on how revenues and expenses in allowable costs and target amount are allocated to each QHP and
across plans. Companies that are required to submit the Risk Corridors Plan-level Data Form for the 2016 benefit year
must also submit the Medical Loss Ratio (MLR) Annual Reporting Form for the 2016 MLR reporting year.
The 2016 MLR Annual Reporting Form and its Form Filing Instructions can be found on the CMS website at:
http://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing.html

GENERAL DEFINITIONS

Any terms that are not explicitly defined or referenced in these instructions have the definitions assigned to them in the
MLR Form filing instructions or Title 45 of the Code of Federal Regulations. The terms below are solely for the purposes
of the Risk Corridors Plan-level Form, and do not apply for any other purpose.
Individual Market
All health insurance policies issued directly to an individual for self-only or dependent coverage.
Small Group Market

All policies issued to small groups (including fully insured State and local government small groups), based on the definition
of small group that applies for the purposes of the risk corridors program. For the purposes of the risk corridors program,
the definition of employer size and the employee counting method applicable under state law will determine whether a
group is a small group.
Premium Earned
As defined at 45 CFR 153.500 and 45 CFR 158.130, all monies paid by a policyholder or subscriber as a condition of receiving
coverage from the issuer, including any fees or other contributions associated with the health plan and reported on a
direct basis. Includes advance payments of the premium tax credit.
ACA-compliant Plans
Plans that were compliant with Affordable Care Act market reforms during the 2016 calendar year. The Affordable Care
Act market reforms are set forth in sections 2701 through 2707 of the Public Health Service Act (Public Law 78-410), and
the implementing regulations in Title 45 of the Code of Federal Regulations.
Exchange QHP
A plan certified and offered through the Federal or State-based Marketplace, as defined at 45 CFR 155.20. For the
purposes of the risk corridors program, a stand-alone dental plan that is offered through the Marketplace is not considered
an “Exchange QHP”, and does not participate in the risk corridors program.
Off-Exchange QHP
A plan offered outside of the Exchange is considered an off-Exchange QHP if it is the same as a certified Exchange QHP
that is offered by the same issuer. A plan offered by a QHP issuer outside the Exchange would be considered “the same
plan” as a QHP only if the two plans were identical with respect to benefits, provider network, service area, and costsharing
structure. Off-Exchange QHPs participate in the risk corridors program. Note: An offering that meets this definition is an
“off-Exchange QHP”, regardless of the HIOS plan ID that was assigned to the offering for the 2016 benefit year. However,
in future guidance, CMS intends to specify that all plans that meet the definition of being the “same plan” must be assigned
the same standard component ID in HIOS.
Guaranteed Availability of an Exchange QHP
CMS has interpreted the guaranteed availability requirement at 45 CFR Part 147 as requiring any plan offered through the
Exchange to be available for enrollment outside of the Exchange. Accordingly, any individual could enroll in the same plan
as an Exchange QHP (as defined above) without having to enroll through the Exchange (for example, the individual could
enroll directly through the issuer in a plan that is the same as an Exchange plan). Because of this requirement, each plan
offered through the Exchange will have an identical offering that is offered outside of the Exchange.
Substantially the Same as an Exchange QHP
As defined in 45 CFR 153.500, a plan offered outside of the Exchange is substantially the same as an Exchange QHP, if it is
the same as an Exchange QHP (according to the definition above), except for any variations in benefits and cost-sharing
structure that are directly tied to Federal or State requirements or prohibitions on the coverage of benefits (for example,
coverage of the pediatric dental essential health benefit) that apply differently to plans depending on whether they are
offered through the Exchange. These plans may also vary from the corresponding QHP with respect to changes in network
(for example, addition of dentists to provide pediatric dental services) and cost sharing (for example, the addition of a
copay for pediatric dental services) to the extent relating directly to the required or prohibited benefits.

GENERAL INSTRUCTIONS

•

Filing MLR and risk corridors data requires a one-time registration by the issuer through the secured CMS
Enterprise Portal for the Health Insurance Oversight System (HIOS). If an issuer registered for a previous MLR
reporting year, it does not need to reregister, but will need to confirm or update its issuer associations. The CMS
Enterprise Portal can be accessed at https://portal.cms.gov/wps/portal/unauthportal/home/.

•

This template will be available for download on June 1, 2017. Uploads will be accepted between July 1- July
31.

•

Submitters MUST upload the MLR Annual Reporting Form for the 2016 benefit year before uploading the Risk
Corridors Plan-level Data Form. Failure to take this step will result in a submission error and the Risk Corridors
Plan-level Data Form will not be uploaded or processed.

•

This form is intended only for issuers that offered certified QHPs in the 2016 benefit year. If CMS cannot verify
a QHP added by the user and listed in this form, we will disregard risk corridors data associated with that QHP.

•

A company with at least one QHP issuer must submit data for each of its QHP issuers on record in HIOS.

•

For issuers that experienced a change of ownership during 2016, data for the full benefit year should be
submitted by the acquiring entity for all issuers under common ownership.

•

If data has been submitted previously, the current submission will completely overwrite existing data.

•

Submitters must complete the company information on the first tab of the Risk Corridors Plan-level Form.
The fields in this table that are required for the Risk Corridors plan level form submission are marked with a
cross symbol (Ɨ).

Tab 1 - Risk Corridors Plan Level Data – Individual
Table 1 - Non-Grandfathered ACA-Compliant Plans: Row Definitions and Instructions
Table 1: Non-Grandfathered ACA-Compliant Plans
Row
1. All nonGrandfathered
ACA-compliant
plans

Definitions & Instructions
Grandfathered plans are plans that were in effect on March 23, 2010, and that have not been
changed in ways that substantially reduce benefits or increase cost-sharing for consumers,
pursuant to the regulations at 45 CFR Part 147.140.
Information should be submitted only for non-grandfathered, ACA-compliant plans (as defined in
the General Definitions section of these instructions).

Tab 1 - Risk Corridors Plan Level Data – Individual
Table 1 - Non-Grandfathered ACA-Compliant Plans: Column Definitions and Instructions
Table 1: Non-Grandfathered ACA-Compliant Plans
Column
A.
Individual
Total
Premium
Earned

Definitions & Instructions
This column requires input from the user.
Total premium earned is the total premium charged for members in all policies that are written directly or
acquired by the issuer during the full reporting year.
This column is the issuer’s total premium earned for the individual market (as defined in the General
Definitions section of these instructions).
Note: the total premium earned amount in column A must match the premium earned amount in Part 3,
Line 2.1, column 4A of the MLR Annual Reporting Form or the submission will be rejected.

B.
Individual
Proportion
of Market
Premium

Please refer to Appendix A - 2016 Risk Corridors Plan-level Data Form: Formula Resource for a
description of this formula.
The proportion of the issuer’s individual market total premium earned represented in column C.
This column is auto-populated with 100%.

Tab 1 - Risk Corridors Plan Level Data – Individual
Table 2 - Exchange QHPs: Column Definitions and Instructions
Table 2: Exchange QHPs
Column
C. Plan
Name

Definitions & Instructions
This column is auto-populated for the user.
The marketing name associated with the plan that is identified by its HIOS plan ID in Column D. This
column will be auto-populated for the user and will be the same marketing name that is provided for the
plan ID in HIOS. This column cannot be blank if data is entered in Column E for the same row.

Names of plans that are in use but are missing from the list: If the user identifies an Exchange QHP that
is missing from the auto-populated list, the user should enter the plan name according to the instructions
above.
D.
HIOS The 14-digit HIOS standard component ID for each plan that the issuer offers through the Exchange. The
Plan ID
list of HIOS plan IDs will include all plans that are certified to be offered through the Federally Facilitated
Marketplace (FFM) and that CMS believes has been certified to be offered through the State-based
Marketplace (SBM).
This column will be auto-populated for the user and will include the plan IDs of all Exchange plans that
are registered in HIOS.
A HIOS plan ID cannot be offered in both the individual and the small group markets.

E.
Individual
Total
Premium
Earned

HIOS plan IDs that are in use but are missing from the list: If the user is aware that the issuer is offering a
plan through the Federal or State Marketplace and that HIOS plan ID is not auto-populated in this
column, the user may manually input the HIOS plan ID for the QHP that it offered during the 2016 plan
year. This column cannot be blank if data is entered in Column E for the same row.
This column is the total premium earned (as defined for Table 1), for the HIOS plan ID in column D.
HIOS plan IDs that are not in use: In some cases, HIOS plan IDs in column D may be auto-populated for
plans that are no longer certified, or that have no enrollment, or that the issuer has consolidated with
another plan, or that the issuer is not actively marketing. In these cases, and in similar cases where the
issuer does not have relevant information related to premium earned because there is no plan operating
under the HIOS plan ID, the issuer should enter “0” in Column E.
Please note that Column E should not be left blank in any case.

F.
Individual
Proportion
of Market
Premium

Please refer to Appendix A - 2016 Risk Corridors Plan-level Data Form: Formula Resource for a
description of this formula.
This column is the proportion of individual market total premium earned (indicated in Table 1, Column A)
attributable to the HIOS plan ID in Column D.
This column equals Column E divided by Column A and will be auto-populated for the user.
Please refer to Appendix A - 2016 Risk Corridors Plan-level Data Form: Formula Resource for a
description of this formula.

Table 3 - Off-Exchange QHPs: Column Definitions and Instructions

Tab 1 - Risk Corridors Plan Level Data – Individual
Table 3: Off-Exchange QHPs
Column
G. Plan
Name

Definitions & Instructions
This column in auto-populated for the user.
The marketing name associated with the plan that is identified by its HIOS plan ID in Column H. This
column will be auto-populated for the user and will be the same marketing name that is provided for the
plan ID in HIOS. This column cannot be blank if data is entered in Column I for the same row.

Names of plans that are in use but are missing from the list: If the user identifies an Exchange QHP that
is missing from the auto-populated list, the user should enter the same plan name added in Table 2, in
this row.
H.
HIOS This column will be auto-populated for the user and will include the HIOS plan IDs of all plans that are
Plan ID
offered off of the Exchange that are identical to Exchange plans that are registered in HIOS.
This HIOS Plan ID will be the same as the 14-digit HIOS standard component ID for each plan that the
issuer offers through the Exchange. The list of HIOS plan IDs will include all off-Exchange offerings that
are identical, meaning the offering has the same benefits, cost-sharing structure, provider network, and
service area as a plan that is certified to be offered through the Federally Facilitated Marketplace (FFM)
or State-based Marketplace (SBM). Each HIOS plan ID that is offered through the Exchange will have a
corresponding, identical offering that is offered outside of the Exchange. [Refer to the discussion of the
guaranteed availability requirement in the General Definitions section of these instructions.]
A HIOS plan ID cannot be offered in both the individual and the small group markets.
HIOS plan IDs that are missing from the list: Each off-Exchange HIOS plan ID in this column must
correspond to an Exchange HIOS plan ID in Table 2, column D. Users will not be permitted to manually
add a HIOS plan ID to column H that does not correspond to a HIOS plan ID in column D. However, if a
user manually inputs the HIOS plan ID for a QHP that is offered through the Exchange in column H [refer
to the instructions for column D for situations where this may occur], the user must input the identical
14digit plan HIOS plan ID that it added to column D in the corresponding row in Column H.

I.
Individual
Total
Premium
Earned

J.
Individual
Proportion
of Market
Premium

Please refer to Appendix A - 2016 Risk Corridors Plan-level Data Form: Formula Resource for a
description of this formula.
This column is the proportion of individual market total premium earned (indicated in Table 1, Column A)
attributable to the HIOS plan ID in Column H.
This column equals Column I divided by Column A for individual plans and will be auto-populated.
Please refer to Appendix A - 2016 Risk Corridors Plan-level Data Form: Formula Resource for a
description of this formula.

Tab 1 - Risk Corridors Plan Level Data – Individual
Table 4 - Plans Substantially the Same as Exchange QHPs: Column Definitions and Instructions
Table 4: Plans Substantially the Same as Exchange QHPs
Column

K. Plan
Name
L. HIOS
Plan ID

Definitions & Instructions
The marketing name associated with the plan that is identified by its HIOS plan ID in Column L. This
column will require manual input by the user. This column cannot be blank if data is entered in Column
M for the same row.
The 14-digit HIOS standard component ID for each off-Exchange plan that the issuer offers that is
substantially the same as an Exchange plan. Each Exchange plan is represented by a HIOS plan ID that
is auto-populated in column D. [Refer to the General Definitions section of these instructions for the
definition of a plan that is substantially the same as an Exchange plan.]
This column will require user input of the 14-digit HIOS plan ID that corresponds to a plan that is
substantially similar to an Exchange plan. The user must input the HIOS plan ID for the substantially
similar plan in column L in the same row as the corresponding Exchange HIOS plan ID that is indicated in
column D.
A HIOS plan ID cannot be offered in both the individual and the small group markets.
Addition of HIOS plan IDs: The number of HIOS plan IDs that a user may input in this column is limited to
the number of Exchange HIOS plan IDs that are listed in column D. No additional HIOS plan IDs will be
permitted in this column. This column cannot be blank if data is entered in Column M for the same row.
User added HIOS plan IDs for substantially the same plans in Table 4 cannot be the same as any HIOS
plan IDs in either Tables 2 or 3.

M.
Individual
Total
Premium
Earned

N.
Proportion
of Market
Premium

No substantially similar plans: If the issuer does not offer any plan that is substantially similar to an
Exchange QHP, the user should leave this column blank.
This column is the total premium earned (as defined for Table 1), for the HIOS plan ID in column L.
Please note that Column M should not be left blank in any case.
Please refer to Appendix A - 2016 Risk Corridors Plan-level Data Form: Formula Resource for a
description of this formula.
This column is the proportion individual market total premium earned (indicated in Table 1, Column A)
attributable to the HIOS plan ID in Column L.
This column equals Column M divided by Column A for individual market plans and will be autopopulated
for the user.
Please refer to Appendix A – 2016 Risk Corridors Plan-level Data Form: Formula Resource for a
description of this formula.

Tab 2 - Risk Corridors Plan Level Data – Small Group
Table 1 - Non-Grandfathered ACA-Compliant Plans: Column Definitions and Instructions
Table 1: Non-Grandfathered ACA-Compliant Plans
Column
A. Small
Group
Total
Premium
Earned

Definitions & Instructions
This column requires input from the user.
Total premium earned is the total premium charged for members in all policies that are written directly or
acquired by the issuer during the full reporting year.
This column is the issuer’s total premium earned for the small group market (as defined in the General
Definitions section of these instructions).
Note: the total premium earned amount in column A must match the premium earned amount in Part 3,
Line 2.1, column 8A of the MLR Annual Reporting Form or the submission will be rejected.

B. Small
Group
Proportion
of Market
Premium

Please refer to Appendix A - 2016 Risk Corridors Plan-level Data Form: Formula Resource for a
description of this formula.
The proportion of the issuer’s small group market total premium earned represented in column C.
This column is auto-populated with 100%.

Tab 2 - Risk Corridors Plan Level Data – Small Group
Table 2 - Exchange QHPs: Column Definitions and Instructions
Table 2: Exchange QHPs
Column
C. Plan
Name

Definitions & Instructions
This column in auto-populated for the user.
The marketing name associated with the plan that is identified by its HIOS plan ID in Column D. This
column will be auto-populated for the user and will be the same marketing name that is provided for the
plan ID in HIOS. This column cannot be blank if data is entered in Column E for the same row.

E. Small
Group
Total
Premium
Earned

HIOS plan IDs that are in use but are missing from the list: If the user is aware that the issuer is offering a
plan through the Federal or State Marketplace and that HIOS plan ID is not auto-populated in this
column, the user may manually input the HIOS plan ID for the QHP that it offered during the 2016 plan
year. This column cannot be blank if data is entered in Column E for the same row.
This column is the total premium earned (as defined for Table 1), for the HIOS plan ID in column D.
HIOS Plan IDs that are not in use: In some cases, HIOS plan IDs in column D may be auto-populated for
plans that are no longer certified, or that have no enrollment, or that the user has consolidated with
another plan, or that the issuer is not actively marketing. In these cases, and in similar cases where the
issuer does not have relevant information related to premium earned because there is no plan operating
under the HIOS plan ID, the user should enter “0” in Column E.

Please note that Column E should not be left blank in any case.

F.
Small
Group
Proportion
of Market
Premium

Please refer to Appendix A - 2016 Risk Corridors Plan-level Data Form: Formula Resource for a
description of this formula.
This column is the proportion of small group market total premium earned (indicated in Table 1, Column
A) attributable to the HIOS plan ID in Column D.
This column equals Column E divided by Column A and will be auto-populated for the user.
Please refer to Appendix A - 2016 Risk Corridors Plan-level Data Form: Formula Resource for a
description of this formula.

Table 3 - Off-Exchange QHPs: Column Definitions and Instructions
Table 3: Off-Exchange QHPs

Tab 2 - Risk Corridors Plan Level Data – Small Group
Column
G. Plan
Name

Names of plans that are in use but are missing from the list: If the user identifies an Exchange QHP that
is missing from the auto-populated list, the user should enter the same plan name added in Table 2, in
this row.
H.
HIOS This column will be auto-populated for the user and will include the plan IDs of all plans that are offered
Plan ID
off of the Exchange that are identical to Exchange plans that are registered in HIOS.
This HIOS Plan ID will be the same as the 14-digit HIOS standard component ID for each plan that the
issuer offers through the Exchange. The list of HIOS plan IDs will include all off-Exchange offerings that
are identical, meaning the offering has the same benefits, cost-sharing structure, provider network, and
service area as a plan that is certified to be offered through the Federally Facilitated Marketplace (FFM)
or State-based Marketplace (SBM). Each HIOS plan ID that is offered through the Exchange will have a
corresponding, identical offering that is offered outside of the Exchange. [Refer to the discussion of the
guaranteed availability requirement in the General Definitions section of these instructions.]
A HIOS plan ID cannot be offered in both the individual and the small group markets.
HIOS plan IDs that are missing from the list: Each off-Exchange HIOS plan ID in this column must
correspond to an Exchange HIOS plan ID in Table 2, column D. Users will not be permitted to manually
add HIOS plan IDs to column H that do not correspond to a HIOS plan ID in column D. However, if an
user manually inputs the HIOS plan ID for a QHP that is offered through the Exchange in column H [refer
to the instructions for column D for situations where this may occur], the user must input the identical
14digit plan HIOS plan ID that it added to column D in the corresponding row in Column H.

I. Small
Group
Total
Premium
Earned

J. Small
Group
Proportion
of Market
Premium

This column cannot be blank if data is entered in Column I for the same row.
This column is the total premium earned (as defined for Table 1), for the HIOS plan ID in column H.
HIOS plan IDs that are not in use: In some cases, the HIOS plan IDs that are auto-populated in column H
may correspond to an Exchange HIOS plan ID in column D that is no longer in use. [Refer to the
instructions for Column D in Table 2 above for a description of Exchange HIOS plan IDs that are no
longer in use.] For each plan ID not in use where “0” is entered in column E of Table 2, the user must
enter “0” in this column.
Please refer to Appendix A - 2016 Risk Corridors Plan-level Data Form: Formula Resource for a
description of this formula.
This column is the proportion of small group market total premium earned (indicated in Table 1, Column
A) attributable to the HIOS plan ID in Column H.
This column equals Column I divided by Column A for small group plans and will be auto-populated for the
user.
Please refer to Appendix A - 2016 Risk Corridors Plan-level Data Form: Formula Resource for a
description of this formula.

Table 4 - Plans Substantially the Same as Exchange QHPs: Column Definitions and Instructions

Tab 2 - Risk Corridors Plan Level Data – Small Group
Table 4: Plans Substantially the Same as Exchange QHPs
Column

K. Plan
Name
L. HIOS
Plan ID

M. Small
Group
Total
Premium
Earned

N.
Proportion
of Market
Premium

No substantially similar plans: If the issuer does not offer any plan that is substantially similar to an
Exchange QHP, the user should leave this column blank.
This column is the total premium earned (as defined for Table 1), for the HIOS plan ID in column L.
Please note that Column M should not be left blank in any case.
Please refer to Appendix A - 2016 Risk Corridors Plan-level Data Form: Formula Resource for a
description of this formula.
This column is the proportion small group market total premium earned (indicated in Table 1, Column A)
attributable to the HIOS plan ID in Column L.
This column equals Column M divided by Column A for small group market plans and will be
autopopulated for the user.
Please refer to Appendix A - 2016 Risk Corridors Plan-level Data Form: Formula Resource for a
description of this formula.

Tab 3: Risk Corridors Payment or Charge Calculation
Column Instructions
Risk Corridors Payment or Charge Calculation
Column

Definitions & Instructions

A. Individual

If an issuer does not participate in the individual market, the user should ignore this column.

B. Small Group

If an issuer does not participate in the small group market, the user should ignore this column.

Tab 3: Risk Corridors Payment or Charge Calculation
Row Definitions and Instructions

Row
1 - Total
percentage of
market premium
in QHPs

2 - Risk corridors
allowable costs

3 - Risk corridors
target amount

4 - Risk corridors
ratio
5 - Risk corridors
aggregate
payment or
charge calculation
by market
6 - Risk corridors
payment expected
from HHS or
charge payable to
HHS

Risk Corridors Payment or Charge Calculation
Definitions & Instructions
The total proportion of premium earned that is attributable to an issuer’s QHPs. This total is
equal to the sum of the proportion of market premium in all of the issuer’s Exchange QHPs, offExchange QHPs, and plans that are substantially the same as an Exchange QHP.
This equals (the sum of all rows in column F + the sum of all rows in column J + the sum of all
rows in column N).
This total is auto-populated for the user and is calculated separately for the individual and
small group markets so that there are separate totals for columns A and B.
Allowable costs that HHS will use to calculate the risk corridors charge or payment amount for
a QHP issuer. Allowable costs are pooled for all of an issuer’s ACA compliant plans in each
market within a state. This represents the numerator of the risk corridors ratio.
This equals Line 3.1 in Part 3 of the MLR Reporting Form.
The target amount that HHS will use to calculate the risk corridors charge or payment amount
for a QHP issuer. The target amount is pooled for all of an issuer’s ACA compliant plans in
each market within a state. This represents the denominator of the risk corridors ratio.
This equals Line 3.5 in Part 3 of the MLR Reporting Form.
This equals the ratio of allowable costs to target amount, which is Line 2 divided by Line 3.
Note that the first column of the Reference Table shows the relationship of this ratio to the risk
corridors calculation. This value is auto-populated for the user.
An aggregate risk corridors amount is calculated separately for each QHP issuer’s individual
and small group market business. This aggregate amount is calculated based on all of a QHP
issuer’s ACA-compliant plans in a market within a state, and does not represent the payment
or charge amount that the issuer will receive or be required to pay. This value is
autopopulated for the user.
The aggregate risk corridors payment or charge amount allocated based on the proportion of
the issuer’s individual or small group total premium earned that is attributable to its QHP
business. This value is auto-populated for the user and is calculated separately for the
individual and small group markets. This represents the risk corridors payment that an issuer
expects to receive from HHS or is required to pay to HHS.
This equals Line 1 x Line 5.

APPENDIX A: Calculation References
Note: The calculations below are valid for both tabs 1 and 2, individual and small business
groups, respectively.
Table 1, Column A

User input: The issuer’s total premium earned.

Table 1, Column B

This is pre-populated with 100%.

Table 2, Column E

User input: The total premium earned (as defined for Table 1), for the HIOS plan ID in column
D.
Auto-calculated for the user: Table 2, Column E divided by Table 1, Column A.

Table 2, Column F
Table 3, Column I
Table 3, Column J

User input: The total premium earned (as defined for Table 1), for the HIOS plan ID in column
H.
Auto-calculated for the user: Table 3, Column I divided by Table 1, Column A.

Table 4, Column M
Table 4, Column N

User input: The total premium earned (as defined for Table 1), for the HIOS plan ID in column
L.
Auto-calculated for the user: Table 4, Column M divided by Table 1, Column A.

Tab 3, “Risk
Corridors Payment
and Charge
Calculation”, Line 1

Auto-calculated for the user: Column F + Column J + Column N.

Tab 3, “Risk
Corridors Payment
and Charge
Calculation”, Line 2

User input: MLR Reporting Form, Part 3, Line 3.1.

Tab 3, “Risk
Corridors Payment
and Charge
Calculation”, Line 3

User input: MLR Reporting Form, Part 3, Line 3.5.

Tab 3, “Risk
Corridors Payment
and Charge
Calculation”, Line 4

Auto-calculated for the user.

Tab 3, “Risk
Corridors Payment
and Charge
Calculation”, Line 5

Auto-calculated for the user. Auto-calculation is based on the Risk Corridors Reference Table
the user’s adjusted risk corridors ratio, and the following rules.

Tab 3, “Risk
Corridors Payment
and Charge
Calculation”, Line 6

Auto-calculated for the user.

Refer to MLR Reporting Form instructions for calculating Line 3.1, Part 3 of the MLR Reporting
Form.

Refer to MLR Reporting Form instructions for calculating Line 3.5, Part 3 of the MLR Reporting
Form.

Risk corridors allowable costs (Line 2) divided by risk corridors target amount (Line 3).

If Line 4 is at least 108%: 80% x (Line 2 – 108% x Line 3) + 2.5% x Line 3.
If Line 4 is at least 103% but less than 108%: 50% x (Line 2 – 103% x Line 3). If
Line 4 is at least 97% but less than 103%: zero (0)
If Line 4 is at least 92% but less than 97%: 50% x (Line 2– 97% x Line 3). If
Line 4 is less than 92%: 80% x (Line 2 – 92% x Line 3) – 2.5% x Line 3.

Total percentage of market premium in QHPs (Line 1) x Risk corridors aggregate payment or
charge calculation by market (Line 5)

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 XX minutes per response, including the time to review instructions, search existing resources, gather the data
needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or
suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Blvd. Baltimore, Maryland 21244.

File Type	application/pdf
File Title	Risk Corridors Plan-level Data Form Filing Instructions for the 2016 Benefit Year
Author	Gregory Segal
File Modified	2017-05-02
File Created	2017-05-02