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45 C.F.R. § 158.221 : Public Welfare — DEPARTMENT OF HEALTH AND HUMAN SERVICES — REQUIREMENTS RELATING TO HEALTH CARE ACCESS — ISSUER USE OF PREMIUM REVENUE: REPORTING AND REBATE REQUIREMENTS — CALCULATING AND PROVIDING THE REBATE — Formula for calculating an issuer's medical loss ratio
Text
(a)
Medical loss ratio.
(1)
An issuer's MLR is the ratio of the numerator, as defined in paragraph (b) of this section, to the denominator, as defined in paragraph (c) of this section, subject to the applicable credibility adjustment, if any, as provided in §
158.232
of this subpart.
(2)
An issuer's MLR shall be rounded to three decimal places. For example, if an MLR is 0.7988, it shall be rounded to 0.799 or 79.9 percent. If an MLR is 0.8253 or 82.53 percent, it shall be rounded to 0.825 or 82.5 percent.
(b)
Numerator.
The numerator of an issuer's MLR for an MLR reporting year must be the issuer's incurred claims, as defined in §
158.140
of this part, plus the issuer's expenditures for activities that improve health care quality, as defined in §
158.150
and §
158.151
of this part, that are reported for the years specified in §
158.220
of this subpart.
(1)
The numerator of the MLR for the 2012 MLR reporting year may include any rebate paid under §
158.240
of this subpart for the 2011 MLR reporting year if the 2012 MLR reporting year experience is not fully credible as defined in §
158.230
of this subpart.
(2)
The numerator of the MLR for the 2013 MLR reporting year may include any rebate paid under §
158.240
for the 2011 MLR reporting year or the 2012 MLR reporting year.
(3)
The numerator of the MLR for policies that are reported separately under §
158.120(d)(3)
of this part must be the amount specified in paragraph (b) of this section, except that for the 2012 MLR reporting year, the total of the incurred claims and expenditures for activities that improve health care quality are then multiplied by a factor of 1.75, for the 2013 MLR reporting year, the total of the incurred claims and expenditures for activities that improve health care quality are then multiplied by a factor of 1.50, and for the 2014 MLR reporting year, the total of the incurred claims and expenditures for activities that improve health care quality are then multiplied by a factor of 1.25.
(4)
The numerator of the MLR for policies that are reported separately under §
158.120(d)(4)
of this part must be the amount specified in paragraph (b) of this section, except that the total of the incurred claims and expenditures for activities that improve health care quality are then multiplied by a factor of 2.00.
(5)
The numerator of the MLR for policies that are reported separately under §
158.120(d)(5)
of this part must be the amount specified in paragraph (b) of this section, except that for the 2013 MLR reporting year the total of the incurred claims and expenditures for activities that improve health care quality is then multiplied by a factor of 1.15.
(6)
The numerator of the MLR in the individual and small group markets in States that adopted the transitional policy outlined in the CMS letter dated November 14, 2013 must be the amount specified in paragraph (b) of this section, except that issuers that provided transitional coverage may multiply the total incurred claims and expenditures for activities that improve health care quality incurred in 2014 in the respective State and market by a factor of 1.0001.
(7)
The numerator of the MLR in the individual and small group markets for issuers participating in the State and Federal Exchanges (sometimes referred to as "Marketplaces") must be the amount specified in paragraph (b) of this section, except that the total incurred claims and expenditures for activities that improve health care quality incurred in 2014 in the respective State and market may be multiplied by a factor of 1.0004.
(8)
Beginning with the 2020 MLR reporting year, an issuer may include in the numerator of the MLR any shared savings payments the issuer has made to an enrollee as a result of the enrollee choosing to obtain health care from a lower-cost, higher-value provider.
(c)
Denominator.
The denominator of an issuer's MLR must equal the issuer's premium revenue, as defined in §
158.130
, excluding the issuer's Federal and State taxes and licensing and regulatory fees, described in §§
158.161(a)
and
158.162(a)(1) and (b)(1)
, and after accounting for payments or receipts related to risk adjustment, risk corridors, and reinsurance, described in §
158.130(b)(5)
.
45 C.F.R. §158.221
75 FR 74921, 12/1/2010, as amended at 76 FR 76593, 12/7/2011; 77 FR 16469, 3/21/2012; 78 FR 15540, 3/11/2013; 79 FR 30352, 5/27/2014; 83 FR 17070, 6/18/2018; 85 FR 72310, 1/11/2021; 86 FR 24294, 5/5/2021
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