Medical Loss Ratio Sample Clauses

Medical Loss Ratio. In calendar year 2017, the MLR shall be calculated as follows: On an annual basis the Contractor shall calculate and submit to FSSA its Medical Loss Ratio (MLR), based on standards and forms established by the National Association of Insurance Commissioners (NAIC). A separate MLR shall be calculated for the Contractor’s Hoosier Healthwise line of business. The MLR calculations shall be exclusive of any taxes. In addition, the State provides the following clarifications: ▪ The MLR calculation shall be performed separately for each MLR reporting year. ▪ The MLR calculation shall be performed separately for each program. The MLR for the Hoosier Healthwise program shall be calculated separately from other managed care programs. The Contractor shall maintain, at minimum, a MLR of eighty-five percent (85%) for its Hoosier Healthwise line of business. The MLR will be calculated exclusive of reimbursement for the health insurance providers’ fee (see Section 2.6.7). The Contractor is required to submit MLR reporting as described in the MCE Reporting Manual for Hoosier Healthwise. FSSA shall recoup excess capitation paid to the Contractor in the event that the Contractor’s MLR, as calculated by FSSA on an annual basis, is less than eighty-five percent (85%) for the Hoosier Healthwise line of business. Beginning in calendar year 2018, the MLR shall be calculated as follows: The Contractor shall calculate and submit to FSSA its Medical Loss Ratio (MLR). The calculation must fully comply with 42 CFR 438.8. In addition, the State provides the following clarifications: ▪ The MLR calculation shall be performed separately for each MLR reporting year. ▪ The MLR calculation shall be performed separately for each program. The MLR for the Hoosier Healthwise program shall be calculated separately from other managed care programs. ▪ For each MLR reporting year, a preliminary calculation will be performed with six months of incurred claims run-out, and a final calculation will be performed with 18 months of incurred claims run-out. ▪ Incurred claims reported in the MLR should relate only to members who were enrolled with the MCE on the date of service, based on data and information available on the reporting date. (Claims for members who were retroactively disenrolled should be recouped from providers and excluded from MLR reporting). ▪ Under Sub-Capitated or Sub-Contracted arrangements, the MCE may only include amounts actually paid to providers for covered services and supplies...

Medical Loss Ratio. In calendar year 2017, the MLR shall be calculated as follows: On an annual basis the Contractor shall calculate and submit to FSSA its Medical Loss Ratio (MLR), based on standards and forms established by the National Association of Insurance Commissioners (NAIC). A separate MLR shall be calculated for the Contractor’s Hoosier Healthwise line of business. The MLR calculations shall be exclusive of any taxes. In addition, the State provides the following clarifications: ▪ The MLR calculation shall be performed separately for each MLR reporting year. ▪ The MLR calculation shall be performed separately for each program. The MLR for the Hoosier Healthwise program shall be calculated separately from other managed care programs. The Contractor shall maintain, at minimum, a MLR of eighty-five percent (85%) for its Hoosier Healthwise line of business. The MLR will be calculated exclusive of reimbursement for the health insurance providers’ fee (see Section 2.6.7). The Contractor is required to submit MLR reporting as described in the MCE Reporting Manual for Hoosier Healthwise. FSSA shall recoup excess capitation paid to the Contractor in the event that the Contractor’s MLR, as calculated by FSSA on an annual basis, is less than eighty-five percent (85%) for the Hoosier Healthwise line of business. Beginning in calendar year 2018, the MLR shall be calculated as follows: The Contractor shall calculate and submit to FSSA its Medical Loss Ratio (MLR). The calculation must fully comply with 42 CFR 438.8. In addition, the State provides the following clarifications:

Medical Loss Ratio. Description Financial consequences

Medical Loss Ratio. ‌ The minimum medical loss ratio (MLR) for each rating period is eighty-five percent (85%). Likewise, the maximum non-benefit premium component for each rating period shall not exceed fifteen percent (15%). Insurer shall identify what components and subcomponents have been included in its non-benefit expenses, as required by FHKC. The MLR shall be calculated in accordance with 42 CFR 457.1203, which incorporates 42 CFR 438.8. FHKC may issue additional written guidance on the definition of medical expense or non-benefit expense to Insurer. Federal and state regulations impacting the calculation of MLRs or non- benefit expense requirements may also be applicable. To the extent permissible by law, FHKC may choose to adopt such regulations early or adopt such regulations that would not otherwise be applicable. Should such guidelines be applied, FHKC shall notify Insurer in writing. In the event Insurer achieves an MLR less than eighty-five percent (85%) for the rating period, Insurer shall return one hundred percent (100%) of the difference between the actual MLR and the minimum MLR to FHKC. Insurer’s MLR rebate shall include both Insurer’s Title XXI Enrollees and Insurer’s Full-pay Enrollees in the Service Area; however, Insurer shall report the portion of the rebate attributable to the Title XXI Enrollees and the Full-pay Enrollees based on the respective proportion of Enrollee member months for the rating period.

Medical Loss Ratio. 1. To provide to the Department a completed MLR Reporting Template, including the MCO attestation and any additional documentation supporting the MLR reporting template (Appendix G), in accordance with 42 CFR 438.8, by November 15th of the calendar year following the MLR reporting year. 2. To provide a remittance for an MLR reporting year if the MLR for that MLR reporting year does not meet the minimum MLR standard of 85 percent.

Medical Loss Ratio. The three-way contract between CMS, ODM, and the MCOPs indicates that ODM and CMS will perform medical loss ratio (MLR) calculations for the MyCare Opt-In program, and the minimum MLR requirement is 88% for demonstration year 8 (DY8). Details of the MLR remittance calculation can be found in the three-way contract between CMS, ODM, and the MCOPs.

Medical Loss Ratio. In calendar year 2017, the MLR shall be calculated as follows: On an annual basis the Contractor shall calculate and submit to FSSA its Medical Loss Ratio (MLR), based on standards and forms established by the National Association of Insurance Commissioners (NAIC). A separate MLR shall be calculated for the Contractor’s HIP line of business. For the HIP line of business, POWER Account expenditures may be included in both the numerator and denominator of the MLR calculation. The MLR calculations shall be exclusive of any taxes. In addition, the State provides the following clarifications:  The MLR calculation shall be performed separately for each MLR reporting year.  The MLR calculation shall be performed separately for each program. The MLR for the HIP program shall be calculated separately from other managed care programs. The Contractor shall maintain, at minimum, a MLR of eighty-seven percent (87%) for its HIP line of business. The MLR will be calculated exclusive of reimbursement for the health insurance providers’ fee (see Section 2.6.7). The Contractor is required to submit MLR reporting as described in the MCE Reporting Manual for HIP. FSSA shall recoup excess capitation paid to the Contractor in the event that the Contractor’s MLR, as calculated by FSSA on an annual basis, is less than eighty- seven percent (87%) for the HIP line of business. Beginning in calendar year 2018, the MLR shall be calculated as follows:

Medical Loss Ratio. The CONTRACTOR shall spend no less than ninety percent (90%) of net Medicaid line of business Net Capitation Revenue on direct medical expenses on an annual basis. HCA reserves the right, in accordance with and subject to the terms of this Agreement, to reduce or increase the minimum allowable for direct medical services over the term of this Agreement provided that any such change: (i) shall only apply prospectively; (ii) shall exclude any retroactive increase to allowable direct medical services; and (iii) shall comply with State and federal law. The MLR calculation and definitions for its calculation are separate from the underwriting gain limitation outlined in Sections 7.2.1 through7.

Medical Loss Ratio. The MLR shall be calculated as follows: Each reporting year, consistent with MLR standards as required in 42 CFR 438.8, t he Contractor shall calculate, attest to the accuracy, and submit to FSSA its Medical Loss Ratio (MLR). For the HIP line of business, POWER Account expenditures may be included in both the numerator and denominator of the MLR calculation. The calculation must fully comply with 42 CFR 438.8(d)-(f) which specifies that the MLR calculation is the ratio of the numerator (as defined in accordance with 42 CFR 438.8(e)) to the denominator (as defined in accordance with 42 CFR 438.8(f)). In accordance with 42 CFR 438.604(a)(3), 42 CFR 438.606, and 42 CFR 438.8, the Contractor is required to submit data on the basis of which the State determines the compliance with MLR requirements. In addition, the State provides the following clarifications: ▪ The MLR calculation shall be performed separately for each MLR reporting year per 42 CFR 438.8(a).

Medical Loss Ratio a. Contractor’s MLR is the ratio of the numerator and the denominator, as defined: i. The numerator of the Contractor’s MLR for an MLR Reporting Year must equal: (1) the Contractor’s incurred claims, plus (2) the Contractor’s expenditures for activities that improve health care quality, plus (3) the Contractor’s expenditures for fraud reduction activities (as discussed in subsection d below). ii. The denominator of the Contractor’s MLR for an MLR Reporting Year must equal the Contractor’s Adjusted Premium Revenue. The Adjusted Premium Revenue is Premium Revenue minus the Contractor’s Federal, State, and local taxes, licensing and regulatory fees (as defined in subsection c of this Section), any Liquidated Damages paid by Contractor during the MLR Reporting Year, and is aggregated in accordance with subsection f below. b. A Contractor’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. c. Federal, State, and local taxes and licensing and regulatory fees. Taxes, licensing and regulatory fees for the MLR Reporting Year include: i. Statutory assessments to defray the operating expenses of any State or Federal department. ii. Examination fees in lieu of premium taxes as specified by State law. iii. Federal taxes and assessments allocated to Contractor, excluding Federal income taxes on investment income and capital gains and Federal employment taxes. iv. State and local taxes and assessments including: (a) Any industry wide (or subset) assessments (other than surcharges on specific claims) paid to the State or locality directly. (b) Guaranty fund assessments. (c) Assessments of state or locality industrial boards or other boards for operating expenses or for benefits to sick employed persons in connection with disability benefit laws or similar taxes levied by states. (d) State or locality income, excise, and business taxes other than premium taxes and State employment and similar taxes and assessments. (e) State or locality premium taxes plus State or locality taxes based on reserves, if in lieu of premium taxes. v. Payments made by Contractor that are otherwise exempt from Federal income taxes, for community benefit expenditures as defined in 45 C.F.R. § 158.162(c), limited to the highest of either: (a) Three percent (3%) of earned premium; or (b) The highest premium tax rate in the State for which the...