Medical Loss Ratio (MLR) Sample Clauses

Medical Loss Ratio (MLR). The proportion of premium revenues spent on clinical services and quality improvement by the Contractor as calculated in accordance with the requirements of 42 C.F.R. § 438.8.

Medical Loss Ratio (MLR). The MLR shall be calculated as follows: Each reporting year, consistent with MLR standards as required in 42 CFR 438.8, the Contractor shall calculate, attest to the accuracy, and submit to FSSA its Medical Loss Ratio (MLR). The MLR submission must fully comply with 42 CFR 438.8(d)-(n) 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: (a) ▪ 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 purposes of MLR reporting, the Contractor should aggregate data for all Medicaid eligibility groups covered under the Contract with the State. ▪ Timing: • For each MLR reporting year, the Contractor must submit the MLR report within 12 months of the end of the reporting year, reflecting nine months of claims run-out. XXXX should not be included in the MLR calculation as the State will apply appropriate completion factors to the reported claims. • The Contractor must require any third-party vendor providing claims adjudication services to provide all underlying data associated with MLR reporting to the Contractor within 180 days of the end of the MLR reporting year or within 30 days of being requested by the Contractor, whichever comes sooner. ▪ The MLR report submitted by the Contractor for each reporting year must include the following elements, as defined in 42 CFR 438.8: • Number of member months in the reporting year • Premium revenue • Taxes • Licensing fees • Regulatory fees • Incurred claims • Expenditures for Quality Improvement activities • Expenditures for Fraud prevention activities as defined in 42 CFR 438.8(e)(4) • Non-claims costs • Any credibility adjustment applied • Remittance owed to the State, if any • A comparison of the information reported on the MLR with the audited financial report • A description of the aggregation method used to calculate total incurred claims • A description of the methodology used to allocate expenses • An attestation as to the accuracy of the calculation, in accordance with MLR standards. ▪ Incurred Claims:...

Medical Loss Ratio (MLR). The proportion of premium revenues spent on clinical services and quality improvement by the CCO.

Medical Loss Ratio (MLR). The MLR shall be calculated as follows: Each reporting year, consistent with MLR standards as required in 42 CFR 438.8, the Contractor shall calculate, attest to the accuracy, and submit to FSSA its Medical Loss Ratio (MLR). The MLR submission must fully comply with 42 CFR 438.8(d)-(n) 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: (a) ▪ The MLR calculation shall be performed separately for each program. The MLR for the PathWays program shall be calculated separately from other managed care programs. ▪ For purposes of MLR reporting, the Contractor should aggregate data for all Medicaid eligibility groups covered under the contract with the state. ▪ Timing

Medical Loss Ratio (MLR). A basic financial measurement used to calculate and categorize costs, profits, and losses of a health insurance plan. Calculation of the MLR is defined at 42 C.F.R. § 438.8.

Medical Loss Ratio (MLR). A. Medical Loss Ratio: Beginning in calendar year 2014, Demonstration Plans will be required each year to meet a Target Medical Loss Ratio (TMLR) threshold of 85 percent, which regulates the minimum amount of revenue that must be used for expenses either directly related to medical claims or care coordination. B. If the Medical Loss Ratio (MLR) calculated annually is less than the TMLR, the Demonstration Plan shall remit to the State and CMS an amount equal to the difference between the calculated MLR and the TMLR (expressed as a percentage) multiplied by the revenue received during the coverage year. Any collected remittances would be distributed proportionally back to the Medicaid and Medicare programs. C. The Three-way Contracts will include additional specifications on the MLR. To the maximum extent possible, the methodology for calculating the MLR will conform to prevailing federal regulatory requirements applicable to the other Medicare products offered by organizations operating Demonstration Plans.

Medical Loss Ratio (MLR). An adjusted metric for measuring the ratio of (i) incurred claims plus expenditures for activities that improve health care quality plus expenditures on activities to comply with certain program integrity requirements divided by (ii) adjusted premium revenue, as defined in [42 C.F.R. § 438.8].

Medical Loss Ratio (MLR). MLR Calculation 6.6.1.1. The Department or its agent will calculate a plan-wide Medical Loss Ratio (MLR) each SFY using medical and administrative cost data from encounter data, audited financial statements and reporting, and flat file submissions. 6.6.1.2. The MLR will be calculated by dividing the sum of the direct, indirect, and sub-contracted costs for providing all Covered Services provided under this Contract (Medical Spend) by total capitation payments made to the Contractor (i.e. Medical Spend / total capitation payments) for every annual measurement period, with supplemental information, subject to Department approval. The first annual measurement period will begin upon execution of this Contract and end on June 30, 2015. Subsequent annual measurement periods will align with the state fiscal year. The Department will allow for four (4) months claims runout before calculating the Contractor’s MLR. The calculation of the MLR may take an additional three (3) months. The Department will calculate the MLR after any annual adjustments are made, including, at a minimum, any risk corridor rate calculations for the Medicaid expansion populations. The Department will provide documentation of the methodology it will use for the MLR and any adjustments, along with supporting data and documentation.

Medical Loss Ratio (MLR). SETTLEMENTS 5.4.1. The Contractor shall maintain a MLR in excess of seventy seven percent (77%) of total Medicaid capitations. MLRs of less than seventy seven percent (77%) shall result in a refund due the Department if the amount of the medical loss is less than the threshold. 5.4.1.1. The Department will calculate the MLR for the Contractor using the audited financial reports, as required in Section 2.11.2.1.3., no later than June 30th. 5.4.1.2. If the Contractor’s MLR is less than seventy seven percent (77%) of the total Medicaid capitations, the Department will issue a demand letter with the settlement amount that the Contractor shall reimburse the Department.

Medical Loss Ratio (MLR). The MLR shall be calculated as follows: Each reporting year, consistent with MLR standards as required in 42 CFR 438.8, the Contractor shall calculate, attest to the accuracy, and submit to FSSA its Medical Loss Ratio (MLR). The MLR submission must fully comply with 42 CFR 438.8(d)-(n) 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: (a) The MLR calculation shall be performed separately for each program. The MLR for the Hoosier Care Connect program shall be calculated separately from other managed care programs. • For purposes of MLR reporting, the Contractor should aggregate data for all Medicaid eligibility groups covered under the Contract with the State. • Timing: ▪ For each MLR reporting year, the Contractor must submit the MLR report within 12 months of the end of the reporting year, reflecting nine months of claims run-out. XXXX should not be included in the MLR calculation as the State will apply appropriate completion factors to the reported claims.