Common use of Medical Loss Ratio Clause in Contracts

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. ‌ ‌‌ 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.