MLR Risk Corridors Submission Checklist and the Risk Corridors Data Discrepancy Worksheet

Centers for Medicare & Medicaid Services (CMS)
Instructions for 2014 Risk Corridors Discrepancy Worksheet

Table of Contents
Centers for Medicare & Medicaid Services (CMS) .......................................................................................................................................................................................................... 1
Instructions for 2014 Risk Corridors Discrepancy Worksheet ..................................................................................................................................................................................... 1
PURPOSE ..................................................................................................................................................................................................................................................................... 3
METHOD OF SUBMISSION ...................................................................................................................................................................................................................................... 3
GENERAL DEFINITIONS .......................................................................................................................................................................................................................................... 4
GENERAL INSTRUCTIONS ...................................................................................................................................................................................................................................... 5
Risk Corridors Discrepancy Worksheet—Claims Discrepancy Column Definitions ................................................................................................................................................... 7
Claims Discrepancy Report (continued) ....................................................................................................................................................................................................................... 8
Claims Discrepancy Report (continued) ....................................................................................................................................................................................................................... 9
Claims Discrepancy Report (continued) ..................................................................................................................................................................................................................... 10
Claims Discrepancy Report (continued) ..................................................................................................................................................................................................................... 11
Claims Discrepancy Report (continued) ..................................................................................................................................................................................................................... 12
Claims Discrepancy Report (continued) ..................................................................................................................................................................................................................... 13
Claims Discrepancy Report (continued) ..................................................................................................................................................................................................................... 14
Claims Discrepancy Report (continued) ..................................................................................................................................................................................................................... 15
Claims Discrepancy Report (continued) ..................................................................................................................................................................................................................... 16
Premium Discrepancy Report ..................................................................................................................................................................................................................................... 17
Premium Discrepancy Report (continued) .................................................................................................................................................................................................................. 18
Premium Discrepancy Report (continued) .................................................................................................................................................................................................................. 19
Premium Discrepancy Report (continued) .................................................................................................................................................................................................................. 20
Premium Discrepancy Report (continued) .................................................................................................................................................................................................................. 21
Premium Discrepancy Report (continued) .................................................................................................................................................................................................................. 22
Premium Discrepancy Report (continued) .................................................................................................................................................................................................................. 23
APPENDIX 1: MLR Risk Corridors Submission Checklist Template ......................................................................................................................................................................... 26
APPENDIX 2: Draft Risk Corridors Discrepancy Worksheet ...................................................................................................................................................................................... 32

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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 XXXX-XXXX. The time required to complete this information collection is estimated to average X 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.

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PURPOSE
The Affordable Care Act created the medical loss ratio (MLR) program beginning for coverage provided beginning 2011 and the temporary risk corridors program
for qualified health plan coverage provided 2014 through 2017. Regulations implementing the MLR program appear in 45 CFR Part 158, and regulations
implementing the temporary risk corridors program appear in 45 CFR Part 153 Subpart F. These regulations require issuers to make a joint submission to CMS for
the MLR and risk corridors programs. The information collection for risk corridors validation is approved by OMB under control number 0938-1155. CMS has
conducted issuer outreach and appreciates the input we have received. CMS recognizes the differences in data submission requirements for MLR/risk corridors
and the EDGE server. The focus of this data validation effort is to collect information necessary to quantify and explain the magnitude of these data differences.
Joint MLR and risk corridor submissions for coverage provided in 2014 (the 2014 benefit year) were due to CMS on July 31, 2015. This submission was the first
to include information specific to the risk corridors program. It is also the first to reflect changes to insurance markets that occurred in 2014, including the single
risk pool requirements and the risk adjustment and reinsurance program.
While conducting reviews of MLR and risk corridors submissions, CMS identified a number of material differences from data that issuers submitted for other
programs, including reinsurance and risk adjustment. CMS also identified a number of errors that could lead to submissions that do not comply with CMS
regulations or guidance. In order to resolve these differences, to ensure that the submissions comply with applicable guidance, and operate the MLR and risk
corridors program accurately and effectively, CMS needs additional information to explain the data in issuers’ MLR and risk corridors submission. Without this
additional information, CMS will be unable to verify the accuracy of the submission and validate the data needed to operate the MLR and risk corridors programs.

METHOD OF SUBMISSION
The MLR and Risk Corridors Submission Checklist is a web-based form. Each company that submitted risk corridors data for the 2014 benefit year will be
required to complete and attest to a checklist which identifies critical components of the risk corridors and MLR submission. Companies will receive an email
with a unique web link to access the checklist and will use the online form to submit the checklist. The checklist will apply to all of a company’s issuers
(identified by 5-digit HIOS issuer ID) that are subject to the risk corridors program, such that each company will only submit one checklist. If a company has
previously submitted a discrepancy report for its EDGE server data, it will indicate which of its issuers submitted a discrepancy by indicating each HIOS issuer ID
for which a discrepancy was submitted, separated by a semicolon.
Information cannot be saved on the web form. Companies should plan accordingly.
The checklist can only be submitted through the web form. It cannot be completed in any other format (e.g., Microsoft Word or PDF), and it cannot be submitted
via email, U.S. mail, or fax.
A sample of the checklist is available on the CMS PRA website at https://www.cms.gov/Regulations-andGuidance/Legislation/PaperworkReductionActof1995/PRA-Listing.html, and in Appendix 1 of these instructions.
Companies will receive emails with a unique pin number in order to verify that only the authorized company is able to access the data validation web form.

The Risk Corridors Discrepancy Worksheet is a web-based form. Companies will complete the Discrepancy Worksheet only if they have been instructed to
do so by CMS in a letter dated August 31, 2015 and have been provided with a unique web link to access the form. Companies will receive an email with a unique
web link to access the checklist and will use the online form to submit the discrepancy worksheet. The discrepancy worksheet will apply to all of a company’s
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QHP issuers (identified by 5-digit HIOS issuer ID) for which a material claims or premium difference has been identified based on its risk corridors and MLR
submissions.
Information cannot be saved on the web form. Once the web form is accessed, the requested information, including uploads of applicable supplemental
documents, must be completed for each issuer before submission will be considered successful. Companies should plan accordingly, and are encouraged to gather
applicable data and documentation for each issuer before attempting to complete and attest to the web form.
The discrepancy worksheet can only be submitted through the web form. It cannot be completed in any other format (e.g., Microsoft Excel), and it cannot be
submitted via email, U.S. mail, or fax. An illustration of the discrepancy worksheet is available in Appendix B and on the CMS PRA website at
https://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 Discrepancy Worksheet 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. For the purposes of the risk corridors program, the individual
market includes only plans that were compliant with ACA market reforms during the 2014 benefit year. Grandfathered plans and non-grandfathered plans that are
not ACA-compliant do not participate in the risk corridors program and should be excluded from premium and claims data submitted for risk corridors.
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 costsharing for consumers, pursuant to the regulations at 45 CFR Part 147.140.
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.
For the purposes of the risk corridors program, the small group market includes only plans that were compliant with ACA market reforms during the 2014 benefit
year.
Earned Premium
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. Earned premium includes the premium tax credit portion of the
advanced payment amounts (APTC), as well as the enrollee portion of the premium. Please note that for the purposes of the risk corridors program, earned
premium should be for reported for coverage in the 2014 MLR/risk corridors reporting year only.
Billed Premium
Total billable premium is the total premium charged for members in all policies that are written directly or acquired by the issuer during the full reporting year.

4

Paid Claims
Direct claims paid to or received by physicians and other non- physician clinical providers, including under capitation contracts with those providers, whose
services are covered by the policy for clinical services or supplies covered by the policy. For the purposes of the risk corridors program, paid claims include
claims incurred only during the 2014 MLR/risk corridors reporting year, paid from 1/01/2014 through 3/31/2015.
Incurred Claims
Claim amounts that reflect expected reimbursement for clinical services provided to an enrollee during the 2014 MLR/risk corridors reporting year.
Incurred But Not Reported (IBNR)
Claims incurred only during the 2014 MLR/risk corridors reporting year and not paid by 3/31/2015. Except where inapplicable, this amount includes reserve
based on past experience, modified to reflect current conditions, such as changes in exposure.

GENERAL INSTRUCTIONS
MLR and Risk Corridors Submission Checklist







The MLR Risk Corridors Submission Checklist must be completed and submitted in one sitting. Users cannot save the information for completion
at a later time. This checklist is a required submission for all companies with issuers that submitted risk corridors data for the 2014 reporting year.
The company should complete only one (1) MLR/Risk Corridors Submission Checklist for all issuers associated with a particular company
(identified by FEIN, for which the point of contact will have received one email). The checklist pertains to the company’s MLR and Risk
Corridors submission for the 2014 benefit year. In the contact information section, the company should provide one primary contact for the MLR
and risk corridors submissions, and one primary contact responsible for EDGE server submissions.
If a company determines that it is unable to attest to all of the elements included in the MLR Risk Corridors Submission Checklist, the
company should resubmit its 2014 MLR and Risk Corridors data by September 8, 2015, or by September 14, 2015, as directed by CMS.
Prior to resubmitting, a representative of the company must contact CMS at MLRquestions@cms.hhs.gov and indicate that it intends to resubmit.
A representative that can financially bind the company must attest to the data for all issuers included in the checklist before submission.

Risk Corridors Discrepancy Worksheet




A company with issuers that has been identified by CMS as having a material difference in claims (not including IBNR) or premiums will be
directed to complete a separate claims or premium report to quantify the difference for each issuer. Where the material difference in claims or
premium can be quantified, the company must also upload documentation explaining the method by which it determined the amount of the
difference. These instructions include definitions of what should be included as supporting documentation.
If CMS has identified that the company’s estimate of IBNR claims accounts for a high proportion of its overall claims liability, the company will
be required to upload documentation that explains its method for determining IBNR. The system will only display the option of uploading
5









supplemental documentation explaining IBNR to those companies whose IBNR is a high proportion of paid claims. These instructions include
definitions of what should be included as supporting documentation for IBNR.
It is not expected that issuers will need to submit claim-by-claim or enrollee-by-enrollee reconciliations to justify dollar quantifications.
Rather, issuers are expected to provide detailed explanations and descriptions of methodologies, and underlying actuarial or financial
assumptions or evidence sufficient for CMS to evaluate the reasonableness of dollar figures submitted as quantifications of the various
explanatory elements offered. Those dollar figures are not required to be accurate to the dollar, but are expected to be accurate to one
quarter of one percent of the claims or premium amount, as applicable.
The Risk Corridors Discrepancy Worksheet must be completed and submitted in one sitting. Users cannot save the information for completion at
a later time. Please note there are some sections that are auto-populated for the issuer as indicated in these instructions.
Only data pertaining to non-grandfathered, ACA-compliant plans should be reported on the worksheet. If a plan was compliant for only a portion
of 2014, the company should report the experience for only the ACA-compliant portion.
Personally identifiable information (PII) and protected health information (PHI) should be excluded or removed/redacted from any
written explanation that is submitted for claims discrepancy, premium discrepancy, or IBNR.
Your company name or affiliation (or other clearly identifying information), including any company letterhead, should also be excluded
from any such written explanation.
A representative that can financially bind the company must attest to the data for all issuers included in the worksheet before submission.
Companies should email questions about risk corridors data validation submissions to: ACAriskcorridors@cms.hhs.gov

6

Risk Corridors Discrepancy Worksheet—Claims Discrepancy Column Definitions
Table 1 – Summary of Individual Market Claims Reported to CMS
Column

Definition

Instructions

A. Company
Name
B. HIOS Issuer
ID
C. Claims
Incurred During
2014, Paid
Through
3/31/2015

The legal name of the issuer that corresponds to
the HIOS issuer ID in column B.
The 5-digit HIOS ID assigned to the issuer.

This column is auto-populated for the user.
This column does not accept data input.
This column is auto-populated for the user.
This column does not accept data input.
This column is auto-populated for the user from
data submitted by the issuer in its 2014 MLR
Reporting Form.
This column does not accept data input. This
user will see this calculation in a summary table
at the end of the claims discrepancy report.

D. Paid Claims
Amount from
EDGE server

Total individual market paid claims submitted
to EDGE server, as indicated on the EDGE
RISR Report. The amount reflects the total
claims amount, not the total number of
individual claim lines.
The actual dollar difference between paid
claims reported for MLR (column C) and paid
individual market claims submitted to EDGE
server for the reinsurance program (column D).
The percentage of total claims loaded to the
EDGE server as of 5/15/2015, calculated as a
proportion of the baseline claim data the issuer
submitted to CMS. The claims percentage in
this column excludes orphan claims that could
not be tied to an enrollee, rejected claims, and
other claims that were not loaded to the EDGE
server

E. Dollar
Difference

F. Percentage of
Total Claims
Loaded to the
EDGE Server,
Excluding
Orphan Claims
(as of 5/15)

Claims incurred only during 2014, paid during
the period from 1/1/2014 – 3/31/2015. This
column is equal to the data in Section 2, Line
2.1b, column 2A (Risk Corridors) in the MLR
2014 Annual Reporting Form.

This column is auto-populated for the user from
data submitted by the issuer to its EDGE server
for the Reinsurance program.
This column does not accept data input.
This column is auto-populated for the user.
This column does not accept data input.

This column is auto-populated for the user.
This column does not accept data input.

7

Claims Discrepancy Report (continued)
Table 2 – Sources of Discrepancy From MLR Form – Individual Market Claims Reporting
Column

Definition

Instructions

G. HIOS Issuer ID

The 5-digit HIOS ID assigned to the issuer.

H. Capitation – Internal
Pricing Methodology

The internal methodology the issuer used for pricing encounters for which
individual enrollee claims were not generated.

H1. Capitation – Internal
Pricing Methodology,
Dollar Amount

The difference between (a) the total amounts included in claims in the MLR
submission with respect to services for which the issuer did not generate
individual enrollee claims in the normal course of business (that is,
capitation amounts), minus (b) the associated dollar amounts of individual
market claims reported to the EDGE server for which the issuer did not
generate individual enrollee claims in the normal course of business, and
derived the cost of the provider encounter using its principal internal
methodology for pricing the encounter, in accordance with the regulations at
45 CFR 153.710(d).

This column is auto-populated for the user. This
column does not accept data input.
This is a header column. This column does not
accept data input.
User input of a positive value (if EDGE amounts
are lower) or negative value (if EDGE amounts are
higher) is required. This field is formatted for the
user, such that amounts are rounded to the nearest
dollar.
If the issuer did not report any capitation amounts
in the MLR/risk corridors submissions that meet
the description in this row, the user should input
“0” in this column.

Exclude from part (a) above, IBNR (that is, claims amounts that were
incurred but not reported for the 2014 MLR/risk corridors reporting year).
H2. Capitation – Internal
Pricing Methodology,
Percentage of Total Claims
Dollar Amount

The percentage of total paid claims reported for MLR/risk corridors
attributable to different reporting requirements between EDGE and
MLR/risk corridors for encounters involving capitated providers.
This column equals column H1 divided by column C.

8

This column is auto-calculated for the user. This
field is formatted for the user. This column does
not accept data input. This user will see this
calculation in a summary table at the end of the
claims discrepancy report.

Claims Discrepancy Report (continued)
Table 2 – Sources of Discrepancy From MLR Form – Individual Market Claims Reporting
Column

Definition

J. Orphan, Rejected and
Claims not loaded to EDGE

Claims reported for MLR/risk corridors that were not accepted by the
EDGE server (rejected claims), were not associated with an enrollee
(orphan claims), or were not otherwise loaded to the EDGE server.
The dollar value of claims reported for MLR/risk corridors that were not
accepted by the EDGE server (rejected claims), were not associated with an
enrollee (orphan claims), or were not otherwise loaded to the EDGE server.

J1. Orphan, Rejected and
Claims not loaded to EDGE

Instructions

Exclude: Claims that were rejected from the Edge server for being
duplicate claims.

J2. Orphan, Rejected and
Claims not loaded to EDGE
, Percentage of Total
Claims Dollar Amount

Exclude: Claims amounts that were incurred but not reported for the 2014
MLR/risk corridors reporting year (IBNR).
The percentage of total paid claims reported for MLR/RC that were either
not accepted by the EDGE server (rejected claims), were not associated
with an enrollee (orphan claims), or were not otherwise loaded to the
EDGE server.

This is a header column. This column does not
accept data input.
User input of a positive value is required. This field
is formatted for the user, such that amounts are
rounded to the nearest dollar.
If the issuer did not report any individual market
claims for MLR/risk corridors that meet the
description in this row, the user should input “0” in
this column.

This column is auto-calculated for the user. This
field is formatted for the user. This column does not
accept data input. This user will see this
calculation in a summary table at the end of the
claims discrepancy report.

This column equals column J1 divided by column C.
J3. Orphan, Rejected and
Claims not loaded to EDGE
, Percentage of Claims
Difference

The percentage of the claims difference in Column E that is attributable to
claims reported for MLR/RC that were not accepted by the EDGE server
(rejected claims), were not associated with an enrollee (orphan claims), or
were not otherwise loaded to the EDGE server. This column equals the
absolute value of column J1 divided by column E.

9

This column is auto-calculated for the user. This
field is formatted for the user. This column does not
accept data input. This user will see this
calculation in a summary table at the end of the
claims discrepancy report.

Claims Discrepancy Report (continued)
Table 2 – Sources of Discrepancy From MLR Form – Individual Market Claims Reporting
Column
K. Paid Claims for Hospital Stays That Crossed Benefit
Years (not already included in IBNR)

K1. Paid Claims for Hospital Stays That Crossed Benefit
Years (not already included in IBNR), Dollar Amount

Definition
Paid claims for inpatient hospital stays that began
in 2014 but were not discharged by 12/31/2014..
These claims were reported for 2014 MLR/RC but
were not submitted to the EDGE server for 2014
(due to EDGE reporting rules). These columns
should not include IBNR amounts.
The dollar value of claims reported for 2014
MLR/risk corridors that is attributable to inpatient
hospital stays that began in 2014, were not
discharged by 12/31/2014, but were paid by
3/31/2015.
Exclude: Claims that were not paid by 3/31/2015,
because these amounts are reflected in IBNR for
the 2014 MLR/risk corridors reporting year.

K2. Paid Claims for Hospital Stays That Crossed Benefit
Years (not already included in IBNR), Percentage of Total
Claims Dollar Amount

The percentage of total paid claims reported for
MLR/RC attributable to inpatient hospital stays
that began in 2014 but were not discharged by
12/31/2014.
This column equals column K1 divided by column
C.

K3. Paid Claims for Hospital Stays That Crossed Benefit
Years (not already included in IBNR), Percentage of Claims
Difference

The percentage of the claims difference in column
E that is attributable to inpatient hospital stays that
began in 2014 but were not discharged by
12/31/2014.
This column equals column K1 divided by column
E.
10

Instructions
This is a header column. This column
does not accept data input.

User input of a positive value is required.
This field is formatted for the user, such
that amounts are rounded to the nearest
dollar.
If the issuer did not report any individual
market claims for MLR/risk corridors that
meet the description in this row, the user
should input “0” in this column.

This column is auto-calculated for the
user. This field is formatted for the user.
This column does not accept data input.
This user will see this calculation in a
summary table at the end of the claims
discrepancy report.

This column is auto-calculated for the
user. This field is formatted for the user.
This column does not accept data input.
This user will see this calculation in a
summary table at the end of the claims
discrepancy report.

Claims Discrepancy Report (continued)
Table 2 – Sources of Discrepancy From MLR Form – Individual Market Claims Reporting
Definition

Column
L. Adjustment(s) to Be Made in Voluntary Resubmission

L1. Adjustment(s) to Be Made in Voluntary Resubmission –
Dollar Amount

Adjustments to MLR/RC claims data that the
issuer intends to make in a voluntary
resubmission.
This column is exclusive of amounts reported in
other columns.
The dollar value of adjustments to paid claims that
the issuer intends to make in a voluntary
resubmission of MLR/RC data.
Exclude: Any amounts reported in Columns H1,
J1, or K1.

L2. Adjustment(s) to Be Made in Voluntary Resubmission –
Percentage of Total Claims Dollar Amount

The adjustment to paid claims reported for
MLR/RC that the issuer intends to make in a
voluntary resubmission of MLR/risk corridors
data as a percentage of total paid claims.
This column equals column L1 divided by column
C.

11

Instructions
This is a header column. This column
does not accept data input.

A positive value represents an increase in
paid claims; a negative value represents a
decrease in paid claims. This field is
formatted for the user, such that amounts
are rounded to the nearest dollar.
If the issuer did not report any individual
market claims for MLR/risk corridors that
meet the description in this row, the user
should input “0” in this column.

This column is auto-calculated for the
user. This field is formatted for the user.
This column does not accept data input.
This user will see this calculation in a
summary table at the end of the claims
discrepancy report.

Claims Discrepancy Report (continued)
Table 2 – Sources of Discrepancy From MLR Form – Individual Market Claims Reporting
Column
Definition
L3. Adjustment(s) to Be Made in Voluntary Resubmission –
Percentage of Claims Difference

The adjustment to paid claims that the issuer
intends to make in a voluntary resubmission of
MLR/RC data as a percentage of the claims
difference in Column E.
This column equals column L1 divided by column
E.

M. Total Discrepancy Accounted For
M1. Total Discrepancy Accounted For, Dollar Amount

The total claims discrepancy accounted for in
columns H, J, K, and L.
The dollar amount of the total claims discrepancy
accounted for in columns H1, J1, K1, and, L1.
This column is the sum of columns H1, J1, K1,
and L1.

M2. Total Discrepancy Accounted For, Percentage of Total
Claims

The total claims discrepancy accounted for in
columns H1, J1, K1, and L1, as a percentage of
total paid claims reported for MLR/risk corridors.
This column equals column M1 divided by
column C.

12

Instructions

This column is auto-calculated for the
user. This field is formatted for the user.
This column does not accept data input.
This user will see this calculation in a
summary table at the end of the claims
discrepancy report.

This is a header column. This column
does not accept data input.
This column is auto-calculated for the
user. This field is formatted for the user.
This column does not accept data input.
This user will see this calculation in a
summary table at the end of the claims
discrepancy report.

This column is auto-calculated for the
user. This field is formatted for the user.
This column does not accept data input.
This user will see this calculation in a
summary table at the end of the claims
discrepancy report.

Claims Discrepancy Report (continued)
Table 2 – Sources of Discrepancy From MLR Form – Individual Market Claims Reporting
Column
M3. Total Discrepancy

Definition

Instructions

The total claims discrepancy accounted for in columns H1, J1, K1,
and L1, as a percentage of the claims difference in column E.

This column is auto-calculated for the user. This field is
formatted for the user. This column does not accept data
input. This user will see this calculation in a summary
table at the end of the claims discrepancy report.

This column equals column M1 divided by column E.

Table 3 – Written Explanations of Claims Discrepancies
Column
N. HIOS Issuer ID

Definition

Instructions

The 5-digit HIOS ID assigned to the issuer.

This is a header column. This column does not
accept data input.

13

Claims Discrepancy Report (continued)
Table 3 – Written Explanations of Claims Discrepancies
Column
O. Capitation –
Internal Pricing
Methodology

Column

Column

Written explanation of the difference between (a) the total amounts included in
claims in the MLR submission with respect to services for which the issuer did not
generate individual enrollee claims in the normal course of business (that is,
capitation amounts), minus (b) the associated dollar amounts of individual market
claims reported to the EDGE server for which the issuer did not generate
individual enrollee claims in the normal course of business, and derived the cost of
the provider encounter using its principal internal methodology for pricing the
encounter, in accordance with the regulations at 45 CFR 153.710(d).
Include: A detailed description of your internal pricing methodology. Please
indicate whether this reflects your principal internal pricing methodology or a
reasonable methodology because you do not have a complete internal pricing
methodology.

Only if the user has input a dollar amount other
than “0” in Column H— the user should upload a
written description of the actuarial or financial
assumptions underlying its internal methodology
for pricing encounters with capitated providers, and
should cite evidence, whether derived from the
company’s internal systems or otherwise,
supporting those assumptions.

Include: A detailed description of the provider payment arrangements that are in
whole or in part capitated. To the extent different providers have different
provider payment arrangements, each arrangement should be described.
Include: Data on the per capita and total payment amounts and corresponding
amounts calculated under the internal pricing methodology, and the actuarial or
financial assumptions underlying the quantification of this discrepancy. Please
describe why the company believes the internal pricing methodology did not
capture the value of the payment amounts. Please describe the major differences in
the internal pricing methodology between claims reported to Edge and claims for
purposes of MLR.

14

The system will accept the following document
formats only: pdf, doc, doc(x), xls, and xlsx.

Claims Discrepancy Report (continued)
Table 3 – Written Explanations of Claims Discrepancies
Column

Column

Column

P. Orphan, Rejected
and Claims not
loaded to EDGE

Written explanation of the claims discrepancy due to claims reported for MLR/RC
that were not accepted by the EDGE server (rejected claims), were not associated
with an enrollee (orphan claims), or were not otherwise loaded to the EDGE
server.

Only if the user has input a dollar amount other
than “0” in Column J1— the user should upload a
document that contains a written explanation of the
claims discrepancy, including specific data on the
number and dollar value of rejected and orphan
claims and rejection codes, if available, and the
number and dollar value of claims that were not
otherwise loaded to the EDGE server.

Include: The reason that your reported number and value of claims were rejected,
orphan, or otherwise not loaded. Please reference any EDGE server discrepancy
filed in connection with these orphan or rejected claims, along with the
discrepancy numbers.

Q. Paid Claims for
Hospital Stays That
Crossed Benefit
Years (not already
included in IBNR)

R. Adjustments to be
Made in Voluntary
Resubmission

Written explanation of the claims discrepancy that is attributable to inpatient
hospital stays that began in 2014, were not discharged by 12/31/2014, but were
paid by 3/31/2015.
Include: The number and dollar value of these claims.

If you wish to provide additional information about adjustments made in a
voluntary resubmission, you may do so; however, an explanation is not necessary.
If you do not wish to provide an explanation, upload a blank document.

The system will accept the following document
formats only: pdf, doc, doc(x), xls, and xlsx.
Only if the user has input a dollar amount other
than “0” in Column K1—the user should upload a
document that contains a written explanation of the
claims discrepancy, including specific data on the
number of these stays if available.
The system will accept the following document
formats only: pdf, doc, doc(x), xls, and xlsx.
Only if the user has input a dollar amount other
than “0” in Column L1— the user should upload a
document that contains a written explanation of the
adjustment(s) to be made to paid claims.
The system will accept the following document
formats only: pdf, doc, doc(x), xls, and xlsx.

15

Claims Discrepancy Report (continued)

Table 3 – Written Explanations of Claims Discrepancies
Column

Definition

S. Remaining Discrepancy NOT Accounted For A detailed explanation of the claims discrepancy
not accounted for in the other categories. Such
explanation should include actuarial or financial
assumptions or evidence, as applicable, and
should permit CMS to reasonably evaluate the
explanation. Also include the dollar amount of
any remaining discrepancy unaccounted for.

T. IBNR Calculation

Written explanation including a detailed
explanation of your methodology for calculating
IBNR. You may also indicate that you intend to
voluntarily resubmit your MLR/risk corridors
submission with a lower IBNR amount, and
provide a justification consistent with that amount.
Include: Information on at least your past two
years of IBNR rates for MLR, and an explanation
of why your assumptions for this year differ, if
applicable.
Include: Actuarial or financial assumptions or
evidence, as applicable, underlying this
calculation, and an explanation, if applicable, why
this rate may be higher than might be the case for
other issuers or other years.
Include: The dollar amount of any adjustments to
the IBNR amount reported in the MLR/risk
corridors submission that the issuer intend to
make in a voluntary resubmission.

16

Instructions
Only if the percentage is in column M3 is
less than 100% should the user should
upload a document that contains a written
explanation of the remaining discrepancies
not accounted for.
The system will accept the following
document formats only: pdf, doc, doc(x),
xls, and xlsx.
The system will only display the option of
uploading supplemental documentation to
those companies whose IBNR is a high
proportion of paid claims.
Users that are presented with an upload
field for the IBNR calculation must upload
the supporting documentation.
The system will accept the following
document formats only: pdf, doc, doc(x),
xls, and xlsx.

Premium Discrepancy Report
Table 1 – Summary of Individual Market and Small Group Market Premiums Reported to CMS
Column
A. Company
Name
B. HIOS Issuer
ID
C. Premium
Earned
including
Federal and
State High Risk
Pool Programs

D. Plan Average
Premium
Amount *
Billable Member
Months

E. Dollar
Difference

Definition
For the individual and small group markets,
respectively, the legal name of the issuer that
corresponds to the HIOS issuer ID in column B.
For the individual and small group markets,
respectively, the 5-digit HIOS ID assigned to
the issuer.
For the individual and small group markets,
respectively, the earned premium reported in
Part 3, Line 2.1 of the 2014 MLR Reporting
Form. The premium for individual market is the
amount reported in risk corridors column 4A
(Part 3, Line 2.1 of MLR Reporting Form), and
the small group premium is the amount in risk
corridors column 8A (Part 3, Line 2.1 of MLR
Reporting Form).
For the individual and small group markets,
respectively, the total billable premium in the
individual market or small group market
calculated based on per-member-per-month
premium and billable member months submitted
to the EDGE server. Premium as indicated on
the EDGE RATEE report.
The actual dollar difference between earned
premium reported for MLR (column C) and
billable premium data from the EDGE server
(column D).

Instructions
This column is auto-populated for the user.
This column does not accept data input.
This column is auto-populated for the user.
This column does not accept data input.
This column is auto-populated for the user from
data submitted by the issuer in its 2014 MLR
Reporting Form.
This column does not accept data input.

This column is auto-populated for the user from
data submitted by the issuer to its EDGE server.
This column does not accept data input.

This column is auto-populated for the user.
This column does not accept data input.

17

Premium Discrepancy Report (continued)
Table 2 – Sources of Discrepancy From MLR Form – Individual and Small Group Market Premium Reporting
Column
F. HIOS Issuer ID
G. Difference between
Premium Billed and Earned
in 2014

G1. Difference between
Premium Earned and Billed
in 2014, Dollar Amount

Definition

Instructions

For the individual and small group markets, respectively, This column is auto-populated for the user. This column does not
the 5-digit HIOS ID assigned to the issuer.
accept data input.
The total premium difference for the 2014 MLR/risk This is a header column. This column does not accept data input.
corridors reporting year that is attributable to the
difference between billable member premium reported to
the EDGE server, and earned premium reported for
MLR/risk corridors.
The dollar amount of total premium difference for the
2014 MLR/risk corridors reporting year that is
attributable to the difference between earned premium
reported for MLR/risk corridors and billable member
premium reported to the EDGE server.

A positive value means that the MLR/risk corridors earned premium
amount is greater than the billable premium submitted to EDGE; a
negative value means that the earned premium reported for
MLR/risk corridors is smaller. This field is formatted for the user,
such that amounts are rounded to the nearest dollar.
If the issuer did not report any individual market or small group
market premium difference that meets the description in this row, the
user should input “0” in this column.

G2. Difference between
Premium Earned and Billed
in 2014, Percentage of Total
Premium Dollar Amount

The percentage of total premium difference for MLR/risk
corridors attributable to different requirements for
reporting premium between EDGE and MLR/risk
corridors.
This column equals column G1 divided by column C.

This column is auto-calculated for the user. This field is formatted
for the user. This column does not accept data input. This user will
see this calculation in a summary table at the end of the premium
discrepancy report.

G3. Difference between
Premium Earned and Billed
in 2014, Percentage of
Premium Difference

The percentage of the premium difference in column E
attributable to different requirements for reporting
premium between EDGE and MLR/risk corridors. This
column equals column G1 divided by column E.

This column is auto-calculated for the user. This field is formatted
for the user. This column does not accept data input. This user will
see this calculation in a summary table at the end of the claims
discrepancy report.

18

Premium Discrepancy Report (continued)
Table 2 – Sources of Discrepancy From MLR Form – Individual and Small Group Market Premium Reporting
Column

Definition

Instructions

H. Premium Not Collected for
QHP Enrollees during the
Grace Period

The total premium difference for the 2014 MLR/risk This is a header column. This column does not accept data
corridors reporting year that is attributable to premium that input.
was not collected for QHP enrollees during the 3 month
grace period, but was reported as billable premium to the
EDGE server.

H1. Premium Not Collected
for QHP Enrollees during the
Grace Period, Dollar Amount

The dollar amount of total premium difference for the 2014
MLR/risk corridors reporting year that is attributable to
premium that was not collected for QHP enrollees during
the 3 month grace period, but was reported as billable
premium to the EDGE server.

H2. Premium Not Collected
for QHP Enrollees during the
Grace Period, Percentage of
Total Premium Dollar Amount
H3. Premium Not Collected
for QHP Enrollees during the
Grace Period, Percentage of
Premium Difference

Exclude: For the individual market, the dollar amount of
premium not collected should exclude the premium tax
credit portion of advance payment amounts (APTCs)
received by the issuer, because those amounts were
collected by the issuer.
The percentage of total premium difference for MLR/risk
corridors attributable to premium that was not collected for
QHP enrollees during the 3 month grace period, but was
reported as billable premium to the EDGE server.
This column equals column H1 divided by column C.
The percentage of the premium difference in column E that
is attributable to premium that was not collected for QHP
enrollees during the 3 month grace period, but was reported
as billable premium to the EDGE server.
This column equals column H1 divided by column E.

19

User input of a positive value is required. This field is formatted
for the user, such that amounts are rounded to the nearest dollar.
If the issuer did not report any individual market or small group
market premium difference that meets the definition in this row,
the user should input “0” in this column.

This column is auto-calculated for the user. This field is
formatted for the user. This column does not accept data input.
This user will see this calculation in a summary table at the end
of the premium discrepancy report.
This column is auto-calculated for the user. This field is
formatted for the user. This column does not accept data input.
This user will see this calculation in a summary table at the end
of the premium discrepancy report.

Premium Discrepancy Report (continued)
Table 2 – Sources of Discrepancy From MLR Form – Individual and Small Group Market Premium Reporting
Column

Definition

I. Premium Impact Resulting from
Retroactive Enrollment Changes
After EDGE Deadline

Premium difference for the 2014 MLR/risk
corridors reporting year that is attributable
to retroactive enrollment changes after the
EDGE deadline.
The dollar amount of total premium
difference for the 2014 MLR/risk corridors
reporting year that is attributable to
retroactive enrollment changes after the
EDGE deadline.

I1. Premium Impact Resulting
from Retroactive Enrollment
Changes After EDGE Deadline,
Dollar Amount

Instructions
This is a header column. This column does not accept data input.

A positive value means that the retroactive enrollment changes resulted in
higher MLR/risk corridors earned premiums compared to billed premiums on
EDGE; a negative value means that they resulted in lowerMLR/risk corridors
earned premiums compared to billed premiums on EDGE. . This field is
formatted for the user, such that amounts are rounded to the nearest dollar.
If the issuer did not report any individual market or small group market
premium difference that meets the description in this row, the user should
input “0” in this column.

I2. Premium Impact Resulting
from Retroactive Enrollment
Changes After EDGE Deadline,
Percentage of Total Premium
Dollar Amount
I3. Premium Impact Resulting
from Retroactive Enrollment
Changes After EDGE Deadline,
Percentage of Premium Difference

The percentage of total premium
difference for MLR/risk corridors
attributable to retroactive enrollment
changes after the EDGE deadline.
This column equals column I1 divided by
column C.
The percentage of the premium difference
in column E that is attributable to
retroactive enrollment changes after the
EDGE deadline. This column equals
column I1 divided by column E.

20

This column is auto-calculated for the user. This field is formatted for the
user. This column does not accept data input. This user will see this
calculation in a summary table at the end of the premium discrepancy report.

This column is auto-calculated for the user. This field is formatted for the
user. This column does not accept data input. This column is auto-calculated
for the user. This field is formatted for the user. This column does not accept
data input. This user will see this calculation in a summary table at the end
of the premium discrepancy report.

Premium Discrepancy Report (continued)
Table 2 – Sources of Discrepancy From MLR Form – Individual and Small Group Market Premium Reporting
Column

Definition

Instructions

J. Partial Month
Proration Differences in
2014
J1. Partial Month
Proration Differences,
Dollar Amount

Partial month proration differences that led to premium
amounts on the EDGE server that differed from earned
premium reported for MLR/risk corridors.
The dollar amount of total premium difference for the 2014
MLR/risk corridors reporting year that is attributable to
partial month proration differences that were applied to
premiums submitted to the EDGE server, but not included
in earned premium reported for MLR/risk corridors.

This is a header column. This column does not accept data input.

A positive value means that the proration differences led to higher
MLR/risk corridors earned premium amounts as compared to billed
premium on EDGE; a negative value means that they led to lower
MLR/risk corridors earned premium amounts as compared to billed
premium on EDGE. . This field is formatted for the user, such that
amounts are rounded to the nearest dollar.
If the issuer did not report any individual market or small group market
premium difference for MLR/risk corridors that meets the description in
this row, the user should input “0” in this column.

J2. Partial Month
Proration Differences,
Percentage of Total
Premium Dollar
Amount

The percentage of total premium difference for MLR/risk
corridors attributable to different reporting requirements
for partial month premium between EDGE and MLR/risk
corridors.
This column equals column J1 divided by column C.

This column is auto-calculated for the user. This field is formatted for
the user. This column does not accept data input. This column is autocalculated for the user. This field is formatted for the user. This user
will see this calculation in a summary table at the end of the premium
discrepancy report.

J3. Partial Month
Proration Differences,
Percentage of Premium
Difference

The percentage of the premium difference in column E that
is attributable to different reporting requirements for partial
month premium between EDGE and MLR/risk corridors.
This column equals column J1 divided by column E.

This column is auto-calculated for the user. This field is formatted for
the user. This column does not accept data input. This user will see
this calculation in a summary table at the end of the premium
discrepancy report.

21

Premium Discrepancy Report (continued)
Table 2 – Sources of Discrepancy From MLR Form – Individual and Small Group Market Premium Reporting
Definition

Column
K. Adjustment(s) to Be Made in Voluntary Resubmission

K1. Adjustment(s) to Be Made in Voluntary Resubmission –
Dollar Amount

Adjustments to MLR/risk corridors premium data
that the issuer intends to make in a voluntary
resubmission.
This column is exclusive of amounts reported in
other columns.
The dollar value of adjustments to premiums that
the issuer intends to make in a voluntary
resubmission of MLR/risk corridors data
Exclude: Any amounts reported in Columns G1,
H1, or J1.

Instructions
This is a header column. This column
does not accept data input.

A positive value indicates the voluntary
resubmission will increase MLR/risk
corridors earned premiums; a negative
value indicates it will decrease MLR/risk
corridors earned premiums. This field is
formatted for the user, such that amounts
are rounded to the nearest dollar.
If the issuer did not report any individual
market or small group premium difference
that meets the description in this row, the
user should input “0” in this column.

K2. Adjustment(s) to Be Made in Voluntary Resubmission –
Percentage of Total Premium Amount

The adjustment to premiums reported for
MLR/RC that the issuer intends to make in a
voluntary resubmission of MLR/risk corridors
data as a percentage of total premiums.
This column equals column K1 divided by column
C.

22

This column is auto-calculated for the
user. This field is formatted for the user.
This column does not accept data input.
This user will see this calculation in a
summary table at the end of the premium
discrepancy report.

Premium Discrepancy Report (continued)
Table 2 – Sources of Discrepancy From MLR Form – Individual and Small Group Market Premium Reporting
Definition
Instructions
Column
K3. Adjustment(s) to Be Made in Voluntary
Resubmission – Percentage of Premium Difference

L. Total Discrepancy Accounted For
L1. Total Discrepancy Accounted For, Dollar Amount

The adjustment to premiums that the issuer intends
to make in a voluntary resubmission of MLR/risk
corridors data, as a percentage of the premium
difference in Column E.
This column equals column K1 divided by column
E.
The total premium discrepancy accounted for in
columns G, H, I, J, and K.
The dollar amount of the total premium discrepancy
accounted for in columns G1, H1, I1, J1, and K1.
This column is the sum of columns G1, H1, I1, J1,
and K1.

L2. Total Discrepancy Accounted For, Percentage of
Total Claims

The total premium discrepancy accounted for in
columns G1, H1, I1, J1, and K1, as a percentage of
total premiums reported for MLR/risk corridors.
This column equals column L1 divided by column
C.

L3. Total Discrepancy

The total premium discrepancy accounted for in
columns G1, H1, I1, J1, and K1, as a percentage of
the claims difference in column E.
This column equals column L1 divided by column
E.
23

This column is auto-calculated for the user.
This field is formatted for the user. This
column does not accept data input. This user
will see this calculation in a summary table at
the end of the premium discrepancy report.

This is a header column. This column does
not accept data input.
This column is auto-calculated for the user.
This field is formatted for the user. This
column does not accept data input.
This user will see this calculation in a
summary table at the end of the premium
discrepancy report.

This column is auto-calculated for the user.
This field is formatted for the user. This
column does not accept data input This user
will see this calculation in a summary table at
the end of the premium discrepancy report.

This column is auto-calculated for the user.
This field is formatted for the user. This
column does not accept data input. This user
will see this calculation in a summary table at
the end of the premium discrepancy report.

Premium Discrepancy Report (continued)
Table 3 – Written Explanations of Premium Discrepancies
Column
L. HIOS Issuer ID

M. Difference between Premium Earned and Billed
Premium in 2014

N. Premium Not Collected for QHP Enrollees during the
Grace Period

O. Premium Impact Resulting from Retroactive Enrollment
Changes After EDGE Deadline

Definition
For the individual and small group markets,
respectively, the 5-digit HIOS ID assigned to the
issuer.
A written explanation of this discrepancy,
including the dollar value of this difference, and
an explanation of the magnitude of this difference.

A written explanation of this discrepancy,
including the number of instances and dollar value
of the uncollected premiums, and an explanation
of the magnitude of this difference. This does not
need to reflect enrollee-by-enrollee reconciliation,
but should provide information sufficient to
understand the magnitude of this impact.

Instructions
This is a header column. This column
does not accept data input.
Only if the user has input a dollar amount
other than “0” in Column G1 should the
user upload a written description of the
difference.
The system will accept the following
document formats only: pdf, doc, doc(x),
xls, and xlsx.
Only if the user has input a dollar amount
other than “0” in Column H1 should the
user upload a written description of the
difference.
The system will accept the following
document formats only: pdf, doc, doc(x),
xls, and xlsx.
Only if the user has input a dollar amount
other than “0” in Column I1 should the
user upload a written description of the
difference.

A written explanation of this discrepancy,
including the dollar value of this difference, and
an explanation of the magnitude of this difference.
This does not need to reflect enrollee-by-enrollee
reconciliation, but should provide information
sufficient to understand the magnitude of this
The system will accept the following
impact.
document formats only: pdf, doc, doc(x),
xls, and xlsx.

24

Premium Discrepancy Report (continued)
Table 3 – Written Explanations of Premium Discrepancies
Column

Definition

P. Adjustment(s) to Be Made in Voluntary Resubmission If you wish to provide additional information
about adjustments made in a voluntary
resubmission, you may do so; however, an
explanation is not necessary. If you do not wish
to provide an explanation, upload a blank
document.

Q. Remaining Discrepancy NOT Accounted For

R. Partial Month Proration Differences

Instructions
Only if the user has input a dollar amount
other than “0” in Column K1 should the
user upload a document that contains a
written explanation of the adjustment(s) to
be made to paid claims.
The system will accept the following
document formats only: pdf, doc, doc(x),
xls, and xlsx.
Only if the percentage is in column L3 is
less than 100% should the user should
upload a document that contains a written
explanation of the remaining discrepancies
not accounted for.

A further detailed explanation of the premium
discrepancy not included in the other categories.
Such explanation should include actuarial or
financial assumptions or evidence, as applicable, a
quantification of the discrepancy (including
directionality) and should permit CMS to
reasonably evaluate the explanation. Include also
the dollar amount of any remaining discrepancy The system will accept the following
unaccounted for.
document formats only: pdf, doc, doc(x),
xls, and xlsx.
A written description of your proration
Only if the user has input a dollar amount
methodology, the number of instances and the
other than “0” in Column J1 should the
dollar value (and directionality) attributable to the user upload a document that contains a
different proration methodologies, and relevant
written explanation of the adjustment.
actuarial or financial assumptions or evidence
backing up this calculation.
The system will accept the following
document formats only: pdf, doc, doc(x),
xls, and xlsx.

25

APPENDIX 1: MLR Risk Corridors Submission Checklist Template
This checklist and the accompanying attestation should be completed by following the web link that will be provided uniquely to each issuer shortly.
Federal Employer Identification Number (FEIN):______________
Please complete the following, and sign on the signature line below. Your signature will serve as an attestation to all of the elements below. The elements of this
form should be reviewed by a senior officer of your company, and any documents necessary to establish the attestation should be retained for future audits,
consistent with 45 C.F.R. §153.520(e) and 45 C.F.R. §158.502. This attestation and checklist applies to the following issuer HIOS IDs:
[INSERT ISSUER HIOS IDS HERE]
2014 MLR/Risk Corridors Submission
Checklist

Applicable Regulation or
Guidance

(Items refer to columns 4A (Individual
Market) and 8A (Small Group Market) of
Part 3 of the 2014 MLR Reporting Form
unless otherwise noted.)1

Reinsurance and Risk Adjustment
amounts in Part 2, Lines 1.9 and 1.10
(Columns 2/2A/7/7A) and Part 3 Lines 1.5
and 1.6 (Columns 4-4A/7-8A) match
Reinsurance and Risk Adjustment
amounts reported by HHS on June 30,
2015 (subject to any later instructions as
to these amounts from CMS). These
amounts are applied as adjustments to
1

If the element is accurate, mark
“Y.” If the element in the
original submission is not
accurate, but will be accurate
upon resubmission, mark “R.”
If the element is not accurate
and no resubmission will be
made because there is no impact
on the amount of risk corridors
payments or charges or MLR
rebates, mark “N” and provide
an explanation as directed
below.

45 CFR 153.530; 45 CFR
158.130; MLR Reporting
Form Instructions, pp. 28
(Part 2, Lines 1.9 and
1.10), 37 (Part 3, Lines
1.5 and 1.6)

MLR 2014 Annual Reporting Form is posted at https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/2014-mlr-reporting-form20150528c.xlsx and the MLR 2014 Annual Reporting Form Instructions can be found at https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-OtherResources/Downloads/2014-MLR-Annual-Reporting-Form-Instructions-20150528c.pdf
26

2014 MLR/Risk Corridors Submission
Checklist

Applicable Regulation or
Guidance

(Items refer to columns 4A (Individual
Market) and 8A (Small Group Market) of
Part 3 of the 2014 MLR Reporting Form
unless otherwise noted.)1

If the element is accurate, mark
“Y.” If the element in the
original submission is not
accurate, but will be accurate
upon resubmission, mark “R.”
If the element is not accurate
and no resubmission will be
made because there is no impact
on the amount of risk corridors
payments or charges or MLR
rebates, mark “N” and provide
an explanation as directed
below.

MLR numerator / Risk Corridors
allowable costs.
Premium earned in Part 3, Line 2.1 does
not include any actual or estimated
Reinsurance, Risk Adjustment, or Risk
Corridors amounts.

45 CFR 153.530(a); 45
CFR 158.130(a); MLR
Reporting Form
Instructions, p. 40 (Part 3,
Line 2.1)

Premium earned in Part 3, Line 2.1,
Columns 4A and 8A includes premium
earned for all ACA-compliant plans (QHP
and non-QHP)in the individual and small
group markets, and excludes premium
earned for grandfathered and nongrandfathered coverage that does not
comply with the 2014 ACA market
reforms.

45 CFR 153.500; 45 CFR
158.130; MLR Reporting
Form Instructions pp. 8
(Individual and Small
Group Health Insurance),
40 (Part 3, Line 2.1)

Premium earned in Part 3, Line 2.1
includes both the premium tax credit
portion of the advance payment amounts
(APTC), as well as the enrollee portion.

45 CFR 153.500; 45 CFR
158.130

27

2014 MLR/Risk Corridors Submission
Checklist

Applicable Regulation or
Guidance

(Items refer to columns 4A (Individual
Market) and 8A (Small Group Market) of
Part 3 of the 2014 MLR Reporting Form
unless otherwise noted.)1

Premium earned in Part 3, Line 2.1
includes 2014 new business experience
that was deferred for MLR reporting
purposes.

45 CFR 153.500; 45 CFR
158.130

Premium earned in Part 3, Line 2.1 of the
MLR Form matches Total Premium
Earned in Table 1 of the Risk Corridors
Plan-level Data Form2, for both the
Individual and Small Group markets

45 CFR 153.500;
REGTAP FAQ 11034

Adjusted incurred claims in Part 3, Line
1.2 includes either the cost-sharing
reduction (CSR) portion of the advanced
premium amounts or a certified estimate
of the amount of CSR included in 2014.

45 CFR 158.140; MLR
Reporting Form
Instructions, pp. 34 (Part
2, Line 2.18), 36 (Part 3,
Line 1.2), 37 (Part 3, Line
1.4)

If the element is accurate, mark
“Y.” If the element in the
original submission is not
accurate, but will be accurate
upon resubmission, mark “R.”
If the element is not accurate
and no resubmission will be
made because there is no impact
on the amount of risk corridors
payments or charges or MLR
rebates, mark “N” and provide
an explanation as directed
below.

CSRs are separately reported on Part 2,
Line 2.18 and Part 3, Line 1.4; and are
subtracted from incurred claims in
calculating the MLR numerator / Risk
2

Risk Corridors 2014 Plan-Level Data Form is posted at https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/2014-risk-corridors-plan-leveldata-form-20150528.xlsx and the Risk Corridors Plan Level Instructions is posted at https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-OtherResources/Downloads/2014-Risk-Corridor-Plan-Level-Instructions-20150528.pdf
28

2014 MLR/Risk Corridors Submission
Checklist

Applicable Regulation or
Guidance

(Items refer to columns 4A (Individual
Market) and 8A (Small Group Market) of
Part 3 of the 2014 MLR Reporting Form
unless otherwise noted.)1

If the element is accurate, mark
“Y.” If the element in the
original submission is not
accurate, but will be accurate
upon resubmission, mark “R.”
If the element is not accurate
and no resubmission will be
made because there is no impact
on the amount of risk corridors
payments or charges or MLR
rebates, mark “N” and provide
an explanation as directed
below.

Corridors allowable costs.
Adjusted incurred claims in Part 3, Line
1.2 includes claims for all plan benefits,
not only essential health benefits (EHBs).

45 CFR 153.500; 45 CFR
158.130

Risk corridors allowable costs and target
amounts were correctly copied over from
MLR Form, Part 3, Lines 3.1, 3.7, and 3.9
to Risk Corridors Plan-Level Data Form,
Part 3, Lines 2, 3, and 7, respectively.

Risk Corridors PlanLevel Data Form
Instructions, p. 15

Risk corridors amount in Part 3, Line 10
of the Risk Corridors Plan-Level Data
Form was correctly copied to MLR Form,
Part 3, Line 3.12. This amount was also
correctly copied to MLR Form Part 2,
Line 1.11, Columns 2/7 and Part 3, Line
1.7, Columns 3-4/7-8; and was used in
MLR and rebate calculations.

MLR Reporting Form
Instructions pp. 28 (Part
2, Line 1.11), 38 (Part 3,
Line 1.7), 43 (Part 3, Line
3.12)

Income taxes reported in Part 1, Section 3,
Columns 2A and 7A exclude the impact
of actual or estimated risk corridors

HHS Notice and Benefit
and Payment Parameters
29

2014 MLR/Risk Corridors Submission
Checklist

Applicable Regulation or
Guidance

(Items refer to columns 4A (Individual
Market) and 8A (Small Group Market) of
Part 3 of the 2014 MLR Reporting Form
unless otherwise noted.)1

amounts on taxable income.

If the element is accurate, mark
“Y.” If the element in the
original submission is not
accurate, but will be accurate
upon resubmission, mark “R.”
If the element is not accurate
and no resubmission will be
made because there is no impact
on the amount of risk corridors
payments or charges or MLR
rebates, mark “N” and provide
an explanation as directed
below.

for 2014 (78 FR 15472)

Please list any HIOS ID for which your organization has submitted a
discrepancy report pursuant to 45 CFR 153.710(e)(1) (if you have
submitted no discrepancy report(s), please indicate N/A):

If the company answered “R” please indicate the date of the
resubmission or expected resubmission. If the company answered “N”
to any of the criteria above, please describe the reason (limit 200
characters).
I certify that, as of the date indicated below, to the best of my information, knowledge, and belief, my organization’s responses to the MLR and Risk Corridors
Submission Checklist [and 2014 Risk Corridors Discrepancy Worksheet (including any information uploaded in connection with the worksheet)] are accurate and
consistent with my organization’s own internal claims, premium, and enrollment data. If my organization becomes aware that any such data are inaccurate or
incomplete, it will promptly inform CMS, and will be prepared to correct its submission. I acknowledge that the provisions of the Affordable Care Act specifically
make payments made by or in connection with an Exchange subject to the False Claims Act if those payments include any federal funds. This includes the
temporary risk corridors program established under Section 1342 of the Affordable Care Act. I further certify that I am authorized to legally and financially bind
my organization.
__________________________
Signature
30

__________________________
Name, Title
__________________________
Company
__________________________
Date
__________________________
Email Address
__________________________
Phone Number

31

APPENDIX 2: Draft Risk Corridors Discrepancy Worksheet
CLAIMS DISCREPANCY
HIOS ID: #####

Company Name:

SUMMARY OF INDIVIDUAL MARKET CLAIMS REPORTED TO CMS
2.1b Claims Incurred
Paid Claims Amount
Difference($)
During 2014, paid
from EDGE RISR
through of 3/31/2015
Report (Individual)
(Column 4A)

INDIVIDUAL MARKET CLAIMS REPORTING
Capitation $
Orphan/Rejected/Not Loaded to EDGE Server $
Incurred but not Discharged $
Voluntary $
Total (Calculated)
Unaccounted for (Calculated: Difference – Total Entered)
View Summary Table

Percent of Total
Individual Market
Claims Loaded to the
EDGE Server Excluding
Orphan Claims (as of
5/15)

____________
____________
____________
____________
____________
____________

Written Explanation of Claims Discrepancy
Attachment Type Picklist (Values: Capitation, Orphan/Rejected/Not Submitted, Incurred but not Discharged, Remaining Discrepancy
NOT Accounted For)
File Name

Attachment Type

32

AUTO-CALCULATED SUMMARY TABLE

Dollar Amount

Percentage of Total
Claims Dollar
Amount

Percentage of
Claims Difference

Capitation - Internal
Pricing
Methodology
Orphan, Rejected, or
Claims Not Loaded
on EDGE
Claims Incurred but
Not Discharged by
12/31 (not already
included in IBNR)
Adjustment(s) to Be
Made in Voluntary
Resubmission
Remaining
Discrepancy NOT
Accounted For
Total Discrepancy
Accounted For

33

Percentage of Total
Claims Volume

PREMIUM INDIVIDUAL DISCREPANCY
HIOS ID: #####

Company Name:

SUMMARY OF INDIVIDUAL MARKET PREMIUMS REPORTED TO CMS
2.1 Premium Earned
including Federal and
State High Risk Pool
Programs (Individual
RC, Column 4A)

Individual Plan Average
Premium Amount *
Billable Member
Months

Difference($)

INDIVIDUAL GROUP MARKET PREMIUM REPORTING
Difference between Premium Earned and Billed in 2014 $
Premium Not Collected for QHP Enrollees during the Grace Period $
Premium Impact Retroactive Enrollment Changes After EDGE Deadline $
Partial Month Proration Differences $
Adjustment(s) to Be Made in Voluntary Resubmission $
Total (Calculated)
Unaccounted for (Calculated: Difference – Total Entered)
View Summary Table
Written Explanation of Premium Discrepancy

____________
____________
____________
____________
____________
____________
____________

Attachment Type Picklist (Values: Difference between Premium Earned and Billed in 2014, Premium Not Collected for QHP Enrollees during the Grace Period, Premium Impact
Retroactive Enrollment Changes After EDGE Deadline, Partial Month Proration Differences, Remaining Discrepancy NOT Accounted For)

File Name

Attachment Type

34

AUTO-CALCULATED SUMMARY TABLE
Dollar Amount

Percentage
of
Total
Premium Dollar Amount

Percentage
Difference

Difference between Premium
Earned and Billed in 2014
Premium Not Collected for QHP
Enrollees during the Grace
Period
Premium Impact Resulting from
Retroactive Enrollment Changes
After EDGE Deadline
Partial
Month
Proration
Differences
Adjustment(s) to Be Made in
Voluntary Resubmission
Remaining Discrepancy NOT
Accounted For
Total Discrepancy Accounted
For

35

of

Premium

PREMIUM SMALL GROUP DISCREPANCY
HIOS ID: #####

Company Name:

SUMMARY OF SMALL GROUP MARKET PREMIUMS REPORTED TO CMS
2.1 Premium Earned
including Federal and
State High Risk Pool
Programs (Small Group
RC, Column 8A)

Small Group Plan
Average Premium
Amount * Billable
Member Months

Difference($)

SMALL GROUP MARKET PREMIUM REPORTING
Difference between Earned Premium and Billed in 2014 $
Premium Not Collected for QHP Enrollees during the Grace Period $
Premium Impact Retroactive Enrollment Changes After EDGE Deadline $
Partial Month Proration Differences $
Adjustment(s) to Be Made in Voluntary Resubmission $
Total (Calculated)
Unaccounted for (Calculated: Difference – Total Entered)
View Summary Table

___________
____________
____________
____________
____________
____________
____________

Written Explanation of Premium Discrepancy
Attachment Type Picklist (Values: Difference between Earned and Billed Premium in 2014, Premium Not Collected for QHP Enrollees during the Grace Period,
Premium Impact Retroactive Enrollment Changes After EDGE Deadline, Partial Month Proration Differences, Remaining Discrepancy NOT Accounted For)
File Name

Attachment Type

36

AUTO-CALCULATED SUMMARY TABLE
Dollar Amount

Percentage of Total
Premium Dollar Amount

Percentage of Premium
Difference

Difference between Premium
Earned and Billed in 2014
Premium Not Collected for QHP
Enrollees during the Grace
Period
Premium Impact Resulting from
Retroactive Enrollment Changes
After EDGE Deadline
Partial Month Proration
Differences
Adjustment(s) to Be Made in
Voluntary Resubmission
Remaining Discrepancy NOT
Accounted For
Total Discrepancy Accounted
For

37