Crosswalk Document

Crosswalk for Changes to the 2015 MLR Annual Reporting Form and Instructions
(CMS 10418) Following the 60 Day Comment Period
Table of Contents
A.

Introduction ...................................................................................................................... 1

B.

Changes to MLR and Risk Corridors Reporting Forms and Instructions ........................ 1

A. Introduction
CMS received 3 public comments regarding the notice of the revised Medical Loss Ratio (MLR)
PRA package published in the Federal Register on February 19, 2016 (81 FR 8498). The 60-day
comment period closed on April 19, 2016. The PRA package contains two collections of
information: the MLR Annual Reporting Form (including the Risk Corridors component) that
issuers must file with CMS each year by July 31 and the accompanying Form Instructions, and
the Rebate Notices that issuers must send to subscribers and policyholders each year no later
than September 30. The PRA package modifies the 2014 MLR Annual Reporting Form, which
was previously approved by OMB under OMB Control Number 0938-1164. The Rebate
Notices, which were also previously approved under the same OMB Control Number, are not
being revised at this time.
B. Changes to MLR and Risk Corridors Reporting Forms and Instructions
Most of the comments on the MLR Form and Instructions requested clarification of the
instructions and correction of errors and inconsistencies, and addressed treatment of cost-sharing
reduction payments and risk adjustment amounts. Comments on the Risk Corridors Plan-Level
Data Form and Instructions additionally requested clarification on definitions of earned premium
and addressed errors in payment and charge calculations. The following table contains the list of
changes made to the 2015 MLR Annual Reporting Form and Risk Corridors Plan-Level Data
Form and the accompanying Form Instructions as a result of internal review and in response to
comments received following the 60-day public comment period.

Page 1 of 8

2015 MLR Annual Reporting Form, Risk Corridors Plan-Level Data Form, and
Form Instruction Changes Following the 60-Day Comment Period
Document

1

MLR
Reporting
Form

2

MLR Form
Instructions

3

MLR Form
Instructions

Section
Edited
Part 1 –
Summary of
Data
Part 1 –
Summary of
Data

Part 1 –
Summary of
Data

Revision
(Red indicates modified language)
Edited the title of Column 11: “Health Insurance Large Group
Total as of 12/31/16 15”
Edited instructions for Line 5.6, “Exclude” list to correct formatting
error
Revised the instructions for Line 3.2a:
Guaranty fund assessments. Note: if such assessments will
be offset in future years through reductions in state taxes or
through premium surcharges, as permitted by the state, the
issuer may defer reporting such guaranty fund assessments
until the year(s) of offset.

Revised instructions for Line 1.9 (Federal Transitional
Reinsurance Program Payments):
3/31 Column – Include expected payments from HHS, as shown
on the notification received from HHS by June 30 of the
year following the MLR reporting year (unless instructed
otherwise by HHS).

4

MLR Form
Instructions

Part 2 –
Premium and
Claims

[RC] 3/31 Column – Include:
-Expected payments from HHS for the 2015 benefit year,
as shown on the notification received from HHS by June
30, 2016 (unless instructed otherwise by HHS).
-Subtract from the above the difference between the
reinsurance payment amount reported by the issuer for
the 2014 benefit year on the 2014 MLR Form and the
reinsurance amount actually paid to the issuer for the
2014 benefit year. Do not include adjustments for
pending appeals unless the appeal has been resolved
(in which case the payment would have been made).

5

MLR Form
Instructions

Part 2 –
Premium and
Claims

Revised instructions for Line 1.10 (Federal Risk Adjustment
Program Net Receipts or Charges):
3/31 Column – Include expected net payments from HHS (enter
as a positive amount) or charges payable to HHS (enter
as a negative amount), as shown on the notification
received from HHS by June 30 of the year following the
MLR reporting year (unless instructed otherwise by
HHS), including any risk adjustment default charges or
default charge allocation amounts.
[RC] 3/31 Column – Include:

Page 2 of 8

Rationale
In response to
comments; to correct
typographical error
In response to a
comment; to correct
typographical error
In response to a
comment requesting the
allowance for the
matching of guaranty
fund assessments with
offsetting revenue
increases in accordance
with state provisions for
such offsets.

To allow for reported
amounts to correctly flow
through Part 3 and risk
corridors calculation.

To allow for reported
amounts to correctly flow
through Part 3 and risk
corridors calculation.

-Expected net payments from HHS (enter as a positive
amount) or charges payable to HHS (enter as a negative
amount) for the 2015 benefit year, as shown on the
notification received from HHS by June 30, 2016 (unless
instructed otherwise by HHS), including any risk
adjustment default charges or default charge allocation
amounts.
-Subtract from the above the difference between the risk
adjustment amount reported by the issuer for the 2014
benefit year on the 2014 MLR Form and the amount
actually paid to the issuer for the 2014 benefit year. Do
not include adjustments for pending appeals unless the
appeal has been resolved (in which case a payment
would have been made).

6

MLR Form
Instructions

Part 2 –
Premium and
Claims

Edited instructions for Line 2.1: Revised “State subsidies based
on a stop-loss payment methodology (include as a negative
adjustment), including receipts from certain state reinsurance
programs” and moved this clause from the “Include” list to the
“Deduct” list
Renamed Part 2, Line 2.18 and Part 3, Line 1.4: “Advance
Reconciled payments for cost-sharing reductions”

7

MLR Form
Instructions

Part 2 –
Premium and
Claims; Part 3
– MLR and
Rebate
Calculation

Revised instructions for Part 2, Line 2.18:
3/31 Column – Include the total reconciled cost-sharing
reductions amount received for the 2015 benefit year
(MLR reporting year).
[RC] 3/31 Column – Include:
-The reconciled cost-sharing reductions amount for the
2015 benefit year (as reported to the issuer by CMS);
minus
-The difference between the cost-sharing reductions
amount for the 2014 benefit year that was reported by
the issuer on the 2014 MLR Form and the reconciled
cost-sharing reductions amount for the 2014 benefit year
(as reported to the issuer by CMS).

In response to a
comment requesting
guidance and
clarification on where to
report state reinsurance
program amounts.

In response to
comments, corrected line
description and clarified
instructions

Revised instructions for Line 1.4:
PY1 Column – Amount of cost-sharing reductions received for
2014, as reconciled in 2016.
8

MLR Form
Instructions

Part 3 – MLR
and Rebate
Calculation

RC Column – Part 2, Line 2.18, Column [RC] 3/31. Report a
reconciled CSR amount that reflects: the reconciled CSR amount
for the 2015 benefit year (as reported to the issuer by CMS),
minus the difference between the CSR amount reported by the
issuer on the 2014 MLR Form and the reconciled CSR amount for
the 2014 benefit year (as reported to the issuer by CMS).

Page 3 of 8

To clarify instructions
and to allow for reported
amounts to correctly flow
through Part 3 and risk
corridors calculation.

Revised instructions for Line 1.5:
PY1 Column – 2014 MLR Form, Part 2, Line 1.9, Columns 3/31 +
Deferred PY1 – Deferred CY. Restate amounts to reflect
any changes or updates to reinsurance payments for the
2014 benefit year communicated by HHS after June 30,
2015, including any changes communicated after the
filing of the 2014 MLR Form.
CY Column – Part 2, Line 1.9, Columns 3/31 + Deferred PY1 –
Deferred CY

9

MLR Form
Instructions

Part 3 – MLR
and Rebate
Calculation

RC Column – Part 2, Line 1.9, Column [RC] 3/31. The issuer can
adjust for differences in reinsurance payments that were
actually received after June 30, 2015 that differ from the
amount reported on the 2014 MLR Form. Therefore,
issuers will report a total reinsurance payment amount
that reflects: the reinsurance payment amount for the
2015 benefit year (as reported to the issuer by CMS on
the June 30, 2016 report), minus the difference between
the reinsurance payment amount reported by the issuer
for the 2014 benefit year on the 2014 MLR Form and the
reinsurance amount that was actually paid to the issuer
for the 2014 benefit year. There are no adjustments for
pending appeals unless the appeal has been resolved
(in which case payment would have been made).

To clarify instructions
and to allow for reported
amounts to correctly flow
through Part 3 and risk
corridors calculation.

Revised instructions for Line 1.6:
PY1 Column – 2014 MLR Form, Part 2, Line 1.10, Columns 3/31
+ Deferred PY1 – Deferred CY.
Restate amounts to reflect any changes or updates to transfer
amounts for the 2014 benefit year communicated by HHS after
June 30, 2015, including any changes communicated after the
filing of the 2014 MLR Form.

10

MLR Form
Instructions

Part 3 – MLR
and Rebate
Calculation

RC Column – Part 2, Line 1.10, Column [RC] 3/31. The issuer
can adjust for differences in risk adjustment transfers
that were actually paid or received after June 30, 2015,
that differ from the amount reported on the 2014 MLR
Form. Therefore, issuers will report a total risk
adjustment amount that reflects: the risk adjustment
transfer amount for the 2015 benefit year (as reported to
the issuer by CMS on the June 30, 2016 report), minus
the difference between the risk adjustment amount
reported by the issuer for the 2014 benefit year on the
2014 MLR Form and the amount that was actually paid
to the issuer for the 2014 benefit year. There are no
adjustments for pending appeals unless the appeal has
been resolved (in which case a payment would have
been made).

Page 4 of 8

In response to
comments, to clarify the
date as of which issuers
should report 2014 risk
adjustment amounts.

11

MLR Form
Instructions

Part 3 – MLR
and Rebate
Calculation

12

MLR Form
Instructions

Part 3 – MLR
and Rebate
Calculation

Revised instructions for Line 1.7:
PY1 Column – Payments: (2014 MLR Form, Part 2, Line 1.11,
Columns 3/31 + Deferred PY1 – Deferred CY) x (Risk corridors
payments for the 2014 benefit year received from HHS as of the
filing date of the 2015 MLR Form) / (2014 Risk Corridors PlanLevel Data Form, Tab 3, Line 96)
Edited instructions for Line 2.1:
PY2 Column – 2013 MLR Form, Part 1, Lines 1.1 + 1.2 + 1.3,
Columns 3/31 + Deferred PY1 – Deferred CY – Part 4 Line 6.1a,
Column CY
PY1 Column – 2014 MLR Form, (Part 1, Lines 1.1 + 1.2 + 1.3,
Columns 3/31 + Deferred PY1 – Deferred CY) – (Part 3, Lines 1.5
+ 1.6 + 1.7, Column CY) + Part 3 Line 7.1a, Column PY1

In response to a
comment; to correct
typographical error

Instructions were revised
to clarify calculations

Edited instructions for Line 2.2:
PY2 Column –
Federal tax-exempt issuers:
2013 MLR Form, Part 1, Lines 3.1a + 3.1b + 3.1c + 3.2a + 3.2b +
3.2c + 3.3, Columns 3/31 + Deferred PY1 – Deferred CY – Part 4
Line 6.1b, Column CY

13

MLR Form
Instructions

Part 3 – MLR
and Rebate
Calculation

14

MLR Form
Instructions

Part 3 – MLR
and Rebate
Calculation

15

MLR Form
Instructions

Part 3 – MLR
and Rebate
Calculation

Non Federal tax-exempt issuers:
2013 MLR Form, Part 1, Lines 3.1a + 3.1b + 3.1c + 3.2a + (the
higher of 3.2b or 3.2c) + 3.3, Columns 3/31 + Deferred PY1 –
Deferred CY – Part 4 Line 6.1b, Column CY
PY1 Column –
Federal tax-exempt issuers:
2014 MLR Form, Part 1, Lines 3.1a + 3.1b + 3.1c + 3.1d + 3.2a +
3.2b + 3.2c + 3.3a + 3.3b, Columns 3/31 + Deferred PY1 –
Deferred CY + Part 3 Line 7.1b, Column PY1
Non Federal tax-exempt issuers:
2014 MLR Form, Part 1, Lines 3.1a + 3.1b + 3.1c + 3.1d + 3.2a +
(the higher of 3.2b or 3.2c) + 3.3a + 3.3b, Columns 3/31 +
Deferred PY1 – Deferred CY + Part 3 Line 7.1b, Column PY1
Edited instructions for Lines 3.6 and 3.7 to delete the Note:
Note: For issuers in States that have not adopted CMS’s
transitional policy, Line 3.6 should equal Line 3.4.
Note: For issuers in States that have not adopted CMS’s
transitional policy, Line 3.7 should equal Line 3.5.
Edited instructions for Line 6.1:
PY1 Column – 2014 MLR Form, Part 4 3, Line 5.1 6.1, Total
Column

Page 5 of 8

Instructions were revised
to clarify calculations and
to correct a typographical
error

In response to a
comment; to correct
typographical error
In response to a
comment; to correct
typographical error

Renamed Part 1, Line 2.11: “Allowable claims recovered through
fraud reduction efforts expenses (MLR Form Part 2, Line 2.17)”
Renamed Part 2, Line 2.17: “Allowable claims recovered through
fraud reduction efforts expenses (the smaller of Lines 2.17a or
2.17b)”
Made corresponding edits to instructions for these lines as well as
Part 3, Lines 1.2 and 7.2b:
Line 1.2 – Adjusted incurred claims as of 3/31 of the year
following the MLR reporting year

16

MLR Form
and
Instructions

Part 1 –
Summary of
Data; Part 2 –
Premium and
Claims; Part 3
– MLR and
Rebate
Calculation

PY2 Column – enter the amount of adjusted incurred claims
reported on Part 1, Lines 2.1 + 2.11, Columns 3/31 +
Deferred PY1 – Deferred CY of the MLR Form 2 years prior
to the MLR reporting year, restated as of 3/31 of the year
following the MLR reporting year. For example, for reporting
year 2014, enter 2012 adjusted incurred claims restated as
of 3/31/2015. (This is also known as claims incurred in 12
months and paid in 39 months.) Restate all applicable
elements of adjusted incurred claims, including reserves and
the allowable claims recovered through fraud reduction
expense efforts, in accordance with the Filing Instructions
from 2 years prior to the MLR reporting year.
PY1 Column – enter the amount of adjusted incurred claims
reported on Part 1, Line 2.1 + 2.11, Columns 3/31 +
Deferred PY1 – Deferred CY of the MLR Form for the
preceding MLR reporting year, restated as of 3/31 of the
year following the MLR reporting year. (This is also known
as claims incurred in 12 months and paid in 27 months).
Restate all applicable elements of adjusted incurred claims,
including reserves and the allowable claims recovered
through fraud reduction expense efforts, in accordance with
the Filing Instructions from the year preceding the MLR
reporting year.
7.2b Adjusted incurred claims as of 3/31 of the year following the
benefit year
Enter the amount of adjusted incurred claims reported on
Part 1, Line 2.1 + 2.11, Column [RC] 3/31 of the 2014 MLR
Form, restated as of 3/31/2016. (This is also known as
claims incurred in 12 months and paid in 27 months).
Restate all applicable elements of adjusted incurred claims,
including reserves and the allowable claims recovered
through fraud reduction expense efforts, in accordance with
the Filing Instructions.

Page 6 of 8

Line descriptions were
corrected to more
accurately reflect the
regulation

Part 3 – MLR
and Rebate
Calculation

17

MLR Form
Instructions

18

RC Form
and
Instructions

Throughout

19

RC Form
and
Instructions

Table 4,
Column N
(Appendix A,
page 16)

RC Form
and
Instructions

Tab 3, “Risk
Corridors
Payment and
Charge
Calculation”,
Line 1

RC Form
and
Instructions

Tab 3, “Risk
Corridors
Payment and
Charge
Calculation”,
Line 3

RC Form
and
Instructions

Tab 3, “Risk
Corridors
Payment and
Charge
Calculation”,
Line 7

20

21

22

Edited instructions for Line 7.1:
7.1a Disclose the deferred portion of premium for each respective
State and market. If this amount was excluded from Line 2.1,
Column CY of the 2013 MLR Form, subtract it from Line 2.1,
Column PY2 (so that Line 2.1, Column PY2 of the 2015 MLR
Form equals the amount reported in Line 2.1, Column CY of
the 2013 MLR Form), and add it to Line 2.1, Column PY1 (so
that Line 2.1, Column PY1 of the 2015 MLR Form equals the
amount reported in Line 2.1, Column CY of the 2014 MLR
Form).
7.1b Disclose the total Federal and State taxes paid on the
associated premium revenue. If this amount was excluded
from Line 2.2, Column CY of the 2013 MLR Form, subtract it
from Line 2.2, Column PY2 (so that Line 2.2, Column PY2 of
the 2015 MLR Form equals the amount reported in Line 2.2,
Column CY of the 2013 MLR Form), and add it to Line 2.2,
PY1 Column (so that Line 2.12, Column PY1 of the 2015
MLR Form equals the amount reported in Line 2.2 Column
CY of the 2014 MLR Form).
Replaced references to “billable premium,” to “premium earned”.

Added in missing text Auto-calculated for the user: Table 4,
Column M divided by Table 1, Column A. which incorrectly
appeared in Tab 3, “Risk Corridors Payment and Charge
Calculation”, Line 1 detail.
Replaced “Auto-calculated for the user: Table 4, Column M
divided by Table 1, Column A.” with “Auto-calculated for the user:
Column F + Column J + Column N”.
Replaced references to MLR Reporting Form, Part 3, Line 3.7
with 3.5:
User input: MLR Reporting Form, Part 3, Line 3.75.

Language was revised to
clarify instructions

Language was updated
to be consistent with
finalized versions of the
previous year.
Language was updated
to add a missing
definition

Language was updated
to correct swapped
definitions (see above)
Revised to be consistent
with renumbered lines in
the MLR Reporting Form

Refer to MLR Reporting Form instructions for calculating Line
3.75, Part 3 of the MLR Reporting Form.
Replaced references to MLR Reporting Form, Part 3, Line 3.9
with 3.7:
User input: MLR Reporting Form, Part 3, Line 3.97.
Refer to MLR Reporting Form instructions for calculating Line
3.97, Part 3 of the MLR Reporting Form.

Page 7 of 8

Revised to be consistent
with renumbered lines in
the MLR Reporting Form

23

24

25

RC Form
and
Instructions

RC Form
and
Instructions

RC
Instructions

Tab 3, “Risk
Corridors
Payment and
Charge
Calculation”,
Line 8
(Appendix A,
page 17)

Tab 3, “Risk
Corridors
Payment and
Charge
Calculation”,
Line 9

General
Instructions

Replaced calculation reference stating that this is a “user input”
cell to say it is auto-calculated for user.

Replaced references to Line 3 with Line 7:
-If Line 8 is at least 108%: 80% x (Line 2 – 108% x Line 3 7)
+ 2.5% x Line 7.
-If Line 8 is at least 103% but less than 108%: 50% x (Line 2
– 103% x Line 3 7).
-If Line 8 is at least 97% but less than 103%: zero (0)
-If Line 8 is at least 92% but less than 97%: 50% x (Line 2–
97% x Line 7).
-If Line 8 is less than 92%: 80% x (Line 2 – 92% x Line 3 7) –
2.5% x Line 7.
Deleted line “Risk Corridor zip file uploads will be allowed after
the full MLR attestation has been completed”

Page 8 of 8

In response to comment
showing inaccuracy
between instructions and
Form

In response to comment

Change made to be
consistent with MLR
instructions