A Practical Guide to Federal Medical Loss Ratio Requirements

Few health reform provisions have greater potential to impact Medicare and commercial health plans than those that set minimum medical loss ratios (MLRs) ... and Medicare Advantage plans that don t comply could possibly face enrollment suspension or the loss of their MA contracts.In A Practical Guide to Federal Medical Loss Ratio Requirements, six of the nation s leading authorities on different angles of MLR implementation will offer valuable insights into these and other big-dollar questions:*How has HHS defined quality improvement activities that may be included in MLR calculations? How will that affect the actuarial value of insurers benefit designs?*Without a pass-through for broker commissions, how will insurers adjust broker pay while maintaining that distribution channel?*What is likely to be the impact of MLR provisions on commercial and Medicare insurers earnings?*What steps are insurers likely to take to ratchet down other administrative spending, without jeopardizing important areas such as technology investment and fraud and abuse prevention?*What are the hidden compliance hurdles in complying with the reporting and rebate requirements? *What steps will Medicare Advantage plans take to adjust benefit designs and distribution channels to meet their 85% minimum MLR requirement?Ramifications of the new MLR provisions are potentially staggering for everyone in the health insurance business. Order A Practical Guide to Federal Medical Loss Ratio Requirements and get the guidance you need to plot your future in this brave new world of MLR regulation.Table of ContentsIntroduction Jill Brown, Executive Editor, Atlantic Information Services, Inc. Chapter 1: Regulatory and Compliance Issues Associated With the Medical Loss Ratio Regulations Kenneth B. Schnoll*The Process HHS Will Use to Collect Data from Health Insurance Issuers*Allocation of Expenses*Calculating an Issuer s MLR*Applying a Credibility Adjustment*Providing the Rebate*Regulatory and Compliance Hurdles in Complying with the Interim Final MLR RegulationsChapter 2: Impact of Medical Loss Ratio Floor on Health Plans Quality Improvement Programs and Benefit Design William A. MacBain, MPS*Quality Improvement*Benefit DesignChapter 3: The Impact of the Medical Loss Ratio Regulations on Administrative Services Henry R. Loubet and Amy B. Donovan*What Is an Expenditure to Improve Health Care Quality?*What Is an Administrative Expense?*Utilization Review*Fraud Prevention*Broker Commissions*ICD-10 Migration*Development of Tools and Technology to Reduce Administrative Expense*Research and Development*ConclusionChapter 4: Financial Impact of Medical Loss Ratio Regulations Carl McDonald, CFAChapter 5: The Actuarial Perspective on the Medical Loss Ratio Regulation David Tuomala, FSA, MAAA, FCA*Introduction*Inclusions and Exclusions in the MLR Calculation*Aggregation Levels for Rebate Calculations*Credibility Adjustments and Three-year Averaging for Rebates*Unique Considerations and Impacts by Product and Line of Business*Health Plan Pricing, Profitability, and Capital and Surplus RequirementsChapter 6: The Impact of the Medical Loss Ratio Regulations on Medicare Advantage Plans Brian Weible, FSA, MAAA*Possible Implementation of MLR Requirements for Individual MA Plans*Employer Group Waiver Plans*Potential Impact of Loss Ratio Requirement*Strategic Responses to the Loss Ratio Requirement