Within the Medical Loss Ratio (MLR) Division, ER has accumulated some of the leading experts from across the country in the examination and analysis of MLR filings. Our sole focus is providing first class MLR-related services to state and Federal regulators. Since 2017, our MLR Team continues to be contracted with The Center for Consumer Information and Insurance Oversight (CCIIO) to perform all MLR examinations conducted on behalf of the Federal government. Our MLR Team has also assisted numerous states in the performance of MLR examinations, largely assessing MLR filings in compliance with the same federally mandated rules and requirements.
As part of the Affordable Care Act (ACA), the MLR regulation (45 CFR Part 158), requires insurance companies who write healthcare coverage to submit annual reports on the proportion of premium earned that is spent on clinical and quality improvement services, and must pay rebates to enrollees if the MLR does not meet minimum standards (most commonly 80% or 85%). The regulation and filing requirements for MLR are complex and filled with complex requirements and nuances that are often interpreted by insurers in ways not intended by CCIIO.
Through our extensive experience in conducting MLR examinations, the MLR Division’s team has developed the expertise and skills necessary to understand the regulation and other requirements, allowing us to provide assistance to regulators in the continual interpretation of rules, technical guidance and other requirements.
In addition, senior leadership of the MLR Division’s team played an instrumental role in the early implementation of the MLR rules, including leading the establishment and continued maintenance of the standard MLR examination procedures and overall project expectations. This depth of experience allows ER to provide expert assistance to states or other regulators in the establishment of their own MLR examination procedures, or in the interpretation of questions that arise regarding companies’ MLR filings.
MLR Services to Regulators: