Health insurance company financial reporting workers who accidentally compress 2013 medical loss ratio filings the wrong way or send a duplicate file can’t just fix the problem and pretend everything went flawlessly.
The Health Insurance Oversight System will send warning emails to the carrier’s chief executive and financial officers.
The user who actually uploaded the problem MLR form also will get error messages that give more information about the nature of any apparent errors.
HIOS is supposed to send users messages about basic formatting errors, such as use of an incorrect “ZIP” compression method or the presence of data in cells that should not contain insurance company data.
HIOS also is supposed to provide some data validation, such as warnings if the amount of direct premium collected per member per month seems to be either far too low or far too high.
Issuers of non-grandfathered major medical coverage will use the MLR tools and HIOS to comply with the Patient Protection and Affordable Care Act minimum MLR requirements.
PPACA requires non-grandfathered plans to spend at least 85 percent of premium revenue on claims and quality improvement efforts for large-group coverage. The minimum MLR for individual and small-group coverage is 80 percent.
Groups representing agents, brokers and other groups have fought for years to get costs moved from the “non-claims costs” category into the “health care and quality improvement expenses incurred” category, or removed from the calculations altogether.
The 2013 worksheet spreadsheet lets carriers spend up to 0.3 percent of premium on converting to the new ICD-10 diagnostic code standard and include that in the quality category.
Insurers must record “agents and brokers fees and commissions” together with “direct sales salaries and benefits” and “cost containment expenses not included in quality improvement expenses.”