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Electronic Code of Federal Regulations

e-CFR data is current as of February 18, 2020

Title 42Chapter IVSubchapter BPart 422Subpart X → §422.2410


Title 42: Public Health
PART 422—MEDICARE ADVANTAGE PROGRAM
Subpart X—Requirements for a Minimum Medical Loss Ratio


§422.2410   General requirements.

(a) For contracts beginning in 2014 or later, an MA organization (defined at §422.2) is required to report the information required under §422.2460 for each contract under this part for each contract year.

(b) MLR requirement. If CMS determines for a contract year that an MA organization has an MLR for a contract that is less than 0.85, the MA organization has not met the MLR requirement and must remit to CMS an amount equal to the product of the following:

(1) The total revenue of the MA contract for the contract year.

(2) The difference between 0.85 and the MLR for the contract year.

(c) If CMS determines that an MA organization has an MLR for a contract that is less than 0.85 for 3 or more consecutive contract years, CMS does not permit the enrollment of new enrollees under the contract for coverage during the second succeeding contract year.

(d) If CMS determines that an MA organization has an MLR for a contract that is less than 0.85 for 5 consecutive contract years, CMS terminates the contract per §422.510(b)(1) and (d) effective as of the second succeeding contract year.

[78 FR 31307, May 23, 2013, as amended at 83 FR 16736, Apr. 16, 2018]

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