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Moderator: Lauren Solkowski

06-25-15/1:30 pm CT

Confirmation #4350842

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NWX-HHS-AOA-1

Moderator: Lauren Solkowski

June 25, 2015

1:30 pm CT

Coordinator: Welcome and thank you for standing by. All participants will be able to listen 

only until the question and answer portion of today’s conference. To ask a 

question, please star 1.

Today’s conference is being recorded. If you have any objections, please 

disconnect at this time. I would now like to turn the conference over to Ms. 

Lauren Solkowski. Miss, you may begin.

Lauren Solkowski: Thank you so much in good afternoon everyone and thank you for joining 

us today for the administration for community living’s business acumen 

webinar on medical loss ratio.

As the operator mentioned, this is Lauren Solkowski with ACL and I will be 

facilitating our Webinar. So for today, we have invited (Tim McNeil), who is 

going to review and also explained the medical loss ratio and go - and discuss 

how it could impact your discussions with potential payers.

So before we start with his presentation, I have a few housekeeping 

announcements. Starting with one, if you have not done so, if you could use 
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the link that was included in your calendar appointment to get onto WebEx so 

that you can follow along with the slides as we go through them, but also you 

can ask your questions or comments, if you have, through the chat function.

If you do not have access to the link that I emailed you, you can also go on to 

www.WebEx.com and click on the attend a meeting button that’s at the top of 

the page and then enter the meeting number.

So for today, our meeting number is 664376475. That’s 664376475. If you 

have any problems getting into WebEx, please call the WebEx technical 

support number and that is 1-866-229-3239. Again that’s 1-866-229-3239.

As the operator has mentioned, all of our participants are in -- excuse me -- a 

listen only mode. However, we do welcome your questions throughout the 

course of the Webinar. There are two ways you can ask your questions, the 

first of which is through the chat function in WebEx.

You can enter your questions and comments there, located on the right-hand 

side of the screen. And then the other is - the other way to ask questions, it 

will be through the audio line.

So when that time comes, the operator will give us instructions as to how to 

queue up to ask your questions. If there are any questions that we do not get to 

during the course of this Webinar, we will be sure to follow them up - follow 

up with you to get them answered.

If you have any questions, you can email them to me and I will enter my email 

address in the chat box here for everyone’s reference before the end of the 

Webinar.
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Also, at the operator has mentioned, we are recording the Webinar and we 

will be posting the recording, the slides and (Tim)’s presentation as well as a 

transcript of the Webinar online for your reference.

So with that, I would like to welcome and introduce our speaker for today 

who is (Tim McNeil). (Tim) is an independent healthcare consultant 

specializing in health program development and sustainability. (Tim), I just

wanted to thank you again for being with us today and with that, I will turn it 

over to you.

(Tim McNeil): Great. Thank you. So the topic for today is the medical loss ratio, some going 

to go through a series of slides and I’m also going to be working with Lauren 

to show you actually how to look at a medical loss ratio and interpreted.

And so hopefully these tools can help you to prepare as you move toward your 

contracts and pursuits to obtain opportunities and leverage the information 

that you can obtain publicly about the medical loss ratio performance of health 

plans in your marketplace and part of your contracting strategy.

Next slide. So I’m going to go through a few things. What is the medical loss 

ratio? Who does it apply to? How to analyze those reports and how to use that 

data in a - as part of an overall contracting strategy.

Next slide. So what is the medical loss ratio? The Affordable Care Act 

requires health insurers to submit data on the proportion of revenue spent on 

clinical services and quality improvement.

And this ratio of health insurance plan income as compared to expenses is the 

medical loss ratio. So you may remember back when the Affordable Care Act 
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was being passed and debated, there was a lot of discussion about health plans

reaping lots of profit and then denying claims for services.

And so there was a perception that some health plans were a little bit 

disingenuous in the fact that they had a profit motive to deny claims to 

increase their profitability.

And so it came about was that they mandated the implementation of the 

medical loss ratio so now that it requires all health plans to spend a certain 

percentage of their total income or the revenue towards direct services for the 

beneficiaries.

So the Affordable Care Act requires all health plans to issue rebates to 

enrollees if they did not meet that minimum medical loss ratio standard. So 

the medical loss ratio standard is 80% or 85%, depending on the size and the 

type of the plan.

A little bit later we’ll actually show you how that figure is created and then 

show you how you can look up a health plan’s medical loss ratio and then 

based on that figure, how you can adjust your contract capture strategy with 

that plan.

Next slide. So the medical loss ratio applies to all commercial health 

insurance plans, and just beginning last year, it was added in and now applies 

to all Medicare Advantage plans and it applies to all Medicare Part D plans.

So on the first slide, I said that there was - some plans have to meet the 80% 

medical loss ratio requirements and some plans have to meet the 85% medical 

loss ratio requirement.
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Plans that have to meet the 80% medical loss ratio requirements our health 

plans that have - that are small plans, so plans that have 100 or fewer members. 

Any plan with greater than 100 members have to meet the 85% medical loss 

ratio requirement and all Medicare Advantage plans, regardless of size, have 

to meet the 85% requirement.

And this also applies to Part D. So you may have a Medicare Advantage plan 

in a particular state and they may only have 75 members in that particular 

state. They still have to meet the 85% medical loss ratio requirement regarbecause for Medicare Advantage plans, that mandate covers them regardless 

of the size of the plan.

Next slide. So just to make sure we’re all speaking on the same terms, the 

Medicare Advantage plan, sometimes called Part C, or (in their plan) -

Medicare Advantage plans have to cover all services that are covered under 

Medicare Part A and Part B.

And so when a beneficiary likes Medicare Part C or Medicare Advantage, and 

they have elected to have their Part A and Part B benefits managed by a 

private health insurance plan is approved by CMS, so the medical loss ratio 

applies to all of those plans.

It does not apply to someone that is in traditional or original Medicare or 

Medicare fee-for-service. The medical loss ratio also does not apply to ACOs, 

because ACOs manager population that is in original Medicare. When a 

beneficiary ops to participate in Medicare Advantage, then they are moved 

from an ACO’s attribution must.
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Next slide. So the key concept is the four parts of Medicare. Part A is all in 

patient care. Part B is all outpatient. Part C is Medicare Advantage. And Part 

D is the prescription benefit.

So you might be thinking right off the bat, it’s the Part D plan that manages 

the prescription benefit for a beneficiary, it’s very interesting that they also 

have to meet this 85% medical loss ratio.

So if their members are not getting more prescriptions or if the prescription 

costs are not at that 85% threshold, some of the things that a Medicare Part D 

plan can do is to increase their cost in the area of quality improvement 

activities.

And quality improvement activities can be things like a comprehensive 

medication review and paying for the services allows the health plans to have 

that cost included in the medical loss ratio.

Next slide. So Medicare Advantage enrollment, when looking at the medical 

loss ratio and assessing how plans in your market performing as it relates to 

the medical loss ratio, it’s important to know what is the penetration of the 

Medicare Advantage plans and your marketplace?

So a Kaiser (Family) Foundation report from January 2015 shows that about 

30% of all Medicare beneficiaries are in a Medicare Advantage plan. And so 

this does vary by market because this is the average across the entire United 

States.

A lot of times, when I have had the opportunity to visit a market, they often 

feel that 90% to 100% of the population of Medicare beneficiaries are in a 

Medicare Advantage plan, but very rarely do you see a market where - I mean, 
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if you have a market where you’re at 40%, 50%, you’re above the average. If 

you’re at 60%, you’re very high.

And so not many markets have a Medicare Advantage penetration rate much 

higher than that. Next slide. This is the map from the Kaiser Family 

Foundation report from January 2015. And the orange areas have the highest 

penetration of Medicare Advantage plans.

Dark blue areas have the lowest penetration. You see Alaska has 0% 

penetration of Medicare Advantage and Minnesota does have a high 

penetration with 52% - or 51%.

Next slide. So you can determine the Medicare Advantage enrollment in your 

area. I just want to remind everyone that the Administration for Community 

Living Center for Disability and Aging Policy, there are two tip sheets there 

that can walk you through exactly how to look up the number of Medicare 

beneficiaries that are in original Medicare and the number that enrolled in a 

Medicare Advantage plan in each county and some territories in the United 

States.

The tip sheets walk you through how to look it up by state and then it breaks it 

down for every county in the United States. And it will be listed there. And 

those tips, the data is provided by CMS. The tip sheet will walk you through 

how to access the data through the CMS Web site.

And CMS updates those tables every single month. And so the data that is 

there is good as of the end of the prior month for which you are looking. So if 

you pulled it up now, you would be seeing they are that’s good as of May 31st.
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Then once you have that data, then looking up the medical loss ratio for those 

particular plans that have high penetration in your market, it provides you 

with in-depth knowledge towards how the plan is performing as it relates to 

cost.

The medical loss ratio does not speak at all to quality. Quality is something 

that is tracked according to something called (HETIS) measures and we’ll 

have - we’re going to be having some additional information provided to 

everyone at a later time around (HETIS) measures.

But the medical loss ratio, along with the (HETIS) measure’s quality 

performance and performance of the plan really gives you information about 

how that plan is performing (and through) (costs) in the medical loss ratio, 

you can begin to craft your strategy to work with the health plan to be a value 

added person because - or a value-added vendor because now you can begin 

to determine their points of pain.

You can address those points of pain based on the knowledge you have about 

how they’re performing as it relates to cost and quality. Next slide. So 

Medicare Advantage plans, so that we’re all clear again, is that they’re 

capitated plans.

They provide all Part A and Part B benefits. And Medicare does have - Part D 

plans are separate for medication, and then under the Balanced Budget Act of 

1997, Medicare pays 95% of the average traditional Medicare costs in the 

county.

Next slide. Part C plan premiums a risk-adjusted, so all Medicare Advantage 

plan receives a risk-adjusted capitated payment. And what that essentially 

means is that health plans get a per member per month payment to provide all 
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of the services for Medicare Advantage, all Part A and Part B services that are 

required for the population.

That’s per me- per patient, per person per month payment is risk-adjusted so 

they can get a higher capitated amount based on the level of health and 

complexity of the population that they’re serving.

So if the health plan is able to provide information to CMS that shows that 

they have a population that has higher health costs and multiple chronic 

conditions, then they’re able to get a higher payment because it’s a riskadjusted capitated payment amount. That’s what that means.

So your ability as a CBO to be working with a health plan and identifying all 

of the conditions and complications that a consumer has, provided information 

to the health plan, the health plan, if they did not already have that information 

in hand and have not already shared that information with CMS, once they do 

share that information, they’re able to risk-adjusted to a higher capitated 

amount if they’re able to accurately demonstrate the level of health and 

complexity of the population they serve.

Next slide. These hierarchal condition category ATC, when talking to (health 

centers), you may come across this so I just want to make sure that you know 

this.

And the reason this is important for the medical loss ratio is because once you 

know how that health plan is performing, once you’re able to provide 

assistance to that plan, the information that they’re able to obtain and talk 

about submitting their information to CMS, this is what they’re submitting it 

on.
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So the hierarchal condition categories, the methodology that incorporates both 

diseases and demographic factors for the population, based on the clinical 

diagnostic information that’s gathered, the Medicare it Advantage plan 

submits that data to CMS and then they give you the appropriate risk 

(adjustment).

So there - if they fail to properly document the need for services or the need to 

- the level of the burden of disease of the population that they are serving, then 

they are essentially going to not get the risk-adjusted payments and they could 

be getting less money than they actually require or should be getting because 

they did not report this.

Next slide. So the medical loss ratio applies to all commercial plans after the 

passage of the Affordable Care Act, but it did not apply to all Medicare 

Advantage plans or Part D plans immediately after the passage of the 

Affordable Care Act.

There was a period of time that allowed the Medicare Advantage plans to 

prepare for the implementation of the medical loss ratio, and so the medical 

loss ratio requirement to not apply to them until January 1, 2014.

Next slide. So that medical loss ratio calculation occurs in - the medical loss 

ratio numerator includes all the healthcare paid claims, along with any quality 

improvement activities.

And the quality improvement activity, I believe, is an area where many 

community-based organizations can really excel and be a very positive 

contributor to the health plan by, one, helping to improve the population and 

allowing the costs that are spent towards reimbursement of the communitybased organization, if it can be applied to the numerator, i.e., the quality 
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improvement activity in the numerator line, then that helps improve the 

medical loss ratio.

That - the healthcare paid claims plus quality improvement activity divided by 

the premium, which is the per person, per month that’s collected, minus 

allowable deductions it was the medical loss ratio. Allowable deductions are 

things like taxes that the health plan has to pay.

Next slide. So what are quality improvement activities? Quality improvement 

activities, the things that can be included in the medical loss ratio numerator 

calculation, they must stand up to audit.

They must be designed to improve health quality and designed to increase the 

likelihood of desired health outcomes. So it sounds like the poster child for 

evidence-based programs because they’re designed to improve health care 

quality. They’re designed to increase the likelihood of positive health 

outcomes.

And when a health plan spends any of their premium dollars towards quality 

improvement activities, it’s added to the numerator and then helps to meet the 

85% medical loss ratio requirement.

Next slide. Specifically in the final rule that CMS provided, they listed some 

quality improvement activities as examples. So some that were specifically 

listed in the final rule, including medication therapy management, things that 

improve health outcomes, including those that increased the likelihood, 

including desired outcomes, things that reduce health disparities, preventing 

hospital admissions, things that help improve patient safety like reducing 

medical errors are lowering infection rates, programs designed to increase 

wellness and promote health activities.
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These things, verbatim, came out of the final rule for CMS that said all of 

these are examples of quality improvement activities that health plan can use 

towards the medical loss ratio requirement.

And this is - this counts for all commercial or applies to all commercial plans 

as well as all Medicare Advantage plans and now even Part D plans can use 

any of these activities to count towards the 85% requirement.

Next slide. So the requirements for individual small group plans as 80% 

which are small plans that have 1 to 100 beneficiaries. If a plan - the 

commercial plan has 101 or more beneficiaries in the plan, then it is - it must 

meet the 85%.

Medicare Advantage plans, beginning January 1, 2014, 85% was the medical 

loss ratio requirement regardless of size in the same thing for Part D plans 

which also began January 1, 2014.

So this is the first reporting year for Medicare Advantage plans and Part D 

plans because they have to report in June for the prior year. So this month, all 

Medicare Advantage plans and Part D plans are reporting to CMS their 

medical loss ratio spending for the 2014 calendar year.

Next slide. Penalties for medical loss ratio noncompliance - commercial plans, 

a commercial plan that does not meet the medical loss ratio must submit a 

prorated rebate to all enrollees in the amount equal to the difference.

So an example, a health plan - when I was going through this process, I pulled 

up health plans in multiple markets and I looked at a health plan that many of 

us know that is in Texas.
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And that health plan had an 80% medical loss ratio for the prior year. And 

then actually in the data, I saw exactly how much money they had to pay to 

the beneficiary, so it essentially equated to five - that 5%.

So they had to send a rebate check to every covered beneficiary during that 

period of time. The essentially took that - the difference of spend that they 

should have spent up to 85%.

The only did 80%. They took that dollar amount and then send out a notice for 

all beneficiaries along with a check stating that because it is not meeting the 

cost ratio, that here is their rebate.

There - one thing that’s interesting is that their cost, as well as the bad PR that 

they’re having to endure as a result of that, is entirely (unintelligible) and also 

is not added to the medical loss ratio for the following year. It’s just a loss for 

them on both sides.

(Medicare Advantage) plans and Part D plans - so Medicare Advantage plans 

are getting their premium dollars from CMS, so they can’t, in turn, send a 

rebate check to the beneficiaries.

What happens with the Medicare Advantage plan and that Part D plan, which 

begins this year, it’s the first reporting year - January of 2014was the start and 

then after this first year if they’re not compliant, they have to send a rebate to 

CMS.

If they are noncompliant for three consecutive years, they are placed on 

prohibition of new enrollments. So the interesting thing that also occurs after 

three years, if they are not meeting that medical loss ratio requirement for 
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Medicare Advantage plans, which is 85%, a notification is sent to all of their 

currently enrolled beneficiaries notifying them that their Medicare Advantage 

plan has failed to meet the medical loss ratio requirement for consecutive 

years.

And that they need to consider looking for a new plan because if that plan 

continues to fail, then they will be terminated and that they will be banned 

from the Medicare Advantage program, which essentially could be the kiss of 

death for health plan because now all the beneficiaries are given the notice 

that they may need to begin looking for another plan because the plan you’re 

in is in jeopardy of being terminated.

The few beneficiaries that remain may leave and then it’s going to be even 

harder for the health plan to meet the medical loss ratio requirement. And so 

now, if they are noncompliant for five consecutive years, their contracts are 

terminated.

Next slide. So the medical loss ratio tip sheet that explains this is a guide - is 

available and it’s available through the Center for Integrated Programs and 

there’s a link for that.

Next slide. So another thing that incentivizes Medicare Advantage plans to 

increase their spending towards quality improvement activities that can be 

counted towards the medical loss ratio requirement is that in - for calendar 

year 2015, the final rule from CMS has expanded the rewards an incentive 

program that encourages Medicare Advantage beneficiaries to participate in 

activities that improve health.
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And so it’s called the Reward Incentive Program and it essentially can - it 

allows statutory authority for the health plan to pay a beneficiary of financial 

reward as an incentive for their participation in a health improvement activity.

And then the cost of all of that can be counted towards the Medicare 

Advantage plan’s medical loss ratio requirements of 85%. So this is a 

significant sweetening of the pot to encourage Medicare Advantage plans to 

take full advantage of encouraging beneficiaries to have better health 

outcomes and participate in evidence-based programs and other quality 

improvement activities.

And they are even allowed to pay the beneficiary a cash reward. I remember 

when this was wrapping up, I was at a Medicare Advantage conference and 

there was a panel and they were talking about how Medicare Advantage plans 

were going to be using and participating in this. And many of them are 

speaking about paying the beneficiaries anywhere from $75 to $150 for their 

participation in a quality improvement activity.

And many times they were talking about things such as diabetes selfmanagement classes and health coaching programs or other types of programs 

that they would pay the beneficiary between $75 to $150 for their 

participation and they were going to pay for the program as well. And then the 

entire cost of that, they would apply to the medical loss ratio.

Next slide. And so an example of that is one of the Medicare Advantage plans, 

at the same conference that we were talking about, they began pulling all of 

their beneficiaries with the known diagnosis of diabetes.

And then they began marketing directly to those beneficiaries that they needed 

to go to one of their Medicare Advantage network diabetes self-management, 
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or DSMT program, and then once the beneficiary completed the diabetes selfmanagement training program, the beneficiary would receive a check for $75 

that they could spend on whatever they wanted.

And this was all now covered under the Medicare Advantage Reward 

Incentive program and many Medicare Advantage plans are now heavily 

marketing.

And they’re - at the same conference, they were talking about in markets 

where Medicare Advantage plans, there’s - where there is heightened 

competition between plans, they’re seeing higher and higher amounts where 

beneficiaries are being paid higher amounts for participation in these reward 

incentive programs, almost as a marketing tool to get - to encourage them to 

switch over to a different plan.

Next slide. So prevention and wellness activities they can be paid for by a 

Medicare Advantage plan and applied to the medical loss ratio - so any type of 

preventive health activities they can reduce the likelihood of high-cost disease 

complications.

It sounds just like a chronic disease self-management class or diabetes selfmanagement class or a fall prevention class. It sounds very much like - and so 

the cost that the health plan spends towards that can be spent towards the 85% 

medical loss ratio.

If a Medicare Advantage plan has a high medical loss ratio, then expanded use 

of preventive health services hopefully can bring down their cost. And they’ll 

show you some examples of that as well.
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Next slide. So where can you find medical loss ratio data? The Centers for 

Medicare and Medicaid Services, there is a site or a section of CMS called the

Center for Consumer Information and Insurance Oversight.

The link that will take you to the main page for that site, (ensures) report each 

year showing the money that was spent on healthcare and activities to improve 

health care for the past year, those reports are due June 1 of the following year.

So for June one of 2015, then every health plan submitted their data for 

performance here 2014. That reporting is done by state and for markets within 

a state.

Some of you are researching a plan that is operated in multiple states, then 

you will - when you go to the Web site, you will see data for that health plan 

in each state that they’re in.

So an example, I was looking up Blue Cross of Texas. When I pulled up Blue 

Cross of Texas in the - for the medical loss ratio data, I saw Blue Cross of 

Arkansas, Blue Cross of Texas, Blue Cross of Oklahoma, so they were all 

listed there because they report by state. And the analysis of the medical loss 

ratio is also done by state.

Next slide. It’s a little tough to see but that link (before) to the Center for 

Consumer Information and Oversight, when you go to that link, you’ll bring 

up this Web page. It’s highlighted at the top - medical loss ratio. When you 

scroll down, then there is a search tool, and the search tool will then allow you 

to pull up medical loss ratio data for analysis.

Next slide. So as you scroll down, then you get to the reporting - this lookup 

tool. So the data is reported by year and by state see with select the reporting 
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year. Right now the most current reporting year available is 2013 because they 

just submitted the 2014 data on June 1.

Once it’s analyzed complete, then CMS will later post the 2014 data. But you 

can see the 2013 data now, and although the 85% medical loss ratio penalty 

did not apply to Medicare Advantage plans until 2014, they still had to report.

And so their data is still available and that is important to know because you 

can begin seeing trends, because if they did poorly for the medical loss ratio in 

2013, the likely did poorly in 2014 as well.

Or it’s doubtful that there was a huge shift because the likely were still 

managing a similar population with a similar disease set, and so you can see 

trends over time.

So with the lookup tool, you first select the year, then you select the state. I 

am going to walk you through an example. I pulled a plan in Maryland. And 

so I put in the year. I put in the date. I put in the state. And then I just put in B 

for boy and clicked search and then came up all the Blue - many of the Blue 

Cross plans.

So we don’t know the full name of the plan, you just put in the first letter and 

then the search tool will pull you everything that begins or is closely related to 

a plan with that name. If you know the full name, you type out the full name 

and then click search. So when I selected Maryland, I selected 2013, I got the 

options below.

Next slide. Once you click on the particular plan of interest, you will see - I 

wanted to see how (Care First Blue Choice) was performing in the Maryland 
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market. So I - the circle there is something I did just for presentation purposes. 

It’s not going to be there when you selected.

You’ll just get the list, and then to the right you see the blue things that say 

selected download zip file, well if you wanted information about the first 

health plan, American Republic Insurance Company, then you’d select the 

corresponding zip file. I wanted information specifically about Care First, 

Blue Choice, so I selected the zip file there to the right.

Next slide. Once I open that, I - it get - you click on the zip file. You know, 

when she download and open the zip file, then they’re going to give you the 

option to look at Excel files, and these are a lot of Excel files for the state in 

reference.

Remember I said that the health plan is reporting and the medical loss ratio 

analysis is done by state. Care First is one that serves people in DC, Maryland 

and Virginia. You all know that there’s a lot of overlap there.

So they still have to split out and report separately, although essentially if 

you’re in Virginia and you’re in Care First, you still have the same health plan 

if you move to Maryland. But for reporting purposes, as it relates to medical 

loss ratio, they’re separated out.

When you see the one in the second item that says grand total, that’s a 

culmination of the entire market. But the culmination of the entire market, 

because the medical loss ratio is calculated per state, there’s not a medical loss 

ratio report for the entire market because every market is assessed on their 

own. Next slide. This is tough to see. Lauren, can you pull up the Maryland 

file?
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Lauren Solkowski: Sure. I’m going to - oops, there - okay, Maryland and down going to - oh, 

Maryland. Okay.

(Tim McNeill): Great. So this is an actual 2013 report for a health plan. And you see - I 

wanted you to see what you’re actually going to get it if you’re going down on 

that file. All of these tables and files are locked so you can make any 

adjustments.

In the first column you see the premiums. Item 1.1, that’s on line 20, it says 

the total direct premium earned, so this is the actual amount that that health 

plan was paid in premium dollars for the performance year in question.

And so the actual amount paid to this health plan over this - over the year was 

$81 million. Now if you go down to Section 2.1, you see the total incurred 

claims. So this is the amount of medical claims that health plans paid out in 

real dollars during the same time period.

So remember, the medical loss ratio is paid claims plus quality improvement 

divided by the total direct premium that’s earned, minus allowable 

productions, which are things like taxes.

Can you scroll down some? So now as you see in Section 4, that’s the 

healthcare quality improvement expenses incurred. And so now you see this is 

exactly, to the penny, because these are audited, how much the health plan 

paid and quality improvement activities for the year in question.

So you see activities to improve health outcomes, $816,000, Line 4.1. 

Activities to prevent hospital readmissions, $74,000. And so if you - if, you 

know, programs that are doing preventive health programs, wellness and 

health promotion activities, Line 4.4 - you see they spent $117,869.
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You can then look at 2012, as well, which I don’t have, can see trends. And so 

you can begin seeing, you know, exactly what that health plan, how much 

they spent.

You don’t know who they spend it with or who their vendors were, but you 

have an idea about how they’re spending their dollars and this is great 

information in terms of analysis of your potential customers.

You see the tabs across the data. When you open up the files, we’re on the 

summary data file. The next important file for all - I mean, the next important 

worksheet in this workbook is the Part 4 - MLR and rebate calculations.

Can you click on that, Lauren? This is where you actually see the medical loss 

ratio calculations are the health plans. So, for this health plan, you see - if you 

go down to Section 4, and it actually gives you the medical loss ratio.

And so the medical loss ratio for this health plan was 90% after adjustments. 

Across the tabs at the bottom, there’s a rebate disbursement, number - Part 5, 

so there’s nothing here because the health plan exceeded 85% medical loss 

ratio, so there was no requirement to pay.

If that same health plan had an 80% medical loss ratio, then, in this section, 

you would see how much the health plan in Section 3 - it would say the total 

amount of rebates and the amount of rebates that they paid out to the 

beneficiary as a result.

And then it also talks - see Section 4. It talks about prior-year rebates, so you 

can begin seeing trends for health plans.
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So this is Maryland and now I want to - by contrast - look at DC for the same 

health plan.

Lauren Solkowski: Okay, this should be the DC. Do you see it?

(Tim McNeill): I do but I don’t see - it’s right - it’s already at the - yes if you can scroll down. 

I mean up to the top.

Lauren Solkowski: Oh, okay. Yes, I see. Okay.

(Tim McNeill): So here’s something striking - I think is striking. Section 1.1 - you see the 

premium collected. The premium collected for Care First in the 

(unintelligible) is 13 million. Then you look at 2.1 - total incurred claims 15 

million. They’re losing money before we even get to quality improvement 

agenda. They’re two million over just from paying claims right off the bat.

So you may say oh my goodness, they’re losing money left and right so 

they’re not going to want to pay for any cost improvement activity. Well 

there’s a dual edge sword. One, they have to improve outcomes. So if their 

medical loss ratio is two million - I mean if their spend - their incurred claims 

just from the beginning is $2 million - 2 1⁄2 -- $2 1⁄2 million more than their 

premium to start, you have to wonder what the performance measures are for 

that population because this population has a lot of costs.

So if they’re healthy and well then their expenses shouldn’t be that high and 

so health plans have to one, meet their cost projections but also have to meet 

their quality projections. So just because a health plan is meeting or exceeding 

the medical loss ratio doesn’t mean there’s not an opportunity. The 

opportunity here is to come in and say you have a population with very high 

costs and possibly without great health outcomes and our wellness prevention 
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programs can help to turn that dial so that we can begin helping you to bring 

down that medical loss ratio to somewhere where you’re making a profit 

because they’re bleeding money right now based on this status.

Can you scroll down a little bit more?

Lauren Solkowski: To four?

(Tim McNeill): To section four.

Lauren Solkowski: Okay.

(Tim McNeill): Yes, four. So now in the quality improvement activity do you see - I don’t 

know what their readmission rate is but they’re only spending $17,000 to 

prevent hospital readmission. In Maryland - I mean in some health plans that’s 

a six figure number there.

So if I had a solid hospital readmission program and I was operating in this 

particular market and I see their medical loss ratio they’re spending on claims 

is out of control and then I see that their readmission spending or their 

readmission prevention spending is very low, I think that’s an opportunity for 

me.

I also say well they’re really spending a very meager amount on wellness and 

health promotion activities. They’re spending 22,000 so they’re spending 2 1⁄2 

million more on claims. So I think that’s also a great opportunity to present 

how they can utilize my health and - my wellness and health promotion 

activities and hopefully we working together with them by them identifying 

their high cost high risk vulnerable population, referring them to my 
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community based program in the district and then serving those consumers so 

that we can help to turn that spending around.

So now that we see the summary data, heaven forbid let’s see what the 

medical loss ratio looks like in part four.

Lauren Solkowski: Hold on one second. I’m going to pull up - I’m trying to make it - oh here we 

are. Okay, go ahead. Sorry.

(Tim McNeill): Can you scroll down a little and over to the left? Okay so you see section four. 

The medical loss ratio - we’re sitting at 110%. So this plan needed, you know, 

it needed to get to 85% clearly because 85% -- they were already 2 1⁄2 million

over in claims of just beginning. They are at 110% so nobody’s making 

money at this health plan because remember if the health plan has to spend 

85% towards claims and quality improvement activities, that means all of their 

administrative overhead, administrative cost, profit - everything has to be 

squeezed into that 15% number.

In this scenario we’re saying they’re already at 110% just in the medical loss 

ratio. Now all of their administrative overhead, their marketing cost is plus, 

plus, plus that 110. So they’re probably - their expenses are probably 130% of 

what they’re getting in so there’s tremendous opportunity for this particular 

plan in terms of working with a strong organization that can help them to 

manage that high risk, high cost population.

And this is also very interesting that this is the same health plan operating in 

the same market and the two populations that I showed you are separated by, 

you know, an imaginary border between the district and Maryland but there’s 

tremendous difference in the cost of the burden of disease between the two 

populations.
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So that’s kind of the flavor of how you’d go about - when pulling up the 

medical loss ratio - assessing the data and then applying it to your market as 

part of a strength, weakness, opportunity and threat through a slot analysis. T 

there’s opportunity here.

I had - to give you an example of another market, I was doing a presentation 

for a group in California and I looked at the medical loss ratio for a particular 

health plan and I found that their medical loss ratio was 95%. So again they 

were spending in terms of quality improvement activity and claims. 95% of 

their premium dollars all went and it was paid out. And so all of their 

marketing, overhead, profit which if your medical loss ratio is 95%, there is 

no profit. It’s all - it’s all spent out. They didn’t make any money.

And so when I talked about that, the community based organization I was 

working with said oh, now we understand that same health plan that had a 

95% medical loss ratio the prior year, made a formal announcement that they 

were upping the premium for all beneficiaries for the subsequent year and it 

was going to be like a 20% increase in premium and a lot of the beneficiaries 

were complaining and saying that they needed to meet with the shift group 

team to see about switching to another plan because they didn’t want that 20% 

increase in the - in their premium payments to participate in that Medicare 

Advantage plan.

So the data drives the decision. That health plan had a 95% medical loss ratio 

so the only two things they can do to fix that medical loss ratio - help bring 

down the cost of the population by making them healthier or increase 

premiums so they have a higher amount of collections so their premium 

collections are higher to offset their higher expenses. So those are the two 

strategies that have been added. That particular health plan I guess felt as 
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though they may have exhausted their efforts to improve the health of the 

population and so we’re going to jump towards increasing the premium.

Many health plans that find themselves in that scenario try to delicately 

balance the two because if you increase premiums too high then you may have 

a wholesale abandonment of your health plan by - which is someone may go 

to your competitor. So it’s much better to control the cost through wellness 

and prevention.

So Lauren if you want to go back to the top one. Great. So what is the 

opportunity with Medicare Advantage plan? So providers that can support 

these items can bring value to a Medicare Advantage plan. So increasing the 

accuracy of the hierarchal conditions floors for risk adjustment - that is one -

and that is done by helping the health plans understand all of the conditions 

and complications of disease that a consumer has.

Often times when I’m working with a group, they say well the hospitals and 

the doctors are already doing that so I don’t see how me as a community 

based organization can provide any value to the plant by helping them 

understand or having more information about the health of the population.

Well you may be mistaken because when the person is admitted to the 

hospital - and think about it - if a person’s admitted to the hospital maybe for 

complications of diabetes so they get admitted to the hospital for complication 

of diabetes. The hospital’s treating the diabetes but they may have heart 

disease. They may have an amputation. They may have a lot of other 

conditions but they’re at the hospital for a complication of diabetes.

That hospital is coding and reporting and seeking reimbursement to the health 

plans for complications of diabetes. All of these other secondary and fourth, 
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fifth, sixth conditions that that person has - it may not get reported. I was 

meeting with Anthem in a particular market and they said that that was one of 

their primary problems is that they would only get one diagnosis from the 

doctor, one diagnosis from the hospital and they knew anecdotally that most 

of their population had three or more chronic conditions. None of that was in 

their database and that impacted them because they could not get the proper 

risk adjustment from CMS because they didn’t have the data.

They didn’t get the risk adjustment. It directly impacted the medical loss ratio 

because without the risk adjustment, they’re getting a lower amount than they 

should be getting for a population that has multiple chronic conditions. If they 

had properly reported the multiple chronic conditions, they get a higher 

premium then the higher premium would go into the denominator which could 

help to offset these claims and quality improvement costs to help improve that 

medical loss ratio.

So that - the other opportunities to increase access and utilization or 

prevention and wellness activities. If that Medicare Advantage plan or 

commercial plan should include state insurance plans for state employees and 

health plans for federal employees, this applies - these medical condition 

requirements apply to all health plans across the country.

So now that health plans can apply the cost that they spend or the expense that 

they spend on prevention and wellness toward quality improvement and we 

can increase access to utilization, the health plan is a win, win for everyone. 

The consumers get access to wellness and prevention activities. Hopefully 

they have less complications of disease so they also have less cost and less 

claims and the health plan can incur all of those expenses and apply them to 

the medical loss ratio so there’s not an offset.
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So some people say well if you bring down the cost too much then the plan’s 

going to be penalized and so they want the cost to be at a certain level. Well if 

they - they would likely much rather spend dollars toward the medical loss 

ratio and prevention than spending it on complications of disease because 

remember the health plan also has to meet the quality requirements because 

they have to maintain a high level of quality and meet the medical loss ratio 

requirement as it relates to cost and expenditure.

Lastly it also provides initiative for health plans to reduce the cost of care and 

actually incentivize them to pay for things like care transition program 

because now that cost of a care transition program - every dollar spent is then 

reported. And you saw in the actual medical loss ratio file that you download 

from CMS that hospital prevention - readmission prevention activities are 

separately reportable line items in the medical loss ratio. So not only can you 

see how a particular plan did, you can compare them side by side with their 

competitors in a particular marketplace. Next slide.

So that’s the information about the medical loss ratio. I’d like to open it up to 

questions at this time.

Lauren Solkowski: Thanks so much (Tim). Oh, go ahead operator.

Coordinator: Thank you. If you would like to ask a question, please press star one and you 

will be prompted to record your first and your last name. Please unmute your 

phone when recording your name and to withdraw your question, press star 

two. One moment.

Lauren Solkowski: Thank you. So while we’re waiting for some questions to come over the 

phone, we received a few over the chat so I’ll start there. The first question is 
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how far can plans go to justify their risk adjustment or how far back can they 

go to justify the risk adjustment?

(Tim McNeill): So if that health plan has had that member for the prior year and they had 

documentation of that condition then it carries over. If that’s a new 

beneficiary for them like after open enrollment they get new beneficiaries then 

the health plan has to verify.

So there’s this after open enrollment in Medicare - this is specific to Medicare 

Advantage plan so it doesn’t apply to commercial plans. But after open 

enrollment for a Medicare Advantage plan, often you can add that to complete 

a health assessment on the population.

The reason that there’s this mad dash to complete that health assessment is 

because they want that data to go into that risk adjustment right away because 

they want to get the maximum premium collection that they can as soon as 

possible.

Lauren Solkowski: Okay and another question is what is the Medicare fee for service 

administrative overhead allowance?

(Tim McNeill): Well health plans don’t administer original Medicare. So original Medicare - a 

beneficiary with original Medicare is essentially managed by the Centers for 

Medicare and Medicaid Services and providers file their claims with 

something called a Medicare administrative contract or MAC contracts which 

used to be called physical intermediary. So they process the claims in their 

pay but they have a contract with the Centers for Medicare and Medicaid 

Services to be a MAC that as the administrator that processes the claims.
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So there’s no payment to - there’s no plan - there’s no health insure involved 

with original Medicare beneficiaries.

Lauren Solkowski: Okay and operator, we’ll check back with you to see if any questions have 

come in on the phone.

Coordinator: At this time I’m showing no phone questions.

Lauren Solkowski: Okay - go ahead (Tim).

(Tim McNeill): So I did not go over - we didn’t show them the sheet. I just realized it - the 

document tip sheet. I don’t know if you wanted me to show that as well.

Lauren Solkowski: Sure. I will pull that up. In the meantime I’ll ask this next question. Who 

reviews the quality improvement activities? Is the data compared over time?

(Tim McNeill): When you said who reviews it - the Medicare - the health plan and I’m talking 

about Medicare Advantage plan so it does only apply to Medicare Advantage 

plan (unintelligible).

So if the plans submit the data to CMS by June 1 of the following year for the 

report year from 2015 - all of the 2014 data to CMS by June 1, 2015. CMS 

analyzes the data of the health plans and a quality assurance decision that 

closely monitors and tracks how that health plan is performing in terms of the 

medical loss ratio. It also tracks (unintelligible).

Lauren Solkowski: (Tim) you’re breaking up some.

(Tim McNeill): Oh sorry. So every health - every health plan has a quality assurance division 

that monitors the medical loss ratio. It also - they also monitor the quality 
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performance for that health plan as it relates to their performance on HETUS 

measures.

And so on both sides the health plan closely tracks and monitors it and then 

they submit that data to CMS and then use the data. All of the data 

(unintelligible) sent up to audit and so if a health plan is selected for audit then 

CMS will have the MAC - likely the MAC contractor or the QIO or whoever 

the vendor is will come in and work with that plan to (unintelligible) in terms 

of this.

Lauren Solkowski: (Tim) you’re breaking up some more.

(Tim McNeill): Is that better?

Lauren Solkowski: Can you hear me? We can’t hear you now.

(Tim McNeill): Is that better?

Lauren Solkowski: Yes, that’s much better.

(Tim McNeill): Okay. Sorry about that. I lost my train of thought.

Lauren Solkowski: Sorry.

(Tim McNeill): Oh the audit - the audit. So the health plan submits the data to CMS and then 

the data has to stand up to audit. And so CMS at any time can have a vendor 

come in, work with the health plan and audit the regs to see what they 

reported in terms of dollars spent on services, IE claims and quality 

improvement activity can stand up to audit, can be verified, justified and if not 

then they will receive a subsequent penalty for not reporting properly.
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So the health plan internally monitors and that’s usually monitored by the 

quality assurance (unintelligible) and they submit the data to CMS and then 

(unintelligible) in case they’re audited. CMS will forward it properly.

Lauren Solkowski: Okay and operator, I’ll check back with you again to see if questions have 

come in.

Coordinator: At this time I am showing no questions but if you would like to ask a 

question, please press star one.

Lauren Solkowski: Thank you. So (Tim) I pulled up the sheet. I don’t know did you just want to 

show it or did we want to walk through it quickly or...

(Tim McNeill): Sure, I can walk through it quickly and then if anyone has any additional 

questions on this one (unintelligible) actually walk through the tip sheet.

Lauren Solkowski: Okay.

(Tim McNeill): So if you go to the ACL link, you’ll pull up this medical loss ratio and it’s a 

file that you download as a PDF and in a sense that it will walk you through 

the medical loss ratio so just the background. If you scroll down some, it talks 

about what are medical loss ratio services. So you see again here how the 

medical loss ratio formula is calculated.

So it’s paid medical services claims plus QIA again is quality improvement 

activities divided by premium revenue minus liable deductions equals the 

medical loss ratio. So the numerator of the paid medical service claims for 

QIA - the denominator is the premium revenue minus the allowable 

deductions and as I said, allowable deductions are things like federal and state 
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taxes, licensing and regulatory fees - all of those things are allowable 

deductions.

So you see if a plan needs to adjust their medical loss ratio, the only thing they 

can do is increase the premium that - so these are just things that they can do. 

Increase the premium that they collect by either changing the monthly 

payments that are required or they can increase or adjust that in quality 

improvement activities.

Their payment for paid medical service claims - I mean if someone needs 

heart bypass surgery, you need heart bypass surgery. There’s not much you 

can do to adjust that other than improving the health of the population. So the 

easiest things to do to adjust the medical loss ratio is you see in looking at in 

comparison to the numerator and the denominator is to adjust the slide rule 

(unintelligible) and or clean the revenue. Scroll down some.

Here again is the list of client improvement activities that I went over in the 

PowerPoint and all of the quality improvement activity must stand up to audit 

and they’re categorized and reported out.

So in the tip sheet it also gives an example of services that meet the medical 

loss ratio requirement and this tip sheet is focused on community based 

organizations. And so we gave an example of community based organization 

contracting (unintelligible) to provide a diabetes sub management training 

program using the Stanford model.

The program method was fully accredited because it met the national 

standards of the credit by the American Association of Diabetes Educators. 

It’s the CBO and the registered dietician. That dietician is credentialed and 

registered with the health plan then they are a network provider for diabetes 
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self-management training program and then that beneficiary that comes to that 

program - the cost of paying the CBO to deliver that diabetes sub management 

class to that beneficiary - the health plan counts toward their costs even in 

claims and quality improvement activities towards that medical loss ratio 

requirement.

So what is not part of the MLR is also on this (unintelligible) of use 

protection. I mentioned services. Cost containment and a broken condition -

so cost containment helped some health plans have divisions where they really 

closely focused on requests for services so that they can contain the cost and 

not pay for medical services that are unnecessary or may be seen unnecessary 

or maybe the beneficiary maybe did not need them at this time.

So a good example of that is sometimes a cost containment management 

activity of the city beneficiary is given a brand name drug. Maybe it’s a very 

high cost antacid like Protonix. Protonix is probably one of the most 

expensive ones and so but they’ve never had a lower cost one like a Pepcid 

and so the health plan says you need to use generic first instead of going to the 

more expensive brand names. That’s a cost containment management activity. 

It’s not anything that’s improving the health and outcomes of that beneficiary.

So any staff time, labor, personnel that are sent towards doing cost 

containment activities - they cannot count towards the medical loss ratio 

whatsoever.

The next portion of the tip sheet talks about the standard so 80% for small 

plans, 85% for large plans. Again all Medicare Advantage plans beginning in 

2014 - 85%. Of course I don’t know (unintelligible). Part D plans 85%. On a 

more important note, the medical loss ratio does not apply to page 

(unintelligible). It also doesn’t apply to original Medicare because there is no 
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health plan involved with original Medicare beneficiaries or fee for service 

beneficiaries as I also referred to.

So what happens if a health plan does not comply with the requirements? And 

to recap here everything that we’ve talked about in the slide where they have 

to pay a rebate and then if they’re a Medicare managed plan, they get of 

course a penalty. Then we gave you a real life example. So there’s a 

hypothetical example whether health ADC is a managed care plan in the 

distribution but this is not the health plan that I chose. So this is totally 

fictional.

So this health plan had 100,000 members and they received $350 per member 

per month for this particular health plan. The medical loss ratio calculated 

claims with client improvement over total premium so if they have 100,000 

members covered over 12 months at $350 per member per month, that’s 420 

million is their total premium. That’s the denominator.

The numerator for this fictional health plan - they spent $294 million on 

claims and 42 million on quality improvement activities. So their total 

numerator is 336 million. So now the medical loss ratio is calculated by that 

numerator of 330 by the denominator of 0.20 million which gives you a 

medical loss ratio of 80.

So if this particular fictional health plan is held to the 85% medical loss ratio, 

they did not meet that requirement so as a result they have to pay 5% of the 

premium (unintelligible) to $21 million. So see, that’s a tremendous amount 

of money and if they just spent that money on services or quality 

improvement activity, they would not have to pay that penalty. They would 

not be put on this watch list and have their whole contract in jeopardy let 

alone that (unintelligible) margin to the beneficiary. And there are multiple 
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plans I want us again looking through (unintelligible). I saw plans all over the 

steps of this.

As we just saw some plans who are right at a percentage, you know, if they’re 

at 85%, they’re at max profitability because profit - their overhead expense, 

their labor cost, their marketing expense all has to be contained so 85% is the 

desired goal. The closer they are to 85%, the greater the likelihood that they’re 

in positive cash flow. If they’re too high in the medical loss ratio, they’re 

losing money. If they’re too low, they’re paying penalties.

Their profit’s gone down some and so now this is just an overview of why 

understanding the medical loss ratio is important. Also it’s important to 

understand how health plans are graded and governed. So health plans have to 

meet quality plus cost. For Medicare Advantage plans the Centers for 

Medicare and Medicaid services have contacted an NCQA to provide 

monitoring and credentialing of health plans that are in the Medicare 

Advantage program.

So every Medicare Advantage plan has to be credentialed by NCQA and be 

accredited by NCQA in order to be a Medicare Advantage plan. Many 

Medicaid managed care plans and the health insurance of safety plans also 

have to adhere to the same performance because CMS is also contracted with 

NCQA to accredit those plans. It’s a little different for Medicaid plans 

because it - it has to go through CMS at the state.

But for the exchange products as well as the Medicare Advantage plan it is -

NCQA is the contractor to accredit those plans which means the health plan 

has to maintain - they have to successfully achieve and maintain accreditation 

by NCQA. The NCQA standards makes the health plans adhere to quality and 

performance metrics and that also flows down to their contractors or vendors.
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And so that’s why we say that it’s important that you’re able to provide 

services to the beneficiaries and report them and you should be aware of the 

NCQA requirements that the health plans have to adhere to especially if 

you’re working with the Medicare Advantage or an insurance exchange 

product because they have to maintain accreditation advised NCQA.

And so one of the - how this applies or think it’s something as simple as the 

case management - there are specific guidelines and regulations to case 

management that are outlined by NCQA that health plans have to adhere to in 

order to maintain the NCQA accreditation. But NCQA goes back and says 

well health plan if you contract out your case management services to a third 

party vendor then that third party has to adhere to the same standards that I’m 

holding you to for case management. So that’s why understanding the NCQA 

accreditation requirements that are held to the health plan are important to you 

as you’re marketing to the health plan.

It doesn’t mean that in order for - there’s no requirement for a community 

based organization to have NCQA accreditation before the health plan can 

apply the cost for the medical loss ratio. But what is important to know is that 

the NCQA accreditation standards applies to the health plans and those 

requirements sometimes roll downhill to their subcontractor. And then at that 

point all of those costs can still be applied because they have to meet the 

quality and the cost containment requirement to operate.

So lastly we talk about what the opportunity is for community based 

organizations and how you can get more information and we’ve highlighted 

kind of around what the opportunities are and how understanding the medical 

loss ratio and performance of a health plan is important before you begin a 

negotiation. So it’s important to do your market analysis up front and that 
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market analysis should include looking to see how that health plan performs in 

the medical loss ratio as well as seeing how that health plan performs from the 

quality metrics.

Lauren Solkowski: Okay operator, I’ll check back to see if any questions have come in.

Coordinator: I am showing no phone questions.

Lauren Solkowski: Okay (Tim) we have another question that came in on the chat that says could 

you connect the dots for us between the language of medical loss ratio and 

return on investment.

(Tim McNeill): So return on investment - the return - the return on investment - for every 

dollar that a health plan pays for an activity, they want to have a greater return 

on the amount of money they spend. So you want that return to always be 

greater than the spend out.

So if I’m spending money for the diabetes self-management training program, 

there’s an expectation that the amount of money that I spend on the diabetes 

self-management training program and the hope is that the outcome of that 

will be less complications of disease. The cost of the complications of disease 

should be greater than the cost of my clad to present or my effort to present 

which is the complication of the disease occurring and therein lies the return 

on investment.

So as it relates to the net loss ratio, increasing access and utilization of quality 

improvement activities should equate out to a reduction in total cost of claims 

which will help that health plan get closer to the 85% because it’s much easier 

to control your costs around prevention than it is for disease complication. 
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You never know when disease complications are going to occur and you never 

know the cost of disease complications.

So the quadruple bypass surgery is always going to be much (unintelligible) 

than preventing that and it’s also much harder to manage when that cost for 

that quadruple bypass is going to occur amongst your population. The return 

on investment is the positive...

Lauren Solkowski: (Tim) we can’t hear you. No, nothing yet.

(Tim McNeill): (Unintelligible). Hello?

Lauren Solkowski: I can vaguely hear you. Like I hear - I think you’re saying hello.

(Tim McNeill): Hello?

Lauren Solkowski: No.

(Tim McNeill): Hello? Can you hear me?

Lauren Solkowski: There you are, yes. Now I can hear you.

(Tim McNeill): Oh, okay. Okay, sorry about that.

Lauren Solkowski: Now it’s clear.

(Tim McNeill): So the - with the medical loss ratio or with the cost the health plan really 

wants to get to 85% because at 85% they’ve maximized their potential profit 

and anything over the 85%, they’re going to - they’re losing money - and 

anything under the 85% they have the problem of they’re going to have to pay 
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this rebate and then they’re going to have that crust because they have the 

additional cost of the rebate.

So they want to manage their expenses very closely. It’s much easier to 

manage your expenses around quality improvement than it is to manage 

complications of disease. And so as long as your - the cost of your program or 

your preventive health service or quality improvement activity is going to be 

lower than your potential complications plus you have the added value of 

helping that health plan to get closer to the medical loss ratio requirements 

and then when you add in this potential of helping to report out HETUS 

measures which we’ll talk about at a later presentation.

All of that is your return on investment that you then have to quantify and 

present.

Lauren Solkowski: Okay and then we’ve got one - another question that came in that says is the 

MLR rounded up or down for payout and do decimals count.

(Tim McNeill): Is the MLR rounded up? So it’s rounded - I think it uses the regular. If it’s 

above five, it goes up. If it’s less than five, it goes down.

Lauren Solkowski: Okay. Operator, are there any questions that have come in on the phone?

Coordinator: I have no phone questions.

Lauren Solkowski: Okay well I think we’ve - those are - let me just check. Those are all the 

questions that we’ve received and since we have about four minutes left -

before we go I did want to say the - so the MLR - the tips sheet that tip 

reviewed is on the ACL website. It’s not the easiest thing to find. We’re 

working on improving that. But if you have any trouble finding it, it’s in the 
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slides that (Tim) just presented that you’ll have a copy of that. But if you are 

having a hard time finding it in the meantime, just send me an email and I can 

direct you to that tips sheet among some of the other tips sheets that (Tim) 

referenced are all listed on our business document page on the ACL website.

So with that I just want to thank you again to (Tim) for his presentation today 

and for answering all of our questions. Thank you to our participants for 

asking such stimulating questions and again if you think of any other 

questions or comments that you have following the webinar, please feel free 

to email them to me. I have added my email address in the chat box here on 

the webinar. So I think we’ll conclude with that and thank you again to 

everyone for joining us and enjoy the rest of your day.

Coordinator: Thank you for your participation. You may disconnect at this time.

END