Jackie Selby, a Member of the Firm in the Health Care and Life Sciences practice, in the New York office, and Joseph Kempf, a Senior Attorney in the Health Care and Life Sciences practice, in the New York office, cowrote an article titled "Alternative Provider Reimbursement Models—How Are They Treated Under MLR Rules?"
Following is an excerpt:
The new rules issued by the Centers for Medicare & Medicaid Services and Department of Health and Human Services regarding the calculation of the medical loss ratio (MLR) pursuant to the Patient Protection and Affordable Care Act (45 CFR Part 158) require individual and group health plans, other than self-funded health plans, to spend a minimum percentage of premium towards medical expense or ''medical loss,'' or else provide rebates to enrollees. Other expenses are generally considered ''administrative'' and not counted toward the minimum. For purposes of this article, medical expense—or medical loss—is defined primarily as ''incurred claims'' and certain quality improvement activities (QIA).
Reprinted with permission from the Bureau of National Affairs, Inc.
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