Medical Loss Ratio
Starting with contract year 2014, Medicare Advantage (MA) organizations, Part D prescription drug plan sponsors, and cost plans are required to submit a medical loss ratio (MLR) report to CMS on an annual basis. The purpose of this page is to share information relating to the MLR reporting process.
Übersicht
The Affordable Care Act of 2010 amended section 1857(e) of the Social Security Act ("the Act") to add new MLR requirements for MA plans. A plan’s MLR is reported at the contract level and is expressed as a percentage, generally representing the percentage of revenue used for patient care, rather than for such other items as administrative expenses or profit. Because section 1860D-12(b)(3)(D) of the Act incorporates by reference the requirements of section 1857(e), the new MLR requirements also apply to Medicare Part D. The MLR requirements for MA organizations and Part D sponsors have been codified in the regulations at 42 CFR Part 422, Subpart X, and 42 CFR Part 423, Subpart X.
For contract year 2014 and subsequent contract years, MA organizations, Part D sponsors, and cost plans are required to report their MLRs and are subject to financial and other penalties for failure to meet the statutory requirement that they have an MLR of at least 85 percent (see §§ 422.2410 and 423.2410). The statute imposes several levels of sanctions for failure to meet the minimum MLR requirement, including remittance of funds to CMS, a prohibition on enrolling new members, and ultimately contract termination. The minimum MLR requirement creates incentives for MA organizations and Part D sponsors to reduce administrative costs and helps to ensure that taxpayers and enrolled beneficiaries receive value from Medicare health plans.
CY 2021 MLR
CY 2021 MLR Workbook and Instructions (ZIP)
Memoranda and other guidance:
- May 31, 2022: Release of Medical Loss Ratio (MLR) Data Form and Filing Instructions for Contract Year 2021 (PDF)
- June 28, 2022: Guidance for Medical Loss Ratio (MLR) Reporting of Part B Premium Reductions for Contract Years 2020 and 2021 (PDF)
- January 3, 2023: MLR Data Form and Attestation Submission Reminder for Contract Year 2021 (PDF)
CY 2020 MLR
CY 2020 MLR Workbook and Instructions (ZIP)
Memoranda and other guidance:
- June 11, 2021: Release of Medical Loss Ratio (MLR) Data Form and Filing Instructions for Contract Year 2020 (PDF)
- January 4, 2022: MLR Data Form and Attestation Submission Reminder for Contract Year 2020 (PDF)
- June 28, 2022: Guidance for Medical Loss Ratio (MLR) Reporting of Part B Premium Reductions for Contract Years 2020 and 2021 (PDF)
Part C and Part D MLR data:
- Public Use File for CY 2020 (ZIP) - This release contains data submitted by MAOs, Part D sponsors, and cost plans in their CY 2020 MLR reports.
CY 2019 MLR
CY 2019 MLR Workbook and Instructions (ZIP)
Memoranda and other guidance:
- June 19, 2020: Release of Medical Loss Ratio (MLR) Data Form and Filing Instructions for Contract Year 2019 (PDF)
- September 24, 2020: MLR Data Form and Attestation Submission Reminder for Contract Year 2019 (PDF)
Part C and Part D MLR data:
- Public Use File for CY 2019 (ZIP) - This release contains data submitted by MAOs, Part D sponsors, and cost plans in their CY 2019 MLR reports.
CY 2018 MLR
CY 2018 MLR Workbook and Instructions (ZIP)
Memoranda and other guidance:
- June 6, 2019: Release of Medical Loss Ratio (MLR) Data Form and Filing Instructions for Contract Year 2018 (PDF)
- October 25, 2019: MLR Data Form and Attestation Submission Reminder for Contract Year 2018 (PDF)
Part C and Part D MLR data:
- Public Use File for CY 2018 (ZIP) - This release contains data submitted by MAOs, Part D sponsors, and cost plans in their CY 2018 MLR reports.
CY 2017 MLR
CY 2017 MLR Report Workbook and Instructions (ZIP)
Memoranda and other guidance:
- June 29, 2018: Release of Medical Loss Ratio (MLR) Reporting Tool for Contract Year 2017 (PDF)
- October 26, 2018: MLR Report and Attestation Submission Reminder for Contract Year 2017 (PDF)
Part C and Part D MLR data:
- Public Use File for CY 2017 (ZIP) - This release contains data submitted by MAOs, Part D sponsors, and cost plans in their CY 2017 MLR reports.
CY 2016 MLR
CY 2016 MLR Report Workbook and Instructions (ZIP)
Memoranda and other guidance:
- June 27, 2017: Release of Medical Loss Ratio (MLR) Reporting Tool for Contract Year 2016 (PDF)
- October 25, 2017: MLR Report and Attestation Submission Reminder for Contract Year 2016 (PDF)
Part C and Part D MLR data:
- Public Use File for CY 2016 (ZIP) - This release contains data submitted by MAOs, Part D sponsors, and cost plans in their CY 2016 MLR reports.
CY 2015 MLR
CY 2015 MLR Report Workbook and Instructions (ZIP)
Memoranda and other guidance:
- May 31, 2016: Release of Medical Loss Ratio (MLR) Reporting Tool for Contract Year 2015 (PDF)
- October 25, 2016: MLR Report and Attestation Submission Reminder for Contract Year 2015 (PDF)
- November 21, 2016: CY 2015 MLR Report Instructions - Errata (PDF)
Part C and Part D MLR data:
- Public Use File for CY 2015 (ZIP) - This release contains data submitted by MAOs, Part D sponsors, and cost plans in their CY 2015 MLR reports.
CY 2014 MLR
CY 2014 MLR Report Workbook and Instructions (ZIP)
Memoranda and other guidance:
- April 4, 2015: Release of Medical Loss Ratio (MLR) Reporting Tool for Contract Year 2014 (PDF)
- October 27, 2015: MLR Report and Attestation for Contract Year 2014 – Submission Reminder and Additional Guidance for Contracts that Terminated, Consolidated or Withdrew in CY 2014 (PDF)
Part C and Part D MLR data:
- Public Use File for CY 2014 (ZIP) - This release contains data submitted by MAOs, Part D sponsors, and cost plans in their CY 2014 MLR reports.
MLR Reporting Q&As
CMS Guidance Regarding MLR Reporting Requirements: Q&A (PDF) (last updated: 10/19/2015)
Medical Loss Ratio and Expenditures Related to COVID-19 Permissive Actions – Questions and Answers (PDF) (dated: 7/10/2020)