MLR Examinations

MLR Examinations

Pursuant to the Secretary of the Department of Health and Human Service’s authority under 45 CFR 158, Subpart D, CCIIO regularly reviews issuers’ annual MLR Reporting Forms to confirm compliance with each reporting element of 45 CFR Part 158.  CCIIO performs two types of reviews: internal compliance reviews as well as external audits (or examinations) of issuers’ annual MLR Reporting Form(s) and, beginning with the 2014 reporting year, if applicable, their annual Plan-Level Risk Corridors Data Reporting Form.

Internal compliance reviews consist of a high-level review of, amongst other things, the Reporting Form for: completion accuracy; obvious omissions, errors or questionable data; and, comparison to each issuer’s state Supplemental Health Care Exhibit (SHCE).

External audits consist of substantively testing each reporting element utilizing the Agreed-Upon Procedures (AUP) that CCIIO created in conjunction with the National Association of Insurance Commissioners (NAIC), as well as a detailed review of the documents and data that were used by the issuer under review in the completion of the Reporting Form.  Document and data reviews are generally conducted remotely but on-site reviews occur as well.  Entrance, status and exit calls are conducted telephonically.

MLR Examination Reports

The MLR examination program commenced in 2015 with review of data reported for the 2013 MLR reporting year.  This page contains MLR examination reports that are organized by the MLR reporting year.  Reports will be uploaded as each examination is completed and the Report, including company responses, is finalized.

Examination Reports by MLR Reporting Year:

Page Last Modified:
09/06/2023 05:05 PM