(a) General rule. An issuer may add to the MLR calculated under Sec. 158.221(a) of this subpart the credibility adjustment specified by Sec. 158.232 of this section, if such MLR is based on partially credible experience as defined in paragraph (c)(2) of this section. An issuer may not apply the credibility adjustment if the issuer's experience is fully credible, as defined in paragraph (c)(1) of this section, or non-credible, as defined in paragraph (c)(3) of this section.
(b) Life-years. The credibility of an issuer's experience is based upon the number of life-years covered by the issuer. Life-years means the total number of months of coverage for enrollees whose premiums and claims experience is included in the report to the Secretary required by Sec. 158.110 of this part, divided by 12.
(c) Credible experience. (1) An MLR calculated under Sec. 158.221(a) through (c) of this subpart is fully credible if it is based on the experience of 75,000 or more life-years.
(1) An MLR calculated under Sec. 158.221(a) through (c) of this subpart is fully credible if it is based on the experience of 75,000 or more life-years.
(2) An MLR calculated under Sec. 158.221(a) through (c) of this subpart is partially credible if it is based on the experience of at least 1,000 life-years and fewer than 75,000 life-years.
(3) An MLR calculated under Sec. 158.221(a) through (c) of this subpart is non-credible if it is based on the experience of less than 1,000 life-years.
(d) If an issuer's MLR is non-credible, it is presumed to meet or exceed the minimum percentage required by Sec. 158.210 or Sec. 158.211 of this subpart.