§ 15-1A-16

(a) (1) For purposes of this section, “medical loss ratio”:

(i) has the meaning established in 45 C.F.R. § 158.221; or

(ii) if the Commissioner adopts regulations as described in paragraph (2) of this subsection, has the meaning established by the adopted regulations.

(2) To the extent necessary, the Commissioner shall adopt regulations that:

(i) establish a definition for “medical loss ratio”; and

(ii) are consistent with 45 C.F.R. § 158.221 and any corresponding federal rules and guidance as those provisions were in effect December 31, 2024.

(b) This section applies to all grandfathered plans and to every health benefit plan that is not a grandfathered plan.

(c) The minimum acceptable medical loss ratio is:

(1) for the large group market, 85% or a higher percentage as determined by the Commissioner in regulations; and

(2) for the small group market and individual market, 80% or a higher percentage as determined by the Commissioner in regulations.

(d) (1) Except as provided in paragraph (2) of this subsection, each carrier shall comply with the requirements for calculating medical loss ratios and related reporting and rebate requirements established in 45 C.F.R. Part 158 and any corresponding federal rules and guidance.

(2) If the Commissioner adopts regulations as described in subsection (e) of this section, each carrier shall comply with the requirements in the adopted regulations.

(e) To the extent necessary, the Commissioner shall adopt regulations that:

(1) establish requirements for calculating medical loss ratios and related reporting and rebate requirements; and

(2) are consistent with 45 C.F.R. Part 158 and any corresponding federal rules and guidance as those provisions were in effect December 31, 2024.