NJ| The New Jersey Department of Banking and Insurance Bulletin No. 26-06 provides guidance to all health carriers (health insurers, health/hospital/medical service corporations, and HMOs) on medical loss ratio (MLR) reporting under the state’s Individual Health Coverage and Small Employer Health Benefits Programs, implementing P.L.2024, c.62.
Beginning with reporting year 2026 (and until regulations are updated), carriers must calculate MLR using a rolling three-year average—the prior calendar year plus the two preceding years—with a three-month claims runout through March 31 for the most recent year, and file annually by August 1 using the new template supplied with the bulletin in lieu of the existing Exhibit J (N.J.A.C.11:20-7) and Exhibit GG (N.J.A.C.11:21-7A) templates, while otherwise following those regulations’ individual/combined and per-carrier filing rules. Claims must use incurred claims with a 3.3% Incurred But Not Reported (IBNR) factor applied only to Prior Year 1 (including the runout) and pharmacy rebates/concessions subtracted; premiums use total premiums for each of the three prior years, net of ACA taxes/fees and adjusted for risk-adjustment payments (subtracting those made and adding those received), with the template automating the calculations, total loss ratio, and refund liability. Finally, carriers may not adjust prior years’ loss ratios for rebates or refunds—except that the 2026 calculation may include NJ-required refund amounts for 2024 and 2023 claims, and the 2027 calculation may include them for 2024 claims only.