The Aordable Care Act (ACA) requires insurers, such as Blue Cross Blue Shield of North Dakota (BCBSND), to
report information related to medical loss ratios (MLR) for large and small employer groups. MLR refers to the
percentage of your premium dollars that an insurance company spends to provide health care and improve the
quality of care, versus how much the company spends on administrative and overhead costs. ACA requires that
insurers spend at least 80 cents of the individual and small group premium dollar and at least 85 cents of the large
group premium dollar on health care services and health care quality improvement.
Because MLR is based on group size, we are asking you to indicate below whether your average number of
employees for the previous calendar year was fewer than 50 employees or 51 or more employees. The ACA
also requires us to identify instances where a sole proprietor and/or a spouse-employee are the only enrolled
employees in a group, so we are asking for this information as well.
ACA requires that you include full-time, part-time, temporary and seasonal employees who receive a W-2 form
in your employee total. Employees should be included in the count regardless of their eligibility to enroll in your
group health plan. Independent contractors are not included in this count. Include all people employed at all
companies within a controlled group or under common control under Internal Revenue code sections 414(b), (c),
(m) or (o) whether or not the related or subsidiary companies have coverage with BCBSND.
You may already report your number of employees for other federal mandates; however, there may be dierences
in the requirements for each federal mandate. As a result, we are providing a sample chart below as a guide to
determine your average number of employees.
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total Average
FT Emp. 21 23 24 25 26 25 28 26 23 27 29 30 307
PT Emp. 3 3 3 2 2 2 1 1 4 4 4 4 33
Seasonal 1 1 1 0 0 0 0 0 59 69 33 0 164
Total 25 27 28 27 28 27 29 27 86 100 66 34 504 42
You can find your average number of employees by dividing your total number by 12 or by the number of months
you were in business in the previous calendar year. In this example, 504 divided by 12 equals 42.
Please complete and return this signed form in the enclosed postage-paid envelope with the other renewal items.
Client Name _____________________________________________________ Client Number ________________
This company is a sole proprietorship and covered no employees other than the owner and/or spouse during
the previous calendar year.
If sole proprietorship does not apply, please check one box below:
This company employed an average of 50 or fewer employees during calendar year 2019.
This company employed an average of 51 or more employees during calendar year 2019.
Authorized signature _____________________________________________ Date _________________________
29318938 • POD 8-19
2019 Medical Loss Ratio Form
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Noridian Mutual Insurance Company
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