Title 42
SECTION 423.2440
423.2440 Credibility adjustment.
§ 423.2440 Credibility adjustment.(a) A Part D sponsor may add the credibility adjustment specified under paragraph (e) of this section to a contract's MLR if the contract's experience is partially credible, as defined in paragraph (d)(1) of this section.
(b) A Part D sponsor may not add a credibility adjustment to a contract's MLR if the contract's experience is fully credible, as defined in paragraph (d)(2) of this section.
(c) For those contract years for which a contract has non-credible experience, as defined in paragraph (d)(3) of this section, sanctions under § 423.2410(b) through (d) will not apply.
(d)(1) A contract's experience is partially credible if it is based on the experience of at least 4,800 member months and fewer than or equal to 360,000 member months.
(2) A contract's experience is fully credible if it is based on the experience of more than 360,000 member months.
(3) A contract's experience is non-credible if it is based on the experience of fewer than 4,800 member months.
(e) The credibility adjustment for partially credible experience is determined based on the number of member months for all enrollees under the contract and the factors shown in Table 1 of this section. When the number of member months used to determine credibility exactly matches a member month category listed in Table 1 of this section, the value associated with that number of member months is the credibility adjustment. The credibility adjustment for a number of member months between the values shown in Table 1 of this section is determined by linear interpolation.
Table 1 to § 423.2440 - Credibility Adjustments for Part D Contracts
| Member months | Credibility adjustment (additional percentage points) |
|---|---|
| <4,800 | N/A (Non-credible). |
| 4,800 | 8.4%. |
| 12,000 | 5.3%. |
| 24,000 | 3.7%. |
| 48,000 | 2.6%. |
| 120,000 | 1.7%. |
| 240,000 | 1.2%. |
| 360,000 | 1.0%. |
| >360,000 | 0.0% (Fully credible). |