Medical Loss Ratio (MLR) Carrier Update
The Affordable Care Act (ACA) requires health insurance issuers to provide information on the proportion of premium revenues spent on clinical services and quality improvement, also known as the Medical Loss Ratio (MLR).
If a health insurance carrier uses 80 cents out of every premium dollar to pay for members’ medical claims and activities that improve the quality of care, the insurance carrier has an MLR of 80%. (The remaining 20 cents of each premium dollar goes to overhead expenses, such as marketing, salaries, administrative costs, agent commissions, and profits.)
According to the National Association of Insurance Commissioners (NAIC), for IFP and Small Group coverage, the minimum annual MLR is 80%; Large Group plans are required to have an 85% MLR.
If an insurer spends less than 80% or 85% of premium revenue on member services, it is required to provide a rebate to customers.
The ACA’s MLR does not apply to self-funded plans, where the employer is responsible for the payment of covered claims.
MLR rebates must be paid annually, and may take the form of a check in the mail, a lump-sum reimbursement (if the premium is paid by credit or debit card), or a direct reduction in future premiums. For individuals with employer-sponsored insurance, the employer may provide one of these methods or otherwise apply the rebate in a manner that benefits employees.
Listed below is MLR information for 2020, as provided by Word & Brown’s carrier partners.
Note: Information is current as of November 2020, although details for Cigna are pending – and will be added in the future.
|WILL YOU BE ISSUING A MEDICAL LOSS RATIO (MLR) REBATE IN 2020 (FOR THE 2019 PLAN YEAR)? IF SO, WHAT IS THE EXPECTED DATE?|
|Aetna (CA)||Aetna, Innovation Health, and Banner/Aetna plans scheduled to receive rebates under the Health Care Reform Minimum Medical Loss Ratio (MLR) requirements were distributed to policyholders by September 30. Link here for the Aetna CA EY2019-Pool-Listing PDF.
More information is on the Aetna member website (in the MLR rebate section):
|Anthem Blue Cross (CA)||Anthem Small Group will have a MLR rebate this year for the 2017-2019 coverage period. To ease the financial burden COVID-19 is creating for many employers and members, Anthem is fast tracking the annual MLR rebates for groups and individual members who typically receive them in late September. The rebates were issued in early to mid-August 2020.|
|Anthem Blue Cross Blue Shield (NV)||Anthem Blue Cross Blue Shield is not providing an MLR rebate in 2020 for Nevada Small Groups.|
|Blue Shield of California (CA)||Blue Shield of California announced a 2019 rebate, which was distributed on 9/30/2020.
For more details, visit:
|CalCPA (CA)||As a Multiple Employer Welfare Arrangement (MEWA) health plan, CalCPA Health does not have to comply with the MLR portion of the ACA.|
|Cigna (CA)||Information for Cigna will be added when available – watch for a future update.|
|Evolved Benefits (CA and NV)||Evolved Benefits’ solutions are self-funded, which are not subject to MLR parameters.
Plans are self-funded, which means a portion of the monthly premium is set aside in a claim funding account to pay out claims as they come in. After a policy year, the company has a three-month run out period to make sure no lingering claims trickle through.
|Health Net (CA)||For California Individual and Large Group Plans in 2019, Health Net met or exceeded the MLR standards.
For California Small Group Plans in 2019, Health Net Life Insurance Company (PPO) met or exceeded the 80% MLR standard.
For California Small Group Plans in 2019, Health Net of California, Inc. (HMO) did not meet the 80% MLR standard and rebated a portion of the premium, either by:
|Kaiser Permanente (CA)||Kaiser Permanente is not be required to issue any Affordable Care Act rebates for 2019 experience.
Click here for the Kaiser Permanente Health Care Reform update on medical benefit ratio.
|National General (CA and NV)||As an ERISA product, Level-Funded Plans do not participate in the MLR regulations.|
|Oscar (CA)||No MLR updates; brokers can follow all of their renewals at by logging in to the Oscar website.|
|Prominence and Prominence Association Health Plans (Nevada)||Prominence Health Plan did not fall below the MLR threshold; no MLR rebates are due.|
|Sharp Health Plan (CA)||No MLR rebates.
|SIMNSA (CA)||Because SIMNSA is a Mexican HMO, the MLR rebate does not apply. The state of California rule specifically applies to plans that contract for health care coverage in California; however, SIMNSA does not provide such coverage and only sells products that provide coverage in Mexico.|
|Sutter Health Plus (CA)||Sutter Health Plus does not anticipate issuing any MLR Rebates for the CY 2019 MLR Reporting Year.|
|UnitedHealthcare (CA)||Rebates for affected fully insured customers were distributed during the weeks of September 14 and 21, 2020.
The MLR Rebate applies to Large Group (Key Accounts) only; there were no MLR rebates this year for Small Group.
Link here to download the UnitedHealthcare 2020 MLR Early Warning Payout Report.
|Western Health Advantage (CA)||Western Health Advantage exceeded the MLR targets for Large Group, Small Group, and individual lines of business, as shown below. As such, no MLR rebates apply for 2019.
Other useful information is contained in an MLR column from August 2020, authored by Paul Roberts, Word & Brown’s Director of Education and Market Development.
If you have any MLR questions, contact your WBCompliance team by telephone or email. You can call 866-375-2039, or send an email to ComplianceSupport@wordandbrown.com.