Posted: August 7, 2019 by Paul Roberts
The Affordable Care Act (ACA) requires group health plans to spend a minimum percentage of premium dollars on members’ health care expenses and services. It also sets a threshold on the maximum amount of premium dollars that can be spent on other administrative costs, such as marketing, profits, salaries, agent commissions, etc. These requirements, known as a plan’s Medical Loss Ratio (MLR), require group health plans to reimburse employers for any premium dollars that exceed MLR limits.
In the Small Group market, the law requires an MLR of 80%. That is, at least 80% of premium dollars must be spent on health care-related expenses, and no more than 20% of premium dollars may be spent on administrative expenses. In the Large Group market, the MLR rises to 85%.
Any year a health plan exceeds its MLR requirements, the health insurance carrier has until 9/30 of the following year to distribute MLR rebate funds. Plans that exceeded MLR requirements in 2018 are required to distribute MLR reimbursement checks by 9/30/2019. Employers have several options when it comes to utilizing or dispersing the MLR rebate funds, but the law gives them just 90 days to take action. Furthermore, employees are also notified about forthcoming MLR rebate checks by their plan(s) as required by law, which can also put pressure on employers.
The MLR rebate checks are generally small, ranging from about $20 to $30 per participant. Forwarding these funds to employees can be a challenge because the funds may result in additional taxable income and can be a burden on payroll. Often, the administrative cost to release the funds to employees is greater than the amount of the rebate checks themselves, which is why employers are granted flexibility when it comes to utilizing the funds.
The DOL provides three options for distributing rebates:
- Reduce subscribers’ portions of the annual premium for the subsequent policy year for all subscribers covered under any group health policy offered by the plan.
- Reduce subscribers’ portions of the annual premium for the subsequent policy year for only those subscribers covered by the health policy on which the rebate is based.
- Provide a cash refund only to subscribers who were covered under the group health policy on which the rebate is based.
The law does not require employers to track down former employees for MLR rebates, but COBRA participants must be included in any premium rebates, if applicable.
If the plan is funded solely by the employer, then the employer may keep the rebate check – as long as the rebate funds are not considered “plan assets” under ERISA law. If the funds are considered “plan assets,” then the funds must be used to enhance employees’ benefits.
If the employer has a Section 125 Premium Only Plan (POP) in place, and its employees pay premium contributions on a pre-tax basis, then any MLR rebate amount given to those employees is generally considered taxable income. It is important for an employer to check with its accountant or payroll personnel for counsel on these tax issues. Because of these tax ramifications, most employers opt to utilize MLR rebate funds for future premium payments, or toward benefit enhancements for employees.
Whatever action the employer takes, a documented plan is critical, and communication of this plan is of equal importance. The employer’s MLR rebate plan should clearly document and summarize the employer’s 90-day action plan, should apply to all similarly-situated employees, and should be available for retrieval and review by employees.
For help with MLR rebate checks and calculations – or anything in the ACA and employee-benefits world – rely on your WBCompliance team for help. WBCompliance can be reached at 866-375-2039, or via email at ComplianceSupport@wordandbrown.com.
More about the author:
Paul Roberts is our Compliance Manager, leading the General Agency’s educational initiatives and providing support for the compliance team in California and Nevada. Paul is a tenured veteran in the health insurance industry, carrying a long history of health insurance experience and an education in business management. He has performed nearly every operational role at Word & Brown General Agency, and has a fervor for education and keeping health insurance brokers and employers in-line with compliance. Paul can be found at many industry events across the nation delivering CE, HRCI & SHRM courses, educating himself, advocating for the role of the agent, and working directly with brokers and employers. This gives Paul the best ability to innovate and improve compliance resources & education curriculums to support the businesses and abilities of brokers. Paul is passionate about education, diversity and helping others. He is grateful for his opportunity to support both brokers and employers and is committed to your success.
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