The 80/20 Rule: Providing Value and Rebates to Millions of Consumers
The new health reform law, the Affordable Care Act, holds health insurance companies accountable to consumers and ensures that American families are reimbursed if health insurance companies don’t meet a fair standard of value.
Because of the Affordable Care Act, insurance companies now must reveal how much of premium dollars they actually spend on health care and how much they spend on administration, such as salaries and marketing. This information was not shared with consumers in the past. Not only is this information made available to consumers for the first time, If an insurance company spends less than 80% of premiums on medical care and quality (or less than 85% in the large group market, which is generally insurance provided through large employers), it must rebate the portion of premium dollars that exceeded this limit.[1] This 80/20 rule is commonly known as the Medical Loss Ratio (MLR) rule.
On June 1, 2012, insurance companies nationwide submitted their annual MLR reports for coverage provided in 2011 to the Department of Health and Human Services (HHS). Based on this data, insurance companies that didn’t meet the 80/20 rule will provide nearly 12.8 million Americans with more than $1.1 billion in rebates this year. Americans receiving the rebate will benefit from an average rebate of $151 per household.
Under the new health care law, rebates must be paid by Aug. 1 each year. As a result, 12.8 million Americans will see one of the following:
* a rebate check in the mail
* a lump-sum reimbursement to the same account that was used to pay the premium if it was paid by credit card or debit card
* a direct reduction in their future premiums
* their employer providing one of the above rebate methods, or applying the rebate in a manner that benefits its employees.
Consumers in every state will also receive notifications from their insurance company about the 80/20 rule. Under the Affordable Care Act, insurance companies will send a letter to subscribers every year they miss the 80/20 mark. The letter will explain the purpose of the 80/20 rule, how far the insurance company fell short of this goal, and the percentage of premium it owes in rebates. In 2012, insurance companies that meet or exceed the standard in the 2011 coverage year will send a notice to consumers explaining the purpose of the 80/20 rule and notifying consumers that they met or exceeded the standard. Insurance companies will provide consumers with unprecedented information about the value consumers get for every dollar spent on premiums. All of this information will be publicly available on HealthCare.gov.
The 80/20 rule is ensuring that insurance companies provide consumers value for their premium dollars. This rule works in combination with other consumer protections in the Affordable Care Act, like the program that reviews insurance companies’ rates to ensure that premium increases are not unreasonable. Insurance companies are now required to subject insurance premium rate increases of 10% or more to a new review process and justify these increases. Most states now have the authority to determine whether these increases are excessive, while HHS reviews rates in states that do not operate effective rate review programs. In making these determinations, HHS and the states closely review insurance companies’ 80/20 or MLR standards.
Summary of All Markets
Americans covered by insurance companies that failed to meet the MLR standard will receive an average rebate of $151 per family across all markets. The average rebate per family is expected to be $152 in the individual market, $174 in the small group market (which is generally insurance provided through small employers), and $135 in the large group market.. The states with average rebates above $500 per family are: Vermont ($807),Oregon ($777) and Indiana ($503) in the large group market; Georgia ($811), Ohio ($783), New York ($632), Alaska ($622), and Illinois ($551) in the small group market; and Mississippi ($651) and Alabama ($582) in the individual market.
Approximately 66.7 million consumers are insured by an insurance company that provides the required value for their premium dollars. This means that a large majority of consumers are insured by companies that meet or exceed the MLR standard: 62% of consumers in the individual market; 83% in the small group market; and 89% in the large group market.
Individual Market
In the individual market, companies that did not meet the standard will pay $394 million in rebates to an estimated 2.6 million households this year.
The average rebate in the individual market is approximately $152 per family. Subscribers in Mississippi ($651), Alabama ($582), Maryland ($496), and Delaware ($461) are likely to see the highest rebates.
Small Group Market (Insurance Provided Through Small Employers)
Over 1.8 million families, which include 3.3 million consumers enrolled in those policies, will see an average rebate of $174 provided to their employers in the small group market. Insurance companies in the small group market will issue $321 million in rebates this year.
The average rebate per family will be more than $500 in Alaska ($622), Georgia ($811), Illinois ($551), New York ($632), and Ohio ($783).
Large Group Market (Insurance Provided Through Large Employers)
Insurance companies in the large group market are expected to return $386 million in rebates. Generally these rebates will be paid directly to the employers to be distributed to their employees according to employees’ contributions to premium, benefiting approximately 2.9 million families or 5.3 million Americans. Though fewer companies in the large group market owe rebates, at a national level these companies are providing roughly the same dollar amount in terms of total rebates. This is because a larger number of consumers benefit from rebates in the large group market when compared to the individual or small group markets.
States whose health insurers have the highest average rebate in the large group market are Vermont ($807), Oregon ($777), Indiana ($503), Colorado ($475), Maine ($463), and New Jersey ($359).
Conclusion
For years, Americans have watched their premiums rise faster than their wages. Although these increases are partly due to rising medical costs and utilization of services, they are exacerbated by rising insurance company administrative costs (including marketing and salaries of CEOs) and profits, which contribute little or nothing to the care of patients or the health of consumers.
Many Americans are working hard to ensure that their families have health insurance coverage, and they do not deserve to have their premium dollars wasted on excessive administrative costs and profits. The Affordable Care Act and the 80/20 rule guarantee this right for consumers, and the over $1.1 billion in rebates provided through this rule show that insurance companies can no longer pass excessive administrative costs and profits on to consumers.
Appendix I: Total Rebates in All Markets for Consumers and Families, by State
Totals
State Total Rebates Total Consumers Benefiting from Rebates Average Rebate per Family
*USA* $1,101,372,250 12,760,266 $151
AK $1,280,908 2,712 $622
AL $4,220,331 13,556 $518
AR $7,787,177 115,461 $114
AZ $27,868,667 413,912 $118
CA $73,905,280 1,877,186 $65
CO $27,452,769 208,197 $227
CT $12,949,130 137,452 $168
DC $47,189,436 592,234 $157
DE $1,846,989 5,639 $351
FL $123,624,635 1,251,397 $168
GA $19,764,771 243,813 $134
HI $195,053 26,900 $15
IA $1,469,276 28,042 $100
ID $1,124,918 32,576 $70
IL $61,802,411 299,544 $380
IN $14,249,673 283,432 $99
KS $4,139,506 67,512 $91
KY $15,326,103 249,275 $114
LA $4,111,975 75,493 $94
MA $11,886,643 163,949 $140
MD $27,882,606 141,129 $340
ME $2,579,922 10,589 $463
MI $13,908,262 113,995 $214
MN $8,956,885 123,171 $160
MO $60,664,564 587,654 $173
MS $10,122,532 51,744 $329
MT $2,607,244 25,353 $194
NC $18,678,898 216,649 $158
ND $10,160 4,229 $5
NE $4,832,049 46,444 $215
NH $77,507 16,023 $9
NJ $7,670,066 44,998 $300
NM $0 0
NV $4,548,500 46,590 $180
NY $86,526,642 1,001,476 $138
OH $11,331,726 143,327 $139
OK $20,296,875 263,404 $126
OR $4,654,772 23,394 $368
PA $51,588,303 575,551 $165
RI $0 0
SC $19,630,152 251,632 $131
SD $47,948 1,370 $68
TN $28,810,557 240,298 $201
TX $166,975,840 1,516,721 $187
UT $3,696,778 109,893 $85
VA $43,127,639 686,738 $115
VT $2,346,018 4,636 $807
WA $594,031 7,681 $185
WI $10,369,793 282,812 $76
WV $2,703,790 16,434 $374
WY $1,112,043 6,290 $350
Territories Total Rebates Total Consumers Benefiting from Rebates Average Rebate per Family
GU $15,394,953 46,390 $852
MP $291,586 1,022 $782
PR $5,508,831 58,648 $225
VI $1,629,124 5,698 $462
Appendix II: Total Rebates by Market and State for Consumers and Families: Table shows state by state rebate data for the individual market, small group market, and large group market.
Appendix II: Total Rebates by Market and State for Consumers and Families
Note: People using assistive technology may not be able to fully access information in the data table above. Instead use the accessible data tables below:
Total Rebates by Market and State for Consumers and Families:
Individual Market | Small Group Market | Large Group Market
Individual Market
State Individual Market
Rebates Enrollees Benefiting from Rebates Avg Rebate
per
Family
*USA* $393,877,421 4,122,682 $152
AK $0 0 $0
AL $3,189,860 8,718 $582
AR $533,645 12,406 $75
AZ $12,692,460 218,153 $97
CA $20,506,850 956,514 $30
CO $3,062,448 109,460 $44
CT $3,989,874 47,990 $124
DC $151,721 1,908 $103
DE $963,002 2,948 $461
FL $47,257,109 308,944 $240
GA $2,889,653 85,442 $51
HI $0 0 $0
IA $0 0 $0
ID $144,303 1,083 $323
IL $7,794,746 60,787 $199
IN $2,838,374 42,320 $128
KS $3,535,948 54,763 $101
KY $232,937 2,830 $150
LA $2,858,378 23,866 $193
MA $226,702 2,487 $116
MD $12,102,203 38,696 $496
ME $0 0 $0
MI $11,872,643 99,919 $205
MN $494,492 30,512 $38
MO $16,329,386 181,007 $139
MS $6,133,419 15,789 $651
MT $1,685,051 16,825 $203
NC $3,111,464 26,185 $218
ND $10,160 4,229 $5
NE $3,704,559 29,827 $267
NH $0 0 $0
NJ $114,290 4,430 $25
NM $0 0 $0
NV $721,052 9,744 $115
NY $6,048,297 83,541 $90
OH $8,195,193 130,898 $106
OK $6,602,858 104,568 $110
OR $2,630,847 13,528 $360
PA $20,677,286 133,264 $238
RI $0 0 $0
SC $15,277,769 105,043 $227
SD $47,948 1,370 $68
TN $18,445,730 140,962 $207
TX $134,482,051 657,993 $356
UT $2,741,795 47,358 $145
VA $5,006,309 265,149 $32
VT $0 0 $0
WA $432,333 4,939 $161
WI $649,028 19,759 $63
WV $2,268,826 10,305 $383
WY $932,840 5,201 $356
Territories Small Group Market
Rebates Enrollees Benefiting from Rebates Avg Rebate
per
Family
GU $0 0 $0
MP $291,586 1,022 $782
PR $0 0 $0
VI $0 0 $0
Small Group Market
State Small Group Market
Rebates Enrollees Benefiting from Rebates Avg Rebate
per
Family
*USA* $321,116,259 3,295,798 $174
AK $1,280,908 2,712 $622
AL $1,030,471 4,838 $387
AR $5,666,923 81,139 $120
AZ $8,852,429 126,619 $131
CA $42,256,439 336,121 $206
CO $653,254 2,916 $403
CT $459,952 4,283 $162
DC $9,156,289 83,599 $186
DE $0 0 $0
FL $50,713,189 476,010 $190
GA $1,754,466 4,614 $811
HI $0 0 $0
IA $1,469,276 28,042 $100
ID $980,615 31,493 $63
IL $47,391,579 164,372 $551
IN $9,243,360 232,887 $78
KS $603,559 12,749 $58
KY $4,119,316 34,007 $207
LA $0 0 $0
MA $9,210,815 143,469 $130
MD $2,281,663 13,333 $310
ME $0 0 $0
MI $2,035,619 14,076 $293
MN $0 0 $0
MO $38,424,482 240,893 $276
MS $951,898 10,838 $150
MT $922,193 8,528 $180
NC $894,587 66,311 $21
ND $0 0 $0
NE $1,127,491 16,617 $131
NH $0 0 $0
NJ $0 0 $0
NM $0 0 $0
NV $3,445,694 27,187 $225
NY $3,663,077 7,958 $632
OH $3,136,533 12,429 $783
OK $13,282,727 118,029 $170
OR $1,209,614 7,359 $282
PA $345,698 3,991 $200
RI $0 0 $0
SC $4,297,790 145,401 $53
SD $0 0 $0
TN $3,251,333 46,106 $125
TX $14,307,687 351,754 $65
UT $97,392 33,534 $7
VA $22,125,579 236,171 $181
VT $0 0 $0
WA $0 0 $0
WI $2,948,238 122,516 $48
WV $434,964 6,130 $334
WY $179,203 1,089 $319
Territories Small Group Market
Rebates Enrollees Benefiting from Rebates Avg Rebate
per
Family
GU $3,997,788 12,018 $1,167
MP $0 0 $0
PR $1,283,046 17,966 $191
VI $1,629,124 5,698 $462
Large Group Market
State Large Group Market
Rebates Enrollees Benefiting from Rebates Avg Rebate
per
Family
*USA* $386,378,570 5,341,787 $135
AK $0 0 $0
AL $0 0 $0
AR $1,586,610 21,916 $114
AZ $6,323,778 69,140 $170
CA $11,141,991 584,551 $43
CO $23,737,066 95,821 $475
CT $8,499,305 85,179 $202
DC $37,881,427 506,727 $152
DE $883,987 2,691 $278
FL $25,654,337 466,444 $94
GA $15,120,652 153,757 $172
HI $195,053 26,900 $15
IA $0 0 $0
ID $0 0 $0
IL $6,616,086 74,385 $176
IN $2,167,939 8,225 $503
KS $0 0 $0
KY $10,973,850 212,439 $97
LA $1,253,598 51,627 $43
MA $2,449,125 17,993 $203
MD $13,498,740 89,100 $268
ME $2,579,922 10,589 $463
MI $0 0 $0
MN $8,462,393 92,660 $197
MO $5,910,696 165,755 $63
MS $3,037,215 25,117 $202
MT $0 0 $0
NC $14,672,847 124,153 $237
ND $0 0 $0
NE $0 0 $0
NH $77,507 16,023 $9
NJ $7,555,776 40,568 $359
NM $0 0 $0
NV $381,755 9,660 $105
NY $76,815,268 909,977 $139
OH $0 0 $0
OK $411,290 40,807 $18
OR $814,312 2,507 $777
PA $30,565,319 438,296 $137
RI $0 0 $0
SC $54,594 1,188 $85
SD $0 0 $0
TN $7,113,493 53,230 $253
TX $18,186,102 506,974 $61
UT $857,591 29,001 $81
VA $15,995,751 185,417 $167
VT $2,346,018 4,636 $807
WA $161,698 2,742 $303
WI $6,772,527 140,537 $104
WV $0 0 $0
WY $0 0 $0
Territories Small Group Market
Rebates Enrollees Benefiting from Rebates Avg Rebate
per
Family
GU $11,397,165 34,372 $779
MP $0 0 $0
PR $4,225,785 40,682 $238
VI $0 0 $0
Posted on: June 21, 2012