PPACA Update : Upcoming Employer Responsibility to Handle MLR Rebates for Group Health Insurance


Under the medical loss ratio or “MLR” provisions of the Patient Protection and Affordable Care Act of 2010 (“PPACA”), health insurance insurers who spend more than a specified percentage of premium dollars on categories of spending other than clinical services and activities designed to improve the quality of health care are required to rebate a portion of the premiums to enrollees. The medical loss ratio is 80% in the small group market and 85% in the large group market. This requirement first applied to insurers in 2011 and, to the extent rebates are required, will be paid in August 2012.

MLR rebates are potentially significant. A study by The Commonwealth Fund released in April 2012 found that if the MLR rules had been in effect in 2010, insurers would have issued an estimated $2 billion in rebates, about half of which was attributable to the group market.

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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