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This email is intended for producers in western Pennsylvania, central Pennsylvania, northeastern Pennsylvania and Delaware.
Notice of Medical Loss Rebate to Group Market, Individual Market, and Student Health Members
The Affordable Care Act (ACA) includes a Medical Loss Ratio (MLR) requirement for health insurers. The MLR provision mandates that insurers rebate all or a portion of the premiums paid if a certain percentage of premiums collected are not spent on claims or quality improvement programs. In the Individual and Small Group Markets, the MLR threshold is 80% of premiums collected. In the Large Group Market, the threshold is 85%.
This year, rebates will be distributed in the Individual, Small Group, Large Group Markets. All rebates are based on calendar year 2019. The companies and markets affected are:
| Entity |
Market |
| First Priority Health |
Individual
Large Group |
| First Priority Life Insurance Company |
Large Group |
| Highmark Choice Company |
Individual |
| Highmark Health Insurance Company |
Individual |
| Highmark Coverage Advantage |
Small Group |
| Highmark Inc. (student plans) |
Large Group |
| Highmark Blue Cross Blue Shield Delaware |
Individual
Small Group |
Lower than expected claims experience is due to several factors. Some of these include:
- Highmark working closely with providers to reduce costs.
- Members working with Highmark’s Care Management Teams to better manage chronic conditions.
- As a result, rebate checks will be mailed to eligible clients (for large and small groups), as well as Individual Market and Student Health Plan contract holders the last week of September.
How the Rebate Works for Group Market Clients
We are required to notify affected employers and their active, covered employees who were covered during the rebate years. Please review the client notification packages for samples of the communications. All clients will receive a roster detailing the employees covered during the year for which the rebate is being made, the coverage type for each employee (self, self and spouse, self and family), and the time that each employee was covered during the year being rebated.
Group Market Sample Communication Package
Communication Timing
| Week of: |
Communication |
| September 7 |
Client notification package |
| September 14 |
Subscriber notification package |
| September 21 |
Checks sent to clients |
How the Rebate Works for Individual Market Members
Individual Market members will receive a postcard informing them that a rebate is coming their way. The Centers for Medicare & Medicaid Services notice and cover letter will be sent with the check for these members. Please review the sample communications. These members will also have access to HighmarkMLR2019.com, that contains FAQs that can help them gain additional understanding of the MLR rebate mandate. This website will be available no later than 9/14/20.
Individual Market Sample Communication Package
Communication Timing
| Week of: |
Communication |
| September 21 |
Check, cover letter, and CMS notice package |
How it Works for Student Health Members
The Student Health members are a unique group in that they are considered a Large Group through the universities they attend, but their rebates are distributed as they are for the Individual Market Members. Please see their communications package below.
Student Heath Member Sample Communication Package
Communication Timing
| Week of: |
Communication |
| September 21 |
Check, cover letter, and CMS notice package |
Questions
If you have questions about Small and/or Large Group rebates, please contact your Highmark Client Manager. If you have questions about the Individual Market rebates, please email: u65trainingcertification@highmark.com.
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| Highmark Inc. is an independent licensee of the Blue Cross Blue Shield Association. Insurance or benefit administration may be provided by or through Highmark Inc. or one of its affiliated Blue companies. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies serve Blue Cross Blue Shield members in the 29 counties of western Pennsylvania, 13 counties in northeast Pennsylvania, the state of West Virginia plus Washington County, Ohio, and the entire state of Delaware. |
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This email and any attachments contain important information about Highmark, including its products, customers and business
processes, and may include information which Highmark considers to be confidential and proprietary ("the Highmark Information").
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posting of such information on a website or social media sites that can be accessed by third parties, is strictly prohibited.
® Highmark is a registered mark of Highmark Inc.
© 2016 Highmark Inc., All Rights Reserved
120 Fifth Avenue Pittsburgh, PA 15222 USA
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