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*This email is intended for producers in Delaware, central Pennsylvania, northeastern Pennsylvania, and western Pennsylvania 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 2020. The companies and markets affected are:
Entity |
Market |
First Priority Health |
Individual Large Group |
First Priority Life Insurance Company |
Large Group Small Group |
Highmark Choice Company |
Individual |
Highmark Health Insurance Company |
Individual |
Highmark Coverage Advantage |
Individual Small Group |
Highmark Inc. (student plans) |
Large Group |
Highmark Delaware |
Individual Small Group |
Highmark Benefits Group |
Individual Small Group |
Highmark (Western and Central) |
Individual |
Lower than expected claims experience is due to several factors. Some of these include:
- Highmark working closely with providers to reduce costs.
- Members taking charge of their health through preventative screenings and other health-improving activities like smoking cessation programs.
- 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 mid-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 13 |
Subscriber notification package |
September 15 |
Checks sent to clients |
How the Rebate Works for Individual Market Members Individual Market members will receive a postcard and email 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 HighmarkMLR2020.com that contains FAQs that can help them gain additional understanding of the MLR rebate mandate.
Individual Market Sample Communication Package
Communication Timing
Week of: |
Communication |
September 13 |
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 13 |
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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