This email is intended for producers with group clients or individual ACA members in Western PA, Central PA, or Northeastern PA.
NOTICE OF MEDICAL LOSS REBATE TO GROUP MARKET AND INDIVIDUAL MARKET
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, and Large Group Markets. While the MLR calculation is based on a 3-year average, all rebates due are calculated using 2022 premiums. The companies and markets affected are:
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 contract holders the last week of September. Student Health Plan contract holders are not being rebated.
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
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 HighmarkMLR.com that contains FAQs that can help them gain additional understanding of the MLR rebate mandate.
Individual Market Sample Communication Package
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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. Highmark Blue Cross Blue Shield of Western New York is a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association. Highmark Blue Shield of Northeastern New York (Highmark BSNENY) is a trade name of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association.
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