Biden Admin Aims to Stymie MLR Inflation Among ACA Plans

  • Jan 21, 2022

    In its annual omnibus regulation for the Affordable Care Act exchanges, CMS revealed that it aims to crack down on some questionable behavior used by health plans when calculating their medical loss ratios (MLRs) — a move that will likely result in insurers paying even higher rebate amounts to consumers than they already are.

    The ACA requires individual and small-group market insurers to spend at least 80% of their premium income on medical care and quality improvement. For the large-group market, that threshold is 85%. If insurers’ MLRs dip below those percentages, they’re required to return the difference to plan members. MLR rebates, which are calculated using a three-year average, have risen considerably in recent years and totaled $2 billion for the 2020 plan year.

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  • Leslie Small

    Leslie has been reporting and editing in various journalism roles for nearly a decade. Most recently, she was the senior editor of FierceHealthPayer, an e-newsletter covering the health insurance industry. A graduate of Penn State University, she previously served in editing roles at newspapers in Pennsylvania, Virginia and Colorado.

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