Health Plan Weekly

Biden Admin Aims to Stymie MLR Inflation Among ACA Plans

  • Jan 21

    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 working in journalism since 2009 and reporting on the health care industry since 2014. She has covered the many ups and downs of the Affordable Care Act exchanges, the failed health insurer mega-mergers, and hundreds of other storylines spanning subjects such as Medicaid managed care, Medicare Advantage, employer-sponsored insurance, and prescription drug coverage. As the managing editor of Health Plan Weekly and Radar on Drug Benefits, she writes and edits for both publications while overseeing a small team of reporters who also focus on the managed care sector. Before joining AIS Health, she was a senior editor for the e-newsletter Fierce Health Payer, and she started her career as a copy editor at multiple local newspapers. She graduated with a dual degree in journalism and political science from Penn State University.

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