It’s Medical Loss Ratio (MLR) Rebate Check Time Again

The Affordable Care Act (ACA) requires fully insured group health plans to spend a minimum percentage of premium dollars on members’ health care expenses and services. Likewise, it sets a threshold on the maximum amount of premium dollars that can be spent on other administrative costs, such as marketing, profits, salaries, agent commissions, etc. These requirements, known as a plan’s Medical Loss Ratio (MLR), require group health plans to reimburse employers for any premium dollars that exceed MLR limits.

In the fully insured Small Group market, the law requires an MLR of 80%. That is, at least 80% of premium dollars must be spent on health care-related expenses, and no more than 20% of premium dollars may be spent on administrative expenses. In the fully insured Large Group market, the MLR rises to 85%. The MLR requirements do not apply to self-funded plans.

Any year a fully insured health plan exceeds its MLR requirements, the health insurance carrier has until the end of September of the following year to distribute MLR rebate funds. Plans that exceeded MLR requirements in 2022 are required to distribute MLR reimbursement checks by 9/30/2023.

Employers have several options when it comes to utilizing or dispersing the MLR rebate funds, but the law gives them just 90 days to act. Furthermore, employees are also notified about forthcoming MLR rebate checks by their plan(s) as required by law, which can also put pressure on employers.

The MLR rebate checks in the group market are generally small, ranging from about $10.00 to $30.00 per participant. Forwarding these funds to employees can be a challenge because the funds may result in additional taxable income and can be a burden on payroll. Often, the administrative cost to release the funds to employees is greater than the amount of the rebate checks themselves, which is why employers are granted flexibility when it comes to utilizing the funds.

The Department of Labor provides three options for distributing rebates:

  1. Reduce subscribers’ portions of the annual premium for the subsequent policy year for all subscribers covered under any group health policy offered by the employer.
  2. Reduce subscribers’ portions of the annual premium for the subsequent policy year for only those subscribers covered by the health policy on which the rebate is based.
  3. Provide a cash refund only to subscribers who were covered under the group health policy on which the rebate is based.

The law does not require employers to track down former employees for MLR rebates, but COBRA participants must be included in any premium rebates, if applicable.

If the plan is funded solely by the employer, then the employer may keep the rebate check – as long as the rebate funds are not considered “plan assets” under ERISA law. If the funds are considered “plan assets,” then the funds must be used to enhance employees’ benefits. Consultation with an ERISA attorney is highly recommended for guidance in this area.

Word & Brown General Agency has developed a proprietary MLR rebate calculator to help your clients calculate MLR payment disbursements, for employers who decide to refund plan participants directly.

If the employer has a Section 125 Premium Only Plan (POP) in place, and its employees pay premium contributions on a pre-tax basis, then any MLR rebate amount given to those employees is generally considered taxable income. It is important for an employer to check with its accountant or payroll personnel for counsel on these tax issues. Because of these tax ramifications, most employers opt to utilize MLR rebate funds for future premium payments or apply them toward benefit enhancements for employees.

Whatever action the employer takes, a documented plan is critical – and communication of this plan is of equal importance. The employer should clearly document and summarize its 90-day action plan, which should apply to all similarly situated employees, and should be available for retrieval and review by employees – and included in ERISA documentation.

We are currently surveying our health plan partners to find out what plans they have with regarding to the MLR distribution for 2022 plans. We will share that information as our survey results come in from carriers.


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