Aug 29, 2024
Background
Under the Affordable Care Act (ACA), all health insurers must spend a minimum percentage of the premiums they collect on healthcare services and quality improvement activities for their members. This percentage is called the Medical Loss Ratio (MLR) and is calculated for an insurer’s overall business based on the market segments in each state, not at the group level.
If the minimum MLR is not met within a market, insurers must pay a rebate to customers in that market segment.
- Small Group & Individual (fully insured groups with 50 or fewer employees): Generally, insurers must spend at least 80 cents of every premium dollar they receive on healthcare services.
- Large Group (fully insured groups with 51 or more employees): Generally, insurers must spend at least 85 cents of every premium dollar they receive on healthcare services.
Current situation
CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. (collectively CareFirst) will distribute four types of MLR rebates that differ by product and jurisdiction. The mailings will begin the week of September 9, 2024, and will be processed in the approximate order as follows:
- Large Group BlueChoice in VA
- Small Group CFMI in MD
- Individual GHMSI in MD
- Individual CFMI Catastrophic MiniMed plans in MD
Further details about eligible groups and rebates will be available via your MLR Representative approximately one week before mailings begin. To obtain further details about eligible groups and/or rebates, please contact the MLR representative in your division after mailing has begun.
Rebate information
- Each eligible Group or Individual subscriber will receive a rebate check with an included notification advising of the reason for the rebate.
- Rebates are calculated at the population set (market segment/legal entity/jurisdiction) level based on the premiums paid for medical products by legal entity (CFMI, GHMSI, or BlueChoice) and jurisdiction (MD, DC, VA).
- As a result, groups that have products with different legal entities may receive a rebate for one product and not for another.
- Certain groups could also receive multiple checks if offering multiple products to their subscribers.
- Employers should determine their legal and accounting obligations relating to the distribution of the rebate. CareFirst cannot provide legal or accounting advice to employers.
- Rebate checks/notices will be sent to employer groups before notices are sent to eligible subscribers.
- Please note: Rebate checks arrive by mail. Please take any opportunity to offer your client a reminder that if they were entitled to a rebate to confirm receipt and cashing of checks.
Contact information
The following MLR Customer Service phone numbers are provided in the notices:
- Individual – Member Service: 855-850-0939
- Small Group – Member Service: 855-850-0940, Broker Service: 888-285-8311/broker@carefirst.com
- Large Group – Member and Broker Service: 855-850-0937
For more information
- For more information about Medical Loss Ratio, please visit www.HealthCare.gov.
- Frequently asked questions are also available online at carefirst.com/mlrfaqs.
If you have general questions, please contact your Amwins Connect Sales Representative. For specific small group or large group MLR questions, please contact the MLR Customer Service Center at the phone numbers above.
