Thread by @charles_gaba

⚠️⚠️⚠️ ADVANCE WARNING: Long wonky MLR rebate thread ahead! All 50 states + DC!

One of the provisions of the #ACA is the “Medical Loss Ratio” provision, which requires health insurance carriers to spend a minimum of 80% or 85% of their premium revenue on actual healthcare/medical claims. It’s 80% for the Individual & Sm. Group markets, 85% for Lg. Group. 1/

Simple version: If an insurance carrier spends *less* than 80% (85%) on medical claims, weighted over a 3-year average, they have to *pay back* the excess to the policyholders.

So, if they bring in $100M in premiums & only pay out $75M in claims, they have to rebate $5M. 2/

Less-simple version: There are some caveats. Besides the 3-yr rolling average, if they have fewer than 1,000 enrollees over that time, the MLR rule is waived; if they have 1K - 75K, the rule is adjusted. Some other formula tweaks also apply, but that’s basically it. 3/

MLR rebates have been quietly paid out every year since 2011. A month ago I wrote this more-detailed MLR explainer. 4/

acasignups.net/19/08/29/impor…

Until this year, MLR rebates have averaged around $180-$200 million per year in each health insurance market: Large Group (big employers), Small Group (small employers) and Individual (ACA exchanges or direct from carriers), for a total of around $560 million/year on average. 5/

THIS year I, along with other healthcare wonks, predicted there’d be HUGE increases in MLR rebates on the *individual* market specifically for several reasons. @KFF projected up to $800 million this year. *I* went one step further & predicted up to $2 BILLION *next* year. 6/

With all this in mind, how much is *actually* getting paid out in #ACA MLR rebates this year? Well, that’s what I’ve spent the past 3 weeks working on. Seriously, that’s ALL I’ve been doing. Late last night I posted the final states, so here they all are in one thread! 7/

In order to enhance the drama, I’ll be listing the states in order from LOWEST to HIGHEST individual market rebate amounts. This doesn’t quite track with total amounts for *all 3 markets*, but I’m using the Indy market for a reason I’ll explain after I’m done. 8/

OK, first up are the states which don’t have ANY MLR rebates going out this year at all. Those are no fun, so let’s get them out of the way quickly: 9/

MAINE: No rebates to anyone in any market this year, though they may have some payout next year: 10/

acasignups.net/19/09/11/maine…

NORTH DAKOTA: No rebates in any market this year, likely nothing next year either: acasignups.net/19/09/11/north… 11/

OREGON: No MLR rebates to anyone this year; likely nominal for the indy market next year: acasignups.net/19/09/13/orego…
12/

RHODE ISLAND: No MLR rebates this year, none on the Indy market likely next year either: acasignups.net/19/09/13/rhode…
13/

SOUTH DAKOTA: NO #MLR REBATES FOR OLD MEN (or old women…or younger men or women, for that matter): acasignups.net/19/09/12/south…
14/

VERMONT: Nope, no rebates for anyone here, either: acasignups.net/19/09/12/vermo…
15/

WYOMING: Big Goose Eggs across the MLR landscape in the home of the Cheney clan this year and likely next as well: acasignups.net/19/09/12/wyomi…
16/

OK, that was…boring. The next batch of states don’t have anything going to *individual* market enrollees, but have *some* rebates going to small or large group policyholders. Under the #ACA, employers gets the rebate initially but have to pass it along to enrollees. 17/

KENTUCKY: 363 people enrolled by large employers will split $44,505 from “Reliance Standard Life Insurance Co.”, which I’ve never heard of: 18/

acasignups.net/19/09/11/kentu…

IDAHO: “Reliance Standard” again: 1,100 large group enrollees should split $140,000.

Individual market enrollees of Blue Cross should keep an eye out next year, however.

acasignups.net/19/09/10/no-lo…
19/

HAWAII: 672 people enrolled in large group plans from UnitedHealthcare should see an average of $412 in MLR rebates this month. Remember, employers pay most of their employee premiums, so most of the rebate will go to them as well: acasignups.net/19/09/10/exclu…

20/

MONTANA: $528,000 will be rebated to large group employers this year, but it’s NEXT year that things start to look interesting:
acasignups.net/19/09/11/monta…
21/

THIS year not a dime is being paid out on Montana’s individual market, mainly because of the 3-year rolling average: 2016 was *horrible*. NEXT year, however, 2016 drops off the calculation, and HCSC (Blue Cross of Montana) did *much* better in 2017 & 2018… 22/

…which means that *if* 2019 is also going well for them, Blue Cross of Montana *could* potentially have to pay back up to $14 million to their individual market enrollees.

⚠️ IMPORTANT: THIS IS BY NO MEANS GUARANTEED. They might not have to pay back a dime.
23/

The 2018 MLR rebates are actuals.

My projections for the *2019* MLR rebates (which will go out *next* August/September) are VERY crude and may be missing some critical wonky data like Risk Adjustment transfers, etc. Please consider them *guidelines only*.

OK, moving on…
24/

NEBRASKA: $827,000 is being paid out to large group enrollees of Cigna, Reliance and UnitedHealthcare: acasignups.net/19/09/11/nebra…
25/

WEST VIRGINIA: $1.3 million in Large Group rebates are going out to Aetna and UnitedHealthcare policyholders: acasignups.net/19/09/13/west-…

Keep an eye on Highmark next year, however…they hovered around the 80% threshold in 2017 & 2018.

26/

DELAWARE: This is the first state where both Lg. *and* Sm. Group employees should receive MLR rebates this year: $1.7 million and $6.5 million respectively. Lg. Group rebates are from Aetna, Ct. General & Highmark BCBS…Sm. Group is all from Highmark:

acasignups.net/19/09/10/exclu…
27/

Again, notice that while Individual market enrollees don’t get any rebates *this* year, there’s a *potential* for up to $10 MILLION next summer…because Highmark’s horrible 2016 is dropping off, while 2017 & 2018 were much better for them. This will be a recurring theme.
28/

⚠️ NOTE: One main REASON insurance carriers did so much better in 2017 & 2018 is simple: They jacked up premiums 23% and 28% respectively, first in response to the federal reinsurance program sunsetting, then in response to the chaos/confusion of Trump/GOP sabotage attempts. 29/

As it turned out, not all of the sabotage attempts have been successful (one in particular actually *backfired* on Trump spectacularly, thanks to #SilverLoading), so the damage, while bad, wasn’t *as* bad as expected. 30/

NEW JERSEY: This is the last state on the list in which Individual market enrollees *don’t* get MLR rebates this year. LARGE employers, however, are getting over $15 million in rebates, almost all of it coming from Oxford Health Insurance: acasignups.net/19/09/11/exclu…
31/

DISTRICT OF COLUMBIA: Here’s where things start getting more interesting. DC is the first on the list to have *any* rebates for Individual Market enrollees. For them, the rebate checks go *directly* to the enrollees themselves.

acasignups.net/19/09/10/exclu…
32/

In DC, officially, 5 people (yes, five!) enrolled in Individual Market plans from “Optimum Choice, Inc.” are supposed to split $313. In practice, however, that “fewer than 1,000” rule may apply here…I’m not sure if they have to actually pay that out or not.

33/

DC’s small group market will see $237,000 in rebates. The *large* group market, however, is pretty stunning given how small DC’s population is: Over $31 million for 106,000 enrollees!

DC’s *total* Lg. Group plan enrollment is nearly as large as their total population. Huh.
34/

ALABAMA: $9,200 is supposedly due to a whopping 413 people from “The United States Life Insurance Company in the City of New York”. Seriously, that’s their full name. No, I’ve never heard of them either.

acasignups.net/19/09/09/exclu…
35/

NEVADA: Around $8.7 million in total rebates. Again, 434 “US Life Ins of NY” enrollees are supposed to get $9,800. Honestly, I’m a bit unclear about what policies this company actually *sells*…I’m told it may be *travel* policies w/medical coverage?

acasignups.net/19/09/11/exclu…
36/

ASIDE: Apparently they’re a subsidiary of AIG, and they mostly sell…property-casualty and life insurance, not *medical*. Thanks to @consultbenefits
for his help with this mystery and some other MLR insights:
insure.com/companies/unit…
37/

SOUTH CAROLINA: $6.7 million in MLR rebate payments going out to group enrollees. On the individual market…$17,000, again from our Mystery Carrier: acasignups.net/19/09/13/south…

Keep an eye on BCBSSC next year, though!

38/

CONNECTICUT: First time on this list: A state which has MLR rebates for *Individual* market enrollees, but *not* for *Group* enrollees (small or large). 1,100 people to split $21,000, for…$19 apiece.

acasignups.net/19/09/10/exclu…
39/

WASHINGTON STATE: For 2018, the Apple State doesn’t look too impressive: $3.7 million in large group rebates and a mere $22,000 to a handful of Individual Market enrollees.

NEXT year, however, could be VERY different: Up to $40 million:

acasignups.net/19/09/13/washi…
40/

LOUISIANA: Large Group policyholders (75,000 enrollees total) will receive over $10 million in MLR rebates this year.

378 individual market enrollees should get…$22,400.

acasignups.net/19/09/11/louis…
41/

MARYLAND: Only $25,000 going out to Individual market enrollees, but *Group Plan* policyholders will receive over $59 MILLION:

acasignups.net/19/09/11/maryl…
42/

MICHIGAN: Only $40,000 for Individual market enrollees…but over $20 million in rebates for group plan policyholders.

Keep an eye on BCBS of Michigan/Blue Care Network next year!

(This data *was* an ACASignups exclusive at the time I posted it…)

acasignups.net/19/09/07/exclu…
43/

CALIFORNIA: You might assume that, as the state with the largest population in the country, California would have the largest MLR rebates…and group plan policyholders *are* getting nearly $90 million.

Individual Market? Just $83,000.

acasignups.net/19/09/11/calif…
44/

This may seem strange, but remember, if an insurance carrier doesn’t fall below the 80% (or 85%) threshold, it doesn’t matter whether they have 1 enrollee or 1,000,000.

45/

NEW YORK: A couple of really important things going on with New York State.

First, large group policyholders will receive $24 million in rebates; on the individual market, it’s just $87,000.

acasignups.net/19/09/11/new-y…
46/

Second: Even that $87,000 is misleading…it averages just $1.46 per enrollee, and @consultbenefits informs me that under the #ACA, the carriers don’t have to pay rebates below $5.
47/

⚠️ The *other* key thing to note about New York is that they have a HIGHER MLR THRESHOLD than the #ACA requires! In NY, Individual and Sm. Group carriers have to spend at least *82%* of premiums on medical care vs. the ACA’s 80%.

48/

This may not seem like much, but if you’re paying $600/mo, that could mean getting an extra $144 back. At $1,000/mo, it could mean another $240 back.

(This year, the only reason those 60,000 NY residents are getting their $1.46 apiece is due to the extra 2% threshold.)
49/

OHIO: Until now, while *group plan* rebates have been huge, the *individual market* rebate totals haven’t broken $100K. That changes with Ohio: Over 7,600 AultCare Insurance enrollees will split $340,000.

Keep an eye on Buckeye Community next year!

acasignups.net/19/09/12/ohio-…
50/

INDIANA: 58,000 Celtic #ACA enrollees will split $703,000.

All told, $5.3 million in MLR rebates.

acasignups.net/19/09/11/exclu…
51/

IOWA: $838,000 in rebates went out to 38,200 #ACA enrollees from Medica. $22 apiece on average, woo-hoo!

(remember, that’s an *average* only).

$2.4 million total.

acasignups.net/19/09/11/iowa-…
52/

OKLAHOMA: The ante was just upped again: Indy Market rebates just jumped from <$1 million to over $3.2 million. Blue Cross Blue Shield of OK has to pay that much out to 142,000 enrollees.

Industry-wide? $16 million.

acasignups.net/19/09/12/oklah…
53/

UTAH: Not only is University of Utah Health Plans paying enrollees back $4.2 million…it’s being divided up among just 20,400 enrollees.

That means each recipient will get over $200 on average.

acasignups.net/19/09/13/utah-…
54/

ILLINOIS: The Land of Lincoln is one-upping Utah this year: Celtic Insurance (aka Ambetter, aka Centene) is rebating over $5.5 million to 21,800 enrollees…averaging $255 apiece:

acasignups.net/19/09/10/no-lo…

Industry-wide total: $19.5 million.

55/

ALASKA: “$255 apiece?”,scoffs Premera Blue Cross…”Screw that! We’re rebating $5.9 million to just 17,000 enrollees! That’s an average of $336 per person!”
acasignups.net/19/09/09/exclu…
56/

NORTH CAROLINA: Blue Cross Blue Shield and Cigna Healthcare, along with Golden Rule, are paying back over $9.8 million to Indy market enrollees…but it’s divided among 490,000 enrollees, so the per-person average is only $20 apiece.

acasignups.net/19/09/08/exclu…
57/

COLORADO: This is the first state to break the $10 million Individual Market rebate milestone: HMO Colorado (aka HMO Nevada) is doling out a cool $10 million to 51,000 enrollees. That’s a per-person avg. of around $200:

acasignups.net/19/09/09/exclu…

Grand total: $19.4 million

58/

ARKANSAS: A single carrier, Celtic/Ambetter, is paying back over $12.2 million to 71,000 enrollees, or $173/apiece on average.

Industry-wide total: $16.2 million.

acasignups.net/19/09/09/exclu…
59/

NEW MEXICO: Molina Healthcare mutters under their breath at Premera AK’s claim. “$336 apiece ain’t nuthin’!” they say. “The ACA requires *us* to pay back over $12.3 million this year…to just 21,300 enrollees!”

Yep, that’s *$580* apiece on average.

acasignups.net/19/09/11/new-m…
60/

WISCONSIN: Common Ground Health Co-Op’s 3-year avg. MLR came in at just 76.6%, so they have to pay back a whopping $18.3 million to their 51,000 enrollees: acasignups.net/19/09/12/wisco…
61/

(by the way: in case you haven’t noticed, the tables have been completely turned…while the first half of the states had a lot of big group rebates but hardly anything for Individual Market enrollees, THESE states have HUGE Indy rebates which often dwarf the Group markets)
62/

FLORIDA: Over $20 million is being rebated to Indy Market enrollees, most of it from BCBS.

It’s being divided among 580,000 people, however, so the per-person average is just $36.

Group market rebates bring the total to over $107 million, though.

acasignups.net/19/09/07/exclu…
63/

NEW HAMPSHIRE: The Granite State only has 1.3 million residents, so you’d assume their #ACA MLR rebates would be pretty small, right? Guess again:

Between Celtic and “Matthew Thornton”, 65,800 enrollees are getting over $24 million in rebates.

acasignups.net/19/09/11/new-h…
64/

MISSOURI: Think of the Show Me State’s 2018 #ACA MLR rebates as Neptune to New Hampshire’s Uranus: 65,500 enrollees of Healthy Alliance are getting $25 million, an average of $382 per person:

acasignups.net/19/09/11/misso…
65/

KANSAS: I’m putting a ⚠️ warning on this one; my data source for Sunflower State Health Plan’s MLR rebate may have a glitch.

IF ACCURATE, however…HOLY CRAP: $25.5 million being paid out to just 17,000 enrollees…for a per-person average of $1,476!

acasignups.net/19/09/11/kansa…
66/

MISSISSIPPI: I’m a lot more confident about this one: Ambetter of Magnolia has to pay $32 million back to 60,000 enrollees, or over $500 apiece:

acasignups.net/19/09/11/missi…
67/

MASSACHUSETTS: Carriers in the home of Obamacare’s (kind of) predecessor, “Romneycare”, have to pay back over $48 million total…including $34.8 million to 150,000 Individual Market enrollees.

There’s something else VERY important here, however…

acasignups.net/19/09/11/massa…

68/

…it turns out that in Massachusetts, the MLR threshold for the Individual and Small Group markets is *88%*!

That’s right…health insurers have to operate on a 12% *gross* margin (vs. the ACA’s 20%).

And yet MA still has the *lowest* ACA exchange premiums of any state!
69/

This seems like a BIG DEAL. The only valid criticism I’ve heard of the ACA’s MLR rule is that it supposedly causes carriers to “collude” w/hospitals/doctors to jack up medical costs, so that the carriers get 20% of a *larger pie*.

MA seems to counter this claim completely??
70/

In fact, if you check the table, you’ll see the ONLY reason ANY Indy or Sm. Group rebates are being paid this year are because fo that 88% threshold…in every other state, the 80% level wouldn’t be enough to force rebates:
71/

MINNESOTA: Carriers in The Land of 10,000 Lakes are paying out…HOLY CRAP:

$50 MILLION to 56,000 people…for a per-person average rebate of $889 apiece!!

More stunning: HMO Minnesota enrollees will avg. $1,523, proving Kansas’ numbers could be real.

acasignups.net/19/09/11/minne…

TENNESSEE: We’ve broken through the $50 million mark, and are into the home stretch.

BlueCross BlueShield of TN and Cigna Health & Life are paying out nearly $57 million to 174,000 enrollees.

acasignups.net/19/09/13/tenne…
73/

GEORGIA: Ambetter of Peach State has 170,000 Individual Market enrollees. They have to pay back nearly $60 million this year thanks to the #ACA.

REMINDER: If the #ACA is struck down by the GOP’s #TexasFoldEm lawsuit, those rebates would be gone.

acasignups.net/19/09/07/exclu…
74/

PENNSYLVANIA: HOLY CRAP.

At $69.5 million, the Keystone State doesn’t have the highest *total* 2018 Indy Market rebates (it’s in 4th place), but check out HMO of NE PA’s per-enrollee average.

Go ahead, I’ll wait.

acasignups.net/19/09/13/penns…
75/

TEXAS: A *bunch* of people have been asking about Texas, with good reason:

Not only is HCSC (Blue Cross Blue Shield of TX) paying out $75 million in rebates (the total w/other carriers is $80.3 million), check out the POTENTIAL rebates *next* year.

acasignups.net/19/09/13/texas…
76/

ARIZONA: Aside from a nominal amount from the “travel insurance” carrier mentioned earlier, there’s only one Arizona insurance carrier paying out Indy market MLR rebates…but holy smokes:

$92.3 million from Health Net of AZ, or $959/enrollee

acasignups.net/19/09/08/exclu…

77/

AND FINALLY…LAST BUT DEFINITELY NOT LEAST: VIRGINIA:

acasignups.net/19/09/13/virgi…

You’re reading that correctly: Optima Health Plan has to pay back nearly $99 MILLION in excess premiums to their 57,000 enrollees.

That’s an AVERAGE of $1,739 apiece.

This is no coincidence.

78/

Optima decided to take advantage of their only competitor pulling out of much of the market in Virginia in 2018 by jacking up their premiums an astonishing 81%…

acasignups.net/17/09/26/virgi…

79/

…but then, for 2019, Anthem reversed course and decided to jump back into the market after all. Optima didn’t scramble to LOWER their rates until it was too late to do so, and…well…things got ugly:

acasignups.net/18/09/17/virgi…

80/

Optima went from paying out 103% of their revenue in 2016 (losing $ big time) to only paying out *50%* in 2018.

This left them with a 64% 3-year average MLR…thus, they have to pay $99 million back.
81/

So there it is: 2018 MLR rebates, broken out by state, carrier, amount and per-person avg for all 50 states + DC.

I don’t do this often these days, but if you find my work useful & can afford to do so, please consider supporting it, thanks!

acasignups.net/donate

/END

P.S. Oh, one more thing: Remember this graph from the top of the thread which included outlandish projections by @KFF of $800M in Indy Market rebates this year and up to $2 BILLION (by me) next year?

Well, it looks like it wasn't so absurd after all: The grand total for this year's Indy Market rebates ended up totaling $769 million, and my own *potential* Indy market rebate projection for *next* year stands at around $1.7 billion nationally.

⚠️ ONE MORE IMPORTANT THING: I include caveats re. *next* year's potential rebates throughout the blog posts and thread, but just to clarify: They assume *identical* enrollment to 2018. That's NOT likely--many carriers will have significantly more or fewer enrollees this year.

For instance, look at Optima in VA--that theoretical $137M *next* year assumes the same 57,000 enrollees...except that they lost 3/4 of them to Anthem with good reason. If they're down to 1/4 the enrollment this year, the MLR rebates would drop 75% as well, to "only" $34 million.

So no, it does NOT mean that they'd get nearly $10,000 apiece. They *would*, however, receive average rebates of something like $2,400, which is still jaw-dropping. Then again, the premiums are pretty jaw-dropping as well, so...