We realize that many people may have health care but don’t know how the systems work or what their premiums are going to each month. We understand that life is busy and that you may not have all the time in the world to research and learn an argumentatively complex system of health care insurance and providers. So we thought that we would start a new series of posts focused on “Did you know…” With this blog, we will be looking at the 80/20 rule.

Did you know… that health insurance companies are required to spend a mandated amount on your healthcare? Insurance Companies are mandated to $.85 of every dollar on your Health Care.

This 80/20 rule is also referred to as Medical Loss Provision Ratio in the Affordable Care Act. The rule states for 80% of premiums collected must be spent on health care or on improving actions for the person. The other 20% can go to administrative needs of the medical insurance company such as marketing or other financial needs. These numbers specifically apply to individual and small group markets. If you are part of a large group market, then the numbers change to 85% and 15% of healthcare and administrative needs respectively. The thought process with this rule is to ensure greater transparency within insurance companies so we can truly see where the money is going. If an insurance company does not spend the 80 to 85% of premiums toward healthcare, then they are required to provide a rebate for the portion that was not spent. This rebate looks at the entire corporation and their spending and not just on one individual’s health care expenditures. Are you someone who has received this kind of rebate in the past? If so you know that the rebates usually come in the form of a check to the individual, are applied as a credit to their account or are reflected in the rates of the following year of insurance. Or if you are part of a small or large group then the rebate is given to your employer who passes it along to their employees. We hope that this “Did you know” blog was helpful. If you have any more questions about the Medical Loss Provision Ratio, please feel free to call and ask us.