Who gets a healthcare rebate? 4 questions answered

Healthcare rebate

Under the Affordable Care Act, insurance companies that spent less than 80 percent of healthcare premiums on medical care are required to refund their customers.

This week the U.S. Department of Health and Human Services announced that nearly 7 million consumers would receive $330 million in refunds from health insurers.  

Under the Affordable Care Act, the carriers must spend 80 cents of every dollar in premiums towards medical care or steps to improve healthcare quality.

That leaves 20 cents for things like salaries, bonuses and other administrative costs.

This provision of the ACA is often called the 80/20 rule.

Q. What’s the reason for the 80/20 rule?

Kaiser Family Foundation Senior Vice President Larry Levitt was pretty succinct when he said “this is really a protection against insurers trying to gouge people.”

When Obamacare architects were designing the law, they wanted to make sure most of the money consumers spent on premiums would actually be dedicated to medical care.

While Levitt says 80/20 was a late addition to the legislation, he believes it’s actually changing the nature of the insurance industry.

“It’s in effect putting a cap on overhead and profits and that’s a pretty dramatic step that I don’t think people fully appreciate,” says Levitt.

Q. I’ve paid my premiums and haven’t visited the doctor once this year. Will I see some money in my mailbox soon?

It depends.

The only way someone qualifies for a rebate is if the particular insurance plan you’ve enrolled in falls short of the 80/20 ratio.

If you’re enrolled in an insurance policy that meets the target, you won’t be getting a check any time soon.

If you get coverage at work, your company gets the refund, or a credit towards next year’s coverage.

Q. How is this rule impacting insurance companies?

When the 80/20 rule began in 2011, insurers paid out more than $1 billion in rebates. This year it’s a third that much.

Matthew Eyles with Avalere Health says the industry has clearly figured out how to calculate their expenses and how money they’ll spend providing medical coverage.

“This is almost pixie dust really if you think about the amount of premiums that insurers collect in hundreds of billions,” he says.

Under this new system there is little incentive for insurers to inflate premium prices, particularly on the health exchanges.

If prices are too high, not only are consumers less likely to buy those plans, insures know they’ll have to return profits at the end of the year.

In that regard, Kaiser’s Larry Levitt says insurers are becoming more like public utilities.

“Insurers still have some flexibility in how they design these products. But an insurance policy is a much more standardized product. And the pricing is much more regimented as well,” he says.

Q. If insurers can’t make as much off of premiums, are they finding new ways to make profits?

HealthLeaders-InterStudy analyst Paula Wade says insurers can make up any lost revenue by increasing deductibles, co-pays and other out-of-pocket expenses consumers face.

“If you look at the how the major insurers are doing, they are doing very well,” she says.

“I wouldn’t lose any sleep worrying about their profits.”

About the author

Dan Gorenstein is the senior reporter for Marketplace’s Health Desk. You can follow him on Twitter @dmgorenstein.

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