Ambetter from Home State Health is mailing $87.5M in rebates to Missouri customers because its spending on claims fell below the minimum medical loss ratio required by the Affordable Care Act.
"Per federal Medical Loss Ratio (MLR) requirements, Ambetter from Home State Health is issuing MLR rebates to eligible Missouri members for the 2024 benefit year, totaling approximately $87.5 million. This is a standard and required process under the Affordable Care Act that ensures Health Plans return a portion of premiums to members if spending on medical care falls below federal thresholds," a Home State Health representative said.
Issuers of individual major medical insurance and fully insured small-group health insurance are required to spend 80% of total premiums on health care. Each year, they must report their revenue from premiums and spending on health care and activities intended to improve care, such as smoking cessation or other programs. This total then is compared to the amount spent on administration.
The Centers for Medicare & Medicaid Services evaluates these reports and determines the rebate amounts if required. Data are examined on a three-year rolling basis, and Ambetter’s rebates are for the years 2022 through 2024. During that period, the insurer told policyholders in that it spent only 71.4% of the approximately $12 billion received in premiums. Ambetter must refund the 8.6% difference.
In addition, customers buying plans from Ambetter likely will see some of the smallest premium increases in the state in the coming year. Ambetter is seeking an average premium increase of 1.9% starting Jan. 1, according to the Missouri Department of Commerce and Insurance. In contrast, seven of the eight other companies offering plans in all or part of the state are proposing increases averaging from 4.6% to 29.2%.
Ambetter, a subsidiary of St. Louis-based Centene, is the largest individual insurance provider in the state, according to KFF. It covers about 46% of the 270,275 people buying individual plans, followed by Elevance (formerly Anthem) with 28% and UnitedHealthcare with about 7%.
UnitedHealthcare also is sending rebates to Missouri customers. It announced earlier this month that it will rebate $192.2 million nationally for group market plans offered in 31 states and $167.1 million for individual insurance market plans offered in 19 states. Missourians in both group and individual UnitedHealthcare markets will be eligible for rebates, although the material supplied by the company did not show the amounts.
Correction: An earlier version of this article incorrectly stated the rebate amount. The actual total rebate amount is $87.5M.
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