November 8, 2022
What Is the ACA’s MLR?
In general, the ACA’s MLR is the percentage of insurance premium dollars that a health insurer spends on health care services and expenses reported as activities to improve health care quality.
The ACA set MLR standards for health insurers. For the REFILED 2020 MLR reporting year, the MLR standard for the Montana large group market is 85%. The MLR standard for the individual and small group markets in Montana is 80%.
The ACA’s commercial MLR standards apply to certain fully insured health insurance coverages in the group and individual markets. If an insurer’s MLR doesn’t meet or exceed the ACA’s MLR standard in a certain market segment of a state, the insurer may provide MLR rebates in that market.
- In our original MLR report filing for 2020, we didn't meet the MLR standard in the Montana individual market and provided MLR rebates in that market for that year. If you were a member of our Individual market in 2020, you may have received a MLR rebate in 2021.
- We have determined that a premium correction for 2020 MLR required a recalculation of MLR. This means additional rebates may be due to members enrolled in this market during 2020.
ACA MLR Rebates
Blue Cross and Blue Shield of Montana (BCBSMT) will NOT provide MLR rebates in the Montana individual, small group or large group markets for the REFILED 2020 MLR reporting year.
For more information, please read Key Questions About the ACA’s MLR.
Key Questions About the ACA’s MLR
Q. What is the ACA’s Medical Loss Ratio (MLR)?
A. In general, the ACA’s MLR is the percentage of premium dollars that a health insurer spends on health care services and expenses reported as activities to improve health care quality.
The ACA set MLR standards for health insurers. For the REFILED 2020 MLR reporting year, the MLR standard for the Montana large group market is 85%. The MLR standard for the individual and small group markets in Montana is 80%.
The ACA’s commercial MLR standards apply to certain fully insured health insurance coverages in the group and individual markets. They don't apply to self-insured group health plans or to Medicare and Medicaid.
If an insurer’s MLR doesn’t meet or exceed the ACA’s MLR standard in a certain market segment of a state, the insurer may provide MLR rebates in that market.
Q. For purposes of the ACA’s MLR, what types of activities are considered to be quality improvement activities?
A. Among other things, activities to improve quality of care are designed to improve health outcomes for members. For example, these activities may include:
- Enhance patient safety
- Promote health and wellness
- Improve transparency
- Support meaningful use of health information technology, or
- Prevent hospital readmissions
In general, these activities are aligned with criteria developed by professional medical associations, government agencies, accreditation bodies and other nationally recognized health care quality organizations.