The Affordable Care Act sets a minimum threshold for what’s known as the “medical loss ratio” — the percentage of premium dollars that go into medical care (a “loss” from Wall Street’s view) rather than into overhead or profits. For plans sold to small businesses or directly to individuals, that ratio must be at least 80 percent; for plans sold to large groups, it must be at least 85 percent.
For big insurance companies that sell predominantly to big employers, the medical loss ratio shouldn’t be hard to meet. With their economies of scale, these insurers and employers together provide coverage at relatively low administrative cost (although, it should be noted, Medicare’s overhead is even lower). But smaller insurers that deal primarily with individuals or small businesses will have a tougher time. Among other things, they typically lose 8 percent of premiums on commissions to agents and brokers who sell policies on their behalf. (Once the insurance exchanges exist, much of that cost will disappear.) These are also the insurers most likely to bilk consumers, since individuals buying coverage on their own typically lack the knowledge — or ability — to bargain as shrewdly as corporate benefits managers do. (The exchanges should also help with improved information and bargaining leverage.)
There’s leeway in the rule in two key places. The law doesn’t dictate a precise formula for calculating the medical-loss ratio. It’s up to the administration which “care management” activities count as medical care, whether taxes should be part of the calculation, and the extent to which carriers can average out the ratio among different plans. And while the law calls for the requirement to take effect starting in January 2011, the Department of Health and Human Services has the authority to phase it in; Sebelius could, for instance, set the floor at 70 percent for 2011 and then gradually ratchet it up until 2014. Some insurance and employer lobbyists have urged the administration to move slowly, lest insurers unable to meet those requirements go out of business. Then again, insurers that can’t meet those requirements are, by definition, less efficient.
For more:Â Â http://www.tnr.com/blog/jonathan-cohn/77080/get-ready-sebelilus-v-insurers
