About 190,000 Georgians with health care policies from Ambetter of Peach State are getting rebates of $314 each. The payouts are required under a rule in the Affordable Care Act.
The insurer owes a total of $59.8 million to its individual policyholders in Georgia, according to newly released federal figures. That’s a large chunk of the more than $65 million that must be paid by Georgia insurers.
Ambetter’s parent company, St. Louis-based Centene, owes $216 million nationally in rebates, according to an analysis last month by the Kaiser Family Foundation.
A Centene official in Georgia said the company declined to comment on the rebates.
The ACA established what’s known as a Medical Loss Ratio for health insurance companies. It requires the insurers to spend at least 80 percent of revenues from premiums (85 percent for large group plans) on health care claims or quality improvement activities. If an insurer does not meet the appropriate threshold, it must pay the rebates to policyholders.
Policyholders each get the same share of a particular rebate (such as $314 in the Ambetter of Peach State payout) because the rebate is based on the company’s overall financial activity, not on its handling of individual medical claims.
The KFF analysis says the national rebate total paid this year, $1.3 billion, is a record amount. By law, insurers were required to begin issuing the latest rebates to eligible consumers by Sept. 30.
Ambetter must pay all but $35,828 of the rebate amount for Georgians in the individual policy market in Georgia.
UnitedHealthcare must pay rebates of $3 million to small employers in Georgia, while Anthem (Blue Cross and Blue Shield of Georgia) must pay $1.58 million to small employers. Nippon Life Insurance Company must pay $1 million to large employers in the state.
An insurer may issue the rebate in the form of a check to the consumer, or may apply it as a credit, reducing the premium the consumer must pay. For people with employer coverage, the rebate may be shared between the employer and the employee.
Rebates issued this year are based on 2016, 2017, and 2018 financial performance.
Individual market insurers appear to have been exceptionally profitable in 2018, on average, which contributed to the high payment total, the Kaiser Family Foundation report said. Rebates in the small and large group insurance markets are similar to past years, at $250 million and $284 million, respectively.
The states with the largest rebates in total include Virginia ($149.6 million), Pennsylvania ($130 million) and Florida ($107.4 million). Georgia’s total is sixth-highest, according to federal figures.
Insurers in seven states do not have to pay rebates this time around.
So far in 2019, health insurers’ financial performance in the individual market remains strong, even though the ACA penalty for people without health insurance has effectively been scrapped, the Kaiser report said. (The penalty was meant to encourage people to buy coverage.) It is likely that individual market insurers will continue to owe large rebates next year, in September 2020, the report added.
Centene runs a health plan – Peach State – that covers tens of thousands of Medicaid and PeachCare members in Georgia. In a pending deal, Centene plans to acquire WellCare, which operates another Georgia Medicaid care management organization.