August 4, 2023
What is the Medical Loss Ratio or “MLR”?
Federal law (the Affordable Care Act) and Massachusetts state law require that health insurance companies spend a minimum percentage of their policyholders’ premiums on medical expenses. Medical expenses are defined as not only the clinical care and services provided to plan members, but activities designed to improve health care quality as well.
This minimum percentage, or threshold, that health insurers must meet is called the Medical Loss Ratio (“MLR”). The MLR standard applies to health insurance plans offering group or individual coverage. It does not apply to self-insured plans.
When setting premium rates for each upcoming year, insurers must make calculated estimates based on the most current cost trends. Due to a number of factors, what’s projected often differs from what’s actually spent (as with setting household budgets).
If a health insurer spent less on medical expenses than what was projected (the amount upon which premiums for the year ahead are based), the MLR requirement ensures that affected consumers receive money back on the unused portion of their premium. Learn more about MLR.
What was the required MLR for 2022?
This grid shows the 2022 MLR thresholds by market and state.
* In Massachusetts, individuals and small groups are treated as merged market
To whom did Tufts Health Plan issue 2022 rebates?
Tufts Health Plan offers plans under different licenses in different markets and states. Harvard Pilgrim will be issuing 2022 MLR rebates in limited markets. This grid shows where and how MLR rebates apply for Tufts Health Plan:
* In Massachusetts, individuals and small groups are treated as merged market
How and when will employers and subscribers be notified?
Notices will be sent to groups who will receive a rebate. Notices will also be sent to subscribers belonging to those groups receiving a rebate. Federal MLR rebates and notification letters will be sent to employer groups and subscribers, postmarked on or before August 31, 2023.
Employer notification letters
- 2022 TAHMO Employer Letter: Small Group
- 2022 TICO Employer Letter: Large Group | Small Group
Subscriber notification letters
- 2022 TAHMO Subscriber Letter: Small Group
- 2022 TICO Subscriber Letter: Large Group | Small Group
How and when will the rebates be issued?
Rebates for Massachusetts Tufts Health Plan will be issued as a check and sent before August 31, 2023.
Are my taxes affected by this rebate?
Rebates may have a tax impact both to plans receiving rebates and to consumers. Please consult with your financial and tax advisors regarding the tax impact of the rebate or contact the IRS at 800-829-1040.