As the last of $1 billion worth of this year's health insurance rebate checks goes out to consumers this week, insurers and government officials say the new regulation may be keeping premiums lower for everyone.
"Consumers who are not getting rebates are benefiting from the plan," said Teresa Miller, acting director of the office of oversight for the Center for Medicare Services. "Insurers are keeping their premiums down."
The 2010 health care law requires health insurers to spend at least 80% of consumers' premiums on health care and not administrative costs such as overhead or salaries. If they don't, they must issue their customers a rebate. That check may go to the consumer or the consumer's employer, depending on how a person purchases her insurance.
But it goes beyond simply lowering premiums. Insurers say they're also working to cut costs.
Miller said insurers are investing in quality measures and equal care standards, such as using the same tests and treatments for each patient who comes in with heart disease.
"Across the board, we are continuing to innovate to rein in rising health care costs," said Alissa Fox, senior vice president of policy for the Blue Cross Blue Shield Association.
For Blue Cross, as well as several other large insurers, avoiding the "medical loss ratio" means new programs that concentrate on paying for effective care, rather than by the number of tests or procedures a patient receives.
They reduce costs by reducing hospital readmission rates by making sure patients receive follow-up care - even if it's a phone call to make sure someone is taking medications.
They are also trying to coordinate medical teams, so each health provider knows what other doctors have prescribed or tested.
Though the health care law requires such programs to cut down on Medicare costs, Fox said some insurers started doing them before the health care law took effect.
The rebates differ substantially because each state has several insurance companies, as well as different laws that regulate how insurers do business.
According to Health and Human Services, 62% of people in the individual market, 83% of people in the small group market, and 89% of people in the large group market fell at or below the medical loss ratio standard.
But consumers will still receive rebate checks because the market can be difficult to predict, Fox said.
"We had to predict 18 months in advance what the premiums would be," she said. Fewer people used medical services, which means less of their premiums went to medical care, causing the medical loss ratio to be higher, she said.
At the state level, there have also been some concerns. Jack McDermott, director of communications for Florida's insurance commissioner, said insurance agents have been "vocal" about their commissions being cut as insurance companies try to keep the ratio down. He said it will be important to keep those agents as more people purchase health insurance as part of the Affordable Care Act.
But the ratio itself hasn't been a huge concern. About a million checks averaging $168 each will go out in Florida by the end of Wednesday, said McDermott.
"We're one of the few states HHS said has an effective rate review process," he said.
"We're hearing most insurers are actually meeting these requirements," he said. "Most of the rebates are pretty small."