Rate Review & the 80/20 Rule (2024)

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Rate Review & the 80/20 Rule

The health care law provides 2 ways to hold insurance companies accountable and help keep your costs down: Rate Review and the 80/20 rule.

Rate Review

Rate Review helps protect you from unreasonable rate increases. Insurance companies must now publicly explain any rate increase of 15% or more before raising your premium. This does not apply to grandfathered plans.

80/20 Rule

The 80/20 Rule generally requires insurance companies to spend at least 80% of the money they take in from premiums on health care costs and quality improvement activities. The other 20% can go to administrative, overhead, and marketing costs.

The 80/20 rule is sometimes known as Medical Loss Ratio, or MLR. If an insurance company uses 80 cents out of every premium dollar to pay for your medical claims and activities that improve the quality of care, the company has a Medical Loss Ratio of 80%.

Insurance companies selling to large groups (usually more than 50 employees) must spend at least 85% of premiums on care and quality improvement.

If your insurance company doesn’t meet these requirements, you’ll get a rebate on part of the premium that you paid.

Will I get a rebate check from my insurance company?

If your insurance company doesn’t meet its 80/20 targets for the year, you’ll get back some of the premium that you paid.

You may see the rebate in a number of ways:

  • A rebate check in the mail
  • A lump-sum deposit into the same account that was used to pay the premium, if you paid by credit card or debit card
  • A direct reduction in your future premium
  • Your employer may also use one of the above rebate methods, or apply the rebate in a way that benefits employees

If you or your employer will get a rebate, your insurance company must notify you by August 1.

If you have an individual insurance policy, you’ll get the rebate directly from your insurance company.

For small group and large group plans, the rebate is usually paid to the employer. It may use one of the above rebate methods, or apply the rebate in a way that benefits employees.

FYI: The 80/20 rebate rules don’t apply when an insurance company has fewer than 1000 enrollees in a particular state or market.

Does this apply to my plan?

It depends.

For Rate Review: These requirements don’t apply to grandfathered plans. Check your plan’s materials or ask your employer or your benefits administrator to find out if your health plan is grandfathered.

For the 80/20 Rule: These rights apply to all individual, small group, and large group health plans, whether your plan is grandfathered or not.

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Rate Review & the 80/20 Rule (2024)

FAQs

What is the 80 20 rule in review? ›

The Pareto principle states that for many outcomes, roughly 80% of consequences come from 20% of causes. In other words, a small percentage of causes have an outsized effect. This concept is important to understand because it can help you identify which initiatives to prioritize so you can make the most impact.

What is the 80 20 rule real examples? ›

80% of the public uses 20% of their computers' features. 80% of crimes are committed by 20% of criminals. 80% of sales are from 20% of clients. 80% of project value is achieved with the first 20% of effort.

What is the 80 20 rule in work? ›

Simply put, the 80/20 rule states that the relationship between input and output is rarely, if ever, balanced. When applied to work, it means that approximately 20 percent of your efforts produce 80 percent of the results.

What is the 80 20 rule for ACA? ›

The 80/20 Rule generally requires insurance companies to spend at least 80% of the money they take in from premiums on health care costs and quality improvement activities. The other 20% can go to administrative, overhead, and marketing costs.

How do you use the 80-20 rule to make decisions? ›

The Pareto Principle states that 80% of the effects come from 20% of the causes. If you want to make a real difference in your business, you need to spend the most amount of time focusing on the 20% of things that will give you 80% of your results—and less time worrying about everything else.

What is the 80-20 rule process improvement? ›

The 80-20 rule is a principle that states 80% of all outcomes are derived from 20% of causes. It's used to determine the factors (typically, in a business situation) that are most responsible for success and then focus on them to improve results.

What is the 80/20 rule for dummies? ›

This rule suggests that 80% of effects come from 20% of causes. For example, 80% of a company's revenue may come from 20% of its customers, or 80% of a person's productivity may come from 20% of their work. This principle can be applied to many areas, including productivity for small business owners.

What does 80-20 rule look like? ›

The 80/20 rule is a guide for your everyday diet—eat nutritious foods 80 percent of the time and have a serving of your favorite treat with the other 20 percent. For the “80 percent” part of the plan, focus on drinking lots of water and eating nutritious foods that include: Whole grains.

What are the flaws of the 80-20 rule? ›

The 80–20 rule can lead to neglecting the root causes: The 80–20 rule can focus on the symptoms rather than the root causes of a problem. For example, assuming that 80% of customer complaints come from 20% of the product features may lead to neglecting the underlying issues that are causing dissatisfaction.

What is the 80/20 rule in working out? ›

The 80/20 rule simply means: 80% of the effects come from 20% of the things u do. 20% from exercise. It isn't just about the weight loss but actually about the fat loss and muscle gain.

What is 80 20 workforce rule? ›

The 80/20 rule underscores the fact that a minority of individuals within an organization possess the ability to consistently produce a majority of the results. These high-performing employees often exhibit exceptional focus, efficiency, and time management skills, enabling them to achieve remarkable outcomes.

What is the 80-20 rule summary? ›

That 20 percent of our time accounts for 80 percent of the work we accomplish? The 80/20 Principle shows how we can achieve much more with much less effort, time, and resources, simply by identifying and focusing our efforts on the 20 percent that really counts.

What is the 80 20 rule for Medicare? ›

When a physician accepts “assignment,” he or she agrees to accept the Medicare approved charge as full payment for the services provided. Medicare pays 80% of the approved charge. Either the patient or supplemental insurance pays the remaining 20% co-payment.

What is the 80 20 rule for home insurance? ›

The 80% rule dictates that homeowners must have replacement cost coverage worth at least 80% of their home's total replacement cost to receive full coverage from their insurance company.

What is the 3 month rule for ACA? ›

The ACA employer mandate rules permit a “limited non-assessment period” as a sort of grace period before which employers will be penalized for failure to offer coverage to a new hire. For new full-time hires, the duration of this period is relatively short (the first three full calendar months of employment).

What is the 80-20 rule in grading? ›

This means that 80% of your grade is summatives like tests, projects, etc. and the other 20% of your grade is smaller assignments like quizzes or homework.

What is the 80-20 rule of content? ›

The 80/20 rule in content marketing states that 80% of your content should focus on providing value to your audience, while only 20% of your content should promote your brand or product. It ensures that you provide valuable content to your audience while promoting your brand or product.

What is the 80/20 rule in study? ›

What is the Pareto Principle? The Pareto Principle, often called the 80/20 rule, is the broad observation that approximately 80% of outcomes or results come from about 20% of your inputs or effort. Therefore you should concentrate on areas where you can get 'big wins' with comparatively little effort.

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