Medical cost ratio (MCR), commonly known as medical loss ratio or medical benefit ratio, compares a health insurance company’s healthcare-related costs to its revenue premium. The ratio is frequently used to determine the financial strength of an insurance company, as it informs the percentage of revenue that goes towards medical claims.
Every insurer must use the same method to calculate MCR. Every year an insurer calculates MCR and must file reports with the U.S. Department of Health and Human Services.
Medical cost ratio (MCR) compares an insurance company’s healthcare cost to its revenue generated through premiums.
The ideal MCR for a large group is 85% and 80% for a small group.
Under the Affordable Care Act (ACA), an insurance company must assign 80% of their premium to activities that develop the healthcare sector. If the insurance company fails to allocate 80% of its premiums, rebates must be paid to the policyholders.
Medical Cost Ratio Formula
The medical cost ratio is calculated as follows:
Understanding Medical Cost Ratios
A health insurance company collects premiums from its customers every month and a portion of the premium may be paid by their employer based on the terms of their employment contract. Hence, individuals that receive their health insurance through their employers are divided into subgroups called large and small groups. According to the federal government, a small group is a company with 1-50 employees and a large group comprises more than 50 employees.
Once an insurance company collects the premium from its customers the premium is retained until a medical claim is filled. The claim can range from doctor visitation to treating a range of illnesses.
The ideal MCR should be 85% for large groups and 80% for small and individual groups. An 85% ratio means for every $1, the insurance company makes a $0.15 profit, and $0.85 is used to treat the individual that raised the claim. The $0.15 profit can be used to cover costs and reinvest back into the business.
The Affordable Care Act (ACA) and Medical Cost Ratios
Under the Affordable Care Act (ACA), an insurance company must allocate 80% of their premium to the development of health quality and clinical services in order to improve the quality and value provided to the insured individual.
If an insurer does not allocate 80% of their premium to improve the value and quality of health care, the insurer will need to refund additional funds to the customer. For example: In 2012, 21.5 million refunds were given out in the U.S.
MCR Formula under the Affordable Care Act
Claims are the payments made by insurance companies to policyholders for the cost of medical care and prescription drugs.
Quality improvement expenses are determined based on the overall improvement in patient safety or patient outcome, patient wellness, prevention of hospital readmission, or improvement in informational technology employed in hospitals to enhance reporting, transparency, and excellence.
On the other hand, fraud prevention activities, and insurance broker and agent compensation fees are considered an administrative expense under the Affordable Care Act MCR.
Premiumis the revenue earned by an insurance company from the monthly payments of their policy
Taxes, licensing, and regulatory feesinclude federal, state, and local taxes on the revenue earned by the insurance company. Taxes on capital gains and investment income are not included. Not-for-profit insurance companies are subject to either state premium taxes or community benefit expenditures, whichever is higher.