How Health Rebates Affect Workers’ Comp

In a popular article published earlier this year, Mark Walls examines the complex relationship between the Affordable Care Act (ACA or PPACA) and workers’ compensation. While I recommend the entire article, today I want to focus on one point that Mark highlights. In preparing for the effects of the fully implemented ACA, Mark advises that employers should: "Carefully manage the approach to healthcare premium rebates, which could affect how payroll is calculated under workers' compensation." I’ll be honest – until I read Mark’s article, I was happily leaving all of Zywave’s ACA discussions to our own Erica Storm, an attorney who’s been monitoring and writing about healthcare reform for several years. But the words payroll and workers’ compensation jumped out at me. If workers’ comp payroll can be affected by the rebates, then so can experience mods and workers’ compensation premium. How much impact are we talking about? With Erica’s help on the ACA side of things, I delved deeper into the topic. Premium rebates introduced by healthcare reform The concept of health insurance premiums affecting workers’ compensation payroll is not new, but ACA-mandated rebates, which began in 2012, have introduced a new level of complexity in the accounting. ACA requires insurers with a certain medical loss ratio (MLR) to issue a rebate to employers. Guidance to employers on rebate options is vague, but options may include

• passing along MLR rebates to employees,
• applying rebates to future premiums, or
• applying rebates to benefit enhancements.

Whatever option is chosen, the plan sponsor must follow the fiduciary duties of prudence, impartiality and acting for the exclusive benefit of plan participants. When employers pass along any portion of the rebates to employees, such rebates must be counted as payroll for the purposes of workers’ comp. Note that this rule applies as long as the rebate to the employee is through the employer and not directly from the insurance provider. The rule also applies regardless of whether the rebate distribution is taxable or non-taxable. Payroll rules in more detail Payroll for the purposes of workers’ compensation is defined in the applicable bureau manual; the majority of states use NCCI’s Basic Manual for Workers Compensation and Employers Liability Insurance. Rule 2-B-1 lists payment types included and rule 2-B-2 lists payment types excluded for the purposes of calculating workers’ compensation payroll. But most helpful with regards to rebates is a separate NCCI article, The Patient Protection and Affordable Care Act and Workers Compensation Premium Determination. Be sure to check out the handy tables to make sense of how both insurance premiums and rebates can be included or excluded from payroll. A sample scenario An employer’s decision on what to do with a rebate can be complex, depending on the type of group health plan and whether the rebate is considered a plan asset.  The workers’ compensation aspect is admittedly almost an aside. Yet as we all know, even small impacts add up. For an employer that passes along a rebate to its employees, how much impact might that employer experience on its mod and premium as a result? To answer that question, it’s first important to note that the state and insurer matter. In many states, the average rebate paid in 2013 (for 2012 premiums) was less than $100 per family. Clearly, for many employers, that isn’t going to significantly affect payroll through rebates. However, in some states and for some plans, the average rebate was much higher. According to government data on 2012 premium rebates, 10 states (excluding territories) had large group rebates averaging from $340 to more than $1,250; eight states had small group averages of $300 or more. Using that information as a rough model, I constructed a sample “high rebate” scenario to test its effects on workers' comp premium. I imagined:

• a 100-employee manufacturing business in Illinois
• an average hourly wage, including most benefits, of $35.00 (roughly based on June 2013 Employer Costs for Employee Compensation data for goods-producing occupations from the Bureau of Labor and Statistics). For simplicity’s sake, I’ve assumed that all costs are reportable for workers’ compensation purposes.
• 80% of the workers in payroll code 2797 – manufacturing
• 20% of the workers in payroll code 8810 – office work
• a relatively high level of losses that has driven the company’s mod to 1.20, while the minimum mod, based on zero losses, is 0.61 (these values were determined using ModMaster)
• two rebate levels to analyze, assuming for each that the full amount is returned to employees:
  • a high but not unrealistic $1,000 rebate
  • a probably unrealistic $3,500 rebate

First let’s take a look at the calculation of this sample company’s manual premium, followed by its final premium at various mod levels. Before any health insurance rebates, our sample company has a mod of 1.20 and associated premium of more than $800,000. Note how low the minimum mod and premium could be. When a $1,000 rebate is introduced, the manual premium is increased by the same percentage as the effective total payroll increase – in this case 1.4%. But what I was very curious to see was whether, in the mod calculation, the increase in payroll was enough to increase expected losses and thus lower the mod, thereby offsetting some of the manual premium increase. As you can see below, this was not the case. Although expected losses (not shown) did increase, they didn’t increase enough to actually change the minimum mod or current debit mod values. A $1,000 per employee rebate edges up payroll, but not enough to significantly change the mod calculation. The effective rate of the payroll increase therefore applies to the final workers’ comp premium regardless of the mod value. So how large would rebates need to be to actually affect the mod as well as the premium? I experimented with several rebate levels and for this payroll scenario found that the magic number was somewhere around $3,500: A $3,500 per employee rebate affects payroll enough to change both the current and minimum mod values. That mod decrease in turn mitigates the overall premium increase. When $3,500 is added to each employee’s salary, the resulting increase in expected losses in the mod formula is enough to drop the minimum mod by 0.01 and the current debit mod by 0.02. For this example, that offsets the 4.8% payroll and premium increase to only 3.1%. In summary The above example is considerably simplified; in reality, the included/excluded payroll calculation would be more complex, and additional premium credits and debits would likely apply. Results could vary greatly with company size, as well. Nevertheless, the example suggests:

• As a rule of thumb for employers considering their rebate options, it seems reasonable to use the total amount being rebated to employees divided by the original included payroll as an approximation of the employers’ workers' comp premium increase. The actual increase may vary when accounting for a change in the mod value or effects of other premium debits and credits.
• Even a rebate of less than 1% may, if returned to employees, add up to thousands of dollars of premium expense for all but the smallest employers, in addition to the administrative costs of processing the rebate.
• While relatively high-dollar rebates may be rare, employers should be especially sensitive to their increased impact on premium.

Employers should also keep in mind that, per NCCI, “an employer is required to keep records of information needed to compute premium. In addition, the employer must provide those records to the carrier, when requested, for the purpose of auditing the employer’s workers compensation policy.” While some insurance professionals suggest that rebates may diminish with time and premium stabilization, others disagree. There’s also been discussion in the press of possible policy endorsement or other changes to protect employers from additional premium charges as a result of rebate distributions. The one thing we can all agree on is that the “bigger picture” relationship between ACA and workers’ compensation is a blurry image that will take years to fully develop. Have you or your clients experienced a mod or workers’ compensation premium increase because of distributing a MLR rebate to plan participants? I’d love to hear your experience in the comments below.