name = "Highmark Benefits Group Inc. — Medical Loss Ratio & rebates (Pennsylvania, 2024)"
description = "Medical Loss Ratio and rebate outcomes for Highmark Benefits Group Inc. (parent group: Highmark GRP, as reported) in Pennsylvania, 2024 MLR reporting year, by market: individual 90.1%, small group 87.6%, large group 82.8%. Owed $102,035 in rebates. RECORDED CMS-published MLR / standard / premium / rebate; rebate-as-%-of-premium is DERIVED. A spending ratio across the whole book in a market — not plan quality or advice. CC0."
license = "CC0-1.0"
jsonld = "https://coverage-atlas.ryanjhunter.workers.dev/coverage/mlr/79962-pa.jsonld"

[[claims]]
id = "https://coverage-atlas.ryanjhunter.workers.dev/coverage/mlr/79962-pa/individual"
warrant = "RECORDED"
name = "Highmark Benefits Group Inc. spent 90.1% of individual premiums on care in PA (2024)"
text = "In the Pennsylvania individual market, Highmark Benefits Group Inc.'s three-year credibility-adjusted Medical Loss Ratio was 90.1% against the 80% floor, on $229,170,014 of 2024 premium earned. It met the floor; no rebate owed. RECORDED CMS-published figures (occurred=true; an actual backward-looking ratio insurers report under the 80/20 rule, adjudged=TRUE — CMS published it); rebate-per-enrollee is a DERIVED sub-figure."
source = "CMS — Medical Loss Ratio (MLR) Public Use File, 2024 reporting year"
sourceUrl = "https://www.cms.gov/marketplace/private-health-insurance/medical-loss-ratio"
falsifier = "A RECORD of measured/reported events (occurred=true) from CMS — Medical Loss Ratio (MLR) Public Use File, 2024 reporting year; superseded when CMS — Medical Loss Ratio (MLR) Public Use File, 2024 reporting year publishes its next release."

[[claims]]
id = "https://coverage-atlas.ryanjhunter.workers.dev/coverage/mlr/79962-pa/small_group"
warrant = "RECORDED"
name = "Highmark Benefits Group Inc. spent 87.6% of small group premiums on care in PA (2024)"
text = "In the Pennsylvania small group market, Highmark Benefits Group Inc.'s three-year credibility-adjusted Medical Loss Ratio was 87.6% against the 80% floor, on $201,288,052 of 2024 premium earned. It met the floor; no rebate owed. RECORDED CMS-published figures (occurred=true; an actual backward-looking ratio insurers report under the 80/20 rule, adjudged=TRUE — CMS published it); rebate-per-enrollee is a DERIVED sub-figure."
source = "CMS — Medical Loss Ratio (MLR) Public Use File, 2024 reporting year"
sourceUrl = "https://www.cms.gov/marketplace/private-health-insurance/medical-loss-ratio"
falsifier = "A RECORD of measured/reported events (occurred=true) from CMS — Medical Loss Ratio (MLR) Public Use File, 2024 reporting year; superseded when CMS — Medical Loss Ratio (MLR) Public Use File, 2024 reporting year publishes its next release."

[[claims]]
id = "https://coverage-atlas.ryanjhunter.workers.dev/coverage/mlr/79962-pa/large_group"
warrant = "RECORDED"
name = "Highmark Benefits Group Inc. spent 82.8% of large group premiums on care in PA (2024) → $102,035 rebate"
text = "In the Pennsylvania large group market, Highmark Benefits Group Inc.'s three-year credibility-adjusted Medical Loss Ratio was 82.8% against the 85% floor, on $4,637,946 of 2024 premium earned. It fell below the floor and owed $102,035 in rebates (≈$216 per enrollee). RECORDED CMS-published figures (occurred=true; an actual backward-looking ratio insurers report under the 80/20 rule, adjudged=TRUE — CMS published it); rebate-per-enrollee is a DERIVED sub-figure."
source = "CMS — Medical Loss Ratio (MLR) Public Use File, 2024 reporting year"
sourceUrl = "https://www.cms.gov/marketplace/private-health-insurance/medical-loss-ratio"
falsifier = "A RECORD of measured/reported events (occurred=true) from CMS — Medical Loss Ratio (MLR) Public Use File, 2024 reporting year; superseded when CMS — Medical Loss Ratio (MLR) Public Use File, 2024 reporting year publishes its next release."

[[claims]]
id = "https://coverage-atlas.ryanjhunter.workers.dev/coverage/mlr/79962-pa/boundary"
warrant = "INTERPRETATION"
name = "What a Medical Loss Ratio is — and is NOT"
text = "A Medical Loss Ratio is a spending ratio across an issuer's WHOLE book in a market for a past period — the share of premium spent on care + quality improvement versus administration and profit. It is NOT a measure of plan quality, of your individual plan's value, or of coverage availability, and it is NOT advice. A low MLR triggers a rebate; it does not rate care."
source = "Coverage Atlas L5 boundary (a book-level spending ratio ≠ plan quality)"
sourceUrl = "https://coverage-atlas.ryanjhunter.workers.dev/"
falsifier = "occurred=FALSE (a framing, not an event) and adjudged=FALSE (an in-house reading, not an authority's verdict) — the LOWEST-warrant claim here. A flat representation would render this identically to the official facts; the four-status does not."

[[mlr-by-market]]
Market = "Individual"
3_yr_MLR = "90.1%"
Floor = "80%"
Met_floor_ = "yes"
Premium__2024_ = "$229,170,014"
Rebate_owed = "$0"
Per_enrollee = "—"
Warrant = "RECORDED"

[[mlr-by-market]]
Market = "Small group"
3_yr_MLR = "87.6%"
Floor = "80%"
Met_floor_ = "yes"
Premium__2024_ = "$201,288,052"
Rebate_owed = "$0"
Per_enrollee = "—"
Warrant = "RECORDED"

[[mlr-by-market]]
Market = "Large group"
3_yr_MLR = "82.8%"
Floor = "85%"
Met_floor_ = "no"
Premium__2024_ = "$4,637,946"
Rebate_owed = "$102,035"
Per_enrollee = "≈$216"
Warrant = "RECORDED"
