Clifton Alford, a Norfolk chauffeur, opened two letters from his health insurer on the same day this summer. One contained a $9.83 rebate check; the other announced a $44 increase in his monthly premiums for the same plan.

Alford, 36, said he was tempted to cash the check in pennies: "The only other thing I can think of to do would be to send it to Washington and tell them where to shove it."

Mark Geduldig-Yatrofsky, an unemployed worker who lives in Portsmouth, also received two letters from his insurer this year: a check for $303 and a notification that his monthly premiums had been lowered by nearly $39. Another $2.59 arrived from the company that provided his insurance for about two months before he changed carriers last year.

Geduldig-Yatrofsky, 63, had expected to benefit from the national health law, but not until 2014: "To me, this is a little bit of gravy."

In the past few weeks, Virginia residents and businesses have received about $43 million in rebates from their health insurance companies. Fourteen insurers returned the money because they failed to spend at least 80 percent of their premium income on medical care and efforts to improve health care quality during the 2011 plan year.

Under the Patient Protection and Affordable Care Act, insurance companies that spent more than 20 percent on salaries, advertising and other administrative costs are required to pay the difference back to customers.

Not everyone qualifies for refunds, though.

The 80/20 rule, also known as the medical loss ratio standard, applies to plans in the individual market and those provided by small businesses or some large employers.

Self-funded plans, in which an employer pays the cost of health benefits from its own assets, are not subject to the rule. People on government plans, such as Medicare or Medicaid, also don't qualify for money back. Rebates for Medicare Advantage plans go back to the Medicare Trust Fund rather than to beneficiaries.

Rebates in Virginia averaged $115 for 376,000 families covered by a policy, according to the U.S. Department of Health and Human Services.

In Hampton Roads, reactions ranged from disappointment to delight.

For the past few years, Arn Salasky has chosen health plans with the highest deductible to keep his monthly premium cost down to around $151. He also skipped physical exams, dental checkups and preventive screenings - until this year, when he turned 65 and could sign up for Medicare.

The Virginia Beach homebuilder was hoping for a rebate of at least $100 from his 2011 individual plan. Instead, he got less than $10.

"It's always a pleasure to get a check in the mail instead of a bill," Salasky said. "However, when you saw how paltry the amount was, you go, 'Oh, OK. Well, what the heck.' "

For Jack Ralston, a $4,500 rebate came as an unexpected boost for his company.

During the past two decades, the president of Bihrle Applied Research in Hampton watched premiums rise from $365 to more than $1,600 a month for a family. Although the rate increases have been smaller recently, he now pays $27,000 a month to insure 20 employees.

The check from UnitedHealthcare helped Ralston pay for enhanced dental coverage for next year, something his employees were requesting. If it works out, he'll look into ways to continue the bolstered benefits in the future, even without a rebate.

"I thought that was a better way to reward the employees than just splitting that money up," he said. "They all were pretty happy about it."

For some businesses, relatively small refunds have presented disproportionately large headaches, said Richard Keat-ley, a principal in the Norfolk office of human resources consultant Mercer. One of his 30 clients received a rebate of about $4,700, he said.

Employers can return the money by check, lump-sum reimbursement, a reduction in future premiums, or by applying the amount "in a manner that benefits its employees," according to the federal government.

Employers can choose to keep their share, Keatley said. Accurately determining how much is owed each employee - and what to do with it - can be difficult, though.

"If somebody walked up to me and handed me 20 bucks, I'm never going to complain about that," he said. "But you want to make sure, as an employer, that you've handled these funds appropriately."

Federal officials say the medical loss ratio rule pressures insurers to keep premiums lower by limiting how much the companies can spend on expenses not directly related to medical care.

Regulators review the ratio when determining whether a rate increase higher than 10 percent is reasonable, said Teresa Miller, acting director of the oversight group at the federal health department's Center for Consumer Information and Insurance Oversight.

"We know that rates are going up because of increases in the cost of medical care and utilization of services," Miller said. "It's really important to ensure that those increases are not because of increases in administrative costs, marketing or CEO salaries."

However, the insurance industry has said the medical loss ratio rule fails to address the actual drivers of health care cost increases.

Scott Golden, spokesman for Anthem Blue Cross and Blue Shield in Virginia, said the new standard won't change how his company calculates premiums, which is based on factors such as benefits offered, increasing medical and prescription drug costs and advances in medical technology.

Anthem in Virginia posted medical loss ratios of 79.7 percent in the individual market and 77.8 percent in the small group market for 2011, narrowly missing the goal of 80 percent. Average rebates for subscribers were $13 in the individual market and $169 for small groups.

"We've got a pretty good track record in projecting," Golden said. "If 2011 was any indication, 2012 we should be pretty close as well."

Optima Health, the insurance arm of Norfolk-based Sentara Healthcare, posted a medical loss ratio of 70.8 for its individual plan in 2011 because medical expenses were lower than anticipated, said Andy Hilbert, Optima's chief financial officer. Subscribers received an average rebate of $246, according to the federal government.

With about 4,000 members, Hilbert said, "You can have deviations from your expectations fairly easily in that small of a population."

Optima considered the medical loss ratio rule an important factor when officials decided to lower the plan's premium by 10 percent in January, he said.

But Hilbert doesn't think the new standard will bring down premiums in the long term:

"Eighty cents of your premium goes to medical costs. So, slowing the growth of that 80 percent is the key to keeping the premium affordable."

Amy Jeter, 757-446-2730, amy.jeter@pilotonline.com

Under the Patient Protection and Affordable Care Act, insurance companies that spent more than 20 percent on salaries, advertising and other administrative costs are required to pay the difference back to customers.

In Virginia, 14 health insurance companies issued rebates because they did not meet the benchmark during the 2011 plan year.

Sunday

Salaries, advertising, administration

Percentage of premiums that are mandated to go toward medical care and programs

what happens if insurers don't meet this ratio?

exceptions

Self-funded plans, in which an employer pays the cost of health benefits from its own assets, are not subject to the rule. People on government plans, such as Medicare or Medicaid, also don't qualify for money back. Rebates for Medicare Advantage plans go back to the Medicare Trust Fund.

Rebates in Virginia averaged $115 for 376,000 families covered by a policy, according to the U.S. Department of Health and Human Services. But amounts vary depending on the performance of the insurer, and companies that met the 2011 benchmark owe nothing.

how much could I get?