The top 10 executives at Blue Cross and Blue Shield of Alabama made more than $1 million each in 2013 and collectively have doubled their pay since 2011.

These raises come amid sweeping health insurance reforms dubbed Obamacare, that have left many frustrated by premium increases.

The million-dollar club is headed by president and CEO Terry D. Kellogg whose total annual compensation was $4.84 million.

That includes a salary of $999,959, bonuses totaling $3,580,651 and other compensation of $257,227.

His total compensation in 2013 is a 95.5 percent raise since 2011 when his total compensation was $2.47 million.

On average, the top 10 executives, as listed on a report filed with the Alabama Department of Insurance, increased their total compensation 103 percent from 2011 to 2013.

Blue Cross Blue Shield of Alabama said in a statement that the executive pay was in line with industry standards, reviewed by an independent auditor, and approved by an independent board.

"Executive compensation is not a factor in determining health insurance premiums," said the emailed statement from spokeswoman Koko Mackin.

"Beginning in 2014, the Affordable Care Act (ACA) substantially changed the way insurers could design health plans and calculate premiums, causing many of our customers' premiums to increase," Mackin said.

"Health insurance premiums are determined by the number of medical treatments and the cost of those treatments that doctors, hospitals and other healthcare professionals provide our customers."

The statement said BCBS of Alabama has low operating costs and returns 92 cents of every premium dollar to the customers "in the form of payments to physicians, hospitals and other providers for our members' medical treatment."

The company would not disclose whether premiums in the individual and family market will go up in 2015. Open enrollment on the federal exchanges begins in November.

Birmingham health care lawyer Jim McFerrin said his review of BCBS's annual financial statement for 2013 found that the company was doing well. It increased its gross assets by $209 million compared to 2012 and its gross cash flow by about $140 million.

The company decreased payments to hospital medical costs by more than $43 million but emergency room costs increased by $36 million and prescription drug costs rose by $42 million, he said.

Because BCBS maintains such a large grip on the commercial health insurance market – 90 percent or more by some measures – it can leverage its strength to negotiate lower reimbursement rates to the doctors and hospitals. Privately doctors and hospitals have complained, but most aren't ready to publicly speak out against an insurer which, by far, covers the most patients.

Rosemary Blackmon, executive VP of the Alabama Hospital Association, said in an email that "Blue Cross definitely has the majority of the commercial market share in Alabama, which can make it difficult for hospital negotiations."

Negotiations broke down recently when Northeast Alabama Regional Medical Center in Anniston asked for more money at the negotiating table.

Said Blackmon: "One of the things that makes the stakes higher for hospitals right now is that their operating margins are so slim. In the last survey we conducted (Dec. 2013), the average hospital margin was less than 3 percent (2.68), with 41 percent of the hospitals with a negative operating margin."

The power of BCBS relative to doctors and hospitals may be what keeps Alabama's rates relatively low, according to a report this week by the Urban Institute and the Robert Wood Johnson Foundation.

The Birmingham-based nonprofit is quick to point out the low premiums.

"For the second year in a row, health insurance premiums for families in Alabama are the lowest in the country among employers, according to the federal government's 2013 Medical Expenditure Panel Survey," BCBS said in its statement.

Corrected Terry Kellogg's name 9:42 p.m. Aug. 16.