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Centers for Medicare & Medicaid Services

Medical Loss Ratio

Background

Many insurance companies spend a substantial portion of consumers’ premium dollars on administrative costs and profits, including executive salaries, overhead, and marketing.

The Affordable Care Act requires health insurance issuers to submit data on the proportion of premium revenues spent on clinical services and quality improvement, also known as the Medical Loss Ratio (MLR). It also requires them to issue rebates to enrollees if this percentage does not meet minimum standards. MLR requires insurance companies to spend at least 80% or 85% of premium dollars on medical care, with the review provisions imposing tighter limits on health insurance rate increases. If they fail to meet these standards, the insurance companies will be required to provide a rebate to their customers starting in 2012.

The new law also directs the National Association of Insurance Commissioners (NAIC) to establish uniform definitions and standardized methodologies for determining what services constitute clinical services, quality improvement and other non-claims costs for carrying out this provision.     

State Information

The law allows the Secretary to adjust the MLR standard for a state if it is determined that meeting the 80% Medical Loss Ratio standard may destabilize the individual market. In order to qualify for this adjustment, a state must demonstrate that requiring insurers in its individual market to meet the 80% MLR has a likelihood of destabilizing the individual market and result in fewer choices for consumers. 

This HHS Bulletin describes the method and format states must use in order to apply for an MLR adjustment.  Applications must be submitted by email to MLRAdjustments@hhs.gov.

A state’s request for an adjustment to the MLR standard is a public document. The Secretary invites public comment regarding a state’s request.  However, public comments must be submitted within 10 calendar days of HHS posting a state's complete request online to guarantee consideration. The public comment period is designed to give all interested parties full opportunity to present relevant information to the Secretary, which will be considered in making a timely determination on whether an adjustment to the statutory MLR standard is justified for the state applicant’s individual market. 

MLR Adjustment Applications

This page contains state applications for an adjustment to the MLR standard for the individual market.  When an application is deemed complete, the webpage will be updated to reflect the deadline for public comment on the state’s application. To guarantee consideration, public comments must be submitted electronically by midnight on the 10th calendar day after the posting of a complete state request.

To submit a comment regarding a State's adjustment application, please email MLRAdjustments@hhs.gov.  Please include the relevant state applicant in the email subject line.

States Requests for MLR Adjustment:

  • Maine (HHS determination issued)
  • New Hampshire (HHS determination issued)
  • Nevada (HHS determination issued)
  • Kentucky  (HHS determination issued)
  • Florida (undergoing review for completeness, public comments due TBD)
  • Georgia (undergoing review for completeness, public comments due TBD)
  • North Dakota (HHS determination issued)
  • Iowa (HHS determination issued)
  • Louisiana (undergoing review for completeness, public comments due TBD) 
  • Guam (application complete, public comments due July 16, 2011) 
  • Kansas  (undergoing review for completeness, public comments due TBD) 
  • Delaware (application complete, public comments due July 21, 2011)
  • Indiana (undergoing review for completeness, public comments due TBD)

Additional Resources: