Medical Loss Ratio (MLR)

The Affordable Care Act (ACA) requires health insurance issuers to spend a minimum percentage of premium dollars on medical care and health care quality improvement, which is intended to lower the cost of care. This percentage is known as “medical loss ratio” (MLR). In the large group insurance market, the required MLR is 85%; the small group and individual markets have a required MLR of 80%. However, each state may set a higher rate.

When an issuer fails to meet the requisite MLR for a year, it must provide a rebate to its policyholders. MLR rebates for the 2022 calendar year are due to policyholders by September 30, 2023. An employer-policyholder that receives a rebate for its insured group health plan will be responsible for determining how to appropriately use the refund, particularly in the context of the Employee Retirement Income Security Act (ERISA).

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