The 80/20 rule, every insurer, every state
The ACA's medical loss ratio rule: insurers must spend at least 80% of premiums (85% for large groups) on health care and quality improvement, or refund the difference. Below: reporting year 2024, all markets, all 50 states + DC.
Health insurers owed $1.65B in 2024 rebates under the 80/20 rule.
States ranked by MLR (least spent on care first)
Higher is better for you: a high MLR means the insurer spent more of every premium dollar on actual medical care. A low MLR means the insurer kept more of your premium for administration and profit, which is why low-MLR states owe the most rebates.
| State | Spent on care | Rebates owed | Insurers |
|---|---|---|---|
| MO | 82.4% | $156.4M | 21 |
| LA | 83.0% | $130.1M | 20 |
| IN | 83.2% | $66.1M | 25 |
| SC | 83.9% | $138.5M | 21 |
| AR | 85.0% | $33.4M | 18 |
| NV | 85.2% | $32.6M | 20 |
| MA | 85.4% | $75.6M | 21 |
| AZ | 85.6% | $10.2M | 20 |
| MS | 86.0% | $3.7M | 20 |
| NC | 86.1% | $99.7M | 19 |
| NH | 86.1% | $8.7M | 11 |
| KY | 86.1% | $1.7M | 21 |
| OH | 86.5% | $78.9M | 31 |
| TN | 86.6% | $16.1M | 22 |
| FL | 86.9% | $91.3M | 30 |
| IA | 87.0% | $7.3M | 21 |
| PR | 87.2% | $0.2M | 9 |
| RI | 87.2% | $0.0M | 14 |
| MD | 87.7% | $33.2M | 17 |
| TX | 87.8% | $127.1M | 38 |
| CT | 87.9% | $1.6M | 16 |
| PA | 88.1% | $55.7M | 39 |
| DC | 88.3% | $0.1M | 17 |
| MI | 88.3% | $11.8M | 26 |
| ID | 88.4% | $1.6M | 15 |
| KS | 88.4% | $11.6M | 19 |
| VA | 88.5% | $43.2M | 29 |
| CO | 88.7% | $11.6M | 20 |
| NY | 88.8% | $9.0M | 28 |
| AL | 89.0% | $182.0M | 15 |
| ME | 89.1% | $0.2M | 13 |
| VI | 89.2% | $0.0M | 3 |
| NE | 89.3% | $5.3M | 16 |
| WA | 89.3% | $0.9M | 25 |
| DE | 89.6% | $0.1M | 12 |
| HI | 89.7% | $3.8M | 7 |
| OR | 89.9% | $0.0M | 16 |
| GA | 89.9% | $24.2M | 28 |
| UT | 89.9% | $1.0M | 15 |
| NJ | 89.9% | $22.8M | 17 |
| SD | 90.0% | $0.0M | 15 |
| WI | 90.8% | $17.7M | 32 |
| OK | 91.2% | $88.7M | 21 |
| WV | 91.2% | $0.0M | 13 |
| AK | 91.4% | $0.0M | 6 |
| IL | 91.8% | $4.7M | 31 |
| MN | 91.9% | $0.0M | 23 |
| CA | 92.0% | $31.2M | 42 |
| ND | 92.0% | $0.0M | 10 |
| NM | 92.7% | $5.3M | 14 |
| MT | 93.1% | $0.0M | 10 |
| WY | 95.3% | $2.0M | 13 |
| VT | 97.1% | $0.0M | 5 |
Insurers paying the biggest rebates
These insurers missed the 80/20 floor and had to refund premium dollars to customers. Big rebates mean the insurer collected far more in premiums than it paid out in care: good news for the members who got the check, but a sign the premium was set too high.
| Insurer | Spent on care | Rebates |
|---|---|---|
| Celtic Insurance Company | 77.4% | $443.6M |
| UnitedHealthcare Insurance Company | 84.8% | $239.5M |
| Absolute Total Care, Inc | 74.0% | $123.7M |
| Ambetter of North Carolina Inc. | 73.5% | $96.1M |
| Ambetter Health of Louisiana, Inc. | 65.3% | $62.2M |
| Buckeye Community Health Plan | 71.3% | $45.5M |
| Healthy Alliance Life Insurance Company | 82.0% | $45.3M |
| Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. | 87.3% | $43.7M |
| HMO Louisiana | 79.7% | $35.4M |
| QualChoice | 74.8% | $31.7M |
| Independence Assurance Company | 81.7% | $30.3M |
| Oxford Health Insurance, Inc. | 83.5% | $24.9M |
| HealthKeepers, Inc. | 80.1% | $23.6M |
| CareFirst BlueChoice, Inc. | 83.8% | $23.1M |
| Blue Cross Blue Shield of Louisiana | 85.7% | $22.1M |
| Anthem Insurance Companies, Inc. | 84.5% | $21.5M |
| Mass General Brigham Health Plan, Inc | 85.1% | $17.2M |
| Health Plan of Nevada, Inc. | 83.4% | $16.8M |
| Nippon Life Insurance Company of America | 77.2% | $15.7M |
| Keystone Health Plan East | 82.0% | $13.7M |
| UnitedHealthcare Benefits Plan of California | 85.9% | $13.4M |
| Ambetter of Peach State Inc. | 79.6% | $13.2M |
| Community Insurance Company | 87.9% | $13.1M |
| Neighborhood Health Partnership, Inc. | 83.2% | $12.9M |
| Meridian Health Plan of Michigan, Inc. | 77.3% | $10.7M |
| Molina Healthcare of Ohio, Inc. | 77.6% | $10.6M |
| Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. | 88.5% | $9.9M |
| MOLINA HEALTHCARE OF SOUTH CAROLINA, INC | 75.5% | $9.6M |
| Aetna Health Inc. (a Florida corporation) | 93.0% | $9.3M |
| HMO Colorado, Inc. | 81.0% | $8.9M |