Understanding The 80/20 Rule In Insurance

  • John A. Osborne
  • Jan 11, 2023
Small Business Insurance Iowa

When it comes to insurance, there are a lot of different terms and concepts that can be confusing for consumers. One of these is the 80/20 rule, which refers to the way that insurance companies allocate their expenses and profits. Understanding this rule is essential for anyone who wants to make informed decisions about their insurance coverage, so let’s take a closer look at what it means and how it works.

Simply put, the 80/20 rule is a provision in the Affordable Care Act (ACA) that requires health insurance companies to spend at least 80% of premium dollars on medical care and quality improvement activities, with the remaining 20% going towards administrative expenses and profits. This is often referred to as the “medical loss ratio” (MLR) and is designed to ensure that insurers are providing value to their customers.

The Benefits of the 80/20 Rule

There are several benefits to the 80/20 rule, both for consumers and for the healthcare industry as a whole:

  • Increased transparency: By requiring insurance companies to disclose how they are spending premium dollars, the 80/20 rule provides greater transparency and accountability.
  • More value for consumers: Because insurers are required to spend the majority of premiums on medical care, consumers can feel confident that their money is going towards the services they need.
  • Improved quality of care: By incentivizing insurers to focus on quality improvement activities, the 80/20 rule can help to improve the overall quality of care provided to patients.

How the 80/20 Rule Works in Practice

So, how does the 80/20 rule actually work in practice? Here are a few key things to keep in mind:

  • Insurers must report their MLR: Each year, insurance companies are required to report their MLR to the Department of Health and Human Services. If an insurer fails to meet the 80% threshold, they may be required to issue rebates to customers.
  • The rule only applies to certain types of insurance: The 80/20 rule applies specifically to health insurance plans sold to individuals and small groups. It does not apply to large group plans or self-insured plans.
  • States can set their own MLR requirements: While the ACA sets a minimum MLR of 80%, some states have implemented even higher requirements. For example, in California, insurers must spend at least 85% of premiums on medical care.


The 80/20 rule is an important provision in the ACA that helps to ensure that insurance companies are providing value to their customers. By requiring insurers to spend the majority of premiums on medical care and quality improvement activities, the rule can improve transparency, increase the value of insurance coverage, and ultimately lead to better quality of care for patients. If you have questions about how the 80/20 rule might affect your insurance coverage, it’s always a good idea to consult with an experienced insurance professional.

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