JEFFERSON CITY, MO — The Missouri Department of Commerce and Insurance (DCI) is reminding consumers of key protections under the Affordable Care Act (ACA) that help ensure value in health insurance coverage. Two essential tools—Medical Loss Ratio (MLR) and Health Insurance Rate Review—work together to promote transparency and accountability in the health insurance marketplace.
Since 2011, insurers have been required to publicly disclose spending on medical care, quality improvement, and administrative costs such as marketing, underwriting, and executive compensation. The Centers for Medicare and Medicaid Services (CMS), part of the U.S. Department of Health and Human Services, manages oversight and enforcement of MLR standards.
Under the ACA, health insurance issuers must report to the CMS how health insurance premium dollars are spent. Federal law requires health insurers to spend a significant percentage of the premium consumers pay on medical care and health care quality improvement activities. This percentage, known as the Medical Loss Ratio, looks back at how health insurers spent premium dollars over the previous three years, and must meet minimum standards:
- 80% for individual and small group markets (2–50 employees)
- 85% for large group markets (more than 50 employees)
If insurers fail to meet these benchmarks, they are required by federal law to pay consumers back. Health insurers can do this by sending rebate checks to policyholders or providing premium credits. Employers who are owed MLR rebates are required to divide the rebate amounts with their employees based on how much the employer and the employee contribute toward the total premium. Rebates must be paid by September 30th each year. These MLR requirements apply only to fully insured plans and exclude self-funded employer plans.
In Missouri, DCI conducts annual reviews of health insurance rates to determine whether proposed premiums are “reasonable.” This forward-looking process requires carriers to evaluate experience from previous years and to submit projections for the upcoming year. Missouri’s rate review rules specifically cite MLR as a factor in assessing whether a rate is “reasonable.”
Together, MLR and rate review enhance transparency and protect consumers by ensuring that premium dollars are used effectively.
- Access MLR data: CMS MLR Data Resources
- View Missouri’s 2026 rate filings: DCI Rate Filings Portal
DCI protects Missouri consumers by overseeing the insurance industry, banks, credit unions, utilities, and various professional licensees operating in the state. For more information about the department, please visit our website at dci.mo.gov.