What is the 8020 rule in health insurance ?

Health Insurance's 80/20 Rule Could Mean Money Back in Your Pocket — here's how the Medical Loss Ratio actually works.

Since 2011, the Affordable Care Act has required health insurers to follow what's commonly called the 80/20 rule: spend at least 80% of every premium dollar on medical claims and quality improvement, and cap administrative costs, marketing, and profit at 20%. For large group plans, that threshold is even stricter — 85% must go to care, leaving just 15% for overhead. If an insurer doesn't hit its required Medical Loss Ratio in a given year, it owes policyholders a rebate. In this video, we break down exactly how this rule works, who it protects, and how to find out if you're owed money.

Here's what you'll learn:

- What the 80/20 rule (Medical Loss Ratio) actually requires insurers to do
- Why large group plans face an 85% threshold instead of 80%
- How individual and small-group plans are more likely to trigger rebates
- Why self-funded employer plans are exempt from MLR rebate rules
- How state-level regulations can go beyond the federal minimum
- Where to check your insurer's MLR filings to see if you qualify for a rebate

Understanding the Medical Loss Ratio isn't just a policy detail — it directly affects whether you get money back from your health insurer. Individual and small-group policyholders face the most exposure to rebate triggers, so knowing your plan type matters.

If you've ever wondered where your premium dollars actually go, this video breaks it down clearly — watch until the end, and let us know in the comments if you've ever received an MLR rebate. Found this helpful? A like and subscribe helps more people understand their health coverage.

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