MLR is the percentage of premium revenue a carrier is required, under the ACA, to spend on medical care rather than administrative costs, 80% for individual/small-group markets and 85% for large-group markets. If a carrier's three-year rolling average MLR falls short, the shortfall must be rebated to policyholders. Insurers issued more than $1.6 billion in MLR rebates in 2025 alone, with the cumulative total since 2011 now at roughly $14.3 billion.
MLR does not apply to self-funded plans at all, which now cover roughly two-thirds of covered workers nationally. A meaningful share of the OnMed CareStation™ cost (75%, per HMA report data) can qualify as QIA/MLR-positive spend, giving carriers a direct incentive to deploy access infrastructure.
Under the ACA's MLR requirement, carriers must spend 80% of premium revenue on medical care in individual and small-group markets, and 85% in large-group markets, or rebate the shortfall to policyholders.
Reducing avoidable ED and urgent care utilization directly improves how efficiently premium dollars are spent on necessary care, and a substantial share of that spend (roughly 75%, per HMA report data) can qualify as QIA/MLR-positive activity.
Insurers issued more than $1.6 billion in MLR rebates in 2025, bringing the cumulative total since the rule took effect in 2011 to roughly $14.3 billion.
No. MLR requirements apply only to fully-insured plans. Self-funded plans, which now cover roughly two-thirds of covered workers nationally, are exempt from the MLR rule entirely.
Every term here points to the same gap in healthcare access. See how the CareStation closes it.
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