The 2010 Patient Protection and Affordable Care Act (PPACA) requires health insurance carriers to meet minimum medical loss ratio (MLR) targets of 80% for small group and individual plans and 85% for large group plans. Insurers who do not meet these targets must refund the excess. These requirements change the risk for all insurers, because the chief cause of deviations from targeted or expected profit margins in health insurance is the effect of unexpected fluctuations in health claim cost trends. This paper discusses how insurers can adjust to major upward shifts in future claim costs.