The “quality improvement” definition recommended by NAIC for medical-loss ratios (MLRs) and adopted by HHS in 2010 was designed to ensure that insurers only classify as quality improving expenditures those that improve healthcare quality. Whether the quality improvement classification compels insurers to make expenditures that benefit policyholders or if it is used by insurers for their own benefit may be a matter of regulatory oversight. We therefore urge the NAIC to recommend strict enforcement of the definition of “quality improvement” in the MLR calculation (and elsewhere).