Claims Denials and Appeals in ACA Marketplace Plans

(By Karen Pollitz, Cynthia Cox and Rachel Fehr for Henry J. Kaiser Family Foundation)

In this report, we analyze transparency data released by the Centers for Medicare and Medicaid Services (CMS) to examine claims denials and appeals among issuers offering individual market coverage on healthcare.gov from 2015-2017. We find that, across issuers with complete data, 19% of in-network claims were denied by issuers in 2017, with denial rates for specific issuers varying significantly around this average, from less than 1% to more than 40%. We also find that consumers rarely appeal claims denials to their issuers, and when they do, issuers typically uphold their original decision. Healthcare.gov consumers appealed less than one-half of one percent of denied claims, and issuers overturned 14% of appealed denials.  Continue reading report here…

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