A new analysis from Kaiser Family Foundation (KFF) found Healthcare.gov marketplace insurers denied nearly 1 in 5 claims submitted for in-network services in 2020, but the reason for the high denial rates are difficult to assess from publicly available data.
Researchers analyzed transparency data released by the Centers for Medicare and Medicaid Services (CMS) on claims denials and appeals for non-group qualified health plans (QHPs) offered on HealthCare.gov. Data were reported by insurers for the 2020 plan year, posted in a public use file in 2021, and updated in 2022. Researchers found that, across HealthCare.gov insurers with complete data, about 18% of in-network claims were denied in 2020. Insurer denial rates varied widely around this average, ranging from less than 1% to more than 80%.