HealthCare.gov insurers denied nearly one out of every five claims (19%) submitted for in-network services and an even larger share (37%) share of claims for out-of-network services in 2023, a new KFF analysis finds.
The analysis examines the main source of publicly available data on claims denials and appeals for individual-market plans available through the federal HealthCare.gov marketplace. The Affordable Care Act requires certain entities to report data about claims denials and appeals to encourage transparency about how insurance coverage works for enrollees. The publicly available data does not include marketplace plans sold on state-based marketplaces or employer health plans, the nation’s primary source of private health coverage.
The analysis finds a huge variation across HealthCare.gov insurers, which had in-network denial rates as low as 1% and as high as 54% in 2023 in some states. Nationwide, high-volume insurers with higher in-network denial rates across HealthCare.gov states included Blue Cross Blue Shield of Alabama (35% for its 12 plans in that state), UnitedHealth Group (33% across 274 plans in 20 states), Health Care Service Corporation (29% across 915 plans in four states), Molina Healthcare (26% across 72 plans in nine states), and Elevance Health (23% across 154 plans in seven states).
Of limited information available on in-network claims denial reasons, the most common reason for denial was a general “other” reason (34%), while 16% involved excluded services, 9% involved lack of prior authorization or referral, and 6% involved medical necessity. Other common reasons for denials included administrative issues (18%) and exceeding benefit limits (12%).
Consumers appealed about 1% of denied in-network claims in 2023. Following those appeals, insurers often upheld their initial denials (56%), and consumers rarely took the next step to file an external appeal.
The analysis examines data from the Centers for Medicare and Medicaid Services on 425 million claims submitted to 175 insurers selling marketplace coverage in 2023, the most recent year available. Additional data files with insurer- and state-specific information are available at kff.org.
