ACA Marketplace Plans Deny Over 16% of In-Network Claims in 2021

About 16.6% of in-network claims were denied by non-group qualified health plans (QHPs) offered on HealthCare.gov in 2021, down from 18.3% in 2020, according to a recent Kaiser Family Foundation analysis. Among the 162 issuers in HealthCare.gov states with complete data on claims received and denied, 65 of them had a denial rate between 10% and 19%. Only 17 issuers had a denial rate over 30%, compared with 28 in 2020. The majority of denials (76.5%) were classified as “all other reasons,” while 8% were for services that lacked a prior authorization or referral. Of the more than 48 million denied claims in 2021, marketplace enrollees appealed 90,599 claims — a 0.2% appeal rate — and insurers upheld 59% of denials that were appealed.

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Jinghong Chen

Jinghong Chen Reporter

Jinghong has been producing infographics and data stories on employer-sponsored insurance, public health insurance programs and prescription drug coverage for AIS Health’s Health Plan Weekly and Radar on Drug Benefits since 2018. She also manages AIS Health’s annual executive compensation database for top insurers and Blue Cross and Blue Shield affiliates. Before joining AIS Health, she interned at WBEZ, Al Jazeera English and The New York Times Chinese. She graduated from Missouri School of Journalism with a focus on data journalism and international reporting.

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