The issuers of the individual major medical plans sold through HealthCare.gov rejected about 19% of the 187 million in-network health care claims they received in 2017, according to a new analysis released by the Henry J. Kaiser Family Foundation.
A team of analysts led by Karen Pollitz found that claim rejection rates for specific issuers ranged from 1% up to 40%.
The analysts came up with those figures by analyzing public use data files created by HealthCare.gov plan issuers and posted on the web by the Centers for Medicare and Medicaid Services (CMS).
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CMS is the arm of the U.S. Department of Health and Human Services that runs HealthCare.gov. HHS set up HealthCare.gov to provide Affordable Care Act (ACA) exchange account setup and administration services for states that are unwilling or unable to provide all of those services themselves.
In the HealthCare.gov states, 2017 exchange plan in-network claim denial rates ranged from 7.6%, in Oregon, up to 41%, in Kentucky.
For 40 issuers, the 2017 denial rates was under 10%.
For 12 issuers, the 2017 denial rate was over 30%.
The analysts also had data on 98 HealthCare.gov stand-alone dental plan issuers, and those issuers denied 25% of the in-network 712,671 in-network claims they received in 2017.
“The data show that consumers rarely appeal denied health insurance claims, although appeals data are also very limited,” the Kaiser analysts write. “For example, data do not show appeals by type of service, or dollar value involved, or based on the reason for the denial. Data on external appeals also do not indicate differences in the type of appeals process applied.”