Healthcare.gov insurers denied 1 in 5 of all in-network claims in 2020

Healthcare.gov marketplace insurers denied 18% of all claims — nearly 1 out of every five — submitted for in-network services in 2020. But the reasons behind the high denial rates and the ultimate consequences for consumers are difficult to determine, according to a new analysis by the Kaiser Family Foundation (KFF).

The Affordable Care Act (ACA) requires insurers to report data about claims denials and appeals to encourage transparency about how insurance coverage works for enrollees. KFF’s analysis examined data released by the Centers for Medicare and Medicaid Services on more than 230 million claims submitted to 144 insurers selling marketplace coverage in 2020, the most recent year for which data is available.

Researchers found a huge variation across insurers, finding average denial rates as low as 1% and as high as 80%. Denial rates also vary by state, though insurers within the same state often show wide variations, as well. The data did include some information about why in-network claims are denied: lack of prior authorization or referral (10%), an excluded service (16%), or lack of medical necessity (2%). And among claims denied for reasons of medical necessity, about 1 in 5 involved behavioral health services.