Claims Denials and Appeals in ACA Marketplace Plans

Written by: Karen Politz, Cynthia Cox and Rachel Feher

This analysis was updated on June 12, 2019 to reflect corrected data released by CMS.

In this report, we analyze transparency data released by the Centers for Medicare and Medicaid Services (CMS) to examine claims denials and appeals among issuers offering individual market coverage on healthcare.gov from 2015-2017. We find that, across issuers with complete data, 18% of in-network claims were denied by issuers in 2017, with denial rates for specific issuers varying significantly around this average, from less than 1% to more than 40%.