{"id":650960,"date":"2025-01-27T10:08:47","date_gmt":"2025-01-27T15:08:47","guid":{"rendered":""},"modified":"2025-08-09T06:18:02","modified_gmt":"2025-08-09T10:18:02","slug":"healthcare-gov-insurers-denied-nearly-1-in-5-in-network-claims-in-2023-but-information-about-reasons-is-limited-in-public-data","status":"publish","type":"post","link":"https:\/\/www.kff.org\/private-insurance\/healthcare-gov-insurers-denied-nearly-1-in-5-in-network-claims-in-2023-but-information-about-reasons-is-limited-in-public-data\/","title":{"rendered":"HealthCare.gov Insurers Denied Nearly 1 in 5 In-Network Claims in 2023, but Information About Reasons is Limited in Public Data"},"content":{"rendered":"\n<div\n\tclass=\"wp-block-kff-shared-content--standard-layout wp-block-kff-shared-content\">\n\t\n\n<section class=\"wp-block-kff-shared-content-main\">\n\t\t\t<div class=\"post-header\">\n\t\t\t<div class=\"post-header__tag\">News Release<\/div>\n\t\t\t\t\t\n\t<h1 class=\"post-header__title\">HealthCare.gov Insurers Denied Nearly 1 in 5 In-Network Claims in 2023, but Information About Reasons is Limited in Public Data<\/h1>\n\n\t\t\t<h2 class=\"post-header__subheading\">Enrollees Rarely Appeal Claims Denials; When They Do, Insurers Often Uphold the Original Denial<\/h2>\n\t\n\t\t\t<div class=\"post-header__meta\">\n\t\t\t\t<div>\n\t\t\t<span class=\"post-header__meta-label\">Published:<\/span>\n\t\t\t<date>Jan 27, 2025<\/date>\n\t\t<\/div>\n\t\t<\/div>\n\t\n\t<div class=\"post-header__social-sharing\">\n\t\t<button class=\"post-header__social-sharing__button print\">\n\t\t\t<svg width=\"16\" height=\"17\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n\t\t\t\t<path d=\"M4.348 2.5v3.391H2.783A.787.787 0 0 0 2 6.674v4.696c0 .429.353.782.783.782h1.565V14.5h7.304v-2.348h1.565c.43 0 .783-.353.783-.782V6.674a.787.787 0 0 0-.783-.783h-1.565V2.5H4.348Zm.522.522h6.26v2.87H4.87v-2.87ZM2.783 6.413h1.782a.26.26 0 0 0 .085 0h6.697a.26.26 0 0 0 .086 0h1.784c.148 0 .261.114.261.26v4.697c0 .147-.113.26-.26.26h-1.566V9.283H4.348v2.347H2.783a.257.257 0 0 1-.261-.26V6.674c0-.147.113-.261.26-.261Zm9.39.783a.522.522 0 1 0 0 1.043.522.522 0 0 0 0-1.043ZM4.87 9.804h6.26v2.043a.264.264 0 0 0 0 .086v2.045H4.87v-2.043a.261.261 0 0 0 0-.085V9.804Zm1.043.783a.262.262 0 0 0-.265.26.26.26 0 0 0 .265.262h4.174a.26.26 0 1 0 0-.522H5.913Zm0 1.043a.26.26 0 1 0 0 .522h3.13a.26.26 0 1 0 0-.522h-3.13Zm0 1.044a.26.26 0 1 0 0 .522h4.174a.262.262 0 0 0 .264-.261.26.26 0 0 0-.264-.261H5.913Z\" fill=\"#004B88\" stroke=\"#004B88\" stroke-width=\".5\"\/>\n\t\t\t<\/svg>\n\n\t\t\tPrint\t\t<\/button>\n\t\t<a href=\"mailto:?subject=HealthCare.gov%20Insurers%20Denied%20Nearly%201%20in%205%20In-Network%20Claims%20in%202023%2C%20but%20Information%20About%20Reasons%20is%20Limited%20in%20Public%20Data&#038;body=https%3A%2F%2Fwww.kff.org%2Fprivate-insurance%2Fhealthcare-gov-insurers-denied-nearly-1-in-5-in-network-claims-in-2023-but-information-about-reasons-is-limited-in-public-data%2F\" class=\"post-header__social-sharing__button\">\n\t\t\t<svg width=\"16\" height=\"17\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n\t\t\t\t<path d=\"M2.333 4.25h-.25v9.14h12.5V4.25H2.333Zm1.083 1.693-.353-.2V5.23h10.54v.513l-.353.2L8.333 8.73 3.416 5.943Zm-.353 6.467V6.884l.107.06 5.04 2.857.123.07.123-.07 5.04-2.857.107-.06v5.526H3.063Z\" fill=\"#004B88\" stroke=\"#004B88\" stroke-width=\".5\"\/>\n\t\t\t<\/svg>\n\n\t\t\tEmail\t\t<\/a>\n\t\t<button class=\"post-header__social-sharing__button copy\">\n\t\t\t<svg width=\"16\" height=\"17\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n\t\t\t\t<path d=\"M11.533 2.9c-.615 0-1.23.235-1.697.702L8.502 4.936a2.4 2.4 0 0 0-.575 2.46l.958-.958a1.32 1.32 0 0 1 .371-.748l1.334-1.333a1.331 1.331 0 0 1 1.886 0c.52.52.52 1.365 0 1.885l-1.334 1.333c-.21.21-.474.331-.748.372l-.958.958a2.393 2.393 0 0 0 2.46-.576l1.334-1.333a2.402 2.402 0 0 0 0-3.394 2.393 2.393 0 0 0-1.697-.702Zm-1.61 3.46a.533.533 0 0 0-.367.162l-3.2 3.2a.533.533 0 1 0 .754.754l3.2-3.2a.534.534 0 0 0-.387-.915ZM6.586 7.973a2.388 2.388 0 0 0-1.816.697l-1.334 1.333a2.403 2.403 0 0 0 0 3.394 2.393 2.393 0 0 0 1.697.702c.614 0 1.229-.234 1.697-.702l1.333-1.334a2.4 2.4 0 0 0 .576-2.46l-.959.958a1.32 1.32 0 0 1-.37.749l-1.334 1.333a1.334 1.334 0 0 1-1.886-1.885l1.334-1.334c.21-.21.474-.331.748-.372l.958-.957c-.21-.07-.426-.11-.644-.122Z\" fill=\"#004B88\"\/>\n\t\t\t<\/svg>\n\n\t\t\t<span>Copy Link<\/span>\n\t\t<\/button>\n\t\t\t<\/div>\n\t<\/div>\n\t\t\t\n\n<p class=\"has-medium-font-size wp-block-paragraph\">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 <a href=\"https:\/\/www.kff.org\/private-insurance\/issue-brief\/claims-denials-and-appeals-in-aca-marketplace-plans-in-2023\">KFF analysis<\/a> finds.<\/p>\n\n\n\n\n<p class=\"has-medium-font-size wp-block-paragraph\">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\u2019s primary source of private health coverage.<\/p>\n\n\n\n\n<p class=\"has-medium-font-size wp-block-paragraph\">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).<\/p>\n\n\n\n\n<p class=\"has-medium-font-size wp-block-paragraph\">Of limited information available on in-network claims denial reasons, the most common reason for denial was a general \u201cother\u201d 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%).<\/p>\n\n\n\n\n<p class=\"has-medium-font-size wp-block-paragraph\">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.<\/p>\n\n\n\n\n<p class=\"has-medium-font-size wp-block-paragraph\">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.<\/p>\n\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n \n\t<div class=\"post-footer\">\n\t<div class=\"post-footer__title\">More On<\/div>\n\t<div class=\"post-footer__links\">\n\t\t\t\t\t\t\t\t<a href=\"https:\/\/www.kff.org\/topic\/affordable-care-act\/\">\n\t\t\t\tAffordable Care Act\t\t\t<\/a>\n\t\t\t\t\t\t\t\t<a href=\"https:\/\/www.kff.org\/topic\/patient-consumer-protections\/\">\n\t\t\t\tPatient and Consumer Protections\t\t\t<\/a>\n\t\t\t\t\t\t\t\t<a href=\"https:\/\/www.kff.org\/topic\/private-insurance\/\">\n\t\t\t\tPrivate Insurance\t\t\t<\/a>\n\t\t\t\t\t\t\t\t<a href=\"https:\/\/www.kff.org\/tag\/aca-marketplaces\/\">\n\t\t\t\tACA Marketplaces\t\t\t<\/a>\n\t\t\t<\/div>\n<\/div>\n\t<\/section>\n\n<section class=\"wp-block-kff-shared-content-sidebar\">\n\t\t\t\n\t\t\n<div class=\"wp-block-kff-shared-contact-info\">\n\n\t<div class=\"wp-block-kff-shared-section-heading wp-block-kff-shared-section-heading--green is-spacing-narrow wp-block-kff-shared-section-heading--stacked\">\n\t\t<h2 class=\"wp-block-kff-shared-section-heading__title\">\n\t\t\tContact\t\t<\/h2>\n\t<\/div>\n\n\t<div class=\"wp-block-kff-shared-contact-info__details\">\n\t\t\t\t<div class=\"wp-block-kff-shared-contact-info__name-wrapper\">\n\t\t\t<span class=\"wp-block-kff-shared-contact-info__name\">\n\t\t\t\tCraig Palosky\t\t\t<\/span>\n\t\t<\/div>\n\t\t\n\t\t\n\t\t\t\t<div class=\"wp-block-kff-shared-contact-info__email-wrapper\">\n\t\t\t<a href=\"mailto:CraigP@kff.org\"\n\t\t\t\tclass=\"wp-block-kff-shared-contact-info__email\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"16\" height=\"16\" fill=\"currentColor\" viewBox=\"0 0 16 17\"><path fill=\"#004B88\" stroke=\"#004B88\" stroke-width=\".5\" d=\"M2.334 4.583h-.25v9.14h12.5v-9.14zm1.083 1.693-.354-.2v-.513h10.54v.513l-.353.2-4.917 2.787zm-.353 6.467V7.217l.106.06 5.04 2.857.123.07.124-.07 5.04-2.857.106-.06v5.526z\" \/><\/svg>\t\t\t\tCraigP@kff.org\t\t\t<\/a>\n\t\t<\/div>\n\t\t\n\t\t\t<\/div>\n<\/div>\n\n<div class=\"wp-block-kff-shared-related-content--green wp-block-kff-shared-related-content\">\n\t<h2 class=\"wp-block-kff-shared-related-content__heading\">Also of Interest<\/h2>\n\t<div>\n\t\t\t<div class=\"wp-block-kff-shared-related-content__card\">\n\t\t\t<a href=\"https:\/\/www.kff.org\/private-insurance\/claims-denials-and-appeals-in-aca-marketplace-plans-in-2023\/\" class=\"wp-block-kff-shared-related-content__link\">\n\t\t\t\t<h3 class=\"wp-block-kff-shared-related-content__card-title\">\n\t\t\t\t\tClaims Denials and Appeals in ACA Marketplace Plans in 2023\t\t\t\t<\/h3>\n\t\t\t\t\t\t\t<\/a>\n\t\t<\/div>\n\t\t\t<div class=\"wp-block-kff-shared-related-content__card\">\n\t\t\t<a href=\"https:\/\/www.kff.org\/private-insurance\/how-narrow-or-broad-are-aca-marketplace-physician-networks\/\" class=\"wp-block-kff-shared-related-content__link\">\n\t\t\t\t<h3 class=\"wp-block-kff-shared-related-content__card-title\">\n\t\t\t\t\tHow Narrow or Broad Are ACA Marketplace Physician Networks?\t\t\t\t<\/h3>\n\t\t\t\t\t\t\t<\/a>\n\t\t<\/div>\n\t\t\t<div class=\"wp-block-kff-shared-related-content__card\">\n\t\t\t<a href=\"https:\/\/www.kff.org\/affordable-care-act\/access-to-ob-gyns-evaluating-workforce-supply-and-aca-marketplace-networks\/\" class=\"wp-block-kff-shared-related-content__link\">\n\t\t\t\t<h3 class=\"wp-block-kff-shared-related-content__card-title\">\n\t\t\t\t\tAccess to OB-GYNs: Evaluating Workforce Supply and ACA Marketplace Networks\t\t\t\t<\/h3>\n\t\t\t\t\t\t\t<\/a>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\n\n\t\t\t<\/section>\n\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>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.<\/p>\n","protected":false},"author":155412894,"featured_media":624269,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"authors":[],"exhibits":[],"jetpack_post_was_ever_published":false,"ep_exclude_from_search":false,"_classifai_error":"","_classifai_text_to_speech_error":"","hide_from_search":false,"show_featured_image":false,"subheading":"Enrollees Rarely Appeal Claims Denials; When They Do, Insurers Often Uphold the Original Denial","tag":"","search_keywords":"News Release","_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"shortlink":"","footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":false,"jetpack_social_options":{"image_generator_settings":{"template":"highway","default_image_id":0,"enabled":false},"version":2}},"categories":[3962798,579145441,1286878],"tags":[954238],"series":[],"partner":[],"content-types":[579145487],"program":[],"class_list":["post-650960","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-affordable-care-act","category-patient-consumer-protections","category-private-insurance","tag-aca-marketplaces","content-types-news-release"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v25.9 (Yoast SEO v25.9) - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>HealthCare.gov Insurers Denied Nearly 1 in 5 In-Network Claims in 2023, but Information About Reasons is Limited in Public Data | KFF<\/title>\n<meta name=\"description\" content=\"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.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.kff.org\/private-insurance\/healthcare-gov-insurers-denied-nearly-1-in-5-in-network-claims-in-2023-but-information-about-reasons-is-limited-in-public-data\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"HealthCare.gov Insurers Denied Nearly 1 in 5 In-Network Claims in 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