![]() Of the 230 major medical issuers in states that reported for the 2021 plan year, 162 reported receiving at least 1,000 in-network claims and show data on claims received and denied. From the public use file, we developed a working file that is posted with this brief. Our analysis excludes stand-alone dental plans and issuers with incomplete data or less than 1,000 claims submitted. This brief focuses on transparency data for the 2021 calendar year submitted by qualified health plans (QHPs) offered to individuals on as part of the 2023 plan certification process. Nor has it required any further detailed reporting (e.g., on claims or appeals by type of service or diagnosis.) Federal agencies have yet to require transparency in coverage data reporting by other non-group plans or employer-sponsored plans. 1 CMS does not collect data on all fields enumerated in the ACA, including out-of-network claims submitted and out-of-network enrollee cost sharing and payments. As a result, for any given issuer, the total plan-level claims reported may not equal the issuer-level claims reported for the 2021 coverage year. Issuers only report plan-level transparency data plans they seek to offer on in the coming year. Since 2018, issuers are also required to report data at the health plan level, including certain reasons for claims denials. ![]() In 2022, issuers reported aggregated data on all QHPs they offered in 2021. Aggregate data are reported at the issuer level. Issuers report only on the number of in-network claims submitted and denied, the number of such denials that are appealed, and the outcome of appeals. To date, reporting is required only by issuers for their qualified health plans (QHP) offered on. Partial implementation of ACA transparency data reporting began with the 2015 plan year. The law requires data to be available to state insurance regulators and to the public. Other information as determined appropriate by the Secretary.Information on enrollee and participant rights under this title.Information on cost-sharing and payments with respect to any out-of-network coverage.Data on the number of claims that are denied.Under the ACA, required reporting fields for transparency-in-coverage data include: Transparency data also are not used in oversight nor to develop other tools or indicators to help consumers see and compare differences across plans. Data to answer these questions are not collected and data that are collected are not audited, for example, to ensure issuers report data consistently. Yet, the federal government’s broad authority to require transparency data reporting has not been fully implemented. It could also make more transparent trends in the incidence and handling of claims for surprise medical bills, now protected under the No Surprises Act. For example, transparency data could be helpful in oversight of compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA), revealing how or whether claims denial rates differ for behavioral health vs other services. Data are to inform regulators and consumers about how health plans work in practice. The Affordable Care Act (ACA) requires transparency data reporting by all non-grandfathered employer-sponsored health plans and by non-group plans sold on and off the marketplace. In 2021, consumers appealed less than two-tenths of 1% of denied in-network claims, and insurers upheld most (59%) denials on appeal. Most plan-reported denials (82%) were classified as ‘all other reasons.’Īs in our previous analysis of claims denials, we find that consumers rarely appeal denied claims and when they do, insurers usually uphold their original decision. Of in-network claims, about 14% were denied because the claim was for an excluded service, 9% due to lack of preauthorization or referral, and only about 2% based on medical necessity. Insurer denial rates varied widely around this average, ranging from 2% to 49%.ĬMS requires insurers to report the reasons for claims denials at the plan level. We find that, across insurers with complete data, nearly 17% of in-network claims were denied in 2021. Data were reported by insurers for the 2021 plan year and posted in a public use file in October 2022. In this brief, we analyze transparency data released by the Centers for Medicare and Medicaid Services (CMS) on claims denials and appeals for non-group qualified health plans (QHPs) offered on.
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