Since 2021, federal law has required hospitals to publicly post information about their standard prices and negotiated discount rates for common health services to encourage consumers to compare prices and to promote competition.

This analysis examines transparency data currently shared by hospitals to comply with the law and finds that they are messy, inconsistent and confusing, making it challenging, if not impossible, for patients or researchers to use them for their intended purpose. Drawing on hospital price transparency data compiled by Turquoise Health, the analysis includes examples that illustrate the difficulty in drawing meaningful conclusions from available data.

Many of these shortcomings stem from a lack of specificity and standardization in the requirements for what hospitals must report and how they report it. To address these challenges, federal regulators have suggested specific ways for hospitals to format and validate their data, but hospitals are not required to follow that guidance.

The analysis is available through the Peterson-KFF Health System Tracker, an online information hub that monitors and assesses the performance of the U.S. health system.

See KFF’s analysis of more recent data in Claims Denials and Appeals in ACA Marketplace Plans in 2023, published in January 2025.

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 HealthCare.gov. Data were reported by insurers for the 2021 plan year and posted in a public use file in October 2022. We find that, across HealthCare.gov insurers with complete data, nearly 17% of in-network claims were denied in 2021. Insurer denial rates varied widely around this average, ranging from 2% to 49%.

CMS requires insurers to report the reasons for claims denials at the plan level. Of in-network claims, about 14% were denied because the claim was for an excluded service, 8% due to lack of preauthorization or referral, and only about 2% based on medical necessity. Most plan-reported denials (77%) were classified as ‘all other reasons.’

As 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. In 2021, HealthCare.gov consumers appealed less than two-tenths of 1% of denied in-network claims, and insurers upheld most (59%) denials on appeal.

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. Data are to inform regulators and consumers about how health plans work in practice. 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. 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. Yet, the federal government’s broad authority to require transparency data reporting has not been fully implemented. Data to answer these questions are not collected; and data that are collected are not audited, for example, to ensure issuers report data consistently. Transparency data also are not used in oversight nor to develop other tools or indicators to help consumers see and compare differences across plans.

ACA Transparency Data

Under the ACA, required reporting fields for transparency-in-coverage data include:

• Claims payment policies and practices
• Periodic financial disclosures
• Data on enrollment
• Data on disenrollment
• Data on the number of claims that are denied
• Data on rating practices
• Information on cost-sharing and payments with respect to any out-of-network coverage
• Information on enrollee and participant rights under this title
• Other information as determined appropriate by the Secretary

The law requires data to be available to state insurance regulators and to the public.

Partial implementation of ACA transparency data reporting began with the 2015 plan year. To date, reporting is required only by issuers for their qualified health plans (QHP) offered on HealthCare.gov. 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. Aggregate data are reported at the issuer level. In 2022, issuers reported aggregated data on all HealthCare.gov QHPs they offered in 2021. Since 2018, issuers are also required to report data at the health plan level, including certain reasons for claims denials. Issuers only report plan-level transparency data plans they seek to offer on HealthCare.gov in the coming year. 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.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. 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.² 

Claims Denials and Appeals in 2021

This brief focuses on transparency data for the 2021 calendar year submitted by qualified health plans (QHPs) offered to individuals on HealthCare.gov as part of the 2023 plan certification process. Our analysis excludes stand-alone dental plans and issuers with incomplete data or less than 1,000 claims submitted. From the public use file, we developed a working file that is posted with this brief.

Claims submitted and denied

Of the 230 major medical issuers in HealthCare.gov 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. Together these issuers reported 291.6 million in-network claims received, of which 48.3 million were denied, for an average in-network claims denial rate of 16.6% (Figure 1)

Issuer denial rates for in-network claims ranged from 2% to 49%. In 2021, 41 of the 162 reporting issuers had a denial rate of less than 10%, 65 issuers denied between 10% and 19% of in-network claims, 39 issuers denied 20-29%, and 17 issuers denied 30% or more of in-network claims. (Figure 2) Issuers that report denying one-third or more of all in-network claims in 2021 included Meridian Health Plan of Michigan, Absolute Total Care in South Carolina, Celtic Insurance in 7 states (FL, IL, IN, MO, NH, TN, TX), Ambetter Insurance in 3 states (GA, MS, NC), Optimum Choice in Virginia, Buckeye Community Health Plan in Ohio, Health Net of Arizona, and UnitedHealthcare of Arizona.

Table 1 shows denial rates for issuers who reported the highest volume of in-network claims in 2021, receiving over 5 million claims. Among these issuers, denial rates ranged from 5.7%. to 41.9%.

Denial rates also varied geographically. (Figure 3) State average denial rates can obscure variation within a state. For example, in Florida, where the average denial rate was 13% in 2021, the five issuers with largest market shares reported denial rates for in-network claims ranging from 15% to 42%.

Plan-level claims denial data

CMS also collects limited transparency data at the plan level. Of the 162 issuers reporting aggregate data, 158 report plan level data on in-network claims received and denied, as well as data on selected reasons for denials. Denial rates varied somewhat based on plan metal levels. On average, in 2021, HealthCare.gov issuers denied 15.9% of in-network claims in their bronze plans, 17.3% in silver plans, 17.1% in gold plans, 11.4% in platinum plans, and 19.7% in catastrophic plans.

Why do health plans deny claims?

HealthCare.gov plans also report on certain categories of reasons for in-network claims denials:

• Denials due to lack of prior authorization or referral
• Denials due to an out-of-network provider
• Denials due to an exclusion of a service
• Denials based on medical necessity (reported separately for behavioral health and other services)
• Denials for all other reasons

A claim might be denied for more than one reason. In addition, insurers are required to report reasons for denials of claims that ultimately are paid. In all, insurers reported 41.7 million denied in-network claims at the plan level for the 2021 coverage year. Insurers also reported 44.7 million reasons for denying in-network claims, including roughly 3 million denials of claims that were later paid.

The distribution of in-network denials by reason is shown in Table 2. (We set aside data for out-of-network claim denials because CMS does not require issuers to report on the number of out-of-network claims received.) About 8% of these 44.7 million denials were for services that lacked prior-authorization or referral, 13.5% were for excluded services, 1.7% for medical necessity reasons, and 76.5% for all other reasons.

Again, totals obscure variation by plan. For example, while about 2% of all in-network claim denials by HealthCare.gov plans were based on medical necessity, several plans with large volume of denials (more than 75,000) reported much higher shares for medical necessity reasons, up to 37%. (Table 3)

Similarly, while about 9% of all in-network denials by HealthCare.gov plans were based on lack of prior-authorization or referral, some plans reported a much larger share of their denials were for that reason – as high as 24%. (Table 4)

The transparency data indicate that plans seem to apply utilization review techniques very differently. However, without more detail on the types of claims subject to these denials, it is not possible to discern what the implications for patients might be.

Of note, Connecticut regulators require health insurers in all market segments, including fully insured employer plans, to report annual data on claims payment practices, and other measures. Denial rates and reasons reported by Connecticut insurers are similar to those reported by HealthCare.gov QHPs. (Table 5)

Appeals

ACA transparency data show the number of denied in-network claims that consumers appealed to the plan (internal appeals) and the number of denials overturned at internal appeal. Consumers whose denial is upheld at internal appeal sometimes have the right to an independent external appeal. (Under federal regulations, eligibility for external appeal is generally restricted to medical necessity denials, though in some states all denials can be externally appealed.) HealthCare.gov issuers also report the number of external appeals made by consumers, and the number of externally appealed denials that were overturned. The CMS public use file suppresses values lower than 10.

Consumers rarely appeal denied claims. Of the more than 48 million in-network denied claims in 2021, marketplace enrollees appealed 90,599 – an appeal rate of less than two-tenths of one percent. (Figure 4) Issuers upheld 59% of denials that were appealed.

Marketplace consumers also rarely file external appeals. From ACA transparency data (and imputing a value of “5” for each cell where values were suppressed) we estimate just over 2,500 external appeals were filed by marketplace enrollees in 2021.

Discussion

Limited ACA transparency data collected by the federal government continues to show wide disparities in the rate at which marketplace plans pay claims. While on average HealthCare.gov insurers denied nearly 17% of in-network claims in 2021, some insurers report denying nearly half of in-network claims submitted. The federal government has not expanded or revised transparency data reporting requirements in years and does not appear to conduct any oversight using data that are reported by marketplace plans. As a result, consumers are not provided any information about how reliably marketplace plan options pay claims and plans reporting high claims denial rates do not appear to face any consequences.

1. If an issuer offered a plan in 2021 that it no longer intends to offer in 2023, it should report issuer-level data for that 2021 plan, but no plan-level 2021 data will be reported for that plan. Similarly, if an issuer seeks to offer a plan in 2023 that it did not offer in 2021, it will report transparency data of “NA” for that plan in 2022.  Under these reporting rules, the total issuer-level claims data for 2021 may include plans that will not be offered in 2023; as a result the plan-level claims total may not equal the issuer-level claims total.  For more detailed transparency data reporting instructions, see “Qualified Health Plan Issuer Application Instructions, Plan Year 2023” starting at page 2E-1. ↩︎
2. In 2020, the Trump Administration issued a final regulation requiring all non-grandfathered plans – including those sponsored by employers or offered by issuers outside of HealthCare.gov – to report billed charges and negotiated allowed amounts for covered items and services, enforceable beginning July 1, 2022. The regulation invokes ACA transparency data reporting authority but does not require plans to report prices to CMS; instead, price data must be posted online by each plan sponsor and issuer, making it unlikely that the price data across plans and issuers will be compiled into a single public use file provided by the federal government. ↩︎

On January 26, the Centers for Medicare and Medicaid Services (CMS) approved California’s Section 1115 request to cover a package of reentry services for certain groups of incarcerated individuals 90 days prior to release. This approval is the first to include a partial waiver of the statutory Medicaid inmate exclusion policy, which prohibits Medicaid from paying for services provided during incarceration (except for inpatient services). Justice-involved individuals are disproportionately low-income and often have complex and/or chronic conditions, including behavioral health needs (mental health conditions and/or substance use disorder (SUD)). Reentry services aim to improve care transitions for these high-need Medicaid enrollees upon release and increase continuity of health coverage, prevent disruptions in care, and lead to improved health outcomes. This Waiver Watch summarizes the California approval and examines similar pending requests from 14 additional states to provide pre-release services.

What is the background?

The 2018 SUPPORT Act directed CMS to issue guidance on how waivers can improve care transitions for incarcerated individuals who are otherwise eligible for Medicaid. The SUPPORT Act required the Secretary of Health and Human Services (HHS) to convene a group of stakeholders to help inform the design of a demonstration opportunity to improve care transitions for individuals leaving incarceration. Findings from that convening were summarized in a report from the Office of the Assistant Secretary for Planning and Evaluation (ASPE), and the report includes promising practices and key considerations for the demonstration opportunity such as giving states options to customize the demonstration population, invest in data infrastructure, implement strategic partnerships, and include pre-arrest diversion activities. CMS has indicated that the guidance for the new waiver opportunity is forthcoming and will closely align with the approved approach to pre-release services in California.

States have used Medicaid strategies to help maintain eligibility and coordinate care for individuals transitioning from incarceration. While California is the first state to receive a partial waiver of the inmate exclusion, states can adopt other strategies to coordinate care for incarcerated Medicaid enrollees, such as by suspending (rather than terminating) eligibility for enrollees who became incarcerated and by developing managed care requirements and fee-for-service initiatives related to pre-release care coordination. The Biden Administration has encouraged states to propose waivers that address health-related social needs, expand coverage, and reduce health disparities, including by investing in initiatives for justice-involved populations.

What is included in the California waiver?

California estimates that approximately 200,000 people each year will be eligible to receive pre-release services under the demonstration waiver. While the waiver is complex and includes many provisions, key aspects of the “Reentry Demonstration Initiative” include the following:

• Eligibility based on health needs: Services will be available to all Medicaid-eligible adults who are inmates in state prisons and county jails and meet health criteria, beginning 90 days prior to their expected date of release. The health criteria aim to identify inmates at high risk of adverse health outcomes pre- and post-release, including those with behavioral health needs or other chronic conditions. Also, all inmates of youth correctional facilities will be eligible for services 90 days pre-release, without meeting any clinical criteria.
• Reentry benefit package: The limited benefit package is intended to improve care transitions for individuals upon release and prevent hospitalization as well as adverse outcomes including suicide, overdose, and recidivism. Covered services include case management, physical and behavioral health clinical consultation services, laboratory and radiology services, medications and medication administration, medication-assisted treatment (MAT) for substance use disorder, and Community Health Worker (CHW) services. Upon release, enrollees will also receive covered outpatient prescribed medications and over-the-counter drugs (a minimum 30-day supply, as clinically appropriate) and durable medical equipment (DME).
• Implementation timing and funds: The waiver also includes authority to spend $410 million on pre-release application planning and information technology through California’s “Providing Access and Transforming Health” (PATH) initiative. California will use these funds to provide capacity grants and case management services beginning in April 2024, with the pre-release service package being phased in over two years. California also must provide pre-release education and outreach, along with Medicaid eligibility and enrollment support, to all incarcerated individuals while the demonstration functions.

CMS recognizes that effective implementation of California’s pre-release services program will require forging new partnerships with and providing significant technical assistance to correctional authorities, providers, and community-based organizations. To help ensure access to care upon release and for other Medicaid enrollees, California is also required to increase and (at least) sustain base Medicaid payment rates of at least 80% of Medicare rates for primary care, behavioral health, and obstetrics providers (this requirement is consistent with other states that recently received approvals to address health-related social needs).

What is pending in other states?

As of February 7, 14 additional states are also seeking partial waivers to the inmate exclusion policy to provide pre-release services to some eligible incarcerated individuals (Figure 1). The parameters of these proposals may change to reflect the California approval and upcoming CMS guidance. Currently, these pending requests vary in scope by pre-release period, eligibility and benefits:

• Pre-release period. Most states (9 out of 15) intend to provide coverage to eligible inmates 30 days prior to release. Of the remaining states, three (New Hampshire, New Jersey, and Vermont) seek to provide coverage between 45 and 90 days prior to release. Kentucky proposes to provide fee-for-service benefits for the duration of an inmate’s commitment and through an MCO beginning 30 days prior to release. The other two states (Oregon and Massachusetts) would cover some inmates throughout the duration of their commitment, while covering other groups for a more limited pre-release period.
• Eligibility. Four states (Oregon, Rhode Island, Vermont, and Washington) are seeking to provide benefits to all inmates of state and county facilities. The remaining states would limit these services to inmates who meet health or risk criteria (frequently related to behavioral health needs).
• Benefits. Four states (Massachusetts, Rhode Island, Utah and Vermont) seek to provide full Medicaid State Plan benefits to eligible inmates during the pre-release period. Oregon proposes to provide full benefits to individuals in jail, while state prison inmates would receive a limited package of care coordination services. The remaining states would provide a limited benefit package for all eligible inmates (typically to include services such as reentry support, enhanced case management, and behavioral health care).

For further state-by-state details on Section 1115 pre-release requests, see Table 1.

Booster update remains modest; half of those already boosted are waiting for updated CDC guidelines to get another dose

Nearly four in ten (38%) people say their households were affected by this winter’s triple threat of viruses, with someone getting sick with the flu, COVID-19, or respiratory syncytial virus (RSV), and nearly half (46%) say the news of these three viruses spreading has made them more likely to wear masks or take other precautions to avoid getting sick, the latest KFF COVID-19 Vaccine Monitor survey finds.

At the same time, almost three years into the COVID-19 pandemic, most of the public says they are “not too” or “not at all” worried about getting seriously ill from the virus (69%), though 31% still say they are worried. That’s somewhat more than say the same about the flu (26%) or RSV (25%).

The flu affected the largest share of households over the past month or so (27%), with smaller shares saying someone in their homes got sick with COVID-19 (15%) or RSV (10%).

A relatively small share (14%) of adults in households affected by COVID-19 say they tried to get Paxlovid, the anti-viral prescription pill used to treat COVID-19. Similarly, among those households affected by the flu, 16% say they tried to get Tamiflu, an antiviral prescription medicine used to treat the flu.

Amid media reports of shortages of over-the-counter medicines often used to treat symptoms of these ailments, the survey finds that 75% of adults in affected households tried to obtain over-the-counter medicines such as Tylenol or cough syrup, including about one in five (representing 6% of all adults) who say they had difficulties getting that medicine.

News about the three viruses also made some people more likely to take preventive measures such as wearing a mask in public (31%), avoiding large gatherings (26%), traveling less (20%), or avoiding eating indoors at restaurants (18%).

People who say they are immunocompromised are more likely than those who aren’t to take many of those extra precautions. In addition, Black and Hispanic adults are more likely than White adults, and Democrats are more likely than Republicans, to say they are more likely to modify their behavior.

Nearly 3 in 10 Adults Now Say They’ve Gotten Updated Bivalent Booster Shot

As the federal government prepares to end its public health emergency declaration, the latest survey finds nearly three in ten (28%) adults report having received an updated COVID-19 bivalent vaccine booster shot, up slightly from December (22%). The increase largely reflects a shift in booster rates among Republicans (from 12% in December to 20% in January, though Democrats still are twice as likely to have gotten the updated booster (39%).

Among high-risk groups, nearly half (47%) of adults at least 65 years old, and about a third (36%) of those who are immunocompromised, say they have already received a bivalent booster dose.

Those who already received a bivalent booster are eager to get an additional booster in the future. The vast majority (86%) say that getting another shot is important to them, and just over half (54%) say they are waiting for the Centers for Disease Control and Prevention (CDC) to issue new guidelines to make them eligible for another booster.

On the other side, vaccinated adults who have not gotten the bivalent booster yet cite a number of reasons for why they haven’t done so.  Half (51%) say they feel they have enough protection from their initial vaccination or a prior infection, and nearly as many (44%) say they don’t think they need the new booster.

Smaller shares say that they have been too busy or have not had the time to get the updated booster (29%), that they had bad side effects from a previous dose (19%), or that they cannot afford to take time off work to get the shot and deal with side effects from the vaccine (15%).

Designed and analyzed by public opinion researchers at KFF, the survey was conducted from January 17-24, 2023, online and by telephone among a nationally representative sample of 1,234 U.S. adults, in English and in Spanish. The margin of sampling error is plus or minus 4 percentage points for the full sample. For results based on other subgroups, the margin of sampling error may be higher.

The KFF COVID-19 Vaccine Monitor is an ongoing research project tracking the public’s attitudes and experiences with COVID-19 vaccinations. Using a combination of surveys and qualitative research, this project tracks the dynamic nature of public opinion as vaccine development and distribution unfold, including vaccine confidence and acceptance, information needs, trusted messengers and messages, as well as the public’s experiences with vaccination.

On Jan. 30, 2023, the Biden Administration announced it will end the public health emergency (and national emergency) declarations on May 11, 2023. Here’s what major health policies will and won’t change when the public health emergency ends.

Vaccines

What’s changing: Nothing. The availability, access, and costs of COVID-19 vaccines, including boosters, are determined by the supply of federally purchased vaccines, not the public health emergency.

What’s the same: As long as federally purchased vaccines last, COVID-19 vaccines will remain free to all people, regardless of insurance coverage. Providers of federally purchased vaccines are not allowed to charge patients or deny vaccines based on the recipient’s coverage or network status.

Although a federal rule temporarily required private insurers to reimburse out-of-network providers for vaccine administration during the public health emergency, vaccine access will be unaffected by insurers ending these payments, as long as federal supplies last, because vaccine providers are not allowed to deny anyone a federally purchased vaccine based the recipient’s coverage or network status and must not charge any out-of-pocket costs.

Due to the Affordable Care Act and other recent legislation, even after the federal supply of vaccines is gone, vaccines will continue to be free of charge to the vast majority of people with private and public insurance. However, costs may become a barrier for uninsured and underinsured adults when federally purchased doses are depleted, and privately insured people may then need to confirm their provider is in-network. For more on what happens after the federal supply of vaccines runs dry, see our briefs on the commercialization of COVID vaccines and the expected growth in prices for COVID vaccines.

Importantly, the Food and Drug Administration (FDA)’s emergency use authorizations for COVID-19 vaccines (and treatments and tests) will remain in effect, as they are tied to a separate emergency declaration, not the public health emergency that ends in May.

At-home COVID tests

What’s changing: At-home (or over-the-counter) tests may become more costly for people with insurance. After May 11, 2023, people with traditional Medicare will no longer receive free, at-home tests. Those with private insurance and Medicare Advantage (private Medicare plans) no longer will be guaranteed free at-home tests, but some insurers may continue to voluntarily cover them.

For those on Medicaid, at-home tests will be covered at no-cost through September 2024. After that date, home test coverage will vary by state.

A temporary Medicaid coverage option adopted by 15 states has given uninsured people access to COVID-19 testing services, including at-home tests, without cost-sharing but that program will end with the public health emergency.

What’s the same: Uninsured people in most states were already paying full price for at-home tests as they weren’t eligible for the temporary Medicaid coverage for COVID testing services. Uninsured and other people who cannot afford at-home tests may still be able to find them at a free clinic, community health center, public health department, library, or other local organization. Additionally, some tests have been provided by mail through the federal government, though supply is diminishing.

PCR and rapid tests ordered or administered by a health professional

What’s changing: Although most insured people will still have coverage of COVID tests ordered or administered by a health professional, these tests may no longer be free.

• For people with traditional Medicare, there will be no cost for the test itself, but there could be cost-sharing for the associated doctor’s visit.
• For people with Medicare Advantage and private insurance, the test and the associated doctor’s visit both might be subject to cost-sharing, depending on the plan. Additionally, some insurers might begin to limit the number of covered tests or require tests be done by in-network providers. People in grandfathered or non-ACA-compliant plans will have no guarantee of coverage for tests and may have to pay full-price.

• For people with Medicaid, there will continue to be free tests through September 2024, after which point, states may limit the number of covered tests or impose nominal cost-sharing.
• Uninsured people in the 15 states that have adopted the temporary Medicaid coverage option will no longer be able to obtain COVID-19 testing services, including at-home tests, with no cost-sharing as this program ends with the public health emergency.

What’s the same: Uninsured people in most states were not eligible for the temporary Medicaid pathway for COVID testing and therefore will continue to pay full price for tests unless they can get tested through a free clinic or community health center.

COVID Treatment

What’s changing: People with public coverage may start to face new cost-sharing for pharmaceutical COVID treatments (unless those doses were purchased by the federal government, as discussed below). Medicare beneficiaries may face cost-sharing requirements for certain COVID pharmaceutical treatments after May 11. Medicaid and CHIP programs will continue to cover all pharmaceutical treatments with no-cost sharing through September 2024. After that date, these treatments will continue to be covered; however, states may impose utilization limits and nominal cost-sharing.

What’s the same: Any pharmaceutical treatment doses (e.g. Paxlovid) purchased by the federal government are still free to all, regardless of insurance coverage. This is based on the availability of the federal supply and is not affected by the end of the public health emergency.

Most insured people already faced cost-sharing for hospitalizations and outpatient visits related to COVID treatment. Private insurers were never required to waive cost-sharing for any COVID treatment. Though some did so voluntarily, most insurers had already phased out these waivers more than a year ago.

Telemedicine

What’s changing: Some flexibilities associated with providing health care via telehealth during the public health emergency will end.

• During the public health emergency, providers writing prescriptions for controlled substances were allowed to do so via telemedicine, but in-person visits will be required after May 11.
• Because of the pandemic, all states and D.C. temporarily waived some aspects of state licensure requirements so that providers with equivalent licenses in other states could practice remotely via telehealth. Some states tied those policies to the end of the federal public health emergency so those policies may end unless those states change their policy.
• The Department of Health and Human Services temporarily waived penalties against providers using technologies that don’t comply with federal privacy and security rues in the provision of telehealth services during the public health emergency. Enforcement of these rules when the public health emergency ends will restrict the provision of telehealth to so-called “HIPAA compliant” technologies and communication productions.

What’s the same: Expanded telehealth for Medicare beneficiaries was once tied to the public health emergency but, due to recent legislation, will remain unchanged through December 31, 2024. Most private insurers already covered telemedicine before the pandemic. In Medicaid, states have broad authority to cover telehealth without federal approval. Most states have made, or plan to make, some Medicaid telehealth flexibilities permanent.

Discussion

Overall, the widest ranging impact from the end of the public health emergency will likely be higher costs for COVID tests – both at-home tests and those performed by clinicians. As many Americans delay or go without needed care due to cost, the end of free COVID tests could have broad implications for the people’s ability to get timely COVID diagnoses or prevent transmission. Other changes to health policies that are tied to the public health emergency, national emergency, and other declarations are discussed in more detail in our earlier brief.

Further, and potentially more significant, changes will come when federal supplies of vaccines, treatments, and tests are depleted, though the timing of that is yet to be determined and is not tied to the public health emergency. The Biden administration has announced that it has no further funding for vaccines, tests, or treatments, and that Congress would need to make more funding available.

Importantly, continuous enrollment for Medicaid enrollees – which has led to record-high enrollment in Medicaid – was once tied to the end of the public health emergency. However, recent legislation decoupled this provision from the public health emergency and ends continuous enrollment on March 31, 2023. States can begin disenrolling people from Medicaid as early as April 1, 2023, though most states will take a year to complete these disenrollments. KFF has estimated that millions of people will lose Medicaid coverage during this unwinding period.

This year, the marking of Lunar New Year was marred by yet another tragic mass shooting in Monterey Park, California, which was closely followed by a second mass shooting in Half Moon Bay, California. Many, but not all, of the victims of both shootings were Asian, as were the perpetrators. These shootings occurred against the backdrop of rising racism and discrimination and hate crimes against Asian people amidst the pandemic. Motives for both shootings remain under investigation and mental illness is not a strong predictor of such shootings. However, as efforts are made to help the victims recover and to respond to the broader ripple effects of violence on the health and well-being in these communities, it is important to consider how our health care system meets the mental health care needs of Asian and Native Hawaiian and other Pacific Islander (NHOPI) people and other people of color and gaps that could be addressed to improve their care. This policy watch provides insight into these issues.

The COVID-19 pandemic has contributed to and coincided with worsening mental health across the population, including Asian and NHOPI people. In addition to the negative health and economic impacts of the pandemic experienced across the population, Asian people also have experienced increased discrimination and hate crimes, which research suggests have negatively impacted their mental health. These issues are not new, as Asian and NHOPI people have faced longstanding racism and discrimination among other challenges, including exclusionary immigration policies, internment, and stresses associated with the model minority stereotype, and acculturation. These experiences are linked to poor mental health.

Overall rates of mental illness are generally lower among Asian people compared to White people, but this may reflect underdiagnosis and undertreatment among the population. In 2021, 16% of Asian adults reported any mental illness in the past year compared to 24% of White adults; there was no statistically significant difference in rates of mental illness between NHOPI and White adults. The lower rate of mental illness among Asian adults may be reflective of underdiagnosis and underreporting. It also may mask variations in mental illness rates among subgroups of the population. Among people with mental illness, Asian people are less likely to utilize mental health services compared to other racial and ethnic groups. In 2021, among adults with any mental illness in the past year, only 25% of Asian adults reported receiving mental health services compared to 52% of White adults (Figure 1). Data on utilization were not available for NHOPI people. Moreover, data show rising rates of suicide death among Asian and Pacific Islander adolescents (ages 12-17). Although they have lower rates of suicide death compared to their White peers, suicides were the leading cause of death among Asian and Pacific Islander adolescents in 2020, and suicide death rates more than doubled among this population from 2010 (2.2 per 100,000) to 2020 (5.0 per 100,000).

Gaps in the mental health care system pose an array of challenges to accessing care for Asian and NHOPI people. While stigma and cultural attitudes towards mental health are factors that may lead to lower reporting of mental health concerns and service utilization among Asian people, it is also important to consider how the health care system shapes their ability to identify needs and access care. For example, research points to the lack of a diverse mental health provider workforce and the absence of culturally informed treatment options for Asian people, which may contribute to lower utilization. Moreover, the Asian population is not a monolith. There is wide variation in the characteristics of Asian and NHOPI people that affects their experiences, health needs, and ability to access health care. Overall, over one in four Asian people is a noncitizen and nearly one in three speaks English less than very well, with even higher rates among some subgroups. Noncitizens and individuals with limited English proficiency may face increased barriers to accessing care, including immigration-related fears and lack of access to linguistically appropriate services. Additionally, some subgroups of Asian and NHOPI people have higher uninsured rates and are more likely to face social and economic challenges that may pose logistical and financial challenges to accessing care.

Research and data to understand mental health needs and care among Asian and NHOPI people remains limited. Many datasets have small samples of data for Asian and NHOPI people and some report data for these individuals in a combined group, limiting the ability to examine experiences of NHOPI people and variations in experiences among Asian subgroups. Moreover, some research suggests that underreporting of mental health concerns among Asian people in national survey data may, in part, be due to limited survey language options. Smaller studies offered in multiple languages have identified greater mental health concerns and underutilization of mental health services among Asian people.

Response to the victims and communities affected by recent mass shooting tragedies has turned national attention and focus to mental health care for Asian and NHOPI people, groups that too often remain overlooked and left out of data and policy discussions related to health disparities. As efforts unfold to assist the victims and prevent and respond to future events, it will be key to reflect on how the system can adapt to better meet the needs of a diverse population, including Asian and NHOPI people.

Medicare Advantage plans denied two million prior authorization requests for health care services in whole or in part in 2021, or about six percent of the 35 million requests submitted on behalf of enrollees that year, a new KFF analysis finds.

Prior authorization is intended to ensure that health care services are medically necessary by requiring providers to obtain approval before a service or other benefit is covered. While prior authorization has long been used to contain spending and prevent people from receiving unnecessary or low-value services, there are some concerns that it may create barriers to receiving necessary care. (Traditional Medicare does not require prior authorization except for a limited set of services.)

The analysis also finds variations in both the volume of prior authorization requests and denial rates across insurers. In general, insurers with higher numbers of prior authorization requests denied a lower share of those requests. The variation across insurers likely reflects differences in the services subject to prior authorization and the frequency with which contracted providers are exempted from these requirements, as well as variations in the use of other tools to manage utilization by plan enrollees.

Only about 11 percent of denials of prior authorization requests were appealed, the analysis finds. However, of the appeals that were filed, the vast majority (82%) resulted in fully or partially overturning the initial denial.

The high rate of successful appeals raises questions about whether a larger share of the initial prior authorization requests should have been approved. Alternatively, it could reflect problems with documentation that were subsequently rectified during the appeal. In either case, medical care ordered by physicians or other practitioners ultimately deemed necessary by the insurers was potentially delayed by the prior authorization process.

As Medicare Advantage enrollment continues to grow, a better understanding of prior authorization will help inform how the policy affects the use of health care services and the quality of the care that beneficiaries receive.

More than six months since the Supreme Court issued their Dobbs decision which overturned Roe v. Wade, there is widespread public confusion about the medication abortion pill and whether it is legal at the state level, according to the latest KFF Health Tracking Poll. The poll also finds many are unsure about the legality of emergency contraceptive pills, sometimes called morning after pills or “Plan B,” and whether the pills can end a pregnancy.

Across the country at least four in ten U.S. adults say they are “not sure” whether mifepristone, the medication abortion drug, is legal where they live. Half of women (49%) are “unsure” about whether medication abortion is legal in the state they live in, including 41% of women ages 18-49.

In the 13 states where there are full abortion bans, including for medication abortion, most adults either wrongly believe that medical abortion is legal in their state (13%) or are “unsure” about whether it is legal or not (47%). Four in ten adults living in states with full abortion bans are aware medication abortion is illegal in their state.

In states where abortion is legal, fewer than half (44%) are aware that medication abortion is legal there. A similar share (44%) is “unsure” whether medication abortion is legal in their state, while one in ten incorrectly believe medication abortion is not legal in their state.

On January 3, the FDA approved a protocol to allow pharmacies that have been certified by the manufacturers to dispense mifepristone directly to the patients, with a prescription. Previously, the pills could be dispensed only by a certified healthcare provider and were not available through a retail pharmacy. Three-quarters of adults (73%) have not heard anything in the news about the decision, including nearly eight in ten (77%) women under the age of 50.

Awareness Of Plan B Is Widespread, But Many Are Unsure About Its Legality and Whether It Ends A Pregnancy

Most U.S. adults (93%) have heard of the morning after pill or “Plan B” and 62% who have heard of it are aware that the pills are not the same as the abortion pill. Nonetheless, a substantial share (73%) incorrectly think that emergency contraceptive pills can end a pregnancy in its early stages. This includes two-thirds of women of childbearing age (18-49) who incorrectly say emergency contraceptive pills can end a pregnancy in its early stages.

Emergency contraceptives like “Plan B” are legal in all 50 states. However, a third of adults (32%) say they are “unsure” if emergency contraceptive pills, or “Plan B,” are legal in their state or not, and five percent of adults incorrectly think emergency contraceptive pills are illegal in their state. Large shares of women, especially those under the age of 50, are among the groups most likely to be aware that emergency contraceptive pills are legal in their state but even among this group, about a quarter are either unsure about the legality of “Plan B” or incorrectly believe they are illegal. Confusion is more widespread in states where abortions are currently banned, with more than half of people living in those states, including half of women, unaware that “Plan B” is still legal.

Designed and analyzed by public opinion researchers at KFF, the survey was conducted from January 17-24, 2023, online and by telephone among a nationally representative sample of 1,234 U.S. adults, in English and in Spanish. The margin of sampling error is plus or minus 4 percentage points for the full sample. For results based on other subgroups, the margin of sampling error may be higher.