Claims Denials and Appeals in ACA Marketplace Plans

Issue Brief
  1. The ACA transparency in coverage data reporting requirements for marketplace plans are at Section 1311(e)(3);  Section 2715A applies the same requirements to group health plans and issuers outside of the marketplace.

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  2. The transparency files also include data on QHP enrollment and disenrollment at the issuer level. Enrollment and disenrollment data are not reported by plans, but reflect information collected by the HealthCare.gov Multidimensional Insurance Data Analytics System (MIDAS). The MIDAS enrollment and disenrollment data are posted in other public use files, as well, with data displayed at the plan level. Data do not reflect monthly changes in enrollment, and in some cases, because of the data methodology used by CMS, reflect more disenrollments than enrollment for a given plan or issuer.

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  3. Of note, the CMS public use files posted online are named in a way that reflects a reporting lag. Issuers seeking healthcare.gov certification of qualified health plans for the coming year report transparency data on that plan for the prior year if the plan was also certified by healthcare.gov in the prior year. As a result, the 2021 public use file contains transparency data for the 2019 plan year.  Data are not reported for 2019 plans if they will not be offered in 2021.

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  4. The average claims denial rate for platinum plans reported was 3.2%, though only 29 platinum plans reported claims denial data for 2019.

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