Patient and Consumer Protections

Prior AUthorization

The Public’s Views and Experiences with Prior Authorization

Following a pledge by insurance companies to reduce the burden of prior authorizations, KFF’s Health Tracking Poll examines the publics experience with the process. The poll finds that most view insurers’ delays and denials as a problem, and few are aware of the newly announced pledge.

Medicare Advantage Insurers And Prior Authorization Determinations

Nearly 50 million prior authorization requests were submitted to Medicare Advantage insurers on behalf of Medicare Advantage enrollees in 2023, of which 3.2 million (6.4%) were denied. Just 11.7% of denied requests were appealed, though 81.7% of appeals overturned the initial denial in Medicare Advantage.

KFF issue brief on Prior Authorization Process Policies in Medicaid Managed Care: Findings from a Survey of State Medicaid Programs

Prior Authorization Process Policies in Medicaid Managed Care

This brief examines state policies related to prior authorization processes in Medicaid managed care and includes findings about how states approach prior authorization decision timeframes, electronic denial notices, and access to external medical reviews, all as of July 1, 2024.

Other Issues

Health Care Debt In The U.S.: The Broad Consequences Of Medical And Dental Bills

The KFF Health Care Debt Survey finds that four in ten adults have some form of health care debt, with most citing one-time or short-term medical expenses as the contributor. Many of those with health care debt report making personal sacrifices and enduring financial consequences as a result of their debt, while nearly one in five think they will never be able to pay off.

Claims Denials and Appeals in ACA Marketplace Plans in 2021

This analysis of HealthCare.gov Marketplace insurers’ transparency data finds that 17% of in-network claims were denied in 2021, with denial rates varying widely across insurers. Consumers appealed less than two-tenths of 1% of denied in-network claims.

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  • The Regulation of Private Health Insurance

    Feature

    This Health Policy 101 chapter explores the complex landscape of private health insurance regulation in the United States, detailing the interplay between state and federal regulations that shape access, affordability, and the adequacy of private health coverage. It focuses on key laws such as the Affordable Care Act (ACA) and the Employer Retirement Income Security Act (ERISA), and discusses how regulations impact the private insurance market, illustrating the challenges consumers face in navigating this system.

  • Charting the Way Forward: New Efforts to Advance Electronic Health Information Sharing

    Issue Brief

    In July 2025, the Trump administration announced a new effort (“Making Health Tech Great Again”) towards health data interchange.. This brief describes the new, voluntary Trump administration interoperability initiative, provides an overview of key health information technology laws and regulations, and highlights some of the challenges and limitations of these efforts.

  • Fraud in Marketplace Enrollment and Eligibility: Five Things to Know

    Issue Brief

    This brief evaluates what is currently known about fraud and abuse in the Affordable Care Act (ACA) Marketplace, including how the final Marketplace Integrity and Affordability Rule and the recently enacted budget reconciliation law change existing Marketplace enrollment and eligibility standards.

  • Claims Denials and Appeals in ACA Marketplace Plans in 2023

    Issue Brief

    This brief analyzes federal 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 in 2023. It finds that HealthCare.gov insurers denied nearly one out of every five claims (19%) submitted for in-network services. Information about the reasons for denials is limited, and few consumers appeal claims denials.

  • KFF Health Tracking Poll: Public Weighs Health Care Spending and Other Priorities for Incoming Administration

    Feature

    With the incoming Trump administration and Republican-led Congress looking to ways to reduce federal spending, this Poll finds that the Medicare and Medicaid programs remain broadly popular, and more people favor more spending on those programs than less spending. Among potential actions on health, the public sees price transparency and limiting chemicals in food as top priorities. Few say so about cuts to Medicaid and restrictions on abortion.