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Prior Authorization Metrics Provide New Insights into Insurer Practices, but Gaps Remain

This analysis of available 2025 prior authorization data finds insurers denied at least 1 in 8 standard requests for prior authorization across three insurance markets: Medicare Advantage, Medicaid managed care, and the federally facilitated ACA Marketplaces. Denial rates varied wide segments by insurer. The analysis highlights limitations of the data and challenges for consumers interpreting it.

TrumpRx: What’s the Value for Customers?

In February, the Trump administration launched TrumpRx, a government website that provides prescription drug discounts to consumers. This brief examines issues that may impact consumers, especially those with private insurance, who access drug discounts through TrumpRx.

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  • New OIG Report Examines Prior Authorization Denials in Medicaid MCOs

    Policy Watch

    Congress asked the U.S Department of Health and Human Services (HHS) Office of the Inspector General (OIG) to investigate whether Medicaid MCOs are providing medically necessary health care services to their enrollees. OIG found that Medicaid MCOs had an overall prior authorization denial rate of 12.5%–more than 2 times higher than the Medicare Advantage rate. Prior authorization denial rates ranged widely across and within parent firms and states. After a prior authorization request is denied,…

  • Rise in Use of Mental Health Apps Raises New Policy Issues

    Issue Brief

    Use of digital behavioral health services increased during the COVID-19 pandemic when in-person visits were limited. This brief examines how different types of mental health apps are used, how federal policies during the pandemic affected the scope of services they could provide, and key issues to watch.

  • KFF Survey of Consumer Experiences with Health Insurance

    Poll Finding

    The survey finds nearly six in 10 people with health insurance experienced a problem using their insurance in the past year, with even larger shares reporting problems among people who are sick or who have mental health needs. It includes data for people with different types of coverage, including employer, Marketplace, Medicare and Medicaid, and also examines affordability issues and mental health access.

  • KFF News Release

    KFF Survey Shows Complexity, Red Tape, Denials, Confusion Rivals Affordability as a Problem for Insured Consumers, With Some Saying It Caused Them to Go Without or Delay Care

    News Release

    Most (58%) people with health insurance say they encountered at least one problem using their coverage in the past year, with even larger shares of people with the greatest health care needs reporting such problems, finds a new KFF survey of consumer experiences with health insurance. Such problems vary across types of insurance but include such things as denied claims for care they thought was covered, difficulty finding an in-network doctor or other provider, and…

  • Standardized Plans in the Health Care Marketplace: Changing Requirements

    Issue Brief

    This brief examines the evolving requirements for insurers on HealthCare.gov to offer standardized plans that follow set cost sharing rules for covered benefits in addition to other plans they might offer. It also reviews how some state-run marketplaces have used standardized plans to limit cost sharing for insulin, mental health care, and other services.

  • Analysis: Inconsistencies Within Hospital Price Transparency Data Make Cost Comparisons Difficult

    News Release

    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. To date, however, the transparency data currently shared by hospitals to comply with the law are messy, inconsistent and confusing, making it challenging, if not impossible, for patients or researchers to use them to compare prices across hospitals or payers, a new…

  • Ongoing Challenges with Hospital Price Transparency

    Issue Brief

    This analysis examines transparency data currently shared by hospitals to comply with federal law and finds that they are messy, inconsistent and confusing, making it challenging if not impossible for patients or researchers to use them to compare prices. Many of these shortcomings stem from a lack of specificity in the requirements for what hospitals must report.

  • Claims Denials and Appeals in ACA Marketplace Plans in 2021

    Issue Brief

    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.