Private Insurance

With the high costs of emergency department visits of significant importance to consumers and policymakers, this analysis examines claims data from privately insured individuals with large employer health plans, to examine the role that facility fees play in rising cost of emergency care.

This analysis finds that, among people with large employer health plans, those with an obesity diagnosis on average have higher total and out-of-pocket spending than those without an obesity diagnosis. It also examines the cost of common surgical and pharmacological treatments for obesity. 

The provision of the Affordable Care Act (ACA) that requires most private health plans to cover many preventive services without any cost-sharing for their enrollees is being challenged in federal court. The U.S. District Court in the Northern District of Texas in September concluded that aspects of the requirement were…

This analysis of  claims data estimates that six in ten people with private health insurance – or about 100 million people – used at least one preventive service covered without any out-of-pocket costs through a provision of the Affordable Care Act (ACA) in a typical year prior to the COVID-19…

A new analysis of health insurers’ 2021 financial data shows that insurers continue to report much higher gross margins per enrollee in the Medicare Advantage market than in other health insurance markets. The analysis examines insurers’ financial data in the Medicare Advantage, Medicaid managed care, individual (non-group), and fully insured…

Using health insurer financial data for 2021, we find that Medicare Advantage insurers reported gross margins that were at least twice as high as those reported by insurers in the individual/non-group, fully-insured group/employer, and Medicaid managed care markets. The four markets report similar simple medical-loss-ratios.

This analysis for the Peterson-KFF Health System Tracker uses claims data from private, large employer-based plan to examine trends in complexity coding across outpatient practice settings from 2004 to 2021. It finds a trend toward higher complexity codes that contributes to higher outpatient spending.

With the depletion of the federal-purchased supply of COVID-19 vaccines, treatments and tests and end to the public health emergency on the horizon, this document provides an overview of the implications of these changes for access to these products by payer.

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.