Health insurance exchange carriers rejected nearly one-in-five in-network claims in 2024.
That’s according to federal health insurance exchange claims data analyzed by the health policy research institute KFF. The 19% denial rate is tied with 2023 for the highest since the Affordable Care Act of 2010 marketplaces debuted in 2015.
Oscar Health, Molina Healthcare, Florida Blue, Community Health Choice, Cigna and BlueCross BlueShield of Tennessee turned down the largest share of in-network claims for plans purchased on the federal enrollment platform, KFF reported Tuesday.
The denial rate has held steady over time, dipping to a low of 14% in 2018.
The KFF report does not include 20 states and the District of Columbia, which operate their own health insurance exchanges and manage enrollments. The analysis is limited to insurers that processed at least 1,000 claims in 2024 and still participate in the federal enrollment system.
Oscar Health rejected the greatest share of in-network federal exchange plan claims in 2024. Its denial rate jumped from 17% in 2023 to 25% in 2024.
Molina Healthcare came in second despite its denial rate declining from 26% in 2023 to 22% in 2024. Florida Blue, Community One Choice, BlueCross BlueShield of Tennessee and Cigna each refused at last 20% of these claims.
UnitedHealth Group subsidiary UnitedHealthcare approves 98% of complete claims for eligible members, the company said in a statement. None of the other insurers responded to interview requests.
“Health plans approve the overwhelming majority of claims they receive,” the trade group AHIP said in a statement. “The vast majority of denials are due to incorrect or incomplete claim submissions from providers, duplicate claims, claims for unproven or unsafe treatments and services, or for services that are not part of covered benefits. An appeal is always available.”
Members appealed fewer than 1% of denials, and insurers stood by their original decisions in 66% of challenges, according to KFF.
The rate of in-network denials was steady across metal levels. Insurers turned down the most in-network claims, or 22%, for catastrophic plans and the least, or 17%, for Gold coverage.
There was a wide range from state to state. South Dakota and New Hampshire insurers rejected 7% of in-network claims, the fewest, while Hawaii carriers declined 27%, the most.
Health insurance companies cited medical necessity or benefit limits in 5% of in-network denials, KFF found. They cited administrative reasons for 25%, excluded services for 13%, lack of prior authorization for 9% and member not covered for 7%. The most common reason they reported was “other,” at 36%.
Last year, the industry groups AHIP, the Blue Cross Blue Shield Association and more than 40 insurance companies committed to reduce the prior authorization burden and to communicate more about denials. The industry pledge followed a federal regulation that set similar requirements for prior authorizations under government health programs.