Media Contact: Diego Sandino, ra-in-press@pa.gov
Harrisburg, PA – Under Governor Josh Shapiro's leadership and commitment to consumer protection, the Pennsylvania Insurance Department (PID) today released Pennsylvania's inaugural 2023 Transparency in Coverage Report, outlining data on claims, claim denials, and appeal information for health insurers doing business in the Commonwealth.
"Pennsylvanians deserve clarity in how their health insurance companies operate, and PID is committed to helping consumers understand the benefits and rights afforded under their health insurance policies," said Pennsylvania Insurance Commissioner Michael Humphreys. "This report provides unprecedented insight into companies' claims denials and appeals processes that consumers may consider in preparing for upcoming healthcare services and underscores the importance of Pennsylvanians knowing that the appeals process is available to them. If any consumer has any questions about their health plan or a denied claim, they should contact PID if they aren't sure where to start. Our consumer services team is here to help and get them to the right place for assistance."
This reporting of data is required under the federal Affordable Care Act (ACA) for health insurance companies that are seeking Qualified Health Plan (QHP) certification. A QHP is an insurance plan that is certified by Pennie®, Pennsylvania's health insurance marketplace, and provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements under the ACA. QHPs are required to disclose certain claims and financial information to Pennie® and the Insurance Commissioner, and to make that information available to the public. The Transparency in Coverage Report therefore helps insurers fulfil that requirement of making information publicly available. This Transparency in Coverage Report provides claims and appeal data from 2020 through 2022.
The report found:
- Total claims received and total claims denied increased over the last two years, but the statewide claims denial rate has been stable, between 12.6 and 14.5 percent of all claims received.
- In 2020, individual market QHPs in Pennsylvania received approximately 10.25 million claims and denied 1.29 million claims.
- By 2022, Pennsylvania's individual market QHPs received approximately 14.9 million claims, and denied 2.02 million claims.
- Based on the latest information reported by insurers for 2022, individual market QHPs in Pennsylvania had an aggregated claim denial rate of 13.6 percent.
PID also reminds consumers of the appeals process for denied claims, as consumers who are denied a claim often do not realize they have the right to file an appeal, and appealing a denied claim can be a valuable resource to ensure that Pennsylvanians are afforded all of the benefits that they are owed. Any member of a QHP has the option of pursuing an appeal when a plan denies a service due to circumstances including, but not limited to, lack of medical necessity, or based on the service being considered investigational, experimental, or cosmetic.
Denied claims can be appealed through an internal appeal process, meaning the insurer that denied the claim internally reconsiders their decision, and a member can appeal through an external independent review process, meaning the case is sent to an external review organization to independently review the claim and determine if it should be paid based on coverage terms.
Members may utilize both appeal options and are not limited to just one. Through the appeals processes, it is possible that the insurer's original decision to deny the claim may be overturned, meaning that the claim has been reconsidered, the services have been deemed medically necessary or appropriate for that member, and the claim must be paid as a result.
However, not all consumers decide to appeal, despite a significant number of internal and external appeals resulting in overturned decisions for those that do file an appeal. In 2022 alone, for individual market QHPs in Pennsylvania, 2,165 internal appeals were filed and 1,149 were overturned – a 53 percent turnover rate. But from 2020 to 2022, for Pennsylvania individual market insurers, less than 1 percent of denied claims were appealed by members annually.
Pennsylvanians with questions about their insurance, health plan, or a denied claim should contact the Insurance Department Consumer Services Bureau online or at 1-877-881-6388. Consumers looking to learn more about health insurance should visit the Department's dedicated Health Insurance page.
Pennie's upcoming Open Enrollment Period is the only time of year to enroll in individual and family health coverage for 2024. Open Enrollment begins this November 1, and December 15 is the deadline for coverage that starts on January 1. To learn more about Pennie, visit pennie.com or call 1-844-844-8040. Pennie offers free help by phone and in person across Pennsylvania.
Follow PID on Twitter and like the department on Facebook.
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