Patient and Consumer Protections

This brief examines the final CMS regulations governing prior authorization in Medicare Advantage, Marketplace, Medicaid, and other plans, how they might address some current consumer concerns, and some issues that remain.

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. Substantially fewer prior authorization requests were made in traditional Medicare, reflecting the small number of services subject to prior authorization requirements.

 Nearly 1 in 5 consumers with health insurance say their insurer delayed or denied care in the past year due to its requirements for prior authorization, a process through which insurers can require patients to obtain approval in advance before they will agree to cover specific services. Insurers point to prior authorization as…More

This Data Note highlights findings from the KFF Consumer Survey on problems consumers have experienced with prior authorization requirements. Overall, those with Medicaid, those who are higher utilizers of care encountered more problems with prior authorization over the past year.

Proposed updates to federal mental health parity rules would make wide ranging changes to current standards that apply to private insurance and coverage provided by most employers. This issue brief focuses on a requirement that plans perform an “outcome analysis.”

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.

The Supreme Court decision overturning “Chevron deference” has profound implications for health care.
It ushers in an era in which courts will not have to accept agency expertise in their review of challenged federal regulations.

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.