Public reporting on coverage denials

Summary#

This bill would require health insurance companies that sell group or individual plans, and Medicare Advantage (MA) organizations, to publicly report yearly data on coverage denials, approvals, and appeals. The reports must be deidentified, broken down by several categories (including whether denials used automated tools), and presented in a consumer-friendly way. The Secretary of Health and Human Services would set reporting definitions and formats and post the collected data on the HHS website.

• Main change: Insurers and MA organizations must submit and publish annual, deidentified statistics on coverage requests denied or approved, and on appeals and reversals.
• Prior authorization lists: Plans must publish a list of all items or services that require prior authorization.
• Disaggregation required: Data must be broken down by type of request, reason for denial, review process (automated/algorithmic/individual), service type, time to decision (days/hours), and whether appeals were expedited.
• Timing: Reports are due no later than one year after the end of each plan year. The rule starts for plan years beginning on or after the first January 1 after the bill becomes law.
• HHS role: The Secretary will set standard definitions and reporting formats and will publish the submissions annually on the HHS website.

What it means for you#

• Patients and plan shoppers: You could see annual, plan-level data on how often coverage requests are denied, how quickly decisions are made, and whether appeals are successful. You would also be able to see what services require prior authorization for a given plan.
• People on Medicare Advantage: MA plan members would get the same types of public reporting for their plans.
• Health insurance companies (issuers): Must collect, format, submit, and publish the required data for each plan year. They must also publish their prior-authorization lists.
• Medicare Advantage organizations: Must meet the same reporting and publication duties for each MA plan they offer.
• Health care providers: Could use publicly reported data to see patterns in denials and appeals by plan, but the bill says reporting should avoid requiring extra information from providers "to the greatest extent practicable."
• Employers and benefit managers: If they use insured group plans, those plans’ published data will be available; it is unclear whether self-funded (ERISA) employer plans are covered by this bill.
• Researchers and regulators: Will have a public source of standardized, deidentified data about denials, appeals, timing, and use of automated reviews.

Expenses#

No publicly available information on estimated federal costs or savings is included with the bill text.

Possible costs (inferred from the bill text):

• Insurers and MA organizations will likely have increased administrative and IT costs to collect, format, and publish the required data each year.
• HHS will need staff time and systems to set standards, receive submissions, and publish consolidated data.
• There may be compliance costs for training, quality control, and auditing of reported data.
  These are likely but not quantified in the bill text.

Proponents' View#

• The bill appears intended to increase transparency about coverage denials, prior authorization, and appeals.
• A possible argument for the bill is that public, standardized data could help consumers compare plans on denial rates, decision times, and use of automated reviews.
• This could be seen as improving accountability and helping regulators and researchers detect problematic denial patterns or unfair practices.
• Requiring publication of prior-authorization lists could make it easier for patients and providers to know up front which services need approval.

Opponents' View#

• One concern is the added administrative and IT burden on insurers and MA organizations to collect, standardize, and publish these data annually.
• The bill does not give any cost estimates or funding for HHS to develop standards and publish the data.
• It is unclear whether the rule covers self-funded employer plans; the bill may leave gaps in which plans are included.
• Even deidentified data can raise privacy or re-identification concerns in some cases; the bill does not detail privacy safeguards beyond requiring deidentification.
• The bill requires the Secretary to set definitions and formats, but it does not specify enforcement mechanisms or penalties for late or inaccurate reporting.
• One possible issue is data usability: aggregated statistics may be hard for consumers to interpret without guidance, and data quality could vary across issuers.