Health coverage in America, by the numbers

The denial and appeal records

1. Denials and appeals: CMS Transparency in Coverage public use files, plan years 2022 to 2027, which report claims from 2020 to 2025. Individual-market medical plans only, in states using HealthCare.gov. Insurers report these figures to CMS themselves. Numbers are FHI's totals of issuer-level figures, not CMS's own. For 2024 they closely match KFF's analysis (KFF leaves out insurers with 1,000 or fewer claims, so it counts 39 fewer appeals); the 2025 figures don't have that outside check yet. The headline figures count in-network claims, as KFF does: 83.5 million denials in 2025, 16% of in-network claims, and 241,596 internal claim appeals, about 1 for every 350 of those denials. The map and the trend chart open on in-network claims too. The trend chart can switch to out-of-network claims or all claims, and the map to all claims; the insurer table counts in-network claims only. Cells CMS suppresses for small counts are left out.

Why should I appeal?

1. Source: the denial and appeal records above.
2. Appeals: the counts aren't split by network, so the 1-in-350 figure compares two totals, as KFF's does. Appeal win rates count only insurers that reported both appeals filed and appeals won, and an appeal won in part counts as won. Three insurers' 2025 appeals-won counts look like reporting errors, so we leave them out too: CMS marked their win rates as suppressed but printed the counts anyway. Their appeals still count as filed. With them, the 2025 rate would be 26.8%. We show only the latest year's win rate, because the insurers reporting change from year to year, and because the 2027 file counts appeals of claims and appeals of requests made before care separately, which earlier files didn't. We use its appeals of claims.
3. Independent medical review: California DMHC IMR determinations, via the CalHHS Open Data Portal, 2010 to 2025 (file as published June 2026), with exact duplicate records removed. That's the step after an insurer's own appeal. Its rate isn't directly comparable with the insurers' own appeal results: different plans, people and review processes.

Back to Why should I appeal?

Who is denying the most?

1. Source: the denial and appeal records above.
2. State map: Grey states run their own marketplace, so their insurers don't report to HealthCare.gov and aren't shown. That now includes Georgia, Illinois and Oregon, which have since moved to their own, so their latest claims aren't here either. Picking a grey state links to the best public source that state has, such as independent review results, appeal reports or complaint records, checked October 25, 2026 (Oregon's on November 1, 2026); Rhode Island and Kentucky publish nothing current, so theirs says so with no link. Those figures come from each state, often cover employer plans or other measures, and aren't comparable with CMS's rates. Picking Georgia, Illinois, Oregon or Virginia also shows its in-network denial rate from the latest CMS file that includes its insurers (2022 claims for Georgia, 2023 for Illinois, 2024 for Oregon, 2021 for Virginia), FHI's calculation from CMS's data on the same measure as the map. Those are older years, so don't rank them against the 2025 states. A state that a view leaves out has an outlined tile, and the line under the map says why. In Hawaii and West Virginia one insurer reports, and in Alaska, Delaware, Mississippi, Montana and Wyoming two do, so those states' figures are those companies' figures. The small type on each tile, shown when the map is wide enough, is the lowest to the highest rate among that state's insurers in the insurer table. The map opens on in-network claims, and we don't map out-of-network claims by state (see What are they denying? below).
3. Every state chart: it puts the map's 2025 rates beside two other kinds of in-network denial rates, both FHI's calculations: from the 2025 claims that 9 insurers in California (the ones with usable reports) and the 2024 claims that 11 in Pennsylvania reported on the same federal form, posted by Covered California and the Pennsylvania Insurance Department, and from the last CMS files that include Georgia, Illinois, Oregon and Virginia, described above. California's rate is 15.7% for 2025 and was 16.8% for 2024, but that isn't a clean comparison: Health Net (22.5% of 4.2 million claims in 2024) has no readable 2025 report, because its link opens another insurer's file, and Inland Empire Health Plan and CCHP Health Plan had no usable 2024 figure. Pennsylvania's 2025 claims weren't posted when we checked.
4. Insurer table: Each insurer that handled at least 50,000 in-network claims. For the 29 HealthCare.gov states, that's each reporting insurer in 2025, from CMS's files. For California and Pennsylvania, it's each insurer in the reports described in the every-state chart note above; the three California insurers we leave out are named under the table, with why. Covered California posts each insurer's plan rows, not its totals, so California's figures add up those rows, and it posts no appeal counts. California's and Pennsylvania's reports can count plans sold outside the marketplace, which CMS's figures leave out, and Kaiser Permanente's and Valley Health Plan's rates moved more than 10 points from their reports for 2024 claims, so compare insurers within a state and read one year with care. Capital Health Plan in Florida isn't listed: it reported denying 448,953 of 466,619 in-network claims in 2025 (96%), after 6.5% the year before, which looks like a reporting error, so its in-network counts are left out of every figure on this page. For Georgia, Illinois, Oregon and Virginia, it's each insurer in the last CMS file that includes the state (2022, 2023, 2024 and 2021 claims), by the same rules; some of them may not sell there now. These are unadjusted rates, not a quality rating: they depend on the kinds of care each plan's members use and how each company counts claims. Appeal win rates are shown only for insurers with at least 30 appeals, and "not reported" means CMS withheld the number won or we left it out as a likely reporting error (see Why should I appeal? above). Why there are no out-of-network or all-claims rates: see What are they denying? below.
5. Picking a 2027 plan: Oregon's move to its own marketplace is from HealthCare.gov's state page, and insurers leaving the marketplace for 2027 from KFF's tracker, checked October 19, 2026.
6. Prior authorization: each insurer's or state's own 2025 report, posted under the CMS prior authorization rule, copied as posted with a link to the source for every row. Reports whose scope or units weren't clear are left out. We gathered them from insurers' and states' own websites.
7. Prior authorization deadlines: the rule as published in the Federal Register (CMS-0057-F, February 2024) and the regulations for each kind of plan: 42 CFR 422.122, 422.568 and 422.572 (Medicare Advantage), 440.230 and 431.80 (state Medicaid), 438.210 and 438.404 (Medicaid plans), 457.495 and 457.1230 (CHIP), and 45 CFR 156.223 and 147.136 (HealthCare.gov insurers). Insurers in states that run their own marketplace through HealthCare.gov aren't covered. Medicaid plans' deadlines start with their first contract year beginning on or after January 1, 2026. A state-run CHIP program may follow its state's existing prior authorization law instead. CMS proposed adding prescription drugs in April 2026; we found no final rule. Checked October 23, 2026.

Back to Who is denying the most?

What are they denying, and why?

1. Source: the denial and appeal records above.
2. In network and out: CMS's data dictionary defines the one claims count in the files for 2020 and 2021 as in-network only, so the other two views start in 2022. In 2025 insurers denied 16.7 million of 53.0 million out-of-network claims (31%) and 98.8 million of 582.4 million claims overall (17%). For 9.4 million of those out-of-network denials, more than half, insurers gave the reason that the plan doesn't cover care outside its network (CMS's closed-network reason, reported per plan; one claim can count under more than one reason). KFF doesn't break out-of-network rates down by state or insurer, and we don't map them by state: in 2025, 99 of the 135 insurers reporting them sold only HMO or EPO plans (from CMS's 2025 plan list), which mostly don't cover out-of-network care by design, so a state's rate would mostly show which kinds of plans its insurers sell, not how they handle claims. We don't show them insurer by insurer either: even among insurers that also sold PPO or POS plans, many had most of their out-of-network claims on HMO or EPO plans, or gave that closed-network reason for most of those denials. The insurer table has no all-claims rates for the same reason: they fold in those out-of-network denials, so an insurer whose plans mostly don't cover out-of-network care could rank worse for that alone. One insurer reported more out-of-network denials than claims in 2025, which can't be right: Blue Care Network of Michigan. We leave it out of the out-of-network and all-claims figures, and the map's all-claims view shows no figure for Michigan. Blue Cross and Blue Shield of Kansas (2022 claims), Blue Cross Blue Shield of North Dakota (2023 and 2024) and Moda Health Plan in Alaska (2024) are left out of those years the same way. There's no out-of-network change from 2024, which mostly reflects which insurers reported, and no out-of-network appeals figure. The states and insurers that report change each year (Georgia, Illinois and Oregon have since left HealthCare.gov, and insurers that leave stop reporting), and rates aren't adjusted for the kinds of care people used.
3. The 2025 drop: the in-network rate fell from 18.7% to 15.6%, but we can't say how much of that is fewer denials. The 2025 file covers only insurers selling plans for 2027, so 40 insurers in the 2024 file aren't in it, and Oregon isn't either. Among the 119 insurers with figures in both years, the rate fell from 18.8% to 16.4%; 76 went down and 43 went up. Most of that fall comes from about ten insurers: without the ten that moved the total most, the rest went from 17.7% to 17.8%. Those ten include several Celtic and other Centene plans, Health Options and Florida Blue, whose reported claims often grew fast at the same time, which could be real or a change in how they count. CMS also reorganized the file for 2025 claims, adding counts of requests made before care and splitting more figures by network; its in-network claims columns keep the same names, so we kept them in the same trend. Insurers report these numbers themselves. We'll check them against outside analyses when those come out.
4. Denial reasons: reported per plan for in-network claims, and one claim can count under several reasons, so they're shown as shares of reasons; like KFF, we leave out CMS's closed-network reason, covered above.

Back to What are they denying, and why?

Who doesn't have coverage?

1. Uninsured: Census Small Area Health Insurance Estimates, under 65, 2023 and 2024. The national figure adds up the state estimates.
2. Uninsured and health: compared across 48 states and DC (Kentucky and Pennsylvania have no 2023 estimates). The uninsured rate goes with the share of adults in fair or poor health (correlation 0.52), less with diabetes (0.36), and not with depression (-0.10).
3. Health measures: CDC PLACES county data, 2025 release (mostly 2023 BRFSS). Adult crude prevalence, county estimates weighted by adult population. Kentucky and Pennsylvania have no 2023 estimates in this release. Use of CDC data does not imply CDC endorsement.
4. Where people get coverage: FHI's tally of the U.S. Census Bureau's Current Population Survey, 2026 Annual Social and Economic Supplement, from its public-use file (asecpub26csv.zip, released September 15, 2026), for people of all ages as of their interviews from February to April 2026. Each person is counted once: anyone with Medicare under Medicare, anyone else with exactly one kind of coverage under that kind, and anyone else with two or more kinds under "more than one kind". Our tally matches the totals and margins of error Census publishes from the same survey (report P60-291, Table 1, and table H-02). Every share is within half a point either way, at 90% confidence. Medicare includes Medicare Advantage plans, which private insurers run. Job-based includes self-funded plans, where the employer pays the claims itself. Medicaid or CHIP includes other state programs for people with low incomes and Basic Health Programs, such as New York's Essential Plan. VA includes CHAMPVA, and someone with both TRICARE and VA counts under "more than one kind".
5. Why this survey: it gives marketplace plans their own category and lets us count each person once. Census's American Community Survey has no marketplace category, and Census changed its coverage question for 2025, so it warns against comparing 2025 with earlier years. Census's own published shares from this survey add up to more than 100%, since people can have more than one kind. The CDC's National Health Interview Survey is a second survey, but its latest figures are for 2025 and its marketplace figures are for people under 65, so it can't show everyone in early 2026.
6. Surveys and records: CMS's records count 19.2 million people with marketplace coverage in February 2026, 68.9 million on Medicare and 75.5 million on Medicaid or CHIP. Only surveys count job-based coverage and the uninsured. Census's survey finds fewer people with marketplace plans than CMS's records count. CMS counts plans in effect in February, the survey asks from February to April, and some coverage ends in between.
7. Medicare and Medicaid: Medicare is CMS's Medicare Monthly Enrollment count for February 2026, from the file with data through July 2026, the 50 states and DC added up; it includes Medicare Advantage. Medicaid and CHIP is February 2026's updated count for the 50 states and DC, from CMS's State Medicaid and CHIP Applications, Eligibility Determinations, and Enrollment Data (the September 2026 release). People with both Medicare and Medicaid are in both counts. Checked October 26, 2026.
8. What Denial Watch's rates cover: This page's claim denial rates are for marketplace plans in HealthCare.gov states and six states that run their own marketplace, where some figures also count plans sold outside it. Its prior authorization rates cover large Medicare Advantage plans, Medicaid plans and programs, and HealthCare.gov insurers. It has no denial rates for job-based plans or Original Medicare.

Back to Who doesn't have coverage?

Drug costs

1. Drug spending: CMS Medicare Part D Spending by Drug, 2020 to 2024. Gross spending: what Medicare, plans and patients paid together, before manufacturer rebates. CMS marks some names with an asterisk where spending per dose mixes routes of administration; no per-dose figure is shown here, so the mark is left off. The short "for" label next to each drug is its main approved use, checked against MedlinePlus or the drug's FDA label; many drugs have other uses too.
2. Medicare prices: CMS's selected drugs and negotiated prices, with its 2026 fact sheet, 2027 fact sheet and 2028 fact sheet. CMS removed Xarelto from the list from January 1, 2027, because a generic is marketed, and is due to publish the 2028 prices by November 30, 2026. The price plans pay can't exceed the negotiated price plus a dispensing fee, and your share is based on it (CMS guidance). Ozempic's price also covers Rybelsus and Wegovy. Checked October 23, 2026.
3. Medicare drug help: the out-of-pocket cap from CMS's 2027 rate announcement (table V-2) and Medicare.gov's pages on drug costs, Extra Help and the Prescription Payment Plan. Checked October 23, 2026.

Back to Drug costs

Everything else

1. Today's counter: 2025 in-network marketplace denials divided by 365 days, counted up from your local midnight. It spreads a yearly total evenly for illustration; it isn't a count of denials happening today.
2. Claim files: free from employer and marketplace plans under the federal claims rules (29 CFR 2560.503-1 and 45 CFR 147.136) and from Medicaid plans (42 CFR 438.406). Medicare Advantage and drug plans may charge a reasonable amount for copying and mailing, under section 50.5.2 of CMS's appeals guidance. Checked October 19, 2026.
3. Phone numbers and other sites: each taken from the office's or group's own page, checked October 23, 2026.