Health Insurers Rejected 19% of Exchange Plan Claims

New data shows high denial rates for ACA marketplace coverage.

Mar. 31, 2026 at 5:29pm

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An extreme close-up X-ray image of a medical claim form, with the internal structures and details revealed as glowing, ghostly lines against a dark background, conceptually illustrating the challenges of accessing care through ACA exchange plans.New data reveals high rates of claim denials in the ACA's individual insurance marketplace, raising concerns about access to affordable and comprehensive healthcare coverage.Oklahoma City Today

According to new data, health insurance companies participating in the federal Affordable Care Act (ACA) exchange rejected nearly one in five claims submitted by policyholders, highlighting ongoing concerns about access to care and coverage gaps in the individual insurance market.

Why it matters

The high claim denial rate raises questions about the affordability and adequacy of ACA exchange plans, which were intended to provide comprehensive and affordable health coverage options for Americans who don't receive insurance through an employer or government program.

The details

The data, compiled by the Centers for Medicare and Medicaid Services (CMS), shows that insurers rejected 19% of claims for ACA exchange plans in 2025. The most common reasons for claim denials were lack of medical necessity, out-of-network services, and pre-existing condition exclusions.

  • The data covers the 2025 plan year for ACA exchange plans.

The players

Centers for Medicare and Medicaid Services (CMS)

The federal agency that oversees the Affordable Care Act and collects data on insurance coverage and claims.

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What’s next

Lawmakers and consumer advocates are expected to scrutinize the high claim denial rates and push for greater transparency and accountability from insurers participating in the ACA exchanges.

The takeaway

The high rate of claim denials in ACA exchange plans underscores the ongoing challenges in ensuring affordable and comprehensive health coverage for Americans, even a decade after the Affordable Care Act was implemented.