Harrisburg, PA – Today, the Pennsylvania Insurance Department (PID) released two annual reports that help Pennsylvanians better understand health insurance options available in the Commonwealth ahead of Pennie’s Open Enrollment season.
PID’s Affordable Care Act (ACA) Quality Health Plans (QHP) Summary Report and Transparency in Coverage (TiC) Report provide consumers with information about health plan benefits, coverage, claims, denials, and appeals. Together, the reports can serve as important tools for Pennsylvanians researching health insurance options and making informed decisions about their coverage.
“Choosing a health insurance plan can be complicated, and Pennsylvanians deserve clear information that helps them understand their options,” said Pennsylvania Insurance Commissioner Michael Humphreys. “These reports give consumers another tool to look at what health plans have to offer, understand how claims and appeals are handled, and ask informed questions as they consider the coverage that works best for them and their families.”
The Transparency in Coverage Report provides consumers with additional information about how insurers handle claims, claim denials, and appeals. Understanding the claims and appeals process can help consumers know what to do if their insurer denies coverage for treatments, medications, or services.
A denied claim does not necessarily mark the end of the process. Pennsylvanians who receive a claim denial can first appeal the decision through their insurer’s internal appeals process. Consumers whose claims remain denied following internal review may also be able to request an external independent review through PID.
By reviewing both reports, consumers can learn more about the benefits and services offered through health plans while also becoming more familiar with their rights and the processes available if they experience issues with their coverage.
Key takeaways from this year’s TiC Report include:
- The percentage of claims denied increased from 14.8% to 17.35%, still below the national average;
- The percentage of overturned internal appeals dropped from 35.8% to 24.25%;
- New federal reporting requirements gave Pennsylvania its first clear view of pre-service (prior authorization) decisions, revealing a statewide denial rate of 17.5%; and
- Appeals continue to be extremely underutilized—fewer than 1% of denied claims or pre-service requests are appealed—despite significant overturn rates when members do appeal.
The QHP Summary Report provides consumers with a look at how PID regulates health insurance plans sold in Pennsylvania. All plans sold in the Commonwealth’s commercial market are reviewed for compliance with state and federal laws and regulations, including reviews of rates, required benefits, formularies, mental health parity, and provider network adequacy.
Qualified Health Plans must meet federal and state coverage requirements, but insurers may offer additional benefits and features. The QHP Summary Report helps make those differences more transparent by examining areas such as preventive and screening services, mental and behavioral health, substance use disorder treatment, maternal and reproductive health, and other health care services. Consumers should review their individual policy or contact their insurer for complete details about their coverage.
The 2026 QHP Summary Report found that:
- Claims denials occur in roughly 17.35% of individual market claims, yet fewer than 1% are appealed; about 30% of appealed denials are overturned;
- Coverage varies among insurers for certain services (e.g., mental health crisis care, menopause treatment, infertility services, breast milk coverage), though many core preventive services, reproductive health benefits, and MAT for opioid use disorder are consistently covered; and
- Network adequacy is reviewed annually to ensure 90% enrollee access, with rural counties posing unique access challenges requiring ongoing monitoring and corrective actions by insurers.
PID encourages Pennsylvanians preparing for Open Enrollment to carefully review available health plans, including covered benefits, provider networks, prescription drug coverage, cost-sharing, and other plan details, and to contact an insurer with questions about specific coverage before selecting a plan.
Pennie’s upcoming Open Enrollment period is the only time of year to enroll in individual and family health coverage for 2027. Open Enrollment typically runs from November 1 to December 15 for coverage that starts on January 1, 2027. Outside of Open Enrollment, only individuals with life changes (such as losing coverage from Medicaid and family events) can enroll.
Consumers looking to learn more about health insurance should visit the Department’s dedicated Health Insurance page.
Individuals interested in obtaining health insurance may purchase a Qualified Health Plan through Pennsylvania’s official health insurance marketplace, Pennie. Consumers purchasing insurance through Pennie may also qualify for financial assistance.
Pennsylvanians with questions about their insurance or who wish to file a complaint can visit pa.gov/consumer or call 1-866-PA-COMPLAINT (1-866-722-6675).