Health Insurance Transparency in Coverage PUF

$79 / year

This dataset shows the issuer-level claims, appeals, and active URL data. The PY2018 PUF contains data from PY2016 for issuers participating in the Exchange in PY2016.

Complexity

The Centers for Medicare & Medicaid Services (CMS) Center for Consumer Information & Insurance Oversight (CCIIO) publishes the Transparency in Qualified Health Plan (QHP) Coverage Public Use File (PUF) in order to increase access to QHP issuer data reported pursuant to section 1311(e)(3) of the Affordable Care Act. The Transparency in QHP Coverage PUF includes data on QHPs and Stand-alone Dental Plans (SADPs) offered in states with Federally-Facilitated Exchanges (FFEs), including issuers in the FFEs where states perform plan management functions (SPEs), and State-based Exchanges on the Federal Platform for eligibility and enrollment (SBE-FPs).

The data provided is an aggregate number for plans sold by an issuer on the FFEs, including FFEs where States perform plan management functions, and SBE-FPs only. This information simply provides a raw number and is not a complete description of issuer or plan enrollment. Enrollment is not necessarily indicative of issuer strength or plan quality. Enrollment may change daily due to a variety of circumstances.

Date Created

2016-11-30

Last Modified

2017-08-19

Version

2017-08-19

Update Frequency

Annual

Temporal Coverage

2018

Spatial Coverage

United States

Source

John Snow Labs => Centers for Medicare and Medicaid Services

Source License URL

John Snow Labs Standard License

Source License Requirements

N/A

Source Citation

N/A

Keywords

Health Insurance, Insurance Marketplace, Transparency in Coverage PUF, Insurance Rate Review, Insurance Rate Increase, Insurance Market Competition, Health Benefits, Transparency in Coverage, Coverage PUF, Exchange PUFs

Other Titles

Health Insurance Exchange Public Use Files, Qualified Health Plan Transparency in Coverage PUF

Name Description Type Constraints
State_AbbreviationTwo-character state abbreviation indicating the state where the plan is offeredstring-
Issuer_NameName of the company issuing the planstring-
Issuer_IDFive-digit numeric code that identifies the issuer organization in the Health Insurance Oversight System (HIOS)integerlevel : Nominal
URL_Claims_Payment_PoliciesURL Claims Payment Policies & other Informationstring-
Claims_ReceivedNumber of claims received by an issuer asking for a payment or reimbursement by or on behalf of an in-network health care provider (such as a hospital, physician, or pharmacy) that is contracted to be part of the network for an issuer (such as an HMO or PPO). Claims are counted by date of serviceintegerlevel : Ratio
Claims_DenialsNumber of claims received by an issuer asking for a payment or reimbursement by or on behalf of an in-network health care provider (such as a hospital or doctor) that is contracted to be part of the network for an issuer (such as an HMO or PPO) that the issuer subsequently denied. For Plan Year 2017 PUF, data is measured on January 1, 2015-December 31, 2015. For Plan Year 2018 PUF, data is measured January 1, 2016-December 31, 2016integerlevel : Ratio
Internal_Appeals_FiledNumber of requests by the insured for internal reviews of grievances involving adverse determinations. An internal review is a process by which the insured may have an adverse determination reviewed by the issuer with respect to a denial of an admission, availability of care, continued stay, or health care service for a coveredperson. For Plan Year 2017 PUF, data is measured January 1, 2015- December 31, 2015. For Plan Year 2018 PUF, data is measured January 1, 2016-December.integerlevel : Ratio
Number_Internal_Appeals_OverturnedNumber of final adverse determinations overturned upon request for internal review. An internal review is a process by which the insured may have an adverse determination reviewed by the issuer with respect to a denial of an admission, availability of care, continued stay, or health care service for a covered person. All overturned internal appeals must be included, including those overturned in whole or in part. For Plan Year 2017 PUF, data is measured January 1, 2015- December 31, 2015. For Plan Year 2018 PUF, data is measured January 1, 2016-December 31, 2016.integerlevel : Ratio
Percent_Internal_Appeals_OverturnedIssuer-level data at the State level, for all QHPs on Exchange. For Plan Year 2017 PUF, data is measured January 1, 2015-December 31, 2015. For Plan Year 2018 PUF, data is measured on January 1, 2016-December 31, 2016.numberlevel : Ratio
External_Appeals_FiledNumber of requests by the insured for appeals on final adverse determinations to an external review organization. For Plan Year 2017 PUF, data is measured on January 1, 2015-December 31, 2015. For Plan Year 2018 PUF, data is measured on January 1, 2016-December 31, 2016.integerlevel : Ratio
Number_External_Appeals_OverturnedNumber of final adverse determinations overturned upon request for external review, in whole or in part. For Plan Year 2017 PUF, data is measured on January 1, 2015-December 31, 2015. For Plan Year 2018 PUF, data is measured on January 1, 2016-December 31, 2016.integerlevel : Ratio
Percent_External_Appeals_OverturnedPercent of final adverse determinations overturned (# external appeals overturned/# of external appeals filed) upon request for external review. For Plan Year 2017 PUF, data is measured on January 1, 2015-December 31, 2015. For Plan Year 2018 PUF, data is measured on January 1, 2016-December 31, 2016.numberlevel : Ratio
Financial_InformationURL link to prior calendar year issuer-level information about premiums, assets, and liabilities.string-
Enrollment_DataIssuer level cumulative enrollment numbers, as measured by non-canceled plan selections, based on the end of the prior calendar year’s information. For Plan Year 2017 PUF, data is measurement period is January 1st 2015 to December 31, 2015. For Plan Year 2018 PUF, data is measured on January 1, 2016-December 31, 2016.integerlevel : Ratio
Disenrollment_DataIssuer level cumulative disenrollment numbers, as measured by canceled plan selections, based on the end of the prior calendar year’s information. For PY 2017 PUF, data measurement period is January 1, 2015- December 31, 2015. For Plan Year 2018 PUF, data is measured on January 1, 2016-December 31, 2016.integerlevel : Ratio
State_AbbreviationIssuer_NameIssuer_IDURL_Claims_Payment_PoliciesClaims_ReceivedClaims_DenialsInternal_Appeals_FiledNumber_Internal_Appeals_OverturnedPercent_Internal_Appeals_OverturnedExternal_Appeals_FiledNumber_External_Appeals_OverturnedPercent_External_Appeals_OverturnedFinancial_InformationEnrollment_DataDisenrollment_Data
WIMercyCare HMO58326https://eapps.naic.org/cis/financialReport.do?entityId=82776731517218
KYDelta Dental of Kentucky62201https://eapps.naic.org/cis/financialReport.do?entityId=6264
MOCeltic Insurance Company99723https://eapps.naic.org/cis/financialReport.do?entityId=8616
TXEducators Health Plans Life91476https://emihealth.com/emi/products/tx-policy-terms.aspx
GAAlliant Health Plans83761https://eapps.naic.org/cis/financialReport.do?entityId=7152821109682290
NVSilverSummit Healthplan, Inc.45142https://eapps.naic.org/cis/financialReport.do?entityId=18466176
ALBright Health Insurance Company73301https://eapps.naic.org/cis/financialReport.do?entityId=18312870
KSSunflower State Health Plan, Inc80065https://eapps.naic.org/cis/financialReport.do?entityId=16636273
TNOscar Insurance Company of Texas23552https://eapps.naic.org/cis/financialReport.do?entityId=17651581
FLBEST Life and Health Insurance Company17121https://eapps.naic.org/cis/financialReport.do?entityId=9561