Others titles
- Health Insurance Exchange Public Use Files
- Qualified Health Plan Transparency in Coverage PUF
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
Health Insurance Transparency in Coverage PUF
This dataset shows the issuer-level claims, appeals, and active URL data. The PY2023 PUF contains data from PY2021 for issuers participating in the Exchange in PY2022.
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Description
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.
About this Dataset
Data Info
Date Created | 2016-11-30 |
---|---|
Last Modified | 2023-10-20 |
Version | 2023-10-20 |
Update Frequency |
Annual |
Temporal Coverage |
2023 |
Spatial Coverage |
United States |
Source | John Snow Labs; Centers for Medicare and Medicaid Services; |
Source License URL | |
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 |
Data Fields
Name | Description | Type | Constraints |
---|---|---|---|
State_Abbreviation | Two-character state abbreviation indicating the state where the plan is offered | string | - |
Issuer_Name | Name of the company issuing the plan | string | - |
Issuer_ID | Five-digit numeric code that identifies the issuer organization in the Health Insurance Oversight System (HIOS) | integer | level : Nominal |
Is_Issuer_New_To_Exchange | Indicate that the issuer is new to exchange or not | boolean | - |
URL_Claims_Payment_Policies | URL Claims Payment Policies & other Information | string | - |
Claims_Received | Number 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 service | integer | level : Ratio |
Claims_Denials | Number 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. | integer | level : Ratio |
Internal_Appeals_Filed | Number 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.. | integer | level : Ratio |
Number_Internal_Appeals_Overturned | Number 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. | integer | level : Ratio |
Percent_Internal_Appeals_Overturned | Issuer-level data at the State level, for all QHPs on Exchange. | number | level : Ratio |
External_Appeals_Filed | Number of requests by the insured for appeals on final adverse determinations to an external review organization. | integer | level : Ratio |
Number_External_Appeals_Overturned | Number of final adverse determinations overturned upon request for external review, in whole or in part. | integer | level : Ratio |
Percent_External_Appeals_Overturned | Percent of final adverse determinations overturned (# external appeals overturned/# of external appeals filed) upon request for external review. | number | level : Ratio |
Number_Claims_Received | Indicate that number of claims received. | number | level : Ratio |
Claims_Denied | Indicate that number of claims denied by issuer. | number | level : Ratio |
Claims_Denied_Referral_Required | Indicate that number of claims denied for reason referral required. | number | level : Ratio |
Claims_Denied_Out_of_Network | Indicate that number of claims denied as out of network. | number | level : Ratio |
Claims_Denied_Services_Excluded | Indicate that number of claims denied as services excluded. | number | level : Ratio |
Claims_Denied_Not_Medically_Necessary | Indicate that number of claims denied as not medically necessary. | number | level : Ratio |
Claims_Denied_Not_Medically_Necessary_Incl_Behav_Health | Indicate that number of claims denied as not medically necessary including behavioral health. | number | level : Ratio |
Claims_Denied_Other | Indicate that number of claims denied for other reasons. | number | level : Ratio |
Financial_Information | URL link to prior calendar year issuer-level information about premiums, assets, and liabilities. | string | - |
Enrollment_Data | Issuer level cumulative enrollment numbers, as measured by non-canceled plan selections, based on the end of the prior calendar year’s information. | integer | level : Ratio |
Disenrollment_Data | Issuer level cumulative disenrollment numbers, as measured by canceled plan selections, based on the end of the prior calendar year’s information. | integer | level : Ratio |
Data Preview
State Abbreviation | Issuer Name | Issuer ID | Is Issuer New To Exchange | URL Claims Payment Policies | Claims Received | Claims Denials | Internal Appeals Filed | Number Internal Appeals Overturned | Percent Internal Appeals Overturned | External Appeals Filed | Number External Appeals Overturned | Percent External Appeals Overturned | Number Claims Received | Claims Denied | Claims Denied Referral Required | Claims Denied Out of Network | Claims Denied Services Excluded | Claims Denied Not Medically Necessary | Claims Denied Not Medically Necessary Incl Behav Health | Claims Denied Other | Financial Information | Enrollment Data | Disenrollment Data |
AK | Moda Assurance Company | 77963 | False | http://www.modahealth.com/members/transparency.shtml | 7965 | 628 | 2573.0 | 181.0 | 20.0 | 152.0 | https://www.naic.org/cis_refined_results.htm?TABLEAU=CIS_FINANCIAL&COCODE=47098&:refresh | 663.0 | 64.0 | ||||||||||
AK | Moda Assurance Company | 77963 | False | http://www.modahealth.com/members/transparency.shtml | 7965 | 628 | 3203.0 | 250.0 | 37.0 | 205.0 | https://www.naic.org/cis_refined_results.htm?TABLEAU=CIS_FINANCIAL&COCODE=47098&:refresh | 463.0 | 59.0 | ||||||||||
AK | Moda Assurance Company | 77963 | False | http://www.modahealth.com/members/transparency.shtml | 7965 | 628 | 1762.0 | 145.0 | 22.0 | 123.0 | https://www.naic.org/cis_refined_results.htm?TABLEAU=CIS_FINANCIAL&COCODE=47098&:refresh | 700.0 | 116.0 | ||||||||||
AK | Moda Assurance Company | 77963 | False | http://www.modahealth.com/members/transparency.shtml | 7965 | 628 | 427.0 | 52.0 | 46.0 | https://www.naic.org/cis_refined_results.htm?TABLEAU=CIS_FINANCIAL&COCODE=47098&:refresh | 168.0 | 28.0 | |||||||||||
AK | Premera Blue Cross Blue Shield of Alaska | 38344 | False | https://www.premera.com/visitor/transparency-coverage?region=pbcak | 440169 | 95724 | 103.0 | 55.0 | 53.4 | 156778.0 | 31123.0 | 4203.0 | 99.0 | 3220.0 | 695.0 | 13.0 | 58104.0 | https://www.naic.org/cis_refined_results.htm?TABLEAU=CIS_FINANCIAL&COCODE=47570&:refresh | 5582.0 | 583.0 | |||
AK | Premera Blue Cross Blue Shield of Alaska | 38344 | False | https://www.premera.com/visitor/transparency-coverage?region=pbcak | 440169 | 95724 | 103.0 | 55.0 | 53.4 | 74494.0 | 16191.0 | 2017.0 | 126.0 | 1528.0 | 186.0 | 29096.0 | https://www.naic.org/cis_refined_results.htm?TABLEAU=CIS_FINANCIAL&COCODE=47570&:refresh | 2063.0 | 321.0 | ||||
AK | Premera Blue Cross Blue Shield of Alaska | 38344 | False | https://www.premera.com/visitor/transparency-coverage?region=pbcak | 440169 | 95724 | 103.0 | 55.0 | 53.4 | 57119.0 | 13778.0 | 1556.0 | 28.0 | 1725.0 | 169.0 | 22111.0 | https://www.naic.org/cis_refined_results.htm?TABLEAU=CIS_FINANCIAL&COCODE=47570&:refresh | 3509.0 | 606.0 | ||||
AK | Premera Blue Cross Blue Shield of Alaska | 38344 | False | https://www.premera.com/visitor/transparency-coverage?region=pbcak | 440169 | 95724 | 103.0 | 55.0 | 53.4 | 42299.0 | 11985.0 | 1608.0 | 12.0 | 897.0 | 155.0 | 17345.0 | https://www.naic.org/cis_refined_results.htm?TABLEAU=CIS_FINANCIAL&COCODE=47570&:refresh | 1056.0 | 172.0 | ||||
AK | Premera Blue Cross Blue Shield of Alaska | 38344 | False | https://www.premera.com/visitor/transparency-coverage?region=pbcak | 440169 | 95724 | 103.0 | 55.0 | 53.4 | 109479.0 | 22647.0 | 3083.0 | 99.0 | 1715.0 | 260.0 | 42184.0 | https://www.naic.org/cis_refined_results.htm?TABLEAU=CIS_FINANCIAL&COCODE=47570&:refresh | 4860.0 | 518.0 | ||||
AK | Premera Blue Cross Blue Shield of Alaska | 38344 | False | https://www.premera.com/visitor/transparency-coverage?region=pbcak | 440169 | 95724 | 103.0 | 55.0 | 53.4 | https://www.naic.org/cis_refined_results.htm?TABLEAU=CIS_FINANCIAL&COCODE=47570&:refresh |