02 · Denials
Who says no, and what happens next
2,446,647 standard requests were denied across the 177 filings in Medicaid Managed Care that publish counts (of 224), a 9.9% rateⓘ. Four ways to read that number: whether urgent requests fare better or worse and how long decisions take, who issued the denials, whether size changes the rate, and how many denials were ever tested on appeal.
01 · Urgent requests and the clock
When the request is urgent
Expedited requests are the ones a doctor marked as time-critical, and the rule puts a clock on both kinds of decisionⓘ. Four pictures of what payers published against it: how long standard and expedited decisions actually take, whether urgent requests are denied more often than routine ones, and whether a filing's own mean and median tell the same story.
53
of 163 filings deny expedited requests more often than standard ones
13
publish a standard mean over 7 days the filings
6
publish an expedited mean over 72 hours the filings
68
publish a mean more than three times their own median, or the reverseⓘ
Standard decisions click a bar for its filings
Published mean time to decision, against the 7-day clock · 218 filings publish one
24
53
37
61
30
13
0–1
1–2
2–3
3–5
5–7
over 7
days; the orange bar is past the clock.
Expedited decisions click a bar for its filings
Published mean time to decision, against the 72-hour clock · 207 filings publish one
47
14
39
82
19
6
0–6
6–12
12–24
24–48
48–72
over 72
hours; the orange bar is past the clock.
Urgent against routine, 163 filings with 100+ expedited requests click a point for the filing
Standard denial rate across, expedited denial rate up, both to 60%. The dashed line is where the two agree; every point above it is a plan that says no more often when the doctor said it was urgent.
015%30%45%60% standard denial rate
● 53 deny urgent requests more often
● 110 deny them less often
The widest gaps
Percentage points by which the expedited rate exceeds the standard rate in the same filing.
Standard: mean against median click a point for the filing
The two figures a filing publishes for the same standard decisions. Median across, mean up, both on a log scale. On the dashed line the two agree; far from it, one filing's two figures do not.
the clock — 7 days, both axes
0110100 days
● mean past the clock
● mean and median three times apart
● 216 filings publish both
● 44 published a zero — drawn on the axis
Expedited: mean against median click a point for the filing
The two figures a filing publishes for the same expedited decisions. Median across, mean up, both on a log scale. On the dashed line the two agree; far from it, one filing's two figures do not.
the clock — 72 hours, both axes
01101001000 hours
● mean past the clock
● mean and median three times apart
● 207 filings publish both
● 58 published a zero — drawn on the axis
The filings behind the charts
Expedited denied more often than standard, the widest gaps
Plan
Organization
Standard
Expedited
Std mean · median
Exp mean · median
Gap
Humana Healthy Horizons in South Carolina Medicaid Managed Care
Humana
10.9%
59.4%
3.0 · 2.0 d
10.0 · 8.0 h
+48.6 pts
Humana Healthy Horizons in Oklahoma Medicaid Managed Care
Humana
8.5%
55.4%
1.0 · 1.0 d
7.0 · 4.0 h
+46.8 pts
Humana Healthy Horizons in Florida Medicaid Managed Care
Humana
2.6%
40.9%
1.0 · 1.0 d
13.0 · 3.0 h
+38.3 pts
Humana Healthy Horizons in Louisiana Medicaid Managed Care
Humana
4.9%
30.5%
2.0 · 1.0 d
7.0 · 3.0 h
+25.6 pts
Humana Healthy Horizons in Virginia Medicaid Managed Care
Humana
11.7%
35.7%
3.1 · 1.0 d
20.4 · 4.1 h
+24.1 pts
Arizona Long Term Care Medicaid Managed Care
UnitedHealth Group
4.6%
28.4%
1.0 · 29.7 d
24.0 · 21.6 h
+23.8 pts
Medicaid Managed Care Medicaid Managed Care
Healthfirst
19.7%
40.5%
1.6 · 0.0 d
— · —
+20.8 pts
Health and Recovery Plan (HARP) Medicaid Managed Care
Healthfirst
15.3%
34.8%
1.6 · 0.0 d
— · —
+19.5 pts
iCare BadgerCare Plus Medicaid Managed Care
Humana / iCare
15.0%
29.7%
4.0 · 1.0 d
17.0 · 9.0 h
+14.7 pts
Aetna Better Health of Oklahoma Medicaid Managed Care
CVS Health / Aetna
10.8%
22.1%
1.9 · 2.0 d
21.6 · 24.0 h
+11.3 pts
Arkansas Total Care (PASSE) Medicaid Managed Care
Centene
19.1%
29.9%
3.0 · 2.0 d
24.0 · 24.0 h
+10.7 pts
Humana Healthy Horizons in Indiana Medicaid Managed Care
Humana
12.7%
23.2%
4.0 · 1.0 d
47.0 · 11.0 h
+10.5 pts
Against the clock, and against themselves
Plan
Organization
Standard
Expedited
Std mean · median
Exp mean · median
Flag
VillageCareMAX Managed Long-Term Care Medicaid Managed Care
VillageCare
—
—
7.3 · 5.0 d
92.6 · 24.0 h
standard mean over 7 days
expedited mean over 72 hours
mean and median three times apart
expedited mean over 72 hours
mean and median three times apart
Colorado Access Medicaid Managed Care
Colorado Access
—
—
21.1 · 1.9 d
3.0 · 1.0 h
standard mean over 7 days
mean and median three times apart
mean and median three times apart
Umpqua Health Alliance Medicaid Managed Care
Umpqua Health
—
—
9.1 · 7.0 d
81.6 · 0.0 h
standard mean over 7 days
expedited mean over 72 hours
expedited mean over 72 hours
Hamaspik Choice (MLTC) Medicaid Managed Care
Hamaspik
—
—
7.6 · 4.3 d
101.3 · 61.4 h
standard mean over 7 days
expedited mean over 72 hours
expedited mean over 72 hours
Humana Healthy Horizons in Indiana Medicaid Managed Care
Humana
—
—
4.0 · 1.0 d
47.0 · 11.0 h
mean and median three times apart
mean and median three times apart
mean and median three times apart
AZ Blue Health Choice (AHCCCS) Medicaid Managed Care
Blue Cross Blue Shield of Arizona
—
—
4.0 · 1.1 d
16.1 · 2.8 h
mean and median three times apart
mean and median three times apart
mean and median three times apart
Humana Healthy Horizons in Virginia Medicaid Managed Care
Humana
—
—
3.1 · 1.0 d
20.4 · 4.1 h
mean and median three times apart
mean and median three times apart
mean and median three times apart
IEHP Medi-Cal Medicaid Managed Care
Inland Empire Health Plan
—
—
2.1 · 0.6 d
5.0 · 0.5 h
mean and median three times apart
mean and median three times apart
mean and median three times apart
Kaiser Permanente Hawaii - Medicaid Medicaid Managed Care
Kaiser Permanente
—
—
1.8 · 0.2 d
7.0 · 1.0 h
mean and median three times apart
mean and median three times apart
mean and median three times apart
Florida Long Term Care Medicaid Managed Care
UnitedHealth Group
—
—
0.0 · 14.1 d
0.0 · 12.0 h
mean and median three times apart
mean and median three times apart
mean and median three times apart
Florida Managed Medical Assistance Medicaid Managed Care
UnitedHealth Group
—
—
0.0 · 0.7 d
0.0 · 9.6 h
mean and median three times apart
mean and median three times apart
mean and median three times apart
Healthy Louisiana Medicaid Managed Care
UnitedHealth Group
—
—
0.0 · 0.7 d
0.0 · 4.8 h
mean and median three times apart
mean and median three times apart
mean and median three times apart
02 · Who denies the most
Organizations, by denials issued
Standard denials summed across every filing the organization published that carries counts. The rate beside each is that organization's own volume-weighted rate.
Highest rates, organizations with 10,000+ requestsⓘ
Plans with the most denials
Plan
Market
State
Requests
Denied
Rate
Ohio Medicaid Managed Care - all plans combinedOhio Department of Medicaid
Medicaid Managed Care
OH
1,175,861
222,965
19.0%
Medicaid Managed CareHealthfirst
Medicaid Managed Care
NY
750,763
147,742
19.7%
CareSource Ohio MedicaidCareSource
Medicaid Managed Care
OH
603,377
120,676
20.0%
Keystone FirstAmeriHealth Caritas
Medicaid Managed Care
PA
314,611
89,408
28.4%
Blue Cross Complete of MichiganBlue Cross Blue Shield of Michigan
Medicaid Managed Care
MI
243,159
84,816
34.9%
Sunshine Health Medicaid MMACentene
Medicaid Managed Care
FL
418,298
76,605
18.3%
Health Net Medi-CalCentene
Medicaid Managed Care
CA
3,096,168
75,814
2.5%
Meridian Illinois MedicaidCentene
Medicaid Managed Care
IL
316,252
71,520
22.6%
AmeriHealth Caritas PennsylvaniaAmeriHealth Caritas
Medicaid Managed Care
PA
278,855
71,027
25.5%
WellCare of KentuckyCentene
Medicaid Managed Care
KY
357,412
53,271
14.9%
Denial rate by stateⓘ
click a state for its filings≤ 8.3%8.3% – 12.2%12.2% – 16.6%16.6% – 18.4%> 18.4%not published
03 · Scale and scrutiny
Does a bigger plan say no more often?
Every filing with 100 or more standard requests: request volume across (log scale), denial rate up, coloured by market. A plan far above its neighbours of the same size and market is the one to read.
Denial rate against request volume, 181 filings click a point for the filing
1001K10K100K1M requests
● Medicaid Managed Care
Median rate by market and size bandⓘ
Highest for their sizeⓘ
Plan
Market · band
State
Requests
Band median
Rate
Prepaid Medical Assistance Program (PMAP)UCare
Medicaid Managed Care · 10K–100K
MN
30,736
12.1%
47.8% +35.7
UCare ConnectUCare
Medicaid Managed Care · 1K–10K
MN
6,578
11.3%
45.2% +33.8
MinnesotaCare (MnCare)UCare
Medicaid Managed Care · 1K–10K
MN
6,208
11.3%
45.1% +33.8
Minnesota Senior Care Plus (MSC+)UCare
Medicaid Managed Care · 1K–10K
MN
1,101
11.3%
41.9% +30.5
Oklahoma Complete Health - SoonerSelectCentene
Medicaid Managed Care · 10K–100K
OK
72,761
12.1%
32.4% +20.3
Blue Cross Complete of MichiganBlue Cross Blue Shield of Michigan
Medicaid Managed Care · 100K+
MI
243,159
14.9%
34.9% +20.0
AmeriHealth Caritas Delaware (Medicaid)AmeriHealth Caritas Family of Companies
Medicaid Managed Care · 10K–100K
DE
70,575
12.1%
28.3% +16.2
Independent Health Medicaid, Essential and CHP (combined)Independent Health
Medicaid Managed Care · 10K–100K
NY
36,266
12.1%
28.2% +16.1
Healthy Blue South Carolina (BlueChoice HealthPlan of South Carolina)Elevance Health
Medicaid Managed Care · 10K–100K
SC
55,220
12.1%
27.9% +15.8
Aetna Better Health of New JerseyCVS Health / Aetna
Medicaid Managed Care · 10K–100K
NJ
55,635
12.1%
27.6% +15.5
Keystone FirstAmeriHealth Caritas
Medicaid Managed Care · 100K+
PA
314,611
14.9%
28.4% +13.5
Priority Health Choice (Medicaid)Priority Health
Medicaid Managed Care · 10K–100K
MI
78,548
12.1%
25.2% +13.1
04 · The appeal gap
Most denials are never tested
Among filings that publish appeal counts (121 of them), 7.4% of standard denials were appealedⓘ, and 31.5% of those appeals overturned the denial. An overturn rate describes the denials someone fought; the denials nobody fought are the larger number, and it is listed here.
1.8M
standard denials in filings that report appeals the filings
134K
appeals filed · 7.4% of denials
31.5%
of appeals overturned the denial
1.7M
denials never appealedⓘ
Plan
Organization
Denied
Appeals
Appeal rate
Overturned
Never appealed
Ohio Medicaid Managed Care - all plans combined Medicaid Managed Care, OH
Ohio Department of Medicaid
222,965
12,366
5.5%
36.9%
210,599
Medicaid Managed Care Medicaid Managed Care, NY
Healthfirst
147,742
12,073
8.2%
14.3%
135,669
CareSource Ohio Medicaid Medicaid Managed Care, OH
CareSource
120,676
7,572
6.3%
37.0%
113,104
Health Net Medi-Cal Medicaid Managed Care, CA
Centene
75,814
1,017
1.3%
39.7%
74,797
Sunshine Health Medicaid MMA Medicaid Managed Care, FL
Centene
76,605
7,401
9.7%
49.4%
69,204
Meridian Illinois Medicaid Medicaid Managed Care, IL
Centene
71,520
4,735
6.6%
48.5%
66,785
WellCare of Kentucky Medicaid Managed Care, KY
Centene
53,271
2,364
4.4%
79.7%
50,907
Sentara Health Plans - Medicaid (Cardinal Care) Medicaid Managed Care, VA
Sentara Health
45,748
1,363
3.0%
32.5%
44,385
Arizona Complete Health - Complete Care Medicaid Managed Care, AZ
Centene
38,302
1,493
3.9%
30.3%
36,809
Anthem HealthKeepers Plus (Virginia Medicaid) Medicaid Managed Care, VA
Elevance Health
40,725
5,186
12.7%
18.2%
35,539
Peach State Health Plan Medicaid Medicaid Managed Care, GA
Centene
36,400
1,861
5.1%
46.0%
34,539
Louisiana Healthcare Connections Medicaid Managed Care, LA
Centene
34,878
967
2.8%
25.9%
33,911
Buckeye Health Plan (Ohio Medicaid) Medicaid Managed Care, OH
Centene
35,982
2,310
6.4%
38.4%
33,672
Medicaid Managed Care, IN
Elevance Health
34,566
1,567
4.5%
—
32,999
Anthem BCBS Ohio Medicaid Medicaid Managed Care, OH
Elevance Health
30,360
850
2.8%
35.9%
29,510
Everything on this page is computed from the published counts in the filings; the plan pages show the source document for each figure. Where a plan published a rate without counts it cannot appear here, because a rate nobody can check is not a number of denials.