Aetna (CVS Health) claim denial rate: 21.6%
Aetna (CVS Health) has no HealthCare.gov filings in the plan year 2026 file (it did not sell Marketplace plans that year), so the latest available year is shown: 2023 claims.
Aetna (CVS Health) issuers selling on HealthCare.gov reported denying 6,796,838 of 31,419,396 in-network claims in 2023 across 12 filings in 11 states. The pooled rate for every issuer in the file is 19.7%. 32.3% of 3,859 internal appeals were overturned.
Three years, pooled
| Claims year | Filings | In-network claims | Denied | Denial rate | Appeals | Overturned | External reviews |
|---|---|---|---|---|---|---|---|
| 2022 (PY2024 file) | 13 | 1,595,846 | 325,082 | 20.4% | 344 | 54.9% | 0 |
| 2023 (PY2025 file) | 12 | 31,419,396 | 6,796,838 | 21.6% | 3,859 | 32.3% | 92 |
| 2024 (PY2026 file) | 0 | 0 | 0 | n/a | 0 | n/a | 0 |
Every Aetna filing, by state (2023 claims)
Sorted by reported denial rate. Filings under 1,000 claims are shown but not ranked. Each row links to the issuer's report card with the plan list and the year-over-year detail.
| State | Issuer (as CMS prints it) | Denial rate | Prior year | Claims | Appeals | Overturned |
|---|---|---|---|---|---|---|
| Texas | Aetna Health Inc. (a TX corp.) | 27.3% | 34.1% | 8,083,776 | 1,811 | 21.3% |
| Delaware | Aetna Health Inc. (a PA corp.) | 22.4% | n/a | 60,919 | n/a | n/a |
| Florida | Aetna Health Inc. (a FL corp.) | 22.3% | n/a | 11,920,740 | 988 | 38.6% |
| Arizona | Banner Health and Aetna Health Plan Inc. | 22.1% | 17.8% | 1,912,839 | 278 | 46.0% |
| Illinois | Aetna Health Inc. (a PA corp.) | 20.2% | n/a | 167,244 | 53 | 49.1% |
| Missouri | Aetna Life Insurance Company | 19.1% | 16.7% | 694,487 | 71 | 43.7% |
| North Carolina | Aetna Health Inc. (a PA corp.) | 15.5% | 16.8% | 8,579,391 | 658 | 44.8% |
| Illinois | Aetna Life Insurance Company | n/a | n/a | 0 | n/a | n/a |
| Indiana | Aetna Health Inc. (a PA corp.) | n/a | n/a | 0 | n/a | n/a |
| Kansas | Aetna Life Insurance Company | n/a | n/a | 0 | n/a | n/a |
| Ohio | Aetna Health Inc. (a PA corp.) | n/a | n/a | 0 | n/a | n/a |
| Utah | Aetna Health of Utah Inc. | n/a | n/a | 0 | n/a | n/a |
If Aetna denied your claim
The rules, the filing window and the next level depend on the plan you hold, not on the brand: the Aetna (CVS Health) page carries the table for every plan type Aetna administers. A denial can be appealed; the plan must give you its file and the criteria it applied.
- Aetna (CVS Health): rules by plan type and appeal guides →
- Decode the wording on the letter →
- Work out the deadline →
- Have a reviewer read the denial (free) →
Questions
What is Aetna (CVS Health)'s claim denial rate?
In the CMS Transparency in Coverage file for plan year 2025, the 12 Aetna (CVS Health) issuer filings on HealthCare.gov reported denying 6,796,838 of 31,419,396 in-network claims received in 2023: 21.6%, against a pooled rate of 19.7% for all issuers in the file. The figure includes duplicate, administrative and eligibility denials and covers Marketplace plans only.
Does Aetna's denial rate vary by state?
Yes. Among filings with at least 1,000 claims, Aetna Health Inc. (a TX corp.) (Texas) reported 27.3% and Aetna Health Inc. (a PA corp.) (North Carolina) reported 15.5%. Each state filing is a separate legal entity with its own claims operation.
How often are Aetna appeals successful?
32.3% of the 3,859 internal appeals reported by Aetna (CVS Health) issuers in 2023 were decided in the member's favour. Members appealed 0.6 of every 1,000 denials. External reviews: 92 requested, 14 reversed the insurer.
Is this Aetna's denial rate for employer or Medicare plans?
No. The CMS file covers individual and small-group Marketplace plans sold on HealthCare.gov in 32 states. Employer plans, Medicare Advantage and Medicaid are not in it. Use it as a comparison across insurers under the same rules, not as your own plan's number.
Other carriers
Method and limits
- Reporting lag: the CMS public-use file for a plan year reports claims from two plan years earlier (the PY2026 file carries 2024 claims). These are not this year's figures.
- In-network only: the denial rate is in-network claims denied divided by in-network claims received. Out-of-network claims are shown separately where the issuer reported them.
- "Denied" is broad: CMS counts every denial, including administrative denials, duplicate submissions, ineligibility, incorrect billing and partial denials, not only medical-necessity decisions.
- Issuer level: CMS reports the counts once per issuer per state and repeats them on every plan row; plan-level counts, where present, list denials only, so no per-plan rate is computed.
- Coverage: only issuers on the federally facilitated marketplace (HealthCare.gov states) report to this file. Employer plans, Medicare and Medicaid are not included.
- No inference of intent: a higher rate can reflect the issuer's mix of claims, its billing rules or its membership as much as its coverage decisions. Compare with the state median and read the N.
- Issuer filings are mapped to Aetna (CVS Health) by the issuer's legal name (conservative brand matching); a filing that is not obviously Aetna's is left out rather than guessed.
Source: CMS Transparency in Coverage Public Use File (Health Insurance Exchange PUFs). Download: CSV · methodology. Cite: Apellica Insurer Denial Report Cards, Aetna (CVS Health), plan years 2024, 2025, 2026, generated 2026-09-14. CC BY 4.0.