20 coverage types
Coverage types
Your deadlines, reviewers and regulators depend on how you get your coverage, not on the name on your card. Pick yours.
Not sure which one is yours?
Use the coverage type finder, or read how to find out what kind of plan you have. The most common mix-up is a job-based plan the employer pays for itself, which looks like an insurer's plan but follows federal law.
Job-based plan
- Employer plan the employer funds itself (self-funded)
Your employer pays your claims from its own money, often with an insurance company handling the paperwork. Federal law governs the plan, so the Department of Labor, not your state, is the agency to call.
- Employer plan bought from an insurer (fully insured)
Your employer buys a policy and the insurance company pays your claims. You have federal appeal rights and your state insurance department and state external review process, so you have more places to turn than with a self-funded plan.
- State or local government employer plan
Your employer is a state, county, city or school district. Federal employer-plan law does not apply, but Affordable Care Act appeal and independent review rules do, unless the plan is grandfathered. The agency that helps depends on how it is funded.
- Church plan
A health plan run by a church is usually outside the federal employer-plan law unless the church chose coverage. Federal appeal rules may still apply through the tax code, but who enforces them is less clear. Read your notice closely.
Marketplace or individual plan
- Marketplace plan
You bought a plan through HealthCare.gov or a state marketplace. Your insurer decides your appeal, then independent reviewers, and your state insurance department regulates the insurer. Disputes with the Marketplace over eligibility are separate.
- Individual plan bought outside the Marketplace
You bought a plan straight from an insurer or through an agent, not through the Marketplace. If it is not grandfathered, your insurer decides one internal appeal, then independent review, and your state insurance department regulates the insurer.
- Grandfathered plan
A plan in place since 23 March 2010 without disqualifying changes. It skips some Affordable Care Act protections, including general independent review. Employer plans under ERISA keep the federal claims rules. Other plans follow their contract and state law.
Medicare
- Original Medicare (Parts A and B)
Medicare paid by the federal government, not a private plan. A denial arrives on a Medicare Summary Notice, with five levels of appeal. If a hospital stay, rehab or nursing care is ending, use the red box below: that clock is much shorter.
- Medicare Advantage (Part C)
Medicare run through a private plan. Appeal to the plan first, within 65 days of the date on its denial notice. If a hospital stay, rehab or nursing care is ending, use the red box below: that clock is much shorter.
- Medicare drug plan (Part D)
A prescription drug plan under Medicare. A drug denial starts with a coverage decision or an exception request. The independent review step is not automatic: you or your prescriber must ask for it in writing.
- Medicare Supplement (Medigap)
Private insurance that pays some costs Original Medicare leaves. Your state regulates it. A dispute usually starts with the insurer, then your state insurance department, not Medicare. We could not confirm that no federal appeal exists.
Medicaid or children's coverage
- Medicaid (fee-for-service)
Medicaid paid directly by your state, not through a managed care plan. Your appeal is a state fair hearing. The deadline is on your notice and varies by state, up to 90 days from the date the notice was mailed.
- Medicaid managed care plan
Medicaid delivered through a private health plan. Appeal to the plan first, within 60 days of the date on its notice. After the plan's decision you have 90 to 120 days to ask your state for a fair hearing.
- Children's Health Insurance Program
Low-cost coverage for children run by your state. A separate program uses an independent external review, not a Medicaid fair hearing. For a managed care plan, the plan appeal comes first, within 60 days.
Military, veteran or federal employee
- TRICARE
Military health coverage. Your first appeal is a written reconsideration, mailed within 90 days of the date on your Explanation of Benefits. The next steps depend on whether the denial is about the facts or about medical necessity.
- Veterans Affairs health care
Two separate tracks. A disagreement with a medical treatment decision goes through a clinical appeal. A disagreement with a health care benefit decision, such as payment, goes through decision review within one year.
- Federal Employees Health Benefits plan
Coverage for federal workers through a private carrier. Ask your carrier in writing to reconsider within 6 months of the date on the denial notice. If the carrier says no again, the Office of Personnel Management reviews it.
- Indian Health Service Purchased/Referred Care
Indian Health Service money for care from outside providers. It is not an entitlement, and a referral does not mean the bill will be paid. Each of the three appeal steps has a 30-day deadline from receiving the notice.
Student, short-term or other
- Student health plan
A health plan sold to students through a college or university. If an insurance company sells it, federal individual-market appeal rules apply and your state insurance department regulates the insurer. A plan the school funds itself is less clear.
- Short-term plan, sharing ministry and other non-compliant products
Short-term plans, sharing ministries and fixed indemnity products sit outside the Affordable Care Act appeal and independent review rules and the No Surprises Act. Your rights come mostly from the contract and state law. Options are fewer; this page says so.