How to find out what kind of plan you have

Before you can count a deadline or pick an appeal route, you need to know what kind of coverage you have. Two plans can have the same insurer’s name on the card and follow different rules. Work from the outside in: who provides the coverage, then what the documents say, then ask.

What this means

The main kinds, and the quickest clue for each:

• Job-based plan. Your employer, union or a former employer offers it. This includes retiree coverage from a former employer: ask the plan administrator whether your retiree plan is an employer plan. It may be self-funded (the employer pays claims itself) or fully insured (the employer buys a policy). If the employer is a state or local government, it is a government employer plan. If it is a religious organization, it may be a church plan.
• Marketplace or individual plan. You bought it yourself, through the Marketplace or off the Marketplace. A plan in place on 23 March 2010 and not changed in disqualifying ways may be a grandfathered plan, which must say that it believes it is grandfathered in any summary of benefits it provides.
• Medicare. Original Medicare sends a Medicare Summary Notice. A Medicare Advantage plan sends its own denial notice on a form numbered CMS-10003 (CMS stands for Centers for Medicare & Medicaid Services, the federal agency that runs Medicare). A Medicare drug plan makes “coverage determinations”. A Medigap policy pays some costs Original Medicare leaves.
• Medicaid or children’s coverage. The notice comes from a state agency and states your right to a fair hearing. In Medicaid managed care a private plan runs your benefits and you appeal to the plan first. See also the Children’s Health Insurance Program (CHIP).
• Military, veteran and federal employee. TRICARE has regional contractors; Veterans Affairs (VA) care runs through a VA facility with a patient advocate; Federal Employees Health Benefits plans have carriers and the Office of Personnel Management; Indian Health Service referrals for outside care are paid through its Purchased/Referred Care program, which is not an entitlement.
• Student, short-term and other. A student health plan sold through a school; or a short-term or non-compliant plan, such as short-term insurance, a health care sharing ministry or fixed indemnity coverage, which are not covered by the Affordable Care Act appeal rules or the No Surprises Act.

What to do

1. Gather three things: your insurance card (both sides), the denial letter or Explanation of Benefits (EOB), and anything from your employer or school about benefits.
2. Ask where the coverage comes from. Job, Marketplace, Medicare, Medicaid, military, VA, school, or something you bought directly.
3. Read the card. Look for the insurer’s name, any words like “administered by”, and any mention of a state department of insurance. Some states publish a card test. Texas tells people that if the card shows “TDI” (Texas Department of Insurance) or “DOI” (department of insurance), the state regulates the plan. A card that says the plan is “administered by” an insurance company, or shows “ASO” (administrative services only), is probably a self-funded employer plan. See Texas.
4. Read the top of the denial letter. Its name, form number and appeal instructions are strong clues.
5. Try the coverage type finder and write down what it concludes.
6. If it is a job-based plan, take the next step: self-funded or fully insured.
7. If you are still unsure, ask in writing. Ask your plan or your employer’s human resources department. The request for plan documents and the human resources script have the words.

What the plan may say, and what to say back

“Your plan is administered by us.” Ask: “Does my employer pay the claims itself, or does your company bear the cost under an insurance policy?”

“I cannot tell you what kind of plan you have.” Ask who can, and whether the summary plan description is available. Then ask your employer’s human resources department.

The rule

A grandfathered plan must say that it believes it is grandfathered, with contact information, in any summary of benefits it provides. Source: Code of Federal Regulations (CFR) Title 45, section 147.140(a)(2).

Watch for

• Retiree coverage from a former employer. We could not confirm how this is treated, so ask the plan administrator whether it is an employer plan, and whether the plan pays claims itself. Until you know, use the shorter deadline on your notice.
• Two plans at once. You may have a job-based plan and a spouse’s plan, Medicare and a retiree plan, or continuation coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA), which lets you keep job-based coverage after you leave. See two plans and COBRA.
• Same card, different rules. An insurer can run both an insured plan and a self-funded plan under one brand.
• Plan types change. A new plan year, a job change or a move onto Medicare changes the answer. Use the type that applied when the care was given or the denial was issued.
• Do not guess at Marketplace appeals. A Marketplace eligibility appeal is about the Marketplace’s own decision, not a claim denial from your plan.

What next

• Narrow a job-based plan: self-funded or fully insured.
• See who oversees each kind: who regulates your plan.
• See the deadlines: appeal deadlines by coverage type.
• Go to the topic page, find out what kind of coverage you have.