Marketplace and individual plans: the appeal path

If you bought your own health plan and the plan refused to pay for care or refused to approve it, you appeal to the insurer first, and then, if it says no again, you ask outside reviewers. This page covers that journey for plans bought through HealthCare.gov, through a state marketplace, or straight from an insurer. The reference pages are Marketplace plan, Individual plan bought outside the Marketplace and Grandfathered plan.

If the problem is a decision about your eligibility or your tax credit, you are on the wrong page. Go to Marketplace eligibility appeals are not claim appeals.

What this means

Buying through the Marketplace does not change who decides your claims. The insurer decides them, and the insurer’s decision is what you appeal. The Marketplace is the place where you enrolled.

A plan that is not grandfathered must follow the federal rule on internal appeals and external review. That rule borrows the employer claims procedure and adds more. The state insurance department is the main regulator.

For scale: KFF, a health policy research organization formerly named the Kaiser Family Foundation, reported that HealthCare.gov insurers denied 19 percent of in-network claims in 2024 and 37 percent of out-of-network claims. Consumers appealed fewer than 1 percent of the in-network denials. This covers only the states that use HealthCare.gov. It says nothing about your claim.

What to do

1. Read your denial notice and note the date (you). It must give the specific reason and say how to appeal and how to ask for independent review.
2. Ask for the claim file and the code meanings (you). Ask the insurer in writing for all documents relevant to your claim and for the diagnosis and treatment codes. Asking for codes is not an appeal.
3. File the internal appeal (you). The insurer must give you at least 180 days after you receive the denial notice. An insurer that sells individual coverage provides only one level of internal appeal before it gives a final decision.
4. If waiting could seriously harm you, say so (you and your doctor). If your doctor says the situation is urgent, the insurer must treat it that way and decide within 72 hours. You can ask for expedited independent review at the same time as an expedited internal appeal.
5. Ask for independent review if the insurer says no (you). You have at least four months after you receive the final denial. A standard decision is due within 45 days after the reviewer receives the request, and an expedited one within 72 hours.
6. Know which process you are in (you). Your state either runs the review or the case goes through the federal process. The denial notice should say which.
7. Use free help (you). Your state insurance department can take a complaint, and HealthCare.gov points consumers to their state’s consumer assistance program, which may file an appeal for you. Your state page on the state pages lists what exists.

The plan’s decision times

For the insurer’s first decision on a claim: up to 72 hours if urgent, up to 15 days if you need approval before care, and up to 30 days if you are asking it to pay a bill for care you already had. The insurer may extend the pre-care and after-care periods once, by up to 15 days, for matters beyond its control. For the appeal decision: 30 days before care, and 60 days after care.

Check the date on your notice, which controls.

The rule

Your plan must allow you at least four months after you receive a denial or final internal denial to request external review. (Title 29 of the Code of Federal Regulations (CFR), section 2590.715-2719(c)(2)(vi))

Watch for

• The wrong appeal. The Marketplace appeal is only for decisions the Marketplace itself makes. A claim denial goes to the insurer.
• Two different numbers for an urgent decision. HealthCare.gov’s internal appeal page says four business days. The regulation says 72 hours. Use 72 hours.
• Prior authorization times. The new 7-day federal deadline covers Medicare Advantage, Medicaid and the Children’s Health Insurance Program. It does not yet shorten the deadline for Marketplace plans. A federal proposal for exchange plans is not final.
• Grandfathered and other plans. A grandfathered plan, meaning coverage in place on 23 March 2010 that has not made disqualifying changes, is exempt from the appeals and external review section of the Affordable Care Act. The plan must say in any summary of benefits that it believes it is grandfathered. For these plans and for short-term plans, the policy and state law set your rights. See Student, short-term and other coverage.
• Process outages. The federal external review process was unavailable in July 2026 and reopened on 31 July 2026. The extra time given for deadlines in that window has ended. If a filing method fails, keep proof of the attempt and use another method named in your notice.
• The state fee. Some state processes charge up to $25, refunded if you win and waived for hardship.

What next

• File an internal appeal walks through the letter and proof of delivery.
• Request external review explains what to send and what the reviewer considers.
• Complain to your state insurance department shows how to use the regulator while your appeal runs.
• Marketplace and individual plans lists every page for this kind of coverage.