Your coverage
Marketplace and individual plans
Coverage you buy yourself, through HealthCare.gov, a state marketplace or directly from an insurer.
Do this today
- Find the kind of plan you have Pick the closest match below. Each page has the appeal steps, deadlines and free help for it.
- Read: Marketplace and individual plans: the appeal path 5 minute read. How to appeal a denial from a plan you bought yourself. It may be through HealthCare.gov, a state marketplace or an insurer directly. You appeal to the plan, then to independent review.
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Put this step on My Plan
So you can come back to it, and keep your dates and calls in one place.
In brief
- A plan you buy yourself has one internal appeal, then independent (external) review. Both are with the insurer and outside reviewers, not with the Marketplace.
- You have at least 180 days after you receive the denial to appeal, and at least four months after the final denial to ask for independent review.
- Your state insurance department is your main regulator. Many states list a consumer assistance program, but the federal list says none now receives federal grant money, so confirm yours is still running.
- A grandfathered plan has fewer of these protections. Check the date on your notice, which controls.
Read the full guide: Marketplace and individual plans: the appeal path
Coverage types in this group
Each page has the appeal steps, deadlines and free help for that coverage.
- 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.
More guides, tools and letters
More guides, tools, letters 2
Guides
- Marketplace and individual plans: the appeal path
How to appeal a denial from a plan you bought yourself. It may be through HealthCare.gov, a state marketplace or an insurer directly. You appeal to the plan, then to independent review.
- Marketplace eligibility appeals are not claim appeals
A Marketplace appeal challenges a decision about your eligibility or tax credit. It cannot overturn an insurer's claim denial. Learn what it covers, the 90-day deadline, and what to do for a claim denial instead.
Questions to keep handy
- What exactly was denied, and under which part of the plan?
- What is my deadline, and what is it counted from?
- Where and how do I send my request, and how will I prove it arrived?
- Who decides, and can I ask for a faster decision?
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