Questions & answers · Health insurance
My health insurance denied my claim. Which appeal rules apply to me?
Health insuranceOtherChecked Nov 5, 2026
From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-05 · Source: eCFR · 29 CFR 2560.503-1(h)(1) (row p-erisa · current as of 2026-11-02) View original ↗
In short
- The rules depend on where your plan comes from.
- Job plans, marketplace plans, and Medicare plans each have their own steps.
- Look at your card or denial letter to see your plan type.
What this means
It depends on where the plan comes from: • Job-based plan through a private employer: every employee benefit plan must have a claims and appeal procedure under the federal ERISA claims regulation [1]. Job-based health plans that are not grandfathered also follow the ACA rules for appeals and external review [4]. • Individual plan, including HealthCare.gov or a state marketplace: the ACA rules require an internal appeal (one level for individual plans) and then external review [2]. • Medicare Advantage: Medicare health plans follow their own federal appeal rules [3].
The federal ACA appeal rules generally do not apply to grandfathered plans [4].
Your next step
find the plan type on your card or denial letter. Your denial notice must describe the internal appeal and external review processes and how to start an appeal [5].
Where this comes from (5)
[1] eCFR · 29 CFR 2560.503-1(h)(1) (row p-erisa · current as of 2026-11-02) · checked 2026-11-05
Every employee benefit plan shall establish and maintain a procedure by which a claimant shall have a reasonable opportunity to appeal an adverse benefit determination to an appropriate named fiduciary of the plan, and under which there will be a full and fair review of the claim and the adverse benefit determination.
[2] eCFR · 45 CFR 147.136(b)(3)(ii)(G) (row p-aca · current as of 2026-11-02) · checked 2026-11-05
a health insurance issuer offering individual health insurance coverage must provide for only one level of internal appeal before issuing a final determination.
[3] CMS · Medicare Managed Care Appeals & Grievances · Overview (row p-ma) · checked 2026-11-05
Medicare health plans, which include Medicare Advantage (MA) plans … must meet the requirements for grievance, organization determination, and appeals processing under the MA regulations found at 42 CFR Part 422, Subpart M.
[4] eCFR · 45 CFR 147.136(a)(1) (row aca-scope) · checked 2026-11-05
This section sets forth requirements with respect to internal claims and appeals and external review processes for group health plans and health insurance issuers. … The provisions of this section generally do not apply to coverage offered by health insurance issuers and group health plans that are grandfathered health plans
[5] eCFR · 45 CFR 147.136(b)(2)(ii)(E) (row aca-notice) · checked 2026-11-05
a description of available internal appeals and external review processes, including information regarding how to initiate an appeal.
How we found this
We matched your question to 5 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-05.
What we don’t know yet
Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.
Every answer is checked against the official rule it quotes.
Information only — not legal advice. Your plan, insurer or agency decides.
This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.
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